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Most people who talk to a psychotic person for the first time very soon find themselves wondering about the patient's insight. Even if the concept of insight is not explicitly invoked, questions will spring to mind. Thoughts such as, "Surely the patient realizes that those ideas can't be true" or "Surely he must realize that there is something wrong with him" or "If she really believed that surely she would act in a different way" are common in this situation. It is therefore quite surprising to search through older text books of psychiatry and find that there is little explicit reference to the concept of insight other than in psychoanalysis. The reason for this is, perhaps, that the psychopathologists most influential at the turn of the century and immediately before had a rather narrow view of madness. They saw it as an all-or-none phenomenon and that insanity, psychosis, madness, and schizophrenia (whatever the preferred term) were all incompatible with insight.1,2 Indeed the discussion of insight in this circumstance suggests that there is a "sane" part of a mentally ill individual that is able to observe or comment on an "insane" part. This "modularity" was simply not conceivable 100 years ago. In fact, the modern view that the mind is made up of several such modules, which are relatively independently functioning processors, expounded from cognitive science and philosophy3 is perhaps one reason behind the recent upsurge in academic study of insight in psychosis.
DEFINING INSIGHT
In this paper we discuss five different perspectives on the concept of lack of insight: (1) as an aspect of psychopathology, (2) as a cognitive deficit, (3) as a defense mechanism, (4) as an aspect of personality, and finally, (5) as a culturally and socially determined attitude.
There are many commonsense ways in which the term insight may be applied. One of the early discussions of insight relevant to modern psychiatry was that by Aubrey Lewis in 1934.4 He questioned the all or none view of insight prevalent at that time and also the view that insight was something that neurotic patients possessed and psychotic patients did not. Instead he came up with a working definition of insight: the recognition that one had an illness and that the illness was mental....