Background: Despite common misconceptions, an individual may be seriously ill with a restrictive eating disorder without an outwardly recognizable physical sign of the illness. The aim of this qualitative study was to investigate the perspectives of individuals who have previously battled a restrictive eating disorder who were considered "not sick enough" by others (e.g., peers, families, healthcare professionals) at some point during their illness, and to understand the perceived impact on the illness and recovery. Such misconceptions are potentially damaging, and have been previously linked with delayed help-seeking and poorer clinical outcomes.
Methods: Seven women who had recovered from anorexia nervosa or atypical anorexia nervosa participated in semi-structured interviews. Interviews were transcribed and interpretive phenomenological analysis was used.
Results: Three main themes emerged: (1) dealing with the focus upon one's physical appearance while battling a mental illness, (2) "project perfect": feeling pressure to prove oneself, and (3) the importance of being seen and understood. Participants reported that their symptoms were occasionally met with trivialization or disbelief, leading to shame, confusion, despair, and for some, deterioration in eating disorder symptoms which drove further weight loss. In contrast, social support and being understood were viewed as essential for recovery.
Conclusion: To facilitate treatment seeking and engagement, and to optimize chances of recovery, greater awareness of diverse, non-stereotypical presentations of restrictive eating disorders is needed which challenge the myth that weight is the sole indicator of the presence or severity of illness.
Keywords: Anorexia nervosa; Atypical anorexia nervosa; Eating disorders; Not sick enough; The thin ideal.
A persistent myth is that restrictive eating disorders are outwardly recognizable due to severely low body weight or emaciation. Atypical anorexia nervosa (AAN) and anorexia nervosa (AN) are both characterized by restrictive eating behavior. Individuals with AAN do not have current low body weight, although some research suggests they have higher levels of impairment and eating disorder pathology than their peers with AN, and their physical health may be equally compromised. Despite this, individuals with AAN are more likely to have a longer duration of illness and less likely to receive inpatient care, suggesting their illness is not always recognized by others. Additionally, thinness is highly valued in today’s society and restrictive eating behavior or “dieting” is commonplace, which may promote trivialization, or even reinforcement, of initial weight loss by friends or family. With this in mind, our study aimed to explore the experiences of seven recovered individuals recovered from AN or AAN who were directly or indirectly told by peers, families, or healthcare professionals that they were “not sick enough” at some point during their course of illness. We explored the perceived effects on symptoms, motivation for treatment, mental health and well-being. Participants reported their symptoms were occasionally trivialized or dismissed, leading to shame, confusion, and self-doubt regarding the seriousness of their symptoms. For some, a deterioration in eating disorder symptoms ensued that led to additional weight loss, sometimes in a competitive or perfectionist pursuit to “succeed” at eating restrictively. Findings demonstrated the value of being seen and understood, as well as the potential damage of being considered as “not sick enough” by others when battling a restrictive eating disorder.
© 2021. The Author(s).