Insight and Mental Health

Like with severe depression, there's a lot of cognitive distortions, like they call them in cbt. But someone might think that they're just a terrible person. They feel guilty, their self esteem is low. And you could make a case that depression has a level of anosognosia. They may not say, oh, depression is an illness. I need to treat this illness. They may say, life is just terrible, it's just a fact.

Hello, I'm Dr. Farah White.

And I'm Dr. Grant Brenner.

We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment. Doorknob comments are important things. We all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob.

Doorknob comments happen not only during therapy, but also in everyday life. The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking and experiencing. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out. Today we're going to be talking broadly about insight, what it means, how it helps to have insight, and the different ways that insight can be low or missing, and how that affects how we deal with illnesses, particularly mental illnesses, how that can affect treatment and the people around us.

I'm really glad that we're bringing this up today because I think along with the sort of rise of therapy speak, there is a layman's term for insight, which just means like the ability to sort of see deeply into things or to be connected to our own intuition and patterns. And then there's the way that mental health clinicians think about insight. When we do what's called, like a mental status exam, we're looking. It's not a physical exam like other doctors do, but we're looking for different markers of mental health and wellness versus pathology and insight, which is really the degree to which someone understands what's going on with them, that the symptoms that they're having are part of an illness is, I would say, a very strong prognostic factor, which means that it can determine things like whether or not they stay in treatment or whether or not they take a medicine that they need. Because if they have no insight and they don't believe anything is wrong, then why would they take Medicine, Yeah.

It can also have a role in the type of treatment that is offered. And so there's a few different ways that that term comes up, as you said. One of them is in the context of talk therapy and traditionally psychodynamic or psychoanalytic therapy, which has been called insight oriented therapy, because the goal of the therapy is over time, for the person to get to know themselves better, to develop more insight. And that's something that's true for everyone. We, you know, could all probably have better insight into our own unconscious motives, for example, or the role of patterns that we carry from growing up, developmental patterns, early relationships into situations in adulthood, in the workplace, or personal relationships. That's the kind of insight that you can build. And so insight building is a form of learning and there's a lot of different factors that feed into it. A big one is personality. So one thing we talk about in terms of psychotherapy, whether someone can benefit from insight oriented therapy or whether they might be better with a nuts and bolts type of therapy that is more like directive or coaching oriented is, is what is their reflective function? Like, how much are they able to take feedback about themselves or think about themselves and make inferences that allow them to deepen their self knowledge? And how much are they more likely to be, you know, quote unquote defensive? So someone who's very narcissistic is less likely to be able to say, oh, that's a good point. I am super narcissistic.

Right. And I do think sometimes when people talk about therapy being really hard or really easy, it can be because, let's say they are struggling and they have very little insight and maybe that therapist isn't challenging them to have more or to look at things that they won't be able to handle. Right. So insight oriented therapy is much, much harder for the patient than supportive therapy or than a manualized therapy where it's like, do this exercise or oh, that sounds really hard. Insight oriented therapy is not something that everyone can participate in. Right.

Well, like harder in what ways? Right. So if we're talking about, yeah, psychodynamic therapy. Yeah, there's lots of different ways of talking about it, but one of the common things is what you said is to look at how much of it is on the supportive end and how much of it is on the uncovering end. And the uncovering is becoming aware of truths about oneself which are often difficult to take in. Though it can also apply to insight about strengths and areas where there is a potential for happiness or joy. Because sometimes People have trouble having insight into what's good about them as well.

Yeah, I think that's a really good point. Maybe we should give some examples of how it would look. Let's say I'm someone who's struggling to get to work on time in the morning and as a result of maybe my poor time management or other limitations, I end up sort of causing chaos in my office, right. Needing a lot of say like intervention from a management team. So a supportive therapy, what would that look like versus what would an insight oriented kind of just saying like okay, let's, these are the facts. And someone who's struggling and is coming in for help, what might they expect to get?

