This document discusses insight and judgment in psychiatry. It defines insight as conscious awareness and understanding of one's own mental condition and symptoms, while judgment involves evaluating choices within a set of values to choose an action. Insight and judgment are interrelated, as good judgment requires adequate insight. The document describes factors that influence insight like culture, intelligence, and symptoms. It also discusses assessing levels of insight from complete denial to true emotional insight. Judgment is assessed through social situations and test questions. Various psychiatric disorders can impair insight and judgment.

1. INSIGHT AND JUDGEMENT
Dr. Anuradha Patel
1st year resident
Department of psychiatry

2. DEFINITIONS
 Insight : conscious recognition of one’s own condition. In
psychiatry, it refers to conscious awareness and
understanding of one’s own psychodynamics and
symptoms of maladaptive behavior.
 Judgement : mental act of comparing or evaluating
choices within the framework of given set of values for
the purpose of electing a course of action.
synopsis of psychiatry 12th edition.

3.  Insight and judgment are interrelated.
 The ability to make sound decision / judgment
presupposes an adequate level of insight.
 A variable amount of insight precedes the
formulation of an opinion or judgment.
 Insight judgement decision
action
Paula T. Trzepacz and robert baker

4. INSIGHT
 Insight begins with one’s own feelings, thoughts and
reactions to other people or situations.
 After this, insight requires comparison of how one
feels and thinks about an issue or problem with what
other people feel and think .
 This permits conscious awareness of one’s
conformity or nonconformity with societal norms.
 Not an indicator of severity of illness
 A person with psychosis may have good insight
while a person with mild anxiety disorder may have
little or no insight.
Paula T. Trzepacz and robert baker and synopsis

5. GRADES OF INSIGHT
 GRADE 1 : complete denial of illness
 GRADE 2 : slight awareness of being sick and
needing help but denying it at the same time
 GRADE 3 : awareness of being sick but blaming it
on others, on external events, on organic factors.
 GRADE 4 : awareness that illness is caused by
something unknown in the patient
 synopsis 10th edition

6.  GRADE 5 : INTELLECTUAL INSIGHT : admission
that patient is ill and that symptoms or failures in
social adjustment are caused by the pt’s own
particular irrational feelings or disturbances without
applying this knowledge to future experiences
 GRADE 6 : TRUE EMOTIONAL INSIGHT :
emotional awareness of motives and feelings within
the pt and the important persons in his/her life
which can lead to basic changes in behavior
 synopsis 10th edition

7. FACTORS INFLUENCING INSIGHT
 Cultural factors
 General intelligence and knowledge
 Stigma
 Symptomatology
 Personality traits
 Predominant defense mechanism
Mental status examination(2014)retrieved February 28, 2014 from http://www.amdc.edu.pk

8.  All mental illnesses will alter the patient’s world view
and capacity to cope with circumstances.
 Assessment of insight measures the awareness of this
change by patient and his ability to adapt to the
change.
 It is the understanding of the individual about his own
state of health, capacity and worth;
 It also relates this assessment of internal state to
other people and the world outside.
 David regards insight as composed of 3 distinct,
overlapping dimensions, namely the recognition of
morbid psychological change, labelling of this change
as deriving from mental illness and understanding that
this change requires treatment .
sims symtomps in the mind

9.  Insight is a complex construct.
 Adequate insight is usually vital for compliance with
ongoing treatment.
 Insight may fluctuate with stress( e.g. usually insightful
but frightened pt with acute MI may deny seriousness of
chest pain & try to leave emergency room ) or current
severity of mental illness (E. g. the patient who does not
realize, when manic, that his hypersexual behavior at
church is inappropriate).
Paula T. Trzepacz and robert baker

10. POSSIBLE QUESTIONS FOR PATIENT
 What brings you here today?
 What seems to be the problem?
 What do you think is causing your problem?
 How do you understand your problem?
 Are you aware of phenomenon others have observed?
 If so, do you recognize the phenomenon as abnormal?
 If so, do you consider that they are caused by mental
illness?
 If so, do you think you need treatment?
Mental status examination(2014)retrieved February 28, 2014 from http://www.amdc.edu.pk

11. JUDGEMENT
 Judgement is a thought that expresses a view of
reality. (sims)
 Judgement involves weighing and comparing the
relative values of different aspects of an issue.
 The ability to make sound judgement requires
intact cognition, capacity to conceptualize, ability to
consider long term effects and possible adverse
outcomes.
 Any impairment of these functions diminishes the
quality of the resultant judgement.
Paula T. Trzepacz and robert baker

12.  Determining whether a particular judgement is sound
is situation dependant. E.g. killing other people is
considered immoral , an exception is made for soldier
in battle.
 To assess whether judgement is disturbed or not, one
need to measure it against objective fact. ( sims)
 Assessment of faulty judgement is not made solely on
the basis of that particular belief or argument but on
taking the whole of patient’s behavior and opinions
into account.(sims)
 The level of judgement may or may not correlate to the
level of insight. A patient may have no insight into
his/her illness but have good judgement. (synopsis)

13. ASSESSMENT OF JUDGEMENT
 In MSE, judgement can be assessed by:
1) social judgement
2) test judgement

14. SOCIAL JUDGEMENT
 It includes basic knowledge of social situations,
knowledge of responses in such situations and
ability apply the correct response personally when
faced with a actual social situation.
 It is observed during hospital stay, interview session
and history of informants who have witnessed the
patient’s actual performance in day to day events.
Mental status examination(2014)retrieved February 28, 2014 from http://www.amdc.edu.pk

15. TEST JUDGEMENT
 It is assessed by asking the patient what he/she
would do in certain test situations
 E.g. what would you do in case of a house on a
fire?
 what is the thing to do if you find an envelop in the
street that is sealed, stamped and addressed?
 If you were in a crowded movie theater and you
were the first one to notice a fire , what would you
do?

16. EXAMPLES OF DISORDERS WHOSE SYMPTOMS MAY
CONTRIBUTE TO IMPAIRED INSIGHT AND
JUDGEMENT
 Drugs and alcohol dependence
 Depression
 Mania
 Anxiety disorders
 Dementia
 Delirium
 Attention deficit disorder
 Impulse control disorders
 Conversion disorder
 OCD
 Psychosis
 Personality disorders
 Central nervous system disorders
Paula T. Trzepacz and robert baker

17.  Phenomenon of loss of insight and disturbed judgement
are also observed in lesions of hypothalmo-parietal
areas of right side of brain and lesions of more central
part of optic radiation.
 In this phenomenon, pt is unaware of paresis of limb or
one side of body.
 Such pt when asked about their paretic limb may say
that limb is alright. When asked to move paralytic limb
they may move other limb and insist that they have
moved paralytic limb.
a guide to clinical psychiatry by namboodiri and john

18.  Insight
 Self appraisal and self
esteem
 Understanding of
current circumstances
 Ability to describe
personal, psychological
and physical status
 Judgement
 Appraisal of major
social relationships
 Understanding of
personal roles and
responsibilities

19. Thank you