Insight in schizophrenia: From conceptualization to neuroscience

Laboratory of Clinical Neuroscience and Mental Health, Faculty of Medicine and Pharmacy, Casablanca, Morocco.
Psychiatry and Clinical Neurosciences (Impact Factor: 1.63). 04/2012; 66(3):167-79. DOI: 10.1111/j.1440-1819.2012.02325.x
Source: PubMed


Lack of insight into illness is a prevalent and distinguishing feature of schizophrenia, which has a complex history and has been given a variety of definitions. Currently, insight is measured and treated as a multidimensional phenomenon, because it is believed to result from psychological, neuropsychological and organic factors. Thus, schizophrenia patients may display dramatic disorders including demoralization, depression and a higher risk of suicide, all of which are directly or indirectly related to a lack of insight into their illness, and make the treatment difficult. To improve the treatment of people with schizophrenia, it is thus crucial to advance research on insight into their illness. Insight is studied in a variety of ways. Studies may focus on the relationship between insight and psychopathology, may view behavioral outcomes or look discretely at the cognitive dysfunction versus anatomy level of insight. All have merit but they are dispersed across a wide body of literature and rarely are the findings integrated and synthesized in a meaningful way. The aim of this study was to synthesize findings across the large body of literature dealing with insight, to highlight its multidimensional nature, measurement, neuropsychology and social impact in schizophrenia. The extensive literature on the cognitive consequences of lack of insight and the contribution of neuroimaging techniques to elucidating neurological etiology of insight deficits, is also reviewed.


Available from: Mounir Ouzir, Oct 14, 2014
Review Article
Insight in schizophrenia: From conceptualization
to neuroscience
pcn_2325 167..179
Mounir Ouzir, PhD,
* Jean Michel Azorin, MD,
Marc Adida, MD, PhD,
Driss Boussaoud, PhD
and Omar Battas, MD
Laboratory of Clinical Neuroscience and Mental Health, Faculty of Medicine and Pharmacy, Casablanca, Morocco,
Institute of Systems Neuroscience, Mixed Research Unit 1106, INSERM and Faculty of Medicine and Pharmacy,
Aix-Marseille University and
Department of Psychiatry, Sainte Marguerite Hospital, Mediterranean University, Marseille,
Lack of insight into illness is a prevalent and distin-
guishing feature of schizophrenia, which has a
complex history and has been given a variety of defi-
nitions. Currently, insight is measured and treated as
a multidimensional phenomenon, because it is
believed to result from psychological, neuropsycho-
logical and organic factors. Thus, schizophrenia
patients may display dramatic disorders including
demoralization, depression and a higher risk of
suicide, all of which are directly or indirectly related
to a lack of insight into their illness, and make the
treatment difficult. To improve the treatment of
people with schizophrenia, it is thus crucial to
advance research on insight into their illness. Insight
is studied in a variety of ways. Studies may focus
on the relationship between insight and psychopa-
thology, may view behavioral outcomes or look
discretely at the cognitive dysfunction versus
anatomy level of insight. All have merit but they are
dispersed across a wide body of literature and rarely
are the findings integrated and synthesized in a
meaningful way. The aim of this study was to synthe-
size findings across the large body of literature
dealing with insight, to highlight its multidimen-
sional nature, measurement, neuropsychology and
social impact in schizophrenia. The extensive litera-
ture on the cognitive consequences of lack of insight
and the contribution of neuroimaging techniques to
elucidating neurological etiology of insight deficits, is
also reviewed.
Key words: cognition impairment
, conceptualiza-
tion, insight, neuroanatomy, schizophrenia.
MONG PATIENTS WITH psychiatric disorders,
patients with schizophrenia more often exhibit
poor insight concerning their mental disorder.
World Health Organization (WHO) International
Pilot Study of Schizophrenia in different cultures
found that ‘lack of insight’ was an almost invariable
feature of acute and chronic schizophrenia. That
study found that 50–80% of patients lack, either par-
tially or totally, insight into their mental disorder.
rich literature indicated that unawareness of illness is
associated with defects in cognitive functions such as
attention, memory, language, executive functioning
and social cognition.
Furthermore, poor insight in
schizophrenia has been proposed to result in poor
treatment compliance,
poor social and interper-
sonal functioning,
poor prognosis, and higher
risk of relapse.
Other studies reported that poor
insight may increase the incidence of depression,
hopelessness, low self-esteem
and more generally
poor quality of life (QOL).
Over the past
decade there has been an increase in research on
the conceptualization and assessment of insight,
but the relationship between insight and neuro-
cognitive impairment, severity of psychopathology or
*Correspondence: Mounir Ouzir, PhD, Laboratory of Clinical
Neuroscience and Mental Health, University Hassan II, Faculty of
Medicine and Pharmacy, 19 Rue Tarik Ibnou Ziad, BP: 9154 Mers
Sultan, 20000 Casablanca, Morocco. Email:
Received 3 October 2010; accepted 25 January 2012.
