It's easy to dismiss anorexia as a pseudo-disorder for rich white girls who want to get thin. Less obviously untrue is the emotionally charged condemnation of anorexia as a profound kind of selfishness. How do we even begin to think about questions of individual agency in mental health?
Mind and body
Like all eating disorders, anorexia is both a mental illness and a physical one. Its physical facets are perhaps more significant than those of eating disorders that don't involve significant weight loss or weight gain, because of the physiological-psychological feedback loop which is initiated as the body is starved. (The equivalent is observed in eating disorders leading to significant overweight, which has its own set of physical and mental consequences.)
I've discussed in a previous post how the simple fact of physical 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 undeserved, or thinness the only thing that gives one value.
The interactions between the physical and the mental go both ways: 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.
All this seems to point towards the conclusion that the person with anorexia is the victim of a disease which comes to control his or her mind and body and makes recovery very difficult. But it is possible to break out of this vicious circle of physiological and psychological cause and effect by making a simple series of decisions. So what is the role of personal responsibility? Can we ask of someone with anorexia that (s)he summon up the resolve to get better, or resist the influences to get ill in the first place, or is that entirely the wrong way of thinking about it all?
Nature and nurture
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 all can 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, whether that's in terms of precipitating the illness or avoiding it. And then there's 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. (Bear in mind also that treatable doesn't necessarily mean curable; this opens another whole can of worms about whether a 'mental illness' like anorexia can be fully recovered from - which I discuss here.)
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 or resolved 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 anorexic years recede further.
It's always difficult if not impossible 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 borne the brunt of the blame, as has exposure to the disordered eating of family members. As Cynthia Bulik (2005, p. 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.' But this doesn't necessarily mean that such environmental exposure is solely or even largely 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, p. 337)
Other aspects of this model include the perpetuation of anorexia through generations: in a positive feedback loop, 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 and websites, 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 self-reinforcing effects of 'dieting' or semi-starvation.
Decisions to not-eat, and to eat again
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 when 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.
At any of these moments - before leaving the house for school before the non-breakfast, when at the Swiss supermarket or in the kitchen on my boat in Oxford - I could have identified the danger in what I was contemplating doing, and decided to do otherwise. In the first of these three examples, I had the 'excuse' of really not knowing where this could lead, although I knew that lying to my family about how I was living couldn't be a good thing; but in the second two examples (the Swiss retreat and the hot food) I knew perfectly well what the likely consequences would be, and went ahead regardless. Yes, numerous physiological, situational, and emotional factors were contributing in each instance to that decision - a decision is not a freely willed thought-act detached from its embodied context - but I did nonetheless have the capacity to do otherwise. Whether that doing-otherwise would on its own have significantly slowed or even halted the progression of the anorexia is impossible now to say, but it's clear that all three decisions did have the opposite effect.
Seen from the other side, though, there are the good decisions that might not have been made: most notably the day when I decided to ask my GP for a referral to the Oxford ED clinic, and the evening on which I decided to go to the supermarket with my friend and let him help me choose the things that would make up 500 calories' worth of extra food for four days. Again, neither of these decisions was made in a vacuum - they came about in large part through my friends' input, for example - but each could have gone the other way, and I might never have felt 'ready' enough until it was too late, and my heart gave out, or I had an accident I was to weak to recover from.
It's a terrible mistake to wait for the perfect moment at which one feels magically inspired to change and to eat again; it's unlikely ever to come. But in the course of every progression deeper into anorexia there are many points at which it is possible to say 'no, this far and no further'. It's much more likely that one will have the confidence to say this if one is well informed not just about the very real dangers of anorexia, but also about the almost inevitable nature of its progression from mild to more severe forms. It is very hard to say and believe, as someone with anorexia, 'how I am now is thin enough', or 'I am now perfectly thin'. The rewards associated with thinness mean that ever greater rewards are sought through ever greater thinness, and the physiological-psychological feedback loops with which we began drive the process of emaciation and disintegration onwards. Knowing this (whether through experience or by informing oneself more theoretically about the trajectory of the illness) is power, as is knowing that while each bad decision makes the next more likely, each good decision makes the next easier. As with any bad habit, change in both directions occurs only gradually, but does become self-reinforcing.
Whether you have developed clinically diagnosable anorexia nervosa or not, it is never too soon, or too late, to exchange a bad decision for a good one. Genetic and environmental factors are playing their part in how you are in all respects, but once you've identified that you have a problem, or even just a potential problem, you have the capacity to act in such a way as to reduce the relative potency of the genetic factors and change the environmental risk factors to which you're exposed, or the ways in which you respond to those you can't change.
Expressing personal responsibility through action against anorexia is an act of freedom and of self-understanding. The striking simplicity of what is at the heart of any such step towards rejecting anorexia - the simple act of eating - was what made slipping into illness so easy, and is now what makes climbing out of it a process that is constituted primarily of those trivial-seeming daily decisions.
Therapy tailored to eating disorders (especially of the cognitive-behavioural variety) may be necessary to bring about the motivation for that decision, and to sustain motivation and keep the progress of weight-gain occurring at a steady but safe pace. In general, therapy may help the sufferer to achieve what he or she cannot with a brain too compromised by starvation for proactive decision-making (although one recent study counters previous findings of impaired decision-making in anorexia - here without depression). But unless the situation is so life-threatening that the extreme measure of intravenous feeding is required, the same basic, repeated act is required of you, the sufferer, which no one else can do for you.
Sitting down now with the meal which you have planned to eat, and deciding to take the first bite, may not be an easy decision to make, but the effects both of doing so and of not doing so are very clear, and the moment at which the decision needs to be made - does this fork go into my mouth now, will I swallow now? - equally evident. All the things that have led you to be sitting here at this table contemplating this plate of food are complex and often opaque, but now that you are here, right now, you can make a good decision or a bad one. And however much an inner voice may whisper afterwards to confuse you, you know which is which.
Bulik, C.M. (2005). Exploring the gene–environment nexus in eating disorders. Journal of Psychiatry and Neuroscience, 30(5), 335-339. Full text here.
Guillaume, S., Sang, C.N., Jaussent, I., Raingeard, I., Bringer, J., Jollant, F., and Courtet, P. (2010). Is decision making really impaired in eating disorders? Neuropsychology, 4(6), 808-812. Full text here.