Disease insight

Insight into illness is a term used in medicine and describes the knowledge and belief that one is ill (according to a medical diagnosis , i.e. not because of imaginary illness or hypochondria ). It is mainly used from a medical perspective and is mainly used in psychiatry . This term is a construct that is strongly influenced by specialist medical and socio-political ideas and norms.

This term is usually used to express doubts that a patient has understood the medical assessments communicated to him or that he is experiencing sufficient suffering and that he is following the therapeutic recommendations that the doctor considers to be useful or necessary.

description

Lack of insight can be in medical reports , psychopathological findings and other medical documents are recorded. According to the AMDP system , however, it should be differentiated from a lack of feeling of illness and - because of the sometimes far-reaching consequences for the patient - only documented in clear cases (longer patient contact and reliable diagnosis) after careful consideration by the doctor.

Insight into the disease depends heavily on the communication and quality of the doctor-patient relationship and, on the medical side, is based on the premise of the objective correctness of his diagnosis and therapy recommendations: However, this premise is not always true. Medical diagnoses , especially in the psychiatric field (and sometimes also in the case of complex or difficult to diagnose somatic diseases), are in principle also (subjective) assessments by the doctor; they are subject to the limits of his specialist medical knowledge (e.g. in the case of difficult differential diagnosis , which requires specialist medical clarification in several areas - sometimes also great medical intuition) and potential diagnostic error possibilities. It can happen (especially with complex or difficult to diagnose chronic diseases or with psychological-psychiatric and psychosomatic findings and the often given time and cost framework) that the completeness and correctness of the anamnesis collected and the examinations carried out and their correct analysis and interpretation by the Doctor cannot always be guaranteed. It should also be taken into account that the concept of disease is never free from evaluative (judgmental) and normative influences and that a value-free , absolutely objectifiable and generally accepted scientific concept of disease cannot exist in medical theory . A possibly inaccurate assessment that a patient lacks insight into the disease can have not inconsiderable consequences for the patient with regard to further treatment and questions regarding benefits related to insurance providers.

The term “insight into disease” is also used in existential philosophy and philosophical anthropology . Provide the doctor's therapeutic communications to the patient and U. necessary, but possibly subjectively evaluative conclusions of the doctor, which result from examination and assessment . However, the question of insight into the disease is not only about the so-called adherence to therapy that ultimately results from the recommendations received , but also about all of the patient's subjective requirements for following the medical advice given to him. Any restrictions on the patient's insight due to their own prejudices, for example in the form of intrapsychic defense mechanisms , must be taken into account, including their ultimately very personal reactions and their own judgment or assessment . All of this must be observed by the doctor and relates to the so-called state of illness of the "responsible patient".

Disease state

If one takes into account the state of illness of a patient, then u. a. Conscious and unconscious attitudes and attitudes before and after undergoing a medical examination. This also involves the question of whether the advice given by the practitioner, including the medical information, is accepted by the patient more or less without reservation and without question, and how it is processed if necessary. This may result in demands for a suitable way of coping with the illness .

In the context of the patient-doctor relationship , the concept of insight into the disease - from a medical perspective tends to be used objectively - contrasts with the subjective terms of the linguistic environment of the state of mind . These are often of decisive importance for one's own judgment of being healthy or sick, not the judgment of the doctor. While every doctor should try to get a correct and comprehensive picture of a patient's general condition and empathize with his condition when examining a patient, the examination does not end there. The doctor depends on an understanding and cooperation with the patient in order to improve the specific condition of the disease that is ultimately only suspected by the patient and diagnosed by the doctor (but sometimes cannot be diagnosed with absolute certainty). In the interests of ideal medical therapy success, it is desirable if the subjective awareness of the disease, which is shaped by the patient's "state of illness", coincides with the regular medical ideas about a certain clinical picture that may have been identified.

Insight into illness is the basis and the definitive result of every medical consultation, whether positive or negative . Medical measures represent an attempt that up to then u. U. to objectify vague subjective assumptions and fears of a suffering patient or his suffering environment and to recognize diseases and disorders and to improve or heal them if possible.

