Insight

What is Insight?

The term insight has been used to describe and define various cognitive functions and mental processes.

Outside of a psychotherapeutic context, insight may connote a sudden understanding of a problem following a period of time in which the brain is organizing seemingly unrelated material in accordance with various organizational strategies (Halpern, 1984).

In a somewhat narrow application, Bastick (1982) defined insight operationally as a sudden increase in the number of correct responses on a learning task.

Differentiation of Insight from Judgment, Knowledge, and Metacognition

Terms such as insight, judgment, knowledge, and metacognition Opens in new window are often used interchangeably in both academic and clinical settings. Differences between the terms do exists, however.

A broad analogy may provide a summary understanding of the relatedness of these terms:

Whereas judgment may be defined as an ability to correctly assess and consequently operate adaptively within the parameters of an assessment (Kaplan & Saddock, 1993), insight refers to a sudden gain in the understanding of a mental set, whether in a learning task or, more generally, in how one operates on his/her environment.

Judgment therefore imbues a sense of discernment and choice of actions among various conceived options of which one is aware.

Perhaps a major distinction between insight and judgment concerns the apparent passivity and the receptive quality of the latter, whereas the former is marked by an active and an expressive mental and behavioral undertaking.

Knowledge, on the other hand, refers to a “store” or “node network” of learned or encoded information that may be available for retrieval and further processing to either solve a problem or to generate new knowledge or node connections (Matlin, 1989).

Knowledge, appears to envelope the concepts of judgment and insight in that sound judgment may be exercised given true insight. The cognitive, affective, and behavioral responses and operations that follow can then be abstracted and encoded as experiential knowledge.

Just as judgment may be affected by the extent of insight one has regarding particular matters, so is knowledge relatively limited by the extent of one’s metacognition.

Metacognition Opens in new window is more broadly akin to insight in that both entail knowledge about and, more importantly, awareness of one’s cognitive processes.

Metacognition is, however, a general cognitive process used to analyze specific and different cognition, stores, and mental processes. It can be used as a guide in the generation of new knowledge and in the selection of mental sets to solve familiar and new problems (Cavanaugh & Perlmutter, 1982).

Whereas metacognition may be conceived of as superintendent of cognition, insight appears to represent more the process in which one gathers understanding.

Terms such as insight, judgment, knowledge, cognition, awareness, and metacognition appear related in meaning, so that generating separate definitions may appear moot or pedantically academic in character.

The phenomenon of blindsight Opens in new window and the phantom limb Opens in new window may highlight the differences when these concepts operate relatively independently.

Different Levels of Insight

Differentiating between varying levels of insight begins to make more sense in clinical and applied settings, particularly as this may provide a qualitative prognostic indication of treatment outcome.

This has traditionally been done by psychiatrists as part of a mental status examination (see Kaplan & Saddock, 1993). Levels of insight range from complete denial to partial insight to full insight.

1. True Emotional Insight

True emotional insight is said to exist when the patient’s awareness and understanding of his or her thoughts, feelings, and motives can be used to exert a change in their behavior.

This is the highest degree of insight possible, characterized by sound judgment and knowledge that is utilized appropriately by metacognitive processes.

2. Intellectual Insight

Intellectual insight is more commonly seen in psychotherapeutic contexts and occurs when patients understand that their degree of maladaptation is due to their own thoughts, feelings, and behaviors.

The characteristic of intellectual insight is that patients cannot or do not apply this metacognitive knowledge to alter behavior patterns and interpersonal tendencies.

In this level of insight, sound judgment is not exercised, and insight and metacognitive processes fail to generate appropriate strategies to solve the problems. Patients in this category are often seen to repeat the same mistakes over and over again. They fail to learn from previous mistakes and prior experiences.

3. Partial Internally Based and Externally Based Insights

Partial internally based and externally based insights occur when there is an awareness of a disorder that is falsely attributed to either unknown factors within the person or external factors such as other’s behaviors or organic factors.

These levels of insights are characterized by persons not being attuned to their own emotional states. In our experience, we see this level of insight predominantly in persons with character disorders, anger management issues, as well as in drug and alcohol abusers.

Level of insight varies to the extent that persons may only exhibit a slight awareness of being maladapted and needing help, while at the same time denying this and actively sabotaging treatment gains.

4. Denial of Illness

Denial of illness is the lowest level of insight possible and likely only occurs in people with severe mental illnesses characterized by predominant chemical and/or anatomical organic deficits as is seen in people during a full blown manic phase, and persons with psychotic and dementing disorders.

Assessment of Insight

The mental status examination Opens in new window provides a means of assessing judgment and insight.

The assessment of judgment entails asking patients questions that tap into their knowledge of conventional standards of behavior, their ability for social judgment, and their level of social maturity.

The format for assessing insight is less structured and entails asking patients directly whether they believe they are ill, what possibly caused this, and whether or not they feel that treatment is necessary.

Depending on answers to these questions, the clinician can then probe further to make a determination as to the patient’s level of insight. Few scales assess insight directly. Only recently has there been an attempt to assess insight more systematically.

Two reliable and valid clinically administered scales are the Brown Assessment of Beliefs Scale (BABS; Eisen et al., 1998) and the Overvalued Ideas Scale (Neziroglu, McKay, Yaryura-Tobias, Stevens, & Todaro, 1999).

The BABS was developed to “assess delusions across a wide range of psychiatric disorders” (p. 102). It is a seven-item scale that is not specific to obssessive compulsive disorder (OCD) but does measure insight of patients diagnosed with OCD, body dysmorphic disorder, and mood disorders with psychotic features.

The seven items comprise conviction, perception of other’s view of beliefs, explanation of differing views, fixity of ideas, attempts to disprove beliefs, insight, and ideas/delusions of reference. The last item is not included in the total score.

The BABS has specific probes and five anchors for each item. The scores for each item range from zero (nondelusional) to four (delusional). The authors of the scale concluded that the scale is a valid measure of delusionality.

According to Kozak and Foa (1994) overvalued ideas Opens in new window are different from delusions Opens in new window. For them patients with delusions accept and are less bothered by their behaviors performed as a response to the thought than patients with overvalued ideas who are highly bothered by the behavioral response to the thought. However, the latter group still has a high degree of conviction that the feared outcome has a high probability of occurring. Regardless of whether the BABS measures delusionality Opens in new window or overvalued ideas Opens in new window it assess insight. It is inferred that in delusions there is less insight as compared to overvalued ideas.

The Overvalued Ideas Scale (OVIS; Neziroglu et al., 1999) is a ten-item clinician administered scale that assess the extent of a patient’s obsessions and associated compulsions on several different continua, each rated from one to ten.

• Item contents reflects strength, reasonableness, and accuracy of the belief, as well as strength of the belief over the past week; the extent to which others share the same beliefs;
• how the patient attributes similar or differing beliefs;
• how effective the compulsions are;
• the extent to which their disorder has caused their obsessive belief; and
• their degree of resistance to the belief.

The average of the items provides an estimate of overvalued ideation OVI, where higher scores represent greater levels of OVI. The OVIS has numerous anchor points and probe questions to aid the clinician in quantifying OVI.