About the Book

• The Lady and the Unicorn: A Psychological Metaphor



• Dreaming�With Eyes Wide Open: Schizophrenic Hallucinations



• Information Processing in Schizophrenia



• Clarification of our Clinical versus Forensic Function: Dual Relationship



• Art Psychotherapy



• Lord of the Rings: A Psychological Metaphor



• Aviation Psychology



• So, You have just been Passed by a Girl! A Holley Carborator may help



• Approaches in Memory Rehabilitation



• Memory Enhancement Module



• Negaunee Center



• The Final Transition



• Is Deinstitution- alzation a Misnomer



• Token System: a Psychiatric Case Study



• A Token Economy System: Inpatient Psychiatric Population



• Insight: An Aspect of Neurocognition

In a recent discussion with my son, he said �You know dad when I was sixteen and said that I knew it all, I realize now that I didn�t know it all�. At this moment, I thought to myself, alas he has achieved the long awaited insightful moment of the {ah ah experience}. Almost before completing my thought, he added that �But now that I am twenty-one, I do know it all.�

When considering the whole question of insight there are numerous thoughts that have been purported regarding its nature. Specifically, insight is our �capacity to apprehend or intuit the inner nature of things, it is an aspect of self-awareness� (Sackeim, p. 5). On the other hand, it has been suggested that �Insight� can also be an important aspect in {understanding} the outside world. Intuitive insight could in fact be a combination of both streams of thought. Steward has stated man�s insight into himself and the world around him �is one of the greatest achievements of man as biological and culture-orientated organism. He has come to know himself both inwardly and outward �scrutiny, can lead to the greater development of science, the growth of a person and his creative potential.� ( p. 1357). A famous philosopher Kierkegaard stated that �To be another than oneself� is perhaps the deepest form of despair. Rogers has stated that some may desire insight for �without, keen psychological insight one suffers the despair at not choosing, or willing to be oneself .� (p. 59).

The metaphor of insight implies that self-awareness is based upon the act of introspection. (Kim, p. 213). One usually considers the capacity for insight as being essentially an innate cognitive function, where everyone has the ability and desire to become more insightful. Although, an alternative question arises as does �Insight� depend upon our own capacity to learn from opportunities and experiences? It is appreciated by Kaplan and Sadock, that �True emotional insight and emotional awareness of the motives and feelings within himself of the underlying meaning of {things}.� (p. 497)

As with most mental health practioner�s while completing our traditional mental status examination upon admission, the patient said he was hearing voices of demons and adamantly believed these demons were going to kill him. After considering and listening carefully to his account of his experiences. This begged the asking him of a simple and direct question, �Do you believe that you may have a mentally illness? His answer was �No, I am not mentally ill all of this that I have told you is real!� My thought was that he was lacking insight into both himself and his situation as well as his experiences. In a report by Kirmayer and Corrin (1998) they critically questioned themselves in a similar case by stating that �You don�t have insight if you don�t believe what I believe. Although I don�t have insight, to note that my belief is a belief rather than some absolute truth�. (Strauss, p. 353). Further, the notion of correctness {truth, insight} raises the question with respects to who and what authority the health professional family calling. We have all been within this situation when treating individuals suffering from mentally illness. In fact, the lack of insight or an inability to recognize their own illness is a criterion if not a hallmark to be considered, when diagnosing mental illness. How is it that an individual so tortured by their symptomatology would fail to recognize the change which has come sweeping over him? Inquiring into their state of insight, Ginsberg (1985) asks questions such as �What brought you to the hospital?� Trying to determine if �the problems is blamed on the malevolence of others, or is there awareness that some of the problems stem from the patients own problems, emotional, thoughts or feelings?�

Insight is having the awareness towards a change in one�s self. Specially, when considering mental health issue, Kaplan and Sadock (1985) stated that, �symptoms: does the awareness {insight} lead to changes in personality and future behavior; openness to new ideas about himself and the important people in his life.� (p. 497). Similar types of questions offer a glimpse into the individual�s capacity for insight.

These issues raised the whole conceptual question of having insight into one�s self or is it measured by various degrees of introspection. The determination of a lack of insight by a practitioner leads to an entire array of decisions, �if I believe he is suffering from mental illness�. Does the concept of �impairment of insight� hinges {solely} on the appreciation of the bizarreness of his perceptual experiences and beliefs.� (Sackeim, p.7). One crucial decision the practitioner faces involves beginning the process of involuntary commitment for treatment. Furthermore, Lysaker and Bell (1998) stated that the lack of insight also parallels the �link observed between impairment of insight and medication noncompliance and suggests that noncompliance with treatment may be associated with the feature of poor insight� (p. 310).

