- Email: [email protected]
Insight in psychosis: A critical review of the contemporary confusion
Journal Pre-proof Insight in Psychosis: A critical review of the contemporary confusion K.S. Jacob
PII:
S1876-2018(19)31021-4
DOI:
https://doi.org/10.1016/j.ajp.2019.101921
Reference:
AJP 101921
To appear in:
Asian Journal of Psychiatry
Received Date:
4 October 2019
Revised Date:
19 December 2019
Accepted Date:
26 December 2019
Please cite this article as: Jacob KS, Insight in Psychosis: A critical review of the contemporary confusion, Asian Journal of Psychiatry (2019), doi: https://doi.org/10.1016/j.ajp.2019.101921
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Insight in Psychosis: A critical review of the contemporary confusion Author’s name K. S. Jacob, MD, PhD, FRCPsych, FRANZCP The author recently retired as professor of psychiatry, Christian Medical College, Vellore 632002 India.
Address for correspondence
ro of
Email: [email protected] Tel: +919789138017
-p
Word count: summary 154, text 1351.
Summary
lP
re
References: 19
ur na
This commentary highlights the context, complexity, conflicting claims and the contemporary confusion related to insight in people with psychosis. Traditional psychiatric precepts suggests that good insight is inversely related to the severity of psychotic symptoms and directly related to depression scores, better
Jo
clinical outcome, and treatment adherence. However, recent studies have recognised that insight does not predict outcomes, changes over time, and is dependent on the trajectory of the individual’s illness and the social and cultural context arguing that “insight” is an explanatory model and a coping strategy. Methodological issues related to the assessment of insight, the limitations of psychiatric classification and complex interaction between biology and the
1
environment make simplistic explanations of the concept of insight less than useful. The paper argues that the biomedical model should be presented without dismissing or devaluing patient beliefs and explanations. Psychiatry needs to embrace the complexity of mental illness and value diverse attempts at restoring homeostasis.
ro of
Keywords: insight, assessment, psychosis, schizophrenia, culture
1. Introduction
Insight involves intellectual understanding and emotional appreciation of issues
-p
related to illness.1, 2 However, insight in people with psychosis is controversial. This commentary highlights the context, complexity, conflicting claims and the
lP
2. Traditional concepts
re
contemporary confusion.
ur na
Traditional psychiatric thought suggests that good insight is inversely related to the severity of psychotic symptoms (E.g. delusions, hallucinations) and directly related to depression scores, better clinical outcome, and treatment adherence.3,4 Many studies have attempted to identify underlying biological substrates.5,6
Jo
However, diverse neural mechanisms have been implicated, albeit without consistency. In addition, the correlation between insight and cognitive and neuropsychological function, is weak.7
3. Recent investigations The majority of the investigations, which correlated clinical phenomena and
2
biology with insight, employed cross-sectional study designs. In contrast, recent longitudinal studies have documented that insight scores at the onset of psychosis have limited predictive value and may not predict long-term outcomes (E.g. psychotic symptoms, disability and insight). 8-10 Investigations have also documented the impact of stigma 11 and low socioeconomic status on insight. 12 In addition, studies have recognised changing insight over time and have documented shifting explanations for causation and interventions at different
ro of
phases of the illness. These seem to be dependent on the trajectory of the
individual’s illness arguing that insight is an explanatory model and a coping
-p
strategy.8, 13
4. Methodological issues
re
These conflicting claims can be partially explained by methodological issues
lP
related to the assessment of insight and limitations of psychiatric classification. The concept of insight, which started as an all-or-none phenomenon evolved to
ur na
single and multi-dimensional constructs. 1-2, 14 While recent dimensional conceptualizations improve our comprehension of the clinical phenomenon, they also add to its complexity. Interpretation is also complicated by the fact that the
Jo
different dimensions of insight are correlated with each other.
