Measuring cognitive insight in schizophrenia and bipolar disorder: a comparative study

The Italian Validation of the Beck Cognitive Insight Scale: Underlying Factor Structure in Psychotic Patients and the General Population

Cognitive insight refers to the ability to question one's judgments and cognitive biases and is underpinned by specific metacognitive processes. The Beck Cognitive Insight Scale was developed to assess cognitive insight and includes two subscales, Self-Reflectiveness and Self-Certainty (SC). The present study aimed to investigate the underlying factor structure of the Italian version of the BCIS in patients with schizophrenia (SZ) and in the general population (GP) for the first time. A cross-sectional design was adopted and a GP sample of 624 subjects and an SZ sample of 130 patients were enrolled. In the SZ group, a two-factor solution was supported. The internal reliability of each factor was satisfactory. Two items were eliminated and one item moved from the SC to the SR subscale. In the GP group, a two-factor solution was highlighted. The internal reliability of each factor was satisfactory. However, four items of the SR subscale were deleted. The Italian-validated version of the BCIS shows different structures for the SZ and the GP and is characterized by different features concerning previous studies. This evidence suggests new interpretations of metacognitive processes in the two populations and implies specific therapeutic approaches.

Insight in patients with bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

Background

There are limited number of studies evaluating insight among patients with bipolar disorder (BD).

Aim

This study aimed to examine insight and its correlates in BD using the data from the multicenter BD course and outcome study from India (BiD-CoIN). The additional aim was to evaluate the insight in patients with BD using different scales and understand the correlates of insight.

Materials and Methods

773 BD patients presently in clinical remission were evaluated on the Insight Scale for Affective Disorders (ISAD), insight items of the Hamilton Depression Rating Scale (HDRS), and the Young Mania Rating Scale (YMRS).

Results

The assessment scales influenced the prevalence of poor insight. Poorer insight irrespective of the assessment scale was consistently associated with higher residual depressive and manic symptoms, and a higher level of cognitive impairment and disability. Poor insight as assessed by ISAD was associated with a higher number of episodes in the lifetime, shorter duration of current remission, a higher number of depressive episodes, a higher amount of time spent in depressive episodes, higher depressive affective morbidity, a higher number of manic episodes, and higher residual depressive and manic symptoms.

Conclusion

Poor insight in BD is consistently associated with higher residual depressive and manic symptoms and a higher level of cognitive impairment and disability. However, in terms of course variables, the correlates vary depending on the assessment method.

Metacognition and insight dynamics exploration in borderline personality disorder: Exploring the underlying dynamics

Metacognition and Insight are related to hard-to-treat disorders and among them is Borderline Personality Disorder (BPD). We recruited 190 BPD patients and measured Insight, Metacognition, Impulsivity, and BPD traits. Results showed BPD's significant links with Insight and Metacognition. Metacognition significantly correlated with two Impulsivity dimensions, whereas Insight significantly correlated with most of them. Regressions analysis revealed a significant relationship between Insight and Metacognition on Impulsivity and Borderline traits. Mediation analysis proved the indirect effect of Metacognition/Insight on Borderline traits through Impulsivity at a significative level. Both seem relevant for research and therapeutic application in BPD following different dynamics even if the limitation of our study stands in its gender ratio and possible comorbidity issues. Urgency appears as a critical factor to assess, notably with Positive emotion-based impulsivity.

Clinical insight in first episode psychosis: the role of metacognition

BACKGROUND

Poor clinical insight has been commonly reported in those with First Episode Psychosis (FEP) and thought to be influenced by a range of factors, including neurocognition and symptoms. Clinical insight may be compromised as a result of alterations in higher-level reflective processes, such as metacognitive ability and cognitive insight.

AIMS

To explore whether metacognitive ability and cognitive insight are associated with clinical insight while controlling for IQ, depression, and symptoms in FEP.

METHODS

60 individuals with FEP completed measures for clinical insight, metacognitive ability, cognitive insight, positive and negative symptoms, depression, and IQ.

RESULTS

Higher levels of metacognitive ability were associated with better clinical insight, even when controlling for IQ, depression, positive and negative symptoms, and medication. Integration subscale of metacognitive ability was most strongly associated with clinical insight. Cognitive insight was associated with clinical insight when controlling for covariates. However, when including metacognitive ability and cognitive insight in the predictive model, only metacognitive ability was significantly related to clinical insight.

DISCUSSION

Metacognitive ability, specifically the ability to describe one's evolving mental state to provide a coherent narrative, was significantly related to clinical insight, independent of covariates, and may be a potentially important target for intervention in FEP.

Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

BACKGROUND

Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.

AIM

To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.

RESULTS

This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.

CONCLUSION

Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.

A comparative study evaluating insight in different phase of illness among patients with bipolar disorder by using multiple scales

AIM

This cross-sectional study aimed to evaluate insight and its correlates among patients with bipolar disorder (BD).

METHODOLOGY

180 patients with BD were evaluated on Scale to Assess Unawareness of Mental Disorders (SUMD), Insight scale for affective disorders (ISAD), Mood Disorders Insight Scale (MDIS), and Beck Cognitive Insight Scale (BCIS).

RESULTS

About half of the patients were in clinical remission (N = 94; 52.2%), one-fifth (N = 37; 20.55%) were in the phase of mania and one-fourth (N = 49; 27.2%) were in a depression. There was no significant difference in the level of insight between those in clinical remission and those in depression except for one of the domains of BCIS. Patients with mania had poorer insight compared to those in remission and depression. In terms of association of insight as assessed by different scales, in the whole sample and all the three subgroups, SUMD current and past scores had a significant positive correlation with the ISAD total score. In the whole sample, among patients currently in remission and those currently in depression, ISAD total score had significant negative correlation with MDIS total score. Poorer insight as assessed on SUMD (current and past), ISAD and MDIS was associated with poorer medication adherence.

CONCLUSION

The present study demonstrates that patients with mania have poor insight when compared to the patients in clinical remission and depression. The present study also demonstrates that the assessment of clinical insight is not affected much by the type of scale used.

