©2018 Romesh Senewiratne-Alagaratnam (MD)
Being insightful is considered a virtue. It is similar to being thoughtful, but insight implies intuitive knowledge and perception of truth. There has been much study of insight in psychology in recent years, mainly looking at the phenomenon from the perspective of problem solving. It has been found that insight is promoted by good mood and sleep, which help solve problems. An insight is described as an “aha moment”, “penny-drop moment”, “eureka moment” or epiphany.
However, ‘insight and judgment’ mean something quite different in psychiatry – in this medical specialty, insight specifically means willingness to accept that you are, and have been, mentally ill. This is problematic and constitutes a widely used circular argument – that refusal to agree you are mentally ill is itself evidence of mental illness. It means that mentally healthy people who are mistakenly admitted as psychiatric patients harm their chances of discharge if they maintain that they are not mentally ill.
The Positive and Negative Syndrome Scale (PANSS), widely used in evaluating antipsychotic drugs for schizophrenia, is explicit about this. Section G12, titled “Lack of Judgment and Insight” states that ‘extreme’ (grade 7) lack of insight is to be recorded due to:
“Emphatic denial of past and present psychiatric illness. Current hospitalization and treatment are given a delusional interpretation (e.g., as punishment for misdeeds, as persecution by tormentors etc.), and the patient may thus refuse to cooperate with the therapists, medication or other aspects of treatment.”
Good judgment involves the ability to make sound decisions, based on knowledge of what is true and what is false. It is insulting to accuse someone of poor judgment, and uncalled for if the accusation is based on reasonable refutation of an incurable mental illness label. People can make sound judgments about many things, but not be convinced that they are mentally ill, especially if the illness is claimed to be due to unmeasurable chemical imbalances in their brains that are of uncertain origin, the dominant paradigm in psychiatry.
This item in the PANSS is one of 16 items taken from the older Brief Psychiatric Rating Scale (BPRS), which was developed in the USA in the 1960s and used to evaluate “general psychopathology”, as well as to evaluate psychoactive drugs. The PANSS also includes 7 “positive symptoms” and 7 “negative symptoms” for a total of 30 items that are evaluated. This results in a score from 30 to 210. “Improving” scores on the PANSS constitute the main claims for efficacy of the newer antipsychotic drugs; the older drugs were evaluated by the BPRS and other scales, usually when compared to the “benchmark drugs” chlorpromazine and haloperidol, rather than placebo.
A glaring problem with the PANSS and BPRS is the fact that known side-effects of dopamine-blocking drugs, such as “flattened affect” are described as signs of schizophrenia, rather than the treatment of the condition. Other signs such as hostility and uncooperativeness can be explained as legitimate objection to being called mad (or insane), by whatever name.
Predictably, people with some mental illness diagnoses resist the label of “illness” more than others. People with phobias, anxiety and depression often come to see doctors for help and so do people with auditory hallucinations (usually diagnosed as schizophrenia or schizo-affective disorder). In these people the diagnosis of illness can be a relief, and they accept drug treatment without objection. In other cases, patients resist the label of illness vehemently, especially when they are said to have elevated mood (diagnosed as hypomania and mania) or delusions.
It is not surprising that many people accused of having an elevated mood resist the judgement. The BPRS grades “moderately severe” elevated mood (rating 5 on a scale from 1 to 7) as:
“Reports excessive or unrealistic feelings of well-being, confidence or optimism inappropriate to circumstances, much of the time. May describe feeling ‘on top of the world’, ‘like everything is falling into place’ or ‘better than ever before’. OR several instances of marked elevated mood with euphoria”.
Needless to say, people who feel on top of the world, better than ever before, or for whom everything is falling into place, are often not inclined to think they are mentally ill, and with good reason. Likewise people with an increase in goal-directed activities, increased zest for life those who see connections they didn’t see before and have insights. Ironically, the process of coming to conclusions through insight, especially if they are unique or ‘idiosyncratic’, is itself viewed as a sign of mental illness.
The Young Mania Rating Scale (YMRS) rates elevated mood on a scale from 1 to 5, with grade 3 being:
“Definite subjective elevation; optimistic, self-confident, cheerful, inappropriate to content.”
