Brief Communication

The Beck Cognitive Insight Scale in Outpatients WithPsychotic Disorders: Further Evidence From aFrench-Speaking Sample

Jérôme Favrod, RN, CNS1; Grégoire Zimmermann, PhD2; Stéphane Raffard, MSc3;

Valentino Pomini, PhD4; Yasser Khazaal, MD5

Key Words: schizophrenia, psychosis, psychometric, assessment, confirmatory factoranalysis, insight

The Canadian Journal of Psychiatry, Vol 53, No 11, November 2008 � 783

Objective: The Beck Cognitive Insight Scale (BCIS) evaluates patients’ self-report of their

ability to detect and correct misinterpretation. Our study aims to confirm the factor

structure and the convergent validity of the original scale in a French-speaking

environment.

Method: Outpatients (n = 158) suffering from schizophrenia or schizoaffective disorders

fulfilled the BCIS. The 51 patients in Montpellier were equally assessed with the Positive

and Negative Syndrome Scale (PANSS) by a psychiatrist who was blind of the BCIS

scores.

Results: The fit indices of the confirmatory factor analysis validated the 2-factor solution

reported by the developers of the scale with inpatients, and in another study with

middle-aged and older outpatients. The BCIS composite index was significantly negatively

correlated with the clinical insight item of the PANSS.

Conclusions: The French translation of the BCIS appears to have acceptable psychometric

proprieties and gives additional support to the scale, as well as cross-cultural validity for its

use with outpatients suffering from schizophrenia or schizoaffective disorders. The

correlation between clinical and composite index of cognitive insight underlines the

multidimensional nature of clinical insight. Cognitive insight does not recover clinical

insight but is a potential target for developing psychological treatments that will improve

clinical insight.

Can J Psychiatry 2008;53(11):783–787

Clinical Implications

� The BCIS is a quick self-assessment of cognitive insight.

� The factor structure of the BCIS is confirmed with an outpatient French-speaking samplesuffering from schizophrenia.

� The study provides additional validity to BCIS with outpatients suffering from schizophreniaor schizoaffective disorders.

Limitations

� Clinical symptoms have been assessed with the PANSS by an independent psychiatrist foronly one-third of the total sample.

� Convergent validity could have been measured with a more precise scale than the livingarrangement or with the insight item of the PANSS.

Acentral cognitive problem in patients with psychosis

exists in the way they interpret the distortion of their

experiences. This deficit in the ability to monitor one’s own

perception and thoughts is associated with a lack of insight.

Beck et al1 have defined cognitive insight as the ability to

detect and correct misinterpretations. They developed the

BCIS to evaluate patients’ report of their objectivity regarding

their delusional thinking, their perspective about errors, their

capacity for reattribution for erroneous explanation, and their

receptiveness to corrective information from other people.

BCIS is a 15-item self-report scale measuring 2 constructs: the

ability to acknowledge fallibility, labelled self-reflectiveness;

and certainty about belief and judgments, labelled self-

certainty. A composite score reflecting cognitive insight is

calculated by subtracting the self-certainty scale from the

self-reflectiveness scale. The BCIS has demonstrated good

convergent, discriminant, and construct validity with inpa-

tients. The composite score differentiated inpatients with

schizophrenia, schizoaffective disorders, or depression with

psychotic symptoms from inpatients diagnosed with depres-

sion without psychotic symptoms. Pedrelli et al2 ran a CFA

with middle-aged and older outpatients that supported the

2-factor structure reported before. A study3 comparing psy-

chotic patients, with and without delusion, with control

subjects indicates that people with psychotic disorders had

impaired cognitive insight relative to control subjects. How-

ever, the 2 groups of patients demonstrated different patterns.

Patients with delusion were overly confident in their judg-

ment, compared with control subjects or those without delu-

s ion. Pat ients without delusion revealed lower

self-reflectiveness than control subjects or patients with delu-

sions. Finally, the BCIS has been used as a process variable in

a randomized controlled trial of social skills training, com-

pared with treatment as usual. The BCIS composite score was

significantly improved for the experimental group, compared

with the control group.4

Our study aims to confirm the factor structure and the conver-

gent validity of the original scale in a French-speaking envi-

ronment with outpatients suffering from schizophrenia and

schizoaffective disorders. There is no other translation and

cross-cultural validation of the scale reported in French.

