Introduction
This aim of this review is to explore the concept of insight in individuals diagnosed with psychosis. We reviewed the challenges in measuring insight both at baseline and longitudinally. Furthermore, we examined research relating to the role of cognitive behavioural therapy (CBT) in improving insight and highlighted future directions for research in this area. We conducted a comprehensive search of PubMed using MeSH terms for schizophrenia (schizophrenia), psychosis (psychotic disorder), insight/awareness of illness (awareness), quoted phrases such as “cognitive insight”, “lack of insight”, “poor insight” with limits set to 10 years, humans, and English language. We conducted a similar search on other relevant databases, including Medline, PsychInfo, the Psychology and Behavioral Sciences Database, and CINAHL. We hand searched reference lists of major studies on insight, and theoretical review papers on this subject. We filtered our results according to relevance and chose 50 papers for final consideration.
Method
What is insight?
Insight, as described by the Oxford Dictionary (Insight, 2010), is the capacity to gain an accurate and deep understanding of someone or something. Given that psychosis, by definition, is a disturbance in the perception of reality, poor insight is often but not always associated with the clinical presentation. Insight can be viewed as a multidimensional concept that includes: awareness of a mental disorder, understanding of the social consequences of the disorder, awareness of the need for treatment, awareness of specific signs and symptoms of the disorder, and the attribution of symptoms to the disorder (Amador and David, Reference Amador and David1998). In addition, patients may have insight into some but not all, signs of illness, indicating that insight can be modality specific (Bayard, Capdevielle, Boulenger and Raffard, Reference Bayard, Capdevielle, Boulenger and Raffard2009). Furthermore, insight can vary over the course of a psychotic episode or over successive episodes (Buckley et al., Reference Buckley, Wirshing, Bhushan, Pierre, Resnick and Wirshing2007). As a result, when working with patients with psychosis, improving insight is an important objective as it provides them with a better understanding of their experiences, which can influence their decision making around engaging with available biopsychosocial treatment options.
Theories of insight
While it is agreed that insight is a multidimensional concept, there are different theories in the literature concerning potential pathways to insight. These can be divided into four broad areas. First, lack of insight has been viewed traditionally as a psychological defence mechanism or a cognitive strategy in the form of denial, either to maintain self-esteem or to retain a positive outlook (Mohamed et al., Reference Mohamed, Rosenheck, McEvoy, Swartz, Stroup and Lieberman2009). The second theory postulates that poor insight is symptomatic of a cognitive deficit, resulting in the patients’ inability to recognize that they suffer from a disorder (Mutsatsa, Joyce, Hutton and Barnes, Reference Mutsatsa, Joyce, Hutton and Barnes2006). Third, it has been proposed that lack of insight is a result of a neurological mechanism similar to anosognosia (unawareness of deficits in neurological disorders) (Parellada et al., Reference Parellada, Boada, Fraguas, Reig, Castro-Fornieles and Moreno2011) where insight in psychosis is not caused by stubbornness or denial but in fact is a deficit caused by brain disease (Amador, Reference Amador2007). Fourth, lack of insight may often reflect the discord between a person and their clinician around their diagnostic label. A diagnosis of psychosis can be extremely distressing and apparent lack of insight may reflect rejection or unwillingness on the part of the person to ascribe their experiences to a diagnostic label (Roe, Hasson-Ohayon, Kravetz, Yanos and Lysaker, Reference Roe, Hasson-Ohayon, Kravetz, Yanos and Lysaker2008).
