Table 1.
Studies Including the Beck Cognitive Insight Scale (BCIS)
| Study | Design | Participants | Main Findings |
| Beck et al.7 | Cross-sectional | 150 inpatients: 43 schizoaffective, 32 schizophrenia, 16 MDD with psychotic features, 59 MDD without psychotic features | ▪ Factor analysis: 2 components (SR and SC) |
| ▪ Reliability (alpha): whole sample (SR = .68, SC = .60); schizophrenia/schizoaffective (SR = .67, SC = .61) | |||
| ▪ Clinical insight (r, BCIS, and SUMD): CI and awareness of mental disorder = −.62; SR and delusions = −.67 | |||
| ▪ Diagnostic (means): psychotic < nonpsychotic (CI and SR); psychotic > nonpsychotic (SC); MDD with psychosis < MDD without psychosis (CI); MDD with psychosis > MDD without psychosis (SC) | |||
| Bora et al.10 | Cross-sectional and longitudinal (n = 30): Turkish-translated BCIS | 138 patients with schizophrenia: 77 inpatients, 61 outpatients | ▪ Clinical insight (r, BCIS, and SUMD total): CI = −.55; SR = −.56; SC = .28 |
| ▪ Symptoms (r, BCIS, and PANSS positive): CI = −.29; SR = −.24; SC = .29 | |||
| ▪ Symptoms (r, BCIS, and PANSS negative): SR = −.25 | |||
| ▪ Diagnostic and CI (means): psychotic symptoms (n = 93) < no psychotic symptoms (n = 45) | |||
| ▪ Posthospitalization: symptoms, SR, and CI improved; neither symptom change nor SUMD correlate with BCIS change | |||
| ▪ Demographic (r): BCIS unrelated to duration of illness, education, age, or hospitalizations | |||
| Buchy et al.27 | Cross-sectional: early intervention service | 70 first-episode patients: 39 schizophrenia, 9 schizoaffective, 1 schizophreniform, 8 psychosis NOS, 1 delusional disorder, 5 bipolar disorder, 3 undetermined | ▪ Symptoms (means): delusional > nondelusional (CI and SR); no difference (SC) |
| Buchy et al.29 | Cross-sectional: early intervention service | 61 first-episode patients: 37 schizophrenia, 9 schizoaffective disorder, 1 schizophreniform disorder, 7 psychosis NOS, 1 delusional disorder, 5 bipolar disorder, 1 undetermined | ▪ Neurocognition (r, BCIS, and verbal learning and memory): CI = .33; SR = .31 |
| ▪ Neuroanatomy: higher CI associated with greater volume of left-hemisphere hippocampus (r = .25); modest proportion of this relationship was attributable to verbal memory performance (partial r = .25, P = .06); greater SC correlated with smaller bilateral hippocampal volumes (r = −.34 for left and r = −.29 for right), independent of verbal memory performance; SR did not significantly correlate with hippocampal volume | |||
| ▪ No significant correlations between SUMD awareness of mental disorder scores and verbal memory or hippocampal volume | |||
| Carlson et al.13 | Cross-sectional + longitudinal (24–48 h, n = 93): Spanish-translated BCIS | 137 inpatients and outpatients with schizophrenia | ▪ Quality of life (Spanish version of Satisfaction with Life Domains Scale): no significant correlations |
| Colis et al.20 | Cross-sectional | 150 inpatients: 12 schizophrenia, 30 schizoaffective disorder, 52 bipolar disorder, 56 MDD | ▪ Reliability (alpha): SR = .73; SC = .70 |
| ▪ Diagnostic (means): MDD > psychotic (CI, d = .51) and bipolar (CI, d = .62); psychotic = bipolar (CI); bipolar last episode mania < bipolar patients last episode mixed or depressive (CI, d = .52) | |||
| ▪ Symptoms (r, BCIS, and anxiety and depression): CI and SR = .27 to .29 | |||
| Engh et al.11 | Cross-sectional: Norwegian-translated BCIS | 235 inpatients and outpatients: 143 schizophrenia spectrum (107 schizophrenia, 26 schizoaffective, 10 schizophreniform), 92 bipolar disorder, 64 healthy controls | ▪ Reliability (alpha): schizophrenia spectrum (SR = .72, SC = .63); bipolar (SR = .73, SC = .61); healthy controls (SR = .73, SC = .63) |
| ▪ Clinical insight (r, BCIS, and PANSS and schizophrenia spectrum): SR = −.21; SC = .38 | |||
| ▪ Diagnostic (means): no significant difference in SR or SC between 3 groups | |||
| ▪ Symptoms (r): SC correlated with mania in schizophrenia-spectrum group | |||
| ▪ Hospitalization (means): inpatients = outpatients (SR and SC, schizophrenia spectrum, n = 78) | |||
