She was exposed to toxic substances as a baby. She was too
mature for her age. She was too smart for her school. She was not smart enough
for her school. Her school was too rigid. Her school was too flexible. She did
ballet as a child. She had a hormonal imbalance. She was just unbalanced. She
was painfully immature. She wanted attention. She wanted to disappear. She
wanted to be Kate Moss. She was part of the zeitgeist.
اضافة اعلان
These are among the 75 explanations given by doctors,
therapists and others to Hadley Freeman for her severe anorexia nervosa.
Freeman, the author of a riveting new memoir, “Good Girls: A
Study and Story of Anorexia,” became sick during the 1990s, but over the last
few years, the incidence of anorexia, which predominantly affects preteen and
teenage girls, seems to have gone up. “During COVID, a lot of published data
showed increases in eating disorders both inpatient and some outpatient as
well,” said Joanna Steinglass, the director of research at the Eating Disorders
Research Clinic at Columbia University and the New York State Psychiatric
Institute. This increase was true not only in the US, where Freeman was born,
but also in other countries, including Britain, where Freeman was given her
diagnosis and treated.
We have known about anorexia for a long time. The question
is why it looks to be getting worse now.
Did the pandemic cause an increase? Can it be tied to social
media? Is it related to the general increase in rates of depression and anxiety
among girls?
When I was a teenager, the “dying to be thin” narrative
predominated in the shadow of Karen Carpenter, the singer who died in 1983 of
complications from the illness. At the time, a combination of parental (mostly
maternal) missteps and a culture that glorified a model-thin physique were
presumed largely culpable for the disorder. Ballet and gymnastics were looked
at as risky endeavors; “perfectionist” tendencies were also a potential red
flag.
The truth is, we still do not know exactly what causes
anorexia. But we have learned more in recent decades. Whereas anorexia was earlier
viewed through the lens of individual and familial behaviors and cultural
influences, it is increasingly understood, as with other psychiatric disorders
like schizophrenia and depression, to involve a neurological element.
“Over the last 20 years, we have an increased understanding
of the neurobiological basis of anorexia,” Steinglass said. “Not that there
isn’t a person there and behaviors — but there are brain mechanisms to all
this.” Recent research shows, for example, that when anorexics decide what to
eat, different parts of the brain are activated than in those of people without
disordered eating. Other research indicates that metabolic features play a
role.
There is also evidence suggesting a genetic component to the
disorder, though the extent to which the cause might be a mix of genes and
environment is still unknown. As one doctor at the Eating Disorders Research
Unit at King’s College London tells Freeman in her book, “You need genetic soil
and environmental triggers.”
Freeman is one of several authors of recent books addressing
their experiences with anorexia. In her best-selling memoir, “I’m Glad My Mom
Died,” Jennette McCurdy writes about having anorexia followed by a severe case
of bulimia. In “Strangers to Ourselves: Unsettled Minds and the Stories That
Make Us,” journalist Rachel Aviv recounts her own hospitalization for anorexia
at age six.
For those predisposed to anorexia, a common element seems to
be a “precipitant” or “trigger” incident. For Aviv, it occurred on Yom Kippur,
when she realized she could say no to food. “The decision retained the
religious energy from the holiday and carried an aura of martyrdom,” she
writes. For McCurdy, it was her quietly anorexic mother instructing her in
“caloric restriction” when she was an 11-year-old child actress desperate to
forestall puberty and look younger and thinner to get roles. For Freeman, it
was in gym class, seated next to a classmate with remarkably bony legs, who,
looking at Freeman’s thighs said, “I wish I was normal like you.” That did it.
As Freeman writes, “A black tunnel yawned open inside me and I tumbled down
it.” Normal, she writes, was boring: “Normal was nothing.”
And so anorexia became Freeman’s identity. “In the ’90s when
I was a teenager, there were other options: goth, skater, punk,” Freeman told
me. “But I chose this.” Her descent into illness was swift and profound,
requiring multiple hospitalizations.
We have known about anorexia for a long time. The question is why it looks to be getting worse now.
Once ingrained, an anorexic identity can be inadvertently
encouraged in group settings, such as hospital wards. While the goal was for
girls to learn new behaviors from their doctors, in practice both Aviv and
Freeman witnessed their fellow sufferers learning behaviors from one another,
reinforcing and even intensifying their disordered eating. Not surprisingly,
one 2016 study shows that girls who attend schools with more girls than boys
and have highly educated parents are more likely to develop anorexia.
It is this evidence of social influence that leads some to
point to social media as either a trigger of or a contributing factor toward
exacerbating the disease. In January, one mother in Hastings-on-Hudson, New
York, filed a lawsuit against Meta and TikTok, along with its parent company,
ByteDance. According to a report about the complaint in The Rivertowns
Enterprise, the apps began showing her daughter, who developed anorexia, posts
related to eating disorders after she began following accounts related to
exercise and diets. Interestingly, some eating disorder clinics now discourage
patients from friending one another on social media because while the mutual
support can be helpful, the tendency to compete and fall into old habits
outweighs the benefit.
Not surprisingly, habits — how they form and how they can be
broken — are one focus of current anorexia research. Not eating becomes its own
ritual and trap. As Aviv notes in her book, “Eventually, an impulsive decision
gathers momentum, becoming increasingly hard to reverse.” Freeman’s anorexia
was abetted by her obsessive compulsive disorder. “Anorexia is super OCD heavy,
obsessively counting calories,” Freeman said. “For me, the routine felt very
reassuring, very soothing.” Starving yourself, she says, can become a way of
self-soothing.
In her book, Freeman also notes some doctors see an
intersection between anorexia and autism spectrum disorder, with a rigidity in
thinking common to both. There may also be a genetic connection here. One 2022
Swedish study found that the children of mothers with eating disorders are
“significantly associated with attention deficit hyperactivity disorder and
autism spectrum disorder,” even after controlling for family histories of these
conditions.
In all three books, a sense of powerlessness and the desire
for control emerges as central features of the disorder. Often those feelings
of powerlessness revolve around discomfort with puberty and adulthood.
But Freeman is eager to dispel the idea that anorexia is
simply about the desire to be thin. Instead, she says, the goal is to look ill,
like a skeleton. It is about courting death. Among psychiatric illnesses,
anorexia is among the deadliest; both Freeman and Aviv’s books describe
revisiting the cases of wardmates after their deaths.
“Anorexia is a way of telling people you’re unhappy without
saying it because saying it looks entitled,” Freeman said. “It’s a highly
visible outward expression of saying something is very wrong here.”
Something is very wrong here. The statistics are
alarming: A 2022 British study of 15,000 students found that girls were twice
as likely as boys to suffer mental health problems. A 2019 Lancet Psychiatry
study found that self-harm among teenage girls and young women had tripled
between 2000 and 2014. The proportion of American girls who’ve had a major
depressive episode in the last year increased 145 percent between 2010 and
2020. Nearly three in five teenage girls reported feeling “persistent sadness”
in 2021, according to the Centers for Disease Control and Prevention, the
highest ratio in a decade. Whichever susceptibilities they are born into and
whatever pain they’re feeling in the world, girls clearly seem to be taking it
out on themselves. We need to ask very seriously why.
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