The neuropsychological basis of insight in first-episode schizophrenia: a pilot metacognitive study.

The aim of the present study was to explore the neuropsychological basis of insight in first-episode schizophrenia, by evaluating its differential and joint links with cognitive vs. metacognitive performance. Thirty first-episode patients were assessed with the Scale of Unawareness of Mental Disorder (SUMD) and a metacognitive version of the Wisconsin Card Sorting Test (WCST). In addition to the standard administration of the WCST, subjects were also asked to rate their level of confidence in the correctness of each sort (prior to getting the feedback), and to choose whether they wanted each sort to be "counted" toward their overall performance score on the test. Each "volunteered" sort received a bonus of 10 cents if correct, but an equal penalty if wrong. Insight into illness had higher correlations with free-choice metacognitive indices derived from confidence ratings and volunteered sorts than with the conventional scores from the WCST. Moreover, prediction of poor insight was significantly improved when adding the new, free-choice metacognitive measures to the conventional WCST measures, but not the other way around. These preliminary results suggest that metacognition is an important mediator between basic cognitive deficits and poor insight, and might be even more relevant to poor insight than cognitive deficits per se.