Elsevier

Psychiatry Research

Volume 230, Issue 3, 30 December 2015, Pages 839-845
Psychiatry Research

The relationship between cognitive insight and quality of life in schizophrenia spectrum disorders: Symptom severity as potential moderator

https://doi.org/10.1016/j.psychres.2015.10.014Get rights and content

Highlights

  • Cognitive insight was related to quality of life (QoL).

  • Self-reflectiveness had an unmoderated positive effect on .QoL

  • Self-certainty was related to better QoL for people with more severe symptoms.

  • Early in treatment, self-reflectiveness may be a better focus than self-certainty.

Abstract

Cognitive insight is implicated in the formation and maintenance of hallucinations and delusions. However, it is not yet known whether cognitive insight relates to broader outcome measures like quality of life. In the current study, we investigated whether the component elements of cognitive insight—self-certainty and self-reflectiveness—were related to quality of life for 43 outpatients with schizophrenia or schizoaffective disorder. Cognitive insight was assessed using the Beck Cognitive Insight Scale (BCIS) while quality of life was assessed with Quality of Life Scale (QLS). We tested whether this relationship was moderated by clinical insight and symptom severity using the Scale to Assess Unawareness of Mental Disorder (SUMD) and the Positive and Negative Syndrome Scale (PANSS). We found that self- reflectiveness had an unmoderated positive relationship with quality of life. Self-certainty was associated with better quality of life for people with more severe symptoms. Theoretical and clinical implications of these findings are discussed and areas of future research are proposed.

Introduction

Individuals with psychotic disorders tend to show a lack of insight that impacts psychosocial functioning, symptom expression, and treatment outcomes (Mohamed et al., 2009, Riggs et al., 2012, Lysaker et al., 2013). In recent years, researchers have contrasted two kinds of insight: clinical insight and cognitive insight (Donohoe et al., 2009, Lysaker et al., 2013). Clinical insight reflects an understanding or acceptance of different aspects of one's diagnosis (Beck and Warman, 2004, Lysaker et al., 2011b). Cognitive insight, on the other hand, reflects an ability to distance oneself from and evaluate one's own beliefs and interpretations. Cognitive insight is typically divided into the dimensions of self-reflectiveness or the ability to consider the possibility that one's current perceptions and beliefs could be wrong, and self-certainty or confidence in the veracity of one's current perceptions and beliefs (Beck and Warman, 2004, Beck et al., 2004). Cognitive insight is lacking when self-reflectiveness is too low or when self-certainty is too high.

Recent studies have revealed a mixed impact of clinical insight on quality of life, forcing researchers to revise earlier conceptions of insight as being unequivocally beneficial to people with schizophrenia (Lysaker et al., 1998, Lysaker et al., 2007b, Hasson-Ohayon et al., 2006, Montemagni et al., 2014). Some preliminary evidence in a sub-clinical sample suggests the possibility that cognitive insight may have a similarly equivocal relationship with quality of life (Weintraub and Weisman de Mamani, 2015), however, the relationship between cognitive insight and quality of life for people with psychotic disorders has yet to be determined. Given that cognitive insight may be affected by psychosocial treatments, it is essential to understand how overall well-being is affected by varying levels of self-reflectiveness and self-certainty.

Some lines of evidence suggest that cognitive insight is related to positive outcomes for people with psychotic disorders. For example, greater cognitive insight is predictive of greater reductions in psychosis with cognitive behavioral therapy (Granholm et al., 2005, Perivoliotis et al., 2010, Premkumar et al., 2011), and lack of cognitive insight is consistently associated with the presence of active delusions (Bora et al., 2007, Warman et al., 2007a, Buchy et al., 2009, Engh et al., 2010). However, greater cognitive insight has also been associated with negative outcomes. Among people with psychotic disorders, cognitive insight appears to be associated with increased self-stigma (Mak and Wu, 2006) and increased anxiety (Colis et al., 2006), though Buchy et al. (2009) did not find an association with anxiety among people with first-episode psychosis. Studies have also shown that cognitive insight is generally related to increased depression (Granholm et al., 2005, Colis et al., 2006, Warman et al., 2007a, Uchida et al., 2009, Mass et al., 2012, Palmer et al., 2015), but some researchers measured no relationship between cognitive insight and depression (Beck et al., 2004, Pedrelli et al., 2004, Zimmermann et al., 2005, Engh et al., 2007, Tranulis et al., 2008), and one study reported that greater cognitive insight was associated with decreased depression for people with schizophrenia (Engh et al., 2011). One trial of cognitive behavioral social skills training for schizophrenia found that reductions in self-certainty were correlated with increased depression midway through treatment, but that the association disappeared by the end of treatment (Granholm et al., 2005).

