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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.
As old as psychiatry itself and especially pertinent to psychosis,1 the concept of insight has undergone considerable refinement over the past 100 years. Early accounts defined insight as a single dimension—awareness of having a disorder—to be applied in a binary fashion such that patients possessed insight or lacked it entirely.2,3 Subsequent writers have developed insight into a multidimensional and continuous construct.4 Patients can now be evaluated by the degree to which they demonstrate awareness of illness, its signs and symptoms, and the need for treatment, attribute benefits to treatment, accept the illness label, understand the social consequences of illness, etc.5 The assessment of “clinical insight” in this manner has become invaluable for the formulation and treatment of psychosis.6
An important extension of the insight concept was introduced with the description of “cognitive insight,” defined as a patient's current capacity to evaluate his or her anomalous experiences and atypical interpretations of events.6 Unlike patients with nonpsychotic disorders (eg, depression or panic disorder), patients with psychosis are severely limited in their capacity to reflect upon their thinking problems and to recognize the errors and correct them. Indeed, Beck and Warman6 described 4 aspects of cognitive insight that can be disrupted in psychosis: (a) impairment of ability to be objective about delusional experiences and cognitive distortions, (b) reduced capacity to put these experiences into perspective, (c) unresponsiveness to corrective information from others, and (d) overconfidence in delusional judgments. The authors proposed that these characteristics were identifiable and quantifiable.
The Beck Cognitive Insight Scale (BCIS) was devised to measure patients' capacity for distancing themselves from and re-evaluating anomalous beliefs and misinterpretations.7 The BCIS is a 15-item self-report measure (the full scale appears in the Appendix) composed of 2 subscales: 9 Self-Reflectiveness items that assess objectivity, reflection, and openness to feedback and 6 Self-Certainty items that tap certainty about being right and resistance to correction. A principle components analysis confirmed the validity of a 2-factor solution, with each factor also shown to be internally consistent.7 The authors derived a composite cognitive insight index score (Composite Index) by subtracting the Self-Certainty score from the Self-Reflectiveness score. The Index significantly correlated with the Awareness of Having a Mental Disorder item on the Scale to Assess Unawareness of Mental Disorder (SUMD)8 and differentiated acutely unwell inpatients with psychotic disorders from those with major depressive disorder without psychotic features, demonstrating convergent and criterion validity, respectively. There were a number of limitations in the methodology of the original study of Beck et al.: Neither the reliability nor the validity of the patient diagnoses was determinable, degree of symptomatology was not measured, test-retest reliability was not estimated, and the sample was disproportionately schizoaffective.
In the time that has elapsed since the BCIS was introduced, 21 empirical studies that employ the cognitive insight construct have been published. These articles address the limitations of the original article and extend the scope of findings. The scale has been accurately translated into Chinese,9 Turkish,10 Norwegian,11 French,12 Spanish,13 Korean,14 and Japanese.15 The present article aims to review and synthesize the published literature with an eye to elucidating the psychometric characteristics and applications of the BCIS. The article is divided into 4 sections. The first section addresses the quality of the scale by reviewing the available psychometric data. The second section reports correlations with clinical features of the disorder. The third section reviews applications of cognitive insight to research on treatment, functional outcome, as well as neurocognition and neurobiology. Finally, the fourth section evaluates the state of this developing literature and introduces a heuristic model that charts out fruitful lines of future research.
Table 1 contains the data for all studies considered in the present review, cross-referenced with the text. For the sake of brevity, the details of each study in terms of sample, design, and results appear in the table.
Seven studies have confirmed the 2-factor structure of the BCIS.12,14–19 While the original article established a 2-factor solution for inpatients, the new studies have replicated this finding14 and shown that the same solution fits outpatient,12,16 first-episode,17 and healthy control15,18 samples, both in English16–18 and non-English12,14,15,19 speakers. These studies have, additionally, employed differing analytic strategies: principle components factor analysis,14,15 confirmatory factor analysis,12,16,18 exploratory factor analysis,19 and correlational analysis.17
Eight studies9,11,12,14–16,18,20 have attempted to replicate the internal consistency findings of Beck et al.;7 6 showed internal consistency for the Self-Reflectiveness subscale greater than or equal to .7 (Cronbach's alpha),9,11,12,16,18,20 with all 8 scoring above .6. Five showed internal consistency for the Self-Certainty subscale greater than or equal to .7,9,14,15,18,20 with an additional 2 scoring between .6 and .7.11,12
Three studies have reported on test-retest reliability of the BCIS.14,15,18 Test-retest was adequate to good in all 3 studies, the correlation being greater than .6 for a 3-month delay in schizophrenia patients,14 greater than .77 for healthy controls over a 45-min delay, and greater than .79 for healthy controls over an undisclosed delay.15
Convergent validity has been determined by correlating the BCIS with 5 different measures of clinical insight. Two groups have replicated the finding of Beck et al. that the Composite Index correlated with the SUMD, finding moderate-to-large correlations with the Awareness of a Mental Illness item21 and the total score.10 Five studies11,12,15,17,21 have reported significant mild-to-moderate correlations between the BCIS and Positive and Negative Syndrome Scale (PANSS) Lack of Insight item.22 Similarly, the BCIS has shown significant mild-to-moderate correlations with the Birchwood Insight Scale,16,23 the Schedule for Assessment of Insight (Japanese version), and the Revised Insight Scale for Psychosis.14 One group of researchers has reported divergent validity because they predicted and found that the BCIS did not correlate with a measure of subjective well-being.13
The BCIS has been shown to distinguish between individuals with a psychotic diagnosis and healthy controls. Two studies have reported patients scoring significantly higher than healthy controls on Self-Certainty, though Self-Reflectiveness did not distinguish the 2 groups in either study.11,24 However, in the largest study of this kind, healthy controls had higher Self-Reflectiveness, lower Self-Certainty, and a higher Composite Index than patients with schizophrenia.18 Finally, the BCIS has also been shown to distinguish healthy individuals who are delusion-prone from those who are not: The delusion-prone subjects scored higher on self certainty than their nondelusion-prone counterparts, though, contrary to hypothesis, they showed higher Self-Reflectiveness.25 It seems likely that the failure of the earlier studies to find differences between patients and controls on Self-Reflectiveness can be attributable to insufficient sample size11,24 and differences in translation of items related to unusual experiences.11
Importantly, the BCIS has been shown to distinguish between psychotic and nonpsychotic patient groups because the original finding of Beck et al.7 has been replicated20 and extended by showing that patients experiencing psychosis had lower cognitive insight than patients not experiencing psychosis.10 However, 2 research groups have found little difference on the BCIS between their schizophrenia and bipolar patients.11,20
Beck and Warman6 have theorized that delusional thinking, in particular, should be related to cognitive insight because low Self-Reflectiveness and high Self-Certainty constitute a reasoning style that would maintain delusional beliefs. Conversely, patients who evidence more Self-Reflectiveness and less Self-Certainty are less intellectually rigid, are more open to alternative explanations for their experiences, and are predicted to be less delusional. Several research groups have employed cross-sectional methodology to investigate the correlation of cognitive insight to delusions, as well as the other characteristic signs and symptoms of schizophrenia.
As a first pass at the hypothesis of Beck and Warman,6 5 studies have reported correlations between the BCIS and the PANSS positive symptoms score. Three did not find any significant correlations,12,15,17 2 studies reported significant positive correlations for Self-Certainty,10,16 and 1 reported significant negative correlations for the Composite Index and Self-Reflectiveness.10
The hypothesis of Beck and Warman6 that patients with active delusions have lower Self-Reflectiveness and higher Self-Certainty than patients without delusions has been supported in both chronic26 and first-episode27 (Self-Certainty was a nonsignificant trend) patients. One group has reported a mixed finding, such that patients with delusions have higher Self-Certainty and, contrary to prediction, higher Self-Reflectiveness.24
Because hallucinations are prototypical unusual experiences, patients with poor cognitive insight might be expected to have worse hallucinations because the severity of auditory hallucinations has been linked to patients' beliefs about their “voices.”28 One published study has addressed this hypothesis: While severity of hallucinations, in general, was not associated with the BCIS, delusional hallucinators demonstrated lower Self-Reflectiveness and higher Self-Certainty (at a trend level) than nondelusional hallucinators.26 This finding further supports the link between cognitive insight and delusions.
