Insight in obsessive-compulsive disorder: a comparative study of insight measures in an Israeli clinical sample

The COGINS: A New Measure of Cognitive Insight in Obsessive-Compulsive and Related Disorders

Research suggests that individuals with obsessive-compulsive and related disorders (OCRDs) with lower insight show a poorer response to cognitive behavioral therapy and might benefit from alternative treatments. However, there are inconsistencies in the literature regarding the definition and measurement of insight. This study endeavored to evaluate the psychometric properties of the Cognitive Obsessional Insight Scale (COGINS), a novel self-report measure of cognitive insight in OCRDs. The sample comprised 166 participants with a diagnosis of obsessive-compulsive disorder or body dysmorphic disorder enrolled in clinical trials. Participants completed the COGINS and a questionnaire battery at baseline and posttreatment. The COGINS demonstrated good internal consistency, test-rest reliability, convergent validity with other OCRD-specific measures of insight, positive associations with OCRD symptomatology, and had a moderating effect on treatment response. The COGINS is a valid and reliable practical tool to measure cognitive insight in OCRDs and might help toward clarifying the role of cognitive insight in this population.

'Excessive and Unreasonable': The Relation Between Clinical Insight and Clinical Correlates and Treatment Outcomes in Obsessive-Compulsive Disorder Across the Life Course

Individuals with mental disorders possess varying levels of clinical insight-the degree to which one understands that they are afflicted with a mental disorder and that their symptoms are manifestations of this psychopathology. Although clinical insight in OCD is thought to play an especially important role in determining various clinical characteristics and treatment outcomes, insight has not been sufficiently addressed developmentally, the importance of which this review will elucidate. Findings from this review suggest that clinical insight is typically associated with more complex cases and worse treatment outcomes across the life course, and also reveal nuances between pediatric and adult OCD cases with low insight. Implications of these findings, future research directions, and recommendations for the field are discussed.

Association between obsession, compulsion, depression and insight in obsessive-compulsive disorder: a meta-analysis

BACKGROUND

Previous studies examining potential relationships of impaired insight with severity obsessive-compulsive (O-C) symptoms and depressive symptoms in patients diagnosed with obsessive-compulsive disorder (OCD) have produced mixed results. Here, we examined differences in these clinical characteristics and their changes after treatment in adult patients with OCD who have poor insight (OCD-PI) versus in those who have good insight (OCD-GI).

METHODS

Fifty-nine full-text articles were screened for eligibility with 20 studies ultimately being included in the present meta-analysis.

RESULTS

The OCD-PI and OCD-GI groups differed from each other with respect to O-C symptom (p < 0.001, g > 0.7) and depressive symptom (p < 0.001, g = 0.614) severity. Significant and moderate correlations were observed between insight and treatment outcomes (O-C symptoms, r = 0.33; depressive symptoms, r = 0.47). Exploratory meta-regression showed that methodological factors influenced the magnitudes of inter-group O-C symptom differences.

CONCLUSIONS

The current meta-analysis indicates that poorer insight is associated with more severe O-C and depression, and less improvement of symptoms in patients with OCD. Insight impairment may be a critical and core OCD-related deficit.

Intact capacity for implicit learning in obsessive-compulsive disorder

BACKGROUND AND OBJECTIVES

Individuals with OCD tend to rely on explicit processing when performing implicit learning tasks. However, it is unclear whether this tendency reflects impaired capacity for implicit processing or a preference toward explicit processing. We sought to use a psychometrically valid task to examine the hypothesis that individuals with OCD have intact capacity for implicit learning.

METHODS

Twenty-four participants with OCD and 24 non-psychiatric controls completed a modified artificial grammar learning task where acquisition and retrieval of the underlying grammatical rules are considered strictly implicit. In an exploratory condition designed to examine the effect of nudging participants toward controlled processing, 12 participants in each group were told that the stimuli presented at acquisition were composed according to grammatical rules and were encouraged to identify these rules.

RESULTS

As predicted, participants with OCD acquired and expressed knowledge of the grammatical rule, demonstrating intact capacity for implicit learning, with no differences found between the OCD and controls on the extent of implicit learning. The exploratory intentional learning instructions had no effect, as participants in this condition were unable to adhere to the instructions, supporting the robust implicit nature of the artificial grammar learning task.

