Myth: Anorexia Nervosa is a Choice
The idea for this blog came to me when I looked up the definition of anorexia nervosa in the Oxford English Dictionary. I’m a big dictionary fan. I’ve used the dictionary to win many an argument. It gives the precise, definitive definition of any word, after all. You can’t disagree with the dictionary, can you?
Turns out you can.
Let’s break this down and take a closer look.
N. The word is a noun. So far so good.
lack of appetite for food (the definition tells us that the word originated in the 16th century and comes from the Greek an (without) and orexis (appetite)).
Can’t argue with that. Everyone with AN has what could be described as a loss of appetite. So far so good. What’s next?
an emotional disorder
A what?
Now, the word ‘emotional’ can have some pretty negative connotations (often sexist) — ‘She’s too emotional’, ‘She’s ruled by her emotions’, ‘They’re an emotional wreck’. I hadn’t heard of the term ‘emotional disorder’ before, but it seems to be quite common and covers a number of conditions. According to the dictionary (another one) of the American Psychology Association, it has two definitions:
1. any psychological disorder characterized primarily by maladjustive emotional reactions that are inappropriate or disproportionate to their cause. Also called emotional illness.
2. loosely, any mental disorder.
Well, someone with anorexia certainly has an inappropriate or disproportionate reaction to eating or food. So that fits. And of course, as it manifests in thoughts and the brain, AN also fits definition 2 — any mental disorder.
Regardless, the phrase is laced with negativity, intentional or not. Why not just say ‘mental illness’ or, even better, ‘brain-based disorder’? I think it’s high time that the phrase ‘emotional disorder’ was consigned to the dustbin of history along with other malefic medical expressions such as ‘geriatric mothers’ or ‘moral insanity’.
But we digress. What’s next?
characterised by an obsessive desire to lose weight
I think I’m going to dispute this bit. Does every person with anorexia nervosa really have an ‘obsessive desire to lose weight’? Is anorexia, in essence, an extreme diet?
Let’s look at what the American handbook of mental health diagnosis, the DSM-5, has to say. It describes one criterion for diagnosis as a fear of becoming fat or gaining weight. This is not the same, dear OED, as an obsessive desire to lose weight. It’s a subtle difference but an important one. Someone with anorexia doesn’t necessarily wish to become thinner. They may be afraid of putting on weight. And some, I would suggest, are simply fearful of food itself. This is an important distinction because if someone suspects they have this eating disorder, they may look up the dictionary definition and think: Well, I don’t want to lose weight. In fact, I’m really bothered by and ashamed of my thinness. But I just can’t eat. And they may decide that they don’t have anorexia nervosa after all and not seek help. Words matter.
And now we come to the most egregious bit, for me anyway.
by refusing to eat
It’s the word ‘refusing’ that bothers me, of course. Because the use of the verb ‘to refuse’ gets to the heart of the matter of this particular myth. That anorexia nervosa is a choice. That the person with this condition is a petulant malcontent who stubbornly says no to food — and could, by implication, just as easily say yes. That they are choosing to starve.
This is not true.
Nobody chooses anorexia nervosa. It develops after a period of caloric reduction, from a diet, religious fasting, exercise, a growth spurt, a period of illness or something else. In people with a predisposition to develop this disorder, a mechanism is triggered by the loss of weight. It creeps up on the person who has it. And even if it begins with a deliberate diet, the person with anorexia nervosa soon finds that they are unable to stop restricting their intake of food.
So where did this myth that anorexia nervosa is a choice originate? And why is it still so prevalent in society, even within the medical and psychological professions, even in the dictionary?
My theory is that — before the beginning — in the immediate weeks prior to the start of the eating disorder, many people (not all) make a conscious choice to do something which results in weight loss. And it looks to the world that this is when the anorexia nervosa starts. But it doesn’t start there. The restriction of calories is the thing which triggers the anorexia nervosa, but the illness doesn’t start on the day that person decides to lose weight. That happens later, after calories are reduced and a switch is tripped in the brain.
Somebody may decide to fast for health or religious reasons, they may decide to diet to lose weight or improve their overall health, or they may decide to exercise to get in shape or to prepare for an upcoming sporting event. In my daughter’s case, aged 16, she decided to alter her diet, to eat what she believed was ‘healthy’ food in order to lose a bit of weight and improve her overall wellness.
Choosing to lose weight, get fitter or embark on a fast is not the same as choosing to become ill. The reduced caloric intake (or failure to add calories in line with an increase in exercise) — ie not giving the body the energy it needs — results in a person who is predisposed to anorexia nervosa developing this disorder. The simple diet ends and the illness starts once the biological mechanism in the brain is turned on. At this point it spirals out of control and can become a serious, potentially deadly, problem.
Another way to look at it is to compare anorexia nervosa with addiction. A person might choose to try drinking alcohol. They might choose to drink a pint or two on a night out. But at some point after that what was just a few drinks for fun might tip over into addiction, and they find they have a compulsive need to consume alcohol. No one would say they chose the addiction. But yet they chose to start drinking. This seems far better understood than the restrictive eating or over-exercising of anorexia. Perhaps this is because society views dieting and exercise as a good thing and alcohol as inherently dangerous.
Regardless, in anorexia a distinction must be made between the initial decision to lose weight, fast or exercise and the development of the eating disorder. They are not the same.
So why do some people who reduce their calories develop anorexia nervosa while others don’t? Well, genetics certainly plays a part. Studies have shown that there is a fourfold increase in susceptibility to anorexia nervosa among family members, and female relatives of a person with the condition have an 11 times greater risk of developing the condition compared to the rest of the population. Also monozygotic (identical, ie genetic clones) twins have a higher likelihood of developing anorexia nervosa then dizygotic (fraternal, non-identical) twins. There probably are other factors, perhaps environmental, definitely biological, which contribute to someone’s susceptibility too, of course. Genetics is probably not the only factor. But it is a powerful one.
I am the mother to identical twin girls. Both decided to diet, and both were subsequently diagnosed with anorexia nervosa. Thankfully, one of my daughters recovered quickly without intervention. Six years on, my other daughter is still unwell. So while genetics is important, it is not everything and does not determine the outcome. It is not a foregone conclusion that you will have anorexia, even if you are a genetic clone of someone who has, or that you cannot recover because you have the genes for anorexia nervosa.
In the early stages of my daughter’s illness, she was begging for help to eat normally again. The intrusive thoughts and feelings were confusing and frightening to her. So too was the idea of food. In fact, the concept of eating generated such fear and anxiety that avoidance seemed the only option for her. At this point no choice was made. There was no refusal. Something was malfunctioning deep in my child’s brain, sending the wrong signals to her mind and body, telling her she felt full when she’d barely eaten, telling her she could eat only once certain conditions were met, telling her that if she ate she would be overcome by overwhelming guilt. She did not feel she had a choice.
Nobody chooses anorexia nervosa.
It’s important to note that just because you don’t choose to be ill doesn’t mean that you can’t choose to get better. The medicine for anorexia nervosa is food. You have to eat and you have to gain weight, probably more weight than you’ve lost if you are to achieve true recovery. It will be difficult, for all the reasons I’ve outlined above. It will be painful. It will probably be the hardest thing you’ve ever done because you will have to face your greatest fears head on and do the thing which scares you the most — eat food without restriction. But know that true and complete recovery is possible. You don’t have to remain lost in the woods. There is a way out. And when you get to the other side, you’ll see that it was worth it.
If you have anorexia or another eating disorder, please seek help. Whether it’s family, friends, professionals or all of the above. And, if you’re not able to get help from any of those people, there are lots of organisations and resources that are there for you. You didn’t choose this illness. But please choose recovery.
You can do it.
And finally, if I was a lexicographer, this would be my entry for anorexia nervosa: