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A new instrument for measuring insight: the Beck …

A new instrument for measuring insight: the Beck cognitive Insight ScaleAaron T. Becka,*, Edward Baruchb, Jordan M. Balterb,Robert A. Steerb, Debbie M. WarmanaaPsychopathology Research Unit, Department of Psychiatry, University of Pennsylvania Medical School, 3535 Market Street, Room #2032,Philadelphia, PA 19104-3309, USAbDepartment of Psychiatry, School of Osteopathic Medicine, University of Medicine and Dentistry of New Jersey, 42 East Laurel Road,SCC 1600, Stratford, NJ 08084-1391, USAR eceived 26 December 2002; received in revised form 29 May 2003; accepted 29 May 2003 AbstractThe clinical measurements of insight have focused primarily on patients unawareness of their having a mental disorder andof their need for treatment ([Acta Psychiatr. Scand. 89 (1994) 62; Am. J. Psychiatry 150 (1993) 873]; etc.). A complementaryapproach focuses on some of the cognitive processes involved in patients re-evaluation of their anomalous experiences and oftheir specific misinterpretations: distancing, objectivity, perspective, and self-correction.

A new instrument for measuring insight: the Beck Cognitive Insight Scale Aaron T. Becka,*, Edward Baruchb, Jordan M. Balterb, Robert A. Steerb, Debbie M. Warmana aPsychopathology Research Unit, Department of Psychiatry, University of Pennsylvania Medical School, 3535 Market Street, Room #2032,

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1 A new instrument for measuring insight: the Beck cognitive Insight ScaleAaron T. Becka,*, Edward Baruchb, Jordan M. Balterb,Robert A. Steerb, Debbie M. WarmanaaPsychopathology Research Unit, Department of Psychiatry, University of Pennsylvania Medical School, 3535 Market Street, Room #2032,Philadelphia, PA 19104-3309, USAbDepartment of Psychiatry, School of Osteopathic Medicine, University of Medicine and Dentistry of New Jersey, 42 East Laurel Road,SCC 1600, Stratford, NJ 08084-1391, USAR eceived 26 December 2002; received in revised form 29 May 2003; accepted 29 May 2003 AbstractThe clinical measurements of insight have focused primarily on patients unawareness of their having a mental disorder andof their need for treatment ([Acta Psychiatr. Scand. 89 (1994) 62; Am. J. Psychiatry 150 (1993) 873]; etc.). A complementaryapproach focuses on some of the cognitive processes involved in patients re-evaluation of their anomalous experiences and oftheir specific misinterpretations: distancing, objectivity, perspective, and self-correction.

2 The Beck cognitive Insight Scale(BCIS) was developed to evaluate patients self-reflectiveness and their overconfidence in their interpretations of theirexperiences. A 15-item self-report questionnaire was subjected to a principle components analysis, yielding a 9-item self-reflectiveness subscale and a 6-item self-certainty composite index of the BCIS reflecting cognitive insight was calculated by subtracting the score for the self-certainty scalefrom that of the self-reflectiveness scale. The scale demonstrated good convergent, discriminant, and construct validity: (a) theBCIS composite index showed a significant correlation with being aware of having a mental disorder on the Scale to AssessUnawareness of Mental Disorder (SUMD; Arch. Gen. Psychiatry 51 (1994) 826) and the self-reflectiveness subscale wassignificantly correlated with being aware of delusions on the SUMD, (b) the composite index score of the BCIS differentiatedinpatients with psychotic diagnoses from inpatients without psychotic diagnoses, and (c) in a separate study, change scores onthe BCIS were significantly correlated with change scores on positive and negative symptoms.

3 The results provided tentativesupport for the validity of the BCIS. Suggestions were made for further investigation of the cognitive processes involved inidentifying and correcting erroneous beliefs and Elsevier All rights :Insight; Schizophrenia; Depression; CognitionLack of insight has been regarded as an importantfeature of psychosis since the time ofKraepelin(1919). More recent authors have described insightas a multidimensional construct that occurs on acontinuum(Amador and David, 1998; David et al.,0920-9964/$ - see front matterD2003 Elsevier All rights (03)00189-0* Corresponding author. Tel.: +1-215-898-4102; fax: + ( Beck). Research 68 (2004) 319 3291992). The contemporary approach focuses on thepatient s awareness (or, more accurately, the unaware-ness) of several attributes. For example, do thepatients recognize (a) that they are suffering from amental illness, (b) that their symptoms are patholog-ical, (c) that they need treatment, and (d) that thecause or source of their symptoms is an illness?

4 Earlier writers, such asJaspers (1968)andLewis(1934)viewed insight as a unitary phenomenon: apatient either had it or did not have it. The absence ofinsight was regarded as the sine quo non of view was challenged byMcEvoy et al. (1989)who described the complexity of the phenomenon andindicated that some acutely psychotic patients hadintact et al. (1989)also noted thata patient s insight did not necessarily improve whenthe acute psychosis abated. They concluded thatinstead of being directly correlated, insight and psy-chosis could be viewed as separate phenomena withcomplex is clear, however, that impaired insight plays arole in the development of psychotic phenomena. Inthe formation and maintenance of delusions, forexample, the aberrant beliefs are sufficiently intenseto override the normal processes of reality testingwhich are already attenuated in psychosis. Similarly,patients conviction that their verbal hallucinations aregenerated by an external agent indicates impairedrecognition of the nature of the anomalous relatively weak relationship of insight tosymptoms pointed out byMcEvoy et al.

