The British Journal of Psychiatry (2000) 177: 572
© 2000 The Royal College of Psychiatrists
Insight and Psychosis
Kenneth Davison, Consultant Psychiatrist
Emeritus, 10 Grange Road, Fenham, Newcastle upon Tyne NE4 9LD
EDITED BY SIDNEY CROWN and ALAN LEE
Edited by Xavier F. Amador & Anthony S. David. New York & Oxford:
Oxford University Press. 1998. 366 pp. £39.50 (hb). ISBN 0 19
5084977
Insight is a familiar clinical concept that we tend to take for granted and
employ without giving much thought to its precise definition and significance.
The past decade has seen an upsurge of interest in the subject, which has
inspired much novel research and theory. The editors of this book, themselves
authorities in the field, have assembled an impressive group of international
multi-disciplinary contributors who examine insight from biological,
psychological and social perspectives. The 17 chapters are arranged in five
sections entitled ‘Phenomenology of insight’,
‘Neuropsychology of insight’, ‘Culture and insight’,
‘Insight and behaviour’ and ‘Clinical implications of poor
insight’. Most of the discussion focuses on insight in relation to
schizophrenia.
As so often in psychiatry, the first hurdle to overcome is finding an
agreed definition. Impaired insight is usually measured in terms of departure
from reality, but this begs the question of whose reality. David's pragmatic
three-pronged definition, which will attract clinicians, is criticised from
the sociological standpoint on the grounds that the clinician's judgement is
being used as the gold standard when it too is shaped by cultural concepts and
values. Linguistic analysis of the meaning of insight also finds the medical
model of psychosis wanting.
Purely psychological explanations for impaired insight, for example,
defensive denial, are giving way to explanations based on neuropsychological
deficits. Parallels are drawn between the loss of insight in schizophrenia and
neurological syndromes such as the various forms of anosognosia, and
mesio-temporal-limbic structures have been implicated.
An interesting contribution from Japan describes how a rigid adherence to
Jaspers's views on loss of insight in schizophrenia led to a national policy
of involuntary incarceration of almost all patients with schizophrenia, which
has been reversed only in the past 15 years. Other consequences of lack of
insight are reviewed, including non-con-compliance with medication and violent
behaviour. Clinical studies reveal that insight is related to outcome and
voluntary v. involuntary commitment, is correlated with IQ and can be
improved by psychosocial treatments. In a thoughtful epilogue, Strauss
proposes that insight should be conceived as a process rather than a static
label.
This is a comprehensive review of an important yet little studied feature
of clinical practice. While absorbing much new knowledge, the reader is
conducted along some fascinating and relatively untrodden byways of
psychiatry, neurology, psychology, philosophy and sociology. The editors
deserve our appreciation for assembling such an intellectual tour de
force, which should appeal to all who are interested in the enigma that
is schizophrenia.
