This post was inspired by an article in the May 30th issue of The New Yorker, “God Knows Where I Am” by Rachel Aviv. Full-text online is only available by subscription, but a free abstract is available here. In the process of telling a riveting and ultimately very sad story, the author discusses psychiatric insight.
Insight is a curious concept as used in psychiatry. In common parlance insight is unquantifiable, something like charm or wisdom. We feel we know it when we see it. But most of us hesitate to make finer distinctions. We may allow that someone strikes us as a little insightful or very wise. Beyond that, it seems ludicrous to attach a scale to it, or to refer to insight as though it could be measured precisely.
Nonetheless, in psychiatry an assessment of insight is part of the “mental status examination” (MSE), the psychiatrist’s version of the physical exam in general medicine. Along with assessments of mood, affect (expressed emotion), paranoia, suicidal feelings, and other issues, the psychiatrist also evaluates the patient’s insight.
Psychiatry has no standardized way to assess this. We may ask our patient: “What is your understanding of the problem that brought you here today?” It’s a great question — the problem is what to do with the answer. Critics note that if the patient’s response accords with the psychiatrist’s own belief, the patient is judged to have good insight. Thus, in an earlier era when psychoanalysis was predominant, a patient with schizophrenia exhibited good insight by agreeing that his “schizophrenogenic” mother caused the problem. Nowadays, this would be evidence of clear impairment; the insightful patient would instead agree with his psychiatrist that he has a “chemical imbalance.”
For better or worse, many such judgments in psychiatry — perhaps most of what we do — cannot be divorced from social context. Exuberance in one crowd may look like hypomania in another. “Inappropriate” affect begs the question, what is appropriate? And likewise, an understanding of one’s own mental health status (or psychiatric label) is meaningful only within one’s social group and culture.
Anosognosia is a term from neurology. As defined in Mosby’s Medical Dictionary, 8th edition:
Etymology: Gk, a + nosos, not disease, gnosis, knowing
a lack of awareness or a denial of a neurologic defect or illness in general, especially paralysis on one side of the body. It may be attributable to a lesion in the right parietal lobe.
The term has lately appeared in psychiatry (and is discussed briefly in the New Yorker piece). This is a worrisome error in my opinion. Its use seems intended to make psychiatry sound better understood, and more biological/neurological, than it really is. A person who denies having a psychiatric disorder may delusionally attribute his or her difficulties to space aliens. This makes a good case for extending anosognosia into psychiatry. But a denial could equally be an honest difference of opinion, as when a patient discounts a diagnosis of Social Anxiety Disorder because shyness is a family trait. Here, denial of an anxiety disorder is certainly not a sign of having such a disorder. And of course social stigma leads many patients to deny having a psychiatric disorder; this denial likewise bears no relationship to having the disorder itself.
The reasons patients may deny having a psychiatric disorder are far too varied to reify such denial with a neurological term. It creates a suspicious “Catch-22,” where disagreeing with one’s doctor is itself a diagnosable condition with a fancy medical name, and the implication of brain-structure underpinnings. This is sophistry, and the mark of a profession whose false certainty belies insecurity.
Many years ago I wrote a short essay arguing that social judgments in psychiatry (e.g., inappropriate affect) are both inevitable and essential to our work. I was not a psychiatrist yet, but nothing I have seen since has changed my view. Despite great advances in biological psychiatry, we still cannot ascribe specific attitudes or viewpoints to neurological damage. Insight is still subjective. And if we ever do identify the seat of “psychiatric anosognosia,” our understanding will no longer be psychiatry, but neurology.