Cognitive insight, medication adherence and methamphetamine cessation in people enrolled in a pharmacotherapy trial for methamphetamine use

BACKGROUND

The current study examined correlates of cognitive insight in people enrolled in a methamphetamine pharmacotherapy trial; whether cognitive insight at the start of the trial predicted medication adherence and reductions in methamphetamine use during the trial; and, whether insight would remain stable over the trial or improve with reductions in methamphetamine use.

METHODS

A subset of people enrolled in a 12-week randomised placebo-controlled pharmacotherapy trial for methamphetamine dependence completed the Beck Cognitive Insight Scale, comprising subscales for Self-Reflection and Self-Certainty, at baseline (n = 152) and at week 12 (n = 79). Medication adherence was expressed as the percentage of non-missed doses measured using eCAP™ technology. Methamphetamine use days were assessed using the Timeline Followback.

RESULTS

At baseline, greater Self-Reflection was correlated with more severe methamphetamine withdrawal, and hostility, whereas Self-Certainty was correlated with less education and longer duration of methamphetamine use. No relationship was found between BCIS subscales at baseline and medication adherence (Self-Reflection b[SE] = -0.73 [0.43] p = .09; Self-Certainty b[SE] = -0.31 [0.48] p = .52,). Neither BCIS subscale was predictive of reduced methamphetamine use at 12 weeks (Self-Reflection b[SE] = 0.001 [0.01] p = .95 Self-Certainty b[SE] = -0.003 [0.01], p = .74). Self-Reflection decreased over the trial (t = 3.42, p = .001) but this was unrelated to change in methamphetamine use (Self-Reflection, b[SE] = -1.68 [1.16] p = .15) Change in methamphetamine use was found to be a significant predictor of Self-Certainty at 12 weeks (b [SE] = -2.71 [1.16] p = .02).

CONCLUSIONS

We found no evidence that cognitive insight predicted medication adherence or methamphetamine reduction in people engaged in this trial. Ongoing or increased methamphetamine use predicted increased Self-Certainty at 12 weeks.

Insight in substance use disorder: A systematic review of the literature

Insight refers to a person's understanding of themselves and the world around them. Recent literature has explored people's insight into their substance use disorder (SUD) and how this is linked to treatment adherence, abstinence rates, and comorbid mental health symptoms. The aim of this systematic review was to synthesise and critically examine the existing literature on insight in SUD. Five academic databases (Medline, PsychINFO, SCOPUS, CINAHL, Web of Science) were searched for key terms related to insight and substance use. Included studies were on humans aged 18 years or over with SUD that examined the relationship between substance use and insight using a quantifiable measure of insight. Of 10,067 identified papers, 20 met the inclusion criteria, employing 13 different measures of insight. The most commonly used measure was the Hanil Alcohol Insight Scale (HAIS) which was the only measure designed for a substance use population and was specific to alcohol use. Based on a pooled sample from five studies (n = 585), 57% of participants had poor insight, 36% had fair insight, and 7% had good insight on the HAIS. Better insight was generally related to negative consequences from substance use, better treatment adherence and maintaining abstinence. Insight appears to be an important factor to consider within SUD. Exploring the most appropriate way to measure insight and assess its role in SUD has implications for intervention design, and engaging and maintaining people with SUD in treatment.

Influences on functional outcome and subjective recovery in individuals with and without First Episode Psychosis: A metacognitive model

Models of functional and subjective recovery in psychosis suggest that the path between neurocognition and functioning is mediated by cognitive processes, which may include metacognition, considered 'thinking about thinking'. Metacognition has several components: metacognitive ability, experience and efficiency, connected by metacognitive monitoring and metacognitive control processes; akin to executive control processes. This study aimed to explore whether metacognitive components are fragmented, how individuals with FEP perform on the metacognitive scores compared to healthy control participants, and whether metacognitive components are associated with functioning and, for FEP only, subjective recovery. 62 individuals with FEP and 73 matched healthy controls completed measures of metacognition, functional capacity, functional outcome, and subjective recovery; covariates: IQ and symptoms. Factor analysis, to assess loading of metacognitive items onto separate factors, demonstrated that metacognitive ability, experience, efficiency and monitoring were separate components, with limited association. Metacognitive ability and metacognitive control process were reduced in FEP sample, but metacognitive experience and monitoring process were higher in FEP. Metacognitive ability predicted functional capacity, functional outcome and subjective recovery. Metacognitive experience predicted functional capacity. This is the first study to assess key metacognitive components within a large model and consider the distinct contributions to both functional and subjective recovery.

Cultural differences and neural correlates of cognitive insight in schizophrenia

Cognitive insight refers to a person's ability to examine their psychotic experiences and the inferences they draw from these experiences. Several studies suggest that cultural factors influence cognitive insight and the processes involved therein; a few studies have suggested differences between Western and Asian societies. However, there are no studies on cognitive insight and its neural correlates in non-Western populations. Hence, we examined factor structure of Beck's cognitive insight scale (BCIS) in a large sample of patients with schizophrenia (SCZ) and healthy volunteers (HV) from India and assessed the relationship between cortical thickness and cognitive insight. We recruited 240 participants (SCZ-140; HV-100). Of these, 58 participants (SCZ-33; HV-25) underwent magnetic resonance imaging. We found a three-factor structure for BCIS which is different from the original two factor structure; self-reflection (SR) of original two-factor structure was sub-divided into- SR1, introspection and SR2, openness to feedback. There was a significant difference between HV and SCZ in the new factors, SR1 and SR2 but not in the original SR factor. Difference was also seen on MRI analysis; while there was a significant positive correlation between original SR factor and thickness of right posterior cingulate cortex, SR2 was positively correlated with thickness of left ventrolateral prefrontal cortex. The difference in factor structure in Indian participants and their distinct neural correlates point to cultural differences in cognitive insight. While in western societies the constructs of introspection and openness to feedback might integrate, they might be separate entities in Asian population.

