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Lack of awareness of illness

inschizophrenia:
conceptualizations, correlates
and treatment approaches
Expert Rev. Neurother. 9(7), 10351043 (2009)

Paul H Lysaker,
KellyDBuck,
Giampaolo Salvatore,
Raffaele Popolo and
Giancarlo Dimaggio
Many individuals with schizophrenia are unaware of the symptoms and consequences of their
illness. Unawareness of schizophrenia is linked to poorer adherence to treatment and is a risk
factor for a range of poorer outcomes. Paradoxically, the achievement of awareness may lead
to depression, low self-esteem and possibly a higher risk of suicide. To explore these issues, this
article reviews emerging literature on the correlates of unawareness of illness in schizophrenia,
describes advances in how to address unawareness of illness in a treatment setting and discusses

Author for correspondence

Roudebush VA Med Center
(116H), 1481West 10th Street,
Roudebush VA Medical Center,
Indianapolis, IN46202, USA
Tel.: +1 317 988 2546
plysaker@iupui.edu
newly developing ways of conceptualizing insight. A plan for further research is presented, along
with an outline for the development of methodologies to assess awareness of illness as a
narrative phenomenon, which calls on a range of neurocognitive and metacognitive capacities,
and which must deal with the social stigma linked with mental illness.
Keywords : insight metacognition neurocognition recovery schizophrenia stigma theory of mind

It has long been recognized that, relative to per-
sons with other psychiatric conditions, many
people who suffer from schizophrenia spectrum
disorders are, to varying degrees, unaware of
major aspects of their illness [1,2] . They may,
to some extent, reject the possibility that they
have had in the past or are currently facing a
mental illness. They may contest the possibility
that specific experiences others think are linked
to a mental illness, such as a peculiar sensory
experience no one else shares, are symptoms of
a mental illness. They may be fully cognizant
of the reasons why the people they love or trust
believe that they have a mental illness and yet
reject, in a large or small degree, this possibil-
ity without doubt. This form of unawareness or
denial may be particularly baffling given that
persons with schizophrenia are generally fully
aware of what is occurring in the world around
them. They may work, go on dates, pay bills and
respond in a fully adaptive manner to other life
demands [3] . Persons with schizophrenia who are
unaware they are ill may also deliver fully valid
and reliable responses to psychological assess-
ments [4] . They may meaningfully appraise their
own physical health [5] or plainly recognize the
symptoms of others who are mentally ill [6] .
Importantly, this phenomenon, sometimes
referred to as poor insight, denial of illness
and unawareness of illness, is complex and
composed of several semi-independent facets.
It may involve, as stated previously, a general
lack of awareness of suffering from a mental
illness. There may be awareness of something
being vaguely wrong but a failure to acknowl-
edge that specific experiences are symptoms of
a mental illness. For example, some people may
acknowledge that they suffer from depression
but insist that the hallucinations or delusions
they experience are not symptoms of a mental
illness. Others may reject the possibility of any
need for treatment. Some may deny the need for
medication, for instance, despite several recent
experiences in which, after stopping medica-
tion, the person exhibited behavior that led to
a hospitalization or that was deeply embarrass-
ing. Still others may fail to be fully aware of
the consequence of their mental illness. They
may not see, for example, a 10-year period of
unemployment or absence of close friends as
signs of a problem. Adding to the complexity of
this issue, individuals may be unaware of some
of the dimensions of their illness while being
aware of others.

www.expert-reviews.com 10.1586/ERN.09.55 2009 Expert Reviews Ltd ISSN 1473-7175 1035

 Review Lysaker, Buck, Salvatore, Popolo & Dimaggio
Unawareness of illness in schizophrenia thus presents practi-
tioners, patients, their friends, families and communities with
a number of frustrating and, at times, desperate challenges [7] .
Generally, contemporary models of helping persons recover from
mental illness are based on the assumption that individuals will
seek appropriate help and support on the basis of their own coher-
ent working model of their abilities and challenges [8,9] . If illness is
denied, or beyond the awareness of the person suffering with it, it
is difficult to see how offers of help could be responded to by the
potential patient as something other than to be humored at best
or, at worst, as absurd and intrusive. Assuming treatments, such
as pharmacotherapy, assist individuals in moving towards states
of wellness [10] and that these may be especially important in early
phases of illness [11] , it seems a matter of intuition that people
who are unaware that they suffer from schizophrenia may be at
risk for relapse and possibly prolonged deficits and unnecessary
psychosocial difficulties.
Given current day understanding that recovery from schizo-
phrenia is possible, and often attained and facilitated by the
development of a sense of autonomy, hope and self-efficacy[1214] ,
there is an obvious conflict. If individuals deny that they suffer
from schizophrenia or any other medical condition for that mat-
ter, how is it possible to be empowered to take actions to recover?
In response to this, the following review will seek to explore three
issues regarding awareness of illness in schizophrenia. First, we
will explore the correlates of unawareness of illness in schizo
phrenia, discussing both the difficulties inherent with being
unaware of illness and the difficulties that may ensue once some-
one has attained insight. Second, we will turn to literature on how
to address unawareness of illness in a treatment setting. Third, we
will focus on emerging ways of conceptualizing the phenomenon.
Lastly, in order to help advance our understanding of these com-
plex issues, suggestions will be put forth regarding the develop-
ment of a research agenda that could study more complex models
of insight based on advances in neuroscience, phenomenology and
associated research.
Unawareness of illness
Consequences
Intuitively, as noted previously, most people might be expected to
resist treatment for any medical conditions they did not recognize
they had. Indeed, the results of a number of recent studies have
added to older literature documenting that denial of illness is sig-
nificantly linked with poorer medication adherence. In particular,
patients who are unaware that they suffer from schizophrenia have
been found to have more negative attitudes towards medication
and longer episodes of antipsychotic nonadherence [1517] . This
appears true among patients in later stages of illness and also those
recovering from a first psychotic episode [18] . However, summariz-
ing studies from 2006 and earlier, Lincoln etal. note that while
a connection can be detected between awareness and medication
adherence in the present, that link appears to become attenuated
with time [19] . Suggested here then is that unawareness of illness
may pose difficulties in the present; although, with time, indi-
viduals may become more aware of their illness and, as a result,
1036
adopt differing attitudes towards treatment. For instance, when
acute problems linked to illness resolve, a fragile awareness of ill-
ness may fade, or as difficulties arise in the face of support from
others, awareness may grow.
With regard to outcomes beyond treatment adherence, con-
temporary research has linked unawareness of illness with greater
instances of hospitalization [17,20] , especially among persons early
in or just prior to the onset of their illness [21,22] . Unawareness
of illness has also been associated with greater levels of positive
and negative symptoms [23,24] , especially in the early stages of ill-
ness [25] , although the degree of association remains a matter of
ongoing research. With closer analysis, unawareness of illness has
been predictive of poorer functioning at the level of basic social
and vocational function [26,27] , although some studies have failed
to replicate this [21] . Consistent with this, new studies point to
the possibility that individuals who are unaware of their illness
have difficulties decoding social situations [2830] , and may have
difficulties discerning and naming their own internal states [31] .
Of note, while the likelihood of stigmatized beliefs of mental ill-
ness has fueled assertions that unawareness of illness may lead to
aggression or violence, there is no evidence supporting this [32] .
In sharp contrast to studies linking unawareness of illness with
poor outcome, other research has suggested, albeit paradoxically,
that awareness of illness may lead to a different set of negative
outcomes [33] . Drake etal. have reported that as persons early in
their illness develop awareness of illness, they are at greater risk for
increased levels of depression [34] , just as Mohamed found changes
in insight were linked to increases in depression [35] . At issue
here is the possibility that as individuals come to believe they are
mentally ill, they are confronted with and demoralized by stigma,
namely stereotypic and inaccurate social beliefs about mental ill-
ness (e.g., the false belief that mental illness is synonymous with
incompetence) [36] . In support of this are findings clearly linking
stigma with poorer self-esteem and hopelessness [37,38] , as well as
another study that reported that greater awareness of cognitive
symptoms of illness is linked with greater risk of internalizing
stigmatizing views [39] . In addition, it has been reported that indi-
viduals aware of their illness who accepted stigma had lower levels
of self-esteem and hope relative to those who denied illness [40]
and others who had insight but who were able to reject stigma.
Beyond painful internal states, awareness of illness has also
been linked to poorer quality of life [41] . Again the interpretation
that has been offered is that with awareness of illness people come
to not only see themselves as mentally ill but also accept that
mental illness means they are not capable of having meaning-
ful lives. Consistent with this are empirical studies that suggest
greater awareness of illness is a risk factor for suicidal ideation
and possible suicide attempts [4244] .
Treatment approaches
As discussed previously, most contemporary views of recovery
stress that some awareness of personal limitations is necessary.
Yet, how should unawareness or poor insight be addressed in
treatment settings? While no single intervention has emerged
as pre-eminent [45] , several different approaches have provided
Expert Rev. Neurother. 9(7), (2009)
 Lack of awareness of illness in schizophrenia
promising results. First, cognitivebehavioral therapy (CBT) is a
form of psychotherapy that helps patients to identify and correct
maladaptive beliefs and behaviors. CBT consequently seems a
natural intervention as unawareness of illness could be conceptu-
alized as possessing a maladaptive belief (e.g., I am not ill) that
could be challenged in an intervention. To date, CBT has proven
to be a treatment that individuals with schizophrenia will accept.
One study has linked participation in CBT with the development
of awareness of illness [46] , although the effect sizes observed were
weak and at least one other study has failed to replicate this [47] .
A promising development for addressing the issue of awareness
of illness is Chadwicks person-based cognitive therapy [48] . This
approach incorporates a range of principles, many of which are
cognitively focused, and seeks to promote self-acceptance and
self-reflection. Similarly, others have published quantitative case
reports suggesting that integrative psychotherapy with a cognitive
basis might help individuals to simultaneously construct a more
coherent account of psychiatric difficulties, personal strengths,
losses and hopes, leading to the development of meaningful
awareness of illness [4951] . The integrative approach empha-
sizes, in common with that of Chadwick, the joint construc-
tion of meaning with patients. For instance, instead of exploring
the plausibility of the belief, or supplying of alternative beliefs,
patients are assisted to develop their own coherent and consensu-
ally acceptable version of what is wrong. As noted, these models
have yet to be tested in randomized controlled trials.
Another possibility is that motivational interviewing might
be utilized to offer individuals with severe mental illness a suf-
ficiently nonthreatening environment to explore their views
about what mental illness means and help them to understand
the positive and negative consequences of their actions [52,53] . This
approach might be helpful as it avoids emphasizing or creating
undesirable power dynamics and focuses on enhancing confi-
dence and self-esteem, perhaps allowing patients to develop an
awareness of their illness that is not contaminated with stigma.
In other words, consistent with integrative approaches [4951] , this
kind of intervention may allow for a safe environment in which to
think about ones own thinking, protected from stigma. Related
to these views are other, more purely rehabilitative approaches,
which have suggested that awareness of illness might improve as
persons have positive and affirming experiences that assist them to
contend with the threats to self-esteem inherent in stigma [54,55] .
Evidence of this can be found in at least one study suggesting that
insight was largely independent of recovery style and that recovery
style was more closely linked to service engagement than aware-
ness of illness [56] . Importantly, Bourgeois etal. have reported
that pateints who attained greater levels of awareness had a lower
suicide risk if they were actively involved in treatment [57] .
Consistent with the observations on the importance of a sup-
portive environment while insight is developed, Lewis empha-
sizes that increasing insight often has the consequence of leaving
patients in the position of having to mourn actual losses result-
ing from illness (e.g., dreams and past opportunities), but also
to grieve the loss of previous ways of making meaning [58] . For
example, to realize a grandiose delusion was a symptom of mental
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Review
illness might first lead to awareness of having lost relationships
with families or lovers. Beyond that, however, awareness of illness
in this example might also disable the manner in which threats to
self-esteem were previously dispelled or neutralized that is, by
calling to mind grandiose beliefs that now have been dismissed
as untenable.
Lastly, concerning two other commonly considered interven-
tions for unawareness of mental illness psychoeducation and
medication there continues to be little-to-no indication that
either are significantly helpful in promoting a lasting form of
awareness of illness [7,48] . It is likely that psychoeducation helps
individuals to learn facts about mental illness but not necessarily
to decide whether those facts are relevant to themselves in a mean-
ingful way. However, new person-centered approaches have been
called for that may be able to work around this problem and lead
to better outcomes [59] . Regarding medication, there remains hope
that newer agents, yet to emerge on the market, which enhance
cognitive functions such as attention, will help individuals to
think more clearly about themselves and their circumstances and
to take advantage of the interventions noted previously.
Evolving conceptualizations
Evolving from the paradoxical findings noted earlier, work has
continued to attempt to conceptualize the roots and nature of
poor insight in schizophrenia. In a recent summary, Osatuke etal.
identified seven major models of the etiology of poor insight, none
of which are necessarily mutually exclusive [60] . The first two of
the models noted by this group suggest that lack of awareness of
illness may itself sometimes be a positive or a negative symptom
of schizophrenia. Framed as a positive symptom, lack of awareness
of illness would itself be considered conceptually as a delusion.
Framed as a negative symptom, lack of awareness would itself be
considered conceptually as a form of withdrawal from a socially
validated portrait of reality.
The next four models proposed by Osatuke and colleagues
point to the possibility that unawareness of illness results from
some form of cognitive dysfunction: cognitive disorganization,
neurocognitive impairment, impaired metacognitive capacity or
neuroanatomic deficit. This group of theories shares the con-
tention that some form of diminishment in previously available
cognitive resources probably clouds a persons ability to recognize
or label a series of chaotic and confusing experiences in the face of
schizophrenia. The final model noted by Osatuke and colleagues
suggests that lack of awareness is essentially a form of adaptation
to illness; that is, a self-protective act or means of coping with the
difficulties linked with the illness.
To date, most research has examined the possibility that
unawareness of illness is linked to difficulties with cognition.
Consistent with previous work summarized elsewhere [61] , a
range of cross-sectional studies have found that participants with
schizophrenia who were unaware of their illness demonstrated
significantly poorer performance on neurocognitive assessments,
particularly those linked to the function of the prefrontal cortex.
With limited flexibility in abstract thought or poorer overall brain
function, it may be that it is especially difficult to perceive and
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 Review Lysaker, Buck, Salvatore, Popolo & Dimaggio
construct a meaningful account of the naturally complex and
often poignant losses and life changes related to the onset and
development of schizophrenia [62] . Examples of studies support-
ing this possibility include those that link poor insight to poorer
executive function [6365] , lesser capacity for perceptual organi-
zation [30] and lower grey matter volumes in the temporal and
parietal regions of the brain [66] . Of note, other studies have failed
to replicate some of these findings, leaving the link of awareness
of illness with neurocognition and brain structure still a matter
open to debate [60] .
Moving beyond neurocognition, other studies and theoreticians
have begun to examine the metacognitive roots of poor insight.
As noted earlier, several studies have found that decrements in
the ability to understand ones own thoughts and feelings, as
well as those of others, may be directly related to the degree to
which persons are aware of their illness [29,30,67,68] . Implied here,
for instance, is the possibility that one must be able to adopt the
perspective of other people to be able to form an idea of how one
is appearing. In other words, a failure to form a thought about
how another might see ones illness might lead to a failure to fully
form a thought oneself about ones own illness. In parallel, it may
be that growth in awareness of ones own thoughts and feelings
may provide a necessary platform for persons unaware of illness to
be able to form an idea of themselves as struggling with internal
difficulties [4951] .
Expert commentary
Lack of awareness of illness in schizophrenia represents a conun-
drum for the allied fields of contemporary mental health. It is linked
with poor adherence to treatment and dysfunction, and yet, when
it resolves, it is linked to depression, low self-esteem and possi-
bly heightened suicidality. Current treatments are promising but
untested, and progress in the area of treatment and a comprehensive
model of the role insight plays in recovery is absent.
We suggest that these difficulties are, in part, a reflection of
a struggle to develop a conceptualization of what it means to
be unaware of illness in schizophrenia. Of note, it has yet to
be explored how insight of a physical disease, such as diabetes,
is phenomenologically different from insight in the context of
schizophrenia. In the case of diabetes, the patient is aware that
changes in energy level or clarity of cognition might mark a rise
in blood sugar. By contrast, in schizophrenia there may be a per-
ception or belief that feels correct or is not confusing but which
others do not share. In fact, this interpersonal dimension is key
here, whereas it is not necessarily so in diabetes. In the case of
positive symptoms in schizophrenia, the fact others do not share
the same view may be the impetus to challenge not just how to
make sense of something (e.g., a voice or a confused feeling), but
also to challenge how well one is able to make sense of things in
general. In other words, what appears in schizophrenia is a need
to challenge how one is making sense of things in general.
One issue hampering considerations of this is the utilization of
older models of information processing that place people as beings
who passively receive and assemble information into a picture that
more or less mirrors reality. These models, when applied to persons
1038
with schizophrenia, in essence equate unawareness of illness with a
lack of information or the absence of a specific piece of knowledge.
In contrast to this, contemporary models of cognition stress that
people actively and purposefully interpret not only the informa-
tion they receive but also how they think about that information
and how they think about themselves. This process furthermore
progresses on the basis of internal (e.g.,desires, wishes and meta-
cognitive and neurocognitive capacities) and external (e.g., social
networks and community resources) phenomena[6972] , which are
not reducible to neurocognitive epiphenomena.
In response to the unique nature of insight in schizophrenia
and an active view of how humans make meaning, one emerging
solution has been to understand insight as a narrative or storied
account of challenges linked to mental illness [73] . In this sense,
unawareness of illness reflects a personally constructed narra-
tive and not an unsuccessful attempt to grasp a specific piece of
knowledge. It is not that a patient has failed to accept the truth
as offered by a physician or family member, but instead that they
have made sense of what is happening to them in a manner that
has led them to arrive at an opposite conclusion (e.g., they do not
need medication). Importantly, this view of insight points to the
fact that any awareness of illness must have two qualities in order
to be adaptive. First, a useful form of awareness of illness must
be evolved or authored primarily by the person suffering from
the condition. Second, any useful narrative of illness has to be
one that can be understood by others. The narratives of human
beings are not constructed in isolation, but evolve with other
people, including friends, rivals, family, bartenders, teachers, reli-
gious leaders and role models. These ongoing dialogues lead to
the perpetual evolution of stories of ones life, making ongoing
meaning of life and sustaining intimate connections with others.
With this frame, some of the difficulties in the literature may
begin to resolve themselves. Turning to the issue of the negative
effects of both awareness and unawareness of illness, this model
demonstrates how insight could fail in two ways with two differ-
ing outcomes that closely parallel what has been found to date. A
person without awareness of their illness could have no consensu-
ally valid model of their difficulties and consequently be less able
to work closely with others, including doctors and coworkers,
in a range of settings, leading to poorer function. Alternatively,
a person could take on an albeit consensually valid story of his
or her illness, but one which is based on the stock medical or
societal story of the illness. Such a person might, therefore, have
an account of their illness, but it would be dictated by others and
possibly, as a result, be inflexible and infected with stigmatized
beliefs about mental illness, leading to hopelessness and despair.
Turning to the issue of the puzzling findings regarding the eti-
ology of poor insight, a narrative understanding of insight also
suggests that insight must be multidetermined and could fail as a
result of the interaction of a number of independent or semi-inde-
pendent factors. Certainly, on their own, deficits in neurocognition
or severe symptoms could make it difficult to synthesize and flex-
ibly evolve a complex account of illness. Intact neurocognition
might also be highly relevant if one has to evolve an account of ill-
ness that contradicts the possibly stigmatizing dominant discourse
Expert Rev. Neurother. 9(7), (2009)
 Lack of awareness of illness in schizophrenia
about mental illness. Nevertheless, other semi-independent factors
may mitigate the impact of impairments in neurocognition or
exposure to stigma upon insight, resulting in a clouded picture
when they are not considered in empirical studies.
One clear candidate that could be a mediating variable for
unawareness of illness is metacognition. In other words, per-
haps metacognition is not merely one of many variables linked
to awareness as reviewed earlier, but is a factor that moderates
the effects of others. Developing a consensually valid narrative
account of almost anything deeply personal would seem to require
an intact ability to think about ones own mental state and the
mental states of other people. To construct a story of ones expe-
riences amidst schizophrenia, regardless of exposure to stigma,
neurocognitive deficits or coping style, a person probably has to
possess the ability to take others perspectives, as well as to reflect
on their own emotions and ideas. Beyond this, a third kind of
metacognitive capacity may also mediate the effects of other fac-
tors on awareness of illness, namely mastery, or the ability to think
about oneself as a problem solver. Indeed, if this third capacity
were to fail while other forms of metacognition remained (i.e.,
people were able to be self-aware and take the perspective of oth-
ers), we might see someone who is fully aware of some elements
of their illness but perhaps unaware of things they could do to
seek help, and consequently feel quite trapped and in despair.
Finally, turning to treatment, if we understand unawareness of
illness as a narrative phenomenon, it is understandable why no
single treatment modality has emerged as being an overall success.
Instead, addressing unawareness of illness would seem to require
a broad and integrative treatment program that could flexibly
address any of a range of phenomena widely observed in schizo-
phrenia that could imperil narrative self-understanding, includ-
ing hopelessness, neurocognitive deficits, lack of metacognitive
capacity and trauma, as well as the internalization of stigma.
Such approaches are notably consistent with some longstanding
approaches to CBT [74] and are likely to require not only oppor-
tunities for learning but also the delivery of pharmacological,
psychosocial and psychotherapeutic interventions.
Five-year view
Research to date poses at least five clear directions for the study
of unawareness of schizophrenia in the next 5years. First, cross-
sectional studies are required with large samples that include a
broad panel of potential correlates, including various domains
of metacognition (e.g., theory of mind, self-reflectivity and
mastery), different domains of neurocognition (e.g., executive
function and memory), symptom severity and related psycho-
logical states, including self-esteem, personality traits, internal-
ized stigma and hope. Second, studies are needed in which these
same variables are assessed over months and years. Such research
would have the power to detect not only concurrent relationships
at multiple points in time but also to examine whether changes
in phenomena such as self-esteem, hope, self-stigma, memory
and anxiety come before, after or at the same time as changes in
awareness of illness. Questions that could be addressed in such
a design include:
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At what rate does insight improve following improvements in
other areas, such as success at work, development of a romantic
attachment or rejection of stigma?
How stable are improvements in insight?
Are there individuals for whom insight is constantly in flux,
rather than stable?
What levels of neurocognition, metacognition and self-esteem
are necessary for a personal narrative of illness to begin to evolve
in an adaptive manner over time?
Does adherence among persons with greater versus lesser
metacognitive deficits require different supports over time?
To date, some research has suggested that changes in function
are linked to changes in insight, although the degree of association
was quite modest and presents only a beginning [35] .
A third issue for potential research involves the importance of
assessing multiple domains of awareness of illness and their shared
versus unique relationships with a host of possibly related factors.
Again a longitudinal study is needed that looks at both the possibly
unique correlates of awareness of symptoms versus consequences
versus treatment need but also their inter-relationship. For instance,
it may be that awareness of the psychosocial consequences of illness
relies more heavily on both the metacognitive domains of theory
of mind (awareness of the thoughts and feelings of others) and
mastery (i.e., thinking about oneself as a problem solver), while
decisions regarding medication adherence are more closely linked
to internalized stigma. Such research could also focus on what sort
of changes naturalistically come before and after changes in insight.
For instance, does the development of awareness of the social conse-
quences of schizophrenia generally occur only after there have been
improvements in self-esteem or agency? Do changes in awareness
of treatment needs follow changes in the capacity for self-reflec-
tivity? Possible methods for assessing metacognition include the
metacognition assessment scale [31] and a range of theory of mind
tests recently linked to insight [28,29] . Also certainly relevant is the
exploration of neurocognition and insight, which, as noted previ-
ously, has been found in many, but not all, studies. One fascinating
question awaiting clarification is whether metacognitive capacity
mediates the impact of neurocognition on insight.
A fourth issue concerns the means by which insight is assessed
quantitatively. If insight is understood as a complex storied
account of different aspects of illness and their consequences,
quantitative assessment methods are required that can capture
this [31,73] . In this spirit, several recent studies have sought to
collect spontaneous speech samples and to rate how the illness
is portrayed [75,76] . According to these processes, participants are
asked to tell the story of their life, and to give an account of
whether they feel they have an illness, what has changed and
not changed as a result of this, what about it feels as if it controls
them, what they do feel they can control about it, how the illness
affects and is affected by other people, and what is anticipated
in the future. These accounts are typed and the coherence and
complexity of these self-generated accounts can then be evaluated
by independent raters, providing researchers with an opportunity
to see how meaning is made and organized about illness.
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Further work that quantitatively assesses awareness of illness
within narratives has suggested that insight may involve a number
of discrete processes that indeed are not synonymous with the
acceptance of a label or admission versus denial of a singular fact.
In addition, unique links have been suggested between the dif-
ferent ways in which a narrative may fail to cohere and deficits in
neurocognitive and social functioning. We hold that this method
may give researchers considerable room for further exploration of
other ways in which a narrative may frame mental illness in man-
ners that are adaptive and allow for greater chance for wellness.
Notably, these procedures are not intended to replace question-
naires that ask participants whether they are ill or interviews that
ask which specific experiences are symptoms of mental illness.
Instead, they may offer a window on the personal way in which
a story of illness is constructed and the different ways in which it
may cohere or fail to cohere.
As a final issue, there appears to be a strong need to develop
integrated treatments to address lack of awareness of schizophre-
nia. This may include pilot work followed by controlled studies of
interventions, which include psychosocial, psychotherapeutic and
educational interventions. These interventions could address the
processes that might enable people with schizophrenia to make
sense of mental illness and to live with it in a manner that allows
them to envision a future that involves their having an accept-
able quality of life and accepting appropriate treatment. Such a
research strategy within the next 5years might first involve integra-
tive efforts to synthesize manuals and interventions from a range
of existing procedures (e.g., CBT and motivational interviewing),
followed by pilot studies and then feasibility studies aimed at ascer-
taining whether patients with schizophrenia are willing to attend
these treatments and whether they have a clinically meaningful
impact. Pending the success of such initial work, randomized con-
trolled trials could be designed with the aim of assessing the impact
of these interventions on quality of life and psychosocial function.
Summary & conclusion
Unawareness of illness in schizophrenia is a multidimensional
construct that refers to a lack of perception or denial of phe-
nomena such as symptoms, their consequences and the utility
of treatment. Research has generally suggested that unawareness
of illness is linked to a range of poorer clinical and psychosocial
outcomes, although the degree to which this is the case remains
a matter of debate. It is also probably the result of a variety of
forces, including neurocognitive impairments, although the
degree to which this is the case again remains a matter of debate.
Simultaneously, evidence has emerged that poor insight may
protect persons with schizophrenia from stigma and that with
increased insight may come a range of undesirable outcomes,
including subjective distress and possibly suicidality.
In this review, we have suggested that one way to make sense
of the evolving literature is to conceptualize awareness of illness
as a storied account of a range of different aspects of ones life.
In this sense, an awareness of an illness is likely to prove to be
adaptive and to promote recovery only if it is authored by the
person suffering from the illness and if it is something that can
be understood and responded to by others. As such, we have
suggested that awareness of illness is probably multidetermined
and affected by a range of factors that are possibly mediated by
metacognitive capacity.
To better understand these processes, a program of research is
suggested that longitudinally assesses a range of potential causes
of poor insight, including neurocognitive, metacognitive and
other psychological factors that may contribute to poor insight,
and that considers how these may impact different aspects of
insight in an inter-related manner. It is also suggested that there
is a pressing need to develop more thorough methods of quantita-
tively assessing how insight may fail to or successfully cohere and
to integrate treatments that assist individuals in making their own
and consensually valid sense of the challenges of schizophrenia
and in developing realistic hopes of a meaningful future.
Financial & competing interests disclosure
Paul H Lysaker is a current recipient of funding from NIMH and the
Department of Veterans Affairs Research and Development Service. The authors
have no other relevant affiliations or financial involvement with any organiza-
tion or entity with a financial interest in or financial conflict with the subject
matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

Key issues
Relative to persons with other forms of mental illness, many people with schizophrenia are unaware of their symptoms, the
consequences of their illness and need for treatment.
Unawareness of illness in schizophrenia is linked to poorer treatment adherence and possibly poorer community, social and
vocationalfunction.
As individuals with schizophrenia gain awareness of their illness, they may be increasingly vulnerable to depression, low self-esteem,
hopelessness and possibly suicidality.
Unawareness of illness in schizophrenia may be the result of a range of factors, including deficits in neurocognition and brain function,
decreased metacognitive capacity and a wish to avoid stigma.
In general, unawareness of illness in schizophrenia remains difficult to treat or address in treatment settings.
Future research that assesses a range of potential contributors to unawareness of illness over time and with consideration of how each
may affect different elements of insight is required.
For persons with schizophrenia who are unaware of illness, future work is required to develop integrated manualized psychological
interventions based on techniques that have proven effective and support persons to make their own consensually valid sense of
schizophrenia, allowing for a fulfilling and meaningful future.

1040 Expert Rev. Neurother. 9(7), (2009)


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raffaele.popolo@fastwebnet.it
Roudebush VA Med Center (116H),
1481West 10th Street, Roudebush VA Giancarlo Dimaggio
Medical Center, Indianapolis, Terzo Centro di Psicoterapia Cognitiva,
IN 46202, USA Associazione di Psicologia Cognitiva,
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plysaker@iupui.edu Tel.: +39 064 423 3878
Fax: +39 064 423 3878
gdimaje@libero.it
1043
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