Methods

Participants

Inclusion criteria were: outpatients aged between 17 and 60

years, diagnoses of schizophrenia or schizoaffective disor-

ders according to the Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition,5 fluency in French, and no

organic syndrome. Participants were recruited in different

community-based mental health services or nursing homes in

Switzerland, France, and Belgium associated to the Commu-

nity Psychiatry Service of Lausanne (n = 107) and from the

outpatient clinic of the University Hospital in Montpellier

(n = 51). The final sample consisted of 158 outpatients, with

132 meeting criteria for schizophrenia, and 26 meeting crite-

ria for schizoaffective disorder. The mean age was 34.8 years

(SD 9.2); 106 were men (67.1%), and 52 were female

(32.9%). Thirty-four patients live in nursing homes and 124

live independently in their own apartment or with their

family.

Procedure

This scale validation study is part of a larger research project

that has been approved by the university hospital centre’s

ethical committee. All participants consented to participate in

the study. Participants completed the BCIS in pretest assess-

ment of a cognitive-behavioural therapy for delusion trial.

The 51 patients in Montpellier were equally assessed with the

PANSS by a psychiatrist who was blind of the BCIS scores.

Measures

Beck Cognitive Insight Scale. The BCIS is a 15-item

self-report measure designed to assess cognitive insight in

patients with psychoses. Participants 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 comprised 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 cognitive insight. One author

translated the scale and 2 authors independently checked the

translation. Corrections were agreed upon and the translation

was accepted by the original author.

Positive and Negative Syndrome Scale. The PANSS is a

30-item scale developed to assess symptom severity in

schizophrenia.6 The PANSS was designed to include 3

subscales for different types of symptoms: positive symp-

toms, negative symptoms, and general psychopathology.

Higher scores indicate higher symptoms severity and

impairment.

� La Revue canadienne de psychiatrie, vol 53, no 11, novembre 2008784

Brief Communication

Abbreviations used in this article

AGFI Adjusted Goodness-of-Fit Index

BCIS Beck Cognitive Insight Scale

CFA confirmatory factor analysis

CFI Comparative Fit Index

GFI Goodness-of-Fit Index

NNFI Non-Normed Fit Index

PANSS Positive and Negative Syndrome Scale

RMSEA root mean square error of approximation

Data Analysis

The factor structure of the French version of the BCIS was

examined using CFA in Amos 4.0.7 We evaluated the 2-factor

model reported by previous studies1,2 using multiple indices

of model fit including the ratio of chi-square to degrees of

freedom, the GFI, the AGFI, the CFI, the NNFI, and the

RMSEA. Because the chi-square statistic is sensitive to effect

size, some researchers have recommended the use of the

chi-square and degrees of freedom ratio, suggesting that ratios

between 2.0 and 1.0 are indicative of an acceptable fit between

the model and the sample data.7 Traditionally, GFI, CFI, and

NNFI values greater than or equal to 0.90, and AGFI values

greater than 0.80 have been accepted as indicators of good

fit.8,9 Finally, recent work by Hu and Bentler10 have shown

that RMSEA is one of the most informative criteria available

and recommend a value close to 0.06. Concerning the power

issue in CFA, one rule of thumb reported by Garson11 based

on literature review “is that sample size should be at least 50

more than 8 times the number of variables in the model.”

Although, GFI indices could be overestimated with small

sample sizes (less than 200), RMSEA and CFI are less

affected by sample size than others.12

Results

Factor Analysis

Results from CFA indicate that the original 2-factor solution

shows a good fit (Table 1). Most of GFI statistics are good

(chi-square and degrees of freedom, GFI, AGFI, and

RMSEA); however, 2 of them (CFI, NNFI) are slightly lower

than the cut off recently recommended and could be consid-

ered as acceptable.

Subscale Internal Consistencies

The alpha coefficients of the self-reflectiveness and self-

certainty subscales for the 158 patients were, 0.73 and 0.62,

respectively, which were higher than those found by Beck

et al1 or Pedrelli et al,2 but lower than the alpha found by Mak

and Wu.13

Convergent Validity

To estimate the convergent validities of the BCIS self-

reflectiveness and self-certainty subscales along with the

composite index, these subscales and index were correlated

with the item G12 of the PANSS for 51 patients. Item G12

rates impaired insight and judgment from 1 (no impairment)

to 7 (severe impairment). BCIS composite index was

significantly negatively correlated with item G12 of the

PANSS (r = –0.42, P = 0.002). Self-reflectiveness subscale

was negatively correlated with item G12 (r = –0.37, P =

0.007), and self-certainty subscale was positively correlated

with G12 (r = 0.29, P = 0.04). Other correlations between

PANSS positive, negative, total, or general psychopathology

and BCIS scales were low and not significant. The magnitude

of these correlations is medium according to Cohen.14

Patients living in nursing homes were compared with patients

living independently on the different scales of the BCIS. As

shown in Table 2, patients from nursing homes scored signif-

icantly lower on the self-reflectiveness scale and the compos-

ite score and significantly higher on the self-certainty scale

than patients living independently.

