Metacognition, clinical insight and symptomatology in chilean outpatients with Schizophrenia

Abstract

Introduction: People with schizophrenia have serious disturbances in forming complex ideas about themselves and others, defined as metacognitive deficits, along with less clinical insight or awareness of mental disorder. The present study assessed these disturbances and the correlations between metacognition, clinical insight and symptomatology in outpatients with schizophrenia. Methods: A quantitative, relational, prospective, cross-sectional and observational study was designed. Thirty-one outpatients of the "Luz y Esperanza" Day Center in Talca (Chile) were evaluated using the Metacognitive Assessment Scale-Abbreviated, Scale of Unawareness of Mental Disorder and the Positive and Negative Syndrome Scale, in the period 2019-2020. Results: Low metacognitive and clinical insight scores were found, highlighting statistically significant correlations of total metacognitive score, Self-Reflectivity and Mastery with low Awareness of mental disorder and the subscales of negative symptoms and disorganization. Conclusions: Our results support the inclusion of metacognitive deficits and clinical insight in schizophrenia models. Its potential contribution to the design of psychotherapeutic interventions that promote these abilities and influence negative and disorganized symptoms is discussed. It is necessary to replicate studies about these variables in our country, including a greater number of participants.

Full text

1
www.journalofneuropsychiatry.cl
RESEARCH ARTICLE
Metacognition, clinical insight and symptomatology
in chilean outpatients with Schizophrenia
ABSTRACT
Introduction: People with schizophrenia have serious disturbances in forming complex ideas about
themselves and others, dened as metacognitive decits, along with less clinical insight or awareness
of mental disorder. The present study assessed these disturbances and the correlations between
metacognition, clinical insight and symptomatology in outpatients with schizophrenia. Methods: A
quantitative, relational, prospective, cross-sectional and observational study was designed. Thirty-
one outpatients of the “Luz y Esperanza” Day Center in Talca (Chile) were evaluated using the
Metacognitive Assessment Scale-Abbreviated, Scale of Unawareness of Mental Disorder and
the Positive and Negative Syndrome Scale, in the period 2019-2020. Results: Low metacognitive
and clinical insight scores were found, highlighting statistically signicant correlations of total
metacognitive score, Self-Reectivity and Mastery with low Awareness of mental disorder and the
subscales of negative symptoms and disorganization. Conclusions: Our results support the inclusion
of metacognitive decits and clinical insight in schizophrenia models. Its potential contribution to
the design of psychotherapeutic interventions that promote these abilities and inuence negative and
disorganized symptoms is discussed. It is necessary to replicate studies about these variables in our
country, including a greater number of participants.
Keywords: Metacognition, clinical insight, symptomatology, schizophrenia.
Received 15-08-2022
Accepted: 30-10-2023
No conict of interest to declare, there was no nancial source of support.
a Psychiatrist. Universidad Católica del Maule, School of Medicine, Department of Clinical Sciences, Talca, Chile.
b Psychiatrist, Talca General Hospital, Psychiatry Service, Talca, Chile.
c Psychiatrist, Curicó General Hospital, Psychiatry Service, Curicó, Chile.
Sergio Vergara-Ramíreza,b, Celeste Manríquez-Sallesb, Daniela Hernández-DíazC

2www.journalofneuropsychiatry.cl
INTRODUCTION
In 1911, Bleuler coined the term “schizophrenia”
to refer to a disorder involving the disruption of
associative processes necessary to form integrated
ideas about oneself and others(1), which would be
at the base of most complex and signicant human
activity(2). Currently, the role of diculties in
reecting one’s and others’ mental states, so-called
metacognitive decits, and the lack of insight or
awareness of having this disorder have stood out
in Schizophrenia(3,4).
The term “metacognition” was initially dened by
Flavell (1979) as “thinking about thinking”(5). For
Semerari et al. (2003), metacognition refers to the
ability of understanding and reecting upon mental
states with the purpose of facing everyday problems
and regulating internal states(6). It is an ability which
is displayed in intersubjective contexts and that
can vary between people with dierent degrees of
decit, being inuenced by social, psychological,
and biological factors(7). Metacognitive abilities
in Schizophrenia are decreased and are evaluated
through four domains: Self-Reectivity or the
ability of becoming aware of one’s own mental
states; Understanding others’ minds, known
as the ability to think about the mental states of
others; Decentration or the ability of taking a non-
egocentric perspective; and Mastery or the ability
to apply useful strategies to solve psychological
conicts or related distress(8,9). In regard to the
metacognitive abilities in schizophrenia, they
are less in comparison to the general population
and other mental health disorders(10-13). The
relationship of metacognitive decits with more
severe symptoms, mainly negative symptoms
and disorganization, in the post-acute fase(14)
and in rst episode schizophrenia(15-18) has been
documented. Furthermore, said decits have been
correlated with neurocognitive disturbances(19,20)
and less social functioning(21,23).
