What is insight in psychiatry?
Insight in psychiatry is defined as
- having awareness of your illness (Awareness)
- knowing that your symptoms are abnormal (Attribution)
- agreeing that you need treatment for that illness (Action)
Insight into your illness is considered a good thing and a positive towards successful treatment, but there can be a devastating paradox that comes with recognizing that you’re sick and need help.
The Paradox of Insight
The paradox of insight in schizophrenia means that increased levels of insight are also associated with higher levels of depression. [Source] This can make it easier to hide, harder to be helped, and more painful to live through.
If you have insight, this indicates that you already know how you’re supposed to act and you see yourself and know that it’s not supposed to be that way – but you can’t change it. It’s easier not knowing.
You unfortunately understand the language of mental health well enough to manipulate the narrative – even unintentionally.
This can mean saying, “I’m fine!”, because you know better than to not say that, you know what could happen, like stigma, involuntary hospitalization, stronger medications, and so on.
There is a core contradiction in this, and it is as follows:
“If I admit I’m struggling, they might not believe me. But if I don’t, they definitely won’t”
Insight makes the pressure to appear okay even though you aren’t, very strong. In my case, some people are watching for signs of illness, and I’m looking back trying to convince them there are none.
- Eye contact? Yup
- Not rambling.. sorta
- Smiling, yep.
“”If I mimic normalcy enough, I can avoid hospitalization, stigma, and disappointing everyone again. “
This leads to being told, “you seem better”, “you don’t sound psychotic”, and “you’re so self aware, what a good sign!”. It makes you the model patient, it sets expectations, and now people are depending on you for something else.
Insight can feel just like a trap sometimes, because you know you’re unwell buy you’re also unable to stop it, which can be just as terrifying, if not more, than being delusional or hearing voices.
- You can pretend it’s not happening
- You still feel crazy
- You can predict your own decline – and dread it
Then the thoughts start
- If I was really sick, I wouldn’t be this aware
- Maybe I’m exaggerating
- If it was serious, someone would have noticed.
It’s a trap, it’s a cycle, and then when things fall apart, you’re at your worst, it really is a crisis now, and it could have been avoided if you tried to get help, or asked for help, a long time ago.
Insight can make you doubt your own suffering more than any delusion ever could.
Sometimes you try to get help and they consider you too insightful to be helped. Insight is often seen as lack of risk, why?
“You’re not yelling or refusing meds? You aren’t claiming to be Jesus? You must be fine!“
However, the people with insight are often the ones most likely to hide distress, and the least likely to be believed when they do disclose it. You can be considered too rational to be a danger to yourself, but you can also be rational enough to lie about how close to the edge you are.
We hide it, there are reasons. I’m not scared of being sick, I’m scared of admitting I am! There’s a huge list of fears here:
- Hospitalization
- Loss of autonomy
- Not being believed
- Disappointing family
- The permanence of your history/diagnosis
And even fear that this time help may not come, and be told you’re too functional, but that’s never happened to me, fortunately. Keeping quiet can make it seem like you’re in control of the eventual fallout. This isn’t 100% true, or guaranteed, either.
Insight doesn’t mean you’re stable, it doesn’t mean you’re safe and it doesn’t mean you’re being honest. Sometimes you’re the most at risk because you’re articulate, and because you’re two steps ahead of the system because you don’t want to get caught in that system. Sometimes the fear of the guilt, the shame, and the fallout, is worse than admitting you’re sick in the first place.
If you know someone you think is sick and may be hiding it
- Ask how hard they’re working to be okay
- Ask what they aren’t saying
- Validate the fear of speaking up
Don’t assume insight means someone wants help – or feels safe getting it.
For Other Patients
- you’re not weak for knowing and still struggling
- you’re not faking it because you can describe it
- you’re not safer because you can understand it
The pain from the whole experience, being told I was insightful, that I was a great patient, all that stuff, just made it harder to be sick, say I were inpatient or something. I hid side effects, paranoia, hallucinations, because I didn’t want to be a bad patient, a burden, medicated against my will.
Insight didn’t save me, it just made me feel the whole thing in high definition
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