Psychiatric Quarterly

, Volume 83, Issue 3, pp 293–310 | Cite as

Insight in Bipolar Disorder

  • Klára LátalováEmail author
Original Paper


Although there has been interest in insight in bipolar disorder, research has not been as developed as in schizophrenia. The Medline, Embase, and PsychInfo data bases were searched. The key words used in the search were “bipolar”, “mania”, “manic”, “awareness”, and “insight”. Books, editorials, letters, and reports on pediatric subjects were excluded. Abstracts or full texts were screened for relevance. Better insight is associated with better adherence to treatment and better outcomes. Impairments of executive functions and memory, as well as higher severity of psychotic symptoms, are associated with impairments of insight. Insight is more impaired during an illness episode than during remission, in mixed than in pure manic episodes, in bipolar II than in bipolar I patients, in pure mania than in bipolar or unipolar depression. Psychosocial treatments improve insight and outcomes. There is a need for integration of quantitative assessment methods and their introduction into research and clinical practice.


Bipolar Mania Manic Awareness Insight 



This paper was supported by the research grant NT11047 IGA MZ ČR.


  1. 1.
    Lewis A: The psychopathology of insight. Journal of Medical Psychology 14:332–348, 1934.CrossRefGoogle Scholar
  2. 2.
    David AS: Insight and psychosis. British Journal of Psychiatry 156:798–808, 1990.PubMedCrossRefGoogle Scholar
  3. 3.
    Hoffman RE, McGlashan TH: Alterations of Speech, Thought, Perception, and Self-Experience. In: Tasman A, Kay J, Lieberman JA (Eds) Psychiatry. Chichester, Wiley, pp. 597–606, 2003.Google Scholar
  4. 4.
    Carpenter WT, Jr, Strauss JS, Bartko JJ: Flexible system for the diagnosis of schizophrenia: Report from the WHO International Pilot Study of Schizophrenia. Science 182(118):1275–1278, 1973.PubMedCrossRefGoogle Scholar
  5. 5.
    Greenfeld D, Strauss JS, Bowers MB, Mandelkern M: Insight and interpretation of illness in recovery from psychosis. Schizophrenia Bulletin 15(2):245–252, 1989.PubMedGoogle Scholar
  6. 6.
    McEvoy JP, Apperson LJ, Appelbaum PS, Ortlip P, Brecosky J, Hammill K, Geller JL, Roth L: Insight in schizophrenia. Its relationship to acute psychopathology. Journal of Nervous and Mental Disease 177(1):43–47, 1989.PubMedCrossRefGoogle Scholar
  7. 7.
    Amador XF, Flaum M, Andreasen NC, Strauss DH, Yale SA, Clark SC, Gorman JM: Awareness of illness in schizophrenia and schizoaffective and mood disorders. Archives of General Psychiatry 51(10):826–836, 1994.PubMedCrossRefGoogle Scholar
  8. 8.
    Lysaker P, Bell M: Work rehabilitation and improvements in insight in schizophrenia. Journal of Nervous and Mental Disease 183(2):103–106, 1995.PubMedCrossRefGoogle Scholar
  9. 9.
    Cuffel BJ, Alford J, Fischer EP, Owen RR: Awareness of illness in schizophrenia and outpatient treatment adherence. Journal of Nervous and Mental Disease 184(11):653–659, 1996.PubMedCrossRefGoogle Scholar
  10. 10.
    Pallanti S, Quercioli L, Pazzagli A: Effects of clozapine on awareness of illness and cognition in schizophrenia. Psychiatry Research 86(3):239–249, 1999.PubMedCrossRefGoogle Scholar
  11. 11.
    Weiler MA, Fleisher MH, rthur-Campbell D: Insight and symptom change in schizophrenia and other disorders. Schizophrenia Research 45(1–2):29–36, 2000.PubMedCrossRefGoogle Scholar
  12. 12.
    Antonius D: Insight and aggression in schizophrenia. American Journal of Psychiatry 162(11):2195, 2005.PubMedCrossRefGoogle Scholar
  13. 13.
    Mohamed S, Rosenheck R, McEvoy J, Swartz M, Stroup S, Lieberman JA: Cross-sectional and longitudinal relationships between insight and attitudes toward medication and clinical outcomes in chronic schizophrenia. Schizophrenia Bulletin 35(2):336–346, 2009.PubMedCrossRefGoogle Scholar
  14. 14.
    Parellada M, Boada L, Fraguas D, Reig S, Castro-Fornieles J, Moreno D, Gonzalez-Pinto A, Otero S, Rapado-Castro M, Graell M, Baeza I, Arango C: Trait and state attributes of insight in first episodes of early-onset schizophrenia and other psychoses: A 2-year longitudinal study. Schizophrenia Bulletin 37(1):38–51, 2011.PubMedCrossRefGoogle Scholar
  15. 15.
    Ghaemi SN, Pope HG, Jr.: Lack of insight in psychotic and affective disorders: a review of empirical studies. Harvard Review of Psychiatry 2(1):22–33, 1994.PubMedCrossRefGoogle Scholar
  16. 16.
    Markova IS, Berrios GE: Insight in clinical psychiatry revisited. Comprehensive Psychiatry 36(5):367–376, 1995.PubMedCrossRefGoogle Scholar
  17. 17.
    Raffard S, Bayard S, Capdevielle D, Garcia F, Boulenger JP, Gely-Nargeot MC: Lack of insight in schizophrenia: A review. Part I: theoretical concept, clinical aspects and Amador’s model [In French]. Encephale 34(6):597–605, 2008.PubMedCrossRefGoogle Scholar
  18. 18.
    Amador XF, Strauss DH, Yale SA, Flaum MM, Endicott J, Gorman JM: Assessment of insight in psychosis. American Journal of Psychiatry 150(6):873–879, 1993.PubMedGoogle Scholar
  19. 19.
    Sanz M, Constable G, Lopez-Ibor I, Kemp R, David AS: A comparative study of insight scales and their relationship to psychopathological and clinical variables. Psychological Medicine 28(2):437–446, 1998.PubMedCrossRefGoogle Scholar
  20. 20.
    Velligan DI, Weiden PJ, Sajatovic M, Scott J, Carpenter D, Ross R, Docherty JP: The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness. Journal of Clinical Psychiatry 70(Suppl): 41–46, 2009.Google Scholar
  21. 21.
    Scott J, Pope M: Nonadherence with mood stabilizers: Prevalence and predictors. Journal of Clinical Psychiatry 63(5):384–390, 2002.PubMedCrossRefGoogle Scholar
  22. 22.
    Yen CF, Chen CS, Ko CH, Yeh ML, Yang SJ, Yen JY, Huang CF, Wu CC: Relationships between insight and medication adherence in outpatients with schizophrenia and bipolar disorder: Prospective study. Psychiatry and Clinical Neurosciences 59(4):403–409, 2005.PubMedCrossRefGoogle Scholar
  23. 23.
    Copeland LA, Zeber JE, Salloum IM, Pincus HA, Fine MJ, Kilbourne AM: Treatment adherence and illness insight in veterans with bipolar disorder. Journal of Nervous and Mental Disease 196(1):16–21, 2008.PubMedCrossRefGoogle Scholar
  24. 24.
    Clatworthy J, Bowskill R, Parham R, Rank T, Scott J, Horne R: Understanding medication non-adherence in bipolar disorders using a necessity-concerns framework. Journal of Affective Disorders 116(1–2):51–55, 2009.PubMedCrossRefGoogle Scholar
  25. 25.
    Aleman A, Agrawal N, Morgan KD, David AS: Insight in psychosis and neuropsychological function: Meta-analysis. British Journal of Psychiatry 189:204–212, 2006.PubMedCrossRefGoogle Scholar
  26. 26.
    Lezak MD: Neuropsychological Assessment. New York, Oxforfd University Press, 1995.Google Scholar
  27. 27.
    Ghaemi SN, Hebben N, Stoll AL, Pope HG, Jr.:Neuropsychological aspects of lack of insight in bipolar disorder: A preliminary report. Psychiatry Research 65(2):113–120, 1996.PubMedCrossRefGoogle Scholar
  28. 28.
    Varga M, Magnusson A, Flekkoy K, Ronneberg U, Opjordsmoen S: Insight, symptoms and neurocognition in bipolar I patients. Journal of Affective Disorders 91(1):1–9, 2006.PubMedCrossRefGoogle Scholar
  29. 29.
    Overall JE, Gorham DR: The Brief Psychiatric Rating Scale. Psychological Reports 10:799–812, 1962.CrossRefGoogle Scholar
  30. 30.
    Endicott J, Spitzer RL, Fleiss JL, Cohen J: The global assessment scale A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry 33(6):766–771, 1976.PubMedCrossRefGoogle Scholar
  31. 31.
    Michalakeas A, Skoutas C, Charalambous A, Peristeris A, Marinos V, Keramari E, Theologou A: Insight in schizophrenia and mood disorders and its relation to psychopathology. Acta Psychiatrica Scandinavica 90(1):46–49, 1994.PubMedCrossRefGoogle Scholar
  32. 32.
    Dias VV, Brissos S, Frey BN, Kapczinski F: Insight, quality of life and cognitive functioning in euthymic patients with bipolar disorder. Journal of Affective Disorders 110(1–2):75–83, 2008.PubMedCrossRefGoogle Scholar
  33. 33.
    Kemp R, David A: Insight and Compliance. In: Blackwell B, (Ed) Treatment Compliance and the Therapeutic Alliance. Newark, Gordon and Breach Publishing Group, pp. 61–84, 1996.Google Scholar
  34. 34.
    Yen CF, Cheng CP, Ko CH, Yen JY, Huang CF, Chen CS: Relationship between insight and neurocognition in patients with bipolar I disorder in remission. Comprehensive Psychiatry 49(4):335–339, 2008.PubMedCrossRefGoogle Scholar
  35. 35.
    Yen CF, Cheng CP, Ko CH, Yen JY, Huang CF, Chen CS: Suicidality and its association with insight and neurocognition in taiwanese patients with bipolar I disorder in remission. Journal of Nervous and Mental Disease 196(6):462–467, 2008.PubMedCrossRefGoogle Scholar
  36. 36.
    Schwartz RC, Smith SD: Suicidality and psychosis: The predictive potential of symptomatology and insight into illness. Journal of Psychiatric Research 38(2):185–191, 2004.PubMedCrossRefGoogle Scholar
  37. 37.
    Kim CH, Jayathilake K, Meltzer HY: Hopelessness, neurocognitive function, and insight in schizophrenia: Relationship to suicidal behavior. Schizophrenia Research 60(1):71–80, 2003.PubMedCrossRefGoogle Scholar
  38. 38.
    Varga M, Babovic A, Flekkoy K, Ronneberg U, Landro NI, David AS, Opjordsmoen S: Reduced insight in bipolar I disorder: Neurofunctional and neurostructural correlates: A preliminary study. Journal of Affective Disorders 116(1–2):56–63, 2009.PubMedCrossRefGoogle Scholar
  39. 39.
    Laroi F, Fannemel M, Ronneberg U, Flekkoy K, Opjordsmoen S, Dullerud R, Haakonsen M: Unawareness of illness in chronic schizophrenia and its relationship to structural brain measures and neuropsychological tests. Psychiatry Research 100(1):49–58, 2000.PubMedCrossRefGoogle Scholar
  40. 40.
    Peralta V, Cuesta MJ: Lack of insight in mood disorders. Journal of Affective Disorders 49(1):55–58, 1998.PubMedCrossRefGoogle Scholar
  41. 41.
    Cassidy F, McEvoy JP, Yang YK, Wilson WH: Insight is greater in mixed than in pure manic episodes of bipolar I disorder. Journal of Nervous and Mental Disease 189(6):398–399, 2001.PubMedCrossRefGoogle Scholar
  42. 42.
    Dell’Osso L, Pini S, Cassano GB, Mastrocinque C, Seckinger RA, Saettoni M, Papasogli A, Yale SA, Amador XF: Insight into illness in patients with mania, mixed mania, bipolar depression and major depression with psychotic features. Bipolar Disorders 4(5):315–322, 2002.PubMedCrossRefGoogle Scholar
  43. 43.
    Pallanti S, Quercioli L, Pazzagli A, Rossi A, Dell’Osso L, Pini S, Cassano GB: Awareness of illness and subjective experience of cognitive complaints in patients with bipolar I and bipolar II disorder. American Journal of Psychiatry 156(7):1094–1096, 1999.PubMedGoogle Scholar
  44. 44.
    Young RC, Biggs JT, Ziegler VE, Meyer DA: A rating scale for mania: Reliability, validity and sensitivity. British Journal of Psychiatry 133:429–435, 1978.PubMedCrossRefGoogle Scholar
  45. 45.
    Hamilton M: A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry 23:56–62, 1960.CrossRefGoogle Scholar
  46. 46.
    Pini S, Cassano GB, Dell’Osso L, Amador XF: Insight into illness in schizophrenia, schizoaffective disorder, and mood disorders with psychotic features. American Journal of Psychiatry 158(1):122–125, 2001.PubMedCrossRefGoogle Scholar
  47. 47.
    Pini S, de Q, Dell’Osso L, Abelli M, Mastrocinque C, Saettoni M, Catena M, Cassano GB: Cross-sectional similarities and differences between schizophrenia, schizoaffective disorder and mania or mixed mania with mood-incongruent psychotic features. European Psychiatry 19(1):8–14, 2004.PubMedCrossRefGoogle Scholar
  48. 48.
    Fennig S, Everett E, Bromet EJ, Jandorf L, Fennig SR, Tanenberg-Karant M, Craig TJ: Insight in first-admission psychotic patients. Schizophrenia Research 22(3):257–263, 1996.PubMedCrossRefGoogle Scholar
  49. 49.
    Young DA, Zakzanis KK, Bailey C, Davila R, Griese J, Sartory G, Thom A: Further parameters of insight and neuropsychological deficit in schizophrenia and other chronic mental disease. Journal of Nervous and Mental Disease 186(1):44–50, 1998.PubMedCrossRefGoogle Scholar
  50. 50.
    Williams CC, Collins A: Factors associated with insight among outpatients with serious mental illness. Psychiatric Services 53(1):96–98, 2002.PubMedCrossRefGoogle Scholar
  51. 51.
    Yen CF, Chen CS, Yeh ML, Yen JY, Ker JH, Yang SJ: Comparison of insight in patients with schizophrenia and bipolar disorder in remission. Journal of Nervous and Mental Disease 190(12):847–849, 2002.PubMedCrossRefGoogle Scholar
  52. 52.
    Kay SR, Opler LA, Lindenmayer JP: The Positive and Negative Syndrome Scale (PANSS): Rationale and standardisation. British Journal of Psychiatry 155(Suppl):59–65, 1989.Google Scholar
  53. 53.
    Latalova K: Bipolar Affective Disorder [In Czech]. Prague, Grada Publishing, 2011.Google Scholar
  54. 54.
    Varga M, Magnusson A, Flekkoy K, David AS, Opjordsmoen S: Clinical and neuropsychological correlates of insight in schizophrenia and bipolar I disorder: Does diagnosis matter? Comprehensive Psychiatry 48(6):583–591, 2007.PubMedCrossRefGoogle Scholar
  55. 55.
    Swanson CL, Jr., Freudenreich O, McEvoy JP, Nelson L, Kamaraju L, Wilson WH: Insight in schizophrenia and mania. Journal of Nervous and Mental Disease 183(12):752–755, 1995.PubMedCrossRefGoogle Scholar
  56. 56.
    Markova IS, Berrios GE: Insight in clinical psychiatry A new model. Journal of Nervous and Mental Disease 183(12):743–751, 1995.PubMedCrossRefGoogle Scholar
  57. 57.
    Birchwood M, Smith J, Drury V, Healy J, Macmillan F, Slade M: A self-report Insight Scale for psychosis: reliability, validity and sensitivity to change. Acta Psychiatrica Scandinavica 89(1):62–67, 1994.PubMedCrossRefGoogle Scholar
  58. 58.
    Jonsdottir H, Engh JA, Friis S, Birkenaes A, Ringen PA, Vaskinn A, Sundet K, Opjordsmoen S, Andreassen OA: Measurement of insight in patients with bipolar disorder: Are self-rated scales developed for patients with schizophrenia applicable? Journal of Nervous and Mental Disease 196(4):333–335, 2008.PubMedCrossRefGoogle Scholar
  59. 59.
    Johnson SL, Fulford D: Development of the treatment attitudes questionnaire in bipolar disorder. Journal of Clinical Psychology 64(4):466–481, 2008.PubMedCrossRefGoogle Scholar
  60. 60.
    McEvoy JP, Freter S, Everett G, Geller JL, Appelbaum P, Apperson LJ, Roth L: Insight and the clinical outcome of schizophrenic patients. Journal of Nervous and Mental Disease 177(1):48–51, 1989.PubMedCrossRefGoogle Scholar
  61. 61.
    Schwartz RC, Cohen BN, Grubaugh A: Does insight affect long-term impatient treatment outcome in chronic schizophrenia? Comprehensive Psychiatry 38(5):283–288, 1997.PubMedCrossRefGoogle Scholar
  62. 62.
    Ghaemi SN, Boiman E, Goodwin FK: Insight and outcome in bipolar, unipolar, and anxiety disorders. Comprehensive Psychiatry 41(3):167–171, 2000.PubMedCrossRefGoogle Scholar
  63. 63.
    WHOQOL Group: Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychological Medicine 28:551–558, 1998.CrossRefGoogle Scholar
  64. 64.
    Yen CF, Chen CS, Yang SJ, Ko CH, Yen JY, Huang CF: Relationships between insight and psychosocial adjustment in patients with bipolar I disorder. Bipolar Disorder 9(7):737–742, 2007.CrossRefGoogle Scholar
  65. 65.
    Yen CF, Chen CS, Yen JY, Ko CH: The predictive effect of insight on adverse clinical outcomes in bipolar I disorder: A two-year prospective study. Journal of Affective Disorders 108(1–2):121–127, 2008.PubMedCrossRefGoogle Scholar
  66. 66.
    Latalova K: Bipolar disorder and aggression. International Journal of Clinical Practice 63(6):889–899, 2009.PubMedCrossRefGoogle Scholar
  67. 67.
    Yen CF, Cheng CP, Huang CF, Ko CH, Yen JY, Chang YP, Chen CS: Relationship between psychosocial adjustment and executive function in patients with bipolar disorder and schizophrenia in remission: The mediating and moderating effects of insight. Bipolar Disorder 11(2):190–197, 2009.CrossRefGoogle Scholar
  68. 68.
    Berk L, Hallam KT, Colom F, Vieta E, Hasty M, Macneil C, Berk M: Enhancing medication adherence in patients with bipolar disorder. Human Psychopharmacology 25(1):1–16, 2010.PubMedCrossRefGoogle Scholar
  69. 69.
    Colom F, Vieta E, Martinez-Aran A, Reinares M, Goikolea JM, Benabarre A, Torrent C, Comes M, Corbella B, Parramon G, Corominas J: A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Archives of General Psychiatry 60(4):402–407, 2003.PubMedCrossRefGoogle Scholar
  70. 70.
    Bieling PJ, MacQueen GM, Marriot MJ, Robb JC, Begin H, Joffe RT, Young LT: Longitudinal outcome in patients with bipolar disorder assessed by life-charting is influenced by DSM-IV personality disorder symptoms. Bipolar Disorder 5(1):14–21, 2003.CrossRefGoogle Scholar
  71. 71.
    George EL, Miklowitz DJ, Richards JA, Simoneau TL, Taylor DO: The comorbidity of bipolar disorder and axis II personality disorders: Prevalence and clinical correlates. Bipolar Disorder 5(2):115–122, 2003.CrossRefGoogle Scholar
  72. 72.
    Colom F, Vieta E, Sanchez-Moreno J, Martinez-Aran A, Torrent C, Reinares M, Goikolea JM, Benabarre A, Comes M: Psychoeducation in bipolar patients with comorbid personality disorders. Bipolar Disorder 6(4):294–298, 2004.CrossRefGoogle Scholar
  73. 73.
    Rollnick S, Butler CC, Kinnersley P, Gregory J, Mash B: Motivational interviewing. British Medical Journal 340:c1900, 2010.PubMedCrossRefGoogle Scholar
  74. 74.
    Kemp R, Hayward P, Applewhaite G, Everitt B, David A: Compliance therapy in psychotic patients: Randomised controlled trial. British Medical Journal 312(7027):345–349, 1996.PubMedCrossRefGoogle Scholar
  75. 75.
    Kahn RS, Fleischhacker WW, Boter H, Davidson M, Vergouwe Y, Keet IP, Gheorghe MD, Rybakowski JK, Galderisi S, Libiger J, Hummer M, Dollfus S, Lopez-Ibor JJ, Hranov LG, Gaebel W, Peuskens J, Lindefors N, Riecher-Rossler A, Grobbee DE: Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: An open randomised clinical trial. Lancet 371(9618):1085–1097, 2008.PubMedCrossRefGoogle Scholar
  76. 76.
    Scott J, Tacchi MJ: A pilot study of concordance therapy for individuals with bipolar disorders who are non-adherent with lithium prophylaxis. Bipolar Disorder 4(6):386–392, 2002.CrossRefGoogle Scholar
  77. 77.
    Lysaker PH, Bell MD, Bryson G, Kaplan E: Neurocognitive function and insight in schizophrenia: Support for an association with impairments in executive function but not with impairments in global function. Acta Psychiatrica Scandinavica 97(4):297–301, 1998.PubMedCrossRefGoogle Scholar
  78. 78.
    Harvey PD, Wingo AP, Burdick KE, Baldessarini RJ: Cognition and disability in bipolar disorder: Lessons from schizophrenia research. Bipolar Disorder 12(4):364–375, 2010.CrossRefGoogle Scholar
  79. 79.
    Yen CF, Chung LC, Chen CS: Insight and neuropsychological functions in bipolar outpatients in remission. Journal of Nervous and Mental Disease 190(10):713–715, 2002.PubMedCrossRefGoogle Scholar
  80. 80.
    Markova IS, Roberts KH, Gallagher C, Boos H, McKenna PJ, Berrios GE: Assessment of insight in psychosis: A re-standardization of a new scale. Psychiatry Research 119(1–2):81–88, 2003.PubMedCrossRefGoogle Scholar
  81. 81.
    Markova IS, Berrios GE: The assessment of insight in clinical psychiatry: A new scale. Acta Psychiatrica Scandinavica 86(2):159–164, 1992.PubMedCrossRefGoogle Scholar
  82. 82.
    Marks KA, Fastenau PS, Lysaker PH, Bond GR: Self-Appraisal of Illness Questionnaire (SAIQ): Relationship to researcher-rated insight and neuropsychological function in schizophrenia. Schizophrenia Research 45(3):203–211, 2000.PubMedCrossRefGoogle Scholar
  83. 83.
    Beck AT, Baruch E, Balter JM, Steer RA, Warman DM: A new instrument for measuring insight: The Beck Cognitive Insight Scale. Schizophrenia Research 68(2–3):319–329, 2004.PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of Psychiatry, Faculty of Medicine and DentistryPalacký University OlomoucOlomoucCzech Republic

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