The long shadow of anorexia

Since the beginning of time women have been dying to be thin.

Around one in 100 female adolescents has anorexia, a disorder characterized by a dangerously low body weight achieved by extreme dieting. Half of these young women will also develop bulimia, a disorder where one vomits to lose weight. Young women in their teens and 20s (and in 10 per-cent of the cases, young men) are most affected by anorexia.

As far back as ancient Egypt when hieroglyphics depicted starving disorders, women have been denying them-selves food. In medieval times women fasted as a way to get closer to God, affording them the label of having anorexia mirabilis (miraculously suppressed appetite). And in the early mod-ern period there were stories of miraculous fasting maids who purported to drink only dew or eat herbs. Skepticism of this practice was strong enough that one such fasting maid was exe-cuted when caught eating clandestinely.

Although these examples all point to eating disorders, the first formal definition of anorexia nervosa was made in 1689 by Richard Morton. It wasnt until 1873 and 1874, however, that Dr. Laseuge in France and Dr. Gull in England wrote what were to be the first articles about anorexia ner-vosa in modern medical publications.

In the beginning, anorexia was viewed as a logical side-effect of diseases like tuberculosis or insanity, or related to hormone imbalances. It wasnt until the 1930s that psychology and emotional factors started being figured into the medical equations. Today physicians, psychiatrists and psychologists agree that anorexia nervosa is a deadly disorder that exists not as a result of one physical disease, but from a combination of factors.

Who is a typical anorexic?

The prototypical young woman with anorexia is between the ages of 12 and 25. She often is eager to please and a very good student. She most typically comes from a middle-to-upper-class family. An anorexic is emotionally closer to, and more involved with, her anorexia than any person or thing. It is common for the young woman, perhaps subconsciously, to fear growing up. Attempting to keep her body from acting as though it has entered puberty by starving herself to the point of losing her breasts and her period is a clear sign of the type of food control indicative of anorexics. An obsession with the weight of others, including models and actresses, is a classic indicator of anorexic behavior. Because of the pressure to be thin, anorexics themselves are often cheerleaders, dancers, gymnasts, models, actresses and runners.

The causes of anorexia are a combination of biological, psychological, familial and social factors.

Biological factors

Personality traits such as obsessive/compulsiveness and high anxiety are at least partially genetically determined. Young women with these predispositions have been found to be more likely to develop anorexia. Compulsive food rituals, like counting or dividing food into minuscule bites, is not uncommon. Obsessive thoughts about ones weight are always present. Anxiety about food grows to the point where only black coffee and water, which have zero calories, become acceptable. Once a person begins to starve herself, the behaviors themselves can alter brain chemistry, causing feelings of peace and euphoria. The emotions cause a cycle that becomes harder to break the longer it progresses.

Psychological factors

Young women with anorexia have been proved to be perfectionists. The driving feature of the disorder is to achieve the thinnest possible body, per-ceived as perfection. Most young women with the disorder see the world in black-and-white terms: Either I am as thin as possible, or I am fat, supreme thinness being a temporary success and any other weight being a failure. Being in control is critical for anyone with anorexia. This feeling of being in power rules schedules, family, food and above all else ones own body.

Family factors

Many people with eating disorders come from families where they feel overwhelmed and smothered, while other young women feel ignored, not understood and alone. It is believed that par-ents who value physical appearance too strongly can contribute to the development of anorexia. Because most of these young women come from affluent families, the pressure for achievement and success is high. This can translate into a young woman managing her surroundings and her problem by manipulating food and weight. Most young women with anorexia have intense trust issues, which, more often than not, originate in the nuclear family. Regardless of whether parents are in actuality dependable and loving, it is the perception of the anorexic that rules the situation.

Social factors

Sometimes friends obsessed with their weight and general appearance can trigger behaviors of eating disorders in young women. These can include romantic partners or groups like sororities, dance classes and companies, or any group where there is substantial pressure to be highly popular or perfect.

Competition is a strong underlying characteristic of anorexia. In a culture that is dominated by competition in athletics, academics, beauty and social hierarchy, this eating disorder fits right in. Characterized by perfection and achievement of the ideal body (read thinnest) at all cost, young women are competing with themselves and other women to the brink of death.

Media influence

We live in society where the media is constantly assaulting us with the reality that thin is in. At this time, 32 percent of female TV characters are underweight, whereas only 5 percent of the women in the U.S. audience are underweight. According to Health magazine, while 25 percent of U.S. women are considered obese, only 3 percent of network characters fall into the same category. On average, a young person in the U.S. views 30,000 TV commercials and countless TV shows every year, a large amount of which are filled with women who are unrepresentatively thin, and some who are blatantly malnourished.

One study indicated that young women who watch TV three or more nights per week were 50 percent more likely to feel that they were fat than those who didnt watch TV. Two-thirds of these teens admitted to dieting in the month prior to the survey, and 15 percent shared that they vomited to help control their weight.

A research study done in Fiji in 1999 corroborates the believed impact of media on self-image and eating disorders. Before 1995, when television didnt exist on Fiji, the ideal body image was one that was round and curvy. Just 38 months after Melrose Place, Beverly Hills 90210 and similar West-ern shows hit the island, teenage girls on Fiji began to evidence serious signs of eating disorders for the first time.

For a young woman whose self-esteem is poor, who is predisposed to anxiety or obsessive-compulsive behavior and who is a perfectionist, these images of models and actresses starved to the point of having bodies bordering on androgyny are pure inspiration. These models and actresses are Thinspiration, as it is known in the anorexic communities.

Triggers for anorexia

For young women predisposed to eating disorders like anorexia, sometimes all it takes is a trigger and the first steps of the disorder are taken. Some triggers include puberty, family problems and life events such as a divorce of parents or positive changes like graduation. Incidents of incest or rape can drive an angry and confused young woman to attempt to gain control of her life any way possible; weight is often a starting place.

According to Steven Levenkron, noted psychotherapist and author of groundbreaking books on anorexia, there are four stages to the progression of the disorder.

The first stage, The Achievement Stage, is not marked by atypical behavior, but rather a simple desire to lose some weight and become accepted by her cohorts. When she has lost the weight, her sense of achievement strengthens her resolve to continue her strict eating model.

Margot was an atypical case as she was 25 when her eating disorder began. She was married with two small children and was about 50 pounds overweight. A soccer player, her weight prohibited her for playing at her best and so she stopped eating and began to drink Tab and smoke cigarettes as her primary diet. She quickly noticed the weight start to come off.

In the second phase, the Security-Compulsive Stage, what starts out as a small weight loss, two pounds a week, quickly becomes not enough. At this stage, behaviors like excessive weighing, measuring body parts and being obsessed with thoughts of measuring food become commonplace. Exercise becomes another obsession, often spending hours a day in cardiac activity. At this point, all relationships take a back seat to her relationship with food and her body. Her thoughts have become twisted to the place where she believes she will become obese even by eating the most minute quantity of food. Most anorexics become both liquid- and food-phobic. Eating less and exercising more are the only way to attain security.

Once the weight started coming off, Margot noticed how easily it reinforced her behavior to keep dieting.

The third phase, The Assertive Phase, shows a marked change in

personality. Where once a young woman might have been well-behaved, nice and obedient, anorexia brings out rebelliousness. The eating behavior is itself viewed as mutinous by many, and the behavioral changes follow. Suddenly she is less worried about what others think of her because she is in ultimate control of herself. Behavior often becomes difficult or downright insolent. It is not uncommon for the young woman to believe that other women are jealous of her and want her to become obese. The disorder has manifested its power externally and, as Levenkron states, her special thinness has become one with her special assertiveness.

Stage four, the Pseudo-Indentity Stage, is characterized by a type of exhibitionism, either making a show of hiding ones thinness or flaunting it by wearing clothes that show off as much of the body as possible. In many ways this is the ultimate show of willpower, dem-onstrating she has more control over her body than other women. This stage is more characterized by personal power than by new food and weight behaviors.

Physical manifestations of anorexia<

These are the typical features of an anorexic:
  • young woman weighs 85 percent or less than weight expected for height and age
  • menstruation ceases or young woman does not begin to menstruate at a typical age
  • loss of or failure to develop sex drive
  • denial of danger of losing weight
  • terror of becoming fat even though she is decidedly underweight
  • reports feeling fat even when very thin
  • has feelings of depression, anxiety, irritability
  • compulsive rituals, unusual eating habits
Advanced anorexia can additionally include:
  • a slowing of heart rate causing danger of arrhythmia
  • cardiac atrophy shrinking of the size of the heart
  • severe hypotension low enough blood pressure to go into shock
  • hypothermia a drop in body temperature to 95 degrees causing temporary or permanent loss of vascular circulation, which can cause numbness or tingling in the feet and hands
  • dehydration of the cerebral cortex, which may cause personality changes

Treatments for anorexia

It is difficult to get women with anorexia to agree to treatment due to the level of denial that surrounds the disorder. Unfortunately, often a serious event concerning the young womans health must occur for her to recognize the problem; sometimes even that isnt enough. Typically, family members and friends make numerous attempts before securing any form of agreement for treatment, and often this agreement is made under great duress and therefore carries varying degrees of success.

Treatment for anorexia comes in three phases. The first and often the most critical is the restoration of weight lost through extreme dieting (and often purging, or vomiting). The second phase involves addressing the underlying issues of damaged self-esteem, body image and interpersonal issues with a psychotherapist. The third phase is that of maintenance and achieving long-term remission. The earlier the treatment is started, the better; research shows the older a young woman gets, the harder it is to treat her as the more set she is in her ways and in her relationships.

Sometimes anti-anxiety or anti-depression drugs are used, but these are usually indicated once a young woman has stabilized her weight. Management of acute anorexia often includes inpatient treatment. For cases where weight has become a life-threatening issue and organs are in danger of shutting down, intravenous feeding is recommended. As soon as a stable weight and level of nutrition has been established, young women with anorexia routinely are established or reestablished into a routine of psychotherapy to help with the psychological issues behind the eating disorder. Due to the familial factors that can be involved with anorexia as well as impact the disorder has on the family, therapy with all family members is common.

The outcome of anorexia?

Without treatment, nearly 20 percent of young women with anorexia will die; with treatment, that percentage drops to 2 or 3 percent. With treatment nearly 60 percent recover to a place of healthy eating, while 20 percent make only partial recoveries, remaining over-connected to food and weight issues. These women have a hard time establishing and maintaining meaningful relationships. The remaining 20 percent fail to get better, even with treatment. They tend to show up repeatedly in treatment programs, emergency rooms and inpatient treatment facilities.

Although Margot had sores inside of her mouth that had made it impossible for her to eat, it was the fact that she hadnt menstruated for three months that finally sent her to her doctor. Since she had had her tubes tied, she knew that she wasnt pregnant and knew that something had to be wrong. Her doctor told her that she was missing her period due to severe weight loss and instructed her to gain weight. Unlike many young women, Margot took the doctors advice to heart and began her journey back to a sensible weight.

What to do if you need help

Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED) has an excellent Web site ( that can answer a lot of questions you might have, although they are not a substitute for medical advice. ANRED has an anonymous self-assessment tool for young women who think they might be at risk for an eating disorder. It is anonymous and can be found at If you are in a position where you can/want to ask for help, approach a trusted adult. Your parents or your doctor are good choices.

What to do if someone you love needs help

If you fear someone you love, or you yourself might have an eating disorder, it is important to seek help immediately. The first call should be to your doctor to get your loved one a full physical. The doctor will then refer you to a therapist or psychiatrist if necessary. It takes a lot of courage for a young woman to agree to seek help, and often she wont agree outright. Remember that often an agreement to see a physician or a therapist will be made only under duress and may generate further disbelief about having the condition. Often young women are exceptionally angry when taken to a professional, as it reinforces the belief that they can trust no one.

It is important to remember these things: Do not comment or scold about how thin she is this will be seen as a victory. Try not to feel guilty; anorexia is a complicated disorder with many originating factors. Start, or continue, modeling healthy eating patterns. Keep the lines of communication open but dont pry, respect her privacy. If a doctor suggests therapy, do it. If the therapist suggests family counseling, do it. If your professionals agree that your loved one needs inpatient treatment, do it. Remember that anorexia is a potentially life-threatening disease, and timing is critical for recovery.

Do you have questions?

ANRED has an information and referral line at 1-800-931-2237. Please call if you would like to speak to someone about your questions or get a referral in your area.

  • The National Eating Disorders Association (NEDA): Web site, www.; e-mail
  • Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED)
  • Anatomy of Anorexia, book by Steven Levenkron
  • When Girls Feel Fat: Helping Girls Through Adolescence, by Sandra Susan Friedman

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