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. Author manuscript; available in PMC: 2026 Mar 1.
Published in final edited form as: J Psychiatr Res. 2025 Feb 5;183:296–301. doi: 10.1016/j.jpsychires.2025.02.004

Persons at risk for psychosis overestimate social functioning compared to persons with major depressive disorder and community controls

Joshua E Mervis 1, Franchesca S Kuhney 2, Madisen T Russell 3, Kyle Kinney 1, Thomas M Olino 1, Vijay A Mittal 4, Jason Schiffman 5, Lauren M Ellman 1,*
PMCID: PMC11959913  NIHMSID: NIHMS2060903  PMID: 40020649

Abstract

Poor insight is common in persons with psychosis, but treatment can improve insight. Individuals with psychosis who exhibit better insight have better social functioning, reduced negative symptoms, and paradoxically worse depression. There is limited research investigating insight among persons at clinical high risk for psychosis (CHR).

Understanding the relationship between insight, social functioning, negative symptoms, and depression might inform treatment. We focused on introspective bias (IB), the overestimation or underestimation of social functioning. Persons with CHR (N = 36), Major Depressive Disorder (MDD; N = 164), and community controls (N=60) were recruited from the Multisite Assessment of Psychosis-risk Study and completed clinical interviews and self-report instruments. The estimation type was operationalized by whether a person was above or below the standardized mean difference between self-reported and interviewer-rated social functioning.

We hypothesized that 1) persons at CHR would have less depressive symptom severity than those with MDD diagnoses, but more depressive symptom severity than control participants accounting for IB within diagnostic groups, 2) CHR and MDD participants would endorse higher levels of negative symptoms, viewed transdiagnostically (e.g., anhedonia, avolition), than controls but not each other, 3) overestimators would endorse higher levels of negative symptoms and depression than underestimators, 4) CHR participants would have the greatest proportions of overestimators, MDD would have the greatest proportion of underestimators, and control participants would have equal proportions of under- and overestimators.

Those at CHR had more overestimators, overestimators overall had worse depression and negative symptoms, and diagnostic group membership did not impact the effects of IB on symptoms. This study suggests that IB has clinically relevant correlates but is not a primary treatment target for persons at CHR.

1. Introduction

Poor insight into cognitive functioning and symptomatology is commonly observed in individuals with psychosis, yet when treatments specifically target insight, it can be improved (Lopez-Morinigo et al., 2020; Lysaker et al., 2018; Pijnenborg et al., 2013). Greater insight is associated with better social functioning, and reduced negative symptoms (Raucher-Chéné et al., 2021; Tranulis et al., 2008) but more severe depressive symptoms (Lysaker et al., 2018). There are a small number of studies investigating insight specifically among persons at clinical high risk (CHR) for psychosis.

Persons at CHR experience poorer social functioning, greater depressive symptoms, and greater negative symptoms than controls, as well as symptom outcomes that have also been associated with impaired insight without comparison to controls (Carrión et al., 2016; Corcoran et al., 2011; Lee et al., 2017; Lysaker et al., 2018; Schlosser et al., 2015). Nevertheless, no studies (to our knowledge) have examined how impaired insight might play a role in symptom outcomes in the CHR period. Multiple scoping reviews suggest that better insight could increase shared decision-making and engagement with treatment through collaborative goal setting, hypothesis testing, and confidence-building in persons with or at risk for psychosis (Harvey and Pinkham, 2015; Lysaker et al., 2020; Lysaker et al., 2018; Mervis et al., 2022; Moritz and Lysaker, 2018; Silberstein and Harvey, 2019).

