The cost of high cognitive insight: chain mediation of stigma and dysfunctional sleep beliefs and attitudes in chronotype among patients with schizophrenia

Objective This study examines the chain mediation effect through which cognitive insight impacts chronotype (eveningness chronotype tendency) via stigma and dysfunctional sleep beliefs and attitudes in patients with schizophrenia. Methods Community-followed patients were sampled cross-sectionally (N = 785). Assessment tools included the Beck Cognitive Insight Scale, Attitudes Towards Mental Health Scale, Dysfunctional Beliefs and Attitudes about Sleep Scale, and Reduced Morningness-Eveningness Questionnaire, with demographic and treatment variables controlled. PROCESS Model 6 and 5000 bootstrapped estimates were used to assess indirect effects (standardized β , 95% CI), alongside collinearity and robustness diagnostics. Results The correlation analysis indicated significant relationships among cognitive insight, chronotype, stigma, and dysfunctional sleep beliefs and attitudes (all p <.05). The chain mediation analysis revealed a significant total indirect effect ( β = −0.083, 95% CI [−0.116, −0.054]). Three indirect pathways were confirmed: Stigma mediated the relationship between cognitive insight and sleep chronotype ( β = −0.064, 95% CI [−0.093, −0.039]). Dysfunctional sleep beliefs and attitudes served as a mediator in the relationship between cognitive insight and sleep chronotype ( β = −0.012, 95% CI [−0.028, −0.001]). Both stigma and dysfunctional sleep beliefs and attitudes acted as a chain mediator between cognitive insight and sleep chronotype ( β = −0.007, 95% CI [−0.013, −0.002]). The direct effect was weakened and marginally significant (β = −0.070, 95% CI [−0.136, 0.000]). Conclusion Higher cognitive insight is potentially associated with increased stigma and enhanced dysfunctional sleep beliefs and attitudes, and these factors are collectively correlated with eveningness chronotype tendency. Given the genetic and correlational evidence that morningness chronotype is associated with better mental health and lower schizophrenia risk, future interventions could focus on enhancing cognitive insight while addressing stigma and reconstructing sleep cognition/rhythm-light management, which may lead to a tendency toward morningness chronotype.