Schizophrenia and the Paradoxes of Insight

Why do patients with schizophrenia often deny they are ill?

Posted Jan 07, 2020

When we think of the symptoms of schizophrenia, perhaps the first examples that emerge in our minds are the chaotic thoughts, disturbing suspicions and invisible voices tormenting the sufferer. These are indeed the most striking manifestations of acute psychosis – delusions, hallucinations and thought disorder – but as I wrote a few months ago, these symptoms are not exclusive to schizophrenia and can even occur (albeit often in milder forms) in healthy people.

Contrary to popular belief, these positive symptoms (positive as in "additions" to normal experiences) are not actually the most common occurrences in a schizophrenic disorder. The most frequent symptom is, in fact, a lack of awareness into the unreality of their own psychosis: in medical terms, a "lack of insight" is thought to occur in 97% of patients compared with 74% for auditory hallucinations and 70% for ideas of reference.

Explanations for this lack of insight range from ego-defence mechanisms to abnormalities in the cortical midline structures (a group of brain regions considered key in differentiating self and other); either way, it is widely accepted that lack of insight contributes significantly to treatment non-adherence and sometimes eventual relapse, simply because many patients do not believe their experiences are not real and are symptoms of mental illness.

From the patients’ perspective, these symptoms create their own reality even though such a reality is often extremely frightening and unwelcomed. It is also indisputable, however, that these symptoms have no factual bases in external reality. Hence a permanent paradox is evident: which of these two realities is to be adopted by the patient?

A mind afflicted with schizophrenia is constantly bombarded by internal mental events disguised as external stimuli, which manifest as conflicting realities. To me, nothing challenges our so-called normal sense of self and reality more than schizophrenia does. Is reality nothing but a representation of our senses and beliefs? If so, who are we to decide that patients with schizophrenia have suffered a break from reality? This, of course, is a very philosophical question, with neuroscientific and social roots.

Moreover, a schizophrenic reality does not even have to be "adopted" – it can enter one’s awareness and take hold as if it was the only position from where one experiences the world. Imbued with significance, salience, and meaning, the patient is simply unable to take on another perspective. A delusional elaboration "fits well" with the structure of their consciousness and feels right. Here, another paradox is apparent: to adopt a "false" reality implies a volitional act, but in order to do so, one has to give up the same volition.

To have an integrated understanding of the world, one must first possess an undisrupted core of awareness. Symptoms of schizophrenia are very effective in destroying this very basic sense of self, upon which one constructs identities and personal narratives. Without this minimal layer of self, it should not be surprising that one will become unable to tell apart the multitude of internal and external worlds. This is why I view schizophrenia fundamentally as a disorder of the self.

Given that the disturbance lies in the most basic level of the self, the paradoxes schizophrenia creates have the ability to carry on without solutions. Even insight itself is intrinsically just another unsolvable paradox: the desperate efforts to keep one’s "sanity" intact pushes one deeper into the abyss of simply being aware.

Indeed, if one was completely unaware, one would not experience any pain or suffering either. In other words, patients with schizophrenia suffer immensely not always because they are unaware of external or everyday reality, but because they are too aware of another kind of reality – namely the reality created by their own minds.

If there is anything of which the patient with schizophrenia is truly unaware, it will be their own self and not the factual, "rational" reality. It may be controversial, but to say that lacking insight is a sign of losing touch with reality is like saying a colour-blind person is unable to see anything at all. Schizophrenia is like colour-blindness in this way; it taints and distorts everything one sees but does not cause one to lose eyesight altogether.

Here is a scary thought: would the world truly become black-and-white if absolutely everyone became colour-blind simultaneously? Many might think the answer is no, because surely people would still remember seeing colours. But one could also argue that remembering is a mental event, therefore a ‘reality’ residing in our minds. How is this different from a schizophrenic reality?

Schizophrenia is defined as an illness because it leads to severe distress, functional decline and disability. Even though the causes of such suffering may well be neural or physical, their consequences cannot be easily disregarded as "unreality" or "lack of insight." Insight, after all, is only determined by another agent’s observation and judgment, who has their own interpretation of the world around them.

Perhaps the discrepancy in all the different realities is one of degree rather than of nature, and one only crosses the line of "normality" if one deviates too much from the consensus. But this should not make one "ill" if there is no distress or impairment to functioning. What is normality without the other end of the spectrum? The paradox of reality is one we all struggle with, and not just one faced by patients with schizophrenia.

This post first appeared on the Cardiff University Mental Health Blog.