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

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Poor Insight in Obsessive-Compulsive Disorder: Examining the Role of Cognitive, Metacognitive, and Neuropsychological Variables POOR INSIGHT IN OBSESSIVE-COMPULSIVE DISORDER: EXAMINING THE ROLE OF COGNITIVE, METACOGNITIVE, AND NEUROPSYCHOLOGICAL VARIABLES by Heather K. Hood Master of Arts, Ryerson University, 2009 Bachelor of Arts, University of Guelph, 2007 A dissertation presented to Ryerson University in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Program of Psychology Toronto, Ontario, Canada, 2014 ©Heather K. Hood 2014 AUTHOR'S DECLARATION FOR ELECTRONIC SUBMISSION OF A DISSERTATION I hereby declare that I am the sole author of this dissertation. This is a true copy of the dissertation, including any required final revisions, as accepted by my examiners. I authorize Ryerson University to lend this dissertation to other institutions or individuals for the purpose of scholarly research. I further authorize Ryerson University to reproduce this dissertation by photocopying or by other means, in total or in part, at the request of other institutions or individuals for the purpose of scholarly research. I understand that my dissertation may be made electronically available to the public. ii Abstract Poor Insight in Obsessive-Compulsive Disorder: Examining the Role of Cognitive, Metacognitive, and Neuropsychological Variables Doctor of Philosophy, 2014 Heather K. Hood Psychology Ryerson University 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 neuropsychological indices of cognitive flexibility 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 iii 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. iv Acknowledgements I would first like to express my sincere appreciation and thanks to my advisor, Dr. Martin Antony, for his ongoing support throughout my graduate training. You have been a tremendous mentor in all aspects of my professional training, and I am fortunate to have had the opportunity to benefit from your wisdom, experience, and guidance. Thank you for always being available, supporting my decisions, encouraging me to pursue relevant and important experiences, providing me with countless opportunities for professional growth and development, and for your willingness to move mountains to make this all possible. Many thanks. Thank you to Dr. Naomi Koerner, who has taught me the importance of clarity, precision, and relevance in all aspects of my research. You have been a wonderful mentor to me from the very early days of my graduate training. I would also like to thank my examination committee, Dr. Todd Girard, Dr. Colleen Derkatch, and Dr. Eric Storch for taking time out of their busy schedules to provide insightful feedback and participate in my defense. I would like to extend a sincere thank you to Drs. Randi McCabe and Karen Rowa, as well as the clinical and research teams at the Anxiety Treatment and Research Centre at St. Joseph’s Healthcare, Hamilton, for supporting the development, recruitment, and data collection for this project. I have been truly fortunate to work with such a skilled team of researchers and clinicians. Finally, to my family, friends, classmates, and colleagues, words cannot express my gratitude for your continued love, support, and encouragement throughout this process. I have so much for which to be thankful. v Table of Contents Page Abstract..................................................................................................................................... iii Acknowledgments.................................................................................................................... v List of Tables............................................................................................................................ viii Introduction.............................................................................................................................. 1 Prevalence and Course of OCD................................................................................... 1 OCD Symptomatology.................................................................................................. 4 Defining Insight in OCD............................................................................................... 9 The Phenomenology of Insight in OCD........................................................................ 15 Prognostic Value of Insight.......................................................................................... 21 Models of Insight in OCD............................................................................................. 25 Summary and Implications........................................................................................... 40 Purpose of the Present Study........................................................................................ 42 Hypotheses.................................................................................................................... 47 Method...................................................................................................................................... 51 Participants.................................................................................................................. 51 Measures....................................................................................................................... 53 Procedure..................................................................................................................... 62 Results...................................................................................................................................... 64 Preliminary Analyses.................................................................................................... 64 Characteristics of Insight............................................................................................. 64 Relationship Between Dimensions of Insight and Cognitive and Metacognitive vi Beliefs........................................................................................................................... 67 Relationship Between Insight and Neuropsychological Indices of Cognitive Flexibility...................................................................................................................... 69 Comparison of In-session Insight and Situational Insight........................................... 72 Discussion................................................................................................................................. 75 Implications.................................................................................................................. 81 Limitations.................................................................................................................... 85 Future Directions......................................................................................................... 88 Summary and Conclusions........................................................................................... 91 References................................................................................................................................ 92 vii List of Tables Page Table 1: Mean BABS Item and Total Scores In Session and When OCD Symptoms are Activated...................................................................................................................... 65 Table 2: Cognitive and Metacognitive Subscale and Total Scores and Relationship with Insight........................................................................................................................... 68 Table 3: Neuropsychological Test Performance and Relationship with Insight........................ 71 Table 4: Summary of Hierarchical Regression Analysis for Variables Predicting BABS Total Scores................................................................................................................. 73 viii Poor Insight in Obsessive-Compulsive Disorder: Examining the Role of Cognitive, Metacognitive,
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