Psychiatry Research 217 (2014) 20–24
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Relationship between cognitive insight and attenuated delusional symptoms in individuals with at-risk mental state Tomohiro Uchida a,n, Kazunori Matsumoto a, Fumiaki Ito b, Noriyuki Ohmuro b, Tetsuo Miyakoshi c, Takashi Ueno d, Hiroo Matsuoka b a
Department of Preventive Psychiatry, Tohoku University, Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan Department of Psychiatry, Tohoku University Graduate School of Medicine, Sendai, Japan c Chiba Prison, Chiba, Japan d Division of Clinical Psychology, Tohoku University, Graduate School of Education, Sendai, Japan b
art ic l e i nf o
a b s t r a c t
Article history: Received 9 May 2013 Received in revised form 10 October 2013 Accepted 1 January 2014 Available online 14 January 2014
Cognitive insight, defined as the ability to evaluate and correct one's own distorted beliefs and misinterpretations, is hypothesized to contribute to the development of psychotic symptoms. We investigated cognitive insight in individuals with at-risk mental state (ARMS), which is associated with a clinically high risk of psychosis. Sixty individuals with ARMS were compared with 200 healthy controls in terms of cognitive insight measured using the Beck Cognitive Insight Scale. We also investigated the relationship between cognitive insight and attenuated delusional symptoms. In addition, we examined differences in the cognitive insight of individuals with ARMS with or without near-threshold delusional symptoms and differences in the cognitive insight of individuals with ARMS with or without later transition to psychosis. The results showed that individuals with ARMS exhibited higher self-certainty than healthy controls, indicating impairments in cognitive insight in the former. More importantly, our results revealed that self-certainty was correlated with attenuated delusional symptoms and that individuals with ARMS who had near threshold delusional symptoms had higher self-certainty. These findings indicate that overconfidence in one's own beliefs or judgments might be related to the formation and maintenance of attenuated delusions in individuals with ARMS. & 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Self certainty Psychosis Schizophrenia Ultra high risk
1. Introduction According to the cognitive model of psychosis (Garety et al., 2001), individuals with psychosis are impaired in considering alternative explanations for anomalous experiences. Such a deficit is thought to be associated with the development and maintenance of the positive symptoms of psychosis. Similarly, Beck et al. (2004) hypothesized that psychotic phenomena, especially delusions, are related to the impaired capacity of psychotic subjects to evaluate their own anomalous experiences. To explore this capacity, Beck et al. proposed the concept of cognitive insight, defined as a patient's capacity to evaluate his or her own anomalous experiences and atypical interpretations of events. In contrast to clinical insight (David, 1990; Amador et al., 1991), which typically refers to a person's awareness of illness, symptoms, treatment need, consequences of illness, and so forth, cognitive insight refers to metacognitive processes of reevaluation and the correction of
n
Corresponding author. Tel./fax: þ 81 22 717 8059. E-mail address: [email protected] (T. Uchida).
http://dx.doi.org/10.1016/j.psychres.2014.01.003 0165-1781 & 2014 Elsevier Ireland Ltd. All rights reserved.
distorted beliefs and misinterpretations (Beck et al., 2004; Riggs et al., 2012). Cognitive insight can be measured with the Beck Cognitive Insight Scale (BCIS; Beck et al., 2004). The BCIS comprises a self-reflectiveness subscale, which includes items related to reflectiveness, objectivity regarding beliefs and interpretations, and openness to the possibility of having misinterpreted experiences, and a self-certainty subscale, which evaluates overconfidence in decision-making and resistance to correction. Overall cognitive insight is estimated by calculating the difference between the self-certainty and self-reflectiveness scores. In accordance with the hypothesis of Beck et al. (2004), previous studies have demonstrated impaired cognitive insight in patients with schizophrenia, and some authors have shown an association between reduced cognitive insight and delusions in schizophrenia. For example, individuals with delusions tend to show higher self-certainty (Engh et al., 2007; Warman et al., 2007) and lower self-reflectiveness (Buchy et al., 2009; Engh et al., 2010) than those without delusions, and higher self-certainty appears to be positively correlated with delusional symptoms (Kimhy et al., 2013). These findings suggest that impaired cognitive insight could be associated with the formation of delusional symptoms and that
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this impairment would likely exist in the prodromal stage of schizophrenia. In order to investigate this possibility, we thought it ideal to examine the putative prodromal state of psychosis known as an at-risk mental state (ARMS; Yung et al., 1998). ARMS can predict the subsequent transition to psychosis (e.g., Fusar-Poli et al., 2012), and many individuals with ARMS experience attenuated psychotic symptoms such as ideas of reference, suspiciousness, odd beliefs, and perceptual distortions. In addition, a previous study examining the clinical insight of those with ARMS reported that such individuals exhibited an impaired ability to appraise anomalous experiences as symptoms of illness (Lappin et al., 2007). To date, only one study has examined cognitive insight in individuals with ARMS. Kimhy et al. (2013) reported that individuals with ARMS showed self-certainty and self-reflectiveness comparable to those of healthy controls and lower than those of patients with schizophrenia. They also examined the relationship between attenuated delusional symptoms and cognitive insight, but, contrary to expectations, they found that self-certainty and self-reflectiveness were not related to attenuated delusional symptoms in people with ARMS. However, they also reported that the self-certainty scores of people with ARMS were between those of patients with schizophrenia and healthy controls; that is, people with ARMS had higher, but not significantly higher, self-certainty scores compared with healthy controls. In addition, individuals with ARMS who had near-threshold persecutory ideation exhibited higher self-certainty scores compared with those with milder or no persecutory ideation, indicating that at least some symptomatic individuals with ARMS exhibit higher self-certainty. Therefore, the Kimhy et al. (2013) study was not sufficient to conclude that individuals with ARMS have impaired cognitive insight, and more research is required to clarify this issue. In the present study, we investigated the following: (i) the degree of cognitive insight of individuals with ARMS compared with healthy controls, (ii) the relationship between attenuated delusional symptoms and cognitive insight, (iii) differences in cognitive insight between individuals with ARMS with and without near-threshold delusional symptoms, and (iv) differences in cognitive insight between individuals with ARMS with and without later transition to psychosis. We hypothesized that the selfcertainty of individuals with ARMS would be higher than that of healthy controls and that attenuated delusional symptoms would be associated with self-certainty in individuals with ARMS. In Table 1 Demographic variables and scores on the Comprehensive Assessment of At-Risk Mental States (Japanese version, CAARMS-J) in participants with an at-risk mental state (ARMS; n ¼60) and healthy controls (n¼ 200). Characteristics
Gender (number of males/ females) Age (years) Education (years) GAF CAARMS-J Thought content Perceptual abnormalities Disorganized speech
Mean (S.D.)
Statistics P
ARMS
Healthy controls
22/38
81/119
χ2 ¼ 0.28
NS
19.48 (4.17) 11.58 (2.25) 47.63 (6.72)
20.34 (1.87)
t ¼1.55
NS
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addition, we predicted that self-certainty scores would be higher in individuals with ARMS who had near-threshold delusional symptoms and those who had later transition to psychosis.
