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Cited by 247Schizophrenia research and treatmentMental Health and PsychiatryPsychoanalysis and Psychopathology Research

Insight in schizophrenia spectrum disorders: relationship with behavior, mood and perceived quality of life, underlying causes and emerging treatments

Open access
Lysaker, Paul H., Pattison, Michelle L., Leonhardt, Bethany L., Phelps, Scott, Vohs, Jenifer L.·2018·World Psychiatry
DOI 10.1002/wps.20508PMC PMC5775127
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Abstract

Poor insight in schizophrenia is prevalent across cultures and phases of illness. In this review, we examine the recent research on the relationship of insight with behavior, mood and perceived quality of life, on its complex roots, and on the effects of existing and emerging treatments. This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function, while good insight predicts a higher frequency of depression and demoralization, especially when coupled with stigma and social disadvantage. This research also suggests that poor insight may arise in response to biological, experiential, neuropsychological, social‐cognitive, metacognitive and socio‐political factors. Studies of the effects of existing and developing treatments indicate that they may influence insight. In the context of earlier research and historical models, these findings support an integrative model of poor insight. This model suggests that insight requires the integration of information about changes in internal states, external circumstances, others’ perspectives and life trajectory as well as the multifaceted consequences and causes of each of those changes. One implication is that treatments should, beyond providing education, seek to assist persons with schizophrenia to integrate the broad range of complex and potentially deeply painful experiences which are associated with mental illness into their own personally meaningful, coherent and adaptive picture.

AI snapshot

Written from the paper’s full text.

TL;DR

This review synthesizes recent research on insight in schizophrenia spectrum disorders, showing that poor insight predicts poorer treatment engagement and community function, while good insight can paradoxically predict depression, demoralization, and lower self-reported quality of life. It proposes an integrative model in which insight requires integrating internal, external, interpersonal, and life-trajectory information, and suggests treatments should help persons make personally meaningful sense of illness experiences.

Key findings

  • Poor clinical insight was associated with negative medication attitudes, medication refusal, non-adherence, poorer therapeutic alliance, higher symptom severity, and poorer community function; in a summary of literature published between 2005 and 2015, poor insight predicted poor adherence in 20 of 26 studies reviewed.
  • Good clinical insight was linked to depression, hopelessness, demoralization, lower self-reported quality of life, and heightened suicidality; a meta-analysis of 50 cross-sectional studies found a weak relationship between clinical insight and depression, but longitudinal studies suggested a stronger, more complex relationship, and several studies found the insight–depression link was mediated by self-stigma.
  • Poor insight has multiple proposed roots: anomalous experiences, brain structure/function abnormalities, neurocognition, social cognition, metacognition, and social/political factors; meta-analyses found a very weak link between neurocognition and insight and a clinically significant but modest link between theory of mind and insight.
  • Existing and emerging treatments may influence insight: CBT-p, motivational interviewing, mindfulness-based interventions, antipsychotics, metacognitive training (MCT), and metacognitive reflection and insight therapy (MERIT); in a first-episode psychosis MERIT trial, treatment completion was 80%, with significant improvements in objective clinical insight versus treatment as usual and no evidence of heightened depression, while MCT findings were equivocal.

Methods

  • Narrative review; literature was found through searches of PubMed, Scopus, PsycINFO, and EBSCO using terms including “insight”, “awareness of illness”, “self-reflection”, “treatment adherence”, “psychosis”, and “schizophrenia”; English articles published from 2014 onward were included.
  • The review considered clinical insight (awareness of symptoms, need for treatment, and psychosocial consequences) and cognitive insight (self-reflectiveness and resistance to excessive certainty); unless otherwise specified, the population studied included adults with a schizophrenia spectrum disorder.
  • Main analysis was a qualitative synthesis of recent studies and earlier models, leading to a proposed integrative model of insight; no formal meta-analysis or quantitative pooling by the authors is reported.

Limitations

  • Stated in the paper: mixed neuroimaging findings may reflect inconsistent definitions of insight, varying instruments used to measure insight, and heterogeneous sample characteristics; longitudinal and more inclusive studies are needed, and many questions remain about causal pathways and whether subtypes of poor insight should be distinguished.
  • Evident from the text: as a narrative review, it does not report systematic quality appraisal, risk-of-bias assessment, or quantitative pooling; the search was restricted to English-language articles from 2014 onward, which may omit earlier or non-English evidence.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1002/wps.20508

Cites

202 of 202 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 167 cited sources checked · 0 supported · 0 flagged

  • Interpretationown data

    Poor insight predicts more impaired community functioning.

