The structural neuroanatomy of metacognitive insight in schizophrenia and its psychopathological and neuropsychological correlates

Lack of insight into illness is a multidimensional phenomenon that has relevant implications on clinical course and therapy compliance. Here, we focused on metacognitive insight in schizophrenia, that is, the ability to monitor one's changes in state of mind and sensations, with the aim of investigating its neuroanatomical, psychopathological, and neuropsychological correlates. Fifty-seven consecutive patients with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) diagnosis of schizophrenia were administered the Insight Scale, and comprehensive psychopathological and neuropsychological batteries. They underwent a high-resolution T1-weighted magnetic resonance imaging investigation. Gray matter (GM) and white matter (WM) volumes were analyzed on a voxel-by-voxel basis using Statistical Parametric Mapping 8. Reduced metacognitive insight was related to reduced GM volumes in the left ventrolateral prefrontal cortex, right dorsolateral prefrontal cortex and insula, and bilateral premotor area and putamen. Further, it was related to reduced WM volumes of the right superior longitudinal fasciculum, left corona radiata, left forceps minor, and bilateral cingulum. Increased metacognitive insight was related to increased depression severity and attentional control impairment, while the latter was related to increased GM volumes in brain areas linked to metacognitive insight. Results of this study suggest that prefrontal GM and WM bundles, all implied in cognitive control and self-reflection, may be the neuroanatomical correlates of metacognitive insight in schizophrenia. Further, higher metacognitive insight is hypothesized to be a risk factor for depression which may subsequently impair attention. This line of research may provide the basis for the development of cognitive interventions aimed at improving self-monitoring and compliance to treatment. Hum Brain Mapp 35:4729-4740, 2014. © 2014 Wiley Periodicals, Inc.