Schizophrenia Research 144 (2013) 118–121

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Schizophrenia Research
journal homepage: www.elsevier.com/locate/schres

Cognitive insight as an indicator of competence to consent to treatment

in schizophrenia
Stéphane Raffard a, b,⁎, 1, Guillaume Fond b, c,⁎⁎, 1, Marie Brittner b, c, Catherine Bortolon a,
Alexandra Macgregor b, c, Jean-Phillipe Boulenger b, c,
Marie-Christine Gely-Nargeot a, Delphine Capdevielle b, c
a
Laboratory Epsylon, EA 4556, Montpellier, France
b
University Department of Adult Psychiatry, CHRU Montpellier, Montpellier, France
c
INSERM U-1061, Montpellier, France

a r t i c l e i n f o a b s t r a c t

Article history: The processes underlying the ability to make decisions about recommended treatments remain poorly understood
Received 8 October 2012 in schizophrenia. The aim of this study was to explore the relationships between capacity to consent to medication
Received in revised form 7 December 2012 and cognitive biases in 60 schizophrenia patients. Main measures included the MacArthur Competence Assessment
Accepted 19 December 2012
tool for Treatment (MacCAT-T) and the Beck Cognitive Insight Scale (BCIS). After Bonferroni's correction for multiple
Available online 10 January 2013
correlations, the Self-Reflectiveness dimension of the BCIS was significantly associated with the dimension “Reason-
Keywords:
ing” of the MacCAT-T. Cognitive therapy, by enhancing patients' Self-Reflectiveness and considering alternative
Schizophrenia explanations, could lead to better capacity to consent to treatment in schizophrenia.
Decisional capacity © 2012 Elsevier B.V. All rights reserved.
Cognitive insight

1. Introduction
Impaired decision-making ability has been repeatedly observed in
schizophrenia patients. Using both experimental tasks, such as the
Iowa Gambling Task (Sevy et al., 2007; Fond et al., in press) and clinical
tools such as the MacArthur Competence Assessment Tool for Clinical
Research (MacCAT-CR) or for Treatment (MacCAT-T) (Stroup et al.,
2011), studies have repeatedly found altered decision-making capaci-
ties in schizophrenia patients. Ability to make treatment decision has
been proposed as one of the most impaired decision-making capacity
in schizophrenia (Appelbaum and Grisso, 1988). Using instruments,
like the MacCAT-T, which is considered the standard measure for
assessment of competence (Cairns et al., 2005), it was found that 10%
to 52% of people with schizophrenia and 0% to 18% of non-psychiatric
control subjects were classified as being impaired in decisional capacity
for treatment (for review see Jeste et al., 2006). Despite substantial
research on overall decision-making capacity levels in schizophrenia,
⁎ Correspondence to: S. Raffard, Laboratory Epsylon, EA 4556, Montpellier Univer-
sity, 39 Avenue Charles Flahault 34295 Montpellier Cedex 5, France. Tel.: + 33 4 67 33
97 02; fax: + 33 4 67 33 96 60.
⁎⁎ Correspondence to: G. Fond, Hospital La Colombière, University Department of Adult
Psychiatry, CHU Montpellier, 39 Avenue Charles Flahault 34295 Montpellier Cedex 5,
France. Tel.: +33 4 67 33 97 02; fax: +33 4 67 33 96 60.
E-mail addresses: s-raffard@chu-montpellier.fr (S. Raffard),
guillaume.fond@gmail.com (G. Fond).
1
Both authors have equally contributed to the manuscript and split first authorship.
the factors that lead individuals to make errors when making decisions
remain poorly understood. Concern about the capacity of individuals
with schizophrenia to consent to treatment has largely focused on im-
pairment due to cognition (Palmer and Jeste, 2006, Raymont et al.,
2004) or psychotic symptoms, particularly negative symptoms (Howe
et al., 2005; Capdevielle et al., 2009). Among other clinical factors un-
derlying impaired ability to make decisions, poor insight has been
found to be highly associated with incompetence in psychotic patients
(for review Ruissen et al., 2012).
Recently, Beck et al. (2004) proposed an important extension of the
classical insight concept, which they term “clinical insight” with the de-
scription of “cognitive insight” defined as an individual's current capac-
ity to reflect upon their thinking problems and to recognize their errors
and correct them. Factorial analyses revealed two distinct dimensions,
Self-Reflectiveness (SR) and Self-Certainty (SC). The first one reflects
introspection and willingness to observe one's own mental produc-
tions and to consider alternative explanations while Self-Certainty
(SC) measures mental flexibility or overconfidence in one's beliefs
(Beck et al., 2004). Although the literature showed that cognitive insight
consistently correlates with clinical insight, there is evidence that these
two constructs are “complementary” rather than “overlapping” (Riggs
et al., 2012).
Therefore, this investigation aims to test 1) whether cognitive insight
dimensions are likely to affect competence to consent to pharmacological
treatment 2) the association between competence to consent to treat-
ment, cognitive insight and clinical variables compared with the existing
literature.

