When a person cannot appreciate that they have a serious psychiatric illness, a tremendous challenge to family members and caregivers follows. About one-half of people living with schizophrenia, and a smaller percentage who live with bipolar disorder, have this clinical feature. Individuals with Alzheimer's disease and dementia also often have this feature. The medical term for not seeing what ails you is anosognosia, or more commonly known as a lack of insight. Having a lack of awareness raises the risks of treatment and service nonadherence. From the person's point of view, if they feel they are not ill why should they go to appointments, take medication or engage in therapy?
Why can't a person see what is so apparent to those around them? The best thinking indicates this is a core feature of the neurobiology of the conditions. Frontal lobes organize information and help to interpret experiences. In conditions like schizophrenia and Alzheimer's disease, frontal lobe difficulty is central to the neurological processes that underlie the disorders. Psychological denial is not the reason for the lack of insight in these illnesses.
Efforts to get people to see that they are ill are frequently fraught with frustration and may be met with denial or anger. Approaching the person in a supportive way will be beneficial for your relationship. Finding out what goals a person has (for instance getting a job, forming relationships, living independently) can be a good place to start engaging in next steps. Check to see if the service system has outreach workers who work on engaging people who lack insight. Working with the person's goals does not mean you have to pretend he or she is well. For example, if the person applies for disability services, encourage the doctor to review the diagnosis; getting a person to agree to disagree can be a first step. You don't need to argue about diagnosis to have a person participate in-or respect-basic household chores and rules.
There are situations where a person's lack of insight can, at times, create dangerous situations. This combination of no insight and dangerous acts often requires intervention. In more than 40 states, there are laws for Assisted Outpatient Treatment (AOT), also known as outpatient commitment. AOT status requires a person to engage in treatment and gives the state authority to bring the person to a treatment center if they do not. All states that have these laws have protections and a process for assessing whether this intervention is appropriate. In most states, doctors are required to submit an affidavit of the person's state and the reasons for the requested AOT status and a judge decides.
NAMI has active support groups all across the nation and local NAMI members may have information on outreach services for service engagement or doctors who are interested in this issue. You do not need to worry alone with this difficult situation.
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