Determination and Documentation of Insight in Psychiatric Inpatients

The following case vignettes draw attention to the symptoms and signs of illness.

Anil is manic with mood-driven behaviors that are so out of control that he meets criteria for an involuntary hospitalization. Janice presents with psychosis-a delusion of impersonation, or Capgras syndrome. For both patients, a factor that will heavily influence treatment decisions, length of stay, medication adherence, need for extra support in the community-indeed the ultimate course of illness-is the patients’ level of insight.

CASE VIGNETTE

Anil, a 20-year-old from India, now a college student in the United States, was involuntarily admitted to the psychiatric inpatient unit in a florid manic state, with rapid speech, flight of ideas, and sleeplessness. Before admission, he had been clocked driving at 100 mph. The intercepting police, noting his abnormal mental status, brought Anil to the emergency department. Mood stabilizer and antipsychotic medication settled him over a week, but he still persisted in believing the police “must have been drunk themselves,” since they assessed him as needing psychiatric help. “I’m not bipolar. Everybody has mood swings!” he insisted. He added, “I will take the medications while I am here, but I am not sure I really need them after I leave.”

Anil clearly does not accept the bipolar disorder diagnosis. Is this part of his illness and a sign that he is not yet stable? Should we trust him in a partial hospital or outpatient program or should he remain on a locked inpatient unit? In view of his lack of insight, does he need a change of medication? What should his family be told about his prognosis, especially if he persists in his denial of illness? Understanding insight is paramount for answering these questions.

CASE VIGNETTE

Janice, a 27-year-old with schizophrenia, stopped taking her prescribed antipsychotic consistently. Within 2 months, her psychotic symptoms returned with full force, and she required hospitalization. She told the admitting psychiatrist that the woman who brought her to the emergency department was not her real mother, but rather “an actress playing her mother.” This misperception had likely played a role in threats she had made toward her mother on the day of admission. Questioned by the psychiatrist as to the plausibility of someone resembling her mother so precisely, she responded, “I don’t know how they did it, but somehow they were able to find someone!” A week after restarting her medication, Janice allowed that her imagination had been “playing tricks on her” and happily embraced her real mother.

Is Janice ready to go home after her week in the hospital? Does she really understand her illness well enough to be allowed to manage her own medications again? Does the risk of violence change the assessment? Should a long-acting injection be prescribed, given her history of nonadherence?

What is already known about insight in psychiatric inpatients?

There is ample literature on insight in psychiatric patients, with much of it concentrating on severely ill inpatients. Insight scales have been used to explore the relationship of insight with various clinical conditions, situations, and outcomes in hospitalized patients.

What new information does this article provide?

Despite the considerable research literature on insight, little information has permeated to the clinical practice of psychiatry. This article reviews the relevant studies involving insight and offers an overview and critique of the various rating scales for insight.

What are the implications for psychiatric practice?

Psychiatric assessments often give only cursory attention to the patient’s level of insight. This article provides practical tips for adding more detail to the assessment of insight in evaluations and progress notes. Improvement in insight assessments can help the clinician with important transitional stages in the patient’s treatment, including decisions around readiness for discharge and the level of monitoring required in the outpatient setting.

What’s insight got to do with it?

In written evaluations of psychiatric patients, many residents and attending psychiatrists include little nuance or detail on the insight component of the mental status examination. A review of initial psychiatric evaluations and progress notes shows that insight, often in a combined item listed as “Insight/Judgment,” is frequently described as “poor,” “fair,” “limited,” “improving,” etc. The use of these nonspecific adjectives can be attributed to time limitations and/or a desire for brevity. But these cursory terms also reflect the limited attention given to the assessment of insight in psychiatric training. After all, other, “sexier” elements of the mental status examination-thought content, thought process, mood, affect-are generally described more fully and with more specificity. Yet, a refined assessment of insight is equally important to the comprehensive patient evaluation, both on initial admission and on subsequent days. Simple adjectives do not capture the separate components of insight. The reader might reasonably ask, “poor insight into what?”

