Anorexia nervosa remains an enigma among Western cultures. Various causal explanations have been offered, encompassing biological, psychological, and sociocultural models. These explanations, however, focus on the immediate or proximal mechanisms of causation. A more thorough understanding of anorexia nervosa can be achieved by understanding the relationship between these factors and ultimate causation, the level of explanation which deals with individual reproductive fitness. This paper reviews the biological, psychological, sociocultural, and evolutionary models and indicates a necessary synthesis between proximate (...) and ultimate levels of causation in examining the anorexia nervosa puzzle. (shrink)

Body checking, characterized by the repeated visual or physical inspection of particular parts of one’s own body (e.g. thighs, waist, or upper arms) is one of the most prominent behaviors associated with eating disorders, particularly Anorexia Nervosa (AN). In this paper, we explore the explanatory potential of the Recalcitrant Fear Model of AN (RFM) in relation to body checking. We argue that RFM, when combined with certain plausible auxiliary hypotheses about the cognitive and epistemic roles of emotions, is able (...) to explain key characteristics of body checking, including how body checking behavior becomes habitual and compulsive. (shrink)

This paper argues that there is a relationship between understandings of anorexia nervosa (AN) and how the ethical issues associated with involuntary treatment for AN are identified, framed, and addressed. By positioning AN as a construct/discourse (hereinafter “AN: the diagnosis”) several ethical issues are revealed. Firstly, “AN: the diagnosis” influences how the autonomy and competence of persons diagnosed with AN are understood by decision-makers in the treatment environment. Secondly, “AN: the diagnosis” impacts on how treatment and treatment efficacy are (...) defined and the ethical justifiability of paternalism. Thirdly, “AN: the diagnosis” can limit the opportunity for persons with AN to construct an identity that casts them as a competent person. “AN: the diagnosis” can thus inherently affirm professional knowledge and values. Postmodern professional ethics can support professionals in managing these issues by highlighting the importance of taking responsibility for professional knowledge, values, and power and embracing moral uncertainty. (shrink)

Body dissatisfaction has long been considered an integral component of and driving force behind anorexia nervosa. In this paper, I characterise body dissatisfaction in terms of problematic beliefs about body size and the value of thinness. I suggest two methods for understanding these beliefs. Regarding body size beliefs, I suggest focusing on certain forms of misleading phenomenal evidence that sufferers of anorexia nervosa are exposed to. Regarding beliefs about the value of thinness, I suggest focusing on the benefits (...) of such beliefs. (shrink)

Contemporary diagnostic criteria for anorexia nervosa explicitly refer to affective states of fear and anxiety regarding weight gain, as well as a fixed and very strong attachment to the pursuit of thinness as an overarching personal goal. Yet current treatments for that condition often have a decidedly cognitive orientation and the exact nature of the contribution of affective states and processes to anorexia nervosa remains largely uncharted theoretically. Taking our inspiration from the history of psychiatry, we argue that (...) conceptualizing anorexia nervosa as a passion is a promising way forward in both our understanding and treatment of that condition. Building on the theory of the passions elaborated by Théodule Ribot, the founder of scientific psychology in France, we argue that there is convincing empirical evidence in defense of the empirical hypothesis that anorexia nervosa is a passion in Ribot’s specific, technical sense. We then explore the implications of this finding for current approaches to treatment, including cognitive–behavioral therapy, and clinical and ethical issues associated with treatment refusals. (shrink)

This is a preprint draft. Please cite published version (DOI: 10.1111/mila.12385). The aim of this paper is to provide a novel analysis of anorexia nervosa (AN) in the context of the sense of agency literature. I first show that two accounts of anorexia nervosa that we ought to take seriously— i.e., the first personal reports of those who have experienced it firsthand as well as the research that seeks to explain anorexic behavior from an empirical perspective— appear to (...) be thoroughly in tension with one another in their descriptions of anorexic actions. Rather than proceeding at this point by way of disregarding anorexic testimony as meaningless or insincere, I instead offer a positive account of the sense of agency in anorexia nervosa that renders these two depictions compatible. The resultant picture of anorexic behavior is one that accommodates current empirical findings while also providing valuable insight into how it is that anorexics can sincerely report feeling fully in control over their food restriction. (shrink)

The principles that usually direct ethical decision making are not easily or straightforwardly applicable to the care and treatment of anorexia nervosa, particularly the care and treatment of severe and enduring anorexia nervosa, where the sufferer seems to be recalcitrant to treatment and where the condition has become life-threatening.There are exceptional circumstances that characterize this puzzling and still scarcely understood condition; I suggest that these exceptional circumstances provide moral reasons for partial derogation from the usual principles of ethical (...) decision making.In what follows I argue... (shrink)

Este trabalho discute as possíveis relações entre a histeria e os chamados distúrbios alimentares que, na atualidade, ganharam um caráter epidêmico. Os discursos dos autores sobre a anorexia e a bulimia são apresentados e organizados em categorias temáticas que abordam as definições de anorexia e bu..