0920-9964/$ – see front matter © 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.schres.2012.12.011
 S. Raffard et al. / Schizophrenia Research 144 (2013) 118–121 119

2. Methods 2.4. Cognitive insight

2.1. Study population
Sixty outpatients with schizophrenia were recruited from the
University Department of Adult Psychiatry in Montpellier and com-
pleted this study (see Table 1 for description of the population). All
patients were treated with antipsychotic treatment that had not
been changed for 1 month. Exclusion criteria were: (a) known neuro-
logical disease, (b) developmental disability or (c) substance abuse in
the past month. No participants had received any Cognitive Behavioral
or Psycho-educational group. Written informed consent was obtained
from all participants.
The Beck Cognitive Insight Scale (BCIS) (Beck et al., 2004; Favrod
et al., 2008 for the French version) is a 15-item self-report measure
designed to assess cognitive insight in patients with psychosis. Partic-
ipants rate the extent to which they agree with statements on a scale
from 0 (do not agree at all) to 3 (agree completely). The BCIS is com-
prised of 2 subscales, Self-Reflectiveness (9 items) and Self-Certainty
(6 items). A composite Reflectiveness–Certainty Index score is obtained
by subtracting the score of the Self-Certainty subscale from the score of
the Self-Reflectiveness subscale and is considered a measure of cogni-
tive insight.
2.5. Clinical variables

2.2. Process Severity of schizophrenia symptoms was evaluated with the

Diagnosis was established using the Patient Edition of the Struc-
tured Clinical Interview for DSM-IV procedures (First et al., 1997)
by two independent psychiatrists (G.F and D.C). Participants were
tested individually in two sessions, the first session consisting of a
psychopathological assessment, conducted by a fully trained Clinical
Psychologist (S.R.) and a second session, completed one or two days
following the first, involving the administration of the MacCAT-T
and the BCIS by fully trained psychiatrists (G.F and M.B).
2.3. Capacity to consent
The MacCAT-T (Grisso and Appelbaum, 1998) was used to evaluate
the four central areas that determinate the competence to consent to
treatment: the patient's understanding of the disorder and treatment
related information (Understanding), rated from 0 to 6; appreciation
of the significance of that information for the patient, in particular the
benefits and risks of treatment (Appreciation) rated from 0 to 4; the
reasoning ability of the patient to compare his/her prescribed treatment
with an alternative treatment (and the impact of these treatments on
their everyday life) (Reasoning) rated from 0 to 8; and ability of the pa-
tient to express a choice between his/her recommended treatment and
an alternative treatment (Expressing a choice) rated from 0 to 2. A high
standard of inter-rater agreement was obtained (all Kappa above 0.80
for all four subscales Understanding, Appreciation, Reasoning, and Ex-
pressing a choice). During administration of the MacCAT-T, the patients
were evaluated for the principal antipsychotic medication prescribed
for their disorder (according to the prescribing psychiatrist). They had
to discuss, to reason and to express a choice between their current
pharmacological treatment and other or not treatment.
PANSS (Kay et al., 1987). Current self-reported emotional status was
assessed using the Beck Depression Inventory-II (BDI-II) (Beck et al.,
1998) and the Spielberger State Trait Anxiety (Spielberger, 1983).
2.6. Statistical analyses
Data were analyzed with SPSS® for Windows. Means and standard
deviations were calculated for demographic and clinical variables as
well as for cognitive insight and capacity to consent to treatment. Pearson
correlations with Bonferroni's correction for multiple correlations were
conducted. Preliminary analyses were performed to investigate possible
confounding factors shared by BCIS and MacCAT-T. Confounding factors
were controlled using Partial correlations. Ultimately, main analyses
aimed to explore the correlations between cognitive insight and capacity
to consent treatment.
3. Results
3.1. Preliminary analyses (Tables 2 and 3)
As illustrated in Table 2, Pearson correlations showed that only a
better understanding of the disorder and treatment related informa-
tion (dimension “Understanding” of the MacCAT-T) was significantly
correlated with higher level of education (r = .40) and negatively
correlated with PANSS Total Score (r= −.56), PANSS Negative Symp-
toms (r= −.51), and PANSS General Psychopathology (r= −.51),
after Bonferroni corrections.
Regarding to the BCIS, no dimension was significantly correlated
to the demographic or clinical variables after Bonferroni's corrections
(Table 3). In sum, these results indicated no confounding factor be-
tween MacCAT-T and BCIS.