Prevalence of poor insight
Research has shown that poor insight is a prevalent feature of schizophrenia, with approximately 50% of patients exhibiting moderate to severe deficits in awareness of mental illness (Schwartz, Cohen and Grubaugh, Reference Schwartz, Cohen and Grubaugh1997). Additionally, up to 80% of those diagnosed do not acknowledge that they have a mental illness (Amador and Gorman, Reference Amador and Gorman1998). In first episode schizophrenia and schizoaffective patients Keshavan, Rabinowitz, DeSmedt, Harvey and Schooler (Reference Keshavan, Rabinowitz, DeSmedt, Harvey and Schooler2004) found impaired insight to be very common, with significant impairments seen in nearly two-thirds of the patients on the Positive and Negative Symptom Scale (PANSS) – G12 (Kay, Fiszbein and Oplerm, Reference Kay, Fiszbein and Oplerm1987). Thompson, McGorry and Harrigan (Reference Thompson, McGorry and Harrigan2001), using the Scale of Unawareness of Mental Disorder (SUMD) (Amador et al., Reference Amador, Strauss, Yale, Flaum, Endicott and Gorman1993), found that first-episode psychosis patients had less awareness of illness than multi-episode patients, which they attributed to the development of the verbal skills necessary to discuss or describe their experiences, or in the lowering of psychological defences, which only occurs after the first episode. Fennig et al. (Reference Fennig, Evertt, Bromet, Jandorf, Fennig and Tannenberg-Karant1996) found that a lower percentage of individuals with schizophrenia had full insight compared to other first episode diagnosis such as bipolar disorder or other forms of psychosis. Furthermore, they were less likely to gain full insight with recovery. In this study insight was measured with the insight item of the Hamilton Depression Scale, which they modified to refer to level of insight into psychosis in general rather than into depression (Fennig et al., Reference Fennig, Evertt, Bromet, Jandorf, Fennig and Tannenberg-Karant1996). Parellada et al. (Reference Parellada, Boada, Fraguas, Reig, Castro-Fornieles and Moreno2011) found that insight on the SUMD in adolescents at 2 years is poorer in schizophrenia spectrum disorders than in adolescents with other forms of psychosis, and that the more severe the psychosis, the lower the insight.
Insight assessment measures
There are several clinical tools used to measure insight that are used in clinical practice. Given that insight is a multidimensional concept and there are a number of different theories put forward to explain lack of insight, it is not surprising that the many assessments used to measure insight reflect this lack of consensus. The shortest measure of insight, as described by Tranulis, Lepage and Malla (Reference Tranulis, Lepage and Malla2008) is the “lack of judgement and insight” item of the uni-dimensional PANSS – G12 (Kay et al., Reference Kay, Fiszbein and Oplerm1987). The Schedule for the Assessment of Insight (SAI) (David, Buchanan, Reed and Almeida, Reference David, Buchanan, Reed and Almeida1992) is based on a tri-dimensional model (awareness of illness, adequate re-labelling of psychotic symptoms and acceptance of prescribed treatment) and provides a global score for insight. An extended version of the SAI is considered preferable for use in at-risk mental states for psychosis (individuals who are experiencing clinically significant and distressing prodromal symptoms, such as attenuated psychotic phenomena) than during first-episode psychosis (Lappin et al., Reference Lappin, Morgan, Valmaggia, Broome, Woolley and Johns2007).
Longer assessments include the Insight and Treatment Attitudes Questionnaire (ITAQ; McEvoy et al., Reference McEvoy, Apperson, Appelbaum, Ortlip, Brecosky and Hammill1989), the SUMD (Amador et al., Reference Amador, Strauss, Yale, Flaum, Endicott and Gorman1993), and the Birchwood Insight Scale (BIS; Birchwood et al., Reference Birchwood, Smith, Drury, Healy, Macmillan and Slade1994). The ITAQ (McEvoy et al., Reference McEvoy, Apperson, Appelbaum, Ortlip, Brecosky and Hammill1989) focuses on acceptance and the need for psychiatric treatment. The SUMD (Amador et al., Reference Amador, Strauss, Yale, Flaum, Endicott and Gorman1993) takes the multidimensional concept of insight into account (Parellada et al., Reference Parellada, Boada, Fraguas, Reig, Castro-Fornieles and Moreno2011) and is used to assess insight in schizophrenia and its relationship to psychopathology (Amador and Gorman, Reference Amador and Gorman1998). The BIS (Birchwood et al., Reference Birchwood, Smith, Drury, Healy, Macmillan and Slade1994) measures three dimensions of insight: the need for treatment, awareness of illness, and appropriate relabelling of symptoms. These multidimensional assessments measure clinically related constructs such as agreement with a diagnosis, medication adherence, awareness of benefit from treatment, and endorsing need of psychiatric treatment (Tranulis et al., Reference Tranulis, Lepage and Malla2008). However, a new concept, cognitive insight, was proposed by Beck, Baruch, Balter, Steer and Warman (Reference Beck, Baruch, Balter, Steer and Warman2004) and is defined by two components: (1) self-reflectiveness; the patients’ capacity and willingness to observe their mental productions and to consider alternative explanations; and (2) self-certainty; their overconfidence in their beliefs. This “cognitive insight” can be measured with Beck Cognitive Insight Scale (BCIS; Beck et al., Reference Beck, Baruch, Balter, Steer and Warman2004).