    “This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function”
    Quote in the paperSubstantial claim
  • Interpretationown data

    Poor insight may arise from biological, experiential, neuropsychological, social-cognitive, metacognitive and socio-political factors.

    “This research also suggests that poor insight may arise in response to biological, experiential, neuropsychological, social-cognitive, metacognitive and socio-political factors.”
    Quote in the paperSubstantial claim
  • Interpretationown data

    Poor insight predicts worse adherence to treatment.

    “This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function”
    Quote in the paperSubstantial claim
  • Interpretationown data

    Poor insight predicts a poorer therapeutic alliance.

    “This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function”
    Quote in the paperSubstantial claim
  • Interpretationnone given

    The association between good insight and depression or demoralization is stronger when coupled with stigma and social disadvantage.

    “while good insight predicts a higher frequency of depression and demoralization, especially when coupled with stigma and social disadvantage.”
    Quote in the paperSubstantial claim
  • May combine two claims. 23
  • Classified as probably not a substantial claim. 10
  • The quote only partly states this claim. 2

  • May combine two claims.

    Premisecitation

    Poor insight in schizophrenia occurs across different cultures and at different phases of the illness.

    “Poor insight in schizophrenia is prevalent across cultures and phases of illness.”
    • Also stated in: § (World Psychiatry 2018;17:12-23) · plain
      “It has been found across cultures 6,7 , and in early as well as later [8][9][10][11] , and in acute as well as non-acute phases of illness 12 .”
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  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The integrative model suggests that insight requires the integration of information about changes in internal states, external circumstances, others' perspectives and life trajectory as well as the multifaceted consequences and causes of each of those changes.

    “This model suggests that insight requires the integration of information about changes in internal states, external circumstances, others' perspectives and life trajectory as well as the multifaceted consequences and causes of each of those changes.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisereasoning

    Insight has a bidirectional relationship with community function.

    “Insight has also been proposed to have a bidirectional relationship with community function.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Better insight predicts reduced risk of relapse and improvement in positive and negative symptoms.

    “Evidence that insight influences symptoms includes findings that better insight predicts reduced risk of relapse 54 and improvement in positive and negative symptoms 55 .”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [54] source

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  • May combine two claims.

    Premisecitation

    Poor cognitive insight is linked with delusions in schizophrenia patients, but not in patients at risk for developing schizophrenia.

    “Kimhy et al 60 found that poor cognitive insight was linked with delusions in schizophrenia patients, but not in patients identified as at risk for developing schizophrenia.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Kimhy et al 60

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  • May combine two claims. The quote only partly states this claim.

    Premisecitation

    Poor insight predicts medication discontinuation and less adherence over time.

    “Examining the relationship of insight and adherence over time, Zhou et al 31 found that poor insight was predictive of medication discontinuation at one-year follow-up.”
    Quote in the paperSubstantial claim0 of 3 sources checked
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  • May combine two claims. The quote only partly states this claim.

    Premisecitation

    Lack of insight predicts drop out from cognitive behavior therapy and poorer therapeutic alliance.

    “Studying interpersonal elements of treatment, Lincoln et al 37 reported that lack of insight predicted drop out from cognitive behavior therapy in patients with psychosis.”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [37] source

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  • May combine two claims.

    Premisecitation

    Good clinical insight may produce distress and compromise well-being (the insight paradox).

    “In what may be referred to as the”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [75] source

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  • May combine two claims.

    Premisecitation

    A meta-analysis of 50 cross-sectional studies found a weak relationship between clinical insight and depression, but longitudinal studies suggested a stronger, more complex relationship which plays out differently depending on circumstances.

    “A metaanalysis of 50 cross-sectional studies found a weak relationship between clinical insight and depression, but reported that longitudinal studies suggested a stronger, more complex relationship which plays out differently depending upon the circumstances of the individual person's life 87 .”
    Quote in the paperSubstantial claim0 of 1 sources checked
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  • May combine two claims.

    Premisecitation

    Clinical insight promotes depression and self-stigma, and negative but not positive symptoms affect that relationship.

    “Schrank et al 81 found mutual and causal relationships in path analyses, with clinical insight promoting depression and self-stigma, and negative but not positive symptoms affecting that relationship.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Schrank et al 81

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  • May combine two claims.

    Premisecitation

    Greater levels of cognitive insight are linked to heightened levels of depression, lower self-reported subjective recovery, and lower subjective quality of life.

