Like all eating disorders, anorexia is in a significant sense both a mental illness and a physical one. Its physical facets are more significant than those of some other eating disorders, such as binge-eating disorder and bulimia, because of the physiological-psychological feedback loop which is initiated as the body is starved. (The equivalent is observed in eating disorders leading to obesity, which has its own set of physical and mental consequences.) I've discussed in a previous post how the simple fact of physical starvation (or semi-starvation) can account for most of the symptoms of anorexia, from preoccupation with food to depression, low self-esteem, and inflexible thought patterns. All this means that in one sense the progression of anorexia rapidly evades the control of the sufferer: the obsession with food that accompanies starvation, for example, is not a straightforward desire to eat, but often involves the postponement and prolonging of eating, the hoarding of food, pleasure in watching others eat, and disgust or rapid satiety due to stomach shrinkage and other internal damage. Similarly, decreased self-esteem can make food seem something that is undeserved, or thinness the only thing that gives one value. Similar observations can be made of most of the symptoms of starvation and seem to point towards the conclusion that the anorexic is the victim of a disease which comes to control his or her mind and body and makes recovery if not impossible, then certainly very difficult. As I'll go on to suggest later in this post, however, it is possible to break out of this vicious circle of physiological and psychological cause and effect by making a simple series of decisions.
The interactions between the physical and the mental are complicated in anorexia as they are in other illnesses and in health: a certain mental state may bring about an inclination to eat less; hormonal responses to hunger may create a form of addiction to the 'hunger high'; feedback from society may encourage weight loss; prolonged inadequate intake may alter appetite and food preferences via bodily changes; bodily changes may in turn alter one's self-perception and social identity, and so on. Again, though, this complex intertwining need not mean that the sufferer must remain trapped by anorexia.
Here it may be useful to think about anorexia in the context of other physical and mental disorders, and to think about the factors that affect the beginning of anorexia and its ending. All illnesses and disorders are affected by both heredity and environment, and might be located somewhere on a spectrum according to the extent to which environment, lifestyle choices, and/or what we might call 'personal responsibility' play a role, in terms of precipitating or avoiding the illness - including heritable genetic disorders, for example, and heart disease with genetic predisposition to metabolic syndrome. (The question of how much environmental factors overlap with lifestyle factors, and these latter with personal decisions, is itself complex, but the issues especially relevant to anorexia are discussed below.) There is also another spectrum, overlapping with but distinct from the first one, which maps the distinction between illnesses that can be recovered from by successful intervention, and those which are terminal and/or untreatable. A given disorder may be highly heritable and untreatable, highly heritable and treatable, minimally heritable and treatable, or minimally heritable and untreatable.
Anorexia is highly treatable, and the core of its treatment is extremely simple. There is no need for complex and expensive drugs (although antidepressants are often prescribed to elevate mood and aid commitment to recovery), the risk of side-effects is real but manageable, and both physical and mental damage, from osteoporosis to depression, can often be wholly reversed, while precursors or contributing causes of the illness - perfectionism, anxiety, etc. - can be better managed when anorexia is no longer present. In my own case, although perfectionism and anxiety are still part of my life, I understand their dangerous potential better for having had anorexia and recovered from it, and see the process of gradually extricating myself from their grip as a continuation of my recovery from anorexia - as something which can be tackled bit by bit, and which gets easier as the years of anorexia recede further.
It is always difficult to disentangle genetic and environmental factors, and in anorexia there has generally been an overemphasis on social and familial factors at the expense of genetic ones: the espousal of the thin ideal in the fashion industry and the media has perhaps most notably been blamed, as has exposure to the disordered eating of family members. As Bulik (2005: 336) notes, 'Patients with eating disorders have consistently reported the presence of either frank eating disorders or suggestive traits in family members. Most commonly, the clinician hears of a relative who ate exceedingly sparingly or had quirky eating behaviours.' However, this need not necessarily mean that such environmental exposure is solely responsible for the development of an eating disorder in a relative. Studies using twins have yielded heritability estimates for anorexia nervosa ranging from 33% to 84% - although this is a broad estimate, there does seem to be a critical genetic risk for the disorder. Seen in interaction with environmental factors, we come closer to understanding why not everyone exposed to images of skeletal fashion models develops anorexia:
'According to [the gene-environment interaction] model, individuals are differentially vulnerable to an insult such as strict dieting because of differences in their genotypes; this differential vulnerability could then be the first step in the development of anorexia nervosa. For example, those with lesser genetic loading for this vulnerability might see slender models, try dieting, find it an aversive experience and return to normal eating. In contrast, those with a greater genetic vulnerability might find dieting to be particularly reinforcing - either by reducing negative or dysphoric affect or by providing a sense of control or accomplishment. These individuals, with their particular genotype and biologic and psychologic responses to dieting, would be at greater risk for anorexia nervosa' (Bulik, 2005: 337).
Other aspects of this model include the perpetuation of anorexia through generations, as premature birth and low birth weight increase the risk of anorexia, and anorexia in turn makes premature and low-weight birth more likely.
Some of these environmental risk factors can be reduced by, for instance, minimising one's own contact with images of very thin men and women (avoiding fashion magazines and certain TV programmes, etc.), or even distancing oneself from a friend or relative whose attitudes to food are upsetting. I'll conclude by exploring the most potent tactic of all: challenging the reinforcing effects of 'dieting' or starvation.
A reader recently made a comment which prompted me to write this post. She said that 'anorexia, despite being a "disease", also involves a series of very
bad decisions, for which we as the sufferers must bear some responsibility'. This made me reflect on my own experience, and the various 'points of no return' at which the development of full-blown anorexia became significantly more likely: the day on which I stopped eating breakfast, and started lying about having eaten it; the day when, after months of successfully regaining weight and practising healthier eating habits, I dealt with a difficult few months with relatives in Switzerland by reverting to my old ways; the day I decided that hot properly cooked food - pasta with a vegetable sauce and sprinkled with nuts or cheese - would no longer be part of my rotating menu of dishes, because there was too much potential for interruption when making it, and because I enjoyed it less than cereal; and many others of a similar nature, some more closely related to social interactions or academic concerns than to eating itself.