The longitudinal course of cognitive insight and mood in bipolar disorder

Cognitive insight or the ability to be self-reflective and to retain from being over-confident in own beliefs is an upcoming topic in research regarding psychiatric disorders. In bipolar disorder investigations are scarce and an important lacuna is the unexamined longitudinal relationship between cognitive insight and mood. Therefore, in this study the level of cognitive insight, mania and depression were assessed in a total of 56 patients with bipolar disorder at baseline, four months and eight months follow-up. In addition, the cognitive insight of 35 healthy controls was assessed at baseline and at four months follow-up. The current research shows that self-reflectiveness and self-certainty remained stable over time in bipolar disorder. The improvement of mood did not affect the course of cognitive insight. However, at baseline higher levels of depression were correlated with more self-reflectiveness. In addition, self-reflectiveness was higher for bipolar disorder patients in comparison with the healthy controls. Our results could imply that higher levels of self-reflectiveness are a specific characteristic in bipolar disorder that is independent from an improvement in mood.

The influence of coercive measures on patients' stances towards psychiatric institutions

OBJECTIVE

To examine the impact of coercive interventions (CI) on patients' evaluations of psychiatric hospitals as adversaries versus allies.

METHODS

Self-constructed interviews were conducted relating to quantitative and subjective aspects of coercion and the attitude towards psychiatry of 79 patients with psychotic and bipolar disorders. The Coercion Experience Scale (CES) and the Admission Experience Survey (AES) were used to establish the subjective impact of CI. Instruments measuring psychopathological symptoms and the Global Assessment of Functioning (GAF) were applied alongside the Schedule for the Assessment of Illness (SAI) and the Beck Cognitive Insight Scale (BCIS). Using a logistic regression approach, considered influencing factors such as number, type and patients' subjective experiences of CI, cognitive and clinical insight, psychopathological symptoms and patients' global perceptions of their hospitalisation were analysed for their predictive value of patients' attitudes towards psychiatry.

RESULTS

Binary logistic regression revealed that the subjective experience of CI and the perception of fairness and effectiveness during the treatment process predict patients' attitudes towards psychiatry to a greater extent than symptom-related measures or the quantity of CI. Patients presenting a higher degree of self-reflectiveness perceive psychiatric institutions more likely as allies.

CONCLUSIONS

The manner in which coercion is subjectively experienced has direct influence on patients' perceptions of psychiatry.

The relationship between cognitive insight and cognitive performance among individuals with at-risk mental state for developing psychosis

Impairments in cognitive insight-the capacity to appraise and modify one's own distorted beliefs-are believed to be associated with the formation of psychosis. Nevertheless, the association between cognitive insight and cognitive function among people with at-risk mental state (ARMS) for developing psychotic illness has not been made clear. In this study, we used the Beck Cognitive Insight Scale (BCIS) to assess cognitive insight and the Brief Assessment of Cognition in Schizophrenia (BACS) and the Wisconsin Card Sorting Test (WCST) to assess cognitive functions. Fifty subjects with ARMS and 29 healthy volunteers were recruited as participants. The scores for the two groups on the BCIS, BACS, and WCST were compared and Spearman's rank correlations between the domains of the BCIS and cognitive performance were examined in each group. No significant differences were found in BCIS scores between these groups, whereas all of the cognitive function scores were poorer in the participants with ARMS. In the ARMS group, higher self-certainty on the BCIS was significantly correlated with lower performance in the mean number of categories achieved (ρ=-0.31, P=0.03) and perseverative errors of the Nelson type (ρ=0.29, P=0.04) on the WCST. This indicates that excessively high self-certainty might be linked with weaknesses in cognitive flexibility or set-shifting ability in people with ARMS.

Cognitive insight and objective quality of life in people with schizophrenia and auditory hallucinations

Poor cognitive insight in schizophrenia has been linked to delusions, hallucinations, and negative symptoms as well as to depressive/anxiety symptoms. Its impact on quality of life has been less studied, especially in schizophrenia subjects with ongoing auditory hallucinations. The Beck Cognitive Insight Scale (BCIS) and the Quality of Life Scale (QLS) were administered to subjects who met DSM IV criteria for schizophrenia after due translation and validation. All subjects reported ongoing auditory hallucinations at recruitment. Mean composite cognitive insight scores from participants (N = 60) (2.97 ± 2.649) were in the lower range as compared to published literature. Cognitive insight scores as well as self-reflectiveness subscale scores, but not self-certainty scores, correlated significantly with the QLS scores p < 0.001. Results suggest that better cognitive insight, especially self-reflectiveness, may be linked to better quality of life. Self-reflectiveness could be a useful construct to address in psychotherapy to improve rehabilitation.

Relationship of depression with cognitive insight and socio-occupational outcome in patients with schizophrenia

AIM

To evaluate the prevalence of depression using different measures in patients with schizophrenia and to study the relationship of depression in schizophrenia with cognitive insight and clinical insight, disability and socio-occupational functioning.

METHODS

A total of 136 patients with schizophrenia were evaluated for depression, cognitive insight and socio-occupational functioning.

RESULTS

Of the 136 patients included in the study, one-fourth ( N = 34; 25%) were found to have depression as per the Mini International Neuropsychiatric Interview (MINI). The prevalence of depression as assessed by Calgary Depression Scale for Schizophrenia (CDSS), Hamilton depression rating scale (HDRS) and Depressive Subscale of Positive and Negative Syndrome Scale (PANSS-D) was 23.5%, 19.9% and 91.9%, respectively. Among the different scales, CDSS has highest concordance with clinician's diagnosis. Sensitivity, specificity, positive predictive value and negative predictive value for CDSS was also higher than that noted for HDRS and PANSS-D. When those with and without depression as per clinician's diagnosis were compared, those with depression were found to have significantly higher scores on Positive and Negative Syndrome Scale (PANSS) positive and general psychopathology subscales, PANSS total score, participation restriction as assessed by P-scale and had lower level of functioning as assessed by Global Assessment of Functioning (GAF). No significant difference was noted on negative symptom subscale of PANSS, clinical insight as assessed on G-12 item of PANSS, disability as assessed by Indian Disability Evaluation and Assessment Scale (IDEAS) and socio-occupational functioning as assessed by Social and Occupational Functioning Assessment Scale (SOFS). In terms of cognitive insight, those with depression had significantly higher score for both the subscales, that is, self-reflective and self-certainty subscales as well as the mean composite index score.