| Engh et al.26 | Cross-sectional: Norwegian-translated BCIS | 143 inpatients and outpatients: 107 schizophrenia, 26 schizoaffective, 10 schizophreniform | ▪ Delusions (PANSS ≥ 4; means): delusions < no delusions (CI and SR); delusions > no delusions (SC); both independent of hallucinations |
| ▪ Hallucinations (PANSS ≥ 4; means): nonhallucinators = hallucinators (CI, SR, or SC); delusional hallucinators have lower SR and higher SC than nondelusional hallucinators | |||
| Favrod et al.12 | Cross-sectional: French-translated BCIS | 158 outpatients: 132 schizophrenia, 26 schizoaffective | ▪ Factor analysis (confirmatory): good fit for original 2-factor solution. |
| ▪ Reliability (alpha): SR = .73; SC = .62 | |||
| ▪ Clinical insight (r, BCIS, and PANSS): CI = −.42; SR = −.37; SC = .29. | |||
| ▪ Symptoms (r, BCIS, and PANSS): no significant correlations | |||
| ▪ Functioning (means): nursing home < living independently (CI and SR); nursing home > living independently (SC) | |||
| Granholm et al.34 | Randomized controlled trial: CBSST vs. TAU | 32 middle-aged and older outpatients with chronic schizophrenia or schizoaffective | ▪ CBSST (r, CI change, and PANSS change): positive symptoms = −.40; negative symptoms = −.41; total symptoms r = −.45 |
| ▪ Depression, psychosocial functioning (r): not associated with change in CI | |||
| ▪ Participation in treatment associated with increase in cognitive insight (R2 = .29). | |||
| Granholm et al.32 | Randomized controlled trial of CBSST vs. TAU | 76 middle-aged and older outpatients: 48 schizophrenia, 28 schizoaffective | ▪ Treatment effect (CI): CBSST > TAU (η2 = .12). |
| ▪ Positive symptom reduction (r, BCIS, and PANSS): CI = −.38; SR = −.36 | |||
| ▪ Midtreatment increase in depression (r): CI = .32: SC = −.59 | |||
| Kao and Liu19 | Cross-sectional + longitudinal (4 weeks, N = 30) | 60 schizophrenia or schizoaffective; 60 MDD without psychotic features; 60 healthy controls | ▪ Factor analysis (exploratory): 2 factors (SR and SC), 4 items load (2 for each scale) on other factor than in the other studies |
| ▪ Researchers used their own factor analysis solution for correlational findings, rendering the results not useful for the present review | |||
| Kim et al.14 | Cross-sectional: Korean-translated BCIS | 78 patients (50 outpatients and 28 inpatients): 72 schizophrenia, 4 schizoaffective, 2 other psychotic disorder | ▪ Factor analysis (principal components): confirmed 2-factor structure |
| ▪ Reliability (alpha): SR = .64; SC = .75 | |||
| ▪ Reliability (r, test-retest): CI = .61 | |||
| ▪ Clinical insight (r, BCIS, and Revised Insight Scale for Psychosis): SR = .53; CI = .51 | |||
| ▪ Symptoms, functioning (r): no significant correlations | |||
| Lepage et al.21 | Cross-sectional: early intervention service | 51 first-episode outpatients: 30 schizophrenia, 7 schizoaffective, 1 schizophreniform, 5 psychosis NOS, 1 delusional disorder, 3 bipolar disorder, 4 unknown | ▪ Clinical insight (r): CI and PANSS = −.39; CI and SUMD awareness of mental illness = −.39 |
| ▪ Neurocognition (r, BCIS, and verbal learning and memory): CI = .32; SC = −.30 | |||
| ▪ Neurocognition (r, PANSS, and SUMD): no significant correlations | |||
| ▪ Full Scale IQ (r): None of the 3 insight measures correlated significantly | |||
| Lysaker et al.36 | Cross-sectional: chronic, postacute phase | 49 male outpatients: 29 schizophrenia, 20 schizoaffective | ▪ Metacognition (rho, BCIS, and Metacognition Assessment Scale): CI and “understanding one's own mind” = .43 |
| Mak and Wu9 | Cross-sectional: Chinese-translated BCIS | 162 outpatients with schizophrenia “or other psychotic disorder” | ▪ Reliability (alpha): SC = .71; SR = .82 |
| ▪ Self-stigma: CI adds 4% to variance explained; higher insight predicts greater self-stigma | |||
| Martin et al.18 | Cross-sectional + longitudinal (45 min, N = 23) | 55 schizophrenia, 38 schizoaffective, 418 nonpsychiatry controls | ▪ Factor analysis (confirmatory): 2-factor structure fits better than 1-factor structure |
