Anosognosia and Objectification – January 30, 2011

Okay, what’s that first big word? From my work writing the Speaker Notes for the National Alliance on Mental Illness – East Bay Chapter, I’ve learned that one of the reasons brain disorders are so hard to treat is a symptom called “anosognosia.” That’s a newly invented1 compound noun from Greek root words that means lack of awareness of an illness or impairment.

Certain sections of the brain—in the prefrontal and parietal lobes—are responsible for our awareness of how we are feeling and functioning. When these brain cells work properly, they let us know when we’re having some difficulty. For example, if you are having temporary balance or memory problems, these cells make you aware of them and let you take precautions like holding the railing when climbing stairs or writing down your shopping list.

Many mental illnesses like schizophrenia, bipolar disorder, brain malfunctions like Alzheimer disease, and sometimes simple brain damage can cause changes in these cells. The patient is no longer aware of lapses in memory, emotional control, or a bodily dysfunction like paralysis. The patient does not believe he or she is ill and so resists treatment and medication as unwanted interference with a normal life.

Two things are important to note here. First, anosognosia is not like a light switch, flipping the patient from “I think I’m having a problem” to “Nope, I feel fine.” Instead, it can be range of awareness, from occasionally forgetting the deficit to angrily refusing any suggestion that it exists. Second, anosognosia is not simple denial. In denial, the patient knows there’s something wrong but refuses to deal with it out of pride, anger, or fear. With anosognosia, the patient is simply not aware.

While anosognosia seems to be safely consigned to the realm of serious illness—people with diagnosed brain and central nervous system disorders—I wonder if the condition isn’t a lot more common in daily life than anyone realizes. The fact that awareness of impairment is not complete or continuous, that it can include a range of patient responses, suggests that people without other notable symptoms may encounter a bit of anosognosia in everyday life.

Consider the problems associated with a sedentary lifestyle and obesity, especially as a person gets older.2 At some point, as you gain weight and the tissue builds up on your thighs, you can’t comfortably cross your legs at the knee. And then you can’t cross your legs at all. As your belly grows, you have trouble moving quickly and maintaining your footing. You compensate by slowing down. Then you have trouble bending to tie your shoes, and you compensate by putting one foot up on a step while tying the laces or gradually shifting to loafers and sandals. The realization comes rarely, if at all, that something is different. “Gee, I used to be able to do this. Now I can’t.”

We are constantly adapting. Our minds adapt to the limitations our bodies place on our lifestyle. It doesn’t take brain damage for a person to become comfortable with a body where you can no longer cross your legs, tie your shoes, or reach the center of your back with a fingertip and so need a backscratcher to chase an itch.3

More than that, our bodies are constantly adapting and changing. Bones are constantly building mass in response to the stresses we place on them through exercise. They also lose mass when those stresses go away. We build muscle and lose it depending on how we use our bodies. We gain fat and lose it depending on the calories we ingest and the physical work we do. Tendons extend or shrink depending on their daily use. Organs like the stomach, liver, and kidneys respond to the stresses and insults we give them by gradually losing function.

But aside from the occasional ache or pain, we usually remain unaware of these changes. Partly this may be due to a malfunction in brain cells, anosognosia. But just as much it may be our own perceptions of what the body actually is.

We tend to think of the body as an object, like a tool or an appliance. It works so long as it remains intact. When it breaks, it stops working and then needs repair. We don’t think of steel hammers as getting stronger when they’re put to use pounding nails and weaker when they sit in the toolbox. We think we are objects, just like hammers—always there when wanted, unless obviously broken. You don’t expect to walk on a broken leg, but once it’s healed you’ll be back in action.

When I’ve been working out regularly and I’m nice and flexible—when I can stand on one foot and raise the other to wash it in the shower, or bend to tie my shoes with both feet on the floor—I tend to think of this as my natural state. I feel good. So I can allow myself to skip a few workouts. I can sit and read my book instead. My body is an object that will always have this flexible condition. But a few workouts missed turns into a few weeks of sedentary relaxation, and suddenly I’m stiff again.

The changes in our bodies are most noticeable when we apply diet and exercise to body weight. The tide reverses—yes, it really does—and suddenly you become trim and slim again. But then you start thinking this is your natural state, the way the object that is your body should be, and you take a donut at the morning meeting, skip a workout, enjoy a big dinner with dessert. Then the weight comes back and the slim body goes away.

We have not accepted, deep down in our psyches where it makes a perceptual difference, that the body is not an object but a process.4 There is nothing objectified about human life. We are not, have never been, and will never be one thing whole and immutable. We started as a joining of egg and sperm into a fertilized egg and then grew into a baby. We changed again and again on the journey from infant to toddler to adolescent to adult. We will change again through maturity to middle and old age. At some point, the active processes of thought and motion will stop and the passive processes of dissolution and decay will start and continue until there is no trace of us left.

We are not things. We are processes and movements and functions. Our awareness rides these changes from moment to moment and considers them to be stable and enduring. But even our awareness—built up as it is from thoughts and sensations, experiences and reactions—is not a stable function. Some days and in some situations we may interpret and track an external, objective reality with great precision and think we understand the world. And sometimes we simply get confused.5 Then we fall asleep to dream and invent whole new versions of reality that never existed.

Awareness of bodily function may indeed be aided or inhibited by a cellular network in the prefrontal and parietal lobes. But it is also supported by a deeply held belief that the body is one thing, an object, which persists in a constant state from one week to the next, one year to the next. We believe in objects, things, states persisting in time. But even steel rusts, the ocean erodes the shore, mountains rise and fall, stars explode. The constant, in life as in the unverse, is change.

1. By French neurologist Joseph Babinski in 1914.

2. Truth time. As a writer, my “day job” incorporates a lot of sitting at the keyboard. And for relaxation I like to sit and read or watch movies. I also try to get in regular workouts with a karate regimen that addresses issues of balance and flexibility. So I understand a bit about weight gain and issues of diet and exercise.

3. For about 30 years I’ve been subject to muscle spasms in my lower back, another artifact of the interplay between weight and exercise. When a spasm has occurred and while it’s healing, I move guardedly against the pain. My gait is shortened. I transition slowly and with hand support from a standing to a sitting position, and from sitting to standing, always alert for the stab of pain that tells me the muscle in question is being forced beyond its limited range. Stangely, I only know that I’m healed when I suddenly realize—usually a day or two later—that I’m moving more freely, standing and sitting without a thought. This is a kind of “reverse anosognosia”: when the impairment is gone, I’m not aware of it until I catch myself moving freely once again.

4. See “Transporter Beaming” from August 22, 2010, in my blogs on Various Art Forms.

5. If you don’t believe this, ingest a large amount of ethanol, conduct a conversation with a friend, and have yourself videotaped during the process. Conscious thought is not an unbroken stream.