Insight in bipolar disorder: relationship to episode subtypes and symptom dimensions

Intersections of phenomenology, voice beliefs and distress in bipolar disorder: a comparison with schizophrenia

BACKGROUND

Auditory verbal hallucinations (AVH), or voice-hearing, can be a prominent symptom during fluctuating mood states in bipolar disorder (BD).

AIMS

The current study aimed to: (i) compare AVH-related distress in BD relative to schizophrenia (SCZ), (ii) examine correlations between phenomenology and voice beliefs across each group, and (iii) explore how voice beliefs may uniquely contribute to distress in BD and SCZ.

METHOD

Participants were recruited from two international sites in Australia (BD=31; SCZ=50) and the UK (BD=17). Basic demographic-clinical information was collected, and mood symptoms were assessed. To document AVH characteristics, a 4-factor model of the Psychotic Symptoms Rating Scale and the Beliefs about Voices Questionnaire-Revised were used. Statistical analyses consisted of group-wise comparisons, Pearson's correlations and multiple hierarchical regressions.

RESULTS

It was found that AVH-related distress was not significantly higher in BD than SCZ, but those with BD made significantly more internal attributions for their voices. In the BD group, AVH-related distress was significantly positively correlated with malevolence, omnipotence and resistance, However, only resistance, alongside mania and depressive symptoms, significantly contributed to AVH-related distress in BD.

DISCUSSION

Our findings have several clinical implications, including identification of voice resistance as a potential therapeutic target to prioritise in BD. Factoring in the influence of mood symptoms on AVH-related distress as well as adopting more acceptance-oriented therapies may also be of benefit.

Comparison of Attitude and Insight Toward Illness Between in Patients with Bipolar I Disorder Manic Episode and Major Depressive Disorder

Background

Studies comparing insight toward illness in patients with bipolar I disorder manic episode and in patients with major depressive disorder are scarce. The aim of this study was to investigate the attitudes and insight of patients with bipolar I disorder in manic episode and in patients with major depressive disorder.

Methods

In total, 86 patients were recruited, including 52 inpatients with bipolar I disorder in manic episodes and 34 inpatients with major depressive disorder. Attitudes toward illness were evaluated using the Self-Appraisal of Illness Questionnaire. Higher Self-Appraisal of Illness Questionnaire scores indicate better awareness and positive attitudes toward one's illness. Insights were assessed using the Insight Scale for Affective Disorders. Higher scores indicate poorer insight. To identify group differences, we used Mann-Whitney U test for statistical analysis.

Results

In the Self-Appraisal of Illness Questionnaire, items 1, 2, 3, 4, 6, 7, 10, 15, and 17 showed significantly lower scores in patients with bipolar I disorder than those with major depressive disorder (P < .05). All 3 subscales (presence/outcome of illness, need for treatment, and worry) of the Self-Appraisal of Illness Questionnaire revealed significantly lower scores in the bipolar I disorder group (P < .05). In the Insight Scale for Affective Disorders, items 3, 4, 12, and 16 showed significantly higher scores in the bipolar I disorder group (P < .05).

Conclusion

Patients with major depressive disorder had significantly more positive attitudes and greater insight than those with bipolar I disorder. Patients with bipolar I disorder are less aware of their symptoms, including changes in mood, speed of mental functioning, and social relationships. The clinicians may integrate the findings into treatment plans for mood disorders.

Insight in patients with bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

Background

There are limited number of studies evaluating insight among patients with bipolar disorder (BD).

Aim

This study aimed to examine insight and its correlates in BD using the data from the multicenter BD course and outcome study from India (BiD-CoIN). The additional aim was to evaluate the insight in patients with BD using different scales and understand the correlates of insight.

Materials and Methods

773 BD patients presently in clinical remission were evaluated on the Insight Scale for Affective Disorders (ISAD), insight items of the Hamilton Depression Rating Scale (HDRS), and the Young Mania Rating Scale (YMRS).

Results

The assessment scales influenced the prevalence of poor insight. Poorer insight irrespective of the assessment scale was consistently associated with higher residual depressive and manic symptoms, and a higher level of cognitive impairment and disability. Poor insight as assessed by ISAD was associated with a higher number of episodes in the lifetime, shorter duration of current remission, a higher number of depressive episodes, a higher amount of time spent in depressive episodes, higher depressive affective morbidity, a higher number of manic episodes, and higher residual depressive and manic symptoms.

Conclusion

Poor insight in BD is consistently associated with higher residual depressive and manic symptoms and a higher level of cognitive impairment and disability. However, in terms of course variables, the correlates vary depending on the assessment method.

Relation between frontal pole volumes and cognitive insight in Schizophrenia

OBJECTIVE

Cognitive insight comprising self-reflection and self-certainty is an important determinant of functional outcomes in Schizophrenia. The neural correlates of cognitive insight in Schizophrenia are underexamined. The frontal pole (FP) is implicated in metacognitive function in healthy individuals, but its role is not well examined in Schizophrenia. We had earlier reported the relationship between Frontal pole volumes and cognitive insight in a small sample of only male patients. Hence, we studied this relationship in an independent sample of schizophrenia patients and healthy controls.

METHODS

We examined 41 healthy volunteers (HV) and 57 patients with Schizophrenia (SCZ). We used a previously validated manual morphometric method to perform FP parcellation on images obtained from a 3 T scanner and calculated the volumes. Cognitive insight was measured using Beck's Cognitive insight scale (BCIS). To assess the relationship between FP volumes and BCIS scores, multiple linear regression analyses were performed.

RESULTS

In the overall sample, age, years of education, and intracranial volume were significant predictors of BCIS scores. Within the SCZ group, age and left FP volume were significant predictors of BCIS composite scores and age, ICV for BCIS-self certainty. There was no significant relationship between age and FP volumes in either SCZ or HV group.

DISCUSSION

The current study in an independent sample further supports the critical role of the frontal pole in cognitive insight, earlier reported by us. As cognitive insight has a vital role in functional outcome, our findings have potential clinical implications.

Psychotic symptoms in bipolar disorder and their impact on the illness: A systematic review

BACKGROUND

Lifetime psychotic symptoms are present in over half of the patients with bipolar disorder (BD) and can have an adverse effect on its course, outcome, and treatment. However, despite a considerable amount of research, the impact of psychotic symptoms on BD remains unclear, and there are very few systematic reviews on the subject.

AIM

To examine the extent of psychotic symptoms in BD and their impact on several aspects of the illness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. An electronic literature search of six English-language databases and a manual search was undertaken to identify published articles on psychotic symptoms in BD from January 1940 to December 2021. Combinations of the relevant Medical Subject Headings terms were used to search for these studies. Articles were selected after a screening phase, followed by a review of the full texts of the articles. Assessment of the methodological quality of the studies and the risk of bias was conducted using standard tools.

RESULTS

This systematic review included 339 studies of patients with BD. Lifetime psychosis was found in more than a half to two-thirds of the patients, while current psychosis was found in a little less than half of them. Delusions were more common than hallucinations in all phases of BD. About a third of the patients reported first-rank symptoms or mood-incongruent psychotic symptoms, particularly during manic episodes. Psychotic symptoms were more frequent in bipolar type I compared to bipolar type II disorder and in mania or mixed episodes compared to bipolar depression. Although psychotic symptoms were not more severe in BD, the severity of the illness in psychotic BD was consistently greater. Psychosis was usually associated with poor insight and a higher frequency of agitation, anxiety, and hostility but not with psychiatric comorbidity. Psychosis was consistently linked with increased rates and the duration of hospitalizations, switching among patients with depression, and poorer outcomes with mood-incongruent symptoms. In contrast, psychosis was less likely to be accompanied by a rapid-cycling course, longer illness duration, and heightened suicidal risk. There was no significant impact of psychosis on the other parameters of course and outcome.

CONCLUSION

Though psychotic symptoms are very common in BD, they are not always associated with an adverse impact on BD and its course and outcome.

A comparative study evaluating insight in different phase of illness among patients with bipolar disorder by using multiple scales

AIM

This cross-sectional study aimed to evaluate insight and its correlates among patients with bipolar disorder (BD).

METHODOLOGY

180 patients with BD were evaluated on Scale to Assess Unawareness of Mental Disorders (SUMD), Insight scale for affective disorders (ISAD), Mood Disorders Insight Scale (MDIS), and Beck Cognitive Insight Scale (BCIS).

RESULTS

About half of the patients were in clinical remission (N = 94; 52.2%), one-fifth (N = 37; 20.55%) were in the phase of mania and one-fourth (N = 49; 27.2%) were in a depression. There was no significant difference in the level of insight between those in clinical remission and those in depression except for one of the domains of BCIS. Patients with mania had poorer insight compared to those in remission and depression. In terms of association of insight as assessed by different scales, in the whole sample and all the three subgroups, SUMD current and past scores had a significant positive correlation with the ISAD total score. In the whole sample, among patients currently in remission and those currently in depression, ISAD total score had significant negative correlation with MDIS total score. Poorer insight as assessed on SUMD (current and past), ISAD and MDIS was associated with poorer medication adherence.

CONCLUSION

The present study demonstrates that patients with mania have poor insight when compared to the patients in clinical remission and depression. The present study also demonstrates that the assessment of clinical insight is not affected much by the type of scale used.

A network structure of manic symptoms

OBJECTIVES

The aim of this study is to explore mania as a network of its symptoms, inspired by the network approach to mental disorders.

METHODS

Network structures of both cross-sectional and temporal effects were measured at three time points (admission, middle of hospital stay, and discharge) in a sample of 100 involuntarily committed patients diagnosed with bipolar I disorder with severe manic features and hospitalized in a specialized psychiatric ward.

RESULTS

Elevated mood is the most interconnected symptom in the network on admission, while aggressive behavior and irritability are highly predictive of each other, as well as language-thought disorder and "content" (the presence of abnormal ideas or delusions). Elevated mood is influenced by many symptoms in the temporal network.

CONCLUSIONS

The investigation of manic symptoms with network analysis allows for identifying important symptoms that are better connected to other symptoms at a given moment and over time. The connectivity of the manic symptoms evolves over time. Central symptoms could be considered as targets for clinical intervention when treating severe mania.

Mobile App-Based Self-Report Questionnaires for the Assessment and Monitoring of Bipolar Disorder: Systematic Review

Background

Bipolar disorder is a chronic, progressive illness characterized by recurrent episodes of mania and depression. Self-report scales have historically played a significant role in the monitoring of bipolar symptoms. However, these tools rely on episodic memory, which can be unreliable and do not allow the clinician to monitor brief episodic symptoms or the course of symptoms over shorter periods of time. Mobile app–based questionnaires have been suggested as a tool to improve monitoring of patients with bipolar disorder.

Objective

This paper aims to determine the feasibility and validity of mobile app–based self-report questionnaires.

Methods

We performed a systematic review of the literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed, PsycInfo, Web of Science, Ovid MEDLINE, and EMBASE databases were searched for papers published in English that assessed adherence to and the validity of mobile app–based self-report questionnaires. Relevant studies published from database creation to May 22, 2020, were identified, and results examining the validity of and rates of adherence to app-based self-report questionnaires are reported.

Results

A total of 13 records were identified for inclusion in this review. Of these studies, 4 assessed the concurrent validity of mobile app–based self-report tools, with the majority of findings indicating significant associations between data collected using these tools and the Young Mania Rating Scale, Hamilton Depression Rating Scale-17, or Montgomery-Åsberg Depression Rating Scale (P<.001 to P=.24). Three studies comparing the variability or range of symptoms between patients with bipolar disorder and healthy controls suggested that these data are capable of differentiating between known groups. Two studies demonstrated statistically significant associations between data collected via mobile app–based self-report tools and instruments assessing other clinically important factors. Adherence rates varied across the studies examined. However, good adherence rates (>70%) were observed in all but 1 study using a once-daily assessment. There was a wide range of adherence rates observed in studies using twice-daily assessments (42%-95%).

Conclusions

These findings suggest that mobile app–based self-report tools are valid in the assessment of symptoms of mania and depression in euthymic patients with bipolar disorder. Data collected using these tools appear to differ between patients with bipolar disorder and healthy controls and are significantly associated with other clinically important measures. It is unclear at this time whether these tools can be used to detect acute episodes of mania or depression in patients with bipolar disorder. Adherence data indicate that patients with bipolar disorder show good adherence to self-report assessments administered daily for the duration of the study periods evaluated.

Daily mobility patterns in patients with bipolar disorder and healthy individuals

BACKGROUND

Alterations in energy and activity in bipolar disorder (BD) differ between affective states and compared with healthy control individuals (HC). Measurements of activity could discriminate between BD and HC and in the monitoring of affective states within BD. The aims were to investigate differences in 1) passively collected smartphone-based location data (location data) between BD and HC, and 2) location data in BD between affective states.

METHODS

Daily, patients with BD and HC completed smartphone-based self-assessments of mood for up to nine months. Location data reflecting mobility patterns, routine and location entropy was collected daily. A total of 46 patients with BD and 31 HC providing daily data was included.

RESULTS

A total of 4,859 observations of smartphone-based self-assessments of mood and mobility patterns were available from patients with BD and 1,747 observations from HC. Patients with BD had lower location entropy compared with HC (B= -0.14, 95% CI= -0.24; -0.034, p=0.009). Patients with BD during a depressive state were less mobile compared with a euthymic state. Patients with BD during an affective state had lower location entropy compared with a euthymic state (p<0.0001). The AUC of combined location data was rather high in classifying patients with BD compared with HC (AUC: 0.83).

LIMITATIONS

Individuals willing to use smartphones for daily self-monitoring may represent a more motivated group.

CONCLUSION

Alterations in location data reflecting mobility patterns may be a promising measure of illness and illness activity in patients with BD and may be used to monitor the effects of treatments.

Trajectory of insight on various dimensions among bipolar disorder in-patients

BACKGROUND

Insight is awareness of one's symptoms, illness, and need for treatment. In bipolar disorder, insight is better in bipolar depression and nonpsychotic depression when compared with mania and psychotic depression. Insight impacts on medication adherence. In our study, we measured and compared with various clinical parameters of insight. The aim of this study is to assess various dimensions of insight recovery prospectively in bipolar affective disorder patients with treatment and drug compliance.

MATERIALS AND METHODS

Patient's insight was assessed using Mood Disorder Insight Scale (MDIS) at baseline, 1^st, 3^rd, and 6^th months. Their insight was then compared with various sociodemographic profiles and correlated with number of mood episodes, family history of mental illness, and 6-month MDIS scores.

RESULTS

Depression patients scored better in insight components (P = 0.001). The good compliance group attributed their symptoms to their illness than the poor compliance group (P = 0.013). The MDIS scores were gradually improving from baseline to 6 months (P ≤ 0.001). There was no relationship between insight and the number of episodes (P = 0.788).

CONCLUSION

Depressive episode patients had better insight during the baseline, which improved during 6 months follow-up compared with manic patients. Among various components of insight, insight on the attribution of symptoms was a predictor of good compliance. Progression of insight was steady and proportionate to the duration of treatment in depressive episode patients.

Daily estimates of clinical severity of symptoms in bipolar disorder from smartphone-based self-assessments

Currently, the golden standard for assessing the severity of depressive and manic symptoms in patients with bipolar disorder (BD) is clinical evaluations using validated rating scales such as the Hamilton Depression Rating Scale 17-items (HDRS) and the Young Mania Rating Scale (YMRS). Frequent automatic estimation of symptom severity could potentially help support monitoring of illness activity and allow for early treatment intervention between outpatient visits. The present study aimed (1) to assess the feasibility of producing daily estimates of clinical rating scores based on smartphone-based self-assessments of symptoms collected from a group of patients with BD; (2) to demonstrate how these estimates can be utilized to compute individual daily risk of relapse scores. Based on a total of 280 clinical ratings collected from 84 patients with BD along with daily smartphone-based self-assessments, we applied a hierarchical Bayesian modelling approach capable of providing individual estimates while learning characteristics of the patient population. The proposed method was compared to common baseline methods. The model concerning depression severity achieved a mean predicted R2 of 0.57 (SD = 0.10) and RMSE of 3.85 (SD = 0.47) on the HDRS, while the model concerning mania severity achieved a mean predicted R2 of 0.16 (SD = 0.25) and RMSE of 3.68 (SD = 0.54) on the YMRS. In both cases, smartphone-based self-reported mood was the most important predictor variable. The present study shows that daily smartphone-based self-assessments can be utilized to automatically estimate clinical ratings of severity of depression and mania in patients with BD and assist in identifying individuals with high risk of relapse.

Resilience and insight in euthymic patients with bipolar disorder

BACKGROUND

The relationship between resilience and insight may be of potential importance for coping with stress in bipolar disorder (BD). The aim of this study was to investigate if there was a relation between insight and resilience in euthymic patients with BD and also to analyze the associations between resilience, impulsivity, aggression, alcohol use and affective temperament.

METHODS

142 patients with BD type I in remission period were involved. Resilience Scale for Adults-Turkish version, Schedule for Assessment of Insight, Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire, Barratt Impulsiveness Scale, Buss-Perry Aggression Questionnaire, Michigan Alcoholism Screening Test were used.

RESULTS

Total insight scores were negatively correlated with the scores of perception of future. As distinct from other subscales of resilience, family cohesion had independent significant associations with insight in relabelling of psychotic experiences and attention impulsivity. There was no relationship between total insight and total resilience scores. Resilience scores were negatively correlated with number of depressive episodes and number of suicide attempts. Degree of aggression, degree of impulsivity, scores of depressive and hyperthymic temperament significantly predicted resilience.

LIMITATIONS

Recruitment of patients from a tertiary centre limits the generalizability of the findings.

CONCLUSIONS

Better insight was related to negative perception of the future and did not have significant associations with total resilience. Number of depressive episodes, number of past suicide attempts correlated with resilience, emphasizing the importance of interventions to increase resilience in BD.

Clinical and Cognitive Correlates of Insight in Bipolar Disorder

Insight is greatly impaired in Bipolar Disorder (BD), especially during mania. Cognitive impairment is also present in BD. Despite that, few studies have investigated a possible association between these two aspects. The main goal of the current study is to compare BD affective states regarding performance in cognitive testing and investigate clinical and cognitive predictors for insight loss in BD. The study investigated a sample of 65 patients who were evaluated in one of the BD phases (mania, euthymia or depression). All the subjects underwent neuropsychological evaluation and completed the Insight Scale for Affective Disorders (ISAD). The relationship between level of insight and clinical/cognitive variables was analyzed through multiple regression models. No significant differences were found among BD phases regarding performance on cognitive testing. Insight was more impaired in mania then in depression or euthymia. Predictors for loss of insight were: severity of manic symptoms and impairments in selective attention (Symbol search test), divided attention (Trail making test) and inhibition (Stroop test). The sample size is a potential limitation of the current study. Nevertheless, the results suggest this had limited impact, with group differences being detected for a number of variables. The results found have important clinical importance, suggesting, for example, that rehabilitation of specific cognitive skills may improve insight in BD.

Objective smartphone data as a potential diagnostic marker of bipolar disorder

OBJECTIVE

Currently, the diagnosis in bipolar disorder relies on patient information and careful clinical evaluations and judgements with a lack of objective tests. Core clinical features of bipolar disorder include changes in behaviour. We aimed to investigate objective smartphone data reflecting behavioural activities to classify patients with bipolar disorder compared with healthy individuals.

METHODS

Objective smartphone data were automatically collected from 29 patients with bipolar disorder and 37 healthy individuals. Repeated measurements of objective smartphone data were performed during different affective states in patients with bipolar disorder over 12 weeks and compared with healthy individuals.

RESULTS

Overall, the sensitivity of objective smartphone data in patients with bipolar disorder versus healthy individuals was 0.92, specificity 0.39, positive predictive value 0.88 and negative predictive value 0.52. In euthymic patients versus healthy individuals, the sensitivity was 0.90, specificity 0.56, positive predictive value 0.85 and negative predictive value 0.67. In mixed models, automatically generated objective smartphone data (the number of text messages/day, the duration of phone calls/day) were increased in patients with bipolar disorder (during euthymia, depressive and manic or mixed states, and overall) compared with healthy individuals. The amount of time the smartphone screen was 'on' per day was decreased in patients with bipolar disorder (during euthymia, depressive state and overall) compared with healthy individuals.

CONCLUSION

Objective smartphone data may represent a potential diagnostic behavioural marker in bipolar disorder and may be a candidate supplementary method to the diagnostic process in the future. Further studies including larger samples, first-degree relatives and patients with other psychiatric disorders are needed.

Clinical correlates of loss of insight in bipolar depression

INTRODUCTION

Affective state may influence insight, especially regarding mania. Nevertheless, studies have so far suggested that depression seems not to significantly impair insight. To the best of our knowledge, this study pioneers the evaluation of how insight variations in bipolar depression correlate with clinical variables.

METHOD

A group of 165 bipolar patients, 52 of whom had depressive episodes according to DSM-5 criteria, were followed during a year. All patients underwent clinical assessment, and insight was evaluated through the Insight Scale for Affective Disorders (ISAD). Repeated-measures ANOVA was calculated comparing scores on the four ISAD factors (insight into symptoms, the condition itself, self-esteem and social relationships) in order to investigate differences in insight according to different objects. Correlational analysis explored which clinical symptoms were linked to reduced insight.

RESULTS

Worse total insight correlated with suicide attempt/ideation and fewer subsyndromal manic symptoms such as mood elevation, increased energy and sexual interest. Worse self-esteem insight was associated with not only suicide ideation/attempt but also with activity reduction and psychomotor retardation. Worse symptom insight also correlated with psychomotor retardation. Better insight into having an affective disorder was associated with more intense hypochondria symptoms. Finally, worse insight into having an illness was associated with psychotic episodes.

CONCLUSION

Our study found that symptoms other than psychosis - suicide ideation, psychomotor retardation and reduction of activity and work - correlate with insight impairment in bipolar depression.

The influence of current mood state, number of previous affective episodes and predominant polarity on insight in bipolar disorder

BACKGROUND

Although many studies have explored the effect of current affective episodes on insight into bipolar disorder, the potential interaction between current mood state and previous affective episodes has not been consistently investigated.

OBJECTIVE

To explore the influence of dominant polarity, number of previous affective episodes and current affective state on insight in bipolar disorder patients in euthymia or mania.

METHODS

A total of 101 patients with bipolar disorder were recruited for the study, including 58 patients in euthymia (30 with no defined predominant polarity and 28 with manic predominant polarity) and 43 in mania (26 with no defined predominant polarity and 17 with manic predominant polarity). Patients underwent a clinical assessment and insight was evaluated through the Insight Scale for Affective Disorders.

RESULTS

Bipolar disorder patients in mania had worse insight than those in euthymia, with no effect of dominant polarity. In addition, positive psychotic symptoms showed a significant effect on insight and its inclusion as a covariate eliminated differences related to mood state. Finally, the number of previous manic or depressive episodes did not correlate with insight level.

CONCLUSIONS

Mania is a predictor of loss of insight into bipolar disorder. However, it is possible that its contribution is linked to the more frequent presence of psychotic symptoms in this state. Dominant polarity and number/type of previous affective episodes have a limited impact on insight.

Characterizing the experience of auditory verbal hallucinations and accompanying delusions in individuals with a diagnosis of bipolar disorder: A systematic review

OBJECTIVES

The aim of the current study was to inform ongoing attempts to identify clinically meaningful subcategories of auditory verbal hallucination (AVH), and to evaluate evidence that might pertain to the suitability of current psychological interventions for people with bipolar disorder (BD) who experience psychotic symptoms.

METHODS

A comprehensive synthesis of findings on the phenomenology of AVH and delusions in BD is included, alongside a critical review of clinical and cognitive correlates. Studies published in the previous 20 years, until December 2016, were retrieved from the following databases: Embase, CINAHL, MEDLINE, PsycINFO and Web of Science. Thirty-two articles were reviewed after applying a set of predetermined inclusion criteria.

RESULTS

Psychotic symptoms were common in both manic and depressive phases, although higher frequencies were indicated in mania. Few detailed characterizations of AVH phenomenology were identified. Delusions with persecutory, grandiose and referential themes were the most common in BD. AVHs were associated with delusions and there was evidence to suggest that delusion subtype may vary according to mood state and type of AVH. Data on clinical correlates of AVH in BD were sparse. However, the results indicated that cognitive appraisals or interpretations of voices might be different in BD from those established to be predictive of clinical outcomes in schizophrenia spectrum disorders.

CONCLUSIONS

Clear gaps exist in our current understanding of the first-person experience of AVH in BD and the potential relationship to co-occurring symptoms, including delusions. Further research into cognitive interpretations of AVH in BD might inform adapted psychological interventions for psychotic symptoms in this population.

The metabolic basis of cognitive insight in psychosis: A positron emission tomography study

The purpose of this study was to investigate the relationship between cognitive insight and cerebral metabolism in patients suffering from psychosis. The Beck Cognitive Insight Scale (BCIS) was administered to 63 patients with psychosis undergoing Positron Emission Tomography investigation. The sample was divided into two groups considering the BCIS score. Data were analyzed using Statistical Parametric Mapping.

RESULTS

patients with low insight, compared to those with high insight, showed decreased metabolism in the right fusiform gyrus, left precuneus, superior temporal gyrus and insula bilaterally, as well as increased metabolism in the left orbito-frontal gyrus (all p<0.005). Our results suggest that reduced posterior (occipito-temporo-insulo-parietal) and increased anterior (orbitofrontal) cerebral metabolism may sustain low cognitive insight in psychosis.

Insight in bipolar mania: evaluation of its heterogeneity and correlation with clinical symptoms

BACKGROUND

Studies on insight in bipolar mania are not numerous and usually consider insight as a unitary construct.

OBJECTIVE

Evaluate how different facets of insight are affected in bipolar mania and investigate correlations between insight for each specific object in bipolar disorder and manic symptomatology.

METHOD

A group of 165 bipolar patients were followed during a year, with 51 patients having manic episodes according to DSM-IV-TR criteria. Patients underwent a clinical assessment and insight was evaluated through the Insight Scale for Affective Disorders.

RESULTS

The study found that insight regarding symptoms is worse than insight of having bipolar disorder, social relationships and self esteem. Moreover, poor global insight (total ISAD) correlates with more severe changes in mood, speech and thought structure, with worse insight about symptoms correlating with the same alterations and also with more severe symptoms of agitation/energy.

LIMITATIONS

Although a large sample of bipolar patients was followed up, the final sample composed of patients with at least one manic episode was relatively smaller. Moreover, the fact that the study was performed in a university hospital may have led to selection biases.

CONCLUSION

Results suggest that patients with BD are reasonably capable of identifying that their condition implies consequences but have more impaired awareness of their energy and activity levels. A lower level of insight specifically about symptoms correlates with more severe symptoms of agitation/energy, which suggests a psychomotor nucleus able to impair insight in mania.

Does Insight Affect the Efficacy of Antipsychotics in Acute Mania?: An Individual Patient Data Regression Meta-Analysis

Patients having an acute manic episode of bipolar disorder often lack insight into their condition. Because little is known about the possible effect of insight on treatment efficacy, we examined whether insight at the start of treatment affects the efficacy of antipsychotic treatment in patients with acute mania. We used individual patient data from 7 randomized, double-blind, placebo-controlled registration studies of 4 antipsychotics in patients with acute mania (N = 1904). Insight was measured with item 11 of the Young Mania Rating Scale (YMRS) at baseline and study endpoint 3 weeks later. Treatment outcome was defined by (a) mean change score, (b) response defined as 50% or more improvement on YMRS, and (c) remission defined as YMRS score less than 8 at study endpoint. We used multilevel mixed effect linear (or logistic) regression analyses of individual patient data to assess the interaction between baseline insight and treatment outcomes. At treatment initiation, 1207 (63.5%) patients had impaired or no insight into their condition. Level of insight significantly modified the efficacy of treatment by mean change score (P = 0.039), response rate (P = 0.033), and remission rate (P = 0.043), with greater improvement in patients with more impaired insight. We therefore recommend that patients experiencing acute mania should be treated immediately and not be delayed until patients regain insight.

The impact of periventricular white matter lesions in patients with bipolar disorder type I

INTRODUCTION

White matter hyperintensities (WMHs) are one the most common neuroimaging findings in patients with bipolar disorder (BD). It has been suggested that WMHs are associated with impaired insight in schizophrenia and schizoaffective patients; however, the relationship between insight and WMHs in BD type I has not been directly investigated.

METHODS

Patients with BD-I (148) were recruited and underwent brain magnetic resonance imaging (MRI). Affective symptoms were assessed using Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale (HDRS17); the presence of impaired insight was based on the corresponding items of YMRS and HDRS17.

RESULTS

Multiple punctate periventricular WMHs (PWMHs) and deep WMHs (DWMHs) were observed in 49.3% and 39.9% of the cases, respectively. Subjects with lower insight for mania had significantly more PWMHs (54.6% vs 22.2%; p < 0.05) when compared to BD-I patients with higher insight for mania. The presence of PWMHs was independently associated with lower insight for mania: patients who denied illness according to the YMRS were 4 times more likely to have PWMHs (95% CI: 1.21/13.42) than other patients.

CONCLUSIONS

Impaired insight in BD-I is associated with periventricular WMHs. The early identification of BD-I subjects with PWMHs and impaired insight may be crucial for clinicians.

Factors predicting the presence of impaired clinical insight in liaison psychiatric patients assessed in the Emergency Room

OBJECTIVES

There are limited studies on the factors that can predict the presence of impaired clinical insight specifically in an Emergency Room (ER) psychiatric patient population. The objective of this study is to examine the factors that can predict the likelihood that a patient presenting to the ER will have impaired clinical insight.

METHODS

Nineteen independent demographic and clinical factors contained on data assessment tools for 337 patients assessed by the crisis team in the ER over 6 months were compiled and analysed using SPSS Version 20 with univariate analyses and logistic regression.

RESULTS

Patients who were unemployed or had a history of self-harm or had psychotic symptoms on mental state examination were about two, three and six times, respectively, more likely to have impaired clinical insight compared with those who were employed, had no history of self-harm or had no psychotic symptoms on mental state examination, controlling for other factors in the logistic regression model.

CONCLUSION

Patients who are unemployed, have a history of self-harm or have psychotic symptoms following as psychiatric assessment in the ER may benefit from an insight-oriented psychotherapy.

Evaluation of potential novel variations and their interactions related to bipolar disorders: analysis of genome-wide association study data

BACKGROUND

Multifactor dimensionality reduction (MDR) is a nonparametric approach that can be used to detect relevant interactions between single-nucleotide polymorphisms (SNPs). The aim of this study was to build the best genomic model based on SNP associations and to identify candidate polymorphisms that are the underlying molecular basis of the bipolar disorders.

METHODS

This study was performed on Whole-Genome Association Study of Bipolar Disorder (dbGaP [database of Genotypes and Phenotypes] study accession number: phs000017.v3.p1) data. After preprocessing of the genotyping data, three classification-based data mining methods (ie, random forest, naïve Bayes, and k-nearest neighbor) were performed. Additionally, as a nonparametric, model-free approach, the MDR method was used to evaluate the SNP profiles. The validity of these methods was evaluated using true classification rate, recall (sensitivity), precision (positive predictive value), and F-measure.

RESULTS

Random forests, naïve Bayes, and k-nearest neighbors identified 16, 13, and ten candidate SNPs, respectively. Surprisingly, the top six SNPs were reported by all three methods. Random forests and k-nearest neighbors were more successful than naïve Bayes, with recall values >0.95. On the other hand, MDR generated a model with comparable predictive performance based on five SNPs. Although different SNP profiles were identified in MDR compared to the classification-based models, all models mapped SNPs to the DOCK10 gene.

CONCLUSION

Three classification-based data mining approaches, random forests, naïve Bayes, and k-nearest neighbors, have prioritized similar SNP profiles as predictors of bipolar disorders, in contrast to MDR, which has found different SNPs through analysis of two-way and three-way interactions. The reduced number of associated SNPs discovered by MDR, without loss in the classification performance, would facilitate validation studies and decision support models, and would reduce the cost to develop predictive and diagnostic tests. Nevertheless, we need to emphasize that translation of genomic models to the clinical setting requires models with higher classification performance.

Insight Across the Different Mood States of Bipolar Disorder

In bipolar disorder, levels of insight vary as a function of the mood state and appear to influence pharmacology compliance, quality of life, the presence of suicidal ideations, and aggressive behavior. To establish a comparison among different mood states in bipolar with regard to level of insight. Forty-eight patients were evaluated in different affective states (i.e., euthymia, mania, depression, and mixed state). Identifying information, sociodemographic data, and clinical records were recorded. The following scales were applied: Hamilton Depression Scale, Young Mania Rating Scale, Positive and Negative Syndrome Scale positive symptoms subscale, and Global Assessment of Functioning and Clinical Global Impressions Scale for use in bipolar disorder. Insight was evaluated using items 11 and 17 of the Young Mania Rating Scale and Hamilton Depression Scale, respectively. Insight in bipolar disorder was found to be more compromised during manic phases and mixed episodes than during periods of depression or euthymia. The factors associated with lower levels of insight were the following: shorter illness duration, older age, and greater severity in mania; the female gender and older age in depression; and shorter illness duration and more severe depressive symptoms in mixed episodes. In the same individual, levels of insight vary as a function of the affective state over the course of bipolar disorder and appear to be influenced by several clinical variables.

Insight in bipolar disorder: a comparison between mania, depression and euthymia using the Insight Scale for Affective Disorders

Objective: To evaluate whether having general insight into bipolar disorder and its symptoms is affected by the mood state of the patient, using the Insight Scale for Affective Disorders, a hetero-application scale for people with mood disorders.Methods: Ninety-five patients with bipolar disorder were evaluated and divided into different groups according to the mood state presented during assessment (i.e., euthymia, mania and depression). Sociodemographic and clinical data (Hamilton Depression Scale, Young Mania Rating Scale, and Clinical Global Impressions Scale) were recorded. Insight was evaluated using the Insight Scale for Affective Disorders.Results: Patients with bipolar disorder in mania show less insight about their condition than patients in depression or euthymia, and less insight about their symptoms than patients with depression, with the exception of awareness of weight change.Conclusions: Loss of insight during mania may have important implications for treatment compliance and adherence and needs to be taken into account in the clinical management of people with bipolar disorder.

Cross-cultural adaptation, validation and factor structure of the Insight Scale for Affective Disorders

BACKGROUND

In the last few decades, several tools for studying insight in bipolar disorders have been used. Olaya and colleagues developed the Insight Scale for Affective Disorders (ISAD), which consists of a scale measuring insight through hetero evaluation for patients with mood disorders. The objective of this work is to translate and adapt the original English version of the ISAD to Brazilian Portuguese (ISAD-BR) and to conduct an evaluation of its psychometric properties.

METHODS

Adaptation procedures included translation/back-translation and consultation with a panel of experts. 95 patients with the diagnosis of Type 1 bipolar disorder were evaluated with the final version of the ISAD-BR, which was applied, simultaneously, but independently, by two examiners. Internal consistency and inter-rater reliability were explored and the latent structure of the scale was investigated with principal axis factoring and promax rotation. A second-order factor analysis was conducted to test if the scale had a hierarchical factor structure.

RESULTS

The ISAD-BR showed good internal consistency and good inter-rater reliability. The analysis pointed to a four-factor solution of the ISAD-BR: awareness of symptoms associated with activity/energy; awareness of having a disorder; awareness of self-esteem and feelings of pleasure; and awareness of social functioning and relationships. The second order factor analysis indicated a hierarchical factor structure for the ISAD-BR, with the four lower-order factors loading on a single higher-order factor.

CONCLUSIONS

Insight into bipolar disorder is a multidimensional construct, covering different aspects of the condition and its symptomatology. Nevertheless, insight about activity/energy changes may be a crucial aspect of insight into bipolar disorder.

Brain activation during self- and other-reflection in bipolar disorder with a history of psychosis: Comparison to schizophrenia

Objectives

Reflecting on the self and on others activates specific brain areas and contributes to metacognition and social cognition. The aim of the current study is to investigate brain activation during self- and other-reflection in patients with bipolar disorder (BD). In addition, we examined whether potential abnormal brain activation in BD patients could distinguish BD from patients with schizophrenia (SZ).

Methods

During functional magnetic resonance imaging (fMRI), 17 BD patients, 17 SZ patients and 21 healthy controls (HCs) performed a self-reflection task. The task consisted of sentences divided into three conditions: self-reflection, other-reflection and semantic control.

Results

BD patients showed less activation in the posterior cingulate cortex (PCC) extending to the precuneus during other-reflection compared to HCs (p = 0.028 FWE corrected on cluster-level within the regions of interest). In SZ patients, the level of activation in this area was in between BD patients and HCs, with no significant differences between patients with SZ and BD. There were no group differences in brain activation during self-reflection. Moreover, there was a positive correlation between the PCC/precuneus activation during other-reflection and cognitive insight in SZ patients, but not in BD patients.

Conclusions

BD patients showed less activation in the PCC/precuneus during other-reflection. This may support an account of impaired integration of emotion and memory (evaluation of past and current other-related information) in BD patients. Correlation differences of the PCC/precuneus activation with the cognitive insight in patients with BD and SZ might reflect an important difference between these disorders, which may help to further explore potentially distinguishing markers.

•

We investigated self-reflection and other-reflection in bipolar disorder.

•

Bipolar had less PCC/precuneus activation during other-reflection than controls.

•

PCC/precuneus activation was unrelated to cognitive insight in bipolar patients.

O insight no transtorno bipolar: uma revisão sistemática

Objetivos Realizar uma revisão sistemática para compreender que fatores estão relacionados a uma maior ou menor consciência de morbidade no transtorno bipolar (TB), como o insight varia em função do estado afetivo e estabelecer uma comparação com outros transtornos mentais. Métodos Realizou-se uma revisão sistemática da literatura científica sobre o insight em pacientes com TB. Foram buscados estudos clínicos originais sobre o tema nas bases de dados Medline, ISI e SciELO. Os termos de busca empregados foram: “insight” OR “awareness” AND “bipolar” OR “mania” OR “manic”. Resultados Foram selecionados 55 artigos. O insight no TB parece ser mais prejudicado do que na depressão unipolar, porém menos do que na esquizofrenia. Com relação ao TB, um menor nível de insight está relacionado à presença de sintomas psicóticos e de alterações cognitivas. Além disso, um comprometimento do insight está associado a uma menor adesão ao tratamento. Por outro lado, uma maior preservação do insight pode estar associada a maior ideação suicida. Finalmente, a fase maníaca cursa com um nível inferior de insight quando comparada à fase depressiva ou de eutimia. Conclusão No TB, o insight está significativamente prejudicado, especialmente na mania. Diversos fatores clínicos parecem influenciar o nível de insight.

A prospective study of the trajectories of clinical insight, affective symptoms, and cognitive ability in bipolar disorder

BACKGROUND

Clinical insight in bipolar disorder is associated with treatment adherence and psychosocial outcome. The short-term dynamics of clinical insight in relationship to symptoms and cognitive abilities are unknown.

METHODS

In a prospective observational study, a total of 106 outpatients with bipolar disorder I or II were assessed at baseline, 6 weeks, 12 weeks, and 26 weeks. Participants were administered a comprehensive neuropsychological battery, clinical ratings of manic and depressive symptom severity, and self-reported clinical insight. Lagged correlations and linear mixed-effects models were used to determine the temporal associations between symptoms and insight, as well as the moderating influence of global cognitive abilities.

RESULTS

At baseline, insight was modestly correlated with severity of manic symptoms, but not with depressive symptoms or cognitive abilities. Insight and depressive symptoms fluctuated to approximately the same extent over time. Both lagged correlations and mixed effects models with lagged effects indicated that the severity of manic symptoms predicted worse insight at later assessments, whereas the converse was not significant. There were no direct or moderating influences of global cognitive abilities.

LIMITATIONS

Our sample size was modest, and included relatively psychiatrically stable outpatients, followed for a six month period. Our results may not generalize to acutely symptomatic patients followed over a longer period.

CONCLUSIONS

Clinical insight varies substantially over time within patients with bipolar disorder. Impaired insight in bipolar disorder is more likely to follow than to precede manic symptoms.

The development of delusion revisited: a transdiagnostic framework

This study proposes a transdiagnostic framework for delusion development, analysing psychiatric (schizophrenia, bipolar disorder, major depressive disorder) and neurological disorders (stroke, and neurodegenerative diseases) in which delusions are predominant. Our aim is to identify a transdiagnostic core of neural and cognitive alterations associated with delusions across distinct clinical disorders. Reviewed empirical evidence suggests delusions are associated: on the neural level with changes in the ventromedial prefrontal cortex (vmPFC) networks, and on the neuropsychological level with dysfunction in the processes (generation of affective value, the construction of internal models of the world, and the reflection about Self and/or Other's mental states) that these network mediate. The concurrent aberration of all these processes could be critical for the clinical transition to a psychotic delusional state. In particular, delusions could become clinically manifest when (1) stimuli are attributed an aberrant affective salience, that (2) is explained by the patient within distorted explanatory internal models that (3) are poorly inhibited by cognitive control systems. This framework extends the two-factor account of delusion model and suggests that common neural mechanisms for the delusions in psychiatric and in neurological disorders.

Association between OPCRIT dimensions and polymorphisms of HPA axis genes in bipolar disorder

The aim of the study was to investigate the possible association between polymorphisms of HPA axis genes-CRHR1 (corticotrophin-releasing hormone receptor), NR3C1 (glucocorticoid receptor) and AVPR1B (arginine vasopressin receptor) and dimensions of bipolar disorder assessed by OPCRIT. We examined 560 patients with diagnosis of bipolar disorder (n=457) and unipolar disorder (n=103). Diagnosis was established by SCID and OPCRIT. We found association between polymorphisms of AVPR1b gene and psychotic dimension and CRHR1 polymorphisms and excitement and psychotic dimension. Our results suggest possible involvement of the AVPR1b and CRHR1 genes in the ethiology of psychotic features in the course of affective disorders, and possible involvement of CRHR1 gene in the ethiology of bipolar disorder.

Mood self-assessment in bipolar disorder: a comparison between patients in mania, depression, and euthymia

BACKGROUND: Some studies indicate that mood self-assessment is more severely impaired in patients with bipolar disorder in a manic episode than in depression. OBJECTIVES: To investigate variations in mood self-assessment in relation to current affective state in a group of individuals with bipolar disorder. METHODS: A total of 165 patients with a diagnosis of bipolar disorder type I or type II had their affective state assessed using the Clinical Global Impressions Scale for use in bipolar illness (CGI-BP), the Positive and Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning (GAF). In addition, participants completed a self-report visual analog mood scale (VAMS). Patients were divided into three groups (euthymia, mania, and depression) and compared with regard to VAMS results. RESULTS: Manic patients rated their mood similarly to patients in euthymia in 14 out of 16 items in the VAMS. By contrast, depressed patients rated only two items similarly to euthymic patients. CONCLUSION: Patients with bipolar disorder in mania, but not those in depression, poorly evaluate their affective state, reinforcing the occurrence of insight impairment in the manic syndrome.

Triggers of mania and depression in young adults with bipolar disorder

BACKGROUND

Early intervention significantly decreases the impact of bipolar disorder. However, there is little research investigating triggers that may be unique precipitants of manic/hypomanic episodes, and how these may differ from triggers specific to bipolar depression, in young adults with the disorder.

METHODS

Individuals aged 18 to 30 years who had been diagnosed with bipolar disorder (n=198) completed an online survey to identify triggers unique to mania/hypomania and depression, as well as triggers which were common to both. Respondents rated how frequently a series of situations and behaviours had precipitated either a manic/hypomanic episode or a depressive episode in the past. Survey data was supplemented by in-depth face-to-face interviews (n=11).

RESULTS

Triggers specifically associated with the onset of manic/hypomanic episodes included falling in love, recreational stimulant use, starting a creative project, late night partying, going on vacation and listening to loud music. Triggers associated with depressive episodes included stressful life events, general stress, fatigue, sleep deprivation, physical injury or illness, menstruation and decreases in physical exercise. A further set of triggers were identified as being common to both manic/hypomanic and depressive episodes. Consistent themes arose from the analysis of face-to-face interviews, which extended and illuminated the findings of the survey data.

CONCLUSIONS

Identification of a unique set of triggers for mania/hypomania and a unique set for depression in young adults with bipolar disorder may allow for earlier identification of episodes, thus increasing opportunities for early intervention.

Development of the insight scale for affective disorders (ISAD): modification from the scale to assess unawareness of mental disorder

BACKGROUND

Research on insight in patients with mood disorders has grown in recent years. Several instruments to assess insight have been used, but most of them have been specifically designed for psychosis and may not appear relevant to mood disorders. The aim of the present study is to develop a short, multidimensional, reliable and valid scale to measure insight in patients with mood disorders, based on the Amador's Scale to Assess Unawareness of Mental Disorders (SUMD).

METHOD

A Delphi method was used to facilitate expert participation and ensure face and content validity. The SUMD structure and items were used as a reference in the scale development. A new scale with 17 items was obtained. Internal consistency, test-retest and inter-rater reliability and validity were studied in a sample of 76 outpatients with a DSM-IV diagnosis of major depression or bipolar disorder (type I or II).

RESULTS

Internal consistency of the general items was moderate, and high for the symptoms awareness subscale. Scores on ISAD correlated with other measures of insight and with some clinical measures, thus supporting its validity.

LIMITATIONS

The majority of the sample came from community services. Future studies should use inpatients or patients with severe symptoms to broaden the range of responses. Moreover, the rating of insight and other measures by the same clinician might introduce a methodological bias.

CONCLUSION

The ISAD, with a multidimensional approach, appears as a short, reliable and valid measure of insight in mood disorders. Expert consensus ensures its face and content validity.

The association between insight and symptoms in bipolar inpatients: An Italian prospective study

Objective

To evaluate potential differences in insight among bipolar manic, mixed and bipolar depressed inpatients and assess the role of clinical and demographic characteristics as possible predictors.

Method

One hundred and twenty consecutive inpatients divided into three diagnostic groups were studied on admission (T0), at discharge (T1) and at 18weeks after hospitalization (T2). The Young Mania Rating Scale (YMRS), the Hamilton Rating Scale for Depression (HAMD) and the Scale to Assess Unawareness of Mental Disorder (SUMD) were used.

Results

Patients with mixed mania showed highest scores on the SUMD than patients with mania or bipolar depression. It was found a significant relationship between improvements in mania and in the insight. The level of insight at baseline was the only predictor of awareness in social consequences, moreover clinical and demographic characteristics were predictors of insight into mental illness. For what concerns insight about therapy benefits it was influenced by level of mania at baseline.

Conclusion

The three general dimensions of insight revealed significant differences among the three groups. Regression models suggest that insight is a multidimensional concept in which some aspects are state-related, associated with psychopathology, whereas others are trait-like qualities, not directly associated with symptoms and predicted only by level at baseline.