Anosognosia: What happens when a person is unaware of their mental disorder?

A certain 80-year-old begins to exhibit embarrassing moments of confusion but believes he is still fit to run the world’s most powerful country until the clamor of those around him forces him to resign. A successful medical student begins to lose weight by subjecting her body to starvation, vomiting and laxatives, but does not consider herself to be suffering from any disorder. She simply thinks she’s fat. Another woman, after a painful separation, develops the idea that her neighbors are plotting against her, and she becomes distressed, isolated and impoverished as her children look on in bewilderment.

None of these three patients will even consider seeing a psychiatrist because they cannot see that they have a mental disorder, a situation experienced in many households which generates a feeling of impotence among family members and is often not even discussed.

As early as 1914, neurologist Joseph Babinski presented a case of anosognosia or lack of awareness of mental illness. When asked to lift her left arm, a woman with hemiplegia which had paralyzed one side of her said that she had already lifted it. Evidently, she could not lift it, but she believed she had done so. Babinski also coined the term anosodiaphoria, applied to patients who were aware of their hemiplegia, but were completely unconcerned and reported no discomfort about it.

Another fascinating neurological scenario is that of cortical blindness, in which blind patients believe they can see. Despite stumbling about, they assume that the problem concerns a lack of light or that things have been moved around. They become enraged or fabricate stories to back their denial of the disorder.

Clearly, in some brain lesions, located predominantly in the right hemisphere, the patient is unaware of any limitation. Anosognosia occurs in 80% of patients with Alzheimer’s and in 60% with mild cognitive impairment. But it is also common in psychiatric disorders: the psychotic patient firmly believes that all his ideas and perceptions are real and not the product of any disorder. The person with bipolar disorder believes that it is the world and not their brain that has changed while the depressed patient becomes sunk in what they perceive as a universal, existential hecatomb, hence a frequent suicidal hopelessness.

These conditions pose a challenge to doctors, because they interfere with the balance between the bioethical principles that govern medicine, namely patient autonomy — acting for the patient’s benefit and seeking their wellbeing, nonmaleficence — not causing harm, and justice — seeking fairness and impartiality. One could proceed as in the past to terrible coercive measures “for the good of the patient.” Allowing the patient full autonomy, on the other hand, would have conditions such as Alzheimer’s, psychosis and anorexia running wild, with disastrous consequences for the patient, his family and others.

In the heated debate on social networks, psychiatrists are sometimes criticized for being too coercive, with the term “psychiatric violence” often employed. Or they are accused of the opposite — not admitting the patient until the situation is borderline, tolerating realities that carry a risk of aggression, and being overly good-natured or contemplative towards their actions. When tackling the arduous task of managing these situations, mental health professionals must be measured and responsible, capable of evaluating and re-evaluating the patient’s capacity for judgment, and, of course, optimizing margins for persuasion, dialogue, agreement and emotional accompaniment.

Can we reduce coercive measures in the treatment of these serious disorders? Yes, there is room to do so. But this requires a change of mentality at different levels — health, social, educational and judicial — and considerably more resources — professionals, training, infrastructure. While humanizing mental health care, we cannot leave families defenseless. Intensive outpatient services, home hospitalization and day hospitals are steps in the right direction. And we must not forget that, in potentially extreme aggressive situations, our duty will continue to be to protect life.

The issue of anosognosia makes us aware of our own deficits and limitations. As individuals and as a society, we also have blind spots. In psychotherapy, there are therapeutic narratives that find agents to blame for personal suffering in the remote past or in the patient’s environment. But there are other responses — harsher but perhaps more therapeutic — that make the patient aware of an ingrained, automatic and harmful interpersonal pattern, which can be modified.

A few decades ago, it seemed normal to smoke tobacco or to make homophobic jokes. Now, we seem to be blind to a new toxicity. What beliefs, convictions or habits will we be ashamed of in a few years? Let us at least be aware of our blindness and be prudent and cautious as we go about our business. Otherwise, as in Anton-Babinski’s cortical blindness, we will stumble, hit objects and people because we will believe that someone has suddenly switched things around. There is a destructive and befuddled fury in anyone who is determined they see but is in fact completely in the dark.

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