Conference Probes Pathology of Self-Awareness

What do you think, I think, of you?

The seemingly simple question was splayed in huge black type across two giant video screens in a darkened room at a conference in Kansas City, Mo. More than 100 psychiatrists were gathered there because many of their patients are unable to find an answer to that question, and their lack of self-awareness may lie at the heart of the treatment-resistance of their conditions.

"We're trying to understand how mind and brain work together," said Bernard D. Beitman, M.D., chair of the psychiatry department at the University of Missouri, Columbia, Health Sciences Center, and organizer of the March conference titled Disorders of Self-Awareness. "We are approaching a remarkable subject and a difficult subject," he told attendees.

The inability of patients with schizophrenia, autism, personality disorders, attention-deficit/hyperactivity disorder, hysteria and substance abuse disorders to fathom their impact on the people who surround them or to recognize that their thoughts fail to conform to the realities of their lives has a negative impact on the course of treatment and decreases the likelihood that any intervention will achieve improved functioning. While psychiatrists have known for a long time that denial or lack of insight can undermine treatment, this conference sought to focus on deficits in self-awareness as pathology.

"What's unique here is that there's never been a conference that has tried to examine pathological functions to figure out what is normal functioning or normal self-awareness," Beitman said in an interview with Psychiatric Times. What may be perceived as a temperamental rejection of care or a psychologically based denial of illness may be a biologically based element of the illness itself. This possibility could have an enormous impact on treatment regimens and the way they are implemented by practitioners.

"We're still struggling with definitions," Beitman said. "We are going to be asking what is self-awareness and what are the brain structures that support our ability to be aware of ourselves. We're going to try to understand normal functioning by looking at pathological functioning, by looking at disorders of self-awareness."

"What do you think, I think, of you," summarizes the basic question involved with self-awareness, Beitman told the attendees. "It requires my ability to construct your theory of me. So that I can help me, I have to know how you think, and I have to know the subset of how you think that includes me."

This is a fairly high-order function, Beitman added, and patients suffering from a number of mental illnesses tend to have difficulties in one or several of these areas. Over the two days of the conference, psychiatrists and other mental health care practitioners learned how much deficits in self-awareness--and their own perceptions of those deficits--could affect outcomes for patients.

"I'm hoping that you come away with some ideas that maybe we don't see ourselves, because this is new territory," Beitman told his colleagues. "I know of no other conference that has made an emphasis on the study of self-awareness through deficits to this degree."

The absence of an accepted definition of self-awareness that could encompass all of its elements led to its representation in the form of the simple question posed at the beginning of the conference, said Jyotsna Nair, M.D., a speaker at the conference and assistant professor of psychiatry at the University of Missouri, Columbia, Health Sciences Center. "Self-awareness depends on a person developing more than just a concept of self, but also requires memory, language, awareness of body and the ability to form some sort of presentation of yourself," she told the attendees. "The concept of self is an evolving process that changes. It changes every day, every moment, even into old age."

Those changes are also reflected in the physiological realm, as people's brain activity shifts in response to perceptions of their environment, according to George I. Viamontes, M.D., Ph.D., a psychiatrist, cell biologist and regional medical director of United Behavioral Health in St. Louis. During a high-tech presentation that included computer-generated, animated simulations of brain functions and reactions, Viamontes showed attendees that the neurocircuitry of self-awareness could be understood by examining it from four different perspectives: evolution, neurobiology, development and states of dysfunction.

While Viamontes described the self as a "collection of tendencies, principles and capabilities that emerge as we organize around different challenges," he also spoke of it metaphorically, calling the brain circuitry that implements self-awareness a beautiful piece of work that is "integrated with such great efficiency--even though in truth it's a patchwork quilt of many components--that it appears to us to be totally seamless."

For instance, activity in the amygdala--bilateral, almond-shaped structures in the brain's temporal lobes--functions to integrate our emotional experiences into our vision of self. Levels of neurotransmitters such as norephinephrine, serotonin and dopamine play a significant role, too. We also have significant cortical development, an evolutionary contribution that's not essential for life, Viamontes said, but that we need to do the things we consider to be absolutely human.

Practitioners who attribute patients' negative responses to treatment to psychological or temperamental factors, therefore, may be missing an important biological component. "Some of these states of illness are simply that some areas in the brain are damaged, missing or not fully functional; and so the ability of a patient to organize around complex principles is limited," Viamontes told PT. "They can only function at a lower level of organization."

When it is a brain-based inability to be self-aware of an illness that results in noncompliance, "the job of the clinician is to help the patient organize at a higher level," Viamontes said. "You do it within the capabilities of the patient. You may not refute the patient's persistent paranoia, but you may be able to somehow get him to function by reorganizing how they react to this paranoia."

To exemplify these neurobiological aspects of self-awareness deficits, Robert G. Robinson, M.D., chair of the psychiatry department at the University of Iowa College of Medicine, discussed anosognosia in patients who suffered right parietal stroke. These individuals, to varying degrees, denied there was anything wrong with their hemiparetic arms. In the most severe cases, no demonstration worked to convince patients of their paralysis. The mechanism most often involved right hemisphere dysfunction, as well as subcortical atrophy.

For patients with schizophrenia, a major mental illness that is comparable in its significance to cancer and cardiovascular disease in terms of its prevalence and morbidity, the idea of psychological denial comes up often, said Laura Flashman, Ph.D., a clinical psychologist and associate professor of psychiatry and neuropsychology at Dartmouth Medical School. "I would argue that there probably is at some level in some people a psychological component," Flashman told conference attendees. "I also think that there is a neurologic underpinning to at least some aspect of denial."

In patients with schizophrenia, there are at least two, and often three, dimensions to their lack of awareness, Flashman said. "The first one is insight ... the failure to recognize the deficit or the symptoms. Then there's the self-awareness level, which is the failure to recognize their impact. And then at a third level there's an attribution problem, so it's a failure to understand what accounts for the symptoms that a person is having."

"Looking at the brain correlates of these deficits is what is driving the reconceptualization of disorders like schizophrenia," Flashman told PT following her presentation. The deficits in self-awareness are a "part of the illness, rather than simply a reaction to the illness or a defense mechanism in response to the illness."

Practitioners and family members need to recognize that a patient's failure to acknowledge symptoms or correctly attribute their cause to illness may not result from poor attitude or the use of a psychological defense mechanism, but rather from "the same brain substrate that's producing the disorder," Flashman said. This recognition could make both caregivers and family a lot more tolerant.

That rethinking of the biological basis for a lack of self-awareness is affecting the way other illnesses are viewed, too. For instance, although dealing with denial is a critical component in alcohol rehabilitation, the self-awareness deficit is not even among the DSM-IV's diagnostic criteria for substance abuse, said Kenneth Sher, Ph.D., professor of psychology in the department of psychological services at the University of Missouri, Columbia. Telling attendees that there was almost no research on the self-awareness component of alcoholism, he urged further investigation.

The probing into self-awareness and how its deficits affect illness will continue, Beitman said. "It is a subject that is a central question for the 21st century: What does self-awareness mean? What does it mean to be conscious, and not just conscious but conscious of ourselves?"