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Treatment of Nonsuicidal Self-Injury in Adolescents
10 CEUs Physical Pain Stops my Pain - Treating Teen Self Mutilation

Section 17
Anorexia and Self-Mutilation Diagnosed as Pathological

Question 17 | Test | Table of Contents | Self-Mutilation CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, MFT CEU

In several ways, modern-day eating disorder behaviors are manifestations of a quest for quasi-spiritual purity and transcendence. Like some religious ascetics and saints attempting to attain spiritual elevation, anorectics and bulimics inflict physical discomfort upon themselves to reach an ideal state of being that is obtained through the body, but has as its goal a state beyond material existence. Not only do they restrict their appetites and practice purging, they often mutilate their flesh.' Although sociocultural analysis is vital to understanding the near-epidemic appearance of eating disorders within the past three decades, the characterization of these disorders as self-infliction of pain has yet to be discussed. Starving oneself hurts. Consuming 15,000 calories in one sitting and then vomiting for an hour to purge oneself hurts. What does it mean when a human inflicts this kind of pain and discomfort upon herself? To answer this question I will discuss anorexia as both an attempt to transcend the self by becoming pure and self-controlled and a simultaneous attempt to create an autonomous self. The implications of the relatively recent correlation of self-mutilation with eating disorders is important to the analysis of eating disorders as attempts to transform and initiate oneself into a new state.

As one of humanity's most common daily acts, eating provides sustenance, pleasure, social ritual, and social bonding. Eating is one of the most potent ways individuals interact with the environment as they incorporate physical elements outside themselves physically into themselves. Eating is one of our most basic and primal ways to manipulate the world around us in order to survive. We are fascinated with eating disorders because they refuse the exigency of nutrition and underscore the power of eating as a real and symbolic crossing of body boundaries. A search for literature on eating disorders results in hundreds of references. Researchers have studied correlations between eating disorders and body image distortion, family conflicts, adolescent separation anxiety, conflicted sexual development, homosexuality, cultural pressure, obsessive-compulsive disorders, and plasma beta-endorphin levels, to name only a handful. Anorexia and bulimia are the two most commonly known eating disorders and have been labeled "modern diseases" due to the dramatic increase in their diagnoses in the past three decades.

Anorexia is also modern by virtue of its exclusivity to countries that are industrialized and have fairly affluent standards of living. It was first diagnosed as a disease in the 1870s, a time of increasing industrialization, urbanization, and concern of the developing American middle class for maintaining civilized values against an onslaught of immigrants. In America, the association of food with spirituality, morality, and sexual identity dates back to Sylvester Graham's diatribes in the early 1800s against eating meat. Graham also preached against the vice of masturbation and claimed that eating meat increased carnal desire. Another early American health food missionary was John Kellogg, who in Victorian times presaged the current health food trend with his invention of granola. Middle-class and affluent Victorians considered appetite a sign of sexuality and lack of self-restraint. Middle-class Victorian women felt pressured to uphold an idealized image of women as frail, morally and spiritually superior beings whose weak appetite and disdain for meat demonstrated purity and daintiness.

Opposing the image of the ideal woman as one who languished in need of bedrest and water-cures, and epitomized temperance and bodiless spirituality were women like Abba Woolson in the "woman movement." In 1873, the same year that the starving disease was labeled "anorexia nervosa," Woolson argued that women should develop their physical stamina to aid in their moral and intellectual development. Perhaps the women who starved themselves were perversely exercising their physical stamina of self-denial. Or perhaps, caught in a cultural mélange of contradictory options and messages, these women sought to create a well-defined identity for themselves. Cultural historian T.J. Jackson Lears characterizes the late nineteenth century as a time when "individual identities began to seem fragmented, diffuse, perhaps even unreal. A weightless culture of material comfort and spiritual blandness was breeding weightless persons who longed for intense experience to give some definition, some distinct outline and substance to their vaporous lives."

Several "fasting girls" did experience what was probably the most noteworthy and attention-garnering experience of their lives by becoming weightless caricatures of the Victorian ideal of womanhood. "Fasting girls" not only captured the attention of their families but fascinated the public, and as late as 1910, the popular American press continued to report their cases. The public read about Sarah Jacobs, a Welsh girl known throughout Britain and the United States, who reportedly began to fast in 1867 and finally died of starvation in 1869. While many people, including Sarah Jacob's family, configured the emaciated girl as evidence of a miracle, doctors were skeptical. The rising prominence of medical authority and medicalization of the body that accompanied the Victorian hesitation between science and religion permitted the medical community to pathologize the anorectic body. Citing medical standards of expected bodily response to lack of food, doctors decried fasting girls as pathologically aberrant, or considered their prolonged fasting as fraud. The medical community considered Molly Fancher, a mystic and clairvoyant who was well known in the 1870s and 1880s and allegedly abstained from all but minute bits of food for fourteen years, hysterical, while Spiritualists believed she exemplified the existence of supernatural realms. British physician Sir William Gull preferred to discard the imprecise diagnosis of hysteria and in 1873 described "anorexia nervosa" as a disorder of the central nervous system. Concurrently, French physician Charles Lasegue described anorexia hysterique as intimately connected to the dynamics and conflicts in the anorectic's family.

Although she differentiates medieval fasting practices from modern eating disorders, Joan Jacobs Brumberg traces the history of anorexia and details the evolution of medical and psychiatric thought about anorexia in Fasting Girls: The Emergence of Anorexia as a Modern Disease. As a cultural history of anorexia, Brumberg's book is invaluable in understanding the contributions of Victorian norms and the ideas of Gull, Lasegue, Freud, and Pierre Janet to the modern perception of eating disorders. In the first half of the twentieth-century doctors continued to describe anorexia as a biological and psychological disturbance, to be treated with change of environment, forced feeding, and psychoanalysis. After World War II psychiatrists began to conceive of anorexia as a developmental issue, and theorists in later decades began to analyze anorexia as a reaction to cultural messages about the female body and gender roles. By 1988 the incidence of the diagnosis "anorexia" had increased to astounding proportions. Although within the general population eating disorders are relatively infrequent, and occur extremely rarely among African Americans, Chicanos, or many first or second generation ethnic groups, the group at-risk for eating disorders shows a high incidence. In the at-risk population of white, educated, middle- or upper-class, adolescent girls, eating disorders may afflict from 5 to 20 percent of individuals. There has been a gross increase in the number of cases diagnosed since 1970.

Eating disorders have recently been seen as a "me too" behavior, and a "group reaction,"2 which exemplifies the poignancy of these disorders as a search for social identity Individuals do not seek an isolated identity but seek to establish themselves in relation to their culture. Recognizing eating disorders as social behaviors forces confrontation of questions central to this book. If enough people indulge in a behavior, is it no longer deviant? If an action is greeted by a small accepting community is it mainstream or subcultural? What does the epidemic of eating disorders communicate about the culture in which it occurs?

Many works have been published in the past twenty years interpreting anorexia and bulimia as responses to cultural pressures on women. Factors that must be analyzed to understand eating disorders include historical and cultural attitudes toward the body, toward women, toward autonomy and the self, toward sexuality, and toward food. These approaches have been amply discussed elsewhere, and I will instead touch upon other, less acknowledged ideas, including a brief historical overview of attitudes about eating, eating disorders as masochistic behavior, and eating disorders as attempted self-transformation. An analysis of eating disorders will ultimately provide an avenue to explore the significance of other forms of self-mutilation.
- Hewitt, Kim, Mutilating the Body: Identity in Blood and Ink, Bowling Green State University Popular Press: Bowling Green, 1997.


Personal Reflection Exercise #3
The preceding section contained information about anorexia and self mutilation diagnosed as pathological. Write three case study examples regarding how you might use the content of this section in your practice.

In the first half of the twentieth-century doctors continued to describe anorexia as a biological and psychological disturbance, to be treated with change of what? Record the letter of the correct answer the Test.

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