Anorexia & Bulimia: When Bodies Become Enemies to be Controlled and Denied
Anorexia Nervosa (AN) and Bulimia Nervosa (BN) are eating disorders which generally develop in teenage girls and young women living in Western countries.
Both are relatively uncommon, affecting 2-3 percent of women but are considered to be “the most dangerous of mental disorders” because of the “significant risks to physical health” and “impact on day-to-day functioning” (Walsh et al.2020, p. 3).
These eating disorders tend to become very entrenched and resistant to treatment with only a third of sufferers achieving full remission, a third achieving partial remission, and a third experiencing ongoing illness.
The core features of Anorexia and Bulimia are:
Fear of becoming ‘fat’ or gaining weight and
Preoccupation with body size and shape
There are two types of Anorexia:
Where individuals restrict their food intake such that they are less than 85% of normal body weight
Where individuals binge eat but maintain a body weight less than 85% of normal as a result of vomiting, excessive use of laxatives, fasting and/or exercising
Bulimics tend to maintain a normal body weight although they engage in repeated episodes of binge eating and purging.
What causes Anorexia and Bulimia?
In the past, parents were frequently blamed for causing their daughters to become anorexic or bulimic by being critical or over emphasizing body weight or shape. More recently, western culture and social media have been blamed but the causes are unknown. Likely, there are several causes and different paths to the development of these eating disorders.
Who are the individuals most at risk for Anorexia and Bulimia?
Females
Females who are dissatisfied with their bodies
Females entering puberty
Females living in cultures that emphasize the beauty of being thin
Females starting a diet
Females who tend to be anxious, depressed and/or perfectionistic
Females experiencing a stressful life event
Anna suffers from Anorexia:
Anna is twenty years old. She has always been socially anxious, sensitive to criticism and dependent on her mother. She has an older brother who is obese, who was teased relentlessly at school, and who is a source of embarrassment for her.
Anna arrived at a university far from her hometown and she struggled to make friends. She felt awkward and shy and didn’t want anyone to know that she hadn’t had any dating or sexual experiences. She felt frightened, exposed, and out of control most of the time and had to force herself to go to class and the dining hall.
She began skipping meals to avoid the dining hall and to test herself by seeing how long she could go without eating and not feeling hungry. She found that vigorous exercise made her less hungry and she loved the feeling of self-control this gave her. She began walking ten or more kilometres a day and buying a vegetable or other small snack at the grocery store on her way home.
She debated in her head during the entire walk what item of food she would consume, weighing the taste, nutritional value, and the number of calories in each item. Anna lost weight rapidly and loved her new shape but mostly she loved how much she could control her appetite and how powerful she felt. Her neighbours in the residence noticed her weight loss and told her she looked terrific. Anna was thrilled.
Anna thought far less about her fears, her insecurities and her being an outsider. She was consumed by thoughts of food, thoughts of banishing thoughts of food, daily exercise regimes, and visits to the scale in the bathroom. What would it say? Had she gained weight, lost weight? She barely had the time or energy to complete her school work but as with everything else, she forced herself, and she kept up her grades.
After several months, Anna had lost thirty pounds, was exhausted and got a terrible bout of flu. She went to the university health clinic and was told by the doctor that she was very ill and needed to see a psychiatrist. Anna was scared about her health but she had no intention of seeing a psychiatrist who would undoubtedly prescribe an antidepressant when everybody knows antidepressants make you gain weight.
She was far more afraid of gaining weight than she was of being sick. She thanked the doctor, took the psychiatrist’s information and left. She tore up the card and tossed it in the first garbage bin she saw.
Lilly suffers from Bulimia:
Lilly is fourteen. Until six months ago, she was a competitive gymnast. She loved her sport, loved competing, loved her teammates, and her coach. Like her teammates, she dreamt of going to the Olympics. Unlike many coaches and gym clubs, hers was supportive of healthy bodies and healthy eating and she was never instructed to control her food intake.
When she began to get her period a year ago, her outside body began to change also. She developed large breasts and her hips and buttocks filled out. Her coach told her this was beyond her control, no amount of dieting or exercise could change her mature body type and she should celebrate her new body and move on from gymnastics.
Lilly’s mom and dad were very supportive and told her the change was a good thing and she would have more time to relax, enjoy new friends, and be less stressed by the demands of competition. Lilly did not agree.
Lilly quickly realized that she had paid little attention to her classmates, and they had little time for her now. She felt lonely, directionless, and angry, but with nowhere to put her anger. She spent long hours in her room, bored and mad, and restless. The only activity she continued to enjoy was mealtime.
She had always loved food and her mom was a good cook and mealtimes were happy times. The fact that she wasn’t doing gymnastics four hours a day didn’t affect her appetite and she ate with relish. Besides, she had little else to do.
In a matter of several weeks, Lilly noticed that in addition to her large breasts and broadened hips, her belly was expanding. She had been unhappy before but this was unacceptable. She couldn’t recognize herself, she hated her body. What to do? She had read somewhere that there was a worm that made people thin no matter what they ate but where was she going to get such a worm?
She saw a TV show about Princess Dianna who ate everything in the fridge and then threw up and she wondered how that worked. She experimented, putting her fingers down her throat and she found she could throw up pretty easily. This might work.
She began spending a lot of time in the bathroom after meals which concerned her parents but she ignored them. She enjoyed food more and more until it was all consuming. Eating made her calm and happy, purging relieved her worries about gaining weight.
When she had trouble throwing up, she took a few laxatives and the diarrhea emptied her soon enough. She discovered that purging was almost as pleasurable as eating because it relieved her tension and made her tired. As a bonus, she was too busy to worry about her classmates, her teammates and what she was going to do with her life.
The cycles of binging and purging got shorter and more intense. The best part was that except for her parents who suspected, and were irritated and worried about all the food missing from the fridge and cupboards, no one knew. It was her little secret. She could look after everything, all by herself.
What are the similarities between Anna and Lilly?
Both feel alienated from peers, feel lonely, and alone.
Neither can ask for help. They both feel the need to look after themselves, to manage and control their predicaments.
They have each had a crisis-Anna moved away to university and Lilly was removed from the world of gymnastics which had been her whole world.
Both have a need to ignore their feelings of helplessness and fear by distracting themselves with food, dieting and weight loss as a panacea.
Both are secretly proud of their strategies.
Both become consumed by their bodies and how to manage them at the expense of their social lives, their sexuality, and true autonomy through connection with others.
Both are increasingly isolated which reinforces their preoccupation with their bodies and controlling their bodies.
Both view their bodies as outside themselves, alien to themselves, enemies to be defeated and controlled, rather than as their embodied ‘selves’ designed for pleasure, intimacy and efficacy.
Treatment Challenges:
Because many women suffering from anorexia and bulimia are used to, and gain comfort from, their disordered eating, many do not seek treatment or actively reject treatment. At one time, young girls and women whose body weight reached dangerously low levels were force fed intravenously but since they promptly lost the weight after release from hospital, this is rarely implemented today.
Most girls and women who experience serious disordered eating have distortions in their body image such that they see themselves as overweight despite being seriously underweight. We see emaciated but they see “fat.” It’s hard to argue with perception- “I’m fat,” “no, you’re not.”
Concern about weight and binging and purging focuses much of the treatment on the disordered behaviour but the underlying issues which gave rise to the problem are never, or insufficiently, addressed-issues of social anxiety, sexuality, low self-esteem, isolation, and inability to ask for help. Complicating the problem is that starvation interferes with cognitive functions such as reality testing and problem solving.
What to do?
Obviously, prevention of anorexia and bulimia is key. There is total agreement on that! Teaching girls that differences in body shape and size is to be celebrated and that our bodies are primarily for pleasure and purpose not aesthetics is essential but, how to do that?
School programs which emphasize nutrition and strength.
Regulation of social media such as Instagram which has been shown to increase girl’s dissatisfaction with their appearance.
Regulation of advertising which targets young women with beauty/diet products
Attention to self-esteem for girls focussing on competence and connection, not physical attributes
Parent and teacher education to recognize eating disorders and to act quickly.
Recognition that black, indigenous, women of colour, and women of all socio-economic groups are affected.
The costs and consequences to girls and women who suffer from anorexia and bulimia are catastrophic and because the process tends to be insidious and intransigent, we have to focus on prevention.
Resources
Jane Morris and Caz Nahman (Eds), New to Eating Disorders, Cambridge University Press, 2020.
B. Timothy Walsh, Evelyn Attia, and Deborah R. Glasofer, Eating Disorders: What Everyone Needs to Know, Oxford University Press, 2020.
About The Author
Janet Morrison, M.A., C. Psych Assoc. is a psychological associate in private practice and a senior lecturer at the Factor-Inwentash Faculty of Social Work, University of Toronto. Over the past 30 years she has assessed, treated and supervised treatment of children in long-term care, as well as, consulted for Children's Aid Society and group homes across Ontario.