2. Methods 2.1. Participants Participants were recruited from the Sendai At-Risk Mental State and First Episode (SAFE) specialized clinic (Mizuno et al., 2009). Subjects had to meet the following inclusion criteria: (i) were aged between 14 and 35 years, (ii) were seeking psychiatric help, and (iii) fulfilled the ultra-high-risk criteria as defined by the Japanese version of the Comprehensive Assessment of At-Risk Mental States (CAARMS-J; Miyakoshi et al., 2009). Individuals were assessed with the CAARMS-J by trained and experienced psychiatrists, and diagnoses were confirmed at consensus meetings with the clinical team. All included subjects met one or more of the following criteria for ARMS: (i) attenuated psychotic symptoms (APS), (ii) brief limited intermittent psychotic symptoms (BLIPS, a brief psychotic episode that resolves spontaneously within 1 week), or (iii) state and trait risk factors (a recent decline in functioning plus a first-degree relative with either psychosis or a schizotypal personality disorder). The exclusion criteria were as follows: (i) a history of psychotic or manic episodes as specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association, 2000); (ii) serious risk of suicide or violence due to a personality disorder; (iii) current substance dependence; (iv) known intellectual disability (IQ o 70); or (v) neurological disorder, head injury, or any other significant medical condition associated with psychiatric symptoms. Sixty individuals (22 men and 38 women; mean [S.D.] age¼ 19.48 [4.17] years) met the required criteria and were included in the ARMS group for this study. The demographic characteristics of this group are shown in Table 1. Among the 60 individuals with ARMS, 35 were medication-free (58.3%), 12 (20.0%) were taking antipsychotic medications (risperidone, 4; olanzapine, 3; sulpiride, 2; and aripiprazole, 3), 12 (20.0%) were taking antidepressants, and 4 (6.7%) were taking mood stabilizers. Two hundred university students (81 men and 119 women; mean [S.D.] age¼20.3 [1.9] years) were recruited at Tohoku University as healthy controls. All participants were asked as a part of the study questionnaire if they had ever been diagnosed with a psychiatric disorder; those who answered affirmatively were excluded from the control group. All study participants provided written informed consent, and the research design was approved by the Ethics Committee of Tohoku University Graduate School of Medicine and Tohoku University Hospital. This study complied with the principles laid down in the Declaration of Helsinki for experiments involving humans.
2.2. Assessment of cognitive insight The BCIS (Beck et al., 2004) is a self-report instrument consisting of 15 items, each rated on a 4-point scale from 0 (do not agree at all) to 3 (agree completely), resulting in two component scores, self-reflectiveness and self-certainty. A composite index representing cognitive insight is calculated by subtracting self-certainty from self-reflectiveness. The psychometric properties of the Japanese version of the BCIS (BCIS-J) were previously examined by Uchida et al. (2009). The reliability of the BCIS-J was confirmed using Cronbach's alpha coefficients and the test–retest method; convergent validity was confirmed through correlation analysis, which found significant correlations between this scale and 2 other measures of clinical insight, the Schedule for the Assessment of Insight and the Lack of Insight item from the Positive and Negative Syndrome Scale. The BCIS-J was administered within 1 week of assessment with the CAARMS-J.
2.3. Assessment of attenuated delusional symptoms
3.37 (1.25) 2.85 (1.44) 1.67 (6.72)
ARMS, At-risk mental state; GAF, the Global Assessment of Functioning; CAARMS-J, The Japanese version of the Comprehensive Assessment of At-Risk Mental States; S.D., standard deviation.
We used the CAARMS to assess attenuated delusional symptoms. The Japanese version of the CAARMS (CAARMS-J) was translated from the original CAARMS by Yung et al. (2005), and reliability and validity were confirmed by Miyakoshi et al. (2009). The CAARMS is a semi-structured interview designed to measure a wide variety of symptoms. It contains seven categories consisting of 28 items that measure attenuated positive symptoms (unusual thought content, non-bizarre ideas, perceptual abnormalities, and disorganized speech), negative symptoms, general psychopathologies, behavioral changes, and Huber's basic symptoms in individuals with ARMS. Each item is rated in terms of intensity (0–6) and frequency or duration (0–6) of the symptom or problem. To assess attenuated delusional symptoms as one entity, we combined the “unusual thought content” and “nonbizarre ideas” items of the CAARMS-J into one item, equivalent to the “disorder of thought content” item in the first edition of the CAARMS (Yung et al., 2005). Near-
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threshold delusional symptoms were defined as severe attenuated delusional symptoms, indicated by ratings of 5 or more on the symptom intensity score. 2.4. Assessment of transition to psychosis Individuals with ARMS were clinically followed up by an experienced psychiatrist of the SAFE clinic and transition to psychosis was monitored by them according to the CAARMS criteria; i.e., at least one fully positive psychotic symptom several times a week for more than 1 week. 2.5. Statistical analysis T-tests were performed to compare the BCIS-J scores of the ARMS and control groups. We also compared the BCIS-J scores of antipsychotic-free individuals with ARMS and controls to check for an effect of antipsychotic medication. T-tests were also conducted to compare BCIS-J scores for participants with ARMS with and without near-threshold delusional symptoms and with and without later transition to psychosis. Pearson's correlations were calculated to examine the relationships between the indices of the BCIS-J (self-reflectiveness, self-certainty, and composite index) and attenuated delusional symptoms in individuals with ARMS for the group as a whole and for antipsychotic-free individuals. To determine the effects of demographic variables on cognitive insight, the correlations of gender, age, education, and the Global Assessment of Functioning with the indices of the BCIS-J were examined. Statistical analyses were conducted with IBM SPSS statistical software, version 20.0 (IBM Japan, Tokyo, Japan). All testing was 2-tailed, and the significance level was set at 5%.
3. Results 3.1. Demographic and clinical characteristics The composition of the ARMS group in terms of intake criteria was as follows: the majority, or 78.3%, had APS (n ¼47); 3.3% had BLIPS (n ¼ 2); 1.7% had only state and trait risk factors (n ¼1); and, finally, 16.7% had APS plus state and trait risk factors (n¼ 10). The demographic and clinical characteristics of the ARMS group are summarized in Table 1, along with basic demographic information for the control group. 3.2. Profile of cognitive insight The mean (S.D.) scores for self-reflectiveness, self-certainty, and the composite index were 12.03 (3.97), 5.78 (3.14), and 6.25 (4.80), respectively, for the ARMS group and 11.53 (3.07), 4.37 (2.35), and 7.16 (3.62), respectively, for the healthy participants. The BCIS-J self-certainty mean score was significantly higher for the ARMS group than for healthy participants (t [58] ¼3.23, P ¼0.002). On the other hand, there were no significant differences in selfreflectiveness or composite index scores between the ARMS and control groups (Fig. 1). The same pattern of results was found when comparing antipsychotic-free individuals with ARMS and controls. No significant correlations were found between any of the indices of the BCIS-J and demographic variables.
Fig. 1. Scores on the self-reflectiveness and self-certainty subscales and composite index of the Beck Cognitive Insight Scale (Japanese version, BCIS-J) for individuals with an at-risk mental states (ARMS; n¼60) and healthy controls (n¼ 200). * P o 0.05.
