SCHRES-07085; No of Pages 2

Schizophrenia Research xxx (2016) xxxxxx

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Schizophrenia Research

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Letter to the Editor

Is cognitive insight relevant to functional capacity in schizophrenia?
Dear Editors,
The UCSD Performance-based Skills Assessment (UPSA) was devel-
oped to assess functional skills in people with severe mental illness by
asking them to perform tasks that mimic real, everyday life situations
(Patterson et al., 2001). It includes the domains of household chores,
communication, nance, transportation, and planning recreational ac-
tivities; a brief version comprises the communication and nance do-
mains (Mausbach et al., 2007). Conceptually, it measures functional
capacity, and the accumulating literature seems to place it as an inter-
mediary between cognition (including social cognition) and real-
world functional outcomes (Bowie et al., 2008; Kalache et al., 2015).
Most models however do not include level of insight, even though it
has strong associations with both clinical and functional outcomes
(Lysaker et al., 2013). One study by Roseman et al. (2008) has found
that severity of negative symptoms were strongly and inversely corre-
lated with UPSA performance, but that when the effect of negative
symptoms was partialled out, insight into illness was also a signicant
predictor of functional capacity. Other types of insight may also play a
role in functional capacity, for example cognitive insight measures
such as the Beck Cognitive Insight Scale (BCIS; (Beck et al., 2004)).
This type of insight is quite different from insight into illness and may
be conceptualized as a form of meta-cognition. Indeed, it consists of 2
sub-scales: self-reectiveness, which is the ability to reect on one's
own thoughts and experiences, and self-certainty, which is the willing-
ness to admit fallibility (Beck et al., 2004). Since the UPSA is closely cor-
related with cognitive performance (Bowie et al., 2008; Green et al.,
2008), the meta-cognitive side of insight may have an important rela-
tionship with UPSA performance. We therefore sought to measure,
using a sample of schizophrenia patients, the correlation between
their performances on the BCIS and the UPSA-Brief hypothesizing that
these measures would be positively correlated.
Thirty patients (17 men, 13 women) with a diagnosis of schizophre-
nia spectrum disorder were recruited as part of a study on cognitive re-
mediation described elsewhere (Benoit et al., 2016). On average, the
sample was 34.8 years old (SD = 9.04), had 11.3 years of education
(SD = 1.95), had an estimated full-scale IQ of 91.43 (SD = 11.11).
Both the BCIS and UPSA-Brief were administered as part of an extensive
clinical and cognitive evaluation prior to taking part in the cognitive re-
mediation therapy.
Cognitive insight was measured using the 3 scores of the BCIS: self-
reectiveness, self-certainty and composite (self-reectiveness self-
certainty) (Beck et al., 2004). The range of UPSA-Brief scores is between
0 and 100, 100 being the best result possible. The correlations were
computed using SPSS 21.0.
Bivariate correlations showed that the self-reectiveness score was
signicantly correlated with the UPSA-Brief score (r = 0.413, p =
0.023) but not the self-certainty score (r = 0.095, p = 0.618). As for
the composite score, the correlation in the same direction could be
considered a statistical trend (r = 0.307, p = 0.099). Fig. 1 illustrates
the statistically signicant correlation.
It seems that patients who scored higher in their ability to self-
reect also had better functional capacity as measured with the UPSA-
Brief. Furthermore, a similar association was discernable with the over-
all cognitive insight of patients (BCIS composite score); its relationship
to the UPSA-Brief shows a decent correlation coefcient but a lack of
statistical power. Self-certainty however, is less likely to play a role in
functional capacity according to our ndings. We did not have a specic
hypothesis regarding a differentiation of the subscales, but since they
are not two extremes of a shared continuum (Beck et al., 2004), they
are likely to have different relationships to other psychological or cogni-
tive variables.
Our ndings are in line with our hypothesis and primarily suggest
that self-reectiveness might be important for functional capacity, how-
ever we cannot infer directionality from the correlational analysis. Fur-
ther research should try to elucidate whether having high self-
reectiveness could be benecial for functional capacity, given the
established impact of good insight on functional outcome (Lysaker
et al., 2013). It could also be examined whether high self-
reectiveness could in some way help acquiring and performing the
daily activities being tested in the UPSA-Brief in treatment studies.
Our results add another dimension to the previous ndings that insight
into illness, as measured by the PANSS insight and judgement item, was
a predictor of UPSA performance (Roseman et al., 2008). The correlation
between self-reectiveness and the UPSA-Brief suggests that in addition
to insight into severity of illness, insight into one's own thoughts and ex-
periences may have an important role. It has been observed recently
that difculties in self-assessment of cognitive and real-world function-
ing better predict real-world functioning than cognitive performance or
the UPSA-Brief (Gould et al., 2015). Given our result, difculties in cog-
nitive insight may have been behind these difculties in self-
assessment, and therefore may have additional information to provide
regarding real-world outcome. Furthermore, this current work adds to
the exploration of variables (for example self-efcacy; Cardenas et al.,
Fig. 1. Correlation between self-reectiveness and UPSA-Brief scores.