Well, what are they saying when they're coming in for help? Right, because the, we call it like the chief complaint or the reason they're in therapy. What are they saying? They're having trouble in work. Are they saying like my workplace is unreasonable. They expect everyone to be on time. They expect me to, you know, like do do these things. And I think that's right. That's not what they said when they hired me. Versus if they're coming in and saying, well I know I'm in the wrong, but I'm having a lot of trouble making changes right from the present the presentation from, from what they're saying they want help with. You immediately start to determine how much insight you think they have. But you also need to gather more information. Like I said, is it a clear job description or is their manager pulling a bait and switch? So what scenario do you want to go with?

Okay, so let's. Because where I sort of want to lead to is that like a good, that a good therapist will dig a little bit. So let's say I came in explore, right? We'll explore. There's some reality testing involved. So if I came in to a supportive therapist and said, oh my manager like won't stop criticizing me and I feel like it's really unfair. And I always find my, I end up in these situations where I'm with really demanding. I, I report to these really demanding people who need me to come in on time or even if I just said they're demanding and I didn't say anything else. What would a supportive therapist say versus what would might you say?

Yeah, I guess I'm having trouble with, with answering the question for kind of the reason you're saying like I would want to explore and get to know the person. So you know, generally speaking supportive therapy would be more reflective and empathetic. So I Really, I don't know how to answer the question based on what you're describing.

My point, My point is that just because someone is coming in for therapy, we don't know exactly what they're getting and we don't know how much insight is going to build. Yes, that's my point.

Yeah. So. Well, I think when you're, when you're, when you're first working with someone, that's important to assess. And so from a therapy point of view, from a psychodynamic therapy point of view, of course, we're getting a sense of what the defenses are that the person is using. And are they more, quote, unquote, sophisticated defenses or are they more. I don't like the words, but these are the words that are often used. More primitive defenses. So people with more primitive defenses, denial, projection, lack insight. And so you would work with them more supportively. You would encourage them to look at what's happening less aggressively. You might offer them some support about, like, what steps to take, but you wouldn't necessarily draw attention that maybe they were not seeing their side in it. And if you, if you did, you know, what would you expect to happen if you were working with someone with limited insight and you tried too soon or too, too assertively to get them to see what they were doing wrong?

Well, I think there are a couple of risks there. So one thing might be this idea that it just doesn't land and they really, you know, because I, I think I would test the waters a little bit. Like, oh, you know, is it okay if I get some more information? I want to see if they're, you know, what your role is in this dynamic. Because I would say, oh, it's always about a dynamic. And I know that we could really sit here and vilify your boss, but I don't think that would be helpful to you. Right. But. So I think I would say the best case is that an interpretation or going down exploring that just doesn't land. And the absolute worst case is that it blows up the alliance. Right. That the patient sees me as totally unsupportive, not on her team, not helpful. And then it reinforces this idea that everyone is just out to get her. Everyone is critical all the time.

Right.

And maybe someplace in between.

Right. So I think, I mean, I think in a general sense, if people don't have as much insight into their role in it, and, you know, it's not always like just the person, you have to look at the situation. Like I said, maybe the manager is being Unreasonable. I think in the process of exploring what the context is, that's a relatively supportive approach because you're not confronting the person with something that could be more challenging. But in the course of exploring it, a lot of times people will start to make connections.

Yeah. And that's ideal, right? That people make the connections themselves and start to understand. Even if, let's say, I can't change my behavior and my morning routine is just so long that I'm never gonna be able to get to the office at 9, at least if I can understand that that might cause frustration, I think that would be. And then maybe there are other things that I could do to adapt. Right, right.

You could do some problem solving without confronting the. The low insight about their role. Is there a way to do some of those things the night before? How would it help you to get in on time? Would it make it easier on the job? Some of that gets into how do you motivate people to work on change? So if someone doesn't have as much insight into the nature of their own function or the impact of their own behaviors, then sometimes you can talk about how it will benefit them. That has been kind of developed into something called motivational interviewing, which is good for people. It was originally developed for treating people with substance and alcohol use disorders who often are, quote, unquote, in denial, who don't have insight or who aren't ready to change. And so you can focus on how it will benefit them and. And where they are on the path to being ready to change. You know, the point where they can recognize they have a problem. I think one. One of the core issues. And let's talk about it from kind of a. Like a psychiatric illness point of view from. From a medical disease model.