    “Greater levels of cognitive insight have also been linked to heightened levels of depression 77,86 , as well as lower levels of self-reported subjective recovery 89 and subjective quality of life 90 .”
    Quote in the paperSubstantial claim0 of 4 sources checked
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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The relationship of insight and suicidality may be fully mediated by depression.

    “Other studies have found that the relationship of insight and suicidality may be fully mediated by depression 97 .”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [97] source

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  • May combine two claims.

    Premisecitation

    Clinical insight predicts capacity for social connectedness and may mediate the relationship of negative symptoms to social function.

    “Montemagni et al 67 found that clinical insight predicted the capacity for social connectedness and may mediate the relationship of negative symptoms to social function.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Montemagni et al 67

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A generally negative appraisal of one's future and tendency to ruminate influence the effects of insight on mood.

    “Others have suggested that, beyond stigma, a generally negative appraisal of one's future 85 and tendency to ruminate 79 influence the effects of insight on mood.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
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    Premisecitation

    Poor insight predicts greater likelihood of involuntary legal commitment to treatment and hospital readmission in first-episode psychosis.

    “Poor insight has also been found to predict a greater likelihood of involuntary legal commitment to treatment 69 and hospital readmission in first-episode psychosis 70 .”
    Quote in the paperNot a substantial claim0 of 2 sources checked
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  • May combine two claims.

    Premisecitation

    Good clinical insight predicts lower self-reported quality of life, with that relationship mediated by depression.

    “Good clinical insight has also been found to predict lower self-reported quality of life 80 , with that relationship mediated by depression, suggesting that good insight may trigger depression, which may then degrade quality of life 80 .”
    Quote in the paperSubstantial claim0 of 1 sources checked
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  • May combine two claims.

    Premisecitation

    Some studies found a direct link between insight and stigma, while others failed to replicate it.

    “Other studies have also found a direct link between insight and stigma 148 , though others have failed to replicate that 149 .”
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    • Rests on an assumption: Social issues beyond individuals affect the development of insight.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Metacognition may protect against the emergence of depression in the wake of the development of insight.

    “Consistent with this, a recent review 145 suggested that greater metacognitive capacity is related to higher levels of both clinical and cognitive insight, and that its contribution to both forms of insight is independent of symptom severity and neurocognitive function and may also protect against the emergence of depression in the wake of the development of insight.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
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  • May combine two claims.

    Interpretationreasoning

    Insight involves more than a single uniform level of unawareness and allows for multiple interacting causes.

    “This model suggests that insight involves far more than a single or uniform level of unawareness and allows for multiple interacting causes.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    The literature reviewed was found through a search of PubMed, Scopus, PsycINFO and EBSCO, including search terms for insight, awareness of illness, self-reflection, treatment adherence, psychosis, and schizophrenia; articles published in English from 2014 onward were included.

    “The literature reviewed was found through a search of PubMed, Scopus, PsycINFO and EBSCO, including the search terms”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Metacognitive training had no effects on psychotic symptoms, reasoning bias, and theory of mind.

    “Gaweda et al 178 reported that MCT led to significant improvements in clinical insight compared with treatment as usual, despite a lack of effects on psychotic symptoms, reasoning bias and theory of mind.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [178] source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    In the MERIT trial, the treatment completion rate was 80%.

    “Treatment completion rate was 80%.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [190]

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Insight improved after four weeks of metacognitive training in detailed case work.

    “Detailed case work has described how insight improved after four weeks of MCT 179 .”
    Quote in the paperNot a substantial claim0 of 1 sources checked
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  • May combine two claims.

    Interpretationnone given

    Poor insight is associated with higher levels of symptoms and poorer community function.

    “Just as poor insight seems associated with higher levels of symptoms and poorer community function, better insight may lead to depression, demoralization and low levels of selfperceived quality of life, especially when coupled with stigma and social disadvantage.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Emerging treatments targeting metacognitive processes may help persons with serious mental illness reflect and make personal meaning of experiences of mental illness without the paradoxical negative consequences of good insight.

    “Emerging treatments targeting the metacognitive processes that cause and sustain poor insight may also help persons with serious mental illness to reflect and make personal meaning of experiences of mental illness without the paradoxical negative consequences of good insight, such as depression or suicidality.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Experiences that could be integrated into adaptive awareness of mental illness are diverse and vary from person to person.

    “Essential here is that the experiences which could potentially be integrated into an adaptive form of awareness of mental illness are strikingly diverse and will vary from person to person.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Poor insight is a failure to make consensually valid sense of complex and potentially traumatic experiences.