3.3. Correlation between cognitive insight and positive symptoms The BCIS-J self-certainty score was significantly correlated with attenuated delusional symptoms as measured by the CAARMS-J (r¼0.26, P¼0.042), whereas the BCIS-J self-reflectiveness and composite index scores were not correlated with attenuated delusional symptoms. The same correlational analysis for antipsychoticfree individuals with ARMS revealed that the self-certainty score was positively (r¼ 0.29, P¼0.044) and the composite index score was negatively (r¼ 0.30, P¼0.036) correlated with delusional symptoms, but the self-reflectiveness score showed no significant correlation. 3.4. Participants with ARMS with and without near-threshold delusional symptoms Ten (16.7%) of the 60 participants with ARMS had nearthreshold delusional symptoms. The self-certainty score was significantly higher for those with near-threshold delusional symptoms (mean [S.D.] ¼7.90 [3.87]) than for those without (mean [S.D.]¼5.36 [2.83]; t [58] ¼ 2.43, P ¼0.018). The composite index score of those who had near-threshold delusional symptoms (mean [S.D.] ¼2.60 [5.64]) was significantly lower than that of participants without near-threshold delusional symptoms (mean [S.D.]¼6.98 [4.31]; t [58] ¼ 2.78, P ¼0.007). However, the mean self-reflectiveness scores were comparable for participants with ARMS with and without near-threshold delusional symptoms. 3.5. Participants with ARMS with and without later transition to psychosis Five (8.3%) of the 60 participants with ARMS transitioned to psychosis during the follow-up period. The mean (S.D.) duration of follow-up was 21.92 (19.00) months. The mean self-certainty score of participants with ARMS who experienced a transition to psychosis (mean [S.D.]¼8.20 [3.27]) was higher than that of participants who did not experience a transition (mean [S.D.] ¼ 5.56 [3.06]), but at a marginally significant level (t [58] ¼1.84, P¼ 0.072). The mean self-reflectiveness and composite index scores of participants with ARMS who had experienced transition to psychosis were comparable to those of participants who had not experienced transition. The results, taken together, are important in revealing a relationship between elevated self-certainty and delusional symptoms as well as impairments in cognitive insight in patients still in the early stages of psychosis.
4. Discussion This study investigated cognitive insight and attenuated delusional symptoms in young individuals with ARMS. Participants with ARMS showed higher self-certainty, an indication of overconfidence in one's beliefs and judgments, than healthy controls. More importantly, our results revealed that self-certainty was correlated with attenuated delusional symptoms, and individuals with ARMS who had near threshold delusional symptoms exhibited higher self-certainty and a reduction in overall cognitive insight. To our knowledge, this is the first study to demonstrate impaired cognitive insight and its association with attenuated delusional symptoms in individuals with ARMS. The present findings of impaired cognitive insight in individuals with ARMS are consistent with previous studies, which have shown impaired cognitive insight in individuals with full-blown psychosis (Warman et al., 2007; Kao and Liu, 2010; Martin et al., 2010). Although self-certainty higher than that of healthy controls
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has been consistently seen in patients with psychosis (Warman et al., 2007; Kao and Liu, 2010; Martin et al., 2010), our results indicate that overconfidence in beliefs or judgments seems to exist not only in people who have established psychosis but also in people still in the prodromal stages of psychosis. Importantly, the present study also found that self-certainty was positively correlated with the severity of attenuated delusional symptoms in individuals with ARMS. This association corresponds with findings that show a significant correlation between self-certainty and positive symptoms in individuals with schizophrenia (Pedrelli et al., 2004; Bora et al., 2007). Furthermore, the results for antipsychotic-free individuals with ARMS indicated that overall cognitive insight, in addition to self-certainty, was also correlated with the severity of attenuated delusional symptoms, consistent with a previous study on schizophrenia (Bora et al., 2007). However, these findings are inconsistent with Kimhy et al.'s (2013) findings, in which the cognitive insight ability of people with ARMS was found to be generally intact, and no association was found between cognitive insight and delusional symptoms. The authors did report impaired cognitive insight in a subgroup of their sample of participants with ARMS; individuals with ARMS who had near-threshold suspiciousness had higher self-certainty compared with those who had lower suspiciousness, consistent with our finding that individuals with ARMS who had near-threshold delusional symptoms exhibited higher self-certainty. Similar patterns have also been observed in patients with schizophrenia and healthy samples. For example, Warman et al. (2007) reported that overconfidence was observed only in patients with schizophrenia who had active delusions and not in those who had no delusions. In another study, Warman and Martin (2006) found that healthy university students prone to delusions were more overconfident than those not prone to delusions. According to these findings, it seems that higher selfcertainty is closely linked to active delusional thinking regardless of diagnosis. Therefore, a possible explanation for the seemingly conflicting results between Kimhy et al. (2013) and the present study might be the differing proportions of participants who had severe delusional features. In our study, 57 of the 60 participants with ARMS met the criteria for attenuated psychotic symptoms and 10 of the 60 subjects had near-threshold delusional symptoms. On the other hand, in the study by Kimhy et al. (2013), only five of the 62 participants with ARMS were judged to have nearthreshold suspiciousness. Although we cannot directly compare the two samples, the present study might have included people who had more severe delusional symptoms, which would account for the differences in results. Because ARMS is supposed to be heterogeneous in its prognosis, pathophysiology, and symptom profiles (Yung et al., 1998; Fusar-Poli et al., 2012; Valmaggia et al., 2013), it seems important to avoid discussing ARMS as a general, but rather to pay attention to subtypes or specific features of ARMS samples. In the present study, the self-reflectiveness of individuals with ARMS was intact, a finding consistent with previous research (Kimhy et al., 2013). To date, studies on self-reflectiveness in psychosis have yielded mixed results: two studies (Kao and Liu, 2010; Martin et al., 2010) have demonstrated reduced selfreflectiveness in patients with psychosis compared with healthy controls, but other studies have not (Warman et al., 2007; Kimhy et al., 2013). Several factors, such as the different ages of the participants and different sample sizes, may explain the inconsistent results. Interestingly, one study demonstrated a counterintuitive finding that healthy people with higher delusional proneness had higher self-reflectiveness than those with lower delusional proneness (Warman and Martin, 2006). This finding implies that higher self-reflectiveness is not always functional, at least in healthy individuals, and overly introspective and
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ruminative people may have delusional thinking within the “normal” range. According to the present and previous studies (Kimhy et al., 2013), individuals with ARMS seem to retain their capacity to be objective about delusional experiences, cognitive distortions, and openness to external feedback, which may have a protective role in preventing the development of full-blown psychosis (Warman and Martin, 2006). On the other hand, the pattern of the present findings, that individuals with ARMS and near-threshold delusional symptoms had higher self-certainty but similar selfreflectiveness compared with those without these symptoms, was consistent with a study by Warman et al. (2007), in which patients with psychosis but without active delusions showed reduced self-reflectiveness and average self-certainty, whereas those with active delusions showed average self-reflectiveness and increased self-certainty. These findings indicate the importance of a balance between self-reflectiveness and self-certainty on an activity of delusional thinking. This notion is corroborated by the present finding of a reduced cognitive insight composite index score in individuals with ARMS and near-threshold delusional symptoms. On the basis of a comprehensive review of cognitive insight research, Riggs et al. (2012) hypothesized that lack of cognitive insight is a contributing factor in the transition to psychosis. Contrary to this hypothesis, cognitive insight could not predict future development of psychosis in the present and previous (Kimhy et al., 2013) studies. However, the current study found a tendency towards higher self-certainty in individuals with ARMS who transitioned to psychosis later on when compared with those who did not transition. Because of the small sample size and the relatively low transition rate in this study, we could not reach a definitive conclusion on this issue. Therefore, further study is necessary to determine if impairment in cognitive insight predicts the future development of psychosis. Given our finding of a link between cognitive insight and attenuated delusions, further research on the possible relationships between cognitive insight and various treatment methods— especially cognitive behavioral therapy (CBT)—in individuals with ARMS would be intriguing. CBT is one of the most promising and beneficial treatments for individuals with ARMS (Phillips et al., 2009; Addington et al., 2012), and several studies have shown that CBT interventions significantly reduce the likelihood of progression to psychosis and improve positive symptoms (e.g., Morrison et al., 2004; Bechdolf et al., 2012; van der Gaag et al., 2012). Previously, one study (Perivoliotis et al., 2010) demonstrated that improvement in delusional beliefs was correlated with improvement in cognitive insight in patients with schizophrenia, suggesting that cognitive insight might be a predictor and mediator of psychotic symptom reduction in CBT. Therefore, we speculate that interventions that reduce overconfidence in their judgments or beliefs may be beneficial for individuals with ARMS. In the future, monitoring cognitive insight and symptom profiles will be useful for treating this population. Several methodological limitations must be considered. First, the sample size of the present study was small, making any conclusions preliminary; a larger sample size would give more precise information on cognitive insight in individuals with ARMS. Second, healthy control status was designated by self-report questionnaire and not by diagnostic interview; therefore we cannot rule out the possibility that we might have included some individuals with psychiatric disorders in the control group. Third, we did not examine the causal relationships between cognitive insight and positive symptoms, so further study is necessary to determine if high self-certainty is a consequence of positive symptoms or leads to the formation of positive symptoms. Finally, we did not investigate the longitudinal relationship of cognitive
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insight and attenuated delusional symptoms, and future longitudinal investigations are necessary to clarify the complex interrelationships between cognitive insight, changes in symptoms, and response to treatment in individuals with ARMS. In conclusion, we demonstrated that cognitive insight is impaired in individuals with ARMS as shown by the higher selfcertainty scores than healthy controls. Furthermore, self-certainty was significantly correlated with the severity of attenuated delusional symptoms in individuals with ARMS, such that individuals with severe delusional thinking were more overconfident than those with less severe delusional thinking. These findings indicate that overconfidence in one's own beliefs or judgments might be related to the formation and maintenance of attenuated delusions in people with ARMS. Future longitudinal research is necessary to determine if enhanced cognitive insight could be a mediator of symptom improvement in individuals with ARMS. This study is significant in demonstrating elevated self-certainty and a positive association between self-certainty and attenuated delusional symptoms in individuals with ARMS.
Acknowledgment This research was supported in part by a Grant-in-Aid for Young Scientists (B) 24730567, and a Grant-in-Aid for Scientific Research (B) 22390219 and (C) 25461747 from the Japan Society for the Promotion of Science, Health and Labor Sciences Research Grants (Comprehensive Research on Disability, Health and Welfare, H25-Seishin- Ippan-009), and Intramural Research Grant (241, 25-1) for Neurological and Psychiatric Disorders of NCNP. References Addington, J., Marshall, C., French, P., 2012. Cognitive behavioral therapy in prodromal psychosis. Current Pharmaceutical Design 18, 558–565. Amador, X.F., Strauss, D.H., Yale, S.A., Gorman, J.M., 1991. Awareness of illness in schizophrenia. Schizophrenia Bulletin 17, 113–132. American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision American Psychiatric Association, Washington, DC Bechdolf, A., Wagner, M., Ruhrmann, S., Harrigan, S., Putzfeld, V., Pukrop, R., BrockhausDumke, A., Berning, J., Janssen, B., Decker, P., Bottlender, R., Maurer, K., Moller, H.J., Gaebel, W., Hafner, H., Maier, W., Klosterkotter, J., 2012. Preventing progression to first-episode psychosis in early initial prodromal states. British Journal of Psychiatry 200, 22–29. Beck, A.T., Baruch, E., Balter, J.M., Steer, R.A., Warman, D.M., 2004. A new instrument for measuring insight: the Beck Cognitive Insight Scale. Schizophrenia Research 68, 319–329. Bora, E., Erkan, A., Kayahan, B., Veznedaroglu, B., 2007. Cognitive insight and acute psychosis in schizophrenia. Psychiatry and Clinical Neurosciences 61, 634–639. Buchy, L., Malla, A., Joober, R., Lepage, M., 2009. Delusions are associated with low self-reflectiveness in first-episode psychosis. Schizophrenia Research 112, 187–191. David, A.S., 1990. Insight and psychosis. British Journal of Psychiatry 156, 798–808. Engh, J.A., Friis, S., Birkenaes, A.B., Jonsdottir, H., Ringen, P.A., Ruud, T., Sundet, K.S., Opjordsmoen, S., Andreassen, O.A., 2007. Measuring cognitive insight in schizophrenia and bipolar disorder: a comparative study. BMC Psychiatry 7, 71. Engh, J.A., Friis, S., Birkenaes, A.B., Jonsdottir, H., Klungsoyr, O., Ringen, P.A., Simonsen, C., Vaskinn, A., Opjordsmoen, S., Andreassen, O.A., 2010. Delusions
