WHY SOME MENTALLY ILL PERSONS
REFUSE TREATMENT:
ANOSOGNOSIA OR LACK OF INSIGHT
Our relatives who suffer from mental illnesses
do not claim that “they are not sick” just because of
denial, but because they suffer from anosognosia or lack of insight.
Anosognosia reflects lack in the same way as “anonymous”
means without a name, or “anorexia” means without appetite.
In the case of anosoognosia, it means the inability of our dear
ones to comprehend that some of the exceptional feelings, thoughts
and behaviors they experience are due to a mental illness. It is
difficult to believe that our dear ones do not know that they are
sick and, usually, we are resentful when they refuse treatment.
The understanding of mental illnesses as
biological disorders and the nature of anosognosia started with
studies done by Emil Kraepelin, (Dementia Praecox and Paraphenia
-Edinburgh: E. S. Living-Stone, 1919/1971) vol, 4, page 212) and
Eugene Bleueler, which established that schizophrenia is an illness
of the frontal lobes.
In 1995, E. Fuller Torrey, M.D. in his book
Surviving Schizophrenia – 3rd. Edition, page 263 describes
“lack of insight” and quotes Emil Kraepelin, who said
in 1919, “understanding of the disease disappears fairly rapidly
as the malady progresses in an overwhelming majority of cases.”…
“two recent studies, carried out in New York and London, concluded
that the percentage is approximately 50 percent. There is recent
evidence that the impaired insight found in some individuals with
schizophrenia is part of the disease process affecting the frontal
lobes, i.e., the area of the brain we use for insight into ourselves
is not functioning properly.” One of the studies he mentions
is by X.F. Amador and D.H. Strauss. “Poor Insight in Schizophrenia”
Psychiatric Quarter, 64 (1993): 305-19.
In 1997, in the July/August issue of the
NAMI Advocate, page 2, Dr. Torrey is quoted by reprinting a testimony
before the Subcommittee on Housing and Community, March 5, 1997,
saying: “ approximately half of all individuals with severe
psychiatric disorders have markedly impaired insight. In other words,
they do not recognize the fact that they are sick and need medication.”
Then, in 2000, Dr. Xavier Amador, in his
book “I Am Not Sick, I Don’t Need Help” teaches
the families and the therapists how to understand and help those
persons with serious mental illnesses to accept treatment. Also,
on page 142 he adds: “Anosognosia, or poor insight, is a symptom
of the brain disorder that often does not improve with medication.”
In 2001, Elkhonon Goldberg in his book The Executive Brain, Frontal
Lobes and the Civilized Mind, beautifully describes on pages 135/6,
the nature of Mind Blindspot: Anosognosia .All the above facts are
confirmed by the experience of the families, which are the default
care- takers of most persons with serious mental illnesses.
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NATIONAL INSTITUE OF MENTAL
HEALTH
NIMH - When Someone Has Schizophrenia
http://www.nimh.nih.gov/publict/schizsoms.cfm
…..
Because schizophrenia sometimes impairs thinking and problem
solving, some people may not recognize they are ill and may refuse
treatment. Others may stop treatment because of medication side
effects, because they feel their medication is no longer working,
or because of forgetfulness or disorganized thinking. People with
schizophrenia who stop taking prescribed medication are at high
risk for a relapse of illness.18 A good doctor-patient relationship
may help people with schizophrenia continue to take medications
as prescribed.19 Developing safer and more effective medications,
as well as identifying strategies to enhance the acceptability of
currently available treatments, are important NIMH priorities.
......
________________________________________
COMPLETE PUBLICATION
NIH publication No. 01-4599
- From web site - February, 2003
 |
When
Someone Has Schizophrenia |
Schizophrenia is a devastating brain disorder—the
most chronic and disabling of the severe mental illnesses. The first
signs of schizophrenia, which typically emerge in young people in
their teens or twenties, are confusing and often shocking to families
and friends. Hallucinations, delusions, disordered thinking, unusual
speech or behavior and social withdrawal impair the ability to interact
with others. Most people with schizophrenia suffer chronically or
episodically throughout their lives, losing opportunities for careers
and relationships. 1 They often are stigmatized
by lack of public understanding about the disease. However, several
new antipsychotic medications developed within the last decade,
which have fewer side effects than the older medications, in combination
with psychosocial interventions have improved the outlook for many
people with schizophrenia. 2
 |
This painting was done for
the Schizophrenia Bulletin, which features art created by people
who have struggled with schizophrenia. The artist, Philip Kurz,
has provided us with the following description of this artwork:
I believed that everything within me and around me was through
my blank mind and my arm onto the paper. I felt that keeping
a blank mind was important to the success of the painting, and
this was relatively easy to do since it approximated my normal
state. This feeling all seems outlandish now. |
Some Facts About
Schizophrenia
In the U.S., approximately 2.2 million adults
3 , or about 1.1 percent of the population age
18 and older in a given year 4 , have schizophrenia.
Rates of schizophrenia are very similar
from country to country—about 1 percent of the population.
5
Schizophrenia ranks among the top 10 causes of disability in developed
countries worldwide. 6
The risk of suicide is serious in people with schizophrenia. 7
News and entertainment media tend to link mental illnesses including
schizophrenia to criminal violence. Most people with schizophrenia,
however, are not violent toward others but are withdrawn and prefer
to be left alone. Drug or alcohol abuse raises the risk of violence
in people with schizophrenia, particularly if the illness is untreated,
but also in people who have no mental illness.8,9
Research Findings
Family studies indicate that genetic vulnerability is a risk factor
for schizophrenia.10 A person with a parent
or sibling with schizophrenia has approximately a 10 percent risk
of developing the disorder compared to a 1 percent risk for a person
with no family history of schizophrenia. At the same time, among
individuals with schizophrenia who have an identical twin, and thus
share the exact genetic makeup, there is only a 50 percent chance
that both twins will be affected with the disease. Scientists conclude
that nongenetic factors, such as environmental stress perhaps occurring
during fetal development or at birth, also may contribute to the
risk of schizophrenia.11, 12
Research suggests that schizophrenia may be a developmental disorder
resulting from impaired migration of neurons in the brain during
fetal development.13
Advances in neuroimaging have shown that some people with schizophrenia
have abnormalities in brain structure consisting of enlarged ventricles,
the fluid-filled cavities deep within the brain.14
Schizophrenia can appear in children, though it is very rare. Neuroimaging
research of childhood-onset schizophrenia has shown evidence of
progressive abnormal brain development.15
While providing clues about the brain regions involved in schizophrenia,
these findings are not yet sufficiently specific to schizophrenia
to be useful as a diagnostic test.
Treatments for Schizophrenia
The newer medications for schizophrenia—the atypical antipsychotics—are
very effective in the treatment of psychosis, including hallucinations
and delusions, and may also help treat the symptoms of reduced motivation
or blunted emotional expression.16 Intensive
case management, cognitive-behavioral approaches that teach coping
and problem-solving skills, family educational interventions, and
vocational rehabilitation can provide additional benefit.2
Evidence suggests that early and sustained treatment involving antipsychotic
medication improves the long-term course of schizophrenia.17
Over time, many people with schizophrenia learn successful ways
of managing even severe symptoms.
Because schizophrenia sometimes impairs thinking and problem solving,
some people may not recognize they are ill and may refuse treatment.
Others may stop treatment because of medication side effects, because
they feel their medication is no longer working, or because of forgetfulness
or disorganized thinking. People with schizophrenia who stop taking
prescribed medication are at high risk for a relapse of illness.18
A good doctor-patient relationship may help people with schizophrenia
continue to take medications as prescribed.19
Developing safer and more effective medications, as well as identifying
strategies to enhance the acceptability of currently available treatments,
are important NIMH priorities.
Present and Future Research Directions
In addition to the development of new treatments, NIMH research
is focusing on the relationships among genetic, behavioral, developmental,
social and other factors to identify the cause or causes of schizophrenia.
Utilizing increasingly precise imaging techniques, scientists are
studying the structure and function of the living brain. New molecular
tools and modern statistical analyses are enabling researchers to
close in on the particular genes that affect brain development or
brain circuitry involved in schizophrenia. Scientists are continuing
to investigate possible prenatal factors, including infections,
which may affect brain development and contribute to the development
of schizophrenia.
New Clinical Trial
NIMH is funding a large-scale clinical trial
to compare the effectiveness of the newer, atypical antipsychotic
medications for the treatment of schizophrenia. For more information
about this study—the Clinical Antipsychotic Trials of Intervention
Effectiveness (CATIE) project—and others, visit the Clinical
Trials page of the NIMH Web site.
For More Information
National Institute of Mental Health (NIMH)
Office of Communications and Public Liaison
Public Inquiries: (301) 443-4513
Media Inquiries: (301) 443-4536
E-mail: nimhinfo@nih.gov
Web site: http://www.nimh.nih.gov
-----------------------------------
All material in this fact sheet is in the public domain and may
be copied or reproduced without permission from the Institute. Citation
of the source is appreciated.
NIH Publication No. 01-4599
-----------------------------------
References:
1 Harrow M, Sands JR, Silverstein ML, et al. Course and outcome
for schizophrenia versus other psychotic patients: a longitudinal
study. Schizophrenia Bulletin, 1997; 23(2): 287-303.
2 Lehman AF, Steinwachs DM. Translating research into practice:
the Schizophrenia Patient Outcomes Research Team (PORT) treatment
recommendations. Schizophrenia Bulletin, 1998; 24(1): 1-10.
3 Narrow WE. One-year prevalence of mental disorders, excluding
substance use disorders, in the U.S.: NIMH ECA prospective data.
Population estimates based on U.S. Census estimated residential
population age 18 and over on July 1, 1998. Unpublished.
4 Regier DA, Narrow WE, Rae DS, et al. The de facto mental and addictive
disorders service system. Epidemiologic Catchment Area prospective
1-year prevalence rates of disorders and services. Archives of General
Psychiatry, 1993; 50(2): 85-94.
5 Report of the international pilot study of schizophrenia.Volume
1. Geneva, Switzerland: World Health Organization, 1973.
6 Murray CJL, Lopez A.D, eds. Summary: The global burden of disease:
a comprehensive assessment of mortality and disability from diseases,
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MA: Published by the Harvard School of Public Health on behalf of
the World Health Organization and the World Bank, Harvard University
Press, 1996. http://www.who.int/msa/mnh/ems/dalys/intro.htm
7 Fenton WS, McGlashan TH, Victor BJ, et al. Symptoms, subtype,
and suicidality in patients with schizophrenia spectrum disorders.
American Journal of Psychiatry, 1997; 154(2): 199-204.
8 Swartz MS, Swanson JW, Hiday VA, et al. Taking the wrong drugs:
the role of substance abuse and medication noncompliance in violence
among severely mentally ill individuals. Social Psychiatry and Psychiatric
Epidemiology, 1998; 33(Suppl 1): S75-S80.
9 Steadman HJ, Mulvey EP, Monahan J, et al. Violence by people discharged
from acute psychiatric inpatient facilities and by others in the
same neighborhoods. Archives of General Psychiatry, 1998; 55(5):
393-401.
10 NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication
No. 98-4268. Rockville, MD: National Institute of Mental Health,
1998.
11 Geddes JR, Lawrie SM. Obstetric complications and schizophrenia.
British Journal of Psychiatry, 1995; 167(6): 786-93.
12 Olin SS, Mednick SA. Risk factors of psychosis: identifying vulnerable
populations premorbidly. Schizophrenia Bulletin, 1996; 22(2): 223-40.
13 Murray RM, O'Callaghan E, Castle DJ, et al. A neurodevelopmental
approach to the classification of schizophrenia. Schizophrenia Bulletin,
1992; 18(2): 319-32.
14 Suddath RL, Christison GW, Torrey EF, et al. Anatomical abnormalities
in the brains of monozygotic twins discordant for schizophrenia.
New England Journal of Medicine, 1990; 322(12): 789-94.
15 Rapoport JL, Giedd J, Kumra S, et al. Childhood-onset schizophrenia.
Progressive ventricular change during adolescence. Archives of General
Psychiatry, 1997; 54(10): 897-903.
16 Dawkins K, Lieberman JA, Lebowitz BD, et al. Antipsychotics:
past and future. National Institute of Mental Health Division of
Services and Intervention Research Workshop, July 14, 1998. Schizophrenia
Bulletin, 1999; 25(2): 395-405.
17 Wyatt RJ, Henter ID. The effects of early and sustained intervention
on the long-term morbidity of schizophrenia. Journal of Psychiatric
Research, 1998; 32(3-4): 169-77.
18 Owens RR, Fischer EP, Booth BM, et al. Medication non-compliance
and substance abuse among patients with schizophrenia. Psychiatric
Services, 1996; 47(8): 853-8.
19 Fenton WS, Blyler CB, Heinssen RK. Determinants of medication
compliance in schizophrenia: empirical and clinical findings. Schizophrenia
Bulletin, 1997; 23(4): 637-51.
Updated: January 01, 2001
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