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Insight and Psychosis. Edited by X. Amador and A. David. (Pp. 366; £42.50.) Oxford University Press: Oxford. 1998.

About a decade ago, when I was a psychiatric resident in training, I came upon a man with severe mania who I treated in our in-patient unit at McLean Hospital. I developed something of a rapport with him, and, with the encouragement of my supervisors, I picked him up for continued out-patient treatment, both with medications and weekly psychotherapy. Our treatment was quite rocky. I found myself spending most of the time in therapy discussing his manic symptoms, what they were, what they meant, how they manifested in his life. But, I also discovered that he was not able to identify those manic symptoms as indeed manic and representative of some kind of mental problem. We spent months going around and around on this topic. About the same time, I wanted to learn about psychiatric research, and I was advised to find a subject that interested me and then devise a plan to study it. One day, while I was reviewing this difficult case in psychopharmacology supervision with Andrew Stoll, he remarked with some excitement : ‘ Insight ! Why don’t you study insight ! ’ My patient lacked insight ; he was not aware that he had an illness, specifically bipolar disorder ; that was his main problem. Obviously, severe bipolar disorder was his underlying condition, but, before we could get very far in treating it, we had to deal with his dense lack of insight. So I went to the library, expecting to find at least a few studies on lack of insight in mania. I found none. Instead, I discovered a contemporary paper by Anthony David, ‘Insight and Psychosis ’ (David, 1990), which spoke directly to my needs. In that review, David discussed the history of ideas about insight, examined the concept and redefined it, proposed a way of measuring it objectively, and critiqued the empirical literature on lack of insight and schizophrenia. To me, the paper served as a watershed, shedding light on a confusing topic, and identifying a field of research that I could pursue (Ghaemi & Pope, 1994; Ghaemi et al. 1995). I may, therefore, have some bias in reviewing this book, because of my own interest in the topic. I think, however, by describing how my interest in insight was born, I can emphasize how clinically relevant this topic should be to mental health professionals in the real world of clinical practice (not just researchers and academics). One advantage of a book like this one is that it pulls together a great deal of scattered literature in one place, an efficiency measure that clinicians in particular should appreciate. A disadvantage that flows from this feature, however, is that some important subjects will inevitably be left out. Perhaps some background would be useful as an introduction to the book. The German psychiatrist Karl Jaspers was probably the first psychiatrist to write explicitly and at some length about the subject of insight (in his 1913 text General Psychopathology, Jaspers, 1997 (1959)). Jaspers made the important point that many patients with psychiatric conditions experience lack of insight, an unawareness of being ill or having psychiatric symptoms. This use of the term ‘insight ’ is different from what has become, for many, a standard definition: the psychoanalytical conception of becoming aware of one’s unconscious feelings and motivations. It is important to make this distinction, and, for this review, I will be using the Jasperian rather than the Freudian definition. While Kraepelin and Bleuler also commented on absence of insight in many patients with schizophrenia, they did not highlight the importance of the subject for psychopathology as Jaspers did. Once Jaspers identified the problem, little was said for two decades, until the British psychiatrist Aubrey Lewis published a lengthy 1934 essay on ‘The psychopathology of insight ’ (Lewis, 1934). This paper is probably the most detailed conceptual study of the topic, leading to Lewis ’s