Insight is multidimensional. It comprises awareness of having a mental disorder, of its symptoms and signs, of the need for treatment, and of the disorder’s social consequences. .Poor insight in to illness is a major contributing factor in treatment non compliance in schizophrenia. Good insight predicts a good outcome. Poor insight is considered as a manifestation of the illness itself.
There is inconsistent results regarding relationship of insight to various clinical and social factors. Though psychoeducation is widely adopted as a strategy to enhance insight and improve outcomes, a metaanalysis by Lincoln et al showed that psychoeducation to improve insight did not benefit medication compliance. Mads G. Henriksen and Josef Parnas from Copenhagen University argues for a fresh look at our thinking on insight to better understand these failures.
Psychoanalytic tradition considered poor insight as a defence mechanism to ward off depressive symptoms arising from awareness of having a chronic mental illness.Neurosciences consider it as a failure of metacognition arising from deficits in dorsomedial frontal cortex. Both consider it as a problem in self reflection ie specific errors in the information processing of their experiences results in poor insight. Authors argue that schizophrenia is rather a specific disorder of the self, which involves a variety of alterations of the structures of experiencing, affecting the very conditions of self-reflection. Psychosis is a disorder of “ipsiety” , ( primary core of self/ minimal self) i.e. the idea that I am always already aware of “I-me-myself” and that there is no need for self-observation or self-reflection to assure myself of being myself. This core self is challenged and made unstable, and oscillating, in schizophrenia resulting in alarming and alienating anomalous self-experiences. This lead to a diminished sense of existing as a bodily subject and patients can live in two different worlds ( ‘double book keeping’ a s Blueler described it) , one the shared social world , the other one the private psychotic world.
The ipseity-disturbance model (IDM), developed by Sass and Parnas, presents distortion/instability of the minimal self /core self as consisting of two complementary aspects: hyper reflexivity (i.e. heightened awareness of aspects of experience that are normally tacit or implicit) and diminished self-affection ( a weakened sense of existing as a subject of awareness). The concepts are largely based on phenomenological account which is yet to have enough empirical evidence.
In the accompanying editorial Nelson , Parnas and Sass describes some of the recent empirical investigation results supporting the IDM concept. They also mention about the recent account of self-disturbance that focus on defects in narrative self where collapse of such processes lead to failure of metacognition,, ie, “thinking about thinking”. Studies using Examination of Anomalous Self-Experience (EASE) show that minimal self-disturbance characterises schizophrenia spectrum disorders independent of intensity or presence of frank psychotic symptoms and that it can predict future onset of schizophrenia spectrum disorders in non psychotic populations.
These ideas are likely to generate more interest in phenomenological research/ thinking and help delineate boundaries between different disorders. Such understandings may improve interventions to enhance insight and outcomes for our patients.
Summary of the article:
Henriksen MG, Parnas J. Schizophr Bull. 2014 May;40(3):542-7
see also the editorial:
Nelson B, Parnas J, Sass LA. Schizophr Bull. 2014 May;40(3):479-82.