Poor insight or unawareness of illness has been commonly observed in schizophrenia and has been long recognized as a potent barrier to treatment adherence and a risk factor for a range of poorer outcomes. Paradoxically, the achievement of insight often poses a different set of problems including depression and low self-esteem. One barrier to the treatment of poor insight has been a lack of understanding of the phenomenon, which causes poor insight to develop and persist over time. Without knowing what promotes poor insight, treatment to date has had little to offer beyond the supportive provision of information. To explore these issues, this article reviews emerging literature on the correlates of poor insight in schizophrenia, and newly developing ways of conceptualizing insight. It then details a number of innovative integrative group and individual treatment approaches in the early stages of development, which take into account some of the potential causal forces behind poor insight, including deficits in neurocognition, social cognition, metacognition and heightened self-stigma. A plan for further research is presented to develop a model of the factors whose interaction influences insight, and to refine and test integrative treatments.
Deficits in metacognitive capacity in schizophrenia can be conceptualized as existing along a spectrum from more discrete to more synthetic activities. These capacities may be of great importance in schizophrenia research given their potential to mediate and moderate the impact of illness-related factors on outcome. To explore this possibility this review summarizes research on synthetic metacognition using a paradigm in which metacognitive capacity is rated on the basis of spontaneously produced personal narratives. Evidence from a review of the literature shows that these deficits are detectable in patients with schizophrenia and are related to, but not reducible to, symptom severity and poorer neurocognitive function. Independent of symptoms and neurocognition, deficits in synthetic metacognition, which are likely linked to the brain's ability to integrate information, are related to a range of outcomes including functional competence, learning potential, and insight. These deficits may also play a role in long term psychosocial functioning via their impact on the ability to sustain social functions.
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