Is “clinical” insight the same as “cognitive” insight in schizophrenia

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Is “clinical” insight the same as “cognitive” insight in schizophrenia

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     Journal of the International Neuropsychological Society  (2009), 15  , 471 – 475 . Copyright © 2009 INS. Published by Cambridge University Press. Printed in the USA.doi:10.1017/S1355617709090559471  INTRODUCTION Poor insight (poor awareness of illness) is commonly reported in schizophrenia. Its clinical significance is well established in terms of treatment adherence (Kemp & David, 1996 ), symp-tom severity (Mintz et al., 2003 ), and poorer global function-ing (Pyne et al., 2001 ). The relationship between insight and outcome is not unidirectional, however; better insight has also been associated with more severe depressive symptoms and increased suicide rates (Crumlish et al., 2005 ). The relationship between poor insight and neuropsycho-logical impairment has been widely investigated. The results of a recent, large meta-analysis (Aleman et al., 2006 ) sug-gest that for schizophrenia, poor insight is most highly as-sociated with a general decline in neuropsychological function, while for psychosis in general (including bipolar disorder), this association appeared to be more specific to “executive” measures. The association with general cogni-tive decline in schizophrenia is further supported by several studies published since this meta-analysis (Donohoe et al., 2006 ; Mutsatsa et al., 2006 ; Ritisner & Blumenkrantz, 2007 ), although not all (Cuesta et al., 2006 ). The test of executive function that has been most widely used in relation to insight in schizophrenia has been the Wis-consin Card Sort test (WCST). WCST performance is often described as indexing attentional flexibility, and Drake & Lewis ( 2003) have suggested that it is this component of executive function that is most important for maintaining an “abstract representation” of health-relevant experiences, as required for illness awareness. However, WCST is likely to index more gen-eral cognitive decline in schizophrenia (Laws, 1999 ), including several executive subcomponents such as attentional flexibility, working memory, and inhibitory control. We previously inves-tigated whether any of these executive subcomponents was es-pecially important to insight and found that working memory capacity rather than attentional flexibility was most strongly as-sociated with insight (Donohoe et al., 2006 ). A further question BRIEF COMMUNICATION  Is “clinical” insight the same as “cognitive” insight in schizophrenia? GARY DONOHOE , 1  JUDY HAYDEN , 1  NICOLA M c GLADE , 2  CARA O’GRÁDA , 3  TERESA BURKE , 4  SANDRA BARRY , 3  CARAGH BEHAN , 2  TIMOTHY G. DINAN , 3  EADBHARD O’CALLAGHAN , 2  MICHAEL GILL , 1   and AIDEN P. CORVIN 1   1  Neuropsychiatric Genetics Research Group , Department of Psychiatry, Trinity College Dublin , Dublin , Ireland 2  Cluain Mhuire Family Centre and Department of Psychiatry, University College Dublin , Dublin , Ireland 3  Department of Psychiatry , University College Cork , Cork , Ireland 4  School of Psychology , University College Dublin , Dublin , Ireland (Received August 20 , 2008 ; Final Revision January 19 , 2009 ; Accepted January 19 , 2009 ) Abstract Poor insight is associated with impaired cognitive function in psychosis. Whether poor clinical insight overlaps with other aspects of self-awareness in schizophrenia, such as cognitive self-awareness, is unclear. We investigated whether awareness of clinical state (“clinical insight”) and awareness of cognitive deficits (“cognitive insight”) overlap in schizophrenia in a sample of 51 stabilized patients with chronic schizophrenia. Cognitive insight was assessed in terms of the agreement between subjective self-report and neuropsychological assessment. Patients who show good cognitive insight did not necessarily show good clinical insight. By contrast, self-report and objective neuropsychological assessment only correlated for patients in the intact clinical insight group and not for those in the impairment clinical insight group. We conclude that while good cognitive insight may not be necessary for good clinical insight, good cognitive awareness is at least partly reliant on the processes involved in clinical insight. (  JINS   , 2009, 15  , 471– 475 .) Keywords   : Schizophrenia , Cognition , Insight , Cognitive failures , Sustained