Poor Insight in Obsessive-Compulsive Disorder: Examining the Role of Cognitive, Metacognitive, and Neuropsychological Variables

The purpose of this study was to examine the cognitive and neuropsychological constructs that are conceptually related to poor insight in obsessive-compulsive disorder (OCD). The relationship between dimensions of insight (Brown Assessment of Beliefs Scale; BABS) and cognitive (magical thinking, paranoia/suspiciousness), metacognitive (metacognition, decentering, cognitive flexibility), and neuroopsychological indices of cognitive flexiblity were examined. Participants with OCD (N = 80) referred for treatment at an outpatient anxiety disorders clinic completed a clinical interview, a brief battery of neuropsychological measures, and a computer-administered questionnaire package assessing the variables of interest. Lower metacognition (i.e., Beck Cognitive Insight Scale [BCIS], composite score) was significantly associated with poorer insight (BABS total; ρ = -.38), and Metacognitions Questionnaire-30 cognitive self-consciousness subscale was negatively correlated with insight regarding a psychiatric source for one’s symptoms (ρ = -.24). Stroop interference was the only neuropsychological variable associated with BABS total score (ρ = -.23), but was not a unique predictor of insight in a regression with BCIS composite scores predicting insight. Nearly all of the variance in insight was accounted for by BCIS composite scores (R = .43, R2 = .18), indicating that metacognition, but not cognitive flexibility, contributes most strongly to clinical insight. Finally, insight decreased when OCD symptoms were activated for both the good and poor insight groups, F(1,78) = 119.29, p < .001, partial η2 = .61, and did not significantly vary as a function of insight group status, F(1, 78) = 3.24, p = .08, partial η2 = .04. Implications, limitations, and directions for future research are discussed.