Psychiatry 68(2) Summer 2005 140

Personal Narratives of Illness in Schizophrenia:

Associations with Neurocognition and Symptoms
Paul H. Lysaker, Christopher M. France, Nicole L. Hunter,
and Louanne W. Davis

Controversy exists regarding whether unawareness/denial of illness in schizophre-

nia 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.

Relative to persons with other psychiat- bute that to a special talent or ability and not
ric disorders, persons diagnosed with schizo- to a “brain disorder.”
phrenia spectrum disorders are often unaware Taken as a whole, this phenomenon, is
of, or willfully contest that they have, what often referred to as “lack of awareness” or
others perceive as their symptoms and/or psy- “poor insight.” It is of wide interest to profes-
chosocial challenges (Amador, Strauss, Yale, sionals and families because it can persist in-
& Gorman, 1991; David, 1990). They may definitely and impact significantly upon out-
deny that they have problems which others come for those with schizophrenia. Lack of
perceive them to have, such as disordered awareness in schizophrenia spectrum disor-
speech. They may alternately acknowledge ders, for instance, has been linked to poorer
that they have experiences that others think treatment compliance (Bartko, Herczeg, &
are symptoms of mental illness, but offer a Zador, 1988; Cuffel, Alford, Fischer, & Owen,
different interpretation. For instance, they 1996; Smith et al., 1999), poorer clinical out-
may hear a voice others cannot hear and attri- come (Schwartz, 1998), poorer social function

Paul H. Lysaker, PhD, is affiliated with the Roudebush VA Medical Center and the Indiana University
School of Medicine in Indianapolis. Christopher M. France, PsyD, is affiliated with Cleveland State University.
Nicole L. Hunter, BA, and Louanne W. Davis, PsyD, are affiliated with the Roudebush VA Medical Center.
Address correspondence to Paul Lysaker, PhD, Day Hospital 116H, 1481 West 10th Steet, Roude-
bush VA Medical Center, Indianapolis, IN 46202; E-mail: [email protected]
Lysaker et al. 141

(Francis & Penn, 2001; Lysaker, Bell, Bryson, the medical model of mental illness. Higher
& Kaplan, 1998a), vocational dysfunction (Ly- levels of insight, for instance, have been asso-
saker, Bryson, & Bell, 2002), and to difficulties ciated with higher levels of dysphoria (Amador
developing working relationships with mental et al., 1994; Mintz, Dobson, & Romney, 2003;
health professionals (Frank & Gunderson, Thompson, 1988) and lowered self-esteem
1990). Thus for some, denying illness appears (Warner, Taylor, Powers, & Hyman, 1989).
linked to refusal to accept medications and a Further, embracing a view of self-as-ill, a view
wide range of psychosocial deficits. On the which leaves one vulnerable to widespread
other hand, acceptance of a “brain disorder” stigma (Corrigan & Penn, 1999; Wahl & Har-
which requires medications that may result in man, 1989), has also been associated with
many enduring and unwanted side effects can greater social dysfunction (Taylor & Perkins,
be demoralizing and result in despair (Dixon, 1991; Warner et. al., 1989). Thus, construct-
King, & Steiger, 1998). ing a personal understanding of schizophrenia
At present, researchers are divided con- in which symptoms or other socially stigma-
cerning the degree to which unawareness/ tized features of disorder are assigned less im-
denial of illness in schizophrenia is best con- portance and personal strengths are acknowl-
ceptualized as the result of cognitive deficits edged may represent for some a willful and
which globally limit persons’ abilities to grasp adaptive attempt to ward off misery and social
complex aspects of their lives. Persons with isolation. It should be noted that awareness
schizophrenia have been found to suffer from of illness appeared unrelated to cognition in
severe impairments in neurocognition (Saykin some samples (Cuesta & Peralta, 1995; Kemp
et al., 1991), and studies have found limited & David, 1996; Kim, Jayathilake, & Meltzer,
insight concurrently and prospectively pre- 2003), lending credence to an argument that
dicts poorer performance on tests of one cru- neurocognitive deficits alone do not fully ex-
cial aspect of neurocognition, executive func- plain poor insight in schizophrenia spectrum
tion (Lysaker & Bell, 1994; Lysaker, Bryson, disorders.
Lancaster, Evans, & Bell, 2003; Marks, Fas- Given that these views regarding the
tenau, Lysaker, & Bond, 2000; Mohamed, role of neurocognition have very different the-
Fleming, Penn, & Spaulding, 1999; Young, oretical and practical implications, some have
Davila, & Scher, 1993; Young, Zakzanis, & attempted a synthesis, suggesting each is par-
Bailey, 1998). Additionally, others have found tially correct and that insight is best accounted
that impairments in executive function predict for when both views are considered together
more intransigent deficits in insight (Lysaker (Startup, 1996). In other words, perhaps some
& Bell 1994). Authors arguing for a link be- contest that they are ill because of cognitive
tween insight and cognitive deficits have also impairments that limit the bounds of their
emphasized the similarity of poor insight in awareness while others deny or willfully reject
schizophrenia with anosognosia or unaware- illness in order to minimize or avoid social
ness of deficits in neurological disorders (Ama- alienation or having to take medications with
dor et al., 1991). undesirable side effects. While there is some
An alternative view in this debate is that empirical support for this synthesis in studies
“poor insight” may not represent a “lack” of using cluster analytic approaches (Lysaker et
awareness but instead reflects an alternative al., 2003), such a view may overlook the com-
and no less valid means of gaining control over plex processes by which persons achieve an
ones own life (Bassman, 2000; Roe & Kravetz, understanding of disabling illness. More im-
2003). For instance, it has been argued that portantly, it may also ignore the possibility
defining rejection of the medical model of that there are specific elements or processes
mental illness as a deficit is potentially a de- necessary to construct a narrative of illness
structive usage of social power (Rudge & that could be limited by neurocognitive defi-
Morse, 2001). In support of this view are find- cits.
ings that it may be adaptive for some to deny Accordingly, this paper seeks to explore
142 Personal Narratives

whether neurocognition, and, in particular, historical events which is inextricably involved

deficits in executive function or the ability to with interpretations of past successes and fail-
think in a flexible and abstract manner about ures as well as ever-developing dreams and
novel problems, could affect persons’ abilities expectations of the future (Davidson & Strauss,
to construct a coherent narrative of their diffi- 1995; Kirmayer & Corin, 1998; Williams &
culties. Of note, we are not asking whether Collins, 1999). As with other types of human
neurocognition limits acceptance of the bio- narratives, an awareness of mental illness is
logical model of schizophrenia. We ask instead less a collection of “cold,” unchanging facts
whether deficits in neurocognition are linked and more an evolving means of framing affects
with difficulties creating a story that others and putting daily life events into a context
can understand and join in dialogue about, which is embedded in conversation within and
a story that might or might not endorse a between persons (Hermans, 1996; Lysaker &
biological view of schizophrenia. France, 1999).
To examine whether certain neurocog- One important implication of regard-
nitive deficits are linked with breakdown in ing lack of insight as a narrative that fails to
the creation of a coherent narrative, we first capture key illness-related processes readily
discuss how awareness or acknowledgment of grasped by others is that this view allows for
illness represents a complex personal con- the possibility that there are different ways in
struction that is established within a life story, which a story of illness might come to be
and the distinctly different reasons such a con- perceived as insightful vs. not insightful. For
struction may fail to develop into a coherent instance, a narrative of illness might be per-
account of schizophrenia. Hypotheses regard- ceived by others as evidencing poor insight if
ing which specific aspects of narrative con- the narrative is missing key facts about the
struction are likely to be related to neurocog- illness and its impact. Alternatively, the narra-
nition are presented next and followed by the tive may include multiple illness-related facts
findings of a study which examines correla- but still be perceived as lacking insight because
tions between a measure of narrative structure the facts lack sufficient temporal conceptual
within a story of illness and measures of neuro- organization and thus do not allow others to
cognition, symptoms and function. discover their meaning. Beyond the presence
or absence of facts and their organization, a
story of illness may be construed as lacking
AWARENESS OF ILLNESS insight because it is utterly improbable.
AS A NARRATIVE ACT

Though insight is often discussed and NEUROCOGNITION AND

measured as the possession or endorsement NARRATIVE STRUCTURE
of specific facts, such as “I have symptom X”
or “I need treatment Y” (Marks et al., 2000), As discussed elsewhere, we have devel-
awareness or acceptance of any type of illness oped the Narrative Coherence Rating Scale
is probably not best understood as an isolated (NCRS) (Lysaker et al., 2002b) that opera-
cognition akin to a solitary entry in a tradi- tionalizes three narrative elements that are hy-
tional database, that is, one that can be entered pothetically necessary for awareness of illness.
or erased without affecting its neighbors. As These include 1) “Richness of Details,” or the
in other medical illnesses (Kleinman, 1988), enumeration of distinct aspects of the disor-
a person’s understanding of her or his schizo- der; 2) “Temporal Conceptual Connections”
phrenia represents an element of a larger per- (previously “Logical Connections”), or the
sonal and narrative understanding of a life presence of associative connections between
(Lysaker, Clements, Plascak-Hallberg, Knip- story elements; and 3) “Plausibility,” or the
scheer, & Wright, 2002b). An understanding perception of likelihood that the story is accu-
of schizophrenia is itself a narrative account of rate. The NCRS is used to rate narratives of
Lysaker et al. 143

illness generated via a semi-structured inter- of life events and also to flexibly shape and
view we have labeled the Indiana Psychiatric reshape their understanding of their disorder.
Illness Interview (IPII) that inquires about This hypothesis seems consistent with recent
deficits as well as abilities, strengths, and findings that deficits in executive function may
hopes. This procedure has the benefit of al- be uniquely linked to difficulties “re-labeling”
lowing for the assessment of how the story of the experience of psychotic symptoms as an
illness as a whole coheres along the three experience of symptoms (Drake & Lewis, 2003)
noted dimensions and thus does not rate in- as well as findings that deficits in executive
sight as adherence to one particular point of function are uniquely linked to greater diffi-
view or as agreement with specific facts or culties understanding the affects of others
theories. (Bryson, Bell, Lysaker, Greig, & Kaplan, 1997).
To better clarify how impairments in To rule out the possibility that any ob-
neurocognition may or may not be related served relationships between the WCST and
to awareness of illness, this study gathered the (NCRS) Temporal Conceptual Connec-
narratives of illness among persons with tions and Plausibility scores were a reflection
schizophrenia spectrum disorders using a of generalized deficits, we also included mea-
semi-structured interview (the IPII), rated sures of verbal memory and premorbid intel-
such narratives using the NCRS, and com- lectual function and anticipated that these
pared the NCRS scores with concurrent as- measures would be relatively unrelated to the
sessments of different aspects of neurocogni- Temporal Conceptual Connections and Plau-
tion. We first hypothesized that the NCRS sibility scores. Regarding the presence or ab-
scores for Temporal Conceptual Connections sence of details (“Richness of Details”) that
would be strongly related to the ability to provide the characters and settings within nar-
think in a flexible and abstract manner as as- ratives, we reasoned that this element most
sessed by the Wisconsin Card Sorting Test likely reflects personal choice rather than be-
(WCST) (Heaton, Chelune, Talley, Kay, & ing susceptible to deficits in executive function
Curtis, 1993). Here we reasoned that lesser and thus would not be strongly related in ei-
levels of these abilities might reduce persons’ ther direction to WCST scores.
abilities to connect story elements over shift- Of note, beyond assessing links between
ing time points, resulting in less conceptually neurocognition and the qualities of illness nar-
organized stories (i.e., lower NCRS Temporal ratives, this study was also designed to allow
Conceptual Connections scores). several more exploratory analyses. First, as
We secondly predicted that poorer noted earlier, previous research has found in
WCST performance would be linked to lesser some samples that lesser awareness of illness
levels of Plausibility. It is generally understood was linked to heightened symptom levels and
that persons construct stories of their lives greater social dysfunction (Lysaker, Bell, Bry-
with an audience in mind (Andersen & Chen, son, & Kaplan, 1998b; Mintz et al., 2003). In
2002; Hermans, 1996). Whether a potential order to explore this area, we included mea-
source of or threat to validation, that audience sures of positive, negative, and depressive
may also serve to limit distortion since aspects symptoms and an assessment of global social
of stories may be revised in anticipation of function. We predicted that higher levels of
how the audience may react to the story. For positive symptoms might be linked to lesser
instance, a story of a humiliating event may levels of narrative plausibility and temporal
be told and retold in our mind according to conceptual connections, and that negative
how we think others will react to it, even if symptoms might predict fewer narrative de-
we plan to tell no one. We thus reasoned that tails. Here we reasoned that greater positive
deficits in the ability to think flexibly might symptoms might interfere with the ability to
limit plausibility because of their potential to organize a coherent account of illness, while
limit persons’ abilities to flexibly anticipate greater negative symptoms might naturally
how others would react to their construction lead to a paucity of details in the narratives.
144 Personal Narratives

We also predicted that greater awareness of ten or typed form during the interview, or
illness across all three NCRS domains would audiotaped and later transcribed. The inter-
be associated with greater emotional distress. view is divided conceptually into four sections.
We further predicted poorer social function First, rapport is established and the participant
would be linked to less plausible and less tem- is asked to tell the story of their lives in as
porally conceptually connected narratives, much detail as they can. Second, the partici-
reasoning that persons may be more likely to pant is asked if they think they have a mental
have difficulty relating to others and/or to be illness and how they understand it. This is
shunned by others if their stories are bizarre followed up with the participant being asked
or difficult to follow. Finally, though we pre- to say more about their experience of mental
viously presented data on the concurrent va- illness, including what has and has not been
lidity of the NCRS (Lysaker et al., 2002b), affected by their condition in terms of work,
we also planned to repeat this analysis and social life, and psychological life. Here, life
therefore included a traditional measure of changes related to mental illness may be ex-
insight which assessed in a categorical fashion pressed in a desirable or undesirable direction.
whether or not persons believed they suffered In the third section, the participant is asked
from a psychiatric disorder. whether and, if so, how their condition “con-
trols” their life and how they “control” their
condition. Fourth, the participant is asked
METHOD what he or she expects will stay the same and
what will be different or improve into the
Participants future.
This measure (the IPII in combination
Fifty-one males and one female with with NCRS ratings) differs from other ratings
DSM-IV diagnoses of schizophrenia (n = 38) of insight derived from interviews such as the
or schizoaffective disorder (n = 14) were re- Scale to Assess Unawareness of Mental Illness
cruited from an outpatient psychiatry clinic at (SUMD) (Amador et al., 1994) in that the
a midwestern VA Medical Center. The mean interview does not introduce content and ask
age was 47.2 (sd = 9.01) and mean education for comments on the content. Thus, if the
was 13.8 (sd = 4.29) years. Participants had a participant does not mention hallucinations,
mean of 7.8 (sd = 7.90) lifetime hospitaliza- the IPII interviewer does not inquire about
tions with the first occurring on average at age hallucinations. The interviewer may ask for
27 (sd = 6.34). Thirty-four participants were clarification when confused and may query
Caucasian, 17 were African American and one non-directively, using language consistent
Latino. All participants were in a post-acute with the participant’s words. The tone of the
phase of illness as defined by having no hospi- interview is intended to be conversational
talizations or changes in medication or hous- rather than interrogatory or judgmental. The
ing in the month prior to entering the study. interviewer’s task is to elicit enough informa-
Excluded from the study were participants tion to understand the story the participant is
with a history of mental retardation or active telling about his or her mental illness, not to
substance abuse. confirm or disagree with that story. The IPII
thus results in a narrative of illness that can
Instruments be analyzed in terms of its overall form and
qualities rather than (as is often the case with
Indiana Psychiatric Illness Interview (IPII) traditional insight measures) its specifics.
(Lysaker et al. 2002b). IPII is the semi struc- Narrative Coherence Rating Scale (NCRS)
tured interview developed to assess illness nar- (Lysaker et al., 2002b). NCRS is the 18-point
ratives. A research assistant conducts the in- rating scale that assesses narrative coherence
terview that lasts between 30 and 60 minutes. of illness narratives. It is completed by a
Responses can be recorded verbatim in writ- trained rater following a review of the IPII
Lysaker et al. 145

transcript. The NCRS is composed of three tice to avoid confusion with what is referred
subscales, each rated 0–3 for both past and to as Plausibility.
present, using anchors described in Table 1. In a previous study (Lysaker et al.,
The first, “Temporal Conceptual Connec- 2002b) utilizing a different sample, we re-
tions,” is the sum of the degree to which the ported evidence of good to excellent interrater
elements of the story of illness are temporally reliability and internal consistency of the
connected in a manner such that events can NCRS as well as evidence of concurrent valid-
be followed as they unfold in the past and ity, including significant correlations with
move into the present. Narratives are rated as standard measures of insight. To assess inter-
lacking in temporal conceptual connections rater reliability for the current study, one-third
when elements of the story fail to follow one of the sample (n = 18) was rated by two sepa-
another in logical manner over time. In their rate raters blind to one another’s ratings. Evi-
most extreme form difficulties in this area dence of acceptable interrater reliability was
would result in a story where events could not again found, with intraclass correlations rang-
be followed or fit according to a time line. ing from .85 to .92 for the Details, Temporal
The second scale, “Richness of Details,” is the Conceptual Connections, and Plausibility to-
sum of ratings of the degree to which the story tal scores and .93 for the overall NCRS total
of illness is sufficiently detailed in the past and score. Acceptable levels of internal consis-
present. In their most extreme form, difficul- tency were also found for the current sample,
ties in this area result in a story in which there with a calculated coefficient alpha of .88 (Ta-
are few if any details, characters or descrip- ble 1).
tions of events. The third scale, “Plausibility,” Of note, the NCRS assesses the struc-
is the sum of separate ratings of the degree of tures within a narrative that allow for persons
plausibility of the story of illness in the past to understand one another’s narratives and to
and present. In their extreme form, difficulties join in dialogue with others about those narra-
in this area result in stories which no one tives. Thus, someone could present a fully
in the participant’s community would likely coherent narrative which is full of rich detail,
believe, such as being abducted by an alien temporally connected, and plausible while de-
resembling Vivaldi. For each item, phenom- nying or being unaware of their illness. Fur-
ena are rated as they are reflected within the thermore, each dimension is conceptualized
narrative as a whole. Anchors for each item as phenomena which can exist independent of
are presented in Table 1. Note that we have one another, such that a story could have few
previously referred to Temporal Conceptual to any details yet be temporally sound and
Connections as “Logical Connections” (Ly- plausible, while another could be implausible
saker et al., 2002b) but discontinued that prac- yet full of rich, temporally connected details

Table 1.
Rating Criteria for the Narrative Coherence Rating Scale

NCRS Scale 0 1 2 3

Temporal Con- Many major instances Some major or many Some minor instances Not missing temporal
ceptual Con- of no conceptual minor instances of of no temporal con- conceptual con-
nections temporal connec- no temporal con- ceptual connections nections
tions ceptual connections
Richness of Missing many major Missing some major Missing some minor No details missing
Details details or many minor de- details
tails
Plausibility Many major moments Some major or many Some minor mo- Not lacking realism
lacking realism minor moments ments lacking re-
lacking realism alism
146 Personal Narratives

and another with the thinnest temporal se- “Common Objects and Activities,” assesses
quence but richly detailed and believable. level of community function. Of note, we were
Positive and Negative Syndrome Scale not interested in the fourth score, “Instrumen-
(PANSS) (Kay, Fizszbein, & Opler, 1987). The tal Function,” which assesses vocational and
PANSS is a 30-item rating scale completed by role function, since all participants were enter-
clinically trained research staff at the conclu- ing vocational rehabilitation and thus were all
sion of chart review and a semi-structured in- equally unemployed. Good to excellent inter-
terview. For the purposes of this study, the rater reliability was found for the QOL factor
Positive, Negative, and Emotional Discom- scores for this study, with intraclass correla-
fort PANSS factor analytically derived com- tions ranging from .88 to .93.
ponents were utilized (Bell, Lysaker, Goulet, Wisconsin Card Sorting Test (WCST)
Milstein, & Lindenmayer, 1994). The factor (Heaton et. al., 1993). WCST is a neuropsy-
structure of the PANSS has been widely repli- chological test in which participants sort cards
cated and information about its predictive va- that vary according to shape, color, and num-
lidity presented elsewhere (Bryson, Bell, Greig, ber of objects depicted. Participants are asked
& Kaplan, 1999). Good to excellent interrater to match cards to “key” cards but are not told
reliability was found for the raters of the cur- the matching principle which changes period-
rent study with intraclass correlations ranging ically without warning to the participant. This
from .80 to .93. study utilized one WCST score: the total
Scale to Assess Unawareness of Mental Dis- number of categories achieved. This measure
order (SUMD) (Amador et al., 1994). SUMD provides an assessment of participants’ abili-
is a rating scale completed by clinically trained ties to obtain an abstract set, to keep that set
research staff following a semi-structured in- over multiple trials, and then to flexibly shift
terview and chart review. For the purposes of that set when unexpectedly required.
this study, we used the total score or the sum Hopkins Verbal Memory Test (HVLT)
of the three central items of the SUMD which (Brandt, 1991). HVLT is an auditory verbal
are: 1) awareness of mental disorder; 2) aware- memory test in which the experimenter orally
ness of the consequences of mental disorder; presents a list of 12 words, each belonging to
and 3) awareness of the effects of medication. one of three semantic categories. After each
Each of these items is rated on a five-point trial, participants are asked to repeat as many
scale which ranges from “1” (complete aware- words from the list as they can remember. For
ness) to “5” (severe unawareness). Interrater the purposes of this study, the age corrected
reliability for this study was found to be in t-score for total correct score on all three trials
the excellent range with an intraclass correla- was utilized.
tion of .89. Vocabulary Subtest of the WAIS-III (Wech-
Quality of Life Scale (QOL) (Heinrichs, sler, 1997). WAIS-III assesses participants’
Hanlon, & Carpenter, 1984). QOL is a 21-item knowledge of vocabulary. The age-corrected
scale completed by clinically trained research scale score is the best single correlate of verbal
staff following a semi-structured interview and intelligence and has been widely used as a brief
chart review. For the purposes of this study, assessment of premorbid intellectual function
we were interested in the sum of three of the (Lezak, 1995).
four factor scores of the QOL. The first, “In-
terpersonal Relations,” measures the fre- Procedures
quency of recent social contacts and includes
separate assessments, for example, of frequency Following informed consent, partici-
of contacts with friends and acquaintances. pants were given the WCST, HVLT, WAIS-
The second, “Intrapsychic Foundations,” III Vocabulary Subtest, PANSS, QOL, and
measures qualitative aspects of interpersonal IPII as part of a baseline assessment for a study
relationships and includes assessments of such of the effects of cognitive behavior therapy on
qualities as empathy for others. The third, work outcome. The IPII interview was audio-
Lysaker et al. 147

taped and later transcribed. All identifying in- with Positive symptoms (partial R2 = .33, p <
formation (e.g., names of others and places) .0001) and WCST (partial R2 = .18, p < .0001)
was removed from the transcripts. Ratings of making unique contributions. A parallel re-
the transcripts were thus made blind to patient gression predicting the NCRS Total from
identity, test performance, symptom level, and Positive symptoms and WCST performance
ratings of function. The NCRS raters thus similarly produced a significant equation (F
were also blind to participants’ PANSS and (2,52) = 24.2, p < .0001) with Positive symp-
QOL scores. The raters were not present dur- toms (partial R2 = .36, p < .0001) and WCST
ing the IPII interviews, nor did they transcribe performance (partial R2 = .13, p < .0001) again
the audiotapes of the interviews. making unique contributions. Univariate cor-
relations revealed that the SUMD total was
Results not related to PANSS scores, QOL total, Vo-
cabulary, or WCST performance. However,
Means and standard deviations for the poor awareness of illness on the SUMD was
NCRS scores were as follows: Temporal Con- associated with poorer verbal memory on the
ceptual Connections: 4.5 (2.0); Richness of HVLT (r = −.38, p < .01).
Details: 3.5 (1.9); Plausibility: 3.4.(2.4); and Last, given disagreement regarding
Total: 11.2 (5.3). NCRS scores were unrelated whether WCST performance is best captured
to age, education, and lifetime number of hos- by number of correct categories or the num-
pitalizations. The NCRS scores of partici- ber of perseverative errors (i.e., errors indicat-
pants with schizophrenia did not differ from ing inflexibility rather than inconsistency of
those of participants with schizoaffective dis- response style), the age and education correc-
order. The three NCRS total scores were sig- tion T-scores for percentage of perseverative
nificantly correlated with one another, ac- errors were correlated with the NCRS scores.
counting for between 12% (Details and Equivalent correlations were again produced
Temporal Conceptual Connections) and 38% between WCST and the NCRS Plausibility
(Plausibility and Temporal Conceptual Con- and Total scores (Table 2).
nections) of the variance. The SUMD total
score was significantly related to the NCRS Discussion
Details (r = −.51, p < .0001), Plausibility (r =
−.41, p < .01), Temporal Conceptual Connec- Results suggest that variations in the
tions (r = −.29, p < .05), and Total scores (r = narrative structure of verbatim accounts of
−.52, p < .0001). schizophrenia are related to different clinical
To examine the relationships between features of illness. As predicted, impairments
narrative coherence of participants’ accounts in flexibility in abstract thought and social iso-
of their illness and neurocognition, symptom lation were related to lesser ratings of plausi-
levels, and social function, we calculated cor- bility of the illness narratives. Persons who
relations between NCRS and WCST, WAIS- achieved fewer categories on the WCST, who
III Verbal Scale, HVLT, PANSS, and QOL had greater difficulty engaging in flexible ab-
scores. As NCRS, PANSS, and QOL scores stract thought, tended to tell less plausible
are ordinal in nature, Spearman Rho coeffi- stories, and persons who told less plausible
cients were obtained. These are summarized stories tended to be more socially isolated.
in Table 2 below. Since Plausibility was signifi- Level of Positive symptoms was also strongly
cantly correlated with WCST, Positive symp- related to Plausibility and to Temporal Con-
toms, and QOL scores, a stepwise multiple ceptual Connections. With more severe levels
regression was performed in which each of of Positive symptoms, accounts of illness were
these three variables was allowed to enter to less organized according to a temporal frame
predict Plausibility. and again less plausible. Notably, the relation-
This regression produced a significant ships of WCST and Positive symptoms to
predictor equation (F (2,52) = 26.7, p < .0001) plausibility were relatively independent of one
148 Personal Narratives

Table 2.
Clinical Social and Neurocognitive Correlates1 of Three Dimensions of Narrative Coherence

WAIS III Quality

WCST HVLT Vocabulary PANSS Component of Life
NCRS Categories Total Scaled Emotional Total
Subscale Achieved Recall Score Positive Negative Discomfort Score

Details .14 .14 .19 −.25 .21 .29 .11

Temporal
Conceptual
Connections .30 −.03 .22 −.51** .00 .07 .10
Plausibility .53** .18 .25 −.56** .27 .04 .37*
Total .44** .26 .26 −.58** .23 .14 .29

