Is it Denial or Something Else?

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Nov 2, 2021 | Dr. Melanie Chandler, HABIT FL Director | @drmelaniechandler | Comments (6)

It is a common scenario:  you think you are doing just fine, but family or friends can see that you are having significant memory loss.  Maybe you have even gone to the doctor and been told you have memory impairment, or a diagnosis of Mild Cognitive Impairment or dementia, but you don't remember it or really don't believe anything is wrong with your memory, particularly not when compared to others your age. Yet, your family is convinced of it. If this is you, you may not have even found our blog, but just in case you (or your loved one) did--You and your family are not alone!

At this point, loved ones often are frustrated with the person with memory loss (and you are frustrated with them always mentioning it!).  "If you would just admit that you had a problem, maybe we could do something about it."  They think you are being stubborn, or just refusing to see the truth.  You cannot see what they are talking about and think they must be mistaken or are overly critical.  Everyone thinks you are being defensive, and tensions start to rise around the topic of your memory and ability to take care of your day-to-day life.

BUT, the issue is, this is not "psychological defensiveness," a refusal to see the issue because of pride or stubbornness, or an inability to face the truth because it is too painful.  Rather, this "refusal" to admit to memory loss or inability to see it isn't defensiveness at all. A person with MCI or dementia often has another change in ability - the ability to see themselves clearly.  Just as memory is a type of cognitive thinking skill, like language, executive function, attention, or concentration, we have metacognition, or the ability to step back and see oneself clearly, which is also a thinking skill.  And, this thinking skill can frequently be impaired in our patients with MCI or dementia.  When it is, we call it anosognosia, or "lack of knowing."

On the face of things, it isn't possible to distinguish anosognosia from defensiveness. Both result in a person denying they have problems. Maybe early on in MCI a degree of psychological defensiveness is at play, and the person does not want to admit to their memory loss--This is often a difficult adjustment for our patients.  However, much more likely, and particularly as the condition becomes worse, it is far more likely this is anosognosia, and the person with memory loss just cannot see it.  And, just as a person may remember something from time to time despite memory problems, they can also seem to have awareness of their memory loss at times, but not at other times.

Some choose to think of this lack of awareness as a blessing (if one is to be had) in the process of a disease like Alzheimer's disease or other causes of MCI or dementia. In other words, maybe it is a kindness to the person that they are not aware of how impaired they have become. Anosognosiais usually much harder on those around the person with memory loss. Loved ones fruitlessly try to reason with the person with MCI or dementia about how they have problems and need help with certain things. Fruitlessly, because the cognitively impaired person does not see the memory problems in the first place, and perhaps also does not have the reasoning skills to come to the same conclusions, even conclusions that are in their best interest. Or even if they agree they have memory problems and should try various treatments in one conversation, that may not "stick" in their memory for a future conversation.

There are no easy solutions in how to handle this situation. For one, we encourage loved ones to pick their battles. It doesn't help if they are always pointing out examples of your memory loss. They should really only push the issue of memory loss when it is absolutely necessary, like for safety. Also, both you and your loved one can practice communication techniques around memory loss as we've written about before (examples are here and here).

But, I think it goes a long way just to understand the concept that there is a difference between psychological defensiveness and anosognosia. It allows a person to blame the disease, and not the person. The disease is causing a lack of awareness of the problem, not willfullness or prideful behavior. This realization helps place the frustration or anger towards the right source--the disease, not you!

We'd love to hear your thoughts and stories about how you've coped with this!