Jerrold Pollak, PhD

Identify 3 patient groups who are characterized by elevated rates of suicidal behavior and co-occurring cognitive/neuropsychological impairment.

1. Increase familiarity with the indications for psychological/neuropsychological testing of patients with suicidal behavior and suspected or known cognitive/neuropsychological impairment.

2. Enhance an appreciation of a good working knowledge of neurocognitive status in assessment and treatment planning with suicidal patients.

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

ACCREDITATION/CREDIT DESIGNATION/FINANCIAL SUPPORT

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Physicians’ Education Resource®, LLC, and 

. Physicians’ Education Resource®, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

Physicians’ Education Resource®, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This activity is funded entirely by Physicians’ Education Resource®, LLC. No commercial support was received.

This accredited CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this accredited CE activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource®, LLC.

FACULTY, STAFF, AND PLANNERS’ DISCLOSURES AND CONFLICT OF INTEREST (COI) MITIGATION

None of the staff of Physicians’ Education Resource®, LLC, or 

, or the planners or the authors of this educational activity, have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients.

For content-related questions, email us at 

. For questions concerning the accreditation of this CE activity or how to claim credit, please contact 

 and include “Cognitive/Neuropsychological Functioning and Suicidal Behavior: A Review of Research and Implications for Clinical Practice” in the subject line.

Once you have read the article, please use the following URL to evaluate and request credit: 

https://education.gotoper.com/activity/ptcme21nov

. If you do not already have an account with PER® you will be prompted to create one. You must have an account to evaluate and request credit for this activity.

Suicidal behavior is a complex and incompletely understood biopsychosocial syndrome. It encompasses suicidal thinking (sometimes accompanied by plan and/or intent), attempted suicide, and death from suicide. Despite intensive study over decades, 

 eludes reliable prevention and prediction and, for many patients, is not a well-treated set of conditions.

In recent years the evidence base regarding suicide etiology, prevention, assessment, and intervention have all expanded, and a number of promising prevention and treatment innovations for suicidal behavior have been developed.

 Still, rates of completed suicide continue to increase among nearly all age groups.

 Since at least the start of this century, death from suicide has become a well-entrenched public health epidemic with no signs of abating.

During the second half of the 20th century, clinical and research studies on suicide were largely focused on the psychosocial and psychodynamic underpinnings of suicidal behavior (a working definition of suicidal behavior appears in 

). By way of contrast, scant attention was paid to possible neurobiological correlates and causal factors.

The idea that suicidal behavior might have its genesis, in part, in neurobiology may have emerged as early as the 1960s.

 However, the study of the interface of neurobiology and what are referred to as 

 in contemporary clinical practice began in earnest only in the 1980s. This helped to galvanize research on cognitive/neuropsychological dysfunction as a possible significant risk factor for 

 and, hence, its importance as a potential target for assessment and intervention. Research findings since the early 2000s have outlined cognitive/neuropsychological correlates of suicidal behavior, with an emphasis on the role that cognitive/neuropsychological impairment may play as both a potential diathesis and stressor with respect to susceptibility to suicidal behavior.

This research can help clinicians in the realms of assessment and intervention. For clinical assessment of risk of suicidal behavior, options include the Stress-Diathesis and Risk-Protective Factors models. According to recent studies, 3 broad clinical groups are characterized by high base rates for both cognitive/neuropsychological impairment and suicidal behavior. Therefore, a good working knowledge of a patient’s neurocognitive status can help guide clinical assessment and intervention. Future research could clarify the relationship between cognitive/neuropsychological impairment and suicide, hopefully leading to advances in 

Stress-Diathesis and Risk-Protective Factors Models

The Stress-Diathesis model conceptualizes suicidal behavior as multi-determined and the outcome of preexisting 

 vulnerabilities (diathesis) interacting with recent and current 

 The latter can contribute to the probability and timing as well as the pattern and relative severity of suicidal behavior in the individual case.

Predisposing vulnerabilities include a blend of neurobiological factors and predisposing influences that are psychosocially/psychodynamically based (

). These factors can, in part, reflect the impact of multiple biological influences (including a history of neurodevelopmental difficulties) but are also thought to be significantly affected by adverse life events and trauma, especially those occurring early in life: mistreatment, neglect, abandonment, and other detrimental life experiences.

