Anosognosia vs. Denial: How To Tell the Difference

Some people with schizophrenia don’t realize they need care. It may seem like stubbornness, but it could be anosognosia. This symptom can happen when changes in the brain make a person truly unaware of their health condition.

The difference between anosognosia and denial can be hard to spot, and only a healthcare provider can make a diagnosis. However, you can help by watching for behaviors that may point to anosognosia or denial.

Anosognosia and denial need different kinds of support. It may be possible to help someone move past denial, but anosognosia is harder to treat and may continue or come and go over time.

This guide will help you understand the differences and how to support someone with either condition.

How Anosognosia Differs From Denial

Anosognosia isn’t a fancy word for denial. They’re distinct conditions. Anosognosia is a neurological disorder caused by brain changes or damage. Denial is a psychological response to extreme emotion or trauma.

People with anosognosia have no control over the condition. Therapy usually can’t make someone with anosognosia fully recognize their condition, but it may help them accept support, follow a treatment plan, and stay safer.

Denial, on the other hand, may improve with support from a mental health professional.

What Is Denial?

Psychologists define denial as the rejection of reality. It’s a defense mechanism that helps people avoid feeling extreme emotional pain, such as overwhelming anxiety or stress.

Psychologists say denial can be a conscious or unconscious process:

• Conscious — The person deliberately chooses to ignore reality.
• Unconscious — The brain automatically rejects reality to protect itself.

Denial can serve as a helpful coping mechanism during difficult situations. For example, someone might downplay a cancer diagnosis to help themselves stay positive.

But denial can also be harmful, such as when someone doesn’t acknowledge that they need medical care or doesn’t take responsibility for their actions.

What Is Anosognosia?

Anosognosia happens when changes or damage in the brain affect a person’s awareness of their own health.

When this “self-image scanner” works properly, we’re aware of injuries and illnesses. When it’s not working properly, a person could have a condition, like schizophrenia, and not know it.

The word anosognosia means “to not know a disease” in ancient Greek. The medical community sometimes calls it “lack of insight,” “lack of awareness,” or “denial of deficit.”

Anosognosia can make it hard for people to accept treatment because they may believe they’re healthy.

What Causes Anosognosia?

Anosognosia happens when part of the brain is damaged. Some medical conditions are known to damage brain tissue or disrupt the neurological connections inside the brain, including:

• Schizophrenia
• Alzheimer’s disease and other types of dementia
• Huntington’s disease
• Bipolar disorder
• Stroke
• Sleep apnea
• Infections
• Seizures
• Brain tumors
• Aneurysms

The brain can also be damaged by a lack of oxygen, certain toxins, and physical trauma.

What Causes Anosognosia in Schizophrenia?

Neurologists still aren’t sure what causes schizophrenia, so it’s hard to know exactly why anosognosia happens in some people with the condition. However, common brain changes include shrunken brain matter, enlarged fluid-filled areas, and fewer connections between nerves in the brain.

A 2023 Nature study found that schizophrenia brain changes happen progressively over time, first in a limited area and later in widespread regions. This suggests that people with schizophrenia may develop anosognosia in the future even if they don’t currently have symptoms.

On the other hand, anosognosia isn’t inevitable with schizophrenia. Some people may never have damage in that area of the brain.

How Anosognosia Affects People With Schizophrenia

Researchers estimate that between 50 percent and 98 percent of people with schizophrenia have anosognosia.

Anosognosia can make it difficult for someone to:

• Realize they have schizophrenia
• Recognize the signs and symptoms of schizophrenia
• Understand how schizophrenia affects them
• Understand the need for schizophrenia treatment

As a result, someone with anosognosia may resist taking schizophrenia medications. A literature review published in The Journal of Clinical Psychiatry found that about 41 percent to 49 percent of people with schizophrenia don’t follow their treatment plan, and that anosognosia was a major reason why.

Without treatment, people with schizophrenia face a greater risk of relapse and hospitalization. They may have a higher risk of conflict with others, safety concerns, and a lower quality of life.

How To Recognize Anosognosia in a Loved One

Someone experiencing schizophrenia-related denial might feel deeply fearful or anxious about their diagnosis, whereas someone with anosognosia may feel the diagnosis is completely made-up.

You might hear someone with anosognosia say, “I’m not sick.” A person in denial might say, “It’s not that bad.”

Anosognosia behavior may also look like:

• Failing to associate their symptoms with a medical condition
• Inventing nonmedical reasons for symptoms or behaviors
• Getting angry when confronted about their symptoms
• Refusing treatment or discontinuing medication because “they don’t need it”
• Taking risks that someone with awareness of their condition would avoid

If your loved one seems to acknowledge their schizophrenia diagnosis one day but rejects it the next, they’re not necessarily in denial. Anosognosia symptoms can change over time.

A healthcare provider can look at what’s behind a person’s dismissive behavior and figure out whether it’s anosognosia or denial.

What Loved Ones Can Do

It’s understandable for caregivers to feel frustrated when anosognosia interferes with schizophrenia treatment, especially because the anosognosia itself can’t usually be treated directly. However, certain strategies can help caregivers provide meaningful care despite this lack of awareness.

Here are some common tips:

• Stay patient and calm.
• Avoid criticism, as it will seem unjustified and could make the person defensive.
• Respond to delusional comments calmly and respectfully.
• Remember that the person isn’t being stubborn or uncooperative on purpose.
• Frame treatment options as a way to accomplish goals, not to address a medical condition.

Although it’s tempting to lay out all the evidence and try to convince a person of their schizophrenia diagnosis, this isn’t likely to work. They may not be able to process this information in the same way you do.

However, it may be possible to help a loved one with anosognosia to gradually become more aware of how their behavior affects other people. Focus on giving specific, concrete feedback about behaviors, and offer praise when possible.

For example, you might say, “You’re less angry when you take your medicine, and I really enjoy spending time with you when you feel good. Thank you for taking it every day.”

You can also try talking about symptoms conversationally. Wait for a calm moment and say, “I read an article about someone who could hear voices. Has anything like that ever happened to you?”

Psychotherapy, also called talk therapy, may provide some benefits for people who have anosognosia and for people who are in denial. Your loved one may feel scared to admit they need help. Offer empathy and compassion to show you understand.

The LEAP approach stands for listen, empathize, agree, and partner. Developed by psychologist Xavier Amador, this approach is often recommended by clinicians. It focuses on building trust, finding shared goals, and working together on practical solutions.

When To Talk With a Healthcare Provider

Understanding the difference between anosognosia and denial can help you respond with more patience and choose the right kind of support. If your loved one doesn’t seem aware of their condition or refuses treatment, talk with their healthcare provider about next steps.

Join the Conversation

On MySchizophreniaTeam, people share their experiences with schizophrenia, get advice, and find support from others who understand.

How did you find out your loved one had anosognosia? Let others know in the comments below.