The social context of insight in schizophrenia

  Background: Psychiatrists place great weight on impaired insight in schizophrenia, generally attributing it to pathological mental processes. However, denial of illness may be based on attitudes common in patients' social and cultural groups. Moreover, even where denial of illness has a pathological element, it may be affected by the social context. In this paper, we predicted that denial of illness would be associated with social distance between clinician and patient, and reduced by access to `normalizing' social interaction. Method: One hundred and fifty patients with schizophrenia in the London arm of the European Schizophrenia cohort were assessed using the `Awareness of Illness' (AI) subscale of David's Assessment of Insight. Clinical and social attributes were related to AI. Results: There was little evidence for our social distance hypotheses: there was little variation in AI by social class, ethnicity, membership of a drug taking culture or the presence of strongly held religious beliefs. However, there were strong relations between AI and the size of primary group, consistent with our normalizing hypothesis. Conclusions: The normalizing function of social support is in line with modern psychological models of delusion formation. Longitudinal data will eventually be available from the current study that will assist in establishing the causal direction of this association.