Neurocognitive function and insight in schizophrenia: support for an association with impairments in executive function but not with impairments in global function

Insight dimensions and cognitive function in psychosis: a longitudinal study

BACKGROUND

It has been reported that lack of insight is significantly associated with cognitive disturbance in schizophrenia. This study examines the longitudinal relationships between insight dimensions and cognitive performance in psychosis.

METHODS

Participants were 75 consecutively admitted inpatients with schizophrenia, affective disorder with psychotic symptoms or schizoaffective disorder. Assessments were conducted at two time points during the study: at the time of hospital discharge after an acute psychotic episode and at a follow-up time that occurred more than 6 months after discharge. A multidimensional approach of insight was chosen and three instruments for its assessment were used: the Scale to Assess Unawareness of Mental Disorder (SUMD), three items concerning insight on the Assessment and Documentation in Psychopathology (AMDP) system and the Insight and Treatment Attitudes Questionnaire. The neuropsychological battery included a wide range of tests that assessed global cognitive function, attention, memory, and executive functions.

RESULTS

After conducting adequate statistical correction to avoid Type I bias, insight dimensions and cognitive performance were not found to be significantly associated at cross-sectional and longitudinal assessments. In addition, baseline cognitive performance did not explain changes in insight dimensions at follow-up. Similar results were found in the subset of patients with schizophrenia (n = 37). The possibility of a Type II error might have increased due to sample attrition at follow-up.

CONCLUSION

These results suggest that lack of insight dimensions and cognitive functioning may be unrelated phenomena in psychosis.

Investigation of insight formation using narrative analyses of people with schizophrenia in remission

Poor insight in schizophrenic patients is a common and multidimensional phenomenon. The purpose of this study was to explore the process of the formation of insight in patients with schizophrenia in remission. A qualitative design was used to analyze first-person narratives of 50 people with schizophrenia in remission. Face to face, semistructured interviews were conducted by investigators, and the narratives were transcribed verbatim. The results of our study showed that there were four stages of illness understanding in patients with schizophrenia: 1) the feeling that symptoms were unbearable or a loss of control, 2) comparisons of experiences with references, 3) perception that medication was working through trial and error experiments, and 4) awareness of illness after medication relieved symptoms. Insight formation is an active process in which schizophrenic patients gain knowledge about their medication, connect the association between their medication and symptoms, and realize they need to deal with issues.

Prefrontal subregions and dimensions of insight in first-episode schizophrenia--a pilot study

Deficits in insight are multidimensional, and include symptom unawareness and misattribution. We and others have observed that these deficits may be related to a prefrontal dysfunction. However, few studies have examined the relationship between specific prefrontal sub-regions and the awareness and attributional dimensions of insight in schizophrenia. This study examined the correlation between insight dimensions of awareness and attribution of symptoms and dorsolateral prefrontal cortex (DLPFC) and orbitofrontal cortex (OFC) volume in 14 subjects with first-episode, antipsychotic-naïve (FEAN) schizophrenia. In addition, 21 healthy subjects provided control data for volumetric assessments. Insight was assessed with Scale to Assess Unawareness of Mental Disorders. Morphometric assessments were adjusted for intra-cranial volume and were conducted by trained raters blind to clinical information using BRAINS-2. Average scores on current awareness of symptoms (1=aware; 5=unaware) were negatively correlated with right DLPFC volume and average scores on current attribution of symptoms (1=attribute; 5=misattribute) with right medial OFC volume. Unawareness and misattribution of symptoms in FEAN schizophrenia may have distinct neuroanatomical bases. DLPFC deficits may have resulted in illness unawareness by interfering with self-monitoring, while OFC abnormalities may have mediated symptom misattribution by conferring aberrant salience to perceived symptomatology.

Are the cognitive deficits associated with impaired insight in schizophrenia specific to executive task performance?

Although impaired insight in schizophrenia has been associated with deficits in executive task performance, the relationship remains unclear. We aimed to clarify this relationship by fractionating executive functioning into the theoretically derived functions of inhibition, working memory, set shifting, and sustained attention. We compared the performance of patients showing impaired insight, patients showing good insight, and a matched control group on measures of each of these executive functions, along with measures of current cognitive functioning and memory. We found that while patients with impaired insight performed significantly below those with good insight on our working memory task, they also performed poorly on measures of general cognitive functioning and memory. We conclude that while impaired insight does appear to be associated with executive deficits, this association may not be specific but may instead relate to cognitive deficits more generally.

Insight into illness in schizophrenia

Lack of insight of patients with schizophrenia into various aspects of their illness and treatment is an important clinical issue. Poor insight has been reported to be associated with neurocognitive deficits, particularly in the frontal and parietal functions. The aim of this study was to examine relationships between insight and cognitive and emotional function in patients with schizophrenia. Thirty-five male forensic patients suffering from chronic schizophrenia participated. The Scale for the Assessment of Unawareness of Mental Disorder was used to assess insight. Neuropsychological function was assessed with a comprehensive battery of tests. Clinical state was also assessed. Of 35 patients, 18 (51%) believed that they had a mental disorder. A similar proportion reported awareness of a need for medication and correctly attributed symptoms to illness. Measures of insight showed significant associations with visual object learning, verbal working memory, and identification of facial emotions but not with measures of frontal lobe function. Poorer insight was associated with a higher occurrence of violent events. Our findings support an association between poor insight and cognitive impairment in patients with chronic schizophrenia but suggest that the relationship may not specifically involve frontal lobe dysfunction.

Disease, deficit or denial? Models of poor insight in psychosis

OBJECTIVE

To examine the evidence for the three kinds of aetiological model that dominate the current literature on poor insight in psychosis: clinical models, the neuropsychological model, and the psychological denial model.

METHOD

Studies pertaining to one or more of these aetiological models were identified, reviewed and critically evaluated.

RESULTS

There is little support for clinical models, partly because they lack testable hypotheses. Several studies reveal a positive relationship between insight and executive function, which may be related to frontal lobe dysfunction. However, the extent to which this relationship is specific and independent of general cognitive impairment remains unclear. There is tentative evidence to support the psychological denial model. Recent data combining the latter two approaches suggest that multiple factors contribute to poor insight.

CONCLUSION

Integration of different aetiological models is necessary for a fuller understanding of insight in psychosis. Future research should assess multiple aetiological mechanisms in single investigations.

Is unawareness of psychotic disorder a neurocognitive or psychological defensiveness problem?

We examined whether deficits in attention and perceptual encoding as well as psychological defensiveness were associated with impaired awareness of disorder in schizophrenia. The Scale for Unawareness of Mental Disorder (SUMD) was administered to 52 outpatients with a recent onset of schizophrenia approximately 1-2 months following hospital discharge. Two versions of the Continuous Performance Test (CPT) were used to measure attentional impairment--the Degraded Stimulus CPT (DS-CPT) and a memory-load version (3-7 CPT). Three scales from the Minnesota Multiphasic Personality Inventory were used as indicators of psychological defensiveness: Scales L (Lie), K (Correction), and R (Repression). The Classification and Regression Tree (CART) program, a nonparametric statistical method, was used to identify relationships among multiple predictor variables and to provide optimal splitting scores for each predictor variable. Different combinations of poor target discrimination (d') on the 3-7 CPT and a cautious response style on the DS-CPT were associated with the three levels of overall unawareness of having a mental disorder. For nonpsychotic patients, better target discrimination (d') on the 3-7 CPT tended to be associated with better awareness of having a mental disorder. In contrast, unawareness among the patients who were psychotic at the time of the SUMD administration was not discriminated by attentional measures, but was associated with a combination of two measures of psychological defensiveness from the MMPI reflecting guardedness, psychological suppression, attempting to present oneself in a socially desirable light, and social acquiescence. Generally similar associations were found for two other dimensions of poor insight: unawareness of the beneficial effects of antipsychotic medication, and inability to attribute unusual thoughts and hallucinatory experiences to a mental disorder.

Personal narratives of illness in schizophrenia: associations with neurocognition and symptoms

Controversy exists regarding whether unawareness/denial of illness in schizophrenia results from neurocognitive deficits or a rejection of stigmatized social roles. One possibility is that some elements of a narrative of mental illness are primarily a matter of personal/social construction while others may be uniquely curtailed by neurocognitive deficits. Accordingly, we gathered narratives of illness among 52 persons with schizophrenia spectrum disorders using a semi-structured interview. Ratings of the plausibility, adequacy of detail, and temporal conceptual organization of each narrative were correlated with assessments of neurocognition, symptoms, and traditional insight measures. Degree of plausibility was significantly related to performance on the Wisconsin Card Sorting Test (WCST), a measure of executive function and levels of Positive symptoms on the Positive and Negative Syndrome Scale (PANSS). When entered into a regression to predict plausibility, positive symptoms and WCST performance made unique contributions (R2 = .51, p < .0001). Higher levels of Positive symptoms were associated with poorer temporal conceptual organization within narratives. Adequacy of detail within narratives of illness was related to traditional insight measures but not neurocognition or symptoms.

Integrated versus sealed-over recovery in schizophrenia: BORRTI and executive function

Ego functioning of 222 outpatients with a diagnosis of schizophrenia or schizoaffective disorder was evaluated using the Bell Object Relations and Reality Testing Inventory (BORRTI). Sixty-one of these had BORRTI profiles identified as sealed-over recovery style, and 36 had profiles interpreted as integrated recovery style. Groups were compared on demographic characteristics, symptom profiles, and the Wisconsin Card Sorting Test, a performance measure of executive function. Groups had comparably low levels of positive symptoms, but the integrated recovery group had higher scores on the BORRTI uncertainty of perception scale. The integrated recovery group had significantly fewer minority patients, higher IQ, and higher levels of emotional discomfort. The sealed-over recovery group had higher levels of cognitive disorganization. When differences in ethnicity and IQ were controlled for, the integrated recovery group had better executive functioning. Wisconsin Card Sorting Test categories completed emerged as the significant predictor in a logistic regression, explaining 19% of the variance. These findings support the discriminant validity of these two recovery styles and reveal the importance of executive function in a recovery style that allows for investment in relationships, affect tolerance, and acknowledgment of symptoms.

Insight and prefrontal cortex in first-episode Schizophrenia

Few studies have investigated the neurobiological basis of impaired insight in antipsychotic-naive schizophrenia. However, the relationship between insight and specific prefrontally mediated cognitive functions suggests that insight deficits may be an expression of prefrontal cortical dysfunction. This study was designed to examine the relationship among insight, neurocognition, and dorsolateral prefrontal cortex (DLPFC) volumes in first-episode antipsychotic-naive schizophrenia subjects. DLPFC volumes were compared between 35 first-episode schizophrenia subjects with good (n = 17) and poor insight (n = 18). Morphometric measurements were based on MRI scans by trained raters blind to clinical information. First-episode schizophrenia subjects with poor insight showed decreased right DLPFC volumes relative to those with good insight. In addition, those with poor insight had higher levels of perseverative errors (PEs) on the Wisconsin Card Sort Test (WCST). No differences in other neuropsychological measures were found between the good and poor insight groups. Similarly, no differences were found between schizophrenia subjects with good versus poor insight on any of the psychopathological measures employed in this study. These findings suggest that poor insight in schizophrenia may be a function of specific prefrontally mediated neurocognitive deficits rather than a global impairment in neuropsychological functioning or different profiles of psychopathology.

Evidence that health attributions and symptom severity predict insight in schizophrenia

Although a relationship between insight and symptomatology in schizophrenia has been repeatedly demonstrated, the influence of psychological variables such as coping mechanisms and attributional style is less clear. We evaluated health attributions, subjective resources for coping, symptomatology, general cognitive functioning, and insight among 38 consecutive admissions with DSM-III-R schizophrenia from a geographically defined catchment area. Health attributions accounted for a significant amount of insight even after symptom severity was accounted for and together predicted 32% of variation in insight scores. This study emphasizes the multifactorial nature of insight and the importance of psychological variables in addition to symptomatology.

Symptomatological and cognitive predictors of insight in chronic schizophrenia

Studies of schizophrenia show lack of agreement about the relationship of symptomatological and cognitive factors to insight. In this study, positive and negative symptomatology and cognitive function were assessed by the Positive and Negative Syndrome Scale (PANSS), the Wisconsin Card Sorting Test (WCST), and the Wechsler Adult Intelligence Scale Revised (WAIS-R) in male chronic schizophrenic patients in relation to level of insight measured with the Japanese version of the Schedule for the Assessment of Insight (SAI-J). Negative symptoms were significantly and negatively associated with overall insight, particularly with treatment compliance and recognition of mental illness. The present findings suggest that aspects of insight such as treatment compliance and recognition of mental illness are negatively associated with negative symptoms.

Insight and hopelessness in forensic patients with schizophrenia

OBJECTIVE

To quantitatively explore the level of insight in forensic patients with schizophrenia, and its relationship to symptoms and to a history of violence. In addition, to test the hypothesis that scores in the insight domains of 'compliance' and 'awareness of illness' are positively correlated with scores on a self-report scale measuring 'hopelessness'.

METHOD

The study consisted of a cross-sectional survey. Subjects were inpatients and outpatients in the rehabilitation service of the Victorian Institute of Forensic Mental Health. Twenty-eight patients with a diagnosis of schizophrenia and a history of serious offending consented to take part. Twenty-two of these had committed homicide. Measures were obtained for each on the Schedule for Assessment of Insight, the Positive and Negative Syndrome Scale for Schizophrenia and the Beck Hopelessness Scale.

RESULTS

The mean insight score for forensic patients was 8.39 (SD 4.88). Insight scores did not differ significantly between those subjects who had a history of violence prior to their index offence and those who did not. Awareness of illness, but not compliance, was positively correlated with level of hopelessness. A higher level of awareness of having a mental illness was thus related to feeling more hopeless about the future.

CONCLUSIONS

Mean insight scores in patients with schizophrenia with a forensic history do not differ significantly from those in non-forensic populations. Being more aware of being mentally ill may be a risk factor for hopelessness about the future. The limitations of the study are the small sample size, and the fact that it is confined to a relatively clinically stable population.

Insight and recovery from psychosis in chronic schizophrenia and schizoaffective disorder patients

Impaired insight is an important contributing factor to poor treatment response and outcome in schizophrenia. Prior studies have attempted to identify the illness characteristics that underlie these deficits, with conflicting results regarding associations with symptoms and neurocognitive deficits. These inconsistencies may be a function of a number of methodological issues, which were addressed in this study. In a prospective, longitudinal study, 50 individuals with schizophrenia or schizoaffective disorder underwent baseline assessments upon discharge from an acute inpatient unit, and again at a 6-month follow-up. Unawareness of positive and negative symptoms were studied separately, with analyses focusing on changes in insight over time as well as associations with disorganized symptoms, depression, and card sorting deficits. Subjects showed greater insight for negative symptoms than for positive symptoms. Insight for positive symptoms improved only slightly over the follow-up period, while negative symptom awareness did not change. Insight for negative symptoms showed modest associations with card sorting deficits, while awareness for positive symptoms showed stronger associations with thought disorder, depression, and card sorting deficits. Awareness for positive symptoms in schizophrenia may be distinct from awareness of negative symptoms. Clinicians should also be aware of the multidetermined nature of impaired insight, and future research should aim to isolate distinct mechanisms that give rise to these deficits.

Insight and neurocognition in schizophrenia

The relationship between neurocognitive impairments in schizophrenia remains unclear. Recent literature was reviewed and the most consistent finding was an association between perseverative errors on the Wisconsin Card Sort Test (WCST) and poor insight. The aim was to confirm and extend this finding using a range of assessments relevant to perseveration, and different dimensions of insight, in a sample of 33 acutely psychotic subjects within 5 years of onset of schizophrenia and related disorders. Results showed a correlation (r=-0.59) between insight and perseverative errors, rather than more general measures of abstraction. A factor representing relabelling symptoms, derived from insight scale items, correlated even more strongly; however, other insight factors correlated more weakly, suggesting they are less dependent on neuropsychological deficits. The ability to monitor output and correct errors appears to be closely related to the core features of insight in psychosis.

Insight and neuropsychological function in patients with schizophrenia and bipolar disorder with psychotic features

OBJECTIVES

This study investigates the pattern of association between patient unawareness of illness and neuropsychological tests of frontal lobe function in subjects with schizophrenia and bipolar disorder (BD) with psychotic features.

METHOD

We administered the Wisconsin Card Sort Test (WCST) and a shortened version of the Scale to Assess Unawareness of Mental Disorder (SUMD) to a sample of 64 patients with psychosis (42 with schizophrenia and 22 with BD).

RESULTS

None of the correlations between WCST scores and insight scores were statistically significant, either in the total group or in each group analyzed separately. Further, no differences were seen in insight scores between sexes and between the diagnostic groups.

CONCLUSIONS

The 3 insight dimensions (that is, awareness of mental disorder, awareness of social consequences of mental disorder, and awareness of the benefits of medication) do not appear to be associated with frontal impairment, as measured by the WCST.

Hopelessness, neurocognitive function, and insight in schizophrenia: relationship to suicidal behavior

Insight and hopelessness have been reported to be associated with suicidality in schizophrenia. In addition, there is evidence that diminished insight is correlated with impairment in some domains of cognitive function in schizophrenia. The purpose of this study was to clarify the relative importance for suicidality in patients with schizophrenia of hopelessness, cognitive dysfunction, and insight. This study included 333 patients with chronic schizophrenia who were prospectively studied. Insight was rated by the insight items from the Schedule for Affective Disorders and Schizophrenia (SADS) and the Hamilton Depression Rating Scale (HDRS). Positive, negative, and anxiety-depression symptoms were measured with the Brief Psychiatric Rating Scale (BPRS). Cognition was assessed with a neurocognitive battery, which included measures of attention and psychomotor speed, verbal fluency, verbal memory, working memory, and executive function. Current and lifetime suicidality was prospectively assessed. Hopelessness, substance abuse, and greater insight were associated with attempted suicide and suicidal ideation. Those with a history of lifetime, but not current, suicidality had better function on tests of psychomotor speed and attention, verbal working memory, verbal fluency, verbal memory, and executive function. Neurocognitive measures were not significantly correlated with hopelessness and insight. Hopelessness was more severe in those with current and lifetime suicidality. A multiple regression analysis was used to predict current and lifetime suicidality from hopelessness, substance abuse, insight, and cognitive factor scores. The regression models predicting current and lifetime suicidality indicated that hopelessness was the most important predictor of both (beta=0.41, p=0.0001; and beta=0.35, p=0.01, respectively). These findings suggest that hopelessness, substance abuse, greater insight into illness, and higher cognitive function are associated with greater suicidality in chronic schizophrenia, but that among these, hopelessness may be the principal predictor of suicidality.

Patterns of neurocognitive deficits and unawareness of illness in schizophrenia

It has been alternately theorized that poor insight in patients with schizophrenia results from deficits in executive function and a preference for denial as a coping strategy. One possibility is there are two distinct groups of persons with poor insight: those with impairments in executive function and those with a generally avoidant coping style. To examine this question, the authors performed a cluster analysis on 64 persons with schizophrenia spectrum disorders on the basis of the PANSS insight and judgment item and executive function assessed with the Wisconsin Card Sorting Test. As predicted, three groups were found: good insight-average executive function (N = 28), poor insight-average executive function (N = 13), and poor insight-poor executive function (N = 23). When self-reported coping styles were compared among groups, as predicted, the poor insight-average executive function group endorsed a significantly greater preference for denial as a coping strategy than the poor insight-poor executive function group, even after controlling for differences in executive function. The coping scores of the good insight group did not differ significantly from either poor insight group. Results suggest that denial may play a role in the unawareness of illness in some persons with schizophrenia who have average executive function.

Insight in schizophrenia: associations with executive function and coping style

It has been suggested that lack of awareness of illness in schizophrenia may result from deficits in executive function and/or an avoidant style of coping. To examine this question, 132 persons with schizophrenia spectrum disorders were rated as either "aware," "partially unaware" or "unaware" of: (a) their illness, (b) need for treatment and (c) consequences of disorder on the abbreviated Scale to Assess Unawareness of Mental Disorder. We next compared the performance of the aware, partially unaware and unaware groups on the "escape-avoidance" and "positive reappraisal" subtests of the Ways of Coping Questionnaire and on two tests of executive function: the Letter Number Sequencing Subtest of the WAIS III and Wisconsin Card Sorting Test. MANCOVA followed by ANCOVA and planned comparisons, controlling for age indicated that the participants who were unaware of symptoms, treatment need and consequences generally performed more poorly than the aware groups on tests of executive function. Participants unaware of symptoms also had a greater preference for positive reappraisal than aware or partially unaware participants. The participants unaware of the consequences of disorder endorsed a greater preference for escape-avoidance than the partially unaware participants. Implications for understanding the etiology of lack of awareness in schizophrenia are discussed.

[Validation of the Italian version of the Self-report Insight Scale]

AIMS

To evaluate the psychometric properties of the Italian version of the Insight Scale (IS), self-report questionnaire assessing the awareness of psychiatric illness. The instrument contains two forms, the first A that enquires about the present status, and the second B that concerns past episodes of illness.

METHOD

Factorial structure, internal consistency and concurrent validity (towards three selected items of the 24-item BPRS, Unusual thought content", Conceptual disorganization and Uncooperativeness) were studied on 80 chronic subjects affected by schizophrenia. Differences between acute and stabilised patients were investigated. Test-retest reliability was assessed in a sub-sample of 22 stable cases.

RESULTS

The Italian IS showed satisfactory concurrent validity and reliability. Acute patients had lower scores than stabilised ones. Factorial analysis brought to the distinction between insight for need for care in the present and in the past, which seems both plausible and clinically-useful.

CONCLUSION

The use of the IS Italian version may be encouraged as a valid insight self-report instrument. Sensitivity to change and predictive power concerning clinical and social outcome and adherence to treatment should be investigated.

Insight in persons with schizophrenia: effects of switching from conventional neuroleptics to atypical antipsychotics

The primary aim of our study is to evaluate the level of insight during the switch from a classical antipsychotic drug to a atypical neuroleptic. Twenty-two schizophrenic patients were admitted to the study, 9 were male and 13 were female. Standardized questionnaire were: Scale for Assessment of Negative Symptoms (SANS), Scale for Assessment of Positive Symptoms (SAPS), Brief Psychiatric Rating Scale (BPRS) and Schedule for Assessing the three components of Insight (SAI). All patients were receiving haloperidol at time of recruitment. Eight patients were switched to clozapine, 3 to risperidone and 11 to olanzapine. The global function, measured with BPRS, increased after administration of atypical antipsychotics. The positive and negative symptoms were reduced. The level of insight was increased after the administration of the atypical antipsychotics. The cognitive effect of the atypical antipsychotics changed the level of insight and augmented the compliance.

Insight into illness in patients with mania, mixed mania, bipolar depression and major depression with psychotic features

BACKGROUND

Poor insight into illness is a common feature of bipolar disorder and one that is associated with poor clinical outcome. Empirical studies of illness awareness in this population are relatively scarce with the majority of studies being published over the previous decade. The study reported here sought to replicate previous report findings that bipolar patients frequently show high levels of poor insight into having an illness. We also wanted to examine whether group differences in insight exist among bipolar manic, mixed and unipolar depressed patients with psychotic features.

METHODS

A cohort of 147 inpatients with DSM-III-R bipolar disorder and 30 with unipolar depression with psychotic features, were evaluated in the week prior to discharge using the Structured Clinical Interview for DSM-III-R-Patient Edition (SCID-P), the Brief Psychiatric Rating Scale (BPRS) and the Scale to assess Unawareness of Mental Disorder (SUMD).

RESULTS

Insight into specific aspects of the illness was related to the polarity of mood episode: patients with mania showed significantly poorer insight compared with those with mixed mania, bipolar depression and unipolar depression. A linear regression analysis using SUMD score as the dependent variable and symptoms of mania as the independent variable found that specific manic symptoms did not account for level of insight. Similar results were obtained when the mean insight scores of patients with and without grandiosity were contrasted.

CONCLUSIONS

We hypothesize that the lack of association between level of insight and total number of manic symptoms or with specific manic symptoms may be related to the persistence of subsyndromal symptoms in patients remitting from a manic episode.

Insight, global neuropsychological functioning, and symptomatology in chronic schizophrenia

It is proposed that poor insight in schizophrenia may be explained by neuropsychological dysfunction and linked to the negative syndrome, which in turn may be related to structural neurological impairment. This study tested the hypothesis that poor insight is related to global neuropsychological impairment and negative symptoms in 89 patients with chronic schizophrenia. No significant association was found between total insight and cognitive impairment. When the dimensions of insight-treatment compliance, awareness of illness, and symptom attribution-were analyzed separately, symptom misattribution was modestly correlated with frontal impairment. However, in subsequent multiple regression analyses, cognitive impairment failed to be a significant predictor of this or any other dimension of insight. Symptoms, particularly positive ones, accounted for approximately one quarter of the variance in symptom misattribution and the total insight score. These results suggest that neuropsychological functioning cannot account for the variance in insight, and that only one quarter of the variance in symptom misattribution can be explained by symptomatology. Future research could also address the role of psychosocial factors in modulating the expression of insight.

Insight and work performance in schizophrenia

Research has linked impaired insight in schizophrenia to poorer medication compliance and poorer treatment outcome. The current study attempts to replicate previous findings that impaired insight is related to deficits in work function. To examine this question, 121 participants with schizophrenia or schizoaffective disorder enrolled in vocational rehabilitation were classified as having unimpaired (N = 65), or impaired (N = 56) insight. Next, participants were assigned a work placement and their work performance assessed on the third, fifth, and seventh weeks of work by using the Work Behavior Inventory. Among the 85 participants who completed these weeks of work, a multivariate analysis of variance and subsequent analysis of variance showed participants with impaired insight had significantly poorer ratings of work quality, work habits, cooperativeness, and personal presentation. When measures of global intelligence and executive function were entered as covariates in individual analysis of covariance, groups differed on measures of cooperativeness and personal presentation. Implications for rehabilitation are discussed.

Insight and personal narratives of illness in schizophrenia

Insight in schizophrenia tends to be assessed as the degree to which one possesses specific knowledge. It therefore often fails to account for the fact that awareness of illness is an inextricable part of a personal narrative and may be incoherent or incomplete for many different narrative reasons. Accordingly, we have developed a means of eliciting narratives of illness: the Indiana Psychiatric Illness Interview, and a method for rating the coherence of those narratives: the Narrative Coherence Rating Scale. In this article we describe these methods and present data on their reliability and validity in a study of the illness narratives of 33 outpatients with schizophrenia or schizoaffective disorder. Results suggest our measures possess sufficient internal consistency and good to excellent interrater reliability. Additionally, as predicted, our measures of narrative coherence were significantly correlated with traditional measures of insight and with measures of cognitive impairment and hopelessness gathered earlier.

Correlates of insight in serious mental illness

This study extends research into insight by examining its relationship to a variety of demographic, clinical, neurocognitive, and psychosocial variables among a broad diagnostic sample of 211 adults with serious mental illness. Participants completed a full battery of instruments measuring these variables. Results support a relationship between ratings of poor insight and a psychotic (vs. mood) diagnosis, increased psychiatric symptoms, poorer social skills, and negative medication attitudes. Minorities and those with a substance abuse diagnosis were also more likely to be rated as having poor insight. No relationship was found between level of insight and age, gender, education level, neurocognitive deficits, hospitalization history, size of one's social network, or quality of life measures. Results are discussed in the context of improving the measurement and assessment of insight, conceptualizing interventions aimed at addressing level of insight, and improving outcomes for patients with severe and persistent mental illness. Findings also support a need for continued investigation of how mental illness is understood, experienced, and expressed across diverse groups of people living with mental illness.

Unawareness of illness in chronic schizophrenia and its relationship to structural brain measures and neuropsychological tests

The present study seeks to elucidate the relationship between unawareness of illness in schizophrenia and frontal lobe dysfunction, in addition to investigating the relationship between lack of insight and sociodemographic and clinical variables. Twenty-one medicated schizophrenic patients, recruited from in- and out-patient wards at Ullevâl Hospital, underwent the Scale to Assess Unawareness of Mental Disorder (SUMD), neuropsychological testing, psychiatric symptom ratings and neuroimaging procedures (CT). Also, 21 matched normal controls were neuropsychologically tested. CT data were assessed blindly by two experienced neuroradiologists, according to the degree of ventricular enlargement and/or sulcal widening, and an assessment of localisation of atrophy was made. Unawareness of illness was correlated with neuropsychological measures related to executive functioning, but not with other neuropsychological measures. Five patients showed slight frontal atrophy, while two showed moderate frontal atrophy. The remaining 13 patients did not show signs of frontal lobe atrophy. Frontal lobe atrophy documented by structural brain measures was associated with poor insight in schizophrenia. Furthermore, Anergia (BPRS), GAF score and 'undifferentiated' sub-diagnosis correlated with SUMD scores. Unawareness of illness in schizophrenia may be related to frontal lobe deficit. Also, awareness of illness may not be related to general psychopathology, but rather to specific aspects.

Insight and interpersonal function in schizophrenia

Research has linked impaired insight in schizophrenia to poorer medication compliance and treatment outcome. It is unclear, however, whether poorer interpersonal function is also associated with impaired insight. To examine this question, subjects with schizophrenia or schizoaffective disorder were classified as having unimpaired (N = 44) or impaired (N = 57) insight, and their scores on Heinrichs et al.'s Quality of Life (QOL) Scale were compared. Multiple regressions were conducted to determine the relationship between individual components and social function. Results indicate that subjects with impaired insight had significantly poorer QOL interpersonal relation and intrapsychic foundation scores than unimpaired subjects, despite having equivalent deficit symptoms. Unawareness of the social consequences of illness was found to be the component of insight more closely linked to social dysfunction. This suggests that impairments in insight may be uniquely associated with social dysfunction.