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April 2015

Assessing and Improving Clinical Insight Among Patients “in Denial”

Author Affiliations
  • 1Division of Substance Abuse, Department of Psychiatry, Columbia University, New York, New York
  • 2Department of Psychiatry, Columbia University Medical Center, New York, New York
  • 3Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University, New York
JAMA Psychiatry. 2015;72(4):303-304. doi:10.1001/jamapsychiatry.2014.2684

Vexing challenges arise in clinical care when patient preferences are at odds with the standard of care. In the hospital setting, such patients on a medicine or surgical service may come to the attention of the psychiatric consultant when “denial” is viewed as an obstacle to appropriate care. In the outpatient setting, these patients are more likely to miss appointments, have persistently poor outcomes, and risk polypharmacy and serial hospitalizations.1 Patients with chronic disease and comorbid mental illness are an especially complicated population in this regard, increasingly recognized as commanding a disproportionate share of health care spending while experiencing inferior outcomes.2 These trends are even starker for patients dually diagnosed with substance use disorders.3 While such patients may represent but a fraction of the nation’s overall population, their effect on the clinical delivery system is profound.

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1 Comment for this article
Insight: a truly bio-psycho-social phenomenon
Anthony S David | Institute of Psychiatry, Psychology and Neuroscience, King's College London, SE5 8AF, UK. Email: anthony.david@kcl.ac.uk
The Viewpoint (JAMA Psychiatry. Published online February 04, 2015. doi:10.1001/jamapsychiatry.2014.2684) on insight is a welcome reminder of the importance of this concept in psychiatry and many biomedical disorders.1 The authors rightly emphasize the complexity of insight and its bio-psycho-social underpinnings. However the contrasts drawn between lack of insight and denial on the one hand and between lack of insight and anosognosia on the other, are both simplistic and in fact reflect the orientation and prejudices of the observer. If an observer wishes to take a moral stand in relation to the patient, s/he may use the vocabulary of denial – the patient could be perfectly aware of their condition and its effects on others, “…if they want to be”. If on the other hand, the observer eschews notions of responsibility, s/he can adopt the language of anosognosia – the patient is unaware and is incapable of being aware of their condition and its effects because of a brain disorder.Most commentators do not find the denial notion satisfactory and the fact that cognitive deficits, particularly in executive function correlate with deficits in insight (albeit to a modest degree2) undermines the denial notion as do reports of correlations with brain structure.3,4 While insight is indeed a “dynamic, multidimensional attribute stemming from a potential combination of primary symptoms, neurocognitive deficits, and cognitive style” the same could easily be said of denial. At the very least, a tendency to minimise difficulties and impairments is a species of cognitive style which is invoked by circumstances (i.e. it’s dynamic) such as developing an illness.5 As for anosognosia this is best understood as a neurological syndrome of lack of awareness usually following right hemisphere damage, which leads to an attentional deficit, most often affecting the contralateral side of the body. But even in such ‘hard cases’ there is often evidence of implicit awareness of disability that eludes consciousness. The same has been shown not to be true in psychotic disorders, that is to say if the psychosis patient says they are unaware of their illness, they do not show implicit awareness.6 In sum, understanding insight means appreciating: that there may be a component that is motivated and adaptive in the same way as denial, which need not entail a judgemental or moral stance from the clinician; that there are definite neurocognitive associations but within our current level of understanding, these are not strong enough to be predictive or fully explanatory; and finally that the analogy with ‘anosognosia’ is limited.


1. Amador, X. F., & David, A. S., (Eds.) 2004 Insight and psychosis: awareness of illness in schizophrenia and related disorders, 2nd edn. Oxford: Oxford University Press.

2. Nair A, Palmer EC, Aleman A, David AS. (2013) Relationship between cognition, clinical and cognitive insight in psychotic disorders: A review and meta-analysis. Schizophr Res, /j.schres.2013.11.033.

3. Morgan KD, Dazzan P, Morgan C, Lappin J, Hutchinson G, Sucking J, Fearon P, Jones PB, Leff J, Murray RM, David AS. (2010). Insight, grey matter and cognitive function in first-onset psychosis. British Journal of Psychiatry, 197: 141-8.

4. Bedford N, Surguladze S, Giampietro V, Brammer MJ, David AS. (2012). Self-Evaluation in Schizophrenia: an fMRI Study with implications for the understanding of insight. BMC Psychiatry 12:106 doi:10.1186/1471-244X-12-106.

5. Bedford NJ, David AS. (2013) Denial of illness in schizophrenia as a disturbance of self-reflection, self-perception and insight. Schizophrenia Res. doi.org/10.1016/j.schres2013.07.006

6. Wiffen BD, O’Connor JA, Russo M, Falcone A, Joseph C, Kolliakou A, Di Forti M, Murray RM, David AS (2013). Do psychosis patients with poor insight show implicit awareness on the emotional Stroop task? Psychopathology. doi:10.1159/ 000350452.