Archives for October 2012

Preventing Suicide Throughout the Nation

At age 16, Jordan Burnham was a popular high school student, always smiling and laughing. Being diagnosed with depression came as a surprise, as he had become an expert in hiding his feelings.

“It seemed as though I had everything that I wanted—a girlfriend, playing sports, popular. But still, it felt like there was a hole inside of me, and I couldn’t figure out why I had a lack of motivation to get out of bed, why I was randomly crying,” Jordan says.

The pressure to do well in school, fit in, and make his parents proud led to drinking and suicidal thoughts. In 11th grade, Jordan was hospitalized. But despite medication and twice-weekly sessions with a counselor, Jordan didn’t immediately take his depression seriously. In therapy, he says, “I was probably 80 percent honest,” and he didn’t admit that he had stopped taking his medication.

It took a suicide attempt at age 18 to shock Jordan into making a commitment to get healthy. That meant taking his medication regularly, being completely honest with his therapist, stopping his drinking, and tapping into a strong support system, including his parents. Knowing it was a miracle to be alive after his suicide attempt, Jordan became determined to make his second chance a positive one.

“I knew that I could cope with depression in a better way,” he realized. “I just wanted to be content with how my life was and try to help other people so that it didn’t get to that point for someone else. The main message is that you’re not the only one going through these problems, but you can verbalize them, and you can cope with them in a healthy way.”

Jordan is sharing his message through media appearances and a video for suicide attempt survivors,Stories of Hope and Recovery, released by SAMHSA this fall. Jordan is not alone; SAMHSA’s 2010 National Survey on Drug Use and Health (NSDUH) shows that 3.8 percent of adults age 18 and older in the United States, or an estimated 8.7 million people, had serious thoughts of suicide within the past year. Approximately 2.5 million adults made suicide plans in the past year, and 1.1 million adults attempted suicide in the past year. Like Jordan, many people who struggle with suicidal thoughts also have problems with substance use; the 2010 NSDUH also indicates that adults who have substance dependence or misuse are more than four times more likely to report serious thoughts of suicide than those who do not.

Suicide Prevention Strategy

To reduce the number of people like Jordan who suffer needlessly from suicidal thoughts, SAMHSA and the U.S. Department of Health and Human Services (HHS) have made suicide prevention a national priority. This fall, U.S. Surgeon General Regina Benjamin, M.D., M.B.A.—along with the National Action Alliance for Suicide Prevention, a national public-private collaboration that includes SAMHSA—issued the2012 National Strategy for Suicide Prevention: Goals and Objectives for Action.

For the past 10 years, the nation has been guided by a 2001 strategy that was released by then-Surgeon General David Satcher, which laid the groundwork by organizing a strategic approach to suicide prevention. One of the major milestones from the first National Strategy was the formation of the National Action Alliance, which advances suicide prevention efforts nationwide and was tasked with updating the National Strategy over time.

The cover of the 2012 National Strategy for Suicide Prevention Report

The newest National Strategy identifies ways to reduce the incidence of suicide across the nation and within high-risk populations, such as older men, individuals bereaved by the suicide of someone close to them, and those with a mental or substance use disorder. It reflects advances in understanding effective suicide prevention approaches, such as talk therapy, crisis lines, use of technology, and close coordination of care among health care professionals.

For example, a 2012 U.K. study cited in the National Strategy shows that suicide rates can be significantly reduced through applying a comprehensive set of suicide prevention recommendations, including providing 24-hour crisis teams and conducting community outreach. Other helpful measures include:

  • Removing access to materials that could be used for suicide
  • Training frontline staff within mental health systems to better manage suicide risk
  • Contacting people within 7 days of their discharge from a mental health program
  • Developing written policies for sharing information about suicide risk with criminal justice agencies
  • Following up with patients who are not adhering to treatment
  • Addressing co-occurring disorders (a combination of a mental and a substance use disorder)
  • Reviewing and sharing information with families after a suicide.

Among these recommendations, providing 24-hour crisis care was linked to the largest decrease in suicide rates. The SAMHSA-funded National Suicide Prevention Lifeline Exit Disclaimer, 1–800–273–TALK (8255), provides more than 800,000 callers a year with confidential, 24/7 crisis counseling and mental health referrals through a national network of more than 155 local crisis call centers.

Comprehensive Solutions Needed

Historically, as the National Strategy outlines, suicide prevention was viewed as the primary territory of mental health agencies because of its close link to mental illness. However, most people who have a mental disorder do not engage in suicidal behaviors, according to an Institute of Medicine study cited in theNational Strategy. Moreover, mental health is only one of many factors that can influence suicide risk; life experiences such as trauma or having chronic physical pain also can affect suicide risk.

The new National Strategy recognizes that it will require comprehensive solutions to address the complicated problem of suicide, with multiple approaches implemented at multiple levels. For example, enhancing people’s connections to others—something anyone can do, regardless of background or profession—can help reduce feelings of depression and isolation, which contribute to suicide risk, according to the Suicide Prevention Resource Center (SPRC) Exit Disclaimer.

