Have you ever met someone with bipolar disorder who insisted they weren’t sick, or even believed everyone else was the problem instead of them? Maybe you’ve even felt this way yourself. This isn’t rare. In fact, up to 50% of people with bipolar disorder experience a symptom called anosognosia — a clinical inability to recognize their own illness. Overall, at least one in five people with a serious mental illness, like bipolar disorder, lack the insight to understand that they’re unwell, according to the Treatment Advocacy Center. This symptom doesn’t just affect the person living with it, either; it has profound impacts on their loved ones, too. Understanding anosognosia in bipolar disorder is key to grasping why treatment nonadherence (or outright medication refusal) happens — and how it can be addressed. Let’s dive into what it means to lack insight into bipolar disorder and the far-reaching effects of anosognosia.
Why Do People Believe They Don’t Have Bipolar?
There are many reasons why a person may not believe they have bipolar disorder. There are coping skills like denial and defensiveness that might make a person state they don’t have bipolar disorder, but this is not the same thing. If a person is merely in denial, they will recognize that their behavior, thoughts, and feelings have changed, but they would not characterize this change as an “illness.” Think about a person addicted to alcohol, for example. They may recognize that they are drinking more and missing work because of it, but they 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 anosognosia, though, it’s different.
What Is Anosognosia in Bipolar Disorder?
Anosognosia in serious mental illness like bipolar disorder is actually a lack of insight that is biological in nature. According to the Treatment Advocacy Center:
“Someone with anosognosia, on the other hand, may have no idea that there has been any change or decline in their mental state, behavior or functioning. Anosognosia is thought to be the most common reason for treatment non-adherence for people with severe mental illness.”
There are other illnesses, like Alzheimer’s, where anosognosia is common as well, and it is often present in those with certain types of traumatic brain injury.
The Brain Differences in Anosognosia in Bipolar Disorder
People with anosognosia have brains that are physically different from those with insight. Yes, anosognosia can often be seen on brain scans.
Much of the research on anosognosia has been done on people with schizophrenia as it has been recognized in that group for longer, and it affects about 60% of those with schizophrenia. However, putting together the research we have, the following are examples of brain differences in those with anosognosia (no, you don’t have to read or understand every word):
- Low insight has been associated with smaller prefrontal grey matter volume, higher frontal lobe dysfunction, and poor memory of autobiographical life events.
- Many studies have found a relationship between damage or decreased volume in the right hemisphere of the brain and anosognosia. Specific areas of the right hemisphere impacted include the inferior temporal lobe, the dorsal lateral prefrontal cortex, and the inferior parietal lobe.
- Smaller amounts of gray matter have been found in many areas of the brains of people with anosognosia, such as the medial superior frontal gyrus, inferior frontal gyrus, inferior temporal gyrus, cerebellum, left posterior cingulate cortex, right precuneus, cuneus, left superior, left middle and right inferior temporal gyri, right inferior parietal lobule, right supramarginal gyrus, right anterior cingulate, left posterior cingulate, and inferior temporal region on both sides of the brain.
- People with anosognosia have been found to have smaller overall brain volume, smaller white matter volume, and smaller cortical thickness in many areas of the brain.
- Associations between anosognosia and brain connectivity, hemispheric asymmetry, and impairments in midline brain structures, among others, have also been shown.
While it is the case that research has found the above, brain scans are not used when dealing with anosognosia. These relationships are still not at a stage where they can singularly be definitive.
Why Do Brain Differences in Anosognosia in Bipolar Disorder Matter?
All of this is to make a point: people with anosognosia are not the same as those in denial. These people have a different brain that functionally can’t understand that it is ill. It is a clinical lack of insight. When they deny they are ill, they believe it just as sure as I’m sitting in front of my laptop. They are refusing treatment for a good reason — they truly believe no illness exists and, thus, nothing needs treating.
