Skip to main content Accessibility help

Insight and psychosis: the next 30 years

  • Anthony S. David (a1)


Academic interest in the concept of insight in psychosis has increased markedly over the past 30 years, prompting this selective appraisal of the current state of the art. Considerable progress has been made in terms of measurement and confirming a number of clinical associations. More recently, the relationship between insight and involuntary treatment has been scrutinised more closely alongside the link between decision-making capacity and insight. Advances in the clinical and cognitive neurosciences have influenced conceptual development, particularly the field of ‘metacognition’. New therapies, including those that are psychologically and neurophysiologically based, are being tested as ways to enhance insight.


Corresponding author

Correspondence: Anthony S. David, UCL Institute of Mental Health, University College London, Maple House, Tottenham Court Road, London, WT1 7NF, UK. Email:


Hide All

Declaration of interest: None.



Hide All
1David, AS. Insight and psychosis. Br J Psychiatry 1990; 156: 798808.
2Anonymous. Real insight (editorial). Lancet 1990; 336: 408.
3Amador, XF, David, AS eds. Insight and Psychosis: Awareness of Illness in Schizophrenia and Related Disorders (2nd edn). Oxford University Press, 2004.
4Lincoln, TM, Lüllmann, E, Rief, W. Correlates and long-term consequences of poor insight in patients with schizophrenia. a systematic review. Schizophr Bull 2007; 33: 1324–42.
5Owen, GS, Richardson, G, David, AS, Szmukler, G, Hayward, P, Hotopf, M. Mental capacity, diagnosis, and insight in psychiatric inpatients: a cross sectional study. Psychol Med 2009; 39: 1389–98.
6Diesfeld, K. Insight: unpacking the concept in mental health law. Psychiatry Psychol Law 2004; 10(1): 6370.
7Fleming, SM, Weil, RS, Nagy, Z, Dolan, RJ, Rees, G. Relating introspective accuracy to individual differences in brain structure. Science 2010; 329: 1541–3.
8Fleming, SM, Ryu, J, Golfinos, JG, Blackmon, KE. Domain-specific impairment in metacognitive accuracy following anterior prefrontal lesions. Brain 2104; 137: 2811–22.
9Rouault, M, Seowa, T, Gillan, CM, Fleming, SM. Psychiatric symptom dimensions are associated with dissociable shifts in metacognition but not task performance. Biol Psychiatry 2018; 84: 443–51.
10David, AS, Bedford, N, Wiffen, B, Gilleen, J. Failures of metacognition and lack of insight in neuropsychiatric disorders. Phil Trans R Soc B 2012; 267: 1379–90.
11van der Plas, E, David, AS, Fleming, SM. Advice-taking as a bridge between decision neuroscience and mental capacity. Int J Law Psychiat, in press.
12Beck, AT, Baruch, E, Balter, JM, Steer, RA, Warman, DM. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophr Res 2004; 68: 319–29.
13Van Camp, LSC, Sabbe, BGC, Oldenburg, JFE. Cognitive insight: a systematic review. Clin Psychol Rev 2017; 55: 1224.
14O'Connor, JA, Ellett, L, Ajnakina, O, Schoeler, T, Kollliakou, A, Trotta, A, et al. Can cognitive insight predict symptom remission in a first episode psychosis cohort? BMC Psychiatry 2017; 17: 54.
15Murri, MB, Respino, M, Innamorati, M, Cervetti, A, Calcagno, P, Pompili, M, et al. Is good insight associated with depression among patients with schizophrenia? Systematic review and meta-analysis. Schizophr Res 2015; 162: 234–47.
16Lopez-Morinigo, JD, Di Forti, M, Ajnakina, O. Insight and risk of suicidal behaviour in two first-episode psychosis cohorts: effects of previous suicide attempts and depression. Schizophr Res 2019; 204: 80–9.
17Philipp, R, Kriston, L, Lanio, J, Kühne, F, Härter, M, Moritz, S, Meistert, R. Effectiveness of metacognitive interventions for mental disorders in adults—A systematic review and meta-analysis (METACOG). Clin Psychol Psychother 2019; 26: 227–40.
18Vohs, JL, Leonhardt, BL, James, AV, Francis, MM, Breier, A, Mehdiyoun, N, et al. Metacognitive reflection and insight therapy for early psychosis: a preliminary study of a novel integrative psychotherapy. Schizophr Res 2018; 195: 428–33.
