And you think I’m crazy? Yeah, you think I’m crazy!
In the past, insight was considered an all-or-none phenomenon, there was no such thing as “having a little insight”. Psychosis and poor insight were seen as two sides of the same coin. Today insight is considered a continuum rather than a dichotomy.
People with psychotic disorders and poor insight in their illness rely on their own beliefs and expectations even in the presence of conflicting evidence. Is this process specific for psychotic disorders? Clearly it is not. All of us interpret what we see, hear, and feel in a way that is in line with our previous experiences and expectations about the future. This is very adaptive in most cases. I remember taking the elevator in the Heymans Building one day. I am in the Clinical Psychology group and my office is located on the third floor. Accidentally, I got out of the elevator on the second floor. But instead of realizing I made a mistake, I stuck with my own ideas and wondered for a few seconds, ‘who replaced the pictures of our group members with posters of the Experimental Psychology group?’ So, I came up with a more or less logical explanation that was in line with my beliefs about where I was. However, then I saw a sign that said ‘second floor’ and I took the stairs one floor up. At that point I realized we often make incorrect interpretations, but we quickly adapt our ideas about a situation when they prove not to be correct. People with psychotic disorders, however, often fail to do this.
“People with poor insight often feel misunderstood, alone, and laughed about, because others don’t share their beliefs.”
Poor insight causes problems in social situations. People with poor insight often feel misunderstood, alone, and laughed about, because others don’t share their beliefs. In my clinical work at the Department of Psychotic Disorders of GGZ Drenthe I often experience how difficult it is to communicate with people who have beliefs I don’t share. However, again this experience is not limited to clinical practice. As a mother of three young children I often have conversations about how they see the world and have found that their views can be quite idiosyncratic. My youngest daughter, currently four years old, had a phase during which she was convinced she was a boy. When she was two, she started to refuse to wear dresses and skirts and she carefully removed each and every pink item from her room. Shortly thereafter, she took to referring to herself as a boy. Other children kept telling her she was a girl, which made her feel very sad and alone. One day she came to me and asked, very hopeful ‘Mom, I am a boy, aren’t I?’ Something in her eyes made me say ‘yes, why not, you can be a boy if you want to’. She immediately ran outside to share this information with her friends. She was so sad when they told her she was wrong and that she was a girl. Her ‘Mom, they are wrong, aren’t they?’ was heart-breaking. I guess this is the same dilemma family members and professionals face when interacting with people suffering from psychosis and poor insight. One the one hand, they really want to be honest, and on the either hand they do not want to endanger the relationship. Such important yet difficult clinical issues are the most important inspiration for my research on processes underlying poor insight and for developing new treatments to increase insight in psychotic disorders.
Impaired insight is one of the main themes of my research. In close collaboration with the Groningen Neuro-Imaging Center we have performed several studies on this topic. A series of studies gave new information about how the brain is involved in poor insight. Our research shows that patients with poor insight show less activation in brain areas related to self-reflection, self/other distinction, and perspective taking. These findings supported the rationale for a new treatment, currently under evaluation, which attempts to increase insight by enhancing self-reflection: REFLEX.
“patients with poor insight show less activation in brain areas related to self-reflection, self/other distinction, and perspective taking”
Currently, we are analyzing the data of a randomized controlled trial evaluating REFLEX. The training focuses on coping with stigmatizing beliefs, stimulation of self-reflection, and stimulation of reflection about ongoing thoughts and feelings. Between sessions, subjects monitor their thoughts and feelings in real life using a diary that is completed six times a day. During sessions, the content of these diaries is discussed. In addition, group exercises and movie vignettes are used to practice perspective-taking (Pijnenborg et al., 2011).
We have also examined which other treatments are effective in increasing insight in psychosis. In a recent study we found that antipsychotic medications have a positive effect on insight in people with a first psychotic episode. Unfortunately, however, not all patients respond to medication in this phase. Also, antipsychotic medications have unpleasant side effects. Therefore, a number of psychosocial interventions to increase insight have been developed. In a meta-analysis (Pijnenborg et al., 2013) we examined their effectiveness. We found that only very few clinical trials report on changes in insight. In other words, insight has rarely been considered as a separate outcome measure in treatment studies. This is unfortunate since insight has been shown to be relatively independent from symptoms and might therefore respond to treatment in specific ways. This specific response might go unnoticed if not considered in its own right. The studies that did consider insight as an outcome measure provided no evidence that psycho-education and cognitive behavioral therapy improved insight, but two other treatments seemed promising: a combination of several interventions including cognitive-behavioral therapy, medication, and psycho-education; and video-confrontation, which involves showing patients a video of an interview about their symptoms conducted at the start of treatment.
The conclusion is that even though we have been studying insight in psychosis for several years now, a lot is still unclear. Better said, there is still room for improving our own insight in poor insight.
Pijnenborg, G.H.M., van Donkersgoed, R., David, A.T., Aleman, A. (2013) Treating insight in psychosis: a meta-analysis. Schizophrenia Research 144(1-3): 109-17.
Pijnenborg, G.H.M., van der Gaag, M., Bockting, C., Aleman, A. (2011) REFLEX: a social-cognitive group treatment to improve insight in schizophrenia: study protocol of a multi-centre RCT. BMC Psychiatry 5(11):161.