woman frustrated with husband

To benefit from treatment, you have to admit that you have a problem: however, some people have a medical condition called anosognosia that prevents them from acknowledging the existence of their symptoms or recognizing they have any type of mental health problem at all.

Recognizing and admitting you have a problem is a fundamental concept in addiction recovery. It also applies to a wide range of other physical, mental, and behavioral health challenges.

But what happens when a person who needs help is literally incapable of acknowledging that something’s wrong?

Mental health professionals refer to this phenomenon as anosognosia. This term may not be familiar, but the condition it describes affects millions of people.

Anosognosia can make it much more difficult to treat people with complex mental health disorders. It also causes significant distress for their loved ones. In some cases, it contributes to the disintegration of relationships and the end of marriages.

Recent research has expanded our understanding of the potential causes and effects of anosognosia. Though the condition is not curable, mental health professionals are now better equipped to care for patients with anosognosia and support their families.

What is Anosognosia?

The first thing to know about anosognosia is this:

It’s not just a fancy way of describing denial.

When someone develops an addiction to alcohol or other drugs, they often refuse to admit they’ve lost control. For those who follow the 12-Step recovery model, the first step requires admitting they have a problem and are powerless over substances.

Overcoming denial is also an important step for a person beginning to heal from depression, posttraumatic stress disorder (PTSD), and several other mental illnesses.

In circumstances like these, people are typically aware of the symptoms they experience or the behaviors they exhibit. Their reluctance to get help is usually due to a belief that they can overcome the challenges they face without professional intervention.

This is not the case with anosognosia.

People with anosognosia are not in denial. Instead, they have a neurological condition that prevents them from understanding – or even being aware of – their symptoms or deficits.

In his book about helping people accept that they need mental health treatment, Xavier Amdor, PhD, noted that anosognosia differs from denial in three key ways:

1. Insight.

The lack of insight exhibited by someone with anosognosia is severe and persistent.

2. Beliefs.

Their beliefs – such as “I am not sick,” or “I don’t have any symptoms” – are fixed and unchangeable, even in the face of overwhelming evidence to the contrary.

3. Dismissal

People with anosognosia often employ Illogical explanations, or confabulations, to dismiss evidence they have an illness.

Some of the more extreme examples of confabulations involve a rare condition called Anton-Babinski syndrome (ABS), or visual anosognosia. This syndrome affects people who have lost their sight due to brain lesions, but who cannot comprehend that they are blind.

People who have ABS will strenuously object to suggestions that they have vision problems. Their confabulations may include insisting that the only reason they bump into furniture or walk into walls is because the room is too dark.

In addition to brain lesions, other risk factors for anosognosia include stroke and traumatic brain injury (TBI). The condition can also occur among people with certain mental illnesses or other neurological disorders. For example, experts estimate that anosognosia affects:

  • 80% of patients with Alzheimer’s disease
  • 50%-90% of people with schizophrenia
  • 60% of people with mild cognitive impairment
  • 40% of people with bipolar disorder

According to the Treatment Advocacy Center (TAC), the impact of anosognosia can fluctuate, even among people with the same mental illness. For example, among people with schizophrenia:

  • 40% have full awareness of their condition
  • 60% are not aware that they have delusions
  • 40% are not aware they experience hallucinations
  • 30% are not aware they have a mental health disorder

The TAC states that as many as one in five people with a serious mental illness (SMI) also have anosognosia.

The Neurobiology of Anosognosia

Research has not yet identified a definitive cause of anosognosia. However, at least one study suggests that changes in how various brain regions communicate with each other may be to blame.

A study performed in Italy involving brain scans of 60 adults with Alzheimer’s disease revealed a new set of facts that help providers better understand how anosognosia affects mental health.

Anosognosia and Mental Health: Impairments in Brain Connectivity

  • Patients with anosognosia had significantly lower functional connectivity within the default mode network (DMN), which includes several brain regions most active when people are in a restful state and not focused on external stimuli.
  • Anosognosia patients showed particularly poor connectivity between the posterior cingulate cortex (PCC) and the precuneus (PCU). The PCC regulates functions such as memory, emotions, and self-reflection. The PCU plays a role in episodic memory, information integration, and affective responses to pain.
  • Anosognosia appears to involve communication deficits between the PCC and the hippocampus, which plays a key role in learning and both short- and long-term memory.
  • Brain scans also found that patients with lower awareness of their condition were likely to exhibit “significant increased functional connectivity” in the anterior cingulate cortex (ACC), a part of the salience network (SN) that contributes to attention, emotion, and both the anticipation and processing of pain.

In the discussion section of their study, the research team theorized that increased connectivity in the salience network may be an attempt by the brain to counterbalance the diminished communication within the default mode network.

According to the National Alliance on Mental Illness (NAMI), humans continually adapt their self-image based on both positive and negative experiences. For example, learning a new skill can make a person feel smarter and more confident, while a job loss or the end of a relationship can cause them to believe that they’re incompetent or undesirable.

In a sense, people constantly revise the narrative of their lives and view themselves differently in response to each revision.

However, the structural and functional brain impairments researchers link with anosognosia can prevent people from taking in new information and updating their self-image.

Over time, NAMI explains, a gap forms between how individuals with anosognosia view themselves and how others see them:

“Without an update, we’re stuck with our old self-image from before the illness started. Since our perceptions feel accurate, we conclude that our loved ones are lying or making a mistake. If family and friends insist they’re right, the person with an illness may get frustrated or angry, or begin to avoid them.”

How Anosognosia Affects Mental Health Treatment

It’s an overstatement to describe everyone with anosognosia as believing they’re completely healthy. A more accurate description is that they lack full insight into how their health is compromised.

Douglas S. Lehrer, MD, and Jennifer Lorenz, MD, authors of a 2014 literature review focused on anosognosia among people with schizophrenia, described full insight as consisting of the following capabilities. A person must:

  1. Be aware that they have an illness
  2. Recognize the signs and symptoms of the illness
  3. Attribute consequences and deficits to the illness
  4. Understand the need for treatment of the illness

Deficits in any or all of these capabilities, Lehrer and Lorenz wrote, can have a negative impact on:

  • Treatment adherence
  • Relapse frequency
  • Symptom remission
  • Psychosocial functioning
  • Vocational attainment
  • Risk of violence toward self or others

According to the Treatment Advocacy report cited above, anosognosia is the most common reason people with severe mental illness either don’t seek professional care or fail to adhere to their treatment plan. As Maria Kozlowsky-Gibson, PhD, explained in the report:

“Logically, persons who are sure of their own good health would not take medications to treat a disease that they do not have.”

Caring for Somone With Anosognosia

It’s not difficult to understand how challenging it is to care for someone with anosognosia. In addition to addressing the impact of schizophrenia, bipolar disorders, or other debilitating conditions, caregivers must also contend with the fact the person in their care has an unwavering belief that they have no need for treatment.

When a structural brain lesion causes anosognosia, treating that lesion can alleviate the condition. If Alzheimer’s disease, schizophrenia, or another mental health or neurological condition causes/is related to anosognosia, the level of  awareness is often connected to the progression of the underlying disorder.

Types of treatment that can help include:

  • Caloric vestibular stimulation (CVS), which involves directing warm or cold water into patients’ ear canals to stimulate specific nerves, can be beneficial, though its effects are typically temporary.
  • Some patients respond well to cognitive behavioral therapy (CBT) and motivational interviewing. CBT is based in part on the view that negative or otherwise distorted thoughts contribute to psychological distress. Motivational interviewing can help people overcome the ambivalence or uncertainty that prevents them from making positive life changes.
  • No medications directly treat anosognosia, but meds that ease the symptoms of the underlying disorder can indirectly improve awareness, especially when combined with effective therapy.

The Association for Frontotemporal Degeneration (AFTD) provides this list of suggestions and strategies for helping people with anosognosia related to various brain disorders.

Find Treatment for Complex Mental Illness in Southern California

If someone in your life experiences acute symptoms of bipolar disorder, schizophrenia, or another complex mental health condition, Crownview Psychiatric Institute may be able to help. To learn more about our programs and services, or to discuss your loved one’s needs with a member of our team, please visit our Contact page or call us today.