The biomedical model undergirds current psychiatric diagnostic systems like the Diagnostic and Statistical Manual 5.15 Nevertheless, DSM 5 acknowledges the importance of culture and supports a Cultural Formulation, which entails the recognition of cultural identity and conceptualisations to ascertain perceived causes, psychosocial stressors, vulnerability, social supports, resilience, help
3
seeking and treatment expectations. However, cultural issues appear mainly in the introduction and appendix of the manual rather than forming part of the diagnostic standard in the main text.16
While the occasional review acknowledges the importance of the role of culture,14 most reviews of the concept and correlates of insight focus solely on biology and neuroscience to the complete exclusion of the psychosocial and
ro of
cultural context.17 Similarly, most instruments,14 which assess insight, also
equate biomedical explanations, attributions and actions with good insight, 11 while non-medical explanations and help seeking are said to be indicative of
-p
poor awareness making the argument tautological, 13 with the conclusion
equivalent to the premise. Therefore, people with severe psychotic illness who
re
refuse to accept disease explanations and medical treatments receive poor
lP
scores on insight scales. On the other hand, those with milder disease are able to acknowledge abnormalities within themselves and accept biomedical
ur na
interventions and are said to have good insight.8,13
Limitations of current psychiatric classification also muddy the waters. The absence of aetiological diagnosis, pathological markers and pathognomonic
Jo
features, has forced the discipline to focus on symptom clusters. These clusters, which started as Euro American idioms of distress, were operationalized and have good diagnostic reliability.18 Nevertheless, the absence of external validation of these diagnostic categories means that these labels remain constellations of symptoms sans validity and predictive power. In addition, diagnostic categories are heterogeneous on clinical features, aetiology,
4
pathology, treatment response, course and outcome. Co-occurrence of and correlation between symptom clusters (i.e. psychotic symptoms, depression and the even the constellation of insight) result in associations sans causal relationships.
Many studies examining insight in psychosis are also prisoners to disciplinary perspectives employed.
Psychoanalytical points of view argue for defense
ro of
mechanisms to protect against painful emotions secondary to awareness, while phenomenological approaches support the contention that schizophrenia is a
primary disturbance of the structure of experience.14 Neurocognitive
-p
perspectives suggest limitations in self-reflection, while neurobiological
re
approaches propose specific abnormalities in biological substrates.14
lP
Some authors have argued that schizophrenia destabilises the person’s experiential framework, weakening their basic sense of reality (natural attitude)
ur na
and allowing other senses of reality (solipsistic attitude) to emerge and co-exist resulting in “double bookkeeping”.19
5. Complex interactions
Jo
On the other hand, longitudinal investigations and those which attempted to study potential confounders support a complex interaction between the person’s trajectory of illness and cultural milieu, between biology and the environment.1213
Recent studies on explanatory models of illness have documented the fact that
people simultaneously hold multiple and contradictory models of causation and treatment (E.g. biomedical beliefs like disease, deficiency, degeneration;
5
supernatural views like evil spirits, black magic, punishment from God, karma, etc.,).8, 13 People with mental illness seek relief, concurrently and in sequence, from diverse sources of support, cure and healing (E.g. Psychiatric facilities, faith and traditional healers). Those who respond to medical interventions and recover seem to agree with biomedical explanations of their illness, while those who have treatment-resistant psychosis seem to hold non-medical explanations, even while complying with medication.8 Simultaneously holding multiple and
ro of
contradictory explanations for their condition seems to justify the trajectory of illness and provide meaning to people’s lives.13 Such narrative insight
emphasises the subject, cultural milieu, the audience and pragmatic needs of the
-p
context.
re
The many theories and hypothesis about the mechanism of insight are
lP
inconsistently supported and remain unproven.5-7,14,17 The examples of “double bookkeeping”, suggested as a mechanism for explaining poor insight in people
ur na
with schizophrenia,19 describes psychotic phenomena during periods of acute exacerbations of psychosis. Many people with schizophrenia hold multiple and contradictory beliefs, both during periods of acute psychosis and during more chronic phase of their illness.8 These beliefs usually reflect the diversity of
Jo
opinion about the nature of mental illness, common in human societies. Studies have also documented medical and non-medical explanatory models of illness in people with schizophrenia, who while citing religious and supernatural explanations for the illness, are also compliant with the psychotropic medication prescribed. The evidence argues that the majority of the explanatory models of illness among people with schizophrenia are consistent with local and culturally
6
accepted explanations and are non-psychotic in nature8 and do not reflect “double bookkeeping”. Equating all non-medical explanations of illness “double bookkeeping” is an error.
