(DiNicola 183).
INTRODUCTION
Anorexia nervosa/bulimia is really not about food at all. This condition is one that is a manifestation of something much deeper. And we are wrong to view anorexia nervosa/bulimia as a disease. While the thoughts of Mr. DiNicola are common today, the key words to his statement are “yet remain unproven”. Anorexia nervosa bulimia is a condition of negativity--one that is confirmed. Though the lack of self-esteem often is cited as a condition of this disorder, the manifestation is really all about selflessness. There is no identity, no sense of self; so, we are speaking of a lack of self. So, it is this lack of self that allows anorexia nervosa/bulimia patients to resign, unconsciously, at living. They feel they should not be allowed to live. And, taking food away is the most obvious thing to prevent living. The patient feels life is not important; they hate themselves (and the mere fact that they HATE themselves). It is as though they live through others--the only way they can justify their existence. The void that exists in their life is their inability to make the world perfect for everybody. Often, anorexia nervosa/bulimia patients are misdiagnosed as suffering from depression. The depression is result of the sufferer’s inability to master perfection. These eating disordered adapt themselves to situations attempting to sharpen their perfection--since their desire is to copy values externally presented by a given society. Those manifesting the illness are extremely sensitive, uncommonly aware, and worry about everyone. It is as though the patient absorbs all the problems society is filled with. What destroys the eating disordered is the contradiction: that life can be perfect. This need for perfection makes them give remarkably of themselves, as well as take care of others.
“I always wanted you to admire my fasting,” said the hunger artist....”But you shouldn’t admire it”....”Because I have to fast, I can’t help it,”….”because I couldn’t find the food I liked. If I had found it, believe me, I should have made no fuss and stuffed myself like you or anyone else.” (Kafka 1971, 277)
OVERVIEW
An aversion to food or extremely small appetite defines anorexia, which is derivative of the Greek (privation, lack of)--and, orexis (appetite). ANOREXIA OR ANOREXY (lack of appetite) first came into use in the 16th century (DiNicola 169). Ephemeral anorexia has been felt by most (i.e. during a flu, cold, emotional trauma, or the night preceding an exam). And, “a host of somatic conditions, from blockages in the alimentary system to hormonal imbalances, may cause an aversion to food in general” (Bell 1). The term ANOREXIA NERVOSA is somewhat deceptive; appetite is not lost by many possessing the illness. “Hungry or not, victims of anorexia nervosa voluntarily starve themselves to the point at which their lives are at risk, and reported mortality rates range from 10 to as high as 20 percent” (Bell 2). Research and current clinical criteria for the eating disorder anorexia nervosa (DSM-IV-R) include: “refusal to maintain body weight over a minimal normal weight for age and height; intense fear of gaining weight or becoming fat, even though underweight; a distorted body image; and amenorrhoea (in females)” (DiNicola 169).
Early medical history of anorexia nervosa conceivably was observed by ancient physicians. “Two Italian writers, Accornero (1943) and Baraldi (1952), have claimed that the earliest account of anorexia nervosa was given by Simone Porta, a sixteenth century Genoverse” (DiNicola 171).
A 1694 treatise by Richard Morton on tubercular disease reported on phthiisis nervosa --a nervous atrophy condition. This is the earliest understood attempt at describing anorexia nervosa. (Brownell and Foreyt 232). Most noteworthy were Morton’s observations: “mutual influences between mental and bodily processes operating in these patients and the pathogenic role of the emotions heralded contemporary thought. (Brownell and Foreyt 232). An, English scientist Richard Whytt, as reported by Strober, indicated in 1767 “that the cause of unusual food aversion and states of compulsive-like food cravings could be localized in the gastric nerves” (Brownell and Foreyt 233). Additionally, one hundred years later another London physician, Gerald Russell, defined distinguishing characteristics concerning anorexia nervosa and bulimia--as well as more explicit observations correlating with the family and personality.) (DiNicola 169).
EARLY HISTORY: BACK TO THE MIDDLE AGES
Circa 1225: The Eucharist was the only thing eaten by a Leichester nun for seven years--from the monograph by William Hammond (1879): “Fasting Girls Their Physiology and Pathology.” According to Michael Strober, the fast continued at the nun’s bedside; while the Bishop of Lincolon had sent fifteen clerks for observations (Brownell and Foreyt 321). Strober also reports the writings of a physician, Bucoldianus (who documents Margaret Weiss’ case); the 10-year-old had not eaten for three years “while walking about, laughing, and talking like other children” (Brownell and Foreyt 231-232). A 14th century saint (female), Linduine of Schiedam, lived much of her life on “nothing but ‘a little piece of apple the size of a holy wafer’ ” (Brownell and Foreyt 231). In University of Vienna professor Moriz Rosenthal’s book (1886), Magenneurosen und Magencatarrh, he wrote (concerning anorexia nervosa):
Already in previous centuries, namely in the era of the Middle Ages dominated by
religion, reports have appeared about ‘fasting maidens,’ who at the expense of
suppressed nutritional needs obtained the appearance of sainthood. Our modern
times, wealthier in nervous illnesses, has included also this variant of gastric
neuroses in the circle of its observations” (Vandereycken et al. 479).
