Department of Psychiatry, Christian Medical College, Vellore, India;
Institute of Psychiatry, De Crespigny Park, London, UK
Correspondence: Professor Anthony David, Section of Cognitive Neuropsychiatry, Institute of Psychiatry and GKT School of Medicine, Denmark Hill, London SE5 8 AF, UK. Tel: 020 7848 0138; fax 020 7848 0572; e-mail: a.david{at}iop.kcl.ac.uk
Insight in psychosis is a complex and controversial phenomenon (David, 1990). A criticism of the concept is that it fails to take into account cultural idioms and is Eurocentric.
CONCEPTS AND CONTROVERSIES
Transcultural studies of schizophrenia carried out under the auspices of the World Health Organization found that lack of insight was an almost invariable feature of acute and chronic schizophrenia, regardless of setting (Wilson et al, 1986). The categorical or unidimensional view of insight has given way to more nuanced and multi-dimensional perspectives (Amador & David, 1998). In the past decade, instruments have been devised to assess and quantify insight and important associations with psychopathology, social functioning and prognosis. These studies are largely from Western countries and problems regarding the cross-cultural validity have not been adequately discussed. Some authors (e.g. Perkins & Moodley, 1993; Johnson & Orrell, 1995; Beck-Sander, 1998) question this Western conceptualisation of insight and argue that it is relative and involves a comparative judgement (but see David, 1998). Our starting point is the biopsychosocial perspective from which we view insight as a culturally mediated human property that has survival value. However, there are several facets to this, each of which will be discussed below.
Poor insight as a defence mechanism
Lack of insight is often seen as a defence against the potentially
devastating realisation of a person's illness. It is thus an active
(motivated) effort to cope with or adapt to distress. In its extreme form -
denial - it is a type of self-deception that protects the individual from
threats to the self and involves exaggerated perceptions of control and
self-efficacy. Sociopsychological research suggests that such biases in
cognitive appraisal are the norm and not exclusive reactions to
crises. The frequently reported finding that preserved insight
is related to depressive symptoms (Mintz
et al, 2003) in patients with schizophrenia and inversely
related to self-deception (Moore et
al, 1999) may be interpreted as evidence that poor insight
serves as a defensive function.
It might be argued that the mechanisms underlying the concept of insight as a defence lie on a continuum encompassing all experiences, whether normal or pathological. The problem is that, outside the psychoses, there is less consensus as to whether an individual does or does not have insight into any given aspect of his or her behaviour or mental life and even less as to whether or not it is genuine.
Poor insight as misattribution
Lack of insight may be viewed as misattribution, a form of cognitive error
based on lack of information, systematic biases or idiosyncratic beliefs.
Misattribution rests on the assumption that there is a correct attribution for
symptoms and experiences with respect to some goal. This notion of correctness
brings up the question of whether insight is a value-laden concept that is
likely to change with changing medical concepts of illness as well as social
norms for illness behaviour. Advocates of the health-belief model argue that
an alternative, allegedly incorrect construction of reality may make sense
within the patient's local world of meaning and, hence, has to be interpreted
as a divergent perspective rather than as a lack of insight
(Hughes et al,
1997).
Work employing case vignettes from both Western and Eastern settings has shown, contrary to these assumptions, that patients with psychosis have a very similar model of mental illness (including the need for medical treatment) to that of mental health professionals (Chung et al, 1997), but this may be separate from their own illness awareness (e.g. McEvoy et al, 1993).
Individual models of mental illness
The concept of insight has been criticised for being
simplistic and restrictive
(Perkins & Moodley, 1993;
Beck-Sander, 1998).
Individuals perspectives, beliefs and values should be taken into
consideration when we assess something as complex as insight. This can provide
the clinician and researcher with a greater understanding of different models
of illness, help-seeking and mental health service acceptability. Some
sociological studies of labelling and stigmatisation suggest that diagnosis,
in effect an imposed biomedical model, has costs in reduced self-esteem and
lower social status for the afflicted individual
(Link et al, 1987).
However, alternative models also have costs: conceptualising lack of insight
in terms of social deviance rather than disease may be allied to the rejection
of psychotropic medications and other effective therapies. Furthermore,
although acceptance of the mental illness label may increase perceived stigma,
this is not necessarily so (Warner et
al, 1989). Explicit acknowledgement of mental illness is
intimately bound up with a sense of loss; nevertheless, promotion of the
medical model may reduce guilt and therapeutic nihilism and need not lead to
lack of autonomy. This balance of costs and benefits will be tilted according
to the person's social and cultural milieu and will be understood only in this
context.
