Are All Anorexia Nervosa Patients Just Afraid Of Being Fat and Can We Blame The Western Media?

A really fun aspect of blogging is seeing what search terms lead people to my blog; a frustrating side-effect is not being able to interact with those people directly. This entry is, in part, an attempt to answer a common question that leads individuals to my blog. Common question or search queries are variants of the following (these are actual search terms that led to this blog, I corrected spelling mistakes): “do models cause eating disorders in women?”, “pictures of skinny models linked to eating disorders”, “do the images of models in magazines cause eating disorders?”, “eating disorders relating to thin models”, “psychiatrists thought on how skinny models are causing eating disorders”, “thin models are to blame for eating disorder.”

Well, you get the point.

I briefly started tackling the notions that the “thin ideal” promoted by Western media is to blame for the prevalence of eating disorders and a related idea that all anorexics are afraid of becoming fat, in a previous post where I examined case studies of eating disorders in (mostly congenitally) blind women.

These assumptions, along with the idea that eating disorders don’t exist in non-Westernized countries (or that they arise only once enough Western media infiltrates the country) are often accepted as facts.

Rieger and colleagues wanted to examine whether these assumptions have any substance to them. More specifically, their goal was to:

To critically examine two assumptions guiding cross-cultural research on the weight concerns of anorexia nervosa: (1) that weight concerns are specific to contemporary, Western manifestations of the disorder and (2) that the dissemination of Western values regarding thinness is primarily responsible for the development of anorexia nervosa in non-Western contexts. [By conducting] a review of theoretical and empirical literature on cross-cultural aspects of anorexia nervosa and the medical records of 14 Asian patients treated for eating disorders in Sydney, Australia.

Essentially, they argue that it is the desire for weight loss as opposed to a fear of weight gain, that’s a defining feature of anorexia nervosa and that the infusion of Western media in other countries cannot be the sole (or likely dominant) cause of AN.

This is not a primary research article or a comprehensive review. It is, however, a thoughtful review with some very cogent and important points.

As it stands right now, a formal diagnosis of anorexia nervosa, using the Diagnostical and Statistical Manual of Mental Disorders (DSM-IV), requires that the patient exhibits:

  • “an intense fear of gaining weight or becoming fat, even though underweight,” and
  • “a disturbance in the way in which one’s body weight or shape is experiences, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of current low body weight”

The weight criterion (<85% of ideal body weight) and absence of menses (amenorrhea) are also controversial. (I’ve discussed it briefly in previous entries, see posts with the ‘DSM’ tag). They weight criterion will be changed in the upcoming edition of the DSM, and amenorrhea taken out altogether.

The former criteria, however, will largely remain unchanged:

  • Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
  • Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

Rieger et al., in essence, evaluate whether this is valid. (Not exactly,  because this paper was published in 2001, way before the revisions on the current DSM edition began. But frankly, I think the writers of the DSM would benefit from revisiting this and other papers of similar nature. But I am not holding my breath.)

Even as early as 1995, a British psychiatrist Gerald Russell wrote:

the time may be approaching when it will be advisable to retreat from our cherished diagnostic criteria of anorexia nervosa, as there may be a false precision in the current formulation.

By the way, Russell was the first to publish a description of bulimia nervosa (and yes, “Russell’s sign” was named after  him).


Cross-cultural studies suggest that weight concerns, and particularly fat-phobia, are diminished or completely absent in patients from non-Western countries. For example, in one study of 70 Chinese patients from Hong Kong, less than half reported feeling fat-phobic at any point during their illness. Of course, attributing weight loss to stomach bloating or abdominal pain, suggests that a diagnosis of anorexia nervosa may be completely inappropriate. Moreover, weight loss due to a lack of appetite may be a sign of depression –  not anorexia nervosa.

Rieger suggests that what is very common (universal?) in cases of anorexia nervosa (“that distinguishes it from other conditions”) is the egosyntonic nature of the disorder. More specifically, the “denial of illness in which extreme emaciation is not perceived by the patient as problematic but, to the contrary, is highly valued.”

Rieger quotes Charles Lasègue‘s description of a patient (from 1873):

Above all, the state of quietude—I might almost say a condition of contentment truly pathological. Not only does she not sigh for recovery, but she is not ill-pleased with her condition, notwithstanding all the unpleasantness it is attended with. In comparing this satisfied assurance to the obstinacy of the insane, I do not think I am going too far. Compare this with all other forms of anorexia, and observe how different they are. At the very height of his repugnance, the subject of cancer hopes for and solicits some aliment which may excite his appetite …

Note, too, that thin was not in when Lasègue first described anorexia nervosa (see paintings by Renoir to get a sense of what was in).

Another interesting patient account from a paper in 1980 by Ciseaux:

It’s like I never knew what self-respect was all about until now. The thinner I get, the better I feel . . . I’m proud of my stoic, Spartan existence. It reminds me of the lives of the saints and martyrs I used to read about when I was a child . . . This has become the most important thing I’ve ever done.

Rieger highlights other examples of patients for whom fat-phobia was not a concern:

… food restriction arose from a sense of powerlessness in the family context, it is possible that the patient experienced her emaciation as egosyntonic, with her low body weight consonant with the goal of not wanting “to ‘give in’ to her family, especially her mother, who forced her to eat even when she was not in a mood to.

In another case, extreme emaciation was a useful way for a patient to “keep boys at a far and ‘safe’ distance and allow her to remain virginal..” But, in all of these patients, the experience of weight loss was egosyntonic.

Riegel concludes this section with a nice quote by Russell:

the dread of fatness is likely to be a modern development in the psychopathology of anorexia nervosa.  That which is immutable, however, is the fact that “the patient avoids food and induces weight loss by virtue of a range of psychosocial conflicts whose resolution she perceives to be within her reach through the achievement of thinness and/or the avoidance of fatness


It was – and to a large extent still is – thought that eating disorders exist only in Western countries and that their appearance in immigrant minorities was due to the influence of Western media and culture. The internalization of the ‘thin ideal’. Some researchers have attributed differing prevalence rates of EDs in non-Western countries to the “level of Westernization” in each country.

This notion, of course, ignores the cases of anorexia nervosa that were present before the Western emphasis on thinness was ever truly dominant (would saying that began post WW-II be fair?). Certainly, when Sir William Gull and Charles Lasègue described cases of anorexia nervosa, thin was not in. 

Studies that suggest there’s a correlation between the acceptance of Western values and concerns about weight, body image and eating disorders are countered by studies that show no such correlation.

For example, one study found that in British Asian girls, dietary restraint was correlated with traditional (rather than Western) values (Hill & Bhatti, 1995). This finding was supported in a study by Mumford and colleagues (1991) who essentially found the same correlation. On a Caribbean Island, with little Western media, Hoek et al (1998) found that the prevalence of AN was comparable to Western countries and a study by Apter et al (1994) showed that a group of village Muslim women (with minimal exposure to Western values) had eating pathology scores that were indistinguishable from patients with AN.

Cross-cultural research is difficult, for one, are the tests and instruments used to evaluate patients in one country applicable and relevant in another? And while such methodological problems may explain the contradictory findings, Rieger suggests that this “may be due to a rarely considered possibility: Non-western culture share with Western cultures an ideology that values thinness.”

As in Christianity, it seems that many other religious practices placed a lot of value on fasting and thinness:

Comparable to the ascetic practices in the history of Christianity are the fasting practices in the Chinese Daoist tradition (Eskildsen, 1998). These practices sought to transform the body as a means of gaining immortality…  The history of Chinese thought thus suggests that, in certain traditions at least, the emaciated body has been highly valued and pursued in a manner highly reminiscent of Western observances.

But, religious and spiritual reasons are not the only factors that could be contributing to AN in non-Western countries (or Western countries before the ‘thin ideal’). Personally, it would seem to be, that anorexics in those times, would just attribute their desire for weight loss to those reasons much like today it is often attributes to a fear of being fat. But, both of those could just be post hoc rationalizations on the part of the sufferer, to make sense of their otherwise perplexing desire to restrict their intake and lose weight. That’s my feeling.

Rieger makes an interesting point here about the role of food restriction as a form of protest (for example, to assert self-autonomy, express anger, frustration, or what have you):

For example, Confucian familial practices do not encourage autonomy or the overt expression of hostility against authority figures (Rhi, 1998; Slote, 1998). These practices may render individuals susceptible to anorexia nervosa, a disorder that is frequently attributed to deficits in the development of an autonomous self. According to Goodsitt (1997): “Excessive attempts to control the shape of one’s body derive from a terrible sense that one’s body, as an aspect of self-organisation, is out of control—easily influenced, invaded, exploited, and overwhelmed by external forces, whether these are peers, parents, or food. (p. 210)”

The authors also analyzed medical records of 14 Asian patients with anorexia (8) and bulimia nervosa (6), treated in Sydney Australia. All patients experienced weight loss and thinness as egosyntonic, but not all patients experienced fat phobia: “One patient, in the context of an unhappy marriage in which she described her husband as expecting obedience from her, described a sense of control in being thin. Although not showing any signs of fat phobia, some patients lacked insight regarding the problematic nature of their low weight status.”

In my personal experience with my ED, I could be considered fat phobic initially – when I had little self-awareness about the nature of my disorder (but I knew I had a problem, probably because we had just learned about EDs a year earlier). Later, I realized I wasn’t actually fat phobic anymore, I just liked restricting my intake, a lot. It was calming. Essentially, I used caloric restriction as a way to curb anxiety. It was also a way to express feelings I couldn’t express verbally,  or if I didn’t, they weren’t heard or valued. Once out of those situations, weight gain was easy.

Indeed, there were many times I wished I could just restrict my intake but not lose weight, because I didn’t want to worry people, but I just didn’t want to eat. I felt better abstaining from food, for many reasons. Of course, there were times I wanted to restrict AND lose weight. However, there was never a time when I wished I could be “naturally thin” (ie, eat all I want and be thin). That never, ever, ever, entered my mind. I never wanted that, it had no appeal. Thinness was just a marker of how good I was at not eating, needing less to live on. I took pride in that – as crazy as it may sound to someone without an ED.

Returning to the paper, Rieger and colleagues have some suggestions for future studies examining the validity of these assumptions. In essence, future studies need to be more exploratory and open to different interpretations. They need to move beyond using tests and questionnaires common to Western countries, and go in with as few biases and assumptions as possible.

These assumptions have guided research efforts and have influenced the interpretation of the data obtained (e.g., rejecting as anomalous results that fail to find an association between the degree of westernization and the occurrence of eating disorder symptomatology). At the same time, these assumptions have limited other possible areas of investigation (e.g., exploring the weight concerns featuring in non-Western contexts). Because misguided assumptions will ultimately limit the understanding of anorexia nervosa, a critical examination of these assumptions is essential.

As I see it, a critical question is: what is the defining feature of anorexia? Is fat phobia with the non fat-phobic cases falling into the “atypical” category, or is it the seemingly more broadly applicable egosyntonic desire to restrict and lose weight? I think the egosyntonic nature of the disorder is definitely more defining of anorexia nervosa. And, by egosyntonic, I suppose I’m being broad, too.

There were certainly times I didn’t want to keep losing weight, because I didn’t want to worry my boyfriend, my family, especially my siblings. I felt ashamed that I still had an ED. But, restricting felt so good, and eating was anxiety provoking. I liked eating less. And, I liked weighing less. To me, those are still egosyntonic reasons, even if I didn’t specifically desire weight loss.

Readers, what are your thoughts and what have your experiences been like? What do you think about the role of fat phobia in anorexia nervosa? What about the role of the Western idealization of thinness? 


Rieger, E., Touyz, S.W., Swain, T., & Beumont, P.J. (2001). Cross-Cultural Research on Anorexia Nervosa: Assumptions Regarding the Role of Body Weight. The International Journal of Eating Disorders, 29 (2), 205-15 PMID: 11429983


Tetyana is the creator and manager of the blog.


  1. I think there are many pathways into anorexia nervosa (AN), with the common denominator being sustained energy deficit (energy intake < energy expenditure). AN can develop after serious illness that incurs a sustained energy deficit, and in athletes who fail to match their energy expenditure with an adequate energy intake (a group I undertook extensive research with; including for my PhD). The two latter groups do not intend to lose weight at the outset but develop a fear of re-gaining the weight and behavioural compulsions that lead to sustained energy deficit.

    On a personal level: I developed AN at age 11-12, in 1977. There was little media pressure to be thin and I had no interest whatsoever in losing weight because I was already thin. I was a 'tomboy' and disinterested in fashion, beauty or looking good. However, I had longstanding OCD and my anxiety escalated in the 18 months before I was diagnosed with AN because of bullying at school and rape by someone outside of my family. (I come from a loving and nurturing family and do not see that my parents in any way 'caused' my AN).

    I was a child athlete and started to over-exercise because it relieved my anxiety. I started to follow my parents' diet because regulating my food intake also made me feel more in control of my anxiety. I became obsessed with planning my diet and counting calories. I lost weight and became depressed. I started to believe that I didn't deserve to be alive – and so I reduced my energy intake further. I had no desire to lose weight, but weight loss was rapid and inevitable because of my high energy expenditure and low energy intake. I got stuck in a pattern of compulsive behaviours and was frightened of changing. When I tried to eat more or to exercise less I felt intolerable panic. My anorexic behaviours made me feel 'in control' of my life. The number on the scales was merely a gauge of the extent of my 'control'.

    I suffered with AN for 28 years. Never in this time did it have anything to do with a desire to lose weight, a fear of fatness, the media, glamour or 'beauty'.

    • ELT: Thank you for your comment! Always appreciated 🙂

      I think the point you make about the fact that prolonged restriction does lead to fear of re-gaining the weight and more obsessive-compulsive symptoms. That’s certainly been true in my case – at least initially when I first got ill. And, then of course, there’s the idea of “scar effects”, as I’m sure you are aware. I also think that has validity.

      I completely agree that weight loss, for me, was just a marker of how good I’ve been with eating less. Calorie counting and keeping a record of things was much more important to me. I didn’t really care if I gained weight per se, but I wanted to know how much I’d gain. I kept a sheet of calories consumed, average per weeks/month, and standard deviations on the months too. It was much more about feeling like I knew what was going on me. I didn’t even own a scale until many years after I was diagnosed with AN. I don’t know my actual pre-ED weight or my lowest weight. I didn’t particularly care. I just wanted to eat less, felt anxiety and panic for eating more, and really, just anxious about any breaks in routine. So, my experiences were definitely similar to yours.

      The one aspect I really liked was a decrease in my libido and less sexual attention from men. I wasn’t attractive, because I was too thin. I liked that. I didn’t mind gaining weight as much as I minded being noticed for my body (and my curves). I don’t think those thoughts caused AN; they didn’t. But, they were important in maintaining it for some time, for sure.

      Again, thanks for your comment 🙂

      • Thanks Tetyana 🙂 You write:

        “I kept a sheet of calories consumed, average per weeks/month, and standard deviations on the months…”

        Yep. So did I. I didn’t just count calories; I also counted grams of all macronutrients. I like data, charts, graphs etc. I loved doing the calculations.. Maths has always been my favourite academic subject. (I was and still am a ‘nerd’).

        So if my AN were ‘about’ wanting to be thin, then why would I engage in such nerdy activities?

        Yet, I also identify with what you write about attention from boys and men. I was terrified of such attention, because I had been duped and then raped. I became convinced (and frightened) that ALL men wanted to rape me – which is a tragic thing for an 11-12 year old to feel. AN made me look ugly because of the emaciation and that felt safe.

        So all-in-all, I can say that for me there were many facets to AN. Now that I am largely recovered I am still obsessive and routine-bound; but I was like that as a small child, before the onset of AN.

        I think that A:) makes a good analogy with PTSD and triggers. There are many triggers for AN, just as there are for PTSD, but perhaps the neurobiology is the same.

        • I really relate to the counting of all nutrients and of calories, steps taken, everything. I used to do that, too, and at that stage I didn’t even weigh myself, even though weight loss was very important to me, counting was more so. I could live with not losing weight, I couldn’t live with not counting, making a mistake, losing track etc. This time of my life was directly in response to sexual abuse and in hindsight, I can see that I directly switched from thinking about how much I was hurting/violated/scared etc to the numbers, to block it out. I couldn’t cope so I just drowned it out with the numbers and I got extremely upset if I lost count or was unable to! I don’t count at all anymore, don’t even allow myself to read nutrition panels, but I still am bound by very strong ritualistic behaviours.

          • I can really relate to:
            “I really relate to the counting of all nutrients and of calories, steps taken, everything. I used to do that, too, and at that stage I didn’t even weigh myself, even though weight loss was very important to me, counting was more so. I could live with not losing weight, I couldn’t live with not counting, making a mistake, losing track etc”

            Counting and keeping track of things was really important. Although, counting calories is the only thing I still do, albeit not as obsessively, because it helps me figure out if I am eating enough or not. (But I don’t plan means, or count prior to eating, I eat and then figure out what I ate). For a long time, I just found calorie counting really relaxing, like a fun part of my day. I wasn’t too worried about the number, but, I was anxious if I didn’t know. (Thankfully, that’s not the case anymore.) But, I think, if my weight were to drop significantly, that anxiety over not knowing will likely (though not necessarily), rise.

        • ELT, you wrote: ‘So if my AN were ‘about’ wanting to be thin, then why would I engage in such nerdy activities?”

          I’m not sure that’s a logical argument though. The assumption is that nerds (or at least, in your case, someone who likes numbers and math in general) don’t want to be thin, or wouldn’t go to extreme measures to be thin. But, I’m not sure how that’s related.

          I think that’s a common assumption; and one I’ve made before too.. stressing that it is not about vanity, or fashion/models (although clearly, as the Susy posted (see comments below), for some, that is a factor).

          We don’t associate nerdy activities with a desire to be thin in that dieting sort of way, I know.

          But, there were plenty moments for me, when I really wanted to be thin – and grossly thin (and I knew it was by most people’s standards ‘too thin’). And those were times when all I did was sit in libraries all day and study, in undergrad.

          I don’t think mine, or anyone’s AN is solely about wanting to be ‘thin’, if that’s the case, I’m not sure that’s AN, but, I wouldn’t rule out the idea that you can be really really nerdy, and really, really, desire thinness – for whatever reasons.

          • I guess I didn’t explain what I meant when I wrote “So if my AN were ‘about’ wanting to be thin, then why would I engage in such nerdy activities?”…

            So I will elaborate:

            I wasn’t suggesting or assuming that nerds don’t want to be thin. What I meant to say was that when I was very stuck in AN I was obsessed with the detail of everything in relation to what I ate and the way I exercised – to the point that I calculated grams of fat, carbohydrate and protein, just for the ‘fun’ of it. This obsession with detail had nothing to do with a desire to be thin or remain thin; I was just very obsessive. The same applied to exercise: I ‘had’ to go to the gym at exactly same time of day and would get very frustrated if someone was on the treadmill I always went on. I was very ritualised and my ritualised had to be ‘just right’.

            So I guess that what I wanted to get across was the fact that my AN comprised a collection of very obsessive and ritualistic behaviours that had nothing to do with a desire to be thin. The reference to being nerdy is somewhat redundant…

          • Yes, that makes sense. Thanks for the clarification!

            But like I said, I don’t think they are mutually exclusive (and I don’t think you do either, I’m just stating that to be clear.)

  2. Hi Tetyana, thank you for this post, it’s really good and thought provoking.
    A lot of people with anorexia who I’ve met haven’t been fat-phobic, especially the younger ones.
    My own anorexia didn’t start off as fat phobic. It started as anxiety/abuse related – feeling too anxious and shaken and fearful etc, feeling disgusted, feeling violated, who could eat? Also it was an attempt to control even one thing in my uncontrollable life.
    People had so much power over me, but they couldn’t make me eat, even when they tried to.
    However years into it, it changed, and DID become fat-phobic. Now, I remember how things used to be and I dearly wish I could once again care more about what my body could do – being strong and healthy – instead of always feeling far too big and seeing far too much there of myself. It’s like a switch was turned on that I cannot turn off again.
    Also I’m not fat-phobic generally, I have always had plenty of overweight/obese friends throughout my life, and I don’t look at them any differently than normal weight or underweight friends. I tend to see people’s personalities and faces when I look at them and think about them, their bodies just being what moves them around and makes them able to talk to me and do things with me. I’m not fat phobic about other people, so it’s puzzling to be that way about my own body.

    • Hi Fiona: thank you for your comment (and the compliments!)

      I agree that I do think the fat-phobic aspect of the disorder is definitely something that can fluctuate, probably depending on weight and caloric intake, history of the ED, initial reasons or causes, I suppose, for the ED.

      You make a good point about the common discrepancy between we often view ourselves and the way we view others. But – EDs are not rational. Rationally, you know, your friends are your friends because of their personalities and the things you share in common; you are not friends with them for how they look. And you probably realize judging people by their body size is nutty. But, when it comes to ourselves, it is different. You might know you are the same person regardless of weight, you still like the music you like, books you like, etc.. but, you FEEL different. Weight gain and perhaps how your see your body impacts how you feel about yourself. That emotional connection isn’t present with other people, because you are not them. But, and this is all just my hypothesis, it is different when it comes to you, because you are you. If you made the connection that weight gain means x,y and z (failure, lack of control, etc..), then it is no surprise you’d feel there “too much of you”.

      I definitely fluctuate, too. It really depends on a lot of things. I can’t say I’ve always been fat-phobic or never been.

      • I think you have good points there. We aren’t connected to other people’s bodies emotionally. Also with an ed we often have given the weight an emotional reason that it doesn’t normally carry (eg abuse etc).
        Again, I agree that it changes. I’ve had times when I’ve hated to be too thin and felt disgusted and ashamed of my body, and yet I couldn’t stop losing weight despite that.
        It is so very irrational. I’ve been told I would not live through the night and my purging was the biggest reason for that, but I still couldn’t bear to eat or drink and purged the drink they gave me. That was terrifying – to face death and STILL be trapped by the ED. It’s not rational at all, and the more unwell you are nutritionally I think the less ability to be rational you have, which fuels it on more and more deeply.
        I don’t know if you have written anything about the Minnesota Semi Starvation Study and I’d be interested if you did, because often it seems like there is a chicken and egg question – did the deeply ritualistic and obsessive thoughts and behaviours come from the starvation caused by anorexia, or were they there before that? Because many people with anorexia do have that level of obsessiveness before they have lost much in terms of nutrition.

        • “Again, I agree that it changes. I’ve had times when I’ve hated to be too thin and felt disgusted and ashamed of my body, and yet I couldn’t stop losing weight despite that.”

          Yes, I’ve definitely been there – but much further along in my ED, years after I was first diagnosed. I think those thoughts were due to acute awareness of why I couldn’t eat, and feeling like I need to get a grip and deal with things without abusing my body. I felt ashamed that I was much older and STILL had an eating disorder. Initially, I did not feel too thin and had horribly body dysmorphia, but later points at low weight were almost completely devoid of body image distortions (though I often didn’t feel “too fat”, I just felt thin, or not thin enough, but I knew I was thin)

          I haven’t written about the MSSS, but what you bring up, the “chicken and egg” sort of problem is very true! It is also really important to keep in mind when reading any studies that look at personality characteristics and risk factors – particularly retrospective studies. I did blog about the “chicken and egg” problem, as you put it. A little bit – I will blog more at some point.

          The post is called “Symptoms in Anorexia: Cause or Consequence”. I probably should have titled it differently, since that’s not attention grabbing or provocative at all!

    • I think of fatphobic AN in its presentation as being a kind of specific form of internalized fatphobia. It gets frustrating how many people think that people with ED’s can’t be feminists, or ‘body positive’, or compassionate towards fat people generally. Like, anorexics don’t exist to get at fat people’s feelings. I say it’s specific because I don’t think it’s like, fatphobia in the sense of hatred towards fat *people* taken to an extreme- the hatred of ‘fat’ tends to be reserved to the sufferer’s body. Sorry for not being very articulate.

      • Sarah, I’m confused! When I say fat-phobic, and I really should have emphasized this in the post (but didn’t because I took it for granted), I mean only toward oneself. I think fatphobia with regard to others is a wholly different thing. Though, sure, at some points someone with AN may feel disgust at someone eating, or someone who is of normal weight, overweight or obese, but I think that’s something that tends to pass when people get better and begin to recover.

        I didn’t think about it in terms that you put it in; I guess I’m lucky that I’ve never met people who think that (at least that I know of)!

        • ‘I’m not fat phobic about other people, so it’s puzzling to be that way about my own body.’
          – I was addressing that comment; I don’t think it’s puzzling personally.
          I think fatphobia *in the sense of prejudice towards fat people* is pretty universal (on a varying scale), like even some of the most liberal people will have fatphobic attitudes. It’s an attitude you have to work to unlearn in our culture imo, I don’t think it makes you a terrible person (this is pretty OT but I just thought I’d say it anyway).

  3. Catherine of Siena (who has since deleted her wordpress) made a post saying how she’d rather be fat and be eating disordered than naturally thin without any disordered behaviours. It just reminded me of what you said in this article. As you might have inferred from the name of her blog, she relates her anorexia to the ‘holy anorexia’ of saints like Catherine.

    • Hey Sarah, thanks for the comment! Do you think that’s a mentality that’s in the minority or majority of patients with AN? Just out of curiosity.

      • I don’t know tbh. She said that she didn’t think most of the people with ED blogs on Tumblr actually had eating disorders, so if her judgement is correct then maybe the majority, but her post didn’t get many reblogs. I c/ped the post below:
        trigger warning for description of ED behaviors

        I’d rather be fat than eat. I’d rather binge and purge and possibly gain than eat semi-normally and maintain or even lose. It’s not the weight I can’t deal with; it’s the eating. Of course I’d love to be thinner, because lower numbers verify that I’ve been “good”, but in truth, the number on the scale is just another language for the number of calories I eat or the number of minutes I work out or how clean I rinse when I purge. They’re all just silly little ways of keeping track, trying to give a tangible value to the intangible disorder.

        Eating is intolerable—the act of eating, not the result. I’m fascinated by food, but consuming it is unclean and weak. When I binge and purge, I force myself through the binge in order to purge, rather than forcing myself to purge because I wanted to binge. And although bingeing and purging is disgusting, it isn’t crouching over a dirty toilet with my fingers down my throat that takes my dignity: it’s eating.

        If I were offered the choice to be “thin”—even by my own ghastly definition—and eat xxxx calories every day without purging, or to be clinically obese and either fast or binge and purge for the rest of my life, I would choose to be obese and disordered. Not because I enjoy bulimia (I don’t), or because I’m “pro-ana” (I’m not). But because I am still absolutely entrenched in this disorder, and at its very core, it is true to its name: an eating disorder.

        Note: Tetyana edited the comment for formatting and to x-out the numbers.

  4. Hmmm, this is an interesting question. Keel et al., (2003) wrote an interesting paper on this, reviewing the evidence of EDs as culture-bound syndromes and I cited this article in a paper I wrote in one of my third year neuroscience classes on the neurobiology of AN.

    I tend to agree with the idea that the defining features of AN are egosyntonic food refusal (accompanied by inability to gain weight) and emaciation. However, it seems that the accompanying “reasons” for these behavioural symptoms (i.e. fear of fat, religious reasons, etc.) vary by culture despite the behavioural uniformity.

    It makes sense (at least to me) to believe that our initial motivation for weight loss and the context within which we frame our illness is mediated by our environmental/ social factors — whereas the neurobiology and the accompanying behavioural outcomes (i.e. anxiolytic effect, resultant positive mood, weight loss) are uniform despite culture or time period.

    This just my point of view based on what I have read of the literature (though I don’t read as much of the ED literature as I used to!)

    I think if we are going to identify a mental illness as BIOLOGICALLY based, its defining characteristics should not be “Western influence.

    For example: PTSD can be caused by many traumatic events (ie. kidnapping, rape, war, murder, etc). No one would classify PTSD as “war disorder” — the triggers are different, the context is different but the underlying neurobiology and behavioural symptoms are similar

    Full citation for the Keel paper is here:

    Keel PK, Klump KL (2003). Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology. Psychol Bull 129: 747-769.


    • A:) Thanks for your comment!

      I completely agree with you with regard to the defining features of AN and the variable motivations we attribute to them, which are likely culture-dependent.

      I have skimmed that paper before, it is somewhere on my hard drive. It was somewhat lengthy and I wanted to make a quick post :P, plus I wasn’t originally going to do this paper, anyway.

      I’ll re-read it, as they seemed to have done a good job summarizing everything. Thanks for the reminder!

      I need to check out what’s been done since 2003.

      • Tetyana 🙂

        The Keel paper is a lengthy paper, but it is worth reading and is pretty good. . . (I think it was written at Harvard?)

        Interestingly, in my neuroscience class (neuroscience of motivation and emotion), the TA (pure psych! :O) who marked the essay I had written on the NEUROBIOLOGY of AN felt the need to comment (on every other page) that I had “failed to mention that EDs were triggered by Western media/body image” and I received a less than desirable mark for the first time in my life. This was the first time I had been introduced to this type of ED “discrimination.” and I realized that this TA(and professor) who had taught me (and many others) simply did not believe that AN was a mental illness in the same manner as schizophrenia or bi-polar disorder.

        So — I received a sub-optimal mark, but I learned a lot (both practically and during the literature review for the paper) from the project.

        However, I need to catch up on current ED literature — with my current PhD work, I have definitely fallen behind on my “hobby ED readings!” — There may have been a more recent article published that I am unaware of!

        It was nice meeting you! 🙂

        A 😛

        • It’s kind of depressing when the people who are supposed to know everything are sub-par on knowledge. I don’t have a degree but I know this stuff. :/

        • @A:) I think it’s appalling that you received a lower mark on an assignment just because of your TA’s ignorance… Of course, I haven’t seen your essay, but you write that the title/subject was ‘The neurobiology of AN’.

          I have said this many times before – on my own blog and elsewhere – that one of the reasons why I remained sick for so long with AN was because my AN presented as non-fat-phobic and I did not identify whatsoever with the idea of media triggers. Yet, I had professionals ramming pop culture down my throat and suggesting that I should try to get over the idea that ‘thin is attractive’…. Ugh.

          Whether the ‘faulty brain circuitry’ that drives AN is the same for everyone diagnosed with the illness is uncertain, but the thoughts that accompanied my AN NEVER once related to a desire to be thin/attractive/pretty. The thoughts were always along the lines of feeling I couldn’t cope with life; feeling I didn’t ‘fit in’; feeling I was a failure – and feeling I didn’t deserve to eat. I had a lot of negative feelings about my self as a person, but not my physical appearance.

          In fact, I am much happier with the way I look now that I have gained weight. I still think I look too thin and would look better heavier – which is why I am trying to gain more weight. The latter isn’t easy nowadays because years of restricting AN has left me with gastroparesis and other digestive problems.

          • ELT, do you have a sense that perhaps non-fat-phobic AN is actually more common than most of us think? It is just that individuals, particularly at the onset of AN, rationalize their behaviours (in Western countries) as being afraid of being a normal weight/being ‘fat’?

          • I think some people exaggerate the role of body image concerns in their own disorder to make sense of what theyre dealing with

  5. The media definitely played a part in my struggle with an eating disorder in my preteen and teens, though I remember having disordered thoughts when I was in first grade. Back then, I wasn’t around much media. What triggered the most serious part of my battle was my father’s emotional abuse. Of course, there is always the biological factor, too.

    Anyways, I’m trying to say that for me, the media played a role, but it wasn’t the biggest one.

    • Hi Susy, thank you for your comment!

      First, I’m terribly sorry to hear about that you’ve had to deal emotional abuse – that’s really awful and no one deserves that.

      I hope I didn’t meant to come off as saying that I don’t think the media plays a role. I think it does for some people – but I feel that that role might be more in the maintenance or perpetuating of ED behaviours, as opposed to a true causative factor.

      What are your thoughts on that? You mention that you had disordered thoughts prior to much media exposure – which leads me to hypothesize that maybe the media’s role was already after you were more prone to developing an ED?

      I’d love to know more about how the media influenced your ED (was it in a “thinspo” type of way)?

      Thanks again for the comment – I always appreciate it 🙂

      • Yes! I think you are right about it not being, at least usually, the starter of an ED. That’s how it was for me.

        From about third grade on up, every month I received catalogs from stores, like Limited Too (now Justice), and Delia’s. I would daydream about my life if it was like the models’ lives that I envisioned. I didn’t want to be a model, I wanted to live the life of the PEOPLE who always wore those clothes and went to the beaches in the background.

        Later on, soon before I was hospitalized, I was into thinspo websites and videos on youtube.

        Does that all make sense?

        • Yup! That makes perfect sense to me! I think a lot of people find those things are perpetuating factors, once you are already in the mindset of sort of, well, associating thinness with all sorts of things – I guess with whatever caused it in the first place. (Although there’s never just one cause, but you know what I mean, I hope.)

          I think the reason I’ve stayed away from posting much about the media’s negative role on self-image is because organizations like NEDA and NEDIC seem obsessed with loving your body and having a positive body-image. Which, don’t get me wrong, I think is important, but I bet that’s not at the core for most people with EDs.

          When I feel happy, I’m fine with my body at any weight, but when I am not, for whatever reason, I can’t stand it at any weight (at least I couldn’t), because I’d project all of my emotions and feelings into that, because it probably felt like there was something I could do about that? (Or maybe that’s just a post hoc rationalization for the fact that restricting and purging were calming?). So, I’ve stayed away from it because I feel it is over-emphasized – but that’s not to say it isn’t an important perpetuating factor.

          Thanks for pointing that out!

          • I understand what you’re saying 🙂

            It seems like a lot of people want to blame eating disorders solely on the media because that’s much more simple than the array of things that actually cause them (which includes the media).

  6. I think this really hit my experience on the head. Mine was egosyntonic – I only realized I had a problem when I looked at actions/behaviors common to AN folks.

    Because of my parent’s abuse, I would restrict: my appetite would die, eating would become a chore to get over with, I wouldn’t even want to be in the same floor with them so I couldn’t go to the kitchen. I stopped paying attention to my hunger, and it was easier not to bother. Soothing, even.

    My therapist won’t diagnose me with even EDNOS because I didn’t lose significant weight, nor did I count calories or weigh myself or anything like that. I’m going to talk to her again soon.

  7. Hi, I commented somewhere about this before, with a suggestion of making all compulsive and damaging behaviours leading to malnutrition defined as an eating disorder, regardless of the exact nature of the compulsion. Can’t find the comment now.

    Anyway, it turns out the DSM 5 is going to do something like that, it’s going to include a separate category for non-fat-phobic dietary restriction, and it’s expected to further reduce the number of people diagnosed with ED-NOS. It’s called Avoidant/Restrictive Food Intake Disorder. Looks like a step in the right direction and it might just end up broad enough to cover your own experiences Tetyana. 🙂

    • Hi Sasha,

      I don’t agree that all damaging behaviours leading to malnutrition be defined as an eating disorder, but, I do think the definition should be broader in some senses (for example, if it is secondary to another disease, like cancer, for example). At the same time, I am not sure I have much hope for the DSM being scientific or evidence-based anytime soon, unfortunately.

      Thanks for your comment!


  8. My 2-cents – as a recovered?/in recovery? anorexic. First I question where I am in the long path to recovery. I don’t actively try to lose weight, in fact, when I do weigh in(still below weight) I get frustrated by my lack of progress. NOT that it’s not low enough.

    14 years ago – weighing myself was just that though, my need weigh less, need to control more of my life.

    At my lowest point, emotionally and perhaps in terms of weight, it wasn’t that I wanted to be incredibly thin. I was drowning in life, and anorexia was the only consistent thing that had been there. Somewhat of an addiction or OCD, I wanted to be okay, I didn’t want to die. I didn’t think I looked good at all, in fact I thought I looked horrible. And the most frustrating thing was knowing what I was doing was wrong, but not being able to “be fixed”.

    I entered into one of the U.S.’s most “prestigeous” eating disorder programs in August 2011. I left in April 2012 weighing less than when I first arrived. And I believe it was because of our fundamental understanding of eating disorders, and me, personally, being misunderstood. My therapy sessions involved sole around food. For 3 weeks, we discussed ad naueseum soup. During this time the rest of my life was a mess (I had to commit my sister twice, my dad diagnosed with terminal cancer, the busy season at work….etc.) I repeatedly asked if I could talk about these things, but nope, just food. It wasn’t until the 4th session about soup that I left that program.

    I started seeing my daughters therapist. I had been trying desperately to follow all the new “eating rules” that the ED program had given me, and that was frustrating too, because I couldn’t eat the foods that didn’t hurt my stomach because those were “safe foods”, but the recommended foods (6 bagels a DAY) were impossible. It wasn’t until we focused on the non-food aspect of my life. And the anxiety.

    I think one of the most freeing things was my new therapist saying, I don’t see why you can’t eat your oatmeal? And slowly, very slowly my diet (in terms of calorie content improved).

    Like I said, I’m not sure where in the road of recovery I am. I stopped the b/p part of my anoerxia 8+ months ago. I can’t even remember the date, even though it should be monumental, but I had gone from everytime I ate, to a few times a months when stressed from certain situations, to….not anymore.

    So I guess my conclusion is that I’m not afraid of being fat. Some of the most loved people in my life are over-weight, and I don’t judge them based on their weight. Why would I judge myself for being fat? Mine resulted as a control mechanism for all the things in my life spiraling out of control. Me not eating doesn’t make my dad not have cancer, but helped me with my own feelings. So I still continue this walk of recovery, as I continue to grow as a person, in knowing myself, and learning coping mechanisms that I never learned before because I was relying on my ED.

  9. “Note, too, that thin was not in when Lasègue first described anorexia nervosa (see paintings by Renoir to get a sense of what was in).”
    Not sure about that statement. I make dresses for Victorian era reenactment, and most of the blueprints and examples of 1873 feature long-limbed women with a cinched waist. The corsets of that time are no longer the “flatten everything” variety of a few decades prior, but the emphasis is definitely on a tiny waist and an artificially created butt which makes the rest of the body appear even leaner.

    • There are quite a number of references historically to women who were ‘Nuns’ starving, or starving for religious reasons – I have never seen a Nun reading fashion magazines or concerned about her appearance besides conforming to the expectations on her as far as dress go.
      Given that many sisterhoods practiced poverty, I can’t see there being much choice when it comes to food, and definitely wastage or purging would have been taken as extremely selfish. These women gave up their lives for their calling and for them to go directly against that and all their beliefs is another example of how strong, irrational and independant of cultural influences ED’s can be.

    • Interesting, thanks for the comment. I did not know that. I still think my point largely holds: there was no mass media and mass thin-normalization and idealization.

      • There wasn’t any mass media or mass thin normalization – true. But I’m assuming these people Zayna was talking about were in the middle to upper class considering the outfits in question, which might mean it was not as common for someone to become anorexic b/c of that simply due to a smaller population in question (upper & middle class).

        What I’m wondering is – are the rates for anorexia nervosa the same or higher now than they were back then? How prevalent is anorexia in western countries vs non-western countries? And what are differing factors in the different environments?

        I think answering those questions would also help in figuring out what might trigger someone to start displaying the behaviors associated with anorexia in a given place, whether it be the US or a non-western country – depending on the social norms/expectations and economy, as well as circumstances, of the given place. And the reasons could be different for each place, but I personally think in the US trauma and/or fatphobia play the main roles as triggers and partly the reason(s) to continue with restricting food intake (people can’t control those two things in their environment so the need/desire for control would be high here). In another country though, someone could start restrictions on their intake if food for religious reasons or to save food for other family members and have it spiral out of control to the extreme – and I’m sure there are more.

        But again, how prevalent were any of these possibly contributing factors years ago and are today? And how have these factors impacted or even correlated with the prevalence of anorexia in a given place? And has it gotten worse b/c so many people have access to media and information on a multitude of things? Or is it simply b/c there are many more people in the world today, and therefore is more conflict and trauma to contribute to anorexia? I sure don’t know at the moment but this all makes me want to research more!

        • Hi Court,

          Thanks for your comment!

          Certainly, no one knows what the rates of AN were back then, as it wasn’t even a recognized disorder.

          “How prevalent is anorexia in western countries vs non-western countries?” It seems the rates are similar, but it is hard to say because I think the factors contributing to the variable rates within studies outweigh any actual differences between countries. The other thing is that what we call anorexia nervosa here might look slightly different in a different country and not be diagnosed as anorexia nervosa.

          “I think answering those questions would also help in figuring out what might trigger someone to start displaying the behaviors associated with anorexia in a given place, whether it be the US or a non-western country – depending on the social norms/expectations and economy, as well as circumstances, of the given place. And the reasons could be different for each place, but I personally think in the US trauma and/or fatphobia play the main roles as triggers and partly the reason(s) to continue with restricting food intake (people can’t control those two things in their environment so the need/desire for control would be high here). In another country though, someone could start restrictions on their intake if food for religious reasons or to save food for other family members and have it spiral out of control to the extreme – and I’m sure there are more.”

          Yeah, I think something like this is likely to be the case. I agree that the factors contributing to onset probably differ quite a bit country-to-country.

  10. So many people need to read this.. the amount of times I have felt like screaming at people on youtube, facebook, instagram, etc.. the blinding ignorance… Thank you. 🙂

  11. I did not have fat phobia at first. I started to restrict in a ‘normal’ way after my parents (who were both quite obsessive about me and my siblings ‘images’) mentioned that I was getting ‘chunky’. Losing weight was easy for me (got that kind of metabolism) and was a quick win when it came to a feeling of pride and achievement. I had always liked achievement since I can remember and I always wanted to do the work of the year above – or several years above – just to see if I could. I was pretty addicted, I suppose, to the feeling of being ‘awfully clever’. Once the achievement was won I did not want to lose it, so I would endeavour to remain at the same weight, not realising at that age that continuing on a restrictive diet would cause me to lose weight. But each time I lost weight I got another ‘achievement’, and then I didn’t want to lose THAT one. And so and and so forth into anorexia…

    I loved my body for most of my anorexia and did not for an instant fear weight gain – I felt I was omnipotent when it came to my weight and had the final decision on it. I don’t remember my parents being particularly worried for most of it, although they started to get a bit more intrusive towards the end and eventually took me to a doctor. For the most part they seemed angry, although I think this is genuinely their way of showing concern.

    I recovered easily at first. I happened to see my naked body in a full length mirror and in a certain light and for a sudden instant saw what I really looked like – I saw the bones jutting out of my stomach, chest and thighs and how odd and angular my elbows and shoulders looked – and for that instant I saw that I looked like I would die and for the first time became afraid (although I didn’t admit it). When my parents took me to the doctor soon after, I still did not admit that I was the cause of my weight loss (I had hidden it well throughout and my parents could find no reliable evidence, so were themselves unsure whether it was anorexia or diabetes). However, the doctor saw through it after my bloods had been taken, didn’t diagnose me with anything (I had no idea I had anorexia at this point) and gave me calorific milkshakes. To be honest, I was relieved that I could have my new ‘medication’ and get better as I was ready to stop.

    The fear of weight gain came afterwards, when during recovery I had my first experience of a ‘binge’. Bingeing feeling out of control – it includes dissociation and a feeling of compulsion that feels a lot like an alien taking over your body. For this reason it is terrifying and I suddenly did not trust in my omnipotence. I then started to believe that if I did not restrict I would never have any control or power at all. I then suffered the BN subtype (not bulimia, apparently, but bingeing anorexia, although I did eventually gain weight through it), for six years and this was ego-DYSTONIC…

    But what I would say is that my fear of weight gain or even obsession with weight loss started when the condition became ego-dystonic. When it was ego-syntonic, I did not have body shape issues. I was just fixated on achievement and blind to what it was doing to me.

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