In this series, I dig a little deeper into the meaning of psychological terms. This week’s term is 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.
What lack of insight is
Anosognosia can happen in a neurological context as a result of traumatic brain injury or some other form of physical damage, like a stroke.
Anosognosia is also used to describe a total lack of insight into mental illness. It refers both to a lack of awareness that one’s experiences are a result of illness as well as an inability to recognize that treatment could be beneficial. Insight can exist on a continuum, ranging from good to none (i.e. anosognosia). 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 lack insight. Poor insight is not uncommon in acute mania. In depression, lack of insight could involve attributing their experiences to being fundamentally a horrible human being.
What it isn’t
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 why. Partial insight could also show up as being aware that certain symptoms are due to illness but believing that others 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 believe is the right fit for them. It involves the effects of the illness diminishing 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.
Evaluating insight
The Beck Cognitive Insight Scale 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 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?
References
- Kao, Y. C., & Liu, Y. P. (2010). The Beck Cognitive Insight Scale (BCIS): Translation and validation of the Taiwanese version. BMC Psychiatry, 10(1), 1-13.
- National Alliance on Mental Illness. (n.d.). Anosognosia.
- Rubin, E. (2016). The importance of insight. Psychology Today.
- Wikipedia
You can find the rest of the what is… series in the Psychology Corner.
Making Sense of Psychiatric Diagnosis aims to cut through the misunderstanding and stigma, drawing on the DSM-5 diagnostic criteria and guest narratives to present mental illness as it really is.
It’s available on Amazon and Google Play.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
Interesting post, Ashley.
I think the one thing that struck me very strange about my bipolar was that between the first diagnosis from the hospital I was bipolar 2, then the first year and a half through the mental health facility I go to,I was rediagnosed with having bipolar 1. I strongly disagree with that. I don’t tend to go through the extremes of manic episodes.
Oh that’s strange.
Ya think? Not that I don’t trust the mental health field, but to diganose me with having bipolar 1 is a bit ridiculous if I don’t experience the severe symptoms of such.
I need to really discuss their findings the next time I go there.
I hope they’ll actually talk reasonably about it with you.
So do I. Thank you for this recent post.
Agnosia is fascinating as a condition in its own right, but anosognosia hardly ever gets a mention in psych course books, social media or the news in any way. It’s interesting that Beck’s test can be used to aid assessment of self-insight, when, as you say, you’d think that many nurses/psychs/metal health workers would likely be able to gauge this without a standardised test. You’ve covered this brilliantly, a fascinating topic to choose for today!
Caz xx
Thank you! xo
Due to ‘my’ illness being familial, my mother, an aunt, and my maternal grandfather (among others, who may be a bit anosognosia (ic?) about their degree or even having any mental illness AT ALL (I personally call them living in the country named denial) were all mentally ill. My father (I’m pretty sure) had chronic depression as well. So I grew up seeing what my particular flavor of mental illness IS. Being subjected to people who had narcissistic personality disorder, borderline personality disorder, depression and possible bipolar. There is also (in my opinion, which could be wrong) autism in our family, on the very mild end of that spectrum. I’m the child of someone with borderline personality disorder and from what I’ve read (recently) that means I may have it too, to some degree. So I think I’m pretty clued in to what’s going on with me and maybe I monitor myself too often, which might be a mental illness symptom of it’s own.
Nobody knew that much (or it was shameful to admit) about mental illness when I first began to exhibit symptoms. There was childhood trauma too, and that (IMHO) added to the whole thing. I watched my mother be institutionalized involuntarily twice, put in jail once and then institutionalized, and put on inappropriate medication to treat her BPD (they gave her thorazine!! That gives me the willies to this day). In my early 20s I sought help because I knew something was gravely wrong with me and suicide was an actual possibility in those early days because nobody ever talked to me about chronic depression, PTSD, S.A.D., and the fact that my family (mother, father and so forth) had been ill too. It was a very shameful thing. For me seeking that initial help was freeing. It helped me know I’m not “weird” or “moody, difficult and shy”. I’ve sought help as needed over the years, and now know I’ll probably be in some sort of therapy until I die. I don’t cope that well even with all the help I’ve received.
That must have been so hard making the decision to seek help despite it being seen as shameful. I’m glad it turned out to be a positive thing.
Interesting. I think I have heard of this before, but didn’t know a whole lot about it.
I have better insight than I used to. When I was around 18/19 I had a very bad period where I was having a lot of severe paranoid delusions. I didn’t believe anyone when they told me I needed to be on medication or in the hospital, I thought I was completely normal and that what I believed was actually logical,spirits and government agents were after me. I didn’t believe I had schizoaffective disorder despite everything going on. I was pretty much on another planet, mentally. The other problems with insight were always during mania, I would stop all my medications because I felt amazing and didn’t believe I needed them, or that God cured me
I’m pretty self aware now, I’m not as out of touch with reality and even when I start to have symptoms I can realize what’s going on before things get too out of control
I’m glad that’s gotten better for you. xo
I tend to lose insight when I get more severely suicidal. I start planning and looking for and collecting possible means for suicide (eg most operating theatre change rooms have a tub to collect random stuff people have put in their pockets in the course of their work day – there won’t be things that have to be signed and accounted for like opioids but sometimes other potentially toxic drugs plus packaged needles and syringes and scalpel blades), all the while thinking and truly believing that this a harmless “game” because I’m not actually ready to go through with anything at that point. The problem then is that if I do get to the point where I want to act, I’ve got all that stuff handy. After many go-arounds of this I’ve finally realised that if I get so much as the slighest urge to “collect”, it’s a warning sign that I need to heed regardless of how harmless it “feels” and I need to apply the same impulse-delaying techniques as I do for the times when I am on the point of actual suicide, and get some additional help. Also, when I’m getting close to the point of going through with a suicide attempt, I go into a kind of mental bubble where it doesn’t feel like other people are real – they have about the same degree of reality as characters in a tv show, as in, I feel sort of close to them and involved in their screen lives but they’re still only characters – so my death won’t really hurt them anyway.
I notice that same kind of mental bubble myself. I can see how easy access to means would definitely pose challenges.