Deficits in insight have implications for numerous clinical inpatient hospitalization issues, including the decision to hospitalize a patient voluntarily or involuntarily in the first place. Other insight-related issues include adherence to treatment after discharge, guardianship/capacity assessments, readiness for discharge decisions, the choice of oral medications versus long-acting depot medication, recommendations for placement in a structured setting after discharge, and the referral of patients to appropriate psychotherapy on hospital discharge.

The etiology of lack of insight has been variously conceptualized as¹:

• Stemming from neuropsychological (brain) deficits

• Part of the primary psychiatric illness itself (eg, poor insight as a symptom of mania)

• A form of defensive denial protecting the patient against the distress of awareness of illness

Regardless of the theoretical model-and it is likely that all apply in different circumstances-the assessment of insight should be detailed and well documented in the clinical record.

A sizable group of clinical researchers, within both psychology and psychiatry, have studied and clarified the concept of insight and its application to clinical states. There is abundant literature on the design and validation of rating scales of insight, and there are studies that correlate deficits in insight with psychiatric diagnoses and with various states of illness.^2,3

A moment’s insight is sometimes worth a life’s experience.
-Oliver Wendell Holmes Jr

Impaired insight is intrinsic to many, if not most, severe psychiatric conditions. Poor insight is a prevalent feature of schizophrenia, and lack of awareness of schizophrenic symptoms is correlated with poor medication adherence and higher rates of recidivism.^4,5 Poor insight is also common in bipolar disorder, and although insight is more state-dependent in bipolar disorder than in schizophrenia, it correlates with poor treatment outcomes.^6,7

Poor insight in mania is not necessarily related to the presence or absence of psychotic symptoms.⁸ Multiple studies have shown correlations between poor medication adherence and lack of insight across diagnostic groupings.³ Assessment of insight has a pivotal role in the decision to give a psychotic patient a long-acting depot medication.⁹

Finally, recent research has expanded into the neuropsychological underpinnings of insight. For instance, the literature suggests that insight deficits in schizophrenia show a greater correlation to the degree of cognitive impairment than to acute psychopathology.¹⁰

Understanding insight

In a general context, meanings assigned to insight generally combine some metaphorical use of terms related to seeing and perception, or words that imply comprehension and self-knowledge. For instance, synonyms for the word “insight” include vision, understanding, awareness, intuition, perception, acumen, comprehension, discernment, and perceptiveness. To illustrate this further, one needs only to note that “insight-oriented psychotherapy” and “insight therapy” are often used interchangeably with other terms for psychodynamic therapies, eg, psychoanalytic psychotherapy, psychodynamically oriented psychotherapy, and even “uncovering therapy.” The insight gained in these therapies can be considered a product of working through of psychological conflict and a concomitant awareness of the self that was previously preconscious or unconscious (the dictionary’s “glimpse or view beneath the surface”).

In contrast to the more comprehensive psychoanalytic concepts, insight has a more circumscribed meaning in the psychiatric mental status examination, especially with severely ill inpatients. In this context, insight refers to awareness of one’s current psychiatric condition or illness, the ramifications of said illness, attribution of the cause of illness, and appreciation of the need for treatment.¹¹ This emphasis on insight into illness is especially fitting in the more severe mental disorders, since much of the research, including the development and validation of rating scales, has centered on schizophrenia, bipolar disorder, dementia and, to a lesser extent, depression.^3,8 Some insight rating scales, which are reviewed in the following section, have only been fully validated for psychotic states.

Patients with Axis II disorders are frequently admitted to acute inpatient units, but the concept of insight in this group is considerably less developed in the general psychiatric insight literature. Assessment of insight in patients with personality disorder can be related to psychodynamic concepts of ego-dystonic and ego-syntonic character traits. Defense mechanisms are also important to consider, since lower-level defenses such as splitting, projection, and externalization lead to the patient’s distorted views of the treatment team, poor recognition of internal emotional states, and lack of awareness of his or her own role in the difficulties that led to hospitalization.