Psychiatry and Clinical Neurosciences 2012; 66: 167–179 doi:10.1111/j.1440-1819.2012.02325.x
167© 2012 The Authors
Psychiatry and Clinical Neurosciences © 2012 Japanese Society of Psychiatry and Neurology
Page 1
functional recovery remains unclear.
ing the mechanism of lack of insight in schizophrenia
and its clinical and social implications is a major
challenge for the care and treatment of people with
this deleterious mental disorder. The aim of the
present study was to give an up-to-date account of
research and to present a coherent view on insight in
schizophrenia, with particular emphasis on the
concept of insight in relation to clinical aspects, psy-
chopathology, and QOL as well as neuroscience to
understand the neurobiological mechanisms under-
lying insight deficit in schizophrenia.
Insight is a concept that is intimately linked to
mental illness, and which is nowadays recognized as
an important phenomenon in psychiatric practice. It
refers to a complex state of awareness of patients of
their own illness, and its earliest definition in rela-
tionship to schizophrenia dates back to the 1930s,
when Aubrey Lewis defined insight as ‘a correct atti-
tude to morbid change in oneself’.
Later, in the
early 1990s, insight was suggested to consist of three
dimensions: recognition that one has a mental
illness; the ability to label unusual mental events as
pathological; and adherence to treatment.
recently, several authors have characterized insight
as awareness of neuropsychological defects includ-
ing attention, memory, and problem solving.
Insight, however, may not be viewed as a simple
balance between awareness and unawareness of
illness. For example, Amador et al. have stressed the
distinction between awareness and attribution of
psychotic symptoms, based on the observation that
some patients may recognize signs of illness but
attribute them to causes other than abnormalities in
their mental states.
The picture can be even more
complex, because schizophrenia is not always asso-
ciated with lack of insight. This observation made
Cole argue for a more accurate diagnostic classifica-
tion of insight that includes the following specifiers:
(i) schizophrenia with preserved insight; (ii) schizo-
phrenia with impaired insight, predominately neu-
ropsychological features; (iii) schizophrenia with
impaired insight, predominately emotional features;
and (iv) schizophrenia with impaired insight, with
mixed neuropsychological and emotional features.
Cole asserted that these additional specifiers will
also improve the validity of predictions regarding
diagnosis and treatment response.
Lack of insight has initially been considered as one of
the most frequent symptoms in schizophrenia,
before it was taken to be as a factor that determines
the other symptoms. Several studies have since exam-
ined the relationship between insight and symptoms
in schizophrenia, and have demonstrated namely the
existence of a negative correlation between insight
and the severity of positive symptomatology.
Nakano et al. found that negative symptoms were
negatively associated with overall insight, especially
with awareness of mental illness and treatment com-
while Smith et al. found a small relation-
ship between awareness of current symptoms and
negative symptoms.
This result, however, failed to
be reproduced by Collins et al.
In a meta-analysis,
Mintz et al. reviewed 40 published studies and found
a significant, but small, relationship between both
positive and negative symptom severity and insight,
with age of onset and acute versus chronic disease
status serving as moderating variables, and that 3–7%
of the variance in insight was explained by severity of
symptomatology in schizophrenia patients.
Adopting a large view of the relationship between
insight and symptoms, several investigations have
examined the link between disorganized symptoms
and clinical insight, and many of them have found a
significant relationship between insight and disorga-
nized symptoms.
Disorganization in patients
with schizophrenia represents the most direct clinical
expression of mental dissociation and may preclude
the capacity to engage in abstract thinking needed to
reflect rationally on their anomalous experiences,
leaving the individual with schizophrenia without a
coherent concept of normality. In a recent study, the
disorganization factors of the Positive and Negative
Syndrome Scale (PANSS) as proposed by Van der
Gaag et al.
emerged as the statistically significant
contributors for insight in relation to the Scale to
assess Unawareness of Mental Disorder (SUMD)
current and past awareness of symptoms.
There are
other studies, however, that have not found such a
relationship between insight and disorganized symp-
toms. One study found no relationship between
these variables.
One study found a significant asso-
ciation between disorganized symptoms and two
subscales of an insight measure but did not find such
an association with seven other indices of insight
In contrast, a few studies have investi-
168 M. Ouzir et al. Psychiatry and Clinical Neurosciences 2012; 66: 167–179
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gated the relationship between cognitive insight
and psychopathology. For example, Pedrelli et al.
reported only mild correlations between positive,
negative symptoms and the Self-Certainty scale of the
Beck Cognitive Insight Scale (BCIS) in outpatients.
Later, in a small sample, Warman et al. demonstrated
that individuals with active delusions (n = 33) had
higher Self-Certainty scores and that non-deluded
patients (n = 11) had higher Self-Reflectiveness
Engh et al. investigated the same question in
a cross-sectional study of 143 patients.
They argued
that the occurrence of delusions is associated with
low self-Reflectiveness and high self-certainty. In con-
trast, Buchy et al. suggested that non-delusional
participants did not differ on their Self-Certainty
compared to delusional participants despite their
higher Self-Reflectiveness.
