Anosognosia: when we do not perceive our disorders

“Pedro suffered a stroke a month ago. Due to this cardiovascular accident, he suffered a hemiplegia that has paralyzed the left side of his body, unable to move his limbs. During a scheduled visit to his doctor, he performed a complete examination, making it clear that Pedro was still unable to move his left arm and leg. However, Pedro indicates that he does not have any physical problems and that he moves normally, indicating with total conviction that in fact during the exploration he has been doing all the movements that have been indicated to him in correct way ”.

This case reflects that Pedro has the belief that his arm is moving normally, there being a clear difference between what he believes he does and his actual performance. We are facing a case of a phenomenon known as anosognosia.

What is anosognosia?

We understand by anosognosia a special subtype of agnosia, in which the patient is unable to recognize the existence of a deficit in functioning despite the fact that it may be evident to others. It is a question of a lack of awareness of the disease circumscribed to the recognition of one's own deficit, and the same individual may be capable of detecting the same problem in other people.

Anosognosia is not a disorder by itself, but is classified as symptom, as it only appears associated with the existence of a disorder and informs us of its existence.

Although the study of anosognosia is very frequent in the treatment of hemiplegia, anosognosia is not limited only to this disorder, but can come from a large number of brain lesions that do not have to be associated only with the problem when motor system, but also the perceptual system (it is typical to observe its presence in patients with cortical blindness) or other disorders, including psychiatric.

Detect anosognosia

In order to diagnose anosognosia, it is necessary, in addition to the presence of ignorance of the deficit, that it be denied by the patient, the fact that the deficit is evidenced in a neuropsychological evaluation, that it is recognized by relatives and close friends and that it represents a clinically significant interference in the life of the patient. patient.

When evaluating this phenomenon, it must be taken into account that it is necessary to distinguish when the patient actually presents anosognosia and when he is making a denial of his problems as a coping strategy before his lost. Despite this complication, some specific assessment instruments have been created to assess anosognosia In which it is requested that the ability and difficulty to carry out specific tasks be assessed.

Anosognosia is not an all or nothing phenomenon, and cases may be observed in which the disorder is not recognized at any time but also others in which patients acknowledge the existence of a problem after being shown the existence of deficits.

Why is it produced? Possible causes

Since this phenomenon was called anosognosia by Babinski in 1914, an attempt has been made to explain why this symptom occurs, having multiple theories about it. The explanatory proposals are varied, focusing on the existence of neurological or neuropsychological problems.

An example of this is the theory called Schachter's Dissociable Interactions and Conscious Experience, according to which there is an interaction between the systems in charge of conscious experience and those of the systems in charge of deficient function, which in the event of an injury or bad operation would stop integrating the information correctly, producing a conscious experience of performance or functionality when it is not given from the system affected.

Despite these generalities, the specific cause of the anosognosia will depend on the type and location of the lesion and the problem that causes it.

Some pictures in which it occurs

As already mentioned, anosognosia is a symptom present in many different problems. Some of them are the following:

1. Hemiplegia

One of the disorders where its appearance is most frequent. In these cases, the patient often believes that he is performing movements that he is not actually performing, and in fact has the conscious experience of doing them.

2. Cortical blindness

Many patients who have destroyed the occipital area of ​​brain or the connections between it and the visual pathways (which prevents visual perception), insist on that they are able to see normally, making exhaustive descriptions of what they believe visualize. Anosognosia also occurs in these cases.

3. Lateral Hemineglect

In this disorder, although the subject perceives the entire perceptual field, neglects or does not attend to one of the visual hemifields, not attending to the part opposite to the hemisphere in which the injury suffers. It is clearly visible when he is asked to make copies of drawings: in these cases he only draws one of the halves and "forgets" to fill in the other part located on the other side of a vertical line imaginary. In this context, it is common for the patient to be unaware of his problem, presenting anosognosia

4. Dementia

Although in the initial moments of a dementia the patient is usually aware of the presence of the various problems of him, this knowledge does not occur in all cases or in all dementias. In addition, as the disease progresses and the degenerative process continues its course, the individual tends to stop being aware of them.

5. Schizophrenia

In some subtypes of schizophrenia, such as disorganized and catatonic, and especially during the acute phases of the disorder, the patient often does not perceive the presence of their own difficulties, such as in the case of the use of disorganized, tangential, derailed or disorganized language incoherent.

Others

Apart from those exposed here, there is a very high amount of both mental and neurological disorders that present anosognosia, being an important symptom to take into account when treating various troublesome

Effects of this symptom

It must be taken into account that the presence of this problem can entail serious dangers.

The presence of anosognosia makes it difficult to follow a treatment or perform a rehabilitation the disorder that causes it. It must be taken into account that for a patient to be involved in his recovery, he must be motivated to do so, which is difficult if he is not aware of the presence of symptoms. Thus, patients with anosognosia tend to underestimate or even deny the need for treatment, hindering their adherence to compliance with established prescriptions.

What's more, the lack of knowledge of the problem may lead the subject to take actions that may endanger their integrity and / or that of third parties. An example of this could be an individual with lateral hemineglect (subjects who only attend to one hemifield, being unable to see the left side or right of things for example) or with cortical blindness who truly believes that he has his preserved and functional capacities, who decides to take the car and lead.

Treatment of anosognosia

Treatment of anosognosia itself is complex. In general, the symptom improves with treatment of the underlying cause, be it a mental or neurological disorder. However, at the clinical level, confrontational strategies are used.

In this sense, the confrontation with the existence of deficits must be progressive, gradually introducing the idea of ​​their existence. It is important not only to show the presence of deficits, but also of the difficulties that they imply in daily life.

Bibliographic references:

• Babinski, J. (1918). Anosognosie. Rev Neurol (Paris). 31: 365-7.

• Baños, R. and Perpiña, C. (2002). Psychopathological exploration. Madrid: Synthesis.

• Belloch, A., Baños, R. and Perpiñá, C. (2008) Psychopathology of perception and imagination. In A. Belloch, B. Sandín and F. Ramos (Eds.) Manual of Psychopathology (2nd edition). Vol I. Madrid: McGraw Hill Interamericana

• Bembibre, J. and Arnedo, M. (2012). Neuropsychology of the dorsolateral prefrontal cortex I. In: M. Arnedo, J. Bembibre and M. Triviño (coord.), Neuropsychology: Through Clinical Cases (pp. 177-188). Madrid: Editorial Médica Panamericana.

• Bisiach E, Vallar G, Perani D, Papagno C, Berti A (1986). Unawareness of disease following lesions of the right hemisphere: anosognosia for hemiplegia and anosognosia for hemianopia. Neuropsychology. 1986;24(4):471-82.

• Orfei, M. D., et al. (2007). Anosognosia for hemiplegia after stroke is a multifaceted phenomenon: A systematic review of the literature. Brain, 130, 3075-3090.

• Ownsworth, T., and Clare, L. (2006). The association between awareness deficits and rehabilitation outcome following acquired brain injury. Clinical Psychology Review, 26, 783–795.

• Prigatano, G. P. (2009). Anosognosia: Clinical and ethical considerations. Current Opinion in Neurology, 22, 606-611.

• Prigatano, G. (2010). The study of anosognosia. Oxford University Press.

• Schachter, D.L. (1992). Consciousness and awareness in memory and amnesia: critical issues. In The Neuropsychology of Consciousness. Milner and Rugg. Academic Press London

• Tremont, G. & Alosco, M.L. (2010). Relationship between cognition and awareness of deficit in mild cognitive impairment. Int J Geriatr Psychiatry.