Family and Caregiver Schizophrenia Discussion Forum

Anosognosia - does it ever diminish?

Sorry, not the best title, but just wondering if anyone knows of a person with sz and anosognosia, ie they absolutely, 100% do not believe that they are unwell (and certainly don’t have sz!), but over the years with treatment has actually accepted that they do have an illness?

My wife, diagnosed with sz over 15 years ago, just will not, or cannot accept that she has an illness. She will now say that she ‘was’ unwell (but not with sz!!!), but that she is better now and there is nothing wrong with her.

I know it’s a symptom of the illness, I know it’s not her fault, but I try to rationalise with her on a daily basis to get her to see some of the obvious signs of her mental illness (such as she’s ‘pregnant with twins’ and has been for 10+ years, the babies talk to her and tell her they are almost ready to come out), but she hasn’t ever gained any insight whatsoever, despite years of antipsycotic meds.

I keep trying to find a little crack in her defense that might lead to her getting just a bit better, but nothing. Anyone know/had experience of someone gaining more insight?

There are some reports of this from the LEAP perspective, but they seem anecdotal and nuanced. Things like saying ‘my blood isn’t right’ or that I have bad karma or am reliving experiences from a past life etc. Best I can tell from what I’ve read so far in Dr. A’s book, LEAP is a behavioral approach, so a subject gains a behavioral understanding of ‘insight’-like behaviors. They might learn that taking drugs is somehow a good idea, but have an idiosyncratic internal framework to justify it that isn’t true insight and closer to mysticism or a cargo-cult understanding of their illness.

There’re also reports that symptoms of SZ ‘mellow-out’ over time and become less severe. Whether this means added insight or improved coping skills or what seems anyone’s guess. From my own experiences, I’ve come to believe while drugs can reduce symptoms, they don’t magically make you start behaving in different ways other than improving your perception and cognitive functioning. I feel my insight into my illness has improved over time, through psychotherapy and my own personal versions of informal CBT and occupational therapy. Drugs helped me focus enough to do that hard work, but only created the ‘space’ for this to occur.

I understand that some people who manage to get their loved ones on Closapine/Closaril often experience a Rip Van Winkle effect where folks awaken from a ‘slumber’ akin to the book/movie Awakenings. The brain is such a complicated organ that we barely understand , so it’s had to say what’s a learned behavior versus a chemical process.

Some say I had insight all along, but I was extremely reticent to take medication and thought my illness was solely something that was a function of circumstances and psychotherapy was all I needed. And through Psychoanalysis I gained insight into my problems and recognized that they may or may not be true, and eventually came to the conclusion that I was likely to lose my job and further relapse or deteriorate and that was not a future I wanted, so I made a pragmatic choice to start taking medication. Looking back on it, my first year of psychotherapy was an extended version of ‘Green Eggs and Ham’. Until I tried medication I did not realize I liked it— Sam I am.(liked it is a strong word here, I think rather I liked what they did for me so I tolerated the trade-off).

Not sure if this helps, as mine is such a very rare case, but what I’ve said visiting people in psych wards in the past is, “play along, and they’ll let you out, and maybe it might do you some good as well.”

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Dr Amador’s book can be really helpful for a spouse or parent to help us understand why trying to convince them doesn’t work. Gosh, I know I tried and tried. Dr Amador’s videos online at youtube are also excellent. My personal favorite is the lecture where he demonstrates how anosognoia feels by using a member of the audience. He tells the woman that she has been brought to the lecture by her sister who hopes Dr Amador can help her. He tells her her husband and children are not her own, that they are people she is stalking and she needs to stop bothering them.

If you can imagine your wife and doctors telling YOU that you are confused, that you are the one with a mental illness not your wife - well -it was eye opening for me. Someone could talk to me all day every day and I know I’m not the one with scz. Its exactly the same for our family members with anosognosia.

We are told as children that we can believe what we see and hear, our family members with anosognosia trust their brains - just like we do.

Since the babies are talking to her she has the proof she needs. My son has good voice friends as well as the bad voices. While watching tv he once turned to the empty chair beside him, laughed, and said - quite delightedly- “how do you think of these things?”

When faced with reality, their brains adjust using confabulation. The brain just makes up and accepts an excuse that further supports the delusion.

