Failures of metacognition and lack of insight in neuropsychiatric disorders.
Open accessAbstract
Lack of insight or unawareness of illness are the hallmarks of many psychiatric disorders, especially schizophrenia (SCZ) and other psychoses and could be conceived of as a failure in metacognition. Research in this area in the mental health field h as burgeoned with the development and widespread use of standard assessment instruments and the mapping out of the clinical and neuropsychological correlates of insight and its loss. There has been a growing appreciation of the multi-faceted nature of the concept and of the different 'objects' of insight, such as the general awareness that one is ill, to more specific metacognitive awareness of individual symptoms, impairments and performance. This in turn has led to the notion that insight may show modularity and may fractionate across different domains and disorders, supported by work that directly compares metacognition of memory deficits and illness awareness in patients with SCZ, Alzheimer's disease and brain injury. The focus of this paper will be on the varieties of metacognitive failure in psychiatry, particularly the psychoses. We explore cognitive models based on self-reflectiveness and their possible social and neurological bases, including data from structural and functional MRI. The medial frontal cortex appears to play an important role in self-appraisal in health and disease.
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Deficits in metacognitive knowledge and awareness are believed to lead to cognitive distortions, dysfunctional beliefs and expectancies, and a lack of cognitive insight into cognitive biases.
“Deficits in metacognitive knowledge and awareness moreover are believed to lead to cognitive distortions (e.g., jumping to conclusions, attributional biases, theory of mind deficits) (60), dysfunctional beliefs and expectancies (associated with a low self-esteem and negative symptoms) (10, 95) and a lack of cognitive insight into those cognitive biases (96).”
From Developing a mechanism-based therapy for acute psychiatric inpatients with psychotic symptoms: an Intervention Mapping approach (2023) · cites this paper as [96]
The citation to David (2012) is attached to the lack-of-cognitive-insight clause, not the preceding claims about distortions or dysfunctional beliefs. Section 5, “Cognitive Insight” (page unavailable), links poor evaluation of one’s thinking to possible metacognitive difficulties and describes cognitive insight as recognizing one’s own fallibility. It does not specifically establish a lack of insight into the cognitive biases named earlier in the citing sentence. (LLM, conf=0.82)
Experimental — accuracy not yet measuredEvidence from human neuropsychology that first- and second-order behavioural performances are dissociable suggests that at least some degree of separate representation will be required to account for second-order behaviours.
“On the other hand, evidence from human neuropsychology that first- and second-order behavioural performances are dissociable suggests that at least some degree of separate representation will be required to account for second-order behaviours [ 6 , 9 , 14 ].”
From Metacognition: computation, biology and function (2012) · cites this paper as [14]
Together, David et al.'s work suggests fractionation between different types of insight, such that insight into one aspect of pathology does not necessarily predict insight into another.
“Together, their work suggests fractionation between different types of insight, such that insight into one aspect of pathology does not necessarily predict insight into another.”
From Metacognition: computation, biology and function (2012) · cites this paper as [14]
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Bortnick, K. (2024) · Routledge eBooks · doi:10.4324/9781003525288-73 · Cited by 41 · see citing works
Flashman, L. A. (2001) · Journal of Neuropsychiatry · doi:10.1176/appi.neuropsych.13.2.255 · Cited by 37 · see citing works
Examination of Clinical and Cognitive Insight in Acute Schizophrenia Patients
Greenberger, C., & Serper, M. R. (2010) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0b013e3181e4f35d · Cited by 34 · see citing works
Banks, S. J., & Weıntraub, S. (2009) · Journal of Neuropsychiatry · doi:10.1176/jnp.2009.21.3.299 · Cited by 31 · see citing works
The neuropsychological correlates of cognitive insight in healthy participants
Orfei, M. D., Caltagirone, C., Cacciari, C., Assogna, F., & Spalletta, G. (2011) · Applied Cognitive Psychology · doi:10.1002/acp.1771 · Cited by 25 · see citing works
Lack of Insight and Awareness in Schizophrenia and Neuropsychiatric Disorders
Gilleen, J., Greenwood, K., & David, A. S. (2010) · Springer eBooks · doi:10.1007/978-4-431-53871-4_3 · Cited by 12 · see citing works
Upthegrove, R. (2005) · The British Journal of Psychiatry · doi:10.1192/bjp.187.3.294-a · Cited by 11 · see citing works
Munk‐Jørgensen, P., Christiansen, B., Stahl, S. M., & Licht, R. W. (2010) · Acta Psychiatrica Scandinavica · doi:10.1111/j.1600-0447.2010.01648.x · Cited by 6 · see citing works
Bedford, N., & David, A. S. (2008) · Schizophrenia Research · doi:10.1016/s0920-9964(08)70353-0 · Cited by 3 · see citing works
POOR INSIGHT IN PSYCHOSIS: COGNITIVE DEFICIT OR BIAS?
David, A. S., & Bedford, N. (2009) · Research Portal (King's College London) · Cited by 2 · see citing works
THE ETIOLOGY OF LACK OF INSIGHT IN SCHIZOPHRENIA
David, A. S., Bedford, N., Gilleen, J., Greenwood, K., Morgan, K. D., & Wiffen, B. D. R. (2011) · Research Portal (King's College London) · Cited by 1 · see citing works
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- Gilleen, J., Greenwood, K. & David, A. S. 2009 Anosognosia in schizophrenia and other neuropsychia- tric disorders: similarities and differences. In The study of anosognosia (ed. G. P. Prigatano), pp. 255-290. Oxford, UK: Oxford University Press.
