The Prejudice Against Eating Disorders

The bias against mental illness has eroded over the past generation. There are still plenty of people who view depression as a lack of will power, psychiatric medication as a sign of weakness or psychotherapy as a salve for people who have no friends, but several changes in our society and the field of psychiatry have eliminated much of this prejudice. The advent of a diagnostic classification system for mental illness gave people a clear, accessible resource to understand the meaning of different diagnoses. The representation of mental illness in the media has exposed the public to the suffering of and healing process from diseases such as depression and schizophrenia. The explosion in direct-to consumer medication advertising--despite all of the deleterious effects I have described in several posts--has improved the public perception of psychotropic drugs. Finally, the recently enacted federal law mandating parity in insurance coverage for "biologically-based" psychiatric diagnoses with medical illness only reinforces our society's gradual acceptance that these are real diseases.

But where do eating disorders fit into the changes in attitude toward the mentally ill? Anorexia and Bulimia are two of the psychiatric diagnoses covered under the parity law. There are no medications advertised to treat eating disorders. And, as I wrote about in the series of posts on the media, eating disorders are everywhere in our national mind. On the surface, it seems like the pervasive view of eating disorders should be changing like it is for other mental illnesses. But, unlike other psychiatric problems, it is a fine line to the community at large between disordered eating--practically an accepted norm about food--and a full-fledged eating disorder. Not everyone has a theory about the cause of Bipolar Disorder or Schizophrenia, but who doesn't feel like they have a right to express their opinion about eating disorders? Even conscientious doctors often believe it is ok to discuss nutrition advice or personal opinions about thinness to patients known to have an eating disorder! The prejudice remains hidden behind a screen of seeming good intentions and judgment laced with complete ignorance of the reality of these illnesses.

The rationale of our preoccupation with food and weight--from any weight loss scheme to daily meal choices--is that we are in control of our destiny. Calories in equals calories out, right? Aren't we all little machines? These tropes drive the multi-billion dollar diet industry but vastly oversimplify the balance of diet and weight. Nevertheless, it is a small step in logic for most people to erroneously apply this line of reasoning to an eating disorder: staying sick is merely a lack of will power.  One fundamental message of this blog is to dispel this myth.

Eating, even for those who struggle with it, is an automatic, natural process. It is impossible to understand, let alone imagine how powerless someone with an eating disorder is when confronted with food. Will power has nothing to do with it. But the endless discussion about food in our culture mistakenly gives the impression that there is little difference between worrying about weight and a mental illness. In this mindset, calling someone anorexic--a label of severe mental illness--can morph into an envious taunt. And nothing more clearly shows the extent of our communal bias.

I have written before how our society essentially exposes all adolescents to the risk factors of developing an eating disorder. The idealization of being thin, the rite of passage of dieting and the acceptability of weight loss and food restriction pressure almost all teenagers to expose themselves to a prolonged semi-starvation state. At that point, other factors including biological predisposition and family and social dynamics--which are clearly out of the child's control--determine the final outcome.

Just as an adolescent girl may be praised for losing weight, despite the inherent risk of getting sick, her inability to recover will be seen as a sign of weakness. In fact, families and friends, after extended periods of support, sadly express their frustration by writing the person off. That doesn't mean eliminating the person from their lives but a more subtle expression of bias. If developing an eating disorder is a sign of weakness, then remaining sick well into adulthood is not an intractable illness but a permanent character flaw. The person with a chronic eating disorder becomes almost less than a person: she no longer deserves to be seen or heard.

The results of this prejudice are subtle. Often the person has a job, friends and even a relationship. But those closest to her dismiss her thoughts or feelings. No one really is around to listen anymore. Under these circumstances, someone with an eating disorder has no one to turn to but the eating disorder itself. The prejudice serves to isolate those suffering even more.

The public message--from industry to the media to government--promoting the understanding of mental illness needs to expand into eating disorders as well. Instead, society continues to reinforce the prejudice. One recent example is the reality television craze depicting severe weight loss in the morbidly obese. This is a symbol of the bias that eating disorders aren't really mental illnesses but instead constitute an evening's entertainment. With the current knowledge in the diagnosis and treatment of eating disorders, what can be done? How can knowledge about the real suffering caused by eating disorders replace the public notion of weak, unmotivated women? I'll talk more about this in the next post.