Have you or a loved one struggling with an eating disorder ever thought, "I'm not sick enough"? Or, "It's not bad enough"? Or maybe, "Other people need more help than I do"? These are common thoughts we hear from individuals in eating disorder treatment, and sometimes these thoughts are signs that someone is in fact "sick enough" and likely needs professional support.
There are a lot of reasons these thoughts pop up for folx struggling with eating disorders, including, but not limited to:
Minimizing our own needs
Being used to our needs being minimized (e.g., "It's not that bad, other people have it way worse than you")
Not believing we are worth receiving support or care
Having a hard time accepting support
Feeling unsure of whether or not we want to let go of disordered eating behaviors
These thoughts can be challenging to shake when struggling with an eating disorder, in part because a person's outward appearance may not exactly match the few media-related examples seen of what someone with an eating disorder “looks like”. Our society’s stereotypical views of eating disorders are often reinforced by insurance requirements for treatment coverage and/or diagnostic criteria for eating disorders as well. Not to mention the disorders themselves make people feel like they are only acceptable if they look a certain way or do more to be "good enough" or "sick enough". A rarely-known fact is that fewer than 6% of people with eating disorders are medically diagnosed as “underweight”— that’s quite far from the perception painted by our society and media!
These thoughts can also feel true to someone who feels they're experiencing "disordered eating" and not an "eating disorder". Disordered eating can often precede an eating disorder, and receiving support for disordered eating is just as valid and needed. While it’s not a guarantee that disordered eating will progress to an eating disorder, it is critical to address these behaviors before they get worse.
Enter the concept of anosognosia.
Typically, a person’s belief that they do not have an eating disorder (or that it’s not bad enough to receive treatment) is a symptom of the disorder itself. The belief that our problem is not that bad, or that it doesn't exist at all, can also be a function of the thing we don't believe we have. The clinical term for this phenomenon is anosognosia, which generally means an inability to recognize a disease/disorder. As the Cleveland Clinic puts it:
Anosognosia means a person can't do one or more of the following:
Recognize that they have an illness or medical problem.
Recognize the signs and symptoms of the condition that they experience.
Connect their signs and symptoms to that condition.
Understand and agree that the condition is serious and needs treatment.
Furthermore, the Cleveland Clinic reports that “your brain keeps track of what's going on with your body using a 'self-image.' If you have an injury, your body updates your self-image to reflect that, and it will keep updating as your body heals.” People with anosognosia are essentially unable to update their self-image due to issues with areas of the brain that engage in that process. Individuals with anorexia, specifically, are known to struggle with a lack of insight as a feature of the disorder. Some clinical studies have reported that as many as 80% of people with Anorexia Nervosa experience this anosognosia and struggle to understand the severity of their eating disorder.
Anosognosia may be why it is so obvious to the person not experiencing an eating disorder that there is an issue, but the person engaging in eating disorder behaviors does not seem to be aware of the problem. We use our brain to ascertain what we like, need, want, are experiencing, and so much more. So, if the brain is ill due to unstable nutrition, an injury, or an illness (mental or physical), it can become more difficult for our brain to recognize a change or problem.
Anosognosia is different from denial though. So how can you tell the difference? Dr. Xavier Amador in his publication titled "I Am Not Sick - I Don't Need Help!" suggests there are 3 ways to know:
The lack of insight is severe and persistent (it lasts for months or years)
The beliefs ("I am not sick," "I don't have any symptoms," etc.) are fixed and do not change even after the person is confronted with overwhelming evidence that they are wrong.
Illogical explanations or false memories that attempt to explain away the evidence of illness are common.
If you recognize yourself having any of the aforementioned thoughts or experiences, know that you are worthy of support, professional treatment, and care. If you recognize any of the above in a loved one, Dr. Amador suggests utilizing the LEAP method when possible:
Listen - try to listen reflectively without disagreeing or arguing
Empathize - with whatever that person is feeling, even if they are not open to treatment; empathizing is not the same as agreeing, which brings us to...
Agree - find common ground and emphasize the things you do agree on
Partner - collaborate to achieve/work towards goals