Curr Psychiatry Rep (2010) 12:356–361
DOI 10.1007/s11920-010-0125-7
Insight in Schizophrenia: A Review
Marjorie Baier
Published online: 8 June 2010
# Springer Science+Business Media, LLC 2010
Abstract About 30% to 50% of people with schizophrenia
experience lack of insight, meaning they may not acknowl-
edge their illness or the need for treatment. Researchers
have developed valid tools for measuring insight. Accord-
ingly, a great deal of descriptive and correlational research
has been done on insight, treatment adherence, symptom
severity, and other associated variables. Several possible
etiologic models and treatment modalities for lack of
insight have been proposed. Possible brain dysfunctions
causing lack of insight are being investigated. Cognitive-
behavioral therapy and motivational interviewing have been
successful in teaching patients to cope with the symptoms
and make changes in health-related behaviors. Ultimately,
people with schizophrenia need to know how to ask for
help with coping with their symptoms.
Keywords Insight . Schizophrenia . Awareness
Introduction
Insight contributes to recovery from schizophrenia. How-
ever, 30% to 50% of people with schizophrenia lack
insight, and their mental health providers are unsuccessful
in helping them gain an awareness of their illness [1].
Insight is a multidimensional concept with various defi-
nitions and corresponding measuring tools. Most of the
definitions of insight include awareness that one has a
mental illness that requires treatment, awareness that the
M. Baier (*)
School of Nursing, Southern Illinois University Edwardsville,
1660 Cobblestone Creek Drive,
Florissant, MO 63031-4374, USA
e-mail: mbaier@siue.edu
illness is ongoing, and awareness of the symptoms and their
consequences.
During the past decade, the definition of insight has
evolved, and new interventions to improve insight and
functioning have emerged. Recent literature addresses the
cultural context of insight and reports the meaning and
experience of insight to the patients themselves. The
progression of knowledge about insight can be seen in the
movement from expert opinion literature and descriptive
research to case-control studies and the increasing appear-
ance of randomized controlled trials.
This review of recent evidence about insight in schizo-
phrenia begins with the most frequently accepted defini-
tions of insight, theories about the etiology of lack of
insight, and findings from systematic reviews of descriptive
research about the clinical correlates of insight. It chrono-
logically follows with more recent theories and perspectives
on insight. Two promising interventions for improving
coping and treatment adherence conclude the review.
Definition of Insight
It is generally believed that when an individual with
schizophrenia can acknowledge the illness, accept the
need for medication, and ask for help when necessary, he
or she has reached a turning point in the illness. Although
appropriate medication is an important aspect of success-
ful treatment, one of the most familiar obstacles to
treatment is refusal to take medications, caused by lack
of insight, denial of illness, delusions, side effects of the
medications, and a poor relationship with mental health
professionals. Crucial to rehabilitation is the person’s
ability to report early signs of relapse based upon the
person’s insight.
Curr Psychiatry Rep (2010) 12:356–361
The DSM considers poor insight an associated feature of
schizophrenia that is a manifestation of the illness rather
than a coping strategy [2]. Although lack of insight is not
listed as a characteristic symptom in the diagnostic criteria,
it is believed to contribute to noncompliance with treat-
ment, increased risk of relapse and involuntary hospital
admissions, poorer psychosocial functioning, and poorer
prognosis [2].
Insight for a person with schizophrenia is a multidimen-
sional construct; many clinical scales provide a reliable and
valid assessment of insight. However, because one-item
measures of insight have high correlations with more
detailed scales, Lincoln et al. [1] suggest that a one-item
measure might suffice for a screening of overall insight. For
example, a single-item numerical rating of a patient’s
insight based on a chart review and semistructured
interview would ask the evaluator to assign a rating from
1 to 7 of the “subject’s awareness of his or her psychiatric
symptoms, his or her need for treatment, and the con-
sequences of the disorder” [3].
On the other hand, multiple-item scales allow research-
ers to draw conclusions about specific aspects of insight.
