Cognitive insight in schizophrenia reflects dissociable temporal and agency-related mechanisms

Background: Cognitive insight impairments in schizophrenia are often conceptualised as a unified deficit; however, emerging evidence suggests that distinct self-processing mechanisms may underlie its components. The sense of self, encompassing domains such as bodily boundaries, agency, body ownership, and interoceptive awareness, relies fundamentally on the experience of continuity over time. The subjective experience of a coherent and enduring self is closely tied to temporal processing, and disturbances in the sense of self in schizophrenia have been linked to alterations in the experience of time [1]. Multiple aspects of temporal processing are impaired in this disorder. Temporal perspective and sense of agency (SoA), therefore represent two fundamental domains of self-related processing; however, their differential contributions to self-reflectiveness and self-certainty aspects of insight remain insufficiently understood.

Aim: This study investigated whether temporal perspective and SoA are differentially associated with components of cognitive insight, and whether SoA mediates the relationship between temporal processing and self-certainty in schizophrenia.

Methods: A total of 117 patients with schizophrenia were recruited. Cognitive insight was assessed using the Beck Cognitive Insight Scale, yielding self-reflectiveness and self-certainty scores. Sense of agency was measured using the Sense of Agency Scale, comprising positive and negative agency dimensions. Temporal perspective was evaluated using the Zimbardo Time Perspective Inventory. Symptom severity, depressive symptoms, and cognitive performance were assessed using the Positive and Negative Syndrome Scale, the Calgary Depression Scale, and a verbal fluency test. Correlational analyses were conducted, and hierarchical regression models examined independent predictors of insight components while controlling for symptom severity, depression, and cognitive performance. Mediation analyses were performed using the PROCESS macro with bootstrapping (5000 samples).

Results: Temporal perspective significantly predicted self-reflectiveness (ΔR² = 0.158, p < 0.001), with past negative orientation emerging as a robust positive predictor (β = 0.336, p = 0.001). In contrast, SoA was not associated with self-reflectiveness. For self-certainty, future orientation initially contributed to the model (ΔR² = 0.049, p = 0.015); however, this effect diminished after inclusion of agency variables. Negative SoA independently predicted higher self-certainty (β = 0.210, p = 0.028), whereas positive agency showed no significant association. Mediation analyses did not support an indirect effect of SoA on the relationship between temporal perspective and self-certainty. The observed associations remained independent of clinical severity, depressive symptoms, and cognitive performance, supporting the specificity of temporal and agency-related mechanisms.

Conclusions: These findings reveal a dissociation in the mechanisms underlying cognitive insight in schizophrenia. Reflective aspects of insight were primarily linked to temporal processing, particularly negatively biased representations of the past, suggesting that increased self-reflectiveness may not necessarily reflect adaptive insight, but rather altered self-evaluative processing. In contrast, belief certainty was more consistently associated with disturbances in SoA than with temporal perspective measures. The absence of mediation indicates parallel rather than hierarchical processes. Together, these results support the view that cognitive insight is a multidimensional construct supported by dissociable neurocognitive systems.

References

1. Foerster, F.R., Joos, E., Martin, B., Coull, J.T., Giersch, A., 2024. Self and time in individuals with schizophrenia: A motor component? Schizophr. Res. 272, 12-19. https://doi.org/10.1016/j.schres.2024.08.008.