Psychosis is a condition that affects the mind, causing abnormalities in one’s thoughts, perceptions, and emotions. The main symptoms of psychosis include hallucinations, delusions, confused thinking, and disorganized behavior. Psychosis occurs in various psychiatric disorders, but most notably in schizophrenia and bipolar disorder.
One key question surrounding psychosis is whether or not the person experiencing it has insight into their condition – that is, whether they have awareness that their experiences are not reality. This lack of insight is known as anosognosia. Understanding the level of insight someone has into their psychosis can have important implications for diagnosis, treatment, and long-term outcomes.
Do people with psychosis know something is wrong?
Research shows that insight in psychosis exists on a continuum. On one end of the spectrum, some people have very little or no insight that their experiences are abnormal. However, others do possess varying degrees of awareness that something is not right.
According to one study, about 50-80% of people with schizophrenia have poor insight into their condition. This means they are unaware or only partially aware that their beliefs and hallucinations are not real. However, the other 20-50% do have awareness that their experiences are not based in reality.
Insight can fluctuate over time and can be better during periods of remission when psychotic symptoms are less severe. Stress and substance abuse are factors that are believed to diminish insight in people with psychosis.
Evidence of early awareness
Although many people lack insight once psychotic episodes become severe, there is evidence that many can detect early warning signs something is amiss.
A 2009 study found that 70% of people recovering from their first episode of psychosis had experienced an “early warning phase” before full psychosis emerged. During this pre-psychotic phase, they had feelings that something was not right, such as:
- Suspiciousness or unease around others
- Having “a weird feeling” something was changing
- Noticing odd sensations, perceptions, or thoughts
- Feeling depressed, anxious, irritable
- Having sleep disturbances
- Noticing a decline in functioning
Although those in the early stages lacked insight into the full severity of their experiences, the majority did have self-awareness that something was not normal and sensed gradual changes in their thoughts, emotions, and perceptions.
Why do some people lack insight?
There are various theories that aim to explain why many people with psychosis lack insight:
The illness itself
One reason is that psychosis genuinely impairs the ability to have accurate self-assessment. The nature of the condition warps one’s sense of reality. When hallucinations and delusions take over, the person believes these experiences to be real and true. Their internal sense of what is real has been hijacked by the illness.
Brain differences
Research shows there are differences in the brains of people with schizophrenia who have insight compared to those who do not. Lack of insight has been linked to decreased volume in the right prefrontal cortex, left insular cortex, and paracingulate gyrus. It is thought these brain regions normally enable self-reflection and awareness.
Cognitive biases
People with psychosis often demonstrate thinking biases that contribute to reduced insight, such as:
- Jumping to conclusions
- Externalizing blame
- Difficulty considering other perspectives
- Problems with error monitoring
These biases lead them to hold rigidly to their beliefs.
Stigma
Fear of stigma can cause some people to deny anything is wrong in order to avoid being labeled “mentally ill.” Admitting their experiences aren’t real means accepting a frightening diagnosis like schizophrenia.
Lack of trust
Some people with psychosis may recognize something is not right but lack trust in doctors or others telling them their beliefs are false or exaggerated. The delusions feel completely real to them, so the perspective of others seems unreliable.
Can insight improve in people with psychosis?
For those who lack insight, treatment focused on building self-awareness can help. Some therapies and approaches that can improve insight include:
Psychotherapy
Talk therapy techniques like cognitive behavioral therapy often aim to develop insight by helping the person view their experiences more objectively and constructively.
Psychoeducation
Education from doctors, nurses, peers, and support groups can gradually enhance insight by providing objective information about the illness and its symptoms.
Medication
Antipsychotic medication can reduce delusions, hallucinations and disordered thinking and allow greater self-reflection. Even small doses can restore some insight for certain individuals.
Brain stimulation
Repetitive transcranial magnetic stimulation (rTMS) is a treatment that uses magnetic fields to alter brain activity. Some research indicates it may improve insight, particularly when directed at the right prefrontal cortex.
Peer support
Talking to others with shared experiences of psychosis can validate concerns the individual may have and spur them to further explore changes they are noticing.
However, lack of insight can still persist and be difficult to treat in those most severely affected. Developing awareness typically requires time, patience, and a trusting relationship between the person and their treatment team.
How Does Insight Affect Outcomes?
Several studies show that insight into one’s condition can lead to significant benefits:
Better treatment response
Those with more insight are more likely to adhere to treatments like therapy and medication. This leads to an improved response to treatment overall.
Increased help-seeking
People with more insight are more aware they need professional care and are more likely to seek it out. This prevents long delays between psychosis onset and treatment.
Lower risk of violence
One study found people with schizophrenia who had good insight were only one-fifth as likely to be violent compared to those lacking insight. Awareness of the condition seems to prevent dangerous behaviors.
Increased social functioning
More insight is linked to an improved ability to maintain relationships and employment. It helps people notice when psychotic symptoms interfere with functioning so they can take action.
Enhanced cognition
Those with insight tend to have better cognitive functioning, particularly executive functioning related to planning and self-control. This helps them make healthy life decisions.
Reduced suicide risk
People who are aware of their illness are less likely to feel hopeless and in turn less prone to suicide. This is likely because they understand their experiences are symptoms that can improve with treatment.
Better quality of life
Overall, higher levels of insight are associated with enhanced well-being and life satisfaction in people with psychosis. Awareness of the condition allows them to more actively manage it.
How is Insight Measured?
Clinicians use validated psychometric scales to get an objective measure of a person’s level of insight. Some examples include:
Scale to Assess Unawareness of Mental Disorder (SUMD)
This tool contains items measuring awareness of:
- Having a mental disorder
- The effects of medication
- The consequences of the disorder
- Having specific symptoms
Each item is rated on a five-point scale, from “aware” to “severely unaware.”
Positive and Negative Syndrome Scale (PANSS)
The PANSS includes an insight item scored from 1 (excellent insight) to 7 (lack of judgement and insight).
Birchwood Insight Scale (IS)
This 8-item self-report scale assesses the following domains:
- Awareness of illness
- Relabeling symptoms as pathological
- Awareness of need for treatment
Higher scores indicate better insight.
Regularly using these scales allows treatment teams to track changes in insight over time and identify unrecognized needs.
Conclusion
In summary, insight in psychosis exists on a spectrum. While many people have very limited awareness their experiences are not real, others do have varying degrees of understanding something is not right. Developing insight is an important component of recovery that is linked to improved treatment outcomes and quality of life. With time, education, therapy, and other interventions, insight can gradually improve even in those who were initially unaware they had psychosis.