Dr Pulkit Sharma explores why a large number of women are vulnerable to these disorders owing to the contemporary culture of being thin.
Charu’s parents reported that as a child she was ‘extremely well-adjusted’ and obedient. She was a high achiever throughout and lived harmoniously with everyone. As she entered adolescence, Charu began feeling that she was turning fat and ugly. She idealized a particular film actress who looked very slim and pretty and Charu wished to have a body like that. She started reducing her food intake, reading about diets and calories in newspapers and magazines. Her academic performance declined as she made a long daily routine of heavy exercise, yoga and special diets. She started cooking for herself and took great care to prepare low calorie food. Each day she would scan her body in front of a huge mirror and though she felt that she had become thin, she was distressed by the ‘fat deposits’ on her abdomen and thighs and wished to reduce them by continuing her daily routine. Charu looked pale and fragile and was grossly underweight by the time her parents realized that her behavior was more than a drive for thinness. When they confronted her she denied that she had a problem and refused to see a clinical psychologist. Nevertheless, her parents got her for counseling and throughout the session she kept on asserting that she was fine and would be happy if she lost those few fat deposits. She was scared as she thought that the psychologist would force her to eat.
Eating disorders are more common in women than men and they usually begin in adolescence or young adulthood. However, the number of older women afflicted by eating disorders is on rise than before. The commonsensical view of eating disorders is that they are problems with food and eating. Though that is exactly what they look like at the surface or behaviorally, they are an expression of deep-seated underlying conflicts and personality problems. The body becomes a medium for expression of these underlying problems.
A large number of women are vulnerable to these disorders owing to the value the contemporary culture places on being thin. In present times, being slim for women has come to be associated with the unreachable ideal of beauty. Physical appearance and slimness is overloaded with value. ‘Thin’ and ‘fat’ seem to represent ‘good’ and ‘bad’, ‘desirable’ and ‘undesirable’ or ‘positive’ and ‘negative.’ Girls and women idealize and envy fashion models with size zero and feel a lot of pressure to be thin. They believe that they will get everything: love, success, happiness and admiration once they are thin. However, once again it needs to be highlighted that eating disorders are not just heightened desires for slimness but complex psychological disturbances.
Types of eating disorders
The person typically declines to maintain even the minimal normal body weight for age and height (body weight is less than 85% of that expected). She lives in a constant fear of gaining weight and becoming obese even though realistically she is underweight and thin. This is because she has a disturbed experience of her own body weight and shape; her mind cannot see what she really looks like. Some patients feel that they are overall overweight while others find themselves thin but are bothered by some body parts where they still find fat deposits. Their attempts to get thinner are severe and they keep on avoiding food even if it implies a close brush with death. Due to loss of weight and disturbed eating pattern there may be an absence or long delays in the menstrual cycles.
These patients derive a sense of self-worth and self-control through weight loss. They are perfectionists and set high standards for their self which they must realize. These standards inevitably revolve around weight loss. These patients continue to live in denial, either they do not see that they are in fact thin or they fail to acknowledge the serious medical complications of weight loss and thinness. There are two types of this disorder: Restricting type (the person does not indulge in binge eating or purging but loses weight mainly through dieting, fasting or excessive exercise) and Bing-Eating/ purging type (the person binges, purges or does both). They do not like the idea of treatment as they feel that it would force them to eat.
Following are the observable signs and behaviors of anorexia nervosa which may indicate that your friend/relative is possibly suffering from the disorder: significant weight loss, withdrawn behavior, frequent weight checks, irritability, labile mood, excessive exercise, consuming only diet foods, fatigability, attempts to hide body, pale complexion, episodes of loss of consciousness, over concern with food and calories, skipping meals and making excuses, slow eating and cutting food into tiny pieces.
The person has repetitive cycles of binge eating followed by compensatory undoing. The cycle starts with the person experiencing voracious appetite and consuming huge amounts of eatables in a discrete time period. In this phase she cannot stop eating no matter how hard she may try and experiences a loss of control over her eating. The food that is binged is usually junk food. Immediately after the binge, the person may feel very relaxed for a short while. After this phase, she feels very guilty and scared and indulges in compensatory behaviors to undo the ‘damage.’ These compensatory behaviors are aimed at elimination of the excess calories from the body and include fasting, excessive exercise, self-induced vomiting, misusing laxatives, enemas or diuretics. The person’s self-concept is heavily determined by her body weight and shape. Patients with this disorder feel very embarrassed and keep these symptoms under closet.
There are two types of this disorder: Purging type (the person routinely engages in self-induced vomiting or misuse of laxatives, diuretics and enemas) and Nonpurging type (to rid the body of excess calories the person uses methods other than purging such as dieting and excessive exercise).
It is very difficult to know whether your close one is suffering from bulimia nervosa as the person appears to eat and look normal and has normal weight. Following are the observable signs and behaviors of bulimia nervosa which may indicate that your friend/relative is possibly suffering from the disorder: loss of control over eating, excessive exercise, strict fasting and dieting, over concern with body weight and calories, irritability and labile mood, frequent trips to bathroom after the meals, fatigability, swollen face, dental problems and bloodshot eyes.
Binge-Eating: The person has episodes of binge eating during which she loses control, experiences voracious appetite and consumes huge amounts of eatables in a discrete time period. Women with this disorder may consume around 15000-20000 calories during a single binge. However, unlike bulimia nervosa she does not attempt to undo this action and as a result a majority of women with this problem are obese or overweight. The individual may feel uncomfortably full, eat alone and feel extremely disgusted after eating.
Feelings of loneliness, stress, depression may precipitate a binge as the person fills herself with food and avoids feeling painful emotions. Following are the observable signs and behaviors of binge eating which may indicate that your friend/relative is possibly suffering from the disorder: loss of control over eating, significant weight gain, hiding food, going on different diets and fluctuations in body weight.
Split between mind and body: Eating disorders are not normal problems with food, diet or the drive for slimness but there seem to be deep-seated unconscious conflicts which the person is simply not aware of. The individual feels scared of intense emotions as she fears a loss of control. Therefore she may not make a genuine interpersonal contact. The person cannot experience her emotions and articulate them and therefore uses her body as a vehicle to express the emotions in a concrete way. Binging, starving and purging become primitive ways of achieving emotional catharsis. Difficult internal states are externalized by expressing them in food and concern with body.
Conflict between dependence and autonomy: As children, these women felt that others imposed their needs and wishes on them and they failed to develop a coherent boundary of self. This results in a huge conflict wherein the person on one hand feels extremely weak and dependent on others but at the same time hates this and struggles to achieve autonomy by the paradoxical mechanism of exercising harsh control on her own body.
Cultural drive for slimness: The cultural accent on slimness provides a background which interacts with personality issues of the individual and creates vulnerability for these disorders.
Faulty family environment: Some people suffering from eating disorders as children lived in families where unreachable ideals were set for them. The family environment did not provide the ‘freedom to be’ to these individuals and they felt confined and enslaved. In such families there is hardly any space for experiencing and expressing emotions such as anger, happiness, sadness, fear or joy. The grown up adult continues to be afraid of imperfection and strives for perfection. The person feels that she will not be loved for what she is but for her appearance. She experiences intense anger towards significant people in her life and she denies it.
Child sexual abuse: Girls who experience physical, emotional or sexual abuse and neglect during childhood may be at a greater risk of developing eating disorders. The disorder helps them establish a false sense of control, direct their anger towards the self and deal with the painful emotions resulting from the abusive experience.
Personality factors: At the core of the self the individual feels unloved and rejected. The whole personality is engulfed by feelings of despair and abandonment. The individual suffers from low self-esteem and feels that she is unworthy, useless and ugly. Individuals suffering from eating disorders also tend to have low tolerance for frustration. Along with this, they tend to have unreasonably high expectations of themselves in all spheres of their lives.
Genetic factors: There may be a genetic predisposition to some of the eating disorders. Monozygotic twins have higher concordance rates for some of the eating disorders as compared to dizygotic twins. The first degree biological relatives of patients with eating disorders have a greater lifetime proneness to suffer from these disorders.
Teenage: During adolescence the body undergoes various changes and psychologically there are demands for separation and carving out an individual identity. These are experienced as highly stressful by many girls and may lead to eating disorders. Some girls are threatened by prospects of sexuality and womanhood and reduce their food intake to retain the child-like appearance and innocence. Other teenagers get influenced by fashion models and feel that they must be thin and look good to be loved, accepted and admired by others.
Older women: Some older women who find that their husbands are having an extramarital affair or do not take interest in sex may blame their looks and excessive body fat and develop a strong preoccupation with it. As children grow up and individuate many women feel a vacuum in their life and to fill in this void they may develop a strong preoccupation with food and body weight.
Concomitant Physiological Problems
Eating disorders have far reaching adverse consequences for the individual’s physical and physiological health. Osteoporosis, menstrual irregularities, infertility, difficult pregnancy, miscarriages, fetal complications, cardiac complications, electrolyte disturbances, renal abnormalities, dental complications and early death may occur in individuals suffering from eating disorders.
If your close one is suffering from an eating disorder be prepared for extreme denial. The person will rarely agree that she has a problem and would try her best to convince you that she is just trying to appear good and once she has lost weight everything would be fine. Rather, than harshly confronting the person respond with care and concern and make the person agree to see a mental health professional. In severe cases an inpatient and multidisciplinary treatment is advised. In the initial phase of treatment, the major emphasis is on facilitating weight gain. Certain antidepressant medications may also help. After this has been achieved, body image disturbances and factors that maintain the disorder are targeted by psychotherapy. Cognitive-behavior therapy restructures the faulty thought patterns which maintain the problematic behavior and uses additional behavior management techniques to develop self-control. Psychodynamic therapy does not specifically target the symptoms of eating disorder but works through the underlying conflicts that lead to eating disorders. The patients with eating disorders tend to drop out in between the treatment and there are frequent relapses if the treatment is not carried out fully. These patients benefit more if treated early when the problem has just begun.
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