Anorexia nervosa is a psychiatric disorder that seems to be closely related to the identity of the person suffering from it. This is referred to in the vast literature on anorexia nervosa by specifying the quality of symptoms as ‘egosyntonic’ (e.g., Vitousek, Watson, and Wilson 1998). The pursuit of excessive thinness is part of a search for identity in which the control of the body—its size and needs—becomes central (Gillett 2009). This need for control seems to be triggered (...) by a state of bodily alienation in which the body is perceived to be foreign and horrifying to its bearer. However, the relentless dieting and excessive exercise pursued by the anorexic person eventually lead to a state of starvation in which .. (shrink)

This article will explore whether the law should allow people with anorexia nervosa to refuse nutrition and hydration with special reference to the English decision in Re E (Medical Treatment: Anorexia). It argues that the judge in that case made the correct decision in holding that the patient, who suffered from severe anorexia nervosa, lacked capacity to make valid advance directives under the Mental Capacity Act 2005 of the United Kingdom, and that medical procedures that are apparently (...) against her wishes should be carried out for the sake of preserving her life. The law should generally not permit patients with anorexia nervosa to decline nutrition and hydration, precisely because their autonomous ability to make such decisions has been substantially circumscribed by this psychiatric condition. (shrink)

Anorexia nervosa involves seemingly irrational beliefs about body size and the value of thinness. Historically, researchers and clinicians have avoided referring to such beliefs as delusions, instead opting for the label ‘overvalued ideas’. I discuss the relationship between the beliefs associated with anorexia nervosa and the distinction between delusions and overvalued ideas, as it is conceived in both European and American psychiatric traditions. In doing so, I question the benefit of applying the concepts of delusion and overvalued idea (...) to anorexia nervosa and raise some issues with contemporary use of the Brown Assessment of Beliefs scale for assessing the level of delusionality associated with the disorder. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Anorexia and the MacCAT-T Test for Mental Competence:Validity, Value, and EmotionLouis C. Charland (bio)Keywordsmental competence, decisional capacity, anorexia, value, emotionValidity of the MacCAT-THow does one scientifically verify a psychometric instrument designed to assess the mental competence of medical patients who are asked to consent to medical treatment? Aside from satisfying technical requirements like statistical reliability, results yielded by such a test must conform to at least some (...) accepted pretheoretical desiderata; for example, determinations of competence, as measured by the test, must capture a minimal core of accepted basic intuitions about what competence means and what a theory of competence is supposed to do. The concepts of "face validity" and "content validity" are both important here. Face validity "indicates that an instrument appears to test what it is supposed to and that it is a plausible method for doing so" (Portney and Watkins 2000, 82). Content validity "means that the test contains all the elements that reflect the variable being studied" (Portney and Watkins 2000, 83). An adequate instrument for measuring mental competence must at minimum satisfy both of these requirements.What Tan and her colleagues (2006) have shown is that the MacArthur Competence Assessment Tool—Treatment (MacCAT-T) test for mental competence may not be an empirically valid measure of mental competence for some cases of anorexia. The data they report show that "competence," as measured by the MacCAT-T, does not conform sufficiently well with what is wanted of a clinical medical theory of competence. More specifically, the MacCAT-T is deficient in both face and content validity. This result is extremely significant; previous challenges to the validity of the MacCAT-T have often been largely theoretical in nature. My own objection that the MacCAT is inadequate because it omits the influence of emotion is based on a combination of empirical theory (Charland 1998a) and philosophical argument (Charland 1998b). However, it is entirely theoretical in nature. So is my argument that in ignoring emotion the MacCAT misses a crucial contributing ingredient in competence, namely, value (Charland 2001, see especially 136 note 2). Tan's study provides valuable empirical evidence for the second of these challenges, which deals more specifically with value. On the one hand, the study clearly demonstrates that patients sometimes do [End Page 283] base their treatment decisions on reasons derived from values. And on the other hand, it also nicely illustrates the centrality of values—"utilities" or "preferences"—in the decision-making process generally; a basic assumption of standard decision theory for which, paradoxically, there appears to be no satisfactory counterpart in the MacCAT-T model of reasoning and decision making.Thus, values figure among the reasons that patients actually use in reasoning when they weigh the risks and benefits of proposed treatment options. The MacCAT-T must be amended to incorporate this fact if it is to be a satisfactory clinical medical tool. Without such a correction, the concept of mental competence it measures is empirically invalid. At the root of the problem is a clash of intuitions. Tan's data provide convincing evidence that some of the patients who are deemed to be mentally competent by MacCAT-T standards should not in fact be considered competent. Note that the language in which this clash is expressed—"should not in fact"—involves a combination of descriptive and prescriptive elements, reminding us that the concept of competence is dual in nature: it is both prescriptive and descriptive (Freedman 1981). These problems underscore the need for greater clarity about what pretheoretically we want a clinical theory and test of competence to capture. It is of course reasonable to say that such a test must be consistent with major tenets of the relevant case law (Appelbaum 1998). But a legally valid concept of competence of this sort is too thin and arbitrary a foundation on which to build a clinical medical theory of competence. An empirically valid theory and test of the latter sort must incorporate the role of values if it is be truly helpful in medical practice.Value and the MacCAT-TI agree with Tan and her colleagues that some notion of "pathological value" needs to be... (shrink)

It feels like there’s two of you inside—like there’s another half of you, which is my anorexia, and then there’s the real K [own name], the real me, the logic part of me, and it’s a constant battle between the two. The anorexia almost does become part of you, and so in order to get it out of you I think you do have to kind of hurt you in the process. I think it’s almost inevitable. We came (...) to the concept of authenticity belatedly, one might say. We had been talking to people who had a diagnosis of anorexia nervosa about their experiences of living with their condition, and though we had not raised issues of authenticity or identity ourselves, they often did. They struggled with questions of .. (shrink)

A large part of the debate around the right to refuse life-prolonging treatment of anorexia nervosa sufferers centers on the issue of competence. Whether or not the anorexic should be allowed to refuse life-saving treatment does not depend solely or primarily on competence. It also depends on whether the anorexic’s suffering is bearable or tractable, and on the degree of involvement of the family in the therapeutic process. Anorexics could be competent to refuse lifesaving treatment (Giordano 2008). However, the (...) anorexic’s refusal of life-saving treatment should not be respected purely because it is a competent decision. In fact, anorexia has two characteristics that weaken the strength of the principle .. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Appreciating Anorexia:Decisional Capacity and the Role of ValuesThomas Grisso (bio) and Paul S. Appelbaum (bio)Keywordscompetence, consent, anorexia, appreciation, decision makingTan and her colleagues (2006) reported that persons with anorexia nervosa typically manifest no difficulty satisfying the criteria for abilities associated with competence to consent to or refuse treatment. Their results led them to conclude that these patients generally had no problem grasping the nature of (...) class='Hi'>anorexia and its possible consequences (understanding), typically did not have difficulty processing information when making treatment decisions (reasoning), and usually neither denied that they had a disorder nor manifested distorted beliefs about the potential consequences of treatment for the disorder.Nevertheless, these authors found, some anorexia patients said that they knew they might die and that they would rather die than suffer the alternative consequences (e.g., loss of identity, feeling of being disgusting). They point out that these beliefs, suggesting questionable competence, were not identified by the usual criteria for competence to consent to treatment. Therefore, they propose that we should consider a modification of the criteria for competence to consent to treatment. They argue for inclusion of "pathological values" as the basis for a finding of incompetence. Their notion of a pathological value (as we summarize it based on their Discussion) includes (a) a personal value (b) on which treatment refusal is based, that (c) is not authentic, and (d) is due to a mental disorder.Second, Tan and colleagues were concerned that the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), currently used widely to assess competence to consent to treatment, did not seem to take values into account when examining deficits related to lack of appreciation or reasoning. They point out that most patients with anorexia nervosa in their study had "pathological values" that influenced their thinking about treatment, yet they did not obtain poor scores on the instrument's appreciation scale, which assesses whether patients deny that they have the illness or offer reasons for accepting or refusing treatment that are based on delusional premises or a serious distortion of reality. Moreover, almost all of the anorexia patients in the study obtained adequate scores on reasoning, which examines the ability to process options and consequences when weighing a treatment decision. [End Page 293]Reasons for Caution in Altering Criteria for CompetenceA fundamental step in considering Tan and her co-worker's proposal is to examine whether it is necessary to add a concept of "pathological values" to the legal construct of competence to consent to treatment. Modifying the legal doctrine of consent is important if that is needed to improve its validity or reliability. But modifications of the doctrine would have considerable costs, including a long process of producing logical and empirical evidence for its necessity, developing methods to assess the new concept, and then a process of debate, persuasion, and education to change laws, ethical guidelines, and medical training. Moreover, principles of theory building urge parsimony. A theory should employ no more concepts or assumptions than are required to account for the phenomena that the theory seeks to organize or explain. So one must be sure that modifications are truly necessary before adding complexity to the theory of decisional competence.In addition, there is an inherent danger in altering a concept like competence to consent to treatment on the basis of the study of any one mental disorder. It is not at all clear how the modification might influence findings of competence when applied to other disorders. Using a study of patients with anorexia nervosa as the impetus for changing the competence concept runs this risk. For example, anorexia is one of a class of mental disorders that is characterized by a failure to abstain from behavior (here, limiting food intake and other behaviors designed to reduce weight) that has negative consequences for the person. Other conditions in this category might include substance abuse disorders and impulse control disorders (e.g., pathological gambling). Even if one concludes that revised criteria for competence would reduce false-positive findings of competence in this group of disorders, one would have to consider carefully its impact on the full range of disabling mental conditions.Moreover, the sensitivity... (shrink)

