{"id":443,"date":"2011-06-20T16:44:00","date_gmt":"2011-06-20T23:44:00","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=443"},"modified":"2011-06-20T16:47:51","modified_gmt":"2011-06-20T23:47:51","slug":"psychiatric-anosognosia","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=443","title":{"rendered":"Psychiatric anosognosia"},"content":{"rendered":"

\"\"This post was inspired by an article in the May 30th issue of The New Yorker<\/em>, “God Knows Where I Am” by Rachel Aviv. \u00a0Full-text online is only available by subscription, but a free abstract is available here<\/a>. \u00a0In the process of telling a riveting and ultimately very sad story, the author discusses psychiatric insight.<\/p>\n

Insight<\/em> is a curious concept as used in psychiatry. \u00a0In common parlance insight is unquantifiable, something like charm or wisdom. \u00a0We feel we know it when we see it. \u00a0But most of us hesitate to make finer distinctions. \u00a0We may allow that someone strikes us as a little<\/em> insightful or very<\/em> wise. \u00a0Beyond that, it seems ludicrous to attach a scale to it, or to refer to insight as though it could be measured precisely.<\/p>\n

Nonetheless, in psychiatry an assessment of insight is part of the “mental status examination” \u00a0(MSE<\/a>), the psychiatrist’s version of the physical exam in general medicine. \u00a0Along with assessments of mood, affect (expressed emotion), paranoia, suicidal feelings, and other issues, the psychiatrist also evaluates the patient’s insight.<\/p>\n

Psychiatry has no standardized way to assess this. \u00a0We may ask our patient: “What is your understanding of the problem that brought you here today?” \u00a0It’s a great question \u2014 the problem is what to do with the answer. \u00a0Critics note that if the patient’s response accords with the psychiatrist’s own belief, the patient is judged to have good insight. \u00a0Thus, in an earlier era when psychoanalysis was predominant, a patient with schizophrenia exhibited good insight by agreeing that his “schizophrenogenic<\/a>” mother caused the problem. \u00a0Nowadays, this would be evidence of clear impairment; the insightful patient would instead agree with his psychiatrist that he has a “chemical imbalance.”<\/p>\n

For better or worse, many such judgments in psychiatry \u2014 perhaps most of what we do \u2014 cannot be divorced from social context. \u00a0Exuberance in one crowd may look like hypomania in another. \u00a0“Inappropriate” affect begs the question, what is appropriate? \u00a0And likewise, an understanding of one’s own mental health status (or psychiatric label) is meaningful only within one’s social group and culture.<\/p>\n

Anosognosia<\/em> is a term from neurology. \u00a0As defined in Mosby’s Medical Dictionary<\/em>, 8th edition:<\/p>\n

\n

[an\u2032\u0259sog\u00b7n\u014d\u2032zh\u0259]<\/p>\n

Etymology: Gk,\u00a0a <\/em>+\u00a0nosos,<\/em> not disease,\u00a0gnosis,<\/em> knowing<\/p>\n

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.<\/p><\/blockquote>\n<\/div>\n

Certain patients with brain disease or injury appear not to know they are paralyzed (or blind, etc). \u00a0Presumably, parts of the brain involved with self-awareness are damaged. \u00a0This lack of knowing then becomes one of the signs of the disease itself, and may help with diagnosis. \u00a0For example, the cause of a paralysis may be localized to the parietal lobe if it is accompanied by anosognosia.<\/div>\n

The term has lately appeared in psychiatry (and is discussed briefly in the New Yorker<\/em> piece). \u00a0This is a worrisome error in my opinion. \u00a0Its use seems intended to make psychiatry sound better understood, and more biological\/neurological, than it really is. \u00a0A person who denies having a psychiatric disorder may delusionally attribute his or her difficulties to space aliens. \u00a0This makes a good case for extending anosognosia into psychiatry. \u00a0But 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. \u00a0Here, denial of an anxiety disorder is certainly not<\/em> a sign of having such a disorder. \u00a0And of course social stigma leads many patients to deny having a psychiatric disorder; this denial likewise bears no relationship to having the disorder itself.<\/p>\n

The reasons patients may deny having a psychiatric disorder are far too varied to\u00a0reify such denial with a neurological term. \u00a0It 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. \u00a0This is sophistry, and the mark of a profession whose false certainty belies insecurity.<\/p>\n

Many years ago I wrote a short essay<\/a> arguing that social judgments in psychiatry \u00a0(e.g., inappropriate affect) are both inevitable and essential to our work. \u00a0I was not a psychiatrist yet, but nothing I have seen since has changed my view. \u00a0Despite great advances in biological psychiatry, we still cannot ascribe specific attitudes or viewpoints to neurological damage. \u00a0Insight is still subjective. \u00a0And if we ever do identify the seat of “psychiatric anosognosia,” our understanding will no longer be psychiatry<\/a>, but neurology.<\/p>\n","protected":false},"excerpt":{"rendered":"

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.<\/p>\n

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