Vandereycken, however, challenges historical cases of anorexia nervosa--especially viewing Lasegue’s case “as hysterical food refusal and Naudeau’s report as a food aversion conditioned by association with attacks of pain” (DiNicola 171). Overall, the most overriding criticism of historical literature appears to be confusion with not only medical terms but critical analysis of medical findings. “Some historical writing, however, displays an uncertain grasp of basic medical definitions and the critical review of medical data” (DiNicola 175).
RELIGION
Throughout the ages fasting has often been referred to in the religious context. And often, food is correlated with different Judaeo-Christian observances (like Lent); particular foods are not allowed to be eaten. In her exploration of anorexia Matra Robertson in Starving in the Silences points out: “Fasting is another form of religious practice in which food may become taboo for specific periods. Jewish people, fasting on Yom Kippur, is an affirmation of faith (10). Fasting by Christians in the West is not viewed as “diseased” behavior--but, simply part of the religious doctrine. “Fasting, in the Judaeo-Christian tradition, became a way of controlling desire and the temptations of the flesh” (Robertson 11). This way of controlling desire and the temptations of the flesh, according to London researchers in “Religious Belief and Anorexia Nervosa” is through religious conversion. This conversion “seemed to serve as a protective function against severe weight loss” (Joughin et al., 397). Severe weight loss has been documented in some saints. Not only are religious connections to anorexia nervosa reported throughout the earliest of literature but “an examination of historical figures has led to the retrospective diagnosis of anorexia in some saints” (Joughin et al. 39). Many theories have been put forth concerning asceticism and anorexia nervosa (Bliss Branch, 1960; Crisp, 1980; Rampling, 1985; Joughin et al. 39). However, despite such an equating of eating disorders with religion, little research exists on the topic. But it is obvious, even in this context (like today), that anorexia nervosa/bulimia is a manifestation resulting out of the need for perfection. These religious figures, lacking any whole self of their own, looked to a higher power to emulate. And, in their quest for perfection were taken down by the contradiction, that life could be perfect. As a religious role model they attempted to put themselves into venues--to sharpen perfection in an attempt to duplicate the external values expected of their society.
Thus, Vincenzo F. DiNicola is correct when challenging the current notion of anorexia nervosa as a culture-bound syndrome, saying: “These predicaments [religious] surely represent vastly different socio-cultural and historical contexts from the young women with anorexia nervosa in twentieth century Western societies” (174).
Diet Diseases Strike Black Women
So, it is not surprising that the eating disorder predicament, mostly relegated to upper class young white women, is respresented in a vastly different socio-cultural context today --outside of Western society. A past reigning Miss Universe of South Africa, Augustine Masilela, represents the idea of other South African women--thin, beautiful, and successful. But with this search for perfection has also come the tragedy of anorexia nervosa/bulimia. Wasn’t this is disease that was only suppose to affect white women? The South African magazine Drum in December 1995 concluded that “recent studies have revealed that the eating disorders anorexia and bulimia are now affecting more and more black women wordlwide” (114). In 1993, the first cases of black South African women suffering from eating disorders were documented “and the number of cases has increased since then, says Dr. Chris Szabio, a psychiatrist at the Eating Disorders Unit at Johannesburgh’s Tara Hospital” (114). He concurs that there are certainly a greater number of young black women who are eating disordered. So, again the situation is presented where women (other than white) fit themselves into venues in order to hone perfection; this is done to copy the external values presented by the Western society they so desire to emulate. By doing so black African women are rejecting a traditional African cultural thought--that there is attractiveness in being plump. For years this thought has been much a part of traditional family thinking.
19th CENTURY HISTORY
Family Role
French, as well as English literature, specified the family’s role (as early as the 19th century), in anorexia nervosa treatment. This thought ruled in anorexia therapy for decades to come, that the anorexia/bulimia patient must be pulled away from her family in order for favorable therapy. “Although this attitude implied, at least indirectly, the conception that parents played a pathogenic part in the eating disorder, this view was not explicitly elaborated. But in the 19th century, the influence of familial factors and interactions on the development of mental illness was rarely explored” (Vandereycken, Kog and Vanderlinden 7). The dominant literature before World War II was psychoanalytical, a one-sided analysis of pathogenic mother-daughter interaction (Vandereycken, Kog and Vanderlinden 7).
Lasegue and Gull: Pioneers
Also one-sided was anorexia nervosa’s first entrance into medical books; the disorder first entered medical books in 1873--depicted in words very close to the same time Earnest Charles Lasegue (French neuropsychiatrist) and William Withey Gull (English physician). On reviewing medical literature in the late 19th century “one notes that German writings on anorexia nervosa are rather scarce compared to the French and English literature (Vandereycken et. al.). Lasegue (1873) reported that an early prime factor early in the illness was denial:
.....An inexhaustible optimism, against which and menaces alike are not avail:
“I do not suffer and must then be well....” So often I heard this phrase repeated by
patients, that now it has come to represent for me a symptom--almost a sign...the
disease is summed up in this intellectual perversion (Garfinkel and Gardner 3).