Insight as a sociocultural process
Conceptions of mental illness and its treatment often stem from normative
social and cultural constructions. People can have various culturally shaped
frameworks to explain their illnesses, all possibly valid
(Kleinman, 1980). Socially
oriented authors contend that technical definitions of insight are Eurocentric
and that the metaphor of insight is profoundly shaped by cultural beliefs and
practices. Interestingly, the growing number of non-Western studies
(Tharyan & Saravanan,
2000; full reference list available from the authors upon request)
that examined the components of insight support its cross-cultural validity
and the local adaptability of the assessment instruments. Although there are
considerable variations in the mean total scores across studies, some
interesting similarities have emerged. The insight item with the most striking
consistency was the ability to relabel psychotic symptoms as pathological.
This taps meta-cognition and is evident when a person begins to talk about and
reflect upon, say, the voices as distinct from either natural or
supernatural communications (David,
1990). This aspect of insight may be, at least in part, a form of
neuropsychological deficit somewhat independent of cultural influences
(Rossell et al,
2003). As an analogy, one would expect a lesion of the frontal
lobes to disrupt self-awareness and other executive functions regardless of
ethnicity and cultural setting.
There are other explanations for this apparent consistency. It could reflect, on the one hand, invariant properties of the phenomena in question (e.g. hallucinations, delusions), or, on the other, the Procrustean nature of Western categories of psychopathology. Culturally informed exploration of these issues is required.
INSIGHT AND CULTURE
Multiple models
Even the multi-dimensional framework for insight mentioned above fails to
acknowledge that people with psychiatric disorders can hold multiple beliefs
about their problem; indeed, they may be diverse and contradictory. Similarly
there is no one-toone correspondence between beliefs and consequent actions.
Help-seeking behaviours have a special place in our concept of insight - as a
dimension in itself and as an external validator. However, clinical experience
suggests that patients can simultaneously seek help (action) from different
sources whose frameworks and treatments contradict each other. Hence,
naturalistic (Western) explanations (e.g. disease, abnormality,
infection, degeneration) may coexist with personalistic
(Eastern) explanations (e.g. supernatural causation, sin and
punishment, karma). Naturalistic explanations are internal whereas
personalistic explanations are often external. However, such explanations
often coexist in many cultures. For example, it is common for people in India
simultaneously to seek help and treatments from practitioners of modern
medicine and from traditional healers/shamans and, provided that each does not
claim exclusivity, this may not lead to conflict
(Joel et al, 2003). We
hypothesise that such multiple models may be advantageous,
buffering notions of loss and stigma and preventing social
disintegration.
Cultural concepts of mental disorder are closely related to insight. International research indicates that the symptomatology, help-seeking and course of schizophrenia, as well as other psychiatric disorders, are strongly influenced by cultural interpretations (Sartorius et al, 1987). The speculations on the underlying mechanisms for the better prognosis of schizophrenia in developing countries have direct implications for the cultural constructions of insight because of the interactions of self and culture. If the individual self is a culturally mediated interpretation, then we might expect that cultures act through self-awareness to shape the natural course of schizophrenia.
Insight signifies a variety of ways in which a person's mental life approximates to that of others - in terms of what constitutes an illness, what beliefs are abnormal and what medical advice it is reasonable to follow. A number of shared assumptions allow these aspects to be incorporated in the mental model that psychiatrists have of what constitutes insight. This takes into account other clinical features, including history, course, culture, etc. In its own way, this is reliable and may even be valid. Hence, if a person could acknowledge some kind of non-visible change in his or her body or mind that affects the ability to function socially, and if he or she feels the need for restitution, then, irrespective of the attribution and the pathways of care that the person seeks, we could call this the presence of insight.
CONCLUSIONS AND FUTURE DIRECTIONS
Insight is not only at the interface of biological and psychosocial explanations in psychiatry but also at the interface of globalisation and related cultural transitions. Globalisation and colonisation in various guises introduce new social effects and spread biomedical systems of thought, including causal explanations. Given these changes, how does a person find his or her way through this maze of differing opinions? And how do we know what to recommend when trying to improve the mental health of a diverse but increasingly interconnected world? Clearly there is a need for multi-disciplinary effort, including sociologists and anthropologists interested in insight research. In addition, future studies on insight should focus on the cross-cultural validity, reliability and methodological issues related to insight assessments. This must be complemented by open-ended enquiry to capture the complexity of representations and local political dimensions relevant to mental health and illness.
ACKNOWLEDGMENTS
B. S. is supported by a grant from the Wellcome Trust. The authors thank Dr C. David Goldberg for comments on an earlier draft.
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Received for publication February 21, 2003. Revision received June 4, 2003. Accepted for publication July 3, 2003.
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