One possible explanation for these equivocal findings is that the impact of cognitive insight upon quality of life depends on the presence of other variables. Two such variables are symptom severity and clinical insight. It is likely that symptom severity moderates the effect of cognitive insight on quality of life because the perspective-taking abilities associated with better cognitive insight would be expected to have very different impacts for persons experiencing different levels of symptom severity. For patients whose symptoms are severe and obvious to others, higher self-certainty may serve as a protective factor against the pervasive social stigma that can interfere with quality of life (Corrigan and Watson, 2002, Corrigan, 2004, Mak and Wu, 2006, Buck et al., 2013). It may therefore be that cognitive insight and symptom severity interact to affect quality of life.

Another potential moderator of the effect of cognitive insight on quality of life is clinical insight. Authors have suggested that clinical insight benefits patients because increased awareness of mental health allows for better adherence to medical recommendations and increased engagement in treatment (Mohamed et al., 2009). While engaged in treatment, those patients with higher cognitive insight may be better able to incorporate the feedback of mental health professionals and consider alternative ways of thinking (De Vos et al., 2015). Supporting evidence for this theory is found in trials of cognitive behavior therapy for psychosis, which consistently find that higher cognitive insight is predictive of better response to psychosocial treatments (Granholm et al., 2005, Perivoliotis et al., 2010, Premkumar et al., 2011). It is therefore possible that clinical insight moderates the effect of cognitive insight on quality of life.

To examine these issues, we gathered concurrent assessments of cognitive insight, clinical insight, symptom severity, and quality of life among patients with schizophrenia spectrum disorders. We formulated four hypotheses. We hypothesized that greater self-reflectiveness would be directly associated with better overall quality of life, while greater self-certainty would be associated with worse overall quality of life. We also hypothesized an interaction between clinical insight and cognitive insight, such that higher cognitive insight would have a positive relationship with quality of life for those patients with high clinical insight. Finally, we hypothesized that symptom severity would moderate the effect of self-certainty on quality of life such that for people with very severe symptoms, self-certainty would have a protective effect on quality of life.

Section snippets

Participants

This study was approved by the Institutional Review Boards of each of the participating institutions. Individuals with schizophrenia spectrum disorders were recruited from a VA medical hospital as part of a larger study (Warman et al., 2007a, Warman et al., 2007b). In order to participate in the study, participants had to be at least 18 years old and have a diagnosis of Schizophrenia or Schizoaffective Disorder as confirmed by the SCID. All participants were outpatients at the time of testing.

Results

Mean scores for the key variables are presented in Table 2. Quality of life was not significantly related to age, r(41)=0.017, p=0.915, or gender, t(41)=−1.448, p=0.155, or diagnosis t(41)=−0.601, p=0.551. Therefore, these demographic variables were not entered as covariates for later analyses. Pearson tests revealed that quality of life was significantly related to SUMD total score, r(41)=−0.345, p<0.05, and PANSS-Total score, r(41)=−0.421, p=0.005. The SUMD and PANSS-Total were also

Discussion

Cognitive insight is broadly described as an important factor in schizophrenia spectrum disorders, especially given its role in the formation and maintenance of psychosis (Granholm et al., 2005, Bora et al., 2007, Warman et al., 2007a, Buchy et al., 2009, Engh et al., 2010, Perivoliotis et al., 2010). However, it is not known how cognitive insight relates to broader outcomes like quality of life. The present study suggests that, as with clinical insight (Hasson-Ohayon et al., 2006), the

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