Possible stages of the disease insight

Resistance to disease and the will to disease

The subjective perception of a disorder goes hand in hand with a loss of well-being of the person concerned. It represents an emotionally negative fact for the patient. The rejection of conscious perception of such an emotion therefore seems understandable. This may be due to resistance to admitting one's own powerlessness and neediness. It can also be understood as an expression of a healthy unwillingness to be true. The disruptive is supposed to be suppressed . The rejection can be transferred to the doctor and thus limit the subordination to his authority and the compliance of the patient with regard to the therapy. This can also inhibit further attention to the perception of one's own state of health.

According to the remarks by Jean-Martin Charcot (1825–1893), self-control and the will to live normally are often countered by a so-called “will to become ill”. He wrote the following sentence: "For the development between health and illness, a moment is decisive that seems to depend on the patient." Both attitudes and forces - defense against illness and the will to illness - have been explored more closely by psychoanalysis. They have found expression in the theories of resistance and disease gain . The subjective overwhelming of physical illness is more independent of such different personal statements of the patient. Serious physical illness is usually associated with a radical change in vital self-confidence. If too much attention is paid to the disease processes, this can have an unfavorable effect on understanding the disease and on adherence to therapy . By paying more attention, the fear of the disease can also be increased.

The gain in inner balance, which is essential for the mental state, is obvious in all such cases. Resistance is to be expected in every direction in medical health management for “difficult patients”. Ontogenetic and psychogenetic factors play a role in gaining insight into illness in the willingness to become ill, which can be traced back to constitution and disposition .

The “will to be ill” has often been referred to as the desire to be ill, the intention to be ill, etc. However, this is not intended to imply a conscious desire or a weakness in character or morality. The success of psychotherapy suggests that, despite the apparently existing “intention to become ill”, healings are desired and realized by those affected themselves. Regardless of moralizing consideration, a mental illness term is defined from a disharmonious overall personality deviating from an understanding of normality, who was unable to deal successfully with the triggering causes of the disorder (see also → moral treatment ). Therapeutic aids in coping can lead to a better uniformity of will, to a change in the ability to reflect and thus ultimately to a changed insight into the disease. In this context, Bleuler's textbook mentions the therapeutically positive example of a war tremor . The war tremors had been a problem that had been widely considered since 1918. This is still relevant today insofar as there is still a conflict of interests between individual and societal claims, see for example a large number of psychiatric misdiagnoses that continue to cause a stir.

Resistance of one's self as an object of knowledge

The experience of mental health and illness is linked to the perception of one's own self . Reflection and introspection facilitate this approach. There are often particular difficulties with self-awareness . Hans-Georg Gadamer (1900–2002) emphasizes this in view of the general resistance of nature in us (inner world, self) and outside of oneself (outer world), which is evident in the knowledge of objects .

Illness awareness as a preliminary stage of illness insight

Karl Jaspers defines the disease awareness as "that position of the sick person in which a feeling of being sick, a feeling of change is expressed, without this awareness extending to all symptoms of the disease and to the disease as a whole".

Insight into illness as the perfection of illness awareness

Jaspers speaks of an insight into the disease only when “all individual symptoms of the disease” are taken into account in the patient's awareness of the disease and “the disease as a whole is correctly assessed according to its type and severity”. In this context, he also mentions the "objectively correct measure in assessing the severity of the disease" for the patient. This objectively correct measure can best be determined in somatic medicine. In connection with this “objective yardstick”, however, Jaspers points to the relativization within different cultural groups (see also → Comparative Psychiatry ), which, as is well known, dominate the value concepts in psychiatry. However, the given understanding of health and illness is influenced by social values, ideas and norms and stands in the way of objectivity. This affects the questionability of a general concept of illness. The demand for regular insight into the disease, especially in psychiatry, is thus equivalent to what Jaspers has described in the eyes of the public as a kind of parallel phenomenon to the Inquisition.

