Insight and psychosis: the next 30 years

Abstract

Academic interest in the concept of insight in psychosis has increased markedly over the past 30 years, prompting this selective appraisal of the current state of the art. Considerable progress has been made in terms of measurement and confirming a number of clinical associations. More recently, the relationship between insight and involuntary treatment has been scrutinised more closely alongside the link between decision-making capacity and insight. Advances in the clinical and cognitive neurosciences have influenced conceptual development, particularly the field of ‘metacognition’. New therapies, including those that are psychologically and neurophysiologically based, are being tested as ways to enhance insight.

Can metacognitive interventions improve insight in schizophrenia spectrum disorders? A systematic review and meta-analysis

“…Impaired clinical insight ( insight thereafter) can be considered as a cardinal feature of psychotic disorders (Carpenter, Strauss, & Bartko, 1973), especially schizophrenia (Amador et al, 1994). The multidimensional model of insight proposed by David (1990), which included: (i) awareness of having a mental illness, (ii) the ability to recall previous psychotic experiences as abnormal and (iii) treatment compliance, has received much support from research over the last three decades (Amador & David, 2004; David, 2019; Lysaker et al, 2018). However, the evidence of that previous treatments targeting insight are effective in schizophrenia spectrum disorders (SSD) is limited, which may have been due to not addressing what appears to underlie poor insight in SSD, namely metacognitive deficits (Lysaker et al, 2018a; Nair, Palmer, Aleman, & David, 2014).…”

“…No systematic reviews or meta-analyses of MERIT trials have been conducted to date. Most importantly, whether these metacognitive interventions may contribute to gaining insight remains unknown (David, 2019) since conflicting results from previous RCTs reporting insight data, which are detailed below, have not been subject to systematic review or meta-analysis to date.…”

Insight is a useful construct in clinical assessments if used wisely

“…However, this would be to gloss over where the true divergence lies. As concerted empirical research into insight began around 30 years ago,1 the clinical use of the construct has become much more refined and explicit, with the deployment of a number of assessment tools with good psychometric properties now in widespread use in research 2. However, it is true and a cause of frustration that such tools are rarely used in routine clinical or even medico-legal settings, although taking account of the variety of cultural and individual circumstances will always need more open-ended and descriptive methods.…”

Removing Compliance: Interpersonal and Social Factors Affecting Insight Assessments

“…In turn, it is then hard to imagine within psychiatric discourse that someone who does not believe they are ill in compliance with the medical model, could "use and weigh" the proposed treatment appropriately to make a decision for themselves (2).…”

“…Considered clinically relevant since 19 th century, it is mainly in the last three decades that a systematic empirical approach has developed. A range of definitions of clinical insight and corresponding insight assessment scales has been proposed (1), and used to examine the thus-defined concept's correlation to various aspects of illness, behavior, and personality, such as psychopathology, mood, IQ, and adherence to treatment (2,3). The definitions of insight vary from a more narrowly understood awareness of a particular condition and/or its aspect, to a wider notion encompassing a variety of different types of judgements about what is happening to the individual [(1) pp.…”