Closet conditions: Six conditions patients hide, and what doctors can do about it

By Nicole LaMarco and Joe Hannan
Published January 28, 2022

Key Takeaways

  • Research shows that it’s surprisingly common for patients to withhold critical health information during visits with providers.

  • Often, this is due to stigma, shame, or fear of being judged.

  • For each of these conditions, research supports specific communication interventions that clinicians can use to open up conversations.

Not every patient is forthcoming about what brings them to your practice. For example, a Journal of the American Medical Association study found that 47% of patients withheld information about imminent health threats, such as depression, suicidality, or sexual assault. Reasons ranged from embarrassment, to fear of receiving a lecture.[]  

Fortunately, research can help identify these so-called closet conditions. Furthermore, through trust-building, clinicians can create a freer information exchange and point patients toward solutions. 

Stigma often forces patients to keep these conditions to themselves, hence the term closet conditions. These are the most common ones.

Mental illness

Unfortunately, shame surrounding mental health conditions and diagnoses persists. According to a 2017 Psychiatric Services review, clinicians looking to open avenues of communication with those who may be suffering from mental illness can use sympathetic narratives.[]

These are “stories that humanize experiences and struggles of individuals with mental illness.” The best sympathetic narratives put personal stories into broader cultural or societal contexts, the researchers wrote. Sympathetic narratives also help people overcome “concerns about the role of individuals in their own misfortune.”

Addiction

Many attempt to keep their addictions to themselves. However, addictive substances, such as drugs and alcohol, can eventually make themselves known as a person’s behavior begins to shift. People with addictions may even struggle to describe their symptoms, let alone discuss them with a provider, making the establishment of familiarity and trust with a provider essential.

According to a 2020 New England Journal of Medicine perspective, clinicians looking to foster an open dialogue on addiction should stick to person-first language that is more sensitive—ie, “a patient with signs of substance abuse,” not a “substance-abuser.”[] Furthermore, emphasizing solutions, such as available treatments, sends a more positive message that may reduce stigma.

Cognitive Impairment

After a lifetime of sound cognitive function, those experiencing cognitive decline may become ashamed of their new limitations. Furthermore, even slight mental lapses can trigger fears of Alzheimer disease or dementia. A 2018 American Journal of Geriatric Psychology analysis suggests that if clinicians want a patient to open up about the potential of Alzheimer’s disease or dementia they should explain that outcomes and presentations of both diseases vary.[]

This “re-framing” may lead to “a more positive and nuanced understanding of AD, and involvement in shared meaningful activities that promote a focus on abilities and strengths outside of cognitive performance.”

Obesity

In many cases, people who have struggled with obesity have endured criticism or harassment. As a result, simply telling a patient that they need to lose weight, without guidance or specificity, may not go over well.

A 2020 Eating and Weight Disorders study suggests that addressing the underlying psychology around food and eating may be more effective.[] Researchers concluded that intuitive eating—a method that relies on our natural hunger and satiety signals—“predicts better psychological change and behavioral health across a range of outcomes.” 

STDs

Sex has a lot of shame and secrecy associated with it. STDs add another layer of both, causing many to forgo potentially life-saving treatments. A 2021 eClinical Medicine commentary suggests that, like addiction, person-first language helps to reduce stigma.[] Clinicians also may implement sex positivity, which highlights “sexual diversity as a healthy norm” that contributes to well-being.

Trauma-informed care, which acknowledges the interpersonal violence that sometimes accompanies STDs, is also constructive. Finally, clinicians must engage vulnerable communities as a whole if they truly want to reduce shame and stigma around STDs.

Eating disorders

According to a 2021 Nutrients meta-analysis, eating disorders, such as anorexia and bulimia nervosa, feature stigma from society at large as well as self-stigma that results from the former.[]

The meta-analysis cautions that simple causal explanations of eating disorders, which focus on sociocultural influences, could add to stigma. What’s more constructive, the researchers wrote, is clinical direction to cognitive behavioral therapies, mindfulness, and peer support, among other interventions.

More meaningful conversations

To have more frank discussions about these conditions, patients must trust you first. According to a 2018 Journal of Healthcare Communications article, that starts with better communication.[]

“The way a doctor communicates with his or her patient is as important as the information he/she is conveying to the patient,” the authors wrote. 

Specific tactics to reach that goal include:

  • Reliance on open-ended questions

  • Solution-focused communication, rather than problem-focused communication

  • Shared decision-making (ie, equipping the patient with information and working with them to reach clinical decisions)

  • External critique of clinician communication skills (One study showed that patients were discontent even though physicians considered their communication excellent or adequate.)

What this means for you

Closet conditions are often kept hidden due to stigma, shame, or fear of being judged. Getting a patient to open up about these conditions—some of which include obesity, STDs, and mental illness—requires tailored communication tactics. Some of these approaches include person-first language, re-framing to add context and clarity around a condition, and focusing on solutions, not problems.

Read Next: What to do when your patient doesn't trust you

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