Anosognosia: The Most Devastating Symptom of Mental Illness

Copyright (c) 2008 by Kevin Thompson.

Mental illness comes in many forms. Depression, bipolar disorder, schizophrenia, and the anxiety disorders all have the potential to be crippling, and ruin lives. Yet as terrible as depression, mania, psychosis, and the other symptoms of these disorders can be, there is one that stands out as the most damaging of all:


This obscure word, which is pronounced "uh-no-sog-no-zha," means "denial of illness," and is more serious than you might think.

Most people understand the psychological concept of denial, which is a refusal to believe an uncomfortable truth. Who hasn't heard heard a heavy drinker, eater, smoker, or drug user say, "I can quite any time I want," or someone with a chronic cough (which may indicate a serious illness) say, "It's not important--It's just a cough." Pressing the denier on the obvious gap between reality and his belief typically yields a flurry of thin excuses that support his position, and can provoke an outburst of anger if continued long enough.

Denial serves a useful purpose in helping people cope with sudden change, and is harmless as long as it is not maintained too long. Denial becomes harmful when it interferes with a person's ability to cope effectively with the challenges he faces. Fortunately, denial is temporary in most cases, and even chronic deniers can can learn better over time.

Anosognosia is quite different. It is not simply denial of a problem, but the genuine inability to recognize that the problem exists. It is a common consequence of brain injuries, and occurs to varying degrees in such disorders such as schizophrenia, bipolar disorder, and Alzheimer's disease. (I hasten to add that "common" does not mean "universal!" Most people who suffer from  these illnesses are quite aware that they are sick.)

Someone who has anosognosia isn't being difficult, or refusing to face the truth. He is literally unable to believe that his illness is, in fact, an illness. As a result, he does not see any reason to take medication that can control his illness. Many people who have anosognosia will refuse to take medication for schizophrenia or bipolar disorder, because they do not believe they are ill. If pushed, they may give the appearance of cooperation, while secretly discarding their medication.

In the case of paranoid schizophrenia, where the patient believes others are conspiring to harm him or control his life, the combination of anosognosia and paranoia can provoke the him to violent action in an attempt to escape his "persecutors." (Sadly, the often debilitating side effects of antipsychotic medication, which, unlike his illness, are all too apparent to the patient, provide supporting evidence for his beliefs.)

For a symptom with such an obscure name, anosognosia plays a prominent role in both law and medicine. Treatment for most illnesses is taken at the discretion of the patient, who is free to seek, select, or decline treatment, as he considers appropriate. However, there are times when the individual's right to control his medical treatment conflicts with other important principles, namely, the sanctity of life, and the protection of others from harm. A person who is in the grip of a severe psychotic episode, who is judged likely to harm himself or someone else, may legally be committed to a psychiatric hospital for evaluation and treatment, on an involuntary basis. Such treatment usually consists of antipsychotic or mood-stabilizer medications, observation, and possibly restraint.

Most patients who are prone to psychosis (primarily, those with schizophrenia) do not have any particular desire to harm other people. The danger comes not from a desire to harm, but from hallucinations and delusions that can drive violent actions. (For example, a patient may sincerely believe he is fighting for his life against an evil force, when in reality he is attacking an innocent person.) So it is not surprising that patients who are aware of the nature of their illness, and the risk of such harm, generally do prefer treatment to prevent violent incidents. Similarly, patients who have anosognosia about their psychotic symptoms, but whose behavior is harmless, may not have a need for medication that justifies removal of their right to make decisions about their treatment

However, those psychotic patients who are at risk for committing violent acts, and also have anosognosia, are both dangerous, and unable to believe that anything is wrong with them. Because of this belief, they will refuse treatment, and remain dangerous. These are the patients whose right to control their own treatment conflicts with the right of others to safety. 

In the end, each case must be handled on its own merits, and someone must make the difficult calls--and be prepared to live with the consequences. It is because of anosognosia that such calls must be made.
Kevin Thompson, Ph.D. is the author of Medicines for Mental Health: The Ultimate Guide to Psychiatric Medication. You can find information about treatments for depression, bipolar disorder, schizophrenia, and sexual problems on his Web site at