Lack of Insight in Psychiatric Illness: A Critical Appraisal.

Abstract

Byline: M. Reddy Setting the Stage for Discussion: Evolution of The Concept and Importance The concept of insight in psychiatric discourse has evolved through various stages. Psychiatrists or 'the doctors of the soul' have sincetimes immemorial been curious about the attitudes and perspectives of persons with mental illness towards their disturbed minds/selves. Though discussed by alienists in the mid-19th century and few psychopathologists in the early 20th century, the concept has seen a great progress in its understanding over the last 25 years. The concept has progressed through the following stages: *Insight into illness as present or absent dichotomy (e.g., IPSS)[sup][1],[2] *One dimensional grading of Insight[sup][3] from Complete Denial (grade 1) to True Emotional Insight (grade 6). This model incorporated understanding of causation as due to internal or external factors. *Multidimensional models[sup][4],[5] which are referred to as 'biomedical models' by their anthropological critics. *The socio-cultural modifications of multidimensional models[sup][6] and the concept of Narrative Insight.[sup][7] The reason so much of global discussion and research is going into this one topic is its clinical, administrative and legal importance. The clinical practice of covert (or surreptitious) medication and involuntary admission into a psychiatric health facility are very difficult things to come to terms with. Not only is the practice of involuntary treatment/admission a clinical concern, it is also an administrative concern for the psychiatric health facility. Issues like use of physical restraints and involuntary treatment/admission usually go against the liberal understanding of Human Rights. Apart from the clinical and administrative concerns, even the legal concerns of criminal responsibility, capacity for informed consent and validity of a will depend upon the understanding of the concept of insight (or the related issues of personal, social and moral judgment) of the person suffering with a mental illness. So, the establishment of the lack of insight in a person suffering from mental illness is of utmost importance for the clinical, administrative and legal reasons. Difficulty in The Clarity and Utility of The Concept of Insight The concept of lack of insight, because of its importance needs clear conceptualization. Clarity in its conceptualization and its utility remain as major problems for four reasons: *Lack of insight means different things in different psychiatric conditions. For example lack of insight means various things in the following conditions: psychosis, depression, obsessive-compulsive disorder, personality disorder, paraphiliac disorders, substance addictions etc. *Criteria or definitions used even for a particular condition like Schizophrenia are different when used by different researchers. Some of which seem very utopian and almost unachievable when applied in routine clinical practice (example: Karl Jaspers' need for a 'completely objective attitude'[sup][8] or Amador & David's need for meeting the five criteria in a fullest sense).[sup][5] Some like Aubrey Lewis' definition[sup][9] are broad and vague. *Different schools of psychiatry ascribe different etiological reasons or reformulations of the concept of lack of insight. The understanding of causation and treatment vary among various schools of psychiatry whereby if one school considers that the person who takes western medical treatment is the one with optimal insight, the other school thinks that use of non-medical treatment is also a correct attitude towards treatment. Cultural psychiatrists[sup][7],[10],[11] discuss the lack of insight as only a coping strategy (or as just a way of explaining the disorder to oneself) without taking neurobiology of disorder into consideration. *The ontological nature of the Human Insight into subjective experiences or lack of it is very complex. …