**6. Cultural critique of insight**

**5. Neurobiology and metacognition research**

94 Psychosis - Biopsychosocial and Relational Perspectives

use of antipsychotic medication.

anterior and posterior cingulate cortex.

toms [15]. This particular finding has to be replicated.

Metacognition is the ability of the human mind to reflect, look upon and influence itself. In the fourth century AD, Saint Augustine in his popular Confessions [6] ponders about the metamemory, a concept akin to metacognition that, "When, therefore, I remember memory, then memory is present to itself by itself, but when I remember forgetfulness then both memory and forgetfulness are present together – the memory by which I remember the forgetfulness which I remember." And in his Allgemeine Psychopathologie [7] Karl Jaspers also similarly writes, "I am not only conscious in the sense of having certain inner experiences, but I am turned back on myself – reflected back – in the consciousness of self. In the course of this reflection, I not only come to know myself, but I also influence myself." Though, as shown, this faculty of human mind was known from ancient times, it was not neuro-biologically investigated.

Over the last decade, interesting research into the neuroscience of self and self-reflection has opened new avenues for the understanding of the human mind and perception of changes within the self. In the study of the concept of insight in psychosis these are relevant findings as they pertain to normal and abnormal self-reflection. We will point out few prominent and replicated functional MRI findings using the Beck Cognitive Insight Scale [8], though these were done on small sample sizes and did not account for the effects of duration of illness and

**1.** Cortical midline structures (CMS) comprising of medial prefrontal cortex, anterior and posterior cingulate cortex are seemingly associated with self-reflection. Researchers [9–12] have found that in people with schizophrenia, the anterior portion of CMS was often functional when self-appraisal was contrasted with other-appraisal and also that within the anterior portion of CMS, the ventro-medial prefrontal cortex is more correlated with information relevant to self than the dorso-medial prefrontal cortex. This suggests that CMS deficits might lead to people with schizophrenia having problems with distinguishing self from others. **2.** Other researchers [13, 14] have shown an anterior to posterior shift in CMS activity in a similar group of people with schizophrenia during self and social reflection tasks. An associated observation was that there was also a functional connectivity change between

**3.** Symptom unawareness component of insight was observed to have widespread brain activation including CMS areas compared to symptom misattribution component which was localized to specific brain regions [13]. This finding is interesting due to its implications on the relationship between the various components in the concept of insight in psychosis. **4.** There was a positive association between posterior CMS activation and cognitive insight in people with schizophrenia but not in those with bipolar disorder with psychotic symp-

Unlike the earlier research which made multiple unsuccessful attempts at finding a specific executive deficit associated with the whole concept of insight as was suggested by Aubrey Lewis at the beginning of the twentieth century [16], the above mentioned research correlates more with specific components of insight rather than a unitary whole. However, caution Markova and Berrios [17, 18] have suggested three broad ways that the field of mental health conceptualizes problems with insight:


Socio-cultural critics of the concept of insight take the third position, and argue that a person who is suffering with psychotic illness may attribute problems to different causes. However as long as the person is able to construct a meaningful explanation of his symptom experience and integrate the psychotic experience into his life, he should be considered to have insight into illness [18]. Insight should not be restricted to just a biomedical explanation, as that explanation itself is argued to be a socially- constructed model among those who subscribe to a western, individualist, post-enlightenment and biologically reductionist position.

A few workers have suggested socio-cultural modifications to the multidimensional model of insight [19], for example accepting any kind of help including nonmedical help should qualify as presence of certain form of insight. As the causal explanations of mental illness are contested across cultures, anthropological critics argue for a wider and an inclusive understanding of the concept of mental illness and a suffering person's judgment about it.

One other aspect of the cultural critique of insight in psychosis is the consistent observation that the prognosis of schizophrenia is demonstrably better in developing countries [2]. These cultures are also often less likely to espouse the biomedical models of causation and treatment by default. The role of strong family systems has long been postulated to be a contributor to the better prognosis in developing countries, and it is worth considering the role of family beliefs in impacting the patient's insight into his illness.