People have different ways of handling dementia in their elderly family members. I really got to see this when my MIL developed dementia. Some people will correct the person with dementia constantly - “NO MOM ITS ME YOUR DAUGHTER” There were days when my MIL thought I was her sister. She was so pleased to see her sister visiting her (the real sister lived several states away) it was quite a treat for her. I didn’t seem much point to correcting her.

My Family to Family teacher said that one of the best Peer to Peer instructors in our area never did believe he had schizophrenia. When pressed as to why he took meds he said he took meds because it made his wife happy and life easier as @Maggotbrane says

My son is unmedicated, his anosognosia seems to cycle, just like his scz cycles. People here on the forum often report that their family members scz cycles to worse periods even when they are on meds.

Anecdotally, some people have reported that their family members did gain “some” insight on meds. You have to love the use of the word “some” and “somewhat” in reference to scz.

Personally, I agree with Amador - its “cannot”. She is unable to understand due to the anosognosia.

I have learned to hope for “some” things to get “somewhat” better. Anything specific is beyond my control.

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I recently read a book called “The Center Cannot Hold” by Elyn R. Saks because it had been mentioned or referenced by somebody here on forum.
It’s one woman’s journey of knowing that ‘something was wrong’ in her own head, but didn’t know what. And also knew that she ‘wasn’t sick’.
It helped me to see a bit into what somebody suffering might actually be processing internally…
Hope, I also watched this particular Amador talk and it really did shine light on what may be going on for our loved ones when they are experiencing full delusion. It was a great way to show that. As far as how to respond? Well… that’s a tough one.
Generally I default back to my experiences with dementia patients. Whatever their delusion is at that time, I try not to fix it or correct it directly. Assuming the delusion is not physically violent. I play along. If the delusion is causing distress or agitation, it only strikes me that there possibly may have been a trauma of some sort, big or small, somehow related to the topic of what they are experiencing, that may not have been addressed and worked through.
I’m no psychiatrist but… (shrug).
Have to say… if dealing with elderly… dementia is a reality in many forms and should not be mistaken for a sudden diagnosis of sk (in my non-professional opinion) but in my experience a few of the same ‘anecdotes’ can apply. Which is to say, how WE respond to crisis moments.
I’d also like to say, for those who will know, my very first experience with severe, debilitating schizophrenia was as a teen a close childhood friend went into full throws of catatonic sk.
That may be, in some ways, one of the scariest varieties for a family member or loved one. Because there’s close to absolute zero response from them. Blank eyes, locked joints, very slow calculated moves when they have them, like moving a solid wax figure… take a med, a shot, if you can legally get it administered anyways, then they get ‘better’, you bargain with them to take it, they succeed at basic and small actuations and sometimes feelings… then they’re better! Then they decide they’re not sick, they’re fine, it’s just ‘water’ when you ask what they think of the meds… then they stop taking the meds…
This seems to be a pretty standard scenario from what I’ve experienced and also heard here…

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My experience with my daughter, now on a working med (Haldol dec shot) for 15 months, seeing a psychiatrist regularly with me present, is that she still doesn’t believe she is ill with a mental illness. She takes her shot because her doctor pointed out to her once a year ago, that it helps her work and keeps her out of the hospital. Otherwise she never asks about her shot or why she takes it.

I found out from a recent neurologist visit, where I was present with her, that she doesn’t remember 3 out of her 5 hospitalizations at all. She incorrectly remembers the two times she was jailed. I have no idea what she remembers out of her psychotic years. She probably doesn’t remember most of it, is my guess. So if she can’t remember the psychosis, she obviously was never ill, per her own memories.

In my opinion, her brain protected itself by not recognizing the mental illness. That way her own other faculties were kept working. She was able to work some jobs, shop, dress herself nicely, talk to some strangers, etc., during psychosis, even while arguing with her voices, hating her step-father, calling the police several times a month, losing contact with friends, never answering her phone, and locking herself in her bedroom at home where she screamed at voices all night long, and picked her face until it bled. I think it would have overwhelmed her other abilities if she started doubting her own reality. Perhaps lost loved ones who committed suicide while suffering from this illness, recognized they were not sane but couldn’t do anything about it. I have no idea.