3.2. Main analysis: correlation between MacCAT-T's and BCIS's

dimensions (Table 4)
Table 1
Demographic and clinical characteristics of 60 patients with schizophrenia.
After Bonferroni's corrections, only Self-Reflectiveness was signifi-
M SD Min Max cantly correlated with the dimension “Reasoning” of the MacCAT-T (r=
Age 36.82 11.14 20 60 .43). Before Bonferroni corrections, education was found to be correlated
% of males 68.3 to all MacCAT-T's and BCIS's dimensions. Therefore, partial correlations
Education (years) 10.77 2.42 7 18 were also performed in order to control for education, once Bonferroni
Age at onset 23.00 5.00 16 39
Duration of illness (years) 12.98 10.55 1 36
corrections can be sometimes too conservative. Results confirmed that
Number of hospitalizations 5.52 4.75 0 20 only Self-Reflectiveness was significantly correlated with the dimension
BDI-II total 16.05 11.23 0 50 “Reasoning” of the MacCAT-T (r=.36, p=.005).
STAI trait anxiety 41.25 11.95 20 71
SATI state anxiety 40.05 13.64 20 69
4. Discussion
PANSS Total 76.57 21.17 36 128
PANSS Negative Symptoms 20.52 6.64 7 42
PANSS Positive Symptoms 18.02 6.91 6 39 As mental illness does not invariably impair decision-making capaci-
PANSS General Psychopathology 38.10 11.72 18 76 ties, to determine which cognitive processes underlie competence to con-
BDI-II: Beck Depression Inventory-II; STAI: State Trait Anxiety Inventory; PANSS: sent to treatment is of major interest from a shared decision-making
Positive and Negative Syndrome Scale; M: Mean; S.D.: Standard Deviation. perspective.
120 S. Raffard et al. / Schizophrenia Research 144 (2013) 118–121

Table 2
Pearson correlations of MacCAT-T with demographic and clinical characteristics (n = 60).

MacCAT-T

Understanding Appreciation Reasoning Expressing a choice

Age −.18 −.16 −.24 −.18

Education (years) .40* .27 .36 .31
Age at onset −.003 −.19 −.22 −.06
Duration of illness (years) −.12 −.09 −.19 −.18
Number of hospitalizations −.05 .11 .09 .04
BDI-II total −.11 .28 .18 .08
STAI trait anxiety −.11 .22 .15 −.04
STAI state anxiety −.01 .36 .27 .14
PANSS total −.56* −.11 −.13 −.23
PANSS negative symptoms −.51* −.19 −.20 −.22
PANSS positive symptoms −.36 −.13 −.19 −.21
PANSS general psychopathology −.51* −.03 −.05 −.18

BDI-II: Beck Depression Inventory-II; STAI: State Trait Anxiety Inventory; PANSS: Positive and Negative Syndrome Scale; MacCAT-T: MacArthur Competence Assessment Tool for
Treatment; *Bonferroni's correction for multiple correlations: pb 0.001.