Neurobiological and Psychosocial Risk Factors

For many patients, the interaction of these biopsychosocial factors results in serious problems with the development of age appropriate behavioral and emotional self-regulation abilities and skills, as well as more general difficulties with adaptation through the lifespan. This includes noteworthy problems coping with adversity, especially attachment and loss issues associated with situational stressors and lifespan developmental transitions.

The interplay of a patient’s diathesis and situational stressors/triggers of varied type (which are commonly experienced by patients as existential threats to their psychological and/or physical well-being) can significantly heighten the risk for 

 The degree/severity of risk is attenuated, to some extent, by protective factors: patient’s personality assets, good social support, access to psychiatric care, and other favorable life circumstances.

The Stress-Diathesis model aligns reasonably well with the Risk-Protective Factors model both conceptually and in terms of its heuristic value for clinical assessment and intervention. This conceptual framework emphasizes the importance of the interaction of distal and proximal influences that augment vulnerability (risk factors) and influences, which reduce susceptibility to suicidal behavior (protective factors). This paradigm is employed to create an overall suicidal risk profile for patients who are seen for clinical assessment.

Three clinical groups are at significant risk for a combination of cognitive/neuropsychological impairment and suicidal behavior: individuals with neurodevelopmental disorders, neuropsychiatric disorders, and acquired cognitive or neuropsychological disorders. Details on each of these conditions appear in 

Clinical Groups at Significant Risk for Suicidal Behavior

Patients who fall into 1 or more of these 3 groups grapple with a number of challenges that can negatively impact psychosocial development, executive functioning, and quality of life. They can struggle with identity formation/consolidation, self-esteem regulation, psychological and cognitive insight, judgment, social cognition, cognitive flexibility, impulse control/response inhibition, task initiation, organization/planning, decision-making, and problem solving.

Additional difficulties often involve 1 or more components of negative affectivity, including anger, irritability, lability, anxiety, and 

. Some patients report intolerable recurrent or chronic emotional and psychological pain together with a proclivity to overreact or emotionally shut down in response to acute and chronic stressors.

 This construct has considerable overlap with the term 

, which is a key component of the 5-factor dimensional personality model and has applicability to DSM-5 personality disorders.

A substantial number of patients who fall into 1 or more of these 3 groups have at least mildly reduced ability to profit from experience. They may have trouble learning and successfully using coping skills for the purpose of distress tolerance, stress reduction, and responding in a flexible manner to problematic life events. Overall, these patients have significant difficulty building resilience in the face of lifespan developmental challenges and demands. Their struggles in this regard are often complicated by high rates of co-occurring mental health and 

The plethora of cognitive and emotional challenges that these patients confront on a daily basis contribute to a significant vulnerability to recurrent as well as persistent behavioral-mood instability.

The plethora of cognitive and emotional challenges that these patients confront on a daily basis contribute to a significant vulnerability to recurrent as well as persistent behavioral-mood instability. Patients who fall into 1 or more of these groups have elevated rates of suicidal behavior.

 There is a nearly 5 times higher rate of suicidal behavior than among patients with 

 For individuals with autism spectrum disorder, rates of suicidal behavior range from 7% to 47%.

 For schizophrenia and other psychotic disorders, the lifetime risk for 1 or more suicide attempts ranges from 25% to 50% percent, and lifetime risk of completed suicide ranges from 4% to 10%.

 Over their lifetimes, individuals with bipolar disorder have a 15% to 50% risk of making 1 or more suicide attempts.

 Among patients who have made 1 or more suicide attempts, more than 70% had histories of anxiety disorder.

 Patients with major depressive disorder have a 

 Among those with borderline personality disorder, the lifetime risk for 1 of more suicide attempts ranges from 50% to 90%; lifetime risk for completed suicide is up to 10%.

 Among patients newly diagnosed with Alzheimer disease and related dementias, the Standardized Mortality Ratio/SMR for completed suicide was 1.53 with a 95% confidence interval of 1.42 to 1.65; however, among newly diagnosed patients aged between 65 and 74 years, the Standardized Mortality Ratio/SMR for completed suicide was 3.40 with a 95% confidence interval of 2.94 and 3.86.

 Reports of lifetime completed suicide rates for individuals with epilepsy range from 1% to 33%.

 have a 2- to 4-fold greater risk of completed suicide than the general population.

