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).
NATURE OF WEIGHT CONCERNS IN ANOREXIA NERVOSA
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
WEIGHT CONCERNS IN ANOREXIA NERVOSA IN NON-WESTERN COUNTRIES
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