Toward a model of cognitive insight in first-episode psychosis: verbal memory and hippocampal structure

Relationship between cognition and suicidal behavior in recent-onset psychosis

Suicidal behavior (SB) is common in first-episode psychosis (FEP), and cognitive impairment has also been described in psychosis. Despite well-established risk factors for SB in psychosis, the role of cognition and insight remains unclear. This study aimed to explore the relationship between history of SB and cognition in recent-onset FEP, distinguishing between neurocognition, social cognition, and metacognition, and including cognitive insight (CI) as a metacognitive variable. The sample consisted of 190 participants with recent-onset FEP recruited from two multicentric studies. Two groups were formed based on presence/absence of a history of SB. Demographic, clinical, and cognitive data were compared by group, including significance level adjustments and size effect calculation. No differences were found regarding demographic, clinical, neurocognitive, social cognition, and metacognitive variables except for CI (18.18 ± 4.87; t = -3.16; p = 0.0020; d = -0.635), which showed a medium effect size. Small to medium effect size were found for attributional style (externalizing bias) (1.15 ± 3.94; t = 2.07; d = 0.482), theory of mind (ToM) (1.73 ± 0.22; t = 2.04; d = -0.403), jumping to conclusions bias (JTC) (23.3 %; X² = 0.94; V = 0.178). In recent-onset psychosis, neurocognitive functioning was not related to the history of SB. As novelty, individuals with previous SB showed higher CI. Also, regarding social cognition and metacognition, individuals with prior SB tended to present extremely low externalizing bias, better ToM, and presence of JTC.

Relation between frontal pole volumes and cognitive insight in Schizophrenia

OBJECTIVE

Cognitive insight comprising self-reflection and self-certainty is an important determinant of functional outcomes in Schizophrenia. The neural correlates of cognitive insight in Schizophrenia are underexamined. The frontal pole (FP) is implicated in metacognitive function in healthy individuals, but its role is not well examined in Schizophrenia. We had earlier reported the relationship between Frontal pole volumes and cognitive insight in a small sample of only male patients. Hence, we studied this relationship in an independent sample of schizophrenia patients and healthy controls.

METHODS

We examined 41 healthy volunteers (HV) and 57 patients with Schizophrenia (SCZ). We used a previously validated manual morphometric method to perform FP parcellation on images obtained from a 3 T scanner and calculated the volumes. Cognitive insight was measured using Beck's Cognitive insight scale (BCIS). To assess the relationship between FP volumes and BCIS scores, multiple linear regression analyses were performed.

RESULTS

In the overall sample, age, years of education, and intracranial volume were significant predictors of BCIS scores. Within the SCZ group, age and left FP volume were significant predictors of BCIS composite scores and age, ICV for BCIS-self certainty. There was no significant relationship between age and FP volumes in either SCZ or HV group.

DISCUSSION

The current study in an independent sample further supports the critical role of the frontal pole in cognitive insight, earlier reported by us. As cognitive insight has a vital role in functional outcome, our findings have potential clinical implications.

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.

Neuroimaging correlates of insight in non-affective psychosis: A systematic review and meta-analysis

OBJECTIVE

Neurological correlates of impaired insight in non-affective psychosis remain unclear. This study aimed to review and meta-analyze the studies assessing the grey matter volumetric correlates of impaired insight in non-affective psychosis.

METHODS

This study consisted of a systematic review of 23 studies, and a meta-analysis with SDM-PSI of the 11 studies that were whole-brain and reported maps or peaks of correlation of studies investigating the grey matter volumetric correlates of insight assessments of non-affective psychosis, PubMed and OVID datasets were independently reviewed for articles reporting neuroimaging correlates of insight in non-affective psychosis. Quality assessment was realized following previous methodological approaches for the ABC quality assessment test of imaging studies, based on two main criteria: the statistical power and the multidimensional assessment of insight. Study peaks of correlation between grey matter volume and insight were used to recreate brain correlation maps.

RESULTS

A total of 418 records were identified through database searching. Of these records, twenty-three magnetic resonance imaging (MRI) studies that used different insight scales were included. The quality of the evidence was high in 11 studies, moderate in nine, and low in three. Patients with reduced insight showed decreases in the frontal, temporal (specifically in superior temporal gyrus), precuneus, cingulate, insula, and occipital lobes cortical grey matter volume. The meta-analysis indicated a positive correlation between grey matter volume and insight in the right insula (i.e., the smaller the grey matter, the lower the insight).

CONCLUSION

Several brain areas might be involved in impaired insight in patients with non-affective psychoses. The methodologies employed, such as the applied insight scales, may have contributed to the considerable discrepancies in the findings.

Insight in nonpsychotic disorders: A new model of insight and a systematic review of measures

OBJECTIVE

There is substantial research examining insight in psychotic disorders and in some nonpsychotic disorders. However, there has been little attention given to many nonpsychotic disorders. Research on insight in psychosis distinguishes between cognitive and clinical insight. In most studies examining insight in nonpsychotic disorders, definitions and assessments of insight vary significantly. The purpose of this review is to suggest a definition of insight in nonpsychotic disorders such that it can be used across different disorders.

METHOD

We systematically review the extant literature of insight in nonpsychotic disorders and analyze the assessments used in order to determine how well they capture these two types of insight. Then, we discuss how these two constructs can provide better understanding of the phenomenology of insight in nonpsychotic disorders.

RESULTS

The systematic search resulted in 99 articles. These articles used 17 different methods of measuring insight, containing 127 questions. Results of the content analysis of items suggested that measures of insight used in nonpsychotic disorders do not distinguish between cognitive and clinical insight, but that most questions (90%) can indeed be reliably differentiated.

CONCLUSION

We provide a multidimensional model of cognitive and clinical insight in nonpsychotic disorders, emphasizing the complexity of assessment and the importance of accurately defining insight. Such definitions have important theoretical and clinical implications, offering a better understanding of the concept of insight in nonpsychotic disorders.

Neuroimaging correlates of insight in non-affective psychosis: A systematic review and meta-analysis

OBJECTIVE

Neurological correlates of impaired insight in non-affective psychosis remain unclear. This study aimed to review and meta-analyze the studies assessing the grey matter volumetric correlates of impaired insight in non-affective psychosis.

METHODS

This study consisted of a systematic review of 23 studies, and a meta-analysis with SDM-PSI of the 11 studies that were whole-brain and reported maps or peaks of correlation of studies investigating the grey matter volumetric correlates of insight assessments of non-affective psychosis, PubMed and OVID datasets were independently reviewed for articles reporting neuroimaging correlates of insight in non-affective psychosis. Quality assessment was realized following previous methodological approaches for the ABC quality assessment test of imaging studies, based on two main criteria: the statistical power and the multidimensional assessment of insight. Study peaks of correlation between grey matter volume and insight were used to recreate brain correlation maps.

