Anosognosia: Causes, Symptoms & Treatment

Anosognosia is characterized by a lack of awareness of physical deficits or illnesses. A right hemispheric parietal lobe lesion is usually present. Because there is no awareness of illness, successful therapy is very difficult.

What is anosognosia?

Stroke is the main cause of organically induced anosognosia. In these cases, the affected patients cannot perceive the failures of one half of the body or some sensory functions. Anosognosia is the failure of the affected person himself to recognize obvious physical disabilities. For example, the patient denies hemiplegia, blindness, or deafness. Translated from the Greek, the term means denial of a disease. Anosognosia occurs in two forms: on the one hand, it can be a failure to recognize the disorder and, on the other hand, a failure to want to recognize the disorder. While the inability to recognize is more likely to be caused by neurological and organic reasons, the unwillingness to recognize is usually a psychopathological disorder. In turn, a total of four subtypes of anosognosia are distinguished:

  • The cortical blindness
  • The asomatognosia (denial of own extremities).
  • The somatoparaphrenia (assignment of own extremity of another person).
  • The anosodiaphoria – in this case, the own disease is called a trifle. The disorder is ignored and denied by patients.

Causes

Anosognosia is very often caused by a right hemispheric parietal lobe defect. This can very often be triggered by a stroke. Due to the damage of the right brain hemisphere, the left brain hemisphere with its speech center dominates. Each brain hemisphere coordinates the functions of the respective opposite half of the body. Therefore, if the right hemisphere of the brain is damaged and at the same time the communication of both hemispheres is interrupted, left-sided body paralysis may occur, which is ignored and explained away by the affected patients. The same applies to cortical blindness or certain forms of deafness, which are based on information processing disorders in the brain. Usually, only left-sided body disorders are ignored, since the intact left hemisphere of the brain coordinates exclusively functions of the right hemisphere of the body. In case of disturbances in the left brain hemisphere, the right brain hemisphere dominates. However, the effects are usually not so serious with regard to anosognosia, because the right brain hemisphere then partially takes over functions of the left brain hemisphere. Stroke is the main cause of organically induced anosognosia. In these cases, the affected patients cannot perceive the failures of one half of the body or of some sensory functions. However, there are also psychopathological causes of anosognosia in a broader sense. These occur in schizophrenia or dementia, among others. Schizophrenia is characterized by disturbances of perception, thinking and ego function. Therefore, there is no possibility of insight into the illness for these patients in the acute phase of the disease. In dementia, extreme memory loss prevents illness awareness.

Symptoms, complaints, and signs

Anosognosia is not a disease in its own right, but a symptom of an underlying disorder. It usually occurs in the context of a stroke. However, other disease processes in the brain can also cause damage to the right hemispheric parietal lobe. As a result, hemiplegia of the left side of the body is ignored by some patients. They continue to behave as if there is no limitation. The result is, for example, frequent falls with injuries. The many minor accidents are explained by clumsiness, among other things. Blindness and deafness, which are caused by disturbances in information processing, are also denied. Blindness is explained by external causes such as darkness, among others. In some cases, mainly left-sided limbs appear strange or nonexistent. The disorder known as neglect is a special form of anosognosia. In neglect, in addition to left-sided impairments, the entire left side of the body and all processes occurring on the left side of the body are often ignored.Patients wash only the right side of the body, shave only the right side of the face, or eat only from the right half of the plate. In psychopathological diseases such as schizophrenia or dementia, anosognosia may refer to all kinds of physical limitations. Here, there is a lack of general disease insight regarding the underlying disease and its symptoms. In dementia, the symptoms of the disease are literally forgotten, and in schizophrenia, they are often reinterpreted.

Diagnosis and course

Anosognosia can often be quickly diagnosed when obvious disabilities are stubbornly denied. Some neuropsychological testing procedures are available to diagnose a neglect. Drawing, search tasks, copying, and reading tasks allow the doctor to quickly diagnose a neglect. For example, drawing a clock only halfway or ignoring words to the left while reading.

Complications

Anosognosia often leads to complications. These can vary depending on the form and severity of the anosognosia. Characterized or defined, anosognosia is the failure to recognize physical deficits and/or diseases. This non-recognition and denial of the obviously existing physical deficits or diseases can lead to various problems in everyday life. To a large extent, this is due to the fact that the patient expects himself to perform activities that he should not or cannot perform due to the actual deficit or illness. This can result in injuries or worsening of the respective existing illnesses. It is difficult or even impossible to convey to the patient that he or she is unable to perform certain activities or should refrain from doing them for health reasons. It is clear to the patient that he himself is not ill and does not suffer from a physical deficit. This is not a case of “ignoring” the suffering but of actually not being aware of it. This makes it difficult to make clear that certain behaviors should be stopped. Furthermore, in the context of anosognosia, so-called confabulation often occurs. Here the patient tells obviously untrue things, which appear to him personally however as true. At the moment of telling, he is convinced of the truth of what has been said. This can lead to problems in the interpersonal sphere, which can also be seen as a “complication” in the context of anosognosia.

When should you go to the doctor?

Going to the doctor in the case of anosognosia should generally be classified as immediate. However, it is problematic that this condition is a kind of paradox. In most cases, the diagnosis of an existing underlying disease has already been made and the patient is fully informed. In addition, there is anosognosia and thus misperception. Despite sufficient symptoms, the affected person himself has a different assessment of the situation and often does not follow the advice of the specialist. If the trust in the relatives and other caregivers of the social environment is great enough, it is possible that a patient of anosognosia consults a doctor regularly. This would be optimal, as influence can be exerted in this way. Nevertheless, it can be expected that the patient will still not follow medical advice due to the selectivity of his own perception and will not seek the way to the doctor. For this reason, it is recommended that relatives consult with the physician, provide comprehensive information about the patient’s state of health and gently try to exert influence. Repeatedly pointing out comparative cases or test results of imaging procedures as well as clinical studies can be helpful to repeatedly activate the awareness of one’s own disease. It is helpful if relatives are able to immediately assist the affected person in situations of overestimation.

Treatment and therapy

Fortunately, prolonged treatment of anosognosia is usually not necessary. It resolves on its own after a few days to a few weeks in most cases. In general, it is difficult to treat patients with anosognosia because of the lack of insight into the disease. Of course, part of the therapy is that the patient participates voluntarily. In severe cases, in which anosognosia persists for a longer period of time, insight into the disease must first be generated through psychotherapeutic treatments. Especially in the case of a neglect, there are a number of therapeutic procedures.Among other things, the damaged hemisphere of the brain can be temporarily activated by caloric stimulation, with either cold or warm water flushed into the auditory canal. Patients with schizophrenia require medication, which may be applied compulsorily. Afterward, insight into the illness usually increases again, which then prompts patients to voluntarily take the medication.

Outlook and prognosis

The disease is based on damage to specific cortical areas on the right side of the cerebral hemispheres. According to current scientific knowledge, the human brain areas can only be inadequately cured or not cured at all. Therefore, the existing impairments remain constantly present or may continue to progress. Worsening of the health condition depends on the present cause of anosognosia. In most cases, the disease is suddenly caused by a suffered stroke. Here it can be assumed that for a long time there will be no changes in the existing symptoms. The symptoms will remain constant because there are few options for effective therapy or medical care due to the patient’s lack of insight into the disease. Many patients refuse medical care due to the lack of awareness of the physical complaints. If an underlying psychopathological condition is present, there may be further deterioration of health and increase in symptoms. In dementia, the deterioration of the functional capacity of brain areas progresses gradually, usually over several years. This leads to an expansion of the damaged tissue with a simultaneous reduction in mental possibilities. Non-recognition and non-memory increase. As the disease progresses, motor impairments continue to occur in addition to orientation problems and loss of knowledge.

Prevention

Anosognosia cannot be prevented. It occurs in the context of strokes and psychopathological disorders. Only the best possible treatment and follow-up of these disorders can reduce the risk of recurrence of anosognosia.

Follow-up

After anosognosia, regular follow-up visits must be taken. Usually, follow-up focuses on providing the patient with appropriate therapy by identifying any triggers. The patient should see a neurologist every six months. In addition, follow-up visits by the ophthalmologist, otologist, or orthopedist must occur at regular intervals, depending on the condition the patient refuses to recognize and the associated symptom picture. Follow-up care includes psychological counseling. Provided that the patient agrees to continue the therapy, further measures can be initiated. For example, behavioral therapies and cognitive training are offered to reduce the risk of recurrence of anosognosia. Follow-up care includes a medical history, during which the patient once again takes a close look at his or her fears. If the patient acknowledges the condition and has it treated, no further medical consultations are needed. If the patient does not acknowledge the illness, further therapies are considered. In older patients, psychological treatment is eventually discontinued if there is no improvement in recognition. Nevertheless, an attempt must be made to convince the patient to seek treatment for the original condition.

This is what you can do yourself

Because the patient in anosognosia either cannot or will not recognize the disorder from which he or she is suffering, self-help is usually out of the question. Supportive measures beyond medical care must be provided by the patient’s social environment. What is required for this depends on the nature of the underlying disease that the patient is suppressing. If it is a case of hemiplegia or deafness, measures that serve to prevent accidents are usually sufficient. As a rule, patients are no longer able to drive a motor vehicle independently. If the patient does not understand this, the car or bicycle must be secured against his or her will if necessary. Patients should not use public transport alone, as the unconscious loss of a sensory organ greatly increases the risk of accidents. Dangerous points in the living environment should also be secured.These include, for example, sharp-edged pieces of furniture, open fires, hot stove tops and steps of all kinds. It is usually also beneficial if the social environment makes the patient aware of his repressed suffering, with due subtlety. In the case of visible deformities, an effective method of confrontation is to photograph the patient and show him the photograph immediately afterwards. Visible deformities can then no longer simply be rationalized away by the affected person. The patient is thus forced to confront his or her suffering.