Relationship between cognition, clinical and cognitive insight in psychotic disorders: a review and meta-analysis

Predictors of clinical insight in first-episode psychosis: Different patterns in men and women

BACKGROUND

We aimed to explore gender-related differences in the associations of insight impairment with clinical symptoms, metacognition, and social cognition in psychosis.

METHODS

Regression analysis of several clinical insight dimensions was conducted on the data from 116 men and 56 women with first-episode psychosis. Various clinical symptoms and measures of metacognition and social cognition were entered as predictors.

RESULTS

In both men and women, delusions emerged as a strong predictor of all insight dimensions, and verbal hallucinations as a strong predictor of symptom relabelling. In men, certain negative symptoms as well as self-certainty, lack of self-reflectiveness, impaired theory of mind, attributional biases, and a jumping-to-conclusions bias were additional predictors of poor insight, while good insight was associated with depression, anxiety, avolition, blunted affect, and impaired emotional recognition. In women, poor insight was associated with a self-serving/externalising bias, impaired emotional recognition, and attention disorders.

CONCLUSIONS

Poor insight in first-episode psychosis is strongly linked to deficits in metacognition and social cognition, with marked differences between men and women with respect to the specific skills involved in the impairment. Meanwhile, good insight is linked to a variety of affective manifestations in men. These findings suggest new avenues for more targeted cognitive interventions to improve clinical insight in psychosis.

Longitudinal characteristics of insight and clinical factors in patients with schizophrenia

AIMS

Schizophrenia is a psychiatric disorder presenting a lack of insight. Although insight changes over time, longitudinal studies of insight in schizophrenia are scarce. Furthermore, most previous studies on insight and intelligence have not measured full-scale IQ and have not been able to examine the relationship between detailed dimensions of cognitive function and insight. In this study, we assessed insight at two time points and assessed dimensions of cognitive function.

METHODS

A total of 163 patients with schizophrenia participated in the study. We evaluated insight at two time points to understand the patterns of change and examined the association between insight and clinical variables. Additionally, we examined the relationship between the dimensions of cognitive function and insight.

RESULTS

The patients were divided into three groups based on their change in insight over time: stable at a low level of insight (poor insight), stable at a high level of insight (good insight), and changed in insight over time (unstable insight). Those in the poor insight group had lower general intelligence scores than those in the good insight and unstable insight groups. Regarding cognitive function, verbal comprehension was associated with the level of insight at baseline and follow-up. Regarding psychiatric symptoms, the poor insight group exhibited more severe symptoms than the other two groups, especially regarding positive symptoms.

CONCLUSIONS

Our classification of patients based on changes in insight revealed that poor insight patients had impaired cognitive function, especially verbal comprehension, and more severe positive symptoms than good insight or unstable insight patients.

Clinical insight among persons with schizophrenia spectrum disorders treated with amisulpride, aripiprazole or olanzapine: a semi-randomised trial

BACKGROUND

Antipsychotic treatment may improve clinical insight. However, previous studies have reported inconclusive findings on whether antipsychotics improve insight over and above the reduction in symptoms of psychosis. These studies assessed homogeneous samples in terms of stage of illness. Randomised studies investigating a mixed population of first- and multiepisode schizophrenia spectrum disorders might clarify this disagreement.

METHODS

Our data were derived from a pragmatic, rater-blinded, semi-randomised trial that compared the effectiveness of amisulpride, aripiprazole and olanzapine. A sample of 144 patients with first- or multiepisode schizophrenia spectrum disorders underwent eight assessments during a 1-year follow-up. Clinical insight was assessed by item General 12 from the Positive and Negative Syndrome Scale (PANSS). We analysed latent growth curve models to test if the medications had a direct effect on insight that was over and above the reduction in total psychosis symptoms. Furthermore, we investigated whether there were differences between the study drugs in terms of insight.

RESULTS

Based on allocation analysis, all three drugs were associated with a reduction in total psychosis symptoms in the initial phase (weeks 0-6). Amisulpride and olanzapine were associated with improved insight over and above what was related to the reduction in total psychosis symptoms in the long-term phase (weeks 6-52). However, these differential effects were lost when only including the participants that chose the first drug in the randomisation sequence. We found no differential effect on insight among those who were antipsychotic-naïve and those who were previously medicated with antipsychotics.

CONCLUSIONS

Our results suggest that antipsychotic treatment improves insight, but whether the effect on insight surpasses the effect of reduced total psychosis symptoms is more uncertain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01446328, 05.10.2011.

Residual or re-emergent impaired insight into delusions following remission is unrelated to later relapse during a randomized clinical trial of continuation pharmacotherapy for psychotic depression - The STOP-PD II Study

BACKGROUND

Impaired insight into delusions is associated with a lower probability of remission of psychotic depression, independent of illness severity. The relationship between participant characteristics and impaired insight into delusions in remitted psychotic depression, and whether impaired insight is associated with risk of relapse of psychotic depression during continuation pharmacotherapy were examined.

METHODS

Data were analyzed from 126 participants in the STOP-PD II study who experienced sustained remission of psychotic depression during 8-week stabilization treatment with sertraline plus olanzapine and were then randomized to 36 weeks of continuation treatment with sertraline plus either olanzapine or placebo. Insight into delusions was assessed with the Resolution of Delusions Scale (RODS). Linear regression analyses examined the associations between participant characteristics and insight into delusions. Cox proportional-hazards models examined whether i) change in RODS during stabilization treatment; or ii) RODS at the end of stabilization treatment predicted risk of relapse during 36 weeks of continuation treatment.

RESULTS

Severity of psychosis before initiation of treatment was the only participant characteristic associated with the change in insight during stabilization treatment. Neither change in insight during stabilization treatment nor insight at the end of stabilization treatment was associated with risk of relapse.

LIMITATIONS

Insufficient statistical power and the lack of variability in RODS scores at the time of randomization may have contributed to the absence of a relationship between RODS and risk of relapse.

CONCLUSION

Residual or reemergent insight impairment following acute treatment does not preclude patients from sustaining remission of psychotic depression in a randomized placebo-controlled trial.

Correlates of poor insight: A comparative fMRI and sMRI study in obsessive-compulsive disorder and schizo-obsessive disorder

BACKGROUND

Despite the several researches on the correlates of insight in psychosis, less is known regarding the specificity of disease diagnosis on the relationship between insight and the correlates. The current study sought to explore the effects of insight and disease diagnosis on those in patients with obsessive-compulsive disorder (OCD) and patients with schizo-obsessive disorder (SOD).

METHODS

We evaluated clinical symptoms and neurocognitions among 111 patients (including 41 OCD with good insight, 40 OCD with poor insight, 14 SOD with good insight and 16 SOD with poor insight. Gray matter volume and spontaneous neural activity were also examined by analyzing the voxel-based morphometry and amplitude of low frequency fluctuation (ALFF), respectively.

RESULTS

Interactive effects of insight and diagnosis was found on working memory and the gray matter volume in right superior and middle temporal gyrus. Main effect of insight was found on working and visual memory, compulsion and obsession, and ALFF in right middle and superior occipital cortex. Main effect of diagnosis was found on severity of compulsion, relative verbal IQ, executive function, verbal and visual memory, working memory and ALFF in precuneus, medial superior frontal gyrus, anterior cingulate and paracingulate gyri, and inferior parietal, postcentral gyrus, paracentral lobule.

CONCLUSIONS

As a common feature in mental disorders, insight has its own special influence on neurocognition and possible structural/functional alterations in brain, and the influence is partly dependent of disease diagnosis.

Relationships between cognitive performance, clinical insight and regional brain volumes in schizophrenia

Impairments in cognitive performance are common in schizophrenia, and these contribute to poor awareness of symptoms and treatment (‘clinical insight’), which is an important predictor of functional outcome. Although relationships between cognitive impairment and reductions in regional brain volumes in patients are relatively well characterised, less is known about the brain structural correlates of clinical insight. To address this gap, we aimed to explore brain structural correlates of cognitive performance and clinical insight in the same sample. 108 patients with schizophrenia (SZH) and 94 age and gender-matched controls (CON) (from the Northwestern University Schizophrenia Data and Software Tool (NUSDAST) database) were included. SZH had smaller grey matter volume across most fronto-temporal regions and significantly poorer performance on all cognitive domains. Multiple regression showed that higher positive symptoms and poorer attention were significant predictors of insight in SZH; however, no significant correlations were seen between clinical insight and regional brain volumes. In contrast, symptomology did not contribute to cognitive performance, but robust positive relationships were found between regional grey matter volumes in fronto-temporal regions and cognitive performance (particularly executive function). Many of these appeared to be unique to SZH as they were not observed in CON. Findings suggest that while there exists a tight link between cognitive functioning and neuropathological processes affecting gross brain anatomy in SZH, this is not the case for clinical insight. Instead, clinical insight levels seem to be influenced by symptomology, attentional performance and other subject-specific variables.

