Insight and psychosis: Comparing the perspectives of patient, entourage and clinician

Background: The construct of insight in psychosis assumes congruence between patient and clinician views of the meaning of symptoms and experience. Current definitions and measures of insight do not give systematic attention to the impact of interpersonal, cultural and socio-economic contexts. Aims: We hypothesized that socio-cultural factors influence insight in patients with schizophrenia. Methods: We tested this hypothesis through comparison of insight in 18 triads, each composed of a patient, a family member and a clinician. The sample consisted of patients who were first diagnosed with psychosis in the last two years, and who were either immigrants from Africa or the Caribbean Islands, or Canadian born. Insight was assessed by analysis of narratives collected from patients, family members and clinicians for a research project on the negotiation of treatment. Each narrative was scored for insight along multiple dimensions with the Extracted Insight Scale (EIS), developed for this project. Results: There was a significant correlation of insight on the EIS between patients and family members (r = 0.51, p = 0.03) but not between patient and clinician or family and clinician. The mean levels of insight across the three groups were comparable. Qualitative analysis of the illness narratives suggested that insight was based on the meanings constructed around psychotic experiences and that the process of interpreting and attributing psychotic experiences reflected each person's cultural background, life experiences, and other social determinants, especially stigma. Conclusion: Forms of insight can occur in the context of discordance or disagreement with the clinician's opinion. We present a testable model of the sociocultural determinants of insight that can guide future studies.