RESULTS

A total of 418 records were identified through database searching. Of these records, twenty-three magnetic resonance imaging (MRI) studies that used different insight scales were included. The quality of the evidence was high in 11 studies, moderate in nine, and low in three. Patients with reduced insight showed decreases in the frontal, temporal (specifically in superior temporal gyrus), precuneus, cingulate, insula, and occipital lobes cortical grey matter volume. The meta-analysis indicated a positive correlation between grey matter volume and insight in the right insula (i.e., the smaller the grey matter, the lower the insight).

CONCLUSION

Several brain areas might be involved in impaired insight in patients with non-affective psychoses. The methodologies employed, such as the applied insight scales, may have contributed to the considerable discrepancies in the findings.

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.

The frontal pole and cognitive insight in schizophrenia

Absence of insight owing to impaired self-reflection and lack of touch with reality is a hallmark of schizophrenia. Functional imaging studies in healthy individuals have implicated the frontal pole (FP), sub-division of the prefrontal cortex in self-reflective processes. Despite the significance of self-referential processing in the pathogenesis of schizophrenia, the relationship between FP volume and cognitive insight in this disorder is underexplored. We examined the relationship between cognitive insight and volume of FP using precise manual morphometry of high resolution magnetic resonance images in 19 schizophrenia patients (SCZ) and 21 healthy-volunteers (HV). The manual morphometry technique was replicated from a previous study based on a cytoarchitectonically and functionally valid definition of FP and cognitive insight was measured using Beck's cognitive insight scale. Left frontal pole volume was a significant predictor of self-reflection sub-score of Beck's cognitive insight scale (β=0.68; t = 2.86; p = 0.01). A significant inverse relationship between age and bilateral FP volumes was noted in HV (left FP - r=-0.45; p = 0.04; right FP - r=-0.57; p = 0.008) but not in SCZ (p>0.05). Our findings provide anatomical substrates to devise intervention strategies targeting cognitive insight, thereby improving treatment adherence and functional outcomes.

Neurocognitive effects of atypical antipsychotics in patients with first-episode schizophrenia

Introduction: Cognitive impairment is a core feature of schizophrenia. The effects of atypical antipsychotics on the cognitive functions of patients with first-episode schizophrenia have not been comprehensively investigated so far. This study aims to compare neurocognitive effects of risperidone, olanzapine, and aripiprazole for first-episode schizophrenia.Methods: The study was a multicenter, randomized, open-label clinical trial. 546 patients were randomly divided into three medication groups, and followed up for 1 year. Cognitive performance was evaluated with a neuropsychological test battery. The Clinical trials.gov ID of the study is NCT01057849.Results: At 6 months, treatment resulted in significant improvements in all three groups in most cognitive domains except verbal learning and memory. At 12 months, three treatment groups had further improvements in three cognitive domains, but visual learning and memory performance dropped back to baseline.Conclusion: All three atypical antipsychotics tested in the study can potentially improve cognitive performance in first-episode schizophrenia, but no significant difference in the degree of improvement was found between drugs.

Verbal memory measurement towards digital perspectives in first-episode psychosis: A review

BACKGROUND

Even in the early phases of psychotic spectrum illnesses such as schizophrenia, patients can experience cognitive decline or deficits prior to the onset of psychotic symptoms such as delusions and hallucinations. In this systematic review, we assessed which verbal memory assessments are most widely used in first-episode psychosis and may be applied via digital technologies (smartphone applications, etc.) for use in early detection.

METHODS

In November 2019, we searched for studies measuring verbal memory in first episode psychosis or schizophrenia over the past 10 years on PubMed and PsycINFO. We screened abstracts of these studies and excluded review studies. Full-texts of included studies were used to identify the verbal memory measurement tests, follow-up frequencies, and sample sizes.

RESULTS

We screened 233 reports and found that 120 original research studies measured verbal memory in first episode psychosis over the past 10 years. Four of these studies specified using a computer, 24 (20%) used a paper-pen format, 1(1%) used both, and 91 (76%) studies did not specify their administration tools or suggest there were offered in digital formats. Thirty-five (30%) studies had follow-up measurements of verbal memory, while 85 (70%) had only a single verbal memory measurement.

DISCUSSION

While many scales are commonly used to measure verbal memory in first episode psychosis, they are not often administered via digital technology. There is an emerging opportunity to administer these and other tests via digital technologies for expanding access to early detection of cognitive decline in clinical high risk and first-episode psychosis.

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.

Brain Structural Correlates of Metacognition in First-Episode Psychosis

Metacognition is impaired in schizophrenia and is an important predictor of functional outcome, but the underlying neuropathology is not clear. Studies have implicated frontal regions and there is also some evidence that the hippocampus might play a pivotal role, but findings are inconsistent. We set out to more comprehensively investigate the neural underpinnings of insight in first-episode psychosis (FEP) using 2 metacognitive measures (the Beck Cognitive Insight Scale [BCIS]) and a perceptual metacognitive accuracy task alongside structural magnetic resonance imaging (MRI). We measured cortical thickness in insula and frontal regions, hippocampal (including subfield) volumes, hippocampal microstructure (using neurite orientation dispersion and density imaging [NODDI]), and fractional anisotropy in fornix. Relative to controls, FEP showed poorer metacognitive accuracy, thinner cortex in frontal regions and lower fornix integrity. In healthy controls (but not FEP), metacognitive accuracy correlated with cortical thickness in frontal cortex and insula. Conversely, in FEP (but not controls), metacognitive accuracy correlated with hippocampal volume and microstructural indices. Subicular hippocampal subregions were particularly implicated. No structural correlates of BCIS were found. These findings suggest that the neural bases of metacognition might differ in FEP: hippocampal (rather than frontal) integrity seems to be critical. Further, the use of objectively measured metacognitive indices seems to be a more powerful method for understanding the neurocircuitry of metacognition in FEP, which has the potential to inform therapeutic strategies and improve outcome in these patients.

Understanding sex differences in cognitive insight across first-and-multiple episode psychosis

OBJECTIVE

Cognitive insight represents the capacity to self-reflect and consider external feedback when re-evaluating faulty beliefs. It is associated with specific cognitive capacities such as verbal memory, of which there is substantial evidence for sex differences in psychotic disorders. Like more general cognitive capacities, cognitive insight might too be modulated by sex differences.

METHOD

One hundred and seventy-one first episode psychosis (FEP; 123 males, 48 females), and 203 multiple episode psychosis (MEP; 147 males, 56 females) participants completed the Beck Cognitive Insight Scale (BCIS). A two-way MANOVA was conducted on the three BCIS measures (self-reflectiveness, self-certainty, composite index) with sex (male, female) and illness stage (FEP, MEP) as factors, followed by two-way ANOVAs and a post hoc test of simple effects.

RESULTS

The only significant interaction to emerge was between sex and illness stage in self-certainty (F(1, 373) = 5.88, p = .016). A test of simple effects revealed that self-certainty group means were significantly different for males and females in FEP, where females had lower self-certainty than males (p = .053) but not during MEP (p = .119).