Regarding the term insight, it refers to the
acknowledgment of having a mental illness and the
possibility of reconstructing some mental events
of the illness as pathological(24). Less ability for
clinical insight has been associated to more severe
positive, negative, disorganization, excitement
and total symptomatology of schizophrenia(25). On
its relation to metacognition, Vohs et al. (2016)
has established that developing greater insight
would require the ability of having a profound
personal sense of how the irruption of mental
illness can interrupt the course of life, the ability
to perceive changes in one’s and others’ mental
states from the disorder’s onset, and the ability
of selecting biographical events associated to
the illness(26). In regard to this, a lower score in
Mastery has been objectively associated to a lesser
clinical insight(19,27,28), lesser awareness of the
eects of medication and lesser awareness of the
consequences of mental disorder(29). In addition,
lower Self-Reectivity has been documented
to correlate with lower awareness of mental
disorder(29), lower awareness of the consequences
of mental disorder(28), and lower overall clinical
insight(20).
Considering cultural, historical, and linguistic
dierences, replicating studies on the subject
in cultures like ours proves necessary(11). This
work’s objective is to know the metacognitive
decits, insight, and symptomatology, as well as
its correlations, in patients with schizophrenia who
attended the “Luz y Esperanza” Talca Day Center,
between the years 2019 and 2020, as outpatients.
We hypothesize nding severe metacognitive
decits in Self-Reectivity and Mastery, low
levels of clinical insight and correlations of these
metacognitive decits with less insight and greater
negative and disorganization symptoms in our
users.
METHODOLOGY
This is a quantitative, relational, prospective,
cross-sectional, and observational study(30).
The population considered were patients with a
conrmed schizophrenia diagnosis who attended
the “Luz y Esperanza” Talca Day Center according
to the CIE-10 criteria, between June 2019 and
December 2020. Patients and their tutors gave
informed consent to participate in the study,
METACOGNITION, CLINICAL INSIGHT AND SYMPTOMATOLOGY IN CHILEAN OUTPATIENTS WITH SCHIZOPHRENIA

3
www.journalofneuropsychiatry.cl
which had the Scientic Ethics Committee of the
Maule Health Service’s approval. Information
about the subjects diagnosed with schizophrenia
was obtained from the “Luz y Esperanza” Talca
Day Center’s records. The sta of said center was
consulted to conrm that the diagnoses registered
in the system related to the current clinical
diagnoses. The exclusion criteria considered
was undergoing an acute phase of the disorder
according to the guidelines established in the
Clinical Schizophrenia Guide from the Chilean
Health Department(31). Three people refused to
participate in the study, it nally included a total
of 31 participants.
Instruments
The instruments were applied by two of the
authors (C.M and D.H) to each participant in a
one-hour session. In order to avoid interfering
with the user’s cognitive performance, the session
began by using the Indiana Psychiatric Illness
Interview (IPII), which seeks to evoke narratives,
followed by the Positive and Negative Syndrome
Scale (PANSS), ending by implementing the three
general items from the Scale of Unawareness of
Mental Disorder (SUMD).
Indiana Psychiatric Illness Interview (IPII). The
IPII is a semi-structured interview that assesses
how people describe their life narrative and their
experience of suering from a mental health
disorder(32). The interview lasts around 30 minutes
and is divided in ve sections: free general
narrative of the story of the patient’s life, narrative
about the experience of suering from a mental
health disorder, what has been or not been aected
by the illness in their interpersonal life, the degree
in which the mental illness has inuenced their life
and their opinion about their future. For this study,
the version translated by Leonor Irarrázaval(8) was
used.
Metacognitive Assessment Scale-Abbreviated
(MAS-A). The MAS-A scale evaluates the
metacognitive abilities as manifested in the
patients’ narratives(19). It comprises four subscales
and a total score, its values hierarchically reect
accomplished metacognitive abilities. A higher
score translates to a more advanced display of
metacognitive abilities of the subject. The subscales
are: Self-Reectivity (0-9 score), Understanding
others’ minds (0-7 score), Decentration (0-3 score),
and Mastery (0-9 score). The sum of these scores
represents the total metacognitive ability (score
of 0-28). Subscales are scored for each function
that the evaluator considers achieved, taking the
transcription data obtained from the IPII. If the
function is completely achieved 1 point is given,
partially achieved 0.5 points, and if it is not
achieved 0 points. This study applied the version
translated to spanish by Leonor Irarrázaval(8). The
data obtained with the north American version of
the MAS-A yield values of internal consistency,
test-retest and inter-rater reliability acceptable,
with intraclass coecients ranging from 0.71 and
0.91(19,33).
Positive and Negative Syndrome Scale (PANSS).
The PANSS is an interview and observational
scale that evaluates the Schizophrenic Syndrome
from a dimensional and categorical point of view.