In addition to delusions,
others symptoms such as hallucinations have been
found to be associated with high self-Reflectiveness
and low self-certainty in the absence of delusions,
reflecting more open-mindedness and higher cogni-
tive insight.
Altogether, these data support a specific
causal link between insight and disorganized symp-
toms. Therefore, more studies with larger samples
involving follow up for longer periods will be valu-
able to understand the nature of the relationship
between the specific dimensions of insight and clini-
cal symptoms of schizophrenia, taking into account
the stages of the disease, age of disease onset, and
clinical factors such as symptom severity.
The etiology of lack of insight in patients with
schizophrenia is not clearly known, but different
explanatory models and theoretical approaches have
emerged. Neuropsychology describes poor insight
in schizophrenia as a result of cognitive deficits
that appear as a consequence of dysfunction in
neural processes,
especially in frontal or parietal
Amador et al. underscored the similari-
ties between lack of insight in schizophrenia and
anosognosia in neurological disorders: they sug-
gested that both conditions shared a common etiol-
ogy in parietal and/or frontal lobe dysfunction.
Little is known about the mechanisms that may
underlie poor insight in schizophrenia. For instance,
the association between neurocognitive deficits and
poor insight was assessed.
In addition, preliminary
findings from a pilot study suggested that poor
insight was more strongly related to meta-cognitive
than to cognitive deficits per se (e.g. free-choice per-
formance accuracy from the Wisconsin Card-Sorting
Test [WCST], which depends on meta-cognitive
skills of monitoring and control, is an important
mediator between basic cognitive skills and the
clinical phenomena of poor insight).
In several
studies, however, poor insight in schizophrenia was
defined as denial of illness, a psychological coping
Psychodynamic explanations
described denial of illness as a defense mechanism
that protects the individual from distress. Acknowl-
edgment and acceptance of one’s own mental illness
would diminish self-esteem.
In clinical studies,
lack of insight was shown to be independent from
positive and negative symptoms in schizophrenia:
poor insight would be a primary symptom of the
disorder, intrinsic to delusions and hallucina-
Unfortunately, the weakness of the existing
relationship between insight and severity of symp-
tomatology on the one hand, and between insight
and emotional state on the other hand, suggests that
both psychodynamic and clinical models are not
sufficient explanatory models.
In clinical/psychopathological and neurocognitive
studies, several instruments exist for assessing insight
and many of them seem to be measuring a similar
construct. The Hamilton Depression Rating Scale
the Present State Examination,
Schedule for Affective Disorders and Schizophrenia,
and the PANSS,
all contain one item that assesses
general insight, and all have high correlations with
more multiple-item insight scales, as reported by
Lincoln et al.
Low correlations between general
insight and scales or subscales that address additional
aspects of insight, such as insight into past disorder,
or which are based on a different concept of insight,
such as cognitive insight,
prove the importance of
semi-structured interview and self-report methods
that have been designed to assess insight as a multi-
dimensional characteristic (Table 1). Compared to
interview techniques that require more time and
inter-rater reliability to be established, self-reporting
methods have several potential benefits. Marks et al.
suggest that the development of a self-report ques-
tionnaire may eliminate potential researcher and
clinician biases, such as the tendency to rate patients
with either lower general intelligence or fewer com-
munication skills, as having poorer insight.
Psychiatry and Clinical Neurosciences 2012; 66: 167–179 Insight in schizophrenia 169
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self-report measures of insight may be more sensitive
to associations with variables relevant to the etiology
of insight than single items from general symptom
rating scales.
The Insight and Treatment Attitudes Questionnaire
was developed to measure two dimensions of insight:
the patient’s failure to acknowledge illness, and the
need for treatment.
Later, Markova and Berrios con-
structed the Insight Scale self-report, which incorpo-
rated additional factors, such as self-knowledge about
not only how the disorder affects the patient, but also
about how the disorder affects the patient’s interac-
tion with the world.
In recent years, SUMD has been
used frequently to assess insight in schizophrenia
and its relationship to psychopathology. This scale
that assesses current and retrospective awareness of
having a mental disorder, the effects of medication,
the consequences of mental illness, and the aware-
ness and attributions for the specific signs and symp-
toms of the disorder, shows high correlation with the
insight item on the HDRS.
Beck and colleagues
noted that patients with major psychoses typically
have reduced capacity to reflect rationally on their
anomalous experiences and to recognize that their
conclusions are incorrect, and developed the BCIS to
assess two domains: Self-Reflectiveness (captures the
willingness to acknowledge fallibility, consider alter-
nate explanations, and recognize dysfunctional rea-
soning) and Self-Certainty (taps overconfidence in
current beliefs and judgments).
