Insight in bipolar disorder
“If you are going through Hell, keep going” – Winston churchill.
Today we are going to review some of the case studies and raise questions which will enhance our understanding of the problem, that’s why this post is categorized under CBT (Cognitive behavior therapy). Friends we will try to be solution oriented as i know there are time and money constraints .
case study # 1.
24 years old Ryan came to the emergency department with auditory hallucinations. He was pacing about the room. His speech was fluent but pressured. His thought process manifested a flight of ideas and the content was entirely about his deals and upcoming success. He was euphoric but he became easily irritated and angry when confronted directly concerning his claims. He was also sexually preoccupied concerning women’s interest in him. There was no suicidal ideation but he made threatening comments to the hospital staff. His insight and judgement were very poor. He was oriented in 3 spheres and was grossly intact cognitively.
History of presenting illness
Ryan reported that he heard a female voice repeatedly saying,”I am after you.”He was unable to recognize the indidividual.
He reported that he was in contact with “some very big people with very big corporations”. He was about to net “billions of dollars”, unable to give more specific details about the deals.
Ryan reported that he was full of energy and could not sleep because of thinking about these deals.
His thoughts were racing very quickly, which he attributed to his great intellect and his ability to absorb an enormous amount of information rapidly.
He said that people were following him around to get hold of the secret about the deal. He became increasingly frightened about this, thus he was seeking help regarding how to deal with these situations. He adamantly denied any previous hospitalizations or psychiatric problems.
Questions and answers.
Q 1. What can you suggest about Ryan’s insight about his illness ?
He had no insight into his disorder as evidenced by his unshakable belief in his delusions and his denial of previous psychiatric difficulties.
Q 2. Why do so many psychiatric disorders share the characteristic of diminished insight?
Psychiatric illnesses interfere with motivational, cognitive, and emotional brain systems. It is likely that the pathologic mechanisms involved in these illnesses lead to dysregulation of the brain systems underlying insight regulation. Multiple brain processing defects likely contribute to problems with insight, and it is important to understand that insight requires a complex set of brain calculations. For any of us to have insight, we must be able to weigh the relative merits of our own internal thinking relative to external environmental circumstances. Thus, in psychiatric illnesses insight must overcome states of high internal emotion and low motivation in the presence of often inaccurate perceptions of the external world. Insight requires the function of higher-order brain networks underlying attention, working memory, and cognitive control. Unfortunately, these higher-order brain systems are dysfunctional in many, if not all, psychiatric disorders.
Q 3. Can you provide some examples explaining the nature of lack of insight ?
Although lack of insight is a common feature of many psychiatric disorders, the nature of this lack of insight can vary depending on the disorder. A person in the midst of a manic episode with grandiose delusions, high energy, little need for sleep, markedly poor judgment, and uncontrolled spending may not understand why friends and family think something is wrong. A person with schizophrenia experiencing auditory hallucinations or persecutory delusions may not be able to understand that the voices and delusions aren’t real. A person with severe depression may not be able to understand why others don’t realize that he is a terrible person, a complete failure, and a burden to all around him. Individuals with drug addiction may believe that they don’t have a problem and that they can quit whenever they want. Persons with severe dementia may truly believe that they are able to fully function at work and that they are completely capable of driving safely.
Q 4. How can you compare lack of insight in most of the psychiatric disorders from other medical conditions ?
Lack of insight is different from not understanding the nature of a particular illness. Most persons with diabetes can fully appreciate that they are sick and need specific medications to control symptoms. They do not need to understand the biology of insulin resistance at the cellular level. Although individuals with medical illnesses may not understand the mechanisms underlying their illnesses, they typically know that they are ill and that they will benefit from treatment. The more discomfort they feel, the more they want relief. In contrast, persons with psychiatric illnesses often don’t recognize that anything is wrong. They don’t think they need help, or they believe there is nothing that can help them.
Q 5. why does hospitalization become necessary sometimes ?
When behaviors reach a point that the patient is in danger of harming self or others, hospitalization becomes necessary. One of the goals of short-term hospitalization, including involuntary hospitalization, is to provide a safe setting where a patient has time to develop enough insight to be safely treated in a less restrictive environment.
Q 6. Lack of insight can make the treatment and compliance with the treatment challenging.What can we do now ?
When trying to help patients who lack insight, it is important for physicians to develop trusting relationships with both the patient and the patient’s family. When a patient trusts her doctor, she is more likely to take the doctor’s advice even if she doesn’t believe that she needs help. The stronger a patient’s social ties with friends and family, the more likely it is that she will listen to their advice. In effect, strong, positive social ties can help patients develop more accurate evaluations of the external world, serving as surrogates or validators for the patient’s own perceptions. Certain psychotherapeutic approaches can also help with insight. For example, the “cognitive” component of Cognitive Behavioral Therapy (CBT) encourages patients to use their attention, working memory, and cognitive control networks to evaluate their internal thinking in relation to observable events in the external world.
Q 7. How is the assessment of insight is made in clinical psychiatry ?
A summary of six levels of insight follows:
Complete denial of illness
Slight awareness of being sick and needing help, but denying it at the same time
Awareness of being sick but blaming it on others, on external factors, or on organic factors
Awareness that illness is caused by something unknown in the patient
Intellectual insight: admission that the patient is ill and that symptoms or failures in social adjustment are caused by the patient’s own particular irrational feelings or disturbances without applying this knowledge to future experiences
True emotional insight: emotional awareness of the motives and feelings within the patient and the important persons in his or her life, which can lead to basic changes in behavior
“A Moment’s Insight Is Sometimes Worth a Life’s Experience” – Oliver Wendell Holmes Jr.