Insight in schizophrenia

About 30 to 50% of schizophrenia patients lack insight. Insight in schizophrenia is multidimensional and has a broad definition. Insight is contained in knowing and acknowledging that you have an illness, the ability to recognise the symptoms and consequences, that it requires treatment which may mean hospitalisation, and that it is ongoing. Lack of insight is recognised by some as being part of the schizophrenia illness.

The consequences of poor insight in schizophrenia is broad and includes non-compliance with medication, increased risk of relapse, increased hospitalisations, impaired psychosocial functioning and poorer prognosis.

But poor insight does not always have to result in poor compliance. Compliance, or lack of it, is the consequence insight, side effects of medication, type of medication (depot vs oral), comorbid disorders such as drug and alcohol abuse, assertiveness of intervention, social support, costs of travel and buying medication, and court treatment orders to name a few.

There are various theories as to the cause of poor insight. One theory is that it is due to neuropsychological deficits which are part of the frontal lobe (executive) dysfunction of schizophrenia. This causes patients to be unable to be aware of all or some of their signs and symptoms.

Sometimes this lack of awareness forms part of a larger lack of awareness which includes the neurocognitive problems of attention, memory, judgement and critical thinking.

Another theory is that poor insight in schizophrenia is a psychological defence, which protects the patient from acknowledging that he has a mental illness and thus avoiding the distress, and hopelessness that may go with this realisation.

Another consideration is that what may appear to be a lack of insight, is actually an alternative health belief which is shaped by that individual’s social and cultural beliefs. A few hundred years ago, it was normal to believe that madness was due to demon possession – some of these alternative views still exist today in indigenous populations and even in segments of our western populations.

What treatments are available for impaired insight?

There is no specific treatment for poor insight. Motivational interviewing and CBT for psychosis are 2 therapies which have shown some success in promoting behaviour change and decreasing distress and improving coping strategies.

CBT for psychosis examines the patient for dysfunctional thinking patterns, assumptions and underlying beliefs, and challenges these in a rational evidence-based manner looking for flaws so that the patient adopts alternative more functional ways of relating to his environment. In CBT for psychosis the therapist will look for dysfunctional thoughts in relation to the psychotic symptoms, and the meaning which the patient puts on these thoughts.

CBT has been shown to be effective in reducing distress caused by symptoms, as well as decreasing hospitalisation rates of length of stay.

Motivational interviewing was originally developed to promote behaviour change for people with alcohol and addiction, but can be adapted to other situations as well. This process relies on an empathetic relationship and directed questioning which allows the patient the opportunity to express their own reasons for the need for change and to come to a position where they will start acting upon this ambivalence. The principles which underpin MI are: 1) express empathy, 2) develop discrepancy, 3) avoid arguments, 4) roll with resistance and 5) support self efficacy.

MI in schizophrenia can focus on helping the patient accept that they have an illness, rather than deny it.

Cognitive remediation (CRT) or cognitive enhancement therapy is another therapy that has been applied to lack of insight. This was developed at King’s College in London and was designed to widen the scope of thinking by improving attention and working memory, planning and executive functioning. CRT has been shown to be effective in schizophrenia. It is usually administered via a computer.