Discussion

The first aim of our study was to confirm the factor structure

of the BCIS with an outpatient French-speaking sample suf-

fering from schizophrenia. The fit indices of the CFA con-

firmed the validity of the 2-factor solution reported by the

developers of the scale with inpatients1 and next by Pedrelli

et al2 with middle-aged and older outpatients. Our results

provided further evidence that the BCIS has sufficient con-

struct validity in outpatient samples and that the BCIS is

appropriate to outpatients with schizophrenia or

schizoaffective disorders. Further, this study gave first evi-

dence of cross-cultural validity of the cognitive insight con-

struct in a French-speaking context and supported the use of

BCIS in cross-cultural research.

A second goal was to assess the external validity of the BCIS

with item G12 of the PANSS. The different scales of the

BCIS were moderately correlated with the items G12 of the

PANSS in the predicted directions. The fact that a clinical

judgment (item G12) is correlated with the subscales of a

self-report instrument is interesting and gives external sup-

port to the scale. However the self-reflectiveness scale is

better correlated than the self-certainty scale. The PANSS

G12 item assesses acknowledgement of illness and need for

treatment. Self-certainty has been associated with active

delusion.3 In the sample from Montpellier, there is no associ-

ation between BCIS subscales and the positive symptoms

The Beck Cognitive Insight Scale in Outpatients With Psychotic Disorders: Further Evidence From a French-Speaking Sample

The Canadian Journal of Psychiatry, Vol 53, No 11, November 2008 � 785

Table 1 Fit indices for the 2-factor model of the BCIS

Study Sample mean age, years n �2 /df GFI AGFI RMSEA CFI NNFI

Pedrelli et al2

53 164 — — — 0.025 0.96 0.96

Favrod et al 35 158 1.38 0.91 0.88 0.049 0.89 0.87

scale of the PANSS. Higher correlation between PANSS G12

with the composite score of the BCIS underlines the multidi-

mensional nature of clinical insight. Cognitive insight does

not recover clinical insight but is a potential target for devel-

oping psychological treatments that will improve clinical

insight. This sample is composed of stabilized outpatients.

The BCIS composite score distinguishes outpatients living in

nursing homes from outpatients living more independently,

adding some external validity to the scale by suggesting that

patients living in an apartment have a better composite cogni-

tive insight than a patient living in a more sheltered

environment.

ConclusionsIn summary, the French translation of the BCIS appears to

have acceptable psychometric proprieties and gives addi-

tional support to the scale, as well as cross-cultural validity for

its use with patients suffering from schizophrenia and

schizoaffective disorders.

Funding and Support

No competing interests.

Acknowledgements

We thank all patients who participated in the study. We thankDr Delphine Capdevielle, who kindly participated in datacollection, and Ms Delphine Sreekumar, who assisted with theEnglish correction of the manuscript.

References

1. Beck AT, Baruch E, Balter JM, et al. A new instrument for measuring insight:

the Beck Cognitive Insight Scale. Schizophr Res. 2004;68:319–329.

2. Pedrelli P, McQuaid JR, Granholm E, et al. Measuring cognitive insight in

middle-aged and older patients with psychotic disorders. Schizophr Res.

2004;71:297–305.

3. Warman DM, Lysaker PH, Martin JM. Cognitive insight and psychotic

disorder: the impact of active delusions. Schizophr Res. 2007;90:325–333.

4. Granholm E, McQuaid JR, McClure FS, et al. A randomized, controlled trial of

cognitive behavioral social skills training for middle-aged and older outpatients

with chronic schizophrenia. Am J Psychiatry. 2005;162:520 –529.

5. American Psychiatric Association. Diagnostic and statistical manual of mental

disorders. 4th ed. Washington (DC): APA; 1994.

6. Kay SR, Opler LA, Lindenmayer JP. Reliability and validity of the positive and

negative syndrome scale for schizophrenics. Psychiatry Res. 1988;23:99–110.

7. Arbuckle JL, Wothke W. Amos 4.0 user’s guide. Chicago (IL): SmallWaters

Corporation; 1999.

8. Cole DA. Utility of confirmatory factor analysis in test validation research.

J Consult Clin Psychol. 1987;55:584 –594.

9. Bentler PM, Bonnett DG. Significance tests and goodness of fit in the analysis

of covariance structures. Psychol Bull. 1980;88:588 –606.

10. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure

analysis: conventional criteria versus new alternatives. Structural Equation

Modeling. 1999;6:1–55.

11. Garson GD. Structural equation modeling. Statnotes: topics in multivariate

analysis [Internet]. Raleigh (NC): North Carolina State University; 2007.

Available from: http://www2.chass.ncsu.edu/garson/pa765/statnote.htm.

12. Fan X, Thompson B, Wang L. Effects of sample size, estimation method, and

model specification on structural equation modeling fit indexes. Structural

Equation Modeling. 1999;6:56–83.

13. Mak WW, Wu CF. Cognitive insight and causal attribution in the development

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Manuscript received October 2007, revised, and accepted March 2008.1Clinical Nurse Specialist, Community Psychiatry Service, Department ofPsychiatry, University Hospital Centre and University of Lausanne,Lausanne, Switzerland.2Senior Researcher, Institute for Psychotherapy, Department ofPsychiatry, University Hospital Centre and University of Lausanne,Lausanne, Switzerland; Junior Assistant Professor Department ofPsychology, University of Fribourg, Fribourg, Switzerland.3Clinical Psychologist, Department of Adult Psychiatry UniversityHospital, INSERM U-888, Montpellier, France.4Tenured Senior Lecturer and Researcher, Community Psychiatry Service,Department of Psychiatry, University Hospital Centre and University ofLausanne, Lausanne, Switzerland.5Tenured Senior Lecturer and Researcher, Department of Psychiatry,University Hospital of Geneva, Geneva, Switzerland.Address for correspondence: J Favrod, Community Psychiatry Service,

Department of Psychiatry, Les C�dres—Site de Cery, CH-1008 Prilly,Switzerland; Jerome.Favrod@chuv.ch

� La Revue canadienne de psychiatrie, vol 53, no 11, novembre 2008786

Brief Communication

Table 2 Comparisons on BCIS subscales and residential status

Nursing home

(n = 34)

Mean (SD)

Living independently

(n = 124)

Mean (SD) t df 2-tailed P

Self-reflectiveness 12.4 (5.1) 14.8 (5.7) 2.2 156 0.03

Self-certainty 10.2 (3.8) 8.6 (3.9) –2.1 156 0.04

Composite scorea

2.2 (5.6) 6.1 (7.7) 3.3 70.572 0.001b

aEqual variances not assumed

bP < 0.05 adjusted for multiple comparisons, �/3 = 0.01

The Beck Cognitive Insight Scale in Outpatients With Psychotic Disorders: Further Evidence From a French-Speaking Sample

The Canadian Journal of Psychiatry, Vol 53, No 11, November 2008 � 787

Résumé : L’échelle d’intuition cognitive de Beck chez des patients externes souffrant

de troubles psychotiques : d’autres données probantes d’un échantillon francophone

Objectif : L’échelle d’intuition cognitive de Beck (BCIS) évalue les déclarations des patients sur

leur capacité de détecter et de corriger la fausse interprétation. La présente étude vise à confirmer la

structure des facteurs et la validité convergente de l’échelle originale dans un milieu francophone.

Méthode : Des patients externes (n = 158) souffrant de schizophrénie ou de troubles

schizo-affectifs ont rempli la BCIS. Les 51 patients de Montpellier ont également été évalués au

moyen de l’échelle des symptômes positifs et négatifs (PANSS) par un psychiatre, à l’insu des

scores à la BCIS.

Résultats : Les indices d’ajustement de l’analyse factorielle confirmatoire validaient la solution

bifactorielle rapportée par les constructeurs de l’échelle avec des patients hospitalisés, puis dans une

autre étude avec des patients externes d’âge moyen et plus âgés. L’indice composé de la BCIS était

significativement négativement corrélé avec l’item d’intuition clinique de la PANSS.

Conclusions : La traduction française de la BCIS semble posséder des propriétés psychométriques

acceptables et offre un appui additionnel à l’échelle, ainsi qu’une validité interculturelle à son

utilisation auprès de patients externes souffrant de schizophrénie ou de troubles schizo-affectifs. La

corrélation entre l’indice clinique et l’indice composé de l’intuition cognitive souligne la nature

multidimensionnelle de l’intuition clinique. L’intuition cognitive ne rétablit pas l’intuition clinique,

mais elle constitue une cible potentielle pour mettre au point des traitements psychologiques qui

amélioreront l’intuition clinique. multidimensionnelle de l’insight clinique. L’insight cognitif ne

recouvre pas l’insight clinique mais est une cible potentielle pour développer des traitements qui

cherchent � améliorer la conscience du trouble.