High scores on the
subscale self-reflectiveness and low scores on the sub-
scale self-certainty is considered normal. The two
Table 1. Different psychometric scales for measuring insight
Type of
insight scale Measure of insight
items Features of scale Study
Scale for Assessment of
Unawareness of Mental
Disorder (SUMD)
37 Evaluates present and past insight into
mental disorder, social consequences,
need for treatment, and attribution of
symptom to disorder
Amador & Strauss
Scale for Assessment of
Insight, Extended
12 Assesses recognition of illness, compliance
with treatment and ability to label mental
events as pathological
Insight and Treatment
Questionnaire (ITAQ)
11 Evaluates perception of treatment and
acceptance of illness label
McEvoy et al.
Measure of Insight into
Cognition Clinician
Rated (MIC-CR)
12 Assesses both awareness and attribution of
relative cognitive status in the areas of
attention, executive functioning, and
Medalia & Thysen
Self-report Birchwood Insight
Scale (BIS)
8 Measures awareness of illness, ability to
re-label psychotic symptoms, and
recognition of the need for treatment.
Birchwood et al.
Insight Scale (IS) 32 Measures individuals’ degree of
Markova & Berrios
Awareness of Being a
Patient Scale (ABPS)
25 Assesses the recognition of the need for
treatment and acceptance of the treatment
Hayashi et al.
Subjective Experience of
Negative Symptoms
24 Measures awareness, causal attribution, and
disruption or distress.
Selten et al.
Beck Cognitive Insight
Scale (BCIS)
15 Measures reflectiveness, objectivity, openness
to feedback and self-certainty
Beck et al.
Self-Appraisal of Illness
Questionnaire (SAIQ)
17 Assesses beliefs about the outcome of illness,
acknowledgment of a need for psychiatric
treatment, and extent of worry about
illness and illness-related issues.
Marks et al.
170 M. Ouzir et al. Psychiatry and Clinical Neurosciences 2012; 66: 167–179
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subscale scores were weakly intercorrelated, indicat-
ing that they represent two different dimensions of
cognitive insight.
Weak to moderate associations
have also been found between the two subscales of
the BCIS, and the Birchwood measure of insight
and the PANSS insight item in schizophrenia,
cating that cognitive and clinical insights represent
different domains.
In recent years, cognitive, emotional and behavioral
consequences of lack of insight in schizophrenia have
been well documented. In particular, several studies
have shown that patients with objective cognitive
impairment exhibit poor insight concerning symp-
toms of schizophrenia such as hallucinations, delu-
sions and paranoia.
In the early stages
of schizophrenia and in the first psychotic episode,
cognitive dysfunctions have been demonstrated.
Longitudinal studies have shown that these impair-
ments are stable in time.
In another study, insight
ability was significantly correlated with performance
in visual object learning, verbal working memory and
identification of facial emotions.
This evidence
suggests that poor insight may be associated with
executive functions, although the literature dealing
with the relationship between insight and neurocog-
nitive functions showed contrasting results. Indeed,
while some studies reported a significant correlation
between poor insight and impairment of executive
and attention,
others did not corroborate these findings.
analyses show that neuropsychological dysfunction,
specifically impairment of set-shifting and error
monitoring, contributes to poor insight.
In a recent
study, lack of insight in schizophrenia patients
was partly explained by their inability to process
new information from the environment.
et al., however, explored the relationships between
cognitive complaints assessed on the Subjective Scale
to Investigate Cognition in Schizophrenia
and sug-
gested that schizophrenia patients might be con-
scious of their cognitive deficits in spite of a lack of
insight concerning their psychotic symptoms.
Few studies have attempted to link lack of insight to
cognitive processes other than those mentioned here,
namely learning, problem solving, decision-making,
reasoning, and calculation abilities. By contrast, it is
interesting to review studies that have addressed
higher order cognition (i.e. meta-cognition). One
newer model of insight that may help resolve some of
these paradoxes suggests that different kinds of defi-
cits in meta-cognition, or the ability to think about
thinking, may play a unique and possibly moderating
role in the development of poor insight.
It is
known that insight requires higher level cognitive
processing. This includes assessment and correction
of distorted beliefs and misinterpretations. How indi-
viduals assess their own judgment is perhaps central
to these complex cognitive and emotional conse-
quence features of poor insight in schizophrenia
patients. To account for this capacity, also termed as
belief flexibility, Beck et al. developed the concept of
‘cognitive insight’ and constructed a scale (BCIS) that
allows its assessment in psychotic disorder.
BCIS captures two domains: (i) Self-Reflectiveness,
the willingness to acknowledge fallibility, consider
alternate explanations, and recognize dysfunctional
reasoning; and (ii) Self-Certainty, overconfidence in
current beliefs and judgments.
Beck and Baruch
showed that psychotic patients expressed, not only
consistent distortions of their experiences, but also,
an inability to distance themselves from these dis-
tortions, and inability to correct feedback.
recently, Raffard et al. showed that poor ‘basic aware-
ness of illness’ and ‘awareness of social consequences
of illness’ were associated with impaired performance
on the Rule Shift Cards subtest, a measure of cogni-
tive flexibility.
Similarly, Chen et al. used the
WCST to assess verbal intelligence, verbal fluency,
and verbal and visual memory.