An interesting and important issue is the failure of the individual to recognize the degree of psychosis that he is suffering from at this moment in time. It has been appreciated by Strauss that �Insight� is a process. There could be other factors which influence our capacity for insight. In a report by Johnson, Hashtroudi, and Lindsay (1993) stated that delusional individuals often are vigilant about seeking supportive information about their delusions since normal supporting memories are not available. (Keefe, p. 155). In a paper by Spear (1978), who stated that �a memory is a representation of the collection of events that constitute an episode of an organism�s experiences� (p. 49). Cognitive memory impairment could lead to the overall lack of insight if one learns by experience.

Clearly, �Having Insight� must be something more then consensus, it must be a type of introspection, self-monitoring or reflection, and an intricate web of neurological process at play. Neuropsychological and neuropsychiatry theories have implicated the role of self-monitoring as a cognitive functioning impairment which perhaps represents deficit within a schizophrenic disorder. The finding of hypofrontality in schizophrenia has been supported in a study using the Single-Photon Emission Computerized Tomography (SPECT) study by Hawton, Shepstone, Soper and Reznek (1990).

Barr (1998) stated that �the biggest advantage is that one is able to compare behaviors resulting from known neurological basis to similar behaviors where the neurological basis can only be inferred and most apparent for the many disturbances of body awareness and delusional disorders results from right parietal lobe dysfunction�. (p. 131)

It has been suggested that �Insight� may be inferred as being similar to a neurological deficit of Anosognosia. It has been suggested by Amador and Kronengold (1998) that �these symptoms are the result of disturbances of the medial frontal system involving the anterior hippocampus cingulate gyrus supplementary motor system in the dorsal lateral prefrontal cortex� or insular cortex (Barr, p. 123-131). Most symptoms affecting awareness appear to be a result of right hemispheric lesions, inferior parietal cortex, right thalamoparietal peduncle (Nielson, 1938) or right supramarginal gyrus and posterior coronary radiata in the _expression of verbal asomatognosia� (Barr, p. 112). Studies by Shelton, Ballinger, Marey, Faux, Cane, Lemay, Cassens, Coleman, Duffy and McCarley (1989) using the CT scan also found more thought disorders in right-temporal deficit patients. These studies perhaps offer a starting point for understanding the complex neuron-network of interactive neural activity within the subcortical regions of the cerebral cortex.

This brings to light the question of whether insight is in fact innate or whether it is learned. Can or should everyone obtain insight, would we be happier with it or without it. Obviously, it depends! As Sackeim has pointed out that �No one champions the view that gross distortions of insight reflect psychological health� (p. 10). Although, Sackeim has also stated that in contrast it can be argued that some degree of �impaired insight characterizes normal functioning and some form of psychopathology may be associated with excess insight�. (p. 11). This may be elucidated by various studies of depressed individuals who see reality for what it is. In contrast, to normal controls in the group that had hope that things may improve or use other defensive mechanisms in an adaptive fashion. In our clinical psychosocial rehabilitation program, we often inquiry as to what the individual thinks of their delusion now. This often can lead to a series of interesting learning experiences. These types of question could play a crucial active learning role in developing insight into their thoughts, moods and emotional behavior. Still from a psychotherapeutic perspective, by asking the individual the question of exactly �who they are?� What the individual personally values and believes. This is coupled with a suggestion that one needs to attempt to live in concert with both their personal values and beliefs. These types of questions and guidance may provide the necessary organized structure for the individual�s thinking although the content may change over time.

On the other end of the continuum �Lack of insight has been viewed as a psychological defense or an adaptive coping strategy. (Amador and Kronengold, p. 23). If one then encounters a new and threatening experience, the person already vulnerable to anxiety, will begin to behave in a defensive way in order to protect his already fragile identity. This defensive functioning distorts experiences and may lead to chronic interpersonal difficulties and a deep personal sense of inadequacy.� (Rogers, p. 57-58).

In conclusion, �Insight� represents a complex function which involves higher cognitive processing. This type of processing appears to have an upstream effect upon how information is received, learned and processed to make sense of our experiences. Specifically, with schizophrenia it is recognized the hypoactivation of the frontal lobes is impaired and results in at least a decrease in their capacity for reasoning, decision making and problem solving. Thus, this structural deficit coupled with limited opportunities to gain insight from experiences, may result in the information not being processed in a way that they can be usefully utilized. Adaptively, this perspective suggest that low insight may also be couple as a defensive strategies use to protect one�s self esteem.

In a discussion with Dr. Pernell he stated that Insight represents a continuum {of awareness}. The act of having insight represents a dynamic process which changes minute by minute. This is because the individual is constantly adapting to changes in the world as well as within themselves simultaneously. It would appear that once an individual has insight you will be forever changed by it.