To exemplify these neurobiological aspects of self-awareness deficits, Robert G. Robinson, M.D., chair of the psychiatry department at the University of Iowa College of Medicine, discussed anosognosia in patients who suffered right parietal stroke. These individuals, to varying degrees, denied there was anything wrong with their hemiparetic arms. In the most severe cases, no demonstration worked to convince patients of their paralysis. The mechanism most often involved right hemisphere dysfunction, as well as subcortical atrophy.
For patients with schizophrenia, a major mental illness that is comparable in its significance to cancer and cardiovascular disease in terms of its prevalence and morbidity, the idea of psychological denial comes up often, said Laura Flashman, Ph.D., a clinical psychologist and associate professor of psychiatry and neuropsychology at Dartmouth Medical School. "I would argue that there probably is at some level in some people a psychological component," Flashman told conference attendees. "I also think that there is a neurologic underpinning to at least some aspect of denial."
In patients with schizophrenia, there are at least two, and often three, dimensions to their lack of awareness, Flashman said. "The first one is insight ... the failure to recognize the deficit or the symptoms. Then there's the self-awareness level, which is the failure to recognize their impact. And then at a third level there's an attribution problem, so it's a failure to understand what accounts for the symptoms that a person is having."
"Looking at the brain correlates of these deficits is what is driving the reconceptualization of disorders like schizophrenia," Flashman told PT following her presentation. The deficits in self-awareness are a "part of the illness, rather than simply a reaction to the illness or a defense mechanism in response to the illness."
Practitioners and family members need to recognize that a patient's failure to acknowledge symptoms or correctly attribute their cause to illness may not result from poor attitude or the use of a psychological defense mechanism, but rather from "the same brain substrate that's producing the disorder," Flashman said. This recognition could make both caregivers and family a lot more tolerant.
That rethinking of the biological basis for a lack of self-awareness is affecting the way other illnesses are viewed, too. For instance, although dealing with denial is a critical component in alcohol rehabilitation, the self-awareness deficit is not even among the DSM-IV's diagnostic criteria for substance abuse, said Kenneth Sher, Ph.D., professor of psychology in the department of psychological services at the University of Missouri, Columbia. Telling attendees that there was almost no research on the self-awareness component of alcoholism, he urged further investigation.
The probing into self-awareness and how its deficits affect illness will continue, Beitman said. "It is a subject that is a central question for the 21st century: What does self-awareness mean? What does it mean to be conscious, and not just conscious but conscious of ourselves?"