Clinical insight in first-episode psychosis: Clinical, neurocognitive and metacognitive predictors

OBJECTIVE

Poor insight is a major problem in psychosis, being detrimental for treatment compliance and recovery. Previous studies have identified various correlates of insight impairment, mostly in chronic samples. The current study aimed to determine clinical, neurocognitive, metacognitive, and socio-cognitive predictors of insight in first-episode psychosis.

METHODS

Regression analyses of different insight dimensions were conducted in 190 patients with first-episode psychosis. Measures of clinical symptoms, neurocognition, metacognition, social cognition, and 'jumping to conclusions' bias were entered as predictors.

RESULTS

Delusions, disorganisation, and certain negative symptoms were associated with unawareness in various domains, while depression was associated with greater awareness of illness. Deficit in theory of mind and self-reflective processes, as well as a 'jumping to conclusions' bias, contributed to poor insight. Several neuropsychological scores also contributed to this but their contribution was no longer observed in regression analyses that included all the previously identified clinical and cognitive predictors. A measure of perseverative errors was still associated with unawareness and misattribution of symptoms.

CONCLUSION

In models that account for 28 % to 50 % of the variance, poor insight in first-episode psychosis is mainly associated with delusions and certain negative symptoms. At the cognitive level it does not appear to result from neuropsychological impairment but rather from altered reasoning bias and dysfunction in metacognitive processes. Therapeutic strategies specifically directed at these mechanisms could help improve the evolution of insight in first episode psychosis.

Relationships Between Multiple Dimensions of Insight and Neurocognition, Metacognition, and Social Cognition: A Meta-Analysis

ABSTRACT

Insight is a complex and multidimensional concept, and has a complex relationship with cognition. A meta-analysis of 102 studies of 9396 patients was conducted to determine the magnitude of the relationship between insight and neurocognition, higher-order cognition in multiple mental disorders. Insight has been found moderately related to higher-order cognition, but only weakly related to neurocognition. The different relationship has been found between the dimensions of insight and higher-order cognition. Almost none of the correlational coefficients of insight and cognitive domains were found to differ significantly among the different diagnostic groups. In conclusion, insight may be essentially related to higher-order cognition, but not to neurocognition. The orientation and expression of different dimensions of insight might be different, and the relationship of insight and cognition might not be explained by specific diagnosis.

The puzzle of quality of life in schizophrenia: putting the pieces together with the FACE-SZ cohort

BACKGROUND

The determinants of quality of life (QoL) in schizophrenia are largely debated, mainly due to methodological discrepancies and divergence about the concepts concerned. As most studies have investigated bi- or tri-variate models, a multivariate model accounting for simultaneous potential mediations is necessary to have a comprehensive view of the determinants of QOL. We sought to estimate the associations between cognitive reserve, cognition, functioning, insight, depression, schizophrenic symptoms, and QoL in schizophrenia and their potential mediation relationships.

METHODS

We used structural equation modeling with mediation analyses to test a model based on existing literature in a sample of 776 patients with schizophrenia from the FondaMental Foundation FACE-SZ cohort.

RESULTS

Our model showed a good fit to the data. We found better functioning to be positively associated with a better QoL, whereas better cognition, better insight, higher levels of depression, and schizophrenic symptoms were associated with a lower QoL in our sample. Cognitive reserve is not directly linked to QoL, but indirectly in a negative manner via cognition. We confirm the negative relationship between cognition and subjective QoL which was previously evidenced by other studies; moreover, this relationship seems to be robust as it survived in our multivariate model. It was not explained by insight as some suggested, thus the mechanism at stake remains to be explained.

CONCLUSION

The pathways to subjective QoL in schizophrenia are complex and the determinants largely influence each other. Longitudinal studies are warranted to confirm these cross-sectional findings.

Patients and physician’s self-assessment regarding clinical stability in severe mental disorders: a cross-sectional study

ABSTRACT Objective This study explores the relationship between patients’ self-assessment and physicians’ evaluation regarding clinical stability. Methods This cross-sectional study was carried out at the general outpatient clinic of the Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB-UFRJ) in a large sample (1,447) of outpatients, of which 67.9% were patients with severe mental disorders (SMD). We collected information using a structured questionnaire developed for this purpose, filled in by the patient’s physician. Clinical stability was assessed by means of five psychiatric instability criteria and by the physician’s global clinical impression over the six previous months. The patients’ self-assessment was based on a question about how they evaluated their health status: stable/better, worse, does not know. For the analyses, patients’ self-evaluation was considered as our standard. Results The sample was composed of 824 (57%) women with an average age of 49 years. The most prevalent diagnoses within the SMD category corresponded to 937 patients, of whom 846 (90.3%) assessed themselves as stable/better. The physicians’ evaluations agreed more with patients with bipolar disorders and less with schizophrenics regarding stability. As for patients with depressive disorder, physicians agreed more with them regarding instability. Conclusion The data analysis confirms our hypothesis that the self-assessment made by patients with SMD was accurate regarding their health condition, and that the self-assessment made by patients who considered themselves stable agree with the physicians’ evaluation.

Investigating the Contribution of Decision-Making, Cognitive Insight, and Theory of Mind in Insight in Schizophrenia: A Cross-Sectional Study

INTRODUCTION

Insight in schizophrenia spectrum disorders (SSD) is associated with outcomes. Although the neurocognitive basis of insight is widely accepted, the specific contribution of decision-making (Jumping to Conclusions [JTC]), Cognitive Insight (CI), and Theory of Mind (ToM) to insight remains unclear.

METHODS

The sample included N = 77 SSD outpatients aged 18-64 years from a randomized controlled trial of metacognitive training. Assessments included JTC-Beads Task, CI-Beck Cognitive Insight Scale, ToM-Hinting Task, and the Emotions Recognition Test Faces.

STATISTICS

hierarchical multivariable linear regression models tested their contribution to total insight (TI) and three insight dimensions - illness recognition (IR), symptom relabelling (SR), and treatment compliance (TC) - measured with the Schedule for the Assessment of Insight - Expanded version, whilst adjusting for potential confounders.

RESULTS

Bivariate analyses showed that CI was associated with TI (R2 change = 0.214; p < 0.001), IR (R2 change = 0.154; p = 0.003), and SR (R2 change = 0.168; p = 0.003), while JTC predicted IR (R2 change = 0.790; p = 0.020). Multivariable regression models showed that CI predicted TI (R2 change = 0.116; p = 0.036) and SR (R2 change = 0.166, p = 0.011), whereas JTC was linked with IR (R2 change = 0.710; p = 0.026). ToM was not linked with any insight score. No cognitive variable was associated with treatment compliance.

DISCUSSION

Results supported the (meta)cognitive model of insight in SSD. JTC and CI emerged as the main (meta)cognitive processes underlying insight. Metacognitive interventions may therefore improve insight in SSD, although these therapies alone may fail to address treatment compliance.

Cognitive impairment in people with schizophrenia: an umbrella review

Cognitive impairment is one of the core symptoms of schizophrenia. Quite a number of systematic reviews were published related to cognitive impairment in people with schizophrenia (PWS). This umbrella review, therefore, aimed at reviewing and synthesizing the findings of systematic reviews related to domains of cognition impaired and associated factors in PWS. We searched four electronic databases. Data related to domains, occurrence, and associated factors of cognitive impairment in PWS were extracted. The quality of all eligible systematic reviews was assessed using A MeaSurement Tool to Assess methodological quality of systematic Review (AMSTAR) tool. Results are summarized and presented in a narrative form. We identified 63 systematic reviews fulfilling the eligibility criteria. The included reviews showed that PWS had lower cognitive functioning compared to both healthy controls and people with affective disorders. Similar findings were reported among psychotropic free cases and people with first episode psychosis. Greater impairment of cognition was reported in processing speed, verbal memory, and working memory domains. Greater cognitive impairment was reported to be associated with worse functionality and poor insight. Cognitive impairment was also reported to be associated with childhood trauma and aggressive behaviour. According to our quality assessment, the majority of the reviews had moderate quality. We were able to find a good number of systematic reviews on cognitive impairment in PWS. The reviews showed that PWS had higher impairment in different cognitive domains compared to healthy controls and people with affective disorders. Impairment in domains of memory and processing speed were reported frequently.

