Understanding Anosognosia in Bipolar Disorder: Why Some People Don’t Believe They’re Sick
Have you ever met someone with bipolar disorder who insisted they weren’t sick or even believed that everyone else was the problem and not them? Maybe even you have felt this way yourself. This is not unusual. In fact, Up to 50% of people with bipolar disorder experience a symptom called anosognosia. — a clinical inability to recognize one’s own illness. Overall, at least one in five people with a serious mental illness, such as bipolar disorder, lack the ability to understand that they are not well. according to the Treatment Advocacy Center. This symptom does not only affect the person who lives with it; It also has profound impacts on your loved ones. Understanding anosognosia in bipolar disorder is key to understanding why treatment noncompliance (or complete medication refusal) occurs and how it can be addressed. Let’s delve into what it means to be unaware of bipolar disorder and the far-reaching effects of anosognosia.
Why do people think they don’t have bipolar disorder?
There are many reasons why a person may not believe they have bipolar disorder. There are coping skills, such as denial and defensiveness, that can cause a person to claim that they do not have bipolar disorder, but these are not the same thing. If a person simply denies it, they would recognize that their behavior, thoughts, and feelings have changed, but they would not characterize this change as an “illness.” Let’s think, for example, of a person addicted to alcohol. They may acknowledge that they drink more and miss work because of it, but deny that it is alcoholism. They deny that they need treatment or that it would help them.
However, when a person has a clinical lack of insight, known as anosognosia, it is different.
What is anosognosia in bipolar disorder?
Anosognosia in serious mental illnesses such as bipolar disorder is actually a lack of perception of a biological nature. According to the Treatment Advocacy Center:
“On the other hand, someone with anosognosia may have no idea that there has been any change or deterioration in their mental state, behavior or functioning. “Anosognosia is thought to be the most common reason why people with serious mental illnesses do not comply with treatment.”
There are other diseases, such as Alzheimer’s, in which anosognosia is also common and is usually present in people with certain types of traumatic brain injury.
Brain differences in anosognosia in bipolar disorder
People with anosognosia have physically different brains than those with insight. Yes, anosognosia can often be seen on brain scans.
Much of the research on anosognosia has been done in people with schizophrenia, as it has been recognized in that group the longest and affects approximately 60% of people with schizophrenia. However, putting together the research we have, The following are examples of brain differences in people with anosognosia. (no, it is not necessary to read or understand every word):
- Low knowledge has been associated with Less prefrontal gray matter volume, greater frontal lobe dysfunction, and poor memory of autobiographical life events..
- Many studies have found a relationship between damage or decreased volume in the right hemisphere of the brain and anosognosia. Specific right hemisphere areas impacted include the inferior temporal lobe, dorsal lateral prefrontal cortex, and inferior parietal lobe.
- Smaller amounts of gray matter. They have been found in many areas of the brain of people with anosognosia, such as the medial superior frontal gyrus, inferior frontal gyrus, inferior temporal gyrus, cerebellum, left posterior cingulate cortex, right precuneus, cuneus, left superior, the middle left and the lower right. temporal gyri, right inferior parietal lobe, right supramarginal gyrus, right anterior cingulate, left posterior cingulate, and inferior temporal region on both sides of the brain.
- People with anosognosia have been found to have smaller overall brain volume, smaller white matter volume, and smaller cortical thickness in many areas of the brain.
- Associations between anosognosia and Brain connectivity, hemispheric asymmetry and deficiencies in midline brain structures.among others, have also been shown.
While research has found the above, brain scans are not used when it comes to anosognosia. These relationships are not yet at a stage where they can be singularly definitive.
Why are brain differences in anosognosia in bipolar disorder important?
All of this is to make it clear that people with anosognosia are not the same as those who deny it. These people have a different brain that is functionally not able understand that he is sick. it’s a clinical lack of insight. When they deny that they are sick, they believe it is as certain as me sitting in front of my laptop. They refuse treatment for a good reason: they truly believe that no disease exists and therefore nothing needs treatment.
Anosognosia can kill people with bipolar disorder
And here lies the crux of the problem. If bipolar disorder were harmless, it wouldn’t matter if a person didn’t believe they had it; The thing is, bipolar disorder is far from harmless. Bipolar disorder is a devastating illness that, if left untreated, can be dangerous for the affected person and those around them. A very recent study observed that a longer duration of untreated illness was associated with a higher risk of suicide attempts, a poorer response to treatment, poorer overall functioning, and a higher number of medical and psychiatric comorbidities. In other words, untreated bipolar disorder makes a person sicker and puts their life at risk.
Treating someone with bipolar disorder who is “not sick”; Treating someone with anosognosia
Trying to help someone with anosognosia can be extremely difficult since they do not want treatment. There is a tremendous book that you should read if you are in this situation: I’m not sick, I don’t need help! How to Help Someone Accept Treatment: 20th Anniversary Edition. This book, for Xavier Amadorguides you through anosognosia and how to deal with it like no other resource. When it comes to convincing someone with anosognosia to try the treatment, I’ll let Amador detail the technique (definitely not a simple sentence).
Treatments for anosognosia
There are treatments that have shown promise in the treatment of anosognosia. Just because a person has a clinical lack of knowledge of their illness does not mean they are doomed to go untreated forever.
Treatment options include:
- Early and effective treatment can prevent or decrease anosognosia. Because anosognosia often occurs in people experiencing psychosis, it means that it is important to aggressively treat these people as soon as psychosis occurs. Early psychosis programs exist and can help people in this situation.
- Psychological therapies that can help They include cognitive behavioral therapy for psychosis, motivational interviewing, metacognitive insight and reflection therapy, and mindfulness-based treatments.
- Transcranial direct current stimulation (tDCS) is a type of non-invasive brain stimulation that can help develop perception.
Unfortunately, treatment does not help everyone.
It may be important to explore treatment options for a person with bipolar disorder and anosognosia, even if the person ultimately accepts treatment, because anosognosia can drive noncompliance with treatment over time. You want a person with bipolar disorder to not only begin treatment but also stay in treatment to avoid relapses, involuntary hospital stays, worse psychosocial functioning, aggressiveness and worse prognosis.
The downside of treating a person with bipolar disorder who has anosognosia
It sounds illogical, but there are actually disadvantages when it comes to knowing your own disease better. Think about what it feels like to discover that you have bipolar disorder. It’s not a fun discovery to make. I remember doing it myself and I remember crying endless tears over it. I couldn’t conceive of a life where I had to take medication every day. The idea of it was unthinkable. So, yes, this type of discovery can make a person feel worse.
High levels of knowledge of a person’s illnesses have been associated with:
And while that list is damning, it’s a far cry from the list I could give you where the person with untreated bipolar disorder ends up on the streets, in jail, or even dead. The above list can be discussed. Ending up in prison is much more difficult to deal with.
Believing that you are not sick and anosognosia
I think I’ve argued that simply denying that you have bipolar disorder is not the same as having anosognosia. I also think I have argued that developing insight is critical in bipolar disorder. I always tell people that you can’t fight an enemy you don’t understand, and you certainly can’t fight an enemy you can’t see.
No matter how frustrating it is to deal with a person who thinks they are not sick, the bottom line is empathy. Remember, it is their illness that makes them believe that. They don’t try to be difficult. They are not arguing with you to argue with you. They literally can’t see what you do. They are blind. Not you. Don’t be mad because they keep crashing into the streetlights.
This is not to say that it is an easy situation; clearly it is not. Everyone who faces it also needs empathy. But read the book I recommended and take one step at a time. Others have found information. Hopefully your loved one can do it too.
Have you experienced anosognosia in yourself or a loved one? Share your thoughts below.
Primary source
- Silver, S., Sinclair Hancq, E. and Treatment Advocacy Center. (2023). Anosognosia. In Anosognosia. https://www.treatmentadvocacycenter.org/wp-content/uploads/2023/12/TAC_ORPA_ResearchSummary_Anosognosia.pdf
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