Maladaptive Denial of Severe Pain and Acute Orthopedic Injuries in a Patient With a Schizoaffective Disorder

Abstract

Persistent denial of severe and acute pain following orthopedic injuries has not been previously reported. We present a case of a 24-year-old woman with a history of schizoaffective disorder who suffered severe pain secondary to acute orthopedic injuries who insisted, "I am fine! There is nothing wrong with me." Her maladaptive denial resulted in an initial refusal of necessary medical/surgical care, but she eventually accepted the necessary treatments despite her persistent belief she did not need such care. Her verbalizations and behaviors were characterized by active avoidance and angry reactions when a consulting psychiatrist spoke to her regarding her clinical condition. A modified version of the Conscious Avoidance subscale of the Denial of Illness Questionnaire was useful in measuring the severity level of her denial. This case report suggests that the behavioral features of psychological denial appear different from those associated impaired self-awareness secondary to an underlying brain disorder.

"‘My Limbs are Not Mine’ A Case of Penile Amputation Secondary to Commanding Hallucination in Schizophrenia"

“…Some studies contended that chronic patient tend to demonstrate a negative affect and therefore less likely to 'report' pain. The apparent analgesia would be the result of a denial "attitude", a different manner of expressing pain in relation with the non-verbal communication difficulties, and not an alteration in the brain functions nor a biological anomaly [7,8].…”

Pain Sensitivity in Schizophrenia Spectrum Disorders: A Narrative Review of Recent Work

“…In the context of schizophrenia, there may be insufficient self-awareness, which may lead to denial of an obvious pain stimulus. Prigatano and collaborators reported the case of a 24-year-old man with a history of schizoaffective disorder who sustained acute orthopedic injuries but denied feeling pain [7]. Psychopharmacological treatment as well as psychiatric comorbidity have the potential to influence response to pain [19].…”

“…Hypoalgesia is also sometimes seen, however, in patients who are antipsychotic naïve [3]. A much-discussed possibility is that schizophrenia symptoms may prevent pain recognition or distort its expression [5][6][7].…”

Studying lack of awareness of cognitive decline in neurodegenerative diseases requires measures of both anosognosia and denial

“…They are not “indifferent” or apathetic in their emotional reactions to such discussions. In fact, they often propose counterarguments which may appear semi-logical (not bizarre in nature) to explain whatever impairments are brought to their attention ( Prigatano et al, 2020 ). They can behave in a manner that actively discourages the examiner from asking further questions about their clinical status.…”

“…Patients with anosognosia of cognitive impairments often appear apathetic or indifferent ( Prigatano et al, 2011 , 2014 ; Mak et al, 2015 ; Bivona et al, 2019 ) rather than anxious or depressed when talking about their cognitive impairments. In contrast, persons who demonstrate denial often appear ill at ease when speaking about their cognitive limitations, even becoming anxious and/or angry when discussing them with family members or a clinician ( Prigatano et al, 2020 ; Prigatano and Sherer, 2020 ).…”