Insight in Schizophrenia – A Comprehensive Update

Objective: To comprehensively review and update the research evidence on insight in schizophrenia. Methods: Search of electronic databases (up to September 2009) as well as manual search of relevant publications or cross references. The search terms used (in various combinations) were: insight, schizophrenia, psychosis, neuropsychology, neurobiology, instruments, model, prognosis, outcome, psychopathology, therapy. Results: There are several ways of defining and conceptualizing insight. Clinical concept of insight refers to awareness of a mental disorder and its consequences, awareness of need for treatment, awareness of symptoms and attribution of the symptoms to the disorder. Numerous conceptual models have attempted to explain insight: as a symptom, as a defence, as psychological (misattribution) or neuropsychological phenomenon, or from a sociocultural perspective. Neurobiologically, insight has been associated with frontal and other cortical structures implicated in higher mental functions. Several instruments exist for assessing insight. Clinical correlates of insight are many but always consistent: severity of illness, psychotic symptoms, depressive symptoms, treatment adherence, quality of life, functioning, violence, and competence to consent. Conclusions: In recent years, there has been a surge of research into the conceptualization and assessment of insight, as well as its relationships with prognosis, compliance, neuropsychological impairment and severity of psychopathology in schizophrenia. However, these studies have yielded inconsistent results. Different dimensions of insight are probably related to different aspects of outcome, and this needs to be reflected in the study planning phase. Although important advances have been made in this area, many questions remain unanswered, and these need to be addressed in future research (German J Psychiatry 2010; 13: 17-30).