Understanding How Lack Of Insight — A Common Symptom Of Serious Mental Illness — Makes Treatment So Hard
Imagine a loved one is very sick, but the illness makes them vehemently believe they aren’t.
It’s a symptom known as anosognosia — or lack of insight — and its very common in serious mental illnesses such as schizophrenia and bipolar disorder. Like any malady, mental illnesses come with a list of possible symptoms: disorganized speech, lack of concentration, even hallucinations. Anosognosia makes suffering people believe they don’t need treatment.
For countless families though, anosognosia is an all too real fact of daily life — and a symptom experts say is a major barrier to lifesaving treatment.
‘Angry Voices’ and a Terrible Accident
A small dog criss-crosses under a table in the kitchen of Nomi Lonky’s home in Yorba Linda, looking for a pat on the head. Through the glass door, a swimming pool shimmers in the late fall sun. But the table was cleared of plates, flatware and glasses. Instead, she had laid out some reading material about mental illness. There’s a heavily-notated book from a renowned psychiatrist, and a recent L.A. Times article chronicling one family’s struggle with serious mental illness.
Such stories resonate with Lonky, she said, because they remind her of the journey with her son, Jeffrey Hoblin.
“He was a phenomenal musician, he was a drummer,” said Lonky, adding that schools fought over him because of his talent.
But towards the end of high school, Lonky noticed changes in her son.
“He wasn’t interested at the end of high school even to go to his graduation,” Lonky said. “He was losing interest in things.”
Sometime in his late teens or early 20s, symptoms of serious mental illness began to take hold of Hoblin’s life. He began hearing voices — angry voices, Lonky said — that urged him to the railroad tracks. Often the voices would tell him that an old girlfriend would be tortured if he didn’t sacrifice himself for her.
Lonky had an excruciating time trying to help her son get the treatment he needed. Diagnosed with schizoaffective disorder, Hoblin continued to have psychotic episodes over the years and did not want to take medication. In 2018, while living with his father in New York, those delusions reached an ultimate crisis point.
Lonky said one day, she became worried because Hoblin wasn’t answering his phone.
“I finally got hold of the mental health unit he spent some time with," Lonky recalled.
"They were the ones that let me know that he had gotten hit by a train."
Hoblin doesn’t remember much of the accident, which left him with injuries to his brain, arm and hip. He struggles to put on his socks, Lonky said.
‘I Don’t Need Your Stupid Hospital’
One of the biggest barriers to getting Hoblin treatment over the years was his lack of insight into his own illness and surroundings — what is known as anosognosia.
“He’s kind of like that movie ‘Beautiful Mind,’” Lonky said. “You logically could explain it to him, but meanwhile he’s still having trouble because he’s still hearing the voices and it’s very real to him.”
Dr. Henry Nasrallah, a professor of psychiatry at the University of Cincinnati, said studies have shown that anosognosia affects up to 98% of patients living with schizophrenia, depending on the stage of the illness.
“Patients will say, 'Nope, there’s nothing wrong with me, I don’t need your stupid hospital, I don’t need any medication, I’m fine,'” Nasrallah, a leading expert on schizophrenia, said.
Patients are very often “absolutely unaware” of how sick they are, Nasrallah said.
The frontal lobe and other areas of the brain in patients experiencing anosognosia is impaired, Nasrallah explained, affecting decision-making and the understanding of concepts.
It’s one of the reasons he’s a big proponent of slow-release injections, which allow a patient to receive medication once a month instead of having to stay on a pill regimen.
“For reasons that are so unbelievably idiotic, many clinicians continue to give the patients pills,” Nasrallah said.
For reasons that are so unbelievably idiotic, many clinicians continue to give the patients pills.
Nasrallah believes injectable medications like the ones he prescribes his patients contradict the belief that serious mental illness such as schizophrenia is irreversible.
“That’s baloney: I have treated patients who were homeless, hearing voices — nobody ever bothered to treat them with the right medication — and they come to me and I completely bring them back to normal,” Nasrallah said.
Dr. Jorge Partida del Toro, chief of psychology at the L.A. County Department of Mental Health, said anosognosia makes it difficult to provide treatment to the estimated roughly 50% of unhoused people who live with a serious mental illness.
But he said there are less visible impacts of the syndrome too.
“I think that this affects family members the most because they do have to live with the unobservable signs of pain and suffering that the client is unwilling to — or unable to — recognize for themselves,” Del Toro said.
Del Toro agrees with Nasrallah that medication injections can be very helpful and he says psychotherapy and other forms of engagement are also key to making progress.
‘I See What People Were Talking About With Me’
These days, at 44, Jeffrey Hoblin is doing much better. He still plays music.
“The last five years of my musician life, I spent playing a lot of guitar,” said Hoblin, adding that he’s filled at least a dozen pages with riffs he plans on turning into songs.
Hoblin said dealing with his own anosognosia over the years has been confusing, but his insight has come back, in part thanks to the new facility where he lives in Orange County.
“Now that I live with 25 other schizophrenics, I see what people were talking about with me,” Hoblin said. “I’m notorious in my past for not wanting to be on any medication at all ... I like my antipsychotics right now.”
Hoblin said he’d like everyone to have a better understanding of mental illness, and over the years he has spoken to classes sponsored by the National Alliance on Mental Illness.
He offered a bit of advice for people who see someone experiencing an alternate reality: give them some space, let them have their volume.
“You know, you see somebody screaming in the streets ... It’s a scary thing, I know,” Hoblin said. “I’m schizophrenic and I get scared when I see other schizophrenics out there.”
When it comes to serious mental illness, we could probably all use a little more insight and awareness.
- Steinberg Institute website, links to mental health resources and care throughout California
- Institute on Aging's 24/7 Friendship Line (especially for people who have disabilities or are over 60), 1-800-971-0016 or call 415-750-4138 to volunteer.
- Los Angeles County Department of Mental Health, 24/7 Access Line 1-800-854-7771, links to COVID-19 information.
- The Crisis Text Line, Text "HOME" (741-741) to reach a trained crisis counselor.
- California Psychological Association Find a Psychologist Locator
- Psychology Today guide to therapist
If You Need Immediate Help
- Find 5 Action Steps for helping someone who may be suicidal, from the National Suicide Prevention Lifeline.
- Six questions to ask to help assess the severity of someone's suicide risk, from the Columbia Lighthouse Project.
- To prevent a future crisis, here's how to help someone make a safety plan.