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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 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]
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“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]
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“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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Bedford, N., & David, A. S. (2008) · Schizophrenia Research · doi:10.1016/s0920-9964(08)70353-0 · Cited by 3
POOR INSIGHT IN PSYCHOSIS: COGNITIVE DEFICIT OR BIAS?
David, A. S., & Bedford, N. (2009) · Research Portal (King's College London) · Cited by 2
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
Flagged first, then by citations
4 of the 110 references couldn’t be matched to a known paper.
Research works printed but not linked: 4
Cited by
Sorted by citations
Fleming, S. M., & Lau, H. C. (2014) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2014.00443 · Cited by 1,408
“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
“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 584
“…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
“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. M., Ryu, J., Golfinos, J. G., & Blackmon, K. (2014) · Brain · doi:10.1093/brain/awu221 · Cited by 331
“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).”
Background
Metadata
- 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
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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