Insight, an attractive and intuitive concept, remains a complex construct. It cannot be reduced to a symptom or sign of mental illness, a psychological mechanism, a neurocognitive function or an underlying biological substrate.14
ro of
These aspects of insight have a complex and dynamic relationship with each
other and with the trajectory of illness, contextual factors and the cultural milieu. It is now widely accepted that insight is determined by multiple and diverse
-p
factors.
re
The dominance of the biomedical model of insight in psychosis highlights the
lP
danger of a single story. Like all simplistic and unidimensional explanations, it is incomplete and patronising; it dismisses context, devalues culture, creates
ur na
stereotypes, overlooks the positives, diminishes personal attempts at giving meaning to life, and disempowers people with mental illness. Psychiatric diagnostic labels and the biomedical approach, despite their good intentions, also seem to increase stigma and discrimination. Psychiatry needs to embrace
Jo
the complexity of mental illness, their varied causes and dissimilar outcomes and value diverse attempts at restoring “homeostasis”.
6. Implications for health care The complexity of mental illness and the complicated nature of the clinical phenomenon of insight have major implications for health care. Clinical care
7
mandates the recognition of the clinical syndrome, elicitation of patient perspectives, evaluation of the local context and culture, education of the patient and their families about possible interventions and negotiation of shared plan of management.16 Consequently, mental health professionals should present the biomedical model without dismissing and devaluing patient beliefs and culture.
Nevertheless, the biomedical approach in particular and the biopsychosocial
ro of
model in general, operate within a paternalistic physician-patient relationship; they need to move towards a shared approach, within a more equal patient-
clinician partnership.16 The diversity of patients, problems, beliefs, and cultures
-p
mandate the need to educate, match, negotiate and integrate psychiatric,
psychological and cultural frameworks and interventions. Such an approach will
lP
re
encourage contextualised and patient-centred psychiatric practice.
The patient’s awareness of their context, their understanding of beliefs and their
ur na
emotional appreciation of problems demand an empathetic approach from mental health professionals. Good clinical practice mandates the negotiation of a shared model of care and treatment between patients and their healers.
Jo
Author contribution
KS Jacob trained in medicine, psychiatry, epidemiology and anthropology. He has studied insight and psychopathology and the impact of culture. He has worked in clinical and academic settings in India, the United Kingdom and in Australia. He recently retired as professor of psychiatry, Christian Medical College, Vellore,
8
India. The author reviewed clinical practice, analysed literature, studied the impact of culture on insight in people with schizophrenia and wrote the paper. Conflicts of interest None Funding
ro of
No specific funding received for this effort
Acknowledgements
-p
No funding was received for this effort.
re
References
1. Sims ACP. Symptoms in the mind: An introduction to descriptive
lP
psychopathology. London, England: Elsevier. 2003. 2. David A. Insight and psychosis. Br J Psychiatry. 1990; 156: 798-809.
ur na
3. David AS. The clinical importance of insight: An overview. In X. F. Amador & A. S. David (Eds.), Insight and psychosis: Awareness of illness in schizophrenia and related disorders (2nd ed., pp. 359–392). Oxford, UK:
Jo
Oxford University Press. 2004.
4. Mohamed S, Rosenheck R, McEvoy J, Swartz M, Stroup S, Lieberman JA. Cross-sectional and longitudinal relationships between insight and attitudes towards medication and clinical outcomes in chronic schizophrenia. Schizophr Bull. 2009; 35: 336-346.
9
5. Shad MU, Keshavan MS. Neurobiology of insight deficits in schizophrenia: An fMRI study. Schizophr Res, 2015; 165; 220-6. 6. Van der Meer L, de Vos AE, Stiekema APM, Pinjnenborg GHM, van Tol MJ, Nolen WA, David AS, Aleman A. Insight in schizophrenia: involvement of self-reflection networks? Schizophr Bull. 2013; 39: 1288-1295. 7. Nair A, Palmer EC, Aleman A, David AS. Relationship between cognition,
Schizophr Res. 2014; 152: 191-200.
ro of
clinical and cognitive insight in psychosis: a review and meta analysis.
