Assessing insight in schizophrenia: East meets West

Abstract

BackgroundLack of insight has been observed in people with schizophrenia across cultures but assessment of insight must take into account prevailing illness models.AimsTo determine whether culturally specific and Western biomedical interpretations of insight and psychosis can be reconciled.MethodPatients with schizophrenia (n=131) were assessed during their first contact with psychiatric services in Vellore, South India. Patients' explanatory models, psychopathology and insight were investigated using a standard schedule translated into Tamil.ResultsSupernatural explanations of symptoms were frequent. Some insight dimensions were weakly associated (inversely) with severity of symptoms whereas preserved insight was associated with anxiety, help-seeking and perception of change. Willingness to attribute symptoms to disease, in others and in one's self, but not to supernatural forces was strongly associated with insight.ConclusionsThe relationship between insight, awareness of illness and other clinical variables is similar in South India to elsewhere. However, the assessment of insight might have failed to capture locally accepted explanatory frameworks. An inclusive conceptual model which emphasises help-seeking is recommended.

Insight, Global Functioning and Psychopathology Amongst In-patient Clients with Schizophrenia

“…However, the direction of causality still remains unclear; it is very difficult to determine whether higher levels of anxiety result from increased insight or when experiencing anxiety, clients are lead to a more self-critical attitude [40] and therefore better recognition of their illness [57]; again, it is difficult to determine whether the treatment process itself (e.g., clients discussing with staff about their treatment options and prognosis) may heighten their anxiety as the level of insight in their illness improves [58]. Nevertheless, from a clinical perspective, it becomes evident that therapeutic interventions developed to enhance insight and treatment compliance need to acknowledge the risk that anxiety levels can be adversely affected as the insight increases.…”

“…Lack of insight has also been closely associated with severe psychopathology [4,15,29], although inverse or no direct relationships have also been reported [8,16,30] Similarly, a number of studies have reported an inverse [31][32][33] but also positive [34][35][36] relationship between insight and positive symptoms, suggesting therefore that insight may be largely independent of psychopathology severity [37,38] as such, recent research interest has now been shifted onto specific symptom dimensions. For instance, weak to modest relationships have been reported between insight and anxiety [23,39,40] or depressive symptomatology [32,41,42]. Finally, significant but weak to modest relationships have been found between insight and general cognitive functioning [19,23,43,44] although results appear inconsistent [45][46][47][48].…”

Culture and Mental Illness: Social Context and Explanatory Models

“…Psychotic experiences are deeply perplexing and prompt a search for meaning that often results in invoking spiritual or other extra-ordinary explanations [60,61]. The explanations that patients consider may be tentative and shift over time [62].…”

Insight in psychosis: An independent predictor of outcome or an explanatory model of illness?

“…Many reports, which have systematically elicited EMs, have documented the presence of multiple and contradictory beliefs about illness across cultures (Kapoor, 1975;Gater et al, 1991;Lloyd et al, 1998;Joel et al, 2003;McCabe and Priebe, 2004;Saravanan et al, 2007aSaravanan et al, ,b, 2010Johnson et al, 2012Johnson et al, , 2013Johnson et al, , 2014. EMs are usually a conglomeration of emic and etic approaches involving ethnocultural, personal and idiosyncratic beliefs and components from both within and outside culture.…”

“…Pluralistic societies employ multiple approaches to health and illness (Jacob, 1999). The fact that people with non-medical beliefs regularly take psychotropic medication (Saravanan et al, 2007a(Saravanan et al, ,b, 2010Johnson et al, 2012Johnson et al, , 2013Johnson et al, , 2014 argues for the complexity of the response to chronic and disabling illness. Research has documented a complex list of reasons and circumstances, which facilitate medication compliance and which are not necessarily voluntary or rational (Tranulis et al, 2011).…”