CONCLUSION

Sex differences do not modulate cognitive insight in MEP, which may be attributable to females having greater positive symptom severity than males. In FEP however, results revealed that females were significantly less self-certain than males. Lower self-certainty relative to self-reflectiveness predicts treatment response in psychological interventions, and as such future FEP studies should explore sex differences in psychological interventions.

Cultural differences and neural correlates of cognitive insight in schizophrenia

Cognitive insight refers to a person's ability to examine their psychotic experiences and the inferences they draw from these experiences. Several studies suggest that cultural factors influence cognitive insight and the processes involved therein; a few studies have suggested differences between Western and Asian societies. However, there are no studies on cognitive insight and its neural correlates in non-Western populations. Hence, we examined factor structure of Beck's cognitive insight scale (BCIS) in a large sample of patients with schizophrenia (SCZ) and healthy volunteers (HV) from India and assessed the relationship between cortical thickness and cognitive insight. We recruited 240 participants (SCZ-140; HV-100). Of these, 58 participants (SCZ-33; HV-25) underwent magnetic resonance imaging. We found a three-factor structure for BCIS which is different from the original two factor structure; self-reflection (SR) of original two-factor structure was sub-divided into- SR1, introspection and SR2, openness to feedback. There was a significant difference between HV and SCZ in the new factors, SR1 and SR2 but not in the original SR factor. Difference was also seen on MRI analysis; while there was a significant positive correlation between original SR factor and thickness of right posterior cingulate cortex, SR2 was positively correlated with thickness of left ventrolateral prefrontal cortex. The difference in factor structure in Indian participants and their distinct neural correlates point to cultural differences in cognitive insight. While in western societies the constructs of introspection and openness to feedback might integrate, they might be separate entities in Asian population.

Cognitive capacity similarly predicts insight into symptoms in first- and multiple-episode psychosis

BACKGROUND

Lack of insight is a frequent characteristic of psychotic disorders, both in patients who recently experienced a first episode of psychosis (FEP) and those who experience recurrent multiple episodes (MEP). Insight is a multifaceted construct: its clinical form notably includes the unawareness of being ill, of symptoms, and of the need for treatment. Cognitive capacity is among the key determinants of insight into symptoms, but less is known about whether stage of illness (FEP vs. MEP) moderates this association.

METHODS

Our aim is to evaluate the association between cognitive capacity and symptom unawareness using structural equation modeling and moderated multiple regression. A total of 193 FEP and MEP patients were assessed using the CogState battery and the Scale to Assess Unawareness of Mental Disorder.

RESULTS

Analyses suggest that cognitive capacity accounts for a relatively small proportion of the total variation in symptom unawareness (6.4%). There was no evidence to suggest a moderating effect of stage of illness on this association.

CONCLUSIONS

The effect of general cognitive capacity on symptom unawareness is relatively small, and this basic relation was unrelated to stage of illness. It is possible that stage of illness could moderate this association only for certain facets of insight not assessed in this study (e.g., unawareness of the need for treatment).

Association of neurocognitive deficits and insight in schizophrenia

AIM

To evaluate the relationship between neurocognitive deficits and insight (clinical & cognitive) among patients with schizophrenia in clinical remission.

METHODOLOGY

60 patients with schizophrenia (diagnosed as per the DSM-IV criteria) in clinical remission were assessed on Beck Cognitive Insight scale (BCIS), Positive and Negative symptom scale (PANSS) and neurocognitive battery (Trail A and B, Stroop Test, Controlled Oral Words Association (COWA) and Tower of London (TOL).

RESULTS

Lower processing speed, low cognitive flexibility and poor executive functions as assessed by Trail A, Trail B and TOL respectively and higher verbal fluency (COWA) were associated with poor cognitive insight in the self-certainty domain. Poor executive functioning (3 moves problem of TOL) was associated with lower cognitive insight in the domain of self-reflectiveness. Clinical insight as assessed by item number 12 of general psychopathology subscale of PANSS did not have any association with any of the neurocognitive domains except for few subsets of executive functions as assessed by TOL. There was no correlation between clinical insight and cognitive insight. However, many of these correlations were weak and could be due to Type-1 error as significance of correlation was fixed at two tailed 0.05 level. Multiple regression analysis demonstrated cognitive flexibility as assessed by Trail B test and executive functions (3 moves and 5 moves problems of TOL) to be the significant predictors of self-certainty and self- reflectiveness domains of the cognitive insight.

CONCLUSIONS

The present study suggests that poor cognitive flexibility and executive dysfunction are associated with poor cognitive insight but the impact of poor neurocognitions on the clinical insight is not very significant.

Duration of untreated psychosis and neurocognitive functioning in first-episode psychosis: a systematic review and meta-analysis

BACKGROUND

Previous reviews suggest there is minimal evidence for an association between duration of untreated psychosis (DUP) and neurocognition. This is based on tallied findings of studies with small samples and neurocognition viewed as a single construct. We aimed to conduct a systematic review and meta-analysis examining the association between DUP and individual neurocognitive domains and tests in first-episode psychosis (FEP).

METHOD

MOOSE and PRISMA guidelines were followed. Forty-three studies involving 4647 FEP patients were included. For studies providing correlations between DUP and neurocognition, 12 separate meta-analyses were performed based on neurocognitive domains/indices. The influence of demographic/clinical variables was tested using weighted linear meta-regression analyses.

RESULTS

The relationship between DUP and most neurocognitive domains/indices was not significant. Longer DUP was associated with a larger cognitive deterioration index, i.e. current minus premorbid intellectual functioning (N = 4; mean ES -0.213, 95% confidence interval (CI) (-0.344 to -0.074), p = 0.003). Findings were homogeneous, with no evidence of publication bias or significant influence from moderators. For studies providing mean and standard deviations for neurocognitive measures and DUP, 20 meta-regressions were performed on individual neurocognitive tests. One significant finding emerged showing that longer DUP was associated with fewer Wisconsin Card Sorting Test-perseverative errors (mean ES -0.031, 95% CI (-0.048 to -0.013), p < 0.001). Exploratory meta-regressions in studies with mean DUP <360 days showed longer DUP was significantly associated with poorer performance on Trail Making Test A and B and higher Full-Scale IQ.

CONCLUSION

There may not be a generalised association between DUP and neurocognition, however, specific cognitive functions may be associated with longer DUP or delayed help-seeking.

Genetic correlates of insight in schizophrenia

Insight in schizophrenia is clinically important as it is associated with several adverse outcomes. Genetic contributions to insight are unknown. We examined genetic contributions to insight by investigating if polygenic risk scores (PRS) and candidate regions were associated with insight.

METHOD

Schizophrenia case-only analysis of the Clinical Antipsychotics Trials of Intervention Effectiveness trial. Schizophrenia PRS was constructed using Psychiatric Genomics Consortium (PGC) leave-one out GWAS as discovery data set. For candidate regions, we selected 105 schizophrenia-associated autosomal loci and 11 schizophrenia-related oligodendrocyte genes. We used regressions to examine PRS associations and set-based testing for candidate analysis.

