CHAPTER THREE: PSYCHOLOGICAL PRECIPITANTS
So far we have seen how disturbed eating patterns are created by the social expectation of thinness and exist for a great majority of the population. However, the pathological extreme to which the eating disorder patient pursues thinness suggests psychological precipitants as well. Garner et al state that “extensive clinical and empirical evidence indicates that psychological disturbance is central to the development of anorexia nervosa and bulimia in many individuals”. The following aspects of psychological functioning are important in understanding the development of an eating disorder.
Body Image Distortion
Body disparagement is rather common among the general population, hence the success of the diet industry. However, the self-loathing and preoccupation with weight observed among eating disorder patients is exceptional. The perception of “being larger than in reality stems more from a deep dissatisfaction with the body and the self than from a true disturbance in perception (Bryant-Waugh and Lask, 1992)”. In a study done by Davies and Furnham in 1986 of adolescent girls with eating disorders, 40% considered themselves overweight, while less than 4% were actually overweight. Fosson’s study in 1987 of early onset eating disorders found that 56% of the patient’s gave fear of fatness as their main reason for restricting intake (Bryant-Waugh and Lask).
Low Self-Esteem
A primary deficit in anorexia nervosa is an overwhelming sense of ineffectiveness (Garner et al). The act of starvation, controlling one’s intake and thereby controlling the body, is in essence a manifestation of the struggle for autonomy, competence, control and self-respect (Garner et al). Particularly for the anorexic patient, exercising such extreme control over the body provides a sense of security while they feel totally out of control of their lives. With eating disordered adolescents, this generally stems from an over-controlling and enmeshed family dynamic. Adults who develop anorexia for the first time are often experiencing a stressful life event, such as marriage, having children or family crisis. Again, it may be the only factor in the person’s life that can be controlled. In this instance the eating disorder becomes a coping mechanism, albeit an unhealthy one, but quite possible the only way the individual manages to function in a chaotic or dysfunctional environment.
Individuals with eating disorders also have an unrealistic striving for perfection and desire to attain success. Bryant-Waugh and Lask report on a study of emotional components of anorexic teenagers compared with a control group. The anorexic subjects scored highly in terms of moral adjustment, impulse control and education goals, but low in emotional tone, body and self-image and sexual attitudes (Bryant-Waugh and Lask). This would reflect family pressure to be well-behaved and striving towards success and excellence.
Fear of Maturity
Starvation becomes the solution for the girl who fears the expectations and responsibilities of adulthood, as she strives to keep her body in its prepubescent appearance. Hormonally and behaviorally, the anorexic can succeed in avoiding maturity. Her emaciated and vulnerable appearance causes family members and others to care for her as if she were a child. This is an individual who, while she is fighting for autonomy, feels quite dependent on others and incapable of dealing with the demands of adult life, which would include the possibility of a sexually intimate relationship.
Depression
The literature indicates that many individuals with an eating disorder also experience the symptoms of depression (Garner et al). A study of children aged 7-13 with eating disorders reported that 56% were clinically depressed. And another study of teenagers identified a high rate of depression amongst those with anorexia nervosa (Bryant-Waugh and Lask).
It is difficult to ascertain whether depression is a predisposing factor of eating disorders, or the result of starvation and electrolyte disturbances. It is likely that both are true. Several studies reported symptom improvement following a trial of antidepressant medication (Garner et al), and are in fact the most frequently prescribed psychotropic medication used to treat anorexia (Jones and Nagel, 1992).
Other Personality Features
Though there are certain personality traits that seem to be more characteristic of either the anorexic or bulimic patient, the most recent consensus is that there is no one personality pattern for either of these patients. Since eating disorder patients typically vacillate between starvation and the binge-purge cycle, perhaps behaving as an anorexic for several months and then switching to bulimia and then back to starvation, one might see features of both disorders at one time or another.
Despite this, there are certain tendencies that seem to emerge repeatedly. Anorexic patients tend to be obsessional, introverted, socially anxious, conscientious, perfectionistic, competitive, over-controlled, socially dependent, shy and “neurotic” (Garner et al). Bulimic patients are more impulsive, prone to addictive behaviors, emotionally turbulent and depressed (Garner et al).
Family Conflicts
Case studies indicate that the family plays an important role in the development of an eating disorder. The anorexic and the bulimic patient appear to have different family dynamics which typify them. In general, the anorexic family is seen as highly rigid and controlling and the bulimic family as more chaotic, or at least perceived that way by the patient (Garner et al). The following are generalizations for both, and are helpful from a therapeutic point of view in understanding the more profound psychological issues of eating disorders.
Anorexia Nervosa – Though anorexia can occur at any time during a woman’s life, the foundation seems to be established in childhood. The real crisis lies in progressing successfully through puberty and managing the primary task of adolescence, which is to establish one’s own identity as separate from one’s family.
Anorexia seems to be characteristic of young women who have felt exploited and controlled by their families. They have not been allowed to lead a life of their own. These families are protective, controlling and extremely enmeshed in the thoughts and feelings of the other family members. In therapy, they will not identify their own feelings, but will speak for one another. They do not allow true expression of feelings, avoid conflict and are overly concerned about what others think. Girls growing up in this environment do not establish their own identity. The parents often control who the girl chooses as friends, what she does in her free time and the direction her life will take educationally and professionally. This leaves the girl feeling helpless and ineffective.
These girls are people-pleasers, seen by parents and teachers as model children. They are overly submissive and lack self-assertion. In need of acceptance, and so fearful of any criticism, they learn early in life exactly what they need to do for each person, in order to gain the love and acceptance they desperately need. They feel tremendous pressure to live up to family expectations of achievement and fear that if they do not, they will lose their parent’s love. These girls are extremely dependent upon their families, feeling safe in the home environment where they can predict exactly how they must act to get approval. They are fearful of leaving home for an unknown environment where they will not know how to function. Since their identities are defined by their parents, there is a need to remain as children, in need of the protection and safety of their parents. By remaining in a child’s body they can avoid the adolescent responsibilities which appear so frightening. The anorexic feels true repugnance for any feminine qualities of her body.
The total lack of control these girls experience in their lives can encourage them to seize control over the one area they feel is their own – their bodies. It is the one act of defiance they feel they can safely get away with. Anorexics are very angry with their controlling families. They turn their anger inward onto themselves by depriving their bodies of food because they cannot express these feelings or assert themselves in any way. Through the act of starvation and severe weight loss, the girl gains a sense of specialness and great achievement. The delusion of achievement is an important one, since she has such a terrible fear of not measuring up to parental expectations. Most anorexics feel superior to others because of this difficult task.
It is the family’s inability to acknowledge the control they have exerted on their child’s life, and the inability to relinquish it, that sustains the illness. A common feature is that the child is not acknowledged as a person in her own right, but rather as someone who would make her parents’ lives more satisfying and complete. The feelings the anorexic girl derives from her starving body are the only true feelings that originate from herself and are her only source of self-identity.
Anorexics often feel responsible for a troubled parent or for parents who have a difficult relationship. By being skinny and needing the protection of their parents, they feel they are the nucleus around which their parents revolve, thus keeping them together.
The anorexic is generally socially isolated. The extreme dependence on family is one explanation for this. However, her need to accommodate is another strong factor. Changing her personality to what she feels each person wants results in the girl feeling fragmented and vacant, as if there is no one inside. This inability to be a real person and foster intimacy which others results in a high turnover of friends. Also, her preoccupation with thinness and the superiority she feels serve to isolate her from other girls.
It must be pointed out that the anorexic is normally not cognizant of the underlying reasons for her unhealthy behavior. In fact, she will deny the existence of any problem at all. She truly believes her issue is one of “fatness” and that she has every reason to behave as she does. She does not consciously choose the behavior. Rather, it is an unconscious and desperate coping mechanism.
Following are two case studies which exemplify the thought processes and behaviors of anorexia nervosa:
Alma – Outwardly, Alma’s family would appear to be ideal. Her parents were very devoted and wanted to give their children everything. Her father was a successful businessman and was also involved in local politics. Alma’s mother was a leader in many social activities. Both parents felt unfulfilled, however, because they had not pursued their own dreams. The father had wanted a professional career and the mother had dreams of the theater. Because circumstances had not supported their pursuit of these goals, both parents had accepted substitutes for what they really desired and were left feeling disappointed. The older daughter was an average student and her lack of achievement was disappointing to her parents. Alma, on the other hand, excelled in all areas – academically, athletically and socially. Her parents looked to her to live out their own unfulfilled dreams. Wanting to please her parents, she was everything they wanted, until the pressure became too great. It was at this point that Alma began to exert some control over her life, by starving herself to extreme thinness (Burch, 1978).
Mabel – In Mabel’s family it seemed to be a house rule to always consider mother first, before making any decisions. Mabel’s father is extremely involved in business and is often away from home. Therefore Mable grew up feeling a special attachment to, and responsibility for, her mother. She allowed her mother to dictate her academic pursuits, her choice of friends and the summer camps she attended, even if she detested them. She always pretended to enjoy her mother’s choices, even volunteering for them, as she became adept at learning what would please her mother. She never wanted her mother to feel as if she had made any mistakes. In college Mabel received treatment for her anorexia. She was able to tell her therapist that her mother was egotistical and raised her children in a way that fulfilled her needs and wishes, and would be approved of by her friends. Regardless of how much progress Mabel made away from home, she continued to relapse whenever around her mother (Burch, 1978).
Bulimia – While anorexics are perceived as rejecting femininity, bulimics are actually deeply committed to the traditional female role. They tend to value the importance of relationships with men above all else, giving men the power to define how they act, think and feel. At the same time, they lack genuine intimate relationships, particularly with men.
With anorexics the problem lies in making the transition from childhood to adolescence, involving their changing body image. For bulimics, who traditionally enter adolescence successfully, the crisis exists in transitioning from adolescent to adult female responsibilities and the ensuing intimate relationships.
Bulimics are typically from homes where the mother occupied the traditional female position, tending to be over-involved with her daughter’s life. The father is generally preoccupied outside the home. Though the mother actually has more power and influence in the home, she defers to her husband when he is present. The mother is often passive towards her husband, but controlling with her children. Garner et al describe a patient who openly admitted that her vomiting was an act of defiance against her controlling mother.
The bulimic girl often has a close alliance with her mother, while at the same time feels angry at her for her submissive role. She also covets the attention and approval of her father, who is often unavailable, and seems to focus on her appearance as an object of praise. She is encouraged to grow up, marry and be like Mom.
Bulimics are perfectionists, dependent, in need of constant approval, filled with self-loathing and feelings of inadequacy and helplessness. They are extremely self-critical. They are conditioned to please others, particularly men. They are generally high achievers, talented and attractive.
Since perfectionism runs their lives, and since perfection is impossible, bulimics live with perpetual insecurity and feelings of unworthiness. These girls are obsessed with the fear of being fat, and therefore not perfect.
Precursors to bingeing are rejection, confrontation, disappointment and anxiety. Since they have been brought up to be agreeable, compliant and non-assertive, these girls have trouble expressing anger and will easily feel victimized by others. They then turn their anger inward by bingeing and purging. They are so sensitive to rejection that any slight can manifest the self-loathing that leads to a bingeing fury. After the binge and the accompanying shame and guilt, they purge in order to gain self-control. The purge has also been described as relieving tension, momentarily helping the individual to feel better and less pressured. Having re-established their disciplined ways, they can initially feel better, perceiving themselves as having achieved the perfection they seek. But often they are tormented by even greater shame and self-loathing. It is a vicious cycle which can lead to the extreme feelings of suicidality if not treated.
Many girls start their binge-purge behavior in college, where food is often used to nurture during periods of loneliness. Also, away from the family’s meal-time routine, college girls will invariably gain weight. Thus begins the endless dieting and purging as they compare themselves with peers. Dating, sororities and other new social activities put pressure on these young women to be thin.
The profile of the bulimic wife appears to be one who was a high achiever prior to marriage, yet sought a relationship where she would be taken care of and not have any responsibilities. This conflict can cause the frustration, helplessness and self-disgust that lead to the binge-purge cycle.
A professional woman who becomes bulimic is generally a high achiever who receives much praise for her accomplishments. She is very often successful, yet inwardly she is insecure about her abilities and fearful that she will eventually be found incompetent. She will often go home and frantically binge and purge after a stressful day, where she has had to keep up a confident facade for her peers.
These women have a difficult time accepting praise or acknowledging their own accomplishments. They may have a professional life which appears full and rewarding, while their personal life is lonely and empty. Because of the isolative nature of the illness, bulimics have few friends.
Since bulimia is an illness carried on in secret, and the girl generally appears of normal weight, it can be difficult to detect. This behavior is often discovered when the young woman seeks professional help for other reasons, such as relationship problems, depression or low self-esteem.
Following are two case studies of bulimic patients:
Anne – Anne had been bingeing and purging for months when she was invited to dinner by a man she felt attracted to. She enjoyed her time out, yet felt wracked with anxiety about the rejection she knew was coming. She went straight home after the date to engage in a bingeing and vomiting fury that left her filled with self-disgust. This served to reinforce her feelings of imperfection and the fact that she was “bad”. She therefore felt unworthy of love, which provided her the excuse to withdraw from any other social interactions (Boskind-White, 1983).
Francine –Francine was filled with self-doubt and fear of failure. She kept up the perfect facade of the confident career woman heading for the top while at work, but at home she would break down and binge and purge on a regular basis. The role model her mother presented as hysterical, demanding and ineffectual did nothing to instill in Francine positive feelings about a woman making it in the work force. She determined to never be like her mother, yet feared perhaps she was. Francine’s bulimia allowed her to reinforce negative feelings about herself, seeing herself as the same weak and ineffectual person as her mother (Boskind-White, 1983).
Demographics
Eating disorders typically affect females from upper income families, where financial, social and educational achievements are high. The behavior is rarely seen in lower socio-economic groups and has not been seen in underdeveloped countries. Until recently, there were no reports of eating disorders in children from other than white western backgrounds (Bryant-Waugh and Lask). However, more recent studies indicate cases of anorexia nervosa in children and adolescents of African and Asian heritage, and increased reports of bulimia nervosa among Asian teenagers. This cross-cultural prevalence of eating disorders has also been observed in adult patients (Bryant-Waugh and Lask). When eating disorders have been noted to cross-over the educational, ethnic and socio-economic lines, these families are generally upwardly mobile or success oriented, where there are siblings who have been successful or a great deal of attention is focused on the girl to succeed (Bruch, 1978).
Though most research refers to persons with an eating disorder as female, it has been found that 10% of the afflicted population is male (U.S. News and World Report, 1988). In fact, it is felt by researchers that this data inaccurately reflects the number of males actually suffering from this illness. Males traditionally are less likely than females to disclose any kind of personal problem or weakness. Furthermore, as anorexia and bulimia have been labeled female disorders, men may feel embarrassed to expose such behavior. As a society we accept the notion that growing boys need large amounts of food and that they become vigorously, often fanatically involved in sports. This seems so normal one might not consider the existence of an eating disorder by such behavior, as we might with girls. However, both males and females suffer from many of the same societal and familial pressures and issues. Undoubtedly, there are more men with eating disorders than statistics would show. As we enhance our awareness of body image issues and as the men in our society begin to feel more comfortable seeking professional help for emotional problems, we will more than likely see a raise in reported cases of males with eating disorders.
Sexual Abuse
Several studies indicate a correlation between childhood sexual abuse and the later development of an eating disorder. The various studies indicate a prevalence of sexual abuse from 23% - 83% of patients studied (Bryant–Waugh and Lask). Though a history of sexual abuse is often seen in eating disorder patients, it is a difficult correlation to make. Since one-third to one-half the female population report incidents of childhood sexual abuse, and most eating disorder patients are female, one could only conclude there would be a high incidence of sexual abuse. The sexual abuse may in fact play a role in the later development of an eating disorder, and/or simply be one more factor in the overall highly dysfunctional family dynamic described earlier. Experts feel this is an issue that warrants further study before a definitive conclusion can be made (Bryant-Waugh and Lask).
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