How eating disorders develop

Although we have discussed some of the possible factors that cause eating disorders, it still does not really explain exactly why they develop. The subject is a difficult one. There is much uncertainty. The following discus­sion attempts to give a view of one kind of explanation that weaves together some of the issues that were mentioned in the previous section. It is a way of looking at things but it is not to be taken as the last word or the whole truth about the nature of eating disorders. We are a long way from being able to claim to know that.

Eating disorders are not just about food and weight. They involve a complex web, or ‘entanglement’, of ideas linking weight and eating control with wider and more personal issues such as self-esteem and emotional control. People with eating disorders tend to think about and evaluate themselves in ways that involve weight and eating to an unusual and exaggerated degree. Although these topics are important to many people, for those with eating disorders it is the extent that is unusual and problematic. For instance, a woman with anorexia nervosa may feel that life would be almost intolerable if she was an average weight for her height and age. Strangely this may be the case even when she is willing to acknowledge that life was much better in the past when she was at a normal weight.

Many people say that anorexia nervosa is not really about weight or eating at all. Instead, they would say that it is about underlying problems of self-esteem and so on. And these underlying problems are seen as related to personal issues which are ‘deeper’ still.

There are problems with this way of thinking. Talking about these matters in terms of ‘depth’ implies that deeper issues are more basic and so more important. And because of this, issues of weight and eating can be dismissed as superficial. This can be avoided through the alternative way of thinking which sees the central issue as being the entanglement between ideas about weight and eating with ideas about wider personal issues. Indeed, in a sense the tangle is the eating disorder. However devas­tating the problems of self-esteem may be, if they are not somehow mixed up with issues of weight and eating, then the person does not have an eating disorder.

Once entangled with wider personal issues, weight and eating become more difficult to control. And these problems of control make it more difficult for the sufferer to manage the wider personal issues. This entanglement can lead to a vicious circle which is difficult to break. An important element in this vicious circle is the regulatory mechanisms which are normally involved in weight and eating control.

THE PROBLEM OF SLIMMING

Anyone who seeks to change his or her weight will run up against these natural regulatory mechanisms of the body. Nevertheless, most people approach the matter with high hopes and expectations based upon the widely held notion that losing weight and eating should be a simple matter. Most believe in the enticingly straightforward principle that if you eat too much your weight goes up, if you eat too little your weight will go down, and if you eat just the right amount your weight will be just what you want it to be.

On this basis, it would seem that with just a bit of effort you can choose to be almost any weight, perhaps even any shape, that you want to be. I like to call this set of ideas ‘the slimming philosophy’. It seems to be the ideology underlying the slimming industry.

However, this line of thinking has at least two drawbacks. First, it encourages a woman to feel that if she is not the weight she wishes to be (or feels that others would wish her to be) then it is not only her misfortune, it is also her fault. A woman who feels she is too fat is thus also likely to feel that she has not tried hard enough and is to blame for her state in a way that she would not do if it was her height with which she was dissatisfied.

The second drawback is that as a picture of weight and eating control the slimming philosophy is much too simple. It largely ignores the fact that our bodies have a marked tendency to maintain a certain stable weight. An alternative view of weight and eating control emphasises this stability. This alternative view suggests that the body tends to behave like a regulated system in respect of weight.

Given the chance, each person’s body tends to regulate itself naturally within a fairly narrow set range of weight particular for that individual. This personal set range may change over time as for instance in the commonplace phenomenon of ‘middle-age spread’. Nevertheless for most people most of the time there seems to be a great deal of inherent stability of body weight.

This means, of course, that body weight is not simply a matter of personal preference as was suggested by the slimming philosophy. For better or worse the body as it were has a vote in the matter. The idea of regulation can be portrayed by the image of a spring which tends to come to rest always at more or less the same point.

Unfortunately, it does not follow that every person is satisfied with the particular weight around which his or her body tends to settle and regulate itself. Many people are dissatisfied and in our society this usually means that they wish to lose some weight. Indeed, many set out to do so. It is when people try to slim that the predictions of this alternative view involving regulation begin to differ markedly from those of the slimming philosophy. Most slimmers are surprised to encounter what might be called ‘the dieter’s dilemma’.

Regulating body weight

When a person sets out to slim it is because of some sense of dissatisfaction with herself. By definition slimmers are dissatisfied with their weight. However, this dissatisfaction is often more than a simple wish to change her body weight. She may feel that she wants to do something to sort herself out in general. Not uncommonly people go on a diet when things are not going well in other ways or when they are feeling badly about themselves. It may feel like a positive thing to do.

So typically, someone who resolves to go on a diet initially feels quite good about it. She feels better because of it and more in control of her life. However, after a while she will usually come to experience the downside of dieting. She may feel hungry and preoccupied with food, experience unwelcome impulses to eat and find herself to be more emotional and irritable than usual.

The body’s regulatory mechanisms are trying to fight against the dieter’s attempts to push them out of kilter. The very things that previously promoted stability are pushing back and promoting a feeling of instability. The more the dieter pushes against them the more the forces push back. This is the ‘dieter’s dilemma’. The action of dieting has provoked a reaction by the body. Most dieters, if they are not succeeding in losing weight, will sooner or later give up, at least temporarily. And such ‘failure’ may be the key to avoiding the trap of eating disorders. People with eating disorders differ from most slimmers. They seem to persist with attempts to lose weight, even when they come up against the dieter’s dilemma.

VICIOUS CIRCLES

Those who develop anorexia nervosa continue to try to lose weight to a point well beyond their original intention. Why is this? It seems likely that the potentially anorectic woman perseveres with slimming because she is afraid to give up. Either she has come to value the feeling of being in control or fears being out of control, or both. She responds to her body’s efforts to maintain a certain level of weight by attempting still tighter control. However, the regulatory forces (represented by the spring in the diagram) feel like a real threat to her sense of control. The more the spring is compressed the more it pushes back and comes to feel like a potential ‘jack in the box’. Though it would be better for her to escape the trap by letting go, this increases the threat of failure and what feels like loss of control and she is too frightened to fail.

She has come to be caught up in the ‘vicious circle of restraint’. She is not only trapped at a lower-than­intended weight. She is also in a position where controlling her eating and weight increasingly seems to be the only way of holding on to her insecure sense of well­being and control. She has anorexia nervosa.
The potentially bulimic woman may respond to the same developing vicious circle by giving in and bingeing. This is itself frightening. She then tries to resume tighter control and restraint, making another binge more likely.

She becomes caught up in the ‘vicious circle of starving and bingeing’. Actions such as vomiting or laxative abuse tend to promote this vicious circle further. She has bulimia nervosa.

In both anorexia nervosa and bulimia nervosa, the issues of weight and eating control come to feel more and more crucial to the person’s sense of well-being and self-esteem. The issues become more entangled with each other. The sufferer tries to make things better but in doing so makes them worse. She comes to feel that her attempts at self-improvement and self-control have ended up quite differently from what she had been aiming to achieve. She feels bad about herself but instead of letting go, she persists because not to do so seems even more risky. This persistence can lead to an even greater sense of failure and suffering. This is the ‘vicious circle of entanglement’.
 

To recapitulate, this way of talking about eating disorders describes them as arising from a number of vicious circles which combine to entrap some people who persist in restraining their eating. The initial motivation for the restraint may reflect the individual’s personal interpretation of the general social context which tends to value slimness and so on. Once started, the career of restraint may itself provoke effects which tend to lead it to continue. Mainly physiological mechanisms such as those portrayed by the spring may produce effects that are responded to in psychological ways. Likewise, the person’s psychological response may lead to the physiological mechanisms being pushed further still.

Other changes in the body may take place as a result, including the ‘switching off’ of the adult hormonal patterns mentioned earlier, and these in turn may have psychological consequences. In the meantime, the sufferer will be feeling and behaving in a different way from usual and other people may be responding to her differently. For instance, she may come to be seen as a sick child rather than as a robust adolescent or as a quirky invalid, rather than a healthy adult. All sorts of con­sequences can come, tending to confirm the sufferer in her trapped position.

WHO IS MORE VULNERABLE?

The people most likely to be trapped by these vicious circles must in some way be especially vulnerable. However, we are not certain of what it is that makes some people more vulnerable than others.

It may in part be biological, as the genetic evidence suggests.

However, psychological factors are likely to be of crucial importance. It is likely that people struggling with certain emotional dilemmas may become more readily trapped. For instance, a person who feels she must keep tight control on her emotions, and/or is in a situation in which she is wary of rocking the boat, may find giving up slimming difficult. Anything that leads a woman to feel less secure and to value herself less may tip the balance towards things going wrong. (Both Heather and Susan in the stories given earlier could be thought of as being vulnerable in these ways.)
Also, some people seem to find any threat of instability and unpredictability especially difficult to cope with. They are often thought of as being perfectionist and obsessional. Although these personality traits have real advantages in some circumstances, they may make a person more vulnerable to eating disorders, perhaps especially to anorexia nervosa.

This section has outlined a way of discussing what eating disorders may be about. It may help to put together what may otherwise seem to be rather fragmented theories and ideas about the causes. However, I would like to emphasise that for the present there are more good questions than there are good answers about the nature of the eating disorders. Nevertheless, most people do recover from these somewhat mysterious disorders. The following chapters discuss what is involved in recovery and some of the methods that are used to help sufferers get better.