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427

The
British
Psychological
British Journal of Clinical Psychology (2006), 45, 427–436
q 2006 The British Psychological Society
Society

www.bpsjournals.co.uk

The role of knowledge and motivation in symptom

identification accuracy among schizophrenic
patients: Application of signal detection theory

Agatha W. S. Wong1*, Chi-yue Chiu2, Jessica W. Y. Mok1,

Josephine G. W. S. Wong1 and Eric Y. H. Chen1
1
University of Hong Kong, Hong Kong
2
University of Illinois at Urbana-Champaign, USA

Objective. Many people with schizophrenia have poor awareness of their symptoms,
a problem that may result from lack of knowledge about their illness and/or
unwillingness to acknowledge it. The present study assessed the joint influence of lack
of knowledge and motivated denial in schizophrenic patients’ low symptom awareness.
Method. Schizophrenic patients (N ¼ 85) and normal control participants (N ¼ 35)
identified psychotic symptoms and general stress symptoms in a symptom checklist.
The signal detection theory was applied to assess levels of sensitivity (which would be
knowledge-mediated) and judgment biases (which would probably be motivated).
Results. Compared with normal control participants, schizophrenic patients had
lower sensitivity and greater aversion to classify a symptom as a psychotic symptom.
Conclusions. These findings suggest that both lack of knowledge and motivated
denial are involved in schizophrenic patients’ low symptom awareness.

Many people with schizophrenia have poor insight into their illness, which may lower
medication compliance and hence result in less optimistic prognosis (Amador & David,
1998). Although researchers have not reached consensus on what insight consists of,
most of them agree that awareness of illness is an important component of insight
(Amador & David, 1998). Some researchers (Mintz, Dobson, & Romney, 2003) even use
awareness of symptoms as an operational definition of insight.
Early investigators have attributed awareness deficits in schizophrenic patients to
psychological defences (Amador & David, 1998; Lally, 1989; Mayer-Gross, 1920). For
example, Mayer-Gross (1920) named denial of psychotic symptoms as one of the four
defensive strategies that prevail among patients with schizophrenia. The remaining
three are denial of future, creation of a new life after the illness and melting of the

* Correspondence should be addressed to Agatha W. S. Wong, Department of Psychiatry, Kowloon Hospital, 147A Argyle
Street, Kowloon, Hong Kong (e-mail: agathaws@graduate.hku.hk).

DOI:10.1348/014466505X86672
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428 Agatha W. S. Wong et al.

psychotic experiences into a new set of life experiences aiming to cope with their
abnormal experiences.
Consistent with this view, McGlashan, Levy, and Carpenter (1975) found that for the
purpose of maintaining self-image, patients may ‘seal over’; that is, prefer not to think
about their psychotic experience during recovery, and adopt an attitude of ‘the less said
the better’. Moreover, while in-patients with schizophrenia attributed their positive
behaviours to the self and negative behaviours to the situation, depressed in-patients
and out-patients did not display such self-serving bias in self-perception (Sackeim &
Wegner, 1986). Additionally, there is evidence that patients’ perceptions of mental
illness and its treatment may shape their understanding of their illnesses (Saravanan,
Jacob, Prince, Bhuga, & David, 2004). For example, patients who are sensitive to the
stigma attached to mental illness may have distorted views of their symptoms and
illnesses. In short, the poor insight among patients with schizophrenia may be an active
(motivated) effort to cope with or adapt to the distress brought by the illness (Saravanan
et al., 2004).
However, it is also possible that people with schizophrenia may fail to recognize
and acknowledge their symptoms not necessarily because they are motivated to deny
these symptoms, but because they lack knowledge of the symptoms. Indeed, there is
some evidence that patients have poor illness awareness because they lack
knowledge about their own illness and related psychotic symptoms (Eckman et al.,
1992; Johnson & Orrell, 1995). For example, although schizophrenic patients with
poor insight fail to recognize certain psychotic symptoms such as conceptual
disorganization, avolition-apathy and affective blunting, they tend to view
hallucinatory behaviours and suspiciousness as signs of mental illness (Mcevoy,
Schooler, Friedman, Steingard, & Allen, 1993). Additionally, Seltzer, Roncari, and
Garfinkel (1980) found that patients who are less knowledgeable about their illness
have poorer insight. Recently, Saravanan et al. (2004) posited that the failure of
people with schizophrenia to recognize their illness and symptoms may stem from a
lack of sufficient information about the illness. Thus, before accepting the
motivational account of schizophrenic patients’ poor insight, it is necessary to
examine whether patients have adequate knowledge about their psychotic symptoms
and illness.
In our view, both motivated denial and lack of knowledge of illness contribute to
schizophrenic patients’ poor insight. However, limited studies are available to evaluate
these two factors’ independent contributions. The current study aimed to fill this gap by
applying the signal detection theory to explore patterns of psychotic symptom
perception.
According to the signal detection theory (Green & Swets, 1966), accuracy in
identification is reflected in both the hit rate and the false-alarm rate. In the context
of the current study, hit rate is the probability of correctly classifying a psychotic
symptom as a psychotic symptom (the conditional probability of making a correct
classification given that symptom is a psychotic symptom). False-alarm rate is
the probability of misidentifying a stress symptom as a psychotic symptom (the
conditional probability of making a misidentification when the symptom is a stress
symptom).
Furthermore, two components are assumed to underlie accuracy in identification.
The first component is sensitivity or perceptual acuity in discriminating between a
psychotic symptom and a stress symptom. The second component is judgment
criterion, which is a generalized tendency (response bias) to classify a symptom as
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Signal detection 429

