Denying and Concealing Eating Disorders

Secrecy and concealment of disordered eating are common. Patients may fake eating, hide food, avoid eating with others, and secretly binge and purge. Results of a recent study offer an intriguing look at what may underly some of these behaviors.

Dr. Walter Vandereycken and Ina Van Humbeck, of Catholic University of Leuven, Belgium, developed a special online questionnaire that was offered to ex-patients with eating disorders, to examine denial and concealment and to determine how patients first recognized that they might have an eating disorder (Eur Eat Disord Rev 2008; 16:109). The researchers focused on former patients because they felt that those with active eating disorders often deny having a problem and either go undetected or avoid any health care. The survey was organized using the websites of two well-known organizations for ex-patients in Belgium (www.qnbn.be) and the Netherlands (www.sabn.nl).

A total of 401 former patients completed the surveys. The average age was 24.8 years (range: 15-54 years); 43% had anorexia nervosa, 31% had BN, and 16% had an eating disorder not otherwise specified. Of the group, 55.6% of patients were still receiving follow-up treatment.

Concealing behaviors

As shown in Table 1, patients used various ways to conceal their behavior and to avoid eating with others. Most claimed to have eaten, or claimed they had eaten slowly at the table. Others used various ways to avoid being weighed, including simply refusing to be weighed, drinking water, or even wearing extra clothing.

When these patients revaluated their behavior at the beginning of their eating disorder, more than half reported that they did not realize their behavior was abnormal. Others minimized their condition. When confronted by the possible health risks they faced, 80% said this had little or no impact upon them. Instead, most reacted with indifference (“I paid no attention to it.”), minimized it (“It’s not so bad.”), or used false optimism about it (“This won’t happen to me.”). The authors noted that although many of the respondents were familiar with eating disorders, they felt the condition did not apply to them (“Those patients are much worse than in my case.”).

The former patients also came up with a variety of reasons for why they didn’t get better. For example, when asked what might have helped the eating disorder come to light or might have helped them seek medical care, most were quite clear in their responses. For example, some blamed family remarks about their weight or lack of health care professionals familiar with treating eating disorders.

A deliberate strategy to hide disordered eating

The researchers’ findings show that the ex-patients used many ways to conceal their eating disorders, and in from 57% to 73% of cases these methods were described by the ex-patients as a deliberate strategy. Any confrontation about this behavior brought about negative reactions. Information about possible health risks had little or no impact. In the beginning phase of their eating disorder, most seemed “untouchable,” according to the authors. Besides their indifference and minimization of the effects, many patients had a remarkable belief that nothing would happen to them. And, perhaps even more remarkable, they actively sought information they could use to better conceal their eating disorder. Thus, even though concerned parents and friends continuously warned the individuals about health risks, the need for self-determination led to all types of methods of concealing disordered eating against any intruders into their “personal world.”

The authors also note that the findings support their conviction that in many cases “denying” should be translated as “not admitting” to having an eating disorder (Eur Eat Disord Rev 2006; 14; 352). Finally, clinicians may underestimate the meaning of the deliberate refusal of self-disclosure among eating disorders patients, not realizing they (the clinicians) are a part of this interpersonal context.