They suggested that
effects of executive dysfunction on insight impair-
ment occurred as a possible mechanism of the rela-
tionship between reduced cognitive flexibility in set
shifting and greater tendency toward relapse in first-
episode schizophrenia. These findings suggest also
that factors other than cognitive functions might be
associated with capacity for insight in patients with
Schizophrenia patients have a higher mortality rate
than healthy people for different reasons, including
Suicide remains a tragically common
outcome, the incidence of which is negatively corre-
lated with patient age,
although demoralization,
hopelessness and depression have been reported
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to lead to suicidal behavior.
Mintz et al.
reported a modest but significant correlation between
depression severity and insight capacity.
in adolescent schizophrenia, Schwartz-Stav et al.
reported that depression, hopelessness and suicidal
risk were strongly correlated with insight capacity.
Taken together, these results suggest that there is a
chain of causality from insight to depression to
suicide. In contrast, Staring et al. suggested the asso-
ciation between insight and depression, low QOL,
and negative self-esteem is moderated by stigma.
Patients with good insight accompanied by stigma-
tizing beliefs have the highest risk of experiencing
low QOL, negative self-esteem, and depressed mood.
In contrast, other studies reported no relationship
between awareness of mental disorder, depression
and suicide intention.
The method used to
assess insight varies across studies. It is highly pos-
sible that the method used to assess insight could
influence the results and the nature of association
between insight and depression and suicide inten-
tion. Thus, current knowledge on the relationship of
insight to depression and suicide is inconclusive.
Contradictory results were found regarding the rela-
tionship between insight into illness and QOL in
patients with schizophrenia. Some studies have
found no relationship between insight and QOL in
Other studies found that good
insight into having a mental illness significantly
related to better social functioning and expert-rated
Later, in a study of 131 patients with a
psychotic disorder (103 with schizophrenia, 28
with schizoaffective disorder), Hasson-Ohayon et al.
noted that greater sense of emotional wellbeing was
associated with awareness into the need for treat-
Sim et al. also reported, in patients with first-
episode schizophrenia, significant improvements in
their level of awareness of the consequences of their
mental illness, effects of treatment as well as psycho-
pathology in relation to a greater subjective sense of
wellbeing over time.
Patients with acute schizo-
phrenia, however, who had greater self- and expert-
rated insight into illness, reported lower subjective
Recently, Staring et al., using the self-report
Euro-QOL, assessed five dimensions of QOL (EQ-
5D) in patients with schizophrenia: mobility, self-
care, usual activities, pain/discomfort, and anxiety/
The authors reported a correlation
between poor insight and low QOL, especially when
accompanied by stigmatizing beliefs. In contrast,
Nakamae et al. found no significant association
between SUMD and EQ-5D scores in patients with
chronic schizophrenia.
In another study, Hasson-
Ohayon et al. assessed schizophrenia patients using
the Wisconsin Client Quality of life Questionnaire-
Mental developed by Becker et al.
They reported
that scores on six out of seven dimensions of QOL
were correlated with level of general awareness of
illness. It is obvious that poor insight impacts nega-
tively on the QOL of people with schizophrenia,
namely by reducing their hope.
More recently,
Kurtz and Tolman, using the Lack of Judgment and
Insight item on the PANSS as a measure of insight
into illness, and Subjective QOL (SQOL), which
targets subjective satisfaction with one’s living situa-
tion, work, social contacts and psychological state,
confirmed that illness insight was inversely related to
SQOL as reported by Aghababian et al. using the
same design.
Similarly, in 1432 schizophrenia
patients Mohamed et al. found a small but significant
correlation between higher insight and lower QOL.
In light of these studies, and the fact that severity of
depression is positively related to SQOL,
dence suggests that the relationship between insight
and QOL might be different between acute and
chronic stages of schizophrenia patients, and that
psychoeducational and cognitive remediation pro-
grams may directly and positively increase their QOL
and the usefulness of their insight into their illness.
Intuitively, one might expect that a complex mental
construct such as insight would be mediated by brain
regions located at a high hierarchical level. These
would culminate in the prefrontal cortex, but would
also involve connected regions of the parietal and
temporal cortex. With the development of brain
imaging techniques, a number of recent studies have
examined the cerebral correlates of poor insight in
schizophrenia, and their results are beginning to
provide answers to this important question. Interest-
ingly, several studies based on cognitive test data
have related lack of insight in schizophrenia to defi-
cits in frontal cortical systems.
a macroscopic level, some studies have used magnetic
resonance imaging, voxel-based morphometry, com-
puted tomography and diffusion tensor imaging to
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Table 2. Studies investigating brain anatomical abnormalities and insight
Study Participants (n)
and insight measures Results
Antonius et al.
26 patients with schizophrenia
and schizoaffective disorder
DTI Symptom unawareness was linked to white matter abnormalities
in various frontotemporal brain regions. Misattribution of
symptoms was related to deficits in the white matter in parietal
and temporal brain regions.
Buchy et al.
79 inpatients and outpatients
with a first-episode psychosis
VBM Regional thickness in frontal cortex is associated with awareness
of illness in the early phase of psychosis. Prominent thickness
reductions in parietal and temporal cortices associated with
awareness of illness and awareness of treatment need and efficacy.
Palaniyappan et al.
57 stable patients MRI White matter volume of the right posterior insula, but not the left,
was related to reduced insight.Insight assessed using a
single sub-item
Morgan et al.
82 individuals with first-onset
MRI Significant correlation between no symptom re-labeling and
global and regional gray matter deficits primarily located at the
posterior cingulate gyrus and right precuneus/cuneus.91 healthy controls SAI-E
Cooke et al.
52 outpatients with chronic
schizophrenia and
schizoaffective disorder
VBM Significant correlations between: higher awareness of problems
and increased regional gray matter volume in the left precuneus;
higher symptom re-labeling and greater absolute gray matter in
the RSTG; and, better awareness of illness and attribution to
illness and greater regional gray matter in the LSMTG, the RITG,
and the LPG.
30 healthy controls SAI–E/BIS
Sapara et al.
28 chronic patients MRI Significant correlation between insight and cortical atrophy in IFG
and SFG.20 healthy controls BIS/SAI-E
Bassitt et al.
50 outpatients VBM No significant inverse correlations between the degree of insight
impairment and total brain volumes.30 healthy controls SUMD
McEvoy et al.
226 first-episode schizophrenia MRI Larger brain volumes associated with more insight
Lee et al.
14 patients MRI Increase in left medial prefrontal cortex activity was specifically
associated with improved insight14 healthy controls Schedule of Assessment of
Shad et al.
14 first-episode schizophrenia MRI Insight deficits were associated with DLPFC/OFC.
Shad et al.
35 first-episode schizophrenia MRI Inverse correlation between insight and right DLPFC volumes
Insight item of HDRS
Ha et al.
35 paranoid schizophrenia VBM A positive correlation between better insight, and gray matter
concentrations in the LPC/RAC as well as the bilateral inferior
temporal regions.
35 healthy controls Insight-item (G12) from
Rossell et al.
78 chronic male patients MRI No significant correlations between whole brain, white and gray
matter volume and degree of insight.36 normal male SAI-E
Flashman et al.
15 patients with schizophrenia
and schizoaffective disorder
MRI Significant correlation between deficits in DLPFC/OFC/MFG and
poor insightSUMD
Flashman et al.
30 patients with schizophrenia
MRI Reduced whole brain volume associated with poor insight
Larøoi et al.
21 patients CT Frontal lobe atrophy was associated with poor insight
21 healthy controls SUMD
David et al.
150 inpatients mixed CT No significant correlations between lack of insight and total
ventricular volume and frontal lobe functionPANSS
Takai et al.
22 chronic schizophrenia MRI Ventricular enlargement associated with poor insight
G12 item of the PANSS
Insight is assessed using a single sub-item with scores ranging from 0 to 4, with higher scores suggesting more severe lack of insight.
BIS, Birchwood Insight Scale; CT, computed tomography; DLPFC, dorsolateral prefrontal cortex; DTI, diffusion tensor imaging; HDRS, Hamilton
Depression Rating Scale; ITAQ, Insight and Treatment Attitudes Questionnaire; LPC, left posterior cingulate cortex; LPG, lateral parietal gyri; LSMTG, left
superior-middle temporal gyrus; MFG, middle frontal gyrus; MRI, magnetic resonance imaging; OFC, orbitofrontal cortex; PANSS, Positive and Negative
Syndrome Scale; RAC, right anterior cingulate cortex; RITG, right inferior temporal gyrus; RSTG, right superior temporal gyrus; SAI-E, Expanded Schedule of
Assessment of Insight; SUMD, Scale to assess Unawareness of Mental Disorder; VBM, voxel-based morphometry.
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examine the relationship between total brain volume
as well as some cortical structures implicated in
higher mental functions, and insight capacity.
Table 2 summarizes a number of structural neuroim-
aging studies of insight. Some studies have reported
an association between poor insight and reduced
total brain volume,
ventricular enlargement,
frontal lobe atrophy,
reduced frontal lobe
and gray matter deficits in the cingulate
temporal lobe,
parietal lobe,
and the right posterior insula.
Other studies, however, have not found any signifi-
cant correlations between lack of insight and total
brain volume, total ventricular volume and gray or
white matter volumes in the prefrontal region.
This inconsistency could arise from the complex
nature of insight and the use of a variety of insight
These neuroimaging approaches support a neuro-
logical etiology of insight deficits in schizophrenia
and suggest that the multidimensional construct of
insight has multiple neural determinants. These
results point to the possibility that other brain
regions including the temporal and parietal lobes
might also be important in determining insight levels
in schizophrenia. Clearly, more research is needed on
the cerebral anatomical/functional correlates in order
to develop a functional anatomy of insight and its
defects in schizophrenia.
