Have you ever met someone with bipolar disorder who insisted they weren’t sick or believed everyone else was the problem instead of them? Perhaps you have felt this way too. This is not rare. Indeed, up to 50% of people with bipolar disorder experience a symptom called anognosia — clinical inability to recognize their own illness. Overall, at least one in five people with a serious mental illness, such as bipolar disorder, lack the ability to recognize that they are unwell, according to the Treatment Advocacy Center. This symptom does not only affect the person living with it. it has profound effects on their loved ones as well. Understanding agnosia in bipolar disorder is key to understanding why treatment non-adherence (or complete refusal of medication) occurs — and how it can be addressed. Let’s dive into what the lack of knowledge means about bipolar disorder and the far-reaching effects of anognosia.
Why do people think they don’t have bipolar?
There are many reasons why a person may not think they have bipolar disorder. There are coping skills such as denial and defensiveness that can make a person say they don’t have bipolar disorder, but that’s not the same thing. If a person is simply in denial, they will recognize that their behavior, thoughts, and feelings have changed, but they would not label this change as an “illness.” Consider a person addicted to alcohol, for example. They may acknowledge that they drink more and miss work because of it, but deny that it is alcoholism. They deny that they need treatment or that it would help.
When a person has a clinical lack of insight, known as anognosia, however, it is different.
What is agnosia in bipolar disorder?
Ignorance in serious mental illnesses like bipolar disorder is actually a lack of insight that is biological in nature. According to the Treatment Advocacy Center:
“Someone with anognosia, on the other hand, may have no idea that there has been any change or impairment in their mental state, behavior, or functioning. Ignorance is believed to be the most common cause of non-adherence to treatment for people with serious mental illness.’
There are other diseases, such as Alzheimer’s, where anognosia is also common, and is often present in people with certain types of traumatic brain injury.
Brain Differences in Agnosia in Bipolar Disorder
People with anognosis have brains that are physically different from those with insight. Yes, anognosia can often be seen on brain scans.
Much of the research on anosognosia has been done in people with schizophrenia, as it has been recognized in this group for the longest time, and it affects about 60% of people with schizophrenia. However, combining the research we have, the following are examples of brain differences in people with anognosis (no, you don’t have to read or understand every word):
- Low insight has been associated with smaller prefrontal gray matter volume, higher frontal lobe dysfunction, and poor memory for autobiographical life events.
- Many studies have found a relationship between damage or reduced volume in the right hemisphere of the brain; and anognosia. Specific regions of the right hemisphere affected include the inferior temporal lobe, the dorsolateral prefrontal cortex, and the inferior parietal lobe.
- Smaller amounts of gray matter have been found in many brain regions of individuals with anognosia, including the medial superior frontal gyrus, inferior frontal gyrus, inferior temporal gyrus, cerebellum, left posterior cingulate cortex, right precuneus, sphenoid, left superior, left middle and lower right temporal gyrus, right inferior parietal lobe, right suprafrontal gyrus, right anterior gyrus, left posterior gyrus and inferior temporal region on both sides of the brain.
- People with anognosis have been found to have smaller total brain volume, smaller white matter volume, and smaller cortical thickness in many areas of the brain.
- Correlations between anognosia and brain connectivity, hemispheric asymmetry and damage to midline brain structuresamong others, have also been shown.
While research has found the above, brain scans are not used when treating agnosia. These relationships are not yet at a stage where they can be definitive.
Why do brain differences in anocognition matter in bipolar disorder?
All this to point out: people in anognosis are not the same as those in denial. These people have different brains that function slope understand that it is sick. It is one clinical lack of insight. When they deny being sick, they believe it just as surely as sitting in front of my laptop. They refuse treatment for good reason – they really believe that there is no disease and therefore nothing that needs treatment.
Unawareness can kill people with bipolar disorder
And here lies the crux of the problem. If bipolar disorder were harmless, it wouldn’t matter if a person didn’t think they had it. The thing is, bipolar disorder is far from harmless. Bipolar disorder is a devastating illness that, when left untreated, can be dangerous to the sufferer and those around them. A very recent study noted that longer duration of untreated illness was associated with higher risk of suicide attempt, poorer response to treatment, poorer overall functioning, and greater number of medical and psychiatric comorbidities. In other words, untreated bipolar disorder makes a person sicker and puts their life at risk.
Treating someone with bipolar who is “not sick”. Treatment of someone with anognosia
Trying to help someone with anognosia can be extremely difficult as they do not want treatment. There is a great book to read if you are in this situation: I’m not sick, I don’t need help! How to Help Someone Accept Therapy — 20th Anniversary Edition. This book, by Xavier Amadorguides you through self-awareness and how to deal with it like no other resource. When it comes to convincing someone with an anointing to try the treatment, I’ll leave it to Amador to clarify the technique (admittedly not a simple line).
Treatments for Anognosia
There are treatments that have shown promise for treating anognosia. Just because a person has a clinical lack of knowledge about their disease does not mean they are doomed to go untreated forever.
Treatment options include:
- Early and effective treatment can prevent or reduce anognosia. Because anognosia occurs frequently in those who develop psychosis, it means that aggressively treating these individuals once psychosis occurs is important. Early psychosis programs do exist and can help people in this situation.
- Psychological treatments that may help they include cognitive behavioral therapy for psychosis, motivational interviewing, metacognitive reflection and insight therapy, and mindfulness-based therapies.
- Transcranial direct current stimulation (tDCS) is a type of non-invasive brain stimulation that can help develop insight.
Unfortunately, treatment does not help all people.
Treatment options may be important to explore for a person with bipolar disorder and anosognosia, even if the person ultimately agrees to treatment, because agnosia can lead to nonadherence to treatment over time. You want a person with bipolar disorder not only principle treatment but also to i stay treatment to avoid relapses, involuntary hospital stays, worse psychosocial functioning, aggression and worse prognosis.
The downside to treating a person with bipolar disorder who is agnostic
It sounds counterintuitive, but there are actually downsides to gaining insight into your own illness. Think about what it’s like to find out you have bipolar disorder. Not a fun discovery. I remember making it myself and I remember crying endless tears over it. I couldn’t imagine a life where I would have to take medicine every day. The idea was unthinkable. So yes, this kind of discovery can make a person feel worse.
High levels of knowledge about a person’s illnesses have been associated with:
And while that list is damning, it’s far from the list I could give you where the person with untreated bipolar disorder ends up on the streets, in jail, or even dead. The above list can be addressed. Ending up in jail is a little harder to deal with.
To think that you are not sick and foolish
I think I’ve argued that simply denying that you have bipolar disorder is not the same thing as being agnostic. I also believe I have argued that the development of insight is critical in bipolar disorder. I always tell people that you can’t fight an enemy you don’t understand — and you certainly can’t fight an enemy you can’t see.
No matter how frustrating it is to deal with a person who thinks they are not sick, what is critical is empathy. Remember, it is their illness that makes them believe it. They’re not trying to be difficult. They don’t argue with you to argue with you. They literally cannot see what you are doing. They are blind. You are not. Don’t be mad that they keep falling into lampposts.
That’s not to say it’s an easy situation — it clearly isn’t. Everyone involved in this also needs empathy. But read the book I suggested and take it one step at a time. Others found insight. I hope your loved one can too.
Have you experienced anognosis in yourself or a loved one? Share your thoughts below.
Primary source
- Silver, S., Sinclair Hancq, E., & Treatment Advocacy Center. (2023). Ignorance. In Ignorance.