Importance of psychiatry

Gadamer takes the view that the importance of psychiatry is to distance oneself from a point of view that sees the functioning of the psyche as "a bundle of services for stated purposes" in accordance with the now outdated conception of asset psychology . Insight into illness cannot be conveyed according to general operational guidelines, similar to the task and goal of a planning and directing authority. It is the subject of individual development and self-realization. The restoration of disturbed health requires in many cases of mental illness the regaining of an individually disturbed self-image. Insight into disease cannot therefore be conveyed in analogy to the task and determination of animal intelligence . Animal intelligence is used to master the same tasks in life.

Criticism of psychiatric care was directed and in many cases continues to be directed against its too clearly pronounced institutional character. B. the criticism on the part of antipsychiatry . For example , psychoeducation , which is more technologically oriented, has recently gained increasing influence. As an attempt at an institution that is expedient for all mentally ill people, it already presupposes some kind of insight into the disease. Psychoeducation is therefore not always unproblematic because the medical diagnosis does not automatically involve insight into the disease and is therefore often perceived as compulsive and indoctrinating. Not improved compliance, but better self-realization taking into account subjective experiences is often desired by patients.

Cases like that of Maria Colwell have created widespread social impetus from 1973 onwards about how to improve health services. Not only was there a demand for improved cooperation between a wide range of social psychological and social psychiatric services with corresponding professional groups in other disciplines, but also new legislative initiatives. This also shook the all too arbitrary self-image of those professional groups who are involved in the performance of public tasks.

Decreased awareness of the disease

With psychosis

Insight into the disease in psychoses is usually assessed as reduced, even if certain signs of insight may be present. In acute psychosis as well as after the past and chronic psychosis there are variable qualitative and quantitative restrictions. This means that in some cases pathologically altered self-perceptions can be observed, such as “being internally rotten” (case of acute depressive psychosis) or “being bewitched” ( schizophrenia ). After the disease is in remission , this perception may subside, but it may still reappear with certain slight hints. In chronic psychoses, Jaspers observed peculiar and half-baked mixtures between medical systematics and the patients' own views.

Psychopathy

In the case of psychopathies , Jaspers noticed constant impairments of insight into the disease.

In forensics

View from the cemetery of the Hadamar Memorial to the grounds of the psychiatric hospital, which has a general psychiatry as well as a forensic psychiatry secured with high fences and barbed wire . This view dates from 2010. In the meantime, from 2014, a significantly expanded forensic facility was set up in the same area, and the building for forensic patients behind the fence was demolished in 2018. Until then, the design of the fence was largely hidden from visitors to the Hadamar memorial due to garden architecture planning. The view of these fences, as shown here in the picture, was only possible in individual places. The cemetery is the place where the ashes of the burned as well as - as testified by gravediggers - the mass graves of the other victims of the 15,000 dead who were brought to Hadamar during their lifetime are located . The Episcopal Konvikt ( diocese of Limburg ) can be seen in the background of the picture . The question arises whether this local atmosphere is suitable for promoting disease insight.

Clinical forensics is a relatively new branch of psychiatry. Asmus Finzen (* 1940) noticed a surge in the number of forensic-psychiatric beds and departments, which for him was an occasion to reflect on the zeitgeist . This zeitgeist evidently moves away from the demands outlined above . Does this also increase the temptation to gain “insight into the disease” through coercion, as happened in the case of the justice victim Horst Arnold ? Here one relied on the apparent legitimacy of punitive measures due to a lack of insight into the disease. Even the judicial responsibility assessed as existing or inadequate does not always agree with insight into the disease.

With dementia

The most extensive lack of insight into the disease in severe organic dementias is primarily due to the loss of intelligence and that on which intelligence is based, namely memory and retentiveness . Speaking can also be affected, so that a patient can only make himself understood with great effort, and he forgets his whole life. However, there is still an intense awareness of the disease in the early stages of the disease, when only the aforementioned prerequisites of intelligence are affected. Nevertheless, even with severe organic dementia, certain personality traits are still preserved. This is what distinguishes organic dementias from congenital ones. In the case of schizophrenic defects , the intelligence appears to be preserved and primarily the personality appears to be affected.