Research on Cognitive/Neuropsychological Functioning

A number of studies include investigations of the cognitive/neuropsychological functioning of patients with neurodevelopmental, neuropsychiatric, and neurologic/medical diagnoses that are associated with elevated rates of suicidal behavior.

 The majority of these involve adult patients with neuropsychiatric disorders, notably major mood disorders and schizophrenic spectrum disorders.

Some studies have focused on the relationships between cognitive/neuropsychological functioning and suicidal thinking while others have examined the relationship of cognitive/neuropsychological functioning and suicidal behavior in the form of 1 or more 

, or a history of suicidality broadly defined to include suicidal thinking and attempts.

Several studies have found positive relationships between cognitive/neuropsychological impairment and suicidal thinking. For example, a study that employed a general population sample and a subgroup with depressive disorders found that a significant positive association between cognitive/neuropsychological impairment and suicidal thinking, including a strong link with higher frequency suicidal thinking.

 An investigation that assessed the cognitive/neuropsychological integrity of patients with 

, with and without suicidal thinking, found that scores on measures of motor speed and executive functioning were significantly lower among patients with suicidal thinking.

 Moreover, greater compromise in cognitive/neuropsychological functioning was correlated with more severe suicidal thinking.

Other studies have compared the cognitive/neuropsychological test performance of psychiatric patients with histories of suicidal behavior (defined as 1 or more serious suicide attempts), with psychiatric controls—patients with comparable mental health difficulties but with negative histories of suicidal behavior, as well as participants with negative mental health histories (ie, healthy controls).

Meta-analytic reviews of the literature comparing these 3 groups highlight an array of cognitive/neuropsychological difficulties in patients with 1 or more mental health condition(s) and histories of suicide attempts, when compared with psychiatric and nonpsychiatric controls. Such difficulties include worse performance on tests of decision-making, category fluency, and response inhibition in patients with depressive and bipolar mood disorders; they also include lower performance on tests of long-term memory and working memory in patients with depressive and bipolar disorders, 

, schizoaffective disorder, and other conditions like borderline personality disorder.

A recent literature review compared patients with diagnoses of schizophrenia, schizoaffective disorder, and major mood disorder (major depression, 

, and bipolar II disorder) and a history of suicide attempts with patients with similar diagnoses but without suicide attempts. The comparison was based on a series of cognitive/neuropsychological tests, many of which can be considered measures of executive functioning.

Patients with histories of 1 or more suicide attempts performed worse than those with comparable neuropsychiatric diagnoses who did not attempt suicide. Findings were mixed, however, with respect to performance on tests of decision-making and constructional praxis. Moreover, measures of working memory did not clearly discriminate between these 2 groups.

Another literature review compared patients across a broad range of neuropsychiatric diagnoses with suicidal thinking with patients who had a history of attempts as well as patients with negative histories for suicidal behavior, looking at various neurocognitive measures.

 Differences between patients with suicidal thinking and those who actually attempted suicide were characterized as “negligible to small.” There were, however, medium size effects between these groups for performance on 2 measures of executive functioning. Those participants who had attempted 

 performed worse in decision-making and inhibition. There were no significant effect size differences on any neurocognitive measures or indices between patients with suicidal thinking and patients without histories of suicidal behavior. The only exception was a large effect size on measures of information processing speed, in favor of the latter group.

A review of the literature that focused on performance on a wide range of tests of executive functioning in relation to suicidal thinking and/or attempted suicide across a number of neuropsychiatric diagnoses found “some evidence” and “tentative support” for links between impaired executive functioning and suicidal behavior. Associations appeared stronger for patients with depressive disorders than with patients with bipolar or psychotic disorders.

The findings of these and other reviews offer modest support for the idea that psychiatric patients with histories of suicidal behavior have more problematic cognitive/neuropsychological functioning than non-suicidal psychiatric patients.

 Moreover, these difficulties with neurocognition may be conceptualized, at least in part, as trait markers, that are relatively separate and distinct from the impact of state-related affective/behavioral factors and co-occurring mental disorders, including 

, on a patient’s cognitive/neuropsychological status.

That said, other studies have not found meaningful relationships between neurocognitive status and suicidal behavior.

 Although counterintuitive, some studies noted better cognitive/neuropsychological functioning among those patients with schizophrenia who attempted suicide as opposed to those who did not attempt with the same diagnoses.