One 11-item scale, the Insight and Treatment Attitudes
Questionnaire, measures whether the hospitalized patient
knows that he or she has an illness that affects mental
functioning, led to the hospitalization, was ongoing, and
required medication to ameliorate the symptoms [4]. The
20-item Scale to Assess Unawareness of Mental Disorder
assesses the “current and retrospective awareness of having
a mental disorder, the effects of medications, the conse-
quences of the mental disorder, and the specific signs and
symptoms” [5]. Prevalence of no to low partial insight,
measured recently by the Scale to Assess Unawareness of
Mental Disorder in a sample of 101 patients, ranged from
56% to 67% [6•].
Recent refinements of the definition reflect new under-
standings of the global sense of insight. Self-stigma is a
force to be encountered by a person with insight deficits.
The power of hope in recovery is acknowledged by the
definition of “usable insight” as insight that allows the
individual to differentiate personal identity from the mental
illness and thereby maintain hope [1, 7].
Theorists considering higher-level cognitive processes
related to insight refer to “cognitive insight” as opposed to
the traditionally understood “clinical insight.” Cognitive
insight refers to metacognition, the ability to examine
distorted views and to revise them [8].
Insight and Treatment Adherence
Although a clear association exists between insight and
treatment adherence during the treatment phase, one
357
cannot assume that the presence of insight improves
adherence. The positive correlation between insight and
treatment adherence does not hold up during the long
course of a patient’s treatment. Several possible explan-
ations have been proposed for inconsistent relationships
between later treatment adherence and insight. Although
insight may be necessary for adherence, additional factors
may be necessary. The cost of the medication; difficulty
getting prescriptions and refills; and unpleasant side
effects, such as weight gain and extrapyramidal and
sexual side effects, all represent barriers to adherence to
medication regimens, even in the presence of insight. In
addition, patients without comorbid substance abuse are
more likely to comply with taking medication. Additional
factors also may be associated with successful medication
adherence. For example, patients receiving long-acting
injectable antipsychotics or patients who are part of
assertive community treatment programs could be adher-
ent without having insight [1].
Insight and Symptom Severity
Greater insight is associated with less positive and
negative symptoms, according to a meta-analysis of 40
published studies of insight and schizophrenia [9]. This
contrasts with a more recent systematic review that
concluded that no study has used a suitable design to
allow the researcher to draw conclusions about predicting
the relationship between insight and severity of symptoms
[1].
Insight and Functional Outcome
Various studies have measured functional outcome as
general level of functioning, work behavior, or social
functioning. Based on a systematic review of 18 studies,
Lincoln et al. [1] concluded that insight is not related to
present functioning but influences improvements in
functioning over time. An explanation proposed by the
authors is that symptom severity likely influences the
long-term relationship between insight and functional
outcome [1].
Insight and Aggressive Behavior
Research findings do not consistently support a causal
relationship between insight and violence. This finding
contradicts the intuitive view of some experts that medica-
tion adherence and substance abuse influence the relation-
ship of violence and insight [1, 10].
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Insight and Depression
A small positive relationship between insight and depres-
sive symptoms could be cause for concern. However, a
cause-and-effect relationship cannot be inferred [1, 9]. It is
possible that increasing awareness of a mental illness and
its effects on one’s life could result in feelings of
worthlessness and hopelessness. On the other hand, experts
in the field suggest that having a higher level of depression
could result in more accurate self-evaluations [1, 5].
Furthermore, the relationship of insight to depression and
suicide has not been supported in research findings [1].
Causes of Poor Insight
Amador and Kronengold [5] maintain that neuropsycho-
logical deficits due to frontal lobe dysfunction are at the
root of poor insight that persists over time. They further
maintain that insight deficits are the equivalent of having
anosognosia for schizophrenia. This parallels views of other
experts who suggest that anosognosia or unawareness of a
neurological disorder is the cause of lack of insight [11].
Anosognosia causes patients to be unable to be aware of
their illness signs and symptoms.
Anosognosia is present in other nervous system disor-
ders such as Alzheimer’s disease, Parkinson’s disease,
Huntington’s disease, and traumatic brain injury [12]. By
comparison with these other brain disorders, it becomes
clear that lack of awareness, anosognosia, is not a circum-
scribed concept. That is, people with schizophrenia may
have insight for some aspects of their illness, symptoms,
and treatment, but not others [13].