RESULTS

We examined data from 730 subjects. Best-fit PRS at p-threshold of 1e-07 was associated with total insight (R²=0.005, P=0.05, empirical P=0.054) and treatment insight (R²=0.005, P=0.048, empirical P=0.048). For models that controlled for neurocognition, PRS significantly predicted treatment insight but at higher p-thresholds (0.1 to 0.5) but did not survive correction. Patients with highest polygenic burden had 5.9 times increased risk for poor insight compared to patients with lowest burden. PRS explained 3.2% (P=0.002, empirical P=0.011) of variance in poor insight. Set-based analyses identified two variants associated with poor insight- rs320703, an intergenic variant (within-set P=6e-04, FDR P=0.046) and rs1479165 in SOX2-OT (within-set P=9e-04, FDR P=0.046).

CONCLUSION

To the best of our knowledge, this is the first study examining genetic basis of insight. We provide evidence for genetic contributions to impaired insight. Relevance of findings and necessity for replication are discussed.

Anosognosia for cognitive and behavioral symptoms in Parkinson's disease with mild dementia and mild cognitive impairment: Frequency and neuropsychological/neuropsychiatric correlates

INTRODUCTION

Anosognosia is a multidimensional phenomenon with detrimental effects on patients' illness course, therapy compliance and quality of life. We aimed at investigating anosognosia for cognitive and behavioral symptoms in Parkinson's Disease (PD) with dementia (PDD) and, for the first time, in PD with Mild Cognitive Impairment (MCI-PD).

METHODS

Community dwelling subjects (47 mild PDD, 136 multidomain MCI-PD (mdMCI-PD), 5 single domain MCI-PD (sdMCI-PD), and 197 PD without cognitive impairment (noCI-PD) were enrolled in a cross-sectional design study. All the subjects were administered the Anosognosia Questionnaire for Dementia, the Mental Deterioration Battery and a number of neuropsychiatric inventories.

RESULTS

A diagnosis of anosognosia was made in 36% of patients with mild PDD and 16% with mdMCI-PD, whether it was negligible in sdMCI-PD and noCI-PD. Higher severity of anosognosia for cognitive impairment was also found in PDD and in mdMCI-PD. SdMCI-PD had the lower severity of anosognosia for cognitive impairment. Higher anosognosia for cognitive impairment was associated to lower depression in noCI-PD (r = -0.227, p = 0.0013) and mdMCI-PD (r = -0.266, p = 0.0016), and to reduced hedonic tone in noCI-PD (r = -0.191, p = 0.0071). Greater anosognosia was associated to lower executive performances in PDD (r = 0.424, p = 0.0074).

CONCLUSIONS

Anosognosia for non-motor symptoms is frequent in PD patients with mild dementia or mdMCI. Results confirm the role of neuropsychiatric characteristics in anosognosia also in PD, the high prevalence of anosognosia in neurodegenerative illnesses and suggest a common pathogenic path for anosognosia in different neurodegenerative and psychiatric disorders.

A longitudinal study of cognitive insight and cortical thickness in first-episode psychosis

Among individuals with psychosis, those with poor cognitive insight (lower Self-Reflectiveness, higher Self-Certainty) show volumetric reductions in cortical structure. We evaluated whether changes in cognitive insight are associated with progressive changes in cortical structure in first-episode psychosis (FEP) and control subjects. Beck Cognitive Insight Scale ratings and magnetic resonance imaging scans were acquired at baseline for 130 FEP and 52 controls, 59 FEP and 28 controls at 1-year, and 53 FEP and 20 controls at 2-years. Cortical thickness was computed across scans and analyzed with linear mixed models. At baseline, groups did not differ on Self-Reflectiveness or Self-Certainty. At baseline, higher Self-Reflectiveness significantly correlated with thinner right occipital cortex in FEP, and higher Self-Certainty was significantly negatively correlated with cortical thickness in left posterior cingulate in controls. Longitudinal analysis showed that Self-Reflectiveness and Self-Certainty did not change over time in either group. Interestingly, the lack of change in cognitive insight aligned with longitudinal cortical thickness results, where no interaction effects were seen with cortical thickness between time and either Self-Reflectiveness or Self-Certainty. Exploratory analyses with a reduced threshold found that in FEP, across all time-points, higher Self-Certainty associated with thinner cortex in left posterior cingulate/precuneus. Results suggest that the posterior cingulate may be a common neural correlate for Self-Certainty in FEP and non-clinical subjects.

The relationship between cognitive insight and cognitive performance among individuals with at-risk mental state for developing psychosis

Impairments in cognitive insight-the capacity to appraise and modify one's own distorted beliefs-are believed to be associated with the formation of psychosis. Nevertheless, the association between cognitive insight and cognitive function among people with at-risk mental state (ARMS) for developing psychotic illness has not been made clear. In this study, we used the Beck Cognitive Insight Scale (BCIS) to assess cognitive insight and the Brief Assessment of Cognition in Schizophrenia (BACS) and the Wisconsin Card Sorting Test (WCST) to assess cognitive functions. Fifty subjects with ARMS and 29 healthy volunteers were recruited as participants. The scores for the two groups on the BCIS, BACS, and WCST were compared and Spearman's rank correlations between the domains of the BCIS and cognitive performance were examined in each group. No significant differences were found in BCIS scores between these groups, whereas all of the cognitive function scores were poorer in the participants with ARMS. In the ARMS group, higher self-certainty on the BCIS was significantly correlated with lower performance in the mean number of categories achieved (ρ=-0.31, P=0.03) and perseverative errors of the Nelson type (ρ=0.29, P=0.04) on the WCST. This indicates that excessively high self-certainty might be linked with weaknesses in cognitive flexibility or set-shifting ability in people with ARMS.

Neurobiological Basis of Insight in Schizophrenia: A Systematic Review

BACKGROUND

Insight in schizophrenia is defined as awareness into illness, symptoms, and need for treatment and has long been associated with cognition, other psychopathological symptoms, and several adverse clinical and functional outcomes. However, the biological basis of insight is not clearly understood.

OBJECTIVE

The aim of this systematic review was to critically evaluate and summarize advances in the study of the biological basis of insight in schizophrenia and to identify gaps in this knowledge.

METHODS

A literature search of PubMed, CINAHL, PsycINFO, and EMBASE databases was conducted using search terms to identify articles relevant to the biology of insight in schizophrenia published in the last 6 years. Articles that focused on etiology of insight in schizophrenia and those that examined the neurobiology of insight in schizophrenia or psychoses were chosen for analysis. Articles on insight in conditions other than schizophrenia or psychoses and which did not investigate the neurobiological underpinnings of insight were excluded from the review.

RESULTS

Twenty-six articles met the inclusion criteria for this review. Of the 26 articles, 3 focused on cellular abnormalities and 23 were neuroimaging studies. Preliminary data identify the prefrontal cortex, cingulate cortex, and regions of the temporal and parietal lobe (precuneus, inferior parietal lobule) and hippocampus as the neural correlates of insight.

