Anosognosia

A clinical phenomenon that is a patient's denial (underestimation) of the defect he has, ignoring the symptoms of the disease is called anosognosia. Such a rejection of one's condition is a way of escaping from reality. Modern psychiatry interprets anosognosia as a mechanism of psychological defense that helps the patient cope with the thought of the disease, to get used to it. At the same time, it is considered a pathological adaptation, since the unwillingness to admit oneself as sick prevents timely treatment, and usually great efforts are required to return the individual to reality and awareness of the fact of the disease. [ 1 ]

Anosognosia is also a characteristic phenomenon for the patient's immediate environment, regardless of the level of education. Relatives do not want to come to terms with the serious illness of a loved one and deny its existence, justifying behavioral deviations in schizophrenia, epilepsy and other mental illnesses by the prevailing circumstances, laziness, eccentricities, and difficult character. With anosognosia, an inability to notice obvious facts and painful manifestations is formed, despite the fact that, in general, the patient often maintains a general orientation. [ 2 ]

Epidemiology

There is evidence that representatives of the stronger sex are more susceptible to developing anosognosia, which is not surprising. They are more often diagnosed by drug addiction specialists, receive head injuries, have strokes more often and develop severe mental illnesses. In addition, it is believed that women are protected from atherosclerosis and stroke by estrogens for most of their lives, react differently to psychotraumatic events (they better express their emotions) and, in general, are more mobile. All this reduces the risk of developing anosognosia in the weaker half of humanity. [ 3 ]

It is also known that anosognosia as a consequence of ischemic stroke is observed in about a quarter of patients in the early rehabilitation period. As recovery progresses, the symptoms smooth out and disappear.

In drug addicted patients, this clinical phenomenon is almost always present.

Anosognosia may occur following acute brain injury such as stroke or traumatic brain injury, but can also occur in other conditions that damage the brain. In stroke patients with hemiparesis, the incidence of anosognosia is between 10 and 18%.[ 4 ] The term anosognosia can also refer to the lack of awareness seen in psychiatric conditions where patients deny or minimize psychiatric symptoms. An estimated 50% of patients with schizophrenia and 40% of patients with bipolar disorder have anosognosia, or what is known as poor judgment or lack of insight into their illness. In dementia, 60% of patients with mild cognitive impairment [ 5 ] and 81% of patients with Alzheimer's disease appear to have some form of anosognosia: patients suffering from these conditions deny or minimize memory impairment. [ 6 ], [ 7 ]

Causes anosognosia

Anosognosia is typical for people with mental illness and may indicate a serious illness, such as schizophrenia or bipolar disorder. In this case, the patient does not realize that he is sick and actively protests against the treatment prescribed to him. People with mental pathologies usually develop a total rejection of their painful condition without a system of evidence. Anosognosia in patients most often develops under the influence of the following factors:

• progressive decline in intelligence and other mental functions, especially memory impairment (amnesia, dementia);
• acute psychosis with disorganization of consciousness, inability to critically evaluate and generally think rationally;
• hysterical psychosis;
• autopsychic disorientation in chronic psychosis;
• all-consuming indifference (apathy);
• stunning of consciousness of any depth, since this affects higher nervous activity.

Anosognosia often develops in chronic alcoholics and drug addicts, they do not want to consider themselves ill, ignore symptoms and refuse treatment. Most psychiatrists attribute this phenomenon in drug addicts to a defensive reaction to information about the development of a persistent addiction, since recognition of this fact harms the patient's self-esteem, some researchers also associate the inability of alcoholics (drug addicts) to critical self-perception with the unconscious activation of defensive repression (denial) of guilt.

According to K. Jaspers, anosognosia in alcoholics and drug addicts is based on their pathological self-perception. Narcological patients have a special personality type, their nature is characterized by a pathological attraction to the use of psychoactive substances. Most alcoholics and drug addicts rarely realize that they are sick and do not notice the symptoms of the development of pathological alcoholism (narcotization), especially mental ones. This contingent has a mindset only for getting the next dose of alcohol or drugs, the harm of which is well known, and addiction to them is considered a vice. Anosognosia allows you to mask the perception of addiction and not be afraid of the consequences, with prolonged abuse, an organic psychosyndrome develops and on this basis a mental disorder develops. [ 8 ]

Rejection of one's disease also develops in patients with central nervous system damage of various genesis. Risk factors: craniocerebral trauma, infections, intoxication, in particular, carbon monoxide or mercury, hypoxia, ischemia, strokes, progressive atherosclerosis. Depending on the localization of the lesion, patients with a completely preserved ability to navigate in a real situation do not recognize their physical disabilities, blindness or deafness, believe that their paralyzed limbs move, etc.

In somatic and somatopsychic patients, anosognosia is observed as a debut symptom of such diseases as cancer, AIDS, tuberculosis, hepatitis, peptic ulcer, arterial hypertension. In these cases, some researchers consider the anosognosic type of attitude to the disease necessary for maintaining psychological health.

Pathogenesis

The pathogenesis of anosognosia, based on the above reasons, at the psychological level appears as a defensive reaction of "denial", considered as an attempt to avoid new unwanted information that runs counter to the individual's established ideas about himself. The patient minimizes the situation that worries him, unconsciously downplaying its significance and thereby avoiding emotional stress.

Those at risk of developing anosognosia include egocentric individuals with a reduced tendency toward self-criticism and inflated self-esteem.

The problem of non-acceptance of one's own illness occurs in many conditions, is under study and has not yet been resolved unambiguously. Criteria for a unified approach to it and its manifestations (total or partial) have also not been developed, therefore there are no statistics on cases of anosognosia. [ 9 ]

Symptoms anosognosia

Anosognosia is observed in different groups of patients and even among relatives of patients, so clinical manifestations differ qualitatively in their content. The patient may deny the presence of symptoms of the disease, may agree that he is sick, but deny the harm caused by the disease, or not want to be treated. The first signs manifest themselves in different ways: the results of diagnostic studies, tests, and medical opinions may be completely ignored or questioned. Some patients choose the tactics of distancing or outright escape-avoidance of contacts with medical personnel, in some cases patients display an imaginary readiness to cooperate, which in fact turns into quiet sabotage and failure to comply with recommendations.

Total and partial anosognosia are distinguished. Among the manifestations of rejection there is an underestimation of the seriousness of the disease, unawareness of its presence, ignoring its manifestations, simple complete rejection and rejection with fictions and delirium. Such manifestations can be constant or change as pathological stages.

Alcoholic anosognosia, like drug anosognosia, is manifested mainly by a total denial of the disease and the behavioral disorders and psychotic symptoms associated with it. Drug addicts tend to shift responsibility for the constant abuse of psychoactive substances and the problems associated with it to other people (usually close people), a confluence of circumstances, and reveal, mainly, a complete inability to critically perceive themselves.

Complications and consequences

Anosognosia becomes a counterbalance to treatment. Because of the rejection of the disease, the time when the patient can be given the most effective help is missed. This often happens in the initial stages of serious diseases, when there is still no noticeable discomfort or pain, which feeds the illusion of well-being. Basically, great efforts are required from medical personnel to make the patient soberly assess the situation and take measures to preserve his health, and often his life.

Diagnostics anosognosia

Firstly, the patient must have a disease. So that there is something to deny. Secondly, in the opinion of doctors and relatives, he is in no hurry to get treatment, ignoring his disease or not adequately assessing its danger.

Basically, the diagnosis is made on the basis of interviews with the patient, sometimes multiple times.

To assess the most common cases, such as alcoholic anosognosia, questionnaires have been created that allow one to assess the patient's attitude to his illness as a simple lack of knowledge about it or, nevertheless, its complete or partial denial. The survey lasts about half an hour, the answers are assessed in points and interpreted according to the instructions.

Post-stroke patients also undergo various tests, in particular, the "Executive Functions Impairment Questionnaire". When taking this test, the patient's answers about his capabilities are compared with the observer's answers. The questionnaire includes four scales: two - subjective and objective assessment of physical capabilities, two - mental.

Basically, the diagnosis of anosognosia of any kind is carried out by neuropsychological testing or clinical interviews with patients.

Almost always, neuroimaging of the brain (computer or magnetic resonance tomography with or without angiography) is performed to establish the presence of organic damage to its structures. [ 10 ], [ 11 ]

Differential diagnosis

Differential diagnosis of anosognosia comes down to determining its type:

• destructive, expressed in rejection of the disease and regression, characterized by maximally distorted ideas about the disease and oneself;
• moderately destructive, in which some part of the information about the disease is allowed to be understood;
• constructive, when information about the disease can be understood by the patient.

Treatment anosognosia

Anosognosia in somatic patients generally requires psychotherapeutic treatment, in psychiatric patients it often involves drug treatment of the patient's psychiatric illness. Medications are prescribed depending on the patient's condition. Often, after the symptoms of psychosis are relieved, the patient's attitude toward the illness changes.

Treatment of alcohol and drug anosognosia involves psychotherapeutic assistance, often family psychotherapy, in combination with drug addiction therapy.

In case of organic brain damage, after injuries and strokes, surgical treatment is sometimes required.

In particularly severe and dangerous cases for the patient and society, involuntary hospitalization is used, although the main goal of treating anosognosia is the patient's awareness of his illness and the need for treatment. The approach in all cases is individual. [ 12 ], [ 13 ]

Prevention

Denial of one's illness is formed as a protective reaction in many diseases, so preventive measures can be very general. Maintaining a high level of mental and physical health, which is facilitated by lifestyle, nutrition, and the absence of bad habits, minimizes the risk of serious pathologies.

In addition, widespread public awareness of the fact that timely and qualified medical care can cure many serious illnesses that become incurable in advanced stages should play a role.

Forecast

Total anosognosia is prognostically more unfavorable than its milder forms. Much depends on the disease in which the clinical phenomenon has formed. The most favorable prognosis is in intellectually intact people, whose rejection of the disease occurred as a protective reaction to new stressful information.