Does insight improve during the course of psychosis?

Insight, awareness of illness, is often impaired in psychotic disorders and relates to symptom severity and cognition, but its association with time since first diagnosis is unclear. We examined insight, cognition, and time since first diagnosis in a large multi-diagnostic sample.

We studied patients with schizophrenia (SZ, n = 957), schizoaffective disorder (SAD, n = 723) and bipolar I disorder with psychotic features (BP, n = 691). Cognitive function was assessed with the Brief Assessment of Cognition in Schizophrenia (BACS) battery. Insight was measured using item G12 from the Positive and Negative Syndrome Scale (PANSS), where higher scores indicate poorer insight.

Insight differed by diagnosis (p < .001), poorest in SZ vs SAD and BP. Within SZ, first-year cases had higher PANSS-G12 than those ≥3 years from first diagnosis (p < .01). Hierarchical regressions showed diagnosis and symptom severity explained most variance in insight; cognition added only a small increment. In SZ, insight was modestly inversely related to time since first diagnosis (ρ = -0.124, p = .001) and weakly to cognition (ρ = -0.084, p = .029). Poorer insight correlated with more severe negative (ρ = 0.259, p < .001) and positive symptoms (ρ = 0.347, p < .001). No associations with time since diagnosis or cognition were seen in SAD or BP.

In SZ, insight showed a statistically significant but very small cross-sectional association with longer time since first diagnosis (better insight with longer duration), with the largest deficit in the first year. Early, diagnosis-tailored psychoeducation and metacognition-focused supports may help support gains in insight and engagement.