Review
Denial in physical illness

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Abstract

Denial is a concept often encountered in literature describing patients' psychological responses to physical illness. Definitions and theories of denial have drawn on clinical, cognitive, psychodynamic, organic, and interpersonal frameworks. Denial is related to other concepts such as lack of insight, self-deception, and anosognosia. Empirical studies have yielded mixed results with regard to the adaptive properties of denial. These results require interpretation in the light of: (1) the definitional complexities of denial; (2) the diversity of methods used for its assessment; and (3) the choice of different clinical samples and heterogeneous outcome measures. The clinical management of maladaptive denial poses a challenging problem which requires consideration of factors pertaining to the patient, the illness, the treating clinician, as well as the patient's social environment. To achieve further clarification of the role of denial in physical illness, future research would benefit from clearer definitions and more refined, consistent methods of assessment. A number of recommendations are outlined.

Introduction

Denial is a concept commonly applied to patients who: (1) do not accept their diagnosis or appear oblivious to it; (2) minimize the implications of their illness; (3) delay seeking medical advice; (4) refuse or comply poorly with treatment; or (5) appear unperturbed and detached in the face of their illness. Denial has been of interest to both clinicians and researchers. Most often, it has been studied in patients with heart disease 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, cancer 2, 12, 23, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, renal disease 54, 55, 56, 57, 58, neurological disorders (see ref. [59]for a comprehensive review), and diabetes 60, 61.

Based on an extensive review of the denial literature, the present article will address the following questions:

  • 1.

    How has denial been defined in the literature and what are difficulties which have emerged from this?

  • 2.

    What are the methods which have been proposed and used for the assessment of denial in physical illness?

  • 3.

    What conclusions can be drawn from empirical studies regarding the adaptive or maladaptive value of denial?

  • 4.

    How is denial best managed in the clinical situation?

References from the literature were obtained by use of both manual and electronic means of search (Medline and PsycLit database keywords: denial, insight, self-deception, anosognosia, and illness awareness).

Section snippets

Definitions and dimensions of denial

Like intelligence or motivation, denial is an abstract and complex psychological concept. Definitions of denial are influenced by the choice of the underlying theoretical or empirical framework. Here, definitions and dimensions of denial will be discussed with reference to each of the following five frameworks: (1) the psychodynamic framework; (2) the cognitive framework; (3) the organic framework; (4) the interpersonal framework; and (5) the clinical framework.

Concepts related to denial

Insight and its opposite, lack of insight, are concepts which are predominantly encountered in the psychoanalytic and psychiatric literature. The assessment of insight continues to be an integral part of the mental state examination 101, 102, and there have been attempts to develop instruments for its formal assessment 103, 104, 105, 106, 107, 108, 109.

Research interest has focused on the relationship between insight and psychopathology 105, 108, 109, 110, 111, 112, treatment compliance 104, 113

The clinical assessment of denial

Methods for the assessment of denial in physical illness have ranged widely but have commonly involved the use of one or several of the following:

  • Clinical judgment 1, 7, 14, 38, 40, 42, 43, 47.

  • Semistructured interviews/observer rating scales 10, 28, 33.

  • Self-reporting questionnaires 26, 34, 36, 48, 58.

  • Psychophysiological measures 11, 23.

Listed below are some of the problems that have emerged from the assessment of denial in the clinical literature:

  • 1.

    Little or no information is provided as to how

Denial—adaptive or maladaptive?

Although often considered a maladaptive coping response to physical illness, denial may have important adaptive value 52, 90, 92, 146. Lazarus [98]suggested that “rather than equating the use of illusion with pathology, a more appropriate and interesting conclusion would be that mental health requires some self-deception.” This notion has received support from both theoretical [137]and empirical work 147, 148.

To determine the adaptive value of a patient's denial, Lazarus [98]has suggested the

The management of denial

The clinical management of denial may pose a considerable challenge. A number of issues require consideration:

  • 1.

    Is the patient's behavior appropriately described as denial or are there other, alternative explanations? Cousins [100]and Shelp and Perl [93]have outlined the dangers of dismissing as denial patient behavior which results from lack of information, lack of understanding, or which represents a devaluing of the patient's views and preferences in favor of those of the clinician. It is

Conclusions

Denial is a complex concept which has adopted different meanings in different contexts. Most commonly, it has been used to describe a strategy or a mechanism of defense, which serves to provide psychological protection against the perception and processing of subjectively painful or distressing information. While psychoanalytic investigators have tended to view denial as pathological in nature, others have used the term denial to describe a response which normal people may show in reaction to

Recommendations

To enhance the quality and comparability of future research, the following recommendations are made:

  • 1.

    Denial should be explicitly defined and conceptualized involving clarification of which facets or dimensions of denial are being considered. The observational basis for the assessment of denial should be stated clearly and should be operationalized.

  • 2.

    Observations should be separated from inferences based on observations.

  • 3.

    Measures employed for the assessment of denial should have adequate interrater

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