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T he medicalization of disorders of eating begins in the seventeenth century. The Christian tradition of self-abnegation meant that fasting became a common form of religious practice in the Middle Ages with spiritual rather than pathological implications (Ove 2002). In the course of the nineteenth century, self-imposed starvation came to be a syndrome clearly delineated by physical signs and symptoms and which was understood to have a psycho-genic origin. This idea that food had a special status was uncontested. Some theoreticians saw the manipulation of the middle-class family by their daughters as the place where rebellion could most meaningfully take place (Brumberg 1988). Yet anorexia nervosa, a name coined by William Gull in 1868, was still a rare and therefore clinically fascinating aberration. In the 1920s, the view of Morris Simmonds dominated: Anorexia was the result of a lesion of the pituitary gland. This endocrinological definition of radical thinness fitted well with the redefinition of obesity as the result of metabolic imbalance. It was only after World War II that Hilde Bruch began to speak of the lack of self-esteem and a distorted body image caused by maternal rejection in such patients. By the mid-1970s, "anorexia" had become a household word through her popular writings. During the 1980s, it was "widely publicized, glamorized, and to some extent romanticized" (Gordon 2000: 3). In 1979, the diagnostic category of "bulimia nervosa," binge-eating and purging, was coined by the British psychiatrist Gerald Russell and was added to the mix of eating disorders, having a similar tangled history (Russell 1997). Certainly, the use of purges and emetics in this context has its origin in ancient medicine and cultural practices concerning excessive eating. By this point, eating disorders such as anorexia and bulimia had become acceptable vehicles for the expression of mental illness in Western, industrialized culture, what George Devereux calls a prescribed template for mental illness: "Don't go crazy, but if you, do it this way" (Devereux 1980).

Today, if one were to play a word-association game, anorexia would be linked to words like: starved, skinny, malnourished, or excessive self-control. While the term "anorexia" technically refers only to low body weight or lack of appetite, anorexia nervosa is a syndrome with both psychological and physical aspects. The latter is a relatively rare illness, as it occurs, even in high-risk groups such as middle-class adolescent girls and young women, in only about 0.05 percent of that population. Considerably more, however, suffer from the broader definition. In contemporary culture, the term "anorexia" is generally used interchangeably with anorexia nervosa. The importance of this is that the frequency (or at least the perceived frequency) of the disorder has increased significantly during the past fifty years (Walsh 2003). The creation of the EAT scale (Eating Attitudes Test) by Garner, Olmstead and Polivy in 1983, provided a scale for evaluating specific (culture-bound) actions from "cutting one's food up into small pieces" to believing that "food controls my life." The score on the EAT seemed to provide documentation for the existence of a specific eating disorder.

In the twenty-first century, it is seen as a "mental disease." The standard American presentation of mental illnesses, the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association 2000) defines anorexia nervosa as:

1. "Refusal to maintain body weight at or above a minimally normal weight for age and height." Specifically, a person with a body weight less than 85 percent of what is expected.

2. "An intense fear of gaining weight or becoming fat, even though underweight."

3. "Disturbance in the way in which one's body weight is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight."

4. "In post-menarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen administration."

(American Psychiatric Association 2000: 583-9)

While the DSM requires all four of these for a clinical diagnosis of anorexia nervosa, individuals suffering from only some of these symptoms are still at serious mental and physical risk.

Following the DSM-IV-TR criteria, anorexia nervosa and bulimia can be seen as "addictive behaviors," in analogy to other psychological states such as chemical dependence, compulsive gambling, sex addiction, work-aholism, and compulsive buying (Coombs 2004). As such, it is seen to have a multifactorial cause. The environment factors are the sociocultural emphasis on thinness, the association between dieting and self-control and self-discipline, participation in sports emphasizing thinness, sexual or physical abuse, and the need for attention from others. The individual risk factors include genetic vulnerability; depression; obsessive-compulsive traits; a cognitive style preferring order, exactness, precision, and sameness; impulse control problems; low self-esteem; extreme need for approval; perfectionism; early onset of puberty; sexual maturation; restrictive dieting; fear of psychosocial maturity; extreme need for control; harm and risk avoidance; pursuit of an eating-disorder identity (Garner and Gerborg 2004). While many of these factors are truly suspect as "causal," even in the broadest sense of the word, an addictive model needs to have a set of primary causes, which are amenable to therapeutic interventions. To simply label such addictions as "genetic," following the older model for the medicali-zation of alcoholism, leaves little space for psychological intervention. The newer model of addiction now does. The treatment of such an addiction to dieting/starvation is "interpersonal therapy," emphasizing the "inner world and dynamics of the patient" (Petrucelli 2004: 312). The irony, of course, is that as obesity is not listed in the DSM-IV-TR, an addiction to food rather than its avoidance is missing in such approaches.

Such a narrow scope constructs the illness in a way that can limit the patients' understanding of their own condition. Anorexia, like other eating disorders, can, and does, vary greatly between individuals. A person may exhibit eating-disordered behavior or emotions without meeting the DSM definition. This has led to questioning of the criteria's absolute nature. Therefore, we must ask where the line should be drawn—and how to go about drawing it—between dieting behavior and anorexia. In light of these difficulties, encapsulating all aspects of eating-disordered behavior into a working definition is problematic.

Anorexia nervosa is often claimed to overlap with clinical depression. It is not clear, however, what is causative: Is the depression the cause of the eating disorder or is it the eating disorder that is the result of the depression, or do they merely share a common cause? Depression is commonly cited as one of the psychological symptoms that can coexist with anorexia. Additionally, the obsession with thinness is a defining aspect of this illness, and it is possible to exhibit eating-disordered behavior without actually being underweight or taking extreme weight-loss measures. Psychiatrist Hilde Bruch, who in the 1970s popularized modern notions of anorexia in her book Eating Disorders, states that its core elements are:

A distorted body image, which consists of the virtually delusional misperception of the body as fat;

An inability to identify internal feelings and need states, particularly hunger, but more generally the whole range of emotions; and

An all-pervasive sense of ineffectiveness, a feeling that one's actions, thoughts, and feelings do not actively originate within the self but rather are passive reflections of external expectations and demands.

(Gordon 2000: 18-19)

Bruch has analyzed the emotional side of anorexia via her psychological training. Specifically, she claims that childhood experiences and problems in psychological maturation can foster eating disorders, which often manifest in adolescence. Psychiatrist Richard Gordon reinforces Bruch's limited time scope in his argument about why teenagers are most vulnerable to a "deficient sense of self" (Gordon 2000: 19). Adolescence is the time period where self-autonomy is usually developed. Thus, refusal to become an active agent in this process can result in an identity centered on control of one's environment, specifically eating. While there is certainly a prevalence of anorexia in teenagers, the illness can present itself at any stage of life.

A possible explanation of anorexia offered in our age that desires to reduce mental illness to physiological causes is that it is caused by serotonin imbalance in the brain. Here, the notion of the common cause of depression and eating disorders is located in brain chemistry. This theory implies that anorexia can be remedied through pharmacological means, specifically selective serotonin reuptake inhibitors (SSRIs) (Hoek et al. 1998). If a lack of serotonin has a causal effect on the existence of anorexia, then the increase in serotonin should eliminate all side effects, including the eating disorder. Another school of thought is more multifaceted than this cause-and-effect relationship. Patient advocates, such as Mary Ann Mar-razzi, believe that those suffering from anorexia are "predisposed to an addiction cycle that is set into motion by chronic dieting [... whereupon] the brain releases opioids, known to cause a 'high' " (Psychology Today Staff 1995). They claim that although such an addiction can be offset by SSRIs, psychological therapy is a crucial phase of the treatment of anorexia.

Yet another view sees a person suffering from anorexia as having an obsessive need to be thin stemming from the need for control (Kalodner 2000: 12-13). Eating often can seem to be more easily controlled than many other aspects of a person's life. Food and body become obsessions that permeate every facet of a person's life, sometimes even intruding into dreams. Karen Way's book Anorexia Nervosa and Recovery, explains, thinness is the obsession and losing weight is the fix. When you're anorexic, watching the numbers go down on the scale is the only thing in the world that matters to you. It's the center of your life, the only meaning to your existence. Pursuing it takes all your time, and energy.

The excessive need to shed pounds at an ever-increasing rate is the result of a desire to a gain control over life. Ironically, this obsession with weight loss becomes life and spirals out of control.

It is further noted in the DSM-IV-TR that a dieting culture is where "being considered attractive is linked with being thin" (American Psychiatric Association 2000: 587). In these circumstances, "weight loss is viewed as an impressive achievement and a sign of extraordinary self-discipline, whereas weight gain is perceived as an unacceptable failure of self-control" (American Psychiatric Association 2000: 584). This seems simply a misplaced extension of the underlying claims of twentieth-century (Western, industrialized) diet culture: that thin is beautiful, that thin is good. If some self-control, even in starvation, is a sign of control, total self-control must be better.

Interestingly, a group known as "pro-ana" (pro-anorexia) resonates with this tenet of the illness in their belief system. This small faction of people believes that excessive thinness is a "lifestyle choice" (Shafran 2002; Ana's Underground Grotto 2005). In short, one who lives a pro-ana lifestyle is someone who has purposely chosen to adopt permanently an extremely limited, low-calorie diet. Pro-ana followers commonly feel that thinness should take precedence above all else and will voluntarily make sacrifices to that end.

Cultural pressures foster both dieting and anorexia. Contrary to popular opinion, anorexia is not only a disease that affects the very young, the very rich, the very white. It is true, however, that anorexia is more common among cultures that value thinness as beautiful (Kalodner 2000: 55). One can add that it appears in those subcultures that acquire such ideals in their integration into a majority view of the body. Thus, the shift in body image and the sudden appearance of anorexia in the African American community at the end of the twentieth century follows African American women entering more and more into the mainstream image of what an appropriate body must be. In 1960, Hilde Bruch found a "conspicuous absence of Negro patients" (Bruch 1966). By the mid-1990s, the rates had begun to approach the numbers in white middle-class (Pumariega et al. 1994). Anorexia does not discriminate, and many groups within modern Western culture are affected by it. Indeed, some groups, such as Jews and Italians in America, living in traditions where food is a major ethnic marker, seem to actually have higher rates of the syndrome (Rowland 1970). The attraction of thinness as a body type has not been prevalent throughout history. Throughout the twentieth century, an ideal of thinness has been constantly evolving throughout the West (Gordon 2000: 135). The incidence of anorexia in non-Western cultures has increased in recent years. As globalization has caused popular culture to infiltrate non-Western cultures, thinness as a necessity of beauty is further popularized, and the attractiveness of anorexia as a "prescribed template for mental illness" also is available. The question of whether there are cultural "pathofacilitative effects" that underlie the appearance of eating disorders has been the subject of studies in India and China. In India at least, while the EAT (Eating Attitudes Test) labeled "cutting one's food into small pieces" as pathological behavior, it was clear that this was understood as appropriate etiquette among those questioned and was in no way a sign of pathology. Likewise, the category of "food controlling one's life" was read in terms of Hindu religious fasting practices, rather than individual anxiety about dieting and body appearance (Tseng 2003: 183-9).

In addition to cultural biases, anorexia has been gender biased as well. While the prevalence among men is much lower than women, it is still evident amongst a faction of the male population. Anorexia and other eating disorders in men have often been neglected by society as well as clinical researchers. Arnold Anderson explains that, "Males with eating disorders may have sought professional help so infrequently that they have become a statistical rarity" (Anderson 1999: 73). Moreover, typical symptoms of anorexia that are present in females are usually correctly identified, whilst the same indicators in males are overlooked. This is due, in part, to the socio-cultural beliefs held in the Western world about men and the assumption that extreme thinness is only a feminine desire. Similarly, dieting culture sidelines men, while it focuses primarily on women.

Thus, men imagine themselves thin, while women imagine themselves fat. By interviewing a selected group of undergraduates at comparable American and Australian universities, Marika Tiggemann and Esther Rothblum tested the "social consequences of perceived weight"

(Tiggemann and Rothblum 1988: 76). When asked about their ideal weight, the women on average wanted to be 9 pounds thinner, while the men wanted to be i pound heavier. While only 20 percent of the participants actually were overweight, 50 percent felt themselves to be so, and women comprised the majority of this percentage. The second part of the project examined to what extent stereotypes about the obese are prevalent in Western society. On average, fat men and women were perceived by all participants as being warm, friendly, lazy, less self-confident and not as attractive as their thinner counterparts. The authors concluded that women have "higher public body consciousness" (Tiggemann and Rothblum i988: 85) than men and that stereotyping persists, leading possibly to social adjustment problems.

Anorexia is often viewed as a diet gone too far, resulting in virtual starvation. The boundary between anorexia and dieting is hazy. Dieting is comparable to anorexia in the strict sense that it is, by nature, a controlling act. When one is dieting, food is being restricted in a variety of different ways, and, if followed, the diet is controlling a facet of life. While dieting does play a large part in life, there is a difference between dieting and an irrational obsession with food. A nonobsessive average dieter's personality and lifestyle are not affected by their dieting regimen. However, someone with anorexia undergoes a radical change in lifestyle. This is due to the controlling nature of the illness. For instance, people with anorexia often plan out their meals when they wake up for the day and cannot waver at all from this schedule. By contrast, an average dieter's daily routine does not solely revolve around food.

Another important difference between anorexia and dieting is that most people with anorexia must receive treatment in order to recover. Eating disorders are seen today as psychological problems that often require the intervention of mental-health professionals and physicians. In general, a combination of treatments—such as individual psychotherapy, group therapy, family therapy, medication, nutritional counseling, support groups, self-help groups, and classes—may be used (Ellis-Ordway 1999: 189). Treatment of the problem has to start with addressing the underlying emotional and mental states. Physicians provide instructions that are necessary to remedy physical consequences.

SLG/Laura Goldstein and Jessica Rissman

See also Aboulia; Binge-Eating; Bruch; China Today; Globalization; Gull; Marcé; Morton

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