The key to the diagnosis is the subjective evaluation of what is “inappropriate to content” or “inappropriate to circumstances”. This is done by the interviewer, and depends on his or her own belief system, judgement and understanding of the patient’s circumstances.
Persecution by Tormentors and Punishment for Misdeeds
The belief that one is persecuted is not necessarily delusional. Many people, over the ages, have been persecuted, for various reasons including their race, their ‘caste’ and their beliefs. People are sometimes tormented by the families, or by their peers (for example victims of bullies at school or work). Siblings sometimes torment each other, and so do cousins and other relatives. Sometimes it is neighbours who do the tormenting. People often gang up against people who are stigmatised as strange, mad, crazy or odd and this can amount to persecution. Children are often punished for disobedience and it is not unreasonable for people to regard their imprisonment as mental patients a punishment. This is not helped by a punitive culture in the mental health systems of many nations.
There are many dysfunctional families, and family dysfunction comes in many forms. Some families are very competitive and sibling rivalry, as well as competition between parents and children, can be a problem. Some parents, especially fathers, are very authoritarian and demand obedience from their children. Disobedient children are labelled as “difficult” and taken to doctors for diagnosis and treatment. Here the power imbalance is obvious. The child has little power to resist being labelled as the “problem”, however much the doctors protest that they can’t help their behaviour because they have a chemical imbalance in their brains. When the children misbehave it is inevitable that the adults and siblings blame the “illness” and ask if they are complying with taking their their tablets.
The adults in this situation include parents and other family members as well as teachers. Some teachers are inclined to suspect their students of having “attention deficit disorder” when they are not interested in their lessons, and become visibly bored, restless and fidgety. Teachers provide a large number of the referrals for ADD and ADHD. It is rarely asked as to whether the teacher is to blame for being boring and failing to engage the student. This requires introspection, which is sometimes lacking in any profession, including teaching.
Apart from scape-goating a particular family member, there are problems with looking for a chemical solution or “magic bullet” to life’s difficulties. This can form a pattern of behaviour in the child and in their carers and family. When they are down, rather than looking for activities and experiences that will bring them back up, the tendency is to take an antidepressant. When they are anxious, instead of listening to music or going for a walk, or any of a wide range of actions that can lessen anxiety, they look for a benzodiazepine.
It is also a problem when children are medicated for what is basically disobedience. The drugs that are used for ADHD are stimulants, related to amphetamines, known on the street as ‘speed’. Though they can improve concentration and keep you awake when you are tired, it has been known for over a century that amphetamines are addictive, and can also cause psychosis. Despite this they were widely used as weight loss drugs and “pep pills” in the 1960s and were again promoted in the 1990s for the newly-named “mental disorder” known as ADHD (Attention Deficit Hyperactivity Disorder). In the 1980s it was said that only 1 in 200 children had ADD; this rocketed up to 1 in 20 with the new label, with a corresponding explosion in prescriptions for stimulant drugs. This was in the 1990s, and was a precursor to the explosion in addiction to amphetamines a decade later. Many of the youth who are addicted to metamphetamine (‘ice’) were initially diagnosed as having ADHD and given stimulant drugs.
Family abuse occurs at all ages. Children and the elderly are especially vulnerable and can easily be pathologised for being “difficult”. Rebellious adolescents are also vulnerable to being given a disease label for their behaviour, as well as young people who reject the religious beliefs of their parents and embrace other philosophies and religions.
The concept of insight should be considered holistically. There is a difference between insight (introspection) and insights (epiphanies). One aspect of introspection is to be able to look critically at our own mistakes, flaws, vices and poor judgements in the past. It requires us to challenge our indoctrination from various sources as we grew up. The process of growing up and learning from our environment (including family and school) inevitably results in some false beliefs and delusions. Some of our beliefs are not congruous with reality, and it is a challenge, throughout life, to rid ourselves of such delusions. Sometimes, when one realises ones previous error, especially about long-held beliefs, it comes as an insight. Such insights are often pleasant, and can be exciting. They can elevate the mood.
Seeing connections you didn’t notice before and making new associations can also be exciting and elevate the mood. Elevating the mood itself has the effect of increasing insights and insightful thinking. How many potentially beneficial insights have been suppressed or destroyed by the practice of regarding “gaining insight” as a synonym for accepting that you are mentally ill?