CONCLUSION

Our results suggest that one-fourth of patients with schizophrenia have depression, compared to HDRS and PANSS-D, CDSS has highest concordance with clinician's diagnosis of depression and presence of depression is related to cognitive insight.

Can cognitive insight predict symptom remission in a first episode psychosis cohort?

BACKGROUND

The outcome of first episode psychosis (FEP) is highly variable and difficult to predict. Cognitive insight measured at illness onset has previously been found to predict psychopathology 12-months later. The aims of this study were to examine whether the prospective relationship between cognitive insight and symptom severity is evident at four-years following FEP and to examine some psychological correlates of cognitive insight.

METHODS

FEP participants (n = 90) completed the Beck Cognitive Insight Scale (BCIS) at illness onset, and associations between BCIS scores with symptom severity outcomes (4-years after FEP) were assessed. The BCIS scales (self-reflectiveness and self-certainty) were examined as a composite score, and individually compared to other cognitive measures (IQ and jumping to conclusions (JTC) bias).

RESULTS

Regression analyses revealed that the cognitive insight composite did not predict 4-year symptom remission in this study while the self-reflection subscale of the BCIS predicted severity of symptoms at 4-years. Self-certainty items of the BCIS were not associated with symptom severity. Significant correlations between the JTC bias, self-certainty and IQ were found, but self-reflection did not correlate with these other cognitive measures.

CONCLUSIONS

Self-reflective capacity is a more relevant and independent cognitive construct than self-certainty for predicting prospective symptom severity in psychosis. Improving self-reflection may be a useful target for early intervention research.

How self-reflection and self-certainty are related to neurocognitive functioning: an examination of cognitive insight in bipolar disorder

INTRODUCTION

The pattern of associations between clinical insight, cognitive insight, and neurocognitive functioning was assessed in bipolar disorder patients.

METHODS

Data from 42 bipolar disorder patients were examined. Cognitive insight was measured using the Beck Cognitive Insight Scale (BCIS). The BCIS is a 15-item self-report instrument consisting of two subscales, self-reflectiveness and self-certainty. Clinical insight was measured by the use of the item G12 of the Positive and Negative Syndrome Scale. Neurocognitive functioning was assessed using the International Society for Bipolar Disorders-Battery for Assessment of Neurocognition.

RESULTS

Correlation analyses revealed significant positive associations between self-reflectiveness and speed of processing, attention, working memory, visual learning, and reasoning and problem solving. The subscale self-certainty was negatively correlated to working memory, however, this correlation disappeared when we controlled for confounding variables. No correlations between clinical insight and neurocognition were found. In addition, there was no association between cognitive insight and clinical insight.

CONCLUSION

Better neurocognitive functioning was more related to higher levels of self-reflectiveness than to diminished self-certainty.

Subjective versus objective cognition: Evidence for poor metacognitive monitoring in schizophrenia

BACKGROUND

Patients with schizophrenia display a number of cognitive biases, particularly a tendency to jump to conclusions, which are implicated in the pathogenesis of the disorder. The present study contrasted the degree of objective reasoning biases with subjective cognitive insight. We expected that patients with schizophrenia would display greater objective than subjective impairment suggestive of poor metacognitive awareness.

METHODS

Patients with schizophrenia (n=140) and healthy controls (n=60) underwent a test battery encompassing a cognitive bias paradigm (beads task) as well as neurocognitive tests (story recall, trail-making tests). In addition, they were administered the Beck Cognitive Insight Scale (BCIS), a subjective measure of (meta)cognitive awareness.

RESULTS

Corroborating prior research on decision making, draws to decisions were significantly delayed in controls relative to patients, whereas the core jumping to conclusion parameter (i.e., decision after one or two pieces of information) bordered significance. Patients with schizophrenia showed a lowered decision threshold and impaired neurocognition relative to nonclinical controls. Despite poor cognitive performance and prior psychotic episodes, patients with schizophrenia showed similar scores on the self-confidence subscale of the BCIS and reported even higher levels of self-reflectiveness relative to healthy controls.

DISCUSSION

The study demonstrates that patients with schizophrenia show severe cognitive biases and neurocognitive deficits but display only partial awareness herein. Raising cognitive insight in a non-insulting fashion and elevating patients' corrigibility as well as willingness to consider others' feedback and advice may help to narrow this gap and improve psychiatric symptomatology.

Unrealistic self-overconfidence in schizophrenia is associated with left presubiculum atrophy and impaired episodic memory

The study aimed at investigating the role of the hippocampal subfields in cognitive insight and the clinical and neuropsychological underpinnings of the related two sub-dimensions, Self-Reflectiveness (SR), i.e., openness to external feedback, and Self-Certainty (SC), i.e., unrealistic overconfidence in one's opinions. In order to do this, 45 patients with a diagnosis of schizophrenia and 45 age- and gender-matched healthy control subjects (HC) were administered the Beck Cognitive Insight Scale (BCIS), along with neuropsychological, clinical and psychopathological assessment, and underwent an MRI investigation. Hippocampal segmentation was carried out. Regression analyses were performed for BCIS indexes, volumetric parameters of hippocampal subfields and clinical and neuropsychological variables. Results highlighted that in the schizophrenia group, higher levels of SC were related to reduced volume of the left presubiculum, and worse episodic memory. No significant relationship emerged for the SR index. There was no significant relationship between any of the BCIS indexes and volumetric data of the hippocampal subfields in the HC group. Our data support the hypothesis that unrealistic self-overconfidence in schizophrenia is related to the hippocampal presubiculum atrophy, which is involved in episodic memory and cognitive control and is supposed to be underpinned by difficulty in integrating new memories and thus in generating new hypotheses about the self.