A perversely distorted body image is prevalent among the anorexic. It is as though the patient is totally not cognizant of their emaciated condition. So, paramount to their denial is the unhealthiness of their body--and, that the “extremely thin” body possessed due to illness is not attractive. In addition, bulimia (gorging) is found in a great number of anorexics; they go back and forth from non-consumption to overeating and throwing up. Gull (1874) recognized the bulimia existing in some anorexics: “Occasionally for a day or two the appetite was veracious” (Garfinkel and Garner 4).
Both Gull (1874) and Lasegue (1873) made interesting observations concerning a lack of awareness of body size--non-recognition of inner states. Observations of Lasegue (1873) included a variability in moods of patients--along with the initial denial of a problem; also, an obstinate disregard of resistance to most anything...and, a non-caring personal attitude: “Not only does she not sigh for recovery, but she is not ill-pleased with her condition” (Garfinkel and Garner 8).
Early Familial Observations
Although an early recognition existed about the familial role in the eating disorder, later the insight was ignored; or, psychoanalysis concentrated on the mother-daughter relationship. Garfinkel and Garner summed up the need to recognize that several predisposing factors exist in trying to comprehend the family’s role in anorexia nervosa: “While familial characteristics that predispose to the disorder may be common in a population, it is their interaction with an individual’s constitutional and psychological make-up and the cultural milieu that determine whether this predisposition will result in disease” (167). Also reported was an inappropriate preoccupation with food that was distinguished in families of the eating disorderd (176)
.
.
“MAGERSUCHT”
(pursuit of thinness)
Germany
Not unduly prominent, as mentioned (scarce), in the 19th century was the German interest in anorexia nervosa: “Apparently, anorexia nervosa did not appeal to them as a nonsociological entity distinct from the popular diagnosis of ‘nervous dyspepsia.’ ” (Vandereycken et al. 473). However, that is not to say German physicians were not abreast with French and English writings. (Anorexia nervosa had few French or English to German translations.) Neurologist Jean Martin Charcot of Paris attracted quite a German following.
Freud: Lack of Interest?
But “hysterical anorexia” lectures translated into German (Charcot’s) appear to have been either ignored or disregarded by the Germans (Vandereycken 475). Freud had familiarized himself with “hysterical nervosa” through Charcot’s study (Vandereycken 476). “Freud himself was not much interested in it. If the term anorexia appears in his works, it usually refers to lack of appetite or distaste for food as one of the characteristics (among many others) of hysteria, and has nothing to do with the typical syndrome of anorexia nervosa’ (Vandereycken 476).
United States--Late Discovery
While the German-speaking showed a lack of interest in the syndrome, the United States did not discover the illness until 1895 (Vandereycken, et al. 487). Digestive problems of anorexics most likely misled doctors into a “nervous dyspepsia” diagnosis (hiding behind the neurasthenic disorder category) (Vandereycken 488). The initial U.S. publication of stiomania (intense dread of food) by William Stout Chipley was in 1859. Chipley did identify details of modern anorexia: “emaciated adolescent girls in ‘high born’ families” (DiNicola 172).
CULTURAL SYNDROME
“A woman can never be too rich or too thin.”
Wallis Warfield Simpson, the Duchess of Windsor
Although girls in high born families appear to suffer more from the disorder, the possibility of the eating disorder exists in all culture. For, food being at the center of organization of social events can be found in all cultures. Even though anthropologist Levi-Strauss has often been faulted for his methodology (even his culinary triangle model), few disagree that “according to Levi-Strauss, the way in which social events are organised around food and drink is part of an unconscious categorisation that belongs to all humans everywhere” (Robertson 7).
Literature overall suggests a rise of anorexia nervosa in Western culture. This is a society, itself, which thrives on over-preoccupation with food, body image, diet, figure, etc. Through the years, “glamour” and “thinness” have been confused in their being equaled. However, what is “normal” and what is “anorexic” have no lines of distinction. Maurer and Sobol in Eating Agendas point out that “normal” and what is “anorexic” appear to lie on the same continuum in our society” and further suggest (concerning eating disorder medicalization--physical and character stigmas used). Maurer and Sobol conclude that “ultimately, stigmas create social distance and apathy, and in the case of eating disorders, lessen the likelihood that audiences will respond to eating disorders as social problems worth “doing something about” ( 91).
Food, Eating Habits, Diet: Tied to Culture
Eating habits, food, diet are tied to culture, according to most cross-cultural studies. Marta Robertson maintains the complexity of about eating and food in culture. “The production and consumption of food are part of the way in which people come to understand the world” (1). Research by eating philosopher Anne Murcott perpetuate ideas of “cultural-based moral attitudes” about diet, food and eating. “Indeed what and how people eat or drink may usefully be understood in terms of a system whose coherence is afforded by the social and cultural organisations with which it is associated” (Robertson 3). What is appropriate to eat and the proper way of consuming it is taught by culture.
So, indeed sociocultural factors, as well as familial, contribute to the prevalence of eating disturbances. Since the mid-1960’s Western society has been overcome with an obsession for fitness, youth, dieting. Women’s changing societal roles contribute, too, to an increase in eating disorders.
Susie Orbach, a feminist psychotherapist, contends the normalcy of women for decades has been to diet profusely, keeping track of not only grams of fat but calories (Maurer and Sobol 92). Culturally, Orbach sees women having with food a paradoxical relationship because “the food she prepares for others as an act of love and an expression of her caring is somehow dangerous to the woman herself” (92).
CROSS-CULTURAL OVERVIEW
Quite apparent in eating disorder literature is the absence of culture issues...ethnicity, race: “are lost often in the small print of results sections or given only passing mention in discussions” (Dolan 67). Overall, research on anorexia nervosa/bulimia is restricted to Western culture’s female white populous. And, the rampant increase in the illness is relegated most exclusively to that segment of society. Bridget Dolan, Research Fellow and Honorary Therapist at St. George’s Hospital Medical School in London, remarks: “Indeed, little has changed since Bruch (1965) commented upon the ‘conspicuous absence’ of black anorectic patients in New York” (Dolan 6).
What About Nonwhite Cultures and Eating Disorders?
The question: Should or can one come to a strong conclusion concerning the occurrence and type of eating disorders in cultures nonwhite? A problem with referral biases is immanent. Dolan contends that, “an estimation of the true rate of eating disorders in nonwhite groups within Western societies is impossible without a large epidemiological survey” (76) Dolan makes the suggestion that the reports, themselves, might “tell us more about the culture and attitudes of the researcher than the complexities of the subjects they describe” (76).
A WORLD VIEW OF EATING DISORDERS
Africa
Buchan and Gregory (1984) studied anorexia nervosa in a Zimbabwean, a 22-year-old woman. Having lived in England from age two, she returned to Zimbabwe at six-and-a-half years old--teased for not speaking the native language and being overweight (Dolan 71). After going to private school at a mostly white school later, she maintained an excellent academic record. After a bout with depression, the young girl was hospitalized...binge eating...vomiting, resulting in extreme weight loss.
Also, Vincenzo F. DiNicola in “Anorexia Multiforme: Self-starvation in Historical and Cultural Context” reports a number of African Blacks with anorexia nervosa. Not only does he cite the aforementioned African case but a the case of a “female Ethiopian political torture victim from a middle class family” (258).
Anorexia nervosa was noticed in three Afro-Caribbean patients living in Britain, the first non-white woman reported there in 1985 (Dolan 73). Non-white British women (five) with “normal-body-weight bulimia” were found in case studies by Lacy and Dolan in 1988.
Cultural and Racial Identity Confusions
Dolan contends that “eating disorders in nonwhite women do not seem limited to a particular social stratum. They have been described in all social classes and in both traditional and Westernized families ( 74). Further suggested is that confusion exists concerning cultural and/or racial identity.
North America
Both first cases of anorexia nervosa on this continent concerned two girls from broken homes and, both were black (Pumariega, Edwards, Mitchell case study--1984). The following year, an Afro-American woman possessed the first clinical case of bulimia (Dolan 72). Seven middle class black patients in a study by Hsu (1987) were documented--as well as an atypical black male meeting bulimia criteria, related to depression (Dolan 72). Hispanics have been the subject of North American research in San Diego but “no significant effect of race upon treatment outcome was found in a matched-pairs analysis’s, supporting the clinical impression” (Dolan 72).
Mexico, a country far less prosperous than the U.S., sees little evidence of anorexia nervosa. Reports from other Spanish-speaking countries in North America are evident. A comparison by Sibler in 1986 (Blacks and Hispanics) concluded the correct diagnosis in only half of seven cases....suggesting that “the prevailing stereotype of the white upper middle class victim may conspire against early recognition” (DiNicola 257).
TRANSCULTURAL FINDINGS
North American findings generally are reflective of Middle European findings and are not transferable. EAT scores that were lower “were found for both East and West Berlin samples when compared with North American samples, and deficient discriminant validity of the EAT is evidenced in the remarkably low mean score of East Berlin patients with anorexia nervosa” (Neumarker et al. 281).
The EAT made its appearance in 1979, designed by Garner and Garfinkel (widely used in both clinical and normal samples). An assessment is made of a wide range of attitudes associated with eating disorders--by 40 items (questions). Factor analysis is employed; “dieting behavior” , “bulimic attitude”, and “oral control” --disturbed eating --are measured. It is observed that “the dieting factor reflects a pathological avoidance of fattening foods and preoccupation with the body shape. The bulimia factor is positively related to bulimia and a greater body weight. The oral control factor reflects self-control [food]....” (Neumarker et al. 281-282). Transcultural differences associated with the EAT do occur, according to Steinhausen (282).
France
Studies at Hopital International de l’Universite de Paris number 17 (epidemiological); a disparity between the approximated level of occurrence had a range of 1% to 20% (women) and 0% to 5% (men). Methods of assessment used in various tests were EDI, EAT and questionnaires. Again, women numbered greater in prevalence. A correlation was found showing depressive disorders higher among bulimics “and their first-degree relatives than among normal controls without however being able to answer the question as to whether the eating disorders or the depressive disorders were first to appear” (Ledoux, Choquet, and Flament 92).
Using the class as the unit and class lists from schools, junior high school students were surveyed in Hautne-Marne, France (general population group). Another larger group was made up of teenagers with exhibiting symptoms of eating disorders (yet, did not meet DSM-IV-R bulimia criteria). Findings included an increase in somatic symptoms and eating disorders among girls (especially) during adolescence (confirming that functional problems and eating disorders were associated); teenagers with eating disorders have increased fatigue, as well as sleeping difficulties. (Ledoux, Choquet, and Flament 85). However, it was concluded that North American eating disorder cases are more prevalent than in France. But “there may also exist cultural differences between the North Americans and European population with regard to normal use, place, and avoidability of food and, subsequently with regard to its pathological use” (86).
Middle East
In “Bulimia of an Egyptian Student: A Case Study” Kathryn A. Ford acknowledges that there is little (if any) documentation of bulimia in underdeveloped countries (407). But more importantly findings again make conclusions about “similarities between the precipitants of bulimia in Western and non-Western women.....sociocultural and cross-cultural factors may play a role in the onset of the disorder” (411).
The rarity of anorexia nervosa in the Middle East is also documented by Vincenzo F. DiNicola in “Anorexia Multiforme: Self-starvation in Historical and Cultural Context”-- a place “where a thin person is referred to as da’eef which means weak in classic Arabic” (260). DiNicola in addition predicts that Israel, a country comparable to Western technological development, is a nation at risk (for eating disorders)--as “a culture-change syndrome” (260).
Asia
Also rare (reported by DiNicola) is Oriental anorexia nervosa. Similar reports (like Ulrike Schmidt in London) concluded the rarity of the disorder among Asians:
In the Chinese, eating disorders are thought to be rare, due to the importance
attached to food, eating, and diet composition in their culture (Change, 1974).
Physical appearance may be less important than success in social role performance
for the development of self-esteem and happiness among Chinese females (Lee,
1991). Nonetheless, there are now reports of anorexia nervosa in the Chinese
populations (Buhric, 1981; Chiu, 1989, Lee, Chiu, Chen, 1989; Lee, Leung, Wing,
Chiu, Chen, 1991; Lee, 1991; Ong Tsoi, 1982; Tseng, Lee, Lee, 1989). Fear of
fatness and body image disturbance are not typical in these patients, and somatic
presentations with complaints of abdominal discomfort are common. Bingeing and
vomiting are thought to be rare (Lee, 1991). Only one series of cases of bulimia
in Hong Kong Chinese women has been reported (Lee, Hsu, Wing, 1992). These
patients mainly abused laxatives rather than inducing vomiting (508).
Pakistan
In that part of the world an eating-disorder survey was completed by Iffat y. Choudry and David B. Mumford, finding bulimia nervosa to be greater among Asian girls than indigenous Caucasian girls. And it was found “there was some evidence that the most “Westernized” girls were at greatest risk of developing an eating disorder....[Asian schoolgirl survey Bradford, UK]....The results are discussed in light of previous claims that eating disorders should be regarded as ‘culture-bound syndromes’” (Mumford, Whitehouse, and Choudry 181).
OTHER CAUSAL THEORIES
Alcohol and Substance Abuse
Furthermore, evidence of some research concerning the relationship of alcohol and drug and abuse to eating disorders exists. In “Borderline Diagnosis and Substance Abuse in Female Patients with Eating Disorders” German and Swiss researchers went over all the files of borderline personality disorder (females)--and, patients were re-categorized (DSM-II-R) concerning borderline personality disorder and eating disorder (Koepp 108). An extensive “examination showed the frequency of abuse of alcohol and tranquilizers to be no higher, but that of laxatives and/or diuretics and/or anorexigenics to be significantly higher in borderline patients with concurrent eating disorder.....incidence of alcohol abuse significant in borderline patients” (108).
Various researchers conclude concerning the frequency of borderline disorder diagnosis that it occurs too often in eating disorder patients. Jonas, who assumes alcohol consumption and eating behavior are “modulated by opiodergic receptors” believes it not very true that “substance abuse is only a symptom of....a concomitant affective disorder” (109).
Antidepressants As a Solution
Studies by Jonas contradict those of the London and Swiss researchers (Koepp et al.) because their report concluded a correlation between the “diagnosis of borderline personality and not with eating disorders” (109). They were able to prove that eating disorder patients are not different from a control group that abuse of tranquilizers.) Yet, many recent studies do document high incidences among women with eating disorders of substance abuse (Beary, Lacey, & Merry, 1986; Brisman & Seigel, 1984; Bulik, 1987a, b; Jones, Cheshire, & Moorhouse, 1985; Lacey & Moureli, 1986; Mitchell, Pomeroy, & Huber, 1988; Mitchell, Soll, Eckert, Pyl & Hatsukami, 1989).
Not only does D. Ploog characterize anorexia nervosa and bulimia as addictions (“course and outcome....coping strategies, subjective feelings, and psychopathology are concerned”)--but reports on beneficial effects of antidepressant drugs to combat the illness (1). He states that “several studies with tricyclic antidepressants and monamine oxidase inhibitors have revealed a possible beneficial influence on various eating and behavioral symptoms of anorexia and bulimia....” (38).
OTHER OBSERVANCES
Siblings of Patients with Eating Disorders
A forgotten study found in the literature of families with eating disturbances is the relationship between patients and family: birth order, family size, eating disorders in siblings, behavioral and mental disorders, personality of siblings, sibling rivalry, and sibling incest ( Vandereycken and Van Vreckem 273). Although many studies are researched concerning twins, very little study has been done on siblings. “In the older literature it has been suggested that anorexic patients are often firstborn children (Rowland, 1970) or the second child, usually after an elder sister (Cobb, 1950; Dongier & Duchesne, 1966). Some reports on large samples mention that firstborns as well as lastborns are observed more frequently than children occupying a middle position...” (273-274).
Hall (1978) studied 110 siblings and found a low incidence of “overt sibling disturbances” in anorexia nervosa families (Vandereycken and Breckem 276). Furthermore, Vandereycken suggests a problem with the fact that research and clinical work is concerned only in the difficulties of the sibling relationship. Ignored is “the positive role brothers and sisters can play either the protection or the recovery from an eating disorder” (276).
PERCEPTIONS
As aforementioned, evidence of anorexia nervosa and bulimia nervosa as a “culture-change syndrome exist--that its change (culture) can “trigger” anorexia nervosa (DiNicola 245). DiNicola explains a weak thesis: “culture is an envelope for the emergency of anorexia nervosa.....culture is a specific socio-cultural address, container or envelope for the expression of the illness” (245-246).
Obviously, the preoccupation with anorexia nervosa in Western culture is overwhelming. Such is its prevalence that Brumberg (1985) remarks that “we use ‘anorectic’ much as we have used ‘syphilitic’, ‘epileptic’, or ‘diabetic’ to mark and individual in a particular way” ( DiNicola 179).
Are Eating Disorders Truly Culture-Bound?
Yet, so called “orphan” cases of the eating disorders are found in areas not bound by the cultural theory...”occurring during rapid culture change (among migrants and in societies undergoing rapid economic and socio-cultural change)” (DiNicola 186). For example, a number of Asian countries fit into this category of “rapid social and economic and socio-cultural change; advertising plays a major role in the newly developed economy (consumer-oriented).
Thus, DiNicola is correct when calling for extensive research on “the ideology of slimness in industrialized nations and its relation to anorexia nervosa” (273). One might question the cultural hypothesis when realizing anorexia nervosa cases from the 19th century, where there was no emphasis on dieting or being thin; or in which there was no emphasis on slimness and dieting. However, the opposite is expressed in the works of the day by Pierre Auguste Renoir’s paintings, Constant Puyo and Robert Demachy’s female nude photography (182).
Mumford, Whitehouse and Choudry correctly address the thinness obsession of the 19th century subjects that “must have arisen from the individual’s internal conflicts, and not from external cultural pressures” (182).
Challenging the Culture-Bound Theory
As addressed by DiNicola, the challenge can be made to the cultural hypothesis since “historical accounts of fasting women have suggested various analogues of anorexia nervosa throughout history” (166). Additionally, he points out the onset of anorexia nervosa before puberty in some, its occurrence in males (166). “Research as of late finds “a higher percentage of boys with anorexia nervosa in prepubertal children than in older groups...27 percent” (DiNicola 253). The larger social-class distribution has been acknowledged, as well as its (eating disorders) occurrence among many different ethnic groups.
So, perhaps an over-exaggeration of the detriment of the cultural component in eating disorder etiology in the Western world has been manifested. While the emphasis by the culture on dieting may increase cases of anorexia or bulimia nervosa, the cultural pressures are not necessary to develop an eating disorder.
And, questions remain: While the explanation is given that upwardly mobile Western women (white) are more apt to diet because of their culture (pressure)--there is no explanation “why this ‘pressure’ is more prevalent in Western upper classes, nor why it selectively affects females” (DiNicola 254).
Family Organizational Patterns and Interactions: A Primary Developmental Factor?
Selecting a factor for eating disorders, one must look at family conditions. It is within the family, fundamentally, during development that the illness arises, and perhaps has its strongest precipitating cause. Paramount to the illness’ onset is the manner in which the family interacts--its organization. Though the feasibility of the family hypothesis can be seen “the focus on the individual does not lead to a model of what sorts of family conflicts trigger anorexia nervosa and relate them to observed interactional patterns” (DiNicola 182). Interaction with the family and organizational patterns are detrimental to the development of eating disorders.
The Need for Control: Fundamental
Although no real proven cause for anorexia nervosa has been documented, there is no question of the need for control in patients:
When feeling “out of control” the young women uses available coping mechanisms
in an effort to manage the perceived, and often real, threat to her emerging
identity. If it is impossible to control or master that which is painful or threatening,
then an effort is made to gain control over those facets of life that are possible to
control. Establishing a greater sense of security through compulsive, disciplined
behavior or rituals in a specific, often restricted environment helps to alleviate
the anxiety. Others cope by submitting to such pressures and instead let go--
perhaps to over indulge, regress or to escape these growing-up responsibilities
(Larocca 186-187).
OTHER FORMULATIONS
Additionally, other “causal” hypotheses have been formulated, as mentioned by DiNicola--including Biomedical, Mood Disorder, Development Psychobiological and Psychodynamic (181)..
Feminist Model
Of particular interest is the Feminist Model: “viewing eating disorders as the consequences of women’s lower status as objectified pawns in a patriarchal, male-dominated society...” (Maurer and Sobol 107). Susie Orbach felt anorexia nervosa a “hunger strike to protest against the social definition of femininity...rejecting their social roles, some women also reject their own bodies” (DiNicola 185). Kim Chernin claimed anorexia nervosa, which spread greatly as a social disease in the 1960’s, “threatened the fashion and diet industries, which responded by promulgating slimmer standards of beauty” (Maurer and Sobol 107) Chernin’s metaphor: equaling slimmer standards of attractiveness to forcing females “to make themselves smaller, to narrow themselves, to become lightweight, to lose gravity, to be-little themselves” (Maurer and Sobol 107). Through their eating disorders (according to Chernin) the female is rejecting her socialized role as a women. DiNicola makes a valid point when questioning the Feminist Model--asking: “Why does the eating disorder occur more frequently in Western societies where women have more opportunities? (185). Also, the question of the occurrence in men arises.
CONCLUDING THOUGHTS
Regardless of anorexia nervosa and bulimia’s past documentation, the eating disorders are reaching a much more widespread segment throughout the social classes. Occurrence arises not only in boys but in children of prepubertal age. And, of paramount importance: its rising spread in areas outside of the West. As aforementioned many times, family interaction and organizational patterns are detrimental to the development of eating disorders. Its prevalence in affluent societies cannot be denied. However, there are too many factors within what appears related to the illness that still need to be addressed, researched.
Related to the illness, most importantly, is the patient’s resignation of life. The anorexic nervosa patient hates himself and feels the only way he can live is through other people. That is the patient’s justification for being around. The taking away of food (to end one’s life) is the result of a battle. This battle is one that starves not only the body but the soul. How can they be of importance to anyone when they haven’t made the world perfect for all involved?
And all involved must recognize this misunderstood condition is not a disease but the manifestation of something very deep. This condition of confirmed negativity allows the patient to feel selfless. There is no identity. Decisions are difficult. The sensitivity possessed by these eating disordered to the others is incredible. The desire to give of themselves to strive for perfection is overwhelming. And their attempts to sharpen their perfection to copy the external values put forth in their society bring them down.
Furthermore, they are brought down even further in our attempts to get them to eat. For the person with anorexia nervosa/bulima thinks that every time they can’t eat as others around them would like...by making themselves okay emotionally and mentally, then they have again failed. We are wrong to treat this condition as one about food. In their failure to eat each time, they reconfirm their condition (negativitity); and, each time they don’t eat their condition will become closer to dangerous.
Dangerous most of all is the patient’s attitude for they, unconsciously, are arranging their own destruction. To concentrate on re-feeding the patient invites recidivism. After the patient admits that he is sick and needs help, small steps must be taken to build the patient’s self-confidence--to rid the subconscious suicide. Constant praise and love that is unconditional is the answer to recovery from this resignation of life. For the patients to succeed, these intuitive people must learn to love themselves. And so it doesn’t have to be to their own demise, living must be reinterpreted for them.
Reinterpreted, also, must be that this is a disease of women. Men are left out. By being overlooked, a general lack of knowledge has existed concerning their dilemma. It is almost as thought women feel, “Hey, this is my problem....you don’t belong in this!” Generally, men don’t seek help because of society’s labeling it a disease for women. Anorexic men often do not ask for help because they feel like a freak. More often than not men see themselves as simply depressed instead.
Finally, a confusion between anorexia nervosa/bulimia and depression exists. That makes perfect sense: When there is a lack of eating, depression is a natural phenomenon. Why wouldn’t one be depressed if not feeding their brain? Without food the brain is certainly changed. Again, anorexia nervosa/bulimia is not about food at all. And, it is a condition that is totally reversible with unconditional love and the reinterpretation of life.
Works Cited
Bell, Rudolph M. Holy Anorexia. Chicago: University of Chicago Press, 1985.
Brownell, Kelly D. and John P. Foreyt. Handbook of Eating Disorders. New York: Basic
Books, Inc., 1986.
Bulik, Cynthia M., et al. “Drug Use in Women with Anorexia and Bulimia Nervosa.”
International Journal of Eating Disorders 10 (1992): 213-225.
Choudry, Iffat Y, et al. “A Pilot Study of Eating Disorders in Mirpur (Pakistan) Using
an Urdu Version of the Eating Attitudes Test.” International Journal of Eating
Disorders 11 (1992): 243-251.
Darby, Padraig L., et al. Anorexia Nervosa Recent Developments in Research.
New York: Alan R. Liss, Inc., 1983.
DiNicola, Vincenzo F. “Anorexia Multiforme: Self-Starvation in Historical and
Cultural Context Part I.” Transcultural Psychiatric Review 27 (1990) 165-189.
DiNicola, Vincenzo F. “Anorexia Multiforme: Self-Starvation in Historical and Cultural
Context Part II.” Transcultural Psychiatric Review 27 (1990): 245-275.
Dolan, Bridget and Kathryn Ford. “Binge Eating and Dietary Restraint: A Cross-Cultural
Analysis.” International Journal of Eating Disorders 10 (1991): 345-353.
Dolan, Bridget. “Cross-Cultural Aspects of Anorexia Nervosa and Bulimia.”
International Journal of Eating Disorders 10 (1991): 67-78.
Ford, Kathryn. “Bulimia in an Egyptian Student: A Case Study.”
International Journal of Eating Disorders 11 (1992): 407-411.
Freeman, Richard, et al. “In the Eye of the Beholder: Processing Body Shape
Information in Anorexic and Bulimic Patients.” International Journal of Eating
Disorders 10 (1991): 9-14.
Hall, Peter and Rich Driscoll. “Anorexia in the Elderly--an Annotation.”
International Journal of Eating Disorders 14 (1994): 497-499.
Hetherington, Marion M., et al. “Eating Pathology in Bulimia Nervosa.”
International Journal of Eating Disorders 13 (1993): 13-14.
Joughin, Nel, et al. “Religious Belief and Anorexia Nervosa.”
International Journal of Eating Disorders 12 (1993): 397-406.
Kent, Andrew and J. Hubert Lacey. “Bulimia and Anorexia Nervosa Alternating with
the Seasons: A Case Report.” International Journal of Eating Disorders 11
(1992): 269-273.
Khumalo, Liz. “Black and Skinny--the New Danger.” Drum. Dec. 1995: 114-117.
Koepp, Werner, et al. “Borderline Diagnosis and Substance Abuse in Female Patients
with Eating Disorders.” International Journal of Eating Disorders 14 (1994): 107-
110.
Larocca, Felix E.F. Eating Disorders Effective Care and Treatment. St. Louis:
Ishiyaku EuroAmerica, 1986.
Ledoux, Sylvie, Marie Choquet and Martine Flament. “Eating Disorders Among
Adolescents in an Unselected French Population.” International Journal of Eating
Disorders 10 (1991): 81-89.
Maurer, Donna and Jeffery Sobol. Eating Agendas Food and Nutrition as Social
Problems. New York: Walter De Gruyter, Inc., 1995.
McKenzie, Jan M. and Peter R. Joyce. “Hospitalization for Anorexia Nervosa.”
International Journal of Eating Disorders 11 (1992): 235-241.
Mumford, David B., Andrew M. Whitehouse and Iffat Y. Choudry. “Survey of Eating
Disorders in English-Medium Schools in Lahore, Pakistan.”
International Journal of Eating Disorders 11 (1992): 173-184.
Nasser, Mervat. “A Prescription of Vomiting: Historical Footnotes.”
International Journal of Eating Disorders 13 (1993): 129-131.
Nielsen, Soren. “Seasonal Variation in Anorexia Nervosa? Some Preliminary Findings
From a Neglected Area of Research.” International Journal of Eating Disorders
11 (1992): 25-35.
Neumarker, Ursula, et al. “Eating Attitudes Among Adolescent Anorexia Nervosa
Patients and Normal Subjects in Former West and East Berlin: A Transcultural
Comparison.” International Journal of Eating Disorders 12 (1992): 281-289.
Pirke, K.M. and D. Ploog. The Psychobiology of Anorexia Nervosa. Berlin:
Springer-Verlag Berlin Heidelberg, 1984.
Raich, Rosa M., et al. “Eating Disorder Symptoms Among Adolescents in the
United States and Spain: A Comparative Study.” International Journal of
Eating Disorders 11 (1992): 63-72.
Robertson, Matra. Starving in the Silences. New York: New York University Press,
1992.
Schmidt, Ulrike. “Bulimia Nervosa in the Chinese.” International Journal of
Eating Disorders 14 (1994): 505-509.
Szekeley, Eva.. Never Too Thin. Toronto: The Women’s Press, 1988.
Vandereycken, Walter, Elly Kog, and Johan Vanderlinden. The Family Approach
to Eating Disorders. New York: PMA Publishing Corp, 1989.
Vandereycken, Walter, et al. “German Publications on Anorexia Nervosa in the
Nineteenth Century.” International Journal of Eating Disorders 10 (1991): 473-
490.
Vandereycken, Walter and Ellie Van Vreckem. “Siblings of Patients with an Eating
Disorder.” International Journal of Eating Disorders 12 (1992): 273-280.
van Strien, Din C., Thecla van der Ham and Herman van Engeland. “Dropout
Characteristics in a Follow-up Study of 90 Eating-Disordered Patients.”
International Journal of Eating Disorders 12 (1992): 341-343.
Waller, Glenn. “Sexual Abuse and Bulimic Symptoms in Eating Disorders: Do Family
Interaction and Self-Esteem Explain the Links?” International Journal of
Eating Disorders 12 (1992): 235-240.
No comments:
New comments are not allowed.