The symptom of ‘lack of insight’ is often a component of major mental illness. Technically referred to as anosognosia, it is the lack of insight that often results in the need for compulsory detention; supervision orders; enforceable medication and the ever-present psychiatric coercion.
Now there’s a whole heap of debate on coercion and understanding the difference between a patient electing an informed choice as opposed to one who simply doesn’t see themselves as ill. However, I have a niggling question about this state of denial that others may be able to shed considered thought or experience on.
In the case of someone who denies the existence of a mental illness, is it ever found to pervade to the denial of other illnesses, particularly new found medical ones?
I’m not sure I’ve ever come across anything that reports on this phenomena. Lots on why patients won’t take their psych drugs or engage in psychosocial therapy – but nothing that establishes any real construct theory on the nature and extent of this ‘lack of insight’ phenomena.
I raise this primarily in light of a particular case of a man with schizophrenia who has since developed diabetes. He has not adjusted to this new condition well and requires much motivation to follow a decent diet. However, he doesn’t deny he has the condition, engages in glucose testing and takes his medication (tho is passively accepting of all other meds anyhow).
His insight into his shizophrenia is limited (ie – he reports experiences of voices and recognises them as why the doctors say he has schizophrenia – but does not accept his fixed delusional beliefs as being odd or delusional or how these increase risk associated with his index offence of stalking a woman).
Surely, as he lacks insight, it would be logical to assume he wouldn’t accept his medical diagnosis either?
If this is not so – then why not so?
Any experiences of how patients are accepting of medical diagnoses – whilst denying the presence of mental illness phenomena/significance?
HANG ON PEOPLE. TWO POSTS A DAY IS TOO MUCH AT ANY TIME, NEVER MIND ON CONSECUTIVE DAYS. GOOD THREADS ARE BEING TRUNCATED PREMATURELY RATHER THAN REACHING ANY NATURAL CONCLUSION. RESTRAIN YOURSELVES PLEASE.
haha!
Insight is often simplistically determined as a patient’s concordance with the doctor’s diagnosis.
“Yes, I’m ill, I have schizophrenia,” ah great, insight present.
“No, I’m not ill, this is just me, it’s all part of life’s rich tapestry, doc,” ah a shame, insight lost.
Correctly, insight is what it says. It’s insight. So not really a medical entity at all, then. Does a patient have insight in to their experiences, an understanding of what the intensity and impact is, an appreciation of consequence?
Whether it’s called schipzophrenia, an acute polymorphic psychotic episode, “a normal blip, for me,” or whatever is almost irrelevant. That’s just the name or label or shorthand formulation. That’s not insight.
Like much of mental health, insight as a concept only has utility if it’s used explicity and precisely.
As an aside, I’ve several folk who have no formal insight but accept I’ve better things to do with my time than visit them at home and harrass them, so recognise I am genuinely trying to help. Although they feel fine, so do most folk with hypertension or increased cholesterol or a past TIA, but those folk take their ramipril, simvastatin or aspirin respectively.
Just ’cause you feel well doesn’t necessarily mean you’re resistant to the notion that health care folk are investing time in your care to try and help keep you well. Thus, taking medication can be a good thing, even if you believe you are currently well.
Lastly, insight is not the same as capacity and it’s perfectly possible to have insight but be an incapacitated adult, or have lost insight but to be a capacitated adult (within the meaning of the Mental Capacity Act 2005).
I think it’s probably natural for it to be easier to accept physical maladies – after all, for (name figure here) thousand years we have been programmed with the mind/body dichotomy.
The mind is the thing that recognises the hurt of the body – although can be overwhelmed by the same. And although, vice versa, the mind in trauma can make the body actually hurt so badly (physically) that you just want to escape it, it seems that we are conditioned to view our bodies as something ‘we’ own – like a car that is swerving – we don’t blame our driving.
P.S. TheShrink makes a fine comment above.
P.P.S. This post led me to put down a few thoughts on ‘insight’ or ‘inwit’ in a generalised sense here: http://abysmalmusings.blogspot.....inwit.html
Shrink – I find more to draw from in your aside than your (accurate) response.
As an aside, I’ve several folk who have no formal insight but accept I’ve better things to do with my time than visit them at home and harrass them, so recognise I am genuinely trying to help
Lack of insight is more oft considered a state of denial by lack of awareness or significance of the experiences patients are otherwise content to report on. I recall the old debate that, if this be the case, then a patient underplaying the potential significance of chest pain as “it’ll pass; it’s nothing” – when they are having an angina event – might be termed ‘lacking insight’.