- McEvoy, J. P., Johnson, J., Perkins, D., Lieberman, J. A., Hamer, R. M., Keefe, R. S., Tohen, M., Glick, I. D. & Sharma, T. 2006 Insight in first-episode psycho- sis. Psychol. Med. 36, 1385-1393. (doi:10.1017/ S0033291706007793) · DOI
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Sorted by citations
Fleming, S. M., & Lau, H. C. (2014) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2014.00443 · Cited by 1,386 · see citing works
“Second, it is of interest to determine whether different subject groups, such as patients and controls (David et al., 2012) or older vs. younger adults (Souchay et al., 2000), exhibit differential metacognitive efficiency after taking into account differences in task performance.”
BackgroundThe neural basis of metacognitive ability
Fleming, S. M., & Dolan, R. J. (2012) · Philosophical Transactions of the Royal Society B: Biological Sciences · doi:10.1098/rstb.2011.0417 · Cited by 747 · see citing works
“A crucial variable of interest is the accuracy of metacognitive report with respect to object-level targets; in other words, how well do we know our own minds? A detailed, and eventually mechanistic, account of metacognition at the neural level is a necessary first step to understanding the failures of metacognition t…”
BackgroundSelf-Evaluation of Decision-Making: A General Bayesian Framework for Metacognitive Computation
Fleming, S. M., & Daw, N. D. (2017) · Psychological Review · doi:10.1037/rev0000045 · Cited by 489 · see citing works
“…judgment and decision-making (Lichtenstein, Fischhoff, & Phillips, 1982), education (Veenman, Wilhelm, & Beishuizen, 2004), social psychology (Heatherton, 2011), consciousness science (Lau & Rosenthal, 2011), and clinical disorders (David, Bedford, Wiffen, & Gilleen, 2012; Goldstein et al., 2009).”
BackgroundMetacognition: computation, biology and function
Fleming, S. M., Dolan, R. J., & Frith, C. D. (2012) · Philosophical Transactions of the Royal Society B: Biological Sciences · doi:10.1098/rstb.2012.0021 · Cited by 344 · see citing works
“David et al. [14] review a series of studies examining metacognitive function in patients with Alzheimer’s disease, brain injury or schizophrenia, and relate these measures to assessment of clinical insight.”
BackgroundDomain-specific impairment in metacognitive accuracy following anterior prefrontal lesions
Fleming, S., Ryu, J., Golfinos, J., & Blackmon, K. E. (2014) · Brain : a journal of neurology · doi:10.1093/brain/awu221 · Cited by 318 · see citing works
“Impairments in metacognition are found in a range of clinical syndromes, includ- ing traumatic brain injury, Alzheimer’s disease, schizophrenia and drug addiction (for reviews see Pannu et al., 2005; Goldstein et al., 2009; David et al., 2012; Cosentino, 2014).”
BackgroundHMeta-d: hierarchical Bayesian estimation of metacognitive efficiency from confidence ratings
Fleming, S. M. (2017) · Neuroscience of Consciousness · doi:10.1093/nc/nix007 · Cited by 314 · see citing works
“…and cognitive processes also has broader application in work on judgment and decision-making (Lichtenstein et al. 1982), developmental psychology (Weil et al. 2013; Goupil et al. 2016), social psychology (Heatherton 2011) and clinical disorders (David et al. 2012; Moeller and Goldstein 2014).”
BackgroundInsight in Schizophrenia: Involvement of Self-Reflection Networks?
van der Meer, L., de Vos, A. E., Stiekema, A. P. M., Pijnenborg, G. H. M., van Tol, M., Nolen, W. A., David, A. S., & Aleman, A. (2012) · Schizophrenia Bulletin · doi:10.1093/schbul/sbs122 · Cited by 221 · see citing works
Neural evidence accumulation persists after choice to inform metacognitive judgments
Murphy, P. R., Robertson, I. H., Harty, S., & O'Connell, R. G. (2015) · eLife · doi:10.7554/elife.11946 · Cited by 170 · see citing works
“Funding: See page 20 Received: 29 September 2015 Accepted: 17 December 2015 Published: 19 December 2015 Reviewing editor: Michael J Frank, Brown University, United States Copyright Murphy et al. This article is distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use and…”
BackgroundNair, A., Palmer-Cooper, E. C., Aleman, A., & David, A. S. (2013) · Schizophrenia Research · doi:10.1016/j.schres.2013.11.033 · Cited by 170 · see citing works
“The field has also expanded beyond purely the concept of clinical insight, to new areas such as ‘cognitive insight’, which is considered to be a type of metacognition (David et al., 2012).”
Effects of age on metacognitive efficiency
Palmer-Cooper, E. C., David, A. S., & Fleming, S. M. (2014) · Consciousness and Cognition · doi:10.1016/j.concog.2014.06.007 · Cited by 163 · see citing works
Rahnev, D., Desender, K., Lee, A. L. F., Adler, W. T., Aguilar-Lleyda, D., Akdoğan, B., Arbuzova, P., Atlas, L. Y., Balcı, F., Bang, J. W., et al. (2020) · Nature Human Behaviour · doi:10.1038/s41562-019-0813-1 · Cited by 151 · see citing works
Self-disorders and Schizophrenia: A Phenomenological Reappraisal of Poor Insight and Noncompliance
Henriksen, M. G., & Parnas, J. (2013) · Schizophrenia Bulletin · doi:10.1093/schbul/sbt087 · Cited by 143 · see citing works
Impaired self-awareness in human addiction: deficient attribution of personal relevance
Moeller, S. J., & Goldstein, R. Z. (2014) · Trends in Cognitive Sciences · doi:10.1016/j.tics.2014.09.003 · Cited by 140 · see citing works
“Deficits in self-awareness can range from complete denial of the entire illness to more specific metacognitive awareness deficits of individual disease-specific symptoms, impairments, or performance, and may vary between psychopathologies (3).”