DISCUSSION

A growing body of literature attests to the neurobiological basis of insight in schizophrenia. Current evidence supports the neurobiological basis of insight in schizophrenia and identifies specific neural correlates for insight types and its dimensions. Further studies that examine the precise biological mechanisms of insight are needed to apply this knowledge to effective clinical intervention development.

How self-reflection and self-certainty are related to neurocognitive functioning: an examination of cognitive insight in bipolar disorder

INTRODUCTION

The pattern of associations between clinical insight, cognitive insight, and neurocognitive functioning was assessed in bipolar disorder patients.

METHODS

Data from 42 bipolar disorder patients were examined. Cognitive insight was measured using the Beck Cognitive Insight Scale (BCIS). The BCIS is a 15-item self-report instrument consisting of two subscales, self-reflectiveness and self-certainty. Clinical insight was measured by the use of the item G12 of the Positive and Negative Syndrome Scale. Neurocognitive functioning was assessed using the International Society for Bipolar Disorders-Battery for Assessment of Neurocognition.

RESULTS

Correlation analyses revealed significant positive associations between self-reflectiveness and speed of processing, attention, working memory, visual learning, and reasoning and problem solving. The subscale self-certainty was negatively correlated to working memory, however, this correlation disappeared when we controlled for confounding variables. No correlations between clinical insight and neurocognition were found. In addition, there was no association between cognitive insight and clinical insight.

CONCLUSION

Better neurocognitive functioning was more related to higher levels of self-reflectiveness than to diminished self-certainty.

Unrealistic self-overconfidence in schizophrenia is associated with left presubiculum atrophy and impaired episodic memory

The study aimed at investigating the role of the hippocampal subfields in cognitive insight and the clinical and neuropsychological underpinnings of the related two sub-dimensions, Self-Reflectiveness (SR), i.e., openness to external feedback, and Self-Certainty (SC), i.e., unrealistic overconfidence in one's opinions. In order to do this, 45 patients with a diagnosis of schizophrenia and 45 age- and gender-matched healthy control subjects (HC) were administered the Beck Cognitive Insight Scale (BCIS), along with neuropsychological, clinical and psychopathological assessment, and underwent an MRI investigation. Hippocampal segmentation was carried out. Regression analyses were performed for BCIS indexes, volumetric parameters of hippocampal subfields and clinical and neuropsychological variables. Results highlighted that in the schizophrenia group, higher levels of SC were related to reduced volume of the left presubiculum, and worse episodic memory. No significant relationship emerged for the SR index. There was no significant relationship between any of the BCIS indexes and volumetric data of the hippocampal subfields in the HC group. Our data support the hypothesis that unrealistic self-overconfidence in schizophrenia is related to the hippocampal presubiculum atrophy, which is involved in episodic memory and cognitive control and is supposed to be underpinned by difficulty in integrating new memories and thus in generating new hypotheses about the self.

Clinical and cognitive insight in patients with acute-phase psychosis: Association with treatment and neuropsychological functioning

BACKGROUND

The severity of psychopathology cannot fully explain deficits in the multi-dimensional construct of insight.

AIMS

The aim of this study was to evaluate the correlates and associations of clinical and cognitive insight in patients in an acute phase of psychosis and to analyse the impact of acute treatment on these variables.

METHODS

This study examined 47 inpatients who were recently hospitalized with acute exacerbation of schizophrenia. All subjects were assessed at both admission and discharge with the Positive and Negative Syndrome Scale (PANSS), Schedule for the Assessment of Insight-Expanded Version (SAI-E), Beck Cognitive Insight Scale (BCIS), and a neurocognition battery.

RESULTS

Patients with schizophrenia gained clinical insight after treatment. Cognitive insight did not change significantly after treatment. Insight showed significant negative correlations with positive symptoms and general psychopathology, but not with negative symptoms. Clinical insight was not associated with neuropsychological functioning in this cohort.

CONCLUSION

Gaining clinical insight in the acute phase of illness was associated with the remission of positive symptoms, but not with neuropsychological functioning. Some significant correlations between clinical and cognitive insights were detected, which suggests that cognitive insight contributes to clinical insight but is not treatment-dependent. Long-term treatment may be required to understand the contribution of insight to the outcome of patients with schizophrenia.

Cognitive insight is associated with cortical thickness in first-episode psychosis

Compared to non-clinical subjects, people with psychosis show poor cognitive insight as reflected in low Self-Reflectiveness and high Self-Certainty. Neuroimaging studies have reported that 1) low Self-Reflectiveness is associated with volumetric reductions in ventrolateral prefrontal cortex (VLPFC), 2) higher Self-Certainty is associated with volumetric reductions in hippocampus, and 3) higher Self-Certainty is associated with fractional anisotropy in the fornix, in people with psychosis. The aims of the current study were to expand on this research by 1) performing an exploratory whole-brain cortical thickness analysis of the neural correlates of cognitive insight, to reveal whether regions outside the VLPFC are important for cognitive insight, and 2) to evaluate associations between cognitive insight and subfields of the hippocampus, which are distinct, interacting, and have different functions. We also aimed to replicate previous research documenting associations between cognitive insight and 3) total hippocampal volumes and 4) fornix fractional anisotropy. Fifteen people with a first-episode psychosis completed the Beck Cognitive Insight Scale and provided magnetic resonance and diffusion tensor imaging scans. Cortical thickness and hippocampal volumes were analyzed in FreeSurfer, and fornixfractional anisotropy was analyzed in Diffusion Toolkit/TrackVis. Higher Self-Reflectiveness and lower Self-Certainty significantly associated with thickness and thinness in VLPFC, respectively, as well as thickness and thinness in widespread frontal, parietal and temporal cortices. No associations emerged between Self-Reflectiveness or Self-Certainty and hippocampal total or sub-field volumes, or fornix fractional anisotropy. Results suggest that the neural correlates of cognitive insight involve a network of frontal, temporal and parietal brain regions.

Does the Beck Cognitive Insight Scale Predict Response to Cognitive Remediation in Schizophrenia?

Cognitive remediation therapy (CRT) has emerged as a viable treatment option for people diagnosed with schizophrenia presenting disabling cognitive deficits. However, it is important to determine which variables can influence response to CRT in order to provide cost-effective treatment. This study's aim was to explore cognitive insight as a potential predictor of cognitive improvement after CRT. Twenty patients with schizophrenia completed a 24-session CRT program involving 18 hours of computer exercises and 6 hours of group discussion to encourage generalization of cognitive training to everyday activities. Pre- and posttest assessments included the CogState Research Battery and the Beck Cognitive Insight Scale (BCIS). Lower self-certainty on the BCIS at baseline was associated with greater improvement in speed of processing (r s = -0.48; p < 0.05) and visual memory (r s = -0.46; p < 0.05). The results of this study point out potential associations between self-certainty and cognitive improvement after CRT, a variable that can easily be measured in clinical settings to help evaluate which patients may benefit most from the intervention. They also underline the need to keep investigating the predictors of good CRT outcomes, which can vary widely between patients.