attention , Memory , Working memory Correspondence and reprint requests to: Gary Donohoe, Department of Psychiatry, Trinity Health Centre, St. James’s Hospital, Dublin 8, Ireland. E-mail: donoghug@tcd.ie  G. Donohoe et al. 472arising from this “neuropsychological” hypothesis of insight is whether illness awareness is related to other aspects of self-awareness such as cognitive self-monitoring and awareness of cognitive errors (Aleman et al., 2006 ); this remains unclear. In this study, we measured “cognitive self-awareness” based on the similarity between subjective (self-reported) cognitive deficits and objective cognitive deficits (neuropsychological performance). We hypothesized that if “clinical” insight over-laps with “cognitive” insight, then patients showing good clinical symptom awareness would also show good awareness of their cognitive performance. We similarly hypothesized that cognitive self-rating and actual neuropsychological perfor-mance would only correlate among those with good clinical insight and not in those with poor clinical insight. METHODS Participants Fifty-one clinically stable patients with a diagnosis of schizo-phrenia participated in the study. Patients were recruited through two urban outpatient clinics (the Southern Health Board in Cork and the St. John of God Cluain Mhuire ser-vice in Dublin), and all provided written informed consent. Inclusion criteria required that participants be aged 18–65 years, with no history of comorbid psychiatric disorder, sub-stance abuse in the preceding 6 months, or prior head injury with loss of consciousness. Diagnosis was confirmed using the Structured Clinical Interview for DSM-IV Axis 1 Diag-noses (First et al., 1996 ) and symptom severity using the Schedule for the assessment of positive symptoms (SAPS) and Schedule for the assessment of negative symptoms (SANS) (Andreasen, 1984a , 1984b ). Patients’ performance on each of the measures included in the study was compared to a sample of 54 healthy partici-pants, matched for age and gender, recruited on the basis of responses to local media advertisements. Control partici-pants were only included if they were aged between 18 and 65 years and satisfied, based on clinical interview, the crite-ria of having no history of major mental health problems, intellectual disability or acquired brain injury, and no history of substance misuse in the preceding 6 months based on self-report. All participant data were collected in accordance with the ethics approval granted by the relevant ethics committee at each site for this study. Neuropsychological Measures Neuropsychological tasks were selected to provide verbal and nonverbal indices of the main areas of cognition reported as impaired in schizophrenia, including general cognitive func-tion, episodic memory, working memory, and attentional con-trol. Current general cognitive function was measured using the Wechsler Adult Intelligence test–third edition (WAIS-III; Wechsler, 1997 ). Episodic memory was assessed using the logical memory subtest and faces subtest from the Wechsler Memory Scale–third edition (WMS-III; Wechsler, 2001 ). Working memory was assessed using the WMS-III Letter Number Se-quencing task and the Spatial Working Memory Task from the Cantab Battery (Cambridge Cognition Ltd, 2002 ). Attentional control was assessed using the Cantab IDED task and the Sus-tained Attention to Response Task(Robertson et al, 1997 ; see O’Grada et al., 2008 for a full description). Insight Measures Clinical insight was measured using the Schedule for Assess-ment of Insight (SAI), which assesses insight on the basis of a semistructured interview (David, 1990 ). Because this study was based on a well outpatient cohort, many of whom were expected to show intact insight, patients were categorized into two groups on a median-based cutoff score of 12. This yielded a “high” or “intact” group (those who scored 13–14 on the SAI) versus  an impaired group (those who scored between 0 and 12). Cognitive insight was measured in terms of the relation-ship between patients’ self-reported errors during everyday activities using the Cognitive Failures Questionnaire (CFQ; Broadbent et al., 1982 ) and their actual cognitive task perfor-mance. The CFQ consists of 25 items, which index daily cognitive failures (e.g., forgetting names, confusing left and right), rated using a 5-point Likert scale (0 = never   , 4 = very often  ) to indicate awareness of mistakes in the past 6 months. Higher scores are