Researchers have studied awareness of neurocognitive
symptoms, including deficits in the areas of attention,
memory, and critical thinking, and compared this aware-
ness with insight for psychotic symptoms. A recent study
found that there were differences between awareness of
neurocognitive symptoms and awareness of clinical
symptoms. In a sample of 71 people with schizophrenia,
70% had full insight into their clinical symptoms, but only
27% had full insight into their neurocognitive symptoms.
Perhaps people with schizophrenia find it more difficult to
maintain perspective on their cognitive symptoms than
their clinical symptoms. If patients understand that they
have cognitive deficits in areas such as memory, attention,
or critical thinking, they could engage in cognitive
remediation [6•, 8, 13–15].
Taking neurocognitive deficits a step further, a rather
complex theory focuses on impairments in metacognition
[16•, 17]. Metacognition refers to the ability to adopt the
“mental perspective of another toward circumstances of
one’s own mental health” [16•] or to see ourselves as others
Curr Psychiatry Rep (2010) 12:356–361
see us. Autistic individuals have difficulty in this area, and
it is suspected that this may contribute to lack of insight in
schizophrenia as well.
Based on the assumption that lack of insight is neurolog-
ically based, treatment would focus on the symptoms and not
the illness. The mental health professional would have more
success in securing treatment adherence by not trying to
convince the patient that he or she is sick. In this view, insight
cannot be successfully forced upon a patient who does not
comprehend that he or she is ill [11, 18].
There is no universal agreement that lack of insight is
neurologically based, however. The authors of a recent review
concluded that more research is needed before we can reach a
solid conclusion about anosognosia of schizophrenia [19•].
A long-held divergent view of the cause of poor insight
holds that psychological defenses protect a person from
experiencing distress and hopelessness by unconsciously
not acknowledging the illness. This view is more intuitive
than research based. In addition, it is not supported by the
American Psychological Association’s DSM-IV-TR, which
takes the position that insight is a symptom and not a
coping mechanism [16•, 19•].
Nevertheless, one would expect that a combination of
etiologic theories might explain the nature of insight in
schizophrenia. No single theoretical etiology has predom-
inant research support. Because insight is a multidimen-
sional construct, it is unlikely that there would be a single
cause or treatment [20].
Insight Versus Health Beliefs
Health beliefs are cognitions that are shaped partially by
social and cultural factors. These subjective beliefs do not
necessarily correspond with medical theories. For this
reason, a person’s beliefs about health and illness need to
be considered [21].
Using the Illness Concept Scale, which covers the basic
dimensions of the Health Belief Model and the Health Locus
of Control to measure health beliefs, researchers found in one
study of 61 patients that poor insight and health beliefs were
not related. For this reason, although lack of insight might
change with improvement in psychopathology, the dysfunc-
tional beliefs toward the illness would not necessarily change.
The dysfunctional health beliefs would need to be addressed
by psychological methods that change health behaviors, such
as motivational interviewing (MI) [21, 22].
Insight and Cultural Context
Cultural, social, and interpersonal factors undoubtedly
influence insight [19•, 23]. The meaning that one attaches
Curr Psychiatry Rep (2010) 12:356–361 359

to symptoms and their effect on the person’s life vary. The therapist. Patients were informed that their ratings would
difference can be as broad as international differences and not be shared with the therapists. At the same 3-week point
as narrow as differences in perspective between patient and in time, therapists completed a parallel questionnaire about
provider [19•]. For example, the consumer model of their view of the therapeutic alliance. The patients’ and
recovery views assessment of insight by a clinician as therapists’ views of the alliance were not correlated with
potentially paternalistic unless such assessment is addressed each other, and the patients considered the therapeutic
as a component of a partnership. The consumer model alliance stronger than did the therapists. Patients with
would explore reasons for noncompliance before attributing greater insight rated the alliance more strongly [26].
it to the consumer’s poor judgment or lack of insight [24]. Because the study was correlational, the direction of a
The definition of illness is anchored in one’s culture. A cause and effect does not appear. Intuitively, a therapeutic
qualitative study illustrates this point well. Fifteen residents alliance would positively influence insight. At the same
of a supervised living setting for severely mentally disabled time, increased insight would allow the patient to achieve
individuals were interviewed to determine their self- maximum benefit from the interpersonal therapy.
perceptions [25]. Two thirds perceived themselves as Very little experimental research has been conducted to
mentally well, one self-identified as mentally ill, and the determine if antipsychotic or antidepressant medications
remaining four were uncertain whether they were mentally improve insight. Perhaps new medications not yet on the
ill or well. When asked about the criteria they used to market would enhance metacognition [27, 28]. This is an
determine their own mental health, three reported “being area for further research.
mentally balanced and having a clear mind,” and six cited
varying physical characteristics as contributing to their
mental health status. One cited the ability to work and New Treatments for Impaired Insight
another cited having money as a criterion for mental health.
