In this series, I dig a little deeper into the meaning of psychological terms. This week’s term: anosognosia
I wouldn’t be surprised if you haven’t heard this term before, so let’s break it down. Agnosia is an inability to recognize people or things. Nosology is the classification of diseases. Throw the two together, and you get anosognosia, which is a lack of self-awareness of one’s own disease/disorder.
Sometimes anosognosia can occur as a result of traumatic brain injury or some other form of physical damage like a stroke. In this case it is treated as a neurological disorder.
Anosognosia is also used to describe a total lack of insight into mental illness. It refers both to a lack of awareness that what one is experiencing is as a result of illness, and an inability to recognize that treatment could be beneficial. Insight can exist on a continuum ranging from good to none (i.e. anosognosia), and it requires higher-level brain functions (particularly involving the prefrontal cortex) to properly self-evaluate. In mental illness, sometimes those higher-level functions are impaired, reducing the individual’s capacity to recognize their own illness.
People with psychotic conditions such as schizophrenia are more likely to have a lack of insight. Poor insight is not uncommon in acute mania. In depression, there may be a lack of insight if the person attributes what they are experiencing to being fundamentally a horrible human being.
Disagreeing with a diagnosis is not in and of itself a lack of insight. Someone might recognize that they are experiencing symptoms of an illness, but disagree with their physician on what condition best accounts for those symptoms. Someone with partial insight might recognize that they’ve had a decline in functioning, but have no idea what accounts for it. Partial insight could also be manifested as awareness that certain symptoms are due to illness, but believing that other effects are not. As an example, someone with schizophrenia might recognize that hallucinations are probably due to their illness, but remain firmly fixed in their belief that a delusional idea is reality-based.
Lack of insight related to the need for treatment isn’t the same as declining a particular form of treatment someone doesn’t wish to have, or deciding that the potential downsides outweigh the potential benefits. It is more of an issue of the effects of the illness reducing one’s capacity to recognize that treatment would be helpful and reasonably consider the pros and cons. This is where involuntary treatment may come into play.
There is a test called the Beck Cognitive Insight Scale, which I hadn’t previously heard of, that was developed to evaluate the extent to which people experiencing psychosis were able to integrate reality-oriented feedback about their delusions. Some of the items on the 15-item scale are:
- “My interpretations of my experiences are definitely right.”
- “Some of the ideas I was certain were true turned out to be false.”
- “If something feels right, it means that it is right.”
- “I cannot trust other people’s opinion about my experiences.”
- “If somebody points out that my beliefs are wrong, I am willing to consider it.”
While a standardized test might be helpful to quantify variations over time, in my work as a mental health nurse it’s usually fairly easy to determine the level of insight someone has without using any form of structured test.
With my own illness, I’ve generally had pretty good insight. I haven’t always agreed with treatment providers, but that has had more to do with my opinion of them than any lack of awareness of my symptoms.
What has your insight been like over the course of your illness?
You can find the rest of my What Is series here.
My book Making Sense of Psychiatric Diagnosis breaks down the different categories of DSM-5 diagnoses, explaining the diagnostic criteria and providing first-hand stories of the various illnesses. It’s available on the MH@H Store, as well as Amazon and other major retailers.