Schizophrenia is a chronic severe mental disorder. Insight is defined as the ability to recognize the existence of a mental disorder. The time period of the article search is between 2000-2016. Journal articles and some books were included. Greater insight in individuals with schizophrenia is associated with high levels of dysphoria, lower self esteem and decreased well being and quality of life. Poor insight in patients with schizophrenia has been linked to more negative attitudes toward medication, longer episodes of antipsychotic non-adherence, more frequent hospitalization, and greater levels of positive and negative symptoms, lower self-esteem as well as poorer psychosocial function and quality of life. Clinical and cognitive insights are not the same. Clinical insight is the awareness of the clinical state and cognitive insight is the awareness of cognitive deficits. Good cognitive insight may be necessary for good clinical insight. Evidenced based treatments for individuals with schizophrenia should focus more systematically on the improvement of the insight. Cognitive behavioral therapy and various rehabilitation programs, such as the Integrated Psychological Therapy and the Integrated Neurocognitive Therapy can improve indirectly the insight. The metacognitive therapy and the metacognitive reflection and insight therapy can improve insight directly. Insight and medication adherence were found to be closely related. Insight impacts on the therapeutic alliance with mental health professionals. The assessment of insight is incorporated in many clinical scales.The improvement of the insight in people with schizophrenia should be a major therapeutic goal in the context of every evidenced based treatment in a long term.

•    Schizophrenia
•    Insight
•    Integrated psychological therapy
•    Cognitive behavioral therapy
•    metacognitive therapy

Rakitzi S, Georgila P, Efthimiou K (2016) Insight and Rehabilitation of Patients with Schizophrenia. J Mem Disord Rehabil 1(1): 1002.

Schizophrenia is a chronic severe mental disorder and is associated with many traumatic moments for the patients and their families. The main therapy for people with schizophrenia is the pharmacotherapy. Cognitive behavioral therapy and various rehabilitation programs present an adjunctive effective and efficacious treatment in combination with the pharmacotherapy.

Insight is defined as the ability to recognize and accept the existence of a mental disorder. Is clinical insight the same as the cognitive insight in schizophrenia? Clinical insight is the awareness of the clinical state and cognitive insight is the awareness of cognitive deficits. Good cognitive insight may be necessary for good clinical insight. Good cognitive insight is at least partly reliant on the processes involved in clinical insight [1]. Cognitive insight is the capacity of patients with psychosis to distance themselves from their psychotic experiences, reflect on them and respond to corrective feedback. The Beck Cognitive Insight Scale was developed to evaluate these aspects of cognitive flexibility. Cognitive insight has predicted positive gains in psychotherapy of psychosis and improvement in cognitive insight has been correlated with improvement in delusional beliefs. Neurocognition, social cognition, metacognition and reduced hippocampus volume are related to cognitive insight [2].

The assessment of insight is incorporated in many clinical scales. The Schedule for Affective Disorders and Schizophrenia, the Hamilton Depression Rating Scale, the Present State Examination, and the Positive and Negative Syndrome Scale. Each includes one insight item. The Manual for the Documentation of Psychopathology includes 3 items assessing lack of feeling of illness, lack of insight, and uncooperativeness [3].

Greater insight in individuals with schizophrenia is associated with high levels of dysphoria, lower self esteem and decreased well being and quality of life [4]. Poor insight in patients with schizophrenia has been linked to more negative attitudes toward medication, longer episodes of antipsychotic non-adherence, more frequent hospitalization, and greater levels of positive and negative symptoms, lower self-esteem as well as poorer psychosocial function and quality of life [5].

Evidenced based treatments for individuals with schizophrenia should include the improvement of the insight as major therapeutic goal with appropriate interventions.

The time period of the article search is between 2000-2016. Journal articles and books were included. In a first step we used the keyword “schizophrenia” combined with “insight”. We selected then articles by searching the abstracts for additional keywords: outcome, compliance, adherence, and positive, negative symptoms, depression, quality of life.

Research has paradoxically linked insight of illness to both better function outcomes and lesser hope and self-esteem. One possible explanation for these findings is that acceptance of having schizophrenia may impact outcomes differently depending on the meanings the person attaches to this acceptance, particularly whether he or she accepts stigmatizing beliefs about mental illness. A cluster analysis of persons in a stable phase of illness revealed 2 groups of persons relatively aware of having a mental illness: one group that did and another that did not endorse having self-stigmatizing beliefs about their condition. Also, as predicted, persons with high insight who endorsed self-stigmatizing beliefs had lower levels of self-esteem and hope and fewer interpersonal relationships than those with high insight who rejected stigmatizing beliefs. Finally, the cluster analyses produced a third group that demonstrated low awareness and also endorsed stigmatizing beliefs, though to a lesser degree than did the high insight/moderate stigma group. This group also had more self-esteem and hope than the group with high insight and moderate stigma but did not differ from them in social functioning. This last finding may suggest that both the acceptance of stigma or unawareness of illness may lead to social isolation [4].

