Anosognosia
Find out about anosognosia, a common symptom of SMI,
and why it keeps people from seeking and adhering to treatment.
What is anosognosia?
Anosognosia, sometimes referred to as a lack of insight, describes a neurological condition that prevents some people from knowing they have a brain disorder or accurately perceiving symptoms they are experiencing. Anosognosia is the most common reason for not seeking or maintaining treatment for people with severe mental illness (SMI).
Anosognosia is different from denial or defensiveness. For example, someone who sees that their mental state has changed might deny that anything is wrong and defend their right to say no to treatment. Someone with anosognosia, on the other hand, will be unable to see that there has been a change in their mental state, behavior, or functioning. They know that they are not sick.
In October 2024, anosognosia was officially recognized as a neurological condition, with an assigned medical insurance billing code: R41.85, which is applicable for patients 15 and older. Being able to track this condition with a unique code can promote better understanding of its clinical significance and treatment challenges.
Widespread knowledge is sorely needed about this common symptom that makes treatment access tricky and needs to be part of conversation related to personal and systems change advocacy.
How do you pronounce anosognosia?
If you struggle to remember or say this long word, you are not alone! Here is help:
Dictionary-style, it’s pronounced like this: A-nō-säg-nō-zh (ē-)ə.
That’s six syllables that sound like this: A No Sog No Zi Ah.
What can cause anosognosia?
Physical changes to the frontal and parietal lobes of the brain, which are responsible for self-awareness, can lead to anosognosia. This can happen because of illnesses such as schizophrenia or bipolar disorder but is also common with Alzheimer’s disease, dementia, stroke, substance use disorder and Huntington’s disease. Brain injury or brain tumors can also cause anosognosia.
The term was coined in 1914 by Joseph Babinski, who noted that some stroke patients with partial paralysis were unable to recognize their loss of function. They would strongly deny that anything was physically wrong with their bodies, refusing treatment and rehabilitation.
Henry A. Nasrallah, M.D., editor of Current Psychiatry, calls anosognosia a “disorder of consciousness” that disables a person’s capacity for self-reflection. Dr. Nasrallah refers to anosognosia as a “fundamental initial symptom of schizophrenia” and acknowledges a need for providers to understand and consider this symptom in care planning.
Is that what’s going on when a person in obvious psychosis says they are fine?
When anosognosia is present with psychosis, the person has limited or no capacity to understand that their perceptions don’t match reality. They are likely to claim they are not sick and that any challenges in their life are related to external problems and other people.
As an example, a person in psychosis might know that their spouse fed them poison laced with microchips to permeate their brain and send signals of their thoughts and location to the CIA. It could be obvious to them that license plates with those three letters (C, I, or A) prove they are being followed. They are certain that the person who claims to be their spouse is an imposter spy. Digging holes in the walls — or even their own skin — may be the only logical option to end the surveillance and escape. These fixed false beliefs are delusions and will not change regardless of evidence presented contradicting the false belief.
Anosognosia’s effect on a person’s ability to perceive illness or symptoms is similarly fixed.
This level of psychosis, combined with anosognosia, could lead a person to become increasingly paranoid if someone tries to convince them of their illness. With these symptoms, it’s highly unlikely that a person will voluntarily engage with treatment. People trying to help will need to proceed cautiously to guide this person into care, and strategies for engagement need to incorporate the symptom of anosognosia to be successful.
Can insight improve with treatment?
Some people with anosognosia can improve their lives with mental health treatment, but they may never gain the capacity to see that they have a mental illness. In those situations, motivational interviewing (MI) may be key to treatment adherence. For example, a person may never believe in their diagnosis but could learn to see that when they take medication and visit with their providers regularly, they are able to maintain an even temper, stay close with people they care about, keep their housing, or something else important to them.
Some people do regain some or all of their insight with interventions, including early episode psychosis programs, antipsychotic medications (including clozapine), some psychotherapeutic interventions, and Transcranial Direct Current Stimulation (tDCS). A Research Summary provides more detail.
How do you motivate someone with anosognosia to seek treatment?
The presentation of anosognosia can be intensely frustrating to family members, caregivers, and treatment providers who know the illness can improve with treatment but cannot convince the person who is ill to want that treatment. Figuring out how to talk with individuals experiencing anosognosia can be very challenging. TAC provides a resource with general communication tips and places to seek further information about engaging with someone experiencing SMI with anosognosia. The clinical approach of motivational interviewing (MI) can help. Dr. Xavier Amador provides his own version of MI, referred to as LEAP (listen, empathize, agree, partner), in a book called “I Am Not Sick; I Don’t Need Help!”