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Do paranoid schizophrenics know they are ill?

Paranoid schizophrenia is a severe mental illness characterized by psychotic symptoms such as delusions and hallucinations. A key feature of paranoid schizophrenia is that those who have it often do not believe they are ill. This lack of insight can make treatment challenging. In this article, we will explore whether paranoid schizophrenics know they are ill and the implications this has for treatment and recovery.

What is paranoid schizophrenia?

Paranoid schizophrenia is a subtype of schizophrenia, a chronic mental health condition caused by changes in brain function. Schizophrenia affects about 1% of the population and usually begins in young adulthood.[1] The main symptoms of schizophrenia include:

– Delusions – fixed, false beliefs not based in reality. In paranoid schizophrenia, delusions often involve themes of persecution.
– Hallucinations – hearing, seeing or sensing things that are not there. Hearing voices is common.
– Disorganized thinking and speech.
– Extremely disorganized or abnormal motor behavior.
– Negative symptoms like reduced expression and lack of motivation.

In addition to these psychotic symptoms, paranoid schizophrenia involves excessive paranoia, suspicion and distrust of others. Sufferers often feel they are being persecuted or plotted against. Other symptoms like anxiety, anger, argumentativeness and violence can occur.

Do paranoid schizophrenics have insight into their illness?

One of the major obstacles in treating schizophrenia is that many individuals do not believe they have an illness. This lack of insight is known medically as anosognosia. Research suggests:

– 50% or more of schizophrenics demonstrate a lack of insight into their condition.[2]
– Lack of insight is more common in paranoid schizophrenia than other subtypes.[3]
– Poor insight is associated with more severe positive symptoms like delusions and hallucinations.[4]

Why don’t paranoid schizophrenics believe they are ill? There are several contributing factors:

– **The illness itself** – Biological changes in the brain related to schizophrenia impair a person’s ability to have self-awareness and accurately evaluate their own behavior and functioning.

– **Delusions** – Strong fixed false beliefs make it difficult to accept other viewpoints. Paranoid delusions involving persecution reinforce that the person is being treated unfairly, rather than ill.

– **Cognitive distortions** – Schizophrenia impairs organized thinking and judgment. Sufferers have trouble integrating information that contradicts their beliefs.

– **External validation** – When family and friends do not confront the person’s odd beliefs or behavior, it reinforces their delusional perception.

– **Stigma** – There is still stigma related to mental illness in society. Admitting they have schizophrenia is very difficult for some.

Consequences of poor insight

Lack of insight has negative consequences for the treatment and wellbeing of paranoid schizophrenia sufferers:

– **Non-compliance** – If someone does not think they are sick, they are unlikely to take medications consistently. Up to 60% of schizophrenics are partially or fully non-compliant with treatment.[5]

– **Worse outcomes** – Poor insight is linked to more frequent relapse, rehospitalizations, self-harm, suicidal behavior and increased functional impairment.[6]

– **Violence** – Schizophrenics with impaired insight show an increased risk of violence. However, adherence to treatment reduces this risk significantly.[7]

– **Homelessness** – Schizophrenics who do not realize they need help are at very high risk of ending up homeless due to an inability to function independently. About a third of the homeless population has schizophrenia.[8]

– **Victimization** – Those with poor insight are more vulnerable to being victimized and exploited by others. They are often unable to recognize dangerous individuals or situations.

– **Strained relationships** – Family members who try to get treatment for their loved one may be accused of malicious intent due to paranoia. This can damage relationships.

Can insight be improved?

While lack of insight is common in paranoid schizophrenia, evidence shows that insight can improve in some cases with proper treatment and support:

– Medications like anti-psychotics often reduce delusions and hallucinations. As symptoms improve, self-awareness may also increase.[9]

– Psychoeducation helps patients and families better understand schizophrenia as an illness and the role of treatment. This promotes insight.[10]

– Cognitive behavioral therapy can teach schizophrenics to reality test unusual beliefs and reduce paranoid thinking over time.

– Family therapy helps relatives learn how to compassionately confront psychotic thinking and encourage treatment participation.

– Peer support provides social reinforcement from other schizophrenics who have achieved insight into their disorder.

– A trusting relationship with a case manager or therapist may help individuals listen to feedback about functioning.

– Recovery of executive functioning and communication skills associated with schizophrenia can improve insight.

However, lack of insight remains a lifelong struggle for some schizophrenics even with treatment. Patience and persistently gentle confrontation are needed. Involuntary hospitalization may be required in cases where poor insight leads to dangerous behavior.

How is insight measured?

Clinicians use insight assessment scales to evaluate patients’ awareness of their mental disorder. Some examples include:

– **Scale to Assess Unawareness of Mental Disorder (SUMD)** – The most widely used scale. It measures awareness of having a mental disorder, the effects of medication and consequences of illness.[11]

– **Schedule for the Assessment of Insight (SAI)** – Assesses awareness of mental illness, need for treatment and symptom attribution.[12]

– **Insight and Treatment Attitudes Questionnaire (ITAQ)** – Looks at perceived need for treatment, awareness of symptoms and attributions for illness.[13]

– **Birchwood Insight Scale (BIS)** – Assesses three dimensions: perceived need for treatment, awareness of illness and illness attribution.[14]

Higher scores indicate better insight on these scales. Repeated assessments over time can track improvements. Information from caregivers is also considered since self-reports may be unreliable.


In summary, lack of insight into having a mental illness is a major impediment to recovery for those with paranoid schizophrenia. While insight can improve in some cases with comprehensive treatment and education, the biological deficits and pervasive delusions associated with schizophrenia make it difficult for many sufferers to acknowledge their own illness. Family support, gentle confrontation and team treatment approaches are often required to overcome poor insight. More research is still needed on how best to instill illness awareness in schizophrenics to enable collaboration in care.