Okay.

As you started out saying a bit, if the nature of an illness is such that you don't know that it is an illness, then the approach is very different and often more difficult in some ways. So let's say you meet with a patient and they tell you that their family thinks they have a drinking problem, and they're drinking eight drinks a night every night, and they've had a couple of DUIs, and they still don't feel that it's a problem. They're able to function, or they're. They're just not able to see it. You might think that they're using denial. That often is the case with things that look like addictions. There is a lack of insight. So you could ask, well, how do you address that? You can tell the Patient, hey, I think this is a problem. Why don't you? You've had these issues, and maybe some of it is the biological effect of the substance on the brain as well. That makes it harder. The nature of the addiction, that causes a kind of a cognitive rigidity so that they're not able to see something that seems obvious to everyone else.

Right. Or that someplace along the way, because they have been so used to making excuses for themselves or their drinking, they have sort of. We would call it, like, externalized. Right. They sort of look at everyone else and keep the focus on what other people could be doing better or differently instead of looking at themselves.

Right. That's the sort of the psychological outcome on relationships, externalizing, like, kind of blaming other people, like, leave me alone. Why are you giving me such a hard time? Again, there's this biological factor which is kind of like what happens in the neurocircuitry of the brain when someone is stuck on something. And addictions can do that. Or substance use disorders, as we call them. If you think about, like, obsessive compulsive disorder, which has, you know, obsessions and compulsions, and people can look up the specific diagnostic criteria. That's interesting, because in the diagnostic criteria, you specify whether they have a low level of insight or good insight. And people with a low level of insight will believe that whatever they're obsessed about is true. And it has, like, almost a delusional quality. It's like a false belief. But it's usually fixated to something like if they don't perform a certain behavior, then a terrible outcome will take place, and they believe that it's true. Or they believe that people think that they're awful, and if they don't keep doing what they're doing, then they will be exposed.

Right. So, you know, it's interesting because a lot of OCD is around, you know, maintaining a sense of safety and around a fear of being seen. And I guess I just thought that that was kind of connected, right, to a fear of being seen, let's say, by others or being hurt by something that could occur. You know, maybe the water is running or the stove is on and you know, that something, someone checking it 10 or 15 times gives them this sense of safety. Right. It's a relief.

Well, yeah, there's underlying fear of a terrible outcome. But with poor insight, with ocd, they literally will believe that if they don't stereotype, but check the stove 10 times, someone will die in a car crash. They believe that it's true. They believe that that is the reality that if they don't perform that behavior, then whatever their obsessional fear is will actually happen. And if you ask them, you know, they'll say that they absolutely believe it. Whereas if they have fair or good insight, they'll say, well, I know it's not true. I just. I can't help myself. And that's definitely an indicator for who will do better when you try to treat that, certainly in therapy, because they're able to kind of ally with the therapy, whereas otherwise, you know, think about it from this point of view. I use this example. If you went to see a therapist and you said, I don't know why I'm here. My family told me I need to see someone because they told. They told me that the sky is actually blue. But when I look up at the sky, it's very clearly purple. Like, there's no question in my mind. So I don't. I don't know, like, why, why I'm here, because obviously the sky is purple. I don't know why everyone else is saying the sky is blue. Maybe they're trying to, you know, they want my money or something, or they're trying to. They're, you know, get me committed. Or, you know, you can start to get a paranoid quality. When there's a lack of insight and you are confronted with reality, then what are you supposed to do?

Right.

Right.

And then. But I also think that as the therapist, it's very, very hard to, you know, there are some of these sort of delusions or beliefs that are harder to address than others. And if we said, well, let's forget about what color this guy is for a second. What does it feel like? What does it mean to you? We're probably going to get farther than, you know, and if we can join with the patient in their frustration or their fear, we're probably going to get farther than. By just trying to reinforce a belief that they can't get on board with. And.