Quality of life is linked to patient awareness of his mental illness. It may be undermined through the effect of internalized stigma and feeling of depression and hopelessness proved in patients with good insight. Patients with schizophrenia with poorer insight showed significantly higher scores in the Quality of Life. A positive correlation was found between insight and internalized stigma of mental illness. Those with poorer insight tent to be less stigmatized by their illness and exhibit less depression [6].

Insight and medication adherence were found to be closely related. Insight impacts on the therapeutic alliance with mental health professionals. These factors are associated to treatment outcomes [7].

Insight is associated with adherence during treatment phase, but the relationship between insight and long-term adherence needs further clarification. Insight is also associated with higher symptom levels during treatment and, for the majority of patients, insight increases while symptoms, particularly disorganization, decrease. Insight seems to have predictive value for functioning, although this finding might be accounted for by the association between symptoms and insight. Finally, in spite of clear evidence for cross-sectional and longitudinal relationships between insight and depression, the causal direction of the relationship remains unclear [8].

The evidenced based treatments for individuals with schizophrenia should focus on the improvement of the insight. This procedure increases the possibility for a long term functional recovery with fewer relapses and hospitalizations and improves the therapeutic alliance.

The individual cognitive behavioral therapy (CBT) focus on the change of dysfunctional beliefs and behavior Individuals with schizophrenia are able to control better their disorder and to cope better with the daily life [9]. Psycho education can be a part of this therapy which increases insight.

The Integrated Psychological Therapy (IPT) can lead to the improvement of the insight [10-12]. In a recently published study about the efficacy of the Integrated Psychological Therapy the patients of the IPT group increased their insight and the patients of the control group showed even better self rating in the overall quality of life than did IPT patients, which may have developed a more realistic pessimistic view of their life [13]. A further development of the IPT, the Integrated Neurocognitive Therapy (INT) can improve the insight of the individuals with schizophrenia [14,15].

The metacognitive intervention [16] and the metacognitive Reflection and insight Therapy [17] are newly developed treatment for the improvement of insight of individuals with schizophrenia. The above research data can be summarized as followed: People with schizophrenia with high insight, which is associated with self-stigmatizing beliefs had lower levels of self-esteem and hope and fewer interpersonal relationships than those with high insight who rejected stigmatizing beliefs. Those with poorer insight showed significantly higher scores in the Quality of Life. Poor insight in patients with schizophrenia has been linked to more negative attitudes toward medication, longer episodes of antipsychotic non-adherence, more frequent hospitalization, and greater levels of positive and negative symptoms, lower self-esteem as well as poorer psychosocial function and quality of life. Insight and medication adherence were found to be closely related. Insight impacts on the therapeutic alliance with mental health professionals. The assessment of insight is incorporated in many clinical scales. Evidenced based treatments should focus on the improvement of Insight. Some of them proceed this directly [16,17] and other indirectly [9-12, 14,15].

The improvement of the insight in people with schizophrenia should be a major therapeutic goal in the context of every evidenced based treatment. Poorer insight increases the suicidal risk in a long term. Higher insight is associated with lack of hope, depression and low self esteem but it has a positive impact on the therapeutic alliance. That means that the therapists have the chance to activate the resources of these people and to help them to make a new beginning in their life. Depression and low self esteem can be reduced in a long term. High insight leads to recovery. The assessment of insight is incorporated in many clinical scales. The development of a better instrument for the evaluation of the clinical insight is necessary.

Stigma is one possible determinant of a lack of insight [18]. The reattribution of beliefs that are associated with stigma can improve in a long term the insight of the patients. The improvement of both aspects of insight-clinical and cognitive-should be a major therapeutic goal for people with schizophrenia.

The individual CBT [9] and various integrated rehabilitation programs for individuals with schizophrenia, such as IPT [10-13] and INT [14,15], increase the insight indirectly. The above treatments must be combined in a long term with the metacognitive intervention [16] and the metacognitive Reflection and insight Therapy [17], which improves the insight directly. The association between a better insight and the improvement of the therapeutic alliance should be evaluated through the combination of the above interventions in a long term.

The above evidenced based treatments for people with schizophrenia contribute to a better understanding of the disabilities of the disorder, which lead to a new restart in the life through the activation of resources and to an effective relapse prevention in a long term. The above procedures improve the therapeutic alliance.