LIMITATIONS

The relatively small sample size did not allow comparisons between OCD symptom subtypes.

CONCLUSIONS

Our results provide evidence for intact implicit learning in OCD, and challenge previous studies suggesting a general deficiency in implicit learning in OCD.

Insight in Obsessive-Compulsive Disorder: Relationship With Sociodemographic and Clinical Characteristics

Insight is considered a multidimensional concept and, in the context of obsessive-compulsive disorder (OCD), impairment in insight has been widely reported to be associated with severity and other clinical and sociodemographic variables. However, the studies concerning insight in OCD have produced heterogenous data as a result of the scales used to measure insight. To overcome this heterogeneity, the study presented here used 4 different widely used and validated insight scales. The objective was to evaluate various aspects of insight using these scales to identify the relationships between different aspects of insight and clinical and sociodemographic variables to assess which scale or scales might possess greater efficiency in clinical practice. For this purpose, a descriptive, observational, and cross-sectional study of 81 patients in treatment in a mental health center was conducted. Patients were evaluated using the Brown Assessment of Beliefs Scale, the Overvalued Ideas Scale, the Scale of Unawareness of Mental Disorders, the Yale-Brown Obsessive Compulsive Scale, the Clinical Global Impressions Scale, the Global Assessment of Functioning Scale, and the Rey-Osterrieth Complex Figure Test. The results reported significant relationships between insight and scores on the Yale-Brown Obsessive Compulsive Scale (Thoughts, Compulsions, and Total scales), Clinical Global Impressions Scale, and the Global Assessment of Functioning Scale, and significant differences with regard to sex, level of education, working status, and course of the disorder. A correlation analysis was conducted to assess the relationships among the 4 insight scales. The results of this analysis suggest that the scales that measure insight in a multidimensional way (Brown Assessment of Beliefs Scale and Overvalued Ideas Scale) provide more information about the severity of the disorder in patients with OCD.

Poor insight in obsessive compulsive disorder (OCD): Associations with empathic concern and emotion recognition

PURPOSE

Insight is currently considered to be responsible for 20% to 40% of the cases of ineffective obsessive-compulsive disorder (OCD) treatment. As 15% to 36% of patients with OCD have reduced insight, we aimed to identify some of the clinical determinants of insight in OCD.

RESULTS

Our sample consisted of 57 OCD patients, of which 34 men (59%) and 23 women (41%). All individuals completed a two-phase interview consisting of a clinical assessment, emotional awareness evaluation and insight measurement, using the Brown Assessment of Beliefs Scale (BABS). The insight score correlated significantly with negative emotion recognition (p < 0.0001) and empathic concern (p = 0.003).

MAJOR CONCLUSIONS

Our results support the hypothesis that insight in OCD is related to emotional awareness, specifically emotion recognition and empathic concern. Future research should investigate the extent to which poor insight and impaired emotional awareness can be modified by psychological or pharmacological therapies and whether this will enhance treatment response.

Concordance of assessment of insight by different measures in obsessive-compulsive disorder: An outpatient-based study from India

AIMS

This study aimed to examine the (a) prevalence of various levels of insight among patients with obsessive-compulsive disorder (OCD) and (b) correlation of insight specifier (Diagnostic and Statistical Manual [DSM]-5) and other established measures of insight in OCD.

METHODS

One hundred and twenty-five outpatients with a diagnosis of OCD were assessed by Brown Assessment of Beliefs Scale (BABS) and DSM-IV's insight specifier. The insight specifier of DSM-5 was determined by item one ("conviction") of BABS. Dimensional Yale-Brown Obsessive-Compulsive Severity Scale was used to assess the frequency and severity of dimensional obsessive-compulsive (OC) symptoms.

RESULTS

The mean age of the participants was 31.2 (±11) years. Seventy-seven (61.6%) of the participants were men. There was a high correlation (r = 0.73) between the insight specifiers of DSM-5 and DSM-IV. Insight categories of DSM-5 had modest correlations with BABS total score and BABS-based insight categories. Significant associations were observed between the level of insight and comorbid psychotic illness, hoarding and symmetry dimensions of OC symptoms, severity of depressive, and OC symptoms. The first two associations were consistent across group comparisons (insight-groups based on DSM-IV and BABS) and correlation (with total BABS score).

