Dimitri Perivoliotis

Assessment of Cognitive Insight: A Qualitative Review

The concept of cognitive insight was introduced in 2004 to describe the capacity of patients with psychosis to distance themselves from their psychotic experiences, reflect on them, and respond to corrective feedback. The Beck Cognitive Insight Scale (BCIS) was developed to evaluate these aspects of cognitive flexibility and to complement scales that describe the lack of awareness of mental illness and its characteristics. The BCIS has generated a moderate research literature, which is the subject of the current review. Several independent groups have demonstrated that the BCIS is reliable, demonstrates convergent and construct validity, and distinguishes patients with psychosis from healthy controls and patients without psychosis. While the majority of the studies have focused on the relationship of the BCIS to delusions, several have examined its relationship to negative symptoms, depression, anxiety, and functional outcome. Cognitive insight has predicted positive gains in psychotherapy of psychosis, and improvement in cognitive insight has been correlated with improvement in delusional beliefs. Finally, preliminary findings relate neurocognition, metacognition, and social cognition, as well as reduced hippocampal volume to cognitive insight. A heuristic framework is presented to guide future research.

Dysfunctional Attitudes and Expectancies in Deficit Syndrome Schizophrenia

The deficit syndrome was proposed over 20 years ago as a separate negative symptom syndrome within schizophrenia with a distinct neurobiological pathophysiology and etiology. Recent research, however, has indicated that psychological factors such as negative attitudes and expectancies are significantly associated with the broad spectrum of negative symptoms. Specifically, defeatist beliefs regarding performance mediate between neurocognitive impairment and both negative symptoms and functional outcome. Additionally, asocial beliefs predict asocial behavior and negative expectancies regarding future pleasure are associated with negative symptoms. The present study explored whether these dysfunctional beliefs and negative expectancies might also be a feature of the deficit syndrome. Based on a validated proxy method, 22 deficit and 72 nondeficit patients (from a pool of 139 negative symptom patients) were identified and received a battery of symptom, neurocognitive, and psychological measures. The deficit group scored significantly worse on measures of negative symptoms, insight, emotion recognition, defeatist attitudes, and asocial beliefs but better on measures of depression, anxiety, and distress than the nondeficit group. Moreover, the deficit group showed a trend for higher scores on self-esteem. Based on these findings, we propose a more comprehensive formulation of deficit schizophrenia, characterized by neurobiological factors and a cluster of psychological attributes that lead to withdrawal and protect the self-esteem. Although the patients have apparently opted-out of participation in normal activities, we suggest that a psychological intervention that targets these negative attitudes might improve their functioning and quality of life.

Cognitive insight predicts favorable outcome in cognitive behavioral therapy for psychosis

Cognitive insight includes the process of re‐evaluating distorted beliefs and misinterpretations and is believed to play a mediating role in the development and maintenance of psychotic symptoms. The primary aim of this study was to examine the relationship between cognitive insight and treatment response during cognitive behavioral therapy for psychosis (CBTp). Seventy‐eight outpatients with psychosis were administered the Beck Cognitive Insight Scale and the Psychotic Symptom Rating Scales on two occasions (pretreatment and posttreatment) during a course of CBTp. Higher baseline cognitive insight predicted reduced delusional severity posttreatment and gains in cognitive insight made during therapy were associated with clinically significant reductions in the severity of both delusions and auditory verbal hallucinations by the end of therapy. The findings support the validity and clinical utility of the cognitive insight construct in psychosis and suggest that cognitive insight may be a predictor and mediator of symptom reduction in CBTp.

Negative Performance Beliefs and Negative Symptoms in Individuals at Ultra-High Risk of Psychosis: A Preliminary Study

Background: Negative beliefs regarding task performance have been shown to correlate with negative symptom severity in patients with chronic schizophrenia. We conducted a pilot study to determine whether the association also exists in individuals at ultra-high risk of psychosis. Sampling and Methods: The sample consisted of 38 individuals at ultra-high risk of psychosis and 51 controls. All participants completed the Abbreviated Dysfunctional Attitudes Scale; the ultra-high-risk participants were assessed with the Positive and Negative Syndrome Scale. Results: High-risk participants endorsed negative performance beliefs to a greater extent than controls and these beliefs were associated with greater negative symptom severity, independent of depression and positive symptoms. Conclusions: The findings are consistent with previous results in chronic patients, and suggest that negative performance beliefs may be a promising psychological factor worthy of further attention in individuals at high risk of psychosis. Longitudinal research with more comprehensive assessment is needed to elucidate the potential role of negative performance beliefs in this population.

Psychosocial functioning on the Independent Living Skills Survey in older outpatients with schizophrenia.

Improving real-life community functioning in patients with severe mental illness has been an important recent focus of treatment outcome research. Few studies, however, have examined psychosocial functioning in older psychotic patients. The Independent Living Skills Survey (ILSS) is a measure of the basic functional living skills of individuals with severe and persistent mental illness. The self-report version of the ILSS was administered to 57 middle-aged and older community dwelling outpatients with schizophrenia and 40 age-comparable nonpsychiatric participants. Regardless of whether patients resided in assisted living or independent settings, they showed significantly impaired functioning on a majority of the functional areas assessed by the ILSS. No consistent relationship was found between symptom severity and functioning. With certain modifications, the ILSS appears to be a sensitive indicator of functional impairment in this older sample of community-dwelling outpatients with schizophrenia. Information provided by the instrument might be useful to guide rehabilitation efforts and measure functioning changes in response to treatment in this population.