Insight Into Illness and Psychological Defense Attitudes in People With Chronic Schizophrenia Using Markova's Insight Scale

ABSTRACT

Insight into illness is a multidimensional phenomenon, and various assessments are available. We focused on Markova's Insight Scale (IS) and investigated the relationship between insight, psychological defenses, and neurocognition in 38 patients with schizophrenia. Results showed that insight was significantly correlated with an immature defense style. Moreover, IS was significantly predicted by immature defense style after adjusting for clinical variables. Although insight is often assumed to be multidetermined with potential contributions from factors such as cognitive function and psychological defensive mechanisms, our results indicated that better insight assessed with the IS is more likely to reflect immature defenses. This may also be reflected in our result that a higher insight score correlated with earlier onset of illness. The insight score may reflect the immature psychological defensive attitudes of schizophrenia and may lead such patients to wish to comply with the views of clinicians.

Moderators of cognitive insight outcome in metacognitive training for first-episode psychosis

Metacognitive training (MCT) is a promising treatment for improving cognitive insight associated with delusional beliefs in individuals with psychotic disorders. The aim of this study was to examine potential moderators of cognitive insight in individuals with first-episode psychosis (FEP) who received either MCT or psychoeducation. The present study was based on data from a randomized control trial comparing MCT to psychoeducation. Baseline sociodemographic and clinical characteristics in a sample of 122 patients with FEP were examined as potential moderators of the self-reflectiveness and self-certainty dimensions of cognitive insight using the SPSS PROCESS macro. The only variable that moderated self-reflectiveness at the post-treatment evaluation was age of onset (b = -0.27, p = .025). The effect of MCT in reducing self-certainty was stronger in women (b = -3.26, p = .018) and in individuals with average or above average baseline self-esteem (b = -0.30, p = .007). Overall, our findings support the generalization of MCT to a variety of sociodemographic and clinical profiles. While some patient profiles may require targeted interventions such as MCT to improve cognitive insight, others may do equally as well with less demanding interventions such as a psychoeducational group.

Clinical insight, cognitive insight and metacognition in psychosis: Evidence of mediation

OBJECTIVE

Schizophrenia is increasingly understood as an interactive network of disturbances in different elements of self-awareness. In this study we have examined the relationship between disturbances in two forms of awareness: cognitive insight and clinical insight by exploring whether their relationship is mediated by a third form of larger awareness: metacognition.

METHODS

Participants were 41 outpatients with schizophrenia and 37 outpatients with early episode psychosis gathered in Moscow, Russia. Metacognition was assessed with the Metacognition Assessment Scale - Abbreviated. Verbal memory and positive symptoms were assessed for use as additional mediators.

RESULTS

Mediation analyses revealed that after accounting for the effects of positive symptoms and verbal memory, the relationship between the self-reflection domain of cognitive insight and clinical insight was significantly mediated by overall metacognitive capacity. Further, positive symptoms were a significant mediator between the cognitive insight self-reflection domain and clinical insight. Neither metacognition nor positive symptoms or verbal memory were found to mediate the relationship of the cognitive insight domain of self-certainty with clinical insight.

CONCLUSIONS

Decrements in some forms of ability to reflect upon one's thinking may reduce the ability to form complex and integrated ideas of oneself and others, leading to less coherent and complete accounts of the experience of schizophrenia.

Insight does not come at random: Individual gray matter networks relate to clinical and cognitive insight in schizophrenia

BACKGROUND

Impaired clinical and cognitive insight are prevalent in schizophrenia and relate to poorer outcome. Good insight has been suggested to depend on social cognitive and metacognitive abilities requiring global integration of brain signals. Impaired insight has been related to numerous focal gray matter (GM) abnormalities distributed across the brain suggesting dysconnectivity at the global level. In this study, we test whether global integration deficiencies reflected in gray matter network connectivity underlie individual variations in insight.

METHODS

We used graph theory to examine whether individual GM-network metrics relate to insight in patients with a psychotic disorder (n = 114). Clinical insight was measured with the Schedule for the Assessment of Insight-Expanded and item G12 of the Positive and Negative Syndrome Scale, and cognitive insight with the Beck Cognitive Insight Scale. Individual GM-similarity networks were created from GM-segmentations of T1-weighted MRI-scans. Graph metrics were calculated using the Brain Connectivity Toolbox.

RESULTS

Networks of schizophrenia patients with poorer clinical insight showed less segregation (i.e. clustering coefficient) into specialized subnetworks at the global level. Schizophrenia patients with poorer cognitive insight showed both less segregation and higher connectedness (i.e. lower path length) of their brain networks, making their network topology more "random".

CONCLUSIONS

Our findings suggest less segregated processing of information in patients with poorer cognitive and clinical insight, in addition to higher connectedness in patients with poorer cognitive insight. The ability to take a critical perspective on one's symptoms (clinical insight) or views (cognitive insight) might depend especially on segregated specialized processing within distinct subnetworks.

Cognitive insight is correlated with cognitive impairments and contributes to medication adherence in schizophrenia patients

OBJECTIVE

Cognitive insight refers to the ability to distance oneself from and evaluate one's own beliefs and interpretations. Little is known about whether cognitive insight could influence medication adherence in schizophrenia patients. This study examined the role of cognitive insight in medication adherence and how it would interact with neuropsychological functions.

METHODS

Ninety clinically-stable schizophrenia patients completed the Beck's Cognitive Insight Scale (BCIS) and tasks measuring prospective (PM) and other neurocognitive functions. Medication adherence was estimated using a multi-axial method comprising interview, clinician-rating, pharmacy refill record and pill counting. Correlational and regression analyses were conducted to examine whether cognitive insight and PM would be associated with mediation adherence. Post-hoc mediational analysis was performed to examine the interplay between cognitive insight, PM and medication adherence.

RESULTS

Clinical insight and cognitive insight together significantly influenced participants' medication adherence, after neurocognitive functions and psychopathology were accounted for. Time-based PM, compared with other neurocognitive functions, affected medication adherence more strongly.

CONCLUSIONS

Cognitive insight complements clinical insight in affecting medication adherence in schizophrenia patients.

Cognitive insight, medication adherence and methamphetamine cessation in people enrolled in a pharmacotherapy trial for methamphetamine use

BACKGROUND

The current study examined correlates of cognitive insight in people enrolled in a methamphetamine pharmacotherapy trial; whether cognitive insight at the start of the trial predicted medication adherence and reductions in methamphetamine use during the trial; and, whether insight would remain stable over the trial or improve with reductions in methamphetamine use.

METHODS

A subset of people enrolled in a 12-week randomised placebo-controlled pharmacotherapy trial for methamphetamine dependence completed the Beck Cognitive Insight Scale, comprising subscales for Self-Reflection and Self-Certainty, at baseline (n = 152) and at week 12 (n = 79). Medication adherence was expressed as the percentage of non-missed doses measured using eCAP™ technology. Methamphetamine use days were assessed using the Timeline Followback.

RESULTS

At baseline, greater Self-Reflection was correlated with more severe methamphetamine withdrawal, and hostility, whereas Self-Certainty was correlated with less education and longer duration of methamphetamine use. No relationship was found between BCIS subscales at baseline and medication adherence (Self-Reflection b[SE] = -0.73 [0.43] p = .09; Self-Certainty b[SE] = -0.31 [0.48] p = .52,). Neither BCIS subscale was predictive of reduced methamphetamine use at 12 weeks (Self-Reflection b[SE] = 0.001 [0.01] p = .95 Self-Certainty b[SE] = -0.003 [0.01], p = .74). Self-Reflection decreased over the trial (t = 3.42, p = .001) but this was unrelated to change in methamphetamine use (Self-Reflection, b[SE] = -1.68 [1.16] p = .15) Change in methamphetamine use was found to be a significant predictor of Self-Certainty at 12 weeks (b [SE] = -2.71 [1.16] p = .02).

