'Insight', and a false message

Interview with Anthony S. David.

Anthony S. David, Professor of Cognitive Neuropsychiatry, Institute of Psychiatry, King's College, London, is a psychiatrist whose areas of interest are schizophrenia and neuropsychiatry, psychological complications of neurological or brain disease. A world-renowned expert, he is a member of the Executive Committee of the International Neuropsychiatry Association.

In Chennai to deliver a lecture on "Recent Advances in Maintenance and Treatment of Schizophrenia" at the first International Neuropsychiatry Association India Symposium, Prof. David spoke to Asha Krishnakumar on the neurological and psychiatric basis of the phenomenon of "insight", a denial of the symptom and the disease. Excerpts:

What is "insight"?

Insight is a phenomenon that explains how much a person is aware or unaware of his own feelings and personality, and the consequences thereof, even when pointed out to him. The person may deny it... In certain conditions, this takes an extreme form. For example, some of those whose right hemisphere of the brain is damaged can lose power and sensation on the left side of the body. But a curious phenomenon occurs when those affected deny there is anything wrong with them. Sometimes, even when they are completely paralysed and unable to walk, they still maintain that there is nothing wrong with them. And, when pointed out that they are in bed and have to be helped to do the daily chores, they just say that they do not feel like doing it that day.

Does it happen only to patients with neurological and psychiatric conditions?

It certainly happens because of many neurological and psychiatric conditions. But it happens across diseases - cancer, HIV/AIDS [human immunodeficiency virus-acquired immune deficiency syndrome], and so on. Perhaps the brain mechanisms are less important than the social and psychological ones. So, people with other kinds of physical conditions may behave in such a way that they do not believe these conditions exist. They deny there is a problem.

Why does this denial happen? Is it psychological or neurological?

A combination of both. That is why a study of this area is very interesting.

There are specific sections in the brain that monitor the activities in the other parts of the brain. They get direct feedback that tells us when we have to perform certain actions, and whether we are successful in them or not. In certain conditions, these monitoring centres in the brain get false feedback. They get information that everything is perfect, when in fact it is not. The evidence of one's own eyes is not enough to override that false internal message.

There can be a general denial phase, as when bad news comes in, particularly about health. This is a normal reaction. But, perhaps, the same brain system that manifests that reaction gets damaged permanently in other conditions so that the denial phase is not merely a phase. And this may lead to serious social problems, as treatment, management and rehabilitation become that much more difficult.

But why is the false message sent out?

We do not understand the mechanism as yet. All we know is that a different section of the brain monitors our activity from the part of the brain that actually performs it. So, you can lose one without losing the other.

In psychiatric conditions like schizophrenia, when patients have hallucinations and often hear voices talking to them, they have delusions or false beliefs that they have special powers, or that the world and the spirits are against them and so on.

Again, though many patients are aware that there is something wrong, most deny that there is any problem whatsoever. This has great consequences for the family members who find it very frustrating, as they cannot reason with the person, persuade him/her to seek help, or get treatment. So, the patient ends up in a worse state than he/she might have otherwise been in.

What is the nature of your research in the area of "insight"?

We are studying the social consequences and also the scientific understanding of which part of the brain is involved in this phenomenon. We find that certain parts in the frontal cortex, known as the anterior cingulate cortex (the medial part of the frontal lobe), seem to be the monitoring centre for the brain. So, activity and plans formulated in the other parts of the brain feed up to the anterior cingulate, which enables us to compare what we would like to do with what we actually do. We have done magnetic resonance imaging [MRI] brain scans of patients who have quite good or preserved "insight" and patients with bad "insight". We find that the difference is in the volume of that part of the brain that monitors the brain - the volume is lower in people with poor "insight".

Have studies been done to understand why this happens?

We think it is part and parcel of the disorder itself, which we know affects brain development. The exact pattern of brain development is probably somewhat down to chance. If you are unlucky to have the disease affect that part of the brain, it leads you to have the disorder without `insight".

Is there no treatment for this? Can't the volume of that part of the brain be increased?

No. The volume of that part of the brain cannot be increased. But all is not lost. We have been developing cognitive therapies to try and enhance "insight". It is possible to re-educate the healthy parts of the mind and the brain and help the person make use of the other brain systems to compensate. We have found that contrary to what is commonly believed, "insight" can be improved by getting the people engaged in experiments where it is proved to them that their beliefs about the world are mistaken. Not in the way of showing them that they are wrong but in a way that they can learn through other routes to appreciate their behaviour better.

Does "insight' vary across age, sex, ethnicity and so on?

So far we do not find any gender differences. The effect of age is interesting as in some ways you expect people to learn from experience. It might be possible to deny problems or illness for a while, but after sometime we think people would gradually come to realise their problems.

The cultural factor is very interesting. I am working on this with colleagues at the Christian Medical College and Hospital, Vellore. What we regard as a symptom of an illness isn't simply a matter of biology and physiology. There are cultural and social aspects to it as well. This is true especially of psychiatric disorders. We feel that the biomedical explanation is not the only explanation and are currently trying to understand a more diverse culture gives people a more flexible approach to understanding illness.

Some people argue that lack of "insight" is not a brain disorder. It is simply a sensible approach, given the stigma attached to mental disorders. They wonder why anyone would want to admit that they have such a problem. They would only be shunned. Maybe if the person explains the hallucinations, mystical or religious beliefs, and so on, rather than label it a medical condition, some of the stigma would be avoided and self-esteem preserved, and yet there is an awareness that something is different. It may be easier for them to accept help. So, we are looking at the cultural as well as biological aspects.

Does "insight" have a genetic basis?

It is part of the human condition. So, in some sense it is genetic. But we are nowhere near suggesting that there are particular genes that make one person more or less susceptible to it.

What kind of research is going on in this area of "insight"?

A lot of work is on in trying to improve "insight" through psychological and cognitive training. There is interest in learning how one area of the brain can monitor other areas using the brain-imaging technique. But these are very early days at the moment.