8. Johnson S, Manoranjitham SD, Charles H, Jeyaseelan V, Jacob KS. Insight,
psychopathology,
explanatory
models
and
outcome
of
-p
schizophrenia in India: a prospective 5-year cohort study. Biomed Central Psychiatry 2012; 12:159.
re
9. Johnson S, Manoranjitham SD, Charles H, Jacob KS. Predictors of
lP
Disability: a 5-year cohort study of first-episode schizophrenia. Asian J Psychiatry. 2014; 9:45-50.
ur na
10. Johnson S, Manoranjitham SD, Charles H, Jeyaseelan V, Jacob KS. Predictors of Insight in first-episode schizophrenia: a 5-year cohort study from India" Int J Soc Psychiatry. 2014; 60; 566-57.
11. Cavelti M, Kvrgic S, Beck EM, Rusch N, Vauth R. Self stigma and its
Jo
relationship with insight, demoralization and clinical outcome among people with schizophrenia spectrum disorders. Compr Psychiatry.2012, 53: 468-479.
12. Belvederi MM, Amore M, Calcagno P, Respino M, Marozzi V, Bugliani M, Innamorati A, Pompili M, Gladerisi S, Maj M. The “insight paradox” in schizophrenia: magnitude, moderators, and mediators of the association
10
between insight and depression. Schizophr Bull. 2016; 42: 1225-1233. 13. Jacob KS. Insight in psychosis: standards, science, ethics and value judgment. Int J Soc Psychiatry. 2017; 63: 345-351. 14. Murri MB, Amore M. The multiple dimensions of insight in schizophreniaspectrum disorders. Schizophr Bull. 2019; 45: 277-283. 15. American Psychiatric Association. Diagnostic and Statistical Manual 5. Arlington, VA: APA.
ro of
16. Jacob KS. DSM-5 and culture: The need to move towards a shared model of care within a more equal patient-physician partnership. Asian J Psychiatry. 2014; 7: 89-91.
-p
17. David AS. Insight and psychosis: the next 30 years. Br J Psychiatry. 1-3. doi:10.1192/bjp.2019.217
re
18. Jacob KS. Idioms of distress, mental symptoms, syndromes, disorders and
lP
transdiagnostic approaches. Asian J Psychiatry. 2019; 46:7-8. 19. Henriksen MG, Parnas J. Self-disorders and schizophrenia: A
ur na
phenomenological reappraisal of poor insight and non compliance.
Jo
Schizophr Bull. 2014; 40:542-547.
11
PII:
S1876-2018(19)31021-4
DOI:
https://doi.org/10.1016/j.ajp.2019.101921
Reference:
AJP 101921
To appear in:
Asian Journal of Psychiatry
Received Date:
4 October 2019
Revised Date:
19 December 2019
Accepted Date:
26 December 2019
Please cite this article as: Jacob KS, Insight in Psychosis: A critical review of the contemporary confusion, Asian Journal of Psychiatry (2019), doi: https://doi.org/10.1016/j.ajp.2019.101921
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Insight in Psychosis: A critical review of the contemporary confusion Author’s name K. S. Jacob, MD, PhD, FRCPsych, FRANZCP The author recently retired as professor of psychiatry, Christian Medical College, Vellore 632002 India.
Address for correspondence
ro of
Email: [email protected] Tel: +919789138017
-p
Word count: summary 154, text 1351.
Summary
lP
re
References: 19
ur na
This commentary highlights the context, complexity, conflicting claims and the contemporary confusion related to insight in people with psychosis. Traditional psychiatric precepts suggests that good insight is inversely related to the severity of psychotic symptoms and directly related to depression scores, better
Jo
clinical outcome, and treatment adherence. However, recent studies have recognised that insight does not predict outcomes, changes over time, and is dependent on the trajectory of the individual’s illness and the social and cultural context arguing that “insight” is an explanatory model and a coping strategy. Methodological issues related to the assessment of insight, the limitations of psychiatric classification and complex interaction between biology and the
1
environment make simplistic explanations of the concept of insight less than useful. The paper argues that the biomedical model should be presented without dismissing or devaluing patient beliefs and explanations. Psychiatry needs to embrace the complexity of mental illness and value diverse attempts at restoring homeostasis.
ro of
Keywords: insight, assessment, psychosis, schizophrenia, culture
1. Introduction
Insight involves intellectual understanding and emotional appreciation of issues
-p
related to illness.1, 2 However, insight in people with psychosis is controversial. This commentary highlights the context, complexity, conflicting claims and the
lP
2. Traditional concepts
re
contemporary confusion.