Developed by Kay, Fiszbein and Opler (1987) and
adapted to spanish by Peralta and Cuesta (1994),
it has 30 items, in a Likert response format from 1
to 7(34). This study used a variation of the original
which consists of a model with ve factors that
evaluates other subscales: Positive (scoring 7 to
49), Negative (scoring 8 to 56), Disorganization
(scoring from 10 to 70), Excitement (scoring from
8 to 56), and Emotional Distress (scoring from 8 to
56). Higher scores in each subscale indicate more
severity in the symptomatology(35). This 5-factor
model allows for the evaluation of other syndromes
(Disorganization, Excitement and Emotional
Distress) that are absent in the original scale and
which are of interest for this study. The internal
consistency values for the ve-factor model of
PANSS were: α Positive= 0.73; α Negative= 0.83;
α Disorganization= 0.81; α Excitement= 0.70; α
Emotional Distress= 0.64(36).
Scale of Unawareness of Mental Disorder
(SUMD). The SUMD is a scale used to evaluate
awareness of illness in patients with psychosis in
SERGIO VERGARA et.al.

4www.journalofneuropsychiatry.cl
a multidimensional manner, developed by Amador
et al. (1993) and adapted to spanish by Ruiz et
al. (2008)(37). As in previous works(29), we used
the scores from three general items that evaluate
awareness of a mental disorder, awareness of
the eects of medication, awareness of the
consequences of mental disorder and the sum of
these, which corresponds to total clinical insight(38).
Each item is scored based on Likert-type scale with
6 values varying in intensity in which 0 is a non-
relevant item, 1 point is complete awareness, and 5
points means there is no awareness. Regarding the
global clinical insight score, authors do not provide
a cut-o point, the higher the score the bigger the
severity(40). Good to excellent interrater reliability
between evaluators has been reported for the
SUMD, with interclass correlations between 0.82
and 0.91(29).
Data Analysis
We took the information obtained through the
selected instruments and a database was structured
and developed for this project. The statistical
program SPSS, version 21 for Mac, was used for
data analysis. A descriptive statistical analysis with
frequency distribution, central tendency measures,
and variability measures for the data collected from
the study’s variables was carried out. In terms of
inferential analysis, the correlations between the
quantitative variables of metacognition, clinical
insight, and symptomatology were evaluated using
the nonparametric Spearman’s rank correlation
coecient. There was no data loss. The level of
signicance was established at 0.05.
RESULTS
The descriptive analysis for the demographic
variables, metacognitive abilities, clinical insight
and symptomatology are shown in Table 1.
The participants’ MAS-A total mean score was
11.9, in the Self-Reectivity scale it was 4.1, in
Understanding others’ minds 3.0, in Decentration
0.7, and 3.7 in Mastery. In terms of insight, the
mean score for total clinical insight in the SUMD
was 7.9, 2.6 in awareness of mental disorder,
2.6 in awareness of the eects of medication,
and 2.7 in awareness of the consequences of
mental disorder. The mean scores of psychotic
symptomatology in PANSS, considering the
5 factors suggested by Van der Gaag (2006)
(35), was 15.8 in Positive subscale, 20.6 in the
Negative subscale, 29.4 in the Disorganization
subscale, 17.2 in the Excitement subscale, and
18.0 for Emotional distress. (Table 1)
The correlations between metacognitive abilities
and clinical insight are listed in Table 2. The
awareness of mental disorder item from the
SUMD presented a signicant negative correlation
to the total MAS-A score (rho= -0.421, p=0.018),
to the Self-Reectivity domain (rho= -0.367,
p=0.042), to Decentration (rho= -0.405, p=0.024)
and to Mastery (rho= -0.386, p=0.032). The
Mastery domain from the MAS-A also presented
a signicant negative correlation to the awareness
of the consequences of mental disorder item (rho=
-0.369, p=0.041) and to the total insight score
of the SUMD (rho= -0.374, p=0.038). No other
signicant correlations were observed between
both variable.
Associations between metacognition and
symptomatology are summarized in Table 2.
The total MAS-A score presented a signicantly
negative correlation to the PANSS Disorganization
subscale (rho= -0.637, p= 0.0001), to the
Negative subscale (rho= -0.445, p= 0.012), and
the Excitement subscale (rho= -0.366, p= 0.043).
The Self-Reectivity domain had a signicantly
negative relation to the Disorganization (rho=
-0.644, p< 0.0001) and Negative (rho= -0.409,
p= 0.022) subscales. Understanding others’ minds
was signicantly related to the Disorganization
(rho= -0.538, p= 0.002) and Negative (rho=
-0.440, p= 0.013) subscales. Decentration
presented a signicantly negative relation to
the Disorganization (rho= -0.432, p= 0.015) and
Excitement (rho= -0.437, p= 0.014) subscales. The
ability of Mastery was only signicantly related
to the Disorganization subscale (rho= -0.528,
p= 0.002). There was no statistically signicant
correlation within any metacognitive domains
with Emotional distress. (Table 2)
METACOGNITION, CLINICAL INSIGHT AND SYMPTOMATOLOGY IN CHILEAN OUTPATIENTS WITH SCHIZOPHRENIA

5
www.journalofneuropsychiatry.cl
Table 1. Demographic variables, metacognitive scores, clinical insight and symptomatology
in schizophrenia, Talca Day Center users.