Individual evidence

^ Working group for methodology and documentation in psychiatry: The AMDP system: Manual for the documentation of psychiatric findings . Hogrefe Verlag, 2006, ISBN 978-3-8409-1925-1 , pp. 120–122 ( limited preview in Google Book search).
^ ^A ^b Philip G. Zimbardo , Richard J. Gerrig: Psychology . Pearson, Hallbergmoos near Munich 2008, ISBN 978-3-8273-7275-8 ; (b) p. 491, 651–653 - on stw. “Therapy loyalty (compliance)”; (b) p. 482 - on head. “Coping with illness”.
^ Markus Antonius Wirtz. (Ed.): Dorsch - Lexicon of Psychology . Verlag Hans Huber, Bern, ¹⁶ 2013, ISBN 978-3-456-85234-8 ; Lexicon lemma: "Subjectivity": online
↑ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l Karl Jaspers : Allgemeine Psychopathologie . Springer, Berlin ⁹ 1973, ISBN 3-540-03340-8 , ( limited preview in the Google book search); (a) pp. 184 ff., 349 ff., 504, (654) - on tax “insight into disease”; (b) pp. 353, 652 , 666 f. - on taxation “subjective motives”; (c) p. 353 f. - on tax office “Will to disease and Charcot quote”; (d) p. 353 - on tax. “Insight into illness and physical illness”; (e) pp. 309 f., 587 f. - Re. “Willingness to be sick as a result of an experience ( disposition , complex )” and pp. 518 f., 531 ff. - Re. “Willingness to be sick as a result of constitution”; (f) pp. 174 f., 322, 324 ff., 602 f., 652 , 353 - on stw. “Accident neurosis, pension neurosis”; (g) p. 349 - re. “Definition of illness awareness”; (h) p. 349 - on tax. “Insight into illness and culture”; (i) P. 652 ff. - on tax “Concepts of value in psychiatry”; (j) p. 651 - on stw. "Questionability of the concept of illness in psychiatry"; (k) + (l) p. 351 ff. - on stw. "Insight into illnesses in psychoses and psychopathies"; (m) p. 184 f. - to tax authority "Insight into disease in organic dementia".
↑ ^a ^b ^c ^d Hans-Georg Gadamer : About the concealment of health . Cape. "To the problem of intelligence". In: Der Nervenarzt, 7, Heidelberg 1964, pp. 281–286 (lecture at the conference of the General Association of German Nerve Doctors in Wiesbaden in September 1963) Library Suhrkamp, Volume 1135, Frankfurt / M 1993, ISBN 3-518-22135-3 ; (a) pp. 77 f., 80 - to the tax “insight into disease”; (b) + (c) pp. 77–79, 81, 83 - on “Fluctuations in the inner balance and resistance to illness”; (d) P. 80 f./S. 82 - Stw .: "Special problems of self-knowledge: multiplicity of possibilities versus adaptation and instinctive obedience"; (e) P. 72, 75 and P. 76 - Stw .: “Relativization of the statements of consciousness: Nietzsche and Koehler”; (f) p. 82 f. - Stw .: "The importance of psychiatry".
↑ ^a ^b ^c Rudolf Degkwitz et al. (Ed.): Mentally ill . Introduction to Psychiatry for Clinical Study. Urban & Schwarzenberg, Munich 1982, ISBN 3-541-09911-9 ; (a + b) pp. 47–50 - on the term “Illness, illness, condition”; (c) p. 436 ff. - on “Antipsychiatry”.
↑ ^a ^b Sven Olaf Hoffmann and Hochapfel, G .: Neurosenlehre, psychotherapeutic and psychosomatic medicine. [1999], Compact textbook, Schattauer, Stuttgart ⁶ 2003, ISBN 3-7945-1960-4 ; (a) p. 376 ff. - on stw. “Coping with illness”, (b) p. 408 f. - to district "Resistance", p. 69 - to district "Gain from illness".
↑ Peter R. Hofstätter (Ed.): Psychology . The Fischer Lexicon, Fischer-Taschenbuch, Frankfurt a. M. 1972, ISBN 3-436-01159-2 ; P. 41 - on head. "Attention and Resistance" and p. 200 - on head. "Attenuation of fear and aversion tendencies in psychotherapy".
↑ AJ Christensen et al .: Monitoring attentional style and medical regimen adherence in hemodialysis patients . In: Health Psychology 16, pp. 256-293, 1997
↑ Eugen Bleuler : Textbook of Psychiatry . Springer, Berlin ¹⁵ 1983; edited by Manfred Bleuler with the assistance of J. Angst et al., ISBN 3-540-11833-0 ; P. 502 ff. - on tax. "Desire for illness, intention to be ill".
↑ Thomas Bock , Dorothea Buck & Ingeborg Esterer : It is normal to be different. Psychiatrie-Verlag, Bonn ² 2000, ISBN 3-88414-206-2 ; Pp. 57, 65 - on tax. “Insight into illness and psychoeducation”.
^ Peter Fiedler : Behavioral Therapy with Groups . Weinheim, 1996
^ Joseph Goldstein , Anna Freud & Albert J. Solnit : Before the best interests of the child. [1979] The Free Press. A Division of Macmillan Publishing Co. Inc.- Dt. This side of the child's best interests . Suhrkamp, Frankfurt am Main 1982 stw 383 suhrkamp pocket book science, ISBN 3-518-27983-1 ; Pp. 125–160, 214, 221, 241 - on St. "Colwell, Maria".
^ Asmus Finzen : Stigma mental illness . How to deal with prejudice, blame and discrimination. Psychiatrie-Verlag, Cologne 2013; ISBN 978-3-88414-5753 (print); P. 114 - to tax unit "Clinical Forensics".
^ Stanley Milgram : Obedience to Authority . Harper & Row, New York 1974.

