Two young women come home to their families for Thanksgiving from their freshman year at college.   Let us call them Susan and Tonya.  They have tales of hard work and good grades, and they look fine to their families, though perhaps a bit tired.   At the holiday meal, Susan’s mother notices that she monopolizes the celery, nibbles at a few bites of turkey, and leaves everything else on her plate untouched.   Tonya’s sister catches her throwing up in the downstairs bathroom after dinner.  The following week a young attorney we will call Margot admits to her therapist that she spent Thanksgiving alone, having made excuses about work deadlines to avoid having to face her parent’s questions about her eating disorder.   She is ten pounds "overweight," according to her rigid expectations.  When work schedules prevent her from working out for an hour or more each day, she skips breakfast and lunch, drinks large quantities of unsweetened ice tea, and finds herself waking up at 2:00 am to binge on whatever is in the refrigerator.    Each of these women, though still healthy, may be on the path to a diagnosable eating disorder: Anorexia Nervosa, Bulimia, or Binge Eating Disorder, any of which can lead to serious health problems.   Low weight and loss of the menstrual period can cause osteoporosis with sometimes irreversible bone loss.  Low protein and chemical imbalances lead to an irregular heartbeat, and actual heart damage with potential cardiac arrest.   Dehydration and low blood sugar cause episodes of dizziness, weakness, and difficulty concentrating.   Excessive vomiting causes damage to teeth and esophagus with chronic heartburn and severe dental problems.  And patterns of yo-yo dieting and break-through bingeing can lead to chronic weight control problems.  In the worst cases these illnesses can be fatal.  But even when the severe health problems don’t emerge, there is a devastating social and emotional cost of eating disorders and the body image disturbance that usually accompanies them. 

The onset of eating disorders and body image distortions comes at a time in life when it is important to be accepted or popular, when judgments are quickly formed and appearance is important.   We live increasingly in a world of projected images.   We are bombarded daily with film, television, and magazine images specifically focused on the current western model of slender beauty.  The images serve both to attract our attention and to associate success and happiness with various featured products.  Even when we are aware of the manipulation, the constant barrage of repeated images makes a lasting impression.  The lesson learned by the young person is,  "this is what I should look like" even if it is not realistic.  It is easy for her to believe, "I can only be popular and happy if I am thin!" To quote an article from the Baltimore Sun, "Anorexia Nervosa seems to follow the subscriptions to Vogue.  If Vogue gets to your country, anorexia will eventually follow."  (McHugh, 1977)  

There are two aspects of body image that make it a compelling focus for our sense of self.  The first is fairly obvious.  The immediacy of the visual image and the facility most of us have for remembering a clear visual image make it an extremely efficient point of comparison.  It is easy to tell, instantly, how you measure up to a visual ideal.  The second aspect is less obvious because it is related to a little known quality of the primary emotion or affect – Shame.  Shame can be thought of as a powerful and painful emotional reaction to the situation of being defeated, rejected, or overwhelmed.  The defeated animal wants to slink away to safety, to avoid the predator’s gaze, to become invisible.   The shamed human being wants to withdraw, to disappear, and lives in terror of exposure and ridicule.  Visible imperfections are magnified in our shamed mind’s eye.   If the shame is great enough, we will do anything to hide or minimize such painful flaws. 

Once a young woman (most, though not all, eating disorders occur in women) begins to act on this compelling emotional dilemma, psychology and physiology interact to generate a vicious cycle.   Extreme dieting creates a chronic state of hunger that, in turn, generates a fear of overeating.  This fear must be constantly suppressed, with any threat to the diet triggering panicky feelings associated with exaggerated expectations of intolerable weight gain.   It is difficult to overstate the intensity of this panic as a motivator for the extreme behaviors of the person with an eating disorder.  The need for control, sometimes involving purging behaviors after eating, leads to social isolation.   Withdrawal may feel safer at first, but eventually leaves the dieter depressed and alone with her fears, which grow ever more frequent and intense with unchallenged repetition. 

The social influences of family and peer groups are as important as the global media images.  Early success in dieting may bring positive attention that confirms the underlying belief in the safety and power of thinness.   On the other hand, the prevalence of teasing among peers or family members is often one of the earliest experiences of social vulnerability.   In the social jungle of adolescence, when the acute importance of belonging and acceptance collides with the chaos of physical and sexual maturation, such teasing generates the kind of horrific shame that can quickly escalate out of control.  When teasing focuses on appearance, it can be painful enough to generate a craving for the kind of safety that either perfect beauty or invisibility seems to offer.   The safety is illusory, however.  For those who are trying to hide from their own painful feelings of shame, no degree of beauty is sufficient protection.  The more relentlessly a dieter is driven by memories or fantasies of being teased or harassed, the more potent those shameful memories or fantasies become.  Though a sort of functional invisibility may be sought in social withdrawal or baggy clothing, the hypersensitive individual who seeks such protection always feels vulnerable to exposure, aware that they are trying to hide something.  Research on sources of body image disturbance in 1993 indicated that specific teasing about weight or size was a consistent predictor of body image dissatisfactions and eating disturbances. 

Not every kid who is teased develops an eating disorder.   The vulnerability to such teasing may also have its roots in a biological predisposition to depression, anxiety, or obsessive compulsive disorder.   Trauma, abuse, or family conflict can so undermine personal security that persistent craving for safety can find connections to body image.   

Understanding the risks and some of the causes of eating disorders is important, but just a beginning.  Dealing with them is rarely easy.   Young women who are confronted by concerned parents on evidence of a potential eating disorder often deny it or hide the evidence, believing that adults don’t understand the pressures on them and the intensity of the shame that plagues them.  Too often, adults are quick to label the young person’s priorities "ridiculous" or "crazy" when it seems that a superficial ideal of appearance is valued more than health or honesty.   This usually confirms the sense of alienation and failure mirrored by the shame-based body image.   Adult women who come to treatment after years of living with an eating disorder have to face the accumulation of years of habit and secret obsession that has strengthened distorted beliefs undermining their self worth.

The good news is that resources for effective assessment and treatment are available, especially in large metropolitan areas like Washington.   The bad news is that most eating disorders go on undetected by family and untreated for years, while the habits of thought and action grow stronger and the self esteem suffers further erosion.