Cognitive behavioral therapy of negative symptoms.

Negative symptoms account for much of the functional disability associated with schizophrenia and often persist despite pharmacological treatment. Cognitive behavioral therapy (CBT) is a promising adjunctive psychotherapy for negative symptoms. The treatment is based on a cognitive formulation in which negative symptoms arise and are maintained by dysfunctional beliefs that are a reaction to the neurocognitive impairment and discouraging life events frequently experienced by individuals with schizophrenia. This article outlines recent innovations in tailoring CBT for negative symptoms and functioning, including the use of a strong goal-oriented recovery approach, in-session exercises designed to disconfirm dysfunctional beliefs, and adaptations to circumvent neurocognitive and engagement difficulties. A case illustration is provided.

Social behavior, interaction appraisals, and suicidal ideation in schizophrenia: The dangers of being alone

Despite the increasing attention to social appraisals in suicide risk, the interpersonal correlates of suicidal thoughts and behavior in schizophrenia are not well understood. Ecological momentary assessment could reveal whether dysfunctional social appraisals and behavior are evident in people with schizophrenia with suicidal ideation. A total of 93 outpatients with diagnoses of schizophrenia with (n=18, 19%) and without (N=75; 81%) suicidal ideation participated in one week of intensive daily monitoring via mobile devices, generating real-time reports on the quantity of social interactions and appraisals about them, as well as information concerning concurrent affect and symptoms. The presence of suicidal ideation was not associated with the quantity of social interactions or time spent alone, but it was associated with the anticipation of being alone as well as greater negative and lower positive affect when alone. Despite this aversive experience of being alone, people with suicidal ideation reported negative appraisals about the value of recent and potential social interactions. These findings suggest that suicidal ideation in schizophrenia may not be associated with the quantity of social interactions, but with negative expectations about the quality of social interactions coupled with an aversive experience of being alone. Cognitive therapy interventions that address negative expectations and pleasure about social interactions, especially when alone, may reduce suicidal ideation.

Advances in Cognitive Therapy for Schizophrenia: Empowerment and Recovery in the Absence of Insight

Lack of awareness of a mental disorder is a prevalent feature of schizophrenia and is associated with poor outcome. Cognitive therapy (CT) is a promising adjunctive treatment for schizophrenia but is believed to be less efficacious for patients with poor insight. This article describes a goal-oriented CT approach that was innovated to circumvent limited insight in a young woman with severe paranoid delusions and auditory hallucinations. The treatment facilitated recovery by targeting avoidance, inactivity, and social withdrawal, and by promoting detachment from psychotic experiences without directly challenging delusional beliefs. The case study demonstrates the involvement of family in CT and the use of behavioral exercises to modify dysfunctional beliefs and behaviors. Results are consistent with recently advanced cognitive conceptualizations of schizophrenia and suggest that when appropriately tailored and focused on functional goals, CT can promote recovery in the absence of insight.

Single-Session Mobile-Augmented Intervention in Serious Mental Illness: A Three-Arm Randomized Controlled Trial

Psychosocial interventions for serious mental illness are resource intensive and poorly accessible. Brief interventions (eg, single session) that are augmented by follow-on automated mobile health intervention may expand treatment access. This was a randomized single-blind controlled trial with 255 individuals diagnosed with schizophrenia or bipolar disorder. Participants were randomized to one of three conditions: CBT2go, which combined one individual session of cognitive behavioral therapy with automated thought challenging/adaptive behavior delivered through mobile devices; Self-Monitoring (SM), which combined single-session illness psychoeducation with self-monitoring of symptoms; and treatment-as-usual (TAU). Participants were assessed at baseline, 6 weeks (midpoint), 12 weeks (posttreatment), and 24 weeks (follow-up) with our primary outcome global psychopathology (Brief Psychiatric Rating Scale-expanded version [BPRS-24]), and secondary outcomes community functioning (Specific Level of Function; SLOF) and defeatist performance beliefs (DPBs). We also collected data on adverse events. Outcome analyses on the primary outcome, BPRS Total score, indicated a significant time (0-24 wk) by group interaction with significant but modest improvement comparing two active conditions (CBT2go and SM) relative to TAU. Effects of CBT2go were not different from SM. There was a significant time × group interaction with better SLOF scores in CBT2go across 24 weeks, but not in SM. There were no time-by-group effects on DPBs. DPBs decreased in the CBT2go condition but not in SM. These results indicated that single intervention augmented by mobile intervention was feasible and associated with small yet sustained effects on global psychopathology and, when inclusive of CBT, community function compared with usual care.

Contents Vol. 42, 2009

R. Bentall, Manchester C.E. Berganza, Guatemala City D. Bhugra, London C. Brewin, London Y.-F. Chen, Beijing D. Clark, London N.M.J. Edelstyn, Keele H. Fabisch, Graz K. Fabisch, Graz P. Falkai, Göttingen H.J. Freyberger, Greifswald/Stralsund N. Ghaemi, Boston, Mass. C. Haasen, Hamburg A. Heerlein, Santiago P. Henningsen, München P. Hoff , Zürich Y. Kim, Tokyo A. Marneros, Halle/Saale M. Musalek, Wien F. Poustka, Frankfurt/Main J. Raboch, Prague P. Salkovskis, London I.M. Salloum, Miami, Fla. F. Schneider, Aachen J.C. Soares, Chapel Hill, N.C. J.S. Strauss, New Haven, Conn. E. Vieta, Barcelona M. Weisbrod, Karlsbad Official Journal of the World Psychiatric Association (WPA),