[Content note: eating disorders]

Anorexia has a cultural component. I’m usually reluctant to assume anything is cultural – every mediocre social scientist’s first instinct is always to come up with a cultural explanation which is simple, seductive, flattering to all our existing prejudices, and wrong. But after seeing enough ballerinas and cheerleaders who became anorexic after pressure to lose weight for the big competition, even I have to throw up my hands and admit anorexia has a cultural component.

But nobody ever tells you the sequel. That ballerina who’s losing weight for the big competition at age 16? At age 26, she’s long since quit ballet, worried it would exacerbate her anorexia. She’s been in therapy for ten years; for eight of them she’s admitted she has a problem, that her anorexia is destroying her life. Her romantic partners – the ones she was trying to get thin to impress – have long since left her because she looks skeletal and weird. She understands this and would do anything to cure her anorexia and be a normal weight again. But she finds she isn’t hungry. She hasn’t eaten in two days and she isn’t hungry. In fact, the thought of food sickens her. She goes to increasingly expert therapists and dieticians, asking them to help her eat more. They recommend all the usual indulgences: ice cream, french fries, cookies. She tries all of them and finds them inexplicably disgusting. Sometimes with a prodigious effort of will she will manage to finish one cookie, and congratulate herself, but the next day she finds the task of eating dessert as daunting as ever. Finally, after many years of hard work, she is scraping the bottom end of normal weight by keeping to a diet so regimented it would make a Prussian general blush.

And nobody ever tells you about all the people who weren’t ballerinas. The young man who stops eating because it gives him a thrill of virtue and superiority to be able to demonstrate such willpower. The young woman who stops eating in order to show her family how much their neglect hurts her. If they pursue their lack of appetite far enough, they end up the same way as the ballerina – admitting they have a problem, admitting they need to eat more, hiring all sorts of doctors and dieticians to find them a way to eat more, but discovering themselves incapable of doing so.

And this is why I can’t subscribe to a purely cultural narrative of anorexia. How does “ballerinas are told they should be thin in order to be pretty” explain so many former ballerinas who want to gain weight but can’t? And how does it explain the weird, almost neurological stuff like how anorexic people will mis-estimate their ability to fit through doors?

All of this makes much more sense in a biological context; it’s as if the same system that is broken in obese people who cannot lose weight no matter how hard they try, is broken in anorexics who cannot gain weight no matter how hard they try. There are plenty of biological models for what this might mean. But then the question becomes: how do we reconcile the obviously cultural part where it disproportionately happens to ballerinas, to the probably biological part where the hypothalamus changes its weight set point?

I’m grateful to Professor del Giudice and Evolutionary Psychopathologyfor presenting the only reasonable discussion of this I have heard, which I quote here basically in its entirety:

The self-starvation cycle arises in predisposed individuals following an initial phase of food restriction and weight loss. Food restriction may be initially prompted by a variety of motives, from weight concerns and a desire for thinness to health-related or religious ideas (eg spiritual purity, ascetic self-denial). In fact, the cycle may even be started by involuntary weight loss due to physical illness. While fasting and exercise are initially aversive, they gradually become rewarding – even addictive – as the starvation response kicks in. At the same time, restricting behaviors that used to be deliberate become increasingly automatic, habitual, and difficult to interrupt (Dwyer et al, 2001; Guarda et al, 2015; Lock & Kirz, 2013; McGuire & Troisi 1998). The self-starvation cycle plays a crucial role in the onset of anorexia. Increased physical activity is a key component of the starvation response in many animal species; in general, its function is to prompt exploration and extend the foraging range when food is scarce. This response is so ingrained that animals subjected to food restriction in conditions that allow physical activity often starve themselves to death through strenuous exercise (Fessler, 2002; Guarda et al, 2015; Scheurink et al, 2010). In humans, pride is a powerful additional rewrad of self-starvation – achieving extraordinary levels of thinness and self-control makes many anorexic patients feel special and superior (Allan & Goss, 2012). The starvation response also brings about some psychological changes that further contribute to reinforce the cycle. In particular, starvation dramatically interferes with executive flexibility/shifting, and patterns of behavior become increasingly rigid and inflexible. The balance between local and global processing is also shifted toward local details. This may contribute to common body image distortions in anorexia, as when patients focus obsessively on a specific body part (eg the neck or hips) but preceive themselves as globally overweight (Pender et al, 2014; Westwood et al; 2016). The self-starvation cycle has been documented across time and cultures, including non-Western ones. In modern Western societies, concerns with fat and thinness are the main reason for weight loss and probably explain the moderate rise of AN incidence around the second half of the 20th century. However, cases of self-starvation with spiritual and religious motivations have been common in Europe at least since the Middle Ages (and include several Catholic saints, most famously St. Catherine of Siena). In some Asian cultures, digestive discomfort is often cited as the initial reason for restricting food intake, but the resulting syndrome has essentially the same symptoms as anorexia in Western countries (Bell, 1984; Brumberg, 1989; Culbert et al, 2015; Keel & Klump, 2003). The DSM-5 criteria for anorexia include fear of gaining weight as a diagnostic requirement; for this reason, most historical and non-Western cases would not be diagnosed as AN within the current system. However, the present emphasis on thinness is likely a contingent sociohistorical fact and does not seem to represent a necessary feature of the disorder. (Keel & Klump, 2003)

My anorexic patients sometimes complain of being forced into this mold. They’ll try to go to therapy for their inability to eat a reasonable amount of food, and their therapist will want to spend the whole time talking about their body image issues. When they complain they don’t really have body image issues, they’ll get accused of repressing it. Eventually they’ll just say “Yeah, whatever, I secretly wanted to be a ballerina” in order to make the therapist shut up and get to the part where maybe treatment happens.

The clear weak part of this theory is the explanation of the “self-starvation cycle”. Aside from a point about animals sometimes having increased activity to go explore for food, it all seems kind of tenuous.

And how come most people who starve never get anorexia? How come sailors who ran out of food halfway across the Pacific, barely made it to some tropical island, and gorged themselves on coconuts didn’t end up anorexic? Donner Party members? Concentration camp survivors? Is there something special about voluntary starvation? Some kind of messed-up learning process?

I am interpreting the point to be something along the lines of “Suppose for some people with some unknown pre-existing vulnerability, starving themselves voluntarily now flips some biological switch which makes them starve themselves involuntarily later”.

Framed like this, it sounds more like a description of anorexia than a theory about it (though see here for an attempt to flesh this out). But it’s a description which captures part of the disease that a lot of other models don’t, and which brings some things into clearer relief, and I am grateful to have it.