I have just become intrugued in the nature of insight and it’s significance as an area of intervention rather than (just) a measure of illness.
[The] multiple ways in which the term is applied suggest that insight is not a unitary entity, the presence or absence of which can be ascertained in a single pass. Rather, as reflected in the most recent methods for measuring insight, …insight might better be conceptualized as a compound construct, composed of several distinct but related elements. Each element may be present or absent, or it may take an intermediate value on a spectrum that includes partial states of acknowledgment.
http://psychservices.psychiatr.....l/50/5/706
(Insight and Psychoses – book review: Applebaum)
Further from the review – and of relevance to the other debate on “research”
More recent work has taken a neuropsychologic approach, analogizing the lack of insight in psychotic disorders to the denial and neglect syndromes often seen with injuries to the right hemisphere of the brain. Researchers talk about “failures of self-monitoring” associated with these impairments. Intriguing as these approaches are, it seems unlikely—even with the miracles of positron emission tomography and functional magnetic resonance imaging—that we will soon identify the precise fold of a gyrus where insight resides. The variegated nature of the phenomenon speaks strongly against its localization in a tight cluster of axons and dendrites.
And I bet someone from neurology is still looking for the “insight” switch.
Mr Ian writes… “I raise this primarily in light of a particular case of a man with schizophrenia who has since developed diabetes. He has not adjusted to this new condition well and requires much motivation to follow a decent diet. However, he doesn’t deny he has the condition, engages in glucose testing and takes his medication (tho is passively accepting of all other meds anyhow)”
Now how does this relate to me… a man with bipolar disorder who has since developed obesity. He has not adjusted to this new condition well and requires much motivation to follow a decent diet. However, he doesn’t deny he has the condition, engages in weight monitoring and takes cholesterol meds (he is passively accepting of all other meds anyhow)
Not dancing to the beat of the medical drum does not necessarily mean a complete lack of insight. Why on earth do people smoke cigarettes when there is irrefutable evidence of the huge increased risk of lung cancer?
I sometimes abuse alcohol, binge drinking to great excess. Have I no insight? I am profoundly aware of the risks associated with alcohol but make an informed decision, or at least a “couldn’t give a toss at the moment” decision. It doesn’t mean I don’t have insight, it just means my priorities are different from yours. I have never heard anyone who takes part in outdoor sports such as rock climbing or snowboarding being accused of lacking in insight. Do these crazy people not realize the health risks involved could cause injury or even prove fatal?
I am often in disagreement with doctors about my condition/situation and the precipitating factors. I’m sure the shrinks question my insight into my condition. But lacking insight into my condition does make me immune from having insight into other areas of my life such as my obesity, my in-laws disdain of me or phone calls telling me I have won a trip to Las Vegas.
As for the mind and body thang. When I get anxious and agitated I am in no doubt that these are psychological problems that I want sorted. I know we’re all different but not having insight into one area of your life does not neccesarily mean you lack insight to all areas.
I completely agree with Mo’s comments.
Also, I think there is a huge difference between denial and lack of insight.
To me, denial suggests that deep down the patient knows the diagnosis could be true, but for whatever reason is unwilling or unable to accept that it is true – often because of the gravity of the situation and the life changes necessary.
Whereas, lack of insight suggests a mental incapacity to see the truth of the situation, for example because the patient is delusional – “I hear voices but it’s not part of an illness. The voices are transmitted to me from aliens/God/another source”.
The voices are transmitted to me from aliens/God/another source
Mo/MMW: I don’t disagree , and I always find it fascinating that, despite the fact we don’t know ourselves where – or how – the voices appear – we can tell the sufferer where they’re not coming from.
Of course, science would tell you they are biological imbalances because we have no room for spirituality anymore. We’re a ‘factoid’ state and everything must have a defined and true meaning that is shared by all.
But these are individual experiences that we have no true knowledge of their cause. We all like and need to rationalise our experiences in ways that make sense to us – so when a patient tells me “they’re voices from God” – who am I to tell them they are wrong?
That’s a fair point, but then I suppose it depends exactly what “God” is telling them.
If, as in the case of Peter Sutcliffe, God is telling you to kill all prostitutes, then we can reasonably conclude that the voice is not that of God’s based on the fact that
1) murder is a sin so God wouldn’t tell you to do that
2) all sinners (including prostitutes) are encouraged and given the opportunity to repent, and
3)heaven rejoices over repentant sinners rather than viewing them as unworthy of forgiveness and therefore worthy of death.
