What explanations have been provided for the onset of anorexia nervosa?

The term anorexia nervosa literally means 'nervous loss of appetite' (Frude, 1998, p76), but as Frude (1998) points out, anorexic people often do not lose their appetites - instead they refuse to eat an appropriate amount of food. Indeed, 600-800 calories a day may be all that an anorexic individual will consume, sometimes this figure may be even lower (Frude 1998). Although the term anorexia nervosa was first coined in 1868, it did not enter the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders lexicon (DSM) until 1994, when it was listed in DSM-IV (Frude 1998; Davison & Neale 1998). A significant primary cause, or vulnerability factor, is extremely difficult to identify in cases of anorexia; the aetiology of anorexia is multi-faceted, with biological, psychological and social processes all spectres haunting the anorexic individual. GENETIC EXPLANATIONS OF ANOREXIA The biological explanations of anorexia are interesting but inconclusive. One attempt has focused on genetic factors - with ambiguous results. Holland et al. (1988) found that around 56% of identical (MZ) twins are concordant for the disorder, compared with 5% for DZ twins; Hsu (1990), after an extensive literature review, found a 47% concordance rate for (DZ) twins and 10% rate for non-identical (DZ) twins. However, the fact that relatives of anorexics run a higher risk than the general population of also becoming anorexic does not, according to Frude (1998), suggest that a firm genetic link for anorexia can be inferred. Instead, the shared family environment may account for these findings. MZ twins are often discordant for the condition & genetic explanations offer no practical possibilities for treatment. BIOLOGICAL EXPLANATIONS OF ANOREXIA Kaye et al. (1988) suggests that a dysfunctioning hypothalmus may offer a partial explanation for anorexia. The lateral hypothalamus (LH) produces hunger & the ventromedial hypothalamus (VH) depresses hunger. The hypothalamus regulates hunger sensation and instigates the eating impulse, however, animal studies have shown that when the hypothalamus is in some way damaged, this process is disrupted. One theory is that a reduction of a neurotransmitter called norepinephrine (epinephrine is a synonym of adrenalin) can disturb the operation of the hypothalamus and lead to anorexia: drugs which increase norepinephrine levels have been reported as helpful in treating anorexia (Frude 1998). However, Doers et al. (1980) suggest that disturbances in the hypothalamus might be the result of self-starvation and not the cause of it, for instance, hormonal abnormalities in the hypothalamus disappear after weight gain. Also, Davison and Neale (1998) point out that anorexic patients starve themselves despite still feeling hungry, however, the animals with hypothalamic disturbances did not exhibit behaviour which suggested hunger, rather they became indifferent to food. They also point out that the hypothalamic explanation cannot account for the anorexic's derogatory self-image. Kaye et al. (1993) has suggested that some of the symptoms of anorexia, such as anxiety, obsessional and compulsive behaviour can be linked to an abnormality in another neurotransmitter - serotonin. Zinc deficiencies are also a common feature of anorexic patients, and it has been suggested that symptoms of anorexia, such as weight loss and depression, could be due to a low level of zinc in the body (Bakan et al., 1993). Some research suggests that endogenous opioids are also released during periods of starvation.

The release of opioid chemicals may produce a feeling of elation and act as a biological reinforcer (Marrazzi & Lubv, 1986). However, research into biological factors of anorexia is still ongoing, and at the moment it is difficult to establish a causal connection. i.e., the reported biological abnormalities of anorexics may be as a result of the disorder, not a cause of it. Furthermore, biological explanations of anorexia genes or hypothalamus do not currently offer the possibility for treatment; the other causal (aetiological) psychological explanations described here do also suggest possibilities for treatment & so are useful for sufferers. PSYCHOLOGICAL EYPLANATIONS OF ANOREXIA: PERSONALITY As biological accounts of anorexia cannot offer a definitive explanation of the disorder, a lot of attention has been focused on psychological factors. One area of interest has been in the typical anorexic 'personality'. Research in this area has revealed characteristics common to anorexics prior to the onset of the illness. For instance, anorexic patients are described as shy, compliant and perfectionists, and recorded high scores on the Minnesota Multiphasic Personality Inventory (MMPI) for neuroticism, anxiety, social isolation and depression; they also tend to lack self-esteem and are likely to maintain traditional, conservative views about the family and social norms (Davison & Neale 1998). It has also be noted (Pliner & Hadock. 1996) that anorexics tend to display high levels of socially orientated perfectionism, i.e., they frequently try to conform to the standards set by others even when these standards are unachievable (Davison & Neale 1998). The personality of the anorexic can thus be seen to affect the decision to lose weight, the approach to dieting itself, and may partly explain why dieting becomes so problematic. As has been noted, anorexics often suffer from low self-esteem and depression, and they are also far more likely to acquiesce to cultural demands and expectations. However, it should be noted that starvation itself affects personality. In a study of semistarvation in male conscientious objectors, Franklin et al. (1948), noted that all the men became obsessed with food and displayed higher than normal levels of fatigue, irritability and moodiness, they also had poor concentration levels and reported a loss of interest in sex. PSYCHOLOGICAL EXPLANATIONS BEHAVIOURIST/REINFORCEMENT ACCOUNTS OF ANOREXIA:

Classical conditioning: an association or habit is formed through stimulus-response

mechanisms an individual learns to associate being thin (stimulus) with admiration & feeling positive about themselves (response).

Operant conditioning: the attention (reinforcement) from parents for not eating may act
as a reward/or the satisfaction of punishing parents through not eating may act as a reward.

Social Learning Theory (SLT): the influence of media & culture identification with role
model (attention, retention, reproduction & motivation). The media portrays thin women very positively & celebrities who have certain body shapes can be praised or vilified, e.g., Heat magazine. Similarly, men are encouraged by media depictions of masculinity to be muscular etc. & rates of body dysmorphia (an obsession with body shape/appearance) is increasing in men, i.e. men obsessing about bulking up & spending hours in the gym.

However, many women are exposed to a huge amount of vicarious reinforcement regarding body size, but very few become anorexic. Dieting can be seen by some anorexics as a way of combating their negative self-image and dealing with the problems in their lives. Dieting, and its positive effects, can be reinforced, for example, the anorexic may begin to feel that their body shape is changing, becoming more like their idea of what constitutes the `perfect' body. Also, clothes that would not previously fit now do, and other people may initially comment positively on the anorexic's weight loss. Frude (1998) argues that such seemingly minor events may act as a positive reinforcement of the dieting process. Dieting can even be negatively reinforced, for instance, the anorexic may feel less dissatisfied with him or herself because they are experiencing less self-critical feelings. Frude (1998) argues that the weight scales themselves provide anorexics with tangible `evidence' of what might be regarded by them as improvement, i.e., weight loss. The perfectionist nature of many anorexics may result in the search for such `improvement' being taken to excessive lengths. However, as Frude points out, what is ultimately being reinforced, either through the behaviour of others, or by the anorexic his or herself, is not dieting per se, but a prohibition on eating. Frude suggests that as anorexia is about restricting one's food intake, and as it is fairly easy to work out the calorie content of most meals, the obsessional and perfectionist nature of many anorexics leads to a calorie control regime which regards decreasing calorie intake as being intrinsically valuable. Indeed, any deviation from the specified calorie target may be regarded as immoral', a sign of greed or lack of self-control (Frude 1998). The anorexic's initial feeling of anxiety and isolation can be replaced by a sense of self-control, the anorexic may see his or herself as `successfully' achieving their desired goal. This sense of control can be extended to the anorexics family and friends, whose concern for the anorexic's condition can be manipulated in a number of ways, for example, they may be made to feel responsible in some way for the illness (Frude 1998). Finally, the process of self-starvation can give the anorexic patient what is referred to as a secondary gain' (Frude, 1998, p87). Their duties and responsibilities will be set aside as a result of the illness, they may even be treated in a more childlike way, thus anxieties about adult pressures are alleviated, suggesting to the anorexic that there can be some advantages to being ill. Behaviourist/learning explanations ignore biological accounts: as anorexics are not studied from birth it is impossible to identify exactly when & how anorexic behaviour is acquired through either classical & operant conditioning or SLT. However, the learning approach can explain why rates of anorexia are higher in women than men as women are more often judged, praised or criticised, for their body size & image than men. PSYCHOLOGICAL EXPLANATIONS OF ANOREXIA: PSYCHODYNAMIC ACCOUNTS Family problems are another explanation for the onset of anorexia nervosa. One of the most famous advocates of this position is Hilde Bruch (1978. 1982). She suggests that poor parenting skills can lead some children to feel they are powerless, helpless and function ineffectually. The parents, especially the mother, may impose their views and values on the child, taking no account of the child's needs or wishes. This manifests itself at mealtimes, the child is fed when the parents deem it appropriate, not necessarily when the child is actually hungry. This leads to confusion about the relationship between hunger and eating, and may cause the child to believe that their own feelings and needs are subservient to those of the parents, causing them to be over-reliant on their parents

(Frude 1998; Davison & Neale 1998). Adolescence, the reputed time of `storm and stress' confronts the anorexic child with multiple pressures, for example, the pressure to conform to society's norms and the pressure to become autonomous. The `dutiful' child resolves this conflict and expresses self-control by rigidly monitoring food intake, a covert act of rebellion which aids personal identity (Frude 1998; Davsion & Neale 1998). Frude (1998) also suggests an elaboration of Bruch's model, where parental pressures on the child for some form of high achievement leave the child feeling helpless and depressed, especially if this achievement cannot be met. The child resolves this conflict by taking control of an aspect of their lives where they alone are responsible for success or failure: selfstarvation. Garfinkel and Garner (1982) have argued that some families are preoccupied with thinness. They may support a child's decision to diet, thus reinforcing the child's belief in the virtues of limited food intake. PSYCHOLOGICAL EXPLANATIONS OF ANOREXIA: PSYCHODYNAMIC ACCOUNTS CONT'D Psychoanalytic accounts of anorexia offer another possible explanation for its onset. One psychoanalytic theory is that some women confuse eating with sex, so that the avoidance of eating is seen as a way of avoiding sex, at least in a symbolic way (Ross, 1977). Other psychodynamic models cited by Frude (1998), are theories about regression and oral confusion. In essence, anorexia is seen as a way of avoiding adult responsibilities. The disruption of the menstrual cycle associated with anorexia means that puberty and ensuing adulthood are postponed and sexual maturity is not reached. This regression to a childhood state can be linked to the fear of sexuality already,, discussed. An oral component also features in psychodynamic explanations of anorexia. Women may starve themselves because, at an unconscious level at least, they associate being fat with being pregnant, an emaciated frame is diametrically opposed to images suggested by pregnancy. Other psychoanalytic theorists suggest that anorexia is a result of stunted psychosexual development. Sexual anxieties are expressed as dysfunctional eating patterns. However, such accounts of anorexia are open to all the usual criticisms associated with psychoanalytical theory, namely the lack of empirical evidence and its lack of scientific validity. It also seems to imply that psychodynamic explanations are best applied to female anorexics, male anorexics surely do not have fears about oral impregnation. Finally, it does not take into account the rapid rise in the number of cases of anorexic in recent decades. PSYCHOLOGICAL EXPLANATIONS OF ANOREXIA: FAMILY ACCOUNTS The research of Minuchin et al. (1978) suggests that families with an anorexic member display some common characteristics, for instance: enmeshment, or an over-involvement with each other resulting in 'claustrophobic' relationships; over-protectiveness; rigidity, or an entrenched desire to maintain the status quo and avoid change; and finally an inability to deal effectively with conflict, or to confront it openly, conversely, families may exhibit a state of chronic conflict. According to Frude (1998), adolescence (when anorexia typically begins) poses a threat to such dysfunctional families, since it is associated with rebellion and individuality. However, anorexia serves to unite the family as it allows them to focus on the illness and not the familial problems which may have caused or contributed to the disease. Davison and Neale (1998) report that empirical support for Minuchin's theory is limited, and some research (Dare et al., 1995; Woodside et al., 1994) even contradicts it.

Some studies have shown that a quite a high number of anorexic women have been the victims of sexual abuse, often perpetrated by a family member (Waller, 1991). Oppenheimer et al. (1985) has suggested that a possible explanation for the link between sexual abuse and anorexia is that as a result of the sexual assault the victim may come to hate her own burgeoning femininity, and the effects of anorexia often arrest the developmental processes associated with adulthood. However, familial sexual abuse does not really account for the dramatic increase in the number of cases of anorexia in the past few decades, or the rise in the number of men who have the disease. It needs to be stressed that family factors provide only one possible explanation for the onset of anorexia, and many families of anorexic patients do not conform to any of the models described above. Indeed, dysfunctional families may be the result of anorexia, not the cause of it. Family factors alone cannot account for the dramatic rise in cases of anorexia in recent years, which suggests that other forces might be at work. One such factor might be societal influences. PSYCHOLOGICAL EXPLANATIONS OF ANOREXIA: SOCIAL ACCOUNTS (NB., link to SLT) Davison and Neale (1998) point out that ideas about what constitutes the perfect body have changed throughout history and have varied between societies. Even in the Victorian era, Frude (1998) writes, there was a desire for women to achieve a certain culturally defined shape, which is why they wore very tight corsets. However, the trend towards thinness, Frude suggests, can be traced back to the 1920s when being thin first started to be a prerequisite for fashion models. Garner et al. (1980) found that American Playboy centrefolds became progressively thinner between 1958 and `78, although Wiseman et al., (1992) found that this trend had since stabilised. Moser (1989) and Sanders and Bazalgette (1993) found that the shape of three of the most popular dolls targeted at young girls presented grossly distorted images of the female form. Frude (1998) argues that it is thus not surprising that from an early age girls in particular believe that their body shape does not conform to society's expectations. Studies have shown that by the age of twelve body image has a significant impact on perceived self-worth, and is seen as an important feature of how people judge others (Wardle & Marsland, 1990; Hill, 1993). Killen et al. (1986) found that in the United States one third of girls in the tenth-grade considered themselves overweight. Davison and Neale (1998), quoting American figures, write that the number of dieters has increased from seven percent of men and fourteen percent of women in 1950, to twenty-four percent of men and forty percent of women in 1993. Nemeroff et al (1994) found that while articles about weight loss in women's magazines decreased in the period 1980-1991, they actually increased in men's magazines (although it should be noted that articles on weight loss occurred much less frequently in men's magazines as opposed to women's). Frude highlights a 1993 MORI poll which showed that a third of British men were on a diet, two thirds of those surveyed believed that in order to become more physically attractive a change of body shape was required. The fact that men are now also coming under pressure to conform to cultural ideals of thinness may have a significant impact on the number of men suffering from anorexia, currently men comprise around ten percent of anorexia cases (Frude 1998). As cultural expectations regarding ideal body shape have changed, so that thinness is seen as positive and any deviation from this normative judgement is viewed in pejorative terms, so incidences of anorexia nervosa have increased (Eagles et al., 1995; Hoek et al., 1993).

The importance of cultural factors in anorexia can be witnessed be the fact that anorexia is far more common in Western industrialised countries, or countries that are heavily influenced by the West, for example, Japan (Davison and Neale 1998). Some studies have shown that when women from a culture where eating disorders are rare migrate to one where they are high, they can be adversely affected by societal pressures to be thin (Yates, 1989). Nasser (1986) studied 50 Egyptian women in London universities with 60 in Cairo universities: 12% of those in London developed eating disorders, none in Cairo did. However, Lee (1994) dismisses notions that there are cross-cultural variations in eating disorders, arguing that illnesses similar to anorexia exist in India, Malaysia, the Philippines and other Asian countries. Also, despite the fact that all Western women are exposed to very similar cultural & social pressures & stereotypes, rates of anorexia are actually very low, most women are seemingly not overwhelmed be social & cultural pressures to be thin - & rates of obesity are actually rising despite the social pressures to be thin. CONCLUSION Anorexia nervosa is a complex and perplexing illness, it defies straightforward explanations. A number of factors, biological, psychological and social all seem to play a part in the disorder, with the victim of anorexia perhaps being affected by all three components. It is interesting to note that when media and cultural pressures to be thin increase, as has happened in the past couple of decades, so has the prevalence of anorexia, however, this does not imply a causal connection. As Davison and Neale (1998) point out, research into cross-cultural variations in anorexia has reported mixed findings, it is a theory which needs more investigation. The diathesis-stress model might be useful again in explaining complex clinical disorders; a genetic predisposition may make an individual vulnerable, but some sort of environmental or stressor will be needed to trigger the condition. Multi-faceted accounts of anorexia seem to offer the best explanation of the disorder.