CONCLUSIONS

Majority of the patients with OCD have good insight and application of different tools influence the assessment of insight in OCD. The DSM-5 insight specifier has strong and significant correlation with the DSM-IV's insight classification and categorization of insight by BABS.

Changes in the daily life experience of patients with obsessive-compulsive disorder following mindfulness-based cognitive therapy: Looking beyond symptom reduction using ecological momentary assessment

The current study examines changes in daily life experiences following mindfulness-based cognitive therapy (MBCT) in a sample of 38 patients with obsessive-compulsive disorder (OCD) and residual symptoms following cognitive behavioral therapy (CBT). Participants were randomized to either an MBCT group (n = 17), or to a psychoeducational group (OCD-EP; n = 21) as an active control condition. Both groups underwent ecological momentary assessment (EMA) six times a day for a period of six consecutive days pre- and posttreatment. Contrary to hypotheses, MBCT participation did not, when compared to OCD-EP, result in significant changes of positive affect, negative affect, acceptance of momentary emotions, or distress associated with obsessive-compulsive (OC) symptoms. In fact, insight into the unreasonableness of OC symptoms improved significantly more in the OCD-EP group compared to MBCT. However, in the MBCT group, the presence of momentary OC symptoms at post assessment predicted increased insight, which indicates an improved ability to detach from OC symptoms in the moments in which they occur. All in all, however, results do not indicate favorable changes in everyday life experiences of OCD patients following MBCT. Owing to the modest sample size, results must be considered preliminary. Implications and directions for future research are discussed.

Mindfulness predicts insight in obsessive-compulsive disorder over and above OC symptoms: An experience-sampling study

Insight in obsessive-compulsive disorder (OCD) is assumed to fluctuate over time. However, temporal variations of insight and its correlates in OCD have never been empirically studied. We used ecological momentary assessment (EMA) to analyze the temporal variation of insight into the unreasonableness of the threat-related core belief (1), into the senselessness of compulsions to prevent this belief from occurring (2), and into the belief, itself, as being due to OCD (3). Furthermore, we analyzed whether worry, self-punishment and mindfulness are associated with these aspects of insight. A total of 50 OCD patients underwent EMA 10 times a day over 6 consecutive days. Data were analyzed using multilevel modelling. Results revealed that multiple time-points within individuals accounted for up to 51.4% of insight variance, indicating a substantial fluctuation of insight over time. Root mean square successive difference (rMSSD) scores indicated significantly higher fluctuation patterns in the doubt/checking dimension as compared to taboo thoughts throughout all aspects of insight. As hypothesized, self-punishment and mindfulness significantly predicted insight into the unreasonableness of the threat-related belief and the senselessness of compulsions to prevent this belief from occurring. Mindfulness demonstrated the greatest predictive value and remained significant after controlling for OC symptoms. Contrary to expectation, worry, as it was measured in our study, was not associated with insight. Besides providing evidence for insight fluctuation, our results indicate that mindfulness-based strategies might be beneficial for increasing insight in OCD.

Utilizing Exposure and Response Prevention to Address Poor Insight in Obsessive-Compulsive Disorder

Studies indicate that approximately 9%-30% of adults diagnosed with obsessive-compulsive disorder have poor insight into their symptoms. That is, they fail to recognize the excessiveness or irrationality of the obsessive thoughts or their compulsive behaviors. Poor insight in OCD is associated with more severe symptoms, earlier age of illness onset, longer illness duration, and higher rates of comorbid depression. Moreover, some studies have also reported that patients with poor insight are less likely than are those with good or fair insight to respond to first-line treatments such as exposure and response prevention (ERP). Despite the clinical relevance of poor insight, very little research has focused on how to enhance therapy with strategies specifically used to target it. In this report, we use a case study to demonstrate how different techniques can be emphasized or integrated with standard ERP to improve treatment outcomes for this subset of patients.