[:0-1] Working group for methodology and documentation in psychiatry: The AMDP system: Manual for the documentation of psychiatric findings . Hogrefe Verlag, 2006, ISBN 978-3-8409-1925-1 , pp. 120–122 ( limited preview in Google Book search).

[PSG-2] A ^b Philip G. Zimbardo , Richard J. Gerrig: Psychology . Pearson, Hallbergmoos near Munich 2008, ISBN 978-3-8273-7275-8 ; (b) p. 491, 651–653 - on stw. “Therapy loyalty (compliance)”; (b) p. 482 - on head. “Coping with illness”.

[3] Markus Antonius Wirtz. (Ed.): Dorsch - Lexicon of Psychology . Verlag Hans Huber, Bern, ¹⁶ 2013, ISBN 978-3-456-85234-8 ; Lexicon lemma: "Subjectivity": online

[APP-4] ↑ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l Karl Jaspers : Allgemeine Psychopathologie . Springer, Berlin ⁹ 1973, ISBN 3-540-03340-8 , ( limited preview in the Google book search); (a) pp. 184 ff., 349 ff., 504, (654) - on tax “insight into disease”; (b) pp. 353, 652 , 666 f. - on taxation “subjective motives”; (c) p. 353 f. - on tax office “Will to disease and Charcot quote”; (d) p. 353 - on tax. “Insight into illness and physical illness”; (e) pp. 309 f., 587 f. - Re. “Willingness to be sick as a result of an experience ( disposition , complex )” and pp. 518 f., 531 ff. - Re. “Willingness to be sick as a result of constitution”; (f) pp. 174 f., 322, 324 ff., 602 f., 652 , 353 - on stw. “Accident neurosis, pension neurosis”; (g) p. 349 - re. “Definition of illness awareness”; (h) p. 349 - on tax. “Insight into illness and culture”; (i) P. 652 ff. - on tax “Concepts of value in psychiatry”; (j) p. 651 - on stw. "Questionability of the concept of illness in psychiatry"; (k) + (l) p. 351 ff. - on stw. "Insight into illnesses in psychoses and psychopathies"; (m) p. 184 f. - to tax authority "Insight into disease in organic dementia".