Challenges in measuring insight
It is important to note that various insight scales are supported by different theories and seem to measure, at least partly, different aspects of the concept of insight (Bora, Erkan, Kayahan and Veznedaroglu, Reference Bora, Erkan, Kayahan and Veznedaroglu2007). This challenges the notion that there is an agreed and widely accepted construct of insight (Tranulis et al., Reference Tranulis, Lepage and Malla2008). Research by Tranulis et al. (Reference Tranulis, Lepage and Malla2008) compared different insight scales in a first-episode psychosis population. They failed to show significant relations between clinical ratings of insight as measured by SUMD and self-ratings of cognitive insight and demonstrated that these scales had different associations with PANSS subscales. They concluded that the clinical concept of insight may be quite different from the cognitive concept of insight and recommended that future research needs to qualify the term “insight” when discussing their findings, specifically in terms of whether the rating is subjective or objective and what aspect of insight is being measured. Their findings are supported by Pedrelli et al. (Reference Pedrelli, McQuaid, Granholm, Patterson, McClure and Beck2004) who reported that the BCIS ratings were only moderately correlated with the BIS in middle-aged and older adult patients with psychotic disorders. Tranulis et al. (Reference Tranulis, Lepage and Malla2008) proposed three explanations as to why the cognitive and clinical constructs of insight differ: (1) different dimensions of the concept of clinical insight may be less correlated during the unstable and evolving period of first episode psychosis; (2) lack of correlations may be because of inter-rater difference; (3) each insight scale measures a different underlying concept, supported by different theories (e.g. anosognosia-like neurological deficit, cognitive distortion, psychological defence mechanism or rejection of diagnostic labels) (Tranulis et al., Reference Tranulis, Lepage and Malla2008). Moreover, a limitation of clinical insight rating scales is that they may reflect the superficial beliefs of the patients or explanations that they received from their treating team rather than a genuine awareness of the illness itself (Bora et al., Reference Bora, Erkan, Kayahan and Veznedaroglu2007). The complexities around what concept or what dimension of insight is being measured makes it difficult to compare and contrast different studies evaluating insight in psychosis, especially in relation to measuring improvement in insight. In the absence of a scale that covers all of the dimensions it might be useful for future research and clinical practice to consider using both a clinical and a cognitive measure of insight (Riggs, Grant, Perivoliotis and Beck, Reference Riggs, Grant, Perivoliotis and Beck2012), with the clinical measure representing its multidimensional components.
Results from clinical studies
Insight and its impact on outcome
Lack of insight in persons with psychosis can have adverse clinical effects. The majority of research in this area suggests that it has a negative impact on treatment adherence and long term outcome. Research has also found that poor insight is correlated with poor global functioning (Parellada et al., Reference Parellada, Fraguas, Bombin, Otero, Castro-Fornieles and Baeza2009), poorer outcome as measured by the SAI (David et al., Reference David, Van Os, Jones, Harvey, Foerster and Fahy1995), and violence or aggressive behaviour (Arango, Barba, Gonzalez-Salvador and Ordonez, Reference Arango, Barba, Gonzalez-Salvador and Ordonez1999). In a unique study of a first-episode psychosis population consisting of children and adolescents, Parellada et al. (Reference Parellada, Fraguas, Bombin, Otero, Castro-Fornieles and Baeza2009) found that baseline insight in having a mental disorder, duration of untreated psychosis, and baseline intelligence quotient (IQ) became the most consistent variables explaining different aspects of insight using the SUMD at 2 years in those that received a diagnosis of schizophrenia. The results of Schwartz et al. (Reference Schwartz, Cohen and Grubaugh1997) suggested that poor insight on the SUMD is a barrier to treatment, resulting in low adherence with medication and treatment plans along with poor psychosocial functioning. Evidence that level of insight predicts non-adherence to treatment is extremely important in terms of long-term outcome, as non adherence to medication is the most common reason for hospital readmission (Bayard et al., Reference Bayard, Capdevielle, Boulenger and Raffard2009). Longitudinal research conducted by Mohamed et al. (Reference Mohamed, Rosenheck, McEvoy, Swartz, Stroup and Lieberman2009) is supportive of studies that have found consistent relationships between both insight and medication attitudes at baseline, and insight, medication adherence and overall quality of life at follow-up (Mohamed et al., Reference Mohamed, Rosenheck, McEvoy, Swartz, Stroup and Lieberman2009). These results were replicated in the study of Acosta et al. (Reference Acosta, Bosch, Sarmiento, Juanes, Caballero-Hidalgo and Mayans2009), which found that those who do not comply with medication demonstrated poorer insight on the Amador Insight Scale in the areas of global insight, need and efficacy of treatment and consequences of the disease. As a result, they recommended interventions aimed at improving insight and cognitive deficits in order to increase adherence. However, it must also be acknowledged that causes of non adherence to medication are multifactorial and may reflect side-effects from medication such as weight gain, extrapyramidal and anticholinergic effects (Lieberman et al., Reference Lieberman, Scott Stroup, McEvoy, Swartz, Rosenheck and Perkins2005) and factors such as higher age, longer illness duration and gender (Villeneuve, Potvin, Lesage and Nicole, Reference Villeneuve, Potvin, Lesage and Nicole2010).