19De Jong, S, van Donkersgoed, R, Timmerman, M, Aan het Rot, M, Wunderink, L, Arends, J, et al. Metacognitive reflection and insight therapy (MERIT) for patients with schizophrenia. Psychol Med 2019; 49: 303–13.
20Pijnenborg, GHM, Vos, AE, Timmerman, ME, van der Gaag, M, Sportel, BE, Arends, J, et al. Social cognitive group treatment for impaired insight in psychosis: a multicenter randomized controlled trial. Schizophr Res 2019; 206: 362–9.
21Wiffen, BDR, Rabinowitz, J, Lex, A, David, AS. Correlates, change and ‘state or trait’ properties of insight in schizophrenia. Schizophr Res 2010; 122: 94103.
22Pijnenborg, GHM, van Donkersgoed, RJM, David, AS, Aleman, A. Changes in insight during treatment for psychotic disorders: a meta-analysis. Schizophr Res 2013; 144: 109–17.
23Pijnenborg, GH, Timmerman, ME, Derks, EM, Fleischhacker, WW, Kahn, RS, Aleman, A. Different effects of antipsychotic drugs on insight in first episode schizophrenia: data from the European First-Episode Schizophrenia Trial (EUFEST). Eur Neuropsychopharmacol 2015; 25: 808–16.
24Béland, S, Makowski, C, Konsztowicz, S, Buchy, L, Chakravarty, MM, Lepage, M. Clarifying associations between cortical thickness, subcortical structures, and a comprehensive assessment of clinical insight in enduring schizophrenia. Schizophr Res 2019; 204: 245–52.
25Morgan, KD, Dazzan, P, Morgan, C, Lappin, J, Hutchinson, G, Sucking, J, et al. Insight, grey matter and cognitive function in first-onset psychosis. Br J Psychiatry 2010; 197: 141–8.
26Asmal, L, du Plessis, S, Vink, M, Fouche, J-P, Chiliza, B, Emsley, R. Insight and white matter fractional anisotropy in first-episode schizophrenia. Schizophr Res 2017; 183: 8894.
27Ćurčić-Blake, B, van der Meer, L, Pijnenborg, GH, David, AS, Aleman, A. Insight and psychosis: functional and anatomical brain connectivity and self-reflection in schizophrenia. Hum Brain Mapp 2015; 36: 4859–68.
28van der Meer, L, Costafreda, SC, Aleman, A, David, AS. Self-reflection and the brain: a theoretical review and meta-analysis of neuroimaging studies with implications for schizophrenia. Neurosci Biobehav Rev 2010; 34: 935–46.
29Holt, DJ, Cassidy, BS, Andrews-Hanna, JR, Lee, SM, Coombs, G, Goff, DC, et al. An anterior-to-posterior shift in midline cortical activity in schizophrenia during self-reflection. Biol Psychiat 2011; 69: 415–23.
30Bedford, N, Surguladze, S, Giampietro, V, Brammer, MJ, David, AS. Self-evaluation in schizophrenia: an fMRI study with implications for the understanding of insight. BMC Psychiatry; 21012(12): 106.
31van der Meer, L, de Vos, AE, Stiekema, APM, Pijnenborg, GHM, van Tol, M-J, Nolen, WA, et al. Insight in schizophrenia: involvement of self-reflection networks? Schizophr Bull 2013; 39: 1288–95.
32Gerretsen, P, Menon, M, Mamo, DC, Fervaha, G, Remington, G, Pollock, BG, et al. Impaired insight into illness and cognitive insight in schizophrenia spectrum disorders: resting state functional connectivity. Schizophr Res 2014; 160: 4350.
33Gerretsen, P, Takeuchi, H, Ozzoude, M, Graff-Guerrero, A, Uchida, H. Insight into illness and its relationship to illness severity, cognition and estimated antipsychotic dopamine receptor occupancy in schizophrenia: an antipsychotic dose reduction study. Psychiatry Res 2017; 251: 20–5.
34Xavier, RM, Vorderstrasse, A, Keefe, RSE, Dungan, JR. Genetic correlates of insight in schizophrenia. Schizophr Res 2108; 195: 290–7.
35Harty, S, Robertson, IH, Miniussi, C, Sheehy, OC, Devine, CA, McCreery, S, et al. Transcranial direct current stimulation over right dorsolateral prefrontal cortex enhances error awareness in older age. J Neurosci 2010; 34: 3646–52.
36Bose, A, Shivakumar, V, Narayanaswamy, JC, Nawani, H, Subramaniam, A, Agarwal, SM, et al. Insight facilitation with add-on tDCS in schizophrenia. Schizophr Res 2014; 156: 63–5.


Insight and psychosis: the next 30 years

  • Anthony S. David (a1)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Insight and psychosis: the next 30 years

  • Anthony S. David (a1)
Submit a response


We encountered an error trying to retrieve eLetters for this article. Please try again or contact Customer Services


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *