Are All Anorexia Nervosa Patients Just Afraid of Being Fat? – Part 2

If you’ve been reading this blog for a while (or literature on this topic) you know the answer is no. I’ve blogged about this before, but I think it is a topic that needs a lot more coverage because the myths that all anorexia nervosa patients are just afraid of being fat, that they lose weight just to be thin, and that thin models are to blame for AN are still very common.

As you’ll see, I am not claiming that this isn’t true for some patients. Instead, what I am claiming is that it is not true for all patients.

And a big personal goal of mine with this blog is to broad the conversation about eating disorders. Let’s get away from stereotypes and painting all anorexia nervosa or bulimia nervosa patients in the same light. Let’s instead have meaningful discussions about research on eating disorders, about our experiences, and let’s develop a more comprehensive understanding of eating disorders that’s enriched by the research and the science, and our personal experiences as patients, friends, family members, partners, clinicians and so on.

The paper is short so I’m going to try to make my blog post short, too.

Essentially, Emily Ngai and colleagues set out to study the variability of phenomenology in Chinese patients with AN. In simpler terms, they wanted to find out how different patients with AN experienced their eating disorder, and what meaning they ascribed to their eating disorder behaviours.

Specifically, they wanted to focus on the fear of fatness: did all patients experience it? Was it the main reason for food refusal? And was it something that changed over time or stayed stable?

In this study they reported on four cases of AN patients in Hong Kong. When it comes to fat phobia, the cases were all different:

  • for one patient, fat phobia was consistently present
  • for another, it was never present
  • and for the other two it fluctuated from non-fat phobic to fat phobic and vice-versa

CASE 1: CONSISTENTLY FAT PHOBIC

Miss A, 24, was consistently fat phobic. Miss A went to study in the UK after form 4/senior secondary education. Ngai wrote that while Miss A was in the UK, her weight increased by a significant amount and this made her feel “obese” and swollen.” Moreover, her friends made negative comments about her body shape and this led her to decide to lose weight through exercise and dieting (from mild food avoidance at first, to quite severe restriction later on.) She regained some weight back during treatment in Hong Kong but remained “ambivalent” about her eating disorder and the use of vomiting to regulate her weight (she engaged in binge eating behaviour as well.)

CASE 2: FAT PHOBIC –> NON-FAT PHOBIC

Miss B, 18, was initially fat phobic, having associated fatness with “ugliness,” “inefficiency,” and “ridicule,” and slimness with “beauty,” “social acceptance,” “confidence,” and “power” but later she became ashamed of her thinness and no longer expressed a fear of fatness. Ngai reported that Miss B, who came from a family of two children, always felt that she was the “lesser” of the two daughters. Her sister had developed AN prior to Miss B (1/2 a year earlier) and Miss B emulated her sister’s behaviours.

She saw such weight reduction as a protest, and the sense of control thus derived gave her great satisfaction. Her peers’ initial praise further boosted the sense of success […] However, when her weight decreased… she no longer felt able to control her intake and was worried that without medical attention she could die. She was also saddened by her parents’ self-blame and her sister’s guilty feelings over having caused her illness. At this point, she no longer felt any fear of fatness and was ashamed of her thinness.

CASE 3: CONSISTENTLY NON-FAT PHOBIC

Miss C, a 38-year-old clerk, had AN for 16 years but never experienced a fear of fatness. As a student, she was anxious about the future due to receiving bad marks. More importantly, however, she suffered sexual abuse by her father. Ngai wrote that this led her to experience “intense but suppressed anger that manifested itself in food refusal.” Food was associated with her father, a “voracious eater,” and she especially avoided foods that were favoured by him in protest.

She ascribed her meagre food intake to stomach bloating and poor appetite instead of fat phobia. Every family meal was a torture for her. When she was hospitalized her father blamed her for faking an illness, while her neighbours labelled her as ‘crazy’ […] As her condition became chronic, she felt that she had wasted the best time of her life. She considered her illness a problem of living, not dieting. Fatness was never an issue for her.

A problem of “living” — what an interesting way to phrase that, I think.

In the discussion, the authors wrote that these types of patients are typically found in older populations, male patients or pre-morbidly slim patients (particularly in non-Western societies).

CASE 4: NON-FAT PHOBIC –> FAT PHOBIC

Finally, the case of Miss D, a 23-year-old university student who had AN for nine years. Ngai wrote that she had a good relationship with her family members and that prior to her illness she seemed comfortable with being nicknamed “a ‘fat little girl'” and was satisfied with her body shape and size. At 13, however, she complained of stomach pain (as a result of examinations) which led her to reduce her intake and lose weight. She did not engage in exercise, or bingeing and vomiting to reduce weight. Initially, she ascribed food refusal as an act of “resistance against her mother” and responded fairly well to treatment.

However, during form 7 while studying for her A-levels, she gained a fair amount of weight due to stress and snacking. This led her to develop a strong fear of fatness and she began to diet, vomit and use laxatives to control her weight. Her weight dropped significantly and she sought help and returned to the weight she had been prior to seeking treatment (her highest recorded weight). At follow-up, she had lost weight again and exhibited a fear of fatness.

In the discussion, the authors noted that among adolescent AN patients (or those that got sick when they were adolescents), fat phobia often emerges during the course of treatment though it may not have been present originally.

I must say, I never had any desire to lose weight or had any “fear of fatness” or body image issues until I had already lost enough weight to be diagnosed with anorexia, only then did those fears seep in.

Anyway, as you can see, the patients attribute their refusal or inability to eat enough food to very different reasons. And these are very sparse descriptions of just four cases. As you can imagine, there are many reasons that individuals ascribe to their refusal and/or inability to eat or maintain a healthy weight. And importantly: these reasons do not have to stay static.

They didn’t for me. My body image didn’t stay static. In high-school I felt so awful about my body I used to skip class because I felt “too fat” to go to school, and yet fast-forward to being at that weight in undergrad, and I felt ashamed and self-conscious of my thinness. I looked in the mirror and thought “holy shit, why can’t you just eat. why can’t you deal with emotions like a normal person?!” I thought I looked too thin at the same weight that just a few years prior I felt so ‘fat’ that I would leave every class for a washroom break to make sure I didn’t “balloon any further”.

Getting back to the paper thought, I must admit, the sparse descriptions of the case reports do make me wonder: would these patients agree with the researchers’ conclusions or descriptions?

I would love to find out from the participants whether Ngai’s descriptions are correct. Of course, I can’t, and so I have to trust the researchers to some extent, but it does make me wonder. I mean, was it really so simple and straight forward? Can the complexity of these cases really be boiled down to a protest against a family member, or a desire to look slim?

Perhaps I’m being overly skeptical, but, it is difficult for me to accept that the patients would actually agree with Ngai’s assessment of them. I hope they would, of course, but, I do wonder.

Moreover, there is absolutely no information about the methodology. Only the abstract mentions that this was a “longitudinal” study of four patients. But how longitudinal? It almost seems like this was taken from just one retrospective interview sometime after the patient’s entered or completed treatment. Recalling why you started restricting 5 or 10 years ago and what your motivations were then is problematic. Often the reasons we ascribe to our behaviours change with time. I bet if you asked me when I was 15, why I was restricting, then waited 9 years and asked me again, when I am 24 (ie, now), why I restricted when I was 15, you’d get wildly different answers.

More importantly, what worries me here isn’t that these case studies are false (because even if the are not 100% correct, they are illustrative and useful, nonetheless) or that the study was done retrospectively, it is that this information is not available. And I think it should be available for the reader to be able to appropriately assess the information.

The authors provide nice quotes illustrating the significance and importance of this data:

Growing cross-cultural evidence has challenged the belief that AN occurs only in western societies, and has indicated that the sociocultural pressure to diet is not always a crucial factor in leading to AN. In non-western societies, AN exists but seems to consist of a heterogeneous group of individuals who do not necessarily attribute their food refusal to fat phobia.

And I absolutely love this:

Clearly, anorexic patients’ attributions for noneating are more complex than the DSM-IV would have us to believe. The second (case 2) and fourth patients (case 4) further indicate that the `typical’ vs. `atypical’ typology of AN is inadequate. In fact, fat phobia in AN is not an immutable core symptom, and that fat phobic and non-fat phobic anorexic experiences are not mutually exclusive. Anorexic attributions can change with body weight, chronicity, age and, above all, many contextual factors.

