Anosognosia

A clinical phenomenon, which is a denial (underestimation) of the patient’s defect, ignoring the symptoms of the disease is called anosognosia. Such a rejection of one’s state is a way of avoiding reality. Modern psychiatry interprets anosognosia as a psychological defense mechanism that helps the patient cope with the thought of the disease and get used to it. At the same time, it is considered as pathological adaptation, since the reluctance to admit to being sick prevents timely treatment, and usually requires great efforts to return the individual to reality and to realize the fact of the disease. [1]

Anosognosia is a characteristic phenomenon for the close environment of the patient, regardless of the level of education. Relatives do not want to put up with a serious illness of a loved one and deny its presence, justifying behavioral abnormalities in schizophrenia, epilepsy, and other mental illnesses under the circumstances, laziness, eccentricities, and a severe 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 members of the stronger sex are more likely to develop anosognosia, which is not surprising. They are often put by patients of narcologists, get head injuries, they more often have strokes 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 traumatic events (emotion is better) and, in general, are more mobile. All this reduces the risk of anosognosia in the weak 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 you recover, the symptoms smooth out and disappear.

In narcological patients, this clinical phenomenon is almost always present.

Anosognosia can occur after acute traumatic brain injury, such as a stroke or a brain injury, but can also occur in other conditions that damage the brain. In patients with stroke suffering from hemiparesis, the frequency of anosognosia is from 10 to 18%. [4] The term anosognosy may also refer to a lack of awareness observed in psychiatric conditions when patients deny or minimize psychiatric symptoms. It is estimated that 50% of patients with schizophrenia and 40% of patients with bipolar disorder have anosognosia or the so-called poor condition or lack of understanding of their disease. In conditions of 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 of the anosognosia

Anosognosia is common in people with a mental illness and can 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 disease state without a system of evidence. Anosognosia in patients develops most often 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 rational thinking;
• hysterical psychosis;
• autopsychic disorientation in chronic psychosis;
• all-consuming indifference (apathy);
• stunning consciousness of any depth, since higher nervous activity suffers.

Anosognosia often develops in chronic alcoholics and drug addicts, they do not want to consider themselves sick, ignore the symptoms and refuse treatment. Most psychiatrists attribute this phenomenon in narcological patients to a defensive reaction to information about the occurrence of persistent addiction, since recognition of this fact is detrimental to the patient’s self-esteem, and some researchers attribute the inability of alcoholics (drug addicts) to critical self-perception with unconscious activation of protective 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 warehouse, their nature is characterized by a pathological attraction to the use of psychoactive substances. Most alcoholics and drug addicts rarely recognize themselves as ill and do not notice symptoms of the development of pathological alcoholization (anesthesia), especially mental ones. This contingent has a disposition only to receive the next dose of alcohol or a drug, the harm of which is well known, and addiction to them is considered a vice. Anosognosia allows you to mask the perception of dependence and not be afraid of the consequences, with prolonged abuse, an organic psychosyndrome develops and a mental disorder develops on this basis. [8]

Rejection of one’s disease also develops in patients with damage to the central nervous system of various origins. Risk factors: traumatic brain injuries, infections, intoxications, in particular, carbon monoxide or mercury, hypoxia, ischemia, strokes, progressive atherosclerosis. Depending on the localization of the lesion focus, 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, and so on.

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 toward the disease necessary to maintain psychological health.

Pathogenesis

The pathogenesis of anosognosia, based on the above reasons, at the psychological level looks like a defensive reaction “denial”, which is seen as an attempt to avoid new undesirable information that runs counter to the individual’s prevailing self-image. The patient minimizes his disturbing situation, unknowingly underestimating its significance and thereby avoiding emotional stress.

At risk of developing anosognosia are egocentric individuals with a reduced tendency to self-criticism and excessive self-esteem.

The problem of rejection of one’s own disease arises in many conditions, is under study and has not yet been resolved unambiguously. The criteria for a unified approach to it and its manifestations (total or partial) have not been developed, therefore, there is no statistics of cases of anosognosia. [9]

Symptoms of the anosognosia

Anosognosia is observed in different groups of patients and even among relatives of patients, therefore, clinical manifestations are qualitatively different 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 wish to be treated. The first signs appear in different ways: the results of diagnostic tests, analyzes, and medical reports may be completely ignored or questioned. Some patients choose the tactics of distance or outright escape-avoiding contact with medical staff, in some cases, patients reveal an imaginary willingness to cooperate, which in fact turns into quiet sabotage and failure to comply with recommendations.

Allocate total and partial anosognosia. Among the manifestations of rejection there is an underestimation of the seriousness of the disease, a lack of awareness of its presence in itself, ignoring its manifestations, simple complete rejection and rejection with fiction and delirium. Such manifestations may be permanent or vary as pathological stages.

Alcoholic anosognosia, like narcotic, is manifested mainly by a total denial of the presence of the disease and related behavioral disorders and psychotic symptoms. Narcological patients tend to shift the responsibility for the constant abuse of psychoactive substances and related problems to other people (often they are close people), confluence of circumstances, and reveal, mainly, a complete inability to critical self-perception.

Complications and consequences

Anosognosia becomes a counterweight to treatment. Due to the rejection of the disease, time is missed when the patient can be provided with the most effective help. Often this happens in the initial stages of serious illness, when there is still no noticeable discomfort and pain, which feeds the illusion of well-being. In general, great efforts are required from the medical staff to make the patient soberly assess the situation and take measures to maintain their health, and often life.

Diagnostics of the anosognosia

First, the patient must have a disease. To have something to deny. Secondly, according to doctors and relatives, he is in no hurry to be treated, ignoring his illness or not adequately assessing its danger.

Basically, the diagnosis is made on the basis of an interview with a patient, sometimes repeated.

To assess the most common cases, such as alcoholic anosognosia, questionnaires have been created to assess the patient’s attitude to his illness as a simple lack of knowledge about it or a complete or partial denial of it. The survey lasts about half an hour, the answers are scored and interpreted accordingly instructions.

Post-stroke patients also undergo various tests, in particular, they use the “Questionnaire of executive function disorders”. When passing this test, the patient's answers about his capabilities are compared with the responses of the observer. The questionnaire includes four scales: two - subjective and objective assessment of physical capabilities, two - mental.

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

Almost always, neuroimaging of the brain (computed or magnetic resonance imaging 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 the most distorted ideas about the disease and oneself;
• moderately destructive, in which some part of the information about the disease is allowed for awareness;
• constructive when information about the disease can be realized by the patient.

Treatment of the anosognosia

Anosognosia in somatic patients mainly requires psychotherapeutic treatment, in psychiatric patients it often consists in medical treatment of a psychiatric disease present in a patient. Medications are prescribed depending on the condition of the patient. Often after the withdrawal of the symptoms of psychosis, the patient's attitude toward the disease changes.

Treatment of alcoholic and narcotic anosognosia involves psychotherapeutic assistance, often family psychotherapy, combined with narcological.

With organic brain lesions, after injuries and strokes, surgical treatment is sometimes required.

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

Prevention

Denial of their illness is formed as a protective reaction in many diseases, therefore, preventive measures can be the most common. 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, the wide awareness of the population that timely and qualified medical care can cure many serious illnesses that will become incurable in the advanced stage should play a role.

Forecast

Total anosognosia is prognostically more unfavorable than its lighter forms. Much depends on the disease in which the clinical phenomenon has formed. The most favorable prognosis is for intellectually safe people whose disease was rejected as a protective reaction to new stressful information.