The New ‘Reefer Madness’?

“Cannabis-induced psychosis is not always ‘denial.’  In many cases, it may well be anosognosia, a brain condition where the person truly cannot recognize that they are ill...To them, the delusions feel real.”  Elle Constantine

To the observer, it may look like denial or defiance. It may not be what can all too often be hedonic recalcitrance perse but actually the manifestation of a condition known as anosognosia. 

Now, let’s be clear from the outset of this read, that this is not just another ‘useful tool’ to avoid accountability for the bio-behavioural disorder commonly referred to as addiction due to the utterly unwise engagement with psychotropic toxins, but it is a ‘flag’ worth having on your diagnostic radar.

I hope I haven’t lost any of you yet – Don’t bail, keep reading!

Walking with a person suffering psychosis or even one of the various forms of dementia, is incredibly difficult and taxing. (This author has very personal experience with this decline) It remains important (and self-care and good personal supports needed for the carer) to maintain a calm demeanour and avoid adversarial, seemingly accusatory or even open ‘corrective’ tones, especially in the dementia dealing context.  Building trust will take time and a consistent affirming of your desire to understand (not agree with the delusions) is part of that. Learning of and working for prevention of a growing dysfunction is also important in assisting you in helping people potentially ‘get’ what they are not currently seeing. 

The following are some of the signs of Anosognosia in Psychosis:

• Insists nothing is wrong even when symptoms are clear to others.
• Rejects treatment or medication because they don’t believe they’re ill.
• Explains away delusions or hallucinations as “real” experiences.
• Gets angry or defensive when told they need help.
• Stops follow-up care after a hospital stay, claiming they’re “fine now.”
• Blames others for problems caused by their illness (e.g., paranoia, loss of work, family conflict).
• Lives with complete conviction inside their false beliefs, unable to recognize them as symptoms.

Anosognosia is a neuropsychiatric condition characterized by a person's lack of awareness or denial of their neurological or psychiatric deficits, often despite clear evidence of impairment. (1)  

Where Did This Come From? Anosognosia means “without knowledge of disease.” The term was introduced in 1914 by the French neurologist Joseph Babinski, who observed that some stroke patients lacked awareness of their paralysis (hemiplegia). (2)

Main Affected Populations: Anosognosia most commonly occurs in individuals with:

• Stroke (especially right hemisphere lesions)
• Traumatic brain injury
• Dementia (notably Alzheimer’s disease)
• Schizophrenia (also drug induced Schizo-affective states)
• Bipolar disorder (3)
• Substance Use Disorders (growing)

Whilst stats on substance users experiencing this are not as readily available, yet it’s important to note that up to 80% of Alzheimer’s patients, around 50–98% of those with schizophrenia, and 40–50% of those with bipolar disorder exhibit anosognosia. One can reasonably speculate that growing numbers of substance users will be experiencing this, as the anecdata below will affirm. (4)  

Symptoms and Presentation: Individuals with anosognosia may:

• Fail to recognize they have a medical or mental health condition
• Not perceive the symptoms they experience
• Be unable to link symptoms to their condition
• Deny the severity or need for treatment (5)

Possible examples of these symptomatic realities are never more clearly manifest than with so called ‘medicinal cannabis’ users who self-medicate with non-pharmaceutical grade offerings.

One such manifestation that goes beyond mere denial or recalcitrant conduct may be found in Cannabis Hyperemesis presentations in areas where cannabis is both legal for ‘recreational’ and ‘medicinal’ use

The following is a synoptic summary of just one Emergency Doctor from Colorado (Ground Zero for cannabis legalisation in the USA). Note how corrupted pro-cannabis bureaucracy and the accompanying of exhaustion of trying to confront the irrationality, not just denial, that led to way UNDER reporting and recording of Cannabis Hyperemesis Syndrome (CHS). 

The following in their own words.

With regards to CHS (Cannabis Hyperemesis Syndrome), we saw it EVERY SINGLE DAY.  

Only ONCE did I have a patient and his girlfriend recognize and accept that it might be the weed.  I had one guy - who had been to the ER every day for a week with ‘scromiting’ [Screaming and vomiting simultaneously] and his 6 previous work ups (including blood work, CT, ultrasound etc) were all negative except that persistently + urine drug screen for THC [tetrahydrocannabinol].  I suggested it might be CHS and his father (who was probably 60) took a swing at me yelling “it’s not the pot!  I’ve smoked pot all my life and look at me!” (BTW, he was not the picture of health)

We had a girl who started with CHS at 15. She presented so frequently to the ED that her parents stopped going to the ER with her.  Just sent by ambulance, get the vomiting controlled, and send her home by whoever would pick her up.  Sadly, after 2 years of this, I think she graduated to other drugs.  She obviously wasn’t in school.  No education, no skills, just an addiction and vomiting.  For her 17th year, I think she had over 70 visits to the ER.  And no, never acknowledged that it was the pot.

I had another guy 63 - also having CHS.  He also refused to believe it was the pot.  

So, honestly, only one person that I can recall admitted (at least to me while in the ED) that it might actually be the pot.

And we literally had at least one a day. 

(Veteran E. R Medicine Doctor and Cannabis trained medical expert)

The lack of insight may be selective, affecting awareness of some deficits but not others. For example, someone may realize they have language difficulties but not recognize their memory loss. (6)

Causes and Pathophysiology: Anosognosia often results from damage to the brain’s right parietal lobe but can also occur with lesions in the temporoparietal area, thalamus, basal ganglia, or prefrontal cortex. (7) Substance use, and particularly illicit and novel psychoactive substances, will mess with brains and these regions of the brain, potentially adding to the development of this condition beyond mere denial.

Key factors include:

• Disruption of brain regions involved in self-monitoring and error awareness (e.g., prefrontal and insular cortex, default mode network)
• Impaired ability to update self-image or incorporate new information about one’s deficits ²

It can also arise with psychiatric disorders, where functional (rather than structural) brain changes affect insight.(8)

Clinical Assessment and Diagnosis: Diagnosis relies primarily on clinical interviews and observation. Physicians assess whether patients recognize, understand, and respond appropriately to their own deficits. (9)  However, as we have seen with the previously mentioned cannabis hyperemesis issue, it can be a tough ask and that is why gathering data on this is slow, but still vital. 

Impact and Importance: Anosognosia can hinder rehabilitation, treatment adherence, and safety. In conditions like Alzheimer’s disease, it is linked to faster progression, greater caregiver burden, and increased risk of dangerous behaviours. Concerningly, this applies very much to recovery efforts with substance users as well. (10)

Correctly identifying, understanding and properly managing anosognosia, especially in the substance using demographic is vital for effective care planning, patient support and ‘substance use exiting’ recovery.

Shane Varcoe - Executive Director, Dalgarno Institute 

Further Reading:  Educate Before Eight