ur na
Traditional psychiatric thought suggests that good insight is inversely related to the severity of psychotic symptoms (E.g. delusions, hallucinations) and directly related to depression scores, better clinical outcome, and treatment adherence.3,4 Many studies have attempted to identify underlying biological substrates.5,6
Jo
However, diverse neural mechanisms have been implicated, albeit without consistency. In addition, the correlation between insight and cognitive and neuropsychological function, is weak.7
3. Recent investigations The majority of the investigations, which correlated clinical phenomena and
2
biology with insight, employed cross-sectional study designs. In contrast, recent longitudinal studies have documented that insight scores at the onset of psychosis have limited predictive value and may not predict long-term outcomes (E.g. psychotic symptoms, disability and insight). 8-10 Investigations have also documented the impact of stigma 11 and low socioeconomic status on insight. 12 In addition, studies have recognised changing insight over time and have documented shifting explanations for causation and interventions at different
ro of
phases of the illness. These seem to be dependent on the trajectory of the
individual’s illness arguing that insight is an explanatory model and a coping
-p
strategy.8, 13
4. Methodological issues
re
These conflicting claims can be partially explained by methodological issues
lP
related to the assessment of insight and limitations of psychiatric classification. The concept of insight, which started as an all-or-none phenomenon evolved to
ur na
single and multi-dimensional constructs. 1-2, 14 While recent dimensional conceptualizations improve our comprehension of the clinical phenomenon, they also add to its complexity. Interpretation is also complicated by the fact that the
Jo
different dimensions of insight are correlated with each other.
The biomedical model undergirds current psychiatric diagnostic systems like the Diagnostic and Statistical Manual 5.15 Nevertheless, DSM 5 acknowledges the importance of culture and supports a Cultural Formulation, which entails the recognition of cultural identity and conceptualisations to ascertain perceived causes, psychosocial stressors, vulnerability, social supports, resilience, help
3
seeking and treatment expectations. However, cultural issues appear mainly in the introduction and appendix of the manual rather than forming part of the diagnostic standard in the main text.16
While the occasional review acknowledges the importance of the role of culture,14 most reviews of the concept and correlates of insight focus solely on biology and neuroscience to the complete exclusion of the psychosocial and
ro of
cultural context.17 Similarly, most instruments,14 which assess insight, also
equate biomedical explanations, attributions and actions with good insight, 11 while non-medical explanations and help seeking are said to be indicative of
-p
poor awareness making the argument tautological, 13 with the conclusion
equivalent to the premise. Therefore, people with severe psychotic illness who
re
refuse to accept disease explanations and medical treatments receive poor
lP
scores on insight scales. On the other hand, those with milder disease are able to acknowledge abnormalities within themselves and accept biomedical
ur na
interventions and are said to have good insight.8,13
Limitations of current psychiatric classification also muddy the waters. The absence of aetiological diagnosis, pathological markers and pathognomonic
Jo
features, has forced the discipline to focus on symptom clusters. These clusters, which started as Euro American idioms of distress, were operationalized and have good diagnostic reliability.18 Nevertheless, the absence of external validation of these diagnostic categories means that these labels remain constellations of symptoms sans validity and predictive power. In addition, diagnostic categories are heterogeneous on clinical features, aetiology,
4
pathology, treatment response, course and outcome. Co-occurrence of and correlation between symptom clusters (i.e. psychotic symptoms, depression and the even the constellation of insight) result in associations sans causal relationships.
Many studies examining insight in psychosis are also prisoners to disciplinary perspectives employed.