CONCLUSIONS

We found no evidence that cognitive insight predicted medication adherence or methamphetamine reduction in people engaged in this trial. Ongoing or increased methamphetamine use predicted increased Self-Certainty at 12 weeks.

Cognitive insight is associated with perceived body weight in overweight and obese adults

Background

Accurate perception of body weight is necessary for individuals with a high body mass index (BMI) to initiate strategies to improve their health status. Furthermore, identifying factors that influence accurate body weight perception can assist in designing appropriate educational and weight management programs. We therefore aimed to investigate whether levels of cognitive functioning and insight influence the ability to correctly judge body weight.

Methods

One hundred and eighty four overweight and obese adults who participated in a cross- sectional case-control study and were controls in the aforementioned study were included. The study was conducted in Cape Town, South Africa. Demographic, weight-related, neuropsychiatric, neurocognitive and cognitive insight measures were administered. Regression analysis was conducted to determine the factors associated with correct weight perception.

Results

The final regression model explained 52.3% of variation in accurate perception of body weight and was significant (p ≤ 0. 001). The model correctly classified 79.3% of individuals who were able to correctly and incorrectly judge their weight. Adults with higher BMI, and lower self-certainty, those who reported that they had gained weight in the previous year and those who were told by a healthcare professional to lose or maintain a healthy weight were more likely to correctly judge their weight.

Conclusion

Some aspects of cognitive insight (self-certainty) but not cognitive functioning were associated with perception of body weight in this sample. Awareness of recent weight changes, higher BMI and advice from of health care professionals were also significantly associated with perception of body weight, while demographic variables were not. Understanding the factors that contribute to the correct perception of weight is important in identifying appropriate health interventions that may address the burden of associated non-communicable diseases in overweight and obese individuals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10559-5.

Schizophrenia patients with poor clinical insight report less subjective memory problems

This study aimed to explore the relationships among clinical insight, subjective memory complaints, and objective memory performance in patients with schizophrenia. We recruited 205 patients with schizophrenia and 221 healthy controls in this study. The participants were administered a subjective-report scale on memory (the Prospective and Retrospective Memory Questionnaire), and several objective memory tasks measuring verbal memory, visual memory, and working memory. Clinical insight was measured with an item in the Positive and Negative Syndrome Scale. We found that when patients with schizophrenia were divided into subgroups with good and poor insight, both subgroups showed impairment in memory performance compared with controls. The schizophrenia patients with good insight reported similar memory complaints as controls whereas patients with poor insight reported less memory complaints than did the controls. These findings suggest that clinical insight may be related to subjective memory complaints, but not objective memory performance.

Co-occurring Deficits in Clinical and Cognitive Insight in Prolonged Schizophrenia-Spectrum Disorders: Relationship to Metacognitive Deficits

People diagnosed with schizophrenia have been broadly observed to experience deficits in clinical and cognitive insight; however, less is understood about how these deficits are related. One possibility is that these deficits co-occur among people when other deficits in cognition are present, such as in executive function, social cognition, and metacognition, which may either promote the development of both forms of poor insight or allow one to negatively influence the other. To explore this possibility, we conducted a cluster analysis using assessments of clinical and cognitive insight among 95 adults with a schizophrenia spectrum disorder. As predicted, this analysis yielded a group with concurrently poor clinical and cognitive insight (n = 36). Additional groups were found with concurrently good clinical and cognitive insight (n = 28) and poor clinical insight and good cognitive insight (n = 31). Groups were then compared on assessments of executive function, social cognition, and metacognition. The group with concurrently lower levels of cognitive and clinical insight had significantly poorer metacognition relative to the other groups. In particular, they tended to form more fragmented and less integrated ideas about themselves and others. No differences were found for executive function or social cognition. The result may suggest that while clinical and cognitive insight is partially orthogonal phenomena, relatively lower levels of metacognition, or difficulties forming integrated ideas about oneself and others, maybe a condition leading to the confluence of lower clinical and cognitive insight. Interventions targeting metacognition may be of particular use for this group.

Knowledge about schizophrenia, insight into illness, and internalized stigma and their associated factors among people diagnosed with schizophrenia in a long-term care facility

PURPOSE

This study assessed the level of knowledge about schizophrenia, insight into illness, and internalized stigma and their associated factors among patients with schizophrenia in Jordan.

DESIGN AND METHODS

A cross-sectional survey was conducted on 135 patients diagnosed with schizophrenia, who had been admitted to the largest psychiatric hospital in Jordan.

FINDINGS

The participants had a low level of knowledge, insight, and a high level of internalized stigma. No correlation was found between these variables. Meanwhile, the educational level and vacation were found to be predictors of knowledge.

PRACTICE IMPLICATIONS

This can help psychiatric nurses to identify which area needs to be improved to ensure the best service and care is provided to patients diagnosed with schizophrenia.

Association Between Lack of Insight and Prefrontal Serotonin Transporter Availability in Antipsychotic-Free Patients with Schizophrenia: A High-Resolution PET Study with [11C]DASB

BACKGROUND

Previous studies suggested a link between serotonergic neurotransmission and impaired insight in schizophrenia. In this study, we examined the relationship between serotonin transporter (SERT) availability in regions of the prefrontal cortex (dorsolateral, ventrolateral, ventromedial, and orbitofrontal cortices) and insight deficits in antipsychotic-free patients with schizophrenia using high-resolution positron emission tomography (PET) with [¹¹C]DASB.

METHODS

Nineteen patients underwent [¹¹C]DASB PET and 7-Tesla magnetic resonance imaging scans. To assess SERT availability, the binding potential with respect to non-displaceable compartment (BP_ND) was derived using the simplified reference tissue model. Patients' level of insight was assessed using the Insight and Treatment Attitude Questionnaire (ITAQ). The relationship between ITAQ scores and [¹¹C]DASB BP_ND values was examined using the region-of-interest (ROI)- and voxel-based analyses with relevant variables as covariates. The prefrontal cortex and its four subregions were selected as a priori ROIs since the prefrontal cortex has been implicated as the critical neuroanatomical substrate of impaired insight in schizophrenia.

RESULTS

The ROI-based analysis revealed that the ITAQ illness insight dimension had significant negative correlations with the [¹¹C]DASB BP_ND in the left dorsolateral, left orbitofrontal, and bilateral ventrolateral prefrontal cortices. The ITAQ treatment insight dimension had significant negative correlations with the [¹¹C]DASB BP_ND in the bilateral dorsolateral, left orbitofrontal, and bilateral ventrolateral prefrontal cortices. The ITAQ total score showed significant negative correlations with the [¹¹C]DASB BP_ND in the bilateral prefrontal cortex and three subregions (dorsolateral, ventrolateral, and orbitofrontal cortices). A supplementary voxel-based analysis corroborated a significant negative association between the ITAQ score and the [¹¹C]DASB BP_ND in the prefrontal cortices.

CONCLUSION

Our study provides in vivo evidence of significant negative correlations between insight deficits and prefrontal SERT availability in patients with schizophrenia, suggesting significant involvement of prefrontal serotonergic signaling in impaired insight, one of the core symptoms of schizophrenia.

Does the Beck Cognitive Insight Scale predict change in delusional beliefs?

OBJECTIVES

The Beck Cognitive Insight Scale (BCIS) is composed of two subscales, self-reflectiveness and self-certainty, assessing reflectiveness and openness to feedback, and mental flexibility. Delusions have previously been associated with low cognitive insight. The aim of this study was to determine whether changes in BCIS scores predict changes in delusional beliefs.

METHODS

The study is a secondary analysis of a previously published randomized controlled trial. All participants had a psychotic disorder diagnosis and received treatment as usual, with half of them also receiving the cognitive restructuring intervention 'Michael's game'. Participants were assessed at three different times: at baseline (T1), at 3 months (T2), and at 9 months (T3). Cognitive insight was measured with the BCIS, belief flexibility with the Maudsley assessment of delusions schedule (MADS), and psychotic symptoms with the Brief Psychiatric Rating Scale (BPRS).

RESULTS

A total of 172 participants took part in the trial. After using generalized estimating equation (GEE) modelling, we observed (1) significant main effects of BCIS self-certainty and Time and (2) significant Time × BCIS self-certainty and Time × treatment group interaction effects on belief flexibility. Improvements in self-certainty (i.e., decrease in scores) were associated with more changes in conviction over time, more accommodation, improved ability in ignoring or rejecting a hypothetical contradiction and increased use of verification of facts. Medication and BPRS total scores were controlled for in the GEE analyses at their baseline values.

