There is a type of denial of mental illness that goes beyond mere psychological denial – this is called anosognosia and it is the clinical term for the lack of insight required to understand you have a mental illness. Anosognosia is a neurological disorder thought to be caused by abnormalities in the frontal lobes (Impaired Awareness of Illness (Anosognosia): A Major Problem for Individuals with Bipolar Disorder).
Anosognosia – What, Who and Why
Is it denial or anosognosia? Put another way, anosognosia is the lack of awareness of the deficits, signs and symptoms of an illness. It is not merely a denial; it is an actual neurological deficit. Anosognosia is seen commonly in psychotic disorders like schizophrenia and bipolar, but it’s also seen in those who have right brain hemisphere lesions due to stroke, dementia and traumatic brain injury. Some studies show that people with schizophrenia also have brain hemispheric asymmetry in the anteroinferior temporal lobe and this asymmetry correlates to a lack of illness awareness.
The important thing to remember is the anosognosia is neurological and beyond a patient’s control. According Puihan Chao, MA and Michelle Kawasaki, MA of the Adult Mental Health Division at the Department of Health in the State of Hawaii, anosognosia is characterised by:
- A severe and persistent lack of insight
- The erroneous beliefs (such as “I am not sick”) are fixed and do not change even after the person is confronted with overwhelming contrary evidence
- Illogical explanations and confabulations that attempt to explain away the evidence
What to Do about Anosognosia
Understandably, anosognosia is one of the more troubling symptoms of severe mental illness as it prevents a person from getting the help they need. The “easy” way to handle this is to rely on a “doctor knows best” approach and simply medicate without consent. And, indeed, sometimes that is the only approach that works and is the most appropriate.
Chao and Kawasaki though, recommend another approach that relies on:
- Listening to the patient
- Empathizing with the patient
- Agreeing with the patient
- Partnering with the patient
This approach, signified as LEAP, is laid out nicely in their PowerPoint presentation.
You Can’t Talk Someone Out of a Delusion
I think the critical thing they stress though, is that you can’t talk someone out of a delusion. That’s the definition of delusion. It is a belief in the face of contrary evidence. And anosognosia is a delusion. If you believe that your cat is sending you signals from god, I will not simply talk you out of that belief because the belief isn’t rational in the first place. If rationale were all it took, then no one would ever be delusional.
And the other thing they seem to stress is listening to the person with anosognosia. Use the patient’s own framework to reach them. If the person doesn’t feel that they are sick, find out what problems they do believe they have and address those. For example, if a person feels their problem is that they are too paranoid to sleep, focus on addressing that issue with treatment rather than trying to convince them of an illness.
The crux of this treatment then, is to get the person to see the need for treatment in their own way rather than forcing medication on them. This is a type of Motivational Enhancement Therapy (common in addition therapy) and motivational interventions were found to be more useful than simple psychoeducation approaches by Zygmunt et al in 2002 in terms of medication adherence in schizophrenia.
Long story short, this might be the more humane way of approaching those with anosognosia for doctors and those around the person with the mental illness.