There is a need for more approaches to measuring insight that consider self-evaluation alongside that of the “other,” such as a clinician or researcher (David, 2020) and escape the binary presence/absence view (Belvederi Murri & Amore, 2019). There are many self-report assessments (e.g., Beck et al., 2004), but their specific topics vary, and they are not always correlated with interviews or each other (Capdevielle et al., 2021). One conceptual challenge is determining if a person is more expert in themselves than the clinician, and each’s perspective might be favored in different contexts or domains (Pratt et al., 2023). Consistent with this need to consider insights from both perspectives, introspective bias (IB) (Pinkham et al., 2018; Silberstein and Harvey, 2019; Springfield and Pinkham, 2020) is a person’s assessment of specific abilities compared to a rater (Gilleen et al., 2011; Nisbett and Wilson, 1977) or objective anchors like cognitive task performance are also commonly (Pinkham et al., 2018; Silberstein and Harvey, 2019; Springfield and Pinkham, 2020). Depending on the measures used, the direction of any difference is described as overestimation, underestimation, or accurate estimation. When assuming a clinician, caregiver, or other rater is the anchor, lower IB (e.g., the person is considered overestimating) has been primarily associated with worse clinical outcomes (with some exceptions) than higher IB (e.g., underestimating) among those with psychosis or psychotic-like experiences (Mervis et al., 2022; Pinkham et al., 2018; Silberstein and Harvey, 2019; Springfield and Pinkham, 2020).

Currently, there are no studies of IB in CHR. Social cognitive IB (e.g., awareness of emotion recognition performance) is the most well-studied in persons with psychosis. While the association between IB and social functioning is inconsistent (Mervis et al., 2022), some individuals who can better appraise their social abilities might learn from errors and revise their approach, leading to better social functioning. Negative symptoms and IB in persons with psychosis are usually unrelated, but the paradoxical associations commonly observed with good insight, broadly construed, such as more severe depression, are frequently observed (Davis et al., 2020; Harvey et al., 2019, 2019, 2017; Jones et al., 2020; Lysaker et al., 2007; Lysaker et al., 2018; Mervis et al., 2022; Siu et al., 2015; Vohs et al., 2016). The present study focuses on the relationship between IB for social functioning with depressive and negative symptoms in those at CHR.

To operationalize IB, we used self-reported social functioning (Birchwood et al., 1994) alongside raters’ assessments (Carrión et al., 2019; Cornblatt et al., 2007) to describe the degree and direction of bias (Harvey et al., 2019). In addition to people at CHR and community controls, we used a psychiatric comparison group design with persons who had a lifetime history of Major Depressive Disorder (MDD), but were not at CHR (Millman et al., 2019). We included individuals with MDD due to similarities in self-assessment patterns observed in community controls with depressive symptoms. For example, young adults from a community sample with higher levels of depression tend to underestimate their social functioning, whereas those with lower depression levels tend to overestimate it (Whitton et al., 2008). Similarly, prior findings suggest that individuals with psychosis who demonstrate better insight often experience greater depression (Lysaker et al., 2018; Pijnenborg et al., 2013) and are more likely to exhibit an overestimating self-assessment bias (Mervis et al., 2022). We used IB as a continuous variable where higher scores indicated greater underestimation and lower scores overestimation, with scores closer to zero indicating less “biased” estimation. To complement a continuous approach, we used an analysis plan that also characterized persons as over or underestimators of their social functioning.

This study had four specific aims. The first aim was to compare outcomes for individuals with MDD, CHR, and controls, accounting for group means for IB’s potential impact on depressive symptoms. We hypothesized that persons at CHR would have less depressive symptom severity than those with MDD diagnoses, but more depressive symptom severity than control participants accounting for IB within diagnostic groups.

The second aim was to compare outcomes for individuals with MDD, CHR, and controls, accounting for group means for IB’s potential impact on negative symptoms. We hypothesized that CHR and MDD participants would endorse higher levels of negative symptoms, viewed transdiagnostically (e.g., anhedonia, avolition), than controls but not each other, accounting for IB within diagnostic groups.

The third aim was to compare clinical outcomes between under and overestimators. Based on past findings in studies of individuals with psychosis that suggest overestimators have the most impaired insight compared to underestimators (Pinkham et al., 2018; Silberstein and Harvey, 2019; Springfield and Pinkham, 2020), and insight impairments are related to worse negative symptoms and depression (Carrión et al., 2016; Corcoran et al., 2011; Lee et al., 2017; Lysaker et al., 2018; Schlosser et al., 2015), we hypothesized that overestimators, compared to underestimators, would have more negative symptoms and less depression. as observed in people with poor insight and psychosis (Lysaker et al., 2018).

The fourth aim was to compare the proportions of under and overestimators in individuals with MDD, CHR, and controls. We hypothesized that CHR participants would have the greatest proportions of overestimators, MDD would have the greatest proportion of underestimators, and control participants would have equal proportions of under- and overestimators.