Schizophrenia is a chronic severe mental disorder. The main therapy for people with schizophrenia is the pharmacotherapy. Cognitive behavioral therapy and various rehabilitation programs present an adjunctive effective and efficacious treatment in combination with the pharmacotherapy. Insight is defined as the ability to recognize and accept the existence of a mental disorder. Greater insight in individuals with schizophrenia is associated with high levels of dysphoria, lower self esteem and decreased well being and quality of life [4]. Poor insight in patients with schizophrenia has been linked to more negative attitudes toward medication, longer episodes of antipsychotic non-adherence, more frequent hospitalization, and greater levels of positive and negative symptoms, lower self-esteem as well as poorer psychosocial function and quality of life [5]. Clinical insight is the awareness of the clinical state and cognitive insight is the awareness of cognitive deficits. Good cognitive insight may be necessary for good clinical insight [1]. Cognitive insight has predicted positive gains in psychotherapy of people with schizophrenia [2]. Evidenced based treatments for individuals with schizophrenia, which can improve insight directly or indirectly, must be combined in the future in a long term. The impact of the improvement of clinical and cognitive insight on the therapeutic alliance and adherence must be a major research and therapeutic goal in the context of the rehabilitation of patients with schizophrenia. A better insight leads to an effective functional recovery in the long term.

1. Donohoe G, Hayden J, McGlade N, O’Gráda C, Burke T, Barry S, et al. Is “clinical” insight the same as “cognitive” insight in schizophrenia? J Int Neuropsychol Soc. 2009; 15: 471-475.

2. Riggs SE, Grant PM, Perivoliotis D, Beck AT. Assessment of cognitive insight: a qualitative review. Schizophr Bull. 2012; 38: 338-350.

3. Lincoln TM, Lüllmann E, Rief W. Correlates and long-term consequences of poor insight in patients with schizophrenia. A systematic review. Schizophr Bull. 2007; 33: 1324-1342.

4. Lysaker PH, Roe D, Yanos PT. Toward understanding the insight paradox: Internalized stigma moderates the association between insight and social functioning, hope and self-esteem among people with schizophrenia spectrum disorders. Schizophr Bull. 2007; 33: 192-199.

5. Lysaker PH, Dimagio G, Buck KD, Callaway SS, Salvatore G, Carcione A, et al. Poor insight in schizophrenia: links between different forms of metacognition with awareness of symptoms, treatment need and consequences of illness. Compr Psychiatry 2011; 52: 253-260.

6. Ramadan ES, El Dod WA. Relation between insight and quality of life in patients with schizophrenia: Role of internalized Stigma and depression. Cur Psychiatry. 2010; 17: 43-48.

7. Novick D, Montgomery W, Treuer T, Aguado J, Kraemer S, Haro JM. Relationship of insight with medication adherence and the impact on outcomes in patients with schizophrenia and bipolar disorder: results from a 1-year European outpatient observational study. BMC Psychiatry. 2015; 15: 189-193.

8. Lincoln TM1, Lüllmann E, Rief W. Correlates and long-term consequences of poor insight in patients with schizophrenia. A systematic review. Schizophr Bull. 2007; 33: 1324-1342.

9. Beck A. Rector N, Stolar N, Grant P. Schizophrenia: Cognitive theory, research and therapy. New York: The Guilford Press. 2009.

10. Roder V, Mueller DR, Brenner HD, Spaulding W. Integrated Psychological Therapy (IPT) for the treatment of neurocognition, social cognition and social competency in schizophrenia patients. Seattle: Hogrefe & Huber. 2010.

11. Roder V, Mueller DR, Schmidt SJ. Effectiveness of integrated psychological therapy (IPT) for schizophrenia patients: a research update. Schizophr Bull. 2011; 37 Suppl 2: S71-S79.

12. Mueller DR, Schmidt SJ, Roder V. Integrated Psychological Therapy (IPT): effectiveness in schizophrenia inpatients settings related to patients age. Am J Geriat Psychiatry. 2013; 21: 231-241.

13. Rakitzi S, Georgila P, Efthimiou K, Mueller DR. Efficacy and feasibility of the Integrated Psychological Therapy for outpatients with schizophrenia in Greece: Final results of a RCT. Psychiatry Res. 2016; 242: 137-143.

14. Roder V, Mueller D. Integrated neurocognitive therapy for schizophrenia patients. Heidelberg: Springer. 2015.

15. Mueller DR, Schmidt SJ, Roder V. One-year randomized controlled trial and follow-up of integrated neurocognitive therapy for schizophrenia outpatients. Schizophr Bull. 2015; 41: 604-616.

16. Hillis JD, Leonhardt BL, Vohs JL, Buck KD, Salvatore G, Popolo R, et al. Metacognitive reflective and insight therapy for people in early phase of a schizophrenia spectrum disorder. J Clin Psychol. 2015; 71: 125- 135.

17. Van Donkersgoed RJ, De Jong S, Van der Gaag M, Aleman A, Lysaker PH, Wunderink L, et al. A manual-based individual therapy to improve metacognition in schizophrenia: protocol of a multi-center RCT. BMC Psychiatry. 2014; 14: 27.

18. Pruß L, Wiedl KH, Waldorf M. Stigma as a predictor of insight in schizophrenia. Psychiatry Res. 2012; 198: 187-193.