The Mysterious Origins of Eating Disorders
Dr. Alex Yellowlees
On this page you will find an article by Dr. Alex Yellowlees, BSc, M.B.ChB., M.R.C. Psych., M.Phil. Dr. Yellowlees is a Consultant Psychiatrist and Medical director of the Priory Hospital in Glasgow, a Self-Esteem Development Consultant and the author of "Working with Eating Disorders and Self-Esteem" published by Ginn & Heinemann. Dr. Yellowlees is also a Patron of Somerset & Wessex Eating Disorders Association and has kindly written this article specifically for our web site.
Sooner or later, everyone who is touched by eating disorders asks the vital question: just what causes these conditions to develop? It is the big question. And it would seem reasonable to expect that science, psychiatry and medical research would have the answers.
After all, its not as if anorexia and bulimia nervosa are not serious enough to merit extensive study. They have been around for long enough. Anorexia nervosa has been known about for centuries even if bulimia is a more modern variant. Consider too , the high levels of morbidity and mortality from these disorders; up to 20% mortality for anorexia nervosa alone. In addition, the distress to the sufferer and the family is enormous and the cost to the health service of long-term treatment considerable.
So surely study, funded research and resources will have followed the problem and solutions will have been sought!
Not so! The field of eating disorders has been ignored, misunderstood and even ridiculed by mainstream medicine and underfunded by health authorities for decades. The amount of research carried out into anorexia nervosa in particular, is so small as to be quite ludicrous! But why?
I am sure the reader may have their own views. I would be pleased to hear them, since I have given this matter some considerable thought, working in this field and seeing the suffering and heartache that these problems cause. I have come to the conclusion that the same issues that recur to block all potential human development in society play their part here too.
Issues such as ignorance, lack of education, misunderstanding, prejudice, fear, the suppression of women, sexism, ageism and medical politics!
Often, the form of an illness alters and develops over the centuries, reflecting the changing attitudes of society. So too does the understanding of an illness; the theories put forward to explain it. In other words, the way a disorder expresses itself and the meaning attributed to it by the world around, is a 'soundbite' of that society : a photoshot of the culture itself at a point in time.
All diseases conform to this evolutionary process, whether they be viral and bacterial illnesses like hepatitis and salmonella or conditions such as heart disease and cancer. Psychological problems such as self-inflicted injury, schizophrenia and eating disorders, similarly mirror the times. One way of considering this further is to explore the myths and mistaken beliefs held by society about eating disorders.
The Myths About Eating Disorders
It is important to realise that myths are a product of society and its culture and are therefore shared by doctors, nurses, therapists, teachers, parents and relatives as members of that society, as well as by the public at large! Here are just a few of them. Do you recognise any?
Anorexia Nervosa is just a slimmers disease.
This implies that its a fad to be experienced , only a phase to be passed through. This mistaken belief considers eating problems to be a reflection of our ' dying to diet culture ' . In other words, merely a form of extreme dieting behaviour. A modern day cocktail of self-absorption, selfishness, egocentricity and vanity! It is true that dieting is often a trigger for the onset of an eating disorder but sufferers do not have puffed-up egos or spend long periods of time admiring their reflection in the mirror! On the contrary , they are commonly self-effacing , even self-deprecating and hold very poor opinions of their bodies and of themselves as human beings.
Eating Disorders are purely adolescent problems.
This suggests that they are a sort of normal developmental teenage 'teething' problem. This is echoed by the "she will grow out of it" comments, still to be heard in the doctor's consulting room or the school common room. Moreover it is 'ageist'! Although eating disorders most commonly have a late teens and early adulthood onset, children as young as 5 and 6 years old are developing these diseases. Also, it is not uncommon to see eating disorders, such as binge eating disorder for example, beginning in 30 and 40 year olds.
A significant number of eating problems become chronic and are life long conditions to be dealt with. Others, follow a subclinical course, not fully manifesting themselves until mid or later life. Often they are triggered by some stressful life event such as divorce or the death of a parent. The truth is that, although most commonly seen in young women, eating disorders can present for the first time at any age!
Only women get eating problems.
This misconception is blatantly sexist! It is the belief that its purely a 'woman's problem' . Once viewed in this way, it is then reduced to the same level of poor consideration and dismissal that plagues issues such as menstruation, the menopause and female sexuality. The truth is that men too suffer from eating disorders . And increasingly so, the more they adopt the female values and beliefs about body shape and size that were once the prerogative of women alone.
Only little rich western girls get eating disorders.
This mistaken belief is a misinterpretation of the facts surrounding the collected data. Some research suggests that anorexia nervosa is more common in upper middle class professional families from more materially privileged backgrounds. It is also the case that many sufferers are high achievers and conform to the image of the 'perfect pupil'. However, affluence is not a reflection of the emotional health and resources of an individual, a family or a country. Neither is academic achievement. In reality, people with eating disorders come from all sections of society and suffer from a number of psychological problems of which disordered eating is only one. They frequently put a face on to the outside world, hiding their true feelings under a mask of conformity and compliance.
The Magic Recipe
So where does this leave us in terms of our understanding of the cause of eating disorders. Let me try to summarise the situation as I see it at this point in time.
The Toxic Mixture
Eating disorders are truly remarkable conditions that defy a simple explanation. They are what is called 'multidetermined' or 'multifactorial'. Many illnesses, particularly psychiatric ones, are caused by a number of factors combining together to generate the disorder. But none more so than anorexia nervosa. I believe it to be quite unique in this regard and very worthy of our consideration and respect.
Much work remains to be done in this area but contributions have come from a wide range of sources and it is appropriate that this is so. These include genetics, physiology, biology, neurobiochemistry, dietetics, psychology, psychiatry, psychoanalysis, family work and sociological and cultural studies.
It is as if factors originating from all these different fields were mixed together to create a TOXIC RECIPE just requiring the right conditions to be baked into a cake constituting the eating disorder itself! The correct conditions are then provided by the oven, an environment of enclosure and heat, somewhat analogous to adolescence!
Let us consider this in stages ,arranged chronologically in terms of the development of the illness. Or, continuing with the above analogy, the baking of the cake!
The Baking Session
This could be divided into three stages.
- MIXING THE INGREDIENTS (Predisposing and Vulnerability factors)
- COOKING IN THE OVEN (Precipitating Factors)
- EATING THE CAKE (Perpetuating Factors
1. MIXING THE INGREDIENTS!
When baking, mixing the correct measures of ingredients is important in determining the outcome. A little too much or too little of this or that and the results can be vastly different - although still in essence a cake! So it is with eating disorders. A stronger or lesser influence from one predisposing or vulnerability factor may determine which eating pattern is developed and when.
THE GENETIC FACTOR
Consider the genetic influence in the picture for example. It is significantly stronger in anorexia nervosa than in bulimia nervosa: higher rates in twin pairs where one twin has anorexia nervosa and in the close relatives of anorexic patients. However it is not exactly clear what is being inherited, whether it is the illness as such or a tendency towards obsessionality or perfectionism or even some other factor.
THINNESS - THE FALSE VIRTUE
The increasing drive towards thinness in western culture remains one of the most important ingredients in the mix. Our society grossly overvalues thinness, making it into a modern day virtue. Women grow up brainwashed into the belief that in order to be considered worthy, successful and attractive they have to be thin!
The ideal female body shape determined by society has changed dramatically over the last 100 years and increasingly rapidly in the last two or three decades. Women must be confused about just how they should look! They have subjected their bodies to manipulation by corsets, had their body fat sucked out, repeatedly had their breasts enlarged surgically (and then often reduced again!) to mention but a few interventions ! Increasingly , they have become obsessed with their appearance, body shape and size. And where are they to look for helpful guidance? Their mothers, who generally share the same views, more or less?! I think not!
Or, to society at large? (which displays its accepted female ideal of the moment on the front cover, and throughout in some, of almost every magazine and newspaper .) Young women's minds are soaked in these images from an early age. And they strive to emulate them. This whole process is fueled by the fashion world and advertising industry whose main goal is financial gain not the well-being of future generations!
We are now a nation obsessed with dieting. And yet everyone knows they do not work! How rare it is to meet a woman who is not on diet, just off a diet (and giving herself a hard time for having lapsed) or feels she should be on one (and bemoaning the fact)!
This dieting behaviour is a risk factor for developing anorexia nervosa . The dieting life style itself, of self restriction followed by loss of control and sometimes binging , serves to maintain the disordered eating pattern once it has become established. Once again ,dieting features prominently in woman's magazines and crops up regularly in social conversation. Preoccupation with body shape and size is similarly expressed and represented as 'normal' in magazines and films and on television.
In fact, women's dissatisfaction with their bodies has now become so widespread as to have merited a special name in the research literature! It has been called 'normative discontent'! And it now has to be taken into account when the results of studies are being analysed, in order to make sense of the findings!
But this obsession with shape, weight and size is far from normal or healthy and is not necessarily shared by other cultures. It is essentially a characteristic of western society.
Another of the main factors involved in the development of eating disorders is self-esteem. It has been recognised for many years that people with established anorexia nervosa and bulimia have very low self-esteem.
This is characterised by two main features. A lack of a sense of SELF-WORTH and a lack of a sense of SELF-COMPETENCE (or self-efficacy). It relates to the way they see themselves not the way others see them.
This may also be connected to the way sufferers see their bodies. Not only do they dislike the body but they may actually view it as 'alien', a threat to be deal with, repulsive and disgusting. It is of note that in our culture 'fat' is not valued and is often equated with disgust. Fat people are perceived as repulsive and may be rejected. Children with low self-esteem are more likely to develop eating problems in adolescence and adulthood.
Perhaps, if self-esteem is poor then pursuing thinness could be seen as an attempt to improve self worth and increase body-esteem. It is true that losing weight, initially does appear to enhance self-regard. But only for a while! This is because deep seated low self-esteem cannot be raised in a meaningful and lasting way by dieting. Self-starvation, bingeing and vomiting do not follow the principles of self-love and self-respect which are an intrinsic part of genuine self-esteem.
SEEING IS NOT BELIEVING
This low body-esteem may help to explain why sufferers perceive their body in a distorted way; actually seeing it as huge and obese when it is not. Sometimes the whole body is viewed this way. On other occasions it may only be parts such as the stomach, thighs, breasts or arms. This is called body image distortion. What is seen by the sufferer is a body image which is much larger and out of proportion to the body shape which is actually present in reality!
It can be so difficult for people to grasp this fact. It is quite remarkable and even a little scary! After all, we would not expect our eyes to lie because seeing is believing. Or so we think!
Not so! What we see when we look in the mirror, our body image, is influenced by how we feel about ourselves; our body-esteem and self-esteem. People with low self-esteem often perceive the body in a disparaging way . It is an aspect of their self-dislike or self-disgust. A society preoccupied with appearance, size and shape serves to intensify these feelings in vulnerable individuals with poor self-worth. You could say that it literally feeds or fuels the problem so to speak!
2. COOKING THE CAKE!
An eating problem does not come out of the blue although it may seem like it! The scene has been set long before symptoms develop. The ingredients have been mixed and all that is needed is the right set of conditions to allow the mixture to rise and for the cake to form!
These conditions are often just perfect in adolescence. This is a time of enormous stress . How any of us ever get through it is amazing! Our bodies are changing almost before our eyes! The body-self we had learned to live with, and in, undergoes rapid transformation.
If we already had low body-esteem then this change is extremely threatening. Especially when the focus of change is on shape, size and weight! And we know what our society thinks about these issues! It appears to dictate clearly, exactly what size and shape and weight is acceptable; and in quite an arbitrary way!
The more we feel the need to be liked and to fit in, the more we may strive to conform, as closely as possible, to these false ideals. In adolescence our self-identity is also being individually formed and defined . A healthy sense of self-worth underpinning this process is really important if it is to go smoothly.
So, if our self-esteem is already low as we approach adolescence, it is easy to see how any set of ready-made rules about diet, shape, fashion, attractiveness etc. that society provides, can seem like an easy way to help form a ready-made self-identity! Or at least to prop up a shaky one!
It is a bit like conveniently picking a dress off the rack from among a dozen of the same reflecting the fashion style of the month, rather than taking the time to seek out one that is really you!
An easy way to solve the problem of what to wear to the party but the dress may not really suit you or truly express your uniqueness and individuality. As a result you may never fully be happy in it or feel that it is 'right'!
And so it is, that specific stressful events at this critical time in life can be the straw that finally breaks the camel's back so to speak.
THE CRISIS OF SELF-ESTEEM
If self-esteem is already low, then any situation which occurs to lower it further can precipitate a sense of inner crisis.
This could be sitting exams, leaving home - or even just the thought of it! It might be trying to form a relationship with the opposite sex or the breaking up of one. Any such experience which threatens our self-esteem can act as a trigger for disordered eating behaviour.
Why? Because if we feel like we are falling apart inside, then anything which seems to give us a sense of being back in control of our lives, bodies, feelings and sense of who and what we are, can appear to provide a very attractive solution! Things like; dieting, overexcersising, starving ourselves or trying in any extreme way to change our size or shape. The trouble is , they don' t actually work ! Certainly not in the long term where they cause even more suffering.
In this sense eating disorders can be viewed as a CRISIS OF SELF-ESTEEM!
The family within which we exist plays an important part too. If our family has been emotionally healthy and our relationships have been ones in which we have felt genuinely loved and valued for who we are as individuals, then we are likely to have developed a good sense of self worth.
If we have been treated with respect and gradually helped throughout our childhood, to develop our individuality and independence and therefore our self-identity, then we will be less vulnerable to developing an eating problem. We will have a better sense of self regard, recover more quickly from setbacks, and generally feel more confident about ourselves. We will feel more able to cope with life in general.
Families do not cause eating disorders but there is no doubt that they can play a very important part in the overall process at various levels.
3. EATING THE CAKE!
So far we have looked at how an eating disorder might develop. The predisposing and precipitating factors. Let's now consider what maintains the symptoms once they are established.
What keeps someone eating this toxic cake when it is so detrimental to physical and emotional health; in other words the perpetuating factors?
It is almost as if the illness acquires a life of its own! It becomes the person somehow. Like a runaway train it gathers momentum, carrying the sufferer along a track towards self-destruction. Sometimes it seems as if nothing can stop it, resulting in feelings of helplessness , fear, and despair.
Carers, relatives as well as therapists and medical professionals can at times share these feelings and even be overcome by them.s
Most sufferers do not fully appreciate the extent of their eating problem. They do not see what others see. They are blinded by a degree of body image distortion as I referred to earlier which distorts their perceived shape, size and weight.
As a result they are not aware of the dangerous situation they may be in physically. Minimising their symptoms and rationalising away the consequences of their behaviour, they get angry when others point out inconsistencies and express worries about them.
Why are they so content to live with such denial and partial awareness of their predicament? Is it some level of brain malfunction or neurochemical abnormality? Or is it a psychological block employed when facing reality would simply be too scary to deal with ? It may be a bit of all of these things. But I believe it may also be because the illness is serving an important function for the individual in terms of their survival!
How can this be when it would appear that all of the symptoms of eating disorders are so negative and potentially harmful? Afterall, physically sufferers get sick, depressed, reclusive and isolated. Psychologically their self-esteem is lowered by the effects of the illness and vocationally they underachieve in the long-term!
Well it comes down to the possibility that at one level the illness can be viewed as an attempt to solve an emotional problem! A dysfunctional attempt certainly, but none the less a strategy designed to maintain the survival of the organism, the human being! At least in the short-term !!
Many illnesses have two sides to them, like different sides of a coin. One a defensive destructive side and the other a positive problem solving side. Both can exist alongside one another and making up the coin, or in this case the entity that constitutes the illness itself.
It therefore follows that to focus exclusively on the negative self-destructive side, ignoring the opposite side of the coin, is really to fail to fully grasp the true nature of the coin itself !
So what is this other side? I believe it is an unconscious attempt to try to raise critically low self-esteem. A desperate way of acquiring some sort of sense of self, self-identity and self-concept that is compatible with life! Ironically and perversely, it results in the opposite! Because this survival mechanism is only a short term solution designed to keep the person going through the next few weeks, days or even hours! It is doomed to failure in the long term because deep down, an authentic sense of self-worth and self-competence cannot be realised by dieting and other behaviours which do not respect the self and reflect genuine self-love.
Let me try to summarise. I think that the closest we can get to understanding eating disorders is to consider them as a disorder of the SELF. It is as if the sense of self, self -concept, self-esteem and self-identity are so fragile, that the eating disorder emerges as an attempt to solve this problem.
- In this sense it has meaning.
- It is serving a purpose.
- It is trying to tell us something!
Perhaps it is best viewed as a desperate way of trying to gain a sense of self-worth and self-control over feelings about the self and the body. This helps us to understand why so many sufferers say that they cannot give up their eating problem because it feels like it is all they have!
Sometimes people feel that their anorexia actually IS them! That it defines who and what they are. That the anorexic self is in fact their true self!
If this is how it seems, to let the eating disorder go must feel very scary indeed! Like jumping out of an aircraft or bursting a balloon causing one to vanish altogether!
Paradoxically, in this struggle for healing and to somehow fill the painful vacuum inside, behaviours are adopted which are actually self-destructive and in the long term cannot help our inner self to develop and grow. This is why I believe that simply treating symptoms alone, with the only aim of removing them, is shortsighted and insulting to the person and to the illness!
It would be a bit like being stripping naked in public; embarrassing, humiliating and degrading . And this is often how sufferers describe the treatment they have received! Attempting to remove the illness without helping something healthier to grow in its place could even be considered cruel!
Before cracking open an egg, a little chicken must be ready to emerge, otherwise all you might get is a mess!
I believe that the illness deserves to be treated with respect; in a sense to be honoured. It is not that I am saying the disorder is a good thing or should be retained. But it is serving a purpose and it is trying to tell us something about our inner world if only we will listen. We need to honour it.
This can be done in three ways:
- First by listening to it with compassion.
- Understanding its personal language and meaning.
- Responding to its message.
We can then start allowing ourselves to grow emotionally, in what ever way seems right at this moment . And for everyone it is a different starting place!
It may mean simply acknowledging to ourselves that we have a problem . Or perhaps telling a friend, partner or parent about it for the first time. You might be amazed just how liberating an experience this can be! The start of the journey towards healing.
You may decide to seek out more information about eating problems or contact a self help group and hear how others cope. Seeking professional help may be an option. But beware, choose your family doctor with care and seek out one whom you think will be sympathetic and have some understanding of the problem. If there is a specialist eating disorder service or association in your area then even better. Connect with them.
Whatever you do, do something! Take the first step, but make it a small one which does not seem too scary.
Do not let fear put you off . It is natural in the circumstances and a part of life. Feeling afraid does not mean you should not do something to chane your situation.
So have courage and take action.
I wish you well.
Dr Alex Yellowlees
Dr. Yellowlees has also written a leaflet "Starting Points for Self-Esteem Growth" for Somerset & Wessex Eating Disorders Association which is available from SWEDA.