Link Between Low Insight, Metacognitive Impairment in Schizophrenia

schizophrenia diagnosis
schizophrenia diagnosis
Awareness of self and others may provide insight into one's own psychiatric challenges.

The findings of a study in Schizophrenia Bulletin suggest that poor insight was predicted by impaired metacognition in patients with schizophrenia.

A lack of insight into one’s own psychiatric difficulties can lead to the avoidance of treatment, allowing symptoms to worsen, but good insight has been thought to put patients at a higher risk for suicide, as awareness of illness may compound emotional distress.

The study investigators examined how metacognitive skills were associated with insight across various symptom profiles. A total of 324 adult outpatients (74% men) received diagnoses of schizophrenia or schizoaffective disorder, according to the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Participants were rated on the Positive and Negative Syndrome Scale (PANSS) and Metacognitive Assessment Scale-Abbreviated.

From these assessments, 4 profiles emerged: good insight (PANSS insight item score ≤2)/low symptoms (n=71), impaired insight (PANSS item score ≥3)/high negative symptoms (n=43), impaired insight/high positive symptoms (n=50), and impaired insight/high diffuse symptoms (n=160).

Metacognition is the skill of integrating awareness of the self and of others and using that knowledge responsively. The group with good insight had better overall metacognition, including the skills of self-reflection, awareness of the other, and mastery (adaptability and problem-solving).

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Some unexpected findings emerged. Women were overrepresented in the impaired insight/positive symptoms group and experienced high emotional distress despite the assumption that lack of insight improves mood. In addition, the metacognitive skill of decentering, or awareness of multiple facets of a situation, was comparable in patients regardless of insight.

Because of the study’s cross-sectional design, it was unclear why metacognition predicted insight independent of symptoms. The investigators also noted that the participants were all receiving treatment, so the sample may have not represented low-insight patients who are unaware of the need for treatment.


Lysaker P, Gagen E, Wright A, et al. Metacognitive deficits predict impaired insight in schizophrenia across symptom profiles: a latent class analysis [published online October 15, 2018]. Schizophrenia Bulletin. doi:10.1093/schbul/sby142