http://dx.doi.org/10.1016/j.schres.2016.12.009
0920-9964/ 2016 Published by Elsevier B.V.

Please cite this article as: Benoit, A., et al., , Schizophr. Res. (2016), http://dx.doi.org/10.1016/j.schres.2016.12.009
2 Letter to the Editor
2013) that may relate to functional capacity and ultimately real-world
outcome.
Even though a small sample size was available for this analysis, its
results indicate that cognitive insight, particularly self-reectiveness,
could be added to statistical models seeking to explain and predict func-
tional capacity. In such analyses, it would be possible to determine
whether self-reectiveness can contribute uniquely to functional out-
comes when it is included among other variables such as cognition. If
a pathway indeed exists through which self-reectiveness benets
functional capacity, it is undoubtedly complex and could be further in-
vestigated as we push towards improving functional outcomes for
patients.
Author disclosure
Dr. Martin Lepage has received honoraria from Janssen-Ortho, Roche
& Lilly and has research grants from BMS, Otsuka/Lundbeck Alliance,
and Janssen-Ortho. Dr. Christopher Bowie has received honoraria from
Boehringer Ingelheim, Lundbeck, Otsuka, and Abbie; research funding
from Pzer Canada, Takeda, and Lundbeck; waivers of license fees
from Scientic Brain Training Pro. Audrey Benoit does not have any po-
tential conict of interest to disclose.
Contributors
Authors Audrey Benoit and Martin Lepage designed the study and wrote the protocol.
Author Christopher Bowie revised the protocol and provided feedback. Author Audrey
Benoit managed the literature searches, statistical analyses and wrote the rst draft of
the manuscript. Authors Martin Lepage and Christopher Bowie revised and corrected
the rst draft. All authors contributed to and have approved the nal manuscript.
Acknowledgments
The authors would like to thank the staff at the DMHUI's Psychosis
Program for their precious help in recruiting patients. This project was
funded by the James McGill Professorship awarded to Dr. Martin Lepage.
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Audrey Benoit
Prevention and Early Intervention Program for Psychoses (PEPP Montre-
al), Douglas Mental Health University Institute, 6875 LaSalle Boulevard,
Montreal, Quebec H4H 1R3, Canada
UQAM, Psychology Department, C.P. 8888 Succursale Centre-ville, Mon-
treal, Quebec H3C 3P8, Canada
E-mail address: audrey.benoit@douglas.mcgill.ca
Christopher R. Bowie
Department of Psychology, Queen's University, 62 Arch Street, Kingston, ON
K7L 3N6, Canada
Centre for Addiction and Mental Health, 250 College St, Toronto, ON M5T
1R8, Canada
E-mail address: christopher.bowie@queensu.ca
Martin Lepage
Prevention and Early Intervention Program for Psychoses (PEPP Montre-
al), Douglas Mental Health University Institute, 6875 LaSalle Boulevard,
Montreal, Quebec H4H 1R3, Canada
UQAM, Psychology Department, C.P. 8888 Succursale Centre-ville, Mon-
treal, Quebec H3C 3P8, Canada
Department of Psychiatry, McGill University, 1033 Pine Avenue West,
Montreal, Quebec H3A 1A1, Canada
Corresponding author at: Douglas Mental Health University Institute,
Frank B. Common Pavilion, F-1134, 3715 LaSalle Blvd., Montreal, Quebec
H4H 1R3, Canada.
E-mail address: martin.lepage@mcgill.ca
2 October 2016
Available online xxxx