2. Material and Methods

2.1. Sample

Participants included 260 adolescents and young adults (CHR = 36, MDD = 164, CC = 60) who were recruited as part of the ongoing Multisite Assessment of Psychosis-Risk (Ellman et al., 2020; MAP, 2017–2022 for the current analytic sample) study. The MAP study focuses on the early identification and evaluation of psychosis risk within communities (e.g., not medical settings). We used Craigslist posts, online sources (e.g., Facebook), and flyers in public locations to recruit participants in the greater Philadelphia, Chicago, Irvine, and Baltimore areas. All participants were proficient in English, ages 16–30, with normal or corrected vision. The study contained two phases: (1) an online survey that included a battery of questionnaires, which included two self-report scales of psychosis risk, and (2) in-person clinical assessments with participants who scored above predetermined cutoffs on the psychosis-risk scales, as well as randomly selected participants below both cutoffs (see Ellman et al., 2020 for more details).

2.2. Measures

The Structured Interview for Psychosis-Risk Syndromes (SIPS) (Miller et al., 2003) was used to determine CHR status.

The Structured Clinical Interview for DSM-5 (First et al., 2015) was used to assess the presence of current or historical DSM-5 diagnoses. This instrument is semi-structured and was used to identify and include persons who did not meet the criteria for any diagnosis (as CC), as well as those with a history of current or past Major Depressive Disorder of any duration. Only CHR participants without a history of MDD were used in this study to compare CHR participants to MDD participants.

The Center for Epidemiologic Studies Depression Scale–Short Form (CES-D-10) is a 10-item self-report assessment of depressive symptoms derived from the original 20-item scale (Radloff, 1991), with good psychometric properties across several samples (Andresen et al., 1994; Björgvinsson et al., 2013; Irwin et al., 1999; Zhang et al., 2012). The ten items are summed for a total score, and in the present study, this instrument showed good internal consistency in CHR (α = 0.84), MDD (α = 0.87), and controls (α = 0.88).

The Negative Symptoms Inventory for Psychosis Risk (NSI-PR) (Pelletier-Baldelli et al., 2017) is a semi-structured clinical interview that includes 13 items that provide comprehensive coverage of negative symptoms, including asociality, anhedonia, avolition, as well as expressive components of facial and vocal affect, gesturing, and alogia. Each of the 13 items is rated on a 0 (absent) to 6 (extremely severe) scale. A total score is obtained by summing all items (range 0 to 86). In the present study, the NSI-PR had good psychometric properties in CHR (α = .79), MDD (α = .83), and controls (α = .87).

The Global Functioning Scale: Social (GFS:S) (Cornblatt et al., 2007) is a gold-standard interview to evaluate social functioning in CHR individuals. The GFS was administered via interview and based on participant report of their own functioning. Postdoctoral Fellows, Graduate students, and postbaccalaureate research assistants administered semi-structured interviews after achieving competency determined by the raters with the most experience at each site. This interview produces scores ranging from 1 to 10 (10 indicating superior functioning), considering peer relationships, peer conflict, age-appropriate intimate relationships, and family involvement. The GFS:S scale produces three results for social functioning that encompass current, highest, and lowest levels of functioning in the past year before the assessment. The GFS:S scale scores for current social functioning were used in this study.

The Social Functioning Scale-Psychosis Risk (SFS-PR) (Kuhney et al., 2022) is a 24-item self-report measure designed to assess social functioning in persons at CHR for psychosis. Items rate engagement and performance in recreational activities, nightlife, and interpersonal behavior (α = 0.86). The SFS (Birchwood et al., 1990) is a measure designed for adults, which the SFS-PR modified to represent impairments of the target adolescent/young adult demographic more accurately. The SFS-PR omits SFS subscales assessing ability and performance of skills necessary for independent living and the occupation/employment subscale, which may not be an appropriate scale for most high school or college-age samples. The current study used a total score of the items, where a higher total SFS score indicated better social functioning.

Introspective Bias (IB) was operationalized using the GFS and SFS-PR. Both measures of social functioning involved specific questions about things like how many friends they have, whether they are involved in romantic relationships, and how they interact with their friends. We standardized interviewer-rated social functioning and self-rated social functioning with Z-transformations. We subtracted the Z-score for self-rated social functioning from that of interviewer-rated social functioning to create an introspective bias score. We then created categories by classifying any self-rated Z-score above the interview-rated Z-score of zero as underestimation or below zero as overestimation. For continuous analysis, we used the introspective bias score without categories.

