New neuropsychological data might help build a model of poor insight in obsessive–compulsive disorder

Identifying cognitive correlates of clinical phenomena is a critical step toward building neuropsychological models of neuropsychiatric illness, and in turn developing targeted interventions to remediate them. Although low insight affects more patients with obsessive–compulsive disorder (OCD) than previously thought, very little research on brainbehavioral aspects of insight in OCD has been conducted to date. The study by Kashyap et al. (1), published in the current issue of Acta, represents a welcome contribution to the understanding of this issue. The authors have compared the performance of 150 patients with DSM-IV OCD to 177 healthy control subjects using a comprehensive battery of neuropsychological tests. Patients with OCD displayed worse performance on a range of tests measuring attention (Color Trails 1 and 2), spatial (Wechsler Memory Scale-III) and verbal working memory (Verbal N-Back), planning (Tower of London 3-disk and 4-disk time), set shifting (Wisconsin Card Sorting Test categories completed), response inhibition (Stroop interference score), decision making (Iowa Gambling Test), and non-verbal memory (Complex Figure Test immediate and delayed recall). These findings are broadly in accordance with previous studies in patients with OCD. While neuropsychological results from the aforementioned tests are of interest, the most intriguing results of the study of Kashyap et al. (1) emerged when the relationships between insight into OCD, as measure by the Brown Assessment of Beliefs Scale (BABS), and neuropsychological measures were assessed. In addition to a correlation between insight and the Stroop interference score, two other original findings were detected: a trend toward correlation between insight with verbal fluency (as measured by the Controlled Oral Word Association Test – COWAT) and with the delayed verbal recall (Auditory Verbal Learning Test – AVLT). Most interestingly, using a linear regression analysis, Kashyap et al. (1) were able to identify that verbal fluency, delayed verbal recall, and intelligence, together with the severity of obsessive– compulsive symptoms and current antipsychotic use, predicted the levels of insight into OCD. Based on their findings, the authors proposed a model whereby patients with poor insight OCD might be: i) unable to inhibit prepotent existing beliefs or resolve the contradiction between their beliefs and incoming corrective information because of greater deficits in conflict resolution ⁄ response inhibition (as suggested by greater Stroop Interference Scores), ii) unable to update their memory with corrective information because of problems with delayed verbal recall (detected by the AVLT), and iii) unable to access corrective information to modify their irrational beliefs as a consequence of difficulties in associative exploration, efficient organization of retrieval and recall, self-monitoring, and self-initiation (as suggested by poor performance on the COWAT). Before commenting on the interesting model reported by Kashyap et al., one must acknowledge a number of problems associated with the concept of poor insight in OCD. For instance, the term has several possible meanings, which can overlap and interact with one another, including anosognosia (lack of awareness of the existence of illness), anosodiaphoria (indifference to the consequences of the illness), defensiveness (the use of denial and argument to resist influence by others), or delusionality (propensity toward fixed and inflexible beliefs) (2). It is also unclear, for example, whether the explanations that patients with poor insight OCD give to their behaviors are better considered a form of confabulation. In their study, Kashyap et al. (1) employed the BABS, an instrument that measures the severity of different types of insight resulting in a total score (3). According to this tool, two patients can have the same score and yet display very significant qualitative differences in Acta Psychiatr Scand 2012: 126: 83–84 All rights reserved DOI: 10.1111/j.1600-0447.2012. 01836.x 2012 John Wiley & Sons A/S