Client Populations Neurobiology

Working with Lack of Insight: Anosognosia

Clients with a physical or mental health condition sometimes lack insight about their problem. One manifestation of this – anosognosia – is the focus of this article.

By Mental Health Academy 2024-10-28 03:57:45

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Clients with a physical or mental health condition sometimes lack insight about their problem. One manifestation of this – anosognosia – is the focus of this article.

Related articles: Working with Lack of Insight: Denial.

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Introduction

Most health professionals have had to contend with the reality of clients being unaware of some or all aspects of their condition, making it even more difficult to help them. But insight matters, and clinicians need to know how to help clients gain self-awareness. When people do not have it, there are legal, administrative, and clinical consequences for treating them (say, without their permission). People lacking self-awareness are not motivated to keep up their treatment regimen, their condition worsens, and their relationships are strained. In the case of mental health clients specifically, the unawareness takes on a sinister tone, as the lack of realisation about their problem can move beyond irritating to dangerous: for themselves and others, such as when a person with brain injury or dementia insists that their driving is competent and many near-lethal driving mistakes show that it is not (Rubin & Zorumski, 2016).  

In this two-part series on working with lack of insight in clients, we explore the two main types of insight deficit: anosognosia, in this article, and denial, in the next. Although they seem similar on the surface, the lack of awareness from each of these conditions arises from different causes and indicates a need for different interventions. In both conditions, treatment is made more complex and more difficult because of the lack of realisation about the condition by the person to be treated. These articles will help you identify which situation you are dealing with, understand the differences, and appropriately frame an intervention. Here we discuss anosognosia.

Overview of anosognosia

Definition

Anosognosia is happening when a client cannot recognise other health conditions or problems that they have. It has also been broadly referred to as “denial of deficit”. We are not using that term to avoid confusion with the defence mechanism of denial, which we take up in the other article of this series. Anosognosia is part of the family of agnosias (neurological disorders), which occur when a person’s brain cannot recognise or process what their senses are telling them.

Who is mainly affected by anosognosia?

While anosognosia can affect people with numerous medical conditions, it is most common with certain mental health disorders, especially including:

Anosognosia is estimated to occur to about 80% of Alzheimer’s patients, between 50 and 98% of those with schizophrenia, and about 40-50% of those with bipolar disorder (Cleveland Clinic, 2022, Treatment Advocacy Center, 2024).

Distinguishing between anosognosia and denial

Lack of “updating software”

To understand why anosognosia, seemingly so similar to denial at a superficial glance, is different at a deeper level, we can look to our brain’s “software” for keeping track of what’s going on in our body. The body creates a “self-image” for us and then, in a healthy person, updates that image as changes occur. So, a person who experiences an injury – say, a broken arm – will normally get an updated image from their brain of “left arm of body is broken”, and the updating will continue as the arm heals, until the cast comes off, there is good mobility, and the arm is healed, at which point the self-image is more like: “both arms normal again.” People with anosognosia have damage in the areas of their brain which update their self-image. When the person’s mind cannot update the image, the person cannot process or recognise that there is a health or medical problem.

Rejection/avoidance of reality

When we are in denial, conversely, we do not have brain damage. Rather, we reject or avoid accepting reality because it’s too unpleasant, distressing, or traumatic. Thus, a gentleman whose cherished wife of 59 years had just died exhibited denial in his comment that, “I keep waiting for Joanie to walk down the hallway any minute in her dressing gown and watch the late news with me.” The person with substance use disorder who states that, “I can quit any time I want to” is also showing denial.

How anosognosia shows up: The symptoms

Having the condition of anosognosia means that a person cannot do one or more of the following:

  • Recognise that they have an illness or medical condition
  • Recognise the signs and symptoms of the condition that they experience
  • Connect their signs and symptoms to that condition
  • Understand and agree that the condition is serious and needs treatment (Cleveland Clinic, 2022)

Causes

The term anosognosia was coined over 100 years ago by a French neurologist, who observed that some patients had lost the ability to use or feel one side of their body (more commonly the left side), but were unaware of the problem, even though they couldn’t use one side of their body (the condition of hemiplegia). Anosognosia can happen for various reasons, most of which fall into the category of either brain damage or degenerative disease.

Brain injury causes lesions, which cause anosognosia. The lesions can occur for any of the following reasons:

  • Aneurysms
  • Brain tumours
  • Head injuries
  • Cerebral hypoxia
  • Infections
  • Seizures and epilepsy
  • Sleep apnoea
  • Strokes
  • Toxins (e.g., carbon monoxide poisoning)
  • Degenerative diseases (Cleveland Clinic, 2022).

Diagnosis of anosognosia

In one way, we could call true anosognosia an invisible condition, because several conditions must obtain before someone can be diagnosed with it. First, the individual must have some sort of health condition, such as dementia, Huntington’s disease, or bipolar disease. Second, the person needs to be exhibiting signs that show they do not realise they have the health condition. Third, their health provider needs to observe that they have a health condition but do not recognise it. One young adult with schizophrenia earnestly stated that he was Jesus reincarnated. But if his psychiatrist had not heard him say that and did not witness any other episodes of psychosis, the conditions for diagnosing anosognosia would not be met.

Commonly, individuals experiencing anosognosia try to cover up or perhaps rationalise their signs of health problems. This is not a case of someone merely trying to pull the wool over the eyes of their family members or health providers! Rather, when the mind cannot explain or understand something, it tries to fill in the gaps with its own explanation. Thus, reaching a diagnosis typically requires a combination of these:

  • A physical and neurological examination
  • A thorough history taken of the person’s health and life circumstances
  • Diagnostic testing/imaging, including:
  • CT (computerised tomography) scan
  • EEG (electroencephalogram)
  • MRI (magnetic resonance imaging) (Cleveland Clinic, 2022).

Strategies to manage lack of insight from Anosognosia

Patience, along with a dose of psychoeducation

Insofar as it is possible, family members and loved ones of the person with anosognosia as well as the person themselves should receive psychoeducation about the nature of brain injury and degenerative diseases (these vary according to which aetiology is present: injury or disease). All parties need to be able to recognise that the person is not being stubborn or difficult, and they do not have the intention of being uncooperative; the changes have made it difficult for them to understand their own behaviour. The challenge in “getting” this is exacerbated by the reality that the person may look and seem the same as before the injury or diagnosis of degenerative disease, with changes being hard to notice and understand.

Thus, in the process of education, all parties – the afflicted individual, family members, and caregivers – need to cultivate patience, allowing awareness to grow over time. Psychoeducation should certainly include talking with the person about the effects of their condition and discussing the kinds of challenges it generates. So, for example, someone observing quickness to anger may refrain from just saying, “You are angry all the time!” To avoid defensiveness, they may ask the person with anosognosia whether they knew that people with brain injury sometimes struggle with their temper, followed by: “Have you ever felt that way?” (Flint Rehab, 2023)

Identify the cause of lack of insight

Below we identify the main symptoms of lack of insight and outline which types of interventions will be most effective for that symptom.

For self-monitoring problems, interventions to raise awareness of performance may be helpful. These could include videos, checklists, and feedback.

For attention and memory issues, cognitive rehabilitation and memory strategies may be most relevant, with insight into behaviour improving as concentration and memory get better.

For deficits of reasoning and thinking skills, the individual can be given assistance with concrete goal setting, planning, and decision-making.

For emotional problems, counselling to increase acceptance of the condition, improve self-awareness, and/or find compensatory strategies likely resolves the problems the best. Mental health professionals may be able to facilitate, directly with clients or indirectly through caregivers, more positive home interactions, helping to reduce or eliminate “triggers” of negative interactions or high frustration.

Obviously, brain injury or degenerative disease will often show up in multiple aspects, so multiple approaches may be needed to increase self-awareness (ABIOS, 2021; Flint Rehab, 2023).

Provide feedback

Information about a person’s newly diminished performance or ability can come from multiple sources: from caregivers or family members, from peers, from professionals working with the person, and from the person themselves as they evaluate specific instances of their performance for themselves.  Feedback should follow the general guidelines for giving information about someone’s performance. Specifically, it is most helpful if the feedback is:

Frequent and non-critical: giving the person numerous opportunities to view their own behaviours as others see them.

Concrete and specific: examples should be as specific as possible, noting what can be observed or could be caught with a camera rather than the feedback giver assuming they know what the person intends or is thinking. Areas of strength and/or improvement should be noted as well. All negative feedback with no positive comments is discouraging!

Gentle and universal: anosognosia is, after all, about not being aware of one’s condition, so feedback givers are more effective if they can give information in ways that trigger less defensiveness. For example, someone with dementia or a brain injury still wanting to drive can be told that their condition makes driving unsafe, or more pointedly, that, say, their reaction times are slow and would make it dangerous for them and others if they drive. They can be reminded that it’s against the law for someone with their condition to drive without a doctor’s permission. Gentle feedback is centred in the art of illustrating the difficulty or constraint as a more universal reality than merely a restriction imposed personally on the person with anosognosia (ABIOS, 2021; Flint Rehab, 2023).

Link activities to the person’s goals

People who exhibit unawareness of a condition they have are far less likely to feel motivated to engage in therapeutic or other activities to make the condition better. People can be helped to set realistic goals linked to detailed plans to increase their potential success rate. So, for example, a health provider might say, “We are doing these memory and attention exercises so that you are able to go back to work (or toilet yourself, or improve your relationship, as examples) (ABIOS, 2021; Flint Rehab, 2023).

Do risk prevention

The clued-up mental health professional will be aware of possible legal or safety issues and be alert to situations in which decision-making may need to happen by other than the person with anosognosia. This could revolve around financial affairs management, need for accommodation or services, or return to work or to driving. In some cases, children must be protected and cared for. Again, the best results are obtained by those who can avoid directly challenging the person’s ideas about their capacity, which would likely lead to conflict. New ideas can be introduced gradually, giving the person time to think about them (Flint Rehab, 2023; ABIOS, 2021).

Gaining insight: Not the whole drama

We’ve been discussing the problems of lack of insight. Let’s say you have a client who has been working to improve their insight following on from an accident in which they sustained a brain injury and came to exhibit anosognosia. Let’s say further that, in the happiest of circumstances, the client, over time, has come to realise how their brain function may have changed in the wake of the accident. Perhaps they accept that they aren’t processing or remembering things as they used to do and have surprised themselves by yelling at the kids for inconsequential things. Once they lift the veil of the anosognosia and join the ranks of the aware, are they cured? Is the problem solved?

A word to the wise before we proceed to the discussion of denial in the next article. Insight is highly associated with healing, but it does not equal cure. For outcomes to be different, the individual who suffered from anosognosia and has now gained insight into their condition still needs to change their behaviours. Even gaining self-awareness is a big step, one not always achieved. When there is a degenerative process going on, such as with Alzheimer’s, or a brain disorder such as with schizophrenia, coming to grips with the issue of lack of insight is a major milestone, yet it is insufficient for change. For this, much additional commitment, hard work, and reinforcement is likely needed. Some cases of anosognosia are permanent and must always be managed (Simon, 2014).

Conclusion

Anosognosia is a common condition for people with the above-mentioned mental illnesses and may only be treatable, not curable. We beg you not to be discouraged, however. In the next article, we take a look at the lack of insight born of the repression and “squashing down” of traumatic or unpleasant experiences which creates denial. With a different aetiology than true anosognosia, there is solid reason to hope for change.

Key takeaways

  • Clients’ lack of insight can either be through anosognosia (in the case of brain injury/disorder or degenerative disease) or through denial (when people struggle to accept a painful or unpleasant reality).
  • Bipolar disorder, schizophrenia, dementia, and Alzheimer’s disease are the primary mental health conditions in which anosognosia is seen.
  • Symptoms are when clients fail to recognise that they have a condition, that they have the symptoms of the condition, that their symptoms belong to the condition, or that the symptoms should be treated.
  • Anosognosia-causing brain lesions can be generated from many factors, including aneurysms, seizures, toxins, strokes, and degenerative diseases.
  • Along with a thorough history and physical examination, diagnosis should include imaging such as CT scans, EEGs, and MRIs.
  • Management of anosognosia includes psychoeducation, identifying the cause of the lack of insight, providing feedback, linking activities to the client’s goals, and doing risk prevention.   
  • Gaining insight is an important milestone in managing anosognosia, but the person’s behaviours also need to change. For this, commitment to hard work and reinforcement are also needed.

References

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