Brief Communication

The Beck Cognitive Insight Scale in Outpatients With

Psychotic Disorders: Further Evidence From a
French-Speaking Sample
Jrme Favrod, RN, CNS1; Grgoire Zimmermann, PhD2; Stphane Raffard, MSc3;
Valentino Pomini, PhD4; Yasser Khazaal, MD5
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):783787

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 sample
suffering from schizophrenia.
The study provides additional validity to BCIS with outpatients suffering from schizophrenia
or schizoaffective disorders.
Limitations
Clinical symptoms have been assessed with the PANSS by an independent psychiatrist for
only one-third of the total sample.
Convergent validity could have been measured with a more precise scale than the living
arrangement or with the insight item of the PANSS.

Key Words: schizophrenia, psychosis, psychometric, assessment, confirmatory factor

analysis, insight

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783

Brief Communication

central cognitive problem in patients with psychosis

exists in the way they interpret the distortion of their
experiences. This deficit in the ability to monitor ones 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 selfcertainty. 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 inpatients. The composite score differentiated inpatients with
schizophrenia, schizoaffective disorders, or depression with
psychotic symptoms from inpatients diagnosed with depression 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 psychotic patients, with and without delusion, with control
subjects indicates that people with psychotic disorders had
impaired cognitive insight relative to control subjects. However, the 2 groups of patients demonstrated different patterns.
Patients with delusion were overly confident in their judgment, compared with control subjects or those without delus io n . P a tien ts w ith o u t d e lu s io n r e v e a le d lo w e r
self-reflectiveness than control subjects or patients with delusions. Finally, the BCIS has been used as a process variable in
a randomized controlled trial of social skills training, compared 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 convergent validity of the original scale in a French-speaking environment with outpatients suffering from schizophrenia and

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

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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 disorders 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 Community 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 criteria 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 centres
ethical committee. All participants consented to participate in
the study. Participants completed the BCIS in pretest assessment 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 ReflectivenessCertainty 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 symptoms, negative symptoms, and general psychopathology.
Higher scores indicate higher symptoms severity and
impairment.
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The Beck Cognitive Insight Scale in Outpatients With Psychotic Disorders: Further Evidence From a French-Speaking Sample

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

Study
Pedrelli et al
Favrod et al

Sample mean age, years

c2 /df

GFI

AGFI

RMSEA

CFI

NNFI

53

164

0.025

0.96

0.96

35

158

1.38

0.91

0.88

0.049

0.89

0.87

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 considered as acceptable.
Subscale Internal Consistencies
The alpha coefficients of the self-reflectiveness and selfcertainty 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 selfreflectiveness 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
The Canadian Journal of Psychiatry, Vol 53, No 11, November 2008 W

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 significantly lower on the self-reflectiveness scale and the composite 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 suffering from schizophrenia. The fit indices of the CFA confirmed 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 construct validity in outpatient samples and that the BCIS is
appropriate to outpatients with schizophrenia or
schizoaffective disorders. Further, this study gave first evidence of cross-cultural validity of the cognitive insight construct 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 support 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 association between BCIS subscales and the positive symptoms
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Brief Communication

Table 2 Comparisons on BCIS subscales and residential status

Nursing home
(n = 34)
Mean (SD)

Living independently
(n = 124)
Mean (SD)

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

df

2-tailed P

0.001b

Equal variances not assumed

P < 0.05 adjusted for multiple comparisons, a/3 = 0.01

scale of the PANSS. Higher correlation between PANSS G12

with the composite score of the BCIS 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. 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 cognitive insight than a patient living in a more sheltered
environment.

Conclusions
In summary, 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 patients suffering from schizophrenia and
schizoaffective disorders.
Funding and Support
No competing interests.
Acknowledgements
We thank all patients who participated in the study. We thank
Dr Delphine Capdevielle, who kindly participated in data
collection, and Ms Delphine Sreekumar, who assisted with the
English 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;68:319329.
2. Pedrelli P, McQuaid JR, Granholm E, et al. Measuring cognitive insight in
middle-aged and older patients with psychotic disorders. Schizophr Res.
2004;71:297305.

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3. Warman DM, Lysaker PH, Martin JM. Cognitive insight and psychotic
disorder: the impact of active delusions. Schizophr Res. 2007;90:325333.
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;23:99110.
7. Arbuckle JL, Wothke W. Amos 4.0 users 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;6:155.
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;6:5683.
13. Mak WW, Wu CF. Cognitive insight and causal attribution in the development
of self-stigma among individuals with schizophrenia. Psychiatr Serv.
2006;57:18001802.
14. Cohen J. A power primer. Psychol Bull. 1992;112:155159.

Manuscript received October 2007, revised, and accepted March 2008.

1
Clinical Nurse Specialist, Community Psychiatry Service, Department of
Psychiatry, University Hospital Centre and University of Lausanne,
Lausanne, Switzerland.
2
Senior Researcher, Institute for Psychotherapy, Department of
Psychiatry, University Hospital Centre and University of Lausanne,
Lausanne, Switzerland; Junior Assistant Professor Department of
Psychology, University of Fribourg, Fribourg, Switzerland.
3
Clinical Psychologist, Department of Adult Psychiatry University
Hospital, INSERM U-888, Montpellier, France.
4
Tenured Senior Lecturer and Researcher, Community Psychiatry Service,
Department of Psychiatry, University Hospital Centre and University of
Lausanne, Lausanne, Switzerland.
5
Tenured 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 CPdresSite de Cery, CH-1008 Prilly,
Switzerland; Jerome.Favrod@chuv.ch

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

Rsum : Lchelle dintuition cognitive de Beck chez des patients externes souffrant
de troubles psychotiques : dautres donnes probantes dun chantillon francophone
Objectif : Lchelle dintuition cognitive de Beck (BCIS) value les dclarations des patients sur
leur capacit de dtecter et de corriger la fausse interprtation. La prsente tude vise confirmer la
structure des facteurs et la validit convergente de lchelle originale dans un milieu francophone.
Mthode : Des patients externes (n = 158) souffrant de schizophrnie ou de troubles
schizo-affectifs ont rempli la BCIS. Les 51 patients de Montpellier ont galement t valus au
moyen de lchelle des symptmes positifs et ngatifs (PANSS) par un psychiatre, linsu des
scores la BCIS.
Rsultats : Les indices dajustement de lanalyse factorielle confirmatoire validaient la solution
bifactorielle rapporte par les constructeurs de lchelle avec des patients hospitaliss, puis dans une
autre tude avec des patients externes dge moyen et plus gs. Lindice compos de la BCIS tait
significativement ngativement corrl avec litem dintuition clinique de la PANSS.
Conclusions : La traduction franaise de la BCIS semble possder des proprits psychomtriques
acceptables et offre un appui additionnel lchelle, ainsi quune validit interculturelle son
utilisation auprs de patients externes souffrant de schizophrnie ou de troubles schizo-affectifs. La
corrlation entre lindice clinique et lindice compos de lintuition cognitive souligne la nature
multidimensionnelle de lintuition clinique. Lintuition cognitive ne rtablit pas lintuition clinique,
mais elle constitue une cible potentielle pour mettre au point des traitements psychologiques qui
amlioreront lintuition clinique. multidimensionnelle de linsight clinique. Linsight cognitif ne
recouvre pas linsight clinique mais est une cible potentielle pour dvelopper des traitements qui
cherchent B amliorer la conscience du trouble.

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