Standardized insight rating scales

Standardized scales of insight have been used in the research setting but are not currently used in common clinical practice. The majority of practicing psychiatrists may not even be aware of the myriad scales that have been developed and validated. Scales are widely used to evaluate levels of insight across various stages of illness, because insight relates to extent of brain pathology (eg, dementia) and correlates with treatment outcomes.^11-13 Although too time-consuming to administer to every patient, a well-chosen insight rating scale could be useful for formally documenting a patient’s insight deficits. Even informally, awareness of the types of questions found on these scales allows a more meaningful assessment of insight than the current general practice in the hospital setting (Table 1).

Sanz and colleagues¹⁴ concluded that there are considerable correlations among the scales; this indicates the construct validity of the concept of insight. Markov³ provides a comprehensive and detailed account of the scales, including historical, philosophical, and clinical dimensions of the entire concept of insight and analysis of the virtues and shortcomings of various insight ratings. Many rating scales are available with which to assess a patient’s insight. The following 7 scales may be useful on the acute psychiatric unit (Table 2).

Item G12. Part of the General Psychopathology section of the Positive and Negative Syndrome Scale (PANSS),¹⁵ Item G12 (lack of judgment and insight), is used separately as an insight scale. The PANSS was developed for use in patients with schizophrenia, and it measures severity of illness and subsequent improvement in trials of new antipsychotic medications. 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, ie, have a “mild” lack of insight. “Extreme” applies to patients with blanket denial of illness, delusional interpretation of hospitalization, and lack of cooperation with treatment staff. Item G12 is closely tied to awareness/acknowledgment of psychiatric illness and the need for treatment. Although formally validated in patients with schizophrenia, the anchor points of item G12 can also describe other psychotic illnesses, including severe manic states.

While Item G12 provides brevity and ease of administration, it is neither comprehensive nor practical. 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.

Schedule for the Assessment of Insight (SAI).¹⁶ Using a semistructured 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. As such, it is also particularly useful in psychotic patients. Using this approach, a psychiatrist might ask questions related to the patient’s interpretation of his psychosis as part of an assessment of insight: “Mr Jones, do you think your voices are coming from a real person or place, or are they related to your illness?”

In the expanded version of the SAI (SAI-E), items are added to more fully address the patient’s awareness of change, practical problems, and symptoms.¹⁴ The original, with 8 items, lends itself to relatively efficient use on the inpatient unit. The longer update is likely a bit unwieldy for day-to-day use but may be appropriate if closer examination is needed. Even if the SAI-E is used occasionally, the 8-item subset of original items could be compared with previous scores for longitudinal assessment.

The Insight and Treatment Attitudes Questionnaire (ITAQ). Developed by McEvoy and colleagues^13,17 specifically for use in patients with schizophrenia, the 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. Consultation-liaison psychiatrists may recognize that the concept underlying this approach is similar to that of Appelbaum’s¹⁸ assessment of capacity, in which patients are asked to explain their understanding of the rationale for a given medical procedure and the reasoning behind their refusal of such.

The premise behind the concept of insight in the ITAQ, with its circumscription to the actual treatment situation, can readily be applied to the evaluation of an acutely hospitalized patient. Specifically, this scale would be especially useful in documenting the extent to which the patient agrees with the treatment plan. This domain is increasingly important because of the close scrutiny of third-party payers (sometimes on a daily basis) and the growing emphasis on patient-centered care.

The Patient’s Experience of Hospitalization (PEH). The PEH scale focuses on a hospitalized patient’s position on a continuum from denial of illness to acknowledgment of illness.¹⁹ This component of insight is highly correlated with treatment adherence. The PEH is an 18-item self-report questionnaire that uses a 4-point Likert scale. It is not too unwieldy for occasional use on an inpatient unit. In addition, many of the items can be rephrased as questions and used in the initial clinical evaluation or subsequent progress notes; for example, Item 16: “I think my condition requires psychiatric treatment” rephrased as “Do you think you have a condition that . . . ?”