The National Strategy notes that with the advent of new technologies, it is becoming even easier to help people in crisis. These include mobile apps that enable people to chart moods and access crisis lines and a new Facebook feature that enables the reporting of suicidal content. Working together to change the conversation and remove barriers to life-saving help can be extremely rewarding, as Jordan Burnham attests: “It’s very therapeutic to be able to tell my story, knowing that it’s helping someone else and knowing that I’m making a difference in adding a positive light to society.”


Mother Unsuccessfully Attempted to Get Help For Her Son

(Oct. 17, 2012) It has been a decade today since the tragic death of 11-year old Gregory Katsnelson, who was killed by Ronald Pituch, a man with untreated schizophrenia. Pituch killed his mother, who unsuccessfully attempted to get help for her son, and then murdered Gregory in the woods near his home.

headshot gregory katsnelsonGregory’s death has left both an irreparable loss and a significant legacy.

On days like today, we are reminded of the importance of assisted outpatient treatment (AOT) laws that allow people with mental illness to get the care they need before a tragedy occurs.

Since Gregory’s death, his parents, Cathy and Mark Katsnelson, have worked as tireless leaders in the fight for AOT for individuals with mental illness, and they have turned their pain into something positive. Driven to prevent tragedies like the one they suffered, the Katsnelsons’ persistent advocacy drove the passage of SB 735 (“Gregory’s Law”). The legislation created an option for court-ordered community treatment (New Jersey’s term for assisted outpatient treatment) for individuals, like Pituch, with severe mental illness and a history of non-compliance with treatment.

After considerable delay in fully implementing the law, the New Jersey Department of Human Services last summer awarded the first contracts to five behavioral health providers to begin creating the state’s AOT law in Burlington, Essex, Hudson, Union and Warren counties.

Thank you to the Katsnelsons for their courage and tenacity in working to improve the lives of people with severe mental illness and their communities.

–Treatment Advocacy Center

Hurricane Preparedness: Useful Websites

Tips to strengthen your emotional well-being before the arrival of a hurricane—This tip sheet from the American Psychological Association (APA) provides ways to recognize common emotional reactions and steps to prepare for a hurricane that will be helpful in safeguarding the emotional well-being of the survivor.

Be Red Cross ready: Hurricane safety checklist—This tip sheet from the American Red Cross explains how to prepare for a hurricane.

Also available in Spanish at ne_SPN.pdf

Key facts about hurricane readiness—This fact sheet from the Centers for Disease Control and Prevention lists supplies needed for a hurricane and provides safety tips related to preparing for a hurricane.

Hurricanes—This website by the Federal Emergency Management Agency provides tips to follow before, during, and after hurricane events.

Also available in Spanish at

Hurricane Response and Recovery

Managing traumatic stress: After the hurricanes—This website from APA describes common reactions to hurricane events, and provides tips for hurricane survivors for understanding and coping with these feelings, thoughts and behaviors. The tip sheet also describes how psychologists and other mental health providers can help those who have severe or prolonged reactions that disrupt daily functioning.

Managing traumatic stress: Dealing with the hurricanes from afar—Individuals who are not directly and physically impacted by a hurricane can still feel anxiety and distress related to the storm. This fact sheet from APA provides coping tips for dealing with these reactions.

Be Red Cross ready: Taking care of your emotional health after a disaster—This fact sheet from the American Red Cross explains normal reactions to a disaster, what a survivor should do to cope, and where to seek additional help if needed.

Mass disasters, trauma, and loss—This fact sheet from the International Society for Traumatic Stress Studies includes information on common stress reactions to mass disaster, trauma, and loss. It explains how to minimize these reactions and when to seek professional help. te=/CM/ContentDisplay.cfm&ContentID=1464

Psychological First Aid (PFA)—NCTSN and the National Center for PTSD provide an evidence- informed approach for assisting children, adolescents, adults, and families in the aftermath of disasters and terrorism. The manual includes handouts and tips for survivors and providers and can be downloaded in English, Spanish, Japanese, or Chinese.

PFA online training—According to its online description, PFA Online is an “interactive course that puts the participant in the role of a provider in a post-disaster scene. It features innovative activities, video demonstrations, and mentor tips from the nation’s trauma experts and survivors.”

Psychological first aid: How you can support well-being in disaster victims—This fact sheet from the Center for the Study of Traumatic Stress explains how disaster response workers can use psychological first aid to help people in distress after a disaster.

Reactions to a major disaster: A fact sheet for survivors and their families—This handout from the National Center for Posttraumatic Stress provides information about normal stress reactions, other mental health problems that commonly occur following a disaster, and the recovery process.

SAMHSA Disaster Kit—This kit contains psychoeducational materials to help guide effective response during and after a disaster. Materials also deal with workplace stress and can be used to educate the general public on disaster concerns. Kits can be ordered from the SAMHSA Store by calling 1-877-SAMHSA7 (1-877-726-4727) or the materials can be downloaded electronically.

Resources Focused on People with Disabilities:

Disabled people and disaster planning—This website provides recommendations to reduce or eliminate the barriers to access that many people with disabilities experience after disasters.

Hurricane health tips: Special needs and the elderly—This webpage provides tips for those who have special needs to help prepare for a hurricane, including information on what items to pack, and how to evacuate or find shelter. page4image18632 page4image18792 page4image18952

Individuals with access and functional needs—This website was developed by the Department of Homeland Security in consultation with AARP, the American Red Cross, and the National Organization on Disability. It provides recommendations for creating an emergency supply kit for people with disabilities.

