بینش شناختی و اختلال روانی: اثر هذیان های فعال

While several studies have determined the Beck Cognitive Insight Scale (BCIS; [Beck, A.T., Baruch, E., Balter, J.M., Steer, R.A., Warman, D.M., 2004. A new instrument for measuring insight: The Beck Cognitive Insight Scale. Schizophr. Res. 68, 319–329] is a useful measure of cognitive insight, a number of questions have remained unanswered. While individuals with psychotic disorders have been shown to have impaired cognitive insight compared to a psychiatric comparison group, it has remained unclear how the cognitive insight of individuals with psychotic disorders compares to healthy individuals. Further, as previous studies have classified participants based on diagnostic classification, it has remained unknown if individuals with delusions and individuals with psychotic disorders without active delusions score differently on this measure. To examine these questions, we assessed the cognitive insight of healthy individuals and individuals with psychotic disorders, both with and without active delusions. Results indicated that individuals with psychotic disorders had impaired cognitive insight relative to healthy controls (p = .005), though individuals with active delusions and individuals with psychotic disorders without delusions had impairments in different domains. Individuals with delusions were overly confident in their own judgment relative to healthy controls and those without delusions (p = .011), though their self-reflectiveness was the same as normal controls. Individuals without delusions reported low self-reflectiveness relative to healthy controls and individuals with delusions (p = .004), though they were not overconfident in their judgment. These results are discussed in terms of existing research on cognitive insight, decision making, and psychosis.

It is widely recognized that many persons with schizophrenia have poor insight or significant difficulties recognizing their deficits and need for treatment (Amador et al., 1993). More recently, Beck et al. (2004) have noted that schizophrenia may involve a compromise in an additional kind of insight — cognitive insight, or the ability to self-reflect, acknowledge the possibility of being mistaken, be open to feedback, and to refrain from overconfidence. This form of insight has been thought to have great clinical significance as it taps directly into how individuals with delusions think, making it particularly relevant for facilitating change in psychotherapy (Beck and Warman, 2004). To assess cognitive insight, the Beck Cognitive Insight Scale (BCIS; Beck et al., 2004) was recently developed. The BCIS, a 15-item self-report instrument, is comprised of two factors, the first labeled Self-Reflectiveness, which includes items related to the willingness to acknowledge fallibility, the recognition of having jumped to conclusions at times, and the possibility of having misinterpreted unusual experiences. The second factor, labeled Self-Certainty, includes items related to overconfidence. It is speculated that overconfidence may serve to impair self-reflectiveness, therefore the Composite Index, the measure of the person's overall cognitive insight, is determined by subtracting the individual's Self-Certainty score from his/her Self-Reflectiveness score. To date, the BCIS has been investigated in three studies, all which examined different populations (Beck et al., 2004, Pedrelli et al., 2004 and Warman et al., 2004). The initial study (Beck et al., 2004), which determined the factor structure of the BCIS and its psychometric properties, investigated a group of inpatients who had psychotic disorders of various diagnoses and also patients with major depressive disorder without psychosis. Pedrelli et al. (2004) examined the BCIS with a sample of middle to older adult outpatients, all of whom had a diagnosis of schizophrenia and schizoaffective disorder and who had, on average, mild to moderate psychotic symptoms, and determined that the factor structure of the measure was the same as it was in the study by Beck et al. In addition, Warman et al. (2004) found that the basic factor structure of the BCIS was the same in a normal population of university students (none of whom had a psychotic disorder) as it was in the original Beck et al. study of inpatients with psychiatric diagnoses. In sum, the studies to date have determined that the BCIS is a useful measure for inpatients with various diagnoses, outpatients with psychotic disorders, and also healthy university students. While these initial investigations indicate the BCIS is a valuable measure of cognitive insight, a number of points remain unclear. First, how cognitive insight relates to active delusions, as opposed to psychotic disorder diagnosis has not yet been determined. Beck et al. (2004) found that individuals with psychotic disorders were significantly less self-reflective and more overconfident than individuals without psychotic disorders; as group classification was based on diagnosis, not active delusional status at the time of testing, the relationship to active delusions cannot be determined. While Pedrelli et al. (2004) did not directly examine individuals with active delusions compared to individuals without active delusions, they noted that severity of positive symptoms was not related to self-reflectiveness or to overall cognitive insight. Severity of positive symptoms was, however, positively (though weakly, r = .24) correlated with overconfidence. These results suggest that active psychosis may impair certainty judgments more than it does self-reflectiveness, though a direct assessment of individuals with active delusions versus individuals with psychotic disorders without active delusions has not yet been done. A further remaining question is how the cognitive insight of individuals with psychotic disorders and/or active delusions compares to a normal population. While it has been determined that individuals with psychotic disorders have impaired cognitive insight relative to those with major depressive disorder without psychosis, the cognitive insight of individuals with psychotic disorders has not yet been compared to healthy individuals. Specifically, no studies have included both a population of individuals with psychotic disorders and a population of healthy individuals with no psychotic disorder diagnosis. Despite the lack of such direct comparisons, by examining the results of the three studies that have examined the BCIS, it is possible to develop some tentative conclusions (see Table 1). Overall, it appears that individuals with psychotic disorders and healthy individuals score approximately the same on the Self-Reflectiveness subscale and that both groups are less self-reflective than individuals with severe depression. In terms of overconfidence, it appears that healthy individuals score midway between individuals with severe depression without psychosis and those with psychotic disorders. It appears that the relationship between cognitive insight and psychosis may not be a simple one. Table 1.

Results are presented in two major sections. In the first section, individuals with schizophrenia or schizoaffective disorder are compared to the individuals in the nonclinical sample. For the first section of the results, these groups are labeled psychotic disorder and healthy controls, respectively. The analyses in the first section were done to be consistent with the original study of Beck et al. (2004) which distinguished participants based on diagnostic classification, not by delusional status at the time of testing. In the second section, individuals with schizophrenia or schizoaffective disorder are distinguished based on their delusional status at time of testing (i.e., their PANSS score on the delusions item) and are compared to the nonclinical sample. Thus, for the second section three groups are compared: schizophrenia/schizoaffective disorder with delusions, schizophrenia/schizoaffective disorder without delusions, and nonclinical sample. For section two of the results section, these groups are labeled psychotic disorder with current delusions (CD), psychotic disorder with no current delusions (ND), and healthy controls (HC), respectively.