Theory of mind correlates with clinical insight but not cognitive insight in patients with schizophrenia

Research on the relationship between insight and social cognition, in particular Theory of Mind (ToM), in schizophrenia has yielded mixed findings to date. Very few studies, however, have assessed both clinical insight and cognitive insight when examining their relationships with ToM in schizophrenia. The current study thus investigated the relationship between clinical insight, cognitive insight, and ToM in a sample of 56 patients with schizophrenia and 30 healthy controls. Twenty-seven patients were classified as low in clinical insight according to their scores on the 'insight' item (G12) of the Positive and Negative Syndrome Scale (PANSS). Moreover, cognitive insight and ToM were assessed with the Beck Cognitive Insight Scale (BCIS) and the Yoni task, respectively. The results indicated that patients with poor clinical insight performed worse on tasks of second-order cognitive and affective ToM, while the ToM performance of patients with high clinical insight was equivalent to that of healthy controls. Furthermore, while clinical insight was correlated with ToM and clinical symptoms, cognitive insight did not correlate with clinical insight, ToM, or clinical symptoms. Clinical insight thus appears to be an important factor related to ToM in schizophrenia.

The relationship between cognitive insight and quality of life in schizophrenia spectrum disorders: Symptom severity as potential moderator

Cognitive insight is implicated in the formation and maintenance of hallucinations and delusions. However, it is not yet known whether cognitive insight relates to broader outcome measures like quality of life. In the current study, we investigated whether the component elements of cognitive insight-self-certainty and self-reflectiveness-were related to quality of life for 43 outpatients with schizophrenia or schizoaffective disorder. Cognitive insight was assessed using the Beck Cognitive Insight Scale (BCIS) while quality of life was assessed with Quality of Life Scale (QLS). We tested whether this relationship was moderated by clinical insight and symptom severity using the Scale to Assess Unawareness of Mental Disorder (SUMD) and the Positive and Negative Syndrome Scale (PANSS). We found that self- reflectiveness had an unmoderated positive relationship with quality of life. Self-certainty was associated with better quality of life for people with more severe symptoms. Theoretical and clinical implications of these findings are discussed and areas of future research are proposed.

The relationship between cognitive insight and depression in psychosis and schizophrenia: a review and meta-analysis

Lack of insight is a commonly observed problem in patients with psychosis and schizophrenia. Clinical insight in patients has been associated with low mood. Cognitive insight is a recently defined concept, relating to the ability to self-reflect and the degree to which patients are over-confident regarding their interpretations of illness-related experiences, and is related to clinical insight. We therefore sought to investigate whether there is a positive relationship between cognitive insight and mood. A literature search identified 17 relevant papers published between 2004 and 2014. Our analysis indicated that there was a small but significant positive correlation between the composite index (CI) of the Beck Cognitive Insight Scale (BCIS) and depression scores, but this was driven by a significant positive relationship between depression and the BCIS self-reflection (SR) sub-scale, where low mood was related to higher SR scores. There was no significant relationship between the self-certainty sub-scale and depression. Post-hoc analysis indicated that different depression scales did not significantly affect the relationship with SR. Our results support the idea that cognitive insight is significantly related to mood in schizophrenia, and the effect size is similar to that between clinical insight and mood. Potential applications of this knowledge into treatment and rehabilitation are discussed and a model of cognitive insight is proposed.

Altered Brain Activation during Emotional Face Processing in Relation to Both Diagnosis and Polygenic Risk of Bipolar Disorder

Objectives

Bipolar disorder (BD) is a highly heritable disorder with polygenic inheritance. Among the most consistent findings from functional magnetic imaging (fMRI) studies are limbic hyperactivation and dorsal hypoactivation. However, the relation between reported brain functional abnormalities and underlying genetic risk remains elusive. This is the first cross-sectional study applying a whole-brain explorative approach to investigate potential influence of BD case-control status and polygenic risk on brain activation.

Methods

A BD polygenic risk score (PGRS) was estimated from the Psychiatric Genomics Consortium BD case-control study, and assigned to each individual in our independent sample (N=85 BD cases and 121 healthy controls (HC)), all of whom participated in an fMRI emotional faces matching paradigm. Potential differences in BOLD response across diagnostic groups were explored at whole-brain level in addition to amygdala as a region of interest. Putative effects of BD PGRS on brain activation were also investigated.

Results

At whole-brain level, BD cases presented with significantly lower cuneus/precuneus activation than HC during negative face processing (Z-threshold=2.3 as cluster-level correction). The PGRS was associated positively with increased right inferior frontal gyrus (rIFG) activation during negative face processing. For amygdala activation, there were no correlations with diagnostic status or PGRS.

Conclusions

These findings are in line with previous reports of reduced precuneus and altered rIFG activation in BD. While these results demonstrate the ability of PGRS to reveal underlying genetic risk of altered brain activation in BD, the lack of convergence of effects at diagnostic and PGRS level suggests that this relation is a complex one.

Metacognitive training (MCT) for schizophrenia improves cognitive insight: a randomized controlled trial in a Chinese sample with schizophrenia spectrum disorders

Metacognitive training (MCT) is a group-based treatment program for people with schizophrenia that targets the cognitive biases thought to contribute to the pathogenesis and maintenance of delusions. Although effective in reducing the severity of delusions, the influence of MCT on cognitive insight, and its feasibility in Chinese culture, has yet to be investigated. The present randomized-controlled trial attempted to address these inconsistencies. A Chinese sample of 80 participants with schizophrenia spectrum disorders was randomized to the eight-module MCT program or continued treatment as usual (TAU). All participants were assessed using the Beck Cognitive Insight Scale, which assesses two components of cognitive insight (self-reflectiveness and self-certainty). Participants in the MCT condition subjectively rated their satisfaction with the training. Retention rates were high after four-weeks of MCT (n = 38) or TAU (n = 39). Clients randomized into the MCT condition rated the program favourably and showed significant improvements in cognitive insight (i.e., increased self-reflectiveness), relative to TAU controls, who exhibited decreases in cognitive insight at follow-up. These findings suggest that the MCT program is not only subjectively efficacious in Chinese samples, but also improves metacognitive awareness of the processes underlying delusional symptoms.

