in Thinking about psychiatry



If you had a cough and were expectorating  lots of green phlegm then you might think that something was amiss; if you broke a bone in your foot, it might hurt to walk.  Either way, if I suggested to you that you had a problem with your health you’d probably agree with me.  With mental illness it is possible to be very severely ill and believe yourself to be well; in fact, on the contrary, you might believe yourself to be at the top of your game.  This ability, or inability, to recognise illness is called ‘insight’ and psychiatrists talk about it a lot. 

Loss of insight is a symptom of severe mental illness and is seen with diagnoses such as schizophrenia and bipolar affective disorder. 

It has been proposed that insight consists of three overlapping dimensions

  1. The ability to relabel unusual mental events as pathological
  2. The recognition that one has a mental illness
  3. Compliance with treatment

Rather than just being an indicator of the severity of other symptoms, lack of insight is thought to be a distinct phenomonological feature in its own right, being similar to anosognosia where a patient shows an unawareness of neurological symptoms.  This is associated with lesions to the frontal lobes and the right parietal lobes.  

It’s important to note that insight is not an all or nothing thing.  Someone with complete lack of insight may deny that anything at all is amiss.  Sometimes though we describe a patient as having ‘partial insight’.  An example of this might be someone who thinks that MI5 is passing messages to  him/her via messages written on Tescos carrier bags.  He or she might concede that this was rather a strange thing to be happening, but would insist on its veracity nevertheless.  With recovery of full insight he or she might say that now they realise that the messages on carrier bags were a function of their illness. 

Loss of insight is also important because it has prognostic implications.  As you might expect, if you don’t think that you have a problem, you’re likely to carry on as before, and won’t be opening the door to health care professionals.  As well as this it is linked to poorer functioning across all areas of a patient’s life.  

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