Lack of Insight in Psychiatric Patients: How it Affects Mental Health
Insight in mental illness is defined as the ability of people to demonstrate awareness or understanding of the disease process (Chakorbatoy & Basu, 2009). The DSM-IV-TR (APA, 2000) reports that majority of persons with schizophrenia have poor insight related to their illness. Most of the studies suggested that lack of insight is not a coping strategy, but in fact deteriorates the patient’s mental health.
Insight in schizophrenia is a complex phenomenon. According to Osatuke et al. (2008) there are many factors contributing to poor insight of the patient which include: a lack of insight as denial, lack of insight as disorganized symptoms and insight as a sociocultural aspect:
- Lack of insight as denial occurs when patients verbalize poor insight as a defense mechanism. In this state patient does not verbalize any psychotic symptoms because he or she doesn’t want to take antipsychotic medications and/or hospitalization. In this state a patient may try to cope with the psychotic symptoms, and if symptoms do not disappear, the patient may end up with complications related to mental health.
- Lack of insight in disorganized symptoms involves a patient who is not able to understand the disease process due to the changes in neurotransmitters associated with a mental health disorder. Such disorganized symptoms are often seen in schizophrenic patients because in schizophrenia, dopamine levels increase and produce symptoms of psychosis. Furthermore, this increased amount of dopamine affects different parts of brain, such as the midbrain and substania nigra, and inhibits pathways responsible for memory, emotions, and coping patterns. As a result of disturbances in a patient’s brain, they exhibit psychiatric symptoms.
According to the study conducted by Marburg (2010); 50-80% of patients having psychiatric illness exhibits poor insight. A patient in my care with a history of schizophrenia exhibited excess levels of the neurotransmitter dopamine in their brain. Such patients are non-compliant to drugs, having ongoing admissions in hospitals and may end up in depression, suicidal thoughts and a relapse phase as well.
- Insight as a socio-cultural aspect: this means that people do not express their disease state because of social stigma. According to Dawn (September, 2014), there are 5 psychiatric hospitals and approximately 400 psychiatrists available in Pakistan but people are reluctant to visit According to Qasim (2012), 16% of the population is suffering from psychiatric illness but not availing health care services because of stigma, stereotypes, discrimination, prejudice, etc. This is the main reason that people do not seek help for psychotic symptoms and end up in chronic illnesses.
Wolfgang Kohler (1920s) was given a theory on insight which talks about the realization of this problem and tries to make solutions for it. This theory results in a good and long-lasting change in a person. For example, after understanding this theory a patient may understand the disease process, be willing for psychiatric consultation, show compliance for medications, and in the end he/she may express good insight.
This theory relates well to the patient in my scenario: the aforementioned individual is not able to realize the illness because of lack of insight which is due to neurotransmitter changes and noncompliance to drugs. In my opinion, if this patient were to take antipsychotic drugs on time, she might develop good insight, and good insight may in turn aid the patient in finding solutions to help her cope with stressors and psychotic symptoms in future.
During hospitalization patient receives depot medication, which plays and important role in non-compliant patients. The effect of this drug is long lasting (2 wks.) and it helps her to gain insight which may improve future compliance to treatment, thus leading to a good quality of life.
There are three models presented by Pejninberg et al.(2011): Clinical Model (lack of insight is the primary symptom of schizophrenia), Neuropsychological Model (cognitive impairment is responsible for poor insight) and lastly, Psychological Denial (person verbalizes poor insight as a coping strategy). The first two models explain my patient’s case. The patient’s lack of insight may be a primary symptom of schizophrenia, of which she has a prominent past history (Clinical Model). Or it may be due to impairment in the brain’s neuro-chemistry, which we have been unable to confirm as MRI or other studies were not conducted on the patient as yet.
At community and institutional level, case management programs are necessary for these individuals, which include careful ongoing monitoring, supervision of medication compliance, and assessment of their symptoms. The case management programs play an important role in mental health because they provide a platform for health care providers to assess patients, their needs and the severity of disease.
Moreover, patient education programs are useful for continuity of care. They help clients to know the symptoms related to their disease and teach them how to deal with it. This also helps the client to learn about the benefits of medication compliance. In addition, support groups are very helpful in mental health because they allow patients to ventilate their feelings and socialize themselves. Rehabilitation programs are also important to manage their illness and help in prevention to relapse.
At individual-level teaching sessions, cognitive behavioral therapy may help a person to gain insight into their illness, as these therapies allow the client/patient to identify the kind of situation that causes a disturbance in their life so that he/she can effectively and positively respond to the situation.
To conclude; lack of insight in schizophrenia is universal but its definition has been varied from person to person. Poor insight leads to noncompliance of drugs or noncompliance to medications, which leads to hospitalization, suicide attempts and relapse of symptoms. Patients with absent insight may end up in to psychological trauma, memory impairment and other chronic conditions as well, and these types of complications leave a person depressed and socially isolated.
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