Impaired Awareness of Mental Illness

Psychiatry_Psychology.jpgThere are about six million severely mentally ill people in the United States. About half of these severely mentally ill do not know they are ill. (1) (Severe mental illness includes schizophrenia, bipolar disorder and a few other diagnoses). There is a medical term for this condition: anosognosia, an impaired awareness of one’s own disturbed mental condition, despite evidence to the contrary. An ill person may claim that everything is fine, when it is not. This impaired awareness of mental illness is caused by damage to specific parts of the brain. Neurocognitive deficits, or symptoms of a brain dysfunction, are part of the mental illness. People with anosognosia do not recognize that hallucinations, mania, delusions, paranoia or other symptoms of mental illness are, in fact, mental illness. For this reason, many refuse medication if it is prescribed. Others may take medication for awhile, but then throw it away. Remaining unmedicated has many dangers, such as the illness might get worse, they may need hospitalization, they may unable to hold a job or their safety may be at risk.

Individuals with impaired awareness will not voluntarily utilize psychiatric services, no matter how attractive those services are, because they do not believe that they have an illness. (2) Without treatment, many of them end up homeless or in jail. This is a large root cause of the stigma against the mentally ill. The image of the crazy homeless person is a stereotype which produces stigmatization against all mentally ill, homeless or not. Or perhaps in small cases the untreated mentally ill individual creates the sort of violence that makes headlines. That too fuels stigmatization against the mentally ill. The public often believes that since the troubled person refused to seek treatment, they “deserve what they got”, another evidence of stigmatization.

Sometimes the individual with anosognosia is aware of their illness, and sometimes not aware. This is because the illness might fluctuate in severity. The individual might be more aware when in remission, but loses the awareness when relapse occurs.

The symptoms of someone in psychosis may be observed by others, but if the person has anosognosia, their feelings and beliefs are so real for them that when others try to persuade them that their feelings and beliefs are not real, they think that others are just insulting them. This may put a wedge between the person’s doctor, friends, family and them because the person may feel victimized, and often becomes even less cooperative. It is difficult to convince them to seek help.

Can the severely mentally ill be treated against their will in the United States? Many state laws require an individual to be an imminent danger to self or others before he or she can involuntarily be committed, but there are other jurisdictions with a broader definition. The process of involuntary commitment involves a judge or presiding panel, who go by their best judgment based on the evidence.

There are various types of involuntary treatment, including both inpatient and outpatient, and laws vary from state to state. Yet it takes a lot to get the homeless mentally ill person who has impaired awareness of illness from the streets into a psychiatric hospital. The complex problem of how to treat the mentally ill with anosognosia involves moral and ethical issues, legal issues, civil rights issues and funding issues. Some argue that “the only answer is to treat them involuntarily”, and say that “there is a budding trend toward this solution in state laws.” (3) But because of past deinstitutionalization of the mentally ill, most of the psychiatric hospital beds have been lost, and funding for outpatient treatment facilities is inadequate. It will take many factions working together to facilitate humane and effective involuntary treatment programs while, hopefully, maintaining civil rights.

Most severely mentally ill who were medicated involuntarily agreed, in retrospect, that the medication was in their best interest. Forced medication often results in a more rapid return of freedom to be discharged from involuntary hospitalization. (4) But involuntary commitment is not the only answer. “Some mentally ill persons are able to overcome the feeling of ‘I Am Not Sick’. The odds favor those whose family and care takers understand the complexities of these no fault mental illnesses. The successes are sometimes fragile and are most common when families and professionals are able to offer, with patience and persistence, opportunities for medical care, psychological counseling and supervision.” (5)


(1) Treatment Advocacy Center. Briefing Paper. “What Percentage of Individuals with Severe Mental Illness are Untreated and Why”.

(2) Ibid.

(3) Lowry, Rich. (July 31, 2003). “Mistreating the Mentally Ill“.

(4) Treatment Advocacy Center. Briefing Paper. “The Effects of Involuntary Medication on Individuals with Schizophrenia and Manic-Depressive Illiness”.

(5) Families of People with Untreated Mental Illness. (September 23, 2005). Lack of Insight Mental Illness. “We are Their Only Voice”.

  • Just once, I’d wish some legal-begal would define “treatment.” I can’t find it in legal code anywhere (CA/USA). I think if the word “treatment” was swamped-out
    for the word “mistreatment”, our position would be much more clear to people. This just out.

