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Anosognosia: How Conjecture Becomes Medical “Fact”

As with the notion of “chemical imbalance”, the term anosognosia has crept into the psychiatric lexicon. Its use confers a certain sophistication of understanding and knowledge that is not supported by the data. Read More

In defense of "anosognosia" in the psychiatric lexicon

Dr Steingard, thank you for this great discussion. I am a a pediatrician and pediatric eating disorder specialist who sees only children and adolescents with anorexia nervosa and other eating disorders. To date we have examined and treated over 1500 such children in our clinic. Anosognosia or “denial of seriousness of illness” or even “denial of presence of illness” is a common, though not invariable, feature of anorexia nervosa, and we see it all the time.

I do not fear to use this term in anorexia nervosa, as I do not consider it to be only relevant to cases where right brain damage leads to a neglect syndrome. Anosognosia is an old term that predates CT/MRI/SPECT and other imagining studies, and like much of medical terminology born before the technological era, is descriptive only. That anosognosia might be present in patients with a specific right brain injury as well as those with less well defined “network errors”(the prefrontal cortex, cingulate, superior and inferior parietal areas, and temporal cortex for example) is understandable. The fact—as you report—that we are unlikely to be able to make a neurological diagnosis from the scans of people with anorexia nervosa and anosognosia, does not diminish the usefulness of the concept. Anosognosia describes an important clinical symptom and is a term like “barking cough” or “fever and chills” characteristic of more than one illness rather than a term implying any discrete diagnosis.

Use of the word “anosognosia” rather than “denial”—with the implication of volitionality and willful ignorance that “denial” carries with it—has been a boon in my field.

I, of course, agree with you that there is an anatomic/network basis to “denial” as to all human thought, for as Eric Kandel says: “mind is a range of functions carried out by the brain”—and I believe as he does that “someday we will see this in imaging studies”.

Anosognosia

Dr. O'Toole. Thank you for your comments. In some ways, I am more comfortable with the use of this term in people who have annorexia since it is used in a much more specifc way. A person who weighs 60 lbs may say that she is overweight. In people who are psychotic, the quality of the denial is extremely varied. A person might have a profound impairment in self care and another one might just dispute the notion that voices are a symptoms of psychiatric illness. More important, however, was the way in which the particular article I referenced was written. The conclusion that there is "brain damage" was not in my opinion supported by the data.

More on starvation, denial, and "brain damage"

Hi,

Thanks so much for writing this article! I have seen no other like it and I am happy for the response regarding anorexia. These both speak so directly to my own experience and I can comment further on this.

I am 55 years old and have been dealing with anorexia and binge eating for 34 years. This past spring and summer I starved myself so severely that my kidney functioning (so I was told) no longer worked well enough to properly nourish my brain. For months, I had been living in a dementia-like dream world. I told no one the full story but I did keep a journal. These pages are fascinating to me now. I also kept a prolific blog and did a few You-Tubes but revealed to no one how little nourishment I was allowing myself.

I finally ended up in a hospital the second week of August and am alive today to tell the story. I am a writer and write quite a bit. What folks don't realize is that the brain does restore. While a person with true dementia has permanent damage, a person who is starved will in fact be able to gain back their cognitive ability simply by eating again. It was tough to explain to the doctors at the hospital that no, I am not normally "out of it" and I didn't need those antipsychotic pills they were trying to force onto me. They mistook my strange habits, which were nothing but compensation and attempts to hide my forgetfulness, for psychosis. The extent of their "neurological tests" were to ask me, each day, where I was and what year it was, and how to spell the word "World" backwards, which I've been doing for decades.

In one of the You-Tubes I did while severely starved, I spoke of the Wall between myself and the World, that is, humankind. I speak of the loneliness and isolation and difficulty communicating. I have often heard folks with real dementia speak of this Wall, except sadly, in their case, the Wall is permanent, as is the brain damage. In the You-Tube, I state that I can feel the World slipping away from me and I beg someone, anyone, to reach out to me from beyond the Wall. I had no clue, at the time, that this Wall was temporary.

If anyone out there with anorexia is reading this, or anyone treating anorexia, please know that this Wall that I speak of is temporary. No one in this world is crap. No one should ever be told they are worthless or crazy or a hopeless case. I got knocked down. I scrambled back up again, and today, I'm standing right here.

Thank you!

Such a well arranged comment on this troubling issue. I live in North Carolina and a certain Duke U. psychiatrist is pushing for forced outpatient treatment. So much rests on his determination that those of us who are opposed to forced treatment are people who suffer from anosognosia and don't believe we have an illness anyway--that's why merciful society members believe it is their position to stop on the personal agency and self-determination of others. Forced treatment and concepts like anosognosia are disabling to people and are certainly antithetical to recovery!

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