The relationship between cognitive insight and depression in psychosis and schizophrenia: a review and meta-analysis

Lack of insight is a commonly observed problem in patients with psychosis and schizophrenia. Clinical insight in patients has been associated with low mood. Cognitive insight is a recently defined concept, relating to the ability to self-reflect and the degree to which patients are over-confident regarding their interpretations of illness-related experiences, and is related to clinical insight. We therefore sought to investigate whether there is a positive relationship between cognitive insight and mood. A literature search identified 17 relevant papers published between 2004 and 2014. Our analysis indicated that there was a small but significant positive correlation between the composite index (CI) of the Beck Cognitive Insight Scale (BCIS) and depression scores, but this was driven by a significant positive relationship between depression and the BCIS self-reflection (SR) sub-scale, where low mood was related to higher SR scores. There was no significant relationship between the self-certainty sub-scale and depression. Post-hoc analysis indicated that different depression scales did not significantly affect the relationship with SR. Our results support the idea that cognitive insight is significantly related to mood in schizophrenia, and the effect size is similar to that between clinical insight and mood. Potential applications of this knowledge into treatment and rehabilitation are discussed and a model of cognitive insight is proposed.

Cognitive insight in first-episode schizophrenia: further evidence for a role of the ventrolateral prefrontal cortex

In people with psychoses, Self-Reflectiveness may rely on the right ventrolateral prefrontal cortex (VLPFC). We used functional magnetic resonance imaging (fMRI) and a novel virtual reality paradigm to evaluate the role of the VLPFC for Self-Reflectiveness in 25 first-episode of schizophrenia (FES) participants and 24 controls. Participants first viewed 20 characters each paired with a unique object/location, and later completed source memory judgements during fMRI scanning. Self-Reflectiveness, measured with the Beck Cognitive Insight Scale, was significantly and positively correlated to activation in bilateral VLPFC in FES, but not in controls, providing further evidence that the VLPFC supports Self-Reflectiveness in FES.

Insight in schizophrenia: relationship to positive, negative and neurocognitive dimensions

Impairment of insight is considered as the hallmark of schizophrenia. Substantial proportion of patients with schizophrenia has either poor or absent insight. Insight is a multidimensional and dynamic construct which appears to have intricate links with other symptom dimensions of the psychotic illness. A better appreciation of the association that insight shares with other symptom clusters in psychosis could help us in gaining knowledge about aetiology, prognosis and treatment-related facets of the disorder. This is likely to have critical implications in the understanding and therapeutics of schizophrenia.

Is personal recovery in schizophrenia predicted by low cognitive insight?

Recovery is a widely discussed concept in the field of research, treatment, and public policy regarding serious mental illness, and mainly schizophrenia. Aim of our study was to assess the relationship between personal recovery and prediction variables, as psychopathology, neurocognition, clinical and cognitive insight, and social functioning in inpatients affected by schizophrenia, with a special interest on cognitive insight. We assessed 76 inpatients affected by schizophrenia at their hospital discharge. Instruments included the Beck Cognitive Insight Scale, the Insight Scale and the Recovery Assessment Scale to assess the cognitive and clinical insight, and personal recovery. The neurocognitive assessment was represented by a single factor score produced by a principal components analysis of a neurocognitive test battery. Social functioning was measured also. Low self-reflectiveness of cognitive insight represented the best predictors of personal recovery. The relationship between cognitive insight and recovery found in this study may contribute to develop tailored interventions, taking into account the personal sense of recovery, despite the psychopathological evaluation.

Reduced hippocampal volume and hypothalamus-pituitary-adrenal axis function in first episode psychosis: evidence for sex differences

Background

Hippocampal volume (HV) decline is an important marker of psychosis and has been associated with hypothalamus–pituitary–adrenal (HPA) axis dysregulation in various disorders. Given recent findings of sex differences in HPA axis function in psychosis, the current study investigated differences in HV in male and female first episode psychosis (FEP) patients and controls and the interaction of HV with the cortisol awakening response (CAR) and symptoms.

Methods

Fifty-eight patients with a diagnosis of FEP (39 men, 19 women) and 27 healthy community controls (15 men, 12 women) underwent structural magnetic resonance imaging (MRI) on a 1.5 T scanner. Hippocampal volume was determined using previously established segmentation protocols. Saliva samples for cortisol assessment were collected at 0, 30 and 60 min after awakening. Psychotic symptoms were assessed with the Scale for Assessment of Positive Symptoms (SAPS), the Scale for Assessment of Negative Symptoms (SANS) and the Global Assessment of Functioning (GAF) scale.

Results

Male patients had significantly smaller left and right HVs compared to male controls, which appeared to be secondary to global brain volume differences. However, even when controlling for overall brain size, male patients showed smaller HV compared to female patients. The CAR was significantly lower in male patients compared to male controls and female patients. Only in male patients, smaller left HV was significantly associated with a blunted CAR, and smaller HV bilaterally was related to positive psychotic symptoms and lower levels of functioning.

Conclusions

We propose that reduced hippocampal volume and an attenuated cortisol awakening response are related markers of increased stress vulnerability in male psychosis patients and that both contribute to the unfavorable clinical picture in men.

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We examined sex differences in neurobiological markers of stress in psychosis.

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Hippocampal volume and cortisol levels to awakening are reduced in male patients.

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Male first episode psychosis patients show markers of high stress vulnerability.

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Neurobiological deficits relate to poor outcome in male but not female patients.

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The neural-diathesis stress model of schizophrenia is particularly valid for men.

Impaired insight into illness and cognitive insight in schizophrenia spectrum disorders: resting state functional connectivity

BACKGROUND

Impaired insight into illness (clinical insight) in schizophrenia has negative effects on treatment adherence and clinical outcomes. Schizophrenia is described as a disorder of disrupted brain connectivity. In line with this concept, resting state networks (RSNs) appear differentially affected in persons with schizophrenia. Therefore, impaired clinical, or the related construct of cognitive insight (which posits that impaired clinical insight is a function of metacognitive deficits), may reflect alterations in RSN functional connectivity (fc). Based on our previous research, which showed that impaired insight into illness was associated with increased left hemisphere volume relative to right, we hypothesized that impaired clinical insight would be associated with increased connectivity in the DMN with specific left hemisphere brain regions.

METHODS

Resting state MRI scans were acquired for participants with schizophrenia or schizoaffective disorder (n=20). Seed-to-voxel and ROI-to-ROI fc analyses were performed using the CONN-fMRI fc toolbox v13 for established RSNs. Clinical and cognitive insight were measured with the Schedule for the Assessment of Insight-Expanded Version and Beck Cognitive Insight Scale, respectively, and included as the regressors in fc analyses.

RESULTS

As hypothesized, impaired clinical insight was associated with increased connectivity in the default mode network (DMN) with the left angular gyrus, and also in the self-referential network (SRN) with the left insula. Cognitive insight was associated with increased connectivity in the dorsal attention network (DAN) with the right inferior frontal cortex (IFC) and left anterior cingulate cortex (ACC).