SERGIO VERGARA et.al.
1
Frequency
Percentage
(%)
Mean
Mode
Median
Standard
Deviation
Age
48,0
51
51,0
11,7
Sex
Masculine
24
77,4
Femenine
7
22,6
Education (school)
Incomplete primary
3
9,7
Complete primary
5
16,1
Incomplete high
1
3,2
Complete high
12
38,7
Incomplete higher
9
29,0
Complete higher
1
3,2
Antipsychotic use
No
0
0
1st generation
0
0
2nd generation
22
71,0
1st and 2nd generation
9
29,0
Previous hospitalizations
2,52
1
1,8
2,52
Time since last hospitalization
(years)
10,39
0
5,0
10,63
MAS-A score
Self-Reflectivity
4,19
3,5
4,0
1,13
Understanding others’ minds
3,08
2,0
3,0
1,03
Decentration
0,77
0
0,5
0,62
Mastery
3,76
3,0
3,0
1,30
MAS-A total
11,98
7,5
11,0
3,79
SUMD
Awareness of mental disorder
2,61
3,0
2,68
0,92
Awareness of the effects of
medication
2,61
3,0
2,73
0,92
Awareness of consequences
2,71
3,0
2,74
1,07
SUMD total
7,94
9
8,38
2,62
PANSS
Positive
15,84
15
15,0
6,57
Negative
20,61
12
21,0
8,53
Disorganization
29,48
35
30,0
7,42
Excitement
17,23
14
16,0
5,24
Emotional distress
18,00
14
18,0
5,24
Note: MAS-A: Metacognition Assessment Scale Abbreviated. SUMD: Scale of Unawareness of Mental Disorder.
PANSS: Positive and Negative Syndrome Scale.

6www.journalofneuropsychiatry.cl
The relation between clinical insight and
symptomatology can be seen in Table 3. A
signicant correlation was observed between
the awareness of mental disorder item from the
SUMD and the PANSS Negative subscale (rho=
0.434, p=0.015), the Disorganization subscale
(rho= 0,516, p= 0,003), and the Excitement
subscale (rho= 0.464, p= 0.008). Furthermore, the
disorganization subscale was signicantly related
to the awareness of the consequences of mental
disorder item (rho= 0.414, p= 0.020) and the total
SUMD insight score (rho= 0.507, p= 0.004).
Finally, the awareness of the eects of medication
item was signicantly correlated to the PANSS
Excitement subscale (rho= 0.380, p= 0.035).
(Table 3)
DISCUSSION
The low metacognitive ability in patients diagnosed
Table 2. Correlations between metacognition, symptomatology and clinical
insight in schizophrenia, Talca Day Center users.
METACOGNITION, CLINICAL INSIGHT AND SYMPTOMATOLOGY IN CHILEAN OUTPATIENTS WITH SCHIZOPHRENIA
2
MAS-A
Total
MAS-A
Self- Reflectivity
MAS-A
Understanding
others’ minds
MAS-A
Decentration
MAS-A
Mastery
PANSS
Positive
-,161
-,205
-,247
-,224
-,075
PANSS Negative
-,445*
-,409*
-,440*
-,317
-,215
PANSS
Disorganization
-,637**
-,644**
-,538**
-,432*
-,528**
PANSS Excitement
-.366*
-,351
-,292
-,437*
-,319
PANSS Emotional
distress
-,103
-,056
-,265
-,083
-,125
SUMD Total
-,313
-,291
-,250
-,273
-,374*
SUMD Awareness of
mental disorder
-,421*
-,367*
-,346
-,405*
-,386*
SUMD Awareness of
the effects of
medication
-,240
-,194
-,295
-,246
-,192
SUMD Awareness of
consequences
-,240
-,229
-,167
-,143
-,369*
Note: Spearman correlation, rho. MAS-A: Metacognition Assessment Scale Abbreviated. PANSS: Positive and
Negative Syndrome Scale. SUMD: Scale of Unawareness of Mental Disorder.
* p ≤ 0,05, correlation is significant at the 0,05 level (bilateral)
**p ≤ 0,01, correlation is significant at the 0,01 level (bilateral)

7
www.journalofneuropsychiatry.cl
with schizophrenia in the “Luz y Esperanza” Talca
Day Center is similar to the results obtained in
samples with long-term schizophrenia(11) and rst
episode psychosis(17,18). In this work, the Self-
Reectivity mean score indicates that users were
able to identify their own cognitive operations and
emotions but not able to achieve more advanced
subfunctions of dierentiation nor of integration.
Moreover, they only identied others’ cognitive
operations with serious diculty to recognize that
they were not the center of others’ mental activities.