In summary, because of a multitude of conceptual-
izations of insight, of theories of its etiology and
measures, insight appears as a multidimensional
and complex phenomenon. Poor insight in schizo-
phrenia, rather than being a simple primary
symptom of the disease, has major consequences on
cognitive and meta-cognitive processes (such as
beliefs), as well as on emotional state. It may also
increase the incidence of depression and suicidal
behavior. The psychopathological assessment of
insight is marked by several paradoxes. It is thus
important to develop tools to accurately assess the
lack of insight in people with schizophrenia. Unfor-
tunately, because of its complexity, measuring
insight still requires the development of specific
laboratory tests and sophisticated tasks derived from
cognitive psychology, taking into account all dimen-
sions of insight. Future research should focus in
detail on the role of meta-cognitive processes, and
examine separate components of the insight con-
struct to explore relationships between insight into
clinical symptoms and insight into cognitive impair-
ment. Although the consequences of acknowledging
one’s disorder may increase feelings of hopelessness
or depression for many patients, increasing the hope
may have a positive impact on QOL and the useful-
ness of their insight into their illness. We do not
know enough about the neuroanatomical and func-
tional basis of insight, but the specific areas of the
prefrontal cortex (i.e. dorsolateral prefrontal cortex,
orbitofrontal cortex, anterior cingulate) may support
poor insight in schizophrenia. The progress from
neuroscience research on the neuronal correlates of
insight may prove to be useful in advancing its
understanding. From this perspective, the functional
neuroanatomy of insight in schizophrenia (i.e. the
details of structural and functional connectivity in
relation to different dimensions of insight) is begin-
ning to yield important data. The available data as at
the time of writing suggest the involvement of
several frontal, parietal and temporal regions. It is
likely that insight, which requires high-level infor-
mation processing, results from functional interac-
tions between these cortical regions, which are
known to be connected.
Finally, it appears essential to better define the phe-
nomenology of insight impairments in schizophre-
nia to integrate neurobiological and psychological
findings as well as the social context as manifested in
a number of studies discussed in the present review.
This work was supported by the ARCUS program
(Ministère des Affaires Etrangères and Région PACA,
France), and the European Project Nuromed,
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    • "More specifically, increased self-reflection is positively correlated with awareness of delusions and negatively with delusion severity (Engh et al., 2010). Additionally, a positive relationship between delusion severity and self-certainty has been consistently reported (Warman et al., 2007; Engh et al., 2010; Ouzir et al., 2012). These studies demonstrate evidence of both overlap and distinctiveness between clinical and cognitive insight and this might have clinical implications (Beck et al., 2011; Pijnenborg et al., 2011; Pijnenborg et al., 2014). "
    [Show abstract] [Hide abstract] ABSTRACT: Lack of insight is a commonly observed problem in patients with psychosis and schizophrenia. Clinical insight in patients has been associated with low mood. Cognitive insight is a recently defined concept, relating to the ability to self-reflect and the degree to which patients are over-confident regarding their interpretations of illness-related experiences, and is related to clinical insight. We therefore sought to investigate whether there is a positive relationship between cognitive insight and mood. A literature search identified 17 relevant papers published between 2004 and 2014. Our analysis indicated that there was a small but significant positive correlation between the composite index (CI) of the Beck Cognitive Insight Scale (BCIS) and depression scores, but this was driven by a significant positive relationship between depression and the BCIS self-reflection (SR) sub-scale, where low mood was related to higher SR scores. There was no significant relationship between the self-certainty sub-scale and depression. Post-hoc analysis indicated that different depression scales did not significantly affect the relationship with SR. Our results support the idea that cognitive insight is significantly related to mood in schizophrenia, and the effect size is similar to that between clinical insight and mood. Potential applications of this knowledge into treatment and rehabilitation are discussed and a model of cognitive insight is proposed. Copyright © 2015 Elsevier B.V. All rights reserved.
    Full-text · Article · Jun 2015 · Schizophrenia Research
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    • "About 30–50% of schizophrenia patients lack insight into illness (Baier, 2010) leading to poor prognosis, treatment non-adherence and adverse outcomes (Lysaker et al., 2013; van der Meer et al., 2013). Functional neuroanatomical studies examining cerebral correlates of poor insight in schizophrenia have specifically implicated prefrontal (Shad et al., 2004; Lee et al., 2006; Shad et al., 2006) and temporo-parietal brain region abnormalities (Antonius et al., 2011; Buchy et al., 2011) [see review Ouzir et al., 2012]. Volume deficit in dorsolateral prefrontal cortex (DLPFC) is reported to be associated with impaired insight in schizophrenia (Berge et al., 2011; Parellada et al., 2011). "
    [Show abstract] [Hide abstract] ABSTRACT: Impaired insight in schizophrenia patients has been linked with prefrontal deficits. In this open-label study, we examined for potential insight facilitation effects of add-on tDCS (with anodal stimulation of left DLPFC and cathodal stimulation over left temporo-parietal junction) in schizophrenia patients (N = 21) with persistent auditory hallucinations despite adequate antipsychotic treatment. Following tDCS, there was a significant improvement in insight with concurrent significant reduction in auditory hallucination severity. Improvement in insight correlated significantly with improvement in severity of auditory hallucinations. These findings suggest improvement of insight with add-on tDCS in schizophrenia with persistent auditory hallucinations.
