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January 1992, Volume 42, Issue 1

Original Article


M. Iqbal Afridi  ( Department of Psychiatry, Jinnah Postgraduate Medical Centre, Karachi. )
S. Haroon Ahmed  ( Department of Psychiatry, Jinnah Postgraduate Medical Centre, Karachi. )


\\\'Insight\\\', which is an indication of patient’s understanding about his/her illness, needs particularly sensitive measures for its assessment. A questionnaire regarding insight, and brief psychosocial profile of the patients was applied to 103 cases. The cases were categorized according to the diagnosis and initial understanding of mental illness and ‘insight’ by the patients in our culture. The study did not support the popular belief that neurotics have and psychotics do not have insight (JPMA42: 7, 1992).


The concept and presentation of mental illness in our culture differs from that in the west. This may be due to various socio cultural and lexical differences. Somatization of symptoms are more frequently the presentation of psychiatric illness in developing countries. Likewise the psychological features are ex plained on cultural factors and religious beliefs, where super natural agents are popularly considered to be the cause of mental illness. In the assessment of mental state ‘insight’ of the patient about his illness is given consider­able importance. The different concepts of mental illness create difficulties as most of our patients do not fulfil the western criteria for having insight i.e., patient’s aware­ness that the illness is due to mental/psychological disorder and needs treatment. This study attempts to explore the initial under­standing of mental illness in our culture, so that sensitive measures for the assessment of ‘insight’ may be developed.


Four simple questions were used to elicit the insight. They were selected from a series of questions which were taken from western literature. Opinion of three psychiatrists was solicited to assure their simplicity and relevance to assess the initial understanding of the patients regarding illness. A structured proforma was designed to collect brief sociodemographic profile, specially the religious and socioeconomic status of the patients. The previous pathways of treatment-seeking behaviour were also recorded. The questionnaire was applied on 103 patients, between the ages of 18 to 60 years, seeking treatment as outpatients at the department of Neuropsy chiatry, Jinnah Postgraduate Medical Centre, Karachi. Patients with mental retardation, organic illness and drug dependence were excluded.


One hundred and three patients between the ages of eighteen to sixty years, attending outpatients clinic were examined. Forty one were males and sixty two females. Most of these cases were from middle (37.8%) or lower (49.5%) socioeconomic classes and all were residents of Karachi except five from rural areas of Sindh. Among them, thirty eight (36.9%) were illiterate, thirty four (33.0%) studied upto class eighth and the others (30.1%) were matriculate and above. For the purpose of beauty and simplicity these patients were categorized into three main groups according to WHO classification. Neuroses 26 patients, anxiety state 14, hysteria 4, obsessive compulsive disorder 7, hypochon driasis 1, depression 58 patients and psychoses 19 patients. Acute schizophrenic episode 4, schizophrenia 5, manic depres­sive psychoses (maniac) 10. The first question was regarding the patient’s ability to de scribe the symptoms and to accept or deny the presence of any illness. Patient’s awareness about the presence or absence of any illness was the second part of the first question. The second question was about the cause of complaints. The third was “how did you conclude that your complaints are attributable to physical, psychological or supernatural factors?" and the fourth question related to the preference of treatment for their corn plaints with choice of hakim, doctor, psychologist and faith healer. Response to those four questions is given in Table I-IV.


The concept of mental illness in our country is a complex matter and shifts from physical, psychological, mental and spiritual causes. Majority consider psychiatric illnesses as a stigma. As reported earlier from Pakistan, somatic manifestations are perceived as symptoms of organic conditions while psychological features are explained on cultural and religious precepts. Karachi is the most developed and cosmopolitan city of Pakistan, yet the patient population exhibited little awareness of psychiatric illness. If the same study is conducted in the remote/rural areas of the country, the results may be even more different from those in the west. A small number of patients fulifiled the present western criteria for having insight into their illness i.e., 26.21% admitted that they had mental illness (that too in psychiatric outpatient clinic) and only 8.73% preferred psycho logical/psychiatric method of treatment. Others, including neurotic (25.24%) and depressed (56.31%) were either unable to recognise their condition as illness or could not relate them to psychological origin. This study does not support the popular western belief that psychotic patients lack insight while the others have it. It favours the earlier reports from Asia and Africa2 that somatizations are frequently the presentations of psychiatric illness in developing countries. Hence there is a need to re-evaluate the concept of insight in the developing countries and its assessment needs par­ticularly sensitive measures, according to their sociocul­tural and religious backgrounds.


We are grateful to Dr. Shifa Naeem and Dr. Mohammad Ishaque for their help in this study.


1. Teja, J.S., Narang. RL. and Aggarawal, A.K. Depression across culture. Br. J. Psychiatry. 1971; 119:253 -260.
2. Binitie. A. A factor-analytical study of depression across cul tures (African and European). Br. J. Psychiatry, 1975; 127:559-563.
3. Ahmed, S.H. Concept of mental illness in Pakistan and direction of planning. JPMA., 1974; 24:113- 114
4. Abmed, S.H. Cultural influence on delusion. Psychiat. Clin., 1978; 2:1-9.
5. Gelder, M., Gath, D. and Mayou, R. Oxford textbook of psychiatry. Oxford, Oxford University Press, 1983, p. 29.
6. Freedman, A.M., Kaplan, H.l. and Sadock, B.J. Comprehensive textbook of psychiatry. 2nd ed. Baltimore, Williams and Wilkins, 1975, p.736 -2591.
7. World Health Orginization. Mental disorders; glossary and guide to their classification in accordance with the ninth revision of International Classification of Mental Disease (ICD-9). Geneva, WHO, 1978~ p. 290-319.

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