Personal Narratives of Illness in Schizophrenia: Associations with Neurocognition and Symptoms

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 primarilya matter of personal/social construction while others may be uniquely curtailed byneurocognitive deficits. Accordingly, we gathered narratives of illness among 52persons with schizophrenia spectrum disorders using a semi-structured interview.Ratings of the plausibility, adequacy of detail, and temporal conceptual organizationof each narrative were correlated with assessments of neurocognition, symptoms,and traditional insight measures. Degree of plausibility was significantly related toperformance on the Wisconsin Card Sorting Test (WCST), a measure of executivefunction and levels of Positive symptoms on the Positive and Negative SyndromeScale (PANSS). When entered into a regression to predict plausibility, positivesymptoms and WCST performance made unique contributions (R2 = .51, p <.0001). Higher levels of Positive symptoms were associated with poorer temporalconceptual organization within narratives. Adequacy of detail within narrativesof illness was related to traditional insight measures but not neurocognition orsymptoms.

Relative to persons with other psychiat- bute that to a special talent or ability and notto a “brain disorder.”ric disorders, persons diagnosed with schizo-

phrenia spectrum disorders are often unaware Taken as a whole, this phenomenon, isoften referred to as “lack of awareness” orof, or willfully contest that they have, what

others perceive as their symptoms and/or psy- “poor insight.” It is of wide interest to profes-sionals and families because it can persist in-chosocial challenges (Amador, Strauss, Yale,

& Gorman, 1991; David, 1990). They may definitely and impact significantly upon out-come for those with schizophrenia. Lack ofdeny that they have problems which others

perceive them to have, such as disordered awareness in schizophrenia spectrum disor-ders, for instance, has been linked to poorerspeech. They may alternately acknowledge

that they have experiences that others think treatment compliance (Bartko, Herczeg, &Zador, 1988; Cuffel, Alford, Fischer, &Owen,are symptoms of mental illness, but offer a

different interpretation. For instance, they 1996; Smith et al., 1999), poorer clinical out-come (Schwartz, 1998), poorer social functionmay hear a voice others cannot hear and attri-

PaulH. Lysaker, PhD, is affiliated with the RoudebushVAMedical Center and the IndianaUniversitySchool ofMedicine in Indianapolis.ChristopherM. France, PsyD, is affiliatedwithCleveland StateUniversity.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. Higherlevels of insight, for instance, have been asso-&Kaplan, 1998a), vocational dysfunction (Ly-

saker, Bryson, & Bell, 2002), and to difficulties ciated with higher levels of dysphoria (Amadoret al., 1994; Mintz, Dobson, & Romney, 2003;developing working relationships with mental

health professionals (Frank & Gunderson, Thompson, 1988) and lowered self-esteem(Warner, Taylor, Powers, & Hyman, 1989).1990). Thus for some, denying illness appears

linked to refusal to accept medications and a Further, embracing a view of self-as-ill, a viewwhich leaves one vulnerable to widespreadwide range of psychosocial deficits. On the

other hand, acceptance of a “brain disorder” stigma (Corrigan & Penn, 1999;Wahl &Har-man, 1989), has also been associated withwhich requires medications that may result in

many enduring and unwanted side effects can greater social dysfunction (Taylor & Perkins,1991; Warner et. al., 1989). Thus, construct-be demoralizing and result in despair (Dixon,

King, & Steiger, 1998). ing a personal understanding of schizophreniain which symptoms or other socially stigma-At present, researchers are divided con-

cerning the degree to which unawareness/ tized features of disorder are assigned less im-portance and personal strengths are acknowl-denial of illness in schizophrenia is best con-

ceptualized as the result of cognitive deficits edged may represent for some a willful andadaptive attempt to ward off misery and socialwhich globally limit persons’ abilities to grasp

complex aspects of their lives. Persons with isolation. It should be noted that awarenessof illness appeared unrelated to cognition inschizophrenia have been found to suffer from

severe impairments in neurocognition (Saykin some samples (Cuesta & Peralta, 1995; Kemp& David, 1996; Kim, Jayathilake, & Meltzer,et al., 1991), and studies have found limited

insight concurrently and prospectively pre- 2003), lending credence to an argument thatneurocognitive deficits alone do not fully ex-dicts poorer performance on tests of one cru-

cial aspect of neurocognition, executive func- plain poor insight in schizophrenia spectrumdisorders.tion (Lysaker & Bell, 1994; Lysaker, Bryson,

Lancaster, Evans, & Bell, 2003; Marks, Fas- Given that these views regarding therole of neurocognition have very different the-tenau, Lysaker, & Bond, 2000; Mohamed,

Fleming, Penn, & Spaulding, 1999; Young, oretical and practical implications, some haveattempted a synthesis, suggesting each is par-Davila, & Scher, 1993; Young, Zakzanis, &

Bailey, 1998). Additionally, others have found tially correct and that insight is best accountedfor when both views are considered togetherthat impairments in executive function predict

more intransigent deficits in insight (Lysaker (Startup, 1996). In other words, perhaps somecontest that they are ill because of cognitive& Bell 1994). Authors arguing for a link be-

tween insight and cognitive deficits have also impairments that limit the bounds of theirawareness while others deny or willfully rejectemphasized the similarity of poor insight in

schizophrenia with anosognosia or unaware- illness in order to minimize or avoid socialalienation or having to take medications withness of deficits in neurological disorders (Ama-

dor et al., 1991). undesirable side effects. While there is someempirical support for this synthesis in studiesAn alternative view in this debate is that

“poor insight” may not represent a “lack” of using cluster analytic approaches (Lysaker etal., 2003), such a view may overlook the com-awareness but instead reflects an alternative

and no less valid means of gaining control over plex processes by which persons achieve anunderstanding of disabling illness. More im-ones own life (Bassman, 2000; Roe &Kravetz,

2003). For instance, it has been argued that portantly, it may also ignore the possibilitythat there are specific elements or processesdefining rejection of the medical model of

mental illness as a deficit is potentially a de- necessary to construct a narrative of illnessthat could be limited by neurocognitive defi-structive usage of social power (Rudge &

Morse, 2001). In support of this view are find- cits.Accordingly, this paper seeks to exploreings that it may be adaptive for some to deny

142 Personal Narratives

whether neurocognition, and, in particular, historical events which is inextricably involvedwith interpretations of past successes and fail-deficits in executive function or the ability to

think in a flexible and abstract manner about ures as well as ever-developing dreams andexpectations of the future (Davidson & Strauss,novel problems, could affect persons’ abilities

to construct a coherent narrative of their diffi- 1995; Kirmayer & Corin, 1998; Williams &Collins, 1999). As with other types of humanculties. Of note, we are not asking whether

neurocognition limits acceptance of the bio- narratives, an awareness of mental illness isless a collection of “cold,” unchanging factslogical model of schizophrenia.We ask instead

whether deficits in neurocognition are linked andmore an evolvingmeans of framing affectsand putting daily life events into a contextwith difficulties creating a story that others

can understand and join in dialogue about, which is embedded in conversation within andbetween persons (Hermans, 1996; Lysaker &a story that might or might not endorse a

biological view of schizophrenia. France, 1999).One important implication of regard-To examine whether certain neurocog-

nitive deficits are linked with breakdown in ing lack of insight as a narrative that fails tocapture key illness-related processes readilythe creation of a coherent narrative, we first

discuss how awareness or acknowledgment of grasped by others is that this view allows forthe possibility that there are different ways inillness represents a complex personal con-

struction that is established within a life story, which a story of illness might come to beperceived as insightful vs. not insightful. Forand the distinctly different reasons such a con-

struction may fail to develop into a coherent instance, a narrative of illness might be per-ceived by others as evidencing poor insight ifaccount of schizophrenia. Hypotheses regard-

ing which specific aspects of narrative con- the narrative is missing key facts about theillness and its impact. Alternatively, the narra-struction are likely to be related to neurocog-

nition are presented next and followed by the tive may include multiple illness-related factsbut still be perceived as lacking insight becausefindings of a study which examines correla-

tions between a measure of narrative structure the facts lack sufficient temporal conceptualorganization and thus do not allow others towithin a story of illness andmeasures of neuro-

cognition, symptoms and function. discover their meaning. Beyond the presenceor absence of facts and their organization, astory of illness may be construed as lackinginsight because it is utterly improbable.AWARENESS OF ILLNESS

AS A NARRATIVE ACT

Though insight is often discussed and NEUROCOGNITION ANDNARRATIVE STRUCTUREmeasured as the possession or endorsement

of specific facts, such as “I have symptom X”or “I need treatment Y” (Marks et al., 2000), As discussed elsewhere, we have devel-

oped the Narrative Coherence Rating Scaleawareness or acceptance of any type of illnessis probably not best understood as an isolated (NCRS) (Lysaker et al., 2002b) that opera-

tionalizes three narrative elements that are hy-cognition akin to a solitary entry in a tradi-tional database, that is, one that can be entered pothetically necessary for awareness of illness.

These include 1) “Richness of Details,” or theor erased without affecting its neighbors. Asin other medical illnesses (Kleinman, 1988), enumeration of distinct aspects of the disor-

der; 2) “Temporal Conceptual Connections”a person’s understanding of her or his schizo-phrenia represents an element of a larger per- (previously “Logical Connections”), or the

presence of associative connections betweensonal and narrative understanding of a life(Lysaker, Clements, Plascak-Hallberg, Knip- story elements; and 3) “Plausibility,” or the

perception of likelihood that the story is accu-scheer, & Wright, 2002b). An understandingof 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 andreshape their understanding of their disorder.view we have labeled the Indiana Psychiatric

Illness Interview (IPII) that inquires about This hypothesis seems consistent with recentfindings that deficits in executive function maydeficits as well as abilities, strengths, and

hopes. This procedure has the benefit of al- be uniquely linked to difficulties “re-labeling”the experience of psychotic symptoms as anlowing for the assessment of how the story of

illness as a whole coheres along the three experience of symptoms (Drake&Lewis, 2003)as well as findings that deficits in executivenoted dimensions and thus does not rate in-

sight as adherence to one particular point of function are uniquely linked to greater diffi-culties understanding the affects of othersview or as agreement with specific facts or

theories. (Bryson, Bell, Lysaker, Greig, &Kaplan, 1997).To rule out the possibility that any ob-To better clarify how impairments in

neurocognition may or may not be related served relationships between the WCST andthe (NCRS) Temporal Conceptual Connec-to awareness of illness, this study gathered

narratives of illness among persons with tions and Plausibility scores were a reflectionof generalized deficits, we also included mea-schizophrenia spectrum disorders using a

semi-structured interview (the IPII), rated sures of verbal memory and premorbid intel-lectual function and anticipated that thesesuch narratives using the NCRS, and com-

pared the NCRS scores with concurrent as- measures would be relatively unrelated to theTemporal Conceptual Connections and Plau-sessments of different aspects of neurocogni-

tion. We first hypothesized that the NCRS sibility scores. Regarding the presence or ab-sence of details (“Richness of Details”) thatscores for Temporal Conceptual Connections

would be strongly related to the ability to provide the characters and settings within nar-ratives, we reasoned that this element mostthink in a flexible and abstract manner as as-

sessed by the Wisconsin Card Sorting Test likely reflects personal choice rather than be-ing susceptible to deficits in executive function(WCST) (Heaton, Chelune, Talley, Kay, &

Curtis, 1993). Here we reasoned that lesser and thus would not be strongly related in ei-ther direction to WCST scores.levels of these abilities might reduce persons’

abilities to connect story elements over shift- Of note, beyond assessing links betweenneurocognition and the qualities of illness nar-ing time points, resulting in less conceptually

organized stories (i.e., lower NCRS Temporal ratives, this study was also designed to allowseveral more exploratory analyses. First, asConceptual Connections scores).

We secondly predicted that poorer noted earlier, previous research has found insome samples that lesser awareness of illnessWCST performance would be linked to lesser

levels of Plausibility. It is generally understood was linked to heightened symptom levels andgreater social dysfunction (Lysaker, Bell, Bry-that persons construct stories of their lives

with an audience in mind (Andersen & Chen, son, & Kaplan, 1998b; Mintz et al., 2003). Inorder to explore this area, we included mea-2002; Hermans, 1996). Whether a potential

source of or threat to validation, that audience sures of positive, negative, and depressivesymptoms and an assessment of global socialmay also serve to limit distortion since aspects

of stories may be revised in anticipation of function. We predicted that higher levels ofpositive symptoms might be linked to lesserhow the audience may react to the story. For

instance, a story of a humiliating event may levels of narrative plausibility and temporalconceptual connections, and that negativebe told and retold in our mind according to

how we think others will react to it, even if symptoms might predict fewer narrative de-tails. Here we reasoned that greater positivewe plan to tell no one. We thus reasoned that

deficits in the ability to think flexibly might symptoms might interfere with the ability toorganize a coherent account of illness, whilelimit plausibility because of their potential to

limit persons’ abilities to flexibly anticipate greater negative symptoms might naturallylead to a paucity of details in the narratives.how others would react to their construction

144 Personal Narratives

We also predicted that greater awareness of ten or typed form during the interview, oraudiotaped and later transcribed. The inter-illness across all three NCRS domains would

be associated with greater emotional distress. view is divided conceptually into four sections.First, rapport is established and the participantWe further predicted poorer social function

would be linked to less plausible and less tem- is asked to tell the story of their lives in asmuch detail as they can. Second, the partici-porally conceptually connected narratives,

reasoning that persons may be more likely to pant is asked if they think they have a mentalillness and how they understand it. This ishave difficulty relating to others and/or to be

shunned by others if their stories are bizarre followed up with the participant being askedto say more about their experience of mentalor difficult to follow. Finally, though we pre-

viously presented data on the concurrent va- illness, including what has and has not beenaffected by their condition in terms of work,lidity of the NCRS (Lysaker et al., 2002b),

we also planned to repeat this analysis and social life, and psychological life. Here, lifechanges related to mental illness may be ex-therefore included a traditional measure of

insight which assessed in a categorical fashion pressed in a desirable or undesirable direction.In the third section, the participant is askedwhether or not persons believed they suffered

from a psychiatric disorder. whether and, if so, how their condition “con-trols” their life and how they “control” theircondition. Fourth, the participant is askedwhat he or she expects will stay the same andMETHODwhat will be different or improve into thefuture.Participants

This measure (the IPII in combinationwith NCRS ratings) differs from other ratingsFifty-one males and one female with

DSM-IV diagnoses of schizophrenia (n = 38) of insight derived from interviews such as theScale to Assess Unawareness of Mental Illnessor schizoaffective disorder (n = 14) were re-

cruited from an outpatient psychiatry clinic at (SUMD) (Amador et al., 1994) in that theinterview does not introduce content and aska midwestern VA Medical Center. The mean

age was 47.2 (sd = 9.01) and mean education for comments on the content. Thus, if theparticipant does not mention hallucinations,was 13.8 (sd = 4.29) years. Participants had a

mean of 7.8 (sd = 7.90) lifetime hospitaliza- the IPII interviewer does not inquire abouthallucinations. The interviewer may ask fortions with the first occurring on average at age

27 (sd = 6.34). Thirty-four participants were clarification when confused and may querynon-directively, using language consistentCaucasian, 17 were African American and one

Latino. All participants were in a post-acute with the participant’s words. The tone of theinterview is intended to be conversationalphase of illness as defined by having no hospi-

talizations or changes in medication or hous- rather than interrogatory or judgmental. Theinterviewer’s task is to elicit enough informa-ing in the month prior to entering the study.

Excluded from the study were participants tion to understand the story the participant istelling about his or her mental illness, not towith a history of mental retardation or active

substance abuse. confirm or disagree with that story. The IPIIthus results in a narrative of illness that canbe analyzed in terms of its overall form andInstrumentsqualities rather than (as is often the case withtraditional insight measures) its specifics.Indiana Psychiatric Illness Interview (IPII)

(Lysaker et al. 2002b). IPII is the semi struc- Narrative Coherence Rating Scale (NCRS)(Lysaker et al., 2002b).NCRS is the 18-pointtured interview developed to assess illness nar-

ratives. A research assistant conducts the in- rating scale that assesses narrative coherenceof illness narratives. It is completed by aterview that lasts between 30 and 60 minutes.

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 referredto as Plausibility.subscales, each rated 0–3 for both past and

present, using anchors described in Table 1. In a previous study (Lysaker et al.,2002b) utilizing a different sample, we re-The first, “Temporal Conceptual Connec-

tions,” is the sum of the degree to which the ported evidence of good to excellent interraterreliability and internal consistency of theelements of the story of illness are temporally

connected in a manner such that events can NCRS as well as evidence of concurrent valid-ity, including significant correlations withbe followed as they unfold in the past and

move into the present. Narratives are rated as standard measures of insight. To assess inter-rater reliability for the current study, one-thirdlacking in temporal conceptual connections

when elements of the story fail to follow one of the sample (n = 18) was rated by two sepa-rate raters blind to one another’s ratings. Evi-another in logical manner over time. In their

most extreme form difficulties in this area dence of acceptable interrater reliability wasagain found, with intraclass correlations rang-would result in a story where events could not

be followed or fit according to a time line. ing from .85 to .92 for the Details, TemporalConceptual Connections, and Plausibility to-The second scale, “Richness of Details,” is the

sum of ratings of the degree to which the story tal scores and .93 for the overall NCRS totalscore. Acceptable levels of internal consis-of illness is sufficiently detailed in the past and

present. In their most extreme form, difficul- tency were also found for the current sample,with a calculated coefficient alpha of .88 (Ta-ties in this area result in a story in which there

are few if any details, characters or descrip- ble 1).Of note, the NCRS assesses the struc-tions of events. The third scale, “Plausibility,”

is the sum of separate ratings of the degree of tures within a narrative that allow for personsto understand one another’s narratives and toplausibility of the story of illness in the past

and present. In their extreme form, difficulties join in dialogue with others about those narra-tives. Thus, someone could present a fullyin this area result in stories which no one

in the participant’s community would likely coherent narrative which is full of rich detail,temporally connected, and plausible while de-believe, such as being abducted by an alien

resembling Vivaldi. For each item, phenom- nying or being unaware of their illness. Fur-thermore, each dimension is conceptualizedena are rated as they are reflected within the

narrative as a whole. Anchors for each item as phenomena which can exist independent ofone another, such that a story could have feware presented in Table 1. Note that we have

previously referred to Temporal Conceptual to any details yet be temporally sound andplausible, while another could be implausibleConnections as “Logical Connections” (Ly-

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 temporalceptual Con- of no conceptual minor instances of of no temporal con- conceptual con-nections temporal connec- no temporal con- ceptual connections nections

tions ceptual connectionsRichness of Missing many major Missing some major Missing some minor No details missingDetails details or many minor de- details

tailsPlausibility 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,” assesseslevel of community function.Of note, we werequence but richly detailed and believable.

Positive and Negative Syndrome Scale not interested in the fourth score, “Instrumen-tal Function,” which assesses vocational and(PANSS) (Kay, Fizszbein, & Opler, 1987). The

PANSS is a 30-item rating scale completed by role function, since all participants were enter-ing vocational rehabilitation and thus were allclinically trained research staff at the conclu-

sion of chart review and a semi-structured in- equally unemployed. Good to excellent inter-rater reliability was found for the QOL factorterview. For the purposes of this study, the

Positive, Negative, and Emotional Discom- scores for this study, with intraclass correla-tions ranging from .88 to .93.fort PANSS factor analytically derived com-

ponents were utilized (Bell, Lysaker, Goulet, Wisconsin Card Sorting Test (WCST)(Heaton et. al., 1993).WCST is a neuropsy-Milstein, & Lindenmayer, 1994). The factor

structure of the PANSS has been widely repli- chological test in which participants sort cardsthat vary according to shape, color, and num-cated and information about its predictive va-

lidity presented elsewhere (Bryson, Bell, Greig, ber of objects depicted. Participants are askedto match cards to “key” cards but are not told& Kaplan, 1999). Good to excellent interrater

reliability was found for the raters of the cur- the matching principle which changes period-ically without warning to the participant. Thisrent study with intraclass correlations ranging

from .80 to .93. study utilized one WCST score: the totalnumber of categories achieved. This measureScale to Assess Unawareness ofMental Dis-

order (SUMD) (Amador et al., 1994). SUMD provides an assessment of participants’ abili-ties to obtain an abstract set, to keep that setis a rating scale completed by clinically trained

research staff following a semi-structured in- over multiple trials, and then to flexibly shiftthat set when unexpectedly required.terview and chart review. For the purposes of

this study, we used the total score or the sum Hopkins Verbal Memory Test (HVLT)(Brandt, 1991).HVLT is an auditory verbalof the three central items of the SUMDwhich

are: 1) awareness of mental disorder; 2) aware- memory test in which the experimenter orallypresents a list of 12 words, each belonging toness of the consequences of mental disorder;

and 3) awareness of the effects of medication. one of three semantic categories. After eachtrial, participants are asked to repeat as manyEach of these items is rated on a five-point

scale which ranges from “1” (complete aware- words from the list as they can remember. Forthe purposes of this study, the age correctedness) to “5” (severe unawareness). Interrater

reliability for this study was found to be in t-score for total correct score on all three trialswas utilized.the excellent range with an intraclass correla-

tion of .89. Vocabulary Subtest of theWAIS-III (Wech-sler, 1997).WAIS-III assesses participants’Quality of Life Scale (QOL) (Heinrichs,

Hanlon, & Carpenter, 1984). QOL is a 21-item knowledge of vocabulary. The age-correctedscale score is the best single correlate of verbalscale completed by clinically trained research

staff following a semi-structured interview and intelligence and has beenwidely used as a briefassessment of premorbid intellectual functionchart review. For the purposes of this study,

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- Proceduresquency of recent social contacts and includesseparate assessments, for example, of frequency Following informed consent, partici-

pants were given the WCST, HVLT, WAIS-of contacts with friends and acquaintances.The second, “Intrapsychic Foundations,” III Vocabulary Subtest, PANSS, QOL, and

IPII as part of a baseline assessment for a studymeasures qualitative aspects of interpersonalrelationships and includes assessments of such of the effects of cognitive behavior therapy on

work outcome. The IPII interview was audio-qualities as empathy for others. The third,

Lysaker et al. 147

taped and later transcribed. All identifying in- with Positive symptoms (partial R2 = .33, p <.0001) andWCST (partial R2 = .18, p < .0001)formation (e.g., names of others and places)

was removed from the transcripts. Ratings of making unique contributions. A parallel re-gression predicting the NCRS Total fromthe transcripts were thusmade blind to patient

identity, test performance, symptom level, and Positive symptoms and WCST performancesimilarly produced a significant equation (Fratings of function. The NCRS raters thus

were also blind to participants’ PANSS and (2,52) = 24.2, p < .0001) with Positive symp-toms (partial R2 = .36, p < .0001) and WCSTQOL scores. The raters were not present dur-

ing the IPII interviews, nor did they transcribe performance (partial R2 = .13, p < .0001) againmaking unique contributions. Univariate cor-the audiotapes of the interviews.relations revealed that the SUMD total wasnot related to PANSS scores, QOL total, Vo-Resultscabulary, or WCST performance. However,poor awareness of illness on the SUMD wasMeans and standard deviations for the

NCRS scores were as follows: Temporal Con- associated with poorer verbal memory on theHVLT (r = −.38, p < .01).ceptual Connections: 4.5 (2.0); Richness of

Details: 3.5 (1.9); Plausibility: 3.4.(2.4); and Last, given disagreement regardingwhether WCST performance is best capturedTotal: 11.2 (5.3). NCRS scores were unrelated

to age, education, and lifetime number of hos- by number of correct categories or the num-ber of perseverative errors (i.e., errors indicat-pitalizations. The NCRS scores of partici-

pants with schizophrenia did not differ from ing inflexibility rather than inconsistency ofresponse style), the age and education correc-those of participants with schizoaffective dis-

order. The three NCRS total scores were sig- tion T-scores for percentage of perseverativeerrors were correlated with the NCRS scores.nificantly correlated with one another, ac-

counting for between 12% (Details and Equivalent correlations were again producedbetween WCST and the NCRS PlausibilityTemporal Conceptual Connections) and 38%

(Plausibility and Temporal Conceptual Con- and Total scores (Table 2).nections) of the variance. The SUMD totalscore was significantly related to the NCRS DiscussionDetails (r = −.51, p < .0001), Plausibility (r =−.41, p < .01), Temporal Conceptual Connec- Results suggest that variations in the

narrative structure of verbatim accounts oftions (r = −.29, p < .05), and Total scores (r =−.52, p < .0001). schizophrenia are related to different clinical

features of illness. As predicted, impairmentsTo examine the relationships betweennarrative coherence of participants’ accounts in flexibility in abstract thought and social iso-

lation were related to lesser ratings of plausi-of their illness and neurocognition, symptomlevels, and social function, we calculated cor- bility of the illness narratives. Persons who

achieved fewer categories on theWCST, whorelations between NCRS and WCST, WAIS-III Verbal Scale, HVLT, PANSS, and QOL had greater difficulty engaging in flexible ab-

stract thought, tended to tell less plausiblescores. As NCRS, PANSS, and QOL scoresare ordinal in nature, Spearman Rho coeffi- stories, and persons who told less plausible

stories tended to be more socially isolated.cients were obtained. These are summarizedin Table 2 below. Since Plausibility was signifi- Level of Positive symptoms was also strongly

related to Plausibility and to Temporal Con-cantly correlated with WCST, Positive symp-toms, and QOL scores, a stepwise multiple ceptual Connections. With more severe levels

of Positive symptoms, accounts of illness wereregression was performed in which each ofthese three variables was allowed to enter to less organized according to a temporal frame

and again less plausible. Notably, the relation-predict Plausibility.This regression produced a significant ships of WCST and Positive symptoms to

plausibility were relatively independent of onepredictor equation (F (2,52) = 26.7, p < .0001)

148 Personal Narratives

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

WAIS IIIPANSS Component

QualityWCST HVLT Vocabulary of Life

NCRS Categories Total Scaled Emotional TotalSubscale Achieved Recall Score Positive Negative Discomfort Score

Details .14 .14 .19 −.25 .21 .29 .11TemporalConceptualConnections .30 −.03 .22 −.51** .00 .07 .10

Plausibility .53** .18 .25 −.56** .27 .04 .37*Total .44** .26 .26 −.58** .23 .14 .29

1Spearman Rho; *p < .01; **p < .001

another. When combined in a regression, condition is sufficiently believable and con-ceptually organized for others to be able tothese variables were able to capture more than

half of the variance in the NCRS Plausibility understand and engage in a dialogue aboutthat story.scores.

As predicted, lesser plausibility was While the correlational nature of thisresearch precludes drawing any conclusionslinked to lesser levels of social function, al-

though this relationship was obscured in the regarding causality, results suggest somehypotheses for future consideration. For one,multiple regression when Positive symptoms

and neurocognition were controlled for, sug- perhaps deficits in flexibility of abstractthought result in an inability to fully considergesting it may have been mediated by these

correlates. As anticipated, SUMD ratings of the perspectives of others when telling andretelling a story of illness, resulting in storiesinsight were correlated with NCRS Totals.

Thus, personswhowere unaware of illness in a that others are likely to discount. Further, per-haps such deficits also interfere with the capac-categorical sense evidenced greater difficulties

constructing a narrative of themselves and ity to flexibly revise and reshape a narrative,resulting in an increasingly less well-orga-their disorder. No relationships were found

between any variable and NCRS Richness of nized narrative of illness over time. With re-gard to clinical variables, it may also be thatDetails score. Negative symptoms scores,

Emotional Discomfort scores, measures of as positive symptoms grow stronger, they in-terfere with the organization of a narrativeVerbal memory, and Premorbid function were

not significantly related to NCRS scores. understanding of illness as well as an appraisalof how believable a narrative will be to others.Results may thus be interpreted as sup-

port for the larger hypothesis that when it Last, it may also be that as persons are moresocially isolated they tend to tell more idiosyn-comes to creating a narrative of one’s illness,

there are structural aspects of that narrative cratic stories of their illness. Again, given thecorrelational nature of this study, alternativeconstruction which are related to cognition

and others which are not. Returning to the hypotheses cannot be ruled out. It may be, forinstance, that with less coherent narratives ofissue of whether awareness of illness should be

construed as a function of cognitive capacity, illness persons are forced to rely onmore delu-sional interpretations of life or that cognitiveperhaps it can be seen as more a matter of

personal construction when referring to the impairments proceed from narrative impover-ishment and not the reverse.richness and choice of details which enhance

others’ ability to understand an illness narra- With replication across broader sam-ples and settings, we would suggest that assess-tive; cognitive capacities may be implicated in

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 morediverse groups, including women, persons inpoor insight not uncovered by traditional

measures. By assessing the different ways in an earlier phase of illness, and those refusingtreatment. Second, the narratives were elicitedwhich a narrative of illness can fail to achieve

coherence, perhaps we can better understand here in a dialogue with an interviewer in aparticular social context. Thus, replicationthe complex relationships between awareness,

denial, neurocognition, and emotional pain. with interviewers in other sites and non-clini-cal settings is also essential, as is research onFor instance, future studies could potentially

ask how narratives of illness might be affected the influence of the interviewer. Third, theNCRS assesses three facets of narrative be-by personality, self-efficacy, attributional styles,

and/or community and self-stigma. Addition- lieved to be intricately involved in narrativecoherence. There may be more aspects of nar-ally, a better understanding andmeans of mea-

suring the coherence of an illness narrative rative yet to be articulated that could be incor-porated in future versions of the scale. Finally,could have important implications for out-

come research. It is widely noted that one since multiple correlations were performed inthe validity analyses, the chances of spuriousof the unique outcomes which psychotherapy

seeks to effect in schizophrenia is increased findings are inflated, even though more con-servative alphas and two-tailed tests were em-narrative coherence (Fenton, 2000; Haugs-

jerd, 1994; Lysaker & Lysaker, 2001). One ployed.As a final note, it is the intent of thismight similarly use these methods to ask

whether pharmacological interventions, which study to supplement current insight researchby providing a means of assessing awarenessappear to increase cognitive capabilities, are

similarly related to increases in narrative coher- of illness as it is embedded within a personalnarrative. We would suggest that both tradi-ence in schizophrenia or related conditions.

Of note, there are several limitations tional and narrative approaches to assessinginsight would complement one another andto this study. Most participants were male,

middle-aged, and generally many years had enrich our understanding of the experiencesand dialogues that play out within a lifetimepassed since the onset of their illness. Addi-

tionally, all were in some form of active treat- of living with mental illness.

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