Last May The New Yorker had a beautiful but paywalled article on on psychosis and insight. Thankfully the full text has found its way online as a pdf.
Psychosis is the psychiatric term for delusions and hallucinations, with insight being the ability to recognise that what you believe or experience is not a fair representation of reality.
The concept of insight is more easily applied to hallucinations than delusions, after all you can hallucinate patterns on the walls but realise that the patterns are not really there, but you can’t really have a belief and not believe it.
With regard to delusions, it is tested by seeing how readily people can accept that there is a chance they might be wrong. In other words, it’s an estimate of certainty with absolute certainty in a false belief being considered abnormal.
In practice, and due to the difficulties on agreeing on or verifying reality, it often comes down to whether you agree with your psychiatrist (indeed, one definition of insight, includes accepting treating as a sign of good insight), sometimes leading to situations where people with genuine psychosis completely reject any form of treatment even where it would be of clear benefit.
Rachel Aviv’s article for The New Yorker is a brilliant exploration not only of the experience of slipping into psychosis but also the politics and practicalities of insight.
By the way, Aviv has written a series of excellent articles about mental health including one called ‘Which Way Madness Lies: Can psychosis be prevented?’ for Harper’s Magazine which is also online as a pdf.
pdf of article on insight in psychosis.
pdf of article on preventing psychosis.
Mind Hacks 
Reblogged this on The Pua Melia Clinic and commented:
This is an interesting article. How can we seperate reality from illusion as well if we re force fed reality also? Would that not be a “psychosis” also? So many questions
Wonderful article and thanks for the links to the other 2. I find it interesting that psychosis and psychotic, certainly in my thinking, have come to mean completely insane, as in exhibiting really outrageous behavior when actually it can mean a much quieter kind of losing touch with “reality”. I am thinking of someone I know who has been acting on what they make up about people rather than seeing any other view. This sounds psychotic to me.
Anyone out there who has a view on this?
Thanks so much for the post!
Off-topic: Vaughan, I was wondering if you could do a post on ASMR, “Autonomous Sensory Meridian Response”. It’s a completely made-up name that describes something a lot of people experience (I think my favorite description is “brain-purring”), but which apparently hasn’t been seriously studied. I was hoping you could provide some insights about the phenomenon, or at least discuss it from a neuroscientific perspective.
Such a touchy subject especially with the growing wave of enlightenment and/or awareness! Those who are of a seemingly “normal or rational” mind are questioning if the material world is merely a manifestation of unseen thoughts. Is that frame of thinking considered psychosis or insight?
Delusions are treatable with medication. That’s why they work so well. But I don’t know “how” they work. Maybe by opening you to suggestion? This could be used for better or for worse depending on the situation.
Aviv writes great articles. I liked reading about the NH region as I grew up there. As wonderful as it is, didn’t NH get a failing grade for their mental health facilities?
Thanks for the article (and the other two). I translated it into Chinese and post it in my blog (I do not know whether you received the trackback), and discussed on the term ‘psychosis’. In Chinese, ‘psychosis’ is expressed by the same sign/symbols as ‘mental disorder’, because of which leads to serious discrimination and misunderstanding.
If you talk to someone with delusions, its like talking to someone from a slanted world. Your world and your truth have nothing to do with their beliefs. My neighbor with schizophrenia goes off her medicine occasionally. The last time she did, she would come over every day and tell me her new name “Duchess of Blubery, Countess of Bingham,etc” Some sort of name you would find in a Harlequin romance. It became a problem when she started telling me she had to move out of her apt — her lease had someone else’s name on it. Or she was afraid the police would evict her at night. No amount of explaining that her real name was on the lease worked. Finally, I and the property manager told her that was her “government name”. The government thought that was her name, so she should use it on leases and other government documents. Repeating this frequently seemed to solve the problem in her mind, and she stopped worrying. We also made sure to contact her case worker about being off meds.
Thank you for these excellent articles, which raise so many questions on just about every level.
They had me completely transfixed, trying to understand the mindset of someone whose reality is so far out of kilter with everyone else’s. I don’t personally have the sort of mind that can conjure up even simple bedtime stories for my kids, so reaching to understand how a mind can confect whole conspiracy scenarios against one or seeing others as dematerialized shadowy particles etc. is like reading about a completely fantastic alternate universe*.
Time and neuro-scientific advances will tell us if, as I suspect, these ‘mind states’ are essentially biologically induced with the aid of an environment that consistently and chronically derogates the patient (cf. brainwashing). Until then, we carry on treating patients as if they’re ‘hermetic nutters’ – that somehow these ‘mind states’ have arisen entirely independently of the world around them (cf. RD Laing’s “If the patient is disturbed then….”). And then we go on to treat these people with medicine we barely understand and with even less knowledge (or insight!) into the delicate, intricate workings of the brain.
Psychiatry is nowhere near that of a scientific discipline and, dare I venture, probably never will be. It’ll be trumped by the much advanced neuro-biologists and left behind, much as we’ve grown out of medieval medicine. Psychiatry will be seen as we view today all those daft, ignorant interpretations of ‘humors’, ‘portents’ and ‘signs’.
Note that the DSM almost forbids the admission of the patient’s subjective and possibly often rational reasons for their thinking (cf. Virginia Satir’s opinion on the probability that the other person’s reasons, no matter how seemingly bizarre, often have merit when all factors and their interplay are understood). This leaves the field wide open for, let’s be frank, clueless psychs to misinterpret and even project their own neuroses and agendas (cf. Freud and his cocaine-fuelled clamber to make a name for himself without much concern for who or how he used patients and colleagues).
I can only begin to imagine how much that fruitless struggle for the ‘objective’, ‘scientific’ approach in the shaky discipline of psychiatry further erodes the pre-psychotic patient’s tenuous grasp on consensus reality – the medical model wreaks havoc again?
The one thing that stood out for me in reading these accounts is that the patients sound so apologetic and even guilty for living. It’s as if they carry immense and deeply buried guilt for something or other. Thus, denying their psyches a full grasp on the realities we others enjoy is a sort of profound and inexplicable self- punishment or self-exclusion from ‘normal’, ‘decent’ society. IMHO, this is where the psychological work needs to be done with compassion (cf. Jung’s tenet that everyone carries a deep, dark secret that needs to be healed – yea, even the psychs!)not amateur chemical tinkering.
*…and who’s to say definitively that we’re not actually all just a heap of shadowy, dematerialized particles?! Oh wait, the quantum physicists tell us exactly this! 😉