Distinct pattern of associations of cognitive insight and clinical insight with theory-of-mind and empathy in schizophrenia patients

Objective: Clinical insight and cognitive insight are two different dimensions. The theoretical model of insight growth posits that cognitive insight and social cognition are central for gaining clinical insight in schizophrenia patients, but empirical evidence remains limited. We aimed to examine the mediating role of two social cognitive constructs (theory-of-mind and empathy) in linking cognitive insight and clinical insight, and to clarify their role in bringing confluence of the two insight dimensions in schizophrenia patients. Method: Our sample comprised 139 schizophrenia patients. The Schedule for the Assessment of Insight (SAIE) and the Beck Cognitive Insight Scale (BCIS) measured the two dimensions of insight. The Faux Pas Task and the self-report Questionnaire of Cognitive and Affective Empathy (QCAE) were used to measure theory-of-mind and empathy respectively. Correlational analyses and mediation modelling were used to clarify the relationships and mediating roles of social cognition with clinical insight and cognitive insight. Explorative cluster analysis was used to categorize patients into different groups with different insight patterns. Results: Theory-of-mind statistically mediated the relationship between clinical insight and cognitive insight. The three groups/clusters with varied insight patterns differed in theory-of-mind, empathy, social functioning, negative and disorganized symptoms. The group with non-confluent insight pattern showed poorer theory-of-mind and empathy than the group with high clinical insight and cognitive insight. Discussion: Theory-of-mind links cognitive insight with clinical insight. Schizophrenia patients may have a "non-confluent" insight pattern. Social cognition may bring confluence of insight dimensions. Together, our findings lend support to the insight-growth model of schizophrenia.