Insight and theory of mind in schizophrenia

• Theory of mind (ToM) deficits and poor insight are associated with poor outcome in schizophrenia.
• Social developmental research suggests that representations of others (ToM) and representations of the self (insight) are related.
• Results showed insight is multidimensional, with ToM uniquely associated with Awareness of Illness, but not other aspects of clinical or cognitive insight.
• ToM also mediated the relationship between neurocognition and Awareness of Illness.
• Findings may suggest that social cognition interventions that teach ToM (e.g., perspective-taking) skills may improve Awareness of Illness and functional outcome in schizophrenia.

Theory of mind (ToM) impairment is common in individuals with schizophrenia and is associated with poor social functioning. Poor insight has also been linked to poor outcome in schizophrenia. Social developmental research has shown representations of self (insight) and representations of others (ToM) are related. In schizophrenia, contradictory reports of associations between insight and ToM have emerged, possibly due to a failure to account for neurocognitive impairments and symptoms associated with both mentalization constructs. This study investigated the relationships between ToM (intentions of others on the Hinting Task) and clinical and cognitive insight, while accounting for shared variance with neurocognitive impairment and symptom severity in 193 individuals with schizophrenia. Clinical, but not cognitive, insight was associated with ToM. A unique association between Awareness of Mental Illness and Hinting Task performance was found, independent of shared variance with neurocognition and symptoms. Importantly, ToM was found to mediate Awareness of Mental Illness and neurocognition. Results suggested that treatments targeting mentalization abilities that contribute to representations of self and others may improve insight deficits associated with poor outcome in schizophrenia.