Cognitive insight and clinical insight in schizophrenia : methodological, neurocognitive and psychopathological aspects and comparison to bipolar disorder

Background: Beck Cognitive Insight Scale (BCIS) has been designed for assessment of selfreflection on patients' anomalous experiences and interpretations of own beliefs. The scale has been developed and validated for patients with schizophrenia. We wanted to study the utility of the scale for patients with bipolar disorder. The relationship between the BCIS as a measure of cognitive insight and established methods for assessment of insight of illness was explored in both diagnostic groups. Methods: The BCIS self-report inventory was administered to patients with schizophrenia (n = 143), bipolar disorder (n = 92) and controls (n = 64). The 15 items of the inventory form two subscales, self-reflectiveness and self-certainty. Results: The internal consistency of the subscales was good for the patient groups and the controls. The mean subscale scores were not significantly different for the three groups. Four items in subscale self-reflectiveness referring to psychotic experiences gave, however, different results in the control subjects. Self-certainty and scores on insight item PANSS correlated significantly in the schizophrenia, but not in the bipolar group. Conclusion: BCIS with its two subscales seems applicable for patients with bipolar disorder as well as for patients with schizophrenia. The self-report inventory can also be applied to control subjects if the items referring to psychotic experiences are omitted. In schizophrenia high scores on self-certainty is possibly associated with poor insight of illness. For the bipolar group the subscales are largely independent of traditional insight measures. Background Insight of illness is an important aspect in diagnostics and treatment of patients with severe mental disorders. Focus has primarily been on awareness of illness and treatment Published: 11 December 2007 BMC Psychiatry 2007, 7:71 doi:10.1186/1471-244X-7-71 Received: 6 March 2007 Accepted: 11 December 2007 This article is available from: http://www.biomedcentral. com/1471-244X/7/71 © 2007 Engh et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. BMC Psychiatry 2007, 7:71 http://www.biomedcentral. com/1471-244X/7/71 Page 2 of 7 (page number not for citation purposes) needs based on the widely used definition by Anthony David [1]. Aaron T. Beck labeled this clinical insight [2]. In addition to attenuated clinical insight, patients with psychosis often have reduced capacity to reflect rationally on their anomalous experiences and to recognize that their conclusions are incorrect [2]. Beck termed such insight cognitive insight. He summarized the relevant components of this concept as "impairment of objectivity about the cognitive distortions, loss of ability to put these into perspective, resistance to corrective information from others and overconfidence in conclusions [2]. " To measure cognitive insight, he developed the Beck Cognitive Insight Scale (BCIS), a 15 item self-report instrument with two subscales, self-reflectiveness and selfcertainty (Beck 2004). Acceptable levels of internal consistency (alpha self-reflectiveness 0.68, alpha self-certainty 0.60) were found for a mixed sample of patients with schizophrenia, schizoaffective disorder and major depression [2]. For middle-aged and older patients with schizophrenia and schizoaffective disorder, acceptable internal consistency was later confirmed for self-reflectiveness (alpha 0.70), but not for self-certainty (alpha 0.50) [3]. The introduction of the BCIS has provided an opportunity to explore cognitive insight among patients with schizophrenia. Beck and colleagues recruited 150 inpatients, 75 diagnosed with schizophrenia and schizoaffective disorder and 75 with major depressive disorder. Twenty-one per cent in the latter group had psychotic depression. The authors [2] showed that the subscale self-certainty differentiated between major depressive patients with and without psychosis. However, the BCIS has not yet been validated for patients with bipolar I and bipolar II disorder, in whom lack of insight may also be a major clinical problem. We have earlier demonstrated that a self-report questionnaire assessing insight of illness with good psychometric properties for patients with schizophrenia may not necessarily function as well for patients with bipolar disorders [4]. It is therefore important to study the psychometric qualities of the BCIS also for this patient group. Self-reflectiveness and self-certainty comprise items that seem to be rather general in content. Possibly, the two subscales cover a spectrum from normality to pathology. Warman et al.