Never, never did pointing out or discussing the odd behavior lead to any realization on her part that it was happening.

I felt as I watched the years of psychosis in my daughter that if I was ever ill like that, I couldn’t take it if I could see the illness in myself, but not be able to stop it. So perhaps the brain won’t recognize the hallucinations and delusions because the parts that still function right depend on believing everything is functioning right.

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Yes, I’ve seen some of Dr A’s stuff on Youtube, I haven’t read the book yet though, but I get what he’s saying, ie it’s ‘cannot’.

But, say for example, you came up to me and said, “that’s a nasty wart on the end of your nose”, I say, “I don’t have a wart on the end of my nose!”. Then another person, and another person, 6, 10, 20 people all come up to me and say exactly the same thing, why would I think that all these people were wrong, yet I was right? That’s probably a terrible analogy, but it’s the best I’ve got!

I suppose I always want to believe life can be like in the movies, in ‘A Beautiful Mind’, when he finally accepts that the people he saw and spoke to over the years were just delusions, not real people - I mean, the little girl never grew up, did she, so how could she be real?

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Its a good analogy isn’t it? It really focuses on how difficult our struggle is to help them.

All of us struggling with anosognosia hope that someday we will say the magic word or make the magic conversational point that will crack the mental wall anosognosia has in place.

I really hope anosognosia diminishes for you and your wife. I really hope it happens for my son. I wish I could still try to convince him logically, but, sadly, my son only grew very suspicious of me when I tried. My attempts alienated him and he needs me in his corner.

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Thank-you, I hope the same for you too.

Unfortunately I think it’s too late for us, I’ve done all I can for my wife, but the last few years have been unbearable - it didn’t help that our home is also our business - but I’ve decided we need to seperate, even though she doesn’t want to of course, but for the sake of my own mental health, I think we need to.

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A very hard decision, @kevin99, and one that highlights the contrasting challenges of being a parent vs a spouse.

And I think you are correct about the additional challenge of having a combined home/work space.

I am self-employed but have an office, which has been the main thing that has kept me sane. If I didn’t have a separate place to go to that makes my husband suspicious but that he also basically “allows” (he understands that I have to work), I don’t know what I’d do.

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In terms of memory, I suspect that part of this is due to the very associational way that the human brain works, which is very state dependent.

It is well known that both emotional valance and other things impacting the state of the brain (such as alcohol or drug use) influence the ease of access to memories.

For example, depressed people are markedly more likely to be able to readily access memories that are colored by sadness and college students who studied while smoking pot find it easier to recall this material when high again as opposed to being sober.

My husband also appears to have forgotten some things entirely and to be able to access other memories but with some difficulty.

When he is paranoid, he seems to be able to access so much of his past experience in that state but really struggles to access more positive memories. When he is stable, it is the reverse.

So I think his brain works very “normally” in this particular way, he is just dealing with two very extreme and contrasting emotional states.

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married 29 years, girl friend 10 years

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I do not feel good about this, but I guess I should admit that I am ambivalent in a certain way about my husband’s recent decisions to try medication again and about the fact that they are helping.

I never considered separation when he became symptomatic a number of years ago and I felt good about my role in his recovery.

Then he relapsed and I think it is really coming home to me that this is forever.

I could deal with the extra burden in terms of finances, labor etc. I could even deal with the lack of intimacy. But when he pulls out of life, it really angers him if I try to maintain friendships etc. And this is not going to work for me in the long-term.

So part of me is glad he is doing better (of course). But it also complicates things for me in a way that I am not proud of.

I’m a rare sort who seems to have access to both sets of memories. The paranoid parts at times burn a little brighter from an emotional perspective, in sort of cinematic or theatrical sense. It’s more of an intuitive feeling or conviction that certain things are true and much of your ‘logic’ surrounding it is based on explaining those fallacies. Delusional systems are sort of a house of cards built on fundamental beliefs that are unsound.

When you recover it’s sometimes hard to shake the possibility of the duality of realities. Which one is ‘real’’ or can it somehow be both. I believe there’s an old quote by Lin Po about whether he was a man dreaming of being a butterfly or a butterfly dreaming of being a man. Movies like 12 Monkeys or The Matrix capture that feeling.

A Beautiful Mind is a less good example for a number of reasons. First the example is fiction, John Nash did not experience delusions that way. They serve only to put the lay audience in the place of a person with delusions and add additional surprise that not only was the sinister ‘Karcher’ not real, but the sometimes benevolent roommate and niece weren’t either. Second it’s extremely difficult to think or reason your way out of delusions. It’s a ton of work, I know because I did it when I was unmedicated. I don’t think it’s sustainable without medication. The movie also fictionalizes that Nash ‘took some of the newer medications.’ My understanding is he didn’t. It’s likely that his SZ symptoms just diminished with age as has been noted in studies.

Per Elyn Saks’ book, I know I mention it all the time, because it’s very close to my experience. She’s also a proponent for Psychotherapy as a treatment, which is why my thinking is Anosognosia is better combatted by talk therapy. Dr. Amador is a Psychologist, not a psychiatrist and I think his work is likely less recognized by folks who are biased toward medical/pharmaceutical only methodologies.

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@kevin99, One last thing to suggest that might make a difference, if you haven’t tried it already, is cognitive behavior therapy - CBT. My son went to a specially trained therapist for help when he wanted to shop for his own groceries. He was convinced I was medicating him through his groceries, he had stopped shopping for himself years before - he couldn’t handle the voices yelling at him in grocery stores. His thought was that he went for help to learn how to handle all the public aggression aimed at him in grocery stores.

From what I have read, and my reading is quite limited on the subject, what you might be looking for is the sort of CBT that helps them do reality checks. One example I did read had a therapist not directly challenging delusions, but making mild statements that might raise questions in the patient’s mind. One example featured a patient claiming to be a spy for the government. The patient talked about their spy job and the therapist commented about how well paid people were for such work and how had they come to do such work?

Does your wife have other good support people in her life? Are her parents supportive parents?

I understand now @GSSP. That’s why you have two homes?

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Forgive yourself, @Itsastruggle . You’ve been fighting the good fight a long time. It is OK to recognize your own needs and wishes.

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I’ve mentioned it before, but through my science training I stumbled onto my own style of CBT reality checking . In my undergrad studies I was introduced to Philosophy, and I used some of my training in logic and epistemology as well as statistics and probability theory toward this effort.

I’ve considered going to a trained CBT practitioner to do a port-mortem on my methods to see how they align with established practices.It’s kinda old hat to me now, and I rarely think about it except to help workmates having trouble with logical mistakes in troubleshooting and data collection.

You may have heard of Occams Razor which is a heuristic often reduced to ‘when you hear hoof beats think horses.” It’s taught to medical students to train them to consider more probable diagnosis’s. With SZ you are more likely to think unicorns when you hear hoofbeats, so this can be helpful to retrain thinking toward more logical and probable explanations for thoughts and perceptions.

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@hope, she was offered CBT a few years ago, I believe she had one session, but because ‘she wasnt ill’, she declined to continue.

She doesn’t have any friends as such, just family, none of whom live close by, so it’s just me and our son. Both parents no longer with us, in fact it might have been the death of her mother that brought on the sz. I had just started going out with my wife, and went round to her mothers (she was living with her at the time), I met her mum briefly before we went out for the evening.

She got home later that evening after our date, and found her mum dead in a chair, heart attack. Unlike her 2 older sisters, she never seemed to greave properly in the months/years after.

I want to help her so much, I want nothing more than for her to get better and start living again, but I’m not not capable it seems, in all the time I’ve stuck with her, she’s only got worse.

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My son’s first break was at 17yo, he went thru multiple years of failed trials of antipsychotics, and no insight - tho I will say I think he had some recognition that “something” wasn’t “right”, and tried many things, such as different nutritional supplements, to try to help himself.

My son is now 30yo, I think it has been 4 years now he has been consistently taking clozapine, and he has some insight now. He will volunteer his diagnosis in some settings. He had one very brief hospitalizaion after beginning clozapine, and the dose was adjusted slightly.

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What an excellent analogy, I am quite familiar with Occams Razor - my son’s rare kidney disease went undiagnosed for years because even the specialists heard horses.

Maggotbrane, isn’t it so very interesting that CBT has been found to work with scz? My son had also had a good deal of science training and is well educated.