2.3. Analysis

All analyses were completed using RStudio Version 1.2.1568 (RStudio Team, 2020). The participant demographic characteristics are shown in Table 1.

Table 1:

Sample Demographic Characteristics

CHR (N = 36) MDD (N = 164) Control (N = 60) Total (N = 260)
Gender
Male 6 (16.7%) 35 (21.3%) 19 (31.7%) 60 (23.1%)
Female 27 (75%) 121 (73.8%) 38 (63.3%) 186 (71.5%)
Another Gender 3 (8.3%) 8 (4.9%) 3 (5.0%) 14 (5.4%)
Age
(Years)
Mean (SD) 21.4 (3.74) 21.9 (3.42) 21.5 (3.73) 21.7 (3.53)
Median [Min, Max] 21.0 [16.0, 30.0] 21.0 [17.0, 30.0] 20.0 [16.0, 30.0] 21.0 [16.0, 30.0]
Ethnicity
Hispanic/Latino 2 (5.6%) 20 (12.2%) 7 (11.7%) 29 (11.2%)
Not Hispanic/Latino 34 (94.4%) 144 (87.8%) 53 (88.3%) 231 (88.8%)
Race
American Indian or Alaskan Native 1 (2.8%) 0 (0%) 1 (1.7%) 2 (0.8%)
Asian 7 (19.4%) 38 (23.3%) 23 (38.3%) 68 (26.2%)
Native Hawaiian or other Pacific Islander 0 (0%) 1 (0.6%) 1 (1.7%) 2 (0.8%)
Black or African American 4 (11.1%) 17 (10.4%) 9 (15%) 30 (11.5%)
White 22 (61.1%) 92 (56.1%) 24 (40.0%) 138 (53.1%)
More than one race 2 (5.6%) 16 (9.8%) 2 (3.3%) 20 (7.7%)
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Based on skewness and kurtosis values and visual inspection, measures of depression (skew = 0.19, kurtosis = −0.30), negative symptoms (skew = 0.65, kurtosis = −0.09), interviewer-rated social functioning (skew = −0.75, kurtosis = 0.77), self-rated social functioning (skew = −0.75, kurtosis = 0.77), and introspective bias (skew = −0.17, kurtosis = 0.02) appeared normal. Primary analyses focused on examining under- and overestimators (as described in methods); however, additional analyses controlled for IB as a continuous variable to determine whether the variance associated with IB overall (i.e., deviation from clinician rated social functioning) influenced clinical symptoms.

Group differences between overestimators and underestimators were assessed via t-tests and group proportions with chi-squared tests. Odds ratios of estimator type within groups were also calculated. Analysis of covariance (ANCOVA) addressed dimensional group differences in symptoms, adjusting for IB, to determine whether clinical symptoms persisted when accounting for variance associated with IB. For post hoc group contrasts for significant effects, we calculated each group’s estimated marginal means for depression and negative symptoms.

3. Results

Regarding diagnostic group differences, there were no differences in age between all groups (F(2, 257) = 0.42, p = 0.658). There were no group differences for race (X2 (10, N = 260) = 15.4, p = 0 .118), ethnicity (X2 (2, N = 260) = 1.33, p = 0 .513), or gender (X2 (4, N = 260) = 4.19, p = 0 .381).

This study categorized introspective bias as overestimators, those whose self-reported social functioning was higher than rater assessments, and underestimators, whose self-reported social functioning was lower than rater assessments. In terms of estimator types, underestimators (MDescriptive = 19.06, SEDescriptive = 0.312) reported less depression than overestimators on the CESD (MDescriptive = 20.39, SEDescriptive = 0.354), twelch(254.13), = −1.99, p = 0.047, ghedges = −0.25). In addition, there was a significant difference in negative symptoms such that underestimators (MDescriptive = 20.01, SEDescriptive = 0.634) reported fewer negative symptoms than overestimators (MDescriptive = 22.87, SEDescriptive = 0.683), twelch(256.59), = −2.17, p = 0.031, ghedges = −0.27).