Anosognosia Can Kill People with Bipolar Disorder
And herein lies the crux of the problem. If bipolar disorder were innocuous, it wouldn’t matter if a person didn’t believe they had it; the thing is, bipolar disorder is the farthest thing from innocuous. Bipolar disorder is a devastating illness that, when left untreated, can be dangerous to the affected person and those around them. One very recent study noted that a longer duration of untreated illness was associated with a higher risk of suicide attempts, a poorer response to treatment, poorer overall functioning, and a greater number of medical and psychiatric comorbidities. In other words, untreated bipolar disorder makes a person sicker and risks their life.
Treating Someone with Bipolar Who Is ‘Not Sick;’ Treating Someone with Anosognosia
Trying to help someone with anosognosia can be extremely difficult as they don’t want treatment. There is a tremendous book you should read if you’re in this situation: I Am Not Sick, I Don’t Need Help! How to Help Someone Accept Treatment — 20th Anniversary Edition. This book, by Xavier Amador, walks you through anosognosia and how to deal with it like no other resource. When it comes to convincing someone with anosognosia to try treatment, I’ll leave it to Amador to detail the technique (it’s decidedly not a one-liner).
Treatments for Anosognosia
There are treatments that have shown promise in treating anosognosia. Just because a person has a clinical lack of insight into their illness, it doesn’t mean they are doomed to be untreated forever.
Treatment options include:
- Early and effective treatment may prevent or diminish anosognosia. Because anosognosia often occurs in those experiencing psychosis, it means that aggressively treating these people as soon as psychosis happens is important. Early psychosis programs do exist and can help people in this situation.
- Psychological therapies that may help include cognitive behavioral therapy for psychosis, motivational interviewing, metacognitive reflection and insight therapy, and mindfulness-based treatments.
- Transcranial direct current stimulation (tDCS) is a type of non-invasive brain stimulation that may help with developing 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 eventually agrees to treatment, because anosognosia can drive treatment noncompliance over time. You want a person with bipolar disorder not only to start treatment but also to stay on treatment to avoid relapses, involuntary hospital stays, poorer psychosocial functioning, aggression, and a poorer prognosis.
The Downside to Treating a Person with Bipolar Disorder Who Has Anosognosia
It sounds illogical, but there actually are downsides to gaining insight into your own illness. Think about what it’s like to discover you have bipolar disorder. That’s not a fun discovery to make. I remember making it myself, and I remember crying endless tears over it. I couldn’t conceive of a life where I would have to take medication every single day. The idea of it was unthinkable. So, yes, this kind of discovery can make a person feel worse.
High levels of insight into a person’s illnesses have been associated with:
And while that list is damning, it’s a far cry 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 treated. Ending up in prison is a good bit tougher to deal with.
Believing You Aren’t Sick and Anosognosia
I think I’ve made the case that merely denying that you have bipolar disorder is not the same thing as having anosognosia. I also think I’ve made the case that developing insight is critical in bipolar disorder. I always tell people that you can’t fight an enemy that you don’t understand — and you certainly can’t fight an enemy that you can’t see.
No matter how frustrating it is to deal with a person who believes they are not sick, what’s critical is empathy. Remember, it’s their illness that is making them believe that. They are not trying to be difficult. They are not arguing with you for the sake of arguing with you. They literally can’t see what you do. They are blind. You are not. Don’t get angry that they keep bumping into lamposts.
This is not to say this is an easy situation — it clearly isn’t. Everyone dealing with it needs empathy, too. But read the book I recommended and take it one step at a time. Others have found insight. Your loved one hopefully can, too.
Have you experienced anosognosia in yourself or a loved one? Share your thoughts below.
Primary Source
- Silver, S., Sinclair Hancq, E., & Treatment Advocacy Center. (2023). Anosognosia. In Anosognosia. https://www.treatmentadvocacycenter.org/wp-content/uploads/2023/12/TAC_ORPA_ResearchSummary_Anosognosia.pdf
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