Toward a Model of Cognitive Insight in First-Episode Psychosis: Verbal Memory and Hippocampal Structure

Abstract

Our previous work has linked verbal learning and memory with cognitive insight, but not clinical insight, in individuals with a first-episode psychosis (FEP). The current study reassessed the neurocognitive basis of cognitive and clinical insight and explored their neural basis in 61 FEP patients. Cognitive insight was measured with the Beck Cognitive Insight Scale (BCIS) and clinical insight with the Scale to assess Unawareness of Mental Disorder (SUMD). Global measures for 7 domains of cognition were examined. Hippocampi were manually segmented in to 3 parts: the body, head, and tail. Verbal learning and memory significantly correlated with the BCIS composite index. Composite index scores were significantly associated with total left hippocampal (HC) volume; partial correlations, however, revealed that this relationship was attributable largely to verbal memory performance. The BCIS self-certainty subscale significantly and inversely correlated with bilateral HC volumes, and these associations were independent of verbal learning and memory performance. The BCIS self-reflectiveness subscale significantly correlated with verbal learning and memory but not with HC volume. No significant correlations emerged between the SUMD and verbal memory or HC volume. These results strengthen our previous assertion that in individuals with an FEP cognitive insight may rely on memory whereby current experiences are appraised based on previous ones. The HC may be a viable location among others for the brain system that underlies aspects of cognitive insight in individuals with an FEP.

Assessment of Cognitive Insight: A Qualitative Review

“…21 A second study by this group largely corroborated these findings, with the exception that Self-Reflectiveness (rather than Self-Certainty) correlated with verbal memory. 29 This last study was also the first to report brain imaging results. Specifically, a smaller overall hippocampal volume was associated with higher Self-Certainty, and reduced left-hemisphere hippocampal volume also correlated with a lower Composite Index score.…”

“…11,12,16,17 However, 2 studies have reported partially contrary findings: In each case, higher Self-Reflectiveness (but not Self-Certainty) was associated with depression in psychotic patients. 20,24 Two studies have investigated the association between anxiety and cognitive insight in psychosis, and the results are similar to depression, with one group finding no significant associations 29 and the other finding significant positive correlations between anxiety and both the Composite Index and SelfReflectiveness. 20 …”

“…30 Further evidence of a complementary relationship between clinical insight and cognitive insight comes from the studies showing the BCIS, and not the SUMD, to be associated with neurocognitive and neurobiological factors. 21,29,36 These findings suggest that cognitive insight is a basic ability that is more proximal to neurobiological vulnerabilities than clinical insight. The development of adequate clinical insight may therefore depend upon a certain degree of cognitive insight-eg, neurocognitive deficits may limit a patient's ability to consider alternative viewpoints and refrain from thinking that is impermeable to outside information, which may in turn limit the patient's ability to understand that he or she has an illness.…”

“…Further, the significant associations between cognitive insight and hippocampal volume were independent of verbal memory performance. 29 …”

“…However, this link is based on 3 studies. 21,29,36 The neuroanatomical finding is also promising, especially the link between hippocampal volume and Self-Certainty. We anticipate considerable growth in this area of study in the coming years and, accordingly, make the following proposals for future research:…”