Regarding proportions of over and underestimators within diagnostic groups, we used the binary operationalization of accuracy. We found that there were differences across all diagnostic groups, X2(2, N = 260) = 14.40, p < .001, VCramer = 0.219. Within each group, chi-squared tests found that there were more overestimators (75%) among persons at CHR, X2(1, N = 36) = 9.00, p = .003, even proportions (50%) in individuals with a history of MDD, X2(1, N = 164) = 0.00, p = 1.00, and more underestimators (65%) in controls, X2(1, N = 60) = 5.40, p < .020. Accordingly, in those at CHR the odds of being an overestimator were three times higher than being an underestimators (OR = 3.0), equal in controls (OR = 1), and lowest among those with a history of MDD (OR = 0.54).

Next, we used a dimensional approach to IB, using it as a control variable, rather than a binary categorical approach. Regarding depression, there were no significant interactions between IB and group, F(5, 254) = 4.82, p < .001, nor IB and group with negative symptoms, F(5, 254) = 4.79, p < .001. We used ANCOVAs with IB as a covariate to examine how the difference between self-reported and interviewer-rated social functioning related to depression and negative symptoms. There were significant main effects for group membership with both depression, F(2, 256) = 8.20, p < .001, and negative symptoms, F(2, 256) = 7.21, p < .001 when controlling for IB. As shown in Figure 1, individuals at CHR (MDescriptive = 21.5, SEDescriptive = 0.274; MEstimated = 21.3, SEEstimated = 0.884) and those with MDD (MDescriptive = 20.3, SEDescriptive = 0.340; MEstimated = 20.3, SEEstimated = 0.408) reported greater depression than controls (MDescriptive = 17.2, SEDescriptive = 0.308; MEstimated = 17.3, SEEstimated= 0.686) but did not significantly differ from each other.

Figure 1:

Figure 1:

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Predicting Depression from Group, Controlling for Introspective Bias for Social Functioning

Post-hoc group contrasts were conducted using Estimated Marginal Means and corrected for False Discovery Rate. IB is used as a control variable.

Regarding negative symptoms, as shown in Figure 2, individuals at CHR (MDescriptive = 27.1, SEDescriptive = 0.644; MEstimated = 26.5, SEEstimated = 1.74) had the most, followed by MDD (MDescriptive = 21.6, SEDescriptive = 0.625; MEstimated = 21.6, SEEstimated = 0. 805), and then controls (MDescriptive = 17.5, SEDescriptive = 0.689; MEstimated = 18.0, SEEstimated = 1.35).

Figure 2:

Figure 2:

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Predicting Negative Symptoms from Group, Controlling for Introspective Bias for Social Functioning

Post-hoc group contrasts were conducted using Estimated Marginal Means and corrected for False Discovery Rate. IB is used as a control variable.

6. Discussion

The present study is the first (to our knowledge) to find that those at CHR exhibit poorer insight into social functioning, with CHR participants more likely to overestimate their levels of social functioning compared to MDD, both of which were more likely to do so than CC. Taken together with our findings and past research, relative differences in insight into social aspects of a person’s life could differentiate those at CHR, at the group level, from other persons seeking help (Lysaker et al., 2018; Mervis et al., 2022). Lower social functioning has been repeatedly linked to conversion to psychosis and poorer prognosis among those at CHR; however, our results add to these findings by suggesting that insight into social functioning also may be an important characteristic of the CHR period (Addington et al., 2017; Carrión et al., 2021, 2013; Kuhney et al., 2021; Tarbox et al., 2013). Within each group, there were more overestimators among persons at CHR, equal proportions of overestimators and underestimators among individuals with a history of MDD, and more underestimators among community controls. One possible explanation for MDD participants having greater overestimation than CC, is that despite depressive symptoms’ association with a negative cognitive bias (Moritz and Roberts, 2020), stigma creates a demand characteristic to appear well and avoid negative stereotypes at the group level.

Even though community controls were not informed of their status, they might have been sensitive to social demand characteristics and underreported their social functioning to not appear overconfident (Corneille and Lush, 2023; Nichols and Maner, 2008; Orne, 1962). Similar demand characteristics in psychosis may explain why better insight is associated with underestimation when rated by caregivers or clinicians (Nishida et al., 2018). Additionally, our results could be skewed because our MDD group consisted of persons who were currently depressed as well as in remission. Since the aims of this study were centered on CHR participants, we did not test the difference between those in current MDD episodes and those in remission for depression. The inclusion of both current and remitted depression presents both a limitation and a future direction, because poorer social cognition is higher during symptomatic phases of current MDD than during MDD in remission, even though there is decreased social cognitive functioning during both MDD phases compared to controls (Bouhuys et al., 1999; Ladegaard et al., 2016).

