'To what extent is anorexia nervosa caused by nature not nurture?'

Hello readers,
It has been dawning on me how intermittent my blog posts are. However, hopefully with the festive season coming up I will have more of a chance to post (although I place emphasis on the adverb "hopefully", as those of you doing A Levels will understand).
I thought I would use this post as a chance to copy you in to the Howard and Mitchell essay competition I entered. I had absolutely no intention of winning the competition, but rather as a chance to keep my mind occupied over the Summer break. Although when choosing a title, I was very conscious that I wanted to research and write something related to mental-health; in particular, eating disorders. Thus, after looking at the nature-nurture debate in Psychology at AS Level,  it gave me the idea of writing an essay based around the discussion; but in relation to a topic of my choice. I will admit that the essay was challenging to write at times, however, I also found it incredibly insightful to look at the illness though a more academic perspective. I really hoped that by sharing this essay it would also give me the opportunity to raise awareness for eating disorders and thus, I was thrilled to find out that I had come runner-up in the process. Anyway, before I ramble on for too long, I hope you find my essay interesting and let me know your thoughts.

Lots of love,

To what extent is anorexia nervosa caused by nature not nurture?

  Anorexia nervosa is a disease characterized by an intense fear of gaining weight and a strong desire to be thin; which is achieved through restriction of food intake. Anorexia nervosa is bracketed under the term of an ‘eating disorder’ which are also defined by having abnormal eating habits; other common eating disorders include bulimia nervosa, binge eating disorder, orthorexia nervosa, eating disorder not otherwise specified (EDNOS) and many more. However, anorexia nervosa is notoriously claimed to be the deadliest of eating disorders due to its alarming mortality rates since one in five sufferers die[1]. In 2015, it was also reported that more than 725,500 people in the United Kingdom are affected by an eating disorder; with around 10% of the population suffering with anorexia nervosa[2]. This has left a huge debate amongst many psychologists whom investigate what causes the disease as a way to help prevent it from developing. The nature versus nurture debate questions whether our human behaviour is determined by our genetic make-up or through the environment in which we exist. I decided to specifically investigate the extent to which the mental health condition anorexia nervosa is caused by our innate, genes, as well as considering the degree to which our surroundings provoke the disease. However, due to the vast complexity of human behaviour, I aim not to take a reductionist approach by claiming that anorexia is influenced by either nature or nurture. Instead, I aim to carefully discuss both sides of the argument, due to its multifactorial nature.

  To an extent, it can be claimed that anorexia nervosa is greatly influenced by our innate, genetic inheritance. Astounding research has shown that ‘within the population, genetic factors account for over 50 per cent of the risk’[3]. Recently, it has been found that biological processes suggest that many of the mechanisms that underlie anorexia are not conscious nor under wilful control. Instead, there is a network of biological systems such as the processing of information, emotions and organisation of behaviour which greatly contribute to the illness. Also, a large portion of these factors are fixed and part of our genetic makeup; supporting why many sufferers of anorexia or other eating disorders are more likely to have members in their family who also have complications around food. A study was carried out by psychologist Grice et. al in 2002 who found a strong genetic basis for anorexia. The study followed 192 families, but particularly focused on a sub-group of 37 families in which two members had been specifically diagnosed with the restrictive-type of anorexia. The results concluded that there was a susceptibility gene on chromosome one; as similar markers were found in the afflicted groups in each family. Thus, Grice et al’s research gives an acute basis for the link between anorexia and our genetic makeup. The study also has a high level of validity since it has been supported by numerous other investigations looking into the same field; for example, Scott-Van Zeeland et al’s research in 2013 and by Boraska et al in 2014.

  Equally, it can be argued that biological factors such as the imbalance of hormones also contribute to the development of anorexia nervosa. Many whom suffer with anorexia use starvation as a form of coping mechanism in order to maintain a low weight characterized by a Body Mass Index of below 18.5 (according to the NHS guidelines)[4]. Starvation has a radical effect on our chemical messengers, known as hormones, which are created in the endocrine gland. In particular, a lack of nutrition from a poor diet affects serotonin, which is a vital hormone since it regulates our sleeping, mood and the digestive process. Therefore, starvation can dramatically reduce the level of serotonin in your brain producing strong hunger cues and symptoms of restlessness; which links to why many suffering with anorexia tend to develop severe mood swings. This also goes hand in hand with why suffers of anorexia have an increased chance of developing depression and anxiety. However, over time, the anorexic typically becomes accustomed to the effects of starvation, making it become an insidious addiction.