5 (1989)andsummarized byMintz et al. (in press)warrants aninvestigation of the patients cognitive processing oftheir experiences. Focusing on the specific structure ofpatients beliefs about the nature of their anomalousexperiences could provide an alternative way ofconceptualizing insight. For example, some patientsaccept the explanation that they are mentally ill andthat their unusual experiences are symptoms of amental disorder without being convinced of questioned about the cause of their symptoms,these patients typically repeat what they have beeninformed, namely that they have a mental illness andthat their symptoms are caused by schizophrenia, oralternatively, by a chemical imbalance. Upon an in-depth clinical exploration of the content and character-istics of these experiences, however, it becomesapparent in many cases that this explanation doesnot reflect their strongly held beliefs. A hallucinatingpatient, for example, may acknowledge that the voicesare caused by a mental illness.

6 However, when ques-tioned in greater depth, he or she may say that thevoices are messages from Satan. The patient s initialexplanation could be described as an expression of intellectual insight as opposed to emotional in-sight. As used in the psychotherapy literature, emo-tional insight represents sufficient self-understandingto modify dysfunctional beliefs and their affective andbehavioral consequences. Even though patients mayhonestly accept an explanation and agree that it makessense (intellectual insight), they may not experienceany appreciable change in their underlying delusionalbelief system (emotional insight).The clinical concept of insight evaluated by avariety of scales(Amador et al., 1993, 1994; Birch-wood et al., 1994; David, 1990; David et al., 1992;Davidhizar, 1987; Marks et al., 2000; McEvoy et al.,1989)has been valuable for determining the presenceof mental illness and its prognosis, as well as pre-scribing appropriate treatment and management(Amador and David, 1998; Mintz et al.)

7 , in press).However, the clinically oriented insight scales do notdirectly address the patients limited capacity forevaluation of their anomalous experiences and theirerroneous inferences. These cognitive deficienciescontribute to the impairment in clinical insight andto the development of delusional beliefs and crucial cognitive problem in psychotic patientsresides not only in their consistent distortions of theirexperiences, but also in their relative inability todistance themselves from these distortions and in theirrelative impermeability to corrective feedback. Somenonpsychotic individuals, such as patients with de-pression or panic disorder, also misinterpret events: thedepressed patient, for example, overinterprets interac-tions with others as a sign of rejection or personalinadequacy(Beck et al., 1979), whereas the panic-prone patient misinterprets physical sensations as asign of a serious ailment(Beck et al., 1985). In bothdisorders, the patients retain the capacity to reflect ontheir experiences and to recognize that their conclu-sions were incorrect.

8 In contrast, this capacity isattenuated to varying degrees in patients with psycho-sis. The relevant components of this refractoriness inpsychosis are: (a) impairment of objectivity about thecognitive distortions, (b) loss of ability to put these Beck et al. / Schizophrenia Research 68 (2004) 319 329320perspective, (c) resistance to corrective informationfrom others, and (d) overconfidence in impairment in these processes of detecting andcorrecting misinterpretations is obviously related tothe clinical phenomenon of impaired insight into thepresence of symptoms and mental illness. If thepatients with psychosis have impaired capacity toevaluate their aberrant interpretations as susceptibleto refutation they are compelled to believe that theexperiences that others call symptoms of illness arereal, that their interpretations are facts, and that theirthinking is lack of awareness of a mental illness requiringtreatment may be regarded as an impairment of clinical insight.

9 This form of insight focuses onthose aspects of clinical phenomenology essential fordiagnosis and treatment, whereas cognitive insight includes the evaluation and correction of distortedbeliefs and misinterpretations. These evaluations arebased on higher level cognitive processes (some-times called metacognition), such as the ability todistance themselves from their misinterpretations andto reappraise first step in the understanding of these processesis to evaluate patients reports of their objectivityregarding their current delusional thinking, their per-spective about previous errors, their capacity forreattribution of erroneous explanations, and theirreceptiveness to corrective information from otherpeople. The purpose of the present study is to inves-tigate the psychometric characteristics and clinicalutility of the Beck cognitive Insight (BCIS), a self-report instrument that was developed to focus on self-reflectiveness about unusual experiences, capacity tocorrect erroneous judgments, and certainty aboutmistaken SampleThe sample was composed of 150 adult (18 yearsold and above) inpatients who were consecutivelyadmitted to the adult psychiatric unit of a generalhospital located in Cherry Hill, NJ, who were diag-nosed with schizophrenia, schizoaffective disorder,major depressive disorder without psychosis, or majordepression with psychotic features (who will be re-ferred to as psychotic depressives for the remainder ofthis paper).

10 All of the patients were required to have aGlobal Assessment of Functioning Scale (DSM-IV-TR Axis V;American Psychiatric Association, 2000)score < 30 indicating severe impairment in function-ing to be eligible for admission to the inpatient inpatients were recruited to representeach of the two broad diagnostic groups (schizophre-nia/schizoaffective and major depressive disorder) sothat there would be a ratio of 1 BCIS item to fiveinpatients in case separate factor analyses had to beconducted for each inpatients (50%) were diagnosedwith schizophrenia or schizoaffective disorder: 43schizoaffective disorder (29%), 26 paranoid schizo-phrenia (17%), 6 undifferentiated schizophrenia(4%). Seventy-five inpatients (50%) were diagnosedwith a major depressive disorder [9 single-episode(6%), 66 recurrent-episode (44%)]. Of the 75 (50%)patients diagnosed with a major depressive disorder,16 were psychotic depressives (21%), and 59 werediagnosed without psychotic features (79%).


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