Psychiatric anosognosia

This post was inspired by an article in the May 30th issue of The New Yorker, "God Knows Where I Am" by Rachel Aviv.  Full-text online is only available by subscription, but a free abstract is available here.  In the process of telling a riveting and ultimately very sad story, the author discusses psychiatric insight. Insight is a curious concept as used in psychiatry.  In common parlance insight is unquantifiable, something like charm or wisdom.  We feel we know it when we see it.  But most of us hesitate to make finer distinctions.  We may allow that someone strikes us as a little insightful or very wise.  Beyond that, it seems ludicrous to attach a scale to it, or to refer to insight as though it could be measured precisely.

Nonetheless, in psychiatry an assessment of insight is part of the "mental status examination"  (MSE), the psychiatrist's version of the physical exam in general medicine.  Along with assessments of mood, affect (expressed emotion), paranoia, suicidal feelings, and other issues, the psychiatrist also evaluates the patient's insight.

Psychiatry has no standardized way to assess this.  We may ask our patient: "What is your understanding of the problem that brought you here today?"  It's a great question — the problem is what to do with the answer.  Critics note that if the patient's response accords with the psychiatrist's own belief, the patient is judged to have good insight.  Thus, in an earlier era when psychoanalysis was predominant, a patient with schizophrenia exhibited good insight by agreeing that his "schizophrenogenic" mother caused the problem.  Nowadays, this would be evidence of clear impairment; the insightful patient would instead agree with his psychiatrist that he has a "chemical imbalance."

For better or worse, many such judgments in psychiatry — perhaps most of what we do — cannot be divorced from social context.  Exuberance in one crowd may look like hypomania in another.  "Inappropriate" affect begs the question, what is appropriate?  And likewise, an understanding of one's own mental health status (or psychiatric label) is meaningful only within one's social group and culture.

Anosognosia is a term from neurology.  As defined in Mosby's Medical Dictionary, 8th edition:

[an′əsog·nō′zhə]

Etymology: Gk, a + nosos, not disease, gnosis, knowing

a lack of awareness or a denial of a neurologic defect or illness in general, especially paralysis on one side of the body. It may be attributable to a lesion in the right parietal lobe.

Certain patients with brain disease or injury appear not to know they are paralyzed (or blind, etc).  Presumably, parts of the brain involved with self-awareness are damaged.  This lack of knowing then becomes one of the signs of the disease itself, and may help with diagnosis.  For example, the cause of a paralysis may be localized to the parietal lobe if it is accompanied by anosognosia.

The term has lately appeared in psychiatry (and is discussed briefly in the New Yorker piece).  This is a worrisome error in my opinion.  Its use seems intended to make psychiatry sound better understood, and more biological/neurological, than it really is.  A person who denies having a psychiatric disorder may delusionally attribute his or her difficulties to space aliens.  This makes a good case for extending anosognosia into psychiatry.  But a denial could equally be an honest difference of opinion, as when a patient discounts a diagnosis of Social Anxiety Disorder because shyness is a family trait.  Here, denial of an anxiety disorder is certainly not a sign of having such a disorder.  And of course social stigma leads many patients to deny having a psychiatric disorder; this denial likewise bears no relationship to having the disorder itself.

The reasons patients may deny having a psychiatric disorder are far too varied to reify such denial with a neurological term.  It creates a suspicious "Catch-22," where disagreeing with one's doctor is itself a diagnosable condition with a fancy medical name, and the implication of brain-structure underpinnings.  This is sophistry, and the mark of a profession whose false certainty belies insecurity.

Many years ago I wrote a short essay arguing that social judgments in psychiatry  (e.g., inappropriate affect) are both inevitable and essential to our work.  I was not a psychiatrist yet, but nothing I have seen since has changed my view.  Despite great advances in biological psychiatry, we still cannot ascribe specific attitudes or viewpoints to neurological damage.  Insight is still subjective.  And if we ever do identify the seat of "psychiatric anosognosia," our understanding will no longer be psychiatry, but neurology.

Embracing psychiatric uncertainty

I always get troubled looks from psychiatry residents when I point out that our field is the domain of the uncertain and the not-well-understood — and that it will always remain so.  As soon as the cause of a disease is known, it automatically leaves psychiatry for another specialty.  General paresis (advanced syphilis), once identified as an infectious disease, became the domain of internists.  Senility (dementia), multiple sclerosis, and many other apparently psychiatric conditions went to the neurologists.  Thyroid disorders belong to endocrinology.  Brain tumors and hemorrhages are surgical conditions.  And so forth.  I have little doubt that schizophrenia will someday be understood as due to a slow virus, a complex genetic error, or something else.  At that point it will no longer be a psychiatric condition.  It will join neurology, internal medicine, or some other specialty.

