Thank you, Hector. Your erudition and exposition of the literature have rescued us from a semantic quagmire that reminds me of Lewis Carrol’s witty epigram: “When I use a word it means just what I choose it to mean – neither more than less.” (In Through the Looking Glass).

       The problem has been both definitional and descriptive. As Hector correctly reminds us, ‘agnosia’ came from neurology and ‘anosognosia’ from psychiatry but both fail to make an agreed on crucial distinction between organic and psychologic etiology (although different dictionaries favor one or the other). It is unclear whether treatment for such conditions resides in psychotherapy directed towards insight or medication to repair a broken brain. This failure to distinguish symptoms from underlying etiology has been the Achilles heel of the DSM diagnostic system.

       The therapeutic implications of clarifying this dichotomy are immense and reminiscent of the classic historical and litigious conflict over the appropriate use of psychoanalysis or ECT for medication refractory major depression.

       It remains unclear to what extent different diagnoses harbor discrete etiologies, when patients deny they are sick and refuse treatment. In hysteria, psychological explanations of physical symptoms seem credible (although miss-diagnosis is rife). The history of deinstitutionalization suggests that with schizophrenia, a majority of patients accept and benefit from medication, although the work of Amador and associates Hector cites suggests lack of awareness of illness is present in up to half of patients. (Which Amador calls anosognosia, in contradiction to OED.) Presumably, this distinguishes frontal lobe pathology from delusional thinking, a wise reluctance to take toxic medications (tardive dyskinesia, metabolic syndromes and sexual dysfunction) and the futility of taking drugs that fail to benefit the cognitive and social deficits that cripple an ability to live in community.

       In severe psychotic manic episodes, my experience suggests that cortical pathology is profound and relatively common; it leads to reluctance to accept diagnosis or treatment with lithium that, properly managed, is non-toxic and fully restores intellectual and social competence. Given that coercion in unsuccessful, constructive bargaining is a logical alternative. Even manic patients can sometimes recognize when they have engineered bankruptcy, destroyed a marriage, ruined a career or shamed themselves.

       The INHN website has a program that provides “Definitions” of classical psychiatric terminology. I would like Tom Ban to invite Hector Warnes to bring this debate to a satisfying conclusion by providing precise meanings for ‘agnosia’ and ‘anosognosia’ that reflect the wisdom he has unearthed for us.

Barry Blackwell
February 4, 2016