Relationship between social-cognitive and social-perceptual aspects of theory of mind and neurocognitive deficits, insight level and schizotypal traits in obsessive-compulsive disorder

OBJECTIVE

The primary aim of the current study was to investigate different aspects of theory of mind (ToM), including social-cognitive (ToM-reasoning) and social-perceptual (ToM-decoding) in obsessive-compulsive disorder (OCD). We also aimed to investigate the relationship between ToM, neurocognition and a number of clinical variables including overvalued ideas, schizotypal personality traits, level of insight, and disease severity.

METHOD

Thirty-four patients who have been diagnosed with OCD according to DSM-IV and 30 healthy controls were included in the study. All participants were given a neuropsychological battery including tasks measuring ToM-reasoning, ToM-decoding and other neurocognitive functions. Schizotypal Personality Questionnaire (SPQ), Yale Brown Obsession and Compulsion Scale (YBOC-S) and Overvalued Ideas Scale (OVIS) were also administered to the participants.

RESULTS

Patients with OCD showed significant deficits in both aspects of ToM. ToM performances of patients showed a significant positive correlation with neurocognitive functions. When controlled for general cognition factor, patient-control difference for ToM-reasoning (F = 3,917; p = 0,05), but not ToM-decoding, remained statistically significant. ToM-reasoning impairment of patients was significantly related to the severity of OCD symptoms and poor insight (p = 0,026 and p = 0,045, respectively). On the other hand, general cognitive factor (β = 0,778; t = 3,146; p = 0,04) was found to be the only significant predictor of ToM-reasoning in OCD patients in the multiple linear regression model.

CONCLUSION

OCD is associated with ToM impairment, which is related to schizotypal traits, disease severity and poor insight, yet neurocognitive deficits also significantly contribute to this finding. However, ToM-reasoning impairment could be considered as a relatively distinct feature of OCD, which is partly separate from general cognitive deficits.

The relationship between clinical characteristics, metacognitive appraisals, and cognitive insight in patients with obsessive-compulsive disorder

BACKGROUND

Cognitive insight, a recently developed insight measure, refers to metacognitive processes of the re-evaluation and correction of distorted beliefs and misinterpretations. However, to the best of the authors' knowledge, no study has specifically examined cognitive insight, demographics, psychopathological variables, and distorted beliefs in OCD.

AIM

The aim of this research was to examine links between cognitive insight and demographics, clinical factors, and distorted beliefs among patients with OCD.

METHOD

Eighty-four consecutive outpatients with a diagnosis of OCD underwent a detailed clinical assessment for OCD, including the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Cognitive Insight Scale (BCIS), Thought-Action Fusion Scale (TAFS), White Bear Thought Suppression Inventory, Metacognition Questioniarre-30 (MCQ-30), and a sociodemographic questionnaire. In addition, 82 control subjects matched for age, education, and gender were tested.

RESULTS

BCIS-self-certainty scores were all substantially higher in subjects with remitted and unremitted OCD than in healthy comparison subjects, while BCIS-composite scores were significantly lower in both patient groups than controls. Obsession and compulsion severity had significant effects on BCIS scores. In addition, it was found that the specific symptoms were linked to self-certainty scores. Self-reflectiveness and composite scores had positive correlations with the sub-scale scores of the MCQ-30, while the TAF-morality score was positively correlated with self-certainty scores.

CONCLUSION

The results demonstrated poor cognitive insight among remitted and unremitted OCD patients. In addition, the present study suggested significant associations between sociodemographic and clinical features and dysfunctional appraisals. Cognitive-behavioural techniques aimed at enhancing cognitive insight may be beneficial for patients with OCD, particularly patients who have prominent dysfunctional beliefs.

Phenomenology of OCD: lessons from a large multicenter study and implications for ICD-11

This study aimed to investigate the phenomenology of obsessive-compulsive disorder (OCD), addressing specific questions about the nature of obsessions and compulsions, and to contribute to the World Health Organization's (WHO) revision of OCD diagnostic guidelines. Data from 1001 patients from the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders were used. Patients were evaluated by trained clinicians using validated instruments, including the Dimensional Yale-Brown Obsessive-Compulsive Scale, the University of Sao Paulo Sensory Phenomena Scale, and the Brown Assessment of Beliefs Scale. The aims were to compare the types of sensory phenomena (SP, subjective experiences that precede or accompany compulsions) in OCD patients with and without tic disorders and to determine the frequency of mental compulsions, the co-occurrence of obsessions and compulsions, and the range of insight. SP were common in the whole sample, but patients with tic disorders were more likely to have physical sensations and urges only. Mental compulsions occurred in the majority of OCD patients. It was extremely rare for OCD patients to have obsessions without compulsions. A wide range of insight into OCD beliefs was observed, with a small subset presenting no insight. The data generated from this large sample will help practicing clinicians appreciate the full range of OCD symptoms and confirm prior studies in smaller samples the degree to which insight varies. These findings also support specific revisions to the WHO's diagnostic guidelines for OCD, such as describing sensory phenomena, mental compulsions and level of insight, so that the world-wide recognition of this disabling disorder is increased.

[Obsessive-compulsive disorders in DSM-5 – what is new?]

Obsessive-compulsive disorders are a frequent and debilitating condition also in children and adolescents. The present paper summarizes the changes in the DSM diagnostic criteria between the IV-TR edition and the DSM-5 edition, and evaluates them critically. A central feature is the revision of the category to which these disorders belong: Obsessive-Compulsive Disorders are no longer considered to be anxiety disorders, but rather now comprise an independent category encompassing a broader spectrum of obsessive-compulsive and related disorders. Minor changes have been made to the description of the criteria, and there is a new emphasis on the clinical assessment of the patient's insight level (good, poor, absent). Obsessive-compulsive disorders associated with tic disorders are classified as a separate subtype. The present paper discusses these changes on the basis of the available studies and literature, and then looks ahead to the implementation of the new criteria in the everyday clinical setting and in research.

Insight in adults with obsessive-compulsive disorder

The present study examined the clinical correlates of insight among adults with obsessive-compulsive disorder (OCD). One hundred and thirty treatment-seeking adults with a primary diagnosis of OCD, aged 18 to 68 years (mean 31.4 years) participated. Measures of clinical severity, obsessive-compulsive symptom dimensions, anxiety symptoms, depressive symptoms, and ability to resist and control OCD symptoms were obtained. Results indicated that poor insight was positively related to greater OCD symptom severity and poorer ability to resist and control OCD symptoms; this pattern of associations held when insight was examined continuously and categorically (i.e., high versus low insight). Insight was generally not associated with other clinical characteristics, except for a relationship with mental neutralizing behaviors. Insight did not mediate the relationship between the ability to resist and control OCD symptoms and obsessive-compulsive symptom severity. Overall, this study provides further information into the nature and role of insight in adults with OCD.

A comparison of insight in body dysmorphic disorder and obsessive-compulsive disorder

Insight/delusionality of beliefs is an important dimension of psychopathology across psychiatric disorders. This construct is of increasing interest in obsessive-compulsive and related disorders, including obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). Even though OCD and BDD are considered closely related, no prior study has compared these disorders across a range of categories of global insight (excellent, good, fair, poor, absent/delusional), and only one study has compared these disorders on individual components of insight. Using the reliable and valid Brown Assessment of Beliefs Scale (BABS), this study examined insight/delusionality of OCD- or BDD-related beliefs in 211 individuals with primary OCD versus 68 individuals with primary BDD. In both disorders, levels of insight spanned the full range, from excellent to absent (i.e., delusional beliefs). However, the distribution of BABS scores across insight categories differed significantly by disorder, with the majority of OCD subjects showing excellent or good insight, and the majority of BDD subjects showing poor or absent insight. Compared to OCD subjects, BDD subjects had significantly poorer insight both overall (total BABS score) and on all individual BABS items. BABS score was significantly correlated with BDD and OCD severity, but in regressions it accounted for only 21% of the variance in OCD and 28% in BDD. In summary, both global insight and its individual components are poorer in BDD than in OCD, which has implications for research and clinical care, as well as understanding of the relationship between these disorders. Disorder severity is associated with but not equivalent to insight/delusionality.