Anosognosia and Anorexia

When a Loved One With Anorexia Does Not Believe They Are Ill

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Perhaps one of the most troublesome symptoms of anorexia nervosa and other restrictive eating disorders – especially for family members and treatment professionals – is the sufferer’s belief that they are not ill. The common consequence of not believing they are ill is that they do not want to get well. 

Indeed, a sufferer’s lack of concern for their problem has long been a defining feature of anorexia.

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 Dr. Vandereycken, 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.” Sufferers 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. Anosognosia, or lack of awareness, has an anatomical basis and is caused by damage to the brain.

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 50% of people with schizophrenia and 40% of people with bipolar disorder, and is believed to be the primary reason that these sufferers 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.


Viewing anorexia through the lens of anosognosia has significant ramifications.  If an individual suffering a severe mental illness with life-threatening complications does not believe they are ill, they are unlikely to be receptive to treatment. This increases the potential risks. They may be incapable of insight-oriented treatment, which has been the traditional 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.

Anosognosia can be confusing for family members. If you are a loved one of someone with an eating disorder who appears to disbelieve they are ill or seems disinterested in recovery, please recognize that they are not being defiant or resistant. It is more likely that they are incapable of insight. 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. Motivation and insight usually return in time for the individual to tackle the remainder of their own recovery.

A review of research studies on anosognosia in mental Illness is available through the Treatment Advocacy Center here.

A helpful blog post on anosognosia by Laura Collins is available here.


Casper, R. C. (1998). Behavioral activation and lack of concern, core symptoms of anorexia nervosa? International Journal of Eating Disorders, 24, 381–393.

Konstantakopoulos, G., Tchanturia, K., Surguladze, S. A., & David, A. S. (2011). Insight in eating disorders: clinical and cognitive correlates. Psychological medicine41(09), 1951-1961.

Vandereycken, W. (2006).  Denial of Illness in Anorexia Nervosa--A Conceptual Review: Part 1 Diagnostic Significance and Assessment. European Eating Disorders Review, Vol 14(5), Sep-Oct 2006, 341-351. 

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