This document discusses the concept of insight and judgment in mental health. It defines insight as involving introspection, empathy, understanding how one's behavior affects others, and recognizing illness and need for treatment. Judgment requires weighing factors to make decisions. Both insight and judgment rely on intact cognitive functions. The document outlines several models of insight and factors that can impair judgment, such as mental illnesses like schizophrenia, bipolar disorder, and depression. It also discusses various scales used to measure insight.

1. Judgment and Insight
Dr wasim
UNDER GUIDANCE OF
DR Gunjan solanki

2.  The concept of insight is much larger than just
knowing whether one is ill or not, and if so, having a
sensible view regarding treatment.
 It involves our capacities for introspection, empathy
and communication.
 It also includes knowing how our behaviour will affect
the emotions and experience of other people as they go
through the same mental mechanisms.

3.  insight requires both inner and outer orientation.
 It is a quality that has been highly valued by mental
health clinicians because a strong link between having
insight and better quality of life.

4. We ask specific questions about the patient's opinions
concerning his illness. These include
 his degree of acknowledgement of illness,
 his attitudes to illness,
 his understanding of the effects of his illness on his
current capabilities and future prospects.
 All this adds up to the assessment of insight into his
condition.

5.  Thus insight is not an all-or-none phenomenon, in
either clinical evaluation or measurement.
 Rather a dimensional one, so that subjects can have
different levels of awareness into their illness.

6.  In gestalt psychology, insight is conceived as a
sudden, unexpected solution to a problem.
 the ‘suddenness’ specifies an abrupt solution to a
problem,
 the ‘unexpectedness’ refers to the surprise element of
the event
 and the term ‘solution to a problem’ signals the
discreteness of the event in time.

7.  In gestalt psychology insight refers to a problem in the
external world.
 however in clinical practice, insight focuses on
understanding of changes or happenings within an
individual.

8.  David (1990) has considered that insight is composed
of three distinct, overlapping dimensions’, namely,
The recognition of morbid psychological change,
The labelling of this change as deriving from mental
illness and
The understanding that this change requires treatment
that needs to be complied with.

9. Amador and David expanded the concept of insight with
five different dimensions for insight in Schizophrenia:
 Awareness of having a mental illness.
 Awareness of symptoms of mental disorder.
 Attribution of symptoms to a mental disorder.
 Awareness of the consequences of mental illness
 Awareness of the effects of medication.

10. Both have:
 A severe lack of awareness of their deficits.
 A strong desire to prove their own assertions.
 Invent confabulations to explain away pathological
symptoms.
 Often demonstrable Frontal lobe deficits.
In psychiatry, lack of insight is often attended by a wider
loss of judgement beyond merely the symptoms or
their implications for the patient.

11. The 3 main schools of thought regarding the etiology of insight:-
1.The Psychological Defense Model,
2. The Cognitive Deficit Model,
3. The Neuropsychological Deficit Model

12.  -Practically the only existing school of thought about insight
prior to 1990.
 -Assumption was that failure to recognize or admit to a
psychiatric illness was a conscious (or sub-conscious) refusal
rather than an inability. It was further assumed that knowledge
of the illness did exist at some cognitive level.
 -Numerous studies have all noted a positive correlation between
increasing insight and increasing depression.*
* (Smith et al. 2004,Weiler et al. 2000, Carroll et al. 1999)

13. -Smith et al. (2004) suggest that poor insight may be a
psychodynamic coping mechanism to reduce anxiety and
depression.
-It is important for caregivers to be aware of the increasing
risk of depression that seems to occur with improving insight.

14. Acknowledges a slightly more organic etiology to impaired
insight.
-Drawing on research that has linked decreasing insight to
increasingly poor scores on the Wisconsin Card Sorting Test
(WCST) and other measures of cognitive function (Keshavan
2004, Lele1998), the Cognitive Deficit Model suggests that
poor insight is a result of progressively degenerating cognitive
functioning over the course of the illness.

15. -Given the high frequency of poor insight seen in first-episode
schizophrenia patients (Keshavan 2004), progressive
degeneration does not seem to be a likely causal factor of poor
insight.
-The link between poor WCST scores (measure of frontal lobe
function), and poor insight in schizophrenia patients may be
evidence for a more neurological basis of impaired insight.