Right.

I think one of the things that it. Things that's really hard is these sort of somatic complaints. And I remember when I was in med school hearing from one of the doctors at the va, like, someone, I guess it's okay to talk about this. Someone had a belief that there was something inside them. And that's very common, like either foreign object, foreign body. And the attending said, well, there's, you know, we've done actually a CT scan and we didn't see anything. So I don't think you're in danger. Right. And it Was interesting that he didn't say, well, we've done a CT scan, and there is nothing that's actually inside you. I think it was a good first example of not wanting to alienate the patient, you know, and to kind of get them talking and thinking about things.

Right. Well, so I think that principle is generally what clinicians will do if someone has a fixed false belief. Number one, you don't confront it directly. It just. It doesn't work. Because if it did, they wouldn't have a problem. Right. If people could just have insight because people tell them stuff, then you wouldn't even need therapy a lot of the times because people would just read a blog on narcissism and start empathizing with people and just follow what the recommendations are. So insight is required for change, and that has that psychological component. It also has this kind of harder neurological component. There's something that happens when people change. The brain has some plasticity.

So.

So in that case, if you said, we did a CT scan, there's no chip implanted in your body anywhere, what would happen? A lot of the times, and it is a very common situation. So the answer would be, well, you know, listen, aliens put it there, and I'm sure they designed a chip that isn't visible on ct. Yeah. So, well, we got an mri. It's not visible on mri. Like, there's no, you know, there's no way to argue someone out of that. And that comes up a lot of times in, you know, outside of therapy. Right. Like when people have a disagreement, they don't see things the same way. They just get into, like. Like a battle over it. They just try to litigate reality and try to convince the other person by sheer force of will. It doesn't ever lead anywhere constructive.

I know.

So. So that's kind of with. With conditions where there's that. What feels like a biological or a neurological lack of insight. The term for that in neurology and in psychiatry is an oz Agnosia. Agnosias in general are a term for neurological condition where something isn't recognized or you lose the ability to know something. Like, you could lose the ability to recognize faces. There's a. A really great book by the neurologist Oliver Sacks, and the title is the man who Mistook His Wife for a Hat. Because this is a man who had proposagnosia. Proposagnosia. I think I forget exactly what. Probably due to a stroke, wasn't able to recognize faces. I think it must have been due to a stroke or, you Know, after a brain tumor or something like that. And so he would learn to recognize people by something else, like a hat that they were wearing or a piece of clothing. And so, you know, that's a really sad and difficult situation. Can you imagine what it would be like to look at someone's face and not be able to see faces anymore? The facial recognition area is like a small region of the brain. And if that is damaged, you can lose specific abilities, which is not unusual, where people sometimes will lose the ability to feel an object. Like you could, you know, if you. If someone hands you a key, you'll say, oh, that's a key. But people can lose the ability to detect what an object is. Sometimes it can be very specific, or sometimes it can be broader. And so that's called that. Those are agnosias. An osagnosia is when people don't know they have an illness or a deficit. So in neurology, a lot of times it's when people have a stroke on the left hemisphere, they get something called right hemi neglect, meaning the whole right side of their body and the world, they don't know it's there anymore. So if you ask them to put on their jacket, they'll only put their left arm in the sleeve, and the right side will just be hanging. And if you ask them, like, what's going on, they'll say, nothing's wrong. In psychiatry, it's very common, relatively common in schizophrenia, where 30% of patients have anosognosia, and in bipolar disorder, where 20% have anosognosia. So that means, like, if you're trying to give people medications which can be very beneficial for people with those conditions, a lot of times, as you said at the beginning, they won't take them. And so similar to the CT example, you discuss with them how the medication will benefit them, say, to get to work, but not to treat an illness they don't believe they have.