| ▪ Reliability (alpha): CI = .76; SR = .74; SC = .75 | |||
| ▪ Reliability (test-retest): CI = .87; SR = .77; SC = .86 | |||
| ▪ Diagnostic (means): patients < control (CI, η2 = .037); patients < control (SR, η2 = .011); patients > control (SC, η2 = .021) | |||
| Pedrelli et al.16 | Cross-sectional | 164 middle-aged and older chronic outpatients: 119 schizophrenia, 45 schizoaffective | ▪ Factor analysis (confirmatory): supported validity of 2-factor structure |
| ▪ Reliability (alpha): CI = .66; SC = .55; SR = .70 | |||
| ▪ Clinical insight (r, BIS): CI and BIS total = .24; CI and BIS relabel = .30; SR and BIS total = .26; SR and BIS relabel = .36 | |||
| ▪ Symptoms (r, PANSS): SC and positive = .24; SC and negative = .19; SC and total = .21; CI and cognitive = −.18 | |||
| Penn et al.31 | Randomized controlled trial: CBT vs. ST | 65 outpatients: 32 schizophrenia, 33 schizoaffective | ▪ Treatment effect on CI: CBT > ST (d = .43, P = .11) |
| Perivoliotis et al.30 | Longitudinal: community CBT clinic | 141 outpatients: 51 schizophrenia, 6 schizoaffective, 11 psychotic NOS, 5 delusional disorder, 2 bipolar, 1 MDD with psychosis, 1 schizotypal, 1 somatoform disorder | ▪ Moderation of symptom reduction (r, BCIS, and PANSS delusions): CI = −.26; SR = −.23 |
| ▪ Gains in cognitive insight during CBT predict symptom reduction (r, BCIS, and PANSS): CI and delusions = −.36; CI and hallucinations = −.40; SR and delusions = −.33; SR and hallucinations = −.28; SC and delusions = .26; SC and hallucinations = .30 | |||
| ▪ Clinically significant symptom reduction: delusions, greater gains in SR and CI; hallucinations, greater reductions in SC and gains in CI | |||
| Tranulis et al.17 | Cross-sectional | 38 first-episode outpatients: 19 schizophrenia, 19 schizoaffective, bipolar with psychosis, delusional disorder, or psychosis NOS | ▪ SR and SC not significantly intercorrelated, supporting 2-factor structure |
| ▪ Clinical insight (r, BCIS, PANSS, and SUMD): SR correlated negatively with both | |||
| ▪ Symptoms (r, BCIS, and PANSS): SR and negative symptoms = −.41; no significant correlations with positive, general, or total symptoms | |||
| Uchida et al.15 | Cross-sectional: Japanese-translated BCIS | 30 inpatients (schizophrenia or schizoaffective), 183 healthy controls (university students) | ▪ Factor analysis (principal components): confirmed original 2-factor structure |
| ▪ Reliability (alpha): SC = .78; SR = .67 | |||
| ▪ Reliability (test-retest, ICC): CI = .82; SC = .79; SR = .86 | |||
| ▪ Clinical insight (r, BCIS, and Japanese Schedule for the Assessment of Insight): CI = .50; SR = .52 | |||
| ▪ Clinical insight (r, BCIS, and PANSS): CI = −.45; SR = −.39 | |||
| ▪ Symptoms (r, BCIS, and BDI-II): CI = .42; no correlations with PANSS symptoms | |||
| ▪ Demographics (r): CI and age = −.47; SR and age = −.37; SC and duration of illness = .46 | |||
| Warman and Martin25 | Cross-sectional | 200 healthy controls (university students without history of psychotic illness) | ▪ Participants with higher delusion proneness showed higher SC and SR |
| Warman et al.24 | Cross-sectional | 49 outpatients with schizophrenia or schizoaffective disorder, 60 healthy controls (university students without history of psychotic illness) | ▪ Diagnostic (means): patients < controls (CI, η2 = .07); patients > controls (SC, η2 = .06); delusional = nondelusional < controls (CI); delusional > nondelusional = control (SC); nondelusional < delusional = control (SR) |
| ▪ Symptoms (r, BCIS, and BDI-II): CI = .20; SR = .19 |
Note: MDD, major depressive disorder; SR, Self-reflectiveness subscale of BCIS; SC, Self-certainty subscale of BCIS; SUMD, Scale to Assess Unawareness of Mental Disorder; CI, Composite Index of BCIS (self-reflectiveness minus self-certainty); PANSS, Positive and Negative Syndrome Scale; CBSST, Cognitive Behavioral Social Skills Training; BIS, Birchwood Insight Scale; CBT, Cognitive Behavior Therapy; TAU, Treatment as Usual; ST, supportive therapy; BDI-II, Beck Depression Inventory II; NOS, Not Otherwise Specified.