It is also important to consider that most medical and/or psychiatric patients with cognitive/neuropsychological impairment have negative histories for suicidal behavior. Substantial numbers of psychiatric patients with histories of suicidal behavior have no apparent problems with their neurocognition.

Indeed, profiles of intact and impaired cognitive/neuropsychological abilities/skills may prove to be more germane to risk for suicidal behavior than impaired abilities/skills per se. For example, the neurocognitive status of a sample of suicidal attempters has been characterized by relatively good problem-solving abilities/skills but relatively poor impulse control/response inhibition.

To date, there is suggestive but insufficient evidence to reliably support robust and independent cause and effect relationships between cognitive/neuropsychological impairment and elevated rates of suicidal behavior among patients with neurodevelopmental, neuropsychiatric, and/or acquired 

As is true of many factors that may be implicated in complex multifactorial outcomes like suicidal behavior, the possible impact of cognitive/neuropsychological impairment on the susceptibility to suicidal behavior is likely to vary as a function of an individual’s clinical profile of intact and impaired cognitive/neuropsychological abilities. A host of medical, psychosocial, psychodynamic, and situational influences might affect outcomes as well. Neuropsychiatric diagnosis may also be a relevant factor.

Additionally, it may be that the number and relative severity and/or the stage of the neurodevelopmental, neuropsychiatric, and medical/neurologic condition(s)—as well as a patient’s particular nexus of self-harm related risk and protective factors—all play key roles. These are moderator variables, which mediate the impact of cognitive/neuropsychological impairment on the risk for suicidal behavior.

 is a risk factor for suicidal behavior, even many years after formal diagnosis. There is some evidence that patients newly diagnosed with mild neurocognitive disorder, possible Alzheimer disease, or cognitive/neuropsychological changes consistent with probable early phase Alzheimer disease may be at greater risk for suicidal self-harm than patients with more advanced illness.

It may also be the case that at least some of the effects of a patient’s cognitive/neuropsychological status are indirect in so far as they negatively impact other risk factors which, in turn, elevate risk for suicidal behavior.

For example, cognitive/neuropsychological impairment can sometimes result in disinhibition and impulsivity, which lead to reckless behavior or exacerbate preexisting personality trait vulnerabilities. In association with potentially destabilizing influences like substance abuse and other proximal psychosocial stressors/triggers, these difficulties would be expected to significantly raise the risk for suicidal behavior. In this scenario, a patient’s profile of cognitive/neuropsychological abilities and deficits may even facilitate the transition from suicidal thinking to a suicide attempt.

Other cases of cognitive/neuropsychological impairment, characterized by problems with conceptual thinking, language processing, working memory, and/or anterograde memory, would likely differentially impact comprehension and retention. These issues could lead to poor understanding and follow-through with crisis/safety and treatment plans.

In both instances, the patient’s neurocognitive profile may elevate risk for suicidal self-harm and, together with other factors, override the potentially mitigating influence of protective factors.

If cognitive/neuropsychological factors can be more firmly established as an important set of causal influences in augmenting the risk of suicidal behavior, then they should be viewed as one of many significant predisposing risk factors. Accordingly, they would begin to play a more frequent and prominent role in suicide assessment and intervention. This might include the development of relatively brief and well-tolerated neurocognitive screening tests, which could be integrated into formal risk assessments to enhance predictive validity, as well as help guide clinical management and harm reduction strategies.

The Role of Psychological/Neuropsychological Testing

To date, the clinical utility of cognitive/neuropsychological testing for the assessment of suicidal behavior lacks a clear evidentiary base. Therefore, the following discussion is based on clinical experience, while considering the aforementioned findings on links between cognitive/neuropsychological impairment and suicidality.

Cognitive/neuropsychological testing may be appropriate in the context of a history of neurodevelopmental disorder, neuropsychiatric disorder, and/or acquired neurologic disorder, as well as suspicion of possible cognitive/neuropsychological impairment. Indications for cognitive/neuropsychological testing include a history of chronic or recurring suicidal thinking with 1 or more workable plans, intent, and/or evidence of preparation and/or a recent history of 1 or more serious (high risk/low rescue) suicidal attempts.