Yeah, yeah. And I think there's been a lot of push towards sort of psycho education and informed consent. And I think it's really tricky, at least with doctors and family members, when someone who needed to take a medication maybe 50 or 60 years ago, they could put it in their tea in the morning, or they could say, oh, hey, here's a vitamin. Now, when we give someone medicine, they deserve to know what it's for, what the risks are, what the benefits are. And so we can just hope that they have the insight to want to take something that's going to be helpful.

Right. We. We interviewed or we spoke with Jacob Appel early on in the podcast. I think it's in less than 10, maybe number six. And Jacob is a brilliant multi degree physician, talks about bioethics among many other things. And what you're saying is true for American culture, for American ethics, informed consent is the gold standard. But in other cultural settings, they don't necessarily have the same guidelines. And it wouldn't at all be unusual not to tell the patient that they were sick. And I've even heard of many stories like this of some, someone who could understand that they were sick, but their family, you know, will tell the doctor. Sometimes in eastern cultures we don't want mom to know she has cancer, so don't tell her. And we'll, you know, we'll give her the medication and yeah, we'll say it's, it's herbal medicine or something like that, but we don't want her to know that she's dying. And so you can make an ethical case for that. And it depends on the guidelines. In the US where we have to give informed consent, if someone didn't know they had an illness and they needed treatment, it's unusual, but sometimes people would, you know, get a power of attorney. Sometimes with patients who have schizophrenia or severe bipolar disorder, they will be taken to court and ordered to get treatment. And there's all kinds of things in place, like ACT teams, assertive community treatment, and there's ways to give people medications that last a long time so you don't have to rely on them taking a medication that they don't think they need. But you know, in that case it comes down to like, formally it would come down to a capacity assessment. Do they have the capacity? So that's a technical discussion of what informed consent is. Because in order for someone to actually give informed consent, they have to understand what they're being treated for, why, what the likely outcomes are, what the alternatives are, what are the risks of no treatment and the benefits of treatment.

Yeah, and that is, I think one of the main places where psychiatry can kind of interface with a lot of the other medical specialties.

Right, right. So getting back to kind of the idea of insight and as agnosia in particular. So we know, right. Schizophrenia and bipolar disorder are considered severe mental illnesses. And you know, a certain percentage of people won't know that they have those problems. And we do the best we can do to treat them with ocd. It's actually like a diagnostic criteria, you know, high or low insight. I've actually treated people with TMS over time where for ocd, where their insight will improve with treatment. And so again, that kind of barometer of how much insight there is, is, is a big measure of how much people can, you know, collaborate in their own care in a direct and knowing way. And so with ocd, it's like kind of written into the rules of diagnosing it. But what I'm curious about is how you think about, say something where it's not as clear cut like depression. Like with severe depression, there's a lot of cognitive distortions, like they call them in cbt, but someone might think that they're just a terrible person, they feel guilty, their self esteem is low. And you could, you could make a case that depression has a level of anosognosia. They may not say, oh, depression is an illness, I need to treat this illness. They may say life is just terrible, it's just a fact. And they may say, well I've, I learned in psychology that people who are depressed are more realistic. I'm just being realistic.

Yeah. And sometimes being more realistic can I think, lead to maybe some, you know, the more we know and understand about some of the terrible things in the world, it might be natural to feel depressed about what's happening where, whereas when people come in for treatment, the, the goal is not always to get them to feel happy, you know, that, that may, you know, I always say like I'm a psychiatrist, not a magician, but certain things that they may be struggling with, like I can't get out of bed in the morning, brushing my teeth, feels like climbing Mount Everest. Right. And they might because they don't have insight into depression. And now people, I would say, have like this social media understanding of certain things which is very hit or miss. So if I were to say, well, taking medicine for your depression should make it easier to get out of bed in the morning and should make things like brushing your teeth or showering just a bit more manageable. And then we go from there, you know, but it's always like, well, what are the goals of the treatment and what does the patient understand about their own struggle? Just do they think they're lazy or do they think they're ill in some different way? We see that a lot where people get worked up for things. The medical workup doesn't find anything wrong, but that is part of what we're looking at.