This makes my residents squirm in their seminar chairs, particularly when I point out that the closest analogy to psychiatry's status in medicine is philosophy's status among the humanities.  Philosophy consists of questions in the humanities that we don't yet know how to answer.  Once we do, that area is no longer considered philosophy.  "Natural philosophy" is what we now call science.  It isn't considered philosophy anymore.  Logic was one of the classic branches of philosophy; now it is better understood as a branch of mathematics.  In the same way, psychiatry consists of questions about human thoughts, feelings, and behavior that we don't yet know how to answer, not down to the level of mechanism anyway.  Once we do, that area is no longer considered part of psychiatry.

It's no mystery why the residents are uncomfortable.  They want and expect certainty.  Why did they study all that organic chemistry, memorize all the bones and muscles, spend years learning to diagnose and treat, if in the end they can't make definitive statements about their chosen specialty?  Many will cling to pseudo-certainties for reassurance.  Simple-minded factoids like "alcoholism is a disease" or "depression is due to a chemical imbalance" give them something to hang onto.  Unfortunately, we don't really know what causes depression, and alcoholism is disease-like in some respects, but not in others.  Most of our field is complicated, messy, and not well understood.  Moreover, this need for certainty in an uncertain field leads many psychiatrists, including and perhaps especially those well out of training, to convey unwarranted confidence regarding diagnosis and treatment recommendations.  We can come across as smugly self-assured.

Frankly, this very uncertainty — mystery, if you will — is one of the things I like about psychiatry.  It isn't a settled area.  It is endlessly debatable, much like an undergraduate philosophy course.  Yes, there are concepts and terms to learn, principles to refine and employ, scientific studies to evaluate.  There is a body of knowledge, a history, practice guidelines to teach and learn.  Most of all, there are real patients to help.  Yet as in philosophy, experts in psychiatry can and do disagree.  Our diagnostic categories are revised periodically. Treatments come and go.  Unscientific fads influence the field, as when American psychiatrists used to diagnose schizophrenia more liberally than our British counterparts, when multiple personality disorder suddenly became common in the 1980s and just as suddenly faded away, and in the way ADHD, PTSD, and bipolar diagnoses are so popular now.

Confident pronouncements of certainty have no place in psychiatry.  Humility is the only honest attitude to take to this work.  At the same time, the questions we face are fascinating, patients are suffering, and neither can wait for definitive knowledge.  We must do the best we can with imperfect knowledge, with limited data and educated guesses, with hunches and subtle impressions.  As in life generally, we cannot wait for certainty before acting.  As in life generally, this makes psychiatry risky, vibrant... alive.

Diagnostic alphabet soup

Earlier this year a reader asked me: "I would be very interested to hear your thoughts on patients becoming too focused on diagnoses. [...] While I was in an RTC as a teenager, and recently in the hospital as an adult, I have found that people almost treat their diagnoses as a competition. I was calling it the alphabet olympics. I also have a friend who will rattle off a bunch of abbreviations for his diagnoses. There is always something new popping up too. Sometimes I wonder if over diagnosing is a mistake some psychiatrists make."

I've seen this too.  Here's my take on the alphabet soup of diagnosis, and whether it's good for patients to focus on it.  First, a little history...

Prior to 1980, before the revolutionary 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry tended to lump disorders into a few broad categories.  Schizophrenia covered a wide range of presentations, from relatively minor symptoms to devastatingly severe ones.  Depression could be brief, prolonged, triggered by obvious stressors or losses, or appear out of nowhere.  Neurosis referred to any presumed unconscious conflicts that interfered with life.

DSM-III changed all that.  (An excellent historical review article, in pdf format, is available here.)  This was the first effort by the American Psychiatric Association (APA) to publish an atheoretical, phenomenological psychiatric nosology.  What do these $10 words mean?  The idea was to create diagnoses that could be used regardless of one's school of thought or theory.  For example, some psychiatrists thought depression was biological, others considered it psychological.  Either way, if a patient had a low mood for two weeks, along with poor sleep, appetite, concentration, and libido, he or she had Major Depressive Disorder according to DSM-III.  It didn't matter why.

This scheme encouraged multiple diagnoses.  A given patient could fulfill criteria for Major Depressive Disorder, an Anxiety Disorder, a Personality Disorder, and other disorders, all at the same time.  This reflects a drawback of atheoretical diagnosis.  An underlying theory, such as Freudian psychoanalytic theory, or a systematic biological or learning theory, can pull together apparently disparate symptoms into a coherent diagnostic formulation.  Without such a theory to guide diagnosis, each set of symptoms stands on its own.  While some DSM diagnoses had exclusion criteria — they could not be listed in the presence of other diagnoses — this still left plenty of opportunity to list multiple disorders in the same person.

Each edition of the DSM grows in size.  One reason is that scientists can't stand to leave a good category alone — if it can be turned into two good categories.  Thus, anorexia and bulimia, which used to be one disorder, are now divided.  Depression is divided into major depression, dysthymia, seasonal affective disorder, adjustment disorder with depressed mood, and so forth.  Bipolar disorder comes in Type I and Type II, as well as lesser versions.  I am not against making these distinctions when there is good reason to do so, and there often is.  But one consequence is diagnostic alphabet soup: a growing set of arcane labels usually shortened to three- or four-letter abbreviations.  And the nature of atheoretical diagnosis means that any given patient may qualify for several.

