Anosognosia

On this page we discuss different degrees of no insight into the disease or reduced insight into the disease.

 

What does it mean?

Anosognosia means a disturbed or denying insight into illness.
It is a lack of awareness that a brain injury has occurred or it is a lack of awareness of its consequences.
Sometimes there is awareness of illness. The person knows he or she has a disease. But there is no insight into the disease. There is no insight into the consequences that the disease has for the person with the injury.

Translated from Greek, anosognosia means 'failure to recognize disease': 'nosos' (disease) and 'gnosis' (knowledge).

Definition: Anosognosia is the clinical phenomenon in which a patient with a brain disorder appears to be unaware of the decline in neurological and/or neuropsychological function, which is apparent to the physician and others.
Anosognosia appears to manifest itself differently in different neurological disorders.
Anosognosia is often caused by the body not sending the right signals. So it arises from inability and not from unwillingness.
This actually makes it a neurological consequence in people with brain damage.

 

How common is it?

Anosognosia occurs in 10% - 18% of people with a stroke with a hemiparesis.
60% of people with mild cognitive impairment have this reduced insight into their illness. The rates of anosognosia in people with severe traumatic brain injury or with a brain tumor are not known.

Some form of anosognosia occurs in 81% of people with Alzheimer's disease. The most common phenomenon is that they deny or trivialize the problems with their memory.

 

Examples

People with anosognosia as a result of brain damage show a lack of awareness of, for example, motor problems such as half-sided loss (hemiparesis), reduced sensation in the arm, leg or face on one side of the body (hemisensory damage), memory problems, cortical visual problems (Anton syndrome), some specific hearing problems and language disorders.

It can occur that people don't understanding that part of their body belongs to him or her. The most extreme form of anosognosia is that a person cannot recognize that he or she is paralyzed and does not experience the limp limbs as her or his own. This is called alien arm syndrome. “That arm and leg are not mine.”
It also occurs with right parietal lobe lesions.

 

Other names for this extreme form of not recognizing one's own limbs are: asomatognosia, somatoparaphrenia, anosodiaphoria, misoplegia, personification, kinesthetic hallucinations, phantom limbs.

 

In anosodiaphoria, the patient realizes that there are motor function limitations but seems indifferent to it. This is probably caused by a disorder in emotional communication or emotional experience.

 

In somatoparaphrenia, the patient has the feeling that the arm and leg are limbs of someone else. For example, these people do not realize that walking is no longer possible and they get out of bed and then fall. People with anosognosia therefore fall more often.

 

Specifically in Alzheimer's disease or other forms of dementia, the patient denies that he or she has memory problems or denies that he or she can no longer properly care for himself or herself or the household.In somatoparaphrenia, the patient has the feeling that the arm and leg are limbs of someone else. For example, these people do not realize that walking is no longer possible and they get out of bed and then fall. 

 

Anton's syndrome

Some people with cortical blindness suffer from a condition called visual anosognosia. Another name for this is Anton's syndrome.

After two-sided (bilateral) damage (usually a cerebral infarction) to the occipital lobe, the patient does not seem to notice that he or she has become blind and therefore does not behave accordingly. In fact, the person can 'invent' what he or she sees (confabulate), or can find his or her way using memory and hearing. The parietal and temporal lobes may also be involved in Anton syndrome.

 

The phenomenon is also described in women who have a temporary loss of vision during childbirth due to hemorrhage of the posterior cerebral and/or communicating arteries. During this time, they may be completely unaware of this complete visual loss.

 

The syndrome is also called Anton-Babinski syndrome. It is named after the doctors who first described the syndrome: Gabriel Anton (neurologist and psychiatrist) and Joseph Babinski (neurologist).

 

Where in the brain?

The phenomenon of anosognosia mainly concerns people with brain damage to the right side of the brain (causing symptoms on the left side of the body). They may have a remarkably poor insight into their possibilities and limitations.

The right parietal lobe is often associated with anosognosia.
Anosognosia can also occur with damage to the frontal lobe, temporo-parietal region, insula, thalamus or basal ganglia.
Most commonly, the middle cerebral artery (MCA) is involved in anosognosia in right parietal lobe stroke.

There are more brain networks that influence the development of self-awareness of a person's motor function in the 'here and now'.
The prefrontal cortex is involved in working memory, self-control and organization.
The insular cortex is involved in emotional processing and error awareness. The reduced cooperation between prefrontal, parietal and cingulate cortex can lead to a lack of awareness of cognitive and sensorimotor function.

 

Impaired self-awareness (ISA)

Limited insight into illness after brain injury means that a person is less able to assess and assess their own strengths and weaknesses and to assess the extent to which the brain injury will affect daily life at the moment and in the future.
ISA is a milder example of anososognosia, which is described on this page. The patent knows that he or she has had a stroke or accident, for example, but does not experience the limitations as the environment does. This can make rehabilitation difficult. If someone does not know what is wrong with him or her, he or she cannot work or train on it. There is a disturbance in 'self-awareness', being aware of one's own situation neurologically and cognitively. The person is therefore genuinely unaware of the problem. It is not unwillingness but inability.
Limited insight into the disease is more common in the recovery phase. As time goes on it becomes less common.

It is known that people with severe traumatic brain injury may significantly underestimate their own disorders in memory and social interaction, for example the ability to control emotional reactions.
Because of this partial insight into their own cognitive and behavioral problems, these people exhibit characteristics of defensive denial.
There also often appear to be problems with taking initiative, self-control and planning (as is the case with some people with anosognosia). Notable may be a slowness in finger speed movements, which has been shown to be a marker of the overall severity of traumatic brain injury.
Using brain scans, researchers have found no evidence of a correlation between reduced insight into the disease and the location of the injury in the brain, but they did find a correlation with the number of lesions in the brain in traumatic brain injury. These studies suggest that impaired disease insight (ISA) is related to an underlying neurological disorder.

 

Measure and treat anagnosia 

There are currently three measuring instruments that have sufficient psychometric qualities and can be used to measure insight into illness.

These are the following measuring instruments:

• the Patient Competency Rating Scale
• the Awareness Questionnaire
• the Self-Awareness of Deficits Interview

 

In order to improve insight into illness, an intervention is required that is exclusively aimed at improving insight into illness, depending on the cause. To improve limited disease insight in the recovery and chronic phase after brain injury, an intervention consisting of the following components can be used:

• training functional skills in realistic situations
• use multiple forms of feedback (verbal and (audio)visual)
• applying a Socratic dialogue

 

How to deal with it as a partner / family member?

If the partner or environment points out the limitations and consequences to the person, this can be accompanied by major arguments about whether or not something is possible.
Someone can insist at all times that he or she is not bothered by this, or try to trivialize the effects or explain the logic of shortcomings.
This can lead to dangerous situations if the person with the injury overestimates him-or herself.
For the person with an injury it feels as if he or she is not taken seriously and is underestimated. After all, he or she does not experience the problem. He or she continues to hold on to the old self-image.

 

It is wise to stay out of the argument and, if necessary, ask a professional to explain what is going on. Realize that the person really doesn't see it. The relationship and bond of trust are and remain important. The person may only start to doubt her or his own experience if she or he feels safe and relaxed with the person who confronts her or him. Not if she or he feels unsafe and remains angry with the partner, caregiver or professional. Keep the conversation going!

 

Continue to explain that you are concerned, in the hope that the person can get used to the idea that the own experience is incorrect. Withhold your judgement. Do inquire how the person with injury experiences the situation. Try to make agreements about things that are not going so well.
Stay aware that the person with brain damage is not deliberately telling 'untruths'.
Give compliments for what is going well. Take into account the feeling that the situation evokes in the person with a brain injury.
Discuss whether (additional) rehabilitation treatment could be useful. 

 

Gradually get to know the invisible consequences

The label of 'disturbed insight into illness' is often given while someone only gradually gains insight into the consequences of a brain injury, especially the invisible consequences. These consequences are only discovered by repeatedly encountering a limitation. That person is usually aware of the illness. Sometimes the environment realizes a consequence more quickly than the person suffering from a brain injury.

 

After all, no one is given a manual of invisible consequences that mean someone is no longer able to do something because of the injury. Take the consequence reduced stress resistance, for example. This is only discovered when someone is in a stressful situation. Not until then. Only in a second or third stressful situation a person may notice that during stress she or he no longer has an overview and has difficulty thinking.

 

There are indications in the literature that a (neuro)psychotherapeutic treatment is more suitable for improving limited insight into illness after brain injury that arose from psychological denial than the application of confrontational feedback.