Although not a useful argument before treatment, I don’t think any drug could stop God from wanting to talk to you if that’s what he wanted to do, so if the drug stops “God” from talking to you, then it probably wasn’t him
so if the drug stops “God” from talking to you, then it probably wasn’t him
A lovely argument.
So if it wasn’t God – why not the devil?
Lol you’re being deliberately awkward aren’t you?
Perhaps you should perform routine exorcisms on the ward – just to make sure
I looked after a man who was described as having no insight, but he accepted his depot medication because he believed it protected him against the evil spirits out to do him ill. Was that lack of insight?
I also vividly remember interviewing a patient with a student nurse. The patient said that what was wrong with him was that he was stressed out and tired, and that when he got like that, the voices started talking to him and the neighbours started bothering him again. The student’s main observation was “well, he doesn’t have any insight does he?”. Seemed to me he had very good insight into the source and the effects of his problems.
MMW: Perhaps you should perform routine exorcisms on the ward – just to make sure
If the occasion calls for it…. you’d be alarmed at the lengths I go to in the name of being ‘patient-centered’. I have been known to stamp out the little spiders that were crawling all over his back; to lay on hands to those who fear the devil himself is inside them; or to share a meal off a plate with the man who fears it’s poison.
he believed it protected him against the evil spirits out to do him ill. Was that lack of insight?
Not at all – and probably better insight than a habitual smoker with COAD.
I’ve always accepted a bit of personal rationalisation and to be honest – explaining them as evil spirits is better than saying “my own mind makes evil comments about me and others”
I always think the question of insight gets very complicated when religion is involved. Thankfully Mr Man’s delusions are much more straight forward!
I even had an email from a sufferer once who said that she knew she needed the medication but her husband told her she was weak/possessed/lacked faith/needed to pray more. Which would suggest that he was the one who lacked insight.
Mr Ian, I wish you were on the same ward as Mr Man. He thought he needed to surround himself with plates to protect him from the beams, and one of the nurses just told him to stop being stupid and to put the plates away. He used plates for protection when he came home for home leave. Why should it matter? We know it’s not true, but if it helps relieve their anxiety and enables them to get some sleep at night, let them do it.
I was told it would reinforce his delusional beliefs, but I found that once his condition started to improve he didn’t feel that he needed them anymore anyway. So why cause them extra anxiety during a time that is traumatic for them already?
Just out of curiosity – did it help when you stamped out the spiders and laid on hands? I’d be afraid of trying to stamp out something that I couldn’t see in case I missed and the patient realised I was a fraud!
Spiders – tactile hallucination – he couldn’t see them either – he just felt them. And my colleague ‘swept them away’ with me. He appreciated our help.
The ‘let’s not reinforce delusions’ thing is historical rather than clinical or scientific.
Reality is always best as it’s the ultimate outcome aim. However, there are times when someone is so afraid that it does more good to simply appease them – and in fact, the final outcome is almost the same – “Look it wasn’t poisoned!” “See, the spiders aren’t there.”
I’ve been caught out many times but I never commit myself to one way or another – I never saw the spiders and I never thought the food was poisoned.
Maybe later I’d talk with them about it and we’d debate “reality”.
I’ve had a whole nursing shift scout the ward for CIA/FBI/Aliens before bedtime and report in to me loud and clear across the ward. (There was someone worried at the time – we didn’t just do that as routine!)
Oddly enough, I tend to have terrible ‘insight’ about physical stuff, while accepting that I’m probably irrevocably mad. Walked into a clinic bleeding from a big hole torn in my jaw: “And it didn’t occur to you to go to A&E?” “Uh, no…?” Nurse ended up escorting me into a taxi because she didn’t trust me not to just go home and try and put a plaster on it. Anyway. Whoops, tangent.
I thought that people were generally bad at taking any medication, not just psychiatric medication. People stopping part-way through antibiotics courses being an obvious example. I mean, yeah, you can’t measure insight by medication compliance. But as a sort-of-parallel issue, it’s interesting. Well, it interests me. But then, so does the Dewey Decimal System, so hey.
I guess the intention of my post was to determine any theories of neurological causation for this ‘lack of insight’ and the nature of delusional thinking.
There is also a relationship with simple ‘denial’ or ‘avoidance’ that pervades all health interests that is like a lack of insight – but in a normal (meaning commonplace) way. In mental health I think there are other issues that include distorted thinking – but whether these are simply an augmentation of ‘normal’ denial/avoidance behaviours I’m not sure.
I need to think more on it tho.