Kathleen MacDonald

A Critical Appraisal of The Measurement of Insight in First-Episode Psychosis.

Introduction: The conceptualization and measurement of insight in mental health has evolved through the years, and the assessment of insight is often regarded as a routine assessment in psychiatry. This has led to generalizations regarding the absence of insight among persons suffering from psychotic disorders and its relationship with clinical outcomes, neuropsychology, severity of psychopathology, medication adherence, and more. However, many standard measures of insight rely heavily and narrowly on medicalized notions of mental illness.

Objectives: The aim of this presentation is to demonstrate the limitations of using standard clinical scales of insight such as the Scale to Assess Unawareness of Mental Disorder, particularly in the context of early intervention services for psychosis.

Methods: This presentation will use case study methodology to describe the illness experiences and explanations of young people (age 14-25) with first-episode psychosis receiving services at an early intervention program in Montreal, Canada, and the standardized measurement of insight in each of these cases. In addition, the presentation will highlight the noticeable tension between positivist perspectives (with a focus on measurability and replicability) and phenomenological perspectives (with a focus on individual experience and meaning) in the context of psychosis and specifically the assessment insight into delusions.

Results: Standard assessments, such as the SUMD, limit the measurement of insight to the degree to which an individual’s account of their illness is in agreement with a medical-model conceptualization. By doing so, the measurement of insight overlooks important constructs of personal meaning, culture, and individuals’ narratives about their experiences which are, or should be, critical to understanding insight.

Implications: The measurement of insight in psychosis has been historically rooted in a profound reluctance on the part of the medical community to acknowledge any value in patients’ experiences and explanations of psychosis. In constraining acceptable definitions of insight to ‘awareness’ of mental disorders and the need for and benefits of medication, clinical and research tools such as the SUMD scale do patients a disservice by denying them a space for the personal and individual meanings they assign to their experiences. This is of particular significance as people with lived experience are calling for more importance to be attributed to personal accounts of mental illness, both in the clinic and in society at large. Such narrative insight has yet to be explored fully in first- episode psychosis, but its potential can be ground- breaking for early intervention services for psychosis in particular and youth mental health in general.