In terms of the Mastery domain, subjects were
able to respond to psychological problems through
avoidance or through passive activities, known as
rst level coping strategies. In regard to the scores
in clinical insight from the SUMD, users presented
an intermediate level of awareness in the following
variables: awareness of mental disorder, awareness
of the eects of medication, and awareness of the
consequences of mental disorder.
The correlation between the total metacognitive
score and the awareness of mental disorder item is
consistent with the integrated model of insight in
psychosis by Vohs et al. (2016), in which subjects
who present metacognitive decits would present
a diminished ability in understanding the fact of
having a mental illness(26). There were signicant
correlations between the Mastery metacognitive
domain and the total insight score in the SUMD,
and the items awareness of mental disorder and
awareness of the consequences of mental disorder.
The SUMD awareness of mental disorder item
also presented a signicant correlation to Self-
Reectivity and Decentration. In other words,
the ability to reect on one’s mental states in a
decentered manner to actively resolve problems
would be related to the diculties of accurately
conceptualizing suering from schizophrenia and
the consequences this could have towards their
environment(19,20,29). Our results support what was
stated by Vohs et al. (2015), on the relevance of
a basic self-reective ability, in order to identify
problems and their resolution, preceding the
awareness of having a mental disorder and its social
consequences(28). In our work, and similarly to the
Table 3. Correlations between clinical insight and symptomatology in schizophrenia, Talca Day Center users.
SERGIO VERGARA et.al.
3
SUMD
Total
SUMD
Awareness of
mental disorder
SUMD
Awareness of
the effects of
medication
SUMD
Awareness of
consequences
PANSS
Positive
,164
,348
,315
-,133
PANSS Negative
,348
,434*
,326
,213
PANSS
Disorganization
,507**
,516**
,354
,414*
PANSS Excitement
,349
,464**
,380*
,116
PANSS Emotional
distress
,185
,309
,256
-,031
Nota: Spearman correlation, rho. SUMD: Scale of Unawareness of Mental Disorder. PANSS: Positive and
Negative Syndrome Scale.
* p ≤ 0,05, correlation is significant at the 0,05 level (bilateral)
**p ≤ 0,01, correlation is significant at the 0,01level (bilateral)

8www.journalofneuropsychiatry.cl
conclusions of Lysaker et al. (2005), Understanding
others’ minds was the metacognitive domain that
presented least correlation to the dierent clinical
insight items(19). It could be proposed, then, that
evaluating this domain through narrative type
tests, such as the IPII, would not evoke abilities
like understanding own and others’ mental states
with the same precision(19).
The correlation discovered between the total
metacognitive ability and its domains, and the
PANSS disorganization and negative subscales,
agrees with studies of english-speaking
patients(14-17), which has led to placing the possible
presence of metacognitive decits at the base of
the disruption in thought organization and of the
negative symptoms of schizophrenia(2). Thus, the
initial diculty in accessing to one’s and others’
mental states, in the context of social interactions,
would lead to social withdrawal processes,
exacerbating the interpersonal diculties that
they present(15). On the other hand, our results are
in line with what Lysaker et al. (2008) pointed
out about the relation between the awareness of
mental disorder and the PANSS Disorganization,
Negative and Excitement subscales, as well as
the association of the Disorganization subscale
with total clinical insight and awareness of the
consequences of mental disorder(25). On the one
hand, Disorganization symptoms in our users
would be an important impediment to develop
a greater capacity for insight, and on the other
hand, less capacity for insight would lead to a
poor adherence to treatment, which can lead to an
exacerbation of these symptoms(26).
In summary, we highlight the associations of
decits in self-reective and decentered ways of
making sense of oneself and the world in order
to solve every day psychological problems,
with the capacity to become aware of suering
schizophrenia and the severity of negative and
disorganization symptoms. From this perspective,
it could be suggested that psychotherapeutic
interventions that address metacognitive decits
in schizophrenia, mainly Mastery and Self-
Reectivity, could promote insight and reduce
disorganization and negative symptoms. On
the impact of these variables in the therapeutics
of schizophrenia, during the last decade
psychotherapeutic models have been developed
such as Metacognitive Reection and Insight
Therapy(39) and Metacognitive Interpersonal
Therapy for Psychosis(40), where developing
metacognitive abilities allows for more insight.
Regarding the methodological aspects of this
study, using PANSS and the 5 factors suggested
by Van der Gaag (2006) proved to be a success,
in contrast to the three subscales in the original
PANSS(35). Using the 5-factor model demonstrated
the correlation between disorganization symptoms
and metacognition that the original model would
not have been able to prove. On the other hand,
this study shows limitations that are important
to clarify. First, it is a correlational study that
acknowledges the presence of associations, but
which cannot suggest causality between variables.
Furthermore, the IPII, MAS-A, and SUMD are
not validated in our population. Another limitation
was the limited number of participants included
in the study, which could be corrected in future
multi-centered studies, in partnership with other
clinical services in the country.