Spearman Rho; *p < .01; **p < .001

1

another. When combined in a regression, condition is sufficiently believable and con-

these variables were able to capture more than ceptually organized for others to be able to
half of the variance in the NCRS Plausibility understand and engage in a dialogue about
scores. that story.
As predicted, lesser plausibility was While the correlational nature of this
linked to lesser levels of social function, al- research precludes drawing any conclusions
though this relationship was obscured in the regarding causality, results suggest some
multiple regression when Positive symptoms hypotheses for future consideration. For one,
and neurocognition were controlled for, sug- perhaps deficits in flexibility of abstract
gesting it may have been mediated by these thought result in an inability to fully consider
correlates. As anticipated, SUMD ratings of the perspectives of others when telling and
insight were correlated with NCRS Totals. retelling a story of illness, resulting in stories
Thus, persons who were unaware of illness in a that others are likely to discount. Further, per-
categorical sense evidenced greater difficulties haps such deficits also interfere with the capac-
constructing a narrative of themselves and ity to flexibly revise and reshape a narrative,
their disorder. No relationships were found resulting in an increasingly less well-orga-
between any variable and NCRS Richness of nized narrative of illness over time. With re-
Details score. Negative symptoms scores, gard to clinical variables, it may also be that
Emotional Discomfort scores, measures of as positive symptoms grow stronger, they in-
Verbal memory, and Premorbid function were terfere with the organization of a narrative
not significantly related to NCRS scores. understanding of illness as well as an appraisal
Results may thus be interpreted as sup- of how believable a narrative will be to others.
port for the larger hypothesis that when it Last, it may also be that as persons are more
comes to creating a narrative of one’s illness, socially isolated they tend to tell more idiosyn-
there are structural aspects of that narrative cratic stories of their illness. Again, given the
construction which are related to cognition correlational nature of this study, alternative
and others which are not. Returning to the hypotheses cannot be ruled out. It may be, for
issue of whether awareness of illness should be instance, that with less coherent narratives of
construed as a function of cognitive capacity, illness persons are forced to rely on more delu-
perhaps it can be seen as more a matter of sional interpretations of life or that cognitive
personal construction when referring to the impairments proceed from narrative impover-
richness and choice of details which enhance ishment and not the reverse.
others’ ability to understand an illness narra- With replication across broader sam-
tive; cognitive capacities may be implicated in ples and settings, we would suggest that assess-
the extent to which a person’s account of their ments of insight at the narrative level may
Lysaker et al. 149

reveal correlates and aspects of etiology of ment. Thus, replication is needed with more
poor insight not uncovered by traditional diverse groups, including women, persons in
measures. By assessing the different ways in an earlier phase of illness, and those refusing
which a narrative of illness can fail to achieve treatment. Second, the narratives were elicited
coherence, perhaps we can better understand here in a dialogue with an interviewer in a
the complex relationships between awareness, particular social context. Thus, replication
denial, neurocognition, and emotional pain. with interviewers in other sites and non-clini-
For instance, future studies could potentially cal settings is also essential, as is research on
ask how narratives of illness might be affected the influence of the interviewer. Third, the
by personality, self-efficacy, attributional styles, NCRS assesses three facets of narrative be-
and/or community and self-stigma. Addition- lieved to be intricately involved in narrative
ally, a better understanding and means of mea- coherence. There may be more aspects of nar-
suring the coherence of an illness narrative rative yet to be articulated that could be incor-
could have important implications for out- porated in future versions of the scale. Finally,
come research. It is widely noted that one since multiple correlations were performed in
of the unique outcomes which psychotherapy the validity analyses, the chances of spurious
seeks to effect in schizophrenia is increased findings are inflated, even though more con-
narrative coherence (Fenton, 2000; Haugs- servative alphas and two-tailed tests were em-
jerd, 1994; Lysaker & Lysaker, 2001). One ployed.
might similarly use these methods to ask As a final note, it is the intent of this
whether pharmacological interventions, which study to supplement current insight research
appear to increase cognitive capabilities, are by providing a means of assessing awareness
similarly related to increases in narrative coher- of illness as it is embedded within a personal
ence in schizophrenia or related conditions. narrative. We would suggest that both tradi-
Of note, there are several limitations tional and narrative approaches to assessing
to this study. Most participants were male, insight would complement one another and
middle-aged, and generally many years had enrich our understanding of the experiences
passed since the onset of their illness. Addi- and dialogues that play out within a lifetime
tionally, all were in some form of active treat- of living with mental illness.

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