Impaired insight as a predictor of psychotic transition in high-risk individuals with attenuated positive symptoms.

Background: Impaired insight is a significant barrier to treatment adherence in psychotic disorders and is linked to positive symptoms, which predict transition to psychosis in individuals at clinical high risk. This study hypothesizes that impaired insight independently predicts conversion outcomes in individuals with attenuated positive symptoms (APS).

Methods: Four hundred forty APS individuals were categorized into low impaired insight (IIL, 209) and high impaired insight (IIH, 231) groups, as well as low positive symptoms (PSL, 217) and high positive symptoms (PSH, 223) groups. Of these participants, 390 (88.64 %) completed a three-year follow-up. Survival analyses were performed to investigate the impact of impaired insight, independent of positive symptoms, on conversion outcomes.

Results: Impaired insight and severe positive symptoms both increase the conversion rate in APS individuals. Significant differences in conversion rates were observed between IIL and IIH (χ=10.141, p = 0.001) and between PSL and PSH (χ=6.667, p = 0.010). The IIL&PSL subgroup showed a lower conversion rate and a longer RMST compared to the IIH subgroups, including the IIH&PSL subgroup (p = 0.041; p = 0.047) and the IIH&PSH subgroup (p = 0.001; p = 0.005 T), with results adjusted using the Holm method. Regardless of the severity of positive symptoms, impaired insight increases the risk of psychotic transition (hazard ratio: 2.344, 95 %CI: 1.246-4.407, p = 0.008), and accelerates the conversion time (time ratio: 0.30, 95 % CI: 0.12-0.75, p = 0.010).

Conclusions: Impaired insight may serve as a stronger predictor of psychotic transition than positive symptoms in high-risk individuals, independently driving both the risk and speed of progression to psychosis.