Acknowledgements: Maule’s Health Service.
METACOGNITION, CLINICAL INSIGHT AND SYMPTOMATOLOGY IN CHILEAN OUTPATIENTS WITH SCHIZOPHRENIA

9
www.journalofneuropsychiatry.cl
REFERENCES
1. Bleuler E. Dementia praecox o el grupo de las
esquizofrenias. Buenos Aires: Polemos; 2011.
2. Lysaker PH, Vohs J, Minor KS, Irarrázaval L,
Leonhardt B, Hamm JA, Kukla M, Popolo R,
Luther L, Buck KD, Wasmuth S, Dimaggio
G. Metacognitive Decits in Schizophrenia:
Presence and Associations With Psychosocial
Outcomes. J Nerv Ment Dis. 2015 Jul;203(7):530-
6. doi: 10.1097/NMD.0000000000000323. PMID:
26121151.
3. Lysaker P, Buck K, Leonhardt K, Buck B,
Hamm J, Hasson-Ohayon I, Vohs J, Dimaggio G.
Metacognitively focused psychotherapy for people
with schizophrenia: eight core elements that dene
practice. In: Lysaker P, Dimaggio G, Brüne M,
editors. Social Cognition and Metacognition in
Schizophrenia. Psychopathology and Treatment
Approaches. London: Academic Press; 2014. p.
196-212.
4. Lysaker PH, Leonhardt BL, Pijnenborg M,
van Donkersgoed R, de Jong S, Dimaggio
G. Metacognition in schizophrenia spectrum
disorders: methods of assessment and associations
with neurocognition, symptoms, cognitive style and
function. Isr J Psychiatry Relat Sci. 2014;51(1):54-
62. PMID: 24858635.
5. Flavell JH. Metacognition and cognitive
monitoring: A new area of cognitive-developmental
inquiry. Am Psychol. 1979;34(10):906-11. doi:
10.1037/0003-066x.34.10.906.
6. Semerari A, Carcione A, Dimaggio G, Falcone M,
Nicolo G, Procacci M, Alleva G. How to Evaluate
Metacognitive Functioning in Psychotherapy?
The Metacognition Assessment Scale and
its Applications. Clin Psychol Psychother.
2003;10(4):238-61. doi: 10.1002/cpp.362.
7. Lysaker PH, Cheli S, Dimaggio G, Buck B,
Bonls KA, Huling K, Wiesepape C, Lysaker JT.
Metacognition, social cognition, and mentalizing
in psychosis: are these distinct constructs when
it comes to subjective experience or are we
just splitting hairs? BMC Psychiatry. 2021 Jul
2;21(1):329. doi: 10.1186/s12888-021-03338-4.
PMID: 34215225; PMCID: PMC8254212.
8. Lysaker P, Buck K, Hamm J. Escala de Evaluación
de la Metacognición: Una breve visión general y
Manual de Codicación para la versión abreviada
(EEM-A) v 2015. Rev GPU. 2016;12(2): 174-90.
9. Vergara S. Metacognición en Esquizofrenia:
décits metacognitivos y psicoterapia. Rev Chil
Neuro-Psiquiat. 2018;56(4): 269-78. doi: 10.4067/
s0717-92272018000400269.
10. Tas C, Brown EC, Aydemir O, Brüne M, Lysaker
PH. Metacognition in psychosis: comparison of
schizophrenia with bipolar disorder. Psychiatry
Res. 2014 Nov 30;219(3):464-9. doi: 10.1016/j.
psychres.2014.06.040. Epub 2014 Jun 28. PMID:
25017619.
11. Lysaker PH, Irarrázaval L, Gagen EC, Armijo
I, Ballerini M, Mancini M, Stanghellini G.
Metacognition in schizophrenia disorders:
Comparisons with community controls and bipolar
disorder: Replication with a Spanish language
Chilean sample. Psychiatry Res. 2018 Sep;267:528-
534. doi: 10.1016/j.psychres.2018.06.049. Epub
2018 Jun 21. PMID: 29980133.
12. Inchausti F, Ortuño-Sierra J, García-Poveda NV,
Ballesteros-Prados A. Habilidades metacognitivas
en adultos con abuso de sustancias bajo tratamiento
en comunidad terapéutica. Adicciones. 2017;29(2):
74–82.
13. Popolo R, Smith E, Lysaker PH, Lestingi K,
Cavallo F, Melchiorre L, Santone C, Dimaggio G.
Metacognitive proles in schizophrenia and bipolar
disorder: Comparisons with healthy controls and
correlations with negative symptoms. Psychiatry
Res. 2017 Nov;257:45-50. doi: 10.1016/j.
psychres.2017.07.022. Epub 2017 Jul 11. PMID:
28719831.
14. Hamm JA, Renard SB, Fogley RL, Leonhardt BL,
Dimaggio G, Buck KD, Lysaker PH. Metacognition
and social cognition in schizophrenia: stability
and relationship to concurrent and prospective
symptom assessments. J Clin Psychol. 2012
Dec;68(12):1303-12. doi: 10.1002/jclp.21906.
