I’ve become increasingly annoyed at the conflation of “body dissatisfaction” with “eating disorder.” The former is a culturally-driven socio-political phenomenon, whereas the latter is a severe, biologically-based mental illness. The former afflicts over 85% of American females, whereas the latter strikes only a small fraction of us (less than 1% for anorexia nervosa and 2-3% for bulimia nervosa).
There has been a great deal of controversy surrounding supermodel Kate Moss’s comment that “Nothing tastes as good as being thin feels,” and around Ralph Lauren’s ridiculously photo-shopped ads. Eating disorder clinicians and activists have been quite vocal about their opposition to these media bytes, arguing that they encourage eating disorders. I know that these professionals and activists have noble intentions, but I believe they are fighting the wrong battles.
I object to underweight models not because I believe they cause eating disorders, but because being underweight is harmful to the models’ physical and mental health, and viewing these images on a regular basis contributes to body dissatisfaction in most people. I refuse to have magazines in my office waiting room not because I believe they cause eating disorders, but because I am opposed to the blatant objectification of women. Besides, I think that fashion magazines are sexist, superficial, and boring.
Hanging in my office is a certificate of membership from NEDA (National Eating Disorders Association) which thanks me for my “support in the effort to eliminate eating disorders and body dissatisfaction.” I really wish they had eliminated those last three words.
I think the conflation of sadness with depression is analogous. The former, in its extreme and persistent form, is one symptom of the latter. The former is a natural, healthy emotional state that every human being experiences from time to time, while the latter is a serious mental illness caused by a combination of neurobiological, psychological, and environmental factors. I remember an incident that illustrates this principle beautifully. I was conducting an initial evaluation with an adolescent girl and her parents. When I asked the father whether he thought his daughter was depressed, he replied: “I don’t believe in depression.” Interesting response, I thought. As if depression were something like God or heaven or Santa Clause, something to be believed in or not. I asked the father to elaborate on his beliefs. He replied: “I think we all get sad sometimes, and that’s OK.” I smiled and gently responded that I agree with him – yes, all of us do get sad sometimes, and yes, that’s OK. However, some people experience prolonged, intense feelings of sadness accompanied by sleep and appetite disturbances, fatigue, thoughts of suicide, loss of interest, and difficulty concentrating. These people are experiencing major depression.”
Imagine if, in exchange for my membership in the National Depression Association, I received a certificate thanking me for my support in the effort to eliminate Major Depressive Disorder and sadness.” Laughable, isn’t it? Well, so is the ED/Body Dissatisfaction comparison. It trivializes the anguish that eating disordered people experience, and it falsely encourages those whose lives have not been touched by eating disorders to think that they “know how it feels.” Well, guess what. They don’t.
Eliminating all sadness in the world would probably not affect the prevalence of Major Depressive Disorder because sadness is but one symptom of depression, whereas depression is not a result of sadness. Likewise, eliminating body dissatisfaction would be fantastic for everyone, but it would not result in the elimination of eating disorders.
Contrary to popular belief (and, sadly enough, the belief of many eating disorders professionals), the media’s glorification of thinness is not responsible for the so-called “epidemic” of anorexia nervosa. Also contrary to popular belief, the incidence of anorexia nervosa has not increased dramatically in recent decades. Cases of what would now be diagnosed as anorexia nervosa have been documented as early as the medieval times, long before thinness was considered fashionable. These fasting saints shunned all sustenance to the point of emaciation not because they wanted to be skinny, but because they believed it brought them closer to God.
Unbeknownst to many, anorexia nervosa occurs in many non-western cultures. For example, recent studies have shown that the prevalence of anorexia nervosa in China and Ghana is equal to its prevalence in the US. The major difference is that patients in non-western cultures relate their starvation to profound self-control, moral superiority, and spiritual wholeness rather than to a desire to be thinner. Today’s American anorexics, like their medieval predecessors and non-western counterparts, all experience prolonged inability to nourish themselves, dramatic weight loss to the point of emaciation, amenorrhea, and denial of the seriousness of their condition. The self-reported reasons for starvation, it seems, are the only things that change across time and culture. I believe that an anorexic’s so-called reasons for starvation are simply her attempts to derive meaning from her symptoms, which are always filtered through a cultural lens. An anorexic does not starve herself because she wants to be thin, or because she wants to be holy, or because she wants to show supreme self-control. She starves herself because she suffers from a brain disease, of which self-starvation is a symptom.
Recent research suggests that anorexia nervosa is not a culture-bound syndrome, but bulimia nervosa is. Anorexia nervosa seems to be a distinct genotype that has been around for centuries and that manifests itself in various cultures and eras. Bulimia nervosa, on the other hand, appears to occur in individuals with a certain genetic / neurobiological predisposition who are exposed to a culture which combines massive amounts of readily available, highly palatable foods with a cultural mandate for thinness. This research implies that reducing or eliminating the cultural glorification of thinness may indeed reduce the prevalence of bulimia nervosa, but will have no effect on the prevalence of anorexia nervosa. I suppose that, once this awful waif model craze blows over, anorexics will simply find another “reason” to starve.