Cognitive/neuropsychological testing is less clearly indicated for patients with histories of suicidal behavior but who do not clearly fall into 1 or more of the 3 clinical groups previously reviewed. It is also less clearly indicated for patients with negative histories for presumptive neurocognitive impairment, and when there is little to no suspicion of concerning recent/current negative change(s) in 

. However, psychological testing with an emphasis on clarifying the possible temperamental, personality trait, psychosocial, and/or psychodynamic contribution to suicidal behavior should be strongly considered for this subset of patients.

Because many referred individuals have a complex diathesis for suicidal behavior that reflects a mix of both neurobiological and psychosocial factors and situational stressors/triggers that have compelling psychodynamic resonance for the patient, a test battery that includes both psychological and cognitive/neuropsychological assessments is often the best choice given.

In some instances, findings from psychometric tests may highlight the potential value of compensatory strategies to work around cognitive/neuropsychological impairments, thereby enhancing symptom management and harm reduction. In this regard, there soon may be a time when patients who have significant histories of suicidal behavior are concurrently seen for cognitive rehabilitation services. These services could target the neurocognitive impairments that appear to play a role in the recurrence and/or persistence of suicidal thinking and behavior.

A considerable amount remains to be learned about the clinical relevance of links between cognitive/neuropsychological functioning and suicidal behavior.

Research is clearly warranted to further elucidate the putative mechanisms and pathways by which cognitive/neuropsychological impairment may heighten risk for suicidal thinking and attempts. As such, research should investigate the ways that neurocognitive status may influence and, in turn, be affected by risk and protective factors as well as contextual variables and the possible synergy between negative cognitive biases/distortions and neurocognitive impairment.

Further evidence is also needed to assess the role that cognitive and neuropsychological impairment may play in disrupting an individual’s ability to adaptively cope with adverse life circumstances and, thus, heighten the risk for 

Presumably, patients who have cognitive/neuropsychological impairment and a combination of neurodevelopmental, neuropsychiatric, and neurologic factors would be at greater risk for suicidal behavior than patients with fewer of these influences when controlling for the relative severity of these factors in a given case. Research would be helpful to address the possible additive or synergistic impact on the susceptibility to various types of suicidal behavior.

Impaired neurocognition (especially compromised executive functioning) may impede the ability to effectively engage in serious suicidal behavior. Evidence-based data are needed to support this idea.

 It would also be desirable to clarify the role of higher level cognitive/neuropsychological functioning as a potential risk vs protective factor. Well-developed executive skills can be a double-edged sword: On the one hand, good executive functioning could be an asset for safety planning and alliance building; conversely, good executive functioning may facilitate the planning and execution of high lethality suicidal behavior.

The potential responsiveness of cognitive/neuropsychological impairments to psychopharmacological interventions as well as nonpsychopharmacologic approaches like cognitive rehabilitation also merits further study.

 This could shed light on trait versus state conceptualizations of cognitive/neuropsychological impairment in relation to suicidal behavior, as well as the role such interventions might play in 

In addition, it would be helpful to have research that incorporates a wider demographic. This is especially true for adolescents and older adults because of well-documented risk for suicidal self-harm.

To properly address these issues, more data are needed to ascertain the ability of specific tests and/or score profiles to differentiate patients with high vs low risk for serious suicidal behavior. This would include the possible identification of test profiles that may heighten vs attenuate risk within varying time frames: imminent (days), near term (weeks), and long term (months).

Future research also could identify patterns of cognitive/neuropsychological functioning related to the spectrum of suicidal 

. Such knowledge could facilitate the prediction of potentially serious outcomes, as well as differential response to harm reduction/safety interventions. This continuum encompasses morbid rumination, passive suicidal thinking, active suicidal thinking with and without plan and/or intent, impulsive versus planned suicide attempts, high vs low lethality attempts, and completed suicide.

If tests or sets of measures have consistently good sensitivity/specificity, they may also help to further an understanding of the neuroanatomical substrates of suicidal behavior.

To advance these research aims, the use of a standardized battery of cognitive/neuropsychological tests, along with good psychometric properties that tap a broad range of neurocognitive domains, would be highly desirable. This data would allow for more meaningful comparisons and conclusions across studies.

 Preferably, assessments should include the domain of social cognition which, to date, does not figure prominently in research on neurocognition and suicidal behavior. Screening tests like the Screen for Cognitive Impairment in Psychiatry might serve as the basis for the development of such a research battery.

