**Author details**

**1.** In the psychological capacity assessment by Appelbaum et al. called McCAT [31], the psychotic loss of capacity is considered an "appreciation disorder." This is distinct from the reasons for the loss of capacity in other illnesses like dementia, which are due to memory and reasoning defects. So the question remains as to what is the relation between delu-

**2.** The concept of delusion is intimately related to the loss of insight, but the difficulty in precisely defining and delineating it is an added problem. Delusion is thought to be pathological either due to problems in perception or in logical reasoning, which purportedly displays a "loss of contact with reality." But there are research studies which report that it is difficult to demonstrate a problem with either aspect in patients with delusions: the posited perceptual basis for a delusion is internal and therefore cannot be accurately measured externally, while problems with logical reasoning are not observed [32]. So, what is the demonstrable criterion by which delusion can be incontrovertibly established? A definite answer to this question has thus far been elusive, even though delusions are certainly reliably assessed, diagnosed and treated in clinical practice regularly. A related—and even more clinically challenging—question is by what criteria can we differentiate a delusion

**3.** What are the relational dynamics and pitfalls of the inter-personal assessment of loss of insight between the clinician and the person with psychotic illness? And what are the bor-

Others who want to delve deeper may want to explore the relation between delusion, belief, discourse, power relations and the nature of reality. Though interesting, they are beyond the

Historically, the concept of insight in psychosis has evolved over time from being part of the very definition of psychosis to being an independent, modifiable aspect of the experience of a patient with psychosis. There has also been an evolution in the understanding of insight from a unitary to a multidimensional construct, with each component being influenced by various biological, individual and cultural factors. The study and understanding of such a complex, multidimensional concept needs to be carried out at various levels and with needed emphasis on the personal and interpersonal aspects of the people suffering with psychotic disorders, aspects that are routinely neglected in the clinical discourse in favor of reductionist biological models. While exciting neurobiological research seems to indicate that certain aspects of insight in psychosis may be biologically driven, it can no longer be justifiably considered a unitary construct. Individual and sociocultural factors play a key role in insight. "Acceptance of mental illness as the cause of symptoms" and "acceptance of treatment" are both factors that may be significantly colored by one's pre-morbid personality, worldview and cultural background. A patient who is able to recognize symptoms as being abnormal experiences and attempts to organize his experience in a meaningful way leading to help-seeking should be considered as having good insight into his illness even if the explanation and treatments he espouses differ from biomedical ones.

sional loss of rationality and the loss of rationality due to cognitive defects?

98 Psychosis - Biopsychosocial and Relational Perspectives

from a strongly held religious, scientific or any other over-valued belief?

derlands between providing care and unethical coercion?

purview of the discussion of the concept of insight in psychosis.

**10. Conclusion**

Starlin Vijay Mythri1 \* and Johann Alex Ebenezer<sup>2</sup>