Although, many sufferers do report experiencing a feeling of euphoria when coping with prolonged restricting; a memoir of a recovered anorexic, Nancy Tucker, reported that she felt like ‘a hardened starvation addict’[5] when she decided to drastically reduce her food intake to lose weight. However, our ability to survive despite not ingesting an adequate amount of nutrients can be traced back to our historical roots where the human species had to adapt to the circumstances of famine, particularly in Europe between 1315 and 1317 and so, this trait was then passed on to successive generations. Thus, it can be arguable as to whether our past ability to function on a scarce amount of food and abnormally low levels of serotonin has impacted us as a species today.  Maybe if the human race had been unable to cope with the strain of starvation, we may not have associated being underweight with a positive feeling. Therefore, has our nature made it easier for our generation to use starvation as a form of self-medication; as a way to make us feel in control by losing weight quickly? Or is it the parameters of society that have suggested that we will only be accepted if we look a certain way?

   More so, one can consider the impact that the toxic, body conscious society has on individuals, which could be potentially fuelling anorexia. The rise of dieting and the lingering quest to be thin has made it appear admirable to be perceived as having enough self-restraint to look skeletal. The phrase ‘nothing tastes as good as skinny feels’ coined by notorious fashion model Kate Moss in 2009[6] has made it seem commendable for society, and in particular young women, to diet in order to feel accepted. This also links to the recent research linking evidently higher rates of anorexia to those in the modelling profession compared to other female students because it is seen as more “normal” for their body size to be smaller than in other groups; this is also the case for dance students (Garner and Garfinkel 1980). The account of a fashion model Victorie Dauxerre describes how she was forced to eat a mere ‘three apples a day’[7] in order to seal the approval of the demanding fashion designers. Despite Victoire being severely malnourished, the brutal modelling industry applauded her skeletal appearance. With this in mind, it can be proven why anorexia is usually more prevalent in artistic based careers, as well as how anorexia is more popular females; since they account for the majority of the dance and modelling profession.

  Following the recent statistics of the population of individuals in the United Kingdom with eating disorders, only 11% of the 1.6 million people are male, meaning that females account for the other 89% of the figure[8]. Hence, the typical thin frame of many fashion models can easily be critiqued for warping predominantly women’s and also men’s body image, leading them to descend into the dangerous clutch of an eating disorder. Despite the recent plea which aimed to prohibit both males and females being allowed to model if under a body mass index of 18.5, one can argue whether we are doing enough to prevent eating disorders developing in the modelling industry. It is only in the last two years that the French government has been able to establish a law which requires models to be declared medically healthy by a doctor in order to participate in fashion shows; as well as requiring re-touched images by Photoshop to be clearly marked in magazines[9]. Any of whom fails to do so can now be fined up to 75,000 euros and up to six months in jail.

  However, despite the French law offering a drastic improvement, it was mainly enforced due to the harrowing amount of deaths caused that the modelling industry has accounted for; caused by anorexia. The list of deaths include the Brazilian model Ana Carolina Reston (2006), sisters Luisel (2006) and Eliana Ramos (2007), Israeli model Hila Elmalich (2007) and famous anorexia activist and fashion model Isabelle Caro (2010). Despite this horrifying amount of deaths caused by anorexia in the modelling industry, it is still not enough for other countries such as the United Kingdom to implement the same law as France. Thus, the modelling industry could be having a hugely detrimental effect to many individuals and can be considered as not positively discouraging anorexic models in the industry. On the other hand, from a models perspective, it can be questioned whether it is fair that we should feel the pressure to censor our career choices due to the impact it could possibly have on society? Should we not be free to choose whatever career path we desire to follow, as opposed to being restricted due to the negative effects of the images published?
  Consequently, the nature argument examines whether from an early onset we are likely to develop anorexia due to the unrealistic ideals set by the media. Even as children, we are endorsed with toys such as Barbie dolls aimed at young girls, and action figures for boys which frames their mental expectation of what they “should” look like. It was reported ‘when the Han Solo action figure based on the Star Wars movies first came out in the 1970’s’[10],  the figure set an unhealthy standard for adolescence, emphasizing the importance of leanness and ever-decreasing body fat, as opposed to displaying normal human proportions. Thus, it is arguable whether we are increasing the chances of future generations developing eating disorders from the distorted perception of perfection that they are indoctrinated with from the media. Should we be producing gender neutral toys so that young girls and boys do not feel the pressure to look or dress a particular way?

  Furthermore, the 2002 study by anthropologist Dr Anne Becker also reinforced the link between the media and upsurge in rates of anorexia; as well as other eating disorders. Becker et al.[11] specifically looked at whether exposure to Western television would trigger disordered eating in two samples of Fijan girls aged between 16 and 17. The study measured the girls’ attitude towards food in 1995 through the standardised EAT-26 Questionnaire[12] which was then followed by an individual semi-structured interview. The quantitative and qualitative data gathered then gave a baseline measure for Becker to analyse and compare the results and see whether she could accept her experimental hypothesis. Becker also repeated the same procedure in 1998 with a different sample of Fijan girls aged between 16 and 17, who had been exposed to the television for three years. The results were significant and gave evidence to suggest that prolonged exposure to Western television does affect behaviour around food. 69% of the girls claimed that they had dieted at some point in their lives, as well as 29.2% of the 1998 sample having reported to have used self-induced vomiting as a technique to purge calories; compared to in 1995 where there were no records of self-induced vomiting. The study also gave light to the impact of culture perhaps influencing eating disorders. In particular, Fiji has been a culture known for having strong notions of beauty and body shape, as well as having no previous history of anorexia. Thus, the results of Becker et al’s investigation can highlight the damaging effect of the media on teenage girls; the pressure to appear slim could easily influence one to start restricting their intake, which could consequently spiral into anorexia.