    Full-text · Article · Jun 2014 · Schizophrenia Research
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    • "Bien que l'alté ration de l'insight soit pré sente dans de nombreuses affections psychiatriques telles que les troubles bipolaires et le trouble obsessionnel-compulsif, les patients atteints de schizophré nie sont les plus sé vè rement touché s par cette dimension pathologique [5] [28] [30] [48] [65]. De nombreux chercheurs ont perpé tué la vision que le dé ficit d'insight e ´ tait au coeur de la pathologie schizophré nique, puisqu'il a e ´ té associé a ` une faible compliance aux soins et au traitement, a ` des taux de rechute plus e ´ levé s, a ` de fré quentes et plus longues pé riodes d'hospitalisation, et un pauvre fonctionnement psychologique et cognitif, ce qui conditionne en dé finitive la prise en charge diagnostique et thé rapeutique du patient [54] [60] [61]. De nos jours, l'existence d'un nombre important de dé finitions et d'e ´ chelles d'e ´ valuation de l'insight explique en partie les ré sultats contradictoires retrouvé s a ` partir des e ´ tudes empiriques [33]. "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives Insight in psychiatry has been defined and conceptualized in a number of ways but none of them was found to be self-explanatory. There has been an exponential rise in studies of insight, in part accelerated by the availability of several psychometric scales for measuring insight. Lack of insight has been associated in schizophrenia with low treatment adherence, a high number of relapses, increased number of hospital admissions, and subsequently poorer psychological and cognitive functioning. For this reason, there is considerable interest in understanding the underlying neural mechanisms of insight, which may have important implications for the development of future insight-oriented neuro-psychiatric treatment. Neuroimaging may be considered an important technique to help understand the anatomical, functional and metabolic neurocircuitry underlying poor insight in schizophrenia. Growing neuroimaging research provides evidence for underlying brain impairment in insight deficits in schizophrenia. In order to expose a panoramic view to the readers, this article reviews the neuroimaging studies conducted to date, which have investigated the neural bases of insight in schizophrenia. Methods Electronic searches were performed in PubMed, PsycINFO, Sciencedirect and Web of Science databases, using the following keywords: Imaging; neuroimaging; Positron Emission Tomography (PET); spectroscopy; functional Magnetic Resonance Imaging (fMRI); structural Magnetic Resonance Imaging (MRI); Single Photon Emission Computed Tomography (SPECT); Voxel Based Morphometry (VBM); Diffusion Tensor Imaging (DTI); Computed Tomography (CT); Insight; schizophrenia; awareness of illness. Searches were also performed from the references of the systematic review articles on neurobiological correlates of insight in schizophrenia. Animal studies and single case reports were excluded. Twenty-five articles were selected for the present review. From these; 12 used structural MRI; 6 used VBM; 3 used fMRI; 2 used CT; 1 used DTI and 1 used VBM combined to DTI. Results The search showed that studies in this area were published recently and that the neuroanatomic substrate of insight in schizophrenia has not yet been consolidated. This inconsistency could arise from the complex nature of insight and the use of a variety of insight assessments. Most of the studies analyzed in this review used structural neuroimaging techniques to assess brain abnormalities associated with poor insight. The functional neuroanatomy of insight has only recently been investigated and to our knowledge, there are only 3 studies that have examined brain activity with fMRI in relation to insight in schizophrenia. Conclusion This review investigated the neural deficiencies underlying poor insight in schizophrenic patients. In spite of methodological differences among studies, results provide evidence of structural and functional brain abnormalities in frontal, parietal and temporal region related to insight deficits. Some studies have found a hemispheric asymmetry in relationship to poor in insight (the majority of brain abnormalities concern the right hemisphere). In addition, growing research indicated that the prefrontal cortex, particularly the dorsolateral prefrontal cortex, the anterior cingulated cortex, the insula, the precuneus and the cerebellum can also underlying insight in schizophrenia. It is interesting to mention that some authors have suggested that each dimension of insight can be specifically linked to certain brain structures. Taking together, data on the neuropsychological and neuroanatomical correlates of clinical insight suggested that lack of insight in schizophrenia could be conceived as a neurocognitive deficit, analogously to anosognosia in brain injury and dementia. On the contrary, to date, the neuroanatomical correlates of cognitive insight have been scarcely studied. Only two studies reported that Self-reflectiveness was positively related to gray matter volume of the right ventro-lateral prefrontal cortex, the BCIS composite index was positively correlated with total left hippocampal volume, and Self-certainty was inversely correlated with bilateral hippocampal volumes. However, it is important to note that neuroimaging research on cognitive insight in schizophrenia is in a preliminary, and the results on this are inconclusive. Further research is needed to better understand the causal relationships between brain abnormalities and degradation of insight in schizophrenia.
    Full-text · Article · Apr 2014 · Annales Médico-psychologiques revue psychiatrique
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