Existing phenomenological accounts of anorexia nervosa suggest that various forms of bodily alienation and distorted bodily self-consciousness are common among subjects with this condition. Subjects often experience a sense of distance or estrangement from their body and its needs and demands. What is more, first-person reports and existing qualitative research reveal struggles with authenticity and a search for identity. Is there a connection between the two? I argue that to gain a fuller understanding of anorexia nervosa, how it (...) is experienced by subjects, and why many of them express concerns about authenticity, we need to look more closely at their experiences of bodily alienation and the ways in which they encounter a diminished sense of bodily ownership. After presenting a general overview of the various sorts of bodily alienation that appear to be characteristic of anorexia nervosa, I outline three conceptions of authenticity and introduce some empirical evidence indicating that many subjects with this condition have concerns about identity and authenticity. Then, I examine how different sorts of bodily alienation have the potential to compromise authenticity at various stages of the disorder. Throughout, I draw from several first-person accounts of anorexia nervosa to illustrate and support my claims. (shrink)

How does one scientifically verify a psychometric instrument designed to assess the mental competence of medical patients who are asked to consent to medical treatment? Aside from satisfying technical requirements like statistical reliability, results yielded by such a test must conform to at least some accepted pretheoretical desiderata; for example, determinations of competence, as measured by the test, must capture a minimal core of accepted basic intuitions about what competence means and what a theory of competence is supposed to do. (...) The concepts of “face validity” and “content validity” are both important here. Face validity “indicates that an instrument appears to test what it is supposed to and that it is a plausible method for doing so” (Portney and Watkins 2000, 82). Content validity “means that the test contains all the elements that reflect the variable being studied” (Portney and.. (shrink)

People who suffer from eating disorders often have to be treated against their will, perhaps by being detained, perhaps by being forced to eat. In this paper it is argued that whilst forcing compliance is generally acceptable, there may be circumstances under which a sufferer's refusal of consent to treatment should be respected. This argument will hinge upon whether someone in the grip of an eating disorder can actually make competent decisions about their quality of life. If so, then the (...) decision to refuse therapy may be on a par with other decisions to refuse life‐prolonging therapy made by sufferers of debilitating chronic, or acute onset terminal illness. In such cases, palliation might justifiably replace aggressive therapy. The argument will also draw heavily on the distinction between competent refusal of therapy and passive euthanasia, and the distinction between incompetent and irrational decisions. Both distinctions will then be applied to decisions to refuse food. The extent to which sufferers from anorexia nervosa can be categorised as either incompetent or irrational will be examined. It is against this background that it will be argued that at least some of those who suffer from eating disorders should have their refusals respected, even if they may die as a result. (shrink)

Starvation arouses evolved protective mechanisms including binge eating and increased metabolic efficiency and fat storage. When aroused by dieting, the experiences of out-of-control eating, increased appetite, and increased fat storage arouse greater fears of obesity, spurring renewed attempts to restrict intake severely. The resulting positive feedback cycle escalates into bulimia for many, and anorexia in a few.

Imposing artificial feeding on people with anorexia nervosa may be unethical. This seems to be Heather Draper's suggestion in her article, ‘Anorexia Nervosa and Respecting a Refusal of Life‐Prolonging Therapy: A Limited Justification.’ Although this is an important point, I shall show that the arguments supporting this point are flawed. Draper should have made a brave claim: she should have claimed that people with anorexia nervosa, who competently decide not to be artificially fed, should be respected because (...) everybody is entitled to exercise their autonomy, not only ‘in the middle’ of their life, but also at the end of it, or when their own life is at stake, because autonomy also extends to the most difficult moments of our life, and, ultimately, ‘stretches [.*T*.*T*.] far out into the distance’ at the end of it. I explain why Draper should have made the brave claim, and why she has not made it. I conclude that a defence of people's entitlement to competently refuse artificial feeding cannot rest upon the arguments developed by Draper. Whether or not we should respect competent refusal of artificial feeding depends on the normative strength that we are ready to ascribe to the principle of autonomy, to the moral relevance that we ascribe to the circumstances in which a person's autonomy is exercised, and, perhaps, eventually, on our sense of compassion. (shrink)