Relationship between cognitive insight and attenuated delusional symptoms in individuals with at-risk mental state

Cognitive insight, defined as the ability to evaluate and correct one׳s own distorted beliefs and misinterpretations, is hypothesized to contribute to the development of psychotic symptoms. We investigated cognitive insight in individuals with at-risk mental state (ARMS), which is associated with a clinically high risk of psychosis. Sixty individuals with ARMS were compared with 200 healthy controls in terms of cognitive insight measured using the Beck Cognitive Insight Scale. We also investigated the relationship between cognitive insight and attenuated delusional symptoms. In addition, we examined differences in the cognitive insight of individuals with ARMS with or without near-threshold delusional symptoms and differences in the cognitive insight of individuals with ARMS with or without later transition to psychosis. The results showed that individuals with ARMS exhibited higher self-certainty than healthy controls, indicating impairments in cognitive insight in the former. More importantly, our results revealed that self-certainty was correlated with attenuated delusional symptoms and that individuals with ARMS who had near threshold delusional symptoms had higher self-certainty. These findings indicate that overconfidence in one׳s own beliefs or judgments might be related to the formation and maintenance of attenuated delusions in individuals with ARMS.

Cognitive insight in individuals at clinical high risk for psychosis

AIM

Reduced cognitive insight has been associated with psychotic symptoms, in particular with the presence of delusions; however, there is little information about whether such reductions are present in at-risk individuals prior to the onset of threshold psychotic symptoms.

METHOD

We conducted a cross-sectional comparison of cognitive insight (as indexed by the Beck Cognitive Insight Scale) in 62 help-seeking individuals at clinical high risk for psychosis, Fifty-nine individuals with schizophrenia-spectrum disorders and 37 healthy controls (HC). In patients, we evaluated associations of insight with positive symptoms, including later transition to psychosis in high-risk patients.

RESULTS

Individuals with schizophrenia reported significantly higher self-certainty scores than the at-risk patients and HCs, with the at-risk patients scoring intermediate to the individuals with schizophrenia and controls. Similarly, individuals with schizophrenia scored significantly higher on self-reflectiveness, with no differences between the at-risk patients and controls. In individuals with schizophrenia, delusions were significantly correlated with self-certainty. In at-risk patients, cognitive insight was not associated with positive symptom severity and did not differentiate those at-risk patients who later developed psychosis from those who did not. However, post hoc analyses suggested that at-risk patients with marked unusual thought content (approaching threshold psychosis) had lower self-reflectiveness; whereas those with high suspiciousness had significantly higher self-certainty.

CONCLUSIONS

The findings are discussed in the context of normal developmental processes occurring during adolescence, their putative links to neurobiological functioning, and their implications for treatment and future research.

Association between cognitive insight and prefrontal function during a cognitive task in schizophrenia: a multichannel near-infrared spectroscopy study

Insight has been studied mostly from a clinical perspective. Recently, the focus of this research field shifted to cognitive insight or the ability to monitor and correct the erroneous convictions of individuals. In this study, we investigated the relationship between cognitive insight and prefrontal function during a cognitive task in 30 patients with clinically stable schizophrenia and 30 age- and gender-matched healthy controls. We measured the changes in hemoglobin concentration in the prefrontal and temporal cortical regions during a verbal fluency task (VFT) by using 52-channel near-infrared spectroscopy (NIRS). Cognitive insight was measured using the Beck Cognitive Insight Scale (BCIS). Regional hemodynamic changes were significantly smaller in the schizophrenia group than in the control group in prefrontal and temporal regions, and significant positive relationship was observed between the score of the BCIS self-reflectiveness subscale and right ventrolateral prefrontal and right temporal functions during the VFT. These results suggest that the right ventrolateral prefrontal and temporal cortical regions are associated with cognitive insight in clinically stable patients with schizophrenia and that NIRS is an efficient medical tool for monitoring these characteristics.

Failures of metacognition and lack of insight in neuropsychiatric disorders

Lack of insight or unawareness of illness are the hallmarks of many psychiatric disorders, especially schizophrenia (SCZ) and other psychoses and could be conceived of as a failure in metacognition. Research in this area in the mental health field h as burgeoned with the development and widespread use of standard assessment instruments and the mapping out of the clinical and neuropsychological correlates of insight and its loss. There has been a growing appreciation of the multi-faceted nature of the concept and of the different 'objects' of insight, such as the general awareness that one is ill, to more specific metacognitive awareness of individual symptoms, impairments and performance. This in turn has led to the notion that insight may show modularity and may fractionate across different domains and disorders, supported by work that directly compares metacognition of memory deficits and illness awareness in patients with SCZ, Alzheimer's disease and brain injury. The focus of this paper will be on the varieties of metacognitive failure in psychiatry, particularly the psychoses. We explore cognitive models based on self-reflectiveness and their possible social and neurological bases, including data from structural and functional MRI. The medial frontal cortex appears to play an important role in self-appraisal in health and disease.

Self-evaluation in schizophrenia: an fMRI study with implications for the understanding of insight

BACKGROUND

Lack of insight is a core feature of schizophrenia and is associated with structural brain abnormalities. The functional neuroanatomy of insight has only recently been investigated. When people evaluate their personality traits compared to those of another, activation is seen in central midline structures (CMS) of the brain. This study set out to compare cerebral activation in schizophrenia patients versus controls during a self-evaluation task which included positive and negative traits as well as mental and physical illness terms.

METHODS

Eleven schizophrenia patients and 8 healthy controls, matched for age were studied. Insight was assessed using the Schedule for the Assessment of Insight-expanded version (SAI-E). FMRI data were obtained with a 1.5 Tesla GE system and interactions between participant group, self versus other, significant at the cluster level, were recorded.

RESULTS

Significant hypoactivation in the medial superior frontal gyrus (dorsomedial prefrontal cortex) was observed in patients vs. controls during self-evaluation of all traits combined. A second cluster of hypoactivation in the posterior cingulate was also detected. When the response to individual traits was explored, underactivation in other frontal regions plus right inferior parietal lobule emerged and this tended to correlate, albeit weakly with lower insight scores. Further, there were areas of hyperactivation relative to controls in anterior cingulate, frontal and parietal regions (especially precuneus) which showed moderate inverse correlations with insight scores.

CONCLUSIONS

We have demonstrated that the CMS, identified as a key system underpinning self-evaluation, is dysfunctional in patients with schizophrenia, particularly dorso-medial PFC. This may have implications for lack of insight in schizophrenia. Hypofunction within the dorsomedial prefrontal region seems to be particularly important although other posterior and lateral cortical regions play a part and may modulate self-evaluative responses depending on the type of trait under consideration.