And, these findings (and those like it) have really important implications for research, prevention, diagnosis and treatment:

All existing psychometric instruments for eating disorders rest on the central construct of fat phobia. If they are used in epidemiological studies, non-fat phobic AN may well be screened out.

So readers, what do you think? I’m especially interested in what you think your reasons are for the inability to eat enough (I dislike the word “refusal” as it is often not a conscious “refusal” but rather an inability)? Have these reasons changed over the course of your illness?

References

Phenomenology">Ngai ,E.S., Lee, S., & Lee, A.M. (2000). The variability of phenomenology in anorexia nervosa. Acta psychiatrica Scandinavica, 102 (4), 314-7 PMID: 11089734

Tetyana

Tetyana is the creator and manager of the blog.

7 Comments

  1. “As you’ll see, I am not claiming that this isn’t true for some patients. Instead, what I am claiming is that it is not true for all patients.”

    I don’t have time to write a long comment, but I just want to say thank you, thank you, THANK YOU for writing this post, and especially the sentence above. I don’t understand why people insist on making false equivalencies between biological and cultural factors in the etiology of EDs. An article that claims runway models cause AN is incorrect and damaging EVEN IF it contains a throwaway line about “genetic predisposition.”

  2. “In the discussion, the authors noted that among adolescent AN patients (or those that got sick when they were adolescents), fat phobia often emerges during the course of treatment though it may not have been present originally.”

    This particular comment stood out when I read it. This is actually a topic I was discussing with my therapist just a few hours ago. Fat phobia was not at all present when I first developed an eating disorder as a child. Concerns over my weight didn’t play a role in my eating disorder until quite a few years later, when my diagnosis shifted over from AN to BN. Even at that point, fat phobia only played a major part in my illness for a year at most before it fell into the back burner. The only other times I’ve noticed fat phobia playing a more active part in my disorder were during my inpatient treatment stays. I’m still not entirely sure why that is and I could be way off the mark, but I suspect that having significant chunks of my treatment revolve around body image, even when it wasn’t currently an issue, may have partly contributed to that faulty line of thought.

    Anyway, I did want to thank you for writing all of this. I’ve been reading the posts on this blog for a few months now and I think that you’re doing marvelous work with your writings here. There aren’t many good resources like this one that are easily accessible to the general public. It’s a much needed change from the “usual” and this is exactly what needs to happen more often in this field.

    • Hi J,

      Thank you for your comment and your compliment!

      I’m always really happy to hear that people find my posts useful! It is very cool, and it makes me feel all warm and fuzzy inside.
      Do let me know (or leave a comment in the “Topic Suggestions” page) if there’s something specific you are interested in. I try to tackle those one by one, especially when I’m out of ideas or interesting papers I want to blog about. And any suggestions on the writing itself (is it too jargon-y or am I dumbing things down too much) are always welcome too!

      What you wrote about fat phobia, I think my experiences were very similar. I wasn’t fat phobic at the start, though when I did lose a sufficient amount of weight, I definitely couldn’t see how thin I was. I wasn’t afraid of being fat per se, I just couldn’t “see” that I was quite thin. Though once I started treatment and weight restoration that became a bigger issue (not wanting to be ‘fat’ – which really meant not wanting to have a BMI above the typical BMI used for AN diagnosis (and don’t get me started on what I think about using arbitrary numbers to diagnose a mental disorder.. ugh). I think when I was AN-BP, the fear of gaining weight played a big role, but not when I was a normal weight and bulimic. Then, bulimia had little (I don’t know if I can say *nothing*) to do with body image and the desire to lose weight, at that point I mostly found purging very anxiolytic and calming, and did it mainly as a way to relieve stress, anxiety, and all sorts of other real feelings (because fat is not a feeling, as we all know). It was very disconnected with my body.

      “I’m still not entirely sure why that is and I could be way off the mark, but I suspect that having significant chunks of my treatment revolve around body image, even when it wasn’t currently an issue, may have partly contributed to that faulty line of thought.”

      This is a very good point! I wonder if there are any papers on this. I often had similar thoughts with regard to other things (ie, is this really true or am I just saying this is the case or thinking it is the case because I’m told that’s what happens?). That seems like yet another possible unintentional adverse effect of treatment.

      Anyway, thanks so much for your comment!
      Tetyana

      • J, this hit me really hard. “I’m still not entirely sure why that is and I could be way off the mark, but I suspect that having significant chunks of my treatment revolve around body image, even when it wasn’t currently an issue, may have partly contributed to that faulty line of thought.”

        I guess I’ve never really broken down the timeline of my symptoms and thoughts; but after reading this article I did realize that my thought patterns did change over time. Thinking back, I don’t recall explicitly focusing on fatness, or even my weight. I don’t think I can explain it well, but now that I’m thinking about it, my AN behaviors were very automatic, and it is literally only now, that I’m connecting behaviors with thoughts at the time. Through all the treatment I’ve done we’ve focused on automatic negative thoughts etc., but I was never asked to explain (for lack of a better word) my behaviors with those thoughts.

        I’m a little mind boggled at the realization that my body image and fear of “being fat” was very much developed AFTER, well even after my first couple tries at treatment. I can’t help but wonder how much of the “fear of being fat” I developed after being told what an eating disorder “looks” like and how those with one think. I’ve struggled greatly with body image over the years, and can connect as one of many “causes” of needing to return to treatment. I almost wonder if, at least for me, it came about from the assumptions people made and said about me.

        Anyway, sorry for my rambling but I REALLY appreciate this article and your comments J. I hope this insight can help me further work through my body image issues and help me put that part this last part of my disorder behind me. Thank you both!

        • Mika, thank you so much for your comment.

          You did not ramble at all!

          “I’m a little mind boggled at the realization that my body image and fear of “being fat” was very much developed AFTER, well even after my first couple tries at treatment. I can’t help but wonder how much of the “fear of being fat” I developed after being told what an eating disorder “looks” like and how those with one think. I’ve struggled greatly with body image over the years, and can connect as one of many “causes” of needing to return to treatment. I almost wonder if, at least for me, it came about from the assumptions people made and said about me.”

          I think this a lot about all sorts of things. I often wonder, is this really true or does it just sound like something that should be true/makes sense based on all the psychology courses I’ve taken?

          Best of luck with recovery, Mika!

          Tetyana

  3. Thank you for this!
    It is so frustrating to constantly see anorexia defined as only something that happens to those that want to be skinny or are weight phobic.

    When I first became anorexic as a teen, I did it for control and depressive reasons. I didn’t want to live. Why eat? I believe it was also some form of self-destructive -punishment-. It was protest against everything, because it is food, a life source. I was denying it all. I also felt I had completely no control over anything else, and I’m sure the subconscious “success” of not eating for a day or two felt like something of my own and -only- my own. Nobody could -make- me eat.

    I have been slightly underweight in the past, but that was a byproduct, not the goal. There is no goal now. I’d like to think I’m much better than I was then, but it has just morphed, evolved into something else. Over the years, it has made me worry about my weight…having anorexia makes me worry about -getting- fat! I restrict randomly and often without realizing, throwing my metabolism and appetite into a constant state of disorder, which makes my weight fluctuate constantly. Starvation mode is very real. Still, I look just like an average person. No one could “spot” me – I’m not razor thin. (Another criteria myth that pains me…)

    All I want is a -fit- and -athletic- body…something impossible without proper nutrition. I’ve been fit and I’ve been unfit, and it rollercoasters back and forth. I don’t -want- to restrict…I want my fitness back, and body shape/figure has never been an indicator of that for me. I have so totally confused and destroyed my body’s natural hunger and fullness signals, shrunk my stomach, and twisted my habits, and associated so much negativity with food itself that not sinking into anorexia is what feels unnatural now. It also feels like an addiction – that “high” is no myth. So, once on a streak, it’s hard to beat (again).

    Anyway! Thanks again! Obviously, I relate to this message and hope others will find some solace too, knowing that not -everyone- misunderstands.

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