Well, so there's other specific conditions that we could talk about and probably will in a couple of minutes with depression and especially with social media. So. Right. There are people who just don't agree with that there are psychiatric illnesses and you'll see things online like, you just need to exercise. I think the psychiatric view is that, yeah, not everyone who feels down has clinical depression. You have to be careful diagnostically. So assuming that there is something that we could consider an illness called major depressive disorder, then within that people can have psychotic depression. They can hear voices and things like that. But what do you think about that distinction between insight as a psychological factor and insight as an osagnosia? Like not knowing you have an illness when it comes to depression, or, you know, believing that the negative view you have of yourself is the reality rather than a symptom of depression. Because you could say, well, listen, the world has always had terrible things and you can read the news today and be very upset by it. And then you could look at, like, the work of people like Steven Pinker who talk about the angels of our better nature, who point out that, you know, during. During the. The Dark ages, things were on average worse for everyone. You know, death rates were way higher. There was more crime. The punishment for committing a crime was like, horrific. Like, we've become more humane and safer in general. So you could try to, like, argue with someone. Well, yeah, of course there's bad things in the world, but your depression is leading you to just see. See them through a glass darkly. So is. Is that a form of anosognosia or do you see that as psychological? Like, at what point do you think that this is essentially like a biological process secondary to the depression? Oh, I mean, or delusional almost.

Right. I guess what's important is how tightly someone is clinging to it versus if they are able to, like people usually say, just like a glimmer. We'll talk about a glimmer of insight. Like if a patient says, well, you might be right, you know, but I doubt it, then we know that there is some chance. Right. There's something that could grow versus if. With an agnosia. I think by definition. Right. It's sort of completely absent and that sort of hopelessness. But I don't. Is that not what you were getting at or.

Yeah, so, yeah, you might assess for it. I just, I wondered if you had an opinion about it, but what you said makes sense to me.

Yeah. And so a lot of. I think the treatment around that, you know, they used to. Before I think meds were really a part of things they would give people with psychotic disorders and severe depression, who today we might say, you know, couldn't even participate in psychotherapy. Like we would probably just treat that person with medicine and maybe a little bit of like manualized therapy. But we wouldn't say, well, this person should like go and you know, have some sort of intensive therapy. But I actually think that the gold standard is really a combination of both because they each sort of support the other. I would say like people who are depressed and get medication are, are more able to participate in therapy.

Yeah, it depends on things like character or logic issues. And people can be very obsessional. And of course we're talking about, you know, what we would want to think of as true clinical depression and not, you know, something else like a complex grief type of picture. But when people are very, very rigid in their thinking and obsessional at baseline, that makes it more difficult to change regardless of what you're treating with depression. I think that's the case particularly because depression treatments are not that successful. Therapy has a better chance of working over the long haul probably than medication. Medication treatments for depression get about at best a 35%, what we call a remission rate using kind of a medical model, like getting rid of and like basically all of the symptoms of depression. But what you said I think really resonates for me in terms of depression can be under treated. And when people are depressed, they do tend to under treat their depression, at least in part because they may not see it as depression and also because they may not feel that they're worth it because there's often feelings of worthlessness. They may not feel like anything will help because symptoms of depression or feelings.

Of helplessness and hopelessness, which makes it so insidious. I think trying to get someone who doesn't really believe that they deserve to feel better because they have such a poor self view or because they felt so bad for so long, it becomes.

A way of life.

Yeah, right. And it can actually feel scary to change or to feel joy or to have hope because I think there's a lot of sort of hope and then acceptance around things. When we see that someone is still fighting and trying to feel better, I think that's a really, really good sign that they're eventually going to feel better.