are associated with poor cognitive insight in schizophrenia. Schizophrenia Bulletin 36, 830–835. Fusar-Poli, P., Bonoldi, I., Yung, A.R., Borgwardt, S., Kempton, M.J., Valmaggia, L., Barale, F., Caverzasi, E., McGuire, P., 2012. Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. Archives of General Psychiatry 69, 220–229. Garety, P.A., Kuipers, E., Fowler, D., Freeman, D., Bebbington, P.E., 2001. A cognitive model of the positive symptoms of psychosis. Psychological Medicine 31, 189–195. Kao, Y.C., Liu, Y.P., 2010. The Beck Cognitive Insight Scale (BCIS): translation and validation of the Taiwanese version. BMC Psychiatry 10, 27. Kimhy, D., Jobson-Ahmed, L., Ben-David, S., Ramadhar, L., Malaspina, D., Corcoran, C.M., 2013. Cognitive insight in individuals at clinical high risk for psychosis. Early Intervention in Psychiatry, http://dx.doi.org/10.1111/eip.12023 (Published online) Lappin, J.M., Morgan, K.D., Valmaggia, L.R., Broome, M.R., Woolley, J.B., Johns, L.C., Tabraham, P., Bramon, E., McGuire, P.K., 2007. Insight in individuals with an at risk mental state. Schizophrenia Research 90, 238–244. Martin, J.M., Warman, D.M., Lysaker, P.H., 2010. Cognitive insight in non-psychiatric individuals and individuals with psychosis: an examination using the Beck Cognitive Insight Scale. Schizophrenia Research 121, 39–45. Miyakoshi, T., Matsumoto, K., Ito, F., Ohmuro, N., Matsuoka, H., 2009. Application of the Comprehensive Assessment of At-Risk Mental States (CAARMS) to the Japanese population: reliability and validity of the Japanese version of the CAARMS. Early Intervention in Psychiatry 3, 123–130. Mizuno, M., Suzuki, M., Matsumoto, K., Murakami, M., Takeshi, K., Miyakoshi, T., Ito, F., Yamazawa, R., Kobayashi, H., Nemoto, T., Kurachi, M., 2009. Clinical practice and research activities for early psychiatric intervention at Japanese leading centres. Early Intervention in Psychiatry 3, 5–9. Morrison, A.P., French, P., Walford, L., Lewis, S.W., Kilcommons, A., Green, J., Parker, S., Bentall, R.P., 2004. Cognitive therapy for the prevention of psychosis in people at ultra-high risk: randomised controlled trial. British Journal of Psychiatry 185, 291–297. Pedrelli, P., McQuaid, J.R., Granholm, E., Patterson, T.L., McClure, F., Beck, A.T., Jeste, D.V., 2004. Measuring cognitive insight in middle-aged and older patients with psychotic disorders. Schizophrenia Research 71, 297–305. Perivoliotis, D., Grant, P.M., Peters, E.R., Ison, R., Kuipers, E., Beck, A.T., 2010. Cognitive insight predicts favorable outcome in cognitive behavioural therapy for psychosis. Psychosis 2, 23–33. Phillips, L., Addington, J., Morrison, A., 2009. At-risk mental state: management. In: Jackson, H.J., McGorry, P.D. (Eds.), The Recognition and Management of Early Psychosis: A Preventive Approach, 2nd ed. Cambridge University Press, Cambridge, pp. 107–122 Riggs, S.E., Grant, P.M., Perivoliotis, D., Beck, A.T., 2012. Assessment of cognitive insight: a qualitative review. Schizophrenia Bulletin 38, 338–350. Uchida, T., Matsumoto, K., Kikuchi, A., Miyakoshi, T., Ito, F., Ueno, T., Matsuoka, H., 2009. Psychometric properties of the Japanese version of the Beck Cognitive Insight Scale: relation of cognitive insight to clinical insight. Psychiatry and Clinical Neurosciences 63, 291–297. Valmaggia, L.R., Stahl, D., Yung, A.R., Nelson, B., Fusar-Poli, P., McGorry, P.D., McGuire, P.K., 2013. Negative psychotic symptoms and impaired role functioning predict transition outcomes in the at-risk mental state: a latent class cluster analysis study. Psychological Medicine 43, 2311–2325. van der Gaag, M., Nieman, D.H., Rietdijk, J., Dragt, S., Ising, H.K., Klaassen, R.M., Koeter, M., Cuijpers, P., Wunderink, L., Linszen, D.H., 2012. Cognitive behavioral therapy for subjects at ultrahigh risk for developing psychosis: a randomized controlled clinical trial. Schizophrenia Bulletin 38, 1180–1188. Warman, D.M., Lysaker, P.H., Martin, J.M., 2007. Cognitive insight and psychotic disorder: the impact of active delusions. Schizophrenia Research 90, 325–333. Warman, D.M., Martin, J.M., 2006. Cognitive insight and delusion proneness: an investigation using the Beck Cognitive Insight Scale. Schizophrenia Research 84, 297–304. Yung, A.R., Phillips, L.J., McGorry, P.D., McFarlane, C.A., Francey, S., Harrigan, S., Patton, G.C., Jackson, H.J., 1998. Prediction of psychosis: a step towards indicated prevention of schizophrenia. British Journal of Psychiatry 172 (Suppl. 33), 14–20. Yung, A.R., Yuen, H.P., McGorry, P.D., Phillips, L.J., Kelly, D., Dell’Olio, M., Francey, S. M., Cosgrave, E.M., Killackey, E., Stanford, C., Godfrey, K., Buckby, J., 2005. Mapping the onset of psychosis: the comprehensive assessment of at-risk mental states. Australian and New Zealand Journal of Psychiatry 39, 964–971.
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Relationship between cognitive insight and attenuated delusional symptoms in individuals with at-risk mental state Tomohiro Uchida a,n, Kazunori Matsumoto a, Fumiaki Ito b, Noriyuki Ohmuro b, Tetsuo Miyakoshi c, Takashi Ueno d, Hiroo Matsuoka b a
Department of Preventive Psychiatry, Tohoku University, Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan Department of Psychiatry, Tohoku University Graduate School of Medicine, Sendai, Japan c Chiba Prison, Chiba, Japan d Division of Clinical Psychology, Tohoku University, Graduate School of Education, Sendai, Japan b
art ic l e i nf o
a b s t r a c t
Article history: Received 9 May 2013 Received in revised form 10 October 2013 Accepted 1 January 2014 Available online 14 January 2014
Cognitive insight, defined as the ability to evaluate and correct one's own distorted beliefs and misinterpretations, is hypothesized to contribute to the development of psychotic symptoms. We investigated cognitive insight in individuals with at-risk mental state (ARMS), which is associated with a clinically high risk of psychosis. Sixty individuals with ARMS were compared with 200 healthy controls in terms of cognitive insight measured using the Beck Cognitive Insight Scale. We also investigated the relationship between cognitive insight and attenuated delusional symptoms. In addition, we examined differences in the cognitive insight of individuals with ARMS with or without near-threshold delusional symptoms and differences in the cognitive insight of individuals with ARMS with or without later transition to psychosis. The results showed that individuals with ARMS exhibited higher self-certainty than healthy controls, indicating impairments in cognitive insight in the former. More importantly, our results revealed that self-certainty was correlated with attenuated delusional symptoms and that individuals with ARMS who had near threshold delusional symptoms had higher self-certainty. These findings indicate that overconfidence in one's own beliefs or judgments might be related to the formation and maintenance of attenuated delusions in individuals with ARMS. & 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Self certainty Psychosis Schizophrenia Ultra high risk
1. Introduction According to the cognitive model of psychosis (Garety et al., 2001), individuals with psychosis are impaired in considering alternative explanations for anomalous experiences. Such a deficit is thought to be associated with the development and maintenance of the positive symptoms of psychosis. Similarly, Beck et al. (2004) hypothesized that psychotic phenomena, especially delusions, are related to the impaired capacity of psychotic subjects to evaluate their own anomalous experiences. To explore this capacity, Beck et al. proposed the concept of cognitive insight, defined as a patient's capacity to evaluate his or her own anomalous experiences and atypical interpretations of events. In contrast to clinical insight (David, 1990; Amador et al., 1991), which typically refers to a person's awareness of illness, symptoms, treatment need, consequences of illness, and so forth, cognitive insight refers to metacognitive processes of reevaluation and the correction of
n
Corresponding author. Tel./fax: þ 81 22 717 8059. E-mail address: [email protected] (T. Uchida).
http://dx.doi.org/10.1016/j.psychres.2014.01.003 0165-1781 & 2014 Elsevier Ireland Ltd. All rights reserved.
