(3-13-18) An article entitled The Perplexing Semantics of Anosognosia: Why an obvious phenomena has sparked controversy, written by Dr. Dinah Miller, co-author of COMMITTED: The Battle Over Involuntary Psychiatric Care, drew strong reactions yesterday after I posted it. Among them was this reply from Dr. E. Fuller Torrey, who has been described by The Washington Post as “perhaps the most famous psychiatrist in America.”
By E. Fuller Torrey, M.D.
Dear Pete,
Dr. Miller questions the appropriateness of using the term “anosognosia” to describe the lack of awareness of illness in individuals with schizophrenia or other psychosis. In The Study of Anosognosia (G.P. Prigatano, ed., Oxford University Press, 2010) anosognosia is defined as “a complete or partial lack of awareness of different neurological…and/or cognitive dysfunctions” which would appear to cover psychoses. She contacted the late Dr. Oliver Sacks who in fact had given an eloquent description of anosognosia in The Man Who Mistook His Wife for a Hat:
“It is not only difficult, it is impossible for patients with certain right-hemisphere syndromes to know their own problems – a peculiar and specific ‘anosognosia,’ as Babinski called it. And it is singularly difficult, for even the most sensitive observer, to picture the inner state; the ‘situation’ of such patients, for this is almost unimaginably remote from anything he himself has ever known.”
Dr. Miller is also incorrect in saying that “we know nothing of the fundamental neural dysfunction” for individuals with anosognosia. Studies of stroke patients have demonstrated that the inferior parietal lobule plays a critical role, especially on the right side. Since 1992, there have been 25 studies comparing the brains of individuals with schizophrenia with and without anosognosia. In all but three studies, significant differences are reported in one or more anatomical structures. Since anosognosia involves a broad brain network concerned with self-awareness, a variety of anatomical structures are involved, especially the anterior insula, anterior cingulate cortex, medial frontal cortex, and inferior parietal cortex. Three of the positive studies included individuals with schizophrenia who had never been treated with medications, discounting the likelihood that the observed brain changes resulted from treatment.
There’s no controversy here. People with psychotic disorders sometimes don’t know they are suffering from a mental illness, and there really is nothing to argue about. And yet, the word “anosognosia”—meaning the patient is unable to see that he is ill—is a charged word.
Why is that? Let me talk a little about the history of this word and the political meaning it has taken on.
Anosognosia is a term that was coined in 1914 by a Hungarian neurologist named Joseph Babinsky. Babinsky noticed that sometimes after a stroke, people are unaware of their deficits. This is presumed to be a result of pathophysiologic changes in the brain, and not the psychological defense mechanism of denial. There is not a precise anatomical finding that predicts anosognosia: you can’t look a patient with anosognosia and say, “ah, the MRI will show a lesion in X area of the brain.” Though certainly, some deficits are more likely to include anosognosia than others.