Insight and depression
McEvoy et al. (Reference McEvoy, Johnson, Perkins, Lieberman, Hamer and Keefe2006) found that higher levels of insight in first episode psychosis patients, as measured by the ITAQ, are associated with less schizophrenic psychopathology, better cognition, larger brain volumes and higher levels of depression. While it is evident that poor insight has adverse clinical effects in patients with psychosis, the finding that good insight is associated with higher levels of depression has been replicated across many studies (Crumlish et al., Reference Crumlish, Whitty, Kamali, Clarke, Browne and McTigue2005; Mintz, Dobson and Romney, Reference Mintz, Dobson and Romney2003; Moore, Cassidy, Carr and O'Callaghan, Reference Moore, Cassidy, Carr and O'Callaghan1999; and Mutsatsa et al., Reference Mutsatsa, Joyce, Hutton and Barnes2006). A positive association between depression and insight also provides support for a cognitive model of insight, in which lack of insight is a form of self-denial in an attempt to deflect feelings of depression (Mintz et al., Reference Mintz, Dobson and Romney2003). However, in adolescents, Paredella et al. (Reference Parellada, Boada, Fraguas, Reig, Castro-Fornieles and Moreno2011) found that at 6-month and 1-year follow-up depressive symptoms were associated with poorer insight, as measured by the SUMD, in those with schizophrenia spectrum diagnosis but not other first-episode psychosis. Good insight, as measured by the PANNS-G12 and the BIS, has also been associated with a greater likelihood of patients attempting suicide during the 4 years post diagnosis (Crumlish et al., Reference Crumlish, Whitty, Kamali, Clarke, Browne and McTigue2005). Staring, Van der Gaag, Van den Berge, Duivenvoorden, and Mulder (Reference Staring, Van der Gaag, Van den Berge, Duivenvoorden and Mulder2009) suggest that perceived stigma can influence clinical variables. They found that poor quality of life, depression and low self-esteem were related to good insight on the BIS (Staring et al., Reference Staring, Van der Gaag, Van den Berge, Duivenvoorden and Mulder2009). Furthermore, the finding by Cooke et al. (Reference Cooke, Peters, Greenwood, Fisher, Kumari and Kuipers2007) that better insight on the BIS is associated with poorer self-esteem led them to conclude that reduced insight may preserve an individual's positive core beliefs and uphold self-esteem. They believed that this could be an adaptive response to a diagnosis in relation to preservation of psychological well-being, although it can have maladaptive effects on other areas of functioning, such as engagement with services and taking medication. As a result of these findings, it is therefore vital that any psychological intervention aimed at increasing insight addresses normalization of psychotic experiences and stigma in order to minimize deterioration in mood, self-esteem and quality of life. Some of the theories of insight are embedded in the medical model, which can be construed as invalidating the clients understanding of the problem, whilst the theory of insight that is explained by a person's rejection of diagnostic labels is explicitly rejecting of the medical model. CBT offers a unifying approach by offering an understanding of insight that is not explicitly embedded in medical terminology and offers an approach to treatment that is respectful and accepting of the client viewpoints whilst challenging them in a supportive manner. These challenges are carried out in a manner that is user-led and collaborative. Mohamed et al. (Reference Mohamed, Rosenheck, McEvoy, Swartz, Stroup and Lieberman2009), along with other authors, provide support for interventions, such as psychoeducation or CBT designed to improve insight (Acosta et al., Reference Acosta, Bosch, Sarmiento, Juanes, Caballero-Hidalgo and Mayans2009; Bayard et al., Reference Bayard, Capdevielle, Boulenger and Raffard2009; Thompson et al., Reference Thompson, McGorry and Harrigan2001).