distorted beliefs and misinterpretations (Beck et al., 2004; Riggs et al., 2012). Cognitive insight can be measured with the Beck Cognitive Insight Scale (BCIS; Beck et al., 2004). The BCIS comprises a self-reflectiveness subscale, which includes items related to reflectiveness, objectivity regarding beliefs and interpretations, and openness to the possibility of having misinterpreted experiences, and a self-certainty subscale, which evaluates overconfidence in decision-making and resistance to correction. Overall cognitive insight is estimated by calculating the difference between the self-certainty and self-reflectiveness scores. In accordance with the hypothesis of Beck et al. (2004), previous studies have demonstrated impaired cognitive insight in patients with schizophrenia, and some authors have shown an association between reduced cognitive insight and delusions in schizophrenia. For example, individuals with delusions tend to show higher self-certainty (Engh et al., 2007; Warman et al., 2007) and lower self-reflectiveness (Buchy et al., 2009; Engh et al., 2010) than those without delusions, and higher self-certainty appears to be positively correlated with delusional symptoms (Kimhy et al., 2013). These findings suggest that impaired cognitive insight could be associated with the formation of delusional symptoms and that
T. Uchida et al. / Psychiatry Research 217 (2014) 20–24
this impairment would likely exist in the prodromal stage of schizophrenia. In order to investigate this possibility, we thought it ideal to examine the putative prodromal state of psychosis known as an at-risk mental state (ARMS; Yung et al., 1998). ARMS can predict the subsequent transition to psychosis (e.g., Fusar-Poli et al., 2012), and many individuals with ARMS experience attenuated psychotic symptoms such as ideas of reference, suspiciousness, odd beliefs, and perceptual distortions. In addition, a previous study examining the clinical insight of those with ARMS reported that such individuals exhibited an impaired ability to appraise anomalous experiences as symptoms of illness (Lappin et al., 2007). To date, only one study has examined cognitive insight in individuals with ARMS. Kimhy et al. (2013) reported that individuals with ARMS showed self-certainty and self-reflectiveness comparable to those of healthy controls and lower than those of patients with schizophrenia. They also examined the relationship between attenuated delusional symptoms and cognitive insight, but, contrary to expectations, they found that self-certainty and self-reflectiveness were not related to attenuated delusional symptoms in people with ARMS. However, they also reported that the self-certainty scores of people with ARMS were between those of patients with schizophrenia and healthy controls; that is, people with ARMS had higher, but not significantly higher, self-certainty scores compared with healthy controls. In addition, individuals with ARMS who had near-threshold persecutory ideation exhibited higher self-certainty scores compared with those with milder or no persecutory ideation, indicating that at least some symptomatic individuals with ARMS exhibit higher self-certainty. Therefore, the Kimhy et al. (2013) study was not sufficient to conclude that individuals with ARMS have impaired cognitive insight, and more research is required to clarify this issue. In the present study, we investigated the following: (i) the degree of cognitive insight of individuals with ARMS compared with healthy controls, (ii) the relationship between attenuated delusional symptoms and cognitive insight, (iii) differences in cognitive insight between individuals with ARMS with and without near-threshold delusional symptoms, and (iv) differences in cognitive insight between individuals with ARMS with and without later transition to psychosis. We hypothesized that the selfcertainty of individuals with ARMS would be higher than that of healthy controls and that attenuated delusional symptoms would be associated with self-certainty in individuals with ARMS. In Table 1 Demographic variables and scores on the Comprehensive Assessment of At-Risk Mental States (Japanese version, CAARMS-J) in participants with an at-risk mental state (ARMS; n ¼60) and healthy controls (n¼ 200). Characteristics
Gender (number of males/ females) Age (years) Education (years) GAF CAARMS-J Thought content Perceptual abnormalities Disorganized speech
Mean (S.D.)
Statistics P
ARMS
Healthy controls
22/38
81/119
χ2 ¼ 0.28
NS
19.48 (4.17) 11.58 (2.25) 47.63 (6.72)
20.34 (1.87)
t ¼1.55
NS
21
addition, we predicted that self-certainty scores would be higher in individuals with ARMS who had near-threshold delusional symptoms and those who had later transition to psychosis.
2. Methods 2.1. Participants Participants were recruited from the Sendai At-Risk Mental State and First Episode (SAFE) specialized clinic (Mizuno et al., 2009). Subjects had to meet the following inclusion criteria: (i) were aged between 14 and 35 years, (ii) were seeking psychiatric help, and (iii) fulfilled the ultra-high-risk criteria as defined by the Japanese version of the Comprehensive Assessment of At-Risk Mental States (CAARMS-J; Miyakoshi et al., 2009). Individuals were assessed with the CAARMS-J by trained and experienced psychiatrists, and diagnoses were confirmed at consensus meetings with the clinical team. All included subjects met one or more of the following criteria for ARMS: (i) attenuated psychotic symptoms (APS), (ii) brief limited intermittent psychotic symptoms (BLIPS, a brief psychotic episode that resolves spontaneously within 1 week), or (iii) state and trait risk factors (a recent decline in functioning plus a first-degree relative with either psychosis or a schizotypal personality disorder). The exclusion criteria were as follows: (i) a history of psychotic or manic episodes as specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association, 2000); (ii) serious risk of suicide or violence due to a personality disorder; (iii) current substance dependence; (iv) known intellectual disability (IQ o 70); or (v) neurological disorder, head injury, or any other significant medical condition associated with psychiatric symptoms. Sixty individuals (22 men and 38 women; mean [S.D.] age¼ 19.48 [4.17] years) met the required criteria and were included in the ARMS group for this study. The demographic characteristics of this group are shown in Table 1. Among the 60 individuals with ARMS, 35 were medication-free (58.3%), 12 (20.0%) were taking antipsychotic medications (risperidone, 4; olanzapine, 3; sulpiride, 2; and aripiprazole, 3), 12 (20.0%) were taking antidepressants, and 4 (6.7%) were taking mood stabilizers. Two hundred university students (81 men and 119 women; mean [S.D.] age¼20.3 [1.9] years) were recruited at Tohoku University as healthy controls. All participants were asked as a part of the study questionnaire if they had ever been diagnosed with a psychiatric disorder; those who answered affirmatively were excluded from the control group. All study participants provided written informed consent, and the research design was approved by the Ethics Committee of Tohoku University Graduate School of Medicine and Tohoku University Hospital. This study complied with the principles laid down in the Declaration of Helsinki for experiments involving humans.
2.2. Assessment of cognitive insight The BCIS (Beck et al., 2004) is a self-report instrument consisting of 15 items, each rated on a 4-point scale from 0 (do not agree at all) to 3 (agree completely), resulting in two component scores, self-reflectiveness and self-certainty. A composite index representing cognitive insight is calculated by subtracting self-certainty from self-reflectiveness. The psychometric properties of the Japanese version of the BCIS (BCIS-J) were previously examined by Uchida et al. (2009). The reliability of the BCIS-J was confirmed using Cronbach's alpha coefficients and the test–retest method; convergent validity was confirmed through correlation analysis, which found significant correlations between this scale and 2 other measures of clinical insight, the Schedule for the Assessment of Insight and the Lack of Insight item from the Positive and Negative Syndrome Scale. The BCIS-J was administered within 1 week of assessment with the CAARMS-J.