BackgroundForming global estimates of self-performance from local confidence
Rouault, M., Dayan, P., & Fleming, S. M. (2019) · Nature Communications · doi:10.1038/s41467-019-09075-3 · Cited by 134 · see citing works
Lysaker, P. H., Vohs, J., Hillis, J. D., Kukla, M., Popolo, R., Salvatore, G., & Dimaggio, G. (2013) · Expert Review of Neurotherapeutics · doi:10.1586/14737175.2013.811150 · Cited by 124 · see citing works
Yamada, T., Hashimoto, R., Yahata, N., Ichikawa, N., Yoshihara, Y., Okamoto, Y., Kato, N., Takahashi, H., & Kawato, M. (2017) · The International Journal of Neuropsychopharmacology · doi:10.1093/ijnp/pyx059 · Cited by 133 · see citing works
“The results of the latter two types of experiments—which may reflect alterations in meta-cognitive processes and the Pavlovian conditioned fear response—suggest that DecNef may be useful as an adjunctive therapy for psychiatric disorders, as meta-cognition and fear are closely related to behavioral changes associated…”
The idiosyncratic nature of confidence
Navajas, J., Hindocha, C., Foda, H., Keramati, M., Latham, P. E., & Bahrami, B. (2017) · Nature Human Behaviour · doi:10.1038/s41562-017-0215-1 · Cited by 125 · see citing works
Cognitive insight: a systematic review.
Van Camp, L. S. C., Sabbe, B. G. C., & Oldenburg, J. F. E. (2017) · Clinical Psychology Review · doi:10.1016/j.cpr.2017.04.011 · Cited by 99 · see citing works
Harty, S., Robertson, I. H., Miniussi, C., Sheehy, O. C., Devine, C. A., McCreery, S., & O’Connell, R. G. (2014) · Journal of Neuroscience · doi:10.1523/jneurosci.5308-13.2014 · Cited by 94 · see citing works
“…are typically good at detecting their errors and adjusting their behavior accordingly, this capacity declines with age (Rabbitt, 1990; Harty et al., 2013) and is also compromised in many clinical conditions (O’Keeffe et al., 2007; Hester et al., 2009; O’Connell et al., 2009; David et al., 2012).”
BackgroundBoness, C. L., Watts, A. L., Moeller, K. N., & Sher, K. J. (2021) · Psychological Bulletin · doi:10.1037/bul0000333 · Cited by 95 · see citing works
The neuropsychology of self-reflection in psychiatric illness
Philippi, C. L., & Koenigs, M. R. (2014) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2014.03.004 · Cited by 94 · see citing works
“With this spectrum-based model of self-reflection in psychopathology in mind, we next consider several self-report scales and experimental paradigms that could be useful for developing clinically-relevant self-report and performance-based measures of self-reflection.”
BackgroundMethodSelf-evaluation in schizophrenia: an fMRI study with implications for the understanding of insight
Bedford, N., Surguladze, S., Giampietro, V., Brammer, M. J., & David, A. S. (2012) · BMC Psychiatry · doi:10.1186/1471-244x-12-106 · Cited by 81 · see citing works
“The medial frontal locus is somewhat more superior (z = 32) than the main focus derived from meta-analyses (z = 6; [31]) although consistent with the self-appraisal imaging literature [29,30,54].”
Formation of global self-beliefs in the human brain
Rouault, M., & Fleming, S. M. (2020) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.2003094117 · Cited by 76 · see citing works
Subjective cognitive decline: Memory complaints, cognitive awareness, and metacognition
Cappa, S. F., Ribaldi, F., Chicherio, C., & Frisoni, G. B. (2024) · Alzheimer s & Dementia · doi:10.1002/alz.13905 · Cited by 74 · see citing works
When and How to use Multiple Informants to Improve Clinical Assessments
Alexander, L. A., McKnight, P. E., Disabato, D. J., & Kashdan, T. B. (2017) · Journal of Psychopathology and Behavioral Assessment · doi:10.1007/s10862-017-9607-9 · Cited by 73 · see citing works
Neural correlates of insight in dreaming and psychosis
Dresler, M., Wehrle, R., Spoormaker, V. I., Steiger, A., Holsboer, F., Czisch, M., & Hobson, J. A. (2014) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2014.06.004 · Cited by 72 · see citing works
Ćurĉić‐Blake, B., van der Meer, L., Pijnenborg, G. H. M., David, A. S., & Aleman, A. (2015) · Human Brain Mapping · doi:10.1002/hbm.22955 · Cited by 68 · see citing works
“It was recently suggested that poor insight is associated with impaired metacognition [David et al., 2012; Lysaker et al., 2005], particularly theory of mind (ToM) [Langdon and Ward, 2009; Pijnenborg et al.”
