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03-07-2013 | Mental health | Article

Cognitive outweighs clinical insight for predicting psychosis outcome


Free abstract

medwireNews: Cognitive insight, rather than clinical insight, may be a useful prognostic indicator of future psychopathology in patients experiencing their first psychotic episode, research suggests.

Clinical insight refers to a patient's awareness of their illness, their need for treatment, and the relabeling of their symptoms as abnormal, whereas cognitive insight looks at an individual's self-reflectiveness (willingness to accept fallibility and external feedback) and self-certainty (overconfidence).

"High self-reflectiveness and low self-certainty are thought to indicate 'good' cognitive insight," Jennifer O'Connor (Institute of Psychiatry, London, UK) and colleagues explain.

They found that poor cognitive insight was associated with more severe psychopathology 1 year after a patient's first psychotic episode and predicted outcome independently of neuropsychologic factors.

Cognitive insight, together with negative symptoms but independently of them, explained 21% of the variance in general psychopathologic outcome, with each unit increase on the Beck Cognitive Insight Scale corresponding to a half unit improvement in psychiatric symptoms on the Global Assessment Functioning (GAF) scale at 12 months. This was after accounting for gender, duration of untreated psychosis, and ethnicity.

By contrast, clinical insight measured on the Schedule for Assessing Insight-Expanded Version did not predict psychiatric outcome scores on the GAF.

"The lack of association across time indicates that clinical insight may be too fluid a construct to be a useful prognostic indicator... especially in the early phases of the illness, presumably because the patient, and indeed their [carers] are struggling to make sense of their experiences in terms of a pathological process," the researchers suggest in Schizophrenia Research.

Neither of the insight measures were very good at predicting negative symptoms at 12 months, but neuropsychologic factors were, particularly verbal and executive function. Specifically, being 10 seconds faster on the Trail Making B test predicted a nearly 4-point reduction in scores on the negative symptom subscale of the Positive and Negative Syndrome Scale (PANSS). And a faster performance on the Trail Making B test was associated with fewer negative symptoms.

Only negative symptoms predicted functional outcome, however. Negative symptoms alone explained 22% of the variance in functional outcome, with a 1-unit decrease in PANSS score corresponding to a 1.6-point increase in GAF score for functional outcome.

The study, which involved 127 patients, shows a positive relationship over time between cognitive insight and psychopathology.

This "suggests a causal role for meta-cognition on later recovery from psychosis," says the team. "Intervention studies to explore the effect of change to cognitive insight might help clarify the relationship as well as providing a novel focus for treatment studies."

medwireNews ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013

By Lucy Piper, Senior medwireNews Reporter

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