Right, right. When people kind of give up, especially if there are treatments that could be helpful, that's tough. The other thing is that when people are depressed, a lot of times the way they make sense of the circumstances in their life kind of lock in the depression. So you know, they tend to focus on the negatives and discount the positives. And so that will interfere with work or they'll get stuck in bad relationships because the fighting makes them more depressed and the depression keeps them from making changes. When I've seen people recover, sometimes with medications, sometimes people recover from depression spontaneously, sometimes with transcranial magnetic stimulation. Everything changes when people are no longer depressed. So they will be able to solve problems more effectively. Depression interferes with problem solving, cognition and as well as motivation and drive. And they'll still feel sad when something happens or distressed, but they will not spiral into a state where they are not able to do anything. I think what's problematic is when people have been depressed for a very long time, it's not just a matter of recovering. It's a matter of building a new life. And that can be daunting.

Right. And also of making sense of the lost time, which I think is really hard grieving. Oh, what if I had met you 10 years ago and had gone on this medication? Like, what could have been different?

Yeah, exactly. And that is a stress that could put people back into depression in some cases is depression has this kind of like stress diathesis model. There's a biological predisposition, and then there's external stressors. Now, what. What about other things that we see often things like body dysmorphic disorder.

Yeah, yeah, I was thinking of that.

Of anxiety or somatic somatoform disorders, which you alluded to earlier, where people believe and experience physical symptoms and they believe it must be from a medical disease, Even if they've had a very extensive workup. It's either a rare disease that hasn't been diagnosed yet, or those very real physical symptoms are coming from a process in the brain and not the body.

Right.

Or something like fibromyalgia, where people experience pain in different areas of the body, but there's no pathology in the spots that feel pain. It's like what they call a centrally mediated pain syndrome. So there's like maybe dysfunctional patterns of brain activity that make it feel like there's pain in the body. The pain is real, but there's no damage in the body that's proportional to the pain that's experienced.

Right. Well, I think part of what insight can do there is it can really direct people away from the wrong treatment and into the correct treatment.

Do you want to stick with body dysmorphic disorder?

Sure, we can. So let's say that somebody believes that they have some sort of congenital malformation that is only visible to them, or they believe something about their body that's not really true. Let's say my. My torso is so long and my legs are so short that I feel, like, totally uncomfortable even leaving my house.

Right. My eyes are too close together. My face isn't proportional. Here's the diagram from my figure drawing class. Like, it doesn't fit. Right. And that's accelerated by social media, like, looks. Maxing, maybe, and.

Yeah.

And mewing, you know, but it's a real problem because people can go, say, into a plastic surgeon.

Yeah.

And they can have multiple, multiple, multiple procedures.

Right.

And still look in the mirror and not feel like it's. Right.

Yeah.

And to other people, they may. They may look unusual. And so someone might say, hey, like, don't get your lips done again. Or you've gotten so much Botox, you have, like, I can't tell what your facial expression is. And then they don't have insight. They're kind of like, well, you're not on my side. Or you just don't get it. Or they don't get angry. They just say, well, I think I just need it to be a little fuller over here. And then there's a lot of conversations around that. There's this sort of the psychiatric thing. And then there's also like, well, when does a cosmetic dermatologist or a plastic surgeon or kind of, God forbid, someone who's doing esthetic work who isn't properly trained, when do they say, you know, I don't feel comfortable doing anything? And sometimes plastic surgeons will require that a patient get psychiatrically cleared for different types of surgery. And part of that would be to evaluate what we said earlier is capacity. But how do you. How do you think about that is sometimes medications can help. And a lot of times this is a good example because we use a lot of medications in psychiatry off label. So we may want to give someone, like, an antidepressant that helps with anxiety. It can help with eating disorders, maybe with edd, not really sure. But we may want to give them an antipsychotic, which can reduce delusional thinking. How do you talk about that?

I think one, you know, making sure that you are sympathizing with the feeling, right. Of, let's say, having something wrong. That feeling of sort of defectiveness or disfigurement is very, very distressing for people, and it can really take over their lives. So that's why, when I see people who have obviously gone through a lot of pain and spent a lot of time and money to try to look a certain way, I have compassion for them. Right. Because I think part of it is it's, you know, whereas the Rest of the world might say, oh, well, this is a bizarre choice. I look at it like that. That is suffering. Right. And it's very, very difficult, I think, particularly in today's world, when appearance, I think has always been important. But the idea that, oh, well, if you go out to dinner with friends that your, your image on that night is probably going to be, you know, immortalized on social media.

