Insight

The clinical assessment of a patient's capacity to understand the nature, significance, and severity of his or her own illness has been called insight. Recently there has been increased interest in describing its characteristics more reliably and establishing how it correlates with other measures of illness. (60,) The attitude of patients towards their illness has clear clinical implications, and the assessment of insight tries to investigate the awareness of patients about the impact that their illness has has had on their world, and their capacity to adapt to the changes brought about by illness. In clinical practice, the patient's awareness of the presence of illness and the extent to which it is interfering with function and compliance with prescribed treatment are of considerable significance. David (60) has proposed that insight is composed of three overlapping dimensions: the ability to relabel unusual mental events as pathological, the recognition that one has mental illness, and compliance with treatment. Some parallels have been drawn between the loss of insight in psychiatric patients and the denial of disease or loss of function that occurs in certain neurological conditions.

Because of its importance for clinical management of the patient there have been many attempts over recent years to measure insight, all of which depend upon a precise operational definition of the concept. McEvoy et al.(61> developed a questionnaire to measure insight based upon the definition that it was patients' awareness of the pathological nature of their experiences and also their agreement with the treating professionals about the need for treatment. The measure constructed by David et al.(62 added the ability to relabel unusual mental events as pathological to the recognition of mental illness and compliance with treatment. Other scales have included different features, but these core symptoms appear to have the most influence on clinical management.

The relationship between impairment of insight and the presence of other aspects of psychopathology is complicated; there is no clear association between impairment of insight and intellectual or neuropsychological deficit. (63> Not surprisingly, patients with unimpaired insight are found to be significantly less likely to require readmission to hospital, tend to be more compliant with treatment, and show an improved prognosis. (65 Surprisingly, and this shows how little is known about this subject, many patients are prepared to comply with treatment, even though they do not believe themselves to be ill, if the social milieu is conducive to receiving treatment.(61)

Insight is a multifaceted phenomenon with considerable clinical significance as it predicts the likelihood of patients complying with treatment. Attempts have been made to operationalize the concept and to devise scales to measure it. However, the features to be included in a definition have not yet been universally agreed. Most studies of insight have been concerned exclusively with patients suffering from schizophrenia, and it is important to extend work to other serious mental illnesses. On this topic descriptive phenomenology has implications for therapeutic practice.

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