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
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.