16.  -Developed out of an identified similarity between the symptoms of
poor insight and a neurological condition called anosognosia.
 Generally developing secondary to a specific lesion (such as focal
traumatic brain injury) or diffuse brain damage (such as a stroke),
anosognosia is an acknowledged neurological deficit.
 Patients afflicted with anosognosia share striking similarities with
psychiatric patients who have impaired insight (Amador and Paul
2000, Lele et al.1998).
 Both have a severe lack of awareness of their deficits, have a strong
desire to prove their own assertions, and as such invent confabulations
to explain away pathological symptoms. Also. both sets of patients
often demonstrate frontal lobe deficits.

17. 1. Cultural models of illness
2. General intelligence and knowledge
3. Doctor-patient relationship.
4. Symptomatology (Delusions/Depression)
5. Denial- Motivation, Preservation of self esteem,
Avoidance of stigma
6. Personality- Compliance non conformity as a trait.

18.  Unawareness and misattribution of symptoms in
schizophrenia may have distinct neuroanatomical
bases.
 DLPFC deficits may result in illness unawareness by
interfering with self-monitoring.
 OFC abnormalities may mediate symptom
misattribution by conferring aberrant salience to
perceived symptomatology.*
 schizophrenia with preserved insight is associated with
greater perfusion of the precuneus, a brain area known
to be involved in self- consciousness.**
*Prefrontal subregions and dimensions of insight in first-episode schizophrenia — A pilot study, mujjeb U Shad et al 2005
**Catherine Faget-Agius et al, Schizophrenia with preserved insight is associatedwith increased perfusion of the precuneus.

19.  There is a “Cortical Midline System” (CMS) —
 The medial frontal cortex (ventromedial, Brodmann
areas [BA] 10, 11, and dorsomedial BA 9)
 cingulate cortex
 These are engaged in tasks encompassing self-
reflection, most often engaged when “self-appraisal”
was contrasted to “other-appraisal.”
 “FAILURE TO DIFFERENTIATE SUFFICIENTLY
BETWEEN SELF AND OTHERS…”

20. 1. Complete denial of illness
2. Slight awareness of being sick and needing help, but denying it
at the same time
3. Awareness of being sick but blaming it on others, on external
factors, or on organic factors
4. Awareness that illness is caused by something unknown in the
patient
5. Intellectual insight: admission that the patient is ill and that
symptoms or failures in social adjustment are caused by the
patient's own particular irrational feelings or disturbances
without applying this knowledge to future experiences
6. True emotional insight: emotional awareness of the motives
and feelings within the patient and the important persons in
his or her life, which can lead to basic changes in behavior.

21.  Mania
Psychosis
Drug and alcohol dependence
Depression
Personality disorders
Dementia
Delirium
Attention deficit disorder
Obsessive-compulsive disorder
Central nervous system disorders
Conversion disorder

22.  Actively psychotic patients with paranoid
schizophrenia often do not appreciate that they are
mentally ill or how treatment can be helpful.
 Psychosis from any cause involves psychotic and
immature defense mechanisms that are not
compatible with being insightful. for example,
projecting onto another person one's own feelings
(believing that the doctor has sexual feelings for the
patient, when the converse is true).
 Persons who use psychotic, immature, and neurotic
defense mechanisms are less capable of achieving full
insight than are those who utilize mature mechanisms.

23.  Manic patients are usually so immersed in their elated
or hyperactive state, they may be having so much fun
that they do not realize they are behaving abnormally
relative to their usual selves or to society.
 Manics and narcissistic personality-disordered
persons tend to be grandiose about their capabilities,
thereby diminishing their ability to be realistically
aware of their condition or their limitations.

24.  Extreme lack of insight is associated with conversion
disorder (a dissociative state), factitious disorder,
addictive disorders, and psychoses.
 By its very nature, conversion disorder implies a lack of
conscious awareness of the underlying psychological
conflict that is masked and or symbolized by the
presenting somatic symptom.
 Alcoholics and drug abusers frequently deny their
addictions and the consequences thereof, externalize
blame, do not take responsibility for themselves,

25.  Many personality-disordered persons have
inadequate insight into their disturbed relationships,
thinking, and feelings, and are often resistant to
changing these patterns.
 Borderline personality-disordered patients often use
black and white thinking•
in which people or events are
viewed as extremely good or bad, without awareness of
gray zones of relativeness.
 Severely depressed, suicidal patients have negatively
distorted views of the world and themselves, which
diminishes their ability to appreciate the positive
aspects of living.

26.  Demented, delirious, amnestic, and brain-injured
patients (e.g., stroke, head trauma) are all cognitively
impaired; because of their attentional, memory,
language, or abstraction deficits, these patients are
often not capable of being insightful.