The primary advantage of the PEH is that because it is self-administered, it takes relatively little of the clinician’s time. Unlike evaluation of symptoms or adverse effects, evaluation of insight really lends itself to self-assessment. Finally, unlike many of the other scales, the PEH has been validated for diagnoses besides psychotic disorders.

The Scale to Assess Unawareness of Mental Disorder (SUMD).^20,21 The SUMD has been validated in schizophrenia and schizoaffective disorder and uses a structured interview administered by trained raters. The SUMD derives from Amador’s complex model of insight and includes a symptom checklist in addition to general items related to awareness of illness, attribution of symptoms to a mental disorder, awareness of effects of medication, and awareness of social consequences of illness. Furthermore, SUMD scoring includes subscales that relate the general items to specific symptom constellations.

This scale is widely used in the literature; however, the complexity of the SUMD, when administered in its entirety, limits its practical application in nonresearch situations. Fortunately, there is an array of studies in which the SUMD was abridged to fit the needs of specific research protocols. One of these abridged SUMDs could be useful on the inpatient unit.

The Beck Cognitive Insight Scale (BCIS).²² The BCIS is a 15-item self-report questionnaire in which patients are asked to rate the degree of their agreement with specific statements. In contrast to other insight scales that focus on awareness of illness, the BCIS assesses the patient’s capacity to evaluate his unusual experiences. Drawing on principles of cognitive-behavioral therapy, the BCIS sees inability to distance oneself from distortions (lack of self-reflectiveness) and difficulty in accepting corrective feedback (self-certainty) as fundamental issues in psychosis.

A cross-comparison study of BCIS scores in schizophrenic spectrum illness and bipolar mania compared with nonpsychotic major depression yielded the expected result of lower index scores (poorer insight) in the former 2 groups.²³ A number of BCIS items can be incorporated as questions into a general insight assessment of psychiatric inpatients. This may be particularly helpful in assessing whether a treated patient is “integrating” or “sealing over” the resolving psychotic experiences²⁴: “Do you think that some of your experiences that have seemed very real may have been due to your imagination?” “Do you think that some of the ideas that you were certain were true may have turned out to be false?”

As with the PEH, the primary advantage of the BCIS is that it is self-administered. It also has been validated over a variety of diagnostic categories. In the scoring scheme (Table 2), the BCIS has the highest score, only losing a point for brevity and a point for practicality. The brevity issue is less relevant, since the patient completes the form on his own.

The Insight Scale (IS). The IS, developed by Markov and colleagues,²⁵ in its most recent form, is a self-report instrument validated for use with patients with schizophrenia. The IS consists of 30 “yes/no” items that are scored as 1 for insight and 0 for no insight, yielding a maximum score of 30. The IS items focus on the patient’s awareness of the changes in subjective experience that occur with psychosis (self-knowledge) and how these changes might affect his interactions and functioning within his environment.

The self-report aspect is useful, and the scale’s seemingly unwieldy length is somewhat tempered by the simple yes/no question structure. The primary limitation of this scale on an inpatient psychiatric unit is the exclusion of items related to the need for treatment. This one issue consumes more clinical time and energy than any other. While some research studies may be better served by this “clean” approach, daily clinical work must consistently include assessment of the patient’s willingness to adhere to treatment recommendations.

Conclusion

The level of insight is virtually always a crucial issue in hospitalized psychiatric patients. Assessment and documentation of insight is thus an important part of the inpatient psychiatric assessment. This determination should include all the components of insight: awareness of illness and its effects, attribution of symptoms to a mental disorder, perception of need for ongoing treatment, and awareness of the achieved effects of current treatment. Insight can be assessed in the course of a typical evaluation or follow-up interview with augmentation by questions borrowed from any of the validated insight rating scales.

References:

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