2.3. Assessment of attenuated delusional symptoms
3.37 (1.25) 2.85 (1.44) 1.67 (6.72)
ARMS, At-risk mental state; GAF, the Global Assessment of Functioning; CAARMS-J, The Japanese version of the Comprehensive Assessment of At-Risk Mental States; S.D., standard deviation.
We used the CAARMS to assess attenuated delusional symptoms. The Japanese version of the CAARMS (CAARMS-J) was translated from the original CAARMS by Yung et al. (2005), and reliability and validity were confirmed by Miyakoshi et al. (2009). The CAARMS is a semi-structured interview designed to measure a wide variety of symptoms. It contains seven categories consisting of 28 items that measure attenuated positive symptoms (unusual thought content, non-bizarre ideas, perceptual abnormalities, and disorganized speech), negative symptoms, general psychopathologies, behavioral changes, and Huber's basic symptoms in individuals with ARMS. Each item is rated in terms of intensity (0–6) and frequency or duration (0–6) of the symptom or problem. To assess attenuated delusional symptoms as one entity, we combined the “unusual thought content” and “nonbizarre ideas” items of the CAARMS-J into one item, equivalent to the “disorder of thought content” item in the first edition of the CAARMS (Yung et al., 2005). Near-
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threshold delusional symptoms were defined as severe attenuated delusional symptoms, indicated by ratings of 5 or more on the symptom intensity score. 2.4. Assessment of transition to psychosis Individuals with ARMS were clinically followed up by an experienced psychiatrist of the SAFE clinic and transition to psychosis was monitored by them according to the CAARMS criteria; i.e., at least one fully positive psychotic symptom several times a week for more than 1 week. 2.5. Statistical analysis T-tests were performed to compare the BCIS-J scores of the ARMS and control groups. We also compared the BCIS-J scores of antipsychotic-free individuals with ARMS and controls to check for an effect of antipsychotic medication. T-tests were also conducted to compare BCIS-J scores for participants with ARMS with and without near-threshold delusional symptoms and with and without later transition to psychosis. Pearson's correlations were calculated to examine the relationships between the indices of the BCIS-J (self-reflectiveness, self-certainty, and composite index) and attenuated delusional symptoms in individuals with ARMS for the group as a whole and for antipsychotic-free individuals. To determine the effects of demographic variables on cognitive insight, the correlations of gender, age, education, and the Global Assessment of Functioning with the indices of the BCIS-J were examined. Statistical analyses were conducted with IBM SPSS statistical software, version 20.0 (IBM Japan, Tokyo, Japan). All testing was 2-tailed, and the significance level was set at 5%.
3. Results 3.1. Demographic and clinical characteristics The composition of the ARMS group in terms of intake criteria was as follows: the majority, or 78.3%, had APS (n ¼47); 3.3% had BLIPS (n ¼ 2); 1.7% had only state and trait risk factors (n ¼1); and, finally, 16.7% had APS plus state and trait risk factors (n¼ 10). The demographic and clinical characteristics of the ARMS group are summarized in Table 1, along with basic demographic information for the control group. 3.2. Profile of cognitive insight The mean (S.D.) scores for self-reflectiveness, self-certainty, and the composite index were 12.03 (3.97), 5.78 (3.14), and 6.25 (4.80), respectively, for the ARMS group and 11.53 (3.07), 4.37 (2.35), and 7.16 (3.62), respectively, for the healthy participants. The BCIS-J self-certainty mean score was significantly higher for the ARMS group than for healthy participants (t [58] ¼3.23, P ¼0.002). On the other hand, there were no significant differences in selfreflectiveness or composite index scores between the ARMS and control groups (Fig. 1). The same pattern of results was found when comparing antipsychotic-free individuals with ARMS and controls. No significant correlations were found between any of the indices of the BCIS-J and demographic variables.
Fig. 1. Scores on the self-reflectiveness and self-certainty subscales and composite index of the Beck Cognitive Insight Scale (Japanese version, BCIS-J) for individuals with an at-risk mental states (ARMS; n¼60) and healthy controls (n¼ 200). * P o 0.05.
3.3. Correlation between cognitive insight and positive symptoms The BCIS-J self-certainty score was significantly correlated with attenuated delusional symptoms as measured by the CAARMS-J (r¼0.26, P¼0.042), whereas the BCIS-J self-reflectiveness and composite index scores were not correlated with attenuated delusional symptoms. The same correlational analysis for antipsychoticfree individuals with ARMS revealed that the self-certainty score was positively (r¼ 0.29, P¼0.044) and the composite index score was negatively (r¼ 0.30, P¼0.036) correlated with delusional symptoms, but the self-reflectiveness score showed no significant correlation. 3.4. Participants with ARMS with and without near-threshold delusional symptoms Ten (16.7%) of the 60 participants with ARMS had nearthreshold delusional symptoms. The self-certainty score was significantly higher for those with near-threshold delusional symptoms (mean [S.D.] ¼7.90 [3.87]) than for those without (mean [S.D.]¼5.36 [2.83]; t [58] ¼ 2.43, P ¼0.018). The composite index score of those who had near-threshold delusional symptoms (mean [S.D.] ¼2.60 [5.64]) was significantly lower than that of participants without near-threshold delusional symptoms (mean [S.D.]¼6.98 [4.31]; t [58] ¼ 2.78, P ¼0.007). However, the mean self-reflectiveness scores were comparable for participants with ARMS with and without near-threshold delusional symptoms. 3.5. Participants with ARMS with and without later transition to psychosis Five (8.3%) of the 60 participants with ARMS transitioned to psychosis during the follow-up period. The mean (S.D.) duration of follow-up was 21.92 (19.00) months. The mean self-certainty score of participants with ARMS who experienced a transition to psychosis (mean [S.D.]¼8.20 [3.27]) was higher than that of participants who did not experience a transition (mean [S.D.] ¼ 5.56 [3.06]), but at a marginally significant level (t [58] ¼1.84, P¼ 0.072). The mean self-reflectiveness and composite index scores of participants with ARMS who had experienced transition to psychosis were comparable to those of participants who had not experienced transition. The results, taken together, are important in revealing a relationship between elevated self-certainty and delusional symptoms as well as impairments in cognitive insight in patients still in the early stages of psychosis.
