Abstract

Poor insight into illness is considered the primary cause of treatment noncompliance in schizophrenia. Yet, the complexity of the phenomenon of poor insight is, in my view, not well understood, and we are still short of solid answers to the most basic questions: why do many patients with schizophrenia not feel ill in the sense of attributing their abnormal experiences to this mental disorder, and what is poor insight into illness really? These are the central questions, which the presentation raises and strives to provide preliminarily answers to. The presentation has two parts. In the first part, I will discuss the definition(s) of poor insight, review the available results from empirical studies, and discuss the predominant conceptual accounts of poor insight (which consider it as an ineffective self-reflection, caused either by psychological defences or impaired metacognition). I will argue that these accounts are at odds with the phenomenology of schizophrenia-according to which schizophrenia is a specific disorder of the self that involves a variety of alterations of the structures of experiencing that affects the very conditions of self-reflection. In the second part, I will propose a phenomenologically oriented account of poor insight in schizophrenia. I will try to argue that the reason why most schizophrenia patients have no or only partial insight and consequently do not comply with treatment is rooted in the nature of their (non-psychotic) anomalous self-experiences (i.e. self-disorders) and the related articulation of their psychotic symptoms. More specifically, I will argue that self-disorders destabilize the patients’ experiential framework, thereby weakening their basic sense of reality (“natural attitude”) and enabling another sense of reality (“solipsistic attitude”) to emerge and coexist. This co-existence of attitudes, which Bleuler termed “double bookkeeping”, is, in my view, central to understanding what poor insight in schizophrenia really is.