27. Any reliable and valid measure of insight in clinical
practice should be based on the following four
assumptions:
 insight is complex and multidimensional
 cultural factors need to be taken into account
 the level of insight can vary across the many
manifestations of mental illnesses
 information about the nature of a person's illness from
situations other than the interview should be taken
into account.

28.  Scale to Assess Unawareness of Mental Disorders
(SUMD)
 Insight and Treatment Attitude Questionnaire(ITAQ)
 Insight Scale (IS).
 Lack of Insight Index.
 Schedule for Assessment of Insight-Expanded (SAI)
 Beck Cognitive IS (BCIS)
 Present State Examination.
 Positive and Negative Syndrome Scale, item G12.

29.  Item G12 (lack of judgment and insight), is used separately
as an insight scale.
 Similar to the other PANSS items, Item G12 is rated on a 7-
point scale ranging from “Absent” to “Extreme.”
 “Mild” applies to patients who recognize their illness but
downplay its seriousness and the need for ongoing
treatment.
 “Extreme” applies to patients with blank denial of illness,
delusional interpretation of hospitalization, and lack of
cooperation with treatment staff.
 However, because it is so brief, this scale could be used at
several points during an inpatient admission as a gauge of
improvement in insight during the course of treatment.

30.  David et al 1990
 -Using a semi structured interview, the SAI scores the
patient’s insight along 3 dimensions:
 recognition of illness, recognition of need for treatment, and
ability to see that psychotic symptoms
(delusions/hallucinations) are not “real” but rather part of the
illness.

31.  -Developed by McEvoy and colleagues
 -ITAQ has 11 questions, each scored between 0 (no
insight) and 2 (maximum insight).
 The ITAQ focuses on the patient’s agreement with the
assessment of illness and the treatment plan as laid
out by the psychiatric treatment team.
 The psychiatrist’s understanding of the patient’s
illness is viewed as the “ideal” and the patient’s degree
of congruence with this determines the level of
insight.

32.  Most of the research work on the clinical correlates of
insight has been on patients with schizophrenia.
 Overall, it does appear that the relationship between
poor insight and aspects of psychopathology is linear
but complicated by other factors, including
compliance with treatment.
 It has often been speculated that poor insight may
have a neurological basis.

33.  subjects with impaired insight performed more poorly
than subjects with unimpaired insight on the
Wisconsin Card Sorting Test (WCST).
 However further studies have not reproduced these
results.
 In another study, Upthegrove et al. (2002) showed that
impaired digit span as a measure of working memory
was significantly associated with insight.
 However, on balance, the issue of whether cognitive
deficits underlie poor insight is still unresolved.

34.  -Patients with bipolar disorders, investigated by the ITAQ,
showed that insight was severly impaired in mania and less
impaired in depressive states. (Michalakeas et al 1994),
(Peralta and Cuesta 1998).
 Patients with seasonal affective disorders possessed a
moderate amount of insight into their depressive
symptoms, as measured by the SUMD, which did not
change after recovery.(Ghaemi et al 1995,1997)

35.  On occassions patients may acknowledge “morbid
change” merely “regurgitating overheard
explanations,” which is a common occurrence in the
inpatient settings, more so in patients with
involuntary admissions.

36.  The recent resurgence of interest in insight has had its
share of criticism.
 Medical anthropologists have criticized the concept of
insight for failing to recognize that people can have various
culturally shaped frameworks to explain their illnesses, all
possibly valid.
 From this point of view, the concept of insight is
‘eurocentric and essentially arrogant.
 patients should, apart from agreeing that they are mentally
ill and requiring treatment, also agree to reconstruct their
experiences within the terms and concepts of western
psychiatry.

37.  Johnson and Orrell (1995) have reviewed work by
social scientists on cultural and social variations in lay
perceptions of mental illness and argue that these
would influence insight.
 Social and cultural backgrounds influence perceptions
of stigma from mental illness and the congruence of
the patients with western medical views of mental
illness.
 For example, differences in the ethnic background of
the psychiatrist and the patient appear to influence
the judgement of the former about insight (Johnson
and Orrell 1996).

38. Interventions

39.  -Clozapine is the only medication reported in literature to
have a substantial effect on patient insight (Pallanti et al,
1999).
 -It wassuggested that clozapine might improve frontal lobe
processing through early gene expression, which correlates
with previous research findings indicating that clozapine
improves WCST scores in schizophrenia patients.
 -clozapine may indirectly improve insight by improving
negative symptom pathology, which in turn might make
patients more amenable to psychosocial intervention
programs.