CONCLUSION

Increased connectivity in DMN and SRN with the left angular gyrus and insula, respectively, may represent neural correlates of impaired clinical insight in schizophrenia spectrum disorders, and is consistent with the literature attributing impaired insight to left hemisphere dominance. Increased connectivity in the DAN with the IFC and ACC in relation to cognitive insight may facilitate enhanced mental flexibility in this sample.

Cognitive insight in schizophrenia patients and their biological parents: a pilot study

BACKGROUND

Clinical insight in schizophrenia patients is partly associated with familial environment but has been poorly studied to date. We aimed to explore (1) the relationship between parents' cognitive insight and their offspring's; (2) the relationship between parents' cognitive insight and their clinical insight into the disease of their offspring; and (3) the clinical and cognitive determinants of cognitive insight in parents.

METHODS

Cognitive insight was assessed in 37 patient-biological parent pairs/dyads with the Beck Cognitive Insight Scale (BCIS). Other measures included the Scale to assess Unawareness of Mental Disorder and cognitive assessments.

RESULTS

We found no significant association between parents' cognitive insight and their offspring's. Conversely, a positive association between parents' cognitive insight and parents' insight into their offspring's symptoms was found. Better awareness of their offspring's specific symptoms was associated with lower levels of overconfidence in one's beliefs and with BCIS total score. BCIS Self-Certainty and BCIS total score were associated with better executive functioning and verbal comprehension.

CONCLUSIONS

Better insight into their offspring's symptoms is associated with cognitive insight in biological parents of schizophrenia patients. Our results support the integration of cognitive intervention targeting parents' cognitive flexibility in family psychoeducational programs and provide an important first step towards developing a more refined understanding of the factors involved in insight into symptoms of illness in parents of schizophrenia patients.

Functional magnetic resonance imaging study of external source memory and its relation to cognitive insight in non-clinical subjects

AIM

Previous research has linked cognitive insight (a measure of self-reflectiveness and self-certainty) in psychosis with neurocognitive and neuroanatomical disturbances in the fronto-hippocampal neural network. The authors' goal was to use functional magnetic resonance imaging (fMRI) to investigate the neural correlates of cognitive insight during an external source memory paradigm in non-clinical subjects.

METHODS

At encoding, 24 non-clinical subjects travelled through a virtual city where they came across 20 separate people, each paired with a unique object in a distinct location. fMRI data were then acquired while participants viewed images of the city, and completed source recognition memory judgments of where and with whom objects were seen, which is known to involve prefrontal cortex. Cognitive insight was assessed with the Beck Cognitive Insight Scale.

RESULTS

External source memory was associated with neural activity in a widespread network consisting of frontal cortex, including ventrolateral prefrontal cortex (VLPFC), temporal and occipital cortices. Activation in VLPFC correlated with higher self-reflectiveness and activation in midbrain correlated with lower self-certainty during source memory attributions. Neither self-reflectiveness nor self-certainty significantly correlated with source memory accuracy.

CONCLUSION

By means of virtual reality and in the context of an external source memory paradigm, the study identified a preliminary functional neural basis for cognitive insight in the VLPFC in healthy people that accords with our fronto-hippocampal theoretical model as well as recent neuroimaging data in people with psychosis. The results may facilitate the understanding of the role of neural mechanisms in psychotic disorders associated with cognitive insight distortions.

Neural correlates of insight in dreaming and psychosis

The idea that dreaming can serve as a model for psychosis has a long and honourable tradition, however it is notoriously speculative. Here we demonstrate that recent research on the phenomenon of lucid dreaming sheds new light on the debate. Lucid dreaming is a rare state of sleep in which the dreamer gains insight into his state of mind during dreaming. Recent electroencephalogram (EEG) and functional magnetic resonance imaging (fMRI) data for the first time allow very specific hypotheses about the dream-psychosis relationship: if dreaming is a reasonable model for psychosis, then insight into the dreaming state and insight into the psychotic state should share similar neural correlates. This indeed seems to be the case: cortical areas activated during lucid dreaming show striking overlap with brain regions that are impaired in psychotic patients who lack insight into their pathological state. This parallel allows for new therapeutic approaches and ways to test antipsychotic medication.

Cognitive insight in individuals at clinical high risk for psychosis

AIM

Reduced cognitive insight has been associated with psychotic symptoms, in particular with the presence of delusions; however, there is little information about whether such reductions are present in at-risk individuals prior to the onset of threshold psychotic symptoms.

METHOD

We conducted a cross-sectional comparison of cognitive insight (as indexed by the Beck Cognitive Insight Scale) in 62 help-seeking individuals at clinical high risk for psychosis, Fifty-nine individuals with schizophrenia-spectrum disorders and 37 healthy controls (HC). In patients, we evaluated associations of insight with positive symptoms, including later transition to psychosis in high-risk patients.

RESULTS

Individuals with schizophrenia reported significantly higher self-certainty scores than the at-risk patients and HCs, with the at-risk patients scoring intermediate to the individuals with schizophrenia and controls. Similarly, individuals with schizophrenia scored significantly higher on self-reflectiveness, with no differences between the at-risk patients and controls. In individuals with schizophrenia, delusions were significantly correlated with self-certainty. In at-risk patients, cognitive insight was not associated with positive symptom severity and did not differentiate those at-risk patients who later developed psychosis from those who did not. However, post hoc analyses suggested that at-risk patients with marked unusual thought content (approaching threshold psychosis) had lower self-reflectiveness; whereas those with high suspiciousness had significantly higher self-certainty.

CONCLUSIONS

The findings are discussed in the context of normal developmental processes occurring during adolescence, their putative links to neurobiological functioning, and their implications for treatment and future research.

The structural neuroanatomy of metacognitive insight in schizophrenia and its psychopathological and neuropsychological correlates

Lack of insight into illness is a multidimensional phenomenon that has relevant implications on clinical course and therapy compliance. Here, we focused on metacognitive insight in schizophrenia, that is, the ability to monitor one's changes in state of mind and sensations, with the aim of investigating its neuroanatomical, psychopathological, and neuropsychological correlates. Fifty-seven consecutive patients with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) diagnosis of schizophrenia were administered the Insight Scale, and comprehensive psychopathological and neuropsychological batteries. They underwent a high-resolution T1-weighted magnetic resonance imaging investigation. Gray matter (GM) and white matter (WM) volumes were analyzed on a voxel-by-voxel basis using Statistical Parametric Mapping 8. Reduced metacognitive insight was related to reduced GM volumes in the left ventrolateral prefrontal cortex, right dorsolateral prefrontal cortex and insula, and bilateral premotor area and putamen. Further, it was related to reduced WM volumes of the right superior longitudinal fasciculum, left corona radiata, left forceps minor, and bilateral cingulum. Increased metacognitive insight was related to increased depression severity and attentional control impairment, while the latter was related to increased GM volumes in brain areas linked to metacognitive insight. Results of this study suggest that prefrontal GM and WM bundles, all implied in cognitive control and self-reflection, may be the neuroanatomical correlates of metacognitive insight in schizophrenia. Further, higher metacognitive insight is hypothesized to be a risk factor for depression which may subsequently impair attention. This line of research may provide the basis for the development of cognitive interventions aimed at improving self-monitoring and compliance to treatment.

