Insight and Judgment are an integral part of everyday life. Insight simply means the ability of a person to gain an accurate and deep understanding of something or someone. In a mentally ill person, there remains a wide gap between awareness regarding his or her own mental illness and that his or her behavior or thought process is not commensurate with reality. In psychiatry this is known as "poor insight" or "lack of insight". The commonly accepted definition of insight, as shown in current researches on the subject include three persistent aspects: recognition of mental illness by the concerned individual, the capacity to appropriately attribute the symptoms to the pathological findings of said illness, and the ability to recognize the benefits of the treatments.
On the other hand, judgment is a mental ability which determines a person's decision making capability and his or her ability to come to a sensible conclusion on a certain matter when he or she needs to choose from a multiple of options. Capacity of Judgment grows with age. It is proved that even the infants less than one year old are capable of making perceptual judgment. Researchers have shown that many mentally ill patients with Depression and Schizophrenia have lesser levels of insight and judgmental abilities making it difficult for them to cope and deal with their situation. Poor insight and judgment are also linked with "Borderline Personality Disorders" (BPD), which leads to serious mental illness marked by unstable mood, relationships and behavior.
What Does Poor Insight and Judgment Mean?
Insight and judgment are inherently linked with each other. Both these terms are linked to the ability of a person to understand certain circumstances and both involve the processes of appraisal or assessment of one's own state of mind, one's relation with the others in a social and familial set-up or attachment with an object and one's motivation and action and thus decide onto something. A person is said to have poor insight and judgment when one or more of the above mentioned abilities are not being performed satisfactorily.
Several external and internal factors influence poor insight and judgment of a person:
- Social and cultural model of illness
- General intelligence of the person as also his or her knowledge regarding different mental health issues.
- The person's capability regarding avoidance of social stigma.
- Social awareness regarding an illness.
- Level of self-esteem and capability to preserve self-esteem.
- Capability to recognize symptoms by the patient.
What is the link between Poor Insight and Judgment with Depression and Schizophrenia?
As per present statistics about 50% patients having maniac depression (with psychosis) and 60% of schizophrenic patients do not believe that they have any illness, which is an indication of poor insight.
Poor insight is among the best predictors of non-adherence to treatment for depression and schizophrenia. Since, poor insight leads to poor judgment, it is really a common sense that who would like to take medicine for a sickness that they do not believe they have? It is not surprising that poor insight also results in a poorer course of the diseases of depression and schizophrenia like decreased quality of social skills and social relationships, increased number of relapses and hospitalizations, deteriorating work performance, recovery of the illnesses and other parameters of course as well.
Poor insight and judgment has very comprehensive and significant meaning as far as psychiatric mental status examination (MSE) is concerned especially for patients with depression and schizophrenia. In this context, it refers to knowledge to one's own current psychiatric condition and illness.
Insight and judgment are complex multidimensional construct which are shaped by each individual's psyche like motivation and denial, the constraints of physiology as happens in cognitive impairment and anosognosia. These two mental health determinants, i.e. insight and judgment are immensely influenced by various factors as mentioned above. Poor insight and judgment was found to be intensively associated with schizophrenia. Such association of poor insight and judgment with schizophrenia is found across all countries and cultures as surveyed by the World Health Organization (WHO) in their international Study on Schizophrenia.
As for depression, poor insight is more linked with manic depression and with those having associated psychosis. People with poor insight often find it difficult to understand that the symptoms exhibited are due to a disease. If psychosis is present with depression, the condition becomes more critical as levels of insight decreases further.
What Can Cause Poor Insight and Judgment?
The cause of poor insight in schizophrenia and depression was initially attributed to denial or defensive coping strategy, lack of proper education regarding the diseases and certain neurocognitive deficits. However, recent researches have shown that rather than being a defensive strategy, poor insight is a symptom of depression and schizophrenia. There are three distinctive schools of thoughts regarding "poor insight" in schizophrenia and depression. These different reasoning regarding etiologies of poor insight in schizophrenic patients that also lead to depression in many cases, not necessarily mutually exclusive, but they may combine together causing poor insight and thereby poor judgment:
- Psychological Defense Model: The prevailing assumption in this model is that failure to understand or admit the existence of a psychiatric illness is a conscious and sometimes a sub-conscious refusal rather than a mere inability. It is also assumed that knowledge of the illness exists at some cognitive level that's why increasing insight leads to increasing depression in the patients in later period. A study (Smith et al. 2004) suggests that poor insight is a psychodynamic coping process to reduce anxiety and depression.
