Insight in psychosis: Metacognitive processes and treatment

Insight is impaired in 50- 80% of the patients with schizophrenia. Annerieke de Vos working at GGZ Drenthe and the University Medical Hospital Groningen, aimed to elucidate which processes underlie impaired insight and tried to improve insight in patients by targeting these processes. On September 21st she will defend her thesis entitled: "Insight in psychosis. Metacognitive processes and treatment.". Patients with impaired insight may fail to recognize that things in life are not going well and that this may have to do with their psychological functioning, deny that they need help and attribute symptoms to external sources. Impaired insight has been related to a worse wellbeing in patients and to problems with family and clinicians. One of the findings of the thesis was that patients with impaired were less able to use feedback to adjust their performance on a cognitive task. The ability to use feedback falls under the umbrella of metacognition, which can be described as “thinking about thinking”. Another metacognitive process, self-reflection (the ability to evaluate yourself) was also related to impaired insight. People with impaired insight showed lower activation in brain areas involved in self-reflection, which suggests that they might have trouble to critically look at themselves. Also, de Vos and colleagues found that insight improved after targeting these metacognitive processes, however they also improved with a simple cognitive training. In conclusion, according to de Vos and colleagues, having good insight does not necessarily entail accepting a diagnosis (e.g. “I have schizophrenia”). Rather it involves a complex process of integrating information from self and others into a rich and complex self-representation, which includes illness related experiences. Improving insight this way may facilitate recovery in people with schizophrenia