“Unawareness of Clinical Symptoms”: Two Separate Hypotheses

The CEO of NAMI mentioned that one of the most frequent complaints from the families centers on the individuals’ apparent unawareness that anything is wrong with them. I presume that the problem lies in the individuals’ rejection of treatment, especially medication. These are two hypotheses:

1. The denial of illness is a reaction to the meaning of mental illness: being insane, stigmatized, abnormal, subject to incarceration, isolation, and devaluing. Approximately half of the patients in our earlier database showed some degree, if not total unawareness/denial of mental illness. As I recall, they scored 0 on the BDI, which is unusual even for a normal population. There are several ways to test this hypothesis; if the reaction is indeed counter-phobic (like the denial of death), we can examine their performance on a variety of other tests, such as the anxiety inventory. We would expect a low score on this test. Of course, the individuals are warding off any fear, etc.

2. The individuals are not using their metacognitive function to evaluate this data. We have found that these individuals get poor scores on the Beck Cognitive Insight Scale, which measures self-reflectiveness, as well as self-certainty (we need to check the correlations between clinical insight and cognitive insight in this population, but the score should behigh). As in the case of the individuals performing very poorly on practically every test they are given, we can speculate that these individuals simply do not want to draw on the metacognitive resources necessary to make these corrections. This would fit in with the SMI population doing poorly on “jumping to conclusions.” The underlying hypothesis is that these individuals attempt to conserve energy by not examining whether they are “mentally ill,” which would require the expenditure of energy to employ necessary self-reflection.