Insight Deficits in Substance Use Disorders Through the Lens of Double Bookkeeping

Abstract: Eugen Bleuler introduced the concept of double bookkeeping in schizophrenia to describe the tendency for people who experience delusions to simultaneously be convinced of the delusional content and yet to act as if the delusion(s) was untrue/irrelevant or be unbothered by discrepancies. We open the question of whether there exists a double reality in individuals with addiction and whether double bookkeeping can be applied to addiction. While double bookkeeping has primarily been explored in schizophrenia, this concept may hold promise in elucidating insight deficits in individuals with substance use disorders. We propose two forms of addiction double bookkeeping: 1) Partial compartmentalization: individuals demonstrate some awareness of the deleterious consequences of drug use, but continue to engage in addictive behaviors; and 2) Total compartmentalization: individuals who act as if the negative consequences of addiction do not exist, reflecting a more generalized and deeper lack of awareness into their own actions. We propose that a basic alteration in the individual’s sense of self occurs in addiction double bookkeeping as it does in schizophrenic double bookkeeping. We describe the proposed double reality in addiction from first-person and third-person perspectives, accounting for their differences. Three clinical exemplar cases are presented, and conceptual implications are explored.