In my article "Controlling the noise," I present a phenomenological investigation of bodily experience in anorexia nervosa. Turning to descriptions of those who have suffered from AN, which repeatedly detail the experience of finding their bodies threatening, out of control and noisy, I suggest that the phenomenological conceptions of body-as-object, body-as-subject and visceral body can help us unpack the complex bodily experience of AN throughout its various stages. My claim is that self-starvation is enacted by a bodily-subject who wishes (...) to quell or reassert authority over a visceral body whose demands and needs she finds threatening to her autonomy.The relationship between body-as-object and... (shrink)

René Girard shows that all desires are contagious—and the desire to be thin is no exception. In this compelling new book, Girard ties the anorexia epidemic to what he calls mimetic desire: a desire imitated from a model. Girard has long argued that, far from being spontaneous, our most intimate desires are copied from what we see around us. In a culture obsessed with thinness, the rise of eating disorders should be no surprise. When everyone is trying to slim (...) down, Girard asks, how can we convince anorexic patients to have a healthy outlook on eating? Mixing theoretical sophistication with irreverent common sense, Girard denounces a “culture of anorexia” and takes apart the competitive impulse that fuels the game of conspicuous non-consumption. He shows that showing off a slim physique is not enough—the real aim is to be skinnier than one’s rivals. In the race to lose the most weight, the winners are bound to be thinner and thinner. Taken to extremes, this tendency to escalation can only lead to tragic results. Featuring a foreword by neuropsychiatrist Jean-Michel Oughourlian and an introductory essay by anthropologist Mark R. Anspach, the volume concludes with an illuminating conversation between René Girard, Mark R. Anspach, and Laurence Tacou. (shrink)

This is a book that attempts to propose itself as a new trigger in the wide world of anorexia nervosa. The originality of its proposal consists in approaching anorexia nervosa, not only by endocrinological and psychological perspectives, but also by anthropological, philosophical and ethical point of view. In this way it's not only an update of specific literature, but also an integration with a new method to study this condition. The purpose of the book is to approach (...) class='Hi'>anorexia nervosa from different points of view, to reach a new interpretation which involves notions from biological and human sciences interpreted in a unique model and which could allow a new method of treatment. (shrink)

Several theorists have tried to model anorexia on Wasser and Barash’s (1983) “reproductive suppression model” (RSM). According to the RSM, individual females adaptively suppress their reproductive functioning under conditions of social or physiological stress. From this perspective, mild anorexia is viewed as an adaptive response to modern conditions; more severe anorexia is viewed as an adaptation gone awry. Previous models have not, however, examined the full richness of the RSM. Specifically, Wasser and Barash documented not only self-imposed (...) reproductive suppression, but also manipulative reproductive suppression of subordinate females by dominants. I propose that the modern “epidemic” of anorexia is explained neither by adaptive self-suppression nor by environmental mismatch (an adaptation gone awry); I propose that the “epidemic” levels of anorexia seen in modern western society are a direct consequence of intrasexual competition, the scope of which has been enhanced by the power and reach of modern communications media. According to this perspective, anorexia, even in its mild forms, is a manipulative strategy imposed on subordinates by dominants. Anorexia is, in both senses, a “losing” strategy. (shrink)

In this paper anorexia nervosa is examined through three lenses to determine its possible causes. This paper contains a clinical analysis of the anorexic personality, a psychoanalytic/religious interpretation of the demands of society, and· a feminist reinterpretationof the effects of those demands on the female body. The societal demands to renounce instincts, when examined through a feminist lens, reveals that these demands, in concert with the detrimental effects of feminine socialization and characteristics of the anorexic personality, may lead some (...) women to view their needs as not important, and cause a detachment from and turning against the body in the form of anorexia nervosa. It is concluded that anorexia is not just women taking a diet “too far.” There are other psychological, philosophical, and social factors leading to a prevalence of anorexia nervosa in Western culture. (shrink)

In this paper anorexia nervosa is examined through three lenses to determine its possible causes. This paper contains a clinical analysis of the anorexic personality, a psychoanalytic/religious interpretation of the demands of society, and· a feminist reinterpretationof the effects of those demands on the female body. The societal demands to renounce instincts, when examined through a feminist lens, reveals that these demands, in concert with the detrimental effects of feminine socialization and characteristics of the anorexic personality, may lead some (...) women to view their needs as not important, and cause a detachment from and turning against the body in the form of anorexia nervosa. It is concluded that anorexia is not just women taking a diet “too far.” There are other psychological, philosophical, and social factors leading to a prevalence of anorexia nervosa in Western culture. (shrink)

Activity anorexia illustrates selection of behavior at the biological, behavioral, and neural levels. Based on evolutionary history, food depletion increases the reinforcement value of physical activity that, in turn, decreases the reinforcement effectiveness of eating – resulting in activity anorexia. Neural opiates participate in the selection of physical activity during periods of food depletion.

