SMI Research Digest: Anosognosia
SMI Research Digest is a monthly publication from TAC’s Public Education and Research (PER) team that summarizes recently published research on topics related to severe mental illness (SMI). This month, we feature three recently published articles that explore anosognosia and its associated impacts on suicidality and capacity to make informed medical decisions.
Anosognosia and cognitive functioning in schizophrenia. Anosognosia, also called lack of insight, is a neurological condition that can make people unaware of their symptoms and experiences. It is estimated to impact 50-98% of people with schizophrenia. People with schizophrenia who have anosognosia may lack insight into several dimensions of their illness including delusions, hallucinations, level of cognitive impairment, level of functional disability, and physical health. A 2024 review article published in CNS Spectrums focused on cognitive aspects of insight like introspective accuracy, which is a person’s ability to accurately assess their own abilities, symptoms, and level of functioning. The review reported that people with schizophrenia may be more likely than others to overestimate their own abilities, underestimate the difficulties of tasks, and that impairments in introspective accuracy may be related to the overall cognitive difficulties that some people with schizophrenia experience. While anosognosia is a distinct condition that does not fully overlap with cognitive challenges in schizophrenia, interventions designed to address cognitive functioning may still help to improve some elements of insight. However, research also indicates that clinical symptoms may need to improve with medication before people with schizophrenia can benefit from therapies that target cognitive functioning.
Anosognosia’s impact on capacity to make informed medical decisions. It has been estimated that up to 25% of psychiatric patients may not have the capacity to make informed medical decisions because of their illness. This 2025 article from CNS Spectrums explores the legal complexities of informed consent among patients with anosognosia and schizophrenia. The author proposes that a person should not be considered competent to make informed medical decisions when lack of insight has lasted more than six months, does not change even when presented with evidence, and when the explanations offered to explain situations or symptoms of the illness are objectively false. However, the authors also propose that to protect patient autonomy, this lack of insight must also have been documented for at least six months, and a medical professional must be willing to testify that the patient’s lack of insight is a symptom of their illness and not denial.
Anosognosia and suicide risk in schizophrenia. Research suggests 1 in 4 people with schizophrenia attempt suicide at some point in their lives. A 2025 perspective paper from Frontiers in Psychiatry highlights several risk factors that may increase a person’s likelihood of attempting suicide, including anosognosia. While anosognosia is associated with negative outcomes like increased hospital readmissions, lower community functioning, and an increased likelihood of committing violent acts, it has also been associated with lower levels of suicidality. Improved insight into illness may increase suicidality when a better understanding of illness-induced life changes causes increased feelings of self-stigma, hopelessness, and depression. This relationship between anosognosia and suicidality has been called the ‘insight paradox.’ To mitigate this risk, it is important to provide patients with psychosocial interventions that help to reduce internalized stigma, maintain hope, and process traumatic experiences, especially as levels of insight improve.
