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Insight and Psychosis: The next 30 years

By tonydavid, on 25 October 2019

I published my first paper on the topic of insight in relation to psychosis about 30 years ago in the British Journal of Psychiatry. An anonymous Lancet editorialist commented at the time that studying insight was, “academically nourishing but clinically sterile”. Torn between feeling flattered by the attention and insulted by the judgement, I persisted. Now seems a good time to take stock and look forward to the next 30 years. We can now say that we have some ‘facts’ about insight in psychosis: first that it is possible to measure in ways that are at least as valid and reliable as any other psychopathological phenomenon. Next, that there are some very well replicated associations: poorer insight, worse psychopathology; lower IQ, lower insight; and lower mood, better insight. Finally there is the obvious and clinically relevant relationship between insight and treatment adherence and hence outcome.

The relation between insight and adherence, or rather poor insight and coercive treatment is, naturally, where critics of the insight concept converge. ‘Insight’ they say is mere agreeing with the doctor. But where a patient’s self-appraisal as not being unwell or needing help is at odds with their peers and family, might this not be regarded as a lack of insight? The interface between insight and capacity to decide upon treatment is where current ethical debate is concentrated and is seen most vividly in the ability to a ‘use and weigh’ information, a key criterion for mental capacity used in the Mental Capacity Act (2005) definition. It is hard to see how the benefits and harms of a proposed treatment can be weighed in the balance if you don’t believe you are ill in the first place.

Metacognition is a relatively new area of psychology examining people’s ability to reflect upon their own cognition and appears to be related to insight as used in psychiatry. The cognitive neuroscience of metacognition is beginning to make important contributions to psychopathology. Lack of metacognitive awareness – not reflecting on whether a decision is correct – underpins much thinking in say, depression, while excessive metacognition can inhibit decision making as in obsessive compulsive disorder. The lack of ability to change one’s mind in the light of new evidence is a core feature of delusions. Paradigms that build on advances in metacognitive research and make use of computational modelling also promise much in this regard.

For insight in psychiatry, the metacognitive challenge posed is to reflect on one’s own mental and interpersonal functioning. It involves an attempt to see one’s thinking and behaviour ‘objectively’ as if through another person’s eyes and then comparing it to some representation of mental health. There is just one fundamental question asked in relation to clinical insight (after Aubrey Lewis): do I have an illness and is the Illness mental? It includes the moment-to-moment evaluation of mental activity (e.g., was someone speaking to me or was it my imagination?) as well as more enduring ‘semantic’ evaluations such as whether my beliefs are true and shared by others. Note that while that representation of mental health will be the amalgam of received opinion and experience, there is no judging doctor, as it were, in sight.

Cognitive insight is a new construct put forward by pioneer of cognitive therapy, Aaron (Tim) Beck. It refers to a cognitive style or propensity to question one’s ideas, beliefs and behaviour. One advantage it affords research is that it enables insight to be studied in healthy individuals without confounders such as stigma and the effects of treatment, and thus linked to normal psychological processes. An early area of interest is the relationship between cognitive and clinical insight – which surprisingly, turns about to be rather weak. We still do not know if poor cognitive insight in a vulnerable individual may be a risk factor for later psychosis per se.

Can insight be fostered?

Restoring or improving insight is a worthwhile psychotherapeutic aim.  It should be in the form of acknowledging difficulties as a first step in gaining mastery over them. Then, encouraging openness to taking up an effective treatment for those symptoms that cause distress at least as a start, and not at all the forced acceptance of some abstract illness model. This was the aim of the now retro-sounding ‘Compliance Therapy’ trials back in the 1990s. Talking therapies designed to improve metacognition (Metacognitive Therapy and Metacognitive Training) across a range of mental disorders have been developed and tested in small clinical trials and subjected to meta-analysis – and the results are promising. To some extent the success of all these therapies depends on the closeness of the link between metacognition and insight which, as discussed is itself a topic of ongoing enquiry.

Apart from medication, which if effective at relieving symptoms is correspondingly effective at improving insight – a new area of therapeutic research is neuromodulation. Transcranial direct current stimulation (tDCS) is a simple, safe and non-invasive method for selectively modulating cortical excitability. Of interest, tDCS over the dorso-lateral prefrontal cortex has been reported to significantly increase awareness of errors on attention tasks in the elderly. Also, a pilot study showed that tDCS to same region increased insight in patients with schizophrenia – replication with a control condition is obviously required.

In conclusion, the study of insight has proved to be both academically simulating and clinically fertile. It is a biopsychosocial construct par excellence.  I am looking forward to what new insights the next 30 years will bring.

A fuller version of this blog will be published soon as a comment piece in the British Journal of Psychiatry. *The full comment can be found at https://doi.org/10.1192/bjp.2019.217


A.S.David, Director, UCL Institute of Mental Health

October 17th 2019

Further Reading

  1. David AS. Insight and psychosis. Br J Psychiatry 1990; 156: 798-808. https://doi.org/10.1192/bjp.156.6.798
  2. Amador XF, David AS. (Eds). Insight and psychosis: awareness of illness in schizophrenia and related disorders. 2nd edn. Oxford: Oxford University Press, 2004.
  3. Beck AT, Baruch E, Balter JM, Steer RA, Warman DM. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res 2004; 68: 319-329.
  4. Philipp R, Kriston L, Lanio J, Kühne F, Härter M, Moritz S, Meistert R. Effectiveness of metacognitive interventions for mental disorders in adults—A systematic review and meta‐analysis (METACOG). Clin Psychol Psychother 2019; 26: 227– 240. https://doi.org/10.1002/cpp.2345
  5. De Jong S, van Donkersgoed R, Timmerman M, Aan het Rot M, Wunderink L, Arends J, Pijnenborg G. Metacognitive reflection and insight therapy (MERIT) for patients with schizophrenia. Psychological Medicine 2019; 49: 303-313
  6. Harty S, Robertson IH, Miniussi C, Sheehy OC, Devine CA, McCreery S, O’Connell RG. Transcranial direct current stimulation over right dorsolateral prefrontal cortex enhances error awareness in older age. J Neurosci 2010; 34:3646 –3652.

Bose A, Shivakumar V, Narayanaswamy JC, Nawani H, Subramaniam A, Agarwal SM, Chhabra H, Kalmady SV, Venkatasubramanian G. Insight facilitation with add-on tDCS in schizophrenia. Schizophr Res 2014; 156:63-65.

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