Epub 2012 Aug 8. PMID: 22886716.
15. Macbeth A, Gumley A, Schwannauer M,
Carcione A, Fisher R, McLeod HJ, Dimaggio
G. Metacognition, symptoms and premorbid
functioning in a rst episode psychosis sample.
Compr Psychiatry. 2014 Feb;55(2):268-73. doi:
10.1016/j.comppsych.2013.08.027. Epub 2013 Oct
SERGIO VERGARA et.al.

10 www.journalofneuropsychiatry.cl
22. PMID: 24262130.
16. Vohs JL, Lysaker PH, Francis MM, Hamm J, Buck
KD, Olesek K, Outcalt J, Dimaggio G, Leonhardt B,
Lick E, Mehdiyoun N, Breier A. Metacognition,
social cognition, and symptoms in patients with
rst episode and prolonged psychoses. Schizophr
Res. 2014 Mar;153(1-3):54-9. doi: 10.1016/j.
schres.2014.01.012. Epub 2014 Feb 4. PMID:
24503175.
17. Trauelsen AM, Gumley A, Jansen JE, Pedersen
MB, Nielsen HL, Trier CH, Haahr UH, Simonsen
E. Metacognition in rst-episode psychosis and its
association with positive and negative symptom
proles. Psychiatry Res. 2016 Apr 30;238:14-23.
doi: 10.1016/j.psychres.2016.02.003. Epub 2016
Feb 15. PMID: 27086205.
18. Vergara-Ramirez S, Leon-Uribe A. Metacognición,
apego y sintomatología en esquizofrenia primer
episodio. Ter Psicol. 2020;38(2): 131-52. https://
doi.org/10.4067/S0718-48082020000200131
19. Lysaker PH, Carcione A, Dimaggio G, Johannesen
JK, Nicolò G, Procacci M, Semerari A.
Metacognition amidst narratives of self and illness
in schizophrenia: associations with neurocognition,
symptoms, insight and quality of life. Acta Psychiatr
Scand. 2005 Jul;112(1):64-71. doi: 10.1111/j.1600-
0447.2005.00514.x. PMID: 15952947.
20. Nicolò G, Dimaggio G, Popolo R, Carcione
A, Procacci M, Hamm J, Buck KD, Pompili
E, Buccione I, Lagrotteria B, Lysaker PH.
Associations of metacognition with symptoms,
insight, and neurocognition in clinically stable
outpatients with schizophrenia. J Nerv Ment
Dis. 2012 Jul;200(7):644-7. doi: 10.1097/
NMD.0b013e31825bfb10. PMID: 22759945.
21. Lysaker PH, Dimaggio G, Carcione A, Procacci
M, Buck KD, Davis LW, Nicolò G. Metacognition
and schizophrenia: the capacity for self-reectivity
as a predictor for prospective assessments of
work performance over six months. Schizophr
Res. 2010 Sep;122(1-3):124-30. doi: 10.1016/j.
schres.2009.04.024. Epub 2009 May 19. PMID:
19457645.
22. Lysaker PH, Shea AM, Buck KD, Dimaggio
G, Nicolò G, Procacci M, Salvatore G, Rand
KL. Metacognition as a mediator of the eects
of impairments in neurocognition on social
function in schizophrenia spectrum disorders.
Acta Psychiatr Scand. 2010 Nov;122(5):405-13.
doi: 10.1111/j.1600-0447.2010.01554.x. PMID:
20346074.
23. Lysaker PH, Erickson MA, Buck B, Buck KD,
Olesek K, Grant ML, Salvatore G, Popolo R,
Dimaggio G. Metacognition and social function
in schizophrenia: associations over a period of ve
months. Cogn Neuropsychiatry. 2011;16(3):241–
55. https://doi.org/10.1080/13546805.2010.530470
24. David A, Buchanan A, Reed A, Almeida O. The
Assessment of Insight in Psychosis. Br J Psychiatry.
1992;161:599-602. https://doi.org/10.1192/
bjp.161.5.599
25. Lysaker PH, Pattison ML, Leonhardt BL, Phelps
S, Vohs JL. Insight in schizophrenia spectrum
disorders: relationship with behavior, mood and
perceived quality of life, underlying causes and
emerging treatments. World Psychiatry. 2018
Feb;17(1):12-23. doi: 10.1002/wps.20508. PMID:
29352540; PMCID: PMC5775127.
26. Vohs JL, George S, Leonhardt BL, Lysaker
PH. An integrative model of the impairments
in insight in schizophrenia: emerging research
on causal factors and treatments. Expert Rev
Neurother. 2016 Oct;16(10):1193-204. doi:
10.1080/14737175.2016.1199275. Epub 2016 Jun
22. PMID: 27278672.
27. Lysaker PH, Erickson M, Ringer J, Buck
KD, Semerari A, Carcione A, Dimaggio G.
