Treating patients who are in denial
Key Takeaways
Denial can result in poor outcomes for the patient, although it can be protective as well.
The terms lack of insight and denial have different meanings, although they are often used interchangeably. A pathologic form of lack of insight is called anosognosia and is often evident in stroke patients.
Shared decision-making and motivational interviewing can help with patient adherence to treatment regimens.
When a patient is in denial of their medical condition, management becomes difficult.
In inpatient settings, the medicine or surgery teams often consult psychiatry when patient denial becomes a barrier to care. In an outpatient setting, patients in denial are more likely to miss appointments and experience poor clinical outcomes, as well as struggle with polypharmacy and repeat hospitalizations.
Definitions of denial
Although the terms denial and lack of insight are often be used synonymously, they can have different meanings.
According to Freud, denial is a psychological defense mechanism, which can be protective and normal, as it helps the patient retain hope when given a poor prognosis.
In patients with cancer, denial can at first be adaptive when facing the future, but can become maladaptive if it gets in the way of appropriate treatments or making end-of-life arrangements.
Results of a case-control study involving 105 patients with digestive-system cancers indicated that denial protected against depression in these patients.[]
Lack of insight, however, can be more pathologic, according to the authors of a review published in JAMA Psychiatry.[] They explain that “lack of insight is a dynamic, multidimensional attribute stemming from a potential combination of primary symptoms, neurocognitive deficits, and cognitive style.”
"Notably, a growing body of evidence suggests that lack of insight may involve neurocognitive deficits that are not disorder specific. "
— Authors, JAMA Psychiatry
For instance, in individuals with schizophrenia, lack of insight could be secondary to frontal and temporal lobe dysfunction.
Anosognosia
An extreme form of denial is called anosognosia. It is a condition where one is unconsciously in denial, due to not being aware that any disability or deficit exists.[] It exists in both neurological and psychiatric disorders, but it most often occurs as a result of of structural damage, such as from ischemic stroke.
Recognizing anosognosia disorder quickly is imperative in emergency situations, particularly for acute stroke.
For the administration of thrombolytic therapy, it is crucial to know when the stroke symptoms occurred. If the patient lacks insight into the timing of the stroke, getting this history from a family member is critical.
Helping patients with anosognosia often centers around safety measures, according to the authors of an article published in StatPearls.
"It is important to do a thorough safety evaluation to avoid injury to the patient suffering from anosognosia. "
— Authors, StatPearls
"Simplifying tasks, maintaining a positive approach, showing concern and empathy, and providing a structured environment are helpful to avoid negative outcomes,” they wrote.
How clinicians can help
Denial of one’s illness can affect adherence to treatment. Some individuals may accept the need for treatment even though their insight regarding their symptoms is poor, whereas others may acknowledge their diagnosis but not make the connection to the need for treatment.
According to the authors of the JAMA Psychiatry article, “Interventions to improve adherence by enhancing insight likely need to address multiple components through a combination of cognitive and psychosocial approaches.”
Two approaches that they highlight include motivational interviewing and shared decision-making to provide some insights into how the patient goes about decision-making and which issues may be barriers to treatment.
These strategies can help boost adherence. Adopting an open, reflective, and adaptive approach helps the patient make more informed and self-determined decisions, alongside mitigating any tendency on the part of the clinician to view the lack of insight as deliberate denial.
Understanding the complicated feelings behind denial is important to preventing judgment.
In an article published in Forbes, Sachin H. Jain, MD, MBA, discusses how a difficult diagnosis can stem from feelings of grief and loss, which need to be acknowledged.[] Denial can be a coping mechanism.
“Physicians and nurses who care for patients facing serious illness must start from a place of curiosity about denial, endeavor to understand its root causes, and sensitively help patients confront it,” he said. “Some of my biggest mistakes with patients—and, also, my own family members—have been in applying judgment without fully stopping to understand the complex feeling and emotion associated with a new or evolving diagnosis.”
Having a family member present can help the patient get through their fear.
"Allow the emotion to exist in the room. "
— Nina Perales, CareMore Health,
“If you can allow it to exist in the room, more than likely the follow-up treatment plans will be more readily understood and followed,” added Perales.
What this means for you
Whether you are treating a patient in denial over a diagnosis or one who has a "lack of insight," management is tricky. Constructive approaches include shared decision-making and motivational interviewing. Denial is complex, and can involve feelings of grief and loss. Working through these feelings with the patient, rather than being judgmental, can often facilitate acceptance of treatment.