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-
ric disorders, persons diagnosed with schizo-
phrenia spectrum disorders are often unaware
of, or willfully contest that they have, what
others perceive as their symptoms and/or psy-
chosocial challenges (Amador, Strauss, Yale,
& Gorman, 1991; David, 1990). They may
deny that they have problems which others
perceive them to have, such as disordered
speech. They may alternately acknowledge
that they have experiences that others think
are symptoms of mental illness, but offer a
different interpretation. For instance, they
may hear a voice others cannot hear and attri-
bute that to a special talent or ability and not
to a “brain disorder.”
Taken as a whole, this phenomenon, is
often referred to as “lack of awareness” or
“poor insight.” It is of wide interest to profes-
sionals and families because it can persist in-
definitely and impact significantly upon out-
come for those with schizophrenia. Lack of
awareness in schizophrenia spectrum disor-
ders, for instance, has been linked to poorer
treatment compliance (Bartko, Herczeg, &
Zador, 1988; Cuffel, Alford, Fischer, & Owen,
1996; Smith et al., 1999), poorer clinical out-
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: paul.lysaker@med.va.gov
Lysaker et al.
(Francis & Penn, 2001; Lysaker, Bell, Bryson,
& Kaplan, 1998a), vocational dysfunction (Ly-
saker, Bryson, & Bell, 2002), and to difficulties
developing working relationships with mental
health professionals (Frank & Gunderson,
1990). Thus for some, denying illness appears
linked to refusal to accept medications and a
wide range of psychosocial deficits. On the
other hand, acceptance of a “brain disorder”
which requires medications that may result in
many enduring and unwanted side effects can
be demoralizing and result in despair (Dixon,
King, & Steiger, 1998).
At present, researchers are divided con-
cerning the degree to which unawareness/
denial of illness in schizophrenia is best con-
ceptualized as the result of cognitive deficits
which globally limit persons’ abilities to grasp
complex aspects of their lives. Persons with
schizophrenia have been found to suffer from
severe impairments in neurocognition (Saykin
et al., 1991), and studies have found limited
insight concurrently and prospectively pre-
dicts poorer performance on tests of one cru-
cial aspect of neurocognition, executive func-
tion (Lysaker & Bell, 1994; Lysaker, Bryson,
Lancaster, Evans, & Bell, 2003; Marks, Fas-
tenau, Lysaker, & Bond, 2000; Mohamed,
Fleming, Penn, & Spaulding, 1999; Young,
Davila, & Scher, 1993; Young, Zakzanis, &
Bailey, 1998). Additionally, others have found
that impairments in executive function predict
more intransigent deficits in insight (Lysaker
& Bell 1994). Authors arguing for a link be-
tween insight and cognitive deficits have also
emphasized the similarity of poor insight in
schizophrenia with anosognosia or unaware-
ness of deficits in neurological disorders (Ama-
dor et al., 1991).
An alternative view in this debate is that
“poor insight” may not represent a “lack” of
awareness but instead reflects an alternative
and no less valid means of gaining control over
ones own life (Bassman, 2000; Roe & Kravetz,
2003). For instance, it has been argued that
defining rejection of the medical model of
mental illness as a deficit is potentially a de-
structive usage of social power (Rudge &
Morse, 2001). In support of this view are find-
ings that it may be adaptive for some to deny
141
the medical model of mental illness. Higher
levels of insight, for instance, have been asso-
ciated with higher levels of dysphoria (Amador
et al., 1994; Mintz, Dobson, & Romney, 2003;
Thompson, 1988) and lowered self-esteem
(Warner, Taylor, Powers, & Hyman, 1989).
Further, embracing a view of self-as-ill, a view
which leaves one vulnerable to widespread
stigma (Corrigan & Penn, 1999; Wahl & Har-
man, 1989), has also been associated with
greater social dysfunction (Taylor & Perkins,
1991; Warner et. al., 1989). Thus, construct-
ing a personal understanding of schizophrenia
in which symptoms or other socially stigma-
tized features of disorder are assigned less im-
portance and personal strengths are acknowl-
edged may represent for some a willful and
adaptive attempt to ward off misery and social
isolation. It should be noted that awareness
of illness appeared unrelated to cognition in
some samples (Cuesta & Peralta, 1995; Kemp
& David, 1996; Kim, Jayathilake, & Meltzer,
2003), lending credence to an argument that
neurocognitive deficits alone do not fully ex-
plain poor insight in schizophrenia spectrum
disorders.
Given that these views regarding the
role of neurocognition have very different the-
oretical and practical implications, some have
attempted a synthesis, suggesting each is par-
tially correct and that insight is best accounted
for when both views are considered together
(Startup, 1996). In other words, perhaps some
contest that they are ill because of cognitive
impairments that limit the bounds of their
awareness while others deny or willfully reject
illness in order to minimize or avoid social
alienation or having to take medications with
undesirable side effects. While there is some
empirical support for this synthesis in studies
using cluster analytic approaches (Lysaker et
al., 2003), such a view may overlook the com-
plex processes by which persons achieve an
understanding of disabling illness. More im-
portantly, it may also ignore the possibility
that there are specific elements or processes
necessary to construct a narrative of illness
that could be limited by neurocognitive defi-
cits.
Accordingly, this paper seeks to explore
142
whether neurocognition, and, in particular,
deficits in executive function or the ability to
think in a flexible and abstract manner about
novel problems, could affect persons’ abilities
to construct a coherent narrative of their diffi-
culties. Of note, we are not asking whether
neurocognition limits acceptance of the bio-
logical model of schizophrenia. We ask instead
whether deficits in neurocognition are linked
with difficulties creating a story that others
can understand and join in dialogue about,
a story that might or might not endorse a
biological view of schizophrenia.
To examine whether certain neurocog-
nitive deficits are linked with breakdown in
the creation of a coherent narrative, we first
discuss how awareness or acknowledgment of
illness represents a complex personal con-
struction that is established within a life story,
and the distinctly different reasons such a con-
struction may fail to develop into a coherent
account of schizophrenia. Hypotheses regard-
ing which specific aspects of narrative con-
struction are likely to be related to neurocog-
nition are presented next and followed by the
findings of a study which examines correla-
tions between a measure of narrative structure
within a story of illness and measures of neuro-
cognition, symptoms and function.
AWARENESS OF ILLNESS
AS A NARRATIVE ACT
Though insight is often discussed and
measured as the possession or endorsement
of specific facts, such as “I have symptom X”
or “I need treatment Y” (Marks et al., 2000),
awareness or acceptance of any type of illness
is probably not best understood as an isolated
cognition akin to a solitary entry in a tradi-
tional database, that is, one that can be entered
or erased without affecting its neighbors. As
in other medical illnesses (Kleinman, 1988),
a person’s understanding of her or his schizo-
phrenia represents an element of a larger per-
sonal and narrative understanding of a life
(Lysaker, Clements, Plascak-Hallberg, Knip-
scheer, & Wright, 2002b). An understanding
of schizophrenia is itself a narrative account of
Personal Narratives
historical events which is inextricably involved
with interpretations of past successes and fail-
ures as well as ever-developing dreams and
expectations of the future (Davidson & Strauss,
1995; Kirmayer & Corin, 1998; Williams &
Collins, 1999). As with other types of human
narratives, an awareness of mental illness is
less a collection of “cold,” unchanging facts
and more an evolving means of framing affects
and putting daily life events into a context
which is embedded in conversation within and
between persons (Hermans, 1996; Lysaker &
France, 1999).
One important implication of regard-
ing lack of insight as a narrative that fails to
capture key illness-related processes readily
grasped by others is that this view allows for
the possibility that there are different ways in
which a story of illness might come to be
perceived as insightful vs. not insightful. For
instance, a narrative of illness might be per-
ceived by others as evidencing poor insight if
the narrative is missing key facts about the
illness and its impact. Alternatively, the narra-
tive may include multiple illness-related facts
but still be perceived as lacking insight because
the facts lack sufficient temporal conceptual
organization and thus do not allow others to
discover their meaning. Beyond the presence
or absence of facts and their organization, a
story of illness may be construed as lacking
insight because it is utterly improbable.
NEUROCOGNITION AND
NARRATIVE STRUCTURE
As discussed elsewhere, we have devel-
oped the Narrative Coherence Rating Scale
(NCRS) (Lysaker et al., 2002b) that opera-
tionalizes three narrative elements that are hy-
pothetically necessary for awareness of illness.
These include 1) “Richness of Details,” or the
enumeration of distinct aspects of the disor-
der; 2) “Temporal Conceptual Connections”
(previously “Logical Connections”), or the
presence of associative connections between
story elements; and 3) “Plausibility,” or the
perception of likelihood that the story is accu-
rate. The NCRS is used to rate narratives of
Lysaker et al.
illness generated via a semi-structured inter-
view we have labeled the Indiana Psychiatric
Illness Interview (IPII) that inquires about
deficits as well as abilities, strengths, and
hopes. This procedure has the benefit of al-
lowing for the assessment of how the story of
illness as a whole coheres along the three
noted dimensions and thus does not rate in-
sight as adherence to one particular point of
view or as agreement with specific facts or
theories.
To better clarify how impairments in
neurocognition may or may not be related
to awareness of illness, this study gathered
narratives of illness among persons with
schizophrenia spectrum disorders using a
semi-structured interview (the IPII), rated
such narratives using the NCRS, and com-
pared the NCRS scores with concurrent as-
sessments of different aspects of neurocogni-
tion. We first hypothesized that the NCRS
scores for Temporal Conceptual Connections
would be strongly related to the ability to
think in a flexible and abstract manner as as-
sessed by the Wisconsin Card Sorting Test
(WCST) (Heaton, Chelune, Talley, Kay, &
Curtis, 1993). Here we reasoned that lesser
levels of these abilities might reduce persons’
abilities to connect story elements over shift-
ing time points, resulting in less conceptually
organized stories (i.e., lower NCRS Temporal
Conceptual Connections scores).
We secondly predicted that poorer
WCST performance would be linked to lesser
levels of Plausibility. It is generally understood
that persons construct stories of their lives
with an audience in mind (Andersen & Chen,
2002; Hermans, 1996). Whether a potential
source of or threat to validation, that audience
may also serve to limit distortion since aspects
of stories may be revised in anticipation of
how the audience may react to the story. For
instance, a story of a humiliating event may
be told and retold in our mind according to
how we think others will react to it, even if
we plan to tell no one. We thus reasoned that
deficits in the ability to think flexibly might
limit plausibility because of their potential to
limit persons’ abilities to flexibly anticipate
how others would react to their construction
143
of life events and also to flexibly shape and
reshape their understanding of their disorder.
This hypothesis seems consistent with recent
findings that deficits in executive function may
be uniquely linked to difficulties “re-labeling”
the experience of psychotic symptoms as an
experience of symptoms (Drake & Lewis, 2003)
as well as findings that deficits in executive
function are uniquely linked to greater diffi-
culties understanding the affects of others
(Bryson, Bell, Lysaker, Greig, & Kaplan, 1997).
To rule out the possibility that any ob-
served relationships between the WCST and
the (NCRS) Temporal Conceptual Connec-
tions and Plausibility scores were a reflection
of generalized deficits, we also included mea-
sures of verbal memory and premorbid intel-
lectual function and anticipated that these
measures would be relatively unrelated to the
Temporal Conceptual Connections and Plau-
sibility scores. Regarding the presence or ab-
sence of details (“Richness of Details”) that
provide the characters and settings within nar-
ratives, we reasoned that this element most
likely reflects personal choice rather than be-
ing susceptible to deficits in executive function
and thus would not be strongly related in ei-
ther direction to WCST scores.
Of note, beyond assessing links between
neurocognition and the qualities of illness nar-
ratives, this study was also designed to allow
several more exploratory analyses. First, as
noted earlier, previous research has found in
some samples that lesser awareness of illness
was linked to heightened symptom levels and
greater social dysfunction (Lysaker, Bell, Bry-
son, & Kaplan, 1998b; Mintz et al., 2003). In
order to explore this area, we included mea-
sures of positive, negative, and depressive
symptoms and an assessment of global social
function. We predicted that higher levels of
positive symptoms might be linked to lesser
levels of narrative plausibility and temporal
conceptual connections, and that negative
symptoms might predict fewer narrative de-
tails. Here we reasoned that greater positive
symptoms might interfere with the ability to
organize a coherent account of illness, while
greater negative symptoms might naturally
lead to a paucity of details in the narratives.
144
We also predicted that greater awareness of
illness across all three NCRS domains would
be associated with greater emotional distress.
We further predicted poorer social function
would be linked to less plausible and less tem-
porally conceptually connected narratives,
reasoning that persons may be more likely to
have difficulty relating to others and/or to be
shunned by others if their stories are bizarre
or difficult to follow. Finally, though we pre-
viously presented data on the concurrent va-
lidity of the NCRS (Lysaker et al., 2002b),
we also planned to repeat this analysis and
therefore included a traditional measure of
insight which assessed in a categorical fashion
whether or not persons believed they suffered
from a psychiatric disorder.
METHOD
Participants
Fifty-one males and one female with
DSM-IV diagnoses of schizophrenia (n = 38)
or schizoaffective disorder (n = 14) were re-
cruited from an outpatient psychiatry clinic at
a midwestern VA Medical Center. The mean
age was 47.2 (sd = 9.01) and mean education
was 13.8 (sd = 4.29) years. Participants had a
mean of 7.8 (sd = 7.90) lifetime hospitaliza-
tions with the first occurring on average at age
27 (sd = 6.34). Thirty-four participants were
Caucasian, 17 were African American and one
Latino. All participants were in a post-acute
phase of illness as defined by having no hospi-
talizations or changes in medication or hous-
ing in the month prior to entering the study.
Excluded from the study were participants
with a history of mental retardation or active
substance abuse.
Instruments
Indiana Psychiatric Illness Interview (IPII)
(Lysaker et al. 2002b). IPII is the semi struc-
tured interview developed to assess illness nar-
ratives. A research assistant conducts the in-
terview that lasts between 30 and 60 minutes.
Responses can be recorded verbatim in writ-
Personal Narratives
ten or typed form during the interview, or
audiotaped and later transcribed. The inter-
view is divided conceptually into four sections.
First, rapport is established and the participant
is asked to tell the story of their lives in as
much detail as they can. Second, the partici-
pant is asked if they think they have a mental
illness and how they understand it. This is
followed up with the participant being asked
to say more about their experience of mental
illness, including what has and has not been
affected by their condition in terms of work,
social life, and psychological life. Here, life
changes related to mental illness may be ex-
pressed in a desirable or undesirable direction.
In the third section, the participant is asked
whether and, if so, how their condition “con-
trols” their life and how they “control” their
condition. Fourth, the participant is asked
what he or she expects will stay the same and
what will be different or improve into the
future.
This measure (the IPII in combination
with NCRS ratings) differs from other ratings
of insight derived from interviews such as the
Scale to Assess Unawareness of Mental Illness
(SUMD) (Amador et al., 1994) in that the
interview does not introduce content and ask
for comments on the content. Thus, if the
participant does not mention hallucinations,
the IPII interviewer does not inquire about
hallucinations. The interviewer may ask for
clarification when confused and may query
non-directively, using language consistent
with the participant’s words. The tone of the
interview is intended to be conversational
rather than interrogatory or judgmental. The
interviewer’s task is to elicit enough informa-
tion to understand the story the participant is
telling about his or her mental illness, not to
confirm or disagree with that story. The IPII
thus results in a narrative of illness that can
be analyzed in terms of its overall form and
qualities rather than (as is often the case with
traditional insight measures) its specifics.
Narrative Coherence Rating Scale (NCRS)
(Lysaker et al., 2002b). NCRS is the 18-point
rating scale that assesses narrative coherence
of illness narratives. It is completed by a
trained rater following a review of the IPII
Lysaker et al. 145

transcript. The NCRS is composed of three
subscales, each rated 0–3 for both past and
present, using anchors described in Table 1.
The first, “Temporal Conceptual Connec-
tions,” is the sum of the degree to which the
elements of the story of illness are temporally
connected in a manner such that events can
be followed as they unfold in the past and
move into the present. Narratives are rated as
lacking in temporal conceptual connections
when elements of the story fail to follow one
another in logical manner over time. In their
most extreme form difficulties in this area
would result in a story where events could not
be followed or fit according to a time line.
The second scale, “Richness of Details,” is the
sum of ratings of the degree to which the story
of illness is sufficiently detailed in the past and
present. In their most extreme form, difficul-
ties in this area result in a story in which there
are few if any details, characters or descrip-
tions of events. The third scale, “Plausibility,”
is the sum of separate ratings of the degree of
plausibility of the story of illness in the past
and present. In their extreme form, difficulties
in this area result in stories which no one
in the participant’s community would likely
believe, such as being abducted by an alien
resembling Vivaldi. For each item, phenom-
ena are rated as they are reflected within the
narrative as a whole. Anchors for each item
are presented in Table 1. Note that we have
previously referred to Temporal Conceptual
Connections as “Logical Connections” (Ly-
saker et al., 2002b) but discontinued that prac-
tice to avoid confusion with what is referred
to as Plausibility.
In a previous study (Lysaker et al.,
2002b) utilizing a different sample, we re-
ported evidence of good to excellent interrater
reliability and internal consistency of the
NCRS as well as evidence of concurrent valid-
ity, including significant correlations with
standard measures of insight. To assess inter-
rater reliability for the current study, one-third
of the sample (n = 18) was rated by two sepa-
rate raters blind to one another’s ratings. Evi-
dence of acceptable interrater reliability was
again found, with intraclass correlations rang-
ing from .85 to .92 for the Details, Temporal
Conceptual Connections, and Plausibility to-
tal scores and .93 for the overall NCRS total
score. Acceptable levels of internal consis-
tency were also found for the current sample,
with a calculated coefficient alpha of .88 (Ta-
ble 1).
Of note, the NCRS assesses the struc-
tures within a narrative that allow for persons
to understand one another’s narratives and to
join in dialogue with others about those narra-
tives. Thus, someone could present a fully
coherent narrative which is full of rich detail,
temporally connected, and plausible while de-
nying or being unaware of their illness. Fur-
thermore, each dimension is conceptualized
as phenomena which can exist independent of
one another, such that a story could have few
to any details yet be temporally sound and
plausible, while another could be implausible
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
and another with the thinnest temporal se-
quence but richly detailed and believable.
Positive and Negative Syndrome Scale
(PANSS) (Kay, Fizszbein, & Opler, 1987). The
PANSS is a 30-item rating scale completed by
clinically trained research staff at the conclu-
sion of chart review and a semi-structured in-
terview. For the purposes of this study, the
Positive, Negative, and Emotional Discom-
fort PANSS factor analytically derived com-
ponents were utilized (Bell, Lysaker, Goulet,
Milstein, & Lindenmayer, 1994). The factor
structure of the PANSS has been widely repli-
cated and information about its predictive va-
lidity presented elsewhere (Bryson, Bell, Greig,
& Kaplan, 1999). Good to excellent interrater
reliability was found for the raters of the cur-
rent study with intraclass correlations ranging
from .80 to .93.
Scale to Assess Unawareness of Mental Dis-
order (SUMD) (Amador et al., 1994). SUMD
is a rating scale completed by clinically trained
research staff following a semi-structured in-
terview and chart review. For the purposes of
this study, we used the total score or the sum
of the three central items of the SUMD which
are: 1) awareness of mental disorder; 2) aware-
ness of the consequences of mental disorder;
and 3) awareness of the effects of medication.
Each of these items is rated on a five-point
scale which ranges from “1” (complete aware-
ness) to “5” (severe unawareness). Interrater
reliability for this study was found to be in
the excellent range with an intraclass correla-
tion of .89.
Quality of Life Scale (QOL) (Heinrichs,
Hanlon, & Carpenter, 1984). QOL is a 21-item
scale completed by clinically trained research
staff following a semi-structured interview and
chart review. For the purposes of this study,
we were interested in the sum of three of the
four factor scores of the QOL. The first, “In-
terpersonal Relations,” measures the fre-
quency of recent social contacts and includes
separate assessments, for example, of frequency
of contacts with friends and acquaintances.
The second, “Intrapsychic Foundations,”
measures qualitative aspects of interpersonal
relationships and includes assessments of such
qualities as empathy for others. The third,
Personal Narratives
“Common Objects and Activities,” assesses
level of community function. Of note, we were
not interested in the fourth score, “Instrumen-
tal Function,” which assesses vocational and
role function, since all participants were enter-
ing vocational rehabilitation and thus were all
equally unemployed. Good to excellent inter-
rater reliability was found for the QOL factor
scores for this study, with intraclass correla-
tions ranging from .88 to .93.
Wisconsin Card Sorting Test (WCST)
(Heaton et. al., 1993). WCST is a neuropsy-
chological test in which participants sort cards
that vary according to shape, color, and num-
ber of objects depicted. Participants are asked
to match cards to “key” cards but are not told
the matching principle which changes period-
ically without warning to the participant. This
study utilized one WCST score: the total
number of categories achieved. This measure
provides an assessment of participants’ abili-
ties to obtain an abstract set, to keep that set
over multiple trials, and then to flexibly shift
that set when unexpectedly required.
Hopkins Verbal Memory Test (HVLT)
(Brandt, 1991). HVLT is an auditory verbal
memory test in which the experimenter orally
presents a list of 12 words, each belonging to
one of three semantic categories. After each
trial, participants are asked to repeat as many
words from the list as they can remember. For
the purposes of this study, the age corrected
t-score for total correct score on all three trials
was utilized.
Vocabulary Subtest of the WAIS-III (Wech-
sler, 1997). WAIS-III assesses participants’
knowledge of vocabulary. The age-corrected
scale score is the best single correlate of verbal
intelligence and has been widely used as a brief
assessment of premorbid intellectual function
(Lezak, 1995).
Procedures
Following informed consent, partici-
pants were given the WCST, HVLT, WAIS-
III Vocabulary Subtest, PANSS, QOL, and
IPII as part of a baseline assessment for a study
of the effects of cognitive behavior therapy on
work outcome. The IPII interview was audio-
Lysaker et al.
taped and later transcribed. All identifying in-
formation (e.g., names of others and places)
was removed from the transcripts. Ratings of
the transcripts were thus made blind to patient
identity, test performance, symptom level, and
ratings of function. The NCRS raters thus
were also blind to participants’ PANSS and
QOL scores. The raters were not present dur-
ing the IPII interviews, nor did they transcribe
the audiotapes of the interviews.
Results
Means and standard deviations for the
NCRS scores were as follows: Temporal Con-
ceptual Connections: 4.5 (2.0); Richness of
Details: 3.5 (1.9); Plausibility: 3.4.(2.4); and
Total: 11.2 (5.3). NCRS scores were unrelated
to age, education, and lifetime number of hos-
pitalizations. The NCRS scores of partici-
pants with schizophrenia did not differ from
those of participants with schizoaffective dis-
order. The three NCRS total scores were sig-
nificantly correlated with one another, ac-
counting for between 12% (Details and
Temporal Conceptual Connections) and 38%
(Plausibility and Temporal Conceptual Con-
nections) of the variance. The SUMD total
score was significantly related to the NCRS
Details (r = −.51, p < .0001), Plausibility (r =
−.41, p < .01), Temporal Conceptual Connec-
tions (r = −.29, p < .05), and Total scores (r =
−.52, p < .0001).
To examine the relationships between
narrative coherence of participants’ accounts
of their illness and neurocognition, symptom
levels, and social function, we calculated cor-
relations between NCRS and WCST, WAIS-
III Verbal Scale, HVLT, PANSS, and QOL
scores. As NCRS, PANSS, and QOL scores
are ordinal in nature, Spearman Rho coeffi-
cients were obtained. These are summarized
in Table 2 below. Since Plausibility was signifi-
cantly correlated with WCST, Positive symp-
toms, and QOL scores, a stepwise multiple
regression was performed in which each of
these three variables was allowed to enter to
predict Plausibility.
This regression produced a significant
predictor equation (F (2,52) = 26.7, p < .0001)
147
with Positive symptoms (partial R2 = .33, p <
.0001) and WCST (partial R2 = .18, p < .0001)
making unique contributions. A parallel re-
gression predicting the NCRS Total from
Positive symptoms and WCST performance
similarly produced a significant equation (F
(2,52) = 24.2, p < .0001) with Positive symp-
toms (partial R2 = .36, p < .0001) and WCST
performance (partial R2 = .13, p < .0001) again
making unique contributions. Univariate cor-
relations revealed that the SUMD total was
not related to PANSS scores, QOL total, Vo-
cabulary, or WCST performance. However,
poor awareness of illness on the SUMD was
associated with poorer verbal memory on the
HVLT (r = −.38, p < .01).
Last, given disagreement regarding
whether WCST performance is best captured
by number of correct categories or the num-
ber of perseverative errors (i.e., errors indicat-
ing inflexibility rather than inconsistency of
response style), the age and education correc-
tion T-scores for percentage of perseverative
errors were correlated with the NCRS scores.
Equivalent correlations were again produced
between WCST and the NCRS Plausibility
and Total scores (Table 2).
Discussion
Results suggest that variations in the
narrative structure of verbatim accounts of
schizophrenia are related to different clinical
features of illness. As predicted, impairments
in flexibility in abstract thought and social iso-
lation were related to lesser ratings of plausi-
bility of the illness narratives. Persons who
achieved fewer categories on the WCST, who
had greater difficulty engaging in flexible ab-
stract thought, tended to tell less plausible
stories, and persons who told less plausible
stories tended to be more socially isolated.
Level of Positive symptoms was also strongly
related to Plausibility and to Temporal Con-
ceptual Connections. With more severe levels
of Positive symptoms, accounts of illness were
less organized according to a temporal frame
and again less plausible. Notably, the relation-
ships of WCST and Positive symptoms to
plausibility were relatively independent of one
148
Table 2.
Clinical Social and Neurocognitive Correlates1 of Three Dimensions of Narrative Coherence
WAIS III
WCST HVLT Vocabulary
NCRS Categories Total Scaled
Subscale Achieved Recall Score
Details .14 .14 .19
Temporal
Conceptual
Connections .30 −.03 .22
Plausibility .53** .18 .25
Total .44** .26 .26
Spearman Rho; *p < .01; **p < .001
1
another. When combined in a regression,
these variables were able to capture more than
half of the variance in the NCRS Plausibility
scores.
As predicted, lesser plausibility was
linked to lesser levels of social function, al-
though this relationship was obscured in the
multiple regression when Positive symptoms
and neurocognition were controlled for, sug-
gesting it may have been mediated by these
correlates. As anticipated, SUMD ratings of
insight were correlated with NCRS Totals.
Thus, persons who were unaware of illness in a
categorical sense evidenced greater difficulties
constructing a narrative of themselves and
their disorder. No relationships were found
between any variable and NCRS Richness of
Details score. Negative symptoms scores,
Emotional Discomfort scores, measures of
Verbal memory, and Premorbid function were
not significantly related to NCRS scores.
Results may thus be interpreted as sup-
port for the larger hypothesis that when it
comes to creating a narrative of one’s illness,
there are structural aspects of that narrative
construction which are related to cognition
and others which are not. Returning to the
issue of whether awareness of illness should be
construed as a function of cognitive capacity,
perhaps it can be seen as more a matter of
personal construction when referring to the
richness and choice of details which enhance
others’ ability to understand an illness narra-
tive; cognitive capacities may be implicated in
the extent to which a person’s account of their
Personal Narratives
Quality
PANSS Component of Life
Emotional Total
Positive Negative Discomfort Score
−.25 .21 .29 .11
−.51** .00 .07 .10
−.56** .27 .04 .37*
−.58** .23 .14 .29
condition is sufficiently believable and con-
ceptually organized for others to be able to
understand and engage in a dialogue about
that story.
While the correlational nature of this
research precludes drawing any conclusions
regarding causality, results suggest some
hypotheses for future consideration. For one,
perhaps deficits in flexibility of abstract
thought result in an inability to fully consider
the perspectives of others when telling and
retelling a story of illness, resulting in stories
that others are likely to discount. Further, per-
haps such deficits also interfere with the capac-
ity to flexibly revise and reshape a narrative,
resulting in an increasingly less well-orga-
nized narrative of illness over time. With re-
gard to clinical variables, it may also be that
as positive symptoms grow stronger, they in-
terfere with the organization of a narrative
understanding of illness as well as an appraisal
of how believable a narrative will be to others.
Last, it may also be that as persons are more
socially isolated they tend to tell more idiosyn-
cratic stories of their illness. Again, given the
correlational nature of this study, alternative
hypotheses cannot be ruled out. It may be, for
instance, that with less coherent narratives of
illness persons are forced to rely on more delu-
sional interpretations of life or that cognitive
impairments proceed from narrative impover-
ishment and not the reverse.
With replication across broader sam-
ples and settings, we would suggest that assess-
ments of insight at the narrative level may
Lysaker et al.
reveal correlates and aspects of etiology of
poor insight not uncovered by traditional
measures. By assessing the different ways in
which a narrative of illness can fail to achieve
coherence, perhaps we can better understand
the complex relationships between awareness,
denial, neurocognition, and emotional pain.
For instance, future studies could potentially
ask how narratives of illness might be affected
by personality, self-efficacy, attributional styles,
and/or community and self-stigma. Addition-
ally, a better understanding and means of mea-
suring the coherence of an illness narrative
could have important implications for out-
come research. It is widely noted that one
of the unique outcomes which psychotherapy
seeks to effect in schizophrenia is increased
narrative coherence (Fenton, 2000; Haugs-
jerd, 1994; Lysaker & Lysaker, 2001). One
might similarly use these methods to ask
whether pharmacological interventions, which
appear to increase cognitive capabilities, are
similarly related to increases in narrative coher-
ence in schizophrenia or related conditions.
Of note, there are several limitations
to this study. Most participants were male,
middle-aged, and generally many years had
passed since the onset of their illness. Addi-
tionally, all were in some form of active treat-
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