CONCLUSIONS

Overall improvement in BCIS self-certainty scores over time predicted better treatment outcomes as assessed with MADS items.

PRACTITIONER POINTS

Treatments for patients with psychosis should focus on improving cognitive insight as this seems to improve overall treatment outcomes and recovery. The Beck Cognitive Insight Scale can be used to measure changes during treatment and can predict treatment outcomes.

Cognitive Insight in First-Episode Psychosis: Changes during Metacognitive Training

Background: Metacognitive training (MCT) has demonstrated its efficacy in psychosis. However, the effect of each MCT session has not been studied. The aim of the study was to assess changes in cognitive insight after MCT: (a) between baseline, post-treatment, and follow-up; (b) after each session of the MCT controlled for intellectual quotient (IQ) and educational level. Method: A total of 65 patients with first-episode psychosis were included in the MCT group from nine centers of Spain. Patients were assessed at baseline, post-treatment, and 6 months follow-up, as well as after each session of MCT with the Beck Cognitive Insight Scale (BCIS). The BCIS contains two subscales: self-reflectiveness and self-certainty, and the Composite Index. Statistical analysis was performed using linear mixed models with repeated measures at different time points. Results: Self-certainty decreased significantly (p = 0.03) over time and the effect of IQ was negative and significant (p = 0.02). From session 4 to session 8, all sessions improved cognitive insight by significantly reducing self-certainty and the Composite Index. Conclusions: MCT intervention appears to have beneficial effects on cognitive insight by reducing self-certainty, especially after four sessions. Moreover, a minimum IQ is required to ensure benefits from MCT group intervention.

Elucidating the relationship between internalized stigma, cognitive insight, illness severity, and functioning in patients with schizophrenia using a path analysis approach

BACKGROUND

There is a paucity of studies examining the interrelationship between internalized stigma, cognitive insight, illness severity, and functioning.

AIMS

This study examined the dynamics of the relationship between these factors using a path modelling approach.

METHODS

Two hundred and seven patients with schizophrenia spectrum disorders were recruited in this cross-sectional study. Patients were assessed on internalized stigma, cognitive insight (including its two domains, self-reflectiveness and self-certainty), illness severity and functioning. Path analysis was used to test the hypothesized model for the interrelationship between the variables.

RESULTS

A direct positive association was observed between self-certainty and internalized stigma. This was also observed via the paths running through illness severity and functioning. Self-reflectiveness was only associated with self-certainty in the model. The residual variance of internalized stigma in the path model was relatively high.

CONCLUSION

Our findings highlight that self-certainty is associated with internalized stigma along with illness severity and functioning in individuals with schizophrenia. Therefore, interventions on reduction of internalized stigma may benefit from a multipronged approach targeting self-certainty, illness severity and functioning. The relatively high residual variance of internalized stigma in the model highlights the need for further research to provide better understanding on the mechanisms underlying internalized stigma.

Overconfidence in social cognitive decision making: Correlations with social cognitive and neurocognitive performance in participants with schizophrenia and healthy individuals

It has been reported that people with schizophrenia are frequently overconfident relative to their performance, a trait observed in healthy individuals as well. In schizophrenia, impaired self-assessments have been found to be associated with functional impairments in various domains. Previous studies examining the correlation of overconfidence and task performance within domains (e.g., social cognition) had found overconfidence was associated with particularly poor performance. This study examines how overconfidence on a social cognitive emotion recognition task is correlated with performance on other social cognitive tests, measures of neurocognition, and intelligence. The sample includes 154 healthy controls and 218 outpatient individuals diagnosed with schizophrenia. For the healthy controls, overconfidence was a significant predictor of poorer performance on social cognitive, but not neurocognitive tasks. For the participants with schizophrenia, overconfidence was a predictor of poorer performance on every performance-based task. In addition, overconfidence in healthy controls was more strongly correlated with intelligence than it was in participants with schizophrenia. The data suggest that a bias toward overestimation of performance aligns with poorer performance social cognitive domains, as well as neurocognitive domains in participants with schizophrenia. In healthy individuals, consistent with previous results, lower general intelligence seems to be a substantial predictor of overconfidence. These data suggest that attention to the accuracy of self-assessment is an area for future clinical interventions in people with schizophrenia.

Exploring the relationship of insight with psychopathology and gender in individuals with schizophrenia spectrum disorders with structural equation modelling

To model the influence of psychopathology on insight deficits in schizophrenia spectrum patients with a gender-stratified analysis. Five hundred sixteen patients (65.1% men) with schizophrenia spectrum disorders were evaluated in four centres of the metropolitan area of Barcelona (Catalonia). Psychopathological assessment was performed using different PANSS factors. Insight and its three main dimensions were assessed by means of the Scale of Unawareness of Mental Disorder: awareness of the disease (SUMD-1), of the effect of medication (SUMD-2) and of the social consequences of the disease (SUMD-3). Structural equation models (SEMs) were used to fix the model in the total sample and by gender. Additional analyses included age, duration of illness (DOI) and education status (ES). There were no significant differences between men and women in the three main dimensions of insight. The SEMs in the total sample showed a modest fitting capacity. Fitting improved after a gender-stratified analysis (particularly in women). In men, positive and excited symptoms were associated with poorer insight in all SUMD dimensions, whereas depressive symptoms were associated with better insight. ES in men was also associated with better SUMD-2 or SUMD-3. In contrast, in women, symptoms did not have a negative effect on SUMD-1 or SUMD-2. However, positive symptoms were associated with a poorer SUMD-3, whereas depressive symptoms were associated with better SUMD-3. Moreover, education level was also associated with a better SUMD-3. A gender approach improved the comprehension of the model, supporting the relevance of gender analysis in the study of insight.

Can metacognitive interventions improve insight in schizophrenia spectrum disorders? A systematic review and meta-analysis

BACKGROUND

Patients with schizophrenia spectrum disorders (SSD) tend to lack insight, which is linked to poor outcomes. The effect size of previous treatments on insight changes in SSD has been small. Metacognitive interventions may improve insight in SSD, although this remains unproved.

METHODS

We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the effects of metacognitive interventions designed for SSD, namely Metacognitive Training (MCT) and Metacognitive Reflection and Insight Therapy (MERIT), on changes in cognitive and clinical insight at post-treatment and at follow-up.

RESULTS

Twelve RCTs, including 10 MCT RCTs (n = 717 participants) and two MERIT trials (n = 90), were selected, totalling N = 807 participants. Regarding cognitive insight six RCTs (n = 443) highlighted a medium effect of MCT on self-reflectiveness at post-treatment, d = 0.46, p < 0.01, and at follow-up, d = 0.30, p < 0.01. There was a small effect of MCT on self-certainty at post-treatment, d = -0.23, p = 0.03, but not at follow-up. MCT was superior to controls on an overall Composite Index of cognitive insight at post-treatment, d = 1.11, p < 0.01, and at follow-up, d = 0.86, p = 0.03, although we found evidence of heterogeneity. Of five MCT trials on clinical insight (n = 244 participants), which could not be meta-analysed, four of them favoured MCT compared v. control. The two MERIT trials reported conflicting results.

CONCLUSIONS

Metacognitive interventions, particularly Metacognitive Training, appear to improve insight in patients with SSD, especially cognitive insight shortly after treatment. Further long-term RCTs are needed to establish whether these metacognitive interventions-related insight changes are sustained over a longer time period and result in better outcomes.

The insight paradox in schizophrenia: A meta-analysis of the relationship between clinical insight and quality of life

Poor clinical insight affects people with schizophrenia and has been cited as a chief cause of poor outcomes. As such, clinical insight is often a target of intervention; however, increases in insight have shown associations with decreased quality of life in a phenomenon known as the "insight paradox." Understanding the relationship between insight and quality of life is important as clients often feel hopeless when quality of life decreases. This meta-analysis sought to clarify relationships between clinical insight, its subdomains, and quality of life in schizophrenia. Further, we explored the role of two moderators (quality of life measurement type, symptom severity) on the insight-quality of life relationship. Studies were identified according to PRISMA guidelines through a focused literature search extending to March 1, 2019. Correlations between clinical insight, its subdomains, and quality of life were extracted and used to calculate overall mean weighted effect sizes using a random-effects model. In support of the insight paradox, overall clinical insight was inversely related to quality of life. Symptom severity moderated the relationship between clinical insight and quality of life, such that greater symptom severity weakened the inverse relationship between overall insight and quality of life. Regarding subdomains of clinical insight, awareness of illness was inversely associated with quality of life; however, other subdomains failed to reach significance. Our findings support the notion that increased insight is associated with lower quality of life and highlight the need for further exploration of the role of meaning-making processes on this relationship.