BackgroundInfluentialVohs, J. L., George, S., Leonhardt, B. L., & Lysaker, P. H. (2016) · Expert Review of Neurotherapeutics · doi:10.1080/14737175.2016.1199275 · Cited by 66 · see citing works
Metacognitive training for schizophrenia: A multicentre randomised controlled trial
Briki, M., Monnin, J., Haffen, E., Sechter, D., Favrod, J., Netillard, C., Cheraitia, E., Marin, K., Govyadovskaya, S., Tio, G., et al. (2014) · Schizophrenia Research · doi:10.1016/j.schres.2014.06.005 · Cited by 65 · see citing works
“Indeed, insight andmetacognitionmight be new therapeutic targets for schizophrenia (Pijnenborg et al., 2011, 2013; David et al., 2012).”
BackgroundNeural substrates of socioemotional self‐awareness in neurodegenerative disease
Sollberger, M. A., Rosen, H. J., Shany‐Ur, T., ULLAH, J., Stanley, C. M., Laluz, V., Weiner, M. W., Wilson, S. M., Miller, B. L., & Rankin, K. P. (2014) · Brain and Behavior · doi:10.1002/brb3.211 · Cited by 66 · see citing works
“201 cognition, or one’s characteristic traits and attitudes (modality-specific unawareness) (Clare 2004b; EcklundJohnson and Torres 2005; David et al. 2012).”
BackgroundJudgements of agency in schizophrenia: an impairment in autonoetic metacognition
Metcalfe, J., Snellenberg, J. X. V., DeRosse, P., Balsam, P. D., & Malhotra, A. K. (2012) · Philosophical Transactions of the Royal Society B Biological Sciences · doi:10.1098/rstb.2012.0006 · Cited by 64 · see citing works
Insight and psychosis: the next 30 years
David, A. S. (2019) · The British Journal of Psychiatry · doi:10.1192/bjp.2019.217 · Cited by 62 · see citing works
Emotion as a boost to metacognition: How worry enhances the quality of confidence
Massoni, S. (2014) · Consciousness and Cognition · doi:10.1016/j.concog.2014.08.006 · Cited by 62 · see citing works
Rouy, M., Saliou, P., Nalborczyk, L., Pereira, M., Roux, P., & Faivre, N. (2021) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2021.03.017 · Cited by 59 · see citing works
“insight into illness (David et al., 2012), disorganisation (Vohs et al.”
BackgroundCella, M., Swan, S., Medin, E., Reeder, C., & Wykes, T. (2013) · Psychological Medicine · doi:10.1017/s0033291713001189 · Cited by 57 · see citing works
“In the attempt to elucidate the discrepancies between subjective and performance-based assessments of cognitive problems, some contributions have suggested that general IQ may limit insight in schizophrenia (David et al. 1992, 1995; Rossell et al. 2003).”
BackgroundBenwell, C., Mohr, G., Wallberg, J., Kouadio, A., & Ince, R. A. A. (2022) · npj Mental Health Research · doi:10.1038/s44184-022-00009-4 · Cited by 59 · see citing works
McWilliams, A., Bibby, H., Steinbeis, N., David, A. S., & Fleming, S. M. (2023) · Cognition · doi:10.1016/j.cognition.2023.105389 · Cited by 57 · see citing works
“…& Mograbi, 2016; Hoven et al., 2019; Wells et al., 2010; White, Sadikot, & Djordjevic, 2016) and psychopathology (Rouault, Seow, Gillan, & Fleming, 2018; Seow, Rouault, Gillan, & Fleming, 2021), and has been related to fluctuating levels of insight (David, Bedford, Wiffen, & Gilleen, 2012).”
Older adults have diminished awareness of errors in the laboratory and daily life.
Harty, S., O’Connell, R. G., Hester, R., & Robertson, I. H. (2013) · Psychology and Aging · doi:10.1037/a0033567 · Cited by 57 · see citing works
Regional White Matter Variation Associated with Domain-specific Metacognitive Accuracy
Baird, B., Cieslak, M., Smallwood, J., Grafton, S. T., & Schooler, J. W. (2014) · Journal of Cognitive Neuroscience · doi:10.1162/jocn_a_00741 · Cited by 54 · see citing works
“This finding bolsters previous evidence for the notion that metacognitive skill in one domain may not necessarily translate to another (David et al., 2012; Metcalfe et al., 2012; Pannu & Kaszniak, 2005; Schnyer et al., 2004).”
ResultThe future of metacognition research: Balancing construct breadth with measurement rigor
Katyal, S., & Fleming, S. M. (2024) · Cortex · doi:10.1016/j.cortex.2023.11.002 · Cited by 63 · see citing works
“…about other emotional states), whether affective metacognition can be trained, and whether and how it is related to interoceptive states (Garfinkel & Critchley, 2016; L. F. Barrett & Simmons, 2015; Seth, 2013), mental health, and clinical insight (David, Bedford, Wiffen, & Gilleen, 2012).”
BackgroundCella, M., Reeder, C., & Wykes, T. (2015) · Frontiers in Psychology · doi:10.3389/fpsyg.2015.01259 · Cited by 54 · see citing works
Subjective versus objective cognition: Evidence for poor metacognitive monitoring in schizophrenia
Moritz, S., Balzan, R. P., Bohn, F., Veckenstedt, R., Kolbeck, K., Bierbrodt, J., & Dietrichkeit, M. (2016) · Schizophrenia Research · doi:10.1016/j.schres.2016.08.021 · Cited by 55 · see citing works
Samaha, J., & Postle, B. R. (2017) · Proceedings of the Royal Society B Biological Sciences · doi:10.1098/rspb.2017.2035 · Cited by 51 · see citing works
The relationship between insight and theory of mind in schizophrenia
Konstantakopoulos, G., Ploumpidis, D. N., Oulis, P., Patrikelis, P., Nikitopoulou, S., Papadimitriou, G. N., & David, A. S. (2013) · Schizophrenia Research · doi:10.1016/j.schres.2013.11.022 · Cited by 52 · see citing works
“the general ability to think about thinking, and their relationships with insight impairment in schizophrenia (Lysaker et al., 2011; David et al., 2012).”
