DENIAL: PSYCHOLOGICAL OR ORGANIC?
By William Loving, MD, ABAM
A severe alcoholic was on the detox unit and was receiving high doses of Librium to prevent seizures, DTs, and other severe withdrawal problems. The man did not appear drugged, he was alert and well-oriented. The second day in the hospital, when the lab results were on the chart, I went over the results with the patient to discuss mainly the liver damage that was discovered in the lab tests. The numbers (elevated GGT, AST, and ALT) indicated liver damage that could objectively make the point, again, that it was unsafe for this man to drink. After showing the attentive man the abnormal numbers and explaining their meaning, the man politely and blandly said, "Now, can I go home today?" His detox symptoms were attenuated by Librium, but he was no where ready for discharge from the hospital. He was grossly unaware of his severe disease even when given concrete and graphic evidence. His unawareness or denial was so profound, that he seemed totally unable to compute the information given to him about the problem.
This man reminded me very much of another patient I had seen who was paralyzed on the left side due to a right-sided traumatic brain injury. She was unable to care for herself due to severe problems related to the paralysis but also due to cognitive problems caused by the brain injury. She was unable to recognize the fact that she was severely impaired and was even unaware of her paralysis. When her paralyzed arm was held up in front of her face, she was still unable to admit to her paralysis. In fact, she had a neurological condition seen in right hemisphere brain damage known as anosognosia. She was totally unable to realize her problem.
Anosognosia is literally "without disease knowledge." The term was coined in 1914 by Babinski to describe the neurological unawareness of the deficit of hemiplegia or paralysis of one half of the body. Curiously, this syndrome happens when the right side of the brain is damaged by a stroke or injury, but not if the left side is damaged instead. This is a biologically or organically based unawareness of a severe deficit. A great discrepancy exists between the patient's knowledge of a disability and the objective evidence of the disability.
Psychological denial is a prominent part of alcoholism and drug dependence. Denial is psychologically motivated to protect the ego from the distress of catastrophic events. It serves to help the person cope with painful emotions that go with the disease of chemical dependency. All chronic diseases come with some degree of denial as no one wants to believe they have a severe or chronic illness. For example, juvenile diabetics often stop taking their insulin and may eat several candy bars early in the course of their diabetes while they are still struggling with denial. Denial interferes with awareness of the problem and, when strong, interferes with and delays recovery.
Besides stroke and traumatic brain injury, anosognosia is seen in other organic brain disorders such as Alzheimer's disease and Korsakoff's psychosis. The severe memory deficits of Alzheimer's disease account for much of the unawareness of the disease that accompany this disorder. Korsakoff's psychosis is a disturbance in recent memory seen in alcoholics with deficiency of the vitamin Thiamine, but is also believed to be due to direct toxic effect of alcohol on the brain. Some long-term alcoholics develop alcohol dementia due to cortical atrophy. Cortical atrophy, or shrinkage of the brain tissue, is the same pathological finding seen in Alzheimer's disease, and produces profound memory problems. Anosognosia is organically caused denial and is seen not just in stroke and traumatic brain injury, but in these diseases mentioned. It is a symptom of injury to a particular part of the brain, and it is not caused simply by poor memory.
The alcoholic patient that was on the detox unit appeared totally unaware of the gravity of his illness even after "undeniable" evidence was given to him. This inability to recognize his deficits had all the attributes of anosognosia. Alcoholism and chemical dependency are brain disorders. At some point psychological denial may give way to organic unawareness or anosognosia. If a patient’s denial seems so strong that it is almost palpable and seems organic, it may be!
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