Tips for first responders— This 28-page booklet provides tips for responders during emergencies and routine encounters to accommodate and communicate with people with disabilities. Separate sections address populations including seniors; people with service animals, autism, multiple chemical sensitivities, or cognitive disabilities; and people who are hearing or visually impaired. It is available in both English and Spanish.

Special Needs of Vulnerable Populations: Resources Focused on Children

Childhood traumatic grief educational materials for parents—These factsheets from NCTSN describe childhood traumatic grief, how it differs from other kinds of grief, common signs and other tips for parents.

Also available in Spanish at

Hurricanes—NCTSN also provides several webpages with specific information on hurricane readiness, response and recovery.

Several resources from NCTSN focus on how hurricanes affect children and youth, including:

Resources Focused on Older Adults:

Hurricane stress and seniors—This webpage from a senior living center provides tips for older adults who are experiencing hurricane-related distress by focusing on six dimensions of wellness.

Hurricane health tips: Stress, adults and seniors—This webpage describes the stress reactions that are common for adult and senior hurricane survivors, including coping techniques, and a step-by-step description of the phases of disaster recovery.

Older adults and disaster: Preparedness and response—This guide from the Geriatric Mental Health Foundation helps older adults, their family members, and their caregivers to prepare for and respond to disasters. The webpage describes who is most vulnerable, lists actions that can be taken before and after a disaster strikes, and provides a list of resources for additional support.

Psychosocial Issues for older adults in disasters—This booklet gives mental health professionals, emergency response workers, and caregivers tools to provide disaster mental health and recovery support to older adults. Defines “elderly” and explores the nature of disasters and older adults’ reactions to them.

What you need to know about…helping the elderly recover from the emotional aftermath of a disaster—This one-page fact sheet lists common reactions older adults may have after a disaster and warning signs that someone may need extra help, as well as strategies to help older adults with their special needs.

Resources for Disaster Response Professionals:

A guide to managing stress in crisis response professions—This manual aids crisis response workers in stress prevention and management before, during, and after a public health crisis. It describes the stress cycle and common stress reactions and offers tips to promote a positive workplace and to monitor and minimize stress.

Guidelines for working with first responders (firefighters, police, emergency medical service and military) in the aftermath of disaster—This online tip sheet lists common characteristics of disaster responders, suggests interventions for working with disaster responders, and provides additional resources in working with this population.

Self-care for disaster behavioral health responders podcast—SAMHSA DTAC’s 60-minute podcast provides information, best practices, and tools that enable disaster behavioral health responders and supervisors to identify and effectively manage stress and secondary traumatic stress through workplace structures and self-care practices. presentation.pdf

You can read a transcript of the podcast at transcript.pdf

Tips for managing and preventing stress: A guide for emergency response and public safety workers—This fact sheet gives organizational and individual tips for stress prevention and management for emergency response workers and public safety workers. It describes normal reactions to a disaster, signs of the need for stress management, and ways to handle stress. emergency-response-public-safety-workers.pdf

Disaster Anniversaries and Traumatic Stress

Addressing the traumatic impact of disaster on individuals, families, and communities— Presented at the After the Crisis Initiative: Healing from Trauma after Disasters Expert Panel Meeting, this white paper addresses healing from the trauma induced by a disaster, especially in terms of regaining normalcy and offering and receiving peer support. In addition, the paper focuses on restoring communities with the supports necessary to be sensitive to the recovery from trauma by individuals, children, and families. r.PDF

Anniversary reactions to a traumatic event: The recovery process continues—This fact sheet describes common anniversary reactions among survivors of a disaster or traumatic event. eactionstoaTraumaticEvent.pdf

Coping with disaster anniversaries and trigger events—This tip sheet includes tips for coping with a disaster anniversary and includes common emotions one may experience during this time.

Tips for survivors of a traumatic event: Managing your stress—This tip sheet outlines the common signs of stress after a disaster and provides stress reduction strategies.

Tips for teachers: Marking disaster anniversaries in the classroom—This tip sheet provides useful information for teachers and activities designed to help children deal with normal recovery issues that may be triggered by the anniversary of a disaster. in-the-classroom.html

Disaster Distress Helpline: Call 1-800-985-5990 or Text “TalkWithUs” to 66746

SAMHSA Disaster Distress PDF

When disaster strikes, often people react with increased anxiety, worry and anger. With support from community and family, most of us bounce back. However, “Some may need extra assistance to cope with unfolding events and uncertainties,” said U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) Administrator Pamela S. Hyde, J.D.

The Disaster Distress Helpline (DDH) is the first national hotline dedicated to providing year- round disaster crisis counseling. This toll-free, multilingual, crisis support service is available 24/7 via telephone (1-800-985-5990) and SMS (text ‘TalkWithUs’ to 66746) to residents in the U.S. and its territories who are experiencing emotional distress related to natural or man-made disasters.

Callers and texters are connected to trained and caring professionals from the closest crisis counseling center in the network. Helpline staff provides counseling and support, including information on common stress reactions and healthy coping, as well as referrals to local disaster-related resources for follow-up care and support.

Visit for additional information and resources related to disaster behavioral health.