reported to negatively correlate with ob- jective measures of cognitive performance, for example, on measures of attention (Manly et al., 1999 ). Total scores vary from 0 to 100: scores below 50 indicate awareness of only occasional cognitive difficulties and scores above 50 indi-cate more frequent cognitive difficulties. RESULTS Both intact and impaired clinical insight groups performed significantly below the healthy comparison group on all neu-ropsychological tests and on educational attainments ( Table 1 ). As general ability in healthy controls was higher than ex-pected, we reran this analysis covarying for WAIS-III block design scores; with the exception of visual memory, all case–control group differences remained significant. Intact and impaired clinical insight groups differed on gender, with im-paired insight group containing significantly fewer females by comparison with the intact insight group (Fischer’s exact test: −3.56;  p  = .0004). Patients with intact clinical insight did not differ significantly from those at statistical or even trend level on neurocognitive variables (lowest  p  value = .17). The range of CFQ scores was comparable for the im-paired and intact clinical insight groups (impaired group: range 15–84; SD  = 13.1; intact group: range 16–66; SD  = 13.1). As a chronic patient group, many patients were being prescribed more than one antipsychotic; there was no differ-ence in numbers in each group being prescribed typical versus  atypical antipsychotics (  p  > .05), or in the total medi-cation dosage prescribed ( Table 1 ). Despite being impaired on most cognitive tasks by comparison with healthy participants, patients subjectively   Insight in schizophrenia 473reported only slightly more cognitive difficulties on the CFQ than controls (controls’ mean CFQ = 39.8 ( SD  = 12.7); pa-tients’ mean CFQ = 44.0 ( SD  = 12.8); t   (1,104) = 1.8;  p  = .074). Two thirds (65.8%) of the patients who demonstrated impairments in one of more areas of cognitive function (de-fined in this study as performing less than 1 SD  below pub-lished norms on both tests of any of the cognitive functions assessed) subjectively recognized moderate to frequent cog-nitive difficulties based on the CFQ. This compared with none of the patients who were without cognitive impairment, and only one participant from the healthy comparison group scoring above this mark (see Table 1 for clinical and cogni-tive mean scores for each group). Do the Same Patients Show Both Good Clinical Insight and Good Cognitive Insight? To investigate the overlap between cognitive awareness and clinical awareness, we compared clinical insight scores be-tween patients who had cognitive deficits and were aware of them and patients who had cognitive deficits but were not aware of these. For this purpose, those with cognitive deficits (defined above) were described as showing awareness if they scored above a cutoff 50 on the CFQ, that is, if they reported more than just “occasional errors” as defined by the CFQ. This resulted in an intact cognitive insight group ( n  = 32) and an impaired cognitive insight group ( n  = 20). We did not observe differences between groups either on the basis of total insight scores ( t   = 0.913;  p  = .37) or SAI subscale scores (SAI treatment compliance: t   = 1.15;  p  = .26; SAI recognition of mental illness: t   = 1.09;  p  = .28; SAI ac-curately relabeling of symptoms: t   = .08;  p  = .93). Similarly, when patients were categorized as showing either intact in-sight (an SAI total score of 13 or 14; n  = 24) or impaired insight (an SAI total score of 12 or below; n  = 27), there was no difference in the numbers of patients showing awareness of cognitive deficits between the two groups (  χ    2  = 0.432;  p  = .552). Is the Correlation Between Cognitive Task Performance and Self-Rated Performance Associated With Clinical Insight? We next sought to investigate the overlap between cognitive and clinical awareness by investigating the correlation be-tween CFQ scores and cognitive task performance separately for patients rated as having intact clinical insight and pa-tients with impaired clinical insight (based on the cutoff of 12 on the SAI already described). For the patients with im-paired clinical insight, no correlation was observed between actual cognitive performance and patients’ own CFQ ratings. By contrast, for patients with intact clinical insight, their CFQ scores correlated with several indices of both general cognitive ability and memory function ( Table 2 ). Table 1. Mean score on demographic, clinical, and neuropsychological measures for patients and controls Measure Control group ( n  = 54), mean ( SD  ) Intact group ( n  = 24), mean ( SD  ) Impaired group ( n  = 27), mean ( SD  ) Test statistic Duration of illness, years — 17.0 (9.3) 17.0 (10.5) t   = 0.003 SAPS total — 2.5 (2.6) 5.2 (3.5) U   = −3.7 *** SANS total — 6.0 (4.0) 8.1 (4.9) t   = −2.15 * SAI total insight score — 13.7 (0.5) 9.3 (2.3) U   = −8.9 *** CFQ total score 39.8 (12.7) 43.5 (13.1) 46.2 (14.0) F   = 1.89 Age on date of testing, years 39.4 (10.5) 39.6 (10.0) 40.0 (12.7) F   = 0.10 Education attainment 6.4 (1.2) 4.5 (1.7) 4.1 (1.5)  χ    2  = 71.55 ** Gender (%female) 31 (48) 22 (41) 9 (17)  χ    2  = 10.25 ** WAIS Vocabulary scaled score 12.2 (2.0) 11.0 (2.8) 10.1 (2.9) F   = 9.58 *** WAIS block design scaled score 13.1 (2.6) 9.7 (3.1) 9.5 (2.9) F   = 28.28 *** Logical Memory 1 total recall scaled score 12.0 (2.8) 7.2 (3.0) 7.0 (3.6)  H   = 60.01 *** Logical Memory 2 total recall scaled score 12.4 (2.3) 7.9 (3.2) 7.8 (3.5)  H   = 60.59 *** Faces 1 scaled score 11.6 (3.0) 9.5 (2.7) 9.1 (3.1) F   = 12.20 *** Faces 2 scaled score 11.6 (3.0) 11.0 (2.7) 9.7 (3.2) F   = 5.21 *** Letter number sequencing scaled score 14.9 (3.2) 8.8 (3.5) 8.6 (3.6) F   = 66.3 *** CANTAB SWM between errors  z  -score 0.5 (0.6) −0.8 (1.1) −0.7 (1.1) F   = 14.3 *** CANTAB ID ED—block 6 errors 0.5 (0.8) 0.4 (0.8) 0.8 (1.1) F   = 3.079 * CANTAB ID ED—block 8 errors 7.0 (8.4) 15.9 (10.9) 14.0 (10.1) F   = 11.670 *** SART fixed errors of omission 4.0 (4.5) 18.8 (17.5) 19.7 (28.4) F   = 5.985 ** SART fixed total errors of commission 2.7 (5.2) 5.6 (4.8) 5.5 (4.8) F   = 3.732 * *  p  < .05. **  p  < .01. ***  p  < .001.  Note  . CFQ, Cognitive Failures Questionnaire; SAI, Schedule for Assessment of Insight; SART, Sustained Attention to Response Task; SWM, Spatial Work-ing Memory Task.  G. Donohoe et al. 474 We also conducted a hierarchical regression analysis, with CFQ scores entered as the dependent variable and neuropsy-chological performance (based on one measure of each cog-nitive function: Vocabulary, Facial recognition, Letter number sequence) as independent variable. Scores on WMS-III Facial recognition and Letter number sequencing accounted for a significant percentage of variance in both the full sam-ple (24.2%; F   = 7.68; df   = 2,48;  p  = .001) and the intact clinical insight group (46.9%; F   = 8.53; df   = 2,30;  p  < .0001) but not the impaired clinical insight group (  p  > .05). DISCUSSION This study investigated the overlap between clinical and cognitive insight in a sample of chronic but stable outpa-tients with schizophrenia. Forty-seven percent of patients were rated as showing impaired clinical insight on the SAI. Based on a discrepancy between CFQ rating and actual cog-nitive deficits, 33% of patients showed poor insight into their cognitive difficulties. Patients lacking clinical insight did not necessarily also lack cognitive insight; however, self-rating of cognitive difficulties only correlated with actual cognitive performance within the intact clinical insight group. These data highlight both overlap and independence be-tween the concepts of clinical and cognitive insight. One interpretation of these findings is that while good clinical insight is required before a correlation between cognitive self-ratings and actual cognitive performance becomes ap-parent, cognitive self-awareness is not sufficient for clinical insight. This accords well with the accumulated evidence in schizophrenia, suggesting that many additional noncognitive factors determine clinical insight, including positive symp-tom severity and psychological defense mechanisms con-cerning illness representations (Lysaker & Buck, 2007 ; Lysaker et al., 2005 ). For example, while evidence of a rela-tionship between insight and gender has been equivocal in schizophrenia, in our study, significantly more females were categorized as showing intact clinical insight than impaired, possibly reflecting the apparently more benign course of ill-ness in females (Grossman et al., 2008 ). Although not a hypothesis of our study, the clinically in-tact insight group showed a relationship between higher sub- jective cognitive failures’ ratings and better visual memory recognition. These findings may relate to a similarity be-tween visual recognition and error recognition either cogni-tively or neuroanatomically. Further study of this finding will be required before a more definitive interpretation of this result can be made. Potential criticism of this study include the fact that cogni-tive insight ratings were based on discrepancies between patients’ self-report and their actual performance rather than the more traditionally used discrepancy between patients’ self-report and either the report of a caregiver or of a treating physician. We preferred the self-reported/actual performance discrepancy because of the evidence that both doctors’ and care-givers’ ratings are inaccurate (Harvey et al., 2001 ; Moritz et al., 2004 ; Sanjuán et al., 2006 ). A second issue is that concordance between patient’s self-rating and objective neuropsychological tests is potentially bidirectional in that some patients with in-tact neuropsychological performance may overestimate their cognitive failures: further study in a larger sample that could consider this issue in a three-group comparison of an intact cognitive insight V underestimation of cognitive deficits V overestimation of cognitive deficits is warranted . In conclusion, this study represents a novel attempt to in-vestigate overlap between the construct of clinical insight and cognitive insight and extends current knowledge on the overlap, but nonidentity, between these two constructs. ACKNOWLEDGMENTS Sincere thanks to all the participants in this study and to the clinical staff who facilitated this participation. This study was carried out with the generous support of grants from the Wellcome Trust (M.G., A.P.C.), the Higher Education Authority (M.G.), Science Founda-tion Ireland (G.D.), and  National Alliance for Research on Schizo- phrenia and Depression  (NARSAD). None of the authors have any financial or other relationships that could be interpreted as a con-flict of interest in relation to this manuscript . REFERENCES Andreasen , N.C. ( 1984 a). Scale for the Assessment of Negative Symptoms/Scale for the Assessment of Positive Symptoms (Man-ual)  . Iowa City, IA : University of Iowa Press . Andreasen , N.C. ( 1984 b ). The Scale for the Assessment of Negative Symptoms (SANS)  . Iowa City, IA : University of Iowa Press . Table 2. Correlation between CFQ scores and actual cognitive performance for patients with impaired and intact clinical insight CFQ total score Impaired awareness Intact awareness General cognitive functioning Predicted FSIQ (WTAR) −.01 −.48 * WAIS Vocabulary .15 −.41 * WAIS block design −.03 −.21 Working memory WAIS LNS (scaled) .13 −.22 CANTAB SWM errors .03 .12 Episodic memory WMS Logical Memory I .23 −.45 * WMS Logical Memory II .24 −.37 * WMS Faces I .35 .39 * WMS Faces II .31 .42 * Attentional control Fixed SART commission errors −.13 .03 Fixed SART omission errors −.20 .19 IDED ID scores (stage 6) .31 −.29 IDED ED scores (stage 8) −.01 .23 *  p  < .05 level.  Note  . CFQ, Cognitive Failures Questionnaire; SART, Sustained Attention to Response Task; SWM, Spatial Working Memory Task; WTAR, Wechsler Test of Adult Reading.   Insight in schizophrenia 475  Aleman , A. , Agrawal , N. , Morgan , K.D. , & David , A.S. ( 2006 ). Insight in psychosis and neuropsychological function: Meta-analysis . The British Journal of Psychiatry  , 189  , 204 – 212 . Broadbent , D.E. , Cooper , P.F. , FitzGerald , P. , & Parkes , K.R. ( 1982 ). The Cognitive Failures Questionnaire (CFQ) and its correlates . The British Journal of Clinical Psychology  , 21  , 1 – 16 . Cambridge Cognition Ltd ( 2002 ). CANTABeclipse Version 12.0, Cambridge Neuropsychological Assessment Battery  . Cambridge : Cambridge Cognition Ltd . Crumlish , N. , Whitty , P. , Kamali , M. , Clarke , M. , Browne , S. , Mc- Tigue , O. , Lane , A. , Kinsella , A. , Larkin , C. , & O’Callaghan , E. ( 2005 ). Early insight predicts depression and attempted suicide after 4 years in first-episode schizophrenia and schizophreniform disorder .  Acta Psychiatrica Scandinavica  , 112  , 449 – 455 . Cuesta , M.J. , Peralta , V. , Zarzuela , A. , & Zandio , M. ( 2006 ). In- sight dimensions and cognitive function in psychosis: A longitu-dinal study .  BMC Psychiatry  , 31  , 26 . David , A.S. ( 1990 ). Insight and psychosis . The British Journal of Psychiatry  , 156   , 798 – 808 . Donohoe , G. , Corvin , A. , & Robertson , I.H. ( 2006 ). Are the cogni- tive deficits associated with impaired insight in schizophrenia specific to executive task performance?  