Handling Anosognosia – Neurological Inability to Recognize Your Mental Illness

Friday, October 12 2012 Natasha Tracy

Anosognosia is the clinical unawareness of one's own mental illness. Learn more about handling this type of delusion. Breaking Bipolar blog.

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

(See also: My Daughter Does Not Want to Recover From Her Eating Disorder.)

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.

You can find Natasha Tracy on Facebook or GooglePlus or @Natasha_Tracy on Twitter.

Author: Natasha Tracy

Natasha Tracy is a renowned speaker, award-winning advocate and author of Lost Marbles: Insights into My Life with Depression & Bipolar.

Find Natasha Tracy on her blog, Bipolar BurbleTwitterGoogle+ and Facebook.

View all posts by Natasha Tracy.

Handling Anosognosia – Neurological Inability to Recognize Your Mental Illness

Sarah
says:
October, 12 2012 at 1:36 pm

It's kind of sad that "listening to the patient" has to be part of a special protocol. It should be done routinely with all patients.

The Bipolar Pianist
says:
October, 12 2012 at 2:43 pm

I think there’s a tendency that people want to shove a pill down someone’s throat, because that’s going to make them normal or less of a problem or a burden. Plus, if someone’s not taking their pills for whatever reason you can blame all their symptoms on them, even my own family loves to do this. It takes so much effort to listen and see someone’s point of view and work with it. To put aside your notions of how things should be and see what they really are and deal with that. You have to look at us as equals and again my experience is that people sometimes chose to see us as an incomprehensible subspecies.

Beth Meyer
says:
October, 12 2012 at 5:51 pm

I believe Xavier Amador first developed the LEAP framework in his book, "I am not Sick, I don't need Help."

Marcela
says:
October, 12 2012 at 11:27 pm

OK, so I think this "Anosognosia" thing is bogus and sounds made up. It just doesn't make sense.
Like a so-called "normal" person is not going to think they have a mental illness. I guess maybe it makes more sense with Alzheimers, but with mental illness, it's a difference in sensory processing that really does change the way people perceive things so they shouldn't be "punished" for being honest about what they are experiencing with an additional label...

Natasha Tracy
says:
October, 13 2012 at 8:47 am

Marcela,

Certainly it is your right to think so, but what about it's presence in other disorders? What about the brain abnormality that correlates to it?

How much experience do you have working with people with delusions vs. simply denial? I've seen both, and they are very different.

- Natasha

Marcela
says:
October, 13 2012 at 3:04 pm

Well I think that the physical structure of the brain is actually more neurology/neuroscience than psychiatry so I'm not as familiar with that part of medicine. I have my own issues with the way neuroscience research is done since mouse models don't always translate well to the complex human brain. And don't even get me started on genetic research since that just reeks of eugenics all over again!!

Quite honestly, when I'm on the wards I sometimes have trouble telling the patients from the staff and since I'm not allowed access to the full records, I can't really say whether the "delusional" patients were just playing a little joke on me to get me to laugh since I still get a little freaked out by being on the wards.

Given that my interest in this stems originally from medical anthropology, I guess I think of it in terms of power structure and who has the power to put a label on someone else. Labels can be very good when used appropriately for people to get the help they need, but sometimes they can be painful and in the end we all should have the power to define ourselves the way we want, since it's still a free country and all that. My main research interest is autism spectrum disorders and I find that often women on the spectrum are misdiagnosed with other disorders because girls aren't supposed to be autistic...

Kathleen Brannon
says:
October, 16 2012 at 10:40 pm

Natasha, this is a very useful and important article, like many of your articles. Toward the end when you are talking about the LEAP approach you seem to equate anosognosia with delusional states. Is there a difference? Is everyone with a delusion about themselves also anosognosic? Or is the distinction in the observed brain anatomy differences?
When I am very depressed I have the opposite delusion: that I am a freak, so obviously abnormal that I can't go out in public or speak to anyone, and that I am to blame for this freakish "sickness" as well as every other bad thing that ever happened to me or my family. And a few therapists have tried arguing me out of these beliefs, which as you predict only served to strengthen them and root them more deeply.

Kathleen Brannon
says:
October, 16 2012 at 10:44 pm

Also, Marcela: The whole "labeling" thing is anthropological hot air that is hardly worth the time to consider it for a person with an actual, severe, right this minute mental illness. Another word for "label" is diagnosis -- and if you had a mental illness you would know that proper diagnosis is what makes a more normal healthy productive life at all possible for the labeled.. So label away -- if that shoe fits, it might enable me to walk away from my dysfunction.

Daan van den Bergh
says:
October, 17 2012 at 9:58 am

Question: many people deny (out of pride mostly) that they don't need therapeutical help. Some of them will admit to going to one or a two appointments, grab a few points from that conversation and lie to themselves that now suddenly their issues disappeared like snow before the sun. Is that also anosognosia?

Daan van den Bergh
says:
October, 17 2012 at 10:02 am

Another small remark: to "convince" a person that they need help using the above technique will ask a lot of someone time. The way I see it, I know a lot of people that have serious issues but refuse to find help. During their denial they have caused so many others, so much pain that I don't see a reason why anyone would want to spend that time trying to talk them into therapy. I think the same goes for a lot of people suffering from anosognosia.

Pema Kennedy
says:
October, 17 2012 at 10:40 am

Has anyone read the works of DR Mate???. Available on line.

Sarah
says:
October, 17 2012 at 10:24 pm

"During their denial they have caused ... so much pain",

I beg to differ. The way you say it sounds like the person with bipolar is intentionally hurting others. If you really try to understand what the reality is for the bipolar person, you will be much more patient and understanding with them. A lot of the pain is caused by a misunderstanding, and yes, people are driven away during this time. Those who have understanding are not driven away nearly so much, except in very extreme circumstances. And these circumstances are generally not the fault of the person with bipolar.

kkzzi
says:
October, 28 2012 at 3:24 am

I understand I have bipolar,I have been diagnosed 20 years. This past. May I wanted to die. I drove my suv into a two story building. I'm still here. I thank god cuz my son Is only 19 and he still needs me.

Jason
says:
October, 31 2012 at 7:52 pm

Nstasha

I appreciate your comments and your passions regarding "anosognosia" as it relates to a mental health diagnosis or mental distress (disharmony) however I respectively agree to disagree. I was diagnosed with manic depression/ bipolar disorder twenty years ago. We both have our own personal experience directly with psychiatry, madness, mental health disorders, characteristics, and spiritual experiences (views). Some of our experiences, and beliefs may even be mutual.

I have researched anosognosia; TAC study, DSM, etc., and I honor various aspects of science. I would like to just share my personal experience and imperfect opinion.

When I was 23 years old I was in a psychiactric hospital where I was told I was a drug addict, and that I had Schizophrenia. This did not resonate with me at all. In the midst of all the drugs that were immersed thoughout body, I felt a presence that I never felt before. This feeling, knowing, and or inner voice told me that there was much more going on. This emotional crisis, psychotic break or whatever language is used became a conscious awakening for me.

If I had listened to the propaganda from the pharmaceutical industry, the APA, my psychiatrists (2 supported me 100%), the mainstream media, my family and friends; I could be locked up in an institution for life or drugged up to the extent of possibly having a multitude of other physical ailments. Most importantly I could have been spiritually asleep!

So why would we tell people that they have a severe or persistent lack of insight to an illness or disorder? I see this as a way control people. Based on my experience what is more demoralizing is the spiritual/ religious insight of who we really are!

A persons self esteem, consciousness, and spirt can be devastated when they are handed a diagnosis that is stigmatized simply due to the fear of mental illness.

Our society is inundated with medical information; some of which is very relevant however most of it manufactures disease for profits. Our society has reached an epidemic status with the number of people taking pharmaceutical drugs. That being said some drugs are very beneficial.

Why are psychiactric medications the primary way we treat a person who is experiencing delusions, a undesirable characteristic (symptom), depression or altered states of consciousness?

My personal experience along with mutually supporting other people has shown me there are healthier as well as more theraputic paths that save society a lot of money.

I have had some very difficult challenges. I struggled with marijuana, filed bankruptcy twice, and I was on disability for five years. I have great credit today, own a home, and I no longer see a therapist or psychiatrist. I have learned who I am and I love myself. For me I am a beautiful spiritual being who is having a human experience.

I have studied what America calls "Alternative Medicine." Unfortunately most people don't realize that there is nothing alternative about it. Most of these ancient medicines have been around for thousands of years. I have studied Reiki for many years and it has transformed my life. I worked with a homeopathic practitioner (psychatrist) which was an enlightening experience. I studied Oriental Medicine for a year before I decided that it wasn't my dream anymore. People gravitate towards me, and are always sharing there experiences.

I don't look at life in terms of "right or wrong." I know that I can learn from any person, plant, animal, situation, etc., and I always remain open minded even when I have a rooted beliefs. Please think about how your thoughts and words affect other people when writing these human experiences.

I hope when you are reading this you are creating a beautiful day!

Jean
says:
December, 18 2012 at 3:30 pm

My daughters partner(currently in hosp. - not the first time ) is very intelligent and it has baffled us all as to why he doesn't really get it -that he has BP and in order to live life has to do certain things like sleep to be healthy. How can you be so smart and so stupid (excuse me) all at once? I scoured the internet and came across the term anosognosia -EUREKA!! At least it explained how he is. This last stay in hosp has been a long one. She is at the end of her rope and I don't know if she can take much more. My husband has BP. Diagnosed 35 years ago. He got it when he woke up in the Psych ward. He didn't ever want to go back again.

Mrs Deborah Foster
says:
March, 9 2013 at 1:04 am

I found this article most interesting and believe I may have found an answer to my sisters condition. Though she has been diagnosed with learning difficulties and a low IQ, I believe it goes deeper. She also suffers with a thyroid condition and the GP has been trying to get her to take medication for it, but she is refusing.Until she realises that there is an underlying problem I don't believe her situation (which is pretty dire at present)will change.

Father searching for answers
says:
June, 9 2014 at 1:06 pm

Hi Jason,

I realize you posted those comments almost 2 yrs ago but thank you for sharing. My son was diagnosed with Bipolar 1 when he was 16, he is now 22. I've read Dr. Amador's book 3 times now on the LEAP method and anasognosia titled "I'm Not Sick and don't need help". The information we learned was invaluable in understanding our son and how to avoid trying to convince him he is ill. Not a real fan of the term "illness" in the first place to be honest. I honestly think he is gifted in many ways. I think the real answers here for all is an OPEN MIND. We have tried LEAP, we have tried traditional western medicine and they have not worked for our son. I know they work for some people but everyone is different. My son refuses to take medication and I do NOT want to continue to hospitalize him against his will. Does not make sense. My son is into yoga and meditation and we have supported him with practicing these and it has helped. I just called a Reiki master in our area and we are now going down that path. Based on your personal experience and my brief conversation with the Reiki master, we are hopeful. My son is very spiritual and has heard of Reiki so he is excited about going. So am I. Old dogs can sometimes learn new tricks too :).

Thanks again and be well

magester interpol
says:
July, 12 2014 at 7:12 pm

you what anderstand i am BY POLAR MISS NATASHA TRREYSI

Debbie
says:
August, 5 2014 at 5:26 am

I think when a person has something wrong with them that began at an early age,they do not realize sometimes that they have a problem...it just feels normal to them because that is what they have always known.When there is something wrong physically one would see that others are different from them them,but something internal is much harder to compare.Unrecognized or ignored it may gradually get worse,becoming more and more apparent to others,yet to the person afflicted,this is what they have always been like,but to a lesser degree.They may feel as if they are having a difficult time but aren't aware of having a more serious issue. Would you say,in this circumstance,that the person has anosognosia?

delorise
says:
October, 16 2014 at 7:53 pm

We are at the point with a 54 yr old woman that no amount of listening, agreeing, walking alongside has gone anywhere over 4 yrs. This person now has lost her house (had to sell), lost her car (doesn't know where she put it), lost a rental car (says it was stolen), is living/sleeping in another rental car jacking up her credit card. We feel the need to go beyond this LEAP method now.

Renita
says:
November, 11 2014 at 5:46 pm

Interesting diagnosis, anosognosia. I've never heard of that one before. I learn so much from these blogs

I belive you can catch more flies with honey. The LEAP approach my pdoc uses on on me is much more effective in ensuring compliance. I don't like to be forced to do ANYTHING the way I was in hospital. It was a terrify experience the way I was treated. I have always been a very independent person with a very strong will. I think there are many reasons why people don't believe they are ill. Psychotic delusions of reference brought on by extreme stress is one. Believing that they are not as ill as those horrific stories sensationalized in the media you hear about is another. Of course the stigma associated with mental illness is always a big one. Abusive family members that want to discredit you so that others won't believe you were abused by them, as was my case. Your credibility can easily be ruined by people more powerful than you. Lawyers do it all the time. The only reason I took meds voluntarily was because I was harrassed so badly that I just broke. It also broke my spirit. It further supported my belief that some people just can't be trusted. I can't bear to go through that experience again. It made me feel like such a victim. For now I feel fine on low doses of meds. I refuse to go on high does of mind numbing chemicals that suck the life out of me!!! So far my pdoc is fine with that

Misty
says:
September, 8 2016 at 12:44 pm

There needs to be more to this here. This should not and never be used as a weapon so that abusive husbands or enemies could torture someone. Domestic Violence has turned into mental abuse so the real criminal can't be caught. We need Science behind this with evidence so that innocent women can't be victimized, terrorized and without question. Men are gas-lighting their wives and this link and information is being used to justify and protect them from their criminal behavior! We need MORE research done into this. Do not just say it's denial because it darn well could be an abusive partner. I know a few people now who have fallen for this and it's growing. If anyone is using this information to continue to torture people they want revenge with it needs to be stopped and it needs to be stopped with Science. The next time someone says "He's abusive" maybe you should listen.

In reply to by Anonymous (not verified)

Hilda COLE
says:
May, 19 2017 at 10:56 am

My son is 18 and has never hurt anyone until now. He is having all the signs of schizophrenia but has no knowledge or insight of his behavior. Here comes the real hell.....he doesn't see what's happening at all, he is a different person. Anosognosia is a symptom like that of someone who has suffered a stroke. They are not aware that the paralized half of their body even exists. I know gas lighting...and I'm afraid this is a real nightmare that happens to good people.

Collette Toner
says:
July, 14 2018 at 9:20 pm

This is happening to my son too. This is a nightmare for all of us. Please contact me if ever want to talk.

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