A variety of phenomena might be considered as reflecting impaired insight in psychosis, like failure to recognize signs, symptoms or disease, failure to derive appropriate cognitive representations, despite recognition of the disease, and misattribution of the source or cause of the disease. The unawareness of tardive dyskinesia symptoms in schizophrenic patients points that self-awareness deficits in schizophrenia may be domain specific. Poor insight is an independent phenomenological and a prevalent feature in psychotic disorders in general, and in schizophrenia in particular, but we don’t know yet if delusions in schizophrenia are the result of an entirely normal attempt to account for abnormal perceptual experiences or a product of abnormal experience but of normal reasoning. The theoretical approaches regarding impaired insight include the disturbed perceptual input, the impaired linkage between thought and emotion and the breakdown of the process of self-monitoring and error checking. The inability to distinguish between internally and externally generated mental events has been described by the metarepresentation theory. This theory includes the awareness of ones’ goals, which leads to disorders of willed action, the awareness of intention, which leads to movement disorders, and the awareness of intentions of others, which leads to paranoid delusions. The theory of metarepresentation implies mainly output mechanisms, like the frontal cortex, while the input mechanism implies posterior brain systems, including the parietal lobe. There are many similarities between the disturbances of awareness seen in schizophrenia and those seen as a result of known neurological impairment. Neuropsychological models of impaired insight typically attribute the disturbance to any of a variety of core deficits in the processing of information. In this respect, lack of insight is on conceptual par with alogia, apraxia or aphasia in reflecting disturbed cognitive processing. In this direction, research have implicated the role of self-monitoring in disorders of awareness and many of the core symptoms of schizophrenia, and has been suggested that these symptoms are the result of a disturbance of a medial frontal system involving anterior hippocampus, cingulated gyrus, supplementary motor area, and dorsolateral prefrontal cortex. Poor insight seems to be something more than a symptom or an epi-phenomenon and its mechanism may constitute a core factor into the psychosis process. Also, poor insight would be involves a common mechanism for many other mental disorders or even it would be an independent and trans-diagnostic factor into the human personality, probably like the dimension of psychotism.

Key words: Psychosis, insight, schizophrenia, psychotism, self-awareness, anosognosia, metarepresentation, self-monitoring, metacognition.

O. Giotakos (page 332)

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