Right. Or you're seeing images on social media that have been modified to look better.

Oh, for sure, that. But I'm just even saying like the average person, when they went out 20 years ago, didn't have to worry about having their picture taken. So it was easier, I think, to leave the house and just be present and enjoy the night in a way that's really difficult to achieve right now.

Right. Some people may worry, right. If I go out, what are the selfies going to look like? And that adds like another layer of concern for their worry.

Yeah.

But then we're also presented with largely impossible ideals, which is kind of a well known problem.

Right, right. And that's where I think the treatment has to be kind of aggressive. Even though I don't treat, treat things aggressively usually, but this really needs to involve a combination of things. And then people having insight enough to say, I don't like my outfit so I could change five more times, but also understanding that their expectations for their appearance are beyond what any normal person could achieve. And then to just say, well, I'm going to put this on because I'm, this is what makes me most comfortable.

So how do you work around the insight piece? Since like, you know, well, how do you think about that? Because there's varying levels of insight. The person may like, oh, I know I have body dysmorphia. Or with social media, a lot of times people will, you know, they'll say, well, that's my body dysmorphia.

Right, right. And then I think it's good that they know that and it doesn't mean that they necessarily feel, let's say, so great about themselves all of a sudden, but that they understand that there is something unhealthy in how they see their body and in action. Right.

So they may, they may kind of know that more intellectually, but emotionally or viscerally in their gut they still feel like something is wrong, but they can tell themselves. And this is kind of comes out of cognitive behavioral therapy, but probably is not unique to cbt. You would say, well, let's say someone's having a panic attack and they feels like they're having a heart attack or they're going crazy is the common report. Right. And they say, well, that's a panic attack. And naming it helps.

Right? Naming it helps, but it's not full insight. It's not full insight. But I do think that it can be a relief to people and also distressing for them to understand that their mind and their anxiety is that powerful.

Yeah. It's useful because it allows them maybe to make a different choice. And also they may be able to tell people around them, like someone they're with.

Yeah.

So that that person doesn't misinterpret. Going back to your example of being late a lot. Right. Like, if someone has difficulty with organization, they have adhd or. Or they're stuck at home because they're. They have trouble getting things just right before they leave the apartment because they're worried about the selfie, you know, they can let other people know. It's. It's not because of you. I very much am looking. Was looking forward to seeing you.

I just.

I can't leave the house because. Because of my ocd.

Right, right. And I think it sort of just being able to name it and to be able to see it takes away a lot of that power because it allows us to leave the house, maybe in spite of the feeling and maybe is the first step to leading a fuller life that's not sort of constrained by the limitations.

Right. That can allow people to have a bit more agency, a little bit more say over what happens, though still, a lot of times there's this inner conflict between what your intellect is telling you and what you feel to be true.

Yeah.

Like in another CBT thing is emotional reasoning. Like, that's emotional reasoning. I feel like no one likes me, but what evidence is there that no one likes me?

Right.

So if you're presented with counterfactuals, are you able to update your beliefs and does that alleviate some of the underlying fear?

Right.

And then does it serve some function? Right. If you. If you look a little deeper, does having the illness serve some function?

Right.

Has it provided some relief from other responsibilities? Does being depressed spare someone from having to face their fears of, you know, pursuing their career and risking failure? You know, is there some kind of expectation management or relief of some other anxiety that's not as evident?

Yeah, that's a good point. I mean, I think these are all really interesting questions, and I know we're wrapping for today, but. Yeah, but I'm glad that we touched on this. I hope to kind of hear from people, and I would love to hear about their personal experiences with this kind of thing.

Yeah, particularly if you have experiences of having had less insight and getting into a point where you have greater insight. We would would love to hear what some of those experiences have been like.

Yeah, sounds good. Okay, thanks so much.

Remember, the Doorknob comments podcast is not medical advice. If you may be in need of professional assistance, please seek consultation without delay.

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