Imminent and short-term suicidal behavior, especially serious suicide attempts and death from suicide, continue to be unpredictable.

However, a good working knowledge of a patient’s neurocognitive status might enhance predictive validity and improve symptom management and safety planning. This information could be obtained from psychometric testing coupled with clinically relevant information gleaned from further research on the relationships between neurocognitive test performance and suicidal behavior. Such improvements could lead to improved quality of life for patients who are suicidal, and to lives being saved.

is a clinical psychologist and neuropsychologist, Emergency Services, Seacoast Mental Health Center, Portsmouth, New Hampshire; and an allied health professional, Department of Medical Services, Section of Psychiatry, Exeter Hospital, Exeter, New Hampshire. He reports no conflicts of interest regarding the subject matter of this article.

What’s in a name: the problem of Zero Suicide.

2. Miller IW, Camargo CA Jr, Arias SA, et al. 

Suicide prevention in an emergency department population: the ED-SAFE study.

Suicide rates up significantly among adolescents, young adults.

Articles

In this CME, learn to identify 3 patient groups who are characterized by elevated rates of suicidal behavior and co-occurring cognitive/neuropsychological impairment.

Cognitive/Neuropsychological Functioning and Suicidal Behavior: A Review of Research and Implications for Clinical Practice

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

The goal of this article is to provide an overview of psychological and cognitive insight, including working definitions for these and other insight-related constructs. The etiologies of compromised insight are outlined. This article also highlights clinically relevant correlates of psychological and cognitive insight.

1. Clarify the similarities and differences between psychological insight and cognitive insight

2. Identify and define different types of pseudo-insight

3. Review common etiologies of compromised insight

4. Discuss the role of rating scales and psychological/neuropsychological testing in the evaluation of insight

This continuing medical education (CME) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership Physicians’ Education Resource®, LLC and Psychiatric Times

 . Physicians’ Education Resource®, LLC is accredited by the ACCME to provide continuing medical education for physicians.

Physicians’ Education Resource®, LLC designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of Physicians’ Education Resource®, LLC.

FACULTY, STAFF, AND PLANNERS’ DISCLOSURES

Neither the author, the peer reviewer, or the staff members of Physicians’ Education Resource®, LLC and Psychiatric Times

 have no relevant financial relationships with commercial interests.

; for questions concerning the accreditation of this CME activity or how to claim credit, please contact 

 and include “Psychological and Cognitive Insight: How to Tell Them Apart and Test for Each” in the subject line.

Once you have read the article, please use the following URL to evaluate and request credit 

https://education.gotoper.com/activity/ptcme21apr

. If you do not already have an account with PER®, you will be prompted to create one. You must have an account to evaluate and request credit for this activity.

The evaluation of patients’ insight into their own conditions has been a cornerstone of psychiatric practice for more than a century.

 Most clinical studies and empirical investigations of insight have focused on patients’ so-called psychological insight (sometimes referred to as 

) and its role in the assessment and treatment of schizophrenia and other psychotic disorders. Since the early 2000s, the construct of 

 has emerged as a complementary form and, like psychological insight, is considered to have important implications for research and clinical practice.

Historically, assessment of patients’ psychological insight has played a prominent part in 

, case formulation, treatment planning, and decision-making. It has been considered an integral component of the mental status examination, intake evaluations, progress/treatment notes, and case closing summaries.

Since the advent of the stress tolerance and coping skills era of 

 in the early 1990s, the construct of insight has played a less significant role in diagnosis and treatment planning. Still, the construct of insight remains an important factor to consider when utilizing a stress tolerance and coping skills approach to assessment and psychotherapy.

The reality is that there is no consensus definition for psychological insight. Broad and vague definitions are vulnerable to subjective judgment, low inter-rater reliability, and a high number of false positives, resulting in the overdiagnosis of insight-related problems. Narrower definitions risk generating unacceptably high rates of false negatives. This can lead to underdiagnosis of both the level and the severity of impaired insight and the erroneous conclusion that a patient has enough insight to benefit from a range of treatment options.

From a historical perspective, 3 components stand out: awareness that one has a mental disorder, the ability to correctly attribute one’s symptoms to this condition, and the capacity to appreciate the need for treatment.

 Additional components include an appreciation of the social and related consequences of one’s illness.

