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031 Self awareness and insight in neuropsychiatric disorders
  1. A David

    Author information: Professor Anthony David graduated in medicine from Glasgow University in 1980 and trained in neurology before entering psychiatry at the Maudsley Hospital, London. He also has a Masters degree in Cognitive Neuropsychology. He has been an honorary consultant at the Maudsley since 1990 and was awarded a personal chair from the Institute of Psychiatry and GKT School of Medicine in 1996. Professor David has a wide and diverse range of research interests including schizophrenia, neuropsychiatry, medically unexplained syndromes and neuroimaging—both structural and functional. He is especially interested in the concept of insight in schizophrenia and how this relates to treatment compliance. Professor David is a Fellow of the Royal College of Physicians, the Royal College of Psychiatrists and the Academy of Medical Sciences. He is a member of the Experimental Psychology Society and a founder member of both the British Neuropsychological Society and British Neuropsychiatry Association and was Chairman to the latter from 2004–7. He is also an associate director of the UK Mental Health Research Network. Professor David is editor of the journal “Cognitive Neuropsychiatry” and has published several books including The Neuropsychology of Schizophrenia (1994) with J Cutting, Disorders of Brain and Mind (1998) with M Ron, The Self in Neuroscience and Psychiatry (2003) with T Kircher, and Insight and Psychosis (2nd Ed) (2004) with X Amador. He is author of over 350 publications in peer reviewed medical and scientific journals.


Abstract: The awareness of one's self as a unique sentient agent might be thought of as fundamental to mental health. Though disrupted in most if not all psychiatric disorders, it is the hallmark of depersonalisation disorder. This is a non-psychotic condition in which sufferers feel themselves to be “unreal” in some way and that their experience of the world is also unreal. Evidence suggests that part of the problem may be due to suppression of physiological arousal especially in response to emotion, which interrupts the experience of a vital sense of self, and that this maps on to lateral prefrontal and insula systems. Insight in neuropsychiatry may be thought of as a particular kind of self-awareness involving the appraisal and judgement on whether one's functions or experiences are pathological in some way. A midline cortical system has been identified as critical for self-appraisal. Lack of awareness of illness or deficits has been studied in patients with for example: schizophrenia, Alzheimer's disease and brain injury. Unawareness may apply to several domains such as social behaviour, psychopathology, memory and executive function and can be measured by different methods including discrepancy scores between patients' own and others' ratings. Our research has shown that patient groups with varying levels of deficit in each domain show varying levels of awareness. Low mood and executive impairment is associated with lack of insight in all groups while insight into memory deficits is closely tied to memory deficits themselves. We can conclude that insight is multidimensional and domain specific but that it also has associations, which are common across domains and disorders. The sense of self and awareness that one is ill or impaired appear to be separate phenomena and may relate to lateral and medial frontal executive systems, respectively.

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