- The Cognitive Deficit Model: According to this model, poor insight is an outcome of progressively degenerating cognitive functioning over the course of a psychological disorder like schizophrenia.
- The Neuropsychological Deficit Model: This model was developed by observing the similarity between the symptoms of poor insight and anosognosia. Anosognosia is a proved neurological deficit that develops secondary to a diffused brain damage or specific lesion. It has striking similarity with impaired insight where both the problems show severe lack of awareness regarding their illness and apathy towards treatments. Neuroanatomic abnormalities are now a proved reality of schizophrenia, as several studies have detected strong evidence of neurological basis for poor insight.
As insight and judgment are inherently linked with one another, it's a fact that impaired insight in schizophrenia and depression may lead to impaired judgment. This is thus a direct outcome of poor insight. On the contrary, in the later period of the illness improvement in insight lead a patient to become more judgmental in nature which ultimately makes him or her more depressed.
What are the Symptoms of Poor Insight and Judgment?
Poor insight and judgment is inherently linked with schizophrenia and depression. Impaired insight and thereby judgment present in schizophrenic patients resulted into noncompliance with treatment as patients do not believe that they need any sort of medications. So, non-adherence to the treatment procedure, rationalization of disordered behavior and creating self-made logic against different pathological outcomes are symptoms of poor insight and judgment. Many patients with very poor insight may be more prone to develop delusional interpretation of hallucination and thereby act upon it aggressively or impulsively.
In later period, as discussed earlier with the improvement in insight and judgment, schizophrenic patients show sheer symptoms of depression since they start to believe that they are suffering from a psychological disorder.
What are the Treatment of Poor Insight and Judgment?
Treatment planning for poor insight and judgment is inherently linked with the treatment of depression and schizophrenia, as improvement in patients with these psychotic problems automatically improves insight and thereby judgment. Since insight is closely associated with both treatment and outcome of the treatment, two factors are considered during a treatment process:
- Compliance with the consistent treatment process.
- Type of psychological disorder that diminishes insight and increases reluctance to adhere to the treatment process.
These two factors highly influence the successfulness of a treatment. If patients follow the treatment process, they show improvement in insight and judgment steadily. Application of psychotic medications is a consistent process for schizophrenic patients. Studies have found that relapse rate of poor insight and judgment is almost 4 times greater in patients who do not support treatment process or for whom there isn't a proper support system available. There have been contradictory evidences from several studies regarding reversible symptoms of poor insight. One such study indicates that insight may be somewhat improved with repetitive training and education regarding the illness and how to cope with the symptoms. On the contrary, many other researchers have detected that patients with anosognosia have severe chance of reversible symptoms even after regular training and education as anosognosia is a condition attached with permanent brain damage.
Cognitive Behavioral Therapy can help patient with depression and schizophrenia improves the insight and judgmental abilities. However, a good support system is very vital for the improvement of the patient so that with improvement of insight, depression symptoms don't increase and they don't feel left out or lonely.
Poor insight and judgment is common in depression as also schizophrenia. Approximately one half of all schizophrenic patients exhibit pervasive and persistent problems with insight. Psycho-education is not sufficient to remedy the problem because it also stems from some neuropsychological deficits as proved by the "Neuropsychological Deficit Model". As it closely resembles anosognosia, some experts proposed the term "Anosognosia for Schizophrenia" as more appropriate than the broader term poor insight and judgment. It results in a poorer course of illness and severe problem in associating a patient with his or her treatment process. Patient's poor judgmental ability and self-created rationalization regarding non-adherence to the treatment lead the experts to innovate some modifications in the treatment process. They opine that these kinds of patients can be better treated with long-acting injectable medications, increased supervision and simplification of dosing. However, if left ignored, the course of the disease itself can be very devastating for the patient.