Insight & Capacity (Scales)

Researchers on insight have produced an array of measures designed to quantify insight.  These ‘insight scales’ have been particularly important in research contexts, where they have been used to explore population-level correlations between impaired insight and other clinically and legally relevant factors such as diagnosis, duration of illness, treatment adherence, readmission, efficacy of treatment and use of coercive measures.  The numerical values provided by insight scales are of limited relevance in the assessment of capacity.  Such scales were never designed with the aim of establishing a ‘cutoff point’ for an ‘acceptable level’ of insight.  Insight scales can nonetheless be useful tools for exploring impaired insight and its relation to capacity.

‘Insight scales’ adopt a variety of different approaches to the challenge of measurement.  There are 3 broad types: (1) self-report or questionnaire-type measures; (2) structured clinical interviews; (3) discrepancy scales.  In discrepancy scales, equivalent questions about the severity of certain behaviours (and problems) are asked of the patient and carer and the discrepancy between the two compared.  Links to some specific insight scales are found here.

Available scales vary considerably in what and how many dimensions of insight they assess, as well as in the range of scoring pertaining to the different dimensions. The scales range from being single items pertaining to insight in a broader battery of questions (‘one-dimensional’ insight scales), to multidimensional scales.  Some dimensions used in insight scales include:

  • awareness of illness
  • recognition of symptoms
  • the ability to relabel these symptoms as pathological
  • awareness of the social consequences of mental disorder

Many scales contain dimensions related to treatment but differ in what aspect of treatment they target, for example

  • perceived need for treatment
  • potential benefit of treatment
  • compliance with treatment

Scales with temporal dimensions assess whether the patient has insight regarding past, present or the risk of possible future episodes of illness.

Insight & Capacity (NICE Guidelines)

Insight & Capacity (Practicable Steps)