Brief report Insight is not associated with insensitivity to future consequences in schizophrenia Stéphane Raffard a,b, ⁎, Delphine Capdevielle b,c , Marie-Christine Gely-Nargeot a , Jérôme Attal b,c , Alexandra Baillard a , Jonathan Del-Monte a , Nawel Mimoun a , Jean-Philippe Boulenger b,c , Sophie Bayard c,d a Laboratoire Epsylon EA Dynamique des Capacites Humaines et des Conduites de Sante ou, Laboratory Dynamics of Human Abilities & Health Behaviors, Universites Montpellier 1, Montpellier 3 et St-Etienne, France b University Department of Adult Psychiatry, Hôpital de la Colombière, CHU Montpellier, University Montpellier 1, Montpellier, France c INSERM U-888, Montpellier, France d University Department of Neurology, Hôpital Gui-de-Chauliac, CHU Montpellier, France, University Montpellier 1, Montpellier, France abstract article info Article history: Received 1 March 2010 Received in revised form 20 July 2010 Accepted 17 November 2010 Keywords: Insight Decision-making Iowa Gambling Task In this study, we examined the association between insight and decision-making capacity in schizophrenia using the Iowa Gambling Task (IGT). No association was found between insight and IGT scores. Our results suggest that impaired decision-making ability in schizophrenia patients cannot be solely predicted by lack of insight. © 2010 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Insight impairment is one of the main clinical features of schizophrenia. Awareness of symptoms is associated with higher rates of recurrence and poor treatment adherence despite the effectiveness of antipsychotic agents in reducing the intensity of psychotic symptoms and preventing relapses (Palmer et al., 2004). A poorer level of insight is generally considered as the best discrimi- nator of capacity status in schizophrenia and bipolar affective disorder, and is the clinical concept that is the most closely associated with the legal concept of capacity (Owen et al., 2009). This view was recently confirmed by Capdevielle et al. (2009), who showed that the level of insight was closely linked to the capacity to consent to treatment. Nevertheless, in this study, mental capacity (see also Owen et al., 2009) was evaluated with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), a semi-structured interview that does not provide an objective measure of decision- making capacity. Therefore, it still has to be determined whether insight impairment is objectively associated with a global deficit in decision-making capacity or is rather associated with decision- making impairment limited to some specific aspects of the disorder such as medication adherence. The present study aimed at examining the relationships between insight and the decision-making process using the Iowa Gambling Task (IGT; Bechara et al., 2000), a task frequently used to evaluate decision-making processes and requiring subjects to learn from feedback and to adapt choices to reward and punishment. This study was designed to clarify whether a deficit in insight could be considered as a general “insensitivity to future consequences” in schizophrenia, leading patients to be guided by immediate prospects only, independently of the future consequences of their actions. Our hypothesis was that insight level would be associated with IGT performance. 2. Methods 2.1. Subjects Sixty-four patients with schizophrenia participated in the study. Diagnoses were established using the Structured Clinical Interview for The Diagnostic and Statistical Manual of Mental Disorders - fourth edition. Exclusion criteria were known neurological disease, developmental disability, and substance use disorders in the past 3 months. All patients were taking antipsychotic medication. Typical antipsychotic agents were taken by 34 patients and atypical antipsychotic agents were given to 30 patients in a standard dose (chlorpromazine equivalents (mg/day) = 764.72, S.D. = 537.26). In addition, 18 patients were receiving benzodiazepines, nine antidepressants, and 14 anticholinergics. Severity of symptoms was evaluated with the Positive and Negative Syndrome Scale (PANSS). The patients were in a stable phase of their illness. The control group comprised 64 healthy participants with no history of psychiatric or neurological disorders recruited from the community. All participants gave informed written consent. 2.2. Assessments 2.2.1. Iowa Gambling Task We used the original computerized version of the Iowa Gambling Task (IGT) (Bechara et al., 2000). Four decks, labelled A, B, C, and D, were set before the participants, each of whom began with $2000 in “game money” and instructions to win Psychiatry Research 187 (2011) 307–309 ⁎ Corresponding author. University Department of Adult Psychiatry, Hôpital La Colombière, 39 avenue Charles Flahault, 34295 Montpellier cedex 5, France. Tel.: + 33 4 67 33 97 53; fax: +33 4 67 33 96 60. E-mail address: s-raffard@chu-montpellier.fr (S. Raffard). 0165-1781/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2010.11.020 Contents lists available at ScienceDirect Psychiatry Research journal homepage: www.elsevier.com/locate/psychres