Anorexia nervosa is a very serious condition because of the suffering and loss of life that it causes. However, the wishes of the people directly involved can be strongly opposed. The person with severe AN may not want treatment, yet her family beseeches professionals to unilaterally intervene and clinical teams are divided over the defensibility of involuntary hospitalization and treatment. The metaphor of a crucible is used in this paper to help identify how much is at stake and how (...) much is in conflict when someone has AN. Frank cautions against ethical analyses that rely mostly on substantive principles or rules and institutional conflict resolution procedures. This paper applies his heuristic concepts of “ethics-as-substance” and “ethics-as-process” to a prototypical AN case to illustrate how process activities can expand understanding of, and responsiveness to, those who are living with this dire condition or those who are obligated to help. (shrink)

Anorectics typically maintain that they perceive their bodies as ‘fat’ and yet also state that they are aware of being ‘too thin.’ In this study, I use phenomenological insights from the work of Merleau-Ponty and Sartre to explore this apparent contradiction. I suggest that the anorectic experiences a pathological corporealization of the body, and show how this bodily experience may be described as ‘feeling fat’ due to cultural influences. In addition, I explore how this anomalous bodily experience may lead to (...) partial feelings of disassociation from visual perceptions of the body, allowing the anorectic to recognize the emaciation of a reflected image of herself without it impacting upon her subjective experience of the body as ‘fat.’. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 8.1 (2001) 13-15 [Access article in PDF] Anorexia:Social World and the Internal Woman Juliet Mitchell This is a nicely presented argument--as far as it goes, but is that far enough? The problems of a reconciliation between psychoanalytic and feminist-social explanations of anorexia seem to me greater than this account allows. Social pressures and intra-family dynamics and innate mental characteristics doubtless all play a (...) part and can perfectly well co-exist side-by-side--that is, anorexia (or whatever else) will be a product of all three. The question is: Do these three dimensions need to interact in such a way that each is transformed by the interaction? By using Kleinian notions of phantasy (unconscious), Sarah Richmond is able to propose a reconciliation with social theory that is reminiscent for me of John Bowlby's work in, say, vol. 3 of his trilogy, Attachment and Loss (1969-73). There is nothing wrong with this--indeed, it must be right, but I think it misses the difficulty. The difficulty can, perhaps, best be addressed if we look not at phantasy but at the symptom. If a phantasy is truly unconscious, its form will not bear a recognizable relationship to what it is about--it will need to be deduced from the "free associations" as with a dream. If it is recognizable, it is almost certainly preconscious and can be made conscious without any intervening association or interpretation--it will look like what it in fact represents.With phantasy a slippage between unconscious and preconscious is common. The unconscious phantasy latent in anorexia may be envy of the mother's fertility and, at the same time, a preconscious refusal of the secondary status accorded in Western society to motherhood (Choderow 1978)--it can be both, as Sarah Richmond says, but the unconscious envy will be distorted. An unconscious envious phantasy about the mother might attack the full "womanly" maternal body--it is more likely to do so in a disguised form. The preconscious hostile response to social pressure to become a mother will attack this body probably in an undisguised form.The "true" anorexic sees a grossly fat person where there is a grotesquely thin one. The "real" is transformed and "unrecognizable." Why is there a delusion at the center of anorexia and what are the features and meanings of this delusion? In phantasy, the line between unconscious and preconscious is often not drawn. This cannot be the case with the symptom. A symptom is always a distortion. The same is the case with a delusion--by definition a delusion has transformed "reality."A second characteristic of a symptom is its driven, compulsive quality: The anorexic cannot stop even though she may want to. Clearly, social theory doesn't touch this--but nor does invoking unconscious phantasy per se because here the "unconscious" is often, technically, preconscious; that is to say, available to consciousness without translation.I have not myself made any proper study of anorexia. The following suggestions are just [End Page 13] that--suggestions. I have studied hysteria (Mitchell 2000), and anorexia was once considered an expression of hysteria rather than a discrete illness. The relationship of unconscious symptom or preconscious phantasy in the two conditions are, I suggest, the same. In Hystories, Elaine Showalter (who also considers anorexia to be hysterical) cites a nineteenth-century case of a man with pendulum spasms and suggests that, the man being poor and inarticulate, his spasms may have indicated his hatred of his job. He was a watchmaker (1997). If so, this would be what I am calling preconscious--unconsciously, we cannot know what it means without associations. We can make a guess that shows the process, however. The sort of meaning it might have had is that the watchmaker could possibly have had forbidden grandiose desires that had been repressed but inadequately so; hence, these desires would have returned in the conflictual form of the compulsive, bizarre symptom. The symptomatic expression of his forbidden desire, I playfully suggested, might have been modeled on Voltaire's well... (shrink)

Anorexia Nervosa (AN) is a complex disorder characterised by self-starvation, an act of self-destruction. It is often described as a disorder marked by paradoxes and, despite extensive research attention, is still not well understood. Much AN research focuses upon the distorted body image that individuals with AN supposedly experience. However, based upon reports from individuals describing their own experience of AN, I argue that their bodily experience is much more complex than this focus might lead us to believe. Such (...) research often presents an overly cognitive understanding of bodily experience in AN, underplaying the affective, felt experience of individuals with AN, as well as descriptions of empowerment, strength and control reported in the early stages of AN. This paper seeks to enrich our understanding of bodily experience in AN as it progresses throughout the various stages of the disorder. I show how the classical phenomenological distinction between the body-as-subject and the body-as-object, as well as Leder’s conception of the visceral body, can inform our understanding of bodily experience in AN. I suggest that the project of self-starvation is an attempt to overcome the noisy demands of the visceral body, which are experienced as threatening the body-as-subject, through a process of objectifying the body-as-object. By cashing out AN as a project of radical bodily control that, tragically, comes to control the individual, we can capture important aspects of the bodily experience of AN and the temporal progression of the disorder. -/- . (shrink)

Lucy Osler's piece, "Controlling the noise: A phenomenological account of Anorexia Nervosa and the threatening body," lays out an important new interpretation of anorexia. Anorexia Nervosa is no longer viewed as primarily a perceptual distortion of body-image, an obsession with thinness, or an attempt to dematerialize—to free the subject from its inert thing-like body. Rather, the body itself, and the visceral body in particular, takes on a "voice" which the anorexic experiences as demanding and threatening. Anorexic monitoring (...) and self-starvation beckons as a way to regain power over this renegade viscerality. Unfortunately, this strategy of self-empowerment is doomed to backfire; hunger, illness, and body/food... (shrink)

In this issue of the Hastings Center Report, Tony Hope, Jacinta Tan, Anne Stewart, and Ray Fitzpatrick, reporting on twenty-nine interviews they conducted with women with so-called anorexia nervosa, note that the participants recurrently raised issues of authenticity. The paper reflects on the way their behaviors, experiences, and choices can be considered authentic , or inauthentic . The authors also pose a question about the normative implications of their analysis—if some choices are inauthentic, then is it ethical to override (...) them? For example, they suggest that “showing respect” for the sufferer “does not necessarily mean simply acceding to the person’s .. (shrink)

HARDIN PK. Nursing Inquiry 2003; 10: 209–217 Shape-shifting discourses of anorexia nervosa: reconstituting psychopathologyThis article explores how the circuitous relationship between individuals, the media, and discursive systems replicate and reinforce the act of self-starvation in young women. Using a feminist poststructuralist methodology, the focus of this article is on how discourses and institutional practices operate to position young women who take up the subject position of wanting to be diagnosed as anorexic. Utilizing data from online accounts and individual interviews, (...) I attend to the ways in which young women are institutionally positioned as ‘anorexics’ and the effects that those positions have on their behaviors, in addition to reinforcing institutional practices that construct anorexia nervosa. Questions addressed through this inquiry are: How do institutional practices create and continue to constitute ‘anorexia nervosa’? How do discourses operate to position young women such that they are either included and/or excluded into the category of ‘anorexia nervosa’? What are the effects and consequences that emanate from these positionings? (shrink)

We are grateful for these two insightful commentaries, which both see novelty and value in the manner in which we invoke the hypothesis that anorexia nervosa is a passion, to help explain data from the Anorexia Experiences Study, which provides the basis of our inquiry. In this response, we wish to clarify and elaborate on our hypothesis; in particular, the difference between passions and moods, the manner in which our hypothesis touches on issues of authenticity and identity, and (...) the compelling parallel with addiction. We also wish to emphasize that, in proposing the hypothesis that anorexia nervosa is a passion, our primary aim is not so much to exclude or replace alternative theoretical approaches. Our focus, really, is to argue that the hypothesis that anorexia nervosa is a passion adds something rich and unique to our current understanding of that condition, which is not fully or adequately captured by alternative accounts... (shrink)

