Fighting the Wrong Battles

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.

9 Replies to “Fighting the Wrong Battles”

  1. A beautiful and powerful post, Dr. Ravin! Thank you so much for it. A question or maybe a clarification (possibly beyond the scope of this post)–you seem to suggest that bulimia, while still a biologically based mental illness, incorporates more of a causal cultural element than anorexia. But where does EDNOS or anorexia succeeded by bulimia fit in? My own experience suggests that anorexia and bulimia (especially when one sufferer manifests both) suggests that the two diagnoses may be, in some cases, different manifestations of the same neurological problems. I know it’s not sound to generalize from anecdote but I do wonder if it’s a little premature to make this kind of cultural/causal claim about bulimia particularly…

  2. Right on, Dr. Ravin! I agree with you completely. We are always trying to “make sense” of what is going on around us. When a person is dragged into the hell of an eating disorder, he/she desperately needs to be able to explain it, to herself and to others. I remember when my D at age 11 manifested ED. The poor dear didn’t even get much comfort from her “wanting to be thin” and “being afraid of getting fat” mantras. She knew she was emaciated, and saw the contradiction between her actions and her words. I think that body dysmorphia, when sufferers see themselves as much bigger than they are, is another way that the mind tries to make self-starvation rational.

  3. Before my daughter was hospitalized for AN, I told the staff there that it was my opinion (as a mother and a mental health professional myself) that she was moderately to severely depressed. I asked if this was something they could ‘co-treat’ along with re-feeding. I also felt her depression to have started before starvation and was concerned it could linger afterwards. The place my daughter was sent (back in ’03) turned out to be old school in philosophy. I didn’t know all this at the time. I didn’t know a lot about AN actually and have learned much in the interim. After a week in their facility, they told me, “We don’t see a depressed child (she was 14), we see an angry one.” Well, she was NG-tubed within 24 hours of arrival for refusal of one meal (despite reassuring us this was rarely used). She stopped talking to us–her parents–totally for the next 5 weeks. Staff never told us she’d been tubed. She was out of state, well over 1,000 miles from home. They wouldn’t allow us to see her (although I’d argued strongly against this prior to admission). We were allowed no access to the doctor, only the social worker. I wanted to pull her, but had had difficulty finding an open bed for her at the time and was told by staff they’d wouldn’t recommend us to any other place should we take her out. I felt very strongly that she was indeed depressed and I was very concerned that it wasn’t being addressed. I kept her there because they did refeed her, something I didn’t seem able to do at the time (no one ever told me about FBT). But talk about long-term damage to our relationship. I am convinced she saw this as abandonment by us, that she felt we viewed her as ‘damaged goods’ that she had to be locked up and so far away. Dr. Ravin, it traumatized me terribly and I still struggle. I loved and love my daughter so much. I had no idea what we were in for, with this illness, with the particular hospitalization approach where I put my trust. I felt burned alive. And, she was depressed. She remains a moody personality to this day, but I’m afraid to say she doesn’t really trust her mother’s opinion as much after this experience.

  4. Rebecca,

    You’re right – research suggests that culture plays a causal role in bulimia nervosa but not in anorexia nervosa. In regards to EDNOS, I’m not aware of any literature on cultural causation, but keep in mind that most people with EDNOS have sub-syndromal AN or sub-syndromal BN (meeting most but not all of the requirements for diagnosis). I would suspect that culture plays less of a role for individuals with sub-syndromal AN and more of a role in sub-syndromal BN. I suspect that culture and environment play a major role in the causation of Binge Eating Disorder (BED). Binge eating is often the result of prolonged dietary restriction, so I would suspect that individuas in cultures that glorify thinness and encourage dieting would produce more people with BED. In addition, in order to binge, one must have ready access to large amounts of highly palatable food, which only occurs in developed, industrialized nations. In response to your question about crossovers (people with AN who later develop BN), I don’t really know the answer to that. I would suspect that culture is not a causal agent for people who have ever met criteria for AN, regardless of whether binge/purge behaviors are present during the AN phase, and regardless of whether the person later develops full-blown BN. In these cases, binge/purge behaviors seem like a biologically-based response to prolinged malnutrition. My view is that in order to starve oneself to the point of emaciation, a person MUST be hard-wired for AN, whether or not bulimic behaviors are present. Many people have tried unsuccessfully to “become anorexic” and ended up with bulimia nervosa instead.

  5. i feel like eating disorder symptoms cross over the disorders so much that it’s not a black and white issue of AN is biologial, BN is cultural.

  6. thank you. i’ve been arguing this point for ten years. How do i get people to understand…my aim was not to look attractive/thin, my aim was to make myself sick. My anxiety eased and i felt confident based on how sick i felt. there was a little voice in my head that wouldn’t allow me to swallow, touch, or eat infront of people. i just could not do it..

  7. Ani,

    Thanks for your comment. I agree that this is not a black-and-white issue. As I mentioned in the blog post, genetics and biological factors clearly play a major role in BN, it’s just that research suggests that culture also plays a major role. In contrast, culture plays a role in the way AN is experienced and interpreted by the patient, and in the way other people interpret the illness. However, the core features of AN seem to transcend time and culture.

    Research shows us that there is a tremendous amount of crossover between AN and BN symptoms. In many cases, BN follows after a period of restrictive or binge/purge AN, and there is evidence that BN (at least the bingeing symptom) is, in large part, the body’s adaptive reaction to a period of starvation (thus biologically-based). Even people with BN who have never had AN often report that their illness was triggered by a period of dieting. I think there are two important elements of BN that seem culture-bound: 1.) The bingeing symptom of BN can only occur in cultures where there is immediate access to very large amounts of highly palatable foods (modern, developed nations such as the USA), and 2.) The purging symptom would probably only occur in cultures in which it is desirable to avoid weight gain (modern Western cultures). There are historical accounts of the wealthy ancient Romans eating very large meals, then retiring to the “vomitorium” to purge before embarking on their next course. However, it sounds like these events were reserved for special social occasions and bear little resemblance to the secretive binge/purge cycle of today’s bulimics. Additionally, I highly doubt that these ancient Romans experienced the extreme anxiety, depression, self-loathing, and body image disturbance that characterizes today’s bulimics.

  8. Jodi,

    I’m glad you have been able to recognize that appearance/weight concerns were not the motivating factor behind your ED. It is extremely difficult for people to understand that AN is not caused by society’s obsession with thinness. In fact, most of my colleagues, trained therapists and physicians and dieticians who treat EDs, continue to persist in believing that EDs are caused by a desire to be thin. The most important things are that 1.) YOU understand the truth about the etiology of EDs and your triggers, and 2.) YOUR TREATMENT TEAM understands the truth. Clinicians who are ill-informed about the causes of EDs are likely to employ treatment methods that are less effective. It would be wonderful if your close friends and family understood, or at least remained open-minded to what you have to say, rather than perseverating in their own uneducated notions. Presenting them with some evidence-based literature on EDs might help.

    Remember, for centuries people (including scholars and scientists) thought that the world was flat. They persisted in this belief even after there was concrete evidence to the contrary, courtesy of 15th-century explorers. The world was round all along. Just because a majority of people, or even a majority of “experts,” believe something, doesn’t mean that it’s true.

    Best wishes in your recovery.

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