The impact of CBT on insight
Research has shown that poor insight is extremely prevalent and has negative consequences on both treatment and medication adherence, and long term outcome. The negative impact of greater insight is the increased risk of depression and suicidal ideation. Therefore, any intervention that aims to improve insight also needs to normalize psychotic experiences and uphold self-esteem. CBT is the most common form of psychological therapy for psychosis (BPS, 2000) and is the psychological therapy recommended for this population in the NICE guidelines (NICE, 2009). CBT examines maladaptive patterns of thinking associated with a range of emotional and behavioural problems but does it improve insight in psychosis?
Wider research is conflicting in terms of whether CBT improves insight in patients with a diagnosis of psychosis. Two major studies have been conducted in this area using randomized controlled trials and treatment as usual (TAU) control groups to investigate whether CBT can improve insight (Rathod, Kingdon, Smith and Turkington, Reference Rathod, Kingdon, Smith and Turkington2005; Startup, Jackson and Startup, Reference Startup, Jackson and Startup2006).
Participants in Rathod et al.'s (Reference Rathod, Kingdon, Smith and Turkington2005) study were from six different centres in the United Kingdom and participants had varying lengths of illnesses and numbers of previous relapses. The CBT delivered was a brief insight-focused intervention. This study found that the intervention led to significant improvement in the total insight score on the SAI compared to the TAU group at both post-therapy (5-month follow-up) and 1-year follow-up. However, whilst the intervention group showed significant improvement in one (patient's insight into adherence with treatment, prompted or unprompted) out of the three components of insight at 1-year follow-up, neither component two of insight (the patient's awareness of their illness) nor component three of insight (correct re-labelling of psychotic symptoms) showed a statistically significant difference between the two groups. Patient's insight into adherence with treatment was the only component to remain significantly improved at posttreatment and 1-year follow-up along with the total insight score. This finding is promising because once patients are engaged with services it allows opportunity for other aspects of insight to be developed. In addition, they found that the younger the patient the better the improvement in insight post-therapy. While these findings are positive, the study had a high dropout rate, especially in African-Caribbean and Black African participants. Furthermore, an insight-focused intervention is rare in clinical settings where CBT would usually be focussing on many different areas of psychosis and recovery with the aim of improving insight through the different modules without having a specific focus on it. Rathod et al.'s (Reference Rathod, Kingdon, Smith and Turkington2005) findings were supported by research by Haddock et al. (Reference Haddock, Lewis, Bentall, Dunn, Drake and Terrier2006) on the influence of age on outcome of psychological treatments in first episode psychosis. They found that younger patients receiving manual-based CBT, compared to a control group receiving supportive counselling, showed greater increases in insight on the BIS than those who received the counselling, and that this pattern was not found in older patients. However, they had a small number of participants (71 out of 309) in the younger age group, which may limit the generalizability of their findings. Additionally, Parellada et al. (Reference Parellada, Boada, Fraguas, Reig, Castro-Fornieles and Moreno2011) found that older age correlated with better insight on the SUMD in first episode psychosis in children and adolescents. In another study based on the data previously published by Turkington, Kingdon and Turner (Reference Turkington, Kingdon and Turner2002), Brabban, Tai and Turkington (Reference Brabban, Tai and Turkington2009) established that the female gender was associated with a 25% increase in insight on the SAI within the CBT group but not those receiving TAU, indicating that gender influences the outcome of CBT in this area. This was a brief intervention consisting of six sessions of manual based CBT; however, the findings only include those who completed the full course of treatment and not those who left prematurely. Based on theories to date, they hypothesize that this gender differential may be due to the fact that women are better able to engage in therapy due to the fact they typically experience fewer negative symptoms and are less emotionally blunted (Brabban et al., Reference Brabban, Tai and Turkington2009).
Startup et al. (Reference Startup, Jackson and Startup2006) conducted their research with patients with schizophrenia-spectrum disorder who had been admitted to psychiatric hospitals within the previous 28 days with an acute psychotic episode. CBT intervention was initiated in hospital and continued on an outpatient basis. They found that patients usually have a modest increase in insight over a 2-year period. In addition, they found no evidence that CBT increases insight more than TAU. However, within the CBT group, dropouts from treatment showed an initial reduction in insight before returning to their baseline level, whilst the stay-ins showed linear improvement up to 12 months. While the sample size in this study was small, their analysis on those who disengaged from treatment yielded interesting findings. In another study of patients with acute psychosis conducted over a 6-month period, Drury, Birchwood, Cochrane and Macmillan (Reference Drury, Birchwood, Cochrane and Macmillan1996) found that a Cognitive Therapy (CT) intervention (focusing on positive symptoms), generalized to features of acute psychosis other than positive symptoms including insight, and concluded that insight is unlikely to recover completely until positive symptoms remit.
