Investigating the Contribution of Decision-Making, Cognitive Insight, and Theory of Mind in Insight in Schizophrenia: A Cross-Sectional Study

Abstract

<b><i>Introduction:</i></b> Insight in schizophrenia spectrum disorders (SSD) is associated with outcomes. Although the neurocognitive basis of insight is widely accepted, the specific contribution of decision-making (Jumping to Conclusions [JTC]), Cognitive Insight (CI), and Theory of Mind (ToM) to insight remains unclear. <b><i>Methods:</i></b> The sample included <i>N</i> = 77 SSD outpatients aged 18–64 years from a randomized controlled trial of metacognitive training. Assessments included JTC-Beads Task, CI-Beck Cognitive Insight Scale, ToM-Hinting Task, and the Emotions Recognition Test Faces. Statistics: hierarchical multivariable linear regression models tested their contribution to total insight (TI) and three insight dimensions – illness recognition (IR), symptom relabelling (SR), and treatment compliance (TC) – measured with the Schedule for the Assessment of Insight – Expanded version, whilst adjusting for potential confounders. <b><i>Results:</i></b> Bivariate analyses showed that CI was associated with TI (<i>R</i><sup>2</sup> change = 0.214; <i>p</i> < 0.001), IR (<i>R</i><sup>2</sup> change = 0.154; <i>p</i> = 0.003), and SR (<i>R</i><sup>2</sup> change = 0.168; <i>p</i> = 0.003), while JTC predicted IR (<i>R</i><sup>2</sup> change = 0.790; <i>p</i> = 0.020). Multivariable regression models showed that CI predicted TI (<i>R</i><sup>2</sup> change = 0.116; <i>p</i> = 0.036) and SR (<i>R</i><sup>2</sup> change = 0.166, <i>p</i> = 0.011), whereas JTC was linked with IR (<i>R</i><sup>2</sup> change = 0.710; <i>p</i> = 0.026). ToM was not linked with any insight score. No cognitive variable was associated with treatment compliance. <b><i>Discussion:</i></b> Results supported the (meta)cognitive model of insight in SSD. JTC and CI emerged as the main (meta)cognitive processes underlying insight. Metacognitive interventions may therefore improve insight in SSD, although these therapies alone may fail to address treatment compliance.

A pilot 1-year follow-up randomised controlled trial comparing metacognitive training to psychoeducation in schizophrenia: effects on insight

“…Of relevance, two core treatment targets of MCT, namely Jumping to Conclusions (JTC) cognitive bias and Theory of Mind (ToM) reasoning, have been linked with clinical insight 31 . Hence, MCT may improve insight via addressing cognitive insight, JTC and/or ToM.…”

“…Hence, MCT may improve insight via addressing cognitive insight, JTC and/or ToM. JTC, i.e., reaching a conclusion based on incomplete evidence, can be considered as a decision-making style common in psychosis 32 – 34 which has been linked with delusions 35 and poor clinical insight 31 . ToM can be defined as ‘the ability to attribute mental states— beliefs, intents, desires, emotions and knowledge—primarily to others’ 36 .…”

“…ToM can be defined as ‘the ability to attribute mental states— beliefs, intents, desires, emotions and knowledge—primarily to others’ 36 . ToM deficits have been linked to lack of clinical insight 31 , consistently reported in patients with psychosis from first presentation 28 associated with paranoia in schizophrenia, and finally, likely involve specific brain regions and pathways 37 . Although MCT targets other cognitive biases leading to delusional ideas, such as Bias Against Disconfirmatory Evidence (BADE), we decided to focus on JTC and ToM based on previous literature linking JTC and ToM (but not BADE) with clinical insight 31 .…”