Overview of the Problem
Anorexia nervosa and bulimia nervosa are two eating disorders with adverse effects on health and wellbeing. Persons with these disorders are preoccupied with their weight, in fact basing their self-esteem mainly on their body image (Suisman et al., 2012). They have an intense fear of weight gain because of a distorted belief that they are fat. For this reason, they refuse to eat and exercise excessively. Alternatively, they engage in binge eating but purge themselves after through self-induced vomiting and laxative abuse increasing the risk of malnutrition that, in severe cases, causes death (Bulik et al., 2005). There is historical evidence of eating disorders, but only in recent studies were the multiple causes of these conditions presented enabling the development of different interventions.
Historical Perspective
Eating disorders are not a recent phenomenon. Throughout history, the prevalence of eating disorders among women must have been high such that legends of fasting cults and voracious females exist dating back to the tenth century (Raphael & Lacey, 1994). However, the earliest written account of anorexia was in 1694 and after more than a century, it was again documented in the late 18th century. In these reports, eating disorders were described as a disease with a physiological but not psychological cause.
It was only in 1979 that bulimia nervosa was described in medical literature. It sparked further research that eventually linked both bulimia nervosa and anorexia nervosa to psychological causes. With the establishment of criteria describing each of these disorders, they were included in the 1987 version and subsequent versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (Raphael & Lacey, 1994).
Prevalence
It is estimated that 0.3% of the population are diagnosed with anorexia (Bulik et al., 2005). Majority of those with this diagnosis are women. While the condition is most prevalent among those aged 15 to 19 years, there have been documented cases being diagnosed before puberty and also in adult women. Whether the prevalence is increasing or decreasing is difficult to ascertain given the conflicting results of studies. The typical course of anorexia involves crossovers to bulimia nervosa at a rate of 8% up to 62% of persons with this diagnosis (Favaro, 2013).
Current Situation
Eating disorders are a major cause of concern especially in the adolescent population. Studies show that psychological disorders have an adverse effect on the brain (Favaro, 2013). Specifically in cases of eating disorders, starvation, weight loss, and the stress of being ill are thought to affect brain development, a process that culminates during adolescence. At the same time, eating disorders result in the conditioning of neural response patterns to food stimuli as well as rigidity in thought patterns leading to the persistence of the fear of food and weight gain throughout adulthood.
In addition, eating disorders are correlated with other psychological problems including anxiety, major depression, social withdrawal, and excessive self-consciousness (Favaro, 2013). Besides delayed physical development during puberty, there are also various medical conditions associated with bulimia and anorexia. Osteoporosis, fatigue, low body mass index, malnutrition, and amenorrhea are some of these conditions. Eating disorders are especially concerning when these occur in conjunction with pregnancy as the wellbeing of the unborn child is threatened as is his or her physical and psychological development from infancy onwards. Thus, it is paramount that this issue be sufficiently understood.
Raphael & Lacey (1994) described a case involving an 18-year-old female who migrated to the United Kingdom from Pakistan at age 2 with her strictly-practicing Muslim family. As a child, she was sexually abused by her father during the times her mother was not in the home. She became depressed and gained weight by up to 210% of the average weight of women her age. Vomiting started two years earlier when she was living with grandparents and coincided with Ramadan rituals dictating that no food or drink must be consumed between dawn and sunset.
Further, binge-eating with laxative abuse began at age 20 when she received a proposal for an arranged marriage made in accordance with Muslim traditions. She was admitted to an eating disorder unit with minimal improvements in her condition. Finally, her family decided for her to return to Pakistan, and it was there that all signs and symptoms of her eating disorder resolved. She remained unmarried and was therefore chaperoned as was the custom in that country for single women.
Another case, also presented by Raphael & Lacey (1994), concerned a woman aged 20 years old who resided in London with her mother and sister. Her family originated from Peru, and her parents divorced when she was young. Her mother was a ballerina whose career ended following an injury sustained from a vehicular accident. The mother wanted to live her dreams through her children and raised them in a protected and rigid home environment. The patient entered a ballet school at 13 years old and came to live with a family friend who allowed her greater freedom than her mother.
While going through the stage of puberty, however, she manifested with signs and symptoms of bulimia nervosa. Treatments led to positive results but only for the short term. It was worth noting that she did not engage in binge eating whenever she travelled to Peru to visit her grandmother. Although she found life in her country of origin restrictive, she also described it as reassuring. Binge eating tended to recur whenever she returned to London and to a lifestyle that was deemed unacceptable by Peruvian cultural standards.
Understanding the Case Examples
There are psychological, genetic, social, and cultural factors contributing to eating disorders. Raphael & Lacey (1994) posit that throughout history, the need to ensure his offspring has led to the domination of men over women and the subsequent control of the latter’s sexuality. There were various mechanisms employed for such control. For instance, the wives of men who fought in the Crusades were made to wear chastity belts while their husbands were at war as a preventive measure for illegitimate children should the women lose control of their sexuality.
With the advent of gender equality in more recent times in the West, such external and overt means of control were replaced by socially accepted norms that women are now responsible for controlling their own sexual behaviors (Raphael & Lacey, 1994). As a fuller body shape and size are associated with sexual maturity and fertility, it became an area for women’s attempts at controlling their sexuality. For some women, dieting constituted such attempts and led to the development of eating disorders.
In the two case examples above, the women emigrated from two countries with strict external controls over the sexual behavior of women. Both maintained their ties to their countries of origin. The woman in the first case was chaperoned all the time when she was in Pakistan because she was unmarried, while the woman in the second case described Peruvian life as restricted during her visits there. The presence of strong restraints in these countries did not require the women to take on personal responsibility over their sexuality by controlling their body weight and shape. As such, their eating disorders resolved during visits to their countries of origin. At the same time, chaperoning as a parental control, also in the second case, accomplished the same effect.
On the other hand, both women were also exposed to life in a Western society as they took up residence in London. There, external controls over sexuality were largely absent given the more liberal views of equality between the sexes although expectations of internal control remained. In this social setting, eating disorders were strategies for both women to fulfill such expectations. In the second case, for example, the woman’s transition into the care of a more liberal-minded adult coincided with the onset of bulimia nervosa.
Another perspective on the cause of eating disorders is the reinforcement of the Western media of norms on female sexuality through the propagation of the thinness ideal (Favaro, 2013). There are views that men favor the image of women with a thin frame because of its association with youth, frailty, dependence, and amenability for control (Raphael & Lacey, 1994). The ideal female body creates pressure on women to achieve the desired shape and size often leading to distorted evaluations of their bodies and dissatisfaction (Suisman et al., 2012). In women who internalize such an image, the risk of eating disorders increases. However, cultures without this ideal do not create such pressures. The woman in the second case validated this assumption when she described life in Peru as reassuring.
In addition, a thin body image must have been reinforced further in the second case by the woman’s study of ballet, an art whose physical standard is an anorexic frame and a flat chest. Her puberty that involved the accumulation of adipose tissue or fat, a normal physical development necessary to induce the first menstrual cycle and her transition from a child to a woman capable of reproduction (Bulik et al., 2005), is likely to have contradicted this body image. Internalization of the thin ideal contributed to a judgment that her body does not fit in and her fear of getting fat likely could have encouraged binge eating and purging especially since these signs and symptoms also coincided with puberty.
Other studies also propose a genetic predisposition for eating disorders and that a favorable environment promotes the expression of such genes given that not all women manifest with these conditions (Suisman et al., 2012; Favaro, 2013). Although there is no information if the mother of the woman in the second case actually suffered from an eating disorder thus providing evidence that the condition runs in the family, her career as a ballerina and her fulfilling her ambitions through her daughter would have required eating restrictions for them to remain thin. For the daughter, mass media, her mother, and peers in ballet constitute the environment that created strong pressure to be thin.
Besides the influences of culture, society, family, and the media, eating disorders may also be associated with major life events, especially traumatic ones (Favaro, 2013; Suisman et al., 2012). In the first case, the woman was sexually abused when she was young, and her depression was reflective of feelings of hopelessness, helplessness, and worthlessness. Her use of food as a mechanism of coping began when she gained weight above the population average for her age. Later in life, her bulimia nervosa symptoms intensified prior to another major life change - receiving a wedding proposal by arranged marriage. In the second case, separation from her family may also have been a major life change that made the woman susceptible to an eating disorder.
Possible Services of Interventions
Referral to a specialist on eating disorders is a one way to assist persons with such conditions (Bulik et al., 2005). Because the manifestations are psychological, social, and physical, treatment involves a team of health professionals including physicians, nurses, dieticians, and psychiatrists. Acute and life-threatening conditions such as malnutrition and severe osteoporosis are treated in the hospital while psychotherapy, counseling, and other mental health interventions may be provided in an outpatient setting. The involvement of the family in treatment is crucial to recovery (Suisman et al., 2012), and support groups can play a role in helping the family cope with the disorder.
Education is also necessary in the prevention of eating disorders. Teaching young girls to love their bodies and develop self-esteem apart from their shape or size is the advocacy of various organizations including the Dove Self-Esteem Program, Girls Inc., and Hardy Girls Healthy Women (APA, 2014). Another area of education is media literacy. Teaching young girls to be critical of what they hear and see in advertisements, news, or entertainment programs increases their awareness of the negative effects of media. Awareness allows them to discern if the media content reflects reality and is useful or not.
Available Materials and Resources
There are resources available to assist persons with eating disorders. The National Eating Disorders Association (NEDA, 2014) maintains a hotline for persons and family members who would like to seek help or information. It also has educational materials available online tailored for parents and educators. In addition, the National Institute of Mental Health (NIMH, 2014) has a booklet available in English and Spanish on the causes, symptoms, and treatments of anorexia and bulimia meant for the general public. The American Psychological Association (APA, 2014) also made available a task force report on the sexualization of girls which is linked to eating disorders among others.
Conclusion
Eating disorders have a long history and continue to affect women’s physical and mental health in drastic ways. It is a complex and persistent problem influenced by genetics and the environment, the latter consisting of the values and norms imposed by the family, media, and the larger society. Women suffering from eating disorders require acute care and outpatient services targeting the various factors contributing to the problem. More importantly, educating young girls on media literacy and body image issues is an indispensable preventive intervention. In addition, supporting parents and families is also important in reducing the risk posed by the immediate social environment. However, additional interventions are also necessary. As schools are institutions that socialize the values and norms of society, the content of curricula should include education on the impact of media on body image. Further research is needed to establish the effectiveness of such an intervention.
References
American Psychological Association (2014). Sexualization of girls: Executive summary. Retrieved from http://www.apa.org/pi/women/programs/girls/report.aspx
American Psychological Association (2014). Sexualization of girls: Media literacy resources. Retrieved from http://www.apa.org/pi/women/programs/girls/report.aspx?item=4
Bulik, C.M., Reba, L., Siega-Riz, A., Reichborn-Kjennerud, T. (2005). Anorexia nervosa: Definition, epidemiology and cycle of risk. International Journal of Eating Disorders, 37(S1), S2-S9. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/eat.20107/pdf
Favaro, A. (2013). Brain development and neurocircuit modeling are the interface between genetic/environmental risk factors and eating disorders: A commentary on Keel & Forney and Friedrich et al. International Journal of Eating Disorders, 46(5), 443-446. doi: 10.1002/eat.22131.
National Eating Disorders Association (2014). Find help and support. Retrieved from http://www.nationaleatingdisorders.org/find-help-support
National Institutes of Mental Health (2014). Publications about eating disorders. Retrieved from http://www.nimh.nih.gov/health/publications/eating-disorders-listing.shtml
Raphael, F.J., & Lacey, H. (1994). The aetiology of eating disorders: A hypothesis of the interplay between social, cultural and biological factors. European Eating Disorders Review, 2(3), 143-154. doi: 10.1002/erv.2400020306.
Suisman, J.L., O’Connor, S.M., Sperry, S., Thompson, J.K., Keel, P.K., Burt, S.A., Klump, K.L. (2012). Genetic and environmental influences on thin-ideal internalization. International Journal of Eating Disorders, 45(8), 942-948. doi: 10.1002/eat.22056.
