An update on clinical insight, cognitive insight, and introspective accuracy in schizophrenia-spectrum disorders: symptoms, cognition, and treatment

ABSTRACT

Introduction

Poor insight, or unawareness of morbid changes in cognition, emotional states, or behavior, is commonly observed among people with schizophrenia. Poor insight represents a persistent barrier to wellness because it interferes with treatment and self-direction. Paradoxically, good insight may also be a barrier to health when awareness of these changes leads to depression or self-stigma.

Areas covered

This paper builds upon this previous work by exploring these issues in schizophrenia separately as they have appeared in published research over the last three years in three different kinds of insight: clinical, cognition, and introspective accuracy. Specifically, studies are reviewed that address: the adverse effects of poor insight, the paradoxical effects of good insight, correlates with other forms of cognition, and emerging treatments.

Expert Opinion

The evidence continues to offer a nuanced picture of the complex effects of good insight in schizophrenia. Incremental improvements were also found in the development of novel integrative treatment approaches. This work also highlights the intricacy of the concept of insight, the need for further exploration of the effects of culture, and conceptual work that distinguishes the points of convergence and divergence of these forms of insight.

PLAIN LANGUAGE SUMMARY

Many people diagnosed with schizophrenia are unaware that they have a mental illness. This is referred to as having poor clinical insight. People struggle to form ideas about themselves or doubt what they think. This is referred to as having poor cognitive insight. Finally, many people diagnosed with schizophrenia may significantly overestimate their abilities. This is referred to as having poor introspective accuracy. This review shares research that shows that problems with these kinds of self-awareness can make it difficult for those with schizophrenia to manage their lives and the challenges of having a mental illness. At the same time, these problems with awareness may also protect people with schizophrenia from feeling depressed and at odds with the world. We discuss how these forms of unawareness result from many different factors and how new treatments may help individuals develop awareness without being vulnerable to significant emotional pain.

KEYWORDS:

• Schizophrenia
• clinical insight
• cognitive insight
• introspective accuracy
• symptoms
• neurocognition
• social cognition
• metacognition
• stigma
• psychosis

Article Highlights

• Good clinical insight is linked to better treatment engagement, less severe symptoms, higher levels of neurocognition, social cognition, and metacognition. However, it is paradoxically linked to adverse outcomes, including depression, stigma, aggression, and poorer quality of life. There is some indication that these issues may be more severe early on in the illness.

• Good cognitive insight is associated with reduced disorganization symptoms, better community functioning, and neurocognition. However, it is also linked with heightened levels of suicidality.s

• Higher levels of introspective accuracy are associated with good community functioning, social cognition, and neurocognition. Poor introspective accuracy that involves overconfident self-appraisal is the most impairing, except in the case of depression, where it has a protective role as per the insight paradox.

• Treatments emphasizing metacognitive processes improve clinical and cognitive insight but are unstudied in introspective accuracy, with no effective treatments.

• Findings are consistent with prior reviews showing that deficits in insight are more than markers of illness severity and sometimes show nonlinear relations with clinically-relevant targets. Declaration of interests

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

J Mervis would like to thank Drew Sambol for her feedback on drafts of the manuscript.