*To whom correspondence should be addressed; Danish National Research Foundation: Center for Subjectivity Research, University of Copenhagen, Njalsgade 140-142, 25.5.23, DK-2300 Copenhagen S, Denmark; tel: +45-3532-8688, fax: +45-3532-8681, e-mail:
Schizophr Bull. 2014 May;40(3):542-7. doi: 10.1093/schbul/sbt087. Epub 2013 Jun 24.
Poor insight into illness is considered the primary cause of treatment noncompliance in schizophrenia. In this article, we critically discuss the predominant conceptual accounts of poor insight, which consider it as an ineffective self-reflection, caused either by psychological defenses or impaired metacognition. We argue that these accounts are at odds with the phenomenology of schizophrenia, and we propose a novel account of poor insight. We suggest that the reason why schizophrenia patients have no or only partial insight and consequently do not comply with treatment is rooted in the nature of their anomalous self-experiences (ie, self- disorders) and the related articulation of their psychotic symptoms. We 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 coexistence of attitudes, which Bleuler termed "double bookkeeping," is, in our view, central to understanding what poor insight in schizophrenia really is. We suggest that our phenomenologically informed account of poor insight may have important implications for early intervention, psychoeducation, and psychotherapy for schizophrenia.
对疾病的认识不足被认为是精神分裂症治疗不依从的主要原因。在本文中，我们批判性地讨论了对认识不足的主要概念解释，这些解释认为认识不足是一种无效的自我反思，要么是由心理防御机制引起的，要么是由元认知受损引起的。我们认为，这些解释与精神分裂症的现象学不符，我们提出了一种新的认识不足的解释。我们认为，精神分裂症患者没有或只有部分认识，因此不遵守治疗的原因在于他们异常的自我体验（即自我障碍）的性质，以及相关的精神病症状的表达。我们认为，自我障碍会破坏患者的体验框架，从而削弱他们对现实的基本感觉（自然态度），并使另一种现实感（唯我论态度）出现并共存。这种态度的共存，布勒勒称之为“双重簿记”，在我们看来，是理解精神分裂症中真正的认识不足的关键。我们认为，我们对认识不足的现象学解释可能对精神分裂症的早期干预、心理教育和心理治疗有重要意义。