The reduced expressivity and withdrawal from constructive activity characteristic of negative symptoms would not seem like obvious correlates of cognitive insight. Nonetheless, 3 research groups have reported significant correlations with PANSS negative symptoms, 2 finding an inverse relationship with Self-Reflectiveness,10,17 and 1 finding a direct relationship with Self-Certainty.16 Three studies also failed to find a significant correlation between the BCIS and negative symptoms.11,12,15
The literature on cognitive insight and depression appears mixed. Four studies have replicated the finding of Beck et al.7 that depression does not correlate with cognitive insight in patients with a psychotic diagnosis.11,12,16,17 However, 2 studies have reported partially contrary findings: In each case, higher Self-Reflectiveness (but not Self-Certainty) was associated with depression in psychotic patients.20,24 Two studies have investigated the association between anxiety and cognitive insight in psychosis, and the results are similar to depression, with one group finding no significant associations29 and the other finding significant positive correlations between anxiety and both the Composite Index and Self-Reflectiveness.20
Given that the literature supports a link between cognitive insight and psychopathology (especially delusions), further questions can be posed regarding possible relationships between cognitive insight and treatment: (a) Is cognitive insight a predictor (moderator) of treatment response? (b) Can cognitive insight be improved in treatment? and (c) Is cognitive insight a mediating variable of treatment outcome? A small literature has begun to address these questions.
To our knowledge, only 1 published study has reported on the prognostic utility of cognitive insight.30 In a naturalistic study, patients with higher cognitive insight at the start of therapy showed a greater reduction in delusion severity at the end of treatment (8 months later) relative to patients who started treatment with poorer cognitive insight.
Four published studies have found that cognitive insight improves over the course of psychosocial treatment. These were 2 group intervention studies,31,32 1 individual therapy study30 and 1 multifaceted inpatient treatment study.10 Across all these studies, Self-Reflectiveness appeared to change more by the end of treatment than Self-Certainty.10,32
While a proper mediation analysis33 has not, to our knowledge, been conducted with the BCIS, there are 2 suggestive findings. In the first, improvements in the Composite Index significantly correlated with reductions in positive, negative, and total symptoms,34 while the second showed that improvements in Self-Reflectiveness, Self-Certainty, and the Composite Index score were significantly correlated with concomitant reductions in the severity of both delusions and hallucinations.30 While these findings are consistent with cognitive insight being a mediating variable in the treatment of psychotic symptoms, future studies should conduct a true mediation analysis using sufficient measurement points.35
One study has addressed whether cognitive insight is related to poor social and vocational functioning: patients living on their own were found to have a significantly higher Composite Index, higher Self-Reflectiveness, and lower Self-Certainty than patients living in nursing homes.12
Recently, investigators have begun to include the BCIS in studies of information processing and neuroimaging. Three studies have been published. In the first, cognitive insight was associated with executive function and understanding one's own mind, suggesting the involvement of neurocognitive and metacognitive processes.36 Similarly, another group of researchers has shown that the neurocognitive domains of verbal learning and memory, as well as attention, were significantly correlated with Composite Index and Self-Certainty; the Composite Index, additionally, was associated with social cognition; and neither the SUMD nor the PANSS correlated with neurocognitive or social cognitive measures.21 A second study by this group largely corroborated these findings, with the exception that Self-Reflectiveness (rather than Self-Certainty) correlated with verbal memory.29 This last study was also the first to report brain imaging results. Specifically, a smaller overall hippocampal volume was associated with higher Self-Certainty, and reduced left-hemisphere hippocampal volume also correlated with a lower Composite Index score. These researchers found no significant correlations between Self-Reflectiveness and total hippocampal volume or between clinical insight (ie, SUMD) and brain volume. Further, the significant associations between cognitive insight and hippocampal volume were independent of verbal memory performance.29
The literature on the BCIS is still at an early stage. Nonetheless, the weight of the evidence supports the conclusion that the BCIS has favorable psychometric properties and is a useful measure for both clinical and research purposes. Figure 1 represents a synthesis of the basic findings into a theoretical model to serve as a template for future research of the BCIS.