 For the purpose of this discussion, psychological insight can be gauged by the criteria in 

Table 1. Criteria for Psychological Insight

Cognitive insight, unlike psychological insight, is a relatively recent arrival in the literature and has its genesis in the work of Aaron Beck, MD, and colleagues.

 Cognitive insight comprises 2 components: self-reflection and self-certainty. The former refers to considering competing perspectives and entertaining alternative explanations for one’s beliefs, ideas, and perceptions. The latter is the ability to be self-critical with respect to the correctness of one’s beliefs, ideas, perceptions, and reasoning process. Self-certainty also includes a willingness to modify one’s conclusions about self and others in response to support and empathetic feedback. Criteria for cognitive insight are included in 

Decreased insight is fairly common among patients with a broad range of mental health, neurodevelopmental, and 

 Decrements in psychological and cognitive insight are associated with a number of difficulties for patients, their loved ones, and the practitioners involved in their care. Insight-related difficulties also have significant implications for diagnosis, case formulation, and treatment. In addition, clinicians need to carefully assess the adequacy of a patient’s level of psychological and cognitive insight in order to facilitate decision-making regarding informed consent to treatment, civil commitment, mandated outpatient treatment, child custody, parental fitness, work capacity, criminal responsibility, legal guardianship, estate planning, and assisted suicide.

, major mood disorders, and psychotic disorders. Although estimates vary, it seems at least 30% of these patients have compromised insight, which adversely affects their judgment and decision-making, response to treatment, functioning, and quality of life, as well as the attitudes and feelings of significant others.

Insight might impact treatment choices, including level of care, alliance building, choice of treatment modalities, treatment adherence, and the overall course and outcome. For example, if a patient has a history of 

 due to persistently impaired insight associated with a psychotic disorder, a long-acting injectable antipsychotic medication may be used to enhance adherence.

 Patients with impaired insight are also more responsive to supportive psychotherapy with distress tolerance and coping skills components than to insight-based psychodynamically oriented 

As well, both psychological and cognitive insight figure prominently in psychoeducation for caregivers and nonpsychiatric health care providers regarding the psychosocial and medical needs of patients with diminished insight.

Measures of psychological and cognitive insight correlate to a modest degree, suggesting that these 2 conceptualizations are relatively distinct (albeit overlapping) and complementary constructs.

Cognitive insight differs from psychological insight because of its emphasis on meta-cognitive capacities and, more specifically, the patient’s capacity for cognitive flexibility. These considerations encompass patients’ awareness of the possible fallibility of their perceptions, beliefs, ideas, and thinking processes. It also includes the ability to hear corrective feedback and then use it to correct the maladaptive reasoning that underlies faulty conclusions about oneself and others.

Moreover, because cognitive insight includes the ability to entertain alternative explanations or viewpoints, it may ultimately undergird psychological insight. As patients’ cognitive insight increases, they should be more aware of their illnesses and recognize salient symptoms and their real-world impact. In this regard, both of these types of insight may work in tandem to enhance self-understanding and treatment responsiveness.

Both psychological and cognitive insights are best understood as complex and interdependent multidimensional phenomena on a continuum and, hence, should be viewed as nonbinary.

 Therefore, the question is not whether a patient possesses or lacks psychological or cognitive insight, but rather to what degree, if at all, they demonstrate self-awareness. In this regard, patients can have adequate or better insight into one or more aspects of their condition but not others.

For example, there is evidence that patients with 

 appear to have better awareness of some of their psychiatric symptoms than of their associated cognitive difficulties.

 Or, a patient may have a very limited understanding of the significance of their psychotic symptoms and decline intervention, but may be painfully aware of their depression and receptive to treatment for 

Thus, clinicians should use their estimation of a patient’s psychological and cognitive insights to create both a case-specific profile of strengths and weaknesses germane to psychological self-reflection and an estimation of the patient’s ability to work in a reasonably productive manner in treatment.

