Anosognosia is a condition in which the person is unaware of his/her existence.
People don’t always feel comfortable admitting to themselves or others that they have a condition they’ve been newly diagnosed with. This isn’t unusual, and most people eventually accept the diagnosis. But sometimes, the rejection is long-lasting, and it’s not simply denial that’s causing a person to reject the facts. It’s a condition called anosognosia. This loosely means “lack of awareness or insight” in Greek.
Anosognosia is a lack of ability to perceive the realities of one’s own condition. It’s a person’s inability to accept that they have a condition that matches up with their symptoms or a formal diagnosis. This occurs despite significant evidence of a diagnosis, and despite second and even third medical opinions confirming the validity of a diagnosis.
Anosognosia is a result of changes to the brain. It’s not just stubbornness or outright denial, which is a defense mechanism some people use when they receive a difficult diagnosis to cope with. In fact, anosognosia is central in conditions like schizophrenia schizophreniaor bipolar disorder Let’s take a closer look at what causes this symptom, how to recognize it, and what you and your loved ones can do to cope.
Causes of Anosognosia
Your perception of yourself changes throughout your life. Just got married? You may feel reassured now that you’ve finally tied the knot with someone you love. New scar on your face? Your brain needs to take it into account so that you remember it’s there when you look in the mirror.
Your frontal lobe is heavily involved in this constant process of reshaping your self-image. And some mental health conditions can cause alterations in this part of your brain. This causes frontal lobe tissue remodeling over time. Eventually, you may lose your ability to take in new information and renew your perception of yourself or your overall health. And since your brain can’t grasp the newer information resulting from your condition, you or your loved ones can get confused or frustrated that you appear not to be taking your condition seriously.
Anosognosia isn’t always all-or-nothing. Some people partially lose the ability to see themselves clearly, or it can come and go. That can confuse friends and loved ones. It’s hard to understand why someone seems to fully understand their diagnosis one moment, then claim they’re perfectly healthy the next, even though objective evidence shows they aren’t.
Anosognosia is relatively common following different causes of brain injury, such as stroke and traumatic brain injury; for example, anosognosia for hemiparesis, (weakness of one side of the body) with onset of acute stroke is estimated at between 10% and 18% However, it can appear to occur in conjunction with virtually any neurological impairment. It is more frequent in the acute than in the chronic phase and more prominent for assessment in the cases with right hemispheric lesions than with the left. Anosognosia is not related to global mental confusion, cognitive flexibility, other major intellectual disturbances, or mere sensory/perceptual deficits.
The condition does not seem to be directly related to sensory loss but is thought to be caused by damage to higher level neurocognitive processes that are involved in integrating sensory information with processes that support spatial or bodily representations (including the somatosensory system). Anosognosia is thought to be related to unilateral neglect, a condition often found after damage to the non-dominant (usually the right hemisphere of the cerebral cortex in which people seem unable to attend to, or sometimes comprehend, anything on a certain side of their body (usually the left).
Symptoms of Anosognosia
The most notable symptom of anosognosia is a lack of understanding, awareness, or acceptance that you have a medical condition. This is possible even if there’s extensive proof that you do.
Here are some ways to understand the difference between anosognosia and denial or other responses to illness:
- Not everyone with this condition shows it in the same way. Some may bluntly acknowledge that they think nothing’s wrong with them. Others may avoid talking about the condition because they think no one believes them. And still others may be confused or frustrated when the people contradict what they believe to be true.
- Anosognosia isn’t static. Someone can be aware of their condition and treat it with medication or doctor’s visits. They may then suddenly become unaware and miss an appointment or forget to take medication shortly afterward because they can no longer perceive their condition. Someone may even acknowledge certain symptoms but not others. For example, someone with hemiplegia may not realize that one side of their body is weak or paralyzed. But they may still be aware of symptoms like difficulty speaking (aphasia) or loss of vision (hemianopia).
- Pay close attention to behaviors before and after a mental health diagnosis. Someone’s level of insight can vary over time. This can cause you to think that they’re just trying to ignore their condition to protect their emotions. But it’s important to focus on the difference between a person’s personality and the symptoms of anosognosia. Did they show these behaviors before their diagnosis? Are they uncharacteristically adamant in denying their condition?
Diagnosis of Anosognosia
Your doctor may recommend that you see a psychiatrist or other mental health specialist if you or a loved one have been diagnosed with a condition that may be associated with anosognosia. A specialist can monitor your overall mental health and any symptoms that arise. A specialist may also recognize anosognosia early on. Even small behavior changes can be detected by a specialist.
One common evaluation technique is the “LEAP” method, which is done by:
- listening to the person
- empathizing with the person
- agreeing with the person
- partnering with the person
This method helps open a dialogue between a doctor and the person with anosognosia. This allows the person to develop an awareness of the objective facts of their situation as well as understand that people around them are supportive and understanding. Another commonly used diagnostic tool is the Scale to Assess Unawareness of Mental Disorder (SUM-D). This test places the idea of “insight” on a spectrum that includes:
- Awareness. Does the person recognize that they have a condition? Do they notice the symptoms of their condition? Do they know that there may be social consequences of their condition?
- Understanding. Does the person realize that they need treatment?
- Attribution. Do they believe that their symptoms result from a mental health condition?
Assessment of Anosognosia
Clinically, anosognosia is often assessed by giving patients an anosognosia questionnaire in order to assess their metacognitive knowledge of deficits. However, neither of the existing questionnaires applied in the clinics are designed thoroughly for evaluating the multidimensional nature of this clinical phenomenon; nor are the responses obtained via offline questionnaire capable of revealing the discrepancy of awareness observed from their online task performance. The discrepancy is noticed when patients showed no awareness of their deficits from the offline responses to the questionnaire but demonstrated reluctance or verbal circumlocution when asked to perform an online task. For example, patients with anosognosia for hemiplegia may find excuses not to perform a bimanual task even though they do not admit it is because of their paralyzed arms.
A similar situation can happen on patients with anosognosia for cognitive deficits after traumatic brain injury when monitoring their errors during the tasks regarding their memory and attention (online emergent awareness) and when predicting their performance right before the same tasks (online anticipatory awareness). It can also occur among patients with dementia and anosognosia for memory deficit when prompted with dementia-related words, showing possible pre-attentive processing and implicit knowledge of their memory problems. Patients with anosognosia may also overestimate their performance when asked in first-person formed questions but not from a third-person perspective when the questions referring to others.
When assessing the causes of anosognosia within stroke patients, CT scans have been used to assess where the greatest amount of damage is found within the various areas of the brain. Stroke patients with mild and severe levels of anosognosia (determined by response to an anosognosia questionnaire) have been linked to lesions within the temporoparietal and thalamic regions, when compared to those who experience moderate anosognosia, or none at all. In contrast, after a stroke, people with moderate anosognosia have a higher frequency of lesions involving the basal ganglia, compared to those with mild or severe anosognosia.
A person’s SUM-D test results may be able to indicate if a person has anosognosia.
Relation to other conditions
The most common conditions associated with anosognosia include:
- dementia (including Alzheimer’s)
- bipolar disorder
- major depressive disorder
Anosognosia is most prevalent in schizophrenia. Around 57–98 percent of people with schizophrenia have some form of anosognosia.
Anosognosia is also especially notable in hemiplegia. Someone with this condition may not realize that they have partial or full paralysis on one side of their body. This is true even when they can observe that their limbs don’t move properly.
Treatment of Anosognosia
Your doctor may recommend medications known as antipsychotics to treat symptoms of conditions like schizophrenia or bipolar disorder. Some examples of antipsychotics that may be used include:
- chlorpromazine (Thorazine)
- loxapine (Loxitane)
- clozapine (Clozaril)
- aripiprazole (Abilify)
Antipsychotics don’t typically work the same way for each person, so your medication will be prescribed based on your symptoms, overall health, and response to the medication. You may even need different types of antipsychotics throughout your life as your cognitive ability changes or your body responds to the medication differently over time.
Motivational enhancement therapy (MET)
MET uses techniques to motivate someone to either alter their self-image to accept that they have a condition or encourage them get treatment for their condition.
MET often consists of helping someone look at their symptoms, behaviors, and relationships objectively. This often leads to a realization that facts point to the existence of a condition.
Support for someone with anosognosia
Here are a few pieces of advice to help you and your loved one’s cope with anosognosia:
- Don’t judge. Remember that this is a medical condition, not stubbornness or self-destructive tendencies.
- Be supportive. Some days may be better than others. Even if someone totally loses their perception of their condition, they’re not doing it on purpose. They need your support to make sure they get treatment and stay consistent with appointments and medications.
- Take notes. Keeping a detailed diary of what the person says and does can help you compile evidence of the condition. This can not only help someone realize that they have anosognosia but also provide your doctor with a basis for a treatment plan.
The outlook for conditions associated with anosognosia, such as schizophrenia, may be helpful early on in treatment, but this is not always the case, and there is no cure for this condition.
Behavioral therapy like the MET technique can increase quality of life significantly by helping people with anosognosia look at their symptoms from an objective standpoint. This can lead to changes in perception and behavior and ensure they follow the treatment plan for their underlying condition.
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