Though it only affects about one percent of the population ( in the United States or any country), schizophrenia is ranked by the World Health Organization as being in the top ten of the most disabling adult diseases (Fischer & Buchanan, 2013). People who have schizophrenia usually experience a combination of positive and negative symptoms. Positive symptoms include psychosis, such as auditory and visual hallucinations, delusions, and difficulty organizing thoughts. Persons with schizophrenia may also experience negative symptoms such as poverty of speech, a flat emotional presentation, lack of social skills, and cognitive difficulties with attention, memory, and making decisions/prioritizing (Sadock, Kaplan, & Sadock, 2007). A majority of people with schizophrenia experience a lack of insight or awareness that they are ill; some in mental health would classify this as a negative trait, while others term it as positive (Osatuke, Ciesla, Kasckow, Zisook, & Mohamed, 2008).
Schizophrenia tends to strike young people just as they are entering adulthood; the disease begins in men between the ages of 15 to 22; for women, the disease process starts a bit later, from ages 25-35, with another small group for whom the age of onset is after forty (Sadock, et al, 2007). Initiating treatment for schizophrenia can be tricky because at least fifty percent of people who have the disease do not believe they are ill; this is called a lack of insight or anosognosia, and should not be underestimated (Amador & Gorman, 1998). The effect is similar to when a person who has had a stroke believes they can move a limb, but they no longer can; there is simply no reasoning or logic that will ‘convince’ a person that they are ill if they are afflicted by lack of insight (Amador & Johanson, 2000). It is also important to note that a person with schizophrenia is not ‘in denial’ of their illness, the way a person might be in denial of how much alcohol they drink. Lack of insight is not a coping mechanism, it is actually a feature of the disease itself, a recent study that reviewed over forty research studies concluded (Mintz, Dobson, & Romney, 2003). This psychiatric definition of ‘insight’ relates not only to the individual’s unawareness of being ill, but also includes whether one is aware of the need for treatment or comprehends what symptoms they might be experiencing (Mintz, et al, 2003). While often people choose not to follow a doctor’s advice about weight loss, what food to eat, or even whether to take their medications, many individuals with schizophrenia are unable to make choices about their illness because they simply do not realize that they are ill, and that their behavior has changed.
Lack of insight is a critical problem because if left untreated, schizophrenia progresses; affected individuals may not be able to attend school, work, retain housing, or maintain relationships with their families and loved ones. In fact, there are studies documenting changes in the brain such as ventricular enlargement as being a feature in schizophrenic persons with lack of insight (Mintz, et al, 2003). There are also at least six research studies which implicate the frontal lobes of the brain as being involved in producing lack of insight; however there are five studies which found no association (Mintz, et al, 2003). One of the difficulties that researchers face is that the concept of insight itself is fairly subtle, and somewhat problematic to measure. Scientists often have differing definitions of insight, or frequently don’t measure it in the same way (Osatuke, et al, 2008).
Differing methods of measurement again emerged as a factor when researchers examined fifteen studies retroactively in order to determine whether lack of insight was a possible influence in the largest cause of death for people with schizophrenia, suicide (López-Moríñigo, Ramos-Ríos, David, & Dutta, 2012). Interestingly, despite the documented finding that lack of insight is often accompanied by low mood, that same lack of awareness was not found to be an indicator for suicide. Unfortunately, the study confirmed that people with schizophrenia have a high risk of attempting suicide, about twenty percent, often in the first few years after diagnosis (López-Moríñigo, et al, 2012). While insight itself was not implicated as a risk factor, the researchers did find that one of the highest predictive indicators for suicide was a person’s sense of hopelessness (López-Moríñigo, et al, 2012).
Besides being associated with low mood, lack of insight has been shown to be a determinant as to whether people with schizophrenia seek treatment, how long it takes them to begin treatment, and whether they are willing to take medications (Osatuke, et al, 2008). One of the best books about this topic details the true story of a man, Xavier Amador, whose brother gets schizophrenia; Amador tries to help his brother, but is unable to convince him to get treatment (Amador & Johanson, 2000). Amador goes to medical school and becomes a psychiatrist and researcher who studies insight, all in an effort to help his brother and others like him. Despite his heroic efforts, ten years pass before Amador’s brother begins reliably participating in treatment. Conversely, patients whose insight is unaffected do seek treatment earlier in the course of their disease, and often experience better outcomes (Sadock, 2007). Given that schizophrenia is a lifelong disease process for which there is currently no cure, lack of insight continues to be one of the most troubling roadblocks that people face when attempting to learn to live with this disease.
Amador, X. F., & Gorman, J. M. (1998). Psychopathologic domains and insight in schizophrenia. The Psychiatric Clinics of North America, 21, 1, 27-42.
Amador, X. F., & Johanson, A.L. (2000). I am not sick, I don’t need help! Helping the seriously mentally ill accept treatment: a practical guide for families and therapists. Peconic, N.Y: Vida Press.
Fischer, B.A. & Buchanan, R.W. (2013) Schizophrenia: Clinical manifestations, course, assessment, and diagnosis. In S. Marder (Ed.) UpToDate. Available from http://www.uptodateonline.com.
López-Moríñigo, J. D., Ramos-Ríos, R., David, A. S., & Dutta, R. (2012). Insight in schizophrenia and risk of suicide: a systematic update. Comprehensive Psychiatry, 53, 4, 313-22.
Mintz, A. R., Dobson, K. S., & Romney, D. M. (2003). Insight in schizophrenia: a meta-analysis. Schizophrenia Research, 61, 1, 75-88.
Osatuke, K., Ciesla, J., Kasckow, J. W., Zisook, S., & Mohamed, S. (2008). Insight in schizophrenia: a review of etiological models and supporting research. Comprehensive Psychiatry, 49, 1, 70-77.
Sadock, B. J., Kaplan, H. I., & Sadock, V. A. (2007). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins.