Insight into current symptoms of schizophrenia. Association with frontal cortical function and affect Introduction Early clinical descriptions of schizophrenia identi- fied lack of insight as a characteristic symptom of the illness (1). The seminal WHO International PilotStudyofSchizophreniaconfirmedthisclinical impression in a large epidemiological cohort: poor insight was one of 12 signs and symptoms selected to define the syndrome based on its discriminatory value(2).Laterresearcherspointedoutthatinsight is not a dichotomous construct, but is best conceptualized as multidimensional (3, 4). Dimen- sions of insight that have been widely accepted include awareness of symptoms, recognition that onesuffersfromamentalillness,andacceptanceof the need for treatment. Rating scales that reliably measure these various aspects of insight are avail- able (5, 6). Despite progress in defining and measuring insight, the nature of unawareness of illness in patients with schizophrenia remains poorly under- stood. The more recent, empirical literature points in several directions. First, insight might simply be part and parcel of schizophrenia, a symptom that cannot be further reduced (7). Secondly, lack of insight could stem from a neurological deficit akin to anosognosia. Amador and colleagues (3) were the first to note the clinical similarities between patients with schizophrenia and anosognosia patients and proposed that the frontal lobes would be the site of pathology. The first study to test this hypothesis used the Wisconsin Card Sorting Test (WCST) and found an association between frontal lobe dysfunction and impaired insight (8). Subsequent studies have yielded results both supporting (9–11) and rejecting (7, 12–17) the anosognosia model. Thirdly, affective experiences, such as euphoria (18), depression or anxiety (19, 20) may play a role in insight. Cross-sectional comparisonsofdifferentdiagnosticgroupspointto more severely deficient insight in schizophrenia than in affective psychoses, such as psychotic depression or schizoaffective disorder (21). Lastly, it has been suggested but not tested empirically Freudenreich O, Deckersbach T, Goff DC. Insight into current symptoms of schizophrenia. Association with frontal cortical function and affect. ActaPsychiatrScand2004:110:14–20. Ó Blackwell Munksgaard 2004. Objective: Examine whether frontal lobe dysfunction or affective experiencescorrelateswithlackofsymptomawarenessinschizophrenia. Method: A total of 122 consecutive adult schizophrenia outpatients were assessed cross-sectionally with standard rating scales of psychopathology and of insight, and underwent neuropsychological assessment with a battery of tests sensitive to frontal lobe dysfunction. Correlational analyses were used to determine relationships between variables. Results: About 62% of patients had at least partial awareness of symptoms. Anxiety correlated modestly with insight into the abnormal nature of positive and negative symptoms. No cognitive variable was significantly correlated with symptom awareness. Conclusion: The pathological nature of symptoms is better recognized by patients who experience dysphoric affect. Neither severity of psychotic symptoms nor frontal lobe cognitive deficits correlates to symptom awareness. Lack of insight, which can be partial for symptoms of the illness, might be a non-reducible symptom of schizophrenia. O. Freudenreich, T. Deckersbach, D. C. Goff Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Key words: schizophrenia; lack of insight; symptom unawareness; dysphoria; frontal lobe dysfunction Oliver Freudenreich, MD, MGH Schizophrenia Program, Freedom Trail Clinic, 25 Staniford Street, 2nd Floor, Boston, MA 02114, USA. E-mail: ofreud@massmed.org Accepted for publication January 23, 2004 Acta Psychiatr Scand 2004: 110: 14–20 Printed in UK. All rights reserved Copyright Ó Blackwell Munksgaard 2004 ACTA PSYCHIATRICA SCANDINAVICA 14