Apparently for these people, having the diagnosis of mental Two innovative, nonpharmacologic treatment models for
illness was different from being mentally ill at the time of schizophrenia emerging in the past 10 years include CBT
the interview. No firm conclusion could be drawn that the for psychosis [1, 8, 29, 30] and MI [20, 22, 28]. Both use
people interviewed accepted or did not accept their illness. strategies that achieve behavior change and improve coping
with psychotic symptoms (Table 1).
Cognitive therapy for depression is based on examina-
Recovery From Illness tion of thought processes for their accuracy and for negative
emotional reactions to distorted thinking [31, 32]. Distorted
The quality of the therapeutic alliance with the patient is thinking leads to feelings of depression. When the thought
associated with the patient’s level of insight. Eighty patients processes are carefully analyzed within the safety of a
with psychotic symptoms who were part of a larger study of therapeutic relationship, flaws are identified and corrected.
cognitive-behavioral therapy (CBT) completed question- CBT begins with engaging the patient, developing a
naires at the end of 3 weeks about their alliance with their problem list, and setting a goal. The therapist then
Table 1 Comparison of inter-
ventions for impaired insight Motivational interviewing [22]
•Developed to promote behavior change for people with alcohol addiction
•Aims for patient-centered, directive, empathic approach
•Focuses on ambivalence and its resolution
•Uses reflective listening, directing questions
•Depends on internal motivation of the patient
•Establishes rapport by avoiding arguments
•Encourages patient to express the arguments for change
Cognitive-behavioral therapy [31, 32]
•Developed for treatment of depression by engaging patient collaboratively
•Aims for questioning of patient’s thoughts and beliefs
•Focuses on the role of faulty beliefs, threat-related stimuli, and biased information processing
•Uses therapeutic alliance based on patient’s perspective
•Avoids persuasion or forceful arguments
•Avoids labeling symptoms, instead reduces impact of symptoms
•Helps patient generate alternate explanations for symptoms
360
questions the patient to discover distortions in thoughts and
assumptions.
When using CBT with a patient with schizophrenia, the
therapist identifies misattributions that occur in relation to
hallucinations and delusions. The emphasis is on the
distress caused to the patient by the meaning he or she
places on the symptoms. Stigma is also addressed in CBT
with patients with schizophrenia as negative beliefs to be
normalized. The purpose of CBT for people with schizo-
phrenia is to allow the patient to understand and cope with
the psychotic symptoms.
Research support exists for the success of CBT for
individuals with schizophrenia. Randomized controlled
trials have shown the efficacy of CBT and sustained
benefits over time when the outcomes are alleviating
distress and relapse prevention. CBT can improve func-
tioning without directly reducing symptoms. However,
when the outcome variable is medication adherence rather
than coping with symptoms, research findings offer less
support for CBT. Moreover, no evidence indicates that CBT
increases insight; focusing on insight is counter to the
theoretical underpinnings of CBT [31, 32].
MI, which grew from the field of addictions counseling,
focuses on health beliefs and behavior change. The five
principles of MI that contribute to its success with this
population are as follows: 1) express empathy, 2) develop
discrepancy, 3) avoid argumentation, 4), roll with resis-
tance, and 5) support self-efficacy [33]. Recognizing again
that the patient’s lack of insight is resistant to change, one
does not argue or coax.
The decision-making tasks associated with MI may
require modification when used with individuals with
schizophrenia. For this reason, this strategy may be more
effective for patients with fewer of the negative symptoms,
such as anhedonia or anergia. MI for people with
schizophrenia may be most useful in combination with
other interventions to help promote change [33]. MI can
help the patient face the reality of his or her schizophrenia
rather than deny it [20]. Very few empiric studies have
examined the effects of MI for increasing treatment
adherence for individuals with schizophrenia.