BackgroundUssorio, D., Giusti, L., Wittekind, C. E., Bianchini, V., Malavolta, M., Pollice, R., Casacchia, M., & Roncone, R. (2016) · Psychology and Psychotherapy: Theory, Research and Practice · doi:10.1111/papt.12059 · Cited by 51 · see citing works
O’Connor, J. A., Wiffen, B. D. R., Forti, M. D., Ferraro, L., Joseph, C., Kolliakou, A., Bonaccorso, S., Murray, R. M., & David, A. S. (2013) · Schizophrenia Research · doi:10.1016/j.schres.2013.06.005 · Cited by 46 · see citing works
“Cognitive insight, a type of metacognitive measure (David et al., 2012) was quantified using the BCIS (Beck et al.”
BackgroundMethodSpalletta, G., Piras, F., Piras, F., Caltagirone, C., & Orfei, M. D. (2014) · Human Brain Mapping · doi:10.1002/hbm.22507 · Cited by 44 · see citing works
“Insight is a multidimensional phenomenon which implies several facets at least partially independent from each other (David et al., 2012; Orfei et al., 2008).”
BackgroundZhang, Q., Li, X., Parker, G. J., Hong, X.-H., Wang, Y., Lui, S. S. Y., Neumann, D. L., Cheung, E. F. C., Shum, D. H. K., & Chan, R. C. K. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.01.044 · Cited by 40 · see citing works
“The cognitive and clinical aspects of insight have been shown to positively correlate with each other (Riggs et al., 2012), although they are conceptualized as being distinct aspects of meta-cognition (David et al., 2012).”
López-Moríñigo, J.-D., Forti, M. D., Ajnakina, O., Wiffen, B. D. R., Morgan, K. D., Doody, G. A., Jones, P. B., Ayesa‐Arriola, R., Canal‐Rivero, M., Crespo‐Facorro, B., et al. (2018) · Schizophrenia Research · doi:10.1016/j.schres.2018.09.016 · Cited by 39 · see citing works
“, 2004) and neuroanatomical correlates (Morgan et al., 2010a; David et al., 2012), which were not evaluated in this study, may contribute to insight.”
BackgroundPousa, E., Ochoa, S., Cobo, J., Nieto, L., Usall, J., Gonzalez, B., Garcia-Ribera, C., Pérez Solà, V., Ruiz, A.-I., Baños, I., et al. (2017) · Schizophrenia Research · doi:10.1016/j.schres.2017.02.016 · Cited by 37 · see citing works
“…of psychotic phenomenology the study of awareness into each symptom is indeed justified on the basis that symptoms are different in nature andmight be influenced by different cultural, neurobiological, psychological factors (Bedford and David, 2014; David et al., 2012; Gilleen et al., 2011).”
BackgroundPsychedelic-Assisted Therapy for Substance Use Disorders and Potential Mechanisms of Action
Rieser, N. M., Herdener, M., & Preller, K. H. (2021) · Current Topics in Behavioral Neurosciences · doi:10.1007/7854_2021_284 · Cited by 37 · see citing works
The neurocognitive basis of insight into illness in anorexia nervosa: A pilot metacognitive study
Arbel, R., Koren, D., Klein, E., & Latzer, Y. (2013) · Psychiatry Research · doi:10.1016/j.psychres.2013.01.009 · Cited by 36 · see citing works
“The current study was motivated by the view that the major limitation of previous studies on the subject (for a further review, see David et al., 2012) stems from their failure to address deficits at a metacognitive level of functioning.”
MethodCan cognitive insight predict symptom remission in a first episode psychosis cohort?
O’Connor, J. A., Ellett, L., Ajnakina, O., Schoeler, T., Kollliakou, A., Trotta, A., Wiffen, B. D., Falcone, A. M., Di Forti, M., Murray, R. M., et al. (2017) · BMC Psychiatry · doi:10.1186/s12888-017-1210-9 · Cited by 37 · see citing works
“It has been suggested that impaired self-reflection may lead to poor sensory and narrative integration of experience, increasing the risk of psychiatric symptoms [2].”
BackgroundNeural correlates of social cognitive introspective accuracy in schizophrenia
Pinkham, A. E., Klein, H., Hardaway, G. B., Kemp, K. C., & Harvey, P. D. (2018) · Schizophrenia Research · doi:10.1016/j.schres.2018.07.001 · Cited by 35 · see citing works
Clinical assessment of decision-making capacity in acquired brain injury with personality change
Owen, G. S., Freyenhagen, F., Martin, W., & David, A. S. (2015) · Neuropsychological Rehabilitation · doi:10.1080/09602011.2015.1053948 · Cited by 33 · see citing works
Insight and gender in schizophrenia and other psychoses
Cobo, J., Nieto, L. L., Ochoa, S., Pousa, E., Usall, J., Baños, I., González, B., Ruiz, I., & Ruiz, A. I. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.04.089 · Cited by 33 · see citing works
“The importance of studying insight in each particular symptom has been repeatedly pointed out, since it has been suggested that the nature of insight into each psychotic symptom may vary widely (Rossell et al., 2003; David et al., 2012).”