Many psychiatrists feel they "understand" a patient better if they can establish one or more DSM diagnoses — although, being atheoretical,  such diagnoses don't actually explain anything.  They do, however, point reassuringly to recommended treatments, usually pharmaceutical.  Moreover, medications are FDA-approved for each of these indications separately.  This has marketing advantages for drug manufacturers.  Shyness doesn't sound like a psychiatric problem to be treated with medication, but "Social Anxiety Disorder," essentially a synonym for shyness, does.  Dividing anxiety into Generalized Anxiety Disorder, Social Anxiety Disorder, and many other types created markets for various medications.  In a parallel fashion, health insurers demanded more specific diagnoses in order to pay for psychiatric treatments.  There is money, and therefore politics, behind dividing human misery in these particular ways.

Perhaps the most interesting part of my reader's question is why some patients are attracted to these labels.  Her experience with teens and young adults may, in part, reflect embracing these labels in an ironic or mocking way:  "Now I have MDD, OCD, and PTSD.  Isn't that a kick?"  Probably more relevant is the concrete way a diagnosis seems to account for one's frightening instability.  Better to be "ADHD" than merely a scattered teen who can't study.  The former confers scientific legitimacy, promises specific treatments, and even justifies entitlements such as extra testing time in school.  These labels can also ease personal responsibility and humiliation, as when outrageous social behavior can later be attributed to Bipolar Affective Disorder or some other "chemical imbalance."  Despite the persistent stigma of psychiatric diagnosis, these labels have enough psychological and practical advantages that some patients wear them proudly.

The downside to all of this is that individuals can become known, even to themselves, by impersonal diagnostic labels.  Knowing oneself as PTSD, ADHD, and/or OCD can dehumanize.  It can prematurely close off inquiry and self-reflection.  And DSM diagnoses do not actually explain anything; they are better conceptualized as statistical categories.  Such diagnoses are useful tools, but like all tools they can be misused.

Schizophrenia among us

I met a young man recently in a setting having nothing to do with psychiatry or mental health. He politely introduced himself and tried to learn the names of the others around him. He seemed socially awkward but inoffensive, and after I left I didn't give the encounter much thought. However, I learned that soon thereafter he showed increasingly odd behavior. He talked to himself, breached social boundaries, and acted aggressively for no apparent reason. Others had to keep an eye on him, and eventually he was escorted peacefully off the premises. The possible causes of such behavior are myriad: brain injury, psychotropic drugs, medical illnesses such as delirium or thyroid disease, and many others. One possible cause is mental illness, specifically schizophrenia. Schizophrenia is surprisingly common, affecting over 1% of the total population. As with many other disorders, schizophrenia can be mild or severe. Only a small minority of sufferers are institutionalized; the great majority live in society with everyone else. The class of medications called neuroleptics (anti-psychotics) have helped to make this possible, although some people with mild schizophrenia can function without medication.

I do not know whether the young man I met has schizophrenia. It would be presumptuous of me to attempt to diagnose someone I met only briefly in a social setting. But our meeting did spark some thoughts about the symptoms and deficits of this disorder.

A major hallmark of schizophrenia is auditory hallucinations (voices). When people "talk to themselves," particularly if they do so without regard to others noticing, it may be in response to hallucinated voices. The voices can be ignored for a while if they are not too severe. At the other extreme, if insistent voices command the person to hurt himself or others, this is a very serious situation that usually requires hospitalization. Medications are often helpful in quieting auditory hallucinations.

(Thanks to cellphones, particularly those with wireless headsets, people seen "talking to themselves" could simply be on the phone.  More than once I've passed someone on the sidewalk and assumed one of these scenarios, only to realize seconds later it was the other.)

Delusions are also prevalent in schizophrenia, as well as in other disorders such as delusional disorder and manic psychosis. Medications help with delusions too, but not as quickly as with hallucinations.

There are also "negative symptoms" in schizophrenia which include lack of emotional expression and a decreased ability to initiate action or speech. These are more resistant to medication, although the "atypical" neuroleptics available for the past 15 years are of some benefit.

More subtle are the "thought process" changes in schizophrenia, and these are what came to my mind regarding the young man I met. Classically, schizophrenic thought is described as concrete. The ability to think abstractly, metaphorically, and symbolically is impaired. For example, in psychiatric evaluations patients are sometimes asked to interpret a proverb such as, "People in glass houses shouldn't throw stones." While most healthy individuals understand this is not literally about glass houses, many with schizophrenia will say something like, "because the glass will break." Likewise, people with schizophrenia often cannot understand jokes or indirect references in the speech of others.

It is a sad and isolated existence to be cut off from so much human interaction, unable to share in common emotional experience.  Much of the meaning and flavor of life is contained therein.  This is not to say that people with schizophrenia cannot lead productive and meaningful lives.  They can, but it's hard.  My "up close and personal" encounter with someone possibly suffering these challenges reminded me that compassion, not fear or disdain, is the most apt response to the tragedy of schizophrenia.