Cet article fait le point sur l’insight dans la schizophrénie et les interventions qui sont susceptibles de modifier la connaissance de la maladie. Après un rappel des définitions et des méthodes d’évaluation de la conscience des troubles dans la schizophrénie, nous suivons deux axes en lien direct avec l’insight. D’abord, nous interrogeons la place du patient dans la prise en charge. Elles deviennent intégratives et biopsychosociales, ce qui modifie la relation soignant–soigné. Les objectifs de la prise en charge ne sont pas uniquement centrés sur les symptômes, mais aussi sur la gestion à long terme d’une maladie chronique en intégrant des notions telles que l’observance, les croyances et les mécanismes d’autorégulation. L’information apparaît donc centrale dans cette perspective. Dans un second temps, nous interrogeons les conséquences d’une information donnée à des patients présentant des troubles cognitifs et un niveau d’insight variable, ainsi que la nature, les indications et les limites des approches psychoéducationnelles. En particulier, quatre types de démarche psychoéducationnelle sont analysées du point de vue de l’insight et de son évolution : l’éducation au traitement et à la santé, le développement des compétences psychosociales, les interventions auprès de la famille et enfin les prises en charge centrées sur l’expérience subjective du patient.

Poor insight is consistently present in schizophrenia and is among the most discriminating symptoms for differentiating schizophrenia from other mental disorders. Patients are unable to see the most obvious symptoms of their illness, despite the fact that their family members can recognize thought disorder, mania or hallucinations. Results suggest that lack of insight is a part of the disorder itself, rather than an adaptive strategy. Poor insight in schizophrenia has been described as a lack of awareness of suffering from an illness, of the symptoms of the illness, of the consequences of the disorder, and of the need for treatment. Similarly to some negative symptoms lack of insight predisposes to an increased number of relapses and hospitalizations, to deteriorating social skills and quality of social relationships, and to a worsening course of illness. Unawareness is among the best predictions of non-adherence to treatment. Patients do not want to take medicine for an illness they do not think they have. The ways in which patients think about their illness experiences have been associated with a variety of behaviours and emotional responses. In schizophrenia, the study of beliefs about mental illness has generally been centered on people’s interpretations of experiences and how these interpretations contribute to the development and maintenance of symptoms. There are less studies of other beliefs such as the causes of the experience, beliefs about treatment, consequences, and how long the illness is likely to last. The need to understand the way in which a patient appraises his/her own experiences has been recognized. People who integrated their experiences more fully, accepting that they had experienced a psychotic episode, actually showed higher levels of depression. This may reflect the demoralization and stigma that patients associate with mental illness. Many clinicians believe that lack of insight is very often a consequence of denial, a defensive mechanism. Terms such as defensive denial, and lack of insight often reflect underlying conceptual differences. Psychoeducational interventions were developed to increase patients’ knowledge of, and awareness about their illness, there is a focus on knowledge. Education is a process by which a patient gains understanding through learning. Patients have a right to an accurate and complete knowledge regarding their illness and treatment. The assumption is that this increased knowledge and insight will enable patients to cope in a more effective way. Learning implies changes in behaviour, skill or attitude. There is some suggestion that psychoeducation may improve compliance with medication and have a positive effect on a patients’ quality of life. Psychoeducational approaches involve interaction between the caregiver and the mentally ill person. Patient education can take a variety of forms and objectives. It may take place in groups or on a one-to-one basis and it may involve the use of videotapes, self-help or other media. The goal may be to better manage the patient’s treatment, illness or condition to help him/her attain an improved level of health. Psychoeducational interventions address the illness from a multidimensional viewpoint, including familial, social and pharmacological information. Patients are provided with support, information and management strategies. Interventions may include elements of behavioural training, social and life skills training, or education performed by professional caregivers. This review studies the links between insight and various psychoeducational interventions: health and treatment education, psychosocial skills training, familial intervention, and intervention focused on subjective illness experience.