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PoL Insight Rating Scale Version 1.0 (PoLIRS 1)

Insight Level	Insight Hierarchy	Yes	No
1	Appreciates that a personal experience (symptom) is different from that expected in normal range of experience
2	Attributes some or all of these experiences (symptoms) to an illness model
3	Seeks help from a formal source for an illness producing these experiences
4	Appreciates need for treatment plan for this illness
5	Complies with an agreed treatment plan
6	Appreciates need for continued compliance or follow-up by formal treatment provider.

Correspondence on the Version 1.0 of the Scale

How do you measure insight?

Insight has been debated by psychiatrists over many years (Jaspers, 1965), but has recently been conceptualaised into three components: awareness of illness, need for treatment, and attribution of symptoms (Birchwood et al, 1994).

The above form represents a first attempt to get a rater judgement on insight levels for psychiatric patients, although in some ways it would be desirable to produce a generic insight rating form for all illnesses. Insight appears to be central to patients seeking help and complying with prescribed treatment in all fields of medicine. In psychiatry it is probably closely related to outcome and prognosis, including dangerousness.

Comments on the above form would be very much appreciated. How well would do people think it would work in practice? Are there any suggestions for improvement? Is anybody interested in researching insight?

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References

Birchwood, M et al. (1994) A self-report Insight Scale for psychosis, reliability, validity and sensitivity to change. Acta Psychiatrica Scandinavica; 89: 62-67.

Jaspers, K (1998) General Psychopathology

Correspondence on Version 1.0

All of the items, except for item 1, seem to me to be tied to the liberal-scientific model and indeed are direct mirrors of Parson's Postulates (Parsons, 1951) that were effectively a manifesto for expectations of patients under the medical model.

I think there is a real difference between what insight IS and what it SHOULD BE. Your scale will no doubt probe quite excellently what most psychiatrists believe to be insight; namely, ease of management. But is this REALLY insight? Hence, what you choose for items in an insight-rating scale will largely be a function on what definition of insight you settle on

at the beginning of the exercise. A "platform-independent" notion of insight might include such notions as:

1) Understanding that the current cognitions or behaviour deviate substantially from the accepted range of personal experience/behaviour (you already have this in item 1).

2) That there be some level of understanding that aberrant behaviour/cognitions have some underlying cause, however, this need not be a medical cause, it may be existential, moral, psychological etc. (but supernatural should not, of course, qualify here).

3) Understanding that others (rightly or wrongly) see the person's behaviour or cognitions as bizarre or problematic.

4) Understanding that the cognitions/behaviour are causing the person distress (if they are not, then should the person be in a psychiatrist's office anyway?) 5) That intervention may achieve some attenuation of the cognitions/behaviour and thus a reduction in concomitant distress.

6) THEREFORE: taking medication and turning up for therapy may be the best way of achieving this (now, because of steps 1-5, medication compliance DOES become relevant to insight as we have "led" the patient through a pattern of understanding, instead of merely requiring him/her to believe medication compliance is correct without an epistemological antecedents or reasoning behind the notion).

I think that these notions of insight may have a greater therapeutic efficacy than simple ascription on behalf of the patient to a system of intervention and medicine that he/she probably doesn't fully understand anyway. All (well, nearly all) psychiatrists would agree that insight is not merely a quantum to be measured, it is something that should be increased, and little will be achieved by simply requiring an allegiance to a particular model. The notions above, I think, will not only give a truer measure of insight, but also engender easier management and treatment through a valid understanding about the causes and consequences of the aberrant behaviour/cognitions. In particular, I think the word illness should be struck from your scale, as it does not engender personal responsibility or understanding, and indeed mystifies the patient's situation (how on earth can most patient's understand the intricacies of the dopamine hypothesis?). But that is a personal opinion.

I think that efficacy of the pharmacological approach has been confused by Western psychiatry with the notion that because antipsychotics etc ameliorate "symptoms", then pharmacology must be involved in the genesis of "disorder". We know that antipsychotics act on dopamine receptors, and ameliorate the symptoms of schizophrenia. Therefore, schizophrenia is due

to an abnormality of dopamine receptors. We also know that paracetamol acts upon pain receptors, and ameliorates the symptoms of 'flu. But would we be correct in saying that therefore 'flu is due to an abnormality of pain receptors?

Requiring that patients believe this through value-judging their insight would be a fallacy (albeit, perhaps, an inescapable artefact of the medical model). I think that perhaps you might settle on some compromise of the notions that I have laid out above and Parson's Postulates in developing the insight scale.

A couple of other psychiatrists who replied to version 1.0 of the scale seemed to think the same as I - that it is a treatment provider point of view. Substitute "compeller" for "provider" and things begin to look a bit more sinister!

The Scoping study wishes to dramatically amend the 1983 MHA by bringing the duty for compulsion, detention etc into line with "physical illness". A person should be compelled only if he/she makes a decision in respect of treatment etc that he/she would not have made if he/she were "well". Insight must be the one of the major constructs, then, that we have for measuring the desirability of compulsion under the proposals.

You can read the Scoping Study at http://www.hyperguide.co.uk/mha/rev-prop.htm

Ed, Mitchell, Fellow in Law, Harvard University

The other area that seems to be important, at least in our practice, is medication compliance. Insight regarding the need, benefit, ways to address side effects, and self-medication, with both prescription and substance abuse. In our programs (partial hospitalization, adult and young adult, and psychiatric rehabilitation) we measure outcomes studies at various treatment issues. It would be interesting to include this scale. Thanks.

Mrs Terri Gregory, RN,C Program Director

1.Not sure that help seeking behaviour and compliance are dependent upon insight.. Help seeking behaviour is dependent upon the aversive or distressing nature of the symptom to the 'sufferer' and others. Compliance is heavily influenced by the type of treatment. Individuals may be aware that symptoms are not within normal range of experience but they are not distressing or previous treatment may have appeared worse than symptoms. Lastly it is also the impact of these symptoms upon others that is important. Awareness of this and 'not acting upon the symptoms'shows some form of insight. 2. There should be discrimination between attribution of some and all in 2

Dr Jeremy Weiner, Psychiatrist.

The form assumes an orthodoxy that seems to come strictly from a provider point of view. "Compliance" with the provider seems to be of high importance.

Dr. David Harris

It seems to me that you are attempting to assess 2 separate dimensions of illness related beliefs/behaviour. I dont know if a single measure can do this. The 'steps'are of arbitrary size - does moving from 1 to 2 mean the same as 4 to 5?

Nick Kosky, Psychiatrist

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