Differential associations of cognitive insight components with pretreatment characteristics in first-episode psychosis

An increasing number of studies have focused on cognitive insight (i.e. awareness of one's own thinking) in psychotic disorders. However, little is known about the premorbid and pretreatment correlates of cognitive insight in the early course of psychosis. One hundred and three patients experiencing first-episode psychosis (FEP) were assessed shortly after treatment initiation for cognitive insight. Pretreatment and baseline clinical, functional and neurocognitive characteristics were examined. The self-reflectiveness dimension of cognitive insight was independently associated with clinical insight and executive functioning, whereas self-certainty was associated with premorbid IQ, premorbid academic adjustment and clinical insight. The amount of variance explained by the independent variables was small to moderate. Self-reflectiveness and self-certainty have differential pretreatment correlates in FEP and may reflect separate cognitive processes which require targeted interventions.

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

The neurocognitive theory of insight posits that poor insight in psychotic illnesses is related to cognitive deficits in cognitive self-appraisal mechanisms. In this paper we perform a comprehensive meta-analysis examining relationships between clinical insight and neurocognition in psychotic disorders. We have also completed a meta-analysis of studies examining 'cognitive insight', as measured by the Beck Cognitive Insight Scale (BCIS), and its relationship with neurocognitive function in patients with psychosis. The clinical insight analysis included data from 72 studies and a total population of 5429 patients. We found that insight in psychosis was significantly associated with total cognition (r=0.16, p<0.001), IQ (r=0.16, p<0.001), memory (r=0.13, p<0.001) and executive function (r=0.14, p<0.001). All of these correlations were stronger when examined in patients with schizophrenia only. In the BCIS analysis we included 7 studies and 466 patients in total. We found that no significant associations were found between the self-reflectiveness sub-component and neurocognition. By contrast there were significant correlations between the self-certainty subcomponent and memory (r=-0.23, p<0.001), IQ (r=-0.19, p<0.001) and total cognition (r=-0.14, p=0.01). We did not find evidence of significant publication bias in any analyses. Overall, our results indicate that there is a small but significant relationship between clinical insight, some aspects of cognitive insight and neurocognition. These findings reflect the complexity of the insight construct and indicate that while the neurocognitive model is important it is likely to be one of many which contribute to the understanding of this phenomenon.

Ten year neurocognitive trajectories in first-episode psychosis

Objective: Neurocognitive impairment is commonly reported at onset of psychotic disorders. However, the long-term neurocognitive course remains largely uninvestigated in first episode psychosis (FEP) and the relationship to clinically significant subgroups even more so. We report 10 year longitudinal neurocognitive development in a sample of FEP patients, and explore whether the trajectories of cognitive course are related to presence of relapse to psychosis, especially within the first year, with a focus on the course of verbal memory.

Method: Forty-three FEP subjects (51% male, 28 ± 9 years) were followed-up neurocognitively over five assessments spanning 10 years. The test battery was divided into four neurocognitive indices; Executive Function, Verbal Learning, Motor Speed, and Verbal Fluency. The sample was grouped into those relapsing or not within the first, second and fifth year.

Results: The four neurocognitive indices showed overall stability over the 10 year period. Significant relapse by index interactions were found for all indices except Executive Function. Follow-up analyses identified a larger significant decrease over time for the encoding measure within Verbal Memory for patients with psychotic relapse in the first year [F_{(4, 38)} = 5.8, p = 0.001, η² = 0.40].

Conclusions: Main findings are long-term stability in neurocognitive functioning in FEP patients, with the exception of verbal memory in patients with psychotic relapse or non-remission early in the course of illness. We conclude that worsening of specific parts of cognitive function may be expected for patients with on-going psychosis, but that the majority of patients do not show significant change in cognitive performance during the first 10 years after being diagnosed.

Systematic review reveals heterogeneity in the use of the Scale to Assess Unawareness of Mental Disorder (SUMD)

The Scale to Assess Unawareness of Mental Disorder (SUMD) is one of the most widely used instruments to measure insight into mental disorders. The aim of this study was to review all studies using the SUMD in the last 20 years. We performed an electronic search of MEDLINE using PubMed to identify all relevant studies published from 1993 to 2012. The following data were extracted from each article: characteristics of the SUMD (version, rating scale, scoring, and item/dimension used), methodological aspects (country, language, subject inclusion criteria, and sample size), and statistical methods to analyse insight. Of the 133 articles screened, 100 studies were included in the review. Fifty-two studies were published over the past five years. The SUMD was rarely used in its entirety, and the use of selected items or subscales was heterogeneous across studies. The studies also varied in terms of response modalities and in the use of 3- or 5-point Likert scales. The calculation of insight scores was highly variable and included the following: treating items as categorical or continuous variables, separate analysis of individual items, items expressed in terms of the sum total or the mean scores, and a range of score values used to define insight. This paper provides a systematic review of studies using the SUMD and reveals important differences in the versions used, the methods of calculation, and the interpretation of scores across studies. The use of a modified SUMD may compromise the psychometric properties of the scale, lead to erroneous conclusions, and prevents comparison of results across studies. Our review underlines the need for the standardised use of the SUMD.

Cognitive insight in Alzheimer's disease

BACKGROUND/RATIONALE

We investigated the cognitive insight profile of patients with Alzheimer's disease (AD) using the Beck Cognitive Insight Scale (BCIS).

METHODS

This study involved 30 patients with probable AD and 15 healthy participants (ie, the controls). All individuals completed the BCIS, the Hamilton Rating Scale for Depression (HAMD), and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

Mean scores of the HADS-depression subscale, HAMD, BCIS-self-reflectiveness (BCIS-R), and BCIS-self-certainty (BCIS-C) subscales were significantly different between the patients and the controls. However, there was no significant difference in BCIS reflectiveness-certainty index scores between the patients and the control groups. Regression analyses showed a moderately positive correlation between hallucinations and BCIS-C scores.

CONCLUSION

This study is the first to investigate cognitive insight in patients with probable AD. The BCIS-R and BCIS-C scores were significantly lower in patients than in control group.

Neurocognition and cognitive biases in schizophrenia

Individuals with schizophrenia have been found to exhibit a number of information processing biases that may play a role in the development and exacerbation of symptoms and may impair overall functioning. However, little is known about the factors that are associated with these cognitive biases. Recently, researchers have begun to consider whether neurocognitive deficits, common in schizophrenia, may be risk factors for the development of cognitive biases. In the present study, we assessed neurocognition (verbal learning, delayed verbal recall memory, and verbal recognition memory) and cognitive biases (knowledge corruption and impaired cognitive insight) in 72 individuals with schizophrenia or schizoaffective disorder. As hypothesized, poorer delayed verbal recall memory was associated with increased knowledge corruption. Contrary to expectations, verbal learning and verbal memory were not associated with cognitive insight. These findings suggest that an inadequate recall memory system may put patients with schizophrenia at greater risk for cognitive distortions.