40.  good insight in schizophrenia patients is related to a strong
social support network.
 -Interventions such as vocational rehabilitation, and a
specifically modified form of motivational interviewing
have shown some success.
 -Thompson et al. (2001) noted that "improving insight"
may be due to the socialization and education of a person
as a schizophrenia patient (i.e. their exposure to hospital
programs and diagnostic labels), or to their improving
ability to communicate about their illness.

41.  Insight therapy or insight orientated psychotherapy are general
terms used to describe a group of therapies that assume that a
person's behavior, thoughts, and emotions become disordered
because they do not understand what motivates them.
 The goal of these therapy is to help an individual discover the
reasons and motivation for their behavior, feelings, and thinking
so that they may make appropriate changes.
 These therapies may all be described as insight orientated:
psychoanalysis, analytical psychology psychodynamic therapy
person-centered therapy.

42.  Judgment is a process of consideration and
formulation regarding a particular issue or situation
that can lead to a decision or action.
 The better and more complete the person's insight, the
more likely the judgment is to be sound.
 Because insight and judgment are related to each
other, much of the above discussion on insight applies
to judgment as well.
 Judgment involves weighing and comparing the
relative values of different aspects of an issue.

43. The ability to make sound judgments requires
 adequate insightfulness,
 intact cognitive function,
 capacity to conceptualize, sensitivity to the impact and
consequences of a decision,
 ability to consider long-term effects and possible
adverse outcomes,
 and appreciation of what a person in society would do.
Any impairment of these functions diminishes the
quality of the resultant judgment.

44.  Judgment is impaired in depressed patients when negative
and pessimistic feelings distort reality; this may even
culminate in suicidal acts.
 Suicide attempts are usually considered abnormal and
evidence of poor judgment in our society, but are more
acceptable in some other societies and less aberrant in our
society when persons are in severe pain from terminal
illness.
 Even if the process of judgment is sound, the outcome can
be bad.
 Judgment may be impaired as a consequence of impaired
insight from the neuropsychiatric effects of intoxication
with drugs or alcohol, as evidenced by the many persons
who confidently drive their cars while intoxicated.

45.  Manics are insensitive to others' feelings and have poor
judgment regarding their social behaviors;
 they often insult or embarrass others by their jokes or
actions.
 Manics who are euphoric have an unrealistically happy
view of the world and do not recognize potential
negative consequences of their behaviors.
 Therefore, they may go on spending sprees when they
have insufficient funds to pay for the purchases;
engage in socially improper behaviors such as
parading nude in public.

46.  Patients with attention deficit disorders cannot
maintain their attention long enough to focus their
thinking and may behave impulsively.
 In contrast, obsessive patients spend a great deal of
time thinking, yet have difficulty formulating
judgments because they get caught up in details or are
rigidly bound by rules.
 Schizophrenics who are actively psychotic may not be
fully capable of sophisticated decision making because
of delusions, thought disorder, or unrealistic
distortions due to referential thinking.

47.  Certainly, a delirious or demented patient who has
significant cognitive deficits cannot be expected to
make a sound, informed decision.
 Patients who have prefrontal cortex damage have
difficulty with higher-level conceptualization.
 Stroke patients may have damage to areas of the brain
required for language, cognition, or executive
functions and thereby be less capable of making sound
judgments.

48.  Disinhibition is the loss of self-restraint or internal
monitoring of behavior, resulting in socially
inappropriate behaviors, such as publicly
masturbating or telling profane jokes in genteel
company.
 A person's defense mechanisms can greatly affect his
or her judgments; the more mature styles increase the
likelihood of making rational judgments.
 Denial, projection, repression, externalization, and
dissociation adversely affect judgment, whereas
humor, altruism, and suppression are less likely to
interfere.

49.  The thinking or psychological performance required to
produce a delusion is quite independent of
intelligence.
 It occurs in clear consciousness with no signs of
organic disturbance of the brain.
 Judgement in other areas of life apart from the
delusion can be preserved, and the very ingeniousness
the patient uses to explain and defend his delusional
belief demonstrates that his essential capacity to think
logically is largely intact.

50.  Social judgement is observed during the hospital
stay and during the interview session. It includes an
evaluation of ‘personal judgement’.
 Test judgement is assessed by asking the patient
what he would do in certain test situations, such as
‘a house on fire’, or ‘a man lying on the road’,
or ‘a sealed, stamped, addressed envelope lying on a
street’.
 Judgement is rated as Good/Intact/Normal or Poor/
Impaired/Abnormal.

51.  Thank you