Hallucinations, delusions, incoherent thought patterns, elevated mood, depressed mood, rapidly fluctuating mood, confusion, suicidal thoughts, memory changes, addictive behaviors, behaviors that just don’t make sense—these are all symptoms of psychiatric illnesses. Specific patterns of these symptoms over time help define specific syndromes.

There is one characteristic that is shared by many psychiatric disorders: impaired insight. People with psychiatric illnesses often have a diminished ability to understand the nature of their illnesses or, in some cases, to understand that they are ill at all. This makes treatment and compliance with treatment challenging.

Lack of insight is different from not understanding the nature of a particular illness. Most persons with diabetes can fully appreciate that they are sick and need specific medications to control symptoms. They do not need to understand the biology of insulin resistance at the cellular level. Although individuals with medical illnesses may not understand the mechanisms underlying their illnesses, they typically know that they are ill and that they will benefit from treatment. The more discomfort they feel, the more they want relief. In contrast, persons with psychiatric illnesses often don’t recognize that anything is wrong. They don’t think they need help, or they believe there is nothing that can help them. 

Although lack of insight is a common feature of many psychiatric disorders, the nature of this lack of insight can vary depending on the disorder. A person in the midst of a manic episode with grandiose delusions, high energy, little need for sleep, markedly poor judgment, and uncontrolled spending may not understand why friends and family think something is wrong. A person with schizophrenia experiencing auditory hallucinations or persecutory delusions may not be able to understand that the voices and delusions aren’t real. A person with severe depression may not be able to understand why others don’t realize that he is a terrible person, a complete failure, and a burden to all around him. Individuals with drug addiction may believe that they don’t have a problem and that they can quit whenever they want. Persons with severe dementia may truly believe that they are able to fully function at work and that they are completely capable of driving safely.

There are treatments for most psychiatric disorders that help decrease, if not eliminate, symptoms. However, in order for treatments to be helpful, the ill person must have the insight to participate in treatment. 

Why do so many psychiatric disorders share the characteristic of diminished insight? Psychiatric illnesses interfere with motivational, cognitive, and emotional brain systems. It is likely that the pathologic mechanisms involved in these illnesses lead to dysregulation of the brain systems underlying insight regulation. Multiple brain processing defects likely contribute to problems with insight, and it is important to understand that insight requires a complex set of brain calculations. For any of us to have insight, we must be able to weigh the relative merits of our own internal thinking relative to external environmental circumstances. Thus, in psychiatric illnesses insight must overcome states of high internal emotion and low motivation in the presence of often inaccurate perceptions of the external world. Insight requires the function of higher-order brain networks underlying attention, working memory, and cognitive control. Unfortunately, these higher-order brain systems are dysfunctional in many, if not all, psychiatric disorders.

When trying to help patients who lack insight, it is important for physicians to develop trusting relationships with both the patient and the patient’s family. When a patient trusts her doctor, she is more likely to take the doctor’s advice even if she doesn’t believe that she needs help. The stronger a patient’s social ties with friends and family, the more likely it is that she will listen to their advice. In effect, strong, positive social ties can help patients develop more accurate evaluations of the external world, serving as surrogates or validators for the patient’s own perceptions. Certain psychotherapeutic approaches can also help with insight. For example, the “cognitive” component of Cognitive Behavioral Therapy (CBT) encourages patients to use their attention, working memory, and cognitive control networks to evaluate their internal thinking in relation to observable events in the external world.

Even with the best of relationships among patients, families, and doctors, psychiatric illnesses can impair a person’s ability to accept the need for treatment. When behaviors reach a point that the patient is in danger of harming self or others, hospitalization becomes necessary. One of the goals of short-term hospitalization, including involuntary hospitalization, is to provide a safe setting where a patient has time to develop enough insight to be safely treated in a less restrictive environment

Better understanding of the brain mechanisms underlying insight could lead to more effective ways of helping psychiatrically ill individuals. Importantly, lack of insight should be viewed and treated as one of the brain processing defects contributing to major psychiatric illnesses and not simply as a form of distrust or arrogance.

This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.

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