4. Discussion This study investigated cognitive insight and attenuated delusional symptoms in young individuals with ARMS. Participants with ARMS showed higher self-certainty, an indication of overconfidence in one's beliefs and judgments, than healthy controls. More importantly, our results revealed that self-certainty was correlated with attenuated delusional symptoms, and individuals with ARMS who had near threshold delusional symptoms exhibited higher self-certainty and a reduction in overall cognitive insight. To our knowledge, this is the first study to demonstrate impaired cognitive insight and its association with attenuated delusional symptoms in individuals with ARMS. The present findings of impaired cognitive insight in individuals with ARMS are consistent with previous studies, which have shown impaired cognitive insight in individuals with full-blown psychosis (Warman et al., 2007; Kao and Liu, 2010; Martin et al., 2010). Although self-certainty higher than that of healthy controls
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has been consistently seen in patients with psychosis (Warman et al., 2007; Kao and Liu, 2010; Martin et al., 2010), our results indicate that overconfidence in beliefs or judgments seems to exist not only in people who have established psychosis but also in people still in the prodromal stages of psychosis. Importantly, the present study also found that self-certainty was positively correlated with the severity of attenuated delusional symptoms in individuals with ARMS. This association corresponds with findings that show a significant correlation between self-certainty and positive symptoms in individuals with schizophrenia (Pedrelli et al., 2004; Bora et al., 2007). Furthermore, the results for antipsychotic-free individuals with ARMS indicated that overall cognitive insight, in addition to self-certainty, was also correlated with the severity of attenuated delusional symptoms, consistent with a previous study on schizophrenia (Bora et al., 2007). However, these findings are inconsistent with Kimhy et al.'s (2013) findings, in which the cognitive insight ability of people with ARMS was found to be generally intact, and no association was found between cognitive insight and delusional symptoms. The authors did report impaired cognitive insight in a subgroup of their sample of participants with ARMS; individuals with ARMS who had near-threshold suspiciousness had higher self-certainty compared with those who had lower suspiciousness, consistent with our finding that individuals with ARMS who had near-threshold delusional symptoms exhibited higher self-certainty. Similar patterns have also been observed in patients with schizophrenia and healthy samples. For example, Warman et al. (2007) reported that overconfidence was observed only in patients with schizophrenia who had active delusions and not in those who had no delusions. In another study, Warman and Martin (2006) found that healthy university students prone to delusions were more overconfident than those not prone to delusions. According to these findings, it seems that higher selfcertainty is closely linked to active delusional thinking regardless of diagnosis. Therefore, a possible explanation for the seemingly conflicting results between Kimhy et al. (2013) and the present study might be the differing proportions of participants who had severe delusional features. In our study, 57 of the 60 participants with ARMS met the criteria for attenuated psychotic symptoms and 10 of the 60 subjects had near-threshold delusional symptoms. On the other hand, in the study by Kimhy et al. (2013), only five of the 62 participants with ARMS were judged to have nearthreshold suspiciousness. Although we cannot directly compare the two samples, the present study might have included people who had more severe delusional symptoms, which would account for the differences in results. Because ARMS is supposed to be heterogeneous in its prognosis, pathophysiology, and symptom profiles (Yung et al., 1998; Fusar-Poli et al., 2012; Valmaggia et al., 2013), it seems important to avoid discussing ARMS as a general, but rather to pay attention to subtypes or specific features of ARMS samples. In the present study, the self-reflectiveness of individuals with ARMS was intact, a finding consistent with previous research (Kimhy et al., 2013). To date, studies on self-reflectiveness in psychosis have yielded mixed results: two studies (Kao and Liu, 2010; Martin et al., 2010) have demonstrated reduced selfreflectiveness in patients with psychosis compared with healthy controls, but other studies have not (Warman et al., 2007; Kimhy et al., 2013). Several factors, such as the different ages of the participants and different sample sizes, may explain the inconsistent results. Interestingly, one study demonstrated a counterintuitive finding that healthy people with higher delusional proneness had higher self-reflectiveness than those with lower delusional proneness (Warman and Martin, 2006). This finding implies that higher self-reflectiveness is not always functional, at least in healthy individuals, and overly introspective and
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ruminative people may have delusional thinking within the “normal” range. According to the present and previous studies (Kimhy et al., 2013), individuals with ARMS seem to retain their capacity to be objective about delusional experiences, cognitive distortions, and openness to external feedback, which may have a protective role in preventing the development of full-blown psychosis (Warman and Martin, 2006). On the other hand, the pattern of the present findings, that individuals with ARMS and near-threshold delusional symptoms had higher self-certainty but similar selfreflectiveness compared with those without these symptoms, was consistent with a study by Warman et al. (2007), in which patients with psychosis but without active delusions showed reduced self-reflectiveness and average self-certainty, whereas those with active delusions showed average self-reflectiveness and increased self-certainty. These findings indicate the importance of a balance between self-reflectiveness and self-certainty on an activity of delusional thinking. This notion is corroborated by the present finding of a reduced cognitive insight composite index score in individuals with ARMS and near-threshold delusional symptoms. On the basis of a comprehensive review of cognitive insight research, Riggs et al. (2012) hypothesized that lack of cognitive insight is a contributing factor in the transition to psychosis. Contrary to this hypothesis, cognitive insight could not predict future development of psychosis in the present and previous (Kimhy et al., 2013) studies. However, the current study found a tendency towards higher self-certainty in individuals with ARMS who transitioned to psychosis later on when compared with those who did not transition. Because of the small sample size and the relatively low transition rate in this study, we could not reach a definitive conclusion on this issue. Therefore, further study is necessary to determine if impairment in cognitive insight predicts the future development of psychosis. Given our finding of a link between cognitive insight and attenuated delusions, further research on the possible relationships between cognitive insight and various treatment methods— especially cognitive behavioral therapy (CBT)—in individuals with ARMS would be intriguing. CBT is one of the most promising and beneficial treatments for individuals with ARMS (Phillips et al., 2009; Addington et al., 2012), and several studies have shown that CBT interventions significantly reduce the likelihood of progression to psychosis and improve positive symptoms (e.g., Morrison et al., 2004; Bechdolf et al., 2012; van der Gaag et al., 2012). Previously, one study (Perivoliotis et al., 2010) demonstrated that improvement in delusional beliefs was correlated with improvement in cognitive insight in patients with schizophrenia, suggesting that cognitive insight might be a predictor and mediator of psychotic symptom reduction in CBT. Therefore, we speculate that interventions that reduce overconfidence in their judgments or beliefs may be beneficial for individuals with ARMS. In the future, monitoring cognitive insight and symptom profiles will be useful for treating this population. Several methodological limitations must be considered. First, the sample size of the present study was small, making any conclusions preliminary; a larger sample size would give more precise information on cognitive insight in individuals with ARMS. Second, healthy control status was designated by self-report questionnaire and not by diagnostic interview; therefore we cannot rule out the possibility that we might have included some individuals with psychiatric disorders in the control group. Third, we did not examine the causal relationships between cognitive insight and positive symptoms, so further study is necessary to determine if high self-certainty is a consequence of positive symptoms or leads to the formation of positive symptoms. Finally, we did not investigate the longitudinal relationship of cognitive
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insight and attenuated delusional symptoms, and future longitudinal investigations are necessary to clarify the complex interrelationships between cognitive insight, changes in symptoms, and response to treatment in individuals with ARMS. In conclusion, we demonstrated that cognitive insight is impaired in individuals with ARMS as shown by the higher selfcertainty scores than healthy controls. Furthermore, self-certainty was significantly correlated with the severity of attenuated delusional symptoms in individuals with ARMS, such that individuals with severe delusional thinking were more overconfident than those with less severe delusional thinking. These findings indicate that overconfidence in one's own beliefs or judgments might be related to the formation and maintenance of attenuated delusions in people with ARMS. Future longitudinal research is necessary to determine if enhanced cognitive insight could be a mediator of symptom improvement in individuals with ARMS. This study is significant in demonstrating elevated self-certainty and a positive association between self-certainty and attenuated delusional symptoms in individuals with ARMS.
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