Correlations between awareness of illness (insight) and history of addiction in heroin-addicted patients

In a group of 1066 heroin addicts, who were seeking treatment for opioid agonist treatment, we looked for differences in historical, demographic, and clinical characteristics, between patients with different levels of awareness of illness (insight). The results showed that, in the cohort studied, a majority of subjects lacked insight into their heroin-use behavior. Compared with the impaired-insight group, those who possessed insight into their illness showed significantly greater awareness of past social, somatic, and psychopathological impairments, and had a greater number of past treatment-seeking events for heroin addiction. In contrast with other psychiatric illnesses, the presence of awareness appears to be related to the passing of time and to the worsening of the illness. Methodologies to improve the insight of patients should, therefore, be targeted more directly on patients early in their history of heroin dependence, because the risk of lack of insight is greatest during this period.

Insight in schizophrenia: from conceptualization to neuroscience

Lack of insight into illness is a prevalent and distinguishing feature of schizophrenia, which has a complex history and has been given a variety of definitions. Currently, insight is measured and treated as a multidimensional phenomenon, because it is believed to result from psychological, neuropsychological and organic factors. Thus, schizophrenia patients may display dramatic disorders including demoralization, depression and a higher risk of suicide, all of which are directly or indirectly related to a lack of insight into their illness, and make the treatment difficult. To improve the treatment of people with schizophrenia, it is thus crucial to advance research on insight into their illness. Insight is studied in a variety of ways. Studies may focus on the relationship between insight and psychopathology, may view behavioral outcomes or look discretely at the cognitive dysfunction versus anatomy level of insight. All have merit but they are dispersed across a wide body of literature and rarely are the findings integrated and synthesized in a meaningful way. The aim of this study was to synthesize findings across the large body of literature dealing with insight, to highlight its multidimensional nature, measurement, neuropsychology and social impact in schizophrenia. The extensive literature on the cognitive consequences of lack of insight and the contribution of neuroimaging techniques to elucidating neurological etiology of insight deficits, is also reviewed.

Assessment of cognitive insight: a qualitative review

The concept of cognitive insight was introduced in 2004 to describe the capacity of patients with psychosis to distance themselves from their psychotic experiences, reflect on them, and respond to corrective feedback. The Beck Cognitive Insight Scale (BCIS) was developed to evaluate these aspects of cognitive flexibility and to complement scales that describe the lack of awareness of mental illness and its characteristics. The BCIS has generated a moderate research literature, which is the subject of the current review. Several independent groups have demonstrated that the BCIS is reliable, demonstrates convergent and construct validity, and distinguishes patients with psychosis from healthy controls and patients without psychosis. While the majority of the studies have focused on the relationship of the BCIS to delusions, several have examined its relationship to negative symptoms, depression, anxiety, and functional outcome. Cognitive insight has predicted positive gains in psychotherapy of psychosis, and improvement in cognitive insight has been correlated with improvement in delusional beliefs. Finally, preliminary findings relate neurocognition, metacognition, and social cognition, as well as reduced hippocampal volume to cognitive insight. A heuristic framework is presented to guide future research.

The relationship between cognitive insight, clinical insight, and depression in patients with schizophrenia

Despite comorbid depression being relatively common even in subjects with schizophrenia, to the best of our knowledge, there is, to date, no report in the literature specifically and detailed examining the cognitive and clinical insight in subjects with schizophrenia and a comorbid depressive syndrome. Hence, in this study, we sought to compare the cognitive and clinical insight in our subjects with schizophrenia with and without a comorbid depressive syndrome. We found that participants in the depressive group scored significantly higher on self-reflectiveness and the reflectiveness-certainty (R-C) index scores than those in the nondepressive group. There was no significant difference among groups on the Scale for the Assessment of Positive Symptoms, Scale for the Assessment of Negative Symptoms, and clinical insight scores assessed by the Scale to Assess Unawareness of Mental Disorder. In addition, self-reflectiveness scores significantly correlated with depression, observed depression, hopelessness, and suicidality subscores of the Calgary Depression Scale for Schizophrenia. A better understanding of the cognitive component of insight in schizophrenia with comorbid depression may contribute to develop more efficient cognitive strategies, thus improving patient outcome. However, clinicians should be aware of the possibility of exacerbating a sense of hopelessness and suicide risk during the interventions that improve cognitive insight.

The neuroanatomical correlates of cognitive insight in schizophrenia

Insight has been mostly studied from a clinical perspective. Recently, attention moved to cognitive insight or the ability to monitor and correct one's erroneous convictions. Here, we investigated the neuroanatomical correlates of cognitive insight. We administered the Beck cognitive insight scale to 45 outpatients with a schizophrenia diagnosis and 45 age- and gender-matched healthy control subjects who underwent a MRI investigation, including high-resolution volumetric and diffusion tensor imaging sequences. Gray and white matter volume, mean diffusivity and fractional anisotropy were used as dependent variables and were analyzed on a voxel-by-voxel basis with reference to the cognitive insight indexes. Self-reflectiveness was positively related to gray matter volume of the right ventro-lateral prefrontal cortex (VLPFC). No statistically significant results emerged from the DTI analyses, and no significant relationships were found for self-certainty and global cognitive insight. Reduced self-reflectiveness is related to a reduced volume of the VLPFC, an area involved in generating and maintaining in working memory different hypotheses about the self. This line of research focusing on the metacognitive features of insight in schizophrenia can provide relevant information to identify patients who are most vulnerable to lack of insight and develop effective cognitive therapeutic strategies.

