Impaired awareness of illness: Anosognosia

By Dr. E. Fuller Torrey

SUMMARY: Impaired awareness of illness (anosognosia) is a major problem because it is the single largest reason why individuals with schizophrenia and bipolar disorder do not take their medications. It is caused by damage to specific parts of the brain, especially the right hemisphere. It affects approximately 50 percent of individuals with schizophrenia and 40 percent of individuals with bipolar disorder. When taking medications, awareness of illness improves in some patients.
Impaired awareness of illness is a strange thing. It is difficult to understand how a person who is sick would not know it. Impaired awareness of illness is very difficult for other people to comprehend. To other people, a person’s psychiatric symptoms seem so obvious that it’s hard to believe the person is not aware he/she is ill. Oliver Sacks, in his book The Man Who Mistook His Wife for a Hat, noted this problem:

It is not only difficult, it is impossible for patients with certain right-hemisphere syndromes to know their own problems …And it is singularly difficult, for even the most sensitive observer, to picture the inner state, the ‘situation’ of such patients, for this is almost unimaginably remote from anything he himself has ever known.

What is impaired awareness of illness?

Impaired awareness of illness means that the person does not recognize that he/she is sick. The person believes that their delusions are real (e.g. the woman across the street really is being paid by the CIA to spy on him/her) and that their hallucinations are real (e.g. the voices really are instructions being sent by the President). Impaired awareness of illness is the same thing as lack of insight. The term used by neurologists for impaired awareness of illness is anosognosia, which comes from the Greek word for disease (nosos) and knowledge (gnosis). It literally means “to not know a disease.”

How big a problem is it?

Many studies of individuals with schizophrenia report that approximately half of them have moderate or severe impairment in their awareness of illness. Studies of bipolar disorder suggest that approximately 40 percent of individuals with this disease also have impaired awareness of illness. This is especially true if the person with bipolar disorder also has delusions and/or hallucinations.

Is this a new problem? I’ve never heard of it before.

Impaired awareness of illness in individuals with psychiatric disorders has been known for hundreds of years. In 1604 in his play “The Honest Whore,” playwright Thomas Dekker has a character say: “That proves you mad because you know it not.” Among neurologists unawareness of illness is well known since it also occurs in some individuals with strokes, brain tumors, Alzheimer’s disease, and Huntington’s disease. The term anosognosia was first used by a French neurologist in 1914. However in psychiatry impaired awareness of illness has only become widely discussed since the late 1980s.

Is impaired awareness of illness the same thing as denial of illness?

No. Denial is a psychological mechanism which we all use, more or less. Impaired awareness of illness, on the other hand, has a biological basis and is caused by damage to the brain, especially the right brain hemisphere. The specific brain areas which appear to be most involved are the frontal lobe and part of the parietal lobe.

Can a person be partially aware of their illness?

Yes. Impaired awareness of illness is a relative, not an absolute problem. Some individuals may also fluctuate over time in their awareness, being more aware when they are in remission but losing the awareness when they relapse.

Are there ways to improve a person’s awareness of their illness?

Studies suggest that approximately one-third of individuals with schizophrenia improve in awareness of their illness when they take antipsychotic medication. Studies also suggest that a larger percentage of individuals with bipolar disorder improve on medication.

Why is impaired awareness of illness important in schizophrenia and bipolar disorder?

Impaired awareness of illness is the single biggest reason why individuals with schizophrenia and bipolar disorder do not take medication. They do not believe they are sick, so why should they? Without medication, the person’s symptoms become worse. This often makes them more vulnerable to being victimized and committing suicide. It also often leads to rehospitalization, homelessness, being incarcerated in jail or prison, and violent acts against others because of the untreated symptoms.

Studies Correlating Anosognosia with Violence

Lack of awareness of being ill is present in up to 50 percent of those with untreated schizophrenia and up to 40 percent of those with untreated bipolar disorder. It may be a form of anosognosia, damage caused to a certain area of the brain. Anosognosia has been corroborated and “photographed” using structural MRI, functional MRI, single photon emission computed tomography (PET), diffusion tensor imaging (DTI), and other techniques.[1] MRIs show better brain activation in the insula and the inferior parietal lobule (top) and medial prefrontal cortex (bottom) in schizophrenia patients with high insight as compared to schizophrenia patients with low insight.[2] However, as Dr. Robert Liberman has pointed out, “in all such studies there is considerable overlap in the normal and abnormal ratings.” Conclusions are sometimes drawn from these brain imaging studies that are not warranted.[3]

In comparison with patients with altered insight, those with preserved insight showed significant increased perfusion in the bilateral precuneus. (Catherine Faget-Agius, Laurent Boyer, Romain Padovani, et al., “Schizophrenia With Preserved Insight is Associated with Increased Perfusion of the Precuneus,” Journal of Psychiatry of Neuroscience 37, no. 5 (September 2012): 297–304, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3447128/ (accessed December 25, 2016).

Over two hundred studies document lack of insight.[4] Following are some of the studies showing the association between lack of insight (likely anosognosia) and violence as compiled by the Treatment Advocacy Center:

<BL>· In Ohio, 115 people with schizophrenia who had committed violent acts for which legal charges were incurred were compared to 111 individuals with schizophrenia who had no history of violent acts. The violent individuals had “marked deficits in insight” and were much more symptomatic. Compared to the nonviolent individuals, those who had been violent scored significantly lower on awareness of mental disorder, awareness of achieved effect of medications, and awareness of social consequences of mental disorders.[5]

In North Carolina, 331 “severely mentally ill” individuals who had been involuntarily admitted to a psychiatric hospital were assessed for their history of assaultive and violent behavior. The findings indicated “that substance abuse problems, medication noncompliance, and low insight into illness operate together to increase violence risk.”[6]
In New York, sixty male patients with psychosis who had been charged with a violent crime were assessed. Severity of community violence was strongly associated with poor insight, medication nonadherence, and substance abuse.[7]
In England, forty-four male inpatients in a forensic psychiatric hospital were assessed for violent behavior. It was found that “a previous diagnosis of mental illness, lack of insight, and active signs of mental illness were the most predictive of inpatient violence.”[8]
In Spain, sixty-three people with a diagnosis of schizophrenia or schizoaffective disorder were assessed for violent behavior during their brief hospitalizations. The strongest predictors of violent behavior were lack of insight into symptoms (especially delusions), being sicker, and past history of violence.[9]
In Sweden, forty “mentally disordered” individuals with a history of “violent criminality” were discharged from two forensic hospitals and followed for between three and twelve years. Twenty-two of them committed additional violent crimes, and eighteen did not. Among the strongest predictors of those who committed additional violent crimes were lack of insight and “noncompliance with remediation attempts.”[10]
In England, 503 patients in two forensic psychiatric hospitals were assessed for aggressive and violent behavior. Lack of insight strongly correlated with higher levels of such behavior.[11]
In Ireland, 157 individuals with first-episode psychosis were assessed for violent behavior. The strongest predictors of violent behavior in the week following admission were poor insight and a past history of violence.[12]

[1] Treatment Advocacy Center, “The Anatomical Basis of Anosognosia (Lack of Awareness of Illness),” September 2012, http://www.treatmentadvocacycenter.org/storage/documents/Anosognosia–Anatomical_Basis_-_August_2012.pdf (accessed July 25, 2016).

[2] Lisette van der Meer, Annerieke E. de Vos, and Annemarie P. M. Stiekema, “Insight in Schizophrenia: Involvement of Self-Reflection Networks?” Schizophrenia Bulletin 39, no. 6 (November 2013): 1288–95. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3796073 (accessed July 25, 2016).

[3] For a discussion of overstated claims being made for brain imaging, see Sally Satel and Scott O. Lilienfeld, Brainwashed: The Seductive Appeal of Mindless Neuroscience (New York: Basic Books, 2013).

[4] Xavier Amador, “Anosognosia and Serious Mental Illness,” video, 9:01, June 1, 2011, http://ssnsc.blogspot.com/2011/03/anosognosia-1-of-2.html (accessed July 10, 2016).

[5] P. F. Buckley, D. R. Hrouda, L. Friedman, “Insight and Its Relationship to Violent Behavior in Patients with Schizophrenia,” American Journal of Psychiatry 161, no. 9 (2004): 1712-14. Abstract at http://www.ncbi.nlm.nih.gov/pubmed/15337667 (accessed December 24, 2016).

[6] Marvin S. Swartz, Jeffrey W. Swanson, Virginia A. Hiday, “Violence and Severe Mental Illness: The Effects of Substance Abuse and Nonadherence to Medication,” American Journal of Psychiatry 155, no. 2 (1998): 226-31. Abstract at http://www.ncbi.nlm.nih.gov/pubmed/9464202 (accessed July 25, 2016).

[7] Nelly Alia-Klein, Thomas M. O’Rourke, Rita Z. Goldstein, et al., “Insight into Illness and Adherence to Psychotropic Medications Are Separately Associated with Violence Severity in a Forensic Sample,” Aggressive Behavior 33, no. 1 (2007): 86-96. Abstract at http://onlinelibrary.wiley.com/doi/10.1002/ab.20170/abstract;jsessionid=A2A18A8D4A27C220186B855F2C5F87D5.f01t04 (accessed July 25, 2016).

[8] Michelle Grevatt, Brian Thomas-Peter, Gary Hughes, “Violence, Mental Disorder and Risk Assessment: Can Structured Clinical Assessments Predict the Short-Term Risk of Inpatient Violence?” Journal of Forensic Psychiatry and Psychology 15, no. 2 (2004): 278-92. Abstract at http://www.tandfonline.com/doi/abs/10.1080/1478994032000199095 (accessed July 25, 2016).

[9] Arango Celso, Alfredo Calcedo Barba, Teresa González-Salvador, et al., “Violence in Inpatients with Schizophrenia: A Prospective Study,” Schizophrenia Bulletin 25, no. 3 (1999): 493-503. Abstract at http://www.ncbi.nlm.nih.gov/pubmed/10478784 (accessed July 25, 2016).

[10] Strand Susanne, Henrik Belfrage, Goran Fransson, “Clinical and Risk Management Factors in Risk Prediction of Mentally Disordered Offenders–More Important than Historical Data?” Legal and Criminological Psychology 4, no. 1 (1999): 67-76. Abstract at http://onlinelibrary.wiley.com/doi/10.1348/135532599167798/abstract (accessed July 25, 2016)

[11] P. Woods, V. Reed, M. Collin, “The Relationship between Risk and Insight in a High-Security Forensic Setting,” Journal of Psychiatric and Mental Health Nursing 10, no. 5 (2003): 510-17. Abstract at http://www.ncbi.nlm.nih.gov/pubmed/12956629 (accessed July 25, 2016).

[12] S. R. Foley, B. D. Kelly, M. Clarke, “Incidence and Clinical Correlates of Aggression and Violence at Presentation in Patients with First Episode Psychosis,” Schizophrenia Research 72, no. 2-3 (2005): 161-68. Abstract at http://www.ncbi.nlm.nih.gov/pubmed/15560961 (accessed July 25, 2016).

Peer reviewed studies: Lack of insight

Awareness of Illness in Schizophrenia and Schizoaffective and Mood Disorders

Archives of General Psychiatry 1994 (51): 826-836 Amador XF, Flaum M, Andreasen NC, Strauss DH, Yale SA, Clark CC, & Gorman JM