Psychoanalytical points of view argue for defense
ro of
mechanisms to protect against painful emotions secondary to awareness, while phenomenological approaches support the contention that schizophrenia is a
primary disturbance of the structure of experience.14 Neurocognitive
-p
perspectives suggest limitations in self-reflection, while neurobiological
re
approaches propose specific abnormalities in biological substrates.14
lP
Some authors have argued that schizophrenia destabilises the person’s experiential framework, weakening their basic sense of reality (natural attitude)
ur na
and allowing other senses of reality (solipsistic attitude) to emerge and co-exist resulting in “double bookkeeping”.19
5. Complex interactions
Jo
On the other hand, longitudinal investigations and those which attempted to study potential confounders support a complex interaction between the person’s trajectory of illness and cultural milieu, between biology and the environment.1213
Recent studies on explanatory models of illness have documented the fact that
people simultaneously hold multiple and contradictory models of causation and treatment (E.g. biomedical beliefs like disease, deficiency, degeneration;
5
supernatural views like evil spirits, black magic, punishment from God, karma, etc.,).8, 13 People with mental illness seek relief, concurrently and in sequence, from diverse sources of support, cure and healing (E.g. Psychiatric facilities, faith and traditional healers). Those who respond to medical interventions and recover seem to agree with biomedical explanations of their illness, while those who have treatment-resistant psychosis seem to hold non-medical explanations, even while complying with medication.8 Simultaneously holding multiple and
ro of
contradictory explanations for their condition seems to justify the trajectory of illness and provide meaning to people’s lives.13 Such narrative insight
emphasises the subject, cultural milieu, the audience and pragmatic needs of the
-p
context.
re
The many theories and hypothesis about the mechanism of insight are
lP
inconsistently supported and remain unproven.5-7,14,17 The examples of “double bookkeeping”, suggested as a mechanism for explaining poor insight in people
ur na
with schizophrenia,19 describes psychotic phenomena during periods of acute exacerbations of psychosis. Many people with schizophrenia hold multiple and contradictory beliefs, both during periods of acute psychosis and during more chronic phase of their illness.8 These beliefs usually reflect the diversity of
Jo
opinion about the nature of mental illness, common in human societies. Studies have also documented medical and non-medical explanatory models of illness in people with schizophrenia, who while citing religious and supernatural explanations for the illness, are also compliant with the psychotropic medication prescribed. The evidence argues that the majority of the explanatory models of illness among people with schizophrenia are consistent with local and culturally
6
accepted explanations and are non-psychotic in nature8 and do not reflect “double bookkeeping”. Equating all non-medical explanations of illness “double bookkeeping” is an error.
Insight, an attractive and intuitive concept, remains a complex construct. It cannot be reduced to a symptom or sign of mental illness, a psychological mechanism, a neurocognitive function or an underlying biological substrate.14
ro of
These aspects of insight have a complex and dynamic relationship with each
other and with the trajectory of illness, contextual factors and the cultural milieu. It is now widely accepted that insight is determined by multiple and diverse
-p
factors.
re
The dominance of the biomedical model of insight in psychosis highlights the
lP
danger of a single story. Like all simplistic and unidimensional explanations, it is incomplete and patronising; it dismisses context, devalues culture, creates
ur na
stereotypes, overlooks the positives, diminishes personal attempts at giving meaning to life, and disempowers people with mental illness. Psychiatric diagnostic labels and the biomedical approach, despite their good intentions, also seem to increase stigma and discrimination. Psychiatry needs to embrace
Jo
the complexity of mental illness, their varied causes and dissimilar outcomes and value diverse attempts at restoring “homeostasis”.
6. Implications for health care The complexity of mental illness and the complicated nature of the clinical phenomenon of insight have major implications for health care. Clinical care
7
mandates the recognition of the clinical syndrome, elicitation of patient perspectives, evaluation of the local context and culture, education of the patient and their families about possible interventions and negotiation of shared plan of management.16 Consequently, mental health professionals should present the biomedical model without dismissing and devaluing patient beliefs and culture.
Nevertheless, the biomedical approach in particular and the biopsychosocial
ro of
model in general, operate within a paternalistic physician-patient relationship; they need to move towards a shared approach, within a more equal patient-
clinician partnership.16 The diversity of patients, problems, beliefs, and cultures
-p
mandate the need to educate, match, negotiate and integrate psychiatric,
psychological and cultural frameworks and interventions. Such an approach will
lP
re
encourage contextualised and patient-centred psychiatric practice.
The patient’s awareness of their context, their understanding of beliefs and their
ur na
emotional appreciation of problems demand an empathetic approach from mental health professionals. Good clinical practice mandates the negotiation of a shared model of care and treatment between patients and their healers.
