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‘Lack of insight’ describes a common outcome of brain injury. I believe this term needs great care to understand properly and respond to appropriately.

It takes a careful, thoughtful, approach to see it as a description; an outcome of brain injury; and not a criticism, or a negative comment.

For people with brain injury this is a real outcome caused by damage to the brain. It is not deliberate.

Maybe using the correct term ‘Anosognosia’ would help depersonalise the term. If you heard a person had ‘anasognosia’ would you think and respond differently, than hearing a person has a ‘lack of insight after brain injury’?

How Does Lack of Insight After Brain Injury Happen?

Insight refers to a person’s ability to see their situation as it is. The skills needed to do this effectively are managed mainly by the frontal lobes. If damage occurs to the frontal lobe of the brain, there may be difficulties recognising and accepting changes. Difficulty seeing the situation as it is.

Possible Outcomes of Lack of Insight

Anosognosia or lack of insight after brain injury can affect your self awareness. You may have limited (or no apparent awareness) in a range of areas;

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• You might see yourself as no different to the person you were before. You do not see what you are not capable of doing now. Despite paralysis and cognitive changes you may think “Yup, I can still drive my car why do I need an assessment?”
• Not understanding and acknowledging the physical, cognitive, personality, and/ or behaviour changes that have happened. You might believe you have had no change in your behaviour yet others see you as a person once gentle who now gets angry quickly.
• Not recognising how future possibilities might change. Telling your boss you will be back at work in a week.
• Insight relies on a close connection with other cognitive skills such as memory, attention, concentration, reasoning and a person’s emotional skills. Reduced insight may be affected by damage to other cognitive functions.
• Appearing to have unrealistic expectations. Telling family and friends you will continue your training as a pilot while having significant cognitive changes that prevent focus and learning.

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Can you see why this whole area is tricky? Think about these competing thoughts:

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• Sometimes people do achieve the unbelievable.
• Every one of us can have ‘unrealistic expectations’.
• Who are we to tread all over another person’s hopes and dreams.
• Yet damage to the brain does cause a person to appear to not be aware of their limitations.

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A careful, thoughtful approach is needed. For further Tips and Suggestions see below.

Tips and Suggestions

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• Learn as much as you can about brain injury and it’s outcomes.
• Gently and carefully explain and discuss the situation. Remember that even when you have explained the situation, the persons’ understanding of it may not change.
• Continue to give the right level and right amount of explanation and realism, about what’s happened and future plans.
• Avoid arguments. Change the subject if the person continues to rationalize, or ignore their difficulties.
• Explain the positive and negative effects of actions clearly and gently.
• Understand and work on the range of cognitive difficulties that might be affecting a person’s ability to see their situation for what it is. Memory and recall difficulties may mean a person forgets their difficulties.
• Find out the best learning mode for each person and focus on that such as visual, auditory, touch/tactile.
• Work together to identify what is reasonable to be achieved. Encourage and support the person to aim for these goals initially.
• Use external limitations where necessary particularly if safety is an issue e.g. remove the car keys if the person is unsafe to drive yet they believe they are safe.
• Take care not to stifle the person’s goals; where possible find what might be achievable and work towards this.
• Look out for increasing safety and awareness as this increases reduce the strategies and control.
• Set goals that incorporate aspects of the person’s goals however unrealistic it might seem.
• For some areas a person may need more formal support; an advocate or administrator for financial decisions.
• Be alert to emotional changes that may come with increasing insight such as depression.
• Take GREAT caution – remember sometimes a “lack of insight” protects us from the tough and ugly real life. It protects self esteem from taking a bit hit. And it can be a protection from depression.
  

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 And Finally

This article “The-anosognosics dilemma something’s wrong but you’ll never know what it is” describes the outcomes of a stroke for Woodrow Wilson, a past President of the USA. With clear examples of anasagnosia after brain injury.

And if you are interested in a bit more history, this article gives a bleak but fascinating look at the early study of anosognosia.

Remember that over time insight will likely improve to some degree for most people with brain injury.