[VDG-5] Hans-Georg Gadamer : About the concealment of health . Cape. "To the problem of intelligence". In: Der Nervenarzt, 7, Heidelberg 1964, pp. 281–286 (lecture at the conference of the General Association of German Nerve Doctors in Wiesbaden in September 1963) Library Suhrkamp, Volume 1135, Frankfurt / M 1993, ISBN 3-518-22135-3 ; (a) pp. 77 f., 80 - to the tax “insight into disease”; (b) + (c) pp. 77–79, 81, 83 - on “Fluctuations in the inner balance and resistance to illness”; (d) P. 80 f./S. 82 - Stw .: "Special problems of self-knowledge: multiplicity of possibilities versus adaptation and instinctive obedience"; (e) P. 72, 75 and P. 76 - Stw .: “Relativization of the statements of consciousness: Nietzsche and Koehler”; (f) p. 82 f. - Stw .: "The importance of psychiatry".

[PSK-6] Rudolf Degkwitz et al. (Ed.): Mentally ill . Introduction to Psychiatry for Clinical Study. Urban & Schwarzenberg, Munich 1982, ISBN 3-541-09911-9 ; (a + b) pp. 47–50 - on the term “Illness, illness, condition”; (c) p. 436 ff. - on “Antipsychiatry”.

[NPP-7] Sven Olaf Hoffmann and Hochapfel, G .: Neurosenlehre, psychotherapeutic and psychosomatic medicine. [1999], Compact textbook, Schattauer, Stuttgart ⁶ 2003, ISBN 3-7945-1960-4 ; (a) p. 376 ff. - on stw. “Coping with illness”, (b) p. 408 f. - to district "Resistance", p. 69 - to district "Gain from illness".

[FLP-8] Peter R. Hofstätter (Ed.): Psychology . The Fischer Lexicon, Fischer-Taschenbuch, Frankfurt a. M. 1972, ISBN 3-436-01159-2 ; P. 41 - on head. "Attention and Resistance" and p. 200 - on head. "Attenuation of fear and aversion tendencies in psychotherapy".

[9] AJ Christensen et al .: Monitoring attentional style and medical regimen adherence in hemodialysis patients . In: Health Psychology 16, pp. 256-293, 1997

[NBL-10] Eugen Bleuler : Textbook of Psychiatry . Springer, Berlin ¹⁵ 1983; edited by Manfred Bleuler with the assistance of J. Angst et al., ISBN 3-540-11833-0 ; P. 502 ff. - on tax. "Desire for illness, intention to be ill".

[NVS-11] Thomas Bock , Dorothea Buck & Ingeborg Esterer : It is normal to be different. Psychiatrie-Verlag, Bonn ² 2000, ISBN 3-88414-206-2 ; Pp. 57, 65 - on tax. “Insight into illness and psychoeducation”.

[12] Peter Fiedler : Behavioral Therapy with Groups . Weinheim, 1996

[DDK-13] Joseph Goldstein , Anna Freud & Albert J. Solnit : Before the best interests of the child. [1979] The Free Press. A Division of Macmillan Publishing Co. Inc.- Dt. This side of the child's best interests . Suhrkamp, Frankfurt am Main 1982 stw 383 suhrkamp pocket book science, ISBN 3-518-27983-1 ; Pp. 125–160, 214, 221, 241 - on St. "Colwell, Maria".

[SPK-14] Asmus Finzen : Stigma mental illness . How to deal with prejudice, blame and discrimination. Psychiatrie-Verlag, Cologne 2013; ISBN 978-3-88414-5753 (print); P. 114 - to tax unit "Clinical Forensics".

[15] Stanley Milgram : Obedience to Authority . Harper & Row, New York 1974.