Journal of Nervous and  Mental Disease  , 193  , 803 – 808 . Drake , R.J. & Lewis , S.W. ( 2003 ). Insight and neurocognition in schizophrenia . Schizophrenia Research  , 62  , 165 – 173 . First , M.B. , Spitzer , R.L. , Gibbon , M. , & Williams , J. ( 1996 ). Structured Clinical Interview for DSM-IV Axis I Disorders, Cli-nician Version (SCID-CV)  . Washington, DC : American Psychi-atric Press Inc . Grossman , L.S. , Harrow , M. , Rosen , C. , Faull , R. , & Strauss , G.P. ( 2008 ). Sex differences in schizophrenia and other psychotic dis-orders: A 20-year longitudinal study of psychosis and recovery . Comprehensive Psychiatry  , 49  , 523 – 529 . Harvey , P.D. , Serper , M.R. , White , L. , Parrella , M.J. , McGurk , S.R. , Moriarty , P.J. , Bowie , C. , Vadhan , N. , Friedman , J. , & Davis , K.L. ( 2001 ). The convergence of neuropsychological testing and clinical ratings of cognitive impairment in patients with schizo-phrenia . Comprehensive Psychiatry  , 42  , 306 – 313 . Kemp , R. & David , A. ( 1996 ). Psychological predictors of insight and compliance in psychotic patients . The British Journal of Psychiatry  , 169  , 444 – 450 . Laws , K.R. ( 1999 ). A meta-analytic review of Wisconsin Card Sort studies in schizophrenia: General intellectual deficit in disguise? Cognitive Neuropsychiatry  , 4  , 1 – 30 . Lysaker , P.H. & Buck , K.D. ( 2007 ). Illness and the disruption of autobiography: Accounting for the complex effect of awareness in schizophrenia .  Journal of Psychosocial Nursing and Mental  Health Services  , 45  , 39 – 45 . Lysaker , P.H. , Carcione , A. , Dimaggio , G. , Johannesen , J.K. , Nicolò , G. , Procacci , M. , & Semerari , A. ( 2005 ). Metacognition amidst narratives of self and illness in schizophrenia: Associa-tions with neurocognition, symptoms, insight and quality of life .  Acta Psychiatrica Scandinavica  , 112  , 64 – 71 . Manly , T. , Robertson , I.H. , Galloway , M. , & Hawkins , K. ( 1999 ). The absent mind: Further investigations of sustained attention to response .  Neuropsychologia  , 37   , 661 – 670 . Mintz , A.R. , Dobson , K.S. , & Romney , D.M. ( 2003 ). Insight in schizophrenia: A meta-analysis . Schizophrenia Research  , 61  , 75 – 88 . Moritz , S. , Ferahli , S. , & Naber , D. ( 2004 ). Memory and attention performance in psychiatric patients: Lack of correspondence between clinician-rated and patient-rated functioning with neuropsychological test results .  Journal of the International  Neuropsychological Society  , 10  , 623 – 633 . Mutsatsa , S.H. , Joyce , E.M. , Hutton , S.B. , & Barnes , T.R. ( 2006 ). Relationship between insight, cognitive function, social function and symptomatology in schizophrenia: The West London first episode study .  European Archives of Psychiatry and Clinical  Neuroscience  , 256   , 356 – 363 . O’Gráda , C. , Barry , S. , McGlade , N. , Behan , C. , Haq , F. , Hayden , J. , O’Donoghue , T. , Peel , R. , Morris , D.W. , O’Callaghan , E. , Gill , M. , Corvin , A.P. , Dinan , T.G. , & Donohoe , G. ( 2008 ). Does the ability to sustain attention underlie symptom severity in schizo-phrenia Res. 2009 Feb;107(2-3):319–23. Schizophrenia Research  , 2  . Pyne , J.M. , Bean , D. , & Sullivan , G. ( 2001 ). Characteristics of pa- tients with schizophrenia who do not believe they are mentally ill . The Journal of Nervous and Mental Disease  , 189  , 146 – 153 . Ritsner , M.S. & Blumenkrantz , H. ( 2007 ). Predicting domain- specific insight of schizophrenia patients from symptomato-logy, multiple neurocognitive functions, and personality related traits . Psychiatry Research  , 149  , 59 – 69 . Robertson , I.H. , Manly , T. , Andrade , J. , Baddeley , B.T. , & Yiend , J. ( 1997 ). ‘Oops!’: Performance correlates of everyday attentional failures in traumatic brain injured and normal subjects .  Neurop-sychologia  , 35  , 747 – 758 . Sanjuán , J. , Aguilar , E.J. , Olivares , J.M. , Ros , S. , Montejo , A.L. , Mayoral , F. , Gonzalez-Torres , M.A. , & Bousoño , M. ( 2006 ). Subjective perception of cognitive deficit in psychotic patients .  Journal of Nervous and Mental Disease  , 194  , 58 – 60 . Wechsler , D. ( 1997 ). Wechsler Adult Intelligence Scale–Third Edi-tion (WAIS-III)  . New York : The Psychological Corporation, Har-court Assessment Company . Wechsler , D. ( 1998 ). Wechsler Memory Scale–Third edition (WMS- III)  . New York : Psychological Corporation . Wechsler , D. ( 2001 ). Wechsler Test of Adult Reading (WTAR)  . New York : The Psychological Corporation, Harcourt Assessment Company .
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