The DSM‐5 highlights two essential psychological features of anorexia nervosa (AN): recalcitrant fear of gaining weight and body image disturbance. Prominent accounts grant false beliefs about body weight and shape a central role in the explanation of AN behavior. In this article, we propose a stronger emphasis on recalcitrant fear. We show that such fear can explain AN behavior without the intermediary of a false belief, and thus without the associated explanatory burdens and conceptual difficulties. We illustrate how shifting (...) the emphasis from false belief to recalcitrant fear can supplement a number of different non‐doxastic models of AN. (shrink)

In this insightful and well-argued article, Osler aims to provide a more fine-grained, phenomenological account of anorectic bodily experience. She notes that although anorexia nervosa often is understood in terms of a distorted body image, this approach does not exhaustively or accurately reflect many subjects' bodily experiences, and also unduly privileges a third-person perspective over first-person accounts. In addition, focusing primarily on body image gives rise to the impression that AN is a form of radical dieting gone wrong as (...) a result of misperceiving or misjudging one's body size or shape. Osler emphasizes that AN is not a static disorder, but rather involves numerous stages. To account for the... (shrink)

In a searching analysis, Radden elucidates key problems in justifying coercive treatment in anorexia nervosa despite a common intuition that it should have a place. Indeed, AN, perhaps more than any other condition, challenges the validity of a test purporting to provide a justification. Our generally accepted model for involuntary treatment is based on impaired decision-making capacity and "best interests." A treatment refusal by a person with "capacity" is to be respected, regardless of the consequences. (I exclude here the (...) criteria under conventional mental health law—a diagnosis of a "mental disorder" coupled with a risk of harm to self or to others—because they discriminate against people with a... (shrink)

Self-illness ambiguity is a difficulty to distinguish the ‘self’ or ‘who one is’ from one's mental disorder or diagnosis. Although self-illness ambiguity in a psychiatric context is often deemed to be a negative phenomenon, it may occasionally have a positive role too. This paper investigates whether and in what sense self-illness ambiguity could have a positive role in the process of recovery and self-development in some psychiatric contexts by focusing on a specific case of mental disorder – anorexia nervosa.

Anorexia nervosa is a very serious condition because of the suffering and loss of life that it causes. However, the wishes of the people directly involved can be strongly opposed. The person with severe AN may not want treatment, yet her family beseeches professionals to unilaterally intervene and clinical teams are divided over the defensibility of involuntary hospitalization and treatment. The metaphor of a crucible is used in this paper to help identify how much is at stake and how (...) much is in conflict when someone has AN. Frank cautions against ethical analyses that rely mostly on substantive principles or rules and institutional conflict resolution procedures. This paper applies his heuristic concepts of “ethics-as-substance” and “ethics-as-process” to a prototypical AN case to illustrate how process activities can expand understanding of, and responsiveness to, those who are living with this dire condition or those who are obligated to help. (shrink)

This article details the making of community and bodies in online environments, specifically the online pro-anorexia community. Building community among members of these groups is particularly fraught because tensions over claims to authenticity permeate these groups. Because these are embodied practices and online spaces are presumably disembodied, participants constantly grapple with authenticity, largely through the threat of the ‘wannarexic’. Participants manage these tensions through engaging in group rituals and deploying individual tools that attempt to make the body evident online. (...) This article documents the way in which tensions around authenticity and embodied practices are managed through treatment of the wannarexic. (shrink)

Comparatively little scholarly attention has been given to the question of futility in chronic psychiatric disorders, with the exception of a small body of work on so-called end-stage anorexia nervosa. A review of this literature provides the background for a critical examination of whether the concept of futility has any clinically meaningful, ethically justifiable, and legally defensible application to AN. In this article, the arguments for and against futility judgments in AN are analyzed with special emphasis on determinations of (...) capacity in this serious mental illness. Parallels between the futility disputes in medical and psychiatric disorders, where applicable, will be drawn to further illuminate whether or not the concept that continued psychiatric treatment for AN is ever truly futile. (shrink)

In this paper, I discuss empirical evidence regarding anorexic patients’ distorted body representations. I fit this evidence into a broader framework for understanding how the spatial content of the body is tracked and represented. This framework is motivated by O’Shaughnessy’s (1980) long-term body image hypothesis. This hypothesis posits a representation that tracks changes in the spatial content of the body and supplies this content to other body representations. I argue that a similar kind of body representation might exist and, in (...) the case of anorexia, be distorted. Finally, I suggest that this body representation might become distorted through influence by affect. -/- . (shrink)