Impaired self-assessment in schizophrenia: Why patients misjudge their cognition and functioning

We concluded that ratings generated by a generic informant—someone who simply knows the patient and is willing to provide ratings—are highly likely to be uninformative. If a friend or relative provides information of limited useful­ness, the report could easily lead to clinical decisions with high potential for bad out­comes. For example, attempts could fail to transition someone with impaired every­day living skills to independent living, or a patient whose potential is underesti­mated might not be offered opportunities to achieve attainable functional goals.

We found that the closer the rater was to a full caregiver role, the better and more accurate the information obtained. Caregivers who had regular contact with patients had much more valid rat­ings when performance on functionally relevant objective measures was consid­ered. Patients with caregivers had greater impairments in everyday outcomes, how­ever, suggesting that this subset was more impaired than the overall sample. For patients without caregivers, other sources of information—including careful obser­vation by high-contact clinicians—seem to be required to generate a valid assessment of functioning.

Direct functional implications of impaired introspective accuracy
Clinical effects of reduced awareness of ill­ness include reduced adherence to medi­cation, followed by relapse, disturbed behavior, leading to emergency room treat­ments or acute admissions, and—more rarely—disturbed behavior associated with violence or self-harm. Relapses such as these can adversely affect brain structure and function, with declines in cognitive functioning early in the illness.

Our recent study¹⁸ quantifies the direct impact of impairments in introspective accuracy on everyday functioning. We asked 214 individuals with schizophrenia to self-evaluate their cognitive ability with a systematic rating scale and to self-report their everyday functioning in social, voca­tional, and everyday activities domains. We used performance-based measures to assess their cognitive abilities and everyday functional skills. Concurrently, high-contact clinicians rated these same abilities with the same rating scales. We then predicted everyday functioning, as rated by the cli­nicians, with the discrepancies between self-assessed and clinician-assessed func­tioning, and patients’ scores on the perfor­mance-based measures.

Impaired introspective accuracy, as indexed by difference scores between cli­nician ratings and self-reports, was a more potent predictor of everyday functional deficits in social, vocational, and every­day activities domains than scores on performance-based measures of cognitive abilities and functional skills. Even when we analyzed only deficits in introspective accuracy for cognition as the predictor of everyday outcomes in these 3 real-world functional domains, the results were the same. Impaired introspective accuracy was the single best predictor of everyday func­tioning in all 3 domains, with actual abili­ties considerably less important.

Patient characteristics that predict introspective accuracy
Patient characteristics associated with impairments in introspective accuracy (Table 3)^19,20 are easy to identify and assess. Subjective reports of depression have a bell-shaped relationship with introspec­tive accuracy. A self-reported score of 0 by a disabled schizophrenia patient suggests some unawareness of an unfortunate life situation; mild to moderate scores are asso­ciated with more accurate self-assessment; and more severe scores, as seen in other conditions, often predict overestimation of disability.¹⁹

Psychosis and negative symptoms are associated with reduced introspective accu­racy and global over-reporting of functional competence.²⁰ Patients who have never worked have no way to comprehend the specific challenges associated with obtain­ing and sustaining employment. Patients who had a job and have not been able to return work may perceive barriers as more substantial than they are.

Tips to manage impairments in introspective accuracy
Ensure that assessment information is valid. If a patient has limited ability to self-assess, seek other sources of data. If a patient has psychotic symptoms, denies being depressed, or has limited life experi­ence, the clinician should adjust her (his) interpretation of the self-report accord­ingly, because these factors are known to adversely affect the accuracy of self-assessment. Consider informants’ level and quality of contact with the patient, as well as any motivation or bias that might influence the accuracy of their reports. Other professionals, such as occupational therapists, can provide useful information as reference points for treatment planning.

Consider treatments aimed at increasing introspective accuracy, such as structured training and exposure to self-assessment situations,⁶ and interventions aimed at increasing organization and skills perfor­mance. Cognitive remediation therapies, although not widely available, have poten­tial to improve functioning, with excellent persistence over time.²¹

Related Resources
• Harvey PD, ed. Cognitive impairment in schizophrenia: characteristics, assessment and treatment. Cambridge, United Kingdom: Cambridge University Press; 2013.
• Gould F, McGuire LS, Durand D, et al. Self-assessment in schizophrenia: accuracy of assessment of cognition and everyday functioning [published online February 2, 2015]. Neuropsychology.
• Dunning D. Self-insight: detours and roadblocks on the path to knowing thyself. New York, NY: Psychology Press; 2012.