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Why some people won’t accept they’re ill: Is it denial or anosognosia, a neurological condition?

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How often have you insisted that you are “fine”, even when you’re sneezing and coughing? You think everyone else is making an unnecessary fuss about your health. It’s a small cold; it will go away.

That is usually stubborn denial.

But what if you didn’t really think you had a cold? What if, you just kept rejecting all the medicines continuously because you didn’t think there was a problem?

This long-term rejection might be anosognosia: When someone is unaware of their illness. It’s a complicated and confusing condition for the one suffering with it, as well as for others to watch it.

‘Lack of insight and awareness’

In 1914, French-Polish neurologist Joseph Babinsky found himself handling an unusual case. In a communication presented to the Neurological Society of Paris as quoted by a 2010 article in the New York Times, he described two patients with “left severe hemiplegia”. This meant that they had suffered a complete paralysis of the left side of the body, including the left side of the face, left leg and foot. However, these patients didn’t know that they were paralysed. To describe their condition, Babinski coined the term anosognosia – taken from the Greek agnosia, lack of knowledge, and nosos, disease.

Babinsky was perplexed. The patient was “willing to talk”, expressed herself well and wished to meet new people. She didn’t suffer from hallucinations or confabulation. She did not complain or allude to the illness. When she was asked to move her right arm, she moved. When asked to move the left, she stayed silent. He noticed that other patients offered a myriad of strange excuses. They developed “odd” rationalisations, as he noted.

And so, began a century’s worth of debates and research surrounding the condition, with neuroscientists asserting that it is caused by damage to higher level neurocognitive processes. There is still much research surrounding this perplexing condition.

Is it a case of extreme denial?

Owing to neurological symptoms caused by structural, functional, and anatomical changes in the brain, people are not able to understand and identify the health symptoms they have, as Girish Banwari, a Dubai-based psychiatrist explains. It indicates “impaired” insight, which means a person’s fractured ability to understand and make informed decisions for the sake of their own health.

They don’t think that anything is wrong, says Banwari. People tend to confuse this condition with simple denial. In the case of denial, a person rejects reality as they find it disturbing and traumatic. “Denial is a psychological defence mechanism or way of coping with an unpleasant or painful situation,” explains Abu Dhabi-based American psychologist Miranda Montgomery. “When you’re in denial, you are absorbing the information, but you prefer to dismiss, minimise, or avoid it altogether.”

When that situation ebbs, the denial response is also calmed. However, anosognosia could also be a result of damage to parts of the brain, as Banwari explains. Denial is temporary; anosognosia can get progressively worse as the disease escalates. It’s a consequence of many illnesses and disorders, including Alzheimer’s, Schizophrenia and Bipolar Disorder. It’s a neurological symptom.

From the neurological point of view…

As a 2014 New York Times blogpost archive explained anosognosia with a rather concise example: Imagine someone who survives a stroke and is paralysed on the left side of his body but is convinced he can walk without assistance. Another example: Someone with moderate memory deficiency gets lost on the road or has accidents, but thinks she is driving just as well as ever.

The exact cause of why it occurs, and its causes, is still being understood. “In anosognosia, damage to specific brain regions, particularly the right hemisphere, disrupts the person’s ability to recognise their own deficits. This contrasts with denial, which is often a psychological defense mechanism without the neurological basis,”explains Upasana Gala, a Dubai-based neuroscientist. The regions implicated in anosogonosia, include the frontal and parietal lobes, as well as connections between them. “Dysfunction in these areas can disrupt self-awareness and the ability to perceive one’s own condition. “It’s a complex interplay of brain structures that contributes to this phenomenon,” she says.

The right parietal lobe is responsible for integrating sensory information, memory, including spatial sense and navigation. When this is damaged, the person’s ability to analyse is affected, along with difficulties in spatial skills, which is the ability to understand, reason, and remember the visual and spatial relations among objects or space. They are unable to see that their problems stem from their injury.

Memory problems are also common, as they’re unable to recognise and store new information about their condition. They also experience phases of intense impulsivity, which pushes them to act spontaneously and without thinking through actions. “This is quite probably for those who suffer injuries in the right hemisphere of the brain,” explains Montgomery. The right side of the brain controls attention, memory, reasoning and problem-solving.

The phenomenon of anosognosia could also be the result of several different lesions in the brain, according to a 2023 study published by US-based researchers Aninda B. Acharya and Juan Carlos Sánchez-Manso in the American medical journal Stats Pearl. They theorised those lesions in the prefrontal cortex, which is responsible for working memory, self-monitoring and organisation, and the insular cortex, could also lead to anosognosia. The insular cortex is involved with emotional processing and error awareness.

It can also be due to the lesions in the thalamus or left parietal region. Owing to the lesions in the brain or dysfunction due to some form of illness, the patient is unable to absorb new information regarding their problems in the context of their self-image. As a result, they deny their illness or downplay the importance of it.

Moreover, people with anosognosia, tend to unintentionally prolong rehabilitation and recovery owing to dismissing the problem. They also suffer more falls, owing to their lack of awareness.

Signs of an anosognosiac:

An anosognosiac could say the following, when confronted with addressing a mental and physical health issue:

“That’s not happening to me.”

“I don’t need any help.”

“What do I need medication for?”

While this could happen to those with denial, here are other signs to watch out for, according to the American medical platform, Psych Central:

• Confusion or irritation about a diagnosis

• Inability to notice symptoms even when pointed out

• Firm belief that there’s no need for treatment

• Refusing to talk about a condition or symptom

• Stopping medication out of feeling it’s not needed

• Suggesting that people are lying or making it up

Can anosognosia be treated?

It’s a particularly tricky condition to treat, as the treatment choice and outcome is usually linked to the cause of anosognosia instead.

While medications and therapy are the extensive solutions,Montgomery suggests being a little patient with people suffering from anosognosia. “They’re not choosing to ignore their symptoms to hurt you. This is a symptom of their condition,” she explains. “You might be scared but approach them with compassion. Do your best to avoid arguments with them, rather than trying to confront them. Otherwise, they will get more defiant and upset, and possibly take reckless steps,” she says.

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