The neuroanatomical correlates of cognitive insight in schizophrenia

Insight has been mostly studied from a clinical perspective. Recently, attention moved to cognitive insight or the ability to monitor and correct one's erroneous convictions. Here, we investigated the neuroanatomical correlates of cognitive insight. We administered the Beck cognitive insight scale to 45 outpatients with a schizophrenia diagnosis and 45 age- and gender-matched healthy control subjects who underwent a MRI investigation, including high-resolution volumetric and diffusion tensor imaging sequences. Gray and white matter volume, mean diffusivity and fractional anisotropy were used as dependent variables and were analyzed on a voxel-by-voxel basis with reference to the cognitive insight indexes. Self-reflectiveness was positively related to gray matter volume of the right ventro-lateral prefrontal cortex (VLPFC). No statistically significant results emerged from the DTI analyses, and no significant relationships were found for self-certainty and global cognitive insight. Reduced self-reflectiveness is related to a reduced volume of the VLPFC, an area involved in generating and maintaining in working memory different hypotheses about the self. This line of research focusing on the metacognitive features of insight in schizophrenia can provide relevant information to identify patients who are most vulnerable to lack of insight and develop effective cognitive therapeutic strategies.

Cognitive insight and its relationship with symptoms in deficit and nondeficit schizophrenia

Patients with deficit schizophrenia have worse cognition and poorer social functioning compared with those with nondeficit schizophrenia. Insight is another domain in which these two groups might differ. However, there is no literature data specifically on cognitive insight impairment in deficit versus nondeficit schizophrenia. We compared 40 patients with deficit schizophrenia with 81 nondeficit patients and found that schizophrenic patients with deficit syndrome were more self-reflective and have higher self-reflectiveness-self-certainty index scores than did those without deficit syndrome. These differences remained significant when analysis was controlled for sex, age, education, and depression severity. On the other hand, there was no significant difference in self-certainty scores between two groups. In addition, we found significant relationships between cognitive insight and specific psychotic symptoms. A better understanding of the cognitive component of insight in schizophrenia with deficit syndrome may help us to understand the true relationship between insight and negative symptoms and contribute to the development of more efficient cognitive strategies, thus improving patients' outcome in a severely disabled psychiatric patient group.

Assessing cognitive insight in nonpsychiatric individuals and outpatients with schizophrenia in Taiwan: an investigation using the Beck Cognitive Insight Scale

BACKGROUND

The Beck Cognitive Insight Scale (BCIS) was designed for the assessment of the cognitive processes involved in self-reflection and the ability to modify erroneous beliefs and misinterpretations. Studies investigating the factor structure of the BCIS have indicated a two-factor model in the psychotic population. The factor structure of the BCIS, however, has not received much consideration in the nonpsychiatric population. The present study examined the factor structure and validity of the BCIS and compared its scores between nonpsychiatric individuals and outpatients with psychosis.

METHOD

The Taiwanese version of the BCIS was administered to 507 nonpsychiatric individuals and 118 outpatients with schizophrenia. The psychometric properties of the BCIS were examined through the following analyses: exploratory and confirmatory factor analyses, reliability, correlation analyses, and discriminative validity.

RESULTS

The BCIS showed adequate internal consistency and stability over time. Exploratory and confirmatory factor analyses on the 15-item measure indicated a two-factor solution that supported the two dimensions of the Taiwanese BCIS, which was also observed with the original BCIS. Following the construct validation, we obtained a composite index (self-reflectiveness minus self-certainty) of the Taiwanese BCIS that reflected cognitive insight. Consistent with previous studies, our results indicated that psychosis is associated with low self-reflectiveness and high self-certainty, which possibly reflect lower cognitive insight. Our results also showed that better cognitive insight is related to worse depression in patients with schizophrenia spectrum disorders, but not in nonpsychiatric individuals. The receiver operating characteristic (ROC) analyses revealed that the area under the curve (AUC) was 0.731. A composite index of 3 was a good limit, with a sensitivity of 87% and a specificity of 51%.

CONCLUSION

The BCIS proved to be useful for measuring cognitive insight in Taiwanese nonpsychiatric and psychotic populations.

Verbal learning contributes to cognitive insight in schizophrenia independently of affective and psychotic symptoms

OBJECTIVE

Patients with schizophrenia exhibit distorted beliefs and experiences, and their own evaluation of this is labeled cognitive insight. We examined the relationship between cognitive insight and neurocognition, as well as the contribution of neurocognition in explaining cognitive insight.

METHOD

Clinically characterized patients with schizophrenia (n=102) were assessed with a measure of cognitive insight, Beck Cognitive Insight Scale (BCIS) and a neuropsychological test battery. The contribution of neurocognition to the explained variance in BCIS components self-reflectiveness (i.e. objectivity and reflectiveness) and self-certainty (i.e. overconfidence in own beliefs) was examined controlling for current affective and psychotic symptoms.

RESULTS

A significant negative correlation was found between self-certainty and verbal learning, whereas no associations were found between self-reflectiveness and any of the neuropsychological tests. Verbal learning was added significantly to the explained variance in self-certainty after controlling for potential confounders.

CONCLUSION

High self-certainty was associated with poor verbal learning. This suggests that overconfidence in own beliefs is associated with cognitive dysfunction in schizophrenia.

Comparison of insight among schizophrenia and bipolar disorder patients in remission of affective and positive symptoms: Analysis and critique

Background

Schizophrenia and bipolar disorder are associated with impairments in insight, leading to a poorer clinical outcome and functioning. Earlier studies comparing the two disorders on the basis of insight included inpatients or patients who were clinically symptomatic. The current study therefore assessed patients in remission of affective symptoms and positive symptoms of schizophrenia.

Methods

Schizophrenia and bipolar disorder patients (n = 32, n = 34; respectively) underwent clinical and functional evaluations. Insight was assessed using the Scale to assess Unawareness of Mental Disorder (SUMD) and the Positive and Negative Syndrome Scale (PANSS). Attention was assessed using a continuous performance task (CANTAB's Rapid Visual Information Processing).

Results

Schizophrenia patients displayed poorer insight into having a mental disorder and into the social consequences thereof compared to the bipolar disorder patients. They were also less aware of their anhedonia-asociality. Age, however, was significantly correlated with insight and differences in insight between the patient groups became nonsignificant when age was used as a covariate in the statistical analyses. Age was not a moderating variable of the relationship between diagnosis and insight.

Conclusions

Significant differences in insight held by the two patient groups might be related to age disparities between patient groups. Earlier studies did not adequately address these age differences, their cause and their potential effects on findings. These issues are explored with regard to the findings of the current study, as well as earlier studies, emphasizing the need for further research of the relationship between age and insight.