Disaster Distress Helpline: 1-800-985-5990

  •   Toll-free
  •   Multilingual
  •   Available 24 hours a day, 7 days a week, year-round
  •   TTY for deaf and hearing impaired: 1-800-846-8517

SMS: Text ‘TalkWithUs’ to 66746

 Standard text messaging / data rates apply (according to each subscriber’s mobile provider plan)

 Spanish-speakers can text ‘Hablanos’ to 66746; Puerto Rico text ‘Hablanos’ to 1-212-461-4635

 Available 24 hours a day, 7 days a week, year-round

 Palau, Marshall Islands, American Samoa, Guam, Northern Mariana Islands, Federated States of Micronesia text ‘TalkWithUs’ to 1-206-430-1097

 US Virgin Islands text ‘TalkWithUs’ to 1-212-461-4635

Many Teens Considering Suicide Do Not Receive Specialized Mental Health Care

Most adolescents who are considering suicide or who have attempted suicide do not receive specialized mental health services, according to an analysis published online August 15, 2012, in Psychiatric Services, a journal of the American Psychiatric Association.


National survey data from the Centers for Disease Control and Prevention (CDC) notes that approximately 14 percent of high school students seriously consider suicide each year, 11 percent have a suicide plan, and 6 percent attempt suicide. Other research has suggested that less than half of teens who attempt suicide received mental health services in the year prior to their attempt.

Kathleen Merikangas, Ph.D., of NIMH and colleagues analyzed data from the National Comorbidity Survey-Adolescent Supplement (NCS-A), a nationally representative, face-to-face survey of more than 10,000 teens ages 13 to 18. They asked teens whether they had any suicidal thoughts, plans, or actions (ideation) over a one-year period prior to the survey. They also completed a structured diagnostic interview regarding the full range of mental disorders including mood, anxiety, eating and anxiety disorders and whether they had received treatment for emotional or behavioral problems in the past 12 months. Respondents were asked to differentiate between receiving care from a mental health specialist such as a social worker, psychiatrist or other mental health professional, and receiving care from a general service provider, such as a primary care physician.

Results of the study

The survey revealed that, within the past year, 3.6 percent of adolescents had suicidal thoughts, but did not make a specific plan or suicide attempt. In addition, 0.6 percent reported having a plan, and 1.9 percent reported having made a suicide attempt within the past year.

Suicidal behavior among youth was not only associated with major depression, but also with a range of other mental health problems including eating, anxiety, substance use and behavior disorders, as well as physical health problems. Between 50 and 75 percent of those teens who reported having suicidal ideation had recent contact with a service provider. However, most only had three or fewer visits, suggesting that treatment tends to be terminated prematurely. Moreover, most teens with suicidal ideation did not receive specialized mental health care.


The results of this study suggest that depression and other mood disorders are not the only pathways to suicide. They also highlight the importance of integrating risk assessment for suicide into routine physical and mental health care for teens. Even if adolescents are in treatment, they should continue to be monitored for suicidal ideation and behaviors, the researchers concluded.


Husky M, Olfson M, He J, Nock M, Swanson S, Merikangas K. Twelve-month suicidal symptoms and use of services among adolescents: results from the National Comorbidity Survey. Psychiatric Services in Advance, Aug 15, 2012.

–Treatment Advocacy Center

Prepare for Hurricane Sandy: Make Sure You Have One Week of Meds

Other tips:

1. Lower the brightness on your cell phone and laptop to lengthen battery life (in case your power goes out and you can’t recharge them)

2. Learn how to use Facebook, Twitter and other phone apps so that you can communicate during the storm if you need help or need to contact family and friends

2. During the storm, get help: Use Twitter and social media, email, text or call family and friends, or call emergency phone numbers. DO NOT make non-essential phone calls because phone lines are tied up by emergency calls

3. Use “Distressed Helpline” SMS service (text ‘TalkWithUs’ to 66746) is avail 24/7 to all 50 states & territories. This is a program sponsored by the U.S. Gov. “Substance Abuse and Mental Health Administration”

4. Write down a list of emergency numbers: police, fire, pharmacy, doctors, suicide hotlines (1-800-273-8255), relatives and friends. In case your phone battery dies, write this list down on a piece of paper as well as entering the numbers into your cell contacts.

5. Stay informed by reading news online, listening to the radio and watching TV

6. Stay calm and have fun if you aren’t in danger. Play board games, finish making your Halloween costume or decorate  your house for Halloween, watch movies, read books, cook some soup, make hot chocolate or bake a cake.

Websites with more info about preparing for and responding to disasters:


CDC info for those with disabilities:

Gene Variants Implicated in Extreme Weight Gain Associated with Antipsychotics

Extreme weight gain associated with taking an antipsychotic medication may be linked to certain genetic variants, according to a study published in the September 2012 issue of the Archives of General Psychiatry.


Antipsychotic medications, especially those known as “second generation” or “atypical” antipsychotics, generally are the first-line of treatment for schizophrenia and other serious mental disorders. They are effective in treating psychotic symptoms, but they are also associated with serious metabolic side effects that can result in substantial weight gain, and other cardiovascular problems.

Some people appear to be more susceptible to severe weight gain than others, but it is difficult to predict who is most at risk. To date, there have been few genetic studies of weight gain associated with antipsychotics, in part because it is difficult to control such variables as prior exposure to the medications, and because patients often stop taking the medications prematurely.

Anil Malhotra M.D., of the Feinstein Institute for Medical Research, and colleagues set out to identify any common gene variants associated with antipsychotic-induced weight gain in a group of patients who had never taken the medications before and who were carefully monitored to ensure they continued to take the medication over the study period. The initial study included a cohort of 139 pediatric patients who were prescribed a second-generation antipsychotic. Patients were examined over a period of 12 weeks to assess weight and metabolic effects of the medications.

To compare and confirm their results, the researchers also conducted similar assessments of three small cohorts with adult patients taking second generation antipsychotics.

Results of the Study

The researchers found markers in a gene called the melanocortin 4 receptor (MC4R) that were associated with severe weight gain in people taking second generation antipsychotics. The MC4R region overlaps somewhat with another region previously identified as being associated with obesity in the general population. In addition, the results were replicated in the three independent cohorts.


In many genetic studies involving obesity, thousands of participants are needed to achieve statistically significant results and to overcome the many environmental factors that can influence a person’s weight. In this study, the critical environmental factor predisposing patients to weight gain was only antipsychotic medication use over a short period of time, thus allowing more control over other variables that could have confounded results. Therefore, even though the study only included 139 individuals, the researchers were able to detect results that implicated specific gene variants.

The results also have potential clinical implications. Patients with the identified gene variants that would predispose them to severe weight gain while taking an antipsychotic could be directed to alternative treatments, especially those who do not have a psychotic disorder.

What’s Next

Although particular gene variants were implicated, the study’s sample size was small. Further research with larger samples is needed to extend the findings.


Malhotra A, et al. Association between common variants near the melanocortin 4 receptor gene and severe antipsychotic drug-induced weight gain. Arch Gen. Psychiatry. 2012 Sep. 69(9):904-912.

–Treatment Advocacy Center

The Anatomical Basis of Anosognosia


Anosognosia, or lack of awareness of illness, is a common symptom of schizophrenia and bipolar disorder with psychotic features. It is one of the most common reasons why individuals with these disorders often refuse to take medication.

To date, 18 studies have been done looking at the relationship between anosognosia and the anatomical structure of the brain; 15 of the studies reported statistically significant correlations and three studies did not. The three negative studies focused on global brain measures, such as total brain or total ventricular volume. The 15 positive studies included many that focused on more specific brain structures. Two of the positive studies were of individuals with first-episode psychosis and included individuals who had never been treated with antipsychotic medications, thus ruling out medications as a cause of the observed brain changes.

Regarding localization, it is now clear that anosognosia is not caused by damage to one specific area. Rather a person’s awareness of illness involves a brain network that includes the prefrontal cortex, cingulate, superior and inferior parietal areas, and temporal cortex and the connections between these areas. Damage to any combination of these areas can produce anosognosia, but damage to the prefrontal and parietal areas together make anosognosia especially likely.

Anosognosia, or lack of awareness of illness, thus has an anatomical basis and is caused by damage to the brain by the disease process. It thus should not be confused with denial, a psychological mechanism we all use.

Click here to read or print the report from PDF.


Anosognosia has been described by neurologists for over a century. Classically, it occurs in a patient who has had a stroke in the right parietal lobe of the brain, producing left hemiplegia. The individual so affected may deny that anything is wrong despite being paralyzed on the left side. This is not simple denial, a subconscious psychological mechanism we all use occasionally. This is anatomical damage to the part of the brain we use to think about ourselves. Thus denial is psychological, whereas anosognosia is anatomical.

Anosognosia is very difficult to imagine or understand. Oliver Sacks, in The Man Who Mistook His Wife for a Hat(p.5), explained anosognosia as follows:

It is not only difficult, it is impossible for patients with certain right-hemisphere syndromes to know their own problems – a peculiar and specific ‘anosognosia,’ as Babinski called it. And it is singularly difficult, for even the most sensitive observer, to picture the inner state, the ‘situation’ of such patients, for this is almost unimaginably remote from anything he himself has ever known.

The anatomical basis of anosognosia in stroke patients has been well described. According to a summary of the studies, anosognosia “seems to be equally frequent when the damage is continued to frontal, parietal or temporal cortical structures…[but] is highest when the lesions involve parietal and frontal structures in combination” (Pia L, et al. The anatomy of anosognosia for hemiplegia: A meta-analysis. Cortex. 2004;40:367-377).


Attention to the problem of anosognosia in schizophrenia is relatively new, dating to the work of Drs. Xavier Amador and Anthony David in the 1990s. Clinicians had long been aware that some patients were unaware of their symptoms and illness, but the similarity of this condition to the anosognosia seen in some stroke patients had not been widely noted. Indeed, being unaware of one’s illness has been known to be a cardinal symptom of psychosis. As early as 1604, playwright Thomas Dekker had a character in his play, “The Honest Whore,” proclaim: “That proves you mad because you know it not.”

In the last decade, there has been an outpouring of studies of anosognosia in individuals with psychosis in general and with schizophrenia in particular. Some studies have examined the relationship between anosognosia and various brain functions (for a review see Shad MU, et al. Insight and frontal cortical function in schizophrenia: A review. Schizophrenia Research 2006;86:54-70). Other studies have examined the relationship between anosognosia and brain anatomy in individuals with schizophrenia. This paper will summarize these studies.

There have been at least 18 such studies, beginning with the most recently published.

  • Awareness of illness is associated with the function of midline brain structures.

In Finland, 21 patients with schizophrenia and 17 normal controls underwent both structural magnetic resonance imaging (MRI) and functional MRI, during which time they were asked to answer specific questions about insight, e.g., “If someone said I had a mental illness they would be right.” Insight was associated with activation of brain midline structure, specifically posterior cingulate, medial prefrontal cortex, and frontal pole, brain areas known to be associated with self-awareness. The authors acknowledged that “the present findings…cover only a portion of the neuronal circuitries involved in the processing of insight.”

Raij TT, Riekki TJ, Hari R. Association of poor insight in schizophrenia with structure and function of cortical midline structures and frontopolar cortex. Schizophr Res. 2012 Aug;139(1-3):27-32. Epub 2012 Jun 2.

  • Anosognosia is associated with impaired cerebral blood flow in the superior parietal area (precuneus).

In France, 31 patients with paranoid schizophrenia and 18 normal controls were assessed for cerebral blood flow by single photon emission computed tomography. Twenty-one patients had good awareness of their illness; 10 did not. Those with poor awareness of their illness showed poor cerebral blood flow to their precuneus bilaterally (p

Faget-Agius CBoyer LPadovani RRichieri RMundler OLançon CGuedj E. Schizophrenia with preserved insight is associated with increased perfusion of the precuneus. J Psychiatry Neurosci. 2012 Apr 3;37(3):110125. doi: 10.1503/cjs.110125. [Epub ahead of print]

These pictures show differences in blood flow to the superior parietal area (precuneus) in individuals with schizophrenia with preserved awareness of illness (left) and impaired awareness of illness or anosognosia (right).


Pictures courtesy of Dr. Eric Guedj and colleagues, Hospital de la Timone, Marseille, France.

  • Anosognosia is associated with widespread impairments in white matter.

At New York University, 36 individuals with schizophrenia and schizoaffective disorder underwent diffusion tensor imaging (DTI), which assesses brain white matter integrity. Those with poorer awareness of their illness were significantly more likely to have impaired white matter function in the frontal lobe (e.g., left middle and right superior frontal gyri); temporal lobe (e.g., bilateral parahippocampal gyri); cingulate; thalamus; and basal ganglia (caudate and lentiform nucleous).

Antonius D, Prudent V, Rebani Y, D’Angelo D, Ardekani BA, Malaspina D, Hoptman MJ. White matter integrity and lack of insight in schizophrenia and schizoaffective disorder. Schizophr Res. 2011 May;128(1-3):76-82. Epub 2011 Mar 22.

  • Anosognosia is associated with decreased cortical thickness.

In Montreal, 79 individuals with first-episode psychosis were assessed clinically and by magnetic resonance imaging (MRI). Poorer awareness of illness was significantly associated with having a thinner brain cortical layer in the left middle frontal gyrus, left inferior frontal gyrus, left inferior temporal gyrus, left and right precentral gyrus, and right occipital gyrus. Impaired awareness of need for treatment was significantly associated with a thinner brain cortical layer in the left middle and medial frontal gyri; parietal precuneus and supramarginal gyrus; temporal parahippocampus and superior, middle and inferior gyri; and middle occipital gyrus. The authors concluded that “insight involves a network of brain structures, and not only the frontal lobes as previously suggested.”

Buchy LAd-Dab’bagh YMalla ALepage CBodnar MJoober RSergerie KEvans ALepage M. Cortical thickness is associated with poor insight in first-episode psychosis. J Psychiatr Res. 2011 Jun;45(6):781-7. Epub 2010 Nov 19.

  • Anosognosia is associated with impairments in midline brain structures (posterior cingulate and precuneus).

In England, 82 individuals with first episode psychosis and 91 normal controls were assessed on neuropsychological tests and by magnetic resonance imaging (MRI). Twenty of the individuals with first-episode psychosis “had no capacity to identify psychotic symptoms as pathological.” Compared with the other 62 individuals, those 20 had “significantly reduced global gray matter volume,” most marked in the left posterior cingulate cortex, the right precuneus, and the cuneus.

Morgan KDDazzan PMorgan CLappin JHutchinson GSuckling JFearon PJones PBLeff J,Murray RMDavid AS. Insight, grey matter and cognitive function in first-onset psychosis. Br J Psychiatry.2010 Aug;197(2):141-8.

  • Anosognosia is associated with impairments of temporal and parietal areas.

In England, 52 individuals with schizophrenia or schizoaffective disorder and 30 normal controls were assessed for awareness of symptoms and underwent magnetic resonance imaging (MRI). Those with poorer awareness of their symptoms had decreased gray matter volume in their left superior, left middle, and right inferior temporal gyri, as well as the right inferior parietal lobule and right supramarginal gyrus (all p

Cooke MA, Fannon D, Kuipers E, Peters E, Williams SC, Kumari V. Neurological basis of poor insight in psychosis: a voxel-based MRI study. Schizophr Res. 2008 Aug;103(1-3):40-51. Epub 2008 Jun 9.

  • Anosognosia is associated with decreased gray matter volume of the prefrontal cortex.

In England, 28 outpatients with stable schizophrenia were assessed for insight and underwent magnetic resonance imaging (MRI). Lower levels of insight were moderately associated with decreased volume of the prefrontal gray matter, especially the inferior frontal gyrus.

Sapara ACooke MFannon DFrancis ABuchanan RWAnilkumar APBarkataki IAasen IKuipers E,Kumari V. Prefrontal cortex and insight in schizophrenia: a volumetric MRI study. Schizophr Res. 2007 Jan;89(1-3):22-34. Epub 2006 Nov 13.

  • No association is found between anosognosia and regional brain volumes.

In Italy, 50 patients with schizophrenia and 30 normal controls were assessed for awareness of illness and by magnetic resonance imaging (MRI). No relationship was found between awareness of illness and the gray and white matter volumes in the frontal or temporal cortex.

Bassitt DPNeto MRde Castro CCBusatto GF. Insight and regional brain volumes in schizophrenia. Eur Arch Psychiatry Clin Neurosci. 2007 Feb;257(1):58-62.

·         Anosognosia is associated with decreased activation of the left medial prefrontal cortex.

In England, 14 individuals with schizophrenia were subjected to functional magnetic resonance imaging (fMRI) both during an acute schizophrenia episode and again after they had been stabilized. During their fMRI, they were asked to do tasks that measured social functioning and awareness of illness. Their left medial prefrontal cortex showed improved activation when they were stabilized, and this correlated with improvement in insight scores (r=0.81, p

Lee KH, Brown WH, Egleston PN, Green RD, Farrow TF, Hunter MD, Parks RW, Wilkinson ID, Spence SA, Woodruff PW. A functional magnetic resonance imaging study of social cognition in schizophrenia during an acute episode and after recovery. Am J Psychiatry. 2006 Nov;163(11):1926-33.

  • Anosognosia is associated with decreased volume of right dorsolateral prefrontal cortex and right orbitofrontal cortex.

At the University of Texas Southwestern, 14 patients with schizophrenia and 21 normal controls were assessed for awareness of illness and symptoms and by magnetic resonance imaging (MRI). Patients with poorer awareness of their illness and symptoms also had significantly smaller right dorsolateral prefrontal cortex (r= -0.72, p= 0.04).

Shad MUMuddasani SKeshavan MS. Prefrontal subregions and dimensions of insight in first-episode schizophrenia–a pilot study. Psychiatry Res. 2006 Jan 30;146(1):35-42. Epub 2005 Dec 19.

  • Anosognosia is associated with reduced gray matter in the cingulate and inferior temporal regions

In South Korea, 35 patients with paranoid schizophrenia and 35 matched normal controls underwent clinical testing and magnetic resonance imaging (MRI). Those with greater “lack of judgment and insight” had reduced gray matter in their right anterior cingulate, left posterior cingulate, and inferior temporal region on both sides.

Ha TH, Youn T, Ha KS, Rho KS, Lee JM, Kim IY, Kim SI, Kwon JS. Gray matter abnormalities in paranoid schizophrenia and their clinical correlations. Psychiatry Res. 2004 Dec 30;132(3):251-60.

  • Anosognosia is associated with decreased volume of the right dorsolateral prefrontal cortex.

At the University of Pittsburgh, 35 individuals with first episode schizophrenia, who had never been treated with any antipsychotic drugs, were assessed clinically, neuropsychologically, and by magnetic resonance imaging (MRI) of the frontal lobes and hippocampus. Eighteen patients had poor awareness of their illness, and 17 had good awareness of their illness. Those with poor awareness had decreased volumes of their right dorsolateral prefrontal cortex (DLPFC) (r= -61, p = 0.008). Unawareness of illness was not associated with hippocampal volume nor with duration of illness or other clinical symptoms.

Shad MU, Muddasani S, Prasad K, Sweeney JA, Keshavan MS. Insight and prefrontal cortex in first-episode Schizophrenia. Neuroimage. 2004 Jul;22(3):1315-20.

  • Anosognosia is not correlated with global brain measures.

In England, 78 men with schizophrenia and 36 normal controls were assessed for awareness of illness and underwent magnetic resonance imaging (MRI). There were “no significant correlations between total insight score and grey, white, CSF, and total brain volume.” The authors concluded that such research was not likely to be useful for such “global brain measures” and that “future investigations should pay attention to more specific cortical regions.”

Rossell SL, Coakes J, Shapleske J, Woodruff PW, David AS. Insight: its relationship with cognitive function, brain volume and symptoms in schizophrenia. Psychol Med. 2003 Jan;33(1):111-9.

  • Anosognosia is associated with specific subregions of the frontal lobes.

At Dartmouth Medical School,15 individuals with schizophrenia and schizoaffective disorder were assessed for awareness of illness and frontal brain structures by magnetic resonance imaging (MRI). Those with less awareness of their illness had significantly smaller bilateral middle frontal gyrus volume (r= -0.92 and -0.72, p

Flashman LA, McAllister TW, Johnson SC, Rick JH, Green RL, Saykin AJ. Specific frontal lobe subregions correlated with unawareness of illness in schizophrenia: a preliminary study. J Neuropsychiatry Clin Neurosci. 2001 Spring;13(2):255-7.

  • Anosognosia is associated with atrophy of the frontal lobes.

In Norway, 21 individuals with schizophrenia and 21 matched normal controls were assessed by computerized tomography (CT) scans. Seven of the 21 individuals with schizophrenia had mild or moderate atrophy of their frontal lobes, and this atrophy correlated with having poorer awareness of their illness (r= -0.52, p

Larøi F, Fannemel M, Rønneberg U, Flekkøy K, Opjordsmoen S, Dullerud R, Haakonsen M. Unawareness of illness in chronic schizophrenia and its relationship to structural brain measures and neuropsychological tests. Psychiatry Res. 2000 Nov 20;100(1):49-58.

  • Anosognosia is associated with having a smaller brain size.

At Dartmouth Medical School, 18 individuals with schizophrenia with a poor awareness of their illness were compared on magnetic resonance imaging (MRI) with 12 individuals with schizophrenia with a good awareness of their illness and 13 healthy controls. There were no differences between the schizophrenia groups on education, symptoms, or severity of illness. However, those with poor awareness of their illness had significantly smaller brains and decreased intracranial volumes, findings consistent with having had a greater loss of brain tissue (atrophy) associated with their schizophrenia.

Flashman LA, McAllister TW, Andreasen NC, Saykin AJ. Smaller brain size associated with unawareness of illness in patients with schizophrenia. Am J Psychiatry. 2000 Jul;157(7):1167-9.

  • Anosognosia does not correlate with total ventricular volume.

In England, 128 individuals with recent-onset psychosis were assessed for awareness of illness and underwent a computerized tomography (CT) scan. No correlation was found between awareness of illness and total ventricular volume.

David A, van Os J, Jones P, Harvey I, Foerster A, Fahy T. Insight and psychotic illness. Cross-sectional and longitudinal associations. Br J Psychiatry. 1995 Nov;167(5):621-8.

  • Anosognosia correlates with enlarged brain ventricles.

In Japan, 22 patients with chronic schizophrenia were assessed for awareness of illness and underwent magnetic resonance imaging (MRI). Those patients with impaired awareness of illness had significant ventricular enlargement (p

Takal A, Uematsu M, Ueki H, Sone K, Kalya H. Insight and its related factors in chronic schizophrenic patients: a preliminary study. Eur J Psychiat. 1992;6:159-170.

–Treatment Advocacy Center

Tired of Fighting the Pain of Mental Illness?

Maybe it’s hard for your friends and family to sympathize with your mental illness because they don’t know very much about it or because of the stigma.It’s easy to stop talking to people who just don’t understand. Then you are alone without support, except for professionals like a doctor, social worker and therapist if you are lucky enough to have insurance or government benefits that cover those. Still, it’s easy to become isolated, which makes it hard to stay grounded. Is reality too hard to deal with? Are you overwhelmed and want to give up trying to fight your problems? Do you feel that you have no control over your problems and that your mental illness controls you? Some people run from their feelings and reality by using drugs and alcohol, planning suicide or other self-destructive behaviors. It’s easy to stop caring about yourself and stop trying to get better. Does it seem easier to stop paying rent and bills, stop going to your doctors appointments, and stop taking your medication? Is it all too hard? Please stop for a moment and think about this: you are a human being, You are valuable. You can make a difference in the world by fighting your illness, being a role model for others who are fighting their mental illness, and showing your family and friends (even if they don’t really understand what you’re going through) that you care about them enough to keep fighting. Let go of fighting reality. Allow yourself to feel the pain, but then move on and fight for your life. Don’t wait for things to get better–ACT. Figure out WHAT YOU CAN CONTROL, and do those things. You CAN control how you react to life events. You CAN decide to take care of your physical body by eating healthy food, exercising, and taking care of your medical problems. You CAN go to a psychiatrist and therapist and advocate for yourself. Tell them that your medication isn’t working and ask them to help you with your problems. You can research housing resources and other resources available in your community. It may be uncomfortable, time-consuming and hard. But it’s NECESSARY. Every day, every hour, every minute, make the decision to keep fighting for your life. Perhaps you can go to a support group, like Schizophrenics Anonymous or NAMI to talk to peers who really understand what you’re going through. Perhaps you can go to a day program with activities or classes that help you stay connected with other people so that you’re not alone all day. If you are suicidal, call a suicide hotline such as 1-800-SUICIDE (1-800-784-2433) or 1-800-273-TALK (1-800-273-8255). You are not alone! Please don’t give up. Get help and keep fighting. Things will get better, even if you can’t imagine it right now.

Anosognosia: Lack of Insight Into Mental Illness

keep-sound-mindsAnosognosia is a lack of awareness about one’s own mental illness and is believed to be the largest reason why individuals with schizophrenia and bipolar disorder do not take their medications.

It affects roughly half of those with the most severe mental illnesses and is believed to be the largest reason why individuals with schizophrenia and bipolar disorder do not take their medications.

Keep Sound Minds iscommitted to preventing similar incidents from occurring by improving society’s understanding and management of mental health issues. They strive to change public perception of mental illness by increasing awareness that if psychiatric disorders are properly diagnosed and treated, people have a greater chance of living healthy, productive lives to their fullest potential.

Our video about anosognosia provides a four-minute glimpse into what the condition is and how it appears in someone actively suffering symptoms.

–Treatment Advocacy Center