Psychological and cognitive insight are dynamic rather than static constructs. A patient’s insight profile may change over time in response to medical, psychological, and situational influences. A patient’s insight may also fluctuate due to the frequency, duration, type, and severity of 

For instance, a young adult with acute onset of a suspected substance-induced psychotic disorder may display a pattern of uniformly 

, but within a few days of supportive and targeted psychiatric treatment, the same patient may demonstrate substantial improvement on one or more insight components or parameters. Conversely, if a patient has waxing and waning insight-related difficulties due to a major mood disorder with intermittent psychosis and then suffers mild head injuries, they may exhibit a more widespread, persistent, and severe profile of impaired insight, referable to postconcussive factors. Therefore, it is important to periodically reevaluate the adequacy of insight.

Psychological and cognitive insight overlap with the construct of anosognosia, which is defined as unawareness or denial of illness.

 This term is generally limited to the detrimental effects of medical conditions that impair central nervous system functioning and adversely affect a patient’s ability to recognize symptoms and their neurologic causes. It also has negative effects on daily functioning and quality of life. Problems with psychological and cognitive insight are considered an integral part of a patient’s 

. Additionally, anosognosia might be extended to describe the insight-related difficulties of patients with neuropsychiatric disorders such as schizophrenia (

This refers to patient reports suggesting greater recognition and understanding of their clinical status than is warranted based on history, collateral information, everyday functioning, recent/current life circumstances, and clinical judgment.

In some instances, pseudo-insight represents a form of positive impression management. Patients may display pseudo-insight when seeking greater autonomy from real or perceived control by family or caregivers. Successful impression management can sometimes lead to quicker discharge from 

, reduced involvement or termination of outpatient services and mental health court, and the voiding of conditional discharges from state hospitals.

In extreme cases, pseudo-insight can be associated with iatrogenic effects. This can occur when caretakers attempt to achieve quicker and more substantial gains in self-understanding than can be realistically assimilated and productively utilized, leading to a potentially serious worsening of the patient’s clinical status.

Patients with psychotic disorders and personality disorders associated with a susceptibility to 

 (and accompanying precipitous loss of self-esteem, rage, dissociation, or transient psychosis) are especially vulnerable to destabilization in response to premature or overzealous efforts of clinicians to bolster insight. In particular, patients with borderline personality disorder are highly prone to negative therapeutic reactions, although this can also be observed in patients with other problematic personality patterns.

Pseudo-insight can also be a problem after an initial psychotic episode, when patients may experience postpsychotic depression (anxiety, depression, lowered self-esteem, increased hopelessness, suicidal preoccupation, and reduced subjective quality of life). A mix of true and pseudo-insight often accompanies and influences this phase. It has also been tied to the pernicious influence of 

 as a mediating variable, including what is referred to as self-stigma or internalized stigma.

 Postpsychotic depression is often accompanied by a mix of accurate insight into one’s condition and pseudo-insight. The pernicious influence of stigma may be a mediating variable here, notably what is referred to as “internalized stigma.”

There is also a variant of pseudo-insight that may be more aptly termed “deceptive insight,” which involves persuasive and seemingly illuminating self-disclosures, frequently coupled with observations of others, that aim to manipulate and exploit others. Patients with salient antisocial or psychopathic traits frequently exhibit this form of pseudo-insight.

 Alexithymia, which roughly translates to “no words for feelings,” involves a striking inability to make sense of and report one’s feelings.

 It is characterized by severe lifelong difficulty recognizing, labeling, describing, and expressing affective states, including psychological symptoms and other mental status change. These individuals have a characterological form of impaired insight, which may be aggravated by psychosocial or other stressors. It may worsen in response to the onset of 

This concept refers to insight that flows from an ongoing treatment that is perceived as supportive and nonthreatening. It can be productively used by the patient to achieve desirable, real- world goals while maintaining hope for continued symptomatic and functional improvement. This insight has received increased attention in the literature on recovery trajectories in psychotic disorders. It potentially has broad application to many other psychiatric conditions, including 

, because improved insight appears to contribute to better treatment outcomes.

Impaired insight may result from major mental illnesses such as schizophrenia and other psychiatric conditions, notably major mood disorders with psychotic features that are associated with diminished awareness of illness.

Earn CME Credit by learning more about psychological and cognitive insight.

Jerrold Pollak, PhD

Articles

Cognitive/Neuropsychological Functioning and Suicidal Behavior: A Review of Research and Implications for Clinical Practice

Psychological and Cognitive Insight: How to Tell Them Apart and Assess for Each

What’s in a Name: The Problem with Zero Suicide

A Call to DSM-V to Focus on the Designation of Borderline Intellectual Functioning