We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Viewpoint |

Assessing and Improving Clinical Insight Among Patients “in Denial”

Arthur Robin Williams, MD, MBE1; Mark Olfson, MD, MPH2; Marc Galanter, MD3
[+] Author Affiliations
1Division of Substance Abuse, Department of Psychiatry, Columbia University, New York, New York
2Department of Psychiatry, Columbia University Medical Center, New York, New York
3Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University, New York
JAMA Psychiatry. 2015;72(4):303-304. doi:10.1001/jamapsychiatry.2014.2684.
Text Size: A A A
Published online


This Viewpoint discusses the differences between patients experiencing denial and those exhibiting lack of insight and addresses interventions that may improve care for patients exhibiting lack of insight.

Vexing challenges arise in clinical care when patient preferences are at odds with the standard of care. In the hospital setting, such patients on a medicine or surgical service may come to the attention of the psychiatric consultant when “denial” is viewed as an obstacle to appropriate care. In the outpatient setting, these patients are more likely to miss appointments, have persistently poor outcomes, and risk polypharmacy and serial hospitalizations.1 Patients with chronic disease and comorbid mental illness are an especially complicated population in this regard, increasingly recognized as commanding a disproportionate share of health care spending while experiencing inferior outcomes.2 These trends are even starker for patients dually diagnosed with substance use disorders.3 While such patients may represent but a fraction of the nation’s overall population, their effect on the clinical delivery system is profound.

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

First Page Preview

View Large
First page PDF preview





Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment
Insight: a truly bio-psycho-social phenomenon
Posted on February 4, 2015
Anthony S David
Institute of Psychiatry, Psychology and Neuroscience, King's College London, SE5 8AF, UK. Email: anthony.david@kcl.ac.uk
Conflict of Interest: None Declared

The Viewpoint (JAMA Psychiatry. Published online February 04, 2015. doi:10.1001/jamapsychiatry.2014.2684) on insight is a welcome reminder of the importance of this concept in psychiatry and many biomedical disorders.1 The authors rightly emphasize the complexity of insight and its bio-psycho-social underpinnings. However the contrasts drawn between lack of insight and denial on the one hand and between lack of insight and anosognosia on the other, are both simplistic and in fact reflect the orientation and prejudices of the observer. If an observer wishes to take a moral stand in relation to the patient, s/he may use the vocabulary of denial – the patient could be perfectly aware of their condition and its effects on others, “…if they want to be”. If on the other hand, the observer eschews notions of responsibility, s/he can adopt the language of anosognosia – the patient is unaware and is incapable of being aware of their condition and its effects because of a brain disorder.Most commentators do not find the denial notion satisfactory and the fact that cognitive deficits, particularly in executive function correlate with deficits in insight (albeit to a modest degree2) undermines the denial notion as do reports of correlations with brain structure.3,4 While insight is indeed a “dynamic, multidimensional attribute stemming from a potential combination of primary symptoms, neurocognitive deficits, and cognitive style” the same could easily be said of denial. At the very least, a tendency to minimise difficulties and impairments is a species of cognitive style which is invoked by circumstances (i.e. it’s dynamic) such as developing an illness.5 As for anosognosia this is best understood as a neurological syndrome of lack of awareness usually following right hemisphere damage, which leads to an attentional deficit, most often affecting the contralateral side of the body. But even in such ‘hard cases’ there is often evidence of implicit awareness of disability that eludes consciousness. The same has been shown not to be true in psychotic disorders, that is to say if the psychosis patient says they are unaware of their illness, they do not show implicit awareness.6 In sum, understanding insight means appreciating: that there may be a component that is motivated and adaptive in the same way as denial, which need not entail a judgemental or moral stance from the clinician; that there are definite neurocognitive associations but within our current level of understanding, these are not strong enough to be predictive or fully explanatory; and finally that the analogy with ‘anosognosia’ is limited.


1. Amador, X. F., & David, A. S., (Eds.) 2004 Insight and psychosis: awareness of illness in schizophrenia and related disorders, 2nd edn. Oxford: Oxford University Press.

2. Nair A, Palmer EC, Aleman A, David AS. (2013) Relationship between cognition, clinical and cognitive insight in psychotic disorders: A review and meta-analysis. Schizophr Res, /j.schres.2013.11.033.

3. Morgan KD, Dazzan P, Morgan C, Lappin J, Hutchinson G, Sucking J, Fearon P, Jones PB, Leff J, Murray RM, David AS. (2010). Insight, grey matter and cognitive function in first-onset psychosis. British Journal of Psychiatry, 197: 141-8.

4. Bedford N, Surguladze S, Giampietro V, Brammer MJ, David AS. (2012). Self-Evaluation in Schizophrenia: an fMRI Study with implications for the understanding of insight. BMC Psychiatry 12:106 doi:10.1186/1471-244X-12-106.

5. Bedford NJ, David AS. (2013) Denial of illness in schizophrenia as a disturbance of self-reflection, self-perception and insight. Schizophrenia Res. doi.org/10.1016/j.schres2013.07.006

6. Wiffen BD, O’Connor JA, Russo M, Falcone A, Joseph C, Kolliakou A, Di Forti M, Murray RM, David AS (2013). Do psychosis patients with poor insight show implicit awareness on the emotional Stroop task? Psychopathology. doi:10.1159/ 000350452.

Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis