E. Fuller Torrey, MD
Sandra Steingard, MD, a psychiatrist practicing in Vermont, recently posted a blog criticizing the concept of anosognosia on the website of Robert Whitaker, “Mad in America.” Dr. Steingard made some important points but ultimately does not appear to understand the biology of anosognosia.
Anosognosia is a condition in which a subset of persons with schizophrenia (and bipolar disorder with psychotic features) are unable (not just unwilling) to understand they are sick because of damage to the parts of the brain which we use to think about ourselves. It is also referred to as a lack of insight or lack of awareness. As “The Anatomical Basis of Schizophrenia" reported, there are now at least 15 imaging studies that demonstrate how the brains of people with schizophrenia who have anosognosia differ anatomically from the brains of people with schizophrenia who are aware of their own illness and thus do not have anosognosia."
Dr. Steingrad asserts that anosognosia does exist for some neurological patients with strokes but that, for patients with schizophrenia, anosognosia is merely “conjecture,” not fact. As proof, she says imaging studies of schizophrenia do not look the same as imaging studies of strokes. But, of course, they do not, because anosognosia in individuals with schizophrenia involves multiple brain regions and especially includes the white matter connecting tracts between these regions. Thus, on a brain scan, anosognosia in schizophrenia looks different from anosognosia when caused by a stroke, which involves well-defined brain areas such as the inferior parietal lobule.
Second, Dr. Steingard doubts the validity of anosognosia in schizophrenia because brain scans cannot be used to verify it. She is correct that brain scans cannot be used diagnostically, but that does not invalidate the existence of anosognosia. Because of the anatomy of schizophrenia, it is not yet possible to diagnose schizophrenia, or patients who have anosognosia, using a brain scan as a diagnostic tool. Statistically significant group differences for such measures as the volume of the dorsal prefrontal cortex can easily be measured, but you cannot use the volume of the dorsal prefrontal cortex to predict whether any individual patient has or does not have anosognosia. Many factors in addition to schizophrenia may affect the volume of the dorsal prefrontal cortex, including genetic differences, anoxia at birth, nutrition in childhood, etc.
Anosognosia results from damage to the brain caused by the schizophrenia disease process. Denial is a thought mechanism we all use to not pay attention to something we would prefer not to be true. Nobody ever said that there are not “brain changes” underlying denial; there are, of course , neurochemical and neuroelectrical brain changes underlying every thought we have. Brain changes occur in all individuals all the time. But it is brain damage caused by the schizophrenia disease process that causes the anosognosia found in some patients with this condition.
The brain damage found in schizophrenia is well- established....