a psychotic symptom (Green & Swets, 1966). Participants might misidentify a

psychotic symptom as a stress symptom because they were not sensitive to the
difference between psychotic symptoms and stress symptoms, or because they had a
generalized tendency not to classify symptoms as psychotic responses. The
respective measures of sensitivity and response bias are d-prime and the criterion
score; both measures can be derived mathematically from the hit rate and the false-
alarm rate.
As an overview, participants who were either patients with schizophrenia or normal
control participants were presented with a symptom checklist, which consisted of
psychotic and stress symptoms arranged in a randomized order, and were asked to
identify the psychotic symptoms. To manipulate the salience of the defensive
motivation, half of the patients, randomly assigned, were explicitly told that the
checklist contained symptoms they had experienced before (related condition), and the
remaining patients were not (unrelated condition).
The design of the current experiments allowed us to make two theoretically
interesting between-group comparisons. First, we compared the patient group with the
normal control group. If patients had poorer performance in identifying psychotic
symptoms, the two patient groups should have lower hit rates than did the normal
control group. We also examined the difference between the patient and the control
groups in terms of sensitivity and response bias. If patients’ relatively poor performance
was due to lack of knowledge, they should have lower sensitivity than did the control
group. However, if their relatively poor performance resulted from motivated denial,
they should use a relatively conservative criterion when identifying psychotic
symptoms.
Second, we compared the patients in the related condition with those in the
unrelated condition. If patients’ poor performance resulted from motivated denial of
illness experiences, patients who knew that their own symptoms were on the list
should have relatively strong motivation to adopt a conservative criterion for classifying
a symptom as a psychotic symptom. If this was the case, patients in the related condition
should have significantly more conservative criterion scores than did their counterparts
in the unrelated condition. On the contrary, if patients’ poor symptom awareness
resulted from a lack of knowledge only, the two patient groups should not differ
significantly on d-primes or criterion scores.

Method
Participants
Normal controls
The normal control group consisted of 35 volunteers (20 women and 15 men) recruited
from the general public. Consenting normal controls completed a screening
questionnaire. We included only those who did not have a personal or family history
of psychiatric illness, substance abuse and mental retardation, were literate and not
under medication and had normal hearing and vision.