Firstly, we found correlations between the MacCAT-T and the PANSS we found no other relationships between the two dimensions of the
negative, general psychopathology, and total scores but not with posi- BCIS and the other subscales of the MacCAT-T.
tive symptoms contrary to some previous studies (Grisso et al., 1997; Taken together our results suggest that the processes underlying abil-
Howe et al., 2005) notably because in our study we used Bonferroni cor- ities for making treatment decisions are multiple and complex involving
rections to correct type I errors. The strong correlation found in our educational level, cognition, psychotic symptoms, and metacognitive/
study between “Understanding” and PANSS General psychopathology cognitive distortions and should be assessed accordingly.
is in accordance with the results of Howe et al. (2005). In their study, This investigation had several limitations. The first limitation is that
the authors highlighted that competence to give informed consent the data used for this analysis are cross-sectional and so do not allow us
was associated with symptoms rather than diagnosis. They evaluated to evaluate insight and capacity to consent over time. A second limita-
the Pearson correlation coefficients between MacCAT scores and symp- tion is the use of the Bonferroni correction usually employed to correct
toms scores. They found a strong correlation between item unusual type I errors and considered to be particularly conservative, might have
thought content (item G9 PANSS), poor attention (item G11 PANSS), increased the risk of rejection of true correlations (Type II errors;
item tension (G4 PANSS) and uncooperativeness (G8 PANSS). These Vialatte and Cichocki, 2008) between the BCIS scores and the clinical
items are included in three dimensions (positive, cognitive and excite- and demographical variables. Finally, as in our study we compared abil-
ment) strongly associated with the capacity to consent, and more par- ity to make decision between current pharmacological treatment and
ticularly with the understanding dimension. other or not pharmacological treatment and as competence is consid-
Interestingly and in contrast with previous studies despite mixed ered as contextual (Ruissen et al., 2012), we cannot strictly generalize
results (see Riggs et al., 2012 for a review), no BCIS dimension was our results to the ability to make decision between current prescribed
significantly correlated with demographic and clinical variables after treatment and another treatment (other pharmacological classes or
Bonferroni's corrections. psychotherapeutic treatment).
Secondly, after controlling for confounding variables, the results
indicated that the dimension “Self-Reflectiveness” of the BCIS was asso-
ciated with the “Reasoning” dimension of the MacCAT-T, that is, higher 4.1. Perspectives
levels of objectivity, reflectiveness and openness to others' feedback
was related to higher ability to compare the prescribed treatment From a clinical perspective, few studies to date have focused on
with an alternative one, to mention the consequences of treatment al- improving capacity to consent to treatment in schizophrenia. En-
ternatives, and to evaluate their impact on everyday life. In contrast, hanced consent procedures consisting of adding more structure and
reviewing important information with patients have shown interest-
ing results in older patients suffering from schizophrenia (Dunn et al.,
2001). Importantly, it has been found that cognitive insight improved
Table 3 over the course of psychological treatment and could be improved by
Pearson correlations of BCIS cognitive insight dimensions with demographic and clin- psychological therapy focusing on hypothetical reasoning (Khazaal et
ical characteristics (n = 60).
al., 2011). In light of our results, enhancing consent procedures by
BCIS — BCIS — adding specific cognitive therapy using cognitive restructuring tech-
Self-Certainty Self-Reflectiveness niques that allow the creation of alternative explanations to distorted
Age .15 −.02 beliefs (Khazaal et al., 2011) could enable people with schizophrenia
Education (years) −.36 .33 to make informed decisions regarding treatment decision.
Age at onset .02 −.13
Duration of illness (years) .21 .03
Number of hospitalizations .17 .26
BDI-II total −.20 .27 Table 4
STAI trait anxiety −.15 .37 Pearson correlations of MacCAT-T with BCIS (n = 60).
STAI state anxiety −.23 .38
BCIS — Self-Certainty BCIS — Self-Reflectiveness
PANSS total −.01 −.05
PANSS negative symptoms .005 −.15 MacCAT-TC understanding .12 .19
PANSS positive symptoms .03 −.08 MacCAT-T appreciation −.20 .33
PANSS general psychopathology −.03 .01 MacCAT-T reasoning −.21 .43*
MacCAT-TCL expressing choice −.11 .18
BDI-II: Beck Depression Inventory-II; STAI: State Trait Anxiety Inventory; PANSS: Posi-
tive and Negative Syndrome Scale; BCIS: Beck Cognitive Insight Scale *Bonferroni's cor- BCIS: Beck Cognitive Insight Scale; MacCAT-T: MacArthur Competence Assessment
rection for multiple correlations: p b 0.002. Tool for Treatment; *Bonferroni's correction for multiple correlations: p b 0.006.
 S. Raffard et al. / Schizophrenia Research 144 (2013) 118–121
Role of funding source
No funding source.
Contributors
Stéphane Raffard, Delphine Capdevielle, Jean-Philippe Boulenger and Marie-Christine
Gely-Nargeot contributed to the study design. Guillaume Fond, Marie Brittner and Marie
Jourdain recruited and assessed the patients. Catherine Bortolon performed the statistical
analysis. Stéphane Raffard, Guillaume Fond and Alexandra Macgregor prepared the man-
uscript, with feedback from the other authors.
Conflict of interest
The authors declare that they have no competing financial or other interests that
might be perceived to influence the results and discussion reported in this paper.
Acknowledgments
We thank Dr. Marie Jourdain (resident, CHU Montpellier) for her contribution for
patients' assessment. We are grateful to all of the patients who contributed to this
study.
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