Amador and Johanson [18] proposed a four-step inter-
vention based on the acronym LEAP, which seems to
incorporate strategies from CBT and MI. First, listen to
learn the patient’s expectations and feelings and to identify
possible cognitive deficits that may be barriers to the
helping relationship. Second, empathize by using reflective
listening and understanding the patient’s position. Third,
agree by acknowledging the patient’s right to choices and
responsibility for decisions. And fourth, partnership means
forming a treatment alliance. This intervention, like CBT,
assumes that the patient has anosognosia of schizophrenia.
Arguing and cajoling would be of no benefit.
Curr Psychiatry Rep (2010) 12:356–361
Finally, an intervention for recovery of insight men-
tioned in the literature in conjunction with metacognition is
cognitive remediation, or cognitive enhancement. This
includes strategies that stretch one’s thinking, such as
divergent thinking exercises, recognition, and comparison
tasks to improve memory and information processing, and
computer software programs to improve attention deficits
and disordered thinking [11].
Conclusions
Lack of insight is a symptom of schizophrenia that has been
defined and measured in descriptive and correlational
studies. An individual with schizophrenia who has insight
can acknowledge the presence of a mental illness that
requires treatment and is aware that relapses can occur.
Insight is correlated with treatment adherence. Therefore,
interventions to promote insight or coping with the
symptoms are crucial. The social and cultural context of
insight influences insight. Insight is a multidimensional and
complex concept. There is not yet universal agreement
about the cause of lack of insight or the most successful
treatment to promote insight. Two new strategies are
beginning to be used: CBT for psychosis and MI.
Disclosure No potential conflict of interest relevant to this article
was reported.
References
Papers of particular interest, published recently, have been
highlighted as
• Of importance
1. Lincoln TM, Lullmann E, Rief W: Correlates and long-term
consequences of poor insight in patients with schizophrenia: a
systematic review. Schizophr Bull 2007, 33:1324–1342.
2. American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, edn 4 (text revision). Washington,
DC, American Psychiatric Association; 2000.
3. Lysaker P, Bell M: Insight and cognitive impairment: performance
on repeated administrations of the Wisconsin Card Sorting test. J
Nerv Ment Dis 1994, 182:656–660.
4. McEvoy JP, Aland J, Wilson WH, et al.: Measuring chronic
schizophrenic patients’ attitudes toward their illness and treat-
ment. Hosp Community Psychiatry 1981, 32:856–858.
5. Amador XF, Kronengold H: Understanding and assessing
insight. In Insight and Psychosis: Awareness of Illness in
Schizophrenia and Related Disorders, edn 2. Edited by Amador
XF, David AS. London: Oxford University Press; 2004:197–
229.
6. • Bayard S, Capdevielle D, Boulenger J-P: Dissociating self-
reported cognitive complaint from clinical insight in schizophre-
Curr Psychiatry Rep (2010) 12:356–361
nia. Eur Psychiatry 2009, 24:251–258. This study clarifies the
difference between clinical insight and cognitive deficits.
7. Hasson-Ohayon I, Kravetz S, Meir T: Insight into severe mental
illness, hope, and quality of life of persons with schizophrenia and
schizoaffective disorders. Psychiatry Res 2009, 167:231–238.
8. Beck AT, Baruch E, Balter JM: A new instrument for measuring
insight: the Beck Cognitive Insight Scale. Schizophr Res 2004,
68:319–329.
9. Mintz AR, Dobson KS, Romney DM: Insight in schizophrenia: a
meta-analysis. Schizophr Res 2003, 61:75–88.
10. Torrey EF: The relationship of insight to violent behavior and
stigma. In Insight and Psychosis: Awareness of Illness in
Schizophrenia and Related Disorders, edn 2. Edited by Amador
XF, David AS. London: Oxford University Press; 2004:243–256.
11. Rickelman BL: Anosognosia in individuals with schizophrenia:
toward recovery of insight. Issues Ment Health Nurs 2004,
25:227–242.
12. Flashman LA: Disorders of awareness in neuropsychiatric
syndromes: an update. Curr Psychiatry Rep 2002, 4:346–353.
