**9. Integrated view of insight in psychosis**

dimension of human person. Therefore it is important to understand the personalist emphasis provided by Dilthey and Husserl. Personalism [20] as a distinctive philosophy which emphasizes the centrality of personhood of human being and his dignity, has been explored promi-

Wilhelm Dilthey [21] notably distinguished natural sciences from human sciences emphasizing that the approach needed for studying distinctly human aspects of men and women has to be different from the methods of natural science. He suggested due to the dual (i.e., biological and psychological) aspects of human nature it has to be studied from both an "erklaren" (causal explanation) perspective and "verstehen" (empathic understanding) perspective. While Erklaren-perspective deals with descriptive aspect of symptoms and tries to give causal explanation, Verstehen-perspective describes the meaningful nature of human experience and therefore is more akin to the personal aspects. Dilthey's ideas, as mentioned earlier, exercised tremendous influence on Jasper's psychopathology. Buber [22], another personalist contemporary of Dilthey, distinguished between two types of relationships possible for us, i.e., the "I-You" relationship and the "I-it" relationship. The "I-You" relationship emphasizes the uniqueness of human personal encounters with other personal beings which is not comparable

Lastly, Wojtyla [23] defined a person as a being towards which the only adequate attitude is one of love and respect. It is in this personalist background, Fulford claims that delusion (and by implication the related concept of insight) is a failure of practical-reason of the person rather than a cognitive deficit [24]. Practical reasoning is the opposite of theoretical reasoning which is concerned with facts, cause–effect relations and impersonal objective explanations, and is the reasoning needed in the practical life to subjectively evaluate choices for actions and therefore is related to values. So, according to Fulford there is a failure of practical reasoning which presents as wrong choices and actions in people with psychotic disorders. We here introduce the alternative viewpoint which emphasizes the regard for the personhood of a

In second half of the last century, there were numerous voices from humanities and even from within the natural sciences decrying the reductionist anthropology in scientific psychiatry. The coercive practices of psychiatry in this context were discussed as violations of human rights and dignity. For example, research suggests that involuntary treatment is overused in some parts of the world based on narrow biomedical models of insight [25] and historically totalitarian governments like the Soviet Union have used (as part of their "official" classifications) unscientific labels like "sluggish schizophrenia" with the alleged symptom of "inflex-

This movement aimed at broadening the narrow emphasis of biological psychiatry was enhanced by the developments in the study of language and discourse. Discourse analysis and the related field of discursive psychology [26] regard human verbal interaction as a performative act within a context, i.e., language is used not only to *describe* internal and external

nently by Immanuel Kant and later by people who were influenced by him.

to a human encounter with an impersonal object (an "it").

96 Psychosis - Biopsychosocial and Relational Perspectives

human being in the discussion of the Insight in psychosis.

**8. Discursive psychology and intersubjectivity**

ibility of ideas" to incarcerate political dissenters.

Considering the various arguments from neuroscience and anthropology, David [28] accepts that the "acceptance or awareness of the mental illness" component of his model can be influenced widely by the pre-existent interpretative frameworks in the suffering person's culture while the "acceptance of the kind or duration of treatment" component may also be depended more on the pre-morbid personality of the suffering person and may not be related to his or her neurobiological deficits due to the illness. Only the component of "acceptance or the relabeling of experience as pathological" may be closely related to the cognitive deficits due to the neurobiological disease process which may be consistent across cultures. This last point is corroborated by the empirical evidence from the developing world [29], that people with schizophrenia when assessed with multidimensional rating scales of insight more often accept the pathological nature of their symptoms but are hesitant to accept the biomedical model of the mental illness as a whole.

When we hold both sides of the argument (the biological and the personal) together it helps us to better understand the complexity of the concept of insight in psychosis. Such a composite view is presented in Jasperian phenomenological psychopathology (with its emphasis on "erklaren" and "verstehen" perspectives in investigating psychopathology), which is more holistic and person-centered than the narrow reductionist focus on symptoms in Kraepelinian descriptive psychopathology. The Jasperian model allows the impersonal disease to be combined with the personal illness, and the biological deficit to be combined with the failure of reasoning which evaluates personal choices and action [30]. Such an integrated view is more reflective of the kind of being that we are discussing about, i.e., the mystery of how the neurobiological and psycho-spiritual components come together in the complex entity we call the Human Person.

The current chapter through a historical, neurobiological and personalist review of the concept of insight, however, raises many questions, while bringing some clarity to the discussion. Some of the questions are:

**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 delusional loss of rationality and the loss of rationality due to cognitive defects?

An imposition of biomedical models into the definition of insight may not only alienate patients from other cultural backgrounds from approaching treatment, it may also impede accurate

Insight in Psychosis: An Integrated Perspective http://dx.doi.org/10.5772/intechopen.79368 99

Fundamental to any effort to understand higher aspects of human experience (such as delusions and insight into illness) is an adequate understanding of the nature of human personhood. Taking after Kraepelinian descriptive psychopathology, biological psychiatry has tended towards reductionist understandings of personhood that emphasize neurobiology and symptoms of illness. We suggest that the more holistic Jasperian phenomenological approach to psychopathology which emphasizes both the "erklaren" (descriptive and causal explanations) and "verstehen" (empathic understanding) aspects of psychopathological assessment is a better reflection of the complexities that make up the human condition. Such a holistic, integrated understanding of the concept of insight in psychosis would in turn guide the therapeutic, administrative and legal management of people with these debilitating illnesses.

clinical judgment by making the assessment of this crucial aspect of illness incomplete.

\* and Johann Alex Ebenezer<sup>2</sup>

1 Asha Bipolar Clinic, Asha Hospital, Hyderabad, Telangana, India

2 Distance Education Unit, Christian Medical College, Vellore, Tamilnadu, India

[1] Berrios G, Markova I. Insight in the psychoses: A conceptual history. In: Amador XF, David AS, editors. Insight and Psychosis - Awareness of Illness in Schizophrenia and

[2] Sartorius N, Shapiro R, Jablensky A. The international pilot study of schizophrenia.

[3] Present State Examination-Oxford Reference [Internet]. [cited May 17, 2018]. Available from: http://www.oxfordreference.com/view/10.1093/oi/authority.20110803100343713 [4] David AS. Insight and psychosis. The British Journal of Psychiatry: The Journal of Mental

[5] Fulford K. Insight and delusion: From jaspers to Kraepelin and back again via Austin. In: Amador XF, David AS, editors. Insight and Psychosis - Awareness of Illness in Schizophrenia

[6] Augustine A. Confessions and enchiridion, newly translated and edited by Albert C. Outler - Christian Classics Ethereal Library [Internet]. Grand Rapids, MI, USA: Christian Classics Ethereal Library; [cited 2018 May 17]. 10.16. Available from: http://www.ccel.

and Related Disorders. 2nd ed. New York: Oxford University Press; 2004

Related Disorders. 2nd ed. New York: Oxford University Press; 2004. pp. 31-50

\*Address all correspondence to: starlinvijay@yahoo.co.in

Schizophrenia Bulletin. 1974;**1**(11):21-34

Science. 1990;**156**:798-808

org/ccel/augustine/confessions

**Author details**

Starlin Vijay Mythri1

**References**


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