Metacognition in schizophrenia: the relationship
of mastery to coping, insight, self-esteem, social
anxiety, and various facets of neurocognition. Br
J Clin Psychol. 2011;50(4):412–424. https://doi.
org/10.1111/j.2044-8260.2010.02003.x
28. Vohs JL, Lysaker PH, Lick E, Francis MM,
Leonhardt BL, James A, Buck KD, Hamm JA, Minor
KS, Mehdiyoun N, Breier A. Metacognitive capacity
as a predictor of insight in rst-episode psychosis. J
Nerv Ment Dis. 2015 May;203(5):372-8. doi: 10.1097/
NMD.0000000000000291. PMID: 25900550.
29. Lysaker PH, Dimaggio G, Buck KD, Callaway
SS, Salvatore G, Carcione A, Nicolò G,
Stanghellini G. Poor insight in schizophrenia:
links between dierent forms of metacognition
with awareness of symptoms, treatment need,
and consequences of illness. Compr Psychiatry.
METACOGNITION, CLINICAL INSIGHT AND SYMPTOMATOLOGY IN CHILEAN OUTPATIENTS WITH SCHIZOPHRENIA

11
www.journalofneuropsychiatry.cl
2011 May-Jun;52(3):253-60. doi: 10.1016/j.
comppsych.2010.07.007. PMID: 21497218.
30. Hernández R. Metodología de la Investigación.
Mexico. D.F: McGraw-Hill; 2010.
31. Ministerio de Salud. Guía Clínica para el
tratamiento de personas desde primer episodio de
Esquizofrenia. Santiago: Minsal; 2009. Available
from: http://www.bibliotecaminsal.cl/wp/wp-
content/uploads/2016/04/Esquizofrenia.pdf.
32. Lysaker PH, Clements CA, Plascak-Hallberg
CD, Knipscheer SJ, Wright DE. Insight and
personal narratives of illness in schizophrenia.
Psychiatry. 2002 Fall;65(3):197-206. doi: 10.1521/
psyc.65.3.197.20174. PMID: 12405078.
33. Lysaker PH, Salyers MP. Anxiety symptoms in
schizophrenia spectrum disorders: associations with
social function, positive and negative symptoms,
hope and trauma history. Acta Psychiatr Scand.
2007 Oct;116(4):290-8. doi: 10.1111/j.1600-
0447.2007.01067.x. PMID: 17803759.
34. Peralta V, Cuesta MJ. Psychometric properties of the
positive and negative syndrome scale (PANSS) in
schizophrenia. Psychiatry Res. 1994 Jul;53(1):31-
40. doi: 10.1016/0165-1781(94)90093-0. PMID:
7991730.
35. Van der Gaag M, Homan T, Remijsen M, Hijman
R, de Haan L, van Meijel B, van Harten PN,
Valmaggia L, de Hert M, Cuijpers A, Wiersma D.
The ve-factor model of the Positive and Negative
Syndrome Scale II: a ten-fold cross-validation of
a revised model. Schizophr Res. 2006 Jul;85(1-
3):280-7. doi: 10.1016/j.schres.2006.03.021. Epub
2006 May 26. PMID: 16730429.
36. Bagaric D, Brecic P, Ostojic D, Jukic V, Goles A.
The relationship between depressive syndrome and
suicidal risk in patients with acute schizophrenia.
Croat Med J. 2013 Oct 28;54(5):436-43. doi:
10.3325/cmj.2013.54.436. PMID: 24170722;
PMCID: PMC3816561.
37. Ruiz A, Pousa E, Duño R, Crosas J, Cuppa S,
García C. Adaptación al español de la escala de
valoración de la no conciencia de trastorno mental
(SUMD) [Spanish adaptation of the Scale to Asses
Unawareness of Mental Disorder (SUMD)]. Actas
Esp Psiquiatr. 2008 Mar-Apr;36(2):111-119.
Spanish. PMID: 18365791
38. Garcia-Portilla M, Bascaran M, Saiz P, Parellada
M, Bousoño M, Bobes J. Banco de instrumentos
básicos para la práctica de la psiquiatría clínica.
Majadahonda, España: Cyesan; 2015.
39. Lysaker PH, Klion R. Recovery Meaning-Making,
and Severe Mental Illness. A Comprehensive Guide
to Metacognitive Reection and Insight Therapy.
New York: Routledge; 2018
40. Salvatore G, Dimaggio G, Ottavi P, Popolo
R. Terapia Metacognitiva Interpersonale della
Schizofrenia. La procedura formalizzata di
intervento. Milán: FrancoAngeli; 2017.
SERGIO VERGARA et.al.
Correspondence:
Sergio Vergara-Ramírez
Dirección postal: Edicio Plaza Poniente 1258, ocina 209, Talca.
Email: vergarasergio1@gmail.com,
Phone: 985493299