    “It is a failure to make consensually valid sense of complex and potentially traumatic experiences.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Potential causes of poor insight include experiences that seem incomprehensible, cortical dysfunction, problems with memory, attention and executive function, deficits in social cognition and metacognition, cultural differences, and sociopolitical factors.

    “Potential causes of poor insight include experiences which seem incomprehensible, cortical dysfunction, problems with memory, attention and executive function, deficits in social cognition and metacognition, cultural differences, and sociopolitical factors.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The path from insight to outcomes is complicated and fails to match traditional models that position acceptance of illness as the first step toward health.

    “From that point, the path is complicated and paradoxically fails to match traditional models of wellness which position acceptance of illness as the first step towards health.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationnone given

    Poor insight is a common and influential element of serious mental illness across cultures and phases of disorder.

    “Research over the last few years confirms that poor insight is a common and influential element of serious mental illness across cultures and phases of disorder.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Better insight may lead to depression, demoralization, and low self-perceived quality of life, especially when coupled with stigma and social disadvantage.

    “Just as poor insight seems associated with higher levels of symptoms and poorer community function, better insight may lead to depression, demoralization and low levels of selfperceived quality of life, especially when coupled with stigma and social disadvantage.”
    Quote in the paperSubstantial claim
31 of 31

  • The paper relies on this without support.

    The constructs of clinical and cognitive insight are sufficiently valid and comparable across the reviewed studies to support synthesis.

    “We considered two forms of insight: clinical insight, which involves awareness of symptoms, need for treatment, and psychosocial consequences of the disorder 14 , and cognitive insight, which involves the capacity for self-reflectiveness and resistance to excessive certainty 15,16 .”

  • The paper relies on this without support.

    The reviewed studies' findings are not substantially biased by methodological limitations or publication bias.

    “A number of methodological factors could contribute to these mixed findings, including inconsistent definitions of insight, varying instruments used to measure insight, and heterogeneous sample characteristics.”

  • The paper relies on this without support.

    Ideas persons form about what is and is not an illness are affected by the larger social group, including family and culture.

    “The ideas that persons form about what is and is not an illness are also affected by the larger social group, including family and culture.”

  • The paper relies on this without support.

    Social issues beyond individuals affect the development of insight.

    “Social issues which are beyond individuals have also been proposed to affect the development of insight.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Number of drug trials differs from cited reference

    Minor

    The text says the analysis used data from more than 14 drug trials, but the cited reference describes results from exactly 14 trials.

1 of 1

Cites

1 retracted

Flagged first, then by citations

Research works printed but not linked: 3

  1. PhelpsS.Blind to their blindness: a history of the denial of illness. PhD Dissertation Harvard University Boston 2014.
  2. LysakerPH KlionRE.Recovery meaning‐making and severe mental illness: a comprehensive guide to metacognitive reflection and insight therapy. Abingdon‐on‐Thames: Routledge (in press).
  3. Leonhardt BL, Emergence of psychotic content in psychotherapy: a qualitative analysis of content, process, and therapist variables, Psychother Res

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Related

Authors
Lysaker, P. H., Pattison, M. L., Leonhardt, B. L., Phelps, S., & Vohs, J. L.
Affiliations
  • Richard L. Roudebush VA Medical Center (US)
  • University of Indianapolis (US)
  • Eskenazi Health (US)
  • Wesleyan University (US)
  • Indiana University School of Medicine (US)
ORCID
Venue
World Psychiatry
Publisher
Wiley
Published
2018-01-19
Volume
17
Issue
1
Pages
12-23
ISSN
  • 1723-8617 (ISSN-L)
  • 2051-5545
DOI
10.1002/wps.20508
PMC
PMC5775127
OpenAlex
W2792686706
Semantic Scholar
afac9c9742017a7e26c76518e9a030b50f51fa05
Cited by
247
References
202
Citations by year
2026: 26 · 2025: 26 · 2024: 15 · 2023: 29 · 2022: 39 · 2021: 34 · 2020: 34 · 2019: 30 · 2018: 11 · 2017: 2 · 2016: 1
FWCI
21.44
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • World Psychiatry (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • IUScholarWorks (Indiana University) (submittedVersion)
  • Purdue University Indianapolis (Indiana University) (submittedVersion)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
  • Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
  • Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
Keywords
lack of insight, schizophrenia spectrum disorders, medication adherence, therapeutic relationship, symptom severity, community functioning, depression, demoralization, stigma, social deprivation, neuropsychological factors, socio-cognitive factors, metacognition, emerging treatments, quality of life

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