As many of you already know, Vogue has recently banned models that are “too-thin” (and “too young”). It is a big step in the right direction, no, a huge step, and one deserving an applause, that’s according to an article on allvoices.com. Cue a drop in the prevalence of eating disorders, right? The logic in most articles, whether implicit or explicit, seems to be: no more skinny models = no more girls aspiring to be like skinny models = no more eating disorders.

Health of models belonging to both genders has been a growing issue in the past, especially after the death of two models in 2006-2007 from what the doctors blame to their acute eating disorders. This important step by Vogue targets not just skinny models, but also the impact they have on the young minds of girls and boys by presenting an image of perfection that is neither attainable nor healthy.

The 19 editors of Vogue magazines around the world made a pact to project the image of healthy models….. They agreed to “not knowingly work with models under the age of 16 or who appear to have an eating disorder,“…. “Vogue believes that good health is beautiful. Vogue Editors… want the magazines to reflect their commitment to the health of the models who appear on the pages… The primary fashion organizations in Italy and Spain banned catwalk models who fall below a certain Body Mass Index level.

Sounds more like a PR move to me, but OK. I do have some questions and thoughts:

What does “appear[ing] to have an eating disorder” mean? Bulimics, by definition, are of normal weight or overweight. Conversely, being thin doesn’t mean having an eating disorder.

BMI above or below a certain number is not a marker of “good health”. BMI demarcations are not scientifically derived and were never meant to be applied on an individual basis.

Finally, this perpetuates the idea that looking at skinny models for too long leads to an eating disorder. It doesn’t. Okay, no one has said it explicitly, but nearly every article mentions ED-related deaths, and the impact on young impressionable girls. Images of thin models may perpetuate the drive for thinness in those already struggling with an eating disorder, but it certainly doesn’t cause an eating disorder. Does it influence a non-eating disordered person’s idea of beauty, their self-esteem and feelings toward their body? I don’t doubt it. But an eating disorder is not the same as an extreme diet.

One naturally arising prediction from the theory that “our thin-obsessed society causes eating disorders” is that visually impaired individuals, especially those blind from birth, will be immune to eating disorders. (There are, of course, many other predictions, I’ll save them for future posts.)

So, I was kind of excited to come across a few case reports of eating disorders in blind patients. Unfortunately, quite a few are from the early-to-mid 1980’s and are not available on-line. I thought it would be interesting to write about them, because it is not something that I’ve seen written about or discussed in the popular press (but I haven’t read everything ever published on EDs). Keep in mind, there are tons more cases I don’t have time to mention.

*** Warning: I took out all of the numbers from the quotes, BUT some of the content below may be triggering, particularly for SI

Case 1: 27 year-old blind woman with AN (Yager, 1986)

Background

Completely blind by age two, she led a very troubled and unhappy childhood, encountering a lot of bullying at school. Her parents, both alcoholics, were always fighting. They divorced when she was 6, remarried at 10, and then divorced again when she was 20. From an early age, she was pressured/encouraged to eat more (“she would claim not to like certain foods, even if she did, because she didn’t like being forced to eat”). This led to a strong aversion to food due to the sound of their name (even if she liked the taste), and she “rarely tried new food after the age of six”. When she learned that her father had been unfaithful to her mother, developed the idea that “men cheat and try to control you”. One of her grandparents had committed suicide and an uncle died of alcohol-related cirrhosis. Her oldest sister had periodic episodes of binge eating, was always overweight and perpetually dieting. Her other sister had run-away and at one point was addicted to drugs, but later settled down.

At 13 she began to menstruate and develop physically, and became horrified by the idea that she might start to get fat… Her first periods frightened her very much, and subsequently she has welcomed the amenorrhea resulting from her weight loss as a boon.

At 18, She gained independence and studied at a music school, but after being abruptly discharged from the university without a reasonable explanation (“because of her blindness, the teachers didn’t know quite how to handle her”), she had a nervous breakdown and became severely depressed. She began cutting her wrists, deeply enough to require sutures, and developed the idea that the wounds needed to stay open or else she would be a “bad person”.

