Dr Peter Rowan MBBS.MRCPsych.
Medical Director Cygnet Hospital Ealing, 22 Corfton Rd, Ealing
London W5 2HT
The Priory Hospital, Priory Lane, Roehampton, London SW15 5JJ
And: 51 Sloane St, London, SW1X 9SW
And: 19 Cliveden Place, Sloane Square, London, SW1W 8HD
Introducing Anorexia Nervosa > Causes of Anorexia Nervosa
There are a number of alternative theories concerning causes of Anorexia. These are some of the main ones. There is a medical model that proposes that the abnormal behaviour of an anorexic is explained by a disorder of some biological process but despite research it is not certain what this might be. Much research centers still on the physical changes in anorexia especially in regard to various hormones and the mechanisms of appetite control. Often the central feature of research interest is around the hypothalamus because this area of the brain appears to control a range of associated functions including sleep, mood and temperature. However it is not at present clear what might lead the hypothalamus to function improperly and any abnormality of function could well be the result of starvation rather than the cause of it.
There is reasonable evidence that Anorexia is more common when there are other sufferers in the family suggesting a possible genetic cause. But the strength of any association is quite weak and really cannot be said to account for more than a small part of the possible causes. As the effect is so weak it raises the possibility that transmission of effect is through multiple genes or that the transmission is not that of the illness itself but is actually the transmission of a factor associated with the illness such as personality type.
There are a range of psychological concepts that have been put forward to explain anorexia. Freud considered the appetite drive part of the libido or life drive and saw the illness as an avoidance both of emerging sexuality and of becoming an adult woman. For many writers anorexia is a mechanism by which young girls avoid adulthood and withdraw from the physical, psychological and social pressures that arise during adolescence. The effect of taking control of eating when otherwise feeling so out of control is thought to lead to the primary symptom of weight loss. This leads the anorexic to look inward emotionally, an effect that is strengthened because her hormones are cut off as a direct result of the weight loss. The emotional and physiological changes of adolescence move into reverse leading to a developmentally frozen state. There is no real doubt in my mind that this model of cause has some validity in at least some patients. The difficulty is that few patients initiate weight loss because they want to avoid growing up. They certainly often are fearful of recovery and the growing up that that involves once they are ill. Also even though they may really want to recover in later stages of illness something traps them there which is separate from fear of maturation.
Self Psychologists such as Alan Goodsit consider that the illness arises as a result of a patient’s inability to provide validation, self regard and self esteem. In these circumstances the eating disorder provides a temporary relief from symptoms of anxiety by providing a sense of identity and purpose and direction. Certainly almost all anorexics express a profound sense of low self esteem and loss of self worth. Though it is not clear how much of this should be considered a cause or an effect of illness.
Some consider anorexia nervosa as the adolescent’s expression of a total family problem that is said to emerge as a result of her development. A normal adolescent needs to separate from her family, and especially her mother. According to this theory the complex needs of the family cause the various members of it to resist this separation. This sets up a conflict within the anorexic which the anorexia serves partially to alleviate because it slows or reverses development and maintains her in a more childlike and vulnerable position. The anorexic is the one who demonstrates illness because of her vulnerability but according to family systems theory the whole family is considered as ill.
The theories above all fail to explain why girls rather than boys are at risk, why it has been more common among the higher social classes and why it is still much more common in “developed”, westernised, countries. They also fail to explain the increasing incidence of anorexia over the past 50 yrs or so. A socio-cultural model attempts to answer many of these unanswered questions.
A theory based on social issues considers that it is society’s attitude to the ideal body shape of women, admiring of and desiring extreme thinness, that is primarily to blame. Role models are thin and being fat is considered totally unacceptable. Wanting to be thin is much more common now than a few decades ago. It has been more common among those of higher social class and it is certainly much more common among girls than boys. It certainly seems that these attitudes lead to an increase of dieting behaviour and that in turn increases the frequency of the development of anorexia nervosa. Therefore these social attitudes seem to be closely associated with the observed frequency of illness in particular groups and places.
The feminist movement base their ideas on this but have taken this model further. In principle the culturally driven attitudes to weight are thought to do harm to the personality of the developing girl. Girls in this society learn to be decorative and powerless and are demeaned by a male dominated society. The illness is seen to develop as an inevitable consequence of the views of society and refusal to eat as a protest against and challenge to society’s expectations.
A purely social model of causes certainly answers some of the questions that other models fail to address. However those who work with these extremely ill patients find that their concerns with what is socially desirable has disappeared by the time they are in an emaciated state and yet the illness doesn’t remit at that time. Looking at a severly ill anorexic it is obvious that her drive to avoid food is not simply the result of society’s view of a desirable body shape. While food restriction may have begun partly as a result of this the motive has certainly changed by the later stages of illness.
Dr Rowan's Secretary is stationed in the Priory Hospital, Roehampton.
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Email peter.rowan@psychiatrist4u.co.uk