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SCHIZOPHRENIA

.OO

PSYCHOPATHOLOGIC DOMAINS
AND INSIGHT IN
SCHIZOPHRENIA
Xavier F. Amador, PhD, and Jack M. Gorman, MD

Toward the end of the 19th century, K r a e ~ e l i ngrouped

~~
together
the then pre-existing diagnostic categories of hebephrenia, catatonia, and
paranoid psychosis into a single disease entity that he termed dementia
praecox. This formulation was modified by Bleulerls and renamed the
group of schizophrenias. During the century following Kraepelins initial
formulation, a number of sets of criteria had been proposed for diagnosing the condition that had received varying degrees of attention and
28, 44, 56, 63, 66, 67 The latest in this succession of modiclinical a~ceptance.~-~,
fied diagnostic formulations is the Diagnostic and Statistical Manual of
Mental Disorders, ed 4 (DSM-IV)? but few would believe that it is the
final word in the endeavor to develop a valid diagnostic category for
what we have come to know as schizophrenia.
It is generally accepted that patients grouped under the schizophrenia rubric, regardless of the system used, vary widely in their clinical
presentation, course, and response to treatment. For this reason, much
effort has also gone into attempts at subtyping schizophrenia to reduce
its heterogeneity. Data coming from studies of the positive, negative,
and disorganized domains of psychopathology argue strongly for broadening our perspective on the type of signs and symptoms that are
relevant to the diagnosis and treatment of schizophrenia. These domains
Supported in part by grants from the National Alliance for Research in Schizophrenia
and Affective Disorders (NARSAD), Great Neck, New York, the Scottish Rite Foundation,
Lexington, Massachusetts, and the Stanley Foundation, Arlington, Virginia.

From the Department of Psychiatry, Columbia University College of Physicians & Surgeons
(XFA, JMG); and Diagnosis and Evaluation Center for Psychotic Disorders (XFA); and
the New York State Psychiatric Institute, New York, New York, (XFA, JMG)

THE PSYCHIATRIC CLINICS OF NORTH AMERICA

VOLUME 21 * NUMBER 1 MARCH 1998

27

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AMADOR & GORMAN

have shown both descriptive validity at the level of symptoms and

predictive validity in terms of treatment response, anatomic substrates,
and illness course. Over the past 5 years the published data on insight,
or awareness of illness, suggest that awareness deficits also possess
strong nosologic and clinical value for schizophrenia. In this article, the
authors briefly review the process by which valid diagnostic categories
are developed. They also review the research literature pertaining to the
positive, negative, and disorganized domains of psychopathology and
awareness deficits. These constructs have been shown to have descriptive validity at the level of the signs and symptoms associated with
schizophrenia and predictive validity in their correlations with underlying anatomic substrates, treatment response, and illness course. Specifically, the authors argue that awareness deficits associated with enduring
negative symptoms and particular neuropsychologic deficits hold particular promise for identifying a subtype of schizophrenia with both descriptive and predictive validity. Before discussing the diagnostic value
of these domains of psychopathology, it is necessary to first examine the
process by which diagnostic categories are validated.
PSYCHIATRIC DIAGNOSES: HOW WE DEFINE
VALIDITY

Historically, diagnostic formulations have differed from one another

in their relative emphasis on one or more aspects of the concept of
schizophrenia: broad versus narrow definitions, cross-sectional versus
longitudinal symptoms, experiential versus behavioral symptoms, and
objective versus inferential assessments. Each new diagnostic formulation was meant to be an improvement on the ones already in existence.
The fact that so many attempts at improvement have been made over
the past 100 years indicates that the diagnostic system has not been able
to fully accomplish what it was meant to accomplish. The two main
components of a good diagnostic system are reliability and validity. Reliability of a diagnostic system refers to the consistency with which subjects
are classified. Application of a reliable diagnostic system to the same
data at different times or by different clinicians should yield the same
diagnoses. In other words, high reliability would minimize variation in
diagnoses stemming from variation in a clinicians background, theoretic
orientation, personal preferences, or emotional state. Reliability is of
great importance for facilitating communication and for research, because it ensures that everyone using the same diagnosis is referring to
the same clinical condition. Validity of a diagnostic category refers to its
meaningfulness and utility. A valid diagnostic category would be able
to help predict future course of the illness, estimate prognosis, and
clarify treatment needs. Moreover, a valid clinical diagnosis of an illness
would be informative with respect to cause and pathophysiology. Because reliability is required to ensure validity, all reliable systems are
not necessarily valid.
Achieving validity for diagnostic categories in psychiatry is much

PSYCHOPATHOLOGIC DOMAINS AND INSIGHT IN SCHIZOPHRENIA

29

more complex than for diagnostic categories in the rest of medicine. In

medicine, diagnoses are usually validated by causal and pathophysiologic mechanisms, and serve as guides to predicting treatment response
and outcome. In psychiatry, the causal and pathophysiologic mechanisms of most conditions are unknown. Consequently, it is necessary to
formulate a diagnosis by selecting patients with a similar clinical picture,
and then attempt to validate the diagnosis based on other measures such
as treatment response, family loading for the disorder, and outcome. It
is assumed that patients so diagnosed, by virtue of similarities in clinical
presentation, familial history, course of the illness, and treatment response would have the same underlying causal or pathophysiologic
condition.
Because reliability and validity are the two most important issues
in constructing a diagnostic system, other factors may also play a role
depending on the purpose for which the diagnostic system is to be used.
For example, diagnostic systems used for research purposes need to be
narrow to minimize false positives and decrease contamination of the
study population with subjects who do not have the illness (i.e., that do
not share the same cause or pathophysiology). Meanwhile, diagnostic
systems meant for use in clinical practice need to be less complex, more
acceptable to clinicians of differing theoretic orientations, contain criteria
limited to symptoms that occur relatively frequently, and may be broader
so as not to exclude too many patients who really have the illness (false
negatives).
Over the past 25 years, modifications to the criteria used for diagnosing schizophrenia have greatly improved the reliability of the diagnosis. However, these modifications have also significantly altered the
concepts of schizophrenia as used in clinical practice. In describing
dementia praecox, K r a e ~ e l i nused
~ ~ the chronic course and poor outcome
of the condition to both define and validate the concept. Although
Kraepelin described several signs and symptoms occurring in dementia
praecox, it was acknowledged that these manifestations can vary widely
and that the essential characteristic of the disorder was the longitudinal
downhill course of the illness. In an attempt to integrate the diverse
clinical presentations covered by Kraepelins dementia praecox, Bleuler18
introduced the concept of basic and accessory symptoms of schizophrenia. The basic symptoms (which included Bleulersfour As) were thought
to derive from the fundamental disease process and were considered to
be permanent and pathognomonic of schizophrenia. When present, they
precluded the diagnosis of any other functional psychiatric disorder.
Bleulers criteria allowed a diagnosis of schizophrenia to be made
cross sectionally and de-emphasized the longitudinal course of the
illness. Application of Bleuler s basic symptoms required relatively
greater subjective and inferential judgement, and was less amenable to
formulation of operational criteria. The concept significantly influenced
diagnostic practices and broadened the scope of schizophrenia to cover
a large spectrum of clinical states. This resulted in a lack of reliability
that was shown by a striking difference in the definitions of schizophre-

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AMADOR & GORMAN

nia used by clinicians in the United States and United Kingdom.25,38 The
disagreement centered on the boundary between psychotic and mood
symptoms.
The 1970s saw an increased emphasis being placed on improving
the reliability of the diagnosis. This was achieved, in part, by formulating
operational criteria and by relying more on observable (or objective)
symptoms to make up the diagnosis. A major influence on these efforts
was the description of first rank symptoms by Kurt S ~ h n e i d e rSchnei.~~
der described eight first rank symptoms, all of which are disturbances
of experiences reported by patients and that were easy to comprehend
and identify in clinical practice. Schneider considered these symptoms as
being pathognomonic for diagnosing schizophrenia once known organic
factors were excluded, although their presence was not an obligatory
requirement for making the diagnosis. These first rank symptoms were
the first implements for an operational definition of schizophrenia, and
played an important role in many subsequent elaborations of diagnostic
criteria and in the construction of interviewing instruments such as the
Present State Examination (PSE)62and the Schedule for Affective Disorders and Schizophrenia (SADS).57Indeed, cross-sectional evaluations and
Schneiders first rank symptoms were given prominence in the PSE that
was used in the US/UK project mentioned above and in the International Pilot Study of S~hizophrenia.~~
Moreover, this conceptualization
of schizophrenia influenced the way the disorder was thought of by
mental health professionals throughout the world. This was followed by
development of operational criteria in 1972 by Feighner et alZ8(St. Louis
Criteria) and by Spitzer et all2 in 1978 (Research Diagnostic Criteria or
RDC). The Feighner and RDC diagnostic systems were the forerunners
of the DSM-III.7 The third edition of the DSM set up nonambiguous
diagnostic criteria that required an illness duration of at least 6 months,
provided exclusion criteria for disorders that shared many of the same
symptoms (i.e., affective disorders), and emphasized the presence of
psychotic symptoms, which were similar to Schneiders first-rank symptoms, during the active phases of the illness. This helped to narrow the
definition and improve upon the reliability of the diagnosis. Relatively
minor changes were made for the next version of this criteria.8 Essentially, this revision entailed a simplification of the criteria and a clearer
definition of the boundary between schizophrenia and delusional disorder.
Although the definitions of schizophrenia published in the DSMI11 and DSM-111-R improved on reliability by emphasizing the easily
identifiable positive psychotic symptoms, they have been criticized for
neglecting negative symptoms that are often the cause for significant
functional disability. Studies have shown that negative symptoms have
predictive power and that they can be identified and measured with
36
good reliability.lO,
To summarize, in the years following the early work of Kraepelin
and Bleuler, the field has continued to focus on many of the same
symptoms and course of illness features. The diagnostic process also

PSYCHOPATHOLOGICDOMAINS AND INSIGHT IN SCHIZOPHRENIA

31

continued in essentially the same way. However, as described previously

in text, important modifications in diagnostic criteria and in the process
of making diagnoses have occurred, especially in the past two decades.
Two issues were considered separately in the authors review; the first
involved the choice of what symptoms the categorys creators considered
to be necessary and sufficient for an individual to receive a diagnosis of
schizophrenia, the second involved how such symptoms were assessed
and the diagnostic criteria implemented. With few exceptions, the choice
of symptoms has been driven by concepts rather than validating data.
The question of what constitutes validation of a criteria are discussed
later in text.
The authors also reviewed the issue of reliability and raised the
question of how these categories have been used, and argued that this
is an essential question that needs to be addressed in the development of
new diagnostic categories. Prior to the advent of the DSM-111, diagnostic
criteria for schizophrenia were found to differ dramatically in their rates
of diagnosing schizophrenia. In large part, the revision of the DSM-I1
was motivated by the discovery that clinicians and researchers alike had
relatively poor diagnostic reliability. This low reliability was hindering
progress in both the clinical and research realms. In the past 15 years,
reliability has successfully improved for the most part. This change came
about through the use of explicitly stated criteria. In addition, each
criterion was designed to emphasize observable objective behavior and
characteristics and to minimize the need for the examiner to rely on
inference. Such criteria were ultimately incorporated into the DSM and
the International Classification of Diseases (ICD) systems. These two
diagnostic systems are the most widely used world wide and have been
designed to serve both clinical, sociologic, and research needs. But with
an increase in reliability does not necessarily come an increase in validity.
In the past several years, the DSM and ICD criteria for schizophrenia
and related disorders (and associated subtype categories) have been
revised again. In both instances, the over-arching goal was to increase
the descriptive validity of these criteria. The revision of the DSM criteria
was additionally driven by the desire to make the criteria more consistent with the ICD system, to incorporate signs and symptoms with
demonstrated criterion validity (i.e., symptoms with predictive power),
and to make the criteria easier to implement (i.e., user friendly).
In summary, there are numerous sets of diagnostic criteria for
schizophrenia and related disorders in use today. No single set has
proven to be more valid than the others with respect to identifying
specific causes. The DSM-111-R and its predecessors the DSM-111, the
RDC, and Feigner criteria, were devised to improve upon various aspects
of the diagnostic endeavor. Most notably, significant gains have been
made in increasing the reliability of diagnoses (i.e., Endicott, 1982).27The
development of many criteria sets has also been guided by the desire to
better characterize what is an extremely heterogenous disorder.
Diagnostic criteria continue to change rapidly. Both the DSM and
ICD criteria have very recently been revised. Nonetheless, the problem

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AMADOR & GORMAN

of the validity of the diagnosis of schizophrenia and related disorders

persist. This problem extends to the subtype criteria currently used in
both schizophrenia and schizoaffective disorder. The authors have no
pathognomic symptom and the various diagnoses are based entirely on
the phenomenology and course of the putative disorders. In this context,
it can be argued that any nosology of schizophrenia and related disorders should not rely solely on traditional signs and symptoms if other
valid characterizations are available. There are many domains of psychopathology with proven criterion validity that can be used to enhance the
characterization of patients with these disorders. This approach involves
characterizing patients diagnosed with schizophrenia and related disorders across multiple domains of psychopathology (i.e., trait related neuropsychologic dysfunction, awareness deficits, enduring negative symptoms, etc.). In the next section, the authors briefly review the literature
related to the classic schizophrenia subtypes.
CLASSIC SCHIZOPHRENIA SUBTYPES

Much effort has gone into subtyping schizophrenia in an attempt to

reduce its heterogeneity. Among the fruits of this labor are the classic
subtypes (currently labeled catatonic, disorganized, paranoid, undiferentiated, and residual) as well as other novel categorical and dimensional
subtyping schemes (deficit syndrome, positive, negative, and disorganized domains among others). Because the validity of the classic subtypes has been examined to a limited extent, the other putative subtypes
have received relatively little attention. Most attempts at validating these
subtypes by their associations with clinical and biologic variables have
been cross-sectional in nature. This is problematic as the course of
schizophrenia is characterized by chronicity in some patients and remissions and exacerbations in others, and the observed phenomenology
often varies over time. This severely limits the predictive power of crosssectional analyses and compromises the search for causal mechanisms
based on symptoms observed at a cross-sectional point in time. Longitudinal studies help in the differentiation of symptoms that are enduring
(trait) from those that wax and wane (state dependent). Such a differentiation may help increase homogeneity for the purpose of searching for
underlying causes and provide clues to predicting prognosis and treatment response. In this respect, establishing whether the classic subtypes
are a trait versus transient feature of the disorder is key to determining
their ultimate validity.
Janzarik31thought that the most impressive feature of the lifelong
course of schizophrenia was the extreme instability of the schizophrenia
subtypes. Bleuler,19in a long-term follow-up study of 208 patients with
schizophrenia, observed that the distinctions between the classic subtypes become blurred over time. He also reported that, over the course
of his study, only a small minority of patients fit into the traditional
subtypes, and most of them revealed a mixed symptomatology that

PSYCHOPATHOLOGIC DOMAINS AND INSIGHT IN SCHIZOPHRENIA

33

could not unambiguously result in classification into one or the other

subtype. He concluded that four subdivisions of schizophrenia were
essentially arbitrary. In a comprehensive review of the literature pertaining to this issue, Carpenter and Stephens" concluded that the four
classic subtypes cannot be reliably distinguished and have not been
shown to have predictive validity. They argued that subtypes classified
along course or prognostic lines may be more clinically useful.
More recently, three studies conducted in the United States have
examined subtype stability over average follow-up periods of 4.5 to 25
found that the hebephrenic and
years.29,30, *O, 55 Pfohl and Winok~15~
catatonic subtypes showed a tendency toward nonspecificity (i.e.,
evolved into undifferentiated and residual) with time. The other two
studies also found only modest stability for classic schizophrenia subtypes, with only the paranoid subtype showing moderate stability. Kendler et a140also noted that specific subtypes evolve into nonspecific but
rarely into each other. Taken together, these reports all suggest that the
classic subtypes are not a trait characteristic of the disorder. However,
these studies are far from definitive as all were retrospective in nature,
depended on reviews of hospital records rather than direct patient
assessment, had modest sample sizes (52 to 139) and used differing
diagnostic systems.
Two follow-up studies examined the classic schizophrenia subtypes
for differences in outcome. Kendler et a139studied 139 patients drawn
~ ~ , ~ ~ 162
from the Iowa 500 sample and Fenton and M c G l a ~ h a nevaluated
patients from the Chestnut Lodge follow-up cohort. Both studies found
that patients diagnosed with the paranoid subtype tended to have better
outcomes. This pattern was more pronounced when the subtype diagnosis was based on the more narrowly defined criteria of Tsuang and
Winok~r.~~
When schizophrenia is subdivided based on paranoid versus nonparanoid distinction there is some evidence suggesting that the genetic
loading for schizophrenia is higher in the nonparanoid group. This is
supported by a study of 60 twin pairs conducted by McGuffin et a153
who found that the twins of nonparanoid probands had a higher risk of
schizophrenia compared to twins of paranoid probands. Also, in support
of the idea that nonparanoid schizophrenia may have a higher genetic
component is the finding of a higher risk of developing schizophrenia
in the offspring of nonparanoid schizophrenic mothers.33However, Kendler and c o l l e a g ~ e s study
' ~ ~ of 723 first-degree relatives of 250 schizophrenia probands failed to support the findings of these two previous
studies. They found that familial factors were not significantly different
across the different subtypes. The results of studies examining subtype
concordance in families have also yielded conflicting results. Since two
53 two others did
41
studies have supported subtype con~ordance,3~,
Sparse data exist on whether the classic schizophrenia subtypes
show a differential neuropsychologic performance profile. There is some
evidence suggesting that paranoid patients perform better on some
neuropsychologic tests compared to patients diagnosed as undifferenti-

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AMADOR & GORMAN

ated or a combined group of undifferentiated and hebephrenic subtype

patients.20However, on the whole there is little to suggest that any one
subtype is associated with a particular neuropsychologic profile.
PSYCHOPATHOLOGIC DOMAINS

A promising new approach to subtyping schizophrenia is to group

the manifest symptoms into different psychopathologic domains. Factor
analytic studies have consistently shown that the symptoms of schizophrenia as rated by the Schedule for the Assessment of Positive Symptoms (SAPS)" and the Schedule for the Assessment of Negative Symptoms (SANS)I2can be grouped into at least three orthogonal syndromes
generally referred to as the positive, negative, and disorganization dorr~ains.~~,
16,
49, 54 Studies that used instruments other than the SAPS and
SANS have suggested the existence of other domains such as activation/
excitation, insight, or awareness of illness, and depression.22,37, 6o The
question of whether these domains are a trait versus state feature of
illness is key to understanding their meaning and to attempts at uncovering underlying cause and pathophysiology.
All of the arguments for using follow-up studies to validate categorical distinctions in a previous generation of studies can be applied to
within-class distinctions that are based on the covariation of symptom
severity. There is now considerable interest in the proposition that multiple psychopathologic disorders exist in various combinations in patients
with schizophrenia and attention to the course of psychopathology
within the positive, negative, and disorganized domains can yield valuable information with regard to this h y p o t h e s i ~Because
.~~
studies using
factor analytic techniques have consistently demonstrated the presence
of at least three psychopathologic domains in different schizophrenia
populations from different geographic regions, little data exist on the
temporal stability of these domains using either intermediate or longterm follow-up studies and no prospective studies of this type.
Relying on retrospective ratings of symptoms manifested during
lifetime acute episodes and interepisode intervals, Maziade et a150 reported that the characteristic three dimensional pattern was not seen
during the interepisode periods. In a 2 year follow-up study of schizophrenia patients under naturalistic treatment conditions, Arndt et a1
found that the positive and disorganization dimensions become less
prominent since the negative dimension retains its stability over the
course of the illness. In summary, the question of whether the dimensions remain stable during exacerbations of illness or during interepisode
periods remains ambiguous.
There is relatively little research aimed at validating the psychopathologic domains by examining their associations with illness course,
treatment response, biologic measures, and neuropsychologic functioning. Although preliminary, the extant data is promising. Using factor
analysis to define the three domains, Arndt et all7 found the three
427

PSYCHOPATHOLOGIC DOMAINS AND INSIGHT IN SCHIZOPHRENIA

35

symptom groups tended to change during the course of a 2-year followup but independently from one another.
Negative symptoms tend to show a relatively poor response to
treatment with neuroleptics,32 although some of the newer compounds
show some promise. Negative symptoms have been found to be associated with cognitive irn~airment,'~
especially impairments in frontal lobe
ta~ks.4~
Because an association between negative symptoms and enlarged
brain ventricles has been reported, this has not been consistently repli~ a t e dAn
. ~ association
~
between negative symptoms and decreased frontal cerebral blood flow or metabolism has been more consistently replicated.'" 46, 64 Much of the available validating evidence tends to support
the negative symptom domain as a distinct entity because there is
relatively little data on the other domains.
The disorganization domain has been studied to a much lesser
extent. The tendency of most earlier studies to treat all positive symptoms as a unitary concept may have contributed to the inability to
find associations between the positive and disorganized domains and
validating variables. Liddle46has proposed that the disorganization domain may reflect dysfunction of the right ventral prefrontal cortex since
the positive domain is primarily a dysfunction of the medial temporal
lobe. However, the associations between these two domains and measures of neuro-cognitive function in these areas have not been conducted.
In summary, although the descriptive validity of the three domain
model is clearly established, the criterion validity is not. However, published studies that have examined the question of criterion validity are
promising.
AWARENESS DEFICITS

In 1896, K r a e ~ l i ndescribed
~~
patients with dementia praecox as
being typically unaware of the gravity of their disorder. Any experienced
clinician knows that a substantial number of patients suffering from
schizophrenia do not believe they have an illness and are unaware of
the specific deficits caused by the disorder. Indeed, many of these individuals feel that the only thing they really suffer from is pressure
from relatives, friends, and doctors to accept treatment. Lack of insight
frequently obstructs treatment, as disagreement that treatment is even
necessary leads to patients feeling coerced to accept care for an illness
they do not believe they have. Large scale studies have suggested that
from 50% to more than 80% of all patients with schizophrenia do not
believe they have an illness.2,5, 22, 65 Owing to its prevalence and
disruption of the therapist-patient relationship, this type of discrepancy
in perspective, or what is commonly labeled poor insight has become
integral to our conception of schizophrenia.
Historically, the study of insight in schizophrenia has been plagued
by both conceptual ambiguities inherent in the term and the lack of
widely used standardized measures. The authors believe that this alone

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AMADOR & G O W N

has accounted for the relatively minute amount of attention this domain
of psychopathology has received in the research literature. Indeed, over
the past decade investigators have begun to develop reliable methods to
assess the multiple dimensions of insight into illness, resulting in more
widespread use of these instruments and concomitant increase in the
number of published studies that focus on this domain. In the next
section, the authors describe recent innovations in the measurement of
insight and the results of studies that provide a clearer understanding
of the causes of poor insight and the role that awareness deficits play in
the expression of schizophrenia.
Measurement of Awareness Deficits

The myriad terms and divergent perspectives used to define and

study insight over the years reflect its complex and multidimensional
nature. For the sake of this discussion, the authors use the term insight
interchangeably with awareness. Both terms are defined broadly, unless
stated otherwise, and indicate either a lack of awareness of having an
illness, unawareness of specific signs and symptoms, ignorance of the
consequences of the disorder, and lack of agreement with health professionals that treatment is indicated.
Most of the early literature on insight in schizophrenia relied heavily
on anecdotal case material. Initial attempts to quantify insight were
typified by crude global ratings that were never tested psychometrically
(i.e., reliability and internal consistency were never established). Until
recently, there was only one standardized method of assessing insight
in psychiatric disorders with proven psychometric strengths. The Insight
and Treatment Attitudes Questionnaire (ITAQ) developed by McEvoy et
a15' has been used in large samples with extensive tests of reliability and
validity, and has been found to be predictive of several measures of
clinical outcome and compliance. Its primary limitation lies in its continuation of the tradition to view insight narrowly (i.e., it assesses whether
the patient agrees with the doctor about the accuracy of his or her
diagnosis and prescription that treatment is needed). Critics of such an
approach, most notably
argued that insight into illness was a
more complex phenomenon than simply awareness of a particular diagnosis and need for treatment.
Several years ago, the authors recommended a more complex terminology, and multidimensional assessment procedure, that they believed
would more accurately reflect those aspects of insight into illness that
clinicians and researchers were interested in studying5 At that time,
we made a distinction between two additional dimensions of insight:
awareness of illness and attribution regarding illness. Unawareness of
illness is defined as a failure to acknowledge the presence of a specific
sign or symptom when confronted with it by an examiner. Incorrect
attribution is the expressed belief that specific deficits, signs, or consequences of illness that are present are unrelated to mental dysfunction.

PSYCHOPATHOLOGIC DOMAINS AND INSIGHT IN SCHIZOPHRENIA

37

The authors also recommend the distinction of current insight from

retrospective insight. Consistent with this conception of insight, the
authors developed the Scale to assess Unawareness of Mental Disorder
(SUMD) that assesses several domains of insight not previously tapped
by the methods used at that time.3 The SUMD distinguishes current and
retrospective awareness of (1) having a mental disorder, (2) the effects
of medication, (3) the consequences of mental illness, and (4) awareness
and attributions for the specific signs and symptoms of the disorder. By
assessing awareness of specific symptoms the SUMD offers the benefit
of providing data on moderating variables useful for studies of psychoeducational strategies, and data on the nature and pervasiveness of poor
insight. The SUMD has proved reliable and valid in several independent
studies.2, 34* It has quickly become one of the most commonly used
instruments designed to measure awareness deficits in schizophrenia,
having been translated into 15 languages as of this writing. With more
studies using identical procedures to evaluate awareness, the rate at
which published data are replicated will continue to increase dramatically. Studies on the role awareness deficits play in the expression of
schizophrenia are described later.
Descriptive Validity of Awareness Deficits

Awareness deficits have descriptive validity at the level of the

phenomenology of schizophrenia and prognostic validity in terms of the
prediction of the course of illness. Cluster analysis of the signs and
symptoms of schizophrenia indicate that level of insight into illness (i.e.,
rated based on patients' response to the question: "Do you have a mental
illness?") has descriptive validity as a dimension on which patients can
be subtyped. Carpenter and his associates employed cluster analytic
techniques on quantified sign and symptom data collected for the International Pilot Study of Schizophrenia.22They reported that poor insight
was a prevalent feature of schizophrenia, and that the level of insight
was an important discriminating factor when making subtype diagnoses.
A more recent multinational study assessed the 12 signs and symptoms
of the Flexible System Criteria, and replicated the IPSS findings6 These
studies are reviewed in greater detail in a paper by Amador et al.5
The authors have additional data that shed light on the nature and
prevalence of unawareness in schizophrenia and schizoaffective disorder. They were part of the group that directed DSM-IV field trial study
that focused on schizophrenia and related disorders. In this study, over
400 patients from geographically diverse regions and one international
site were evaluated for a wide range of symptoms including unawareness. Using the SUMD, the authors sought to determine the prevalence of various awareness deficits in psychotic disorders and to examine
their specificity to schizophrenia. Our results indicated that nearly 60%
of the patients with schizophrenia had moderate to severe unawareness
of having a mental disorder. This finding is in agreement with the IPSS

38

AMADOR & GORMAN

and the Classification of Chronic Hospitalized Schizophrenics studies,

which both indicate that a majority of patients with schizophrenia believe they do not have a mental disorder. In addition, the authors found
that between 27% and 57% of the patients with schizophrenia were
severely unaware of specific symptoms (i.e., delusions, thought disorder,
blunt affect, anhedonia, asociality, and other dimensions of illness).2
Less agreement exists regarding the relationship between level of
insight and severity of positive, negative, and mood symptoms. Two
earlier studies examining this question found contradicting results, and
more recent reports using standardized assessments of symptoms (i.e.,
BPRS, SAPS, SANS, Hamilton Rating Scale for Depression, the Comprehensive Assessment of Symptoms and History, etc.) indicate that neither
positive nor negative symptoms, general measures of psychopathology,
depressive symptoms, or manic symptoms were significantly correlated
with insight.2, However, a few studies have reported clinically insignificant, modest correlations, between positive symptoms, depressive
symptoms, and insight.2,
Criterion Validity of Awareness Deficits

The majority of studies that examine the relations between insight

and clinical outcome indicate that better insight into illness correlates
positively with a more favorable course. Not surprisingly, various awareness deficits are also strongly correlated with noncompliance with medication and psychosocial treatment^.^, In a recent study, the authors also
found that schizophrenia patients with recurrent suicidal thoughts and
behavior were generally more aware of their negative symptoms and of
delusions in particular, than were the nonsuicidal patients. Contrary to
expectations, global awareness of having a mental disorder did not
predict suicidal behavior. These results suggest that awareness of particular aspects of illness may be more demoralizing than awareness of other
aspects. Taken together, these associations suggest several areas for future
research with obvious clinical importance, particularly the exploration of
whether specific domains of insight may be more or less related to different
aspects of compliance, course of illness and suicidality.
Associations with Neurocognitive and Affective
Deficits

Previously, the authors argued that unawareness of illness in neurologic disorders (anosognosia) bears a striking resemblance to poor insight in schizophrenia, which includes both phenomenological and neuropsychologic similarities5 Patients with anosognosia frequently offer
confabulations or delusional explanations to explain observations that
contradict their belief that they are not ill. Similarly, individuals with
schizophrenia are frequently observed to attribute their hospitalizations

PSYCHOPATHOLOGICDOMAINS AND INSIGHT IN SCHIZOPHRENIA

39

to factors such as fights with parents, or misunderstandings. Patients

with both disorders tend to be similarly rigid in their display of affective
indifference and their inability to integrate new information contrary to
their erroneous beliefs. Finally, the unawareness phenomena observed
in both anosognosia and schizophrenia are frequently modality specific.
For example, the anosognosic patient may be aware of a memory deficit,
but unaware of paralysis. Similarly, the authors have published data
indicating that many patients with schizophrenia are aware of particular
symptoms, while maintaining complete unawareness of others.*,
Particular brain areas implicated in anosognosia provide a practical
starting point for generating hypotheses about neuropsychologic contributions to poor insight in schizophrenia. Functional and structural lesions of the frontal lobes and the nondominant hemisphere temporal
parietal system, specifically implicated in anosognosia, are seen in many
patients with schizophrenia as well. As mentioned earlier, Young and
his colleagues found that various aspects of poor insight, as assessed on
the SUMD, were associated with poorer performance on tests sensitive
to frontal lobe dysfunction (verbal fluency, trails A-B, and Wisconsin
Card Sort). Similarly, Lysaker and BellMhave reported that patients with
poorer insight as measured by the PANSS insight item, had worse scores
on tests of frontal lobe function. The authors also have data that replicate
and extend the findings of Young et al.35
Consistent with the frontal lobe hypothesis are more recent findings
indicating that severe unawareness is strongly associated with the deficit
syndrome in schizophrenia.' These results come from three different
samples and are consistent across studies. Many patients with schizophrenia have enduring negative symptoms that have been understood
as being primary to the disorder. Such symptoms have been termed
deficit symptoms and are distinguished from negative symptoms that
are a consequence of depression, demoralization, medications, positive
symptoms, or socio-environmental deprivation. A deficit syndrome has
been described that is characterized by the presence of such
Of particular interest is the finding that the deficit syndrome in schizophrenia is associated with neuropsychologic deficits of the frontal lobes
and right parietal lobe.21
The finding that a broad range of awareness deficits are more
common in deficit compared with nondeficit patients and that both
domains of psychopathology are associated with frontal lobe dysfunction, suggests that an anosognosic syndrome may exist in many patients
with schizophrenia. This syndrome is characterized by a cluster of symptoms indicative of frontal lobe dysfunction (primary negative symptoms
and awareness deficits) and associated with a poorer course of illness
and loss of normal affective function.
CONCLUSION

The study of awareness deficits offers important opportunities for

improving the meaningfulness of diagnoses, understanding the neuro-

40

AMADOR & G O W N

psychology, and enhancing the treatment of persons with schizophrenia.

Because the neuropsychologic underpinnings of poor insight in schizophrenia have not been definitively identified, recent studies strongly
suggest that frontal lobe dysfunction may account for a large proportion
of awareness deficits in this disorder. As data continue to emerge as to
the specificity, trait stability, and neurobiologic basis of unawareness of
illness, further support is lent to the suggestion that awareness deficits
stem from an important core symptom of the syndrome. As such, deficits
in awareness of illness are a potentially indispensable means of subtyping patients with schizophrenia.

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Address reprint requests to

Xavier F. Amador, PhD
Columbia University
Department of Psychiatry
722 West 168th Street, Unit 2
New York, NY 10032