At this hospital she first encountered women with AN, and initially thought they were “very weird”. During this period the idea that she needed to lose weight first took hold [(though she had never attained a normal adult weight)….While in hospital she dieted down to xx kg, and felt that she was “bad” when her weight increased… Over the next four years she had five additional admissions for impulsive suicidal behaviour.

At the time she was referred for evaluation of AN:

At [a low weight] she felt far too fat, and was so terrified and depressed by her weight gain that she frequently felt suicidal. She did [several] hours per day of aerobic exercises, depending on her weight; she also bought a computerised talking scale that called out her weight, and weighed herself several times a day… She used two types of diuretic tablets, many over-the-counter diet pills, and one or more enemas on a daily basis for at least two years…. her daily caloric intake was [very low] – primarily in the form of vegetables….. She began to experience herself as fat through tactile exploration of her arms and her legs, but her perceptions of her limbs were inconstant: “sometimes they felt thin, and sometimes they didn’t, changing sometimes from minute to minute or hour to hour”. She was aware that some of the changes were actually related to fluid shifts rather than fat. But, she said, “anything that is weight I don’t like. When I feel fat I get depressed and suicidal.” During this period she was chronically depressed, and was given the DSM-III diagnosis of atypical depression… She made additional multiple suicide attempts. . .

She was treated with many different drugs (antidepressants, lithium, and many others), including 12 sessions of ECT, with no effect. She maintained a low weight and remained terrified of weight gain.

The discussion in this and other case reports is quite interesting. There is usually an implicit suggestion that bad mother or troubled family life is a huge/main factor in leading to the ED (which may be true in these cases, but certainly not true for all ED cases). While no discussion seems to mention genetic factors, most state quite explicitly that continuous visual exposure to the “thin-ideal” is not necessary for the development of an ED.

… the meticulous records she kept regarding her intake. Her fussiness with food, use of food in control struggles with her parents during childhood, and weight preoccupation during early adolescence all provided a background of vulnerability. Her subsequent AN coalesced during a time when she was without a sense of direction or purpose – when her sense of self, always shaky at best, was lowest since she was no longer a musician or university student; AN then provided her with an identity, at a time when she desperately needed one… The perfectionistic strivings she had as a student and musician, the presence of binge eating episodes in one sister, and the harsh, critical nature of her father are all possible contributing factors.

Case 2: Rita (Vandereycken, 1986)

Background

Rita was visual impairment since birth (myopia and congenital nystagmus with distant vision of 1/20 after correction). Her parents had a “problematic” marriage, with her father in continuous psychiatric treatment due to chronic depression. Rita excelled at school and was described as a “perfectionistic girl with a strong fear of failure”. She was admitted to hospital for anorexia nervosa at the age of 17 (in 1978).

She started losing weight I year before through a severe diet. The parents ascribed the weight loss to Rita’s unusual efforts at school. During the summer holidays, the family physician intervened and Rita gained weight… but apparently because of binge eating [that is more common than you may think]. As soon as school resumed, she began dieting again and also vomiting after her mother tried to feed her. She was physically hyperactive and had more and more difficulties in studying since she became obsessed by food and body shape. Because of progressive weight loss and increasing conflicts at home, she was hospitalized in our special unit.. She was extremely dependent upon her mother without whom she felt completely helpless. But, at the same time, she became more often irritated by her mother’s overprotectiveness towards her…

The author concludes, with seemingly very little thought on the matter, with:

So, after all, it was the anorexia nervosa that appeared to express the inescapable attachment-autonomy conflict …

And while that conclusion doesn’t seem wholly justifiable, and ignores the genetic and biological factors, these case studies illustrate the fact that there’s more to eating disorders than wanting to be thin like a model. Actually, in most cases, it has nothing to do with wanting to be like a model.

Case 3: Claire (Vandereyhen, 1986)

Background

Claire was born blind. She was “a model child”, very intelligent and accomplished. However, at 14, shortly after starting menarche, she was told by a physician that she was “a bit too heavy” (she was overweight). This prompted dieting, and like all the other tasks she undertook, she was quite successful. She was initially praised for it, but soon those around her began to express concern. This, however, fuelled her drive to lose more weight. She became hyperactive and very pre-occupied with food and weight (to the point of it severely interfering with school work).

At the moment she showed amenorrhea, the parents went to the family physician who referred her to a psychiatrist. An outpatient treatment, including a weight restoration program, was tried but Claire refused to cooperate (she felt “healthy and happy” with her appearance). The weight loss continued until she went below xx kg at which time she suddenly became afraid that something could go wrong with her body.

At that point, she was admitted to a hospital. Initially, she acted as autonomously as possible, but felt self-conscious and depressed about her handicap. She showed no improvement.

…until a dramatic family session wherein the parents, encouraged by the therapist, overtly expressed their strong guilt feelings about her handicap in Claire’s presence. From that moment on, Claire recovered remarkably. She is 16 now and left the hospital 6 months ago….. Both Claire and her parents, though facing the problems far more realistically, are still uncertain as to the future and prefer to have regular family sessions with us.

In the discussion, Vandereycken states that although the idea that “body image distortion and cultural valuation of thinness” are very important in leading to AN, it “starts from unjustified premises.”

First, the assumption that overestimation of body width is a typical and pathognomonic [characteristic of a disease] sign of anorexia nervosa has never been proven. Since it also occurs in females other than anorexics, Hsu’ even suggested to delete disturbance of body image from the diagnostic criteria for anorexia nervosa. But then another mistake is made (by Hsu as well as by Quigley and Doane), notably to equate body image with body estimation. All experimental studies on body image in anorexia nervosa largely rely upon the external or visual perception (exteroception) of one’s own body or bodily appearance while ignoring other factors such as interception, proprioception, and cognition. When an anorexic claims to ‘feel fat’ even when emaciated, this phenomenon is far more complex than simply misjudging bodily dimensions. Another false premise is to consider body image disturbance as an etiological factor in anorexia nervosa; we still don’t know whether it is a primary or secondary phenomenon (e.g., a consequence of self-starvation). It is equally simplistic to assume that cultural influences, such as the overvaluation of thinness, causes serious eating disorders like bulimia and anorexia nervosa: “Culture is mediated by the psychology of the individual as well as the more immediate social context of the family”’ (p. 81). But it does make sense to presume that the current culture of slenderness has contributed to an increase of eating disorders.8 Anorexia nervosa, however, can only be understood from a multidimensional, biopsychosocial viewpoint. It is the final common pathway of a number of predisposing, precipitating, and perpetuating factors. Looking for the ‘adolescent- at-risk’,’ any kind of dieting behavior might be suspicious for being potentially the first step in the downward spiralling of a pursuit of thinness when some combination of the following factors is present: accentuated weight sensitivity, adolescent attachment-autonomy conflicts, interpersonal problems, stress and failure experiences, and perfectionist tendencies.”

I really like the point they make about body image disturbance not necessarily being an etiological factor.

Personally, I never had body image distortions, felt “fat” or wanted to lose weight until I was deep in anorexia. It was only when I realized that I might have a problem, and decided to get help, that it hit me. The fear of weight gain, the inability to eat more, and the deterioration of my body image.

I wanted to gain weight. I wanted to be normal. To eat like a normal person. I couldn’t, and I kept losing weight.

My body image (my sense of my body, how I saw myself in the mirror, the accuracy of my self-perception compared to my actual size, etc) was never as bad as it was when I first lost weight due to anorexia. I never had body image issues, felt “too fat” or wanted consciously to lose weight UNTIL I was already anorexic (by DSM-IV criteria).

Case 4: anorexia nervosa in a 19 year old woman totally blind since birth (Touyz, 1988)

Background

Also blind at birth, she was first admitted to hospital after drug overdose, following argument with parents about her eating behaviours. As a child, she had eating problems, refusing to eat solid foods until about the age of 6 or 7. Like others, she had above average intelligence. And although she initially denied any serious problems, she later opened up and blamed her father’s alcohol abuse and mother’s interest in her food intake as reasons for her dieting. She limited herself to a very, very low number of calories a day and partook in excessive exercise which followed a tightly scheduled regimen. Moreover, she abused laxatives and engaged in self-induced vomiting.

A comment by her mother that she looked “a bit overweight” was given as the original cause for her dieting. She stated that “Mum can see me, I can’t see myself”. A cousin who also had a diagnosis of anorexia nervosa was said to have “put me on the right track” and she was very satisfied that she won a bet with her cousin that she could lose xx kg in 4 weeks.

She became “terrified that she might lose control of any weight gain if she changed her habits, and increasingly depressed”.

Shortly after her menarche at age 14, she was sexually molested by a male teacher at the blind school who would “touch her” and she refused to attend school for some months. Eventually she confided the information to a trusted head teacher, who dismissed the man involved. To her great embarrassment and humiliation, she found that her parents and the whole school had come to learn of the event. She had had no sexual experience since, and was discouraged by her parents from going-out with any of her friends…. She continued to be repelled by her menstruation... She “did not want to get too deep and meaningful, it could be dangerous”. When asked to explain, she said, “I’ve trusted people before and I’ve got hurt. If someone knows your deepest secrets you’ve got no control” . . .

The discussion in this case study is limited, with the authors essentially blaming family dynamics:

The patient’s weight loss began in the context of her striving for autonomy and individuation. Her mother’s overprotectiveness had intensified during her late adolescence….

Case 5: Blindness and Bulimia (Fernandez-Aranda, 2006)

We report a single diagnosed and treated case of BN in a blind, 47-year-old Spanish woman. This case presented as its main characteristics the late onset of the ED, restrictive dieting, bingeing, and consequent purging behavior characterized by vomiting and great difficulties of coping with stress. From the beginning, the woman’s body image was not essential.. Since the age of 43 years (onset of the ED), the patient described the presence of … bingeing and vomiting episodes, which were frequently triggered by psychosocial stressors. In addition, due to psychosocial stressors, anxious and depressive symptoms were constantly present. During the last 4 years, the patient had gained >xx kg. Before this weight gain, the patient had exhibited a lower weight and revealed that during the time when she was thinner, she neither exhibited any body image concerns nor wanted to lose weight.

What do Fernandez-Aranda et al conclude?

In the current case, the ED seems to be a consequence of inappropriate coping skills with stress. .. in many cases, the ED is not due to an overemphasis on physical attractiveness, but to a personal difficulty to cope with stress… the onset of the patient’s ED was not associated with her body shape dissatisfaction…

I have my own thoughts on these case studies and the discussions in the papers, but, I’m wondering what do you guys think about these cases? Is there anything that is surprising in these cases and the authors’ interpretations? Share any thoughts you have!

Follow-up can be found here.

References

Fernández-Aranda F, Crespo JM, Jiménez-Murcia S, Krug I, & Vallejo-Ruiloba J (2006). Blindness and bulimia nervosa: a description of a case report and its treatment. The International Journal of Eating Disorders, 39 (3), 263-5 PMID: 16498584

Touyz, S., O’Sullivan, B., Gertler, R., & Beumont, P. (1988). Anorexia nervosa in a woman totally blind since birth The British Journal of Psychiatry, 153 (2), 248-250 DOI: 10.1192/bjp.153.2.248

Vandereycken, W. (1986). Anorexia nervosa and visual impairment Comprehensive Psychiatry, 27 (6), 545-548 DOI: 10.1016/0010-440X(86)90058-1

Yager, J., Hatton, C., & Ma, L. (1986). Anorexia nervosa in a woman totally blind since the age of two The British Journal of Psychiatry, 149 (4), 506-509 DOI: 10.1192/bjp.149.4.506