13. Medalia A, Thysen J: A comparison of insight into clinical
symptoms versus insight into neuro-cognitive symptoms in
schizophrenia. Schizophr Res 2010, 118:134–139.
14. Medalia A, Thysen J: Insight into neurocognitive dysfunction in
schizophrenia. Schizophr Bull 2008, 34:1221–1230.
15. Aleman A, Agrawal N, Morgan KD: Insight in psychosis and
neuropsychological function. Meta-analysis. Br J Psychiatry 2006,
189:204–212.
16. • Langdon R, Ward P: Taking the perspective of the other
contributes to awareness of illness in schizophrenia. Schizophr
Bull 2009, 35:1003–1011. This study differentiates the two
traditional views of insight—psychological defense and anosog-
nosia—from metacognition deficits.
17. Bora E, Sehitoglu G, Aslier M: Theory of mind and unawareness
of illness in schizophrenia. Is poor insight a mentalizing deficit?
Eur Arch Psychiatry Clin Neurosci 2007, 257:104–111.
18. Amador XF, Johanson A-L: I Am Not Sick, I Don’t Need Help:
Helping the Seriously Mentally Ill Accept Treatment. A
Practical Guide for Families and Therapists. Peconic, NY: Vida
Press; 2002.
19. • Osatuke K, Ciesla J, Kasckow JW, et al.: Insight in
schizophrenia: a review of etiological models and supporting
research. Compr Psychiatry 2008, 49:70–77. This review
describes seven possible causative models and reports on the
research base for each.
361
20. Rusch N, Corrigan PW: Motivational interviewing to improve
insight and treatment adherence in schizophrenia. Psychiatr
Rehabil J 2002, 26:23–32.
21. Linden M, Godemann F: The differentiation between ‘lack of
insight’ and ‘dysfunctional health beliefs’ in schizophrenia.
Psychopathology 2007, 40:236–241.
22. Emmons KM, Rollnick S: Motivational interviewing in health
care settings: opportunities and limitations. Am J Prev Med 2001,
20:68–74.
23. Kirmayer LJ, Corin E, Jarvis GE: Inside knowledge: cultural
constructions of insight in psychosis. In Insight and Psychosis:
Awareness of Illness in Schizophrenia and Related Disorders, edn
2. Edited by Amador XF, David AS. London: Oxford University
Press; 2004:197–229.
24. Bellack AS: Scientific and consumer models of recovery in
schizophrenia: concordance, contrasts, and implications. Schiz-
ophr Bull 2006, 32:432–442.
25. Dzurec LC: How do they see themselves? Self-perception and
functioning for people with chronic schizophrenia. J Psychosoc
Nurs Ment Health Serv 1990, 28:10–14.
26. Wittorf A, Jakobi U, Bechdolf A, et al.: The influence of baseline
symptoms and insight on the therapeutic alliance early in the
treatment of schizophrenia. Eur Psychiatry 2009, 24:259–267.
27. Buckley PF, Wirshing DA, Bhushan P: Lack of insight in
schizophrenia: impact on treatment adherence. CNS Drugs 2007,
21:129–141.
28. Lysaker PH, Buck KD, Salvatore G: Lack of awareness of illness
in schizophrenia: conceptualizations, correlates and treatment
approaches. Expert Rev Neurother 2009, 9:1035–1043.
29. Naeem F, Kingdon D, Turkington D: Predictors of response to
cognitive behaviour therapy in the treatment of schizophrenia: a
comparison of brief and standard interventions. Cognit Ther Res
2008, 32:651–656.
30. Brabban A, Tai S, Turkington D: Predictors of outcome in brief
cognitive therapy for schizophrenia. Schizophr Bull 2009,
35:859–864.
31. Tai S, Turkington D: The evolution of cognitive behavior therapy
for schizophrenia: current practice and recent developments.
Schizophr Bull 2009, 35:865–873.
32. Turkington D, Kingdom D, Weiden PJ: Cognitive behavior
therapy for schizophrenia. Am J Psychiatry 2006, 163:365–373.
33. Corrigan PW, McCracken SG, Holmes EP: Motivational inter-
views as goal assessment for persons with psychiatric disability.
Community Ment Health J 2001, 37:113–122.