The present study also compared outcomes for individuals with MDD, CHR, and controls on depression and negative symptoms, covarying for any influence of IB to examine differences within each group. Individuals at CHR and MDD reported significantly more depression than CC when controlling for IB, but did not significantly differ from each other in levels of depression when controlling for IB. When controlling for IB’s possible influence, individuals at CHR had the most negative symptoms, followed by MDD, and then control participants. As hypothesized, CHR and MDD showed higher depression than CC, though contrary to expectations, CHR and MDD depression levels did not significantly differ; for negative symptoms, CHR showed the highest levels, followed by MDD, then CC. Finally, findings also suggested that irrespective of group status, underestimators had less depression and negative symptoms than overestimators. This finding supports our hypothesis that overestimators would have more significant negative symptoms, but not that they would have greater depression, bPrevious insight studies differ from these findings because in persons with a history of psychosis, increased insight is consistently associated with greater depression, and suicidal ideation, especially over time in and outside of episodes (Belvederi Murri et al., 2015; Lysaker et al., 2018; Mervis et al., 2022). Additionally, the directionality of bias matters in that overestimators tend to show outcomes more similar to those with poor insight than do persons who underestimate themselves (Harvey and Pinkham, 2015; Mervis et al., 2022), which may explain why we have differing results in our MDD group’s estimations of social functioning than might be implied by other studies (Colis et al., 2006), but also more detailed and valuable results for clinicians.

Overestimators, particularly those in the CHR group, showed more severe symptom presentations than underestimators. However, people with psychosis who are categorized as having overestimating biases do not show increased depression, as is often true for those self-reporting good insight (Lysaker et al., 2018; Mervis et al., 2022). Since most studies are in people who already experience frank psychosis, the relationship between better insight and greater depression might emerge with greater overall psychotic symptoms that have not emerged yet during the CHR period.

While the reasons for overestimation of social functioning are unclear, it is important for clinicians’ to be aware of this IB given that social functioning is a primary risk factor for conversion to psychosis among those at CHR (Cannon et al., 2008). Nevertheless, IB does not appear to influence symptom ratings of depression and negative symptoms, suggesting that the overestimation in CHR participants may not influences assessment of other key symptom domains. However, understanding potential biases associated with self-assessment of social functioning among those at CHR could be paramount to clinicians, given the ubiquity of social functioning challenges during this period, even among those who do not transition to psychosis (Addington et al., 2019), and difficulty treating them (Devoe et al., 2019).

The methodological strengths of the current study include the fact that it is a large, multisite study that affords recruitment of at-risk individuals. A limitation of this study is that neither external rater nor reporter is infallibly “correct,” and our findings might not generalize beyond interviewer-based assessments of insight. Although this limitation influences the interpretation of the findings, it is still important for clinicians to be aware of how certain patients’ self-assessments may compare to their assessments of those patients, as this information could influence rapport, treatment planning, and assessment interpretations. One limitation is that we did not include an objective measure of participant’s social functioning to compare with participant self-report (e.g., a task and a true “accurate”), which is a future direction for studies investigating self-assessment in CHR. For example, asking an individual how many trials were correct out of the total presented (Pinkham et al., 2018; Silberstein and Harvey, 2019; Springfield and Pinkham, 2020), where an objective measure is helpful given mixed relationships with insight into cognition in psychosis and cognitive functioning is a common clinical target (Lysaker et al., 2018; Mervis et al., 2022).

7. Conclusions

The present study found that persons at CHR overestimated, rather than underestimated, their social functioning more than MDD and controls. Overestimation was linked to negative symptoms, but it was not related to depression, suggesting a connection with how CHR individuals view their social world and negative symptoms. Clinicians and researchers should consider potential differences in how persons at CHR and assessors rate social functioning given the importance of social functioning in predicting outcomes.

Footnotes

The authors have no conflicts of interest to declare.

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