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David Baxter

Mar 26, 2004
Insight and Schizophrenia
by Michael T. Compton, MD, MPH; John Newcomer, MD
Medscape Psychiatry & Mental Health

Question: What can be done to improve insight in schizophrenia?
Relatively few targeted treatments exist for the problematic domain of illness features encompassed by the term impaired insight. Although most patients with schizophrenia have some awareness of a change in their mental state, some level of impaired insight is present in nearly every individual with the disorder. Impaired insight in the context of schizophrenia often refers to a lack of awareness of illness or need for treatment even though this is evident to others. However, insight is a complex and multidimensional construct -- including the recognition of the presence of a mental illness, ability to adhere to treatment, and attribution of unusual perceptual experiences to pathological phenomena -- that varies between patients and across time for individual patients.[1] Impairment in insight is a predictor of poor outcome (eg, more hospitalizations, poorer psychosocial functioning), and this relationship may be largely mediated by nonadherence to treatment (both failure to attend appointments and not consistently taking medication). It has been suggested that treatment non-adherence might be considered the behavioral-external manifestation of insight, which is the internal-subjective perspective of one's illness.[2] Thus, enhancing insight is a critical therapeutic goal for nearly all patients with schizophrenia. Numerous studies show correlations between insight and neurocognitive functioning[3] as well as both positive and negative symptoms.[4,5] It should also be noted that impaired insight (especially regarding positive symptoms) may represent a coping strategy in which incomplete awareness of illness is an attempt to avoid realization of experiencing a severe mental illness and all its personal consequences.[2] In this context, enhanced insight may lead to greater psychological distress. This is supported by the observation that poorer insight is associated with less depression. However, McGorry and McConville[6] have noted that while insight may be a 'two-edged sword' at some level, gross impairments in insight commonly cause significant problems.

The mainstays for enhancing insight are psychoeducation about the illness and the use of motivational interviewing techniques. Studies of psychoeducational approaches have yielded mixed results,[6,7] although this is the most commonly used modality for enhancing insight in the clinical setting. Psychoeducation should be tailored to individual patients and their family members to maximize learning based on personal and cultural characteristics. Motivational interviewing is a directive, client-centered counseling style used for a variety of problems characterized by ambivalence (eg, HIV risk behavior, substance abuse). Rusch and Corrigan have described modifications to motivational interviewing that can be applied in the clinical setting to target impaired insight and poor treatment adherence.[2] Several empirical studies support the effectiveness of this approach. Similarly, cognitive-behavioral approaches have been shown to be beneficial. For example, a study from the United Kingdom demonstrated that a short, insight-focused cognitive-behavioral therapy intervention delivered by trained nurses in the community had lasting effects on insight and adherence.[8] Other psychosocial treatments, such as vocational rehabilitation, may have secondary effects on improving insight, especially in patients with less severe cognitive deficits.[9]

A confrontational approach, in which the clinician's view of the illness is considered right while the patient's perspective is wrong, is very likely to be problematic.[2] Since insight is associated with positive and negative symptoms, as well as neurocognitive impairments, treatment efforts to improve these other symptom domains may have improve insight substantially. Programs that incorporate as role models more experienced patients who have either recovered or are successfully self-managing their illness (eg, peer support programs) may be beneficial.[6]

Group interventions may also be useful. Malla and colleagues[1] describe a group psychotherapeutic intervention for individuals recovering from a first episode of psychosis, which includes a focus on recognizing the presence of the illness, while acknowledging the potential need to deny or underestimate the impact of the illness and the potential stigma that comes along with the label. McGorry and McConville suggest that insight may be better if assessment and intervention are provided during the very early stages of psychosis.[6] Thus, like many other domains of the illness, phase-specific interventions early in the course of the illness may be critical with regard to longer-term outcomes.

  1. Malla AK, McLean TS, Norman RMG. A group psychotherapeutic intervention during recovery from first-episode psychosis. In: Gleeson JFM, McGorry PD. Psychological Interventions in Early Psychosis: A Treatment Handbook. West Sussex, England: John Wiley & Sons, 2004:117-135.
  2. Rusch N, Corrigan PW. Motivational interviewing to improve insight and treatment adherence in schizophrenia. Psychiatr Rehabil J. 2002;26:23-32. Abstract
  3. Aleman A, Agrawal N, Morgan KD, David AS. Insight in psychosis and neuropsychological function: Meta-analysis. Br J Psychiatry. 2006;189:204-212. Abstract
  4. McEvoy JP, Johnson J, Perkins D, et al. Insight in first-episode psychosis. Psychol Med. 2006;36:1385-1393. Abstract
  5. Saeedi H, Addington J, Addington D. The association of insight with psychotic symptoms, depression, and cognition in early psychosis: a 3-year follow-up. Schizophr Res. 2007;89:123-128. Abstract
  6. McGorry PD, McConville SB. Insight in psychosis: an elusive target. Compr Psychiatry. 1999;40:131-142. Abstract
  7. Henry C, Ghaemi NS. Insight in psychosis: A systematic review of treatment interventions. Psychopathology. 2004;37:194-199. Abstract
  8. Rathod S, Kingdon D, Smith P, Turkington D. Insight into schizophrenia: The effects of cognitive behavioural therapy on the components of insight and association with sociodemographics -- data on a previously published randomised controlled trial. Schizophr Res. 2005;74:211-219. Abstract
  9. Lysaker P, Bell M. Work rehabilitation and improvements in insight in schizophrenia. J Nerv Ment Dis. 1995;183:103-106. Abstract

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