    Kathi Stringer
    A Director for the California Network of Mental Health Clients

  • Ok … I know I’m mentally ill & I take my medications … but I can’t get anyone to do anything else to help me towards recovery. What is wrong with this picture

  • Elise Stobbe

    Kathi, as a mental health professional you already know that stabilizing the patient with medication that works is the main treatment option. But state laws govern the parameters of involuntary treatment, so it varies in what the law allows them to do. The debate over the right of the unaware mentally ill to remain sick and medicated (sometimes homeless) vs. it is more humane to help them with involuntary commitment is a huge debate with many on both sides.

  • Elise Stobbe

    dragonfriend, here are things you can do in addition to medication:
    -psychosocial or cognative therapy;
    -peer support groups
    -nutritional supplements

    But you are right, there are huge barriers to getting well. What is available is one question, and can you pay for it is another.

  • Elise, Speaking myself as an individual that has been hospitalized over 30 times in many different hospitals, I can make the following statements looking from the inside out.

    Elise, In a PERFECT world one might say, “Stabilizing the patient with medication that works is the main treatment option.� In the real world, I view this as a very naive statement. More often then not, patients are abused by rude staff, and/or handed a misdiagnosis that leads to medication errors, which leads to excessive involuntary confinement. (In fact, forensic psychiatry makes the claim as a defense in court “Psychiatry is not an exact science.�) It’s not by accident that nearly every county hospital has an oversight agency that is the Department of Patients Rights. Why the need for a Patients Rights Department if the mentally ill population is served with good “treatment?� That sad fact is, more often then not, it is mistreatment and the Department of Patients Rights has a hard time keeping up with the mistreatment complaints.

    Another sad fact, civil laws that allow involuntary treatment makes the assumption that “treatment� is what the patient is going to get, when the reality of the situation is that the patient is getting “mistreatment.� Perhaps this is why one won’t find the word “treatment� legally defined within California W&I code, Title 9, Title 22 or Civil code. I would imagine that law suites would pile up in reference to patients not getting “treatment.�

    Kathi Stringer
    A Director for the California Network of Mental Health Clients

  • Kathi, I am so glad that you are a part of this world!!!!!

    Elise, “can you pay for it”, now that is what it all seems to boil down to isn’t it? For the record, that is the most arrogant, pompous, insensitive, uncaring, callous comment that anyone could ever have replied with.

    I may have multiple mental disorders, but I am by no means STUPID!

    In my lifetime I have been the head of a checking account dept at a bank (5 yrs), and been the lead trainer of a 125+ person dept at a major securities firm (10 yrs) … and had to work my way up the corporate ladder to reach each of those positions.

    But due to mental disabilities my brain can no longer function at the high, over-achiever, work-aholic, stress level that it takes to obtain employment that will allow for frivolities such as rent, utilities, and food; much less $50+ per hour for “psychosocial” or “cognitive” therapy.

    My disabilities caused me to lose EVERYTHING … my home, my belongings, my family, my friends. I have spent almost 3 years medicated, but homeless, and searching for the help I need.

    I would give my right arm for “psychosoical” or “cognitive” therapy.

    I do have “peers”, and there are a “group” of us, and we do try to “support” each other as best we can. But 1) even if there were peer support groups available nearby, I would 2) still have to have the ability to get to them and back again.

    As far as “Nutritional Supplements” are concerned, I can’t even keep anemia under control … if I cannot get enough nutrition for my physical health how do you suggest I find the nutrition for my mental health? Should I eat more spinach? Can I buy it with food stamps? Can I cook it on YOUR STOVE?

    So, again I say:

    I know I’m mentally ill & I take my medications … but I can’t get anyone to do anything else to help me towards recovery. What is wrong with this picture?????????

  • Elise Stobbe

    Hi Kathi, very good comment! Realize that what I replied was not MY opinion but what research says. “Can you pay for it” is indeed a dilemma, not my suggestion. Is it available and can you pay for it is what the world has answered…It is again a subject of debate. I will post more on funding mental illness soon. Also the other treatment options are again, what research says is available, not me. I am glad you are demonstrating the inadequacies of our mental health system in your post, yet of course my heart goes out to you with this struggle and I wish you the best.

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