Barnby, J. M., Raihani, N., & Dayan, P. (2022) · Cognition · doi:10.1016/j.cognition.2022.105098 · Cited by 33 · see citing works
Metacognitive Deficiency in a Perceptual but Not a Memory Task in Methadone Maintenance Patients
Sadeghi, S., Ekhtiari, H., Bahrami, B., & Ahmadabadi, M. N. (2017) · Scientific Reports · doi:10.1038/s41598-017-06707-w · Cited by 33 · see citing works
“003) and no main effect of imageability was found(F(1,45) = 0.”
InfluentialNeural correlates of altered insight in frontotemporal dementia: a systematic review
Muñoz‐Neira, C., Tedde, A., Coulthard, E. J., Thai, N. J., & Pennington, C. M. (2019) · NeuroImage Clinical · doi:10.1016/j.nicl.2019.102066 · Cited by 31 · see citing works
“The term metacognition has been recently used in dementia when investigating self-perception and self-monitoring (DeLozier and Davalos, 2016; Eslinger et al., 2005).”
Low self-esteem and the formation of global self-performance estimates in emerging adulthood
Rouault, M., Will, G., Fleming, S. M., & Dolan, R. J. (2022) · Translational Psychiatry · doi:10.1038/s41398-022-02031-8 · Cited by 35 · see citing works
“Many clinical and subclinical psychiatric symptoms are associated with alterations to various aspects of metacognition [35, 36].”
Doss, M. K., Samaha, J., Barrett, F. S., Griffiths, R. R., de Wit, H., Gallo, D. A., & Koen, J. D. (2023) · Psychological Review · doi:10.1037/rev0000455 · Cited by 33 · see citing works
Are neurological and psychiatric disorders different?
David, A. S., & Nicholson, T. R. (2015) · The British Journal of Psychiatry · doi:10.1192/bjp.bp.114.158550 · Cited by 30 · see citing works
Spencer, B. W. J., Gergel, T., Hotopf, M., & Owen, G. S. (2018) · The British Journal of Psychiatry · doi:10.1192/bjp.2018.85 · Cited by 28 · see citing works
Subjectivity and Schizophrenia: Another Look at Incomprehensibility and Treatment Nonadherence
Parnas, J., & Henriksen, M. G. (2013) · Psychopathology · doi:10.1159/000351837 · Cited by 29 · see citing works
Metacognitive knowledge and experience in recently diagnosed patients with bipolar disorder
Torres, I. J., Mackala, S. A., Kozicky, J.-M., & Yatham, L. N. (2016) · Journal of Clinical and Experimental Neuropsychology · doi:10.1080/13803395.2016.1161733 · Cited by 28 · see citing works
Cognitive deficit awareness in schizophrenia: absent, intact, or somewhere in-between?
Balzan, R., Neaves, A., Denson, L., Liu, D., & Galletly, C. (2014) · Cognitive Neuropsychiatry · doi:10.1080/13546805.2014.909311 · Cited by 28 · see citing works
The relationship between jumping to conclusions and neuropsychological functioning in schizophrenia.
Krężołek, M., Pionke, R., Banaszak, B., Kokoszka, A., & Gawęda, Ł. (2019) · Psychiatry Research · doi:10.1016/j.psychres.2019.01.035 · Cited by 1 · see citing works
Walvoort, S. J. W., van der Heijden, P. T., Kessels, R. P. C., & Egger, J. I. M. (2016) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s104442 · Cited by 27 · see citing works
“Impaired illness insight can be regarded as a continuum ranging from total denial of the disease to more subtle metacognitive awareness deficits.(11) Illness insight comprises of awareness of illness, the capacity to view symptoms of the disease as pathological, and treatment adherence.”
InfluentialSymptom attribution and frontal cortical thickness in first‐episode schizophrenia
Asmal, L., du Plessis, S., Vink, M., Chiliza, B., Kilian, S., & Emsley, R. A. (2016) · Early Intervention in Psychiatry · doi:10.1111/eip.12358 · Cited by 27 · see citing works
“This is in keeping with the findings of our study and supports the hypothesis that symptom attribution is metacognitive in nature.(42) Although it is argued that distinct neurobiological substrates underlie the different insight dimensions,(9) there may be shared neuroanatomical and clinical elements between the dimen…”
BackgroundResultWalvoort, S. J. W., van der Heijden, P. T., Wester, A. J., Kessels, R. P. C., & Egger, J. I. M. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.08.007 · Cited by 25 · see citing works
Bègue, I., Vaessen, M. J., Hofmeister, J., Pereira, M., Schwartz, S., & Vuilleumier, P. O. (2018) · Social Cognitive and Affective Neuroscience · doi:10.1093/scan/nsy102 · Cited by 24 · see citing works
“Moreover, deficits in metacognition are thought to contribute to failures in social cognition (and vice versa) in several neuropsychiatric disorders (David et al., 2012).”
BackgroundReddy, M. S. S. (2015) · Indian Journal of Psychological Medicine · doi:10.4103/0253-7176.162909 · Cited by 25 · see citing works
“[10] • Meta cognition impair ment: Impaired metarepresentation and impaired self-reflection (a component of Beck’s Cognitive Insight), relate lack of insight to the neuropsychological perspective.”