On the other hand, it can also be argued that nurture alone does not cause anorexia due to the evidence provided by twin studies. Many psychologists use the study of twins as a way of separating the degree to which behaviour traits are triggered by either the environment or through our genes. In March 2000, psychologist Tracy Wade from Flinders University in Australia conducted a study investigating the rates of anorexia in monozygotic (MZ) and dizygotic (DZ) pairs of twins[13]. The aim of the twin study was to examine the similarities and differences between MZ and DZ twin pairs to identify and delineate genetic and environmental causes for a particular trait; in this circumstance, abnormalities around eating. Wade assessed an opportunity sample of 2163 females and concluded that anorexia nervosa was estimated to have a heritability of 58%. This significantly suggests that genetic factors do contribute to anorexia since MZ twins share 100% of their DNA; as well as DZ twins sharing 50% of their DNA from their parents.

Nevertheless, another factor to consider when assessing what causes anorexia is our childhood experiences. Renowned psychologist Sigmund Freud is widely established as the founder of psychoanalysis, which is a set of therapeutic techniques that study the unconscious mind. The term ‘psychoanalysis’ was coined by Freud in France in 1986, and has now been utilized by psychologists ever since. When analysing what causes anorexia, Freud investigated the oral period in adolescence and claimed that ‘orally fixated people may develop a serious eating disorder, anorexia’ [14] since they may tend to eat when particularly stressed or lonely. The oral period in a child’s development corresponds to the child’s first concerns with nourishment; the child begins to understand their own frustrations of hunger and thirst. Therefore, a child may begin to suck his thumb even after having sucked his mother’s breast for milk, since he or she begins to understand that one can achieve that same feeling of satisfaction without his or her mother being present. Despite the habit of thumb sucking being regressed as the child matures, it still remains powerfully in the unconscious mind. Thus, if the adult goes back to sucking his/her thumb at a later period in their life, they may regress into a time of feeling younger; which may account for the need of sufferers of anorexia to become small again. The memoir of ‘Hunger and Hope’ by Nancy Tucker describes how she once felt ‘overwhelmed by the prospect of change… unprepared for the physical changes of puberty and the expectation of increased independence during adolescence’[15]. Thus, the term regression can be used to describe one returning to a point of fixation when a person is frustrated or frightened. Therefore, someone with anorexia, like Nancy, could use the fixation of being young and child-like again as a way of gaining control; without being able to see themselves being consumed by the eating disorder.

 Freud’s hypothesis of sufferers of anorexia trying to regress to a childlike state provides a convincing basis for the nature side of the argument. Equally, psychologists such as Hilda Bruch in 1980, also traced the origins of the illness in early childhood. Bruch claimed that anorexia is the result of poor parenting and the struggle of the child for independence from the mother. Therefore, in adolescence the child faces a struggle to break free from their mother causing the child to not develop self-reliance and become more sensitive to criticism than others. This then causes the child to feel ineffectual and so anorexia is the tool by which he or she can exert self-control through restricting their food intake. Thus, the mother’s continuing relationship problems with their child encourages the immaturity and leaves the mother more of a desire to retain dependence. As the sufferer of anorexia starts to stop eating, this avoids the consequences of puberty such as menstruation in girls, development of breasts and hair growth; more broadly avoiding the worries that arrive with adulthood. Therefore, Bruch’s explanation for anorexia accounts for why the illness is most commonly developed in males and females between the ages of 14 and 25[16] and why anorexia is more likely to develop in families since the child can be predisposed by their parents negative or positive behaviour around food.

In conclusion, one can argue that anorexia can strongly be proven to be caused by nature due to the research provided by science about our genetic make-up. However, it would be impossible to pin point the disease as a product of a single cause since equally, the nurture elements significantly give a basis as to why anorexia develops; such as the evidence of Bruch and Freud. Due to the illness being very personal, I focused specifically on anorexia nervosa to give a realistic depiction of the eating disorder. Despite the insidious nature of anorexia and the pain it has inflicted on my family and I, it has undoubtedly given me an invaluable insight into society which I am truly grateful for. Without the awareness of the factors that may have triggered my own experience of anorexia, such as our genetic inheritance, I certainly would not have the broad understanding of my illness that I have today. I would like to say that I am extremely hopeful in time