Analysis: recent research suggests that psychological factors play a major part in the development of anorexia
By Rosaleen McElvaney and Joyce Ring, DCU
"I always thought that if I was smaller or skinnier … that people would like me more, that I'd feel better … I thought I’d feel good if I was just skinny…" (Sarah, 26)
This was how Sarah started her journey into anorexia. It is hard to adequately capture the agony of the lived experience of anorexia. From the outside, the person may appear calm. However, internally they are tormented by a compulsion to restrict food intake, which usually takes the form of obsessing about calories, fasting or engaging in strict rules about eating but may also include binging or purging behaviour (vomiting or using laxatives to expel food at regular times during the day).
While physically suffering, the person may feel further compelled to engage in a harsh exercise regime. They feel an intense fear of putting on weight while continuously obsessing about food. They may also be disgusted by their own body due to a distorted perception of what they look like. In short, anorexia means that the person is living in mental, physical and emotional hell:
"… totally consumed with thoughts of food and exercise, I was suffering really badly … I was out of control even though I was totally controlling every aspect of my life" (Alison, 32).
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From RTÉ One's Prime Time, Emma O'Toole speaks about her battle with anorexia
Those who only restrict their food may experience a sense of feeling disciplined and self-assured, a 'best self’ while those who binge and purge often feel guilt, shame and fear so that self-loathing is both a cause of, and is caused by, the anorexic behaviours. It is common to progress from restricting to binging/purging leading to entrenched difficulties, which is why early intervention is so vital.
In terms of the development of anorexia, recent research findings suggest that psychological factors such as perfectionism, obsessiveness, compulsiveness, inflexible thinking and reduced ability to recognise or describe emotions interact with environmental factors, especially the striving for the "thin ideal", to create a perfect storm. However, there is also the suggestion that these traits are exacerbated by the effects of starvation on the brain and may recede as the person recovers.
Other risk factors include childhood emotional, physical or sexual abuse, parental influences and early development issues (particularly around food). Such experiences impact self-esteem resulting in difficulty managing emotions and negotiating personal relationships. Unsurprisingly, the "thin ideal" may be internalised as the solution to all these emotional problems.
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From RTÉ 2fm's Jennifer Zamparelli show, Lorna Ahern on suffering from anorexia for most of her teenage years
A recent study carried out at the DCU School of Nursing, Psychotherapy and Community Health captured women’s experiences of the restricting form of anorexia. Women described how they got trapped as initial weight loss made them feel good about themselves. Wanting more of this good feeling, one participant described how she became obsessed with the moving target on the scales so that she was oblivious to her physical deterioration:
"I wasn’t noticing how bad my thoughts were getting, how much it was quickly taking over my life and how much I was actually spiralling" (Sarah, 26)
By the time, she began to sense that something was wrong, she was already hooked on the compulsion to restrict. She felt powerless to resist this compulsion and the obsessive and critical thoughts which flooded her head. Over time, these thoughts developed into a hyper-critical, tyrannical and domineering voice that became one of the most agonising aspects of anorexia. Enslavement to this voice drove her to restrict her food even more and to over-exercise, even when she was near collapse:
"… it’s so powerful … it’s a person that’s inside of you … she is constantly talking to you … she’ll tell you what’s right, she’ll tell you what’s wrong" (Tamara, aged 26)
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From RTÉ Radio 1's Liveline, listeners talk about the poor facilities and services for people with anorexia in Ireland
However, this continuous restriction also resulted in a sense of 'numbness', which wasn’t unwelcome as it quietened the ‘anorexic voice’ and helped her cope:
"… the lovely numbness that anorexia gives you, you just don't have to think … and … it was incredibly appealing to not have to think" (Saibhdh, 24)
The progression of the condition often resulted in her becoming isolated and lonely. For many, this anguish was one of the worse aspects of anorexia. Often attempts to seek help were met with hopelessness, blaming and misunderstanding on the part of professionals:
"… people that I felt didn’t really get it … were more so like the doctors and the consultants … I just felt like there wasn’t really an understanding in how they were saying they were understanding" (Clarisse, 23)
Such experiences reinforced feelings of shame, unacceptability and powerlessness and inhibited their recovery. This is a critical issue because almost half of those attending for treatment drop out. Eventually these women found both a medical professional who understood them and their anorexia, as well as the long-term, in-depth, counselling they described as crucial to their recovery.
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From RTE Radio 1's Ray D'Arcy Show, how to help a child who is suffering from anorexia
In moving towards recovery, women described a constant internal battle and frequently experiencing some form of relapse. The study findings suggest that recovery comes in stages. Women described how they first engaged in eating to get released from hospital, then to keep other people happy, before doing it for themselves. Progress was interspersed with relapse which, while devastating to experience at the time, forced the person to draw deep on her own resources to motivate her to fight for herself and her own recovery.
Over time, a newfound awareness of personal choice, and a sense of having some control over life, helped each woman connect with her authentic self. This authentic self did not seek external approval, but rather followed her own passions, gathered her own supports, and learnt to ignore the anorexic voice when it whispered:
"I feel like I’ve gained the whole universe … I’ve lost everything, except for I’ve gained myself"" (Amy, 50)
All names used in this article have been changed. Although anorexia is typically experienced by women, men can also be affected.
Dr Rosaleen McElvaney lectures in psychotherapy at the School of Nursing and Human Sciences at DCU, Joyce Ring is a psychotherapist in private practice and graduate of DCU
The views expressed here are those of the author and do not represent or reflect the views of RTÉ. If you have been affected by issues raised in this article, support information is available online