Psychometrically, the BCIS has been found to consist of 2 internally consistent factors; the scale is stable across time; it shows convergent validity with measures of clinical insight; and, importantly, it distinguishes patients with psychotic disorders from healthy controls and patients with nonpsychotic disorders. We make the following proposals for future research:
The neurocognitive findings suggest that deficiency in cognitive insight is related to impairment of basic neurocognitive functions such as verbal memory, attention, and mental flexibility. In figure 1, the arrow from neurocognition to cognitive insight represents the hypothesis that neurocognitive impairment limits cognitive insight. However, this link is based on 3 studies.21,29,36 The neuroanatomical finding is also promising, especially the link between hippocampal volume and Self-Certainty. We anticipate considerable growth in this area of study in the coming years and, accordingly, make the following proposals for future research:
While the literature shows that cognitive insight consistently correlates with clinical insight, there is evidence that the 2 constructs are “complementary” rather than “overlapping.” For example, cognitive insight taps capacities rather than pathology and therefore may be a better indicator of prognosis. Indeed, it has already shown to be a good marker for prognosis in Cognitive Therapy for psychosis.30 Further evidence of a complementary relationship between clinical insight and cognitive insight comes from the studies showing the BCIS, and not the SUMD, to be associated with neurocognitive and neurobiological factors.21,29,36 These findings suggest that cognitive insight is a basic ability that is more proximal to neurobiological vulnerabilities than clinical insight. The development of adequate clinical insight may therefore depend upon a certain degree of cognitive insight—eg, neurocognitive deficits may limit a patient's ability to consider alternative viewpoints and refrain from thinking that is impermeable to outside information, which may in turn limit the patient's ability to understand that he or she has an illness. We have represented the complementary relationship between clinical and cognitive insight with a dashed arrow in the middle of figure 1. We make the following suggestions for future research:
The central portion of figure 1 illustrates the links between cognitive insight and the characteristic symptoms of schizophrenia. However, the direction of the arrows between these variables is hypothetical because the necessary longitudinal research has yet to appear.
The review supports, at most, a weak association between a general index of positive symptoms and the BCIS. There is stronger evidence for the association of delusions and the BCIS26,27 and one study implicating the BCIS in hallucinations.26 The clinical research showing that change in cognitive insight is correlated with change in hallucinations and delusions also buttresses the link between the BCIS and positive symptoms.30 Our recommendations for future research are as follows:
The present review supports a tentative link between cognitive insight and negative symptoms. We theorize 2 possible paths underlying this association, as represented in figure 1. First, cognitive insight may impact negative symptoms directly via a rigid reasoning style that fosters disengagement in constructive activity as well as reduced interpersonal expressivity. However, the pathway may be indirect, such that cognitive insight affects positive symptoms, which in turn lead the patients to withdraw from productive pursuits (eg, command hallucination tells the patient to lie down for hours). Our proposals for future research are as follows:
While the aggregate literature supports a null relationship between depression and the BCIS in patients with psychotic disorders, there are 2 inconsistent findings that show elevated Self-Reflectiveness associated with elevated depression. A similar finding has been reported between anxiety and the BCIS. We make the following proposals:
Patients with higher cognitive insight are more likely to be living independently.12 Further, the relationship between cognitive insight and both metacognition and social cognition suggests that it might also affect social information processing and interpersonal interactions. Does cognitive insight impact acts of daily living directly or is the relationship best characterized as indirect, and secondary, to symptoms? The figure features an indirect path. Additionally, the relationship between quality of life and cognitive insight is relatively unexplored. Figure 1 contains an arrow from functional outcome to quality of life, reflecting the idea that patients who are functioning better will also report higher life satisfaction.
Foundation for Cognitive Therapy and Research; Heinz Foundation.
The authors thank Letitia Travaglini, Nadine Chang, Jessica Olli, Gloria Huh, and Daniel Himelstein for assistance in preparation of the manuscript. The Authors have declared that there are no conflicts of interest in relation to the subject of this study.
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