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The Thin Ideal and Anorexia Nervosa: It’s Not What You Think

It is commonly assumed in popular culture that the “thin ideal” is responsible for causing Anorexia Nervosa (AN). In other words, girls develop AN by embarking on an extreme diet in attempt to look like their favorite celebrity, and if we just showed “real women” in the media, AN would become obsolete.

There is no doubt that the ideal female body is much too thin and unrealistic for the vast majority of people. And yes, the majority of girls and women, as well as many men, aspire to be thinner and attempt to diet in order to lose weight. But the thin ideal plays a different, and more peripheral, role in AN than most people think.

The thin ideal does not cause AN. Contrary to popular belief, AN has existed for centuries, long before television or internet or fashion magazines, long before thinness was associated with attractiveness or health. Girls do not “become anorexic” in order to look like supermodels. Many girls have tried to “become anorexic” and failed. You cannot choose to “become anorexic” any more than you can choose to become schizophrenic or autistic or epileptic. It is impossible to develop AN if you do not have the genes for it. Dieting, while ubiquitous in American society, does not cause AN. In fact, it’s quite the opposite – dieting reliably predicts weight gain. At least 95% of dieters regain all of the weight they lost within a few years, and research suggests that the rise in obesity in recent decades is at least in part the result of repeated dieting.

Although the thin ideal does not cause AN, it impacts AN in other very important ways:

• It delays diagnosis and treatment.

Since the population is so consumed with dieting and losing weight, children and adolescents in the early stages of AN are usually praised for their willpower around food, for their strenuous exercise regimens, for their avoidance of “fatty foods.” Parents, friends, and even pediatricians will commend kids for losing weight and compliment them on their slim appearance. In their own zest for thinness, adults seem to have forgotten that it is neither normal nor healthy for a child or teenager to lose weight. In this “thin is in” culture, a patient’s AN is often not recognized until he or she is emaciated and visibly ill. By that point, the illness is very entrenched and treatment is much more difficult. It would save so much time, energy, suffering, and money (yes, money) to diagnose and treat AN at its first manifestation, before it spirals into dramatic weight loss.

• It prevents full recovery.

Clinicians often set a target weight range that is much too low for full physical and mental recovery. Eating disorder thoughts and behaviors, as well as the associated anxiety and depression, begin to melt away only when a patient has reached and maintained his or her unique optimal weight range.

Clinicians themselves are often so afraid of weight gain that they settle for, or even worse, actively encourage patients to stop at, a “low normal” weight. We seem to have forgotten that there is a natural diversity of body sizes. Some people are genetically built to be thin; others to be average; some to be muscular; some to be stocky; some to be large-framed. Each individual is optimally healthy at his or her ideal weight range.

Recovering patients who have reached that magical BMI of 18.5 (at which they are no longer considered “underweight” on the charts) are often complimented for their thinness, which is considered desirable and attractive and healthy. The thin ideal feeds into patients’ disordered belief that they should maintain a “low normal” weight even if their own body is healthiest at a higher weight.

• It exacerbates patients’ suffering.

The ever-present chatter about diets and calories and weight loss and exercise programs creates an unhealthy environment for recovery. When the vast majority of the population is trying to eat less, exercise more, and lose weight, it exacerbates the suffering of a patient who has received doctor’s orders to eat more, exercise less, and gain weight despite her compulsive urges to do the opposite. Patients who do achieve their healthy weight goals tend to see themselves as colossal failures – unattractive, ugly, and disgusting – as they have moved away from the societal ideal that everyone else is striving to achieve.

• It trivializes the illness.

As a result of our society’s thin ideal, patients with anorexia are often viewed as vain, superficial, spoiled rich girls who starve themselves for the sake of beauty and fashion. Anyone who has witnessed AN up close will testify that nothing could be further from the truth.

• It creates an environment of fear and guilt around food and fat.

Most people these days make moral judgments of themselves and others based on dietary intake and body size. How many times have you heard people say things like: “I was so bad last night – I had 2 cookies” or “I was really good yesterday – I only had a salad for lunch.” Extreme fear of eating and gaining weight is a symptom of AN. So is extreme guilt after eating, or when not exercising. This societal moralizing around food and weight validates the symptoms of AN in its early stages and triggers their recurrence when a patient is trying to recover.

If our society’s ideal female body were a plump, voluptuous figure, would AN still exist? Absolutely. Would the incidence of AN be reduced? Probably not. But I believe that patients would be diagnosed sooner, treated earlier, restored to higher (and healthier) weights, and feel somewhat less triggered to restrict after remission. Perhaps the public would also be more apt to see AN for what it really is: an agonizing, life-threatening mental illness that destroys a person’s physical and emotional health. The broader context in which AN occurs would be less validating of the anorexic symptoms and more supportive of full recovery.

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We’ll Always Have Fiji

I do not believe that the media plays a major role in the etiology of eating disorders. And yet, in much of the eating disorder world, it has become accepted as an unspoken, self-evident truth that patients with anorexia and bulimia have developed their illnesses in large part due to their desire to emulate “the thin ideal” which our media promotes. Those who espouse this idea cite the Fiji Study, which demonstrated dramatically increased rates of body dissatisfaction and disordered eating amongst Fijian adolescent girls within the first few years after television was first introduced to the island.

I, along with several of my like-minded colleagues, have raised concern over NEDA’s choice of Naomi Wolfe as the conference’s keynote speaker. As a feminist, I am a huge fan of Wolfe’s work. In her groundbreaking book The Beauty Myth, she presents convincing arguments about the myriad ways in which our culture and society are toxic to women. I couldn’t agree more.

Our culture and society are harmful to all women and men, and certainly the media plays a huge role in triggering body dissatisfaction and disordered eating. (Incidentally, the media is a major culprit in the perpetuation of myths about eating disorders.) But disordered eating is not the same as an eating disorder. The Fiji study measured body dissatisfaction and disordered eating, not eating disorders.

The disordered eating / eating disorder distinction is not just a matter of semantics. In fact, I believe that eating disorders are quantitatively AND qualitatively distinct from disordered eating, much as major depression is both quantitatively AND qualitatively different from sadness. Anorexia nervosa has existed for centuries, long before the advent of television and internet and fashion magazines, and long before disordered eating became the norm.

I think it would benefit our profession tremendously to arrive at a consensus regarding the definition of “disordered eating” and how it differs from eating disorders.

The confusion between eating disorders vs. disordered eating is a major contributor to society’s (and some professionals’) lack of understanding of eating disorders. People who engage in disordered eating are, on some level, responding to their environment in choosing to engage in certain eating behaviors, whereas people with eating disorders are caught in the grips of a terrifying mental illness which will not allow them to do otherwise.

Disordered eating is very widespread in our country, especially among women. I define disordered eating as a persistent pattern of unhealthy or overly rigid eating behavior – chronic dieting, yo-yo dieting, binge-restrict cycles, eliminating essential nutrients such as fat or carbohydrates, obsession with organic or “healthy” eating – coupled with a preoccupation with food, weight, or body shape.

By this definition, I think well over half of the women in America (and many men as well) are disordered eaters.

The way I see it, disordered eating “comes from the outside” whereas eating disorders “come from the inside.” What I mean is this: environment plays a huge role in the onset of disordered eating, such that the majority of people who live in our disordered culture (where thinness is overvalued, dieting is the norm, portion sizes are huge, etc) will develop some degree of disordered eating, regardless of their underlying biology or psychopathology.

In contrast, the development of an eating disorder is influenced very heavily by genetics, neurobiology, individual personality traits, and co-morbid disorders. Environment clearly plays a role in the development of eating disorders, but environment alone is not sufficient to cause them. The majority of American women will develop disordered eating at some point, but less than 1% will fall into anorexia nervosa and 3% into bulimia nervosa.

The Fiji study was indeed groundbreaking. It demonstrated the enormous impact of the media on teenage girls’ feelings about their bodies and attitudes towards food. But the study did not demonstrate a causal link between the media and eating disorders. Furthermore, our knowledge that the media makes girls dislike their bodies, while important in its own right, has not yielded useful information with regards to developing effective treatments for eating disorders. And isn’t that the whole point?

I would like for our field to accept the Fiji study for what it is – a fascinating sociological study which confirmed empirically what we already knew intuitively – and push forward towards a deeper understanding of eating disorders so that we may develop and implement more effective treatments.

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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.

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Reflections from a Rocking Chair

The recent media frenzy over the “balloon boy” hoax has gotten me thinking about the use of the media in today’s society and how it impacts our youth. The explosion of mass media over the past 10 – 15 years, from 24-hour news networks to the internet and email to blackberries and cell phones for everyone, has undoubtedly had a positive impact in many ways. Vital information can be widely disseminated at the click of a button. Parents can keep close tabs on their children. Businesspeople can check their email and voicemail during the metro ride home. Practically anyone can contact anyone else in the world, anytime, from virtually anywhere, using at least two different forms of instant communication. So much has changed since the bygone days of my own adolescence (we’re talking mid-1990’s) that I am beginning to feel like a grandparent on a rocking chair, pontificating about how, back in my day, we had to walk 10 miles to school in the snow uphill both ways.

And then there’s the ugly side. We spend precious time surfing the internet, watching YouTube videos and facebooking and twittering and texting. This is time that could have been spent reading or playing outside or exercising or engaging in a hobby or spending quality time with family and friends. Going a day, or even a few hours, without internet access leaves some people paralyzed. We feel naked without our cell phones; out of touch without instant access to emails. The amount of time we spend chained to various electronic devices continues to increase exponentially to the point where many people can no longer really relax or get away from their work or their social obligations.

My greatest concern about the mass media explosion is the impact it has on youth – their perceptions of reality, their aspirations for fame or recognition, their interpersonal boundaries, their privacy, their sense of what is normal and reasonable and right. I find it disconcerting when a young patient decorates her myspace with pictures of the scars on her wrists or photos of herself at a dangerously low weight. I am frightened when a teenage girl shares intimate details of her abuse history and her multiple psychiatric hospitalizations with her “friends” on facebook. “Everyone does it,” they say. “It’s not a big deal. It’s who I am.” It IS a big deal, I argue. And no, it’s NOT who you are. Therein lies the rub.

A person who presents herself online in this fashion is engaging in a disturbing form of emotional exhibitionism that has proliferated alongside recent technological advances. She is promoting dangerous stereotypes, over-identifying with her illness, and encouraging others to do the same. I do my best to chip away at the silence and stigma surrounding mental illness, and I firmly believe that having depression or bulimia or borderline personality disorder is not something to be ashamed of. But it’s also not something to advertise to a world-wide audience of anonymous viewers with questionable motives. These are issues to be discussed with a therapist, with family members, with a select group of long-time, trusted friends.

I am ambivalent about the proliferation of websites and blogs about personal experiences with mental illnesses. On one hand, as a therapist, I fully appreciate the healing power of writing, sharing, and connecting. Individuals who share their personal stories of psychological disorders with a worldwide audience are providing hope, support, and inspiration to others who are in similar positions, while slowly chipping away at the shame, secrecy, and stigma that continues to surround mental illness.

I frequent several blogs (Carrie Arnold’s ED Bites, Laura Collins’ Eating With Your Anorexic, and Harriet Brown’s Feed Me) authored by individuals who have personally struggled with eating disorders or helped loved ones recover. I admire these authors’ commitment to advocating for improved awareness, understanding, information, and evidence-based treatment for eating disorders. The authors’ personal experiences are interwoven with scientific research in ways that educate, enlighten, and inspire.

On the other hand, I have also read numerous websites and blogs, authored by individuals with mental illnesses, which I can only characterize as glaring emotional exhibitionism. These blogs are not-so-subtle cries for help, yearnings for deeper connection through a superficial medium. I am not quite sure who is benefitting from a young woman’s blog posts detailing her various creative methods of purging or her meager consumption of carrot sticks for days on end. How about writing in a good old fashioned journal? Seeing a therapist? Joining a support group? Calling a friend? Meanwhile, how about developing a healthy identity apart from your symptoms and making real-life friends outside your diagnostic category?

The individuals who use the internet in this way are not the source of the problem. They are the victims of a society that fails to teach appropriate interpersonal boundaries and encourages people to sacrifice their self-respect for a chance at instant notoriety. What happens ten years down the road, when the teenage “cutter” with a provocative personal website applies for a job as a high school teacher? How will this deeply personal, globally publicized information impact the course of her life? Only time will tell. For now, I’ll step away from my computer, get back on my rocking chair, and try to remember what life was like before blogging.