Insight in schizophrenia: involvement of self-reflection networks?

Abstract

Background: Impaired insight is a common feature in psychosis and an important predictor of variables such as functional outcome, prognosis, and treatment adherence. A cognitive process that may underlie insight in psychosis is self-reflection, or the conscious evaluation of one's traits and characteristics. The current study aims to investigate the neural correlates of self-reflective processing and its relationship with insight in schizophrenia.

Methods: Forty-seven schizophrenia patients and 21 healthy controls performed a self-reflection task in a functional magnetic resonance imaging (fMRI) scanner. The tasks comprised a self-reflection, close other-reflection, and a semantic (baseline) condition. Insight scores were obtained with the Schedule of Assessment of Insight Expanded. In addition, cognitive insight scores were obtained (Beck Cognitive Insight Scale [BCIS]).

Results: Schizophrenia patients demonstrated less activation in the posterior cingulate cortex in the self- and other-reflection conditions and less activation in the precuneus in the other-reflection condition compared with healthy controls. Better insight was associated with greater response in the inferior frontal gyrus, anterior insula, and inferior parietal lobule during self-reflection. In addition, better cognitive insight was associated with higher activation in ventromedial prefrontal cortex during self-reflection.

Conclusion: In the current study, evidence for a relationship between self-reflection and insight in patients with schizophrenia was found in brain areas related to self-reflection, self/other distinction and source attribution. The findings support the rationale for a treatment that is currently under evaluation, which attempts to increase insight by enhancing self-reflection.

Keywords: cognitive insight; fMRI; insight; psychosis; schizophrenia; self-reflection.

Fig. 1.

Brain activation self-reflection task. Main effects for (A) self > semantic (B) other > semantic (C) self > other (D) other > self. Group differences healthy controls > patients. (E) self > semantic; (F) other > semantic.

Fig. 2.

Associations with insight and brain activation for self > semantic. (A) Activation positively related to insight subtotal score. Correlation mean response of activation with subtotal score of insight in (B) insula/IFG (r = 0.53) and (C) IPL/angular gyrus (r = 0.54). Activation positively related to self-reflectiveness in (D) left vMPFC and (E) right vMPFC. Correlation mean response of activation with self-reflectiveness in (F) left vMPFC (r = 0.51) and (G) right vMPFC (r = 0.48).