[5] have recently published an article which points out that the factor loadings and internal consistencies of the BCIS were similar for healthy controls and the two groups of inpatients in Beck's original paper. We intended to replicate the investigation of the subscales' utility for normal controls. The aims of the present study were: 1) to examine the subscale scores, internal consistency and intercorrelation of the BCIS' subscales for the schizophrenia group, the bipolar group and for normal controls, 2) to explore the relationship between the BCIS and affective symptom scores, and established scales for assessment of insight for the two diagnostic groups, and 3) to compare mean scores for patients and controls. Methods The subjects participated in a large ongoing study on schizophrenia and bipolar disorders (TOP Study, Thematic Organized Psychoses Research) and were recruited from out-patient and in-patient psychiatric units at four University Hospitals in Oslo, Norway, from March, 2005 through July, 2007. The health care system is catchment area based and the patients are referred from primary care. The patients were invited to participate in the study by the clinician responsible for their treatment. All participants gave written informed consent, and the study was approved by the Regional Committee for Medical Research Ethics and the Norwegian Data Inspectorate. Participants The inclusion criteria were as follows: age 18 to 65 years, able to understand and speak a Scandinavian language, meeting the DSM-IV criteria for schizophrenia, schizoaffective, schizophreniform or bipolar disorder, no history of severe head trauma, IQ score of above 70 and willing and able to give informed consent. A total of 235 patients met the criteria. The schizophrenia group consisted of 143 patients with the DSM-IV diagnoses schizophrenia (n = 107), schizophreniform disorder (n = 10), and schizoaffective disorder (n = 26). Ninety-two patients were included in the bipolar group, diagnosed with either bipolar I disorder (n = 45), bipolar II disorder (n = 43) or bipolar NOS (n = 4). Sixty-four healthy subjects took part in the control group. Twenty-seven of these individuals were randomly selected from statistical records from the same catchment area as the patients. The remaining 37 persons were a mixed group of volunteering professionals. Detailed analyses of the subscale scores and intra class correlation showed similar results in the two control samples, and hence we refer only to one control group in this article. Diagnosis was established using the Structured Clinical Interview for DSM-IV-TR-axis I disorders (SCID-I) [6]. All interviewers finished a training course in SCID assessment based on the training program at UCLA [7] and participated in diagnostic evaluation meetings on regular basis led by a clinically experienced professor in psychiatry (S.O.). Mean overall kappa for SCID diagnoses assessed by the UCLA was 0.77 (95 % CI: 0.60–0.94). BMC Psychiatry 2007, 7:71 http://www.biomedcentral. com/1471-244X/7/71 Page 3 of 7 (page number not for citation purposes) Measures General assessments History of mental illness, present symptoms, life style, and pharmacological treatment were obtained from interview with the patient, with additional information collected from treatment records and clinical staff. Severity of symptoms was assessed by the Positive and Negative Syndrome Scale PANSS (PANSS) [8], the Young Mania Rating Scale-Clinician rated (YMRS-C) [9] and the Inventory of Depressive Symptoms-Clinician rated (IDS-C) [10]. The assessment of depression was conducted partly with the Inventory of Depressive Symptoms-Clinician rated (IDSC), partly with CDSS (Calgary Depression Scale), but only the former scores are utilized in the study. Hence, there is a discrepancy between the number of patients with IDS scores and the number of patients with other symptom scores (PANSS, YMRS). Psychosocial functioning was measured by the Global Assessment of Functioning Scale (GAF) [11,12], and the scores were split into scales of symptoms (GAF-S) and function (GAF-F) to improve psychometric properties. The inter-rater reliability of the investigators was good for the GAF with an intra class correlation, ICC 1.1, of 0.86 [13]. Assessment of cognitive insight and insight of illness The BCIS is a self-report inventory consisting of 15 statements rated on a 4-point Likert scale (0 = do not agree at all to 3 = agree completely). Based on factor analyses Beck and coworkers divided the 15 items into 2 subscales (Figure 1). The first component consisted of 9 items measuring objectivity, reflectiveness and openness to feedback and given the label self-reflectiveness. Under the umbrella of decision-making and resistance to feedback, 6 items were united in a second component of the scale, labeled self-certainty. High scores on the subscale self-reflectiveness and low scores on subscale self-certainty is considered as normal. With approval from the authors the inventory was translated from English into Norwegian and the procedure was reversed under blinded conditions back into English. Th