Jo
Author contribution
KS Jacob trained in medicine, psychiatry, epidemiology and anthropology. He has studied insight and psychopathology and the impact of culture. He has worked in clinical and academic settings in India, the United Kingdom and in Australia. He recently retired as professor of psychiatry, Christian Medical College, Vellore,
8
India. The author reviewed clinical practice, analysed literature, studied the impact of culture on insight in people with schizophrenia and wrote the paper. Conflicts of interest None Funding
ro of
No specific funding received for this effort
Acknowledgements
-p
No funding was received for this effort.
re
References
1. Sims ACP. Symptoms in the mind: An introduction to descriptive
lP
psychopathology. London, England: Elsevier. 2003. 2. David A. Insight and psychosis. Br J Psychiatry. 1990; 156: 798-809.
ur na
3. David AS. The clinical importance of insight: An overview. In X. F. Amador & A. S. David (Eds.), Insight and psychosis: Awareness of illness in schizophrenia and related disorders (2nd ed., pp. 359–392). Oxford, UK:
Jo
Oxford University Press. 2004.
4. Mohamed S, Rosenheck R, McEvoy J, Swartz M, Stroup S, Lieberman JA. Cross-sectional and longitudinal relationships between insight and attitudes towards medication and clinical outcomes in chronic schizophrenia. Schizophr Bull. 2009; 35: 336-346.
9
5. Shad MU, Keshavan MS. Neurobiology of insight deficits in schizophrenia: An fMRI study. Schizophr Res, 2015; 165; 220-6. 6. Van der Meer L, de Vos AE, Stiekema APM, Pinjnenborg GHM, van Tol MJ, Nolen WA, David AS, Aleman A. Insight in schizophrenia: involvement of self-reflection networks? Schizophr Bull. 2013; 39: 1288-1295. 7. Nair A, Palmer EC, Aleman A, David AS. Relationship between cognition,
Schizophr Res. 2014; 152: 191-200.
ro of
clinical and cognitive insight in psychosis: a review and meta analysis.
8. Johnson S, Manoranjitham SD, Charles H, Jeyaseelan V, Jacob KS. Insight,
psychopathology,
explanatory
models
and
outcome
of
-p
schizophrenia in India: a prospective 5-year cohort study. Biomed Central Psychiatry 2012; 12:159.
re
9. Johnson S, Manoranjitham SD, Charles H, Jacob KS. Predictors of
lP
Disability: a 5-year cohort study of first-episode schizophrenia. Asian J Psychiatry. 2014; 9:45-50.
ur na
10. Johnson S, Manoranjitham SD, Charles H, Jeyaseelan V, Jacob KS. Predictors of Insight in first-episode schizophrenia: a 5-year cohort study from India" Int J Soc Psychiatry. 2014; 60; 566-57.
11. Cavelti M, Kvrgic S, Beck EM, Rusch N, Vauth R. Self stigma and its
Jo
relationship with insight, demoralization and clinical outcome among people with schizophrenia spectrum disorders. Compr Psychiatry.2012, 53: 468-479.
12. Belvederi MM, Amore M, Calcagno P, Respino M, Marozzi V, Bugliani M, Innamorati A, Pompili M, Gladerisi S, Maj M. The “insight paradox” in schizophrenia: magnitude, moderators, and mediators of the association
10
between insight and depression. Schizophr Bull. 2016; 42: 1225-1233. 13. Jacob KS. Insight in psychosis: standards, science, ethics and value judgment. Int J Soc Psychiatry. 2017; 63: 345-351. 14. Murri MB, Amore M. The multiple dimensions of insight in schizophreniaspectrum disorders. Schizophr Bull. 2019; 45: 277-283. 15. American Psychiatric Association. Diagnostic and Statistical Manual 5. Arlington, VA: APA.
ro of
16. Jacob KS. DSM-5 and culture: The need to move towards a shared model of care within a more equal patient-physician partnership. Asian J Psychiatry. 2014; 7: 89-91.
-p
17. David AS. Insight and psychosis: the next 30 years. Br J Psychiatry. 1-3. doi:10.1192/bjp.2019.217
re
18. Jacob KS. Idioms of distress, mental symptoms, syndromes, disorders and
lP
transdiagnostic approaches. Asian J Psychiatry. 2019; 46:7-8. 19. Henriksen MG, Parnas J. Self-disorders and schizophrenia: A
ur na
phenomenological reappraisal of poor insight and non compliance.
Jo
Schizophr Bull. 2014; 40:542-547.
11