Psychiatric anosognosia

This post was inspired by an article in the May 30th issue of The New Yorker, “God Knows Where I Am” by Rachel Aviv.  Full-text online is only available by subscription, but a free abstract is available here.  In the process of telling a riveting and ultimately very sad story, the author discusses psychiatric insight.

Insight is a curious concept as used in psychiatry.  In common parlance insight is unquantifiable, something like charm or wisdom.  We feel we know it when we see it.  But most of us hesitate to make finer distinctions.  We may allow that someone strikes us as a little insightful or very wise.  Beyond that, it seems ludicrous to attach a scale to it, or to refer to insight as though it could be measured precisely.

Nonetheless, in psychiatry an assessment of insight is part of the “mental status examination”  (MSE), the psychiatrist’s version of the physical exam in general medicine.  Along with assessments of mood, affect (expressed emotion), paranoia, suicidal feelings, and other issues, the psychiatrist also evaluates the patient’s insight.

Psychiatry has no standardized way to assess this.  We may ask our patient: “What is your understanding of the problem that brought you here today?”  It’s a great question — the problem is what to do with the answer.  Critics note that if the patient’s response accords with the psychiatrist’s own belief, the patient is judged to have good insight.  Thus, in an earlier era when psychoanalysis was predominant, a patient with schizophrenia exhibited good insight by agreeing that his “schizophrenogenic” mother caused the problem.  Nowadays, this would be evidence of clear impairment; the insightful patient would instead agree with his psychiatrist that he has a “chemical imbalance.”

For better or worse, many such judgments in psychiatry — perhaps most of what we do — cannot be divorced from social context.  Exuberance in one crowd may look like hypomania in another.  “Inappropriate” affect begs the question, what is appropriate?  And likewise, an understanding of one’s own mental health status (or psychiatric label) is meaningful only within one’s social group and culture.

Anosognosia is a term from neurology.  As defined in Mosby’s Medical Dictionary, 8th edition:


Etymology: Gk, a nosos, not disease, gnosis, knowing

a lack of awareness or a denial of a neurologic defect or illness in general, especially paralysis on one side of the body. It may be attributable to a lesion in the right parietal lobe.

Certain patients with brain disease or injury appear not to know they are paralyzed (or blind, etc).  Presumably, parts of the brain involved with self-awareness are damaged.  This lack of knowing then becomes one of the signs of the disease itself, and may help with diagnosis.  For example, the cause of a paralysis may be localized to the parietal lobe if it is accompanied by anosognosia.

The term has lately appeared in psychiatry (and is discussed briefly in the New Yorker piece).  This is a worrisome error in my opinion.  Its use seems intended to make psychiatry sound better understood, and more biological/neurological, than it really is.  A person who denies having a psychiatric disorder may delusionally attribute his or her difficulties to space aliens.  This makes a good case for extending anosognosia into psychiatry.  But a denial could equally be an honest difference of opinion, as when a patient discounts a diagnosis of Social Anxiety Disorder because shyness is a family trait.  Here, denial of an anxiety disorder is certainly not a sign of having such a disorder.  And of course social stigma leads many patients to deny having a psychiatric disorder; this denial likewise bears no relationship to having the disorder itself.

The reasons patients may deny having a psychiatric disorder are far too varied to reify such denial with a neurological term.  It creates a suspicious “Catch-22,” where disagreeing with one’s doctor is itself a diagnosable condition with a fancy medical name, and the implication of brain-structure underpinnings.  This is sophistry, and the mark of a profession whose false certainty belies insecurity.

Many years ago I wrote a short essay arguing that social judgments in psychiatry  (e.g., inappropriate affect) are both inevitable and essential to our work.  I was not a psychiatrist yet, but nothing I have seen since has changed my view.  Despite great advances in biological psychiatry, we still cannot ascribe specific attitudes or viewpoints to neurological damage.  Insight is still subjective.  And if we ever do identify the seat of “psychiatric anosognosia,” our understanding will no longer be psychiatry, but neurology.

6 comments to Psychiatric anosognosia

  • M

    It was indeed a very sad article. Most troubling was that even though her sister and daughter had sought to help her, they couldn’t save her from herself.

  • Interesting post. I agree with all of it except the idea that once we understand the underlying biology of (whatever might be called “psychiatric anosognosia”), it will become the subject of neurology. I do not see additional neurobiological insight as diminishing psychiatry. I think that the additional insight will expand psychiatry.

    For example, neurologists are apparently not interested in why people do not have insight into blood sugar levels, blood pressure, etc. Those remain the interests (and frustrations) of internists.

    Thanks for the interesting post.

    • Thanks for visiting (The Alienist is a fellow psychiatric blogger). As I see it, neurologists aren’t interested in lack of insight (or denial of illness) in diabetes or hypertension because there is no known neurological substrate. If one is discovered, they will be. In the meantime, minor denial is a frustration of internists, and gross denial comes to the attention of psychiatric consultants. See my post “Embracing psychiatric uncertainty” for historical examples of psychiatric diagnoses that were picked up by other specialties once the pathophysiology was known.

  • Laura

    I’d love you to hear this video. It’s a success story I hope my son will have someday.
    I keep the vision my son will have Eric’s same outcome, despite his diagnosed “poor insight”. He sits in prison now, 22, schizoaffective, unmedicated, untreated, despite 3 hospitalizations all within the 17 month timespan of his second major pshychotic break at 20. Since then, he’s accrued 5 criminal cases on his previously clean record. Not getting him help because he had “poor insight” caused his illness and his record to worsen. Without insight, he sits in prison awaiting sentencing that could be 20 years, given a choice between hospital or jail, he chooses jail because he thinks hospitals are too nice and won’t teach him his lesson. He thinks his illness is just stress or breakdowns, therefore fights his judges to give him the worst of the punishments, not even allowing them access to his 9 hospitals he’s been seen in. Poor insight is certainly a term. But it doesn’t fully encapsulate the consequences of having it.

  • Laura

    Can you speak about the difference between anosognosia due to psychosis and any other kind of mental illness? If you could, what would you term “poor insight” other than (or in addition) to the anosognosia accompanying schizophrenia ?

    • Hi Laura,

      Thanks for writing. I clicked the YouTube link, but the video is an hour and 20 minutes long. I’m sorry but I don’t have time for that.

      My point in criticizing the term “anosognosia” is not to trivialize lack of insight. While I can’t relate a personal story as horrible as yours, in my own practice I’ve seen patients ruin careers, destroy long-time personal and professional relationships, and go deeply into debt while manic. It’s heartbreaking to loved ones, and awful all around.

      Given this reality, I may seem to be splitting hairs when I criticize the use of a particular word. But it’s important in psychiatry to be careful with words. Anosognosia in neurology is a sign of specific anatomical damage in the brain (usually in the parietal lobe). It doesn’t mean lack of insight in general, or poor judgment. And it doesn’t mean a simple denial of one’s disease — that can occur in cancer, for instance, purely out of fear of the diagnosis.

      While the lack of insight in schizophrenia, mania, and severe depression are of a particular sort, this still doesn’t rise to the level of a specific anatomical disorder in the brain. Thus, I believe “anosognosia” has been misused in my field for the past decade or so. I think “delusion” is a better term for the particular type of poor insight that accompanies these severe psychiatric disorders.

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