Insight in Schizophrenia: Involvement of Self-Reflection Networks?

Lisette van der Meer, Annerieke E. de Vos*, Annemarie P. M. Stiekema, Gerdina H. M. Pijnenborg, Marie-Jose van Tol, Willem A. Nolen, Anthony S. David, Andre Aleman

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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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.

Original languageEnglish
Pages (from-to)1352-1362
Number of pages11
JournalSchizophrenia Bulletin
Issue number6
Publication statusPublished - Nov-2013


  • self-reflection
  • schizophrenia
  • psychosis
  • insight
  • cognitive insight
  • fMRI
  • FMRI

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