I’m Judging You – The Emergence of Disorderly Eating

Trigger Warning

Disorderly eating behaviours are increasing within the Western world. Eating disorders are serious and potentially fatal conditions with anorexia nervosa having the highest mortality rate of any psychiatric illness.[1] According to figures from the National Institute of Mental Health (NIMH), approximately 0.5%[2] of anorexics each year die prematurely from complications related to self-starving behaviour, including ‘suicide and heart problems’.[3] The longer the duration of the illness, the greater the probability of death.[4]

 

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Within the United Kingdom, cases of eating disorders have risen dramatically over the last decade. The Eating Disorders Review from March/April 2014 reports that ‘[r]ates of eating disorders among females increased between 2000 to 2009, from 51.8 per 100,000 population to 62.6 per 100,000’.[5] More recent figures from the Health and Social Care Information Centre (HSCIC) ‘show a national rise of 8 per cent in the number of admissions to hospital for an eating disorder’[6] in England from 2013-1014. Of eating disorder sufferers, NHS research estimates that ‘10% are anorexic; 40% are bulimic, and the rest fall into the EDNOS category, including those with binge eating disorder.’[7]

Despite their prevalence within contemporary Western society, patterns of disorderly eating are not a modern phenomenon. There is evidence of abnormal food-related behaviours throughout history from the fasting saints of Medieval Europe to the hunger striking Suffragettes. It was not until the end of the 1800s, however, that eating disorders became subject to medicalisation when anorexia nervosa was simultaneously diagnosed in England and France by Sir William Withey Gull and Ernest Charles Lasèque. While Lasèque named the condition anorexie hystérique, the term anorexia nervosa was coined by Gull whose description of extreme self-starvation first appeared in Transactions of the Clinical Society of London (1874).[8] In an 1888 issue of the Lancet, Gull attributed ‘perversion of the “ego” being the cause and determining the course of the malady’,[9] crediting his patients’ refusal to eat to a psychological affliction.

Contemporary medical conceptions of anorexia nervosa continue to draw their aetiology from the work of nineteenth century physicians. These discourses attempt to explain disorderly eating in terms of individual pathology. While the current edition of the Diagnostic and Statistical Manual (DSM V) now distinguishes two subtypes of anorexia – the binge-eating/purging type[10] and the restricting type, in which there are ‘no recurrent episodes of bingeing or purging’[11] – these behaviours are still attributed to a pathological cause.

The modern diagnostic criteria for anorexia nervosa are outlined in the DSM V.[12] There must be evidence of ‘[e]nergy restriction leading to significantly low body weight’;[13] ‘[f]ear of weight gain or behaviour interfering with weight gain’;[14] and ‘[d]isturbance in self-perceived weight or shape’.[15] According to Beating Eating Disorders (BEAT), in order to be classified as suffering from anorexia nervosa, the individual must refuse ‘to maintain, or to reach, 85% of the expected body weight for someone of that age and height.’[16] The severity of the condition is based on Body Mass Index (BMI). For an adult, a normal BMI score ranges from 18.5-24.9.[17] Mild cases of anorexia nervosa are classified as having a BMI score of more than 17, while at the other end of the spectrum, extreme cases have a score of less than 15.[18]

While anorexia nervosa was identified over a century ago, a newer disorder, bulimia nervosa, came to medical attention during the 1980s. In the decades following its diagnosis, there was a dramatic increase in its prevalence,[19] with statistics suggesting that it currently affects approximately 1-3% of women within the general population.[20] Bulimia nervosa is characterized by ‘recurrent binge eating, recurrent inappropriate compensatory behaviours to prevent weight gain (e.g., misuse of laxatives or other medications, self-induced vomiting, excessive exercise), and self-image unduly influenced by the shape or weight of his body’.[21]

While medical terms such as anorexia nervosa and bulimia nervosa are the commonly accepted labels for self-starvation and binging/purging behaviour, they are avoided in this work. This is for three reasons. Firstly, the terms are misleading since the Latin word anorexia literally translates as lack of appetite; or, in the case of anorexia nervosa, loss of appetite owing to nervous causes. ‘Disorderly’ eating, however, does not necessarily entail a lack of appetite. On the contrary, most individuals who engage in self-starvation experience constant hunger and desperately attempt to suppress their appetite.

Secondly, since they belong to the project of medicalisation, these terms are a site of power relations and historically contingent cultural values. These terms therefore obscure aspects of female experience which this book endeavours to recover. Some modern critiques of disorderly eating have been undermined by their use of medical terminology. In The Social Construction of Anorexia, Julie Hepworth points out this deficiency in various feminist arguments. Rather than creating a radical agenda for female emancipation, feminist use of pathological language maintains a form of discrimination against women by reproducing the discourse that is used to justify the patriarchal order. While the works of feminist theorists such as Susie Orbach and Susan Bordo strongly critique medicine’s role in the subjugation of women, their use of terms such as anorexia nervosa reveals an internalisation of masculine values. By failing to adequately engage with the erroneous foundation of medicalisation, particularly regarding the psychosomatic nature of eating disorders, feminist criticism has lost the basis from which to effectively critique such practices.

The final reason for this book’s rejection of medical terminology in is owing to the fact that there is a difference between abnormal eating behaviours and their pathological definition. Medical and psychiatric interpretations posit various eating disorders as distinct categories. This is problematic however, since some women may exhibit symptoms of disorderly eating that do not accord with the medical aetiology. An individual who engages in self-starvation may have a BMI that is higher than the upper boundary required for the diagnosis of anorexia nervosa as defined by the DSM V. Likewise, despite evidence of binging/purging behaviour, its occurrence may be too infrequent to meet the criteria of bulimia nervosa.

Therefore, the general descriptive term within this study will be ‘disorderly eating’, which includes sub-clinical eating disorders as well as those which meet full DSM V criteria. Rejecting a narrow, medicalised aetiology allows for an inclusive understanding of a wide variety of eating-related practices.

[1] http://www.elementsbehavioralhealth.com/eating-disorders/whos-to-blame-for-anorexia/ [accessed 19/01/15]

[2] http://www.elementsbehavioralhealth.com/eating-disorders/whos-to-blame-for-anorexia/ [accessed 19/01/15]

[3] http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/ [accessed 20/01/15], referencing  The Renfrew Center Foundation for Eating Disorders, “Eating Disorders 101 Guide: A Summary of Issues, Statistics and Resources,” published September 2002, revised October 2003, http://www.renfrew.org

[4] https://www.nationaleatingdisorders.org/anorexia-nervosa [accessed 23/01/15]

[5] An Upswing in Eating Disorders Is Noted In Great Britain: Some important implications for provision of health care. Reprinted from Eating Disorders Review, March/April Volume 25, Number 2, ©2014 IAEDP http://eatingdisordersreview.com/nl/nl_edr_25_2_9.html  [accessed 19/01/15] The incidence of AN, BN, and EDNOS was highest in girls aged 15 to 19 years, This increase was accounted for by increases in the incidence of EDNOS cases.

[6] http://www.hscic.gov.uk/article/3880/Eating-disorders-Hospital-admissions-up-by-8-per-cent-in-a-year  Source of stats HSCIC [accessed 12/01/15]

[7] BEAT http://www.b-eat.co.uk/about-beat/media-centre/facts-and-figures/ [accessed 09/01/15]

[8] E.L. Bliss and C.H. Hardin Branch, Anorexia Nervosa: Its History, Psychology, and Biology (New York: Paul B. Hoeber, 1960), p.13

[9] W. Gull, ‘Clinical Notes’, The Lancet, March 17 (1888), p.517

[10] Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric

Publishing (Washington; London, 2013), p.101

[11] Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013), p.101

[12] Screening questions: What do you think of your appearance? Do you ever restrict or avoid particular foods so much that it negatively affects your health or weight? If yes, ask: When you consider yourself, is the shape or weight of your body one of the most important things about you? If yes, proceed to anorexia nervosa criteria Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013), p.101

[13] Screening questions: Have you limited the food you eat to achieve a low body weight? What was the least you ever weighted? What do you weigh now? Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013), p.101

[14] Screening questions: Have you ever experienced intense fear of gaining weight or becoming fat? Has there ever been time when you were already at a low weight and still did things to interfere with gaining weight? Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013), p.101

[15] Screening questions: How do you experience the weight and shape of your body How do you think having a significantly low body weight will affect your physical health? Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013), p.101

[16] BEAT http://www.b-eat.co.uk/about-beat/media-centre/facts-and-figures/ [accessed 09/01/15]

[17] http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/ [accessed 16/02/15]

[18] Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013), p.102, Intermediate values are: moderate = 16-16.99; severe = 15-15.99

[19]http://www.aedweb.org/web/index.php/education/eating-disorder-information/eating-disorder-information-14 [accessed 20/01/15]

[20]http://www.aedweb.org/web/index.php/education/eating-disorder-information/eating-disorder-information-14 [accessed 20/01/15]

[21] Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013), p.102

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