Cortical thickness and trait empathy in patients and people at high risk for alcohol use disorders
Schmidt, T., Roser, P., Ze, O., Juckel, G., Boris Suchan, A., & Thoma, P. (2017) · Psychopharmacology · doi:10.1007/s00213-017-4741-3 · Cited by 25 · see citing works
“Possibly, structural deficits in these regions lead to poorer insight and thus overestimation of one’s perspective taking skills, particularly given that impaired metacognition is common in AUD (David et al. 2012).”
BackgroundInsight and white matter fractional anisotropy in first-episode schizophrenia
Asmal, L., du Plessis, S., Vink, M., Fouche, J.-P., Chiliza, B., & Emsley, R. (2017) · Schizophrenia Research · doi:10.1016/j.schres.2016.11.005 · Cited by 24 · see citing works
Elowe, J., & Conus, P. (2016) · European Psychiatry · doi:10.1016/j.eurpsy.2016.07.007 · Cited by 23 · see citing works
“Patients can present two types of deficit: an inability to reflect on their thought content and to control its flow (strategic metacognition) and a systematic bias in the attribution of beliefs to oneself (attributive metacognition) [41].”
BackgroundDigital Phenotyping in Child and Adolescent Psychiatry: A Perspective
Nisenson, M., Lin, V., & Gansner, M. (2021) · Harvard Review of Psychiatry · doi:10.1097/hrp.0000000000000310 · Cited by 21 · see citing works
“In the near future, these digital markers could be validated for detection of relapse or recovery, providing a potential early-warning system to alert providers or family members to the patient’s decompensation.(26)”
BackgroundSoldatos, R. F., Cearns, M., Nielsen, M. Ø., Kollias, C. T., Xenaki, L., Stefanatou, P., Ralli, I., Dimitrakopoulos, S., Hatzimanolis, A., Kosteletos, I., et al. (2021) · Schizophrenia Bulletin · doi:10.1093/schbul/sbab107 · Cited by 22 · see citing works
Camp, L. S. C. V., Sabbe, B., & Oldenburg, J. F. E. (2019) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2019.06.001 · Cited by 23 · see citing works
Revisiting Poor Insight into Illness in Anorexia Nervosa
Arbel, R., Latzer, Y., & Koren, D. (2014) · Journal of Psychiatric Practice · doi:10.1097/01.pra.0000445243.00683.30 · Cited by 21 · see citing works
Pijnenborg, G. H. M., de Vos, A. E., Timmerman, M. E., van der Gaag, M., Sportel, B. E., Arends, J., Koopmans, E. M., van der Meer, L., & Aleman, A. (2018) · Schizophrenia Research · doi:10.1016/j.schres.2018.10.018 · Cited by 21 · see citing works
“Although literature on the relationship between cognitive insight and clinical insight is inconsistent (David et al., 2012), hypo-activation in brain areas traditionally associated with self-reflection was found in relation to both poor clinical and poor cognitive insight (Van Der Meer et al.”
ResultExploring the effects of cognitive remediation on metacognition in people with schizophrenia
Cella, M., Edwards, C., Swan, S., Elliot, K., Reeder, C., & Wykes, T. (2019) · Journal of Experimental Psychopathology · doi:10.1177/2043808719826846 · Cited by 19 · see citing works
Kumar, R., Chhikara, B. S., Gulia, K., & Chhillar, M. (2021) · Nanotheranostics · doi:10.7150/ntno.49619 · Cited by 20 · see citing works
“Such complications make it even more complicated [140].”
Confidence at the limits of human nested cognition
Recht, S., Jovanović, L., Mamassian, P., & Balsdon, T. (2022) · Neuroscience of Consciousness · doi:10.1093/nc/niac014 · Cited by 20 · see citing works
Self-reflection and set-shifting mediate awareness in cognitively preserved schizophrenia patients
Gilleen, J., David, A., & Greenwood, K. (2016) · Cognitive Neuropsychiatry · doi:10.1080/13546805.2016.1167031 · Cited by 23 · see citing works
Foffani, G. (2023) · PNAS Nexus · doi:10.1093/pnasnexus/pgad442 · Cited by 18 · see citing works
“Nevertheless, the authors themselves refer to their results as preliminary (82), indicating the need for further studies on lucid dreaming in schizophrenia/psychosis and on the multifaceted relationships between insight and metacognition in health and disease (83).”
ResultThe denial of aggression in violent patients with schizophrenia
KRAKOWSKI, M. I., & Czobor, P. (2012) · Schizophrenia Research · doi:10.1016/j.schres.2012.08.037 · Cited by 19 · see citing works
Béland, S., & Lepage, M. (2017) · Psychiatry Research · doi:10.1016/j.psychres.2017.09.082 · Cited by 19 · see citing works
Davies, G., Rae, C. L., Garfinkel, S. N., Seth, A. K., Medford, N., Critchley, H., & Greenwood, K. (2018) · Cognitive Neuropsychiatry · doi:10.1080/13546805.2018.1444597 · Cited by 19 · see citing works
Neural Substrate for Metacognitive Accuracy of Tactile Working Memory
Gogulski, J., Zetter, R., Nyrhinen, M., Pertovaara, A., & Carlson, S. (2017) · Cerebral Cortex · doi:10.1093/cercor/bhx219 · Cited by 19 · see citing works
Moeller, S. J., Hanley, A. W., & Garland, E. L. (2019) · Psychological Medicine · doi:10.1017/s0033291719000461 · Cited by 17 · see citing works
“, 2019) and in other psychopathologies such as schizophrenia (Keefe et al., 2006; van der Meer et al., 2010; David et al., 2012; Lysaker et al., 2018).”
BackgroundMethodGuillén-Font, M. A., Cervera, M., Puigoriol, E., Boreu, Q. F., Arrufat, F. X., & Serra, M. (2021) · Journal of Psychiatric Practice · doi:10.1097/pra.0000000000000580 · Cited by 18 · see citing works
A bivariate logistic regression model based on latent variables
Kristensen, S. B., & Bibby, B. M. (2020) · Statistics in Medicine · doi:10.1002/sim.8587 · Cited by 18 · see citing works
Camp, L. S. C. V., Oldenburg, J. F. E., & Sabbe, B. (2016) · Cognitive Neuropsychiatry · doi:10.1080/13546805.2015.1137214 · Cited by 17 · see citing works
Association of neurocognitive deficits and insight in schizophrenia
Grover, S., Sahoo, S., Nehra, R., Chakrabarti, S., & Avasthi, A. (2018) · Asian Journal of Psychiatry · doi:10.1016/j.ajp.2018.07.001 · Cited by 17 · see citing works
Metacognitive Computations for Information Search: Confidence in ControlPreprint
Schulz, L., Fleming, S. M., & Dayan, P. (2021) · bioRxiv (Cold Spring Harbor Laboratory) · doi:10.1101/2021.03.01.433342 · Cited by 15 · see citing works
“…Ryu, Golfi-nos, & Blackmon, 2014; Goldstein et al., 2009; Per-saud, McLeod, & Cowey, 2007; Shimamura & Squire, 1986) and psychological disorders (David et al., 2012; Hoven et al., 2019; Rouault et al., 2018) as well as aging (Palmer, David, & Fleming, 2014; Weil et al., 2013) specifically…”
Poyraz, B. Ç., Arıkan, M. K., Poyraz, C. A., Turan, Ş., Kani, A. S., Aydin, E. T., & İnce, E. (2016) · Nordic Journal of Psychiatry · doi:10.1080/08039488.2016.1178328 · Cited by 16 · see citing works
Multitasking costs on metacognition in a triple-task paradigm
Konishi, M., Berberian, B., de Gardelle, V., & Sackur, J. (2021) · Psychonomic Bulletin & Review · doi:10.3758/s13423-021-01967-0 · Cited by 16 · see citing works
Anxiety Disorders: The Relationship between Insight and Metacognition
Halaj, A., Konstantakopoulos, G., Ghaemi, S. N., & David, A. S. (2024) · Psychopathology · doi:10.1159/000538096 · Cited by 14 · see citing works
“In contrast to the more clearly de fi ned phenomena observed in psychosis such as abnormal experiences and dysfunctional behaviors, where the connection between metacognition and insight is more evident [8, 9], understanding insight into anxiety has unique challenges [10].”
Remmert, N., Schmidt, K. M. B., Mussel, P., Hagel, M. L., & Eid, M. (2022) · PLoS ONE · doi:10.1371/journal.pone.0269428 · Cited by 15 · see citing works
“This conceptual classification of insight is defined to be a meta-cognitive process [26] and an aspect of self-knowledge involving information about defense mechanisms and coping strategies [27].”
BackgroundClinical insight in first episode psychosis: the role of metacognition
Wright, A. C., Lysaker, P. H., Fowler, D. G., & Greenwood, K. (2021) · Journal of Mental Health · doi:10.1080/09638237.2021.1922629 · Cited by 14 · see citing works
“There was a specific association between metacognitive ability and self-reflectiveness subscale of the cognitive insight measure (BCIS), supporting previous studies (David et al., 2012; Gilleen et al., 2016).”
Result
- Authors
- David, A. S., Bedford, N., Wiffen, B., & Gilleen, J.
- Affiliations
- King's College London (GB)
- Section of Cognitive Neuropsychology, Department of Psychosis Studies, Institute of Psychiatry, King's College London, De Crespigny Park, London, SE5 8AF, UK
- Venue
- Philosophical Transactions of the Royal Society B Biological Sciences
- Publisher
- The Royal Society
- Published
- 2012-05-19
- Volume
- 367
- Issue
- 1594
- Pages
- 1379-1390
- ISSN
- 0962-8436 (ISSN-L)
- 1471-2970
- PMC
- PMC3318769
- OpenAlex
- W2133743374
- Cited by
- 227
- References
- 110
- Citations by year
- 2026: 9 · 2025: 8 · 2024: 11 · 2023: 18 · 2022: 22 · 2021: 22 · 2020: 11 · 2019: 18 · 2018: 15 · 2017: 21 · 2016: 18 · 2015: 15 · 2014: 17 · 2013: 16 · 2012: 6
- FWCI
- 12.34
- Type
- journal article
- Language
- en
- Update notices
- correction (2014-01-19)
- Open access
- bronze
- doi.org
- Locations
- Philosophical Transactions of the Royal Society B Biological Sciences (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Research Portal (King's College London) (submittedVersion)
- Funders
- National Institute for Health and Care Research (NF-SI-0510-10129)
- 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
- metacognition, insight, anosognosia, schizophrenia, psychosis, neuropsychiatric disorders, disease awareness, self-reflection, medial frontal cortex, self-assessment, memory impairment, Alzheimer's disease, brain injury, functional MRI, structural MRI
- MeSH terms
- Cognition Disorders, Frontal Lobe, Humans, Models, Neurological
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