Conclusion
Research in this area has shown that reduced insight across the various dimensions is very common in people who suffer from psychosis and that insight levels greatly impact on treatment adherence and prognosis. The multidimensionality of insight is reflected in the variety of different insight measures in clinical use. This situation is further complicated by the fact that both clinical insight and cognitive insight appear to reflect quite different concepts of insight (Tranulis et al., Reference Tranulis, Lepage and Malla2008). It is feasible that the clinical insight scales used in the research outlined here did not capture the changes in cognitive insight that would be expected from CBT interventions. Furthermore, the numerous different underpinning theories discussed (defence mechanism, cognitive deficit, neurological mechanism or rejection of diagnostic labels) are fundamental in terms of the theoretical paradigms behind interventions to improve insight in psychosis. Apart from Rathod et al. (Reference Rathod, Kingdon, Smith and Turkington2005) who state that their intervention was a short “insight focused CBT intervention”, the other research does not give any detail on the theory behind the psychoeducational content of their CBT interventions. Insight based on psychoeducation that provides information on the normal cognitive processes, for example “jumping to conclusions”, “attribution style” and “selective attention for threat” (Garety and Freeman, Reference Garety and Freeman1999), which can lead to the development of psychotic symptoms, may help individuals to cope with their psychosis, de-stigmatize the disorder and reduce the risk of suicide. This is achieved by instilling hope in the strong possibility of recovery through correction of the cognitive biases involved in positive and negative symptoms, for example “low expectancies for pleasure” and “low expectancies for success” and “low expectancies due to stigma” (Beck, Rector, Stolar and Grant, Reference Beck, Rector, Stolar and Grant2009).
Psychoeducation based on the biopsychosocial stress vulnerability model of psychosis (Zubin and Spring, Reference Zubin and Spring1977) is in stark contrast to a more biologically based psychoeducation whereby people who have experienced psychotic symptoms are told that they have deficits caused by brain disease (Amador, Reference Amador2007). The various theories in relation to psychosis that are part of psychoeducation programmes and found in the literature distributed to individuals and their families will impact on their insight, adherence to treatment, depression levels and outcome. This may explain why the research into the impact of CBT on insight in people with psychosis has had conflicting findings. The importance of this is emphasized in Johnson and Orrell's (Reference Johnson and Orrell1995) article examining the social perspective of insight and psychosis. They argue that lay patterns of beliefs about mental illness and cultural variations may shape a patient's insight. This was further emphasized by Jorm (Reference Jorm2000) who claims that because of a lack of knowledge of mental disorders (mental health literacy) the public does not share many of the core beliefs of clinicians with regard to treatment and aetiology of mental disorders. A better understanding of this in clinical practice may lead to more effective psychoeducational work with patients. It is challenging to measure insight as a fixed concept and to establish if interventions such as CBT improve insight unless we are aware of the underpinning theory behind the intervention and what information and explanations are being given during psychoeducation modules. When measuring changes in insight as a result of an intervention such as CBT, the assessment measure needs to match the dimensions of insight targeted through the intervention and ideally take a broad paradigm to reflect a biopsychosocial approach. Alternatively, more than one insight measure should be used to capture the different concepts of insight (clinical and cognitive) and its multi-dimensional components. A new insight measure that encapsulates all of the dimensions of insight would be helpful in addressing difficulties with insight in psychosis presentations to ensure better outcomes of interventions.
The results of this review should be considered within the following limitations. While the literature focusing on insight in psychosis is conflicting and lacks a single paradigm, it makes comparing studies problematic. As we have highlighted, there are many theories of insight, and diverse views on why poor insight may be present in those with psychosis. The quality of research in this area is likely to be improved by taking into consideration the views of service users, some of whom would contest the validity of terms such as “poor insight/lack of insight”. Furthermore, involving service users in research design or conducting qualitative research with service users around the concept of insight and to hear their views on the insight measures would add to both the debate and to practitioners’ understanding, which may influence clinical practice and ultimately improve outcomes for those with psychosis.
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