I work part-time in the psychiatric inpatient unit of a hospital. I was talking with a patient there who was sad and frustrated because he really wanted to go home. He couldn’t leave because of a court-order for hospitalization. According to the people who brought him in, he had said things that sounded delusional but it was hard to understand what he meant because he speaks poor English and French and so do the people who brought him in. Even with the help of a translator it was hard to understand what he had said and what he was thinking. Was he expressing anger and frustration or was he expressing delusions, including some thoughts of self-harm? “Why can’t I go. I am okay. You see I am okay. I talk normally. I’m not sick,” he said. I said, “We see two kinds of people in psychiatry who say they are not sick. There are people who aren’t sick and there are people who are sick but can’t understand it because of what the sickness does to them.” I was trying to explain the concept of insight.
Insight has two distinct meanings in psychological parlance; one is understanding something through non-logical means, the “un-huh” experience. The other meaning, which I will use here, is the ability to reflect on one’s own mental processes. This second meaning of insight includes the ability to understand when one’s mind is acting in ways that don’t seem normal. Many people who experience delusions or hallucinations, depression, anxiety or mania understand that those experiences are strange mental states. But insight can be affected by mental illness. I saw a patient who was able to have reasonable conversations shortly after coming into hospital for some pretty strange and dangerous behaviour both for herself and for others. She seemed a little unusual, her speech was a little disjointed, a little pressured but she didn’t seem mentally ill until the psychiatrist who was interviewing her asked about delusions and hallucinations she had expressed. The patient, who was quite smart, was absolutely convinced that these things were real; she talked about them in the same relatively reasonable way that she talked about conditions and the routine in the hospital. After a few weeks in hospital and a lot of psychiatric medication, when I asked her about the thing she had been hearing and thinking, she said they were almost gone. I assumed that she would see her previous psychotic symptoms as strange, perhaps embarrassing, perhaps frightening, maybe amusing, or as a piece of herself she had to contend with. Instead she expressed no surprise that she had experienced these things, no recognition that they were odd and no sense that they were connected with her mental illness. The voices had stopped. They had been real, a feature of her life. It was as if the grocery store down the street had gone out of business. It was there, then it was closed, neither its presence nor its absence was remarkable or connected with her mental state.
I asked a psychiatrist who had seen her about this. He said that years of untreated psychosis had “burned out” the patient’s capacity for insight. There is a “kindling hypothesis” in psychiatric illness. The idea of ‘kindling’ in psychiatry comes from the study of epilepsy and other seizure disorders where it is demonstrated that more frequent and intense seizures cause lower thresholds for future seizures. Seizures cause a change that leaves an organism more prone to future seizures, seizures create the kindling for future seizures. Some psychiatric research think that affective disorders such as bipolar disorder may have work in a similar way, early and intense manic episodes may create ‘kindling’ for future manias. I couldn’t find any compelling evidence that this is the case in psychotic illnesses or a clear explanation of what the mechanism might be.
It is clear that certain kinds of brain trauma can cause severely impaired insight. Anosognosia is the phenomenon of not recognizing that one has an illness and is usually applied to someone has suffered a brain injury. A patient may be paralyzed on one side of the body and find reasons not to perform a particular task that requires both hands. The patient is not deceiving; the brain’s capacity to recognize impairment is, itself, impaired.
In psychiatry, insight into one’s illness may be more complicated than in neurology. Going back to the first patient, cultural and linguistic factors can make it very hard to assess. It is also subject to a lot psychological ‘noise.’ When I talked with this patient it became clear he dreaded the idea that people would think he had a psychiatric illness. There are good reasons why people - whatever the state of their mental health - don’t want to be seen as crazy by others. And recognizing one’s own mental illness is a mixed bag. Schizophrenic patients with better insight are more likely to take their medication regularly but are also more likely to be depressed . Paradoxically, denying that one is mentally ill looks pretty friggin’ adaptive if your idea of mental illness is a life sentence of misery and social ostracization.
For me lack of insight was always deeply, primitively, frightening. First of all, it evokes a trap played by the powerful; say you are unwell to prove you are well. At the same time what was always most frightening about mental illness to me was the primal terror of my own insight failing me, the extinction of something that is at the heart of my ‘self’.
I talked to a former patient this week, who had expressed very strange ideas when she was in hospital and who had little idea at the time that these ideas were strange. She is back in her apartment working hard to keep herself well. She still has paranoid thoughts sometimes but she recognizes that they probably aren’t accurate reflections of reality. She is able to challenge them. She tries not to let them govern what she does. She doesn't find it all that upsetting that some portion of her mind is so cruel. It made me feel happy to hear about her improved insight and I think it bodes well for her.
I find that after working with mentally ill people I am less fearful of losing my own insight. I suspect that like any other mental process, especially those connected with creating a sense of self, insight is nine-tenths smoke and mirrors, an illusion played by our brain on our mind. Insight is a kind of delusion itself, the folly that we can know our own minds.