Patients
We recruited 85 patients (38 women, 47 men) with schizophrenia from the Out-Patient
Psychiatric Department of the Queen Mary Hospital, Hong Kong. All were diagnosed as
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430 Agatha W. S. Wong et al.

suffering from schizophrenia according to the DSM IV criteria (American Psychiatric

Association, 2000) on the basis of clinical interview and medical records. Patients with a
history of traumatic brain injury, co-morbid substance abuse, mental retardation and
illiteracy were excluded. All the patients had either full or partial remission of psychotic
symptoms.
Patients identified to be eligible for the study by experienced psychiatrists were
randomly assigned to the related or unrelated condition. Prior to completing the
identification task, patients in the related condition (N ¼ 43, 20 women, 23 men) were
told that the checklist contained psychotic symptoms they had experienced before.
Patients in the unrelated condition (N ¼ 42, 18 women, 24 men) and the control
participants did not receive this instruction.
The two patient groups and normal controls were matched on age and years of
education. The three groups did not differ in age (M Control ¼ 34:55, SD ¼ 11:57,
M Related ¼ 38:63, SD ¼ 13:13, M Unrelated ¼ 37:45, SD ¼ 12:12), Fð2; 110Þ ¼ 1:08, ns,
and education level (M Control ¼ 8:91, SD ¼ 5:51, M Related ¼ 8:02, SD ¼ 4:70,
M Unrelated ¼ 7:98, SD ¼ 4:62), Fð2; 116Þ ¼ 0:40, ns. The gender ratio of the three
groups also did not differ, x2 ð2Þ ¼ 1:65, ns.
The two patient groups did not differ in their duration of illness (M Related ¼ 111
months, M Unrelated ¼ 132 months), tð82Þ ¼ 20:76, ns. Detailed clinical profiles based on
the Positive and Negative Symptoms Scale (Kay, Fizszbein, & Opler, 1987) were available
from 30 patients. As shown in Table 1, patients in the related and unrelated conditions
did not differ in the number of positive symptoms present (M Related ¼ 9:94,
M Unrelated ¼ 9:77), tð28Þ ¼ 20:11, ns, the number of negative symptoms present
(M Related ¼ 17:00, M Unrelated ¼ 13:31), tð28Þ ¼ 1:34, ns, or the total number of
symptoms present (M Related ¼ 50:76, M Unrelated ¼ 45:62), tð28Þ ¼ 1:27, ns. Further-
more, these 30 patients and the remaining patients did not differ on any of the
dependent measures reported below, and this was the case in both the related condition
(all Fs , 2.03, ns) and the unrelated condition (all Fs , 0.43, ns). In short, the random
assignment procedure was successful, and the results regarding the two patient groups
reported below were not confounded with the patients’ demographic and specific
clinical profiles.
There were five participants (two normal controls, three patients) who did not
follow instructions and classified all symptoms as psychotic symptoms. Their data were
not included in the analyses reported below.

Table 1. Clinical profile (PANSS) of patients in the related and unrelated conditions (N ¼ 30)

Related (N ¼ 17) Unrelated (N ¼ 13)

Positive symptoms
Mean 9.94 9.77
SD 4.13 4.13
Negative symptoms
Mean 17.00 13.31
SD 8.77 5.22
Total
Mean 50.76 45.62
SD 11.81 9.74
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Signal detection 431

Measures and procedures

A 30-item symptom checklist consisting of 15 psychotic symptoms and 15 stress
symptoms was constructed. For each symptom, the participant decided whether it was
a psychotic symptom or a stress symptom. The symptom checklist consisted of clinical
symptoms of schizophrenia, anxiety disorder and depression listed in DSM-IV, as well as
complaints from patients with schizophrenia and anxiety-depression during clinical
interviews. Some sample psychotic symptoms are ‘feel that personal thoughts are being
broadcast and that many people know what the self is thinking’, ‘upon seeing a traffic
light turns red, realize that the self is God’s ambassador’ and ‘feel that a brother is a serial
killer, and the next target will be the self’. Some sample stress symptoms are ‘feel dizzy,
weakness in legs and that the self is about to faint’, ‘feel heart beating faster and faster,
and that the self is difficult to breathe’ and ‘often thinks of something unhappy, even to
the point that the self cannot stop thinking about them’.
A pilot study including 15 normal controls and 15 patients showed that all pilot
participants understood what the symptoms referred to. The participants were
debriefed after they had completed the checklist.

Results
As mentioned, in the context of the current study, the hit rate refers to the conditional
probability of identifying a psychotic symptom as a psychotic symptom, and the false-
alarm rate refers to the conditional probability of identifying a non-psychotic symptom
as a psychotic symptom. A one-way ANOVA performed on the hit rates and false-alarm

Table 2. Comparison of the three groups of participants on hit rates, false-alarm rates, sensitivity and
response bias

Patients

Normal control Related condition Unrelated condition

Hit rate
Mean 0.91 0.58 0.69
SD 0.15 0.37 0.33
False-alarm rate
Mean 0.69 0.64 0.60
SD 0.15 0.24 0.25
d-prime
Mean 1.59 0.08 0.70
SD 1.54 2.97 2.73
Criterion (c)
Mean 2 1.34 20.60 20.64
SD 0.66 0.86 0.89
Beta
Mean 2 2.94 21.73 21.90
SD 3.11 2.94 2.93
Beta ratio
Mean 0.41 0.78 0.68
SD 0.40 0.68 0.52
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432 Agatha W. S. Wong et al.

rates revealed a significant effect of condition on the hit rate, Fð2; 112Þ ¼ 10:33,
p , .001, partial h2 ¼ :16. As shown in Table 2, post hoc LSD test showed that patients
in the unrelated condition (M ¼ 0:69) had significantly lower hit rates than did the
normal controls (M ¼ 0:91), p , .05. The hit rates of patients in the related condition
(M ¼ 0:58) were also significantly lower than those of the normal controls, p , :05.
This finding is consistent with the idea patients have relatively poor performance on
symptom identification. The hit rates of the two patient groups did not differ reliably.
The effect of condition was not significant in a similar ANOVA performed on the false-
alarm rates, Fð2; 112Þ ¼ 1:61, ns.
To identify the psychological processes that mediate errors in symptom
identification, based on the signal detection theory, we computed d-prime and three
criterion scores (c, beta and beta ratio) as measures of perceptual acuity and response
bias respectively. We obtained d-prime by subtracting z(false-alarm rate) from z(hit rate),
where z is a function that converts the pertinent conditional probability into the z score
under the standard normal distribution. An ANOVA performed on d-prime revealed a
significant main effect of condition, Fð2; 112Þ ¼ 3:23, p , :05, partial h2 ¼ :06. Two
planned contrasts were performed to address our research questions. The first contrast
evaluated if the normal group was reliably different from the two patient groups. The
second contrast evaluated if the related patient group was reliably different from the
unrelated patient group. The first contrast was significant, Fð1; 112Þ ¼ 5:22, p , .05;
the normal control group (M ¼ 1:59, SD ¼ 1:54) had higher sensitivity than did the
patient groups (M ¼ 0.39, SD ¼ 2:85). The second contrast was not significant,
tð80Þ ¼ 0:99, ns. The related group (M ¼ 0:08, SD ¼ 2:97) and the unrelated group
(M ¼ 0:70, SD ¼ 2:73) had a similar level of sensitivity in identifying psychotic
symptoms. This result suggests that lack of knowledge contributes to schizophrenic
patients’ low symptom awareness.
Response bias can be indexed by several different criterion scores, c, beta and beta
ratio. The formula for c is 2 0.5*(z[hit] þ z[false-alarm rate]). The more negative the c
score was, the more liberal the criterion was – the participants had a greater tendency to
classify a symptom as a psychotic symptom (versus a stress symptom).
The formula for beta is 2 0.5*d-prime*(z[hit rate] þ z[false-alarm rate]). Beta ratio is
the exponent of beta applied to the base of e. A lower beta or beta ratio indicates a
stronger bias towards classifying a symptom as a psychotic symptom.
The mean c score was negative for the whole sample (M ¼ 20:83), indicating that
the participants were more likely to classify a symptom as a psychotic symptom than as a
stress symptom. A one-way ANOVA performed on the c scores revealed a significant
main effect of condition, Fð2; 112Þ ¼ 9:27, p , .001, partial h2 ¼ :14. Consistent with
the motivated denial account of symptom awareness, planned analyses showed that the
two patient groups (M ¼ 0:62, SD ¼ 0:87) adopted a less liberal classification criterion
than did the normal control group (M ¼ 21:34, SD ¼ 0:66), Fð1; 113Þ ¼ 18:66,
p , .001. However, contrary to the prediction of the motivated denial account, the two
patient groups (M Unrelated ¼ 20:64, M Related ¼ 20:60) did not differ on c score,
tð80Þ ¼ 20:18, ns.
Although the effect of condition on beta was not significant, Fð2; 112Þ ¼ 1:70,
p ¼ :19, there was a trend for the two patient groups (M ¼ 21:82, SD ¼ 2:92) to use a
less liberal criterion for identifying psychotic symptoms than did the normal control
group (M ¼ 22:94, SD ¼ 3:11), Fð1; 113Þ ¼ 3:36, p ¼ :07. Again, the two patient
groups (M Unrelated ¼ 21:90, M Related ¼ 21:73) did not differ on beta, tð80Þ ¼ 20:26, ns.
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Signal detection 433

The effect of condition on beta ratio was significant, Fð2; 112Þ ¼ 4:19, p , .05,
partial h2 ¼ :07. The difference between the patient groups and the normal control
group was highly significant, Fð1; 113Þ ¼ 7:72, p , 0.01. Compared with the normal
control group (M ¼ 0:41, SD ¼ 0:40), the two patient groups (M ¼ 0:73, SD ¼ 0:61)
displayed a more conservative response bias in identifying psychotic symptoms. Again,
the two patient groups (M Unrelated ¼ 0:68, M Related ¼ 0:78) did not differ from each other
on beta ratio, tð80Þ ¼ 20:76, ns.
In summary, the two patient groups differed from the normal control group in both
sensitivity and response bias, suggesting the possible involvement of both lack of
knowledge and motivated denial in schizophrenic patients’ lack of awareness of their
symptoms. However, the self-involvement manipulation did not produce any significant
difference in either sensitivity or response bias.

Discussion
The current study aimed to examine the joint contribution of lack of knowledge and
motivated denial to low symptom awareness among patients with schizophrenia. The
results showed that patients had lower hit rates than did normal participants; they were
less able to identify a psychotic symptom as a psychotic symptom. However, as the
finding on false-alarm rate indicated, patients were not more likely than normal
participants to misidentify a stress symptom as a psychotic symptom. Moreover,
compared with normal participants, patients had lower sensitivity to the distinction of
psychotic symptoms and stress symptoms, as revealed by their lower d-primes. This
finding indicated that lack of knowledge for correct categorization of psychotic
symptoms and stress symptoms contributes to the patients’ low awareness of their
illness.
In the signal detection theory, decision accuracy is decomposed into two separate
components: sensitivity and response bias. In the context of the current study, the signal
detection theory enables us to assess the independent contributions of knowledge (via
sensitivity) and motivation (via response bias) to symptom identification. As the findings
revealed, independent of the group difference in sensitivity, the patient groups tended
to have a relatively stronger aversion to classifying a symptom as a psychotic symptom,
compared with normal control participants. This was reflected in the significant
differences between patients and normal control participants on several measures of
response bias (c scores, beta ratios and, to a lesser extent betas). This finding is in line
with the motivated denial account of low symptom awareness; the patients were more
motivated to see a symptom as a stress symptom than to see it as a psychotic symptom.
Contrary to the prediction of the motivated denial account, the self-relevance
manipulation did not alter the schizophrenic patients’ response bias. Those in the
related condition displayed similar levels of response bias as those in the unrelated
condition. There are two possible explanations for this finding. First, although we did
not tell the patients in the unrelated condition that the symptom checklist contained
symptoms that they themselves had experienced, they might recognize some of the
symptoms on the list as their own symptoms. This could have compromised the
effectiveness of the self-relevance manipulation. Second, there could be a ceiling effect
for motivated denial: among schizophrenic patients, the symptom denial motivation was
so high that further elevation of response bias through the experimental manipulation
became ineffectual.
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434 Agatha W. S. Wong et al.

Why are schizophrenic patients motivated to deny their symptoms? Some

researchers (Alloy & Abramson, 1979; Mintz et al., 2003; Moore, Cassidy, Carr, &
Callaghan, 1999; Sackeim & Wegner, 1986) believe that motivated symptom
identification failure might be a mood regulatory strategy patients develop to cope
with the sting of the illness. For example, patients with schizophrenia often experience
severe depression symptoms during early episodes of psychosis. Furthermore, in first
episode psychosis, good insight predicts concurrent level of depression (e.g. Drake
et al., 2004). Specifically, Schwartz (2001) has proposed an insight-demoralization-
depression-suicidality syndrome to explain the association between insight and
suicidality in patients with schizophrenia found in previous studies (Amador & Strauss,
1993; Schwartz, 1999; Schwartz & Peterson, 2000; Wolfersdorf, Keller, & Kaschka,
1997). As patients experience various cognitive distortions accompanied by increased
difficulty coping with their mental illness (Wilder-Willis, Shear, Steffen, & Borkin, 2002),
they become more susceptible to impaired coping skills and general intellectual deficits.
Additionally, post-psychotic depression may also arise when patients lessen their
defensive denial and become more aware of the tragic circumstances of their illness
(McGlashan & Carpenter, 1976). With increased awareness of their illness and
impairments, patients with schizophrenia, particularly those with ineffective coping,
become increasingly susceptible to demoralization and subsequent feelings of
depression. Under these circumstances, lack of insight can be a form of self-denial
directed towards warding off the feelings of depression (Mintz et al., 2003).
The present results are relevant to identifying the therapeutic components in
‘insight therapy’. Educating patients about their psychotic symptoms plays a big part in
insight therapy. The present findings suggest that patients’ knowledge of symptoms is
not the only factor that could affect accuracy in symptom identification. What is also
important is the patients’ readiness to use such knowledge to grasp their illness
experiences. Consistent with this view, past research has shown that patients with good
knowledge of illness may not always hold positive beliefs about their illness or have
good insight (Lewinsohn, Mischel, Chaplain, & Barton, 1980; Seltzer et al., 1980). For
example, schizophrenic patients with good insight into other schizophrenic patients’
conditions may not have good insight into their own illness. In one study, Startup (1997)
had patients of high and low insight and matched normal controls separate descriptions
of psychotic symptoms from those of normal thoughts, feelings and behaviours in
hypothetical clinical cases. Patients with poor insights into their own illness performed
equally well in this task as the matched controls, suggesting that patients with poor
insights do not lack knowledge about symptoms, although they may fail to apply such
knowledge to understand their own illness experiences. Thus, education geared
towards transmission of knowledge regarding psychotic symptoms exclusively may not
be sufficient to bring about an effective insight therapy. Clinicians may also need to work
on patients’ motivation and distorted beliefs about mental illness.
The present study has several limitations. First, it focused on a single component of
insight (i.e. perception of psychotic symptoms) and does not take into account other
components (e.g. awareness of drug compliance, attribution of the illness). Including a
measure of global insight in future research would allow investigators to assess the
correlation between failure to recognize psychotic symptoms and global insight
impairment.
Finally, the current study focused exclusively on the independent contributions of
knowledge and motivation to patients’ poor symptoms awareness. However, aside from
lack of knowledge and motivated denial, other factors may also be responsible for
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Signal detection 435

schizophrenic patients’ low symptom awareness. These factors include psychopathol-

ogy (Amador et al., 1993, 1994; Collins, Remington, Coulter, & Birkett, 1997; David,
Buchanan, Reed, & Almeida, 1992; Kemp & Lambert, 1995; Rossell, Coakes, Shapleske,
Woodruff, & David, 2003) and neurocognitive deficits (Amador & Strauss, 1993;
Amador, Strauss, Yale, & Gorman, 1991; David, 1990; Rossell et al., 2003; Silverstein &
Zerwic, 1985) are also found to impair patients’ ability to reflect and aware their own
illness and situation. Therefore, the joint contribution of knowledge, motivation,
neurocognitive functioning and psychopathology to symptom identification failure
merits future investigation.

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Received 13 December 2004; revised version received 7 August 2005