Anosognosia and Anorexia Symptoms

Perhaps one of the most troublesome symptoms of anorexia nervosa and other restrictive eating disorders–especially for family members and treatment professionals—is the patient’s belief that he or she is not ill.

The common consequence of not believing one is ill is that he or she does not want to get well. Indeed, a patient’s lack of concern for the problem has long been a defining feature of anorexia nervosa.

As far back as 1873, Ernest-Charles Lasègue, a French doctor who was one of the first to describe anorexia nervosa, wrote: “'I do not suffer and must then be well,' is the monotonous formula.”

Clinical studies, as reported by Walter Vandereycken, MD, have reported “denial of illness” to be present in as many as 80% of the anorexia nervosa patients surveyed. In some populations of anorexia nervosa patients, this percentage may be lower.

In a study by Konstantakopoulos and colleagues, a subgroup of anorexia nervosa patients (24%) had severe impairment of insight. They also found that patients with restrictive anorexia nervosa had poorer overall insight than patients with anorexia nervosa, binge-purge subtype.

The diagnostic criteria for anorexia nervosa include a “disturbance in the way in which one’s body weight or shape is experienced.” Patients may be extremely emaciated, yet believe they are overweight.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), states: “individuals with anorexia nervosa frequently either lack insight into or deny the problem.”

In earlier writings about anorexia nervosa, this lack of awareness of the problem was often called denial, having been first described when psychodynamic theories predominated.

However, the condition has more recently been renamed anosognosia. This term was originally used by neurologists to describe a neurological syndrome in which people with brain damage have a profound lack of awareness of a particular deficit.

More recently the term began to also be applied to psychiatric conditions such as schizophrenia and bipolar disorder. Brain imaging studies seem to indicate a brain connection between anosognosia and these conditions. 

The National Alliance on Mental Illness (NAMI) reports that anosognosia affects 30% of people with schizophrenia and 20% of people with bipolar disorder, and is believed to be the primary reason that patients with these disorders often do not take their medication.

Applying the term anosognosia to anorexia nervosa makes sense because we know that the brain is affected by malnutrition. In a paper in 2006, Dr. Vanderycken wrote, “In many cases of anorexia nervosa, the striking indifference in the face of emaciation looks akin to the anosognosia described in neurological disorders.”

In 1997, Dr. Casper wrote, “The lack of concern to the potentially dangerous consequences of undernutrition indeed suggests that alarming information might not be processed or might not reach awareness.” Someone with a malnourished or damaged brain may not be thinking clearly enough to use denial as an emotional defense mechanism.

Implications

Viewing anorexia nervosa through the lens of anosognosia has significant ramifications. If an individual suffering a severe mental illness with life-threatening complications does not believe he or she is ill, he or she is unlikely to be receptive to treatment. This increases the potential risks for medical problems as well as a long course of illness.

These individuals may be incapable of insight-oriented treatment, which was, until recently, a common treatment for anorexia nervosa. This is one reason there is often a need for more intensive treatment such as residential care. It is also why family-based treatment (FBT) may be more successful: in FBT, parents do the behavioral heavy lifting of restoring a patient’s nutritional health.

Fortunately, motivation is not required for recovery if your loved one is a minor or is a young adult who is financially dependent. You can be firm and insist on treatment for them.

Dr. Vandereycken writes that “communicating with someone who has an eating disorder but denies it is not easy.” He suggests three strategies for loved ones:

1. Show support and concern (otherwise you will seem uncaring);
2. Express empathy and understanding; and
3. Tell the truth.

In summary, anosognosia is a brain condition; it is not the same as denial. Fortunately, the brain recovers with renourishment and a return to a healthy weight. Motivation and insight usually return in time for the individual to tackle the remainder of their own recovery.

Further Reading

A review of research studies on anosognosia in mental Illness is available through the Treatment Advocacy Center. Laura Collins has written about anosognosia in anorexia nervosa.