Anosognosia is a clinical phenomenon consisting in the denial, ignoring or underestimation of the patient’s disease. With this disorder, patients do not recognize the presence of health problems, refuse treatment, do not realize the consequences of such behavior. Anosognosia is diagnosed by psychological methods: using questionnaires, conversations, clinical interviews. The causes of pathology are clarified during cerebral CT, MRI, MR angiography. Treatment includes etiopathogenetic pharmacotherapy, psychotherapy, neuropsychological correction, if necessary, coding for alcoholism, rehabilitation.
R41.8 Other and unspecified symptoms and signs related to cognitive ability and awareness
Anosognosia (Greek. “anosognosia– – denial of knowledge about the disease) – non-recognition by the patient of his physical or mental illness, its severity. For the first time, this phenomenon was described in 1899 by the Austrian neuropsychiatrist G. Anton in patients who became blind after a stroke and considered themselves sighted. In 1914 , the French doctor J. Babinsky observed a similar condition in patients with hemiplegia who were not aware of their motor defect. In honor of the authors, the disorder was named Anton-Babinsky syndrome, and later – anosognosia. In the acute period of stroke, pathology affects 10-17% of patients, with Alzheimer’s disease – about 40%, with alcoholism – 43-76%.
Causes of anosognosia
Underestimation of the state of one’s own health may be associated with an organic cerebral lesion or the phenomenon of psychological protection in patients without structural brain damage. Anosognosia is most often associated with the following conditions:
- Neurological pathologies: stroke, neuroinfections, TBI, cerebral atherosclerosis, poisoning with neurotropic poisons (mercury, carbon monoxide).
- Chronic intoxication: alcoholism, substance abuse, drug addiction.
- Mental disorders: dementia, Alzheimer’s disease, manic syndrome, Korsakov psychosis.
- Somatic and psychosomatic pathology: arterial hypertension, peptic ulcer disease, tubinfection, oncology, HIV, viral hepatitis.
The pathophysiological mechanisms of anosognosia remain controversial. There are many hypotheses explaining the uncriticism to the state of health: neurological, psychogenic, psychophysiological. In the first direction, anosognosia is interpreted as a consequence of diffuse or local foci of cerebral destruction (right hemisphere or bilateral, in the parietal, parietal-temporal, frontal lobes). A number of researchers associate anosognosia with amnestic disorders. At the same time, it is noted that the lack of a critical assessment of one’s problem does not develop due to a decrease in intelligence and dementia.
Psychogenic theory considers anosognosia as an unconscious psychological defense against information that causes anxiety, anxiety, and guilt. With the help of the strategy of denying the disease, patients try to isolate themselves from what threatens their habitual self-perception, causes the strongest emotional experiences and pain.
At the neurophysiological level, anosognosia is explained by an increase in the threshold of susceptibility by neocortex neurons to signals emanating from the structures of the limbic system. At the same time, serving at a certain stage as a means of psychological protection, in the future anosognosia begins to hinder the formation of the necessary adaptive mechanisms, adequate cognitive and emotional reactions to the disease, i.e. it acts as a maladaptive form of behavior.
Psychophysiological theories consider various aspects of anosognosia, including sensory and cognitive deficits. Sensory disorders are caused by a violation of proprioceptive sensitivity, an individual’s adequate perception of his own body and physical dysfunctions. Attempts are also being made to explain the rejection of information about the disease by selective cognitive deficits, deterioration of regulatory functions, and violation of interhemispheric interaction.
The lack of criticism of one’s condition can be expressed in various degrees and forms. Anosognosia can be total (complete non-recognition of the problem without any arguments) and partial (partial denial of the disease based on evidence). Also , according to the degree of severity of the attitude to pathology , the following manifestations of denial are distinguished:
- Ignoring – not noticing an obvious defect (paresis, paralysis) against the background of awareness of it.
- Underestimation – recognition of the problem, but downplaying its severity.
- Unconsciousness – rejection of information about your condition.
- Denial – unwillingness to know about your problem and its complete non-recognition.
- Denial with delusional disorder, confabulations, pseudo-reminiscences.
By the nature of the denied defect , the following types of disorder are distinguished:
- anosognosia of hemiplegia – denial of motor defects by patients; occurs with paralysis of the left half of the body in right-handed people with CVA;
- anosognosia of blindness (Anton’s syndrome) – denial of vision loss; characteristic of persons with damage to the cortical part of the visual analyzer, atrophy of the optic nerve;
- anosognosia of deafness – non-recognition of hearing loss; associated with damage to the auditory cortex or the conductive pathways of the auditory analyzer;
- anosognosia of aphasia – ignoring errors and violations of the meaning of speech; occurs with acoustic-gnostic aphasia;
- anosognosia of pain is the loss of an adequate response to pain, associated with right-sided or bilateral damage to the parietal lobes.
Symptoms of anosognosia
Manifestations of the disorder consist in the fact that a sick person continues to consider himself physically healthy and full-fledged, despite the objective need for treatment. The patient lives in captivity of the illusion of imaginary well-being, does not recognize his physical infirmity, does not accept offers of help.
Anosognosia in focal brain damage
Patients with left-sided hemiplegia caused by acute cerebral circulation disorder believe that they can control their left limbs, and unsuccessful attempts to make arbitrary movements are explained by the fact that they do not want to do this at the moment. At the same time, they can tell that they recently walked, did some work. With a mild degree of anosognosia, patients underestimate the severity of motor disorders, do not show concern about this. Their orientation in time and space is not broken.
With Anton’s syndrome (cortical blindness), there is a denial of blindness, and illusory visual images are perceived by patients as real. Often patients rely on their premorbid memories and correctly describe certain objects, but currently they cannot see them.
Sensory aphasia is accompanied by logorrhea and paraphasias, while patients do not recognize errors in speech. They believe that they are speaking correctly, they get angry when others do not understand them.
People who abuse psychoactive substances deny the existence of chemical dependence, citing various arguments (“alcohol relieves stress”, “light drugs are allowed in other countries”, “I can stop whenever I want”). They shift responsibility for their morbid addiction to others, usually to close relatives.
Symptoms of addiction – tremor of the hands, shakiness of walking, sloppy appearance, signs of withdrawal – are not noticed. Patients do not associate the deterioration of physical health with alcoholism. They react aggressively or indifferently, disinterestedly to the offer of help from others. At the same time, they may overestimate their capabilities, build unreasonably optimistic plans, and show unreasonable optimism about the forecast.
Anosognosia in relatives of alcoholics and drug addicts can be expressed in the form of codependency, passive acceptance of the situation, denial of the presence of a problem in a loved one.
Avoiding recognition of the disease acts as an insurmountable barrier to its treatment. Anosognosia can lead to the progression of the disease, deterioration of the condition and life-threatening complications. It is proved that a decrease in awareness of paralysis significantly worsens the recovery of both motor and cognitive functions during rehabilitation, contributes to the aggravation of post-stroke depression.
In addition to the underlying disease, patients may also be denied concomitant pathologies, which further aggravates the condition. As a result of ignoring alcohol addiction, people lose their professional skills, lose their jobs, family. In the advanced stages of alcoholism, alcoholic encephalopathy, cirrhosis of the liver develops.
Assessment of the decrease in awareness of the disease is carried out by a psychotherapist (clinical psychologist, neuropsychologist). Depending on the underlying pathology, patients may be observed by a neurologist, a narcologist. At the initial admission, the physical status (motor, sensory abilities) is examined, clinical observation is carried out, family members are interviewed about the real capabilities of the patient. To clarify the diagnosis , use:
Pathopsychological testing. The severity of awareness of sensory-motor deficit is assessed using special questionnaires and scales (Anosognosia scale, Neurorehabilitation scale for assessing patient competence, DEX questionnaire, Alcohol Dependence Test). In some cases, questionnaires are offered to be filled out simultaneously by the patient, relatives caring for, and the attending physician.
Methods of structural neuroimaging. To analyze the morphological basis that led to anosognosia, MRI and cerebral CT are performed. Assessment of cerebral blood flow is carried out using ultrasound of the vessels of the head and neck, MR angiography.
Treatment of anosognosia
The primary task in denying the disease is to convince the patient that there is a problem and motivation for treatment. Medical rehabilitation is carried out by a multidisciplinary team consisting of a neurologist (psychiatrist-narcologist), a psychologist, a physical therapy doctor, a speech therapist.
- Psychotherapy. Cognitive-behavioral, rational psychotherapy, hypnosuggestion are used in working with patients with anosognosia. In severe mental disorders that threaten the life of the patient and others, forced hospitalization is used.
- Drug therapy. Depending on the genesis of anosognosia, antihypertensive drugs, nootropics, neuroprotectors, anticoagulants, antidepressants, neuroleptics are prescribed. Against the background of drug therapy of the underlying disease (TBI, stroke, psychosis), the attitude towards the disease changes, awareness of the need for treatment comes.
- Addiction therapy. It is carried out in several stages: detoxification, drug treatment, rehabilitation. Detoxification includes infusion therapy, ILIB, plasmapheresis. The coding of alcoholism can be carried out with the help of the introduction of drugs, the insertion of implants, hypnosis, psychotherapeutic techniques. Subsequently, the patients were shown socio-psychological rehabilitation in special centers.
Prognosis and prevention
Anosognosia caused by local cerebral injuries regresses as the course of neurorehabilitation is carried out. The prognosis for chemical addictions and neurodegenerative processes is more complicated and uncertain. A lot depends on the competence of medical workers and the participation of relatives in the patient’s mood for treatment. Prevention of anosognosia consists of a set of measures to prevent vascular, infectious pathologies, head injuries, substance abuse. They include medical examinations, measures of social and psychological assistance to at-risk groups for the development of addictive disorders.