Insight, personality, and symptoms among individuals with psychosis: Cross-sectional and longitudinal relationships

BACKGROUND

Reports on the relationship between clinical insight and psychotic symptoms have shown inconsistent results, and the association between clinical insight and personality has rarely been addressed. The aim of this study was to examine whether personality is correlated cross-sectionally with insight level, and longitudinally with change in insight, beyond symptoms.

METHODS

Participants were a sub-sample of the Dutch Genetic Risk and Outcome of Psychosis (GROUP) project. Two hundred and eleven participants diagnosed with non-affective psychotic disorders took part in the cross-sectional part of the study, of whom 136 took part in the three-year follow-up assessment. They were administered with self-report Birchwood insight scale and NEO-Five Factor Inventory, and clinicians assessed them according to PANSS and CDS symptoms scales.

RESULTS

Cross-sectional analysis showed baseline self-report insight was positively related to neuroticism and agreeableness and negatively related to extraversion. Longitudinal analysis showed change in level of self-reported insight was predicted by baseline-insight and change in symptoms of disorganization. Personality factors did not predict insight change (as measured either by self-report or by clinician assessment).

DISCUSSION

The cross-sectional findings showed self-report insight (as opposed to clinician-rated) is associated with personality traits, suggesting negative affect is related to higher level of insight and that having insight may be influenced by the wish to comply with views of professionals, or a tendency to cover up problems. The longitudinal findings imply that not personality but change in severity of symptoms of disorganization, and possibly other variables, predicts change in insight.

Body representations and basic symptoms in schizophrenia

Patients with schizophrenia report a wide range of anomalous body experiences. According to the basic symptom model of schizophrenia, disturbances of body perception and awareness are among the most powerful predictors of the changes in the subjective experience of the self in schizophrenia. In this study we first investigated the body structural representation (BSR), a specific aspect of body awareness, and its association to basic symptoms in patients with schizophrenia. Using a finger localization task, we found that patients are significantly less accurate than healthy controls when asked to identify pairs of fingers touched by the experimenter, when the hand is hidden from view. Most importantly, patients' performance at the finger localization task was negatively associated to basic symptoms: the worse the individual accuracy, the higher the SPI-A total score. Moreover, the accuracy at the finger localization task was also negatively correlated with the malleability of the sense of body ownership: the less the individual ability to localize fingers, the stronger the rubber hand illusion. These results are in agreement with the idea that self-disorders in schizophrenia reveal a disconnectedness that can be regarded as a problem of disembodiment and traced back to abnormal body experiences.

Brain areas associated with clinical and cognitive insight in psychotic disorders: A systematic review and meta-analysis

In the past years, ample interest in brain abnormalities related to clinical and cognitive insight in psychosis has contributed several neuroimaging studies to the literature. In the current study, published findings on the neural substrates of clinical and cognitive insight in psychosis are integrated by performing a systematic review and meta-analysis. Coordinate-based meta-analyses were performed with the parametric coordinate-based meta-analysis approach, non-coordinate based meta-analyses were conducted with the metafor package in R. Papers that could not be included in the meta-analyses were systematically reviewed. Thirty-seven studies were retrieved, of which 21 studies were included in meta-analyses. Poorer clinical insight was related to smaller whole brain gray and white matter volume and gray matter volume of the frontal gyri. Cognitive insight was predominantly positively associated with structure and function of the hippocampus and ventrolateral prefrontal cortex. Impaired clinical insight is not associated with abnormalities of isolated brain regions, but with spatially diffuse global and frontal abnormalities suggesting it might rely on a range of cognitive and self-evaluative processes. Cognitive insight is associated with specific areas and appears to rely more on retrieving and integrating self-related information.

Relationship of poor insight to neurocognition, social cognition, and psychiatric symptoms in schizophrenia: A meta-analysis

BACKGROUND

Poor insight (unawareness) about having a mental disorder is considered to be a core feature of the disorder. Further, poor insight has been associated with another core feature of schizophrenia, neurocognitive deficits. However, previous meta-analyses have shown that poor insight is more strongly related to positive symptoms and social cognition than to neurocognitive functioning.

METHOD

A meta-analysis of 123 studies of schizophrenia patients (combined n = 14,932) was conducted to determine the magnitude of the relationship between poor insight and neurocognition, social cognition, and positive symptoms, as well as negative symptoms, disorganization, and depression. The neurocognitive constructs were defined empirically using dimensions identified by the MATRICS initiative.

RESULTS

Meta-analytic findings showed that relationships were weak between poor insight and the six neurocognitive domains (r's range from -0.04 to -0.13), but that poor insight was moderately correlated with one aspect of social cognition, theory of mind (r = -0.23, p < .01). In addition, poor insight was moderately associated with reality distortion (r = 0.28, p < .01), disorganization (r = 0.29, p < .01), and negative symptoms (r = 0.20, p < .01).

DISCUSSION

Organizing the neurocognitive variables using the MATRICS domains continues to demonstrate that the relationship between insight and neurocognition is relatively weak. In comparison, we found moderate correlations between insight and theory of mind and several symptom domains. These moderate relationships are generally consistent with previous meta-analyses but are demonstrated more rigorously by examining more studies within the same meta-analysis.

UnReal? Investigating the Sense of Reality and Psychotic Symptoms with Virtual Reality

Distortions of reality, such as hallucinations, are common symptoms of many psychiatric conditions. Accordingly, sense of reality (SoR), the ability to discriminate between true and false perceptions, is a central criterion in the assessment of neurological and psychiatric health. Despite the critical role of the SoR in daily life, little is known about how this is formed in the mind. Here, we propose a novel theoretical and methodological framework to study the SoR and its relation to psychotic symptoms. In two experiments, we employed a specialized immersive virtual reality (VR) environment allowing for well-controlled manipulations of visual reality. We first tested the impact of manipulating visual reality on objective perceptual thresholds (just noticeable differences). In a second experiment, we tested how these manipulations affected subjective judgments of reality. The results revealed that the objective perceptual thresholds were robust and replicable, demonstrating that SoR is a stable psychometric property that can be measured experimentally. Furthermore, reality alterations reduced subjective reality judgments across all manipulated visual aspects. Finally, reduced sensitivity to changes in visual reality was related to self-reported prodromal psychotic symptoms. These results provide evidence for the relevance of SoR in the assessment of psychosis and other mental disorders in which reality is distorted.

Trait self-reflectiveness relates to time-varying dynamics of resting state functional connectivity and underlying structural connectomes: Role of the default mode network

BACKGROUND

Cognitive insight is defined as the ability to reflect upon oneself (i.e. self-reflectiveness), and to not be overly confident of one's own (incorrect) beliefs (i.e. self-certainty). These abilities are impaired in several disorders, while they are essential for the evaluation and regulation of one's behavior. We hypothesized that cognitive insight is a dynamic process, and therefore examined how it relates to temporal dynamics of resting state functional connectivity (FC) and underlying structural network characteristics in 58 healthy individuals.

METHODS

Cognitive insight was measured with the Beck Cognitive Insight Scale. FC characteristics were calculated after obtaining four FC states with leading eigenvector dynamics analysis. Gray matter (GM) and DTI connectomes were based on GM similarity and probabilistic tractography. Structural graph characteristics, such as path length, clustering coefficient, and small-world coefficient, were calculated with the Brain Connectivity Toolbox. FC and structural graph characteristics were correlated with cognitive insight.

RESULTS

Individuals with lower cognitive insight switched more and spent less time in a globally synchronized state. Additionally, individuals with lower self-reflectiveness spent more time in, had a higher probability of, and had a higher chance of switching to a state entailing default mode network (DMN) areas. With lower self-reflectiveness, DTI-connectomes were segregated less (i.e. lower global clustering coefficient) with lower embeddedness of the left angular gyrus specifically (i.e. lower local clustering coefficient).

CONCLUSIONS

Our results suggest less stable functional and structural networks in individuals with poorer cognitive insight, specifically self-reflectiveness. An overly present DMN appears to play a key role in poorer self-reflectiveness.

Early improvements of individual symptoms as a predictor of treatment response to asenapine in patients with schizophrenia

Aim

It is well accepted that early improvement with antipsychotics predicts subsequent response in patients with schizophrenia. However, no study has examined the contribution of individual symptoms rather than overall symptom severity as the predictors. Thus, we aimed to detect individual symptoms whose improvements could predict subsequent response in patients with schizophrenia during treatment with asenapine and examine whether a prediction model with individual symptoms would be superior to a model using overall symptom severity.

Methods

This study analyzed a dataset including 532 patients with schizophrenia enrolled in a 6‐week double‐blind, placebo‐controlled, randomized trial of asenapine. Response to asenapine was defined as a ≥30% decrease in Positive and Negative Syndrome Scale (PANSS) total score from baseline to week 6. Stepwise logistic regression analyses were performed to investigate the associations among response and PANSS total/individual item score improvements at week 1 or week 2.

Results

Response was associated with early improvement in the following PANSS items: disturbance of volition, active social avoidance, poor impulse control at week 1; and active social avoidance, poor attention, lack of judgment and insight at week 2. Prediction accuracy was almost compatible between the model with individual symptoms and the model with PANSS total score both at weeks 1 and 2 (Nagelkerke R²: .51, .42 and .55, .54, respectively).

Conclusion

Early improvement in negative symptoms, poor attention and impulse control, and lack of insight, in particular predicted subsequent treatment response in patients with schizophrenia during treatment with asenapine as accurately as prediction based on overall symptom severity.

This study found that treatment response to asenapine was predicted by early improvements of individual symptoms such as negative symptoms, poor attention and impulse control, and lack of insight in patients with schizophrenia. In addition, prediction accuracy was almost comparable between the model with individual symptoms and the model with the PANSS total score, supporting the importance to assess both individual symptoms and the whole severity in the clinical settings.

Neurocognitive and clinical correlates of insight in schizophrenia

BACKGROUND

Schizophrenia is a heterogeneous disorder characterized by various symptom dimensions and neurocognitive deficits. Impairment of insight is a core clinical symptom of the disorder. There has been an increasing focus on neurocognition and insight in schizophrenia; although, many studies fail to control for premorbid cognitive status.

MATERIALS AND METHODS

Schizophrenia patients (n = 60) selected for adequate background education were recruited from outpatient services of a tertiary care hospital and community care homes in Southern India. These patients were comprehensively assessed using a neurocognitive battery. Clinical assessments were done using the Positive and Negative Syndrome Scale (PANSS) and Schedule for the Assessment of Insight-expanded version (SAI-E). Partial correlation was performed to examine the relationship of insight with clinical and neurocognitive measures. Statistical significance was set at P = 0.004 (Bonferroni correction for 12 tests of association). Linear regression analysis was performed to examine the predictors of insight.

RESULTS

The mean PANSS positive, negative, general psychopathology, and total scores were 14.2 ± 4.9, 17.4 ± 5.0, 34.3 ± 6.8, and 65.8 ± 13.9, respectively. Mean insight score (SAI-E) was 8.5 ± 2.9. In partial correlation done after controlling for IQ, significant negative correlations were observed between insight score and the Wisconsin Card Sorting Test (WCST) total errors (P = 0.001), WCST perseverative errors (P < 0.001). Insight scores had negative correlations with PANSS negative (P < 0.002) and total scores (P < 0.002). WCST perseverative errors were the primary predictor of insight in the regression analysis.

CONCLUSION

Insight has a strong relationship with executive functioning in schizophrenia. This could indicate shared neurobiological substrates for insight and executive functioning.

Insight in psychosis: A critical review of the contemporary confusion

This commentary highlights the context, complexity, conflicting claims and the contemporary confusion related to insight in people with psychosis. Traditional psychiatric precepts suggests that good insight is inversely related to the severity of psychotic symptoms and directly related to depression scores, better clinical outcome, and treatment adherence. However, recent studies have recognised that insight does not predict outcomes, changes over time, and is dependent on the trajectory of the individual's illness and the social and cultural context arguing that "insight" is an explanatory model and a coping strategy. Methodological issues related to the assessment of insight, the limitations of psychiatric classification and complex interaction between biology and the environment make simplistic explanations of the concept of insight less than useful. The paper argues that the biomedical model should be presented without dismissing or devaluing patient beliefs and explanations. Psychiatry needs to embrace the complexity of mental illness and value diverse attempts at restoring homeostasis.

Study protocol of a randomised clinical trial testing whether metacognitive training can improve insight and clinical outcomes in schizophrenia

BACKGROUND

Although insight in schizophrenia spectrum disorders (SSD) has been associated with positive outcomes, the effect size of previous treatments on insight has been relatively small to date. The metacognitive basis of insight suggests that metacognitive training (MCT) may improve insight and clinical outcomes in SSD, although this remains to be established.

METHODS

This single-center, assessor-blind, parallel-group, randomised clinical trial (RCT) aims to investigate the efficacy of MCT for improving insight (primary outcome), including clinical and cognitive insight, which will be measured by the Schedule for Assessment of Insight (Expanded version) (SAI-E) and the Beck Cognitive Scale (BCIS), respectively, in (at least) n = 126 outpatients with SSD at three points in time: i) at baseline (T0); ii) after treatment (T1) and iii) at 1-year follow-up (T2). SSD patients receiving MCT and controls attending a non-intervention support group will be compared on insight level changes and several clinical and cognitive secondary outcomes at T1 and T2, whilst adjusting for baseline data. Ecological momentary assessment (EMA) will be piloted to assess functioning in a subsample of participants.

DISCUSSION

To the best of our knowledge, this will be the first RCT testing the effect of group MCT on multiple insight dimensions (as primary outcome) in a sample of unselected patients with SSD, including several secondary outcomes of clinical relevance, namely symptom severity, functioning, which will also be evaluated with EMA, hospitalizations and suicidal behaviour.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04104347. Date of registration: 26/09/2019 (Retrospectively registered).

Using virtual reality to explore differences in memory biases and cognitive insight in people with psychosis and healthy controls

Memory biases (e.g. overconfidence in false memories) are implicated in the pathogenesis of delusions. Virtual reality (VR) may provide an opportunity to observe such biases and improve cognitive insight in patients with psychosis via corrective feedback. Thirty-nine patients with psychosis and 20 healthy controls explored VR environments designed to elicit false memories and subsequently had to recollect items and faces. We used a randomised-controlled design where half of the sample received performance feedback on the recollection task in order to correct overconfidence. Changes in cognitive insight were measured using the Beck Cognitive Insight Scale. Regarding accuracy, patients performed worse on the social task (recollection of faces) only. Patients displayed overconfidence in false memories for emotions and gave more high-confident responses compared to healthy controls on the social task. Feedback did not improve cognitive insight. Patients rated their cognitive insight higher than healthy controls. Future research should address problems with subjective measurements for cognitive insight. To conclude, patients with psychosis showed impaired social cognition and there was evidence for impaired metacognition, as patients reported higher cognitive insight despite comparable or worse performance as well as overconfidence relative to controls.

Placing Cognitive Rigidity in Interpersonal Context in Psychosis: Relationship With Low Cognitive Reserve and High Self-Certainty

Introduction: People with psychosis show impairments in cognitive flexibility, a phenomenon that is still poorly understood. In this study, we tested if there were differences in cognitive and metacognitive processes related to rigidity in patients with psychosis. We compared individuals with dichotomous interpersonal thinking and those with flexible interpersonal thinking. Methods: We performed a secondary analysis using two groups with psychosis, one with low levels of dichotomous interpersonal thinking (n = 42) and the other with high levels of dichotomous interpersonal thinking (n = 43). The patients were classified by splitting interpersonal dichotomous thinking (measured using the repertory grid technique) to the median. The groups were administered a sociodemographic questionnaire, a semi-structured interview to assess psychotic symptoms [Positive and Negative Syndrome Scale (PANSS)], a self-report of cognitive insight [Beck Cognitive Insight Scale (BCIS)], neurocognitive tasks [Wisconsin Card Sorting Test (WCST) and Wechsler Adult Intelligence Scale (WAIS)], and the repertory grid technique. We used a logistic regression model to test which factors best differentiate the two groups. Results: The group with high dichotomous interpersonal thinking had earlier age at onset of the psychotic disorder, higher self-certainty, impaired executive functioning, affected abstract thinking, and lower estimated cognitive reserve than the group with flexible thinking. According to the logistic regression model, estimated cognitive reserve and self-certainty were the variables that better differentiated between the two groups. Conclusion: Cognitive rigidity may be a generalized bias that affects not only neurocognitive and metacognitive processes but also the sense of self and significant others. Patients with more dichotomous interpersonal thinking might benefit from interventions that target this cognitive bias on an integrative way and that is adapted to their general level of cognitive abilities.

Clinical insight in anorexia nervosa: Associated and predictive factors

Clinical and cognitive factors associated with clinical insight regarding both baseline level and its time-related changes, in outpatients treated for anorexia nervosa. The 193 participants were recruited at 13 French centers specializing in eating disorders (FFAB network) and assessed for insight (SAI-ED), body mass index (BMI), eating disorder severity, symptoms of depression and anxiety, emotional state, silhouette, and functionality; two cognitive tests were also administered. The 137 patients were then re-assessed 18 weeks later. Minimum and ideal subjective BMI and premorbid intelligence were associated with poor baseline insight. Contrary to nearly all other clinical factors, the level of insight revealed no improvement after four months of care. Only the higher value of the minimum lifetime BMI was significantly predictive of increased insight. More positive emotions (PANAS), less symptoms of depression and anxiety (HADS scores), and fewer syndromes (HADS above threshold) were the only factors that covaried with the changes in the level of insight. In conclusion, poor insight has little time variability, contrary to nearly all clinical and cognitive factors. As increased insight is mainly accompanied by improvements in the emotional domain, the latter could represent potential targets for patients with lack of awareness about their eating disorder.

Impulsivity issues in borderline personality disorder and it's links with insight: the role of urgency

Objective

Impulsivity plays a major role in a wide range of disorders including Borderline Personality Disorder. Another crucial clinical dimension is insight. This clinical dimension is linked with symptomatology and treatment issue. The present study aims to investigate the impact of positive and negative urgency on insight in Borderline Personality Disorder.

Methods

We recruited eighty-one women with Borderline Personality Disorder and assessed insight level and impulsivity scores using the Beck Cognitive insight scale and the UPPS-short form scale.

Results

Our results showed interesting links between positive urgency and insight quality.

Conclusion

Negative emotions play a fundamental role for the insight quality, but positive emotions are surprisingly related to clinical insight. We discuss the possible therapeutical impact of this results on treatment adaptation.

Insight Into Illness and Defense Styles in Schizophrenia

Although the psychological denial model argues that poor insight is a result of defense mechanisms, the direct relationship between the two remains unclear. This study aimed to examine the relationship between insight into illness and defense mechanisms while considering cognitive dysfunction in schizophrenia. A total of 38 patients with schizophrenia were evaluated for level of insight (Schedule for the Assessment of Insight), defense mechanisms (Defense Style Questionnaire), neurocognitive function (Brief Assessment of Cognition in Schizophrenia), and psychotic symptoms (Brief Psychiatric Rating Scale). Regarding level of insight, partial correlation analysis controlling neurocognitive and psychotic variables showed that "recognition of illness" was positively correlated with immature defense styles and negatively correlated with mature defense styles. Stepwise regression analyses revealed that "recognition of illness" was significantly predicted by immature defense styles. Our findings suggest that patients who tend to use immature defense styles are more likely to accept their own mental illness.

A Functional Neuroimaging Meta-Analysis of Self-Related Processing in Schizophrenia

Background: Schizophrenia is characterized by self-disturbances, including impaired self-evaluation abilities and source monitoring. The cortical midline structures (e.g., medial prefrontal cortex, anterior and posterior cingulate cortex, and precuneus) and the temporoparietal junction are known to play a key role in self-related processing. In theory, self-disturbances in schizophrenia may arise from impaired activity in these regions. We performed a functional neuroimaging meta-analysis to verify this hypothesis. Methods: A literature search was performed with PubMed and Google Scholar to identify functional neuroimaging studies examining the neural correlates of self-processing in schizophrenia, using self-other or source monitoring paradigms. Fourteen studies were retrieved, involving 245 patients and 201 controls. Using peak coordinates to recreate an effect-size map of contrast results, a standard random-effects variance weighted meta-analysis for each voxel was performed with the Seed-based d Mapping software. Results: During self-processing, decreased activations were observed in schizophrenia patients relative to controls in the bilateral thalamus and the left dorsal anterior cingulate cortex (dACC) and dorso-medial prefrontal cortex. Importantly, results were homogeneous across studies, and no publication bias was observed. Sensitivity analyses revealed that results were replicable in 93-100% of studies. Conclusion: The current results partially support the hypothesized impaired activity of cortical midline brain regions in schizophrenia during self-processing. Decreased activations were observed in the dACC and dorsomedial prefrontal cortex, which are involved in cognitive control and/or salience attribution, as well as decision-making, respectively. These alterations may compromise patients' ability to direct their attention toward themselves and/or others and to make the decision whether a certain trait applies to one's self or to someone else. In addition, decreased activations were observed in the thalamus, which is not a core region of the default-mode network, and is involved in information integration. These thalamic alterations may compromise self-coherence in schizophrenia.

Effect of adding individualized occupational therapy to standard care on rehospitalization of patients with schizophrenia: A 2-year prospective cohort study

AIM

We examined the effect of individualized occupational therapy (IOT) compared to the usual group occupational therapy (GOT) on the rehospitalization of patients with schizophrenia.

METHODS

A prospective cohort study included patients with schizophrenia who were discharged within 1 year from a psychiatric hospital. Time to rehospitalization by treatment group (GOT + IOT or GOT-alone) was evaluated with Kaplan-Meier survival analysis. The impact of demographics and clinical factors associated with rehospitalization was investigated using Cox proportional hazards models.

RESULTS

Of the 111 patients who met the criteria, 54 were in the GOT + IOT group and 57 in the GOT-alone group. Over the 2 years from discharge, the overall rehospitalization rate was 51.376% (56 patients); the GOT + IOT group demonstrated a significantly lower rehospitalization rate with 16 patients rehospitalized compared to 40 patients from the GOT-alone group. Time to rehospitalization was significantly longer for the GOT + IOT group compared to those in the GOT-alone group (P < 0.001). The multivariate Cox proportional hazards models showed that type of occupational therapy (hazard ratio [HR] = 0.543), medication adherence (HR = 0.343), access to resident support persons (HR = 0.450), and executive function at discharge (HR = 0.740) were all significantly associated with rehospitalization.

CONCLUSION

Our results provide support for the prolonging effects of IOT in relation to rehospitalization and the reduction of rehospitalization risk compared to patients with schizophrenia who receive GOT alone, in addition to supporting good cognition at discharge and favorable medication adherence.

Enhancement of cognitive insight and higher-order neurocognitive function by fronto-temporal transcranial direct current stimulation (tDCS) in patients with schizophrenia

No studies have examined the effects of fronto-temporal transcranial direct current stimulation (tDCS) on cognitive insight and neurocognitive function in schizophrenia patients and the dynamic interplay between tDCS-induced changes in these two outcomes. In this double-blind, randomized, sham-controlled study, we investigated the effects of fronto-temporal tDCS [anode corresponding to left dorsolateral prefrontal cortex and cathode to left temporo-parietal junction; 2-mA, twice-daily sessions for 5 days] on illness severity, psychosocial functioning, cognitive insight and neurocognitive function in schizophrenia patients (N = 60). The authors observed significant trends that tDCS ameliorated the severity of total and general psychopathology as measured by the Positive and Negative Syndrome Scale. No significant effects were observed for other psychopathological symptoms and psychosocial functioning. Cognitive insight as measured by the Beck Cognitive Insight Scale (BCIS) was rapidly enhanced by 10-session tDCS (F = 10.80, Cohen's d = 0.44, p = 0.002) but the beneficial effect became borderline significant 1 month after stimulation. A trend-level improvement with tDCS of planning ability (F = 6.40, Cohen's d = 0.339, p = 0.014) as measured by the accuracy in Tower of London task was also observed. In the active tDCS group, the change in cognitive insight from baseline to immediately after tDCS assessment was positively correlated with that in planning ability (r = 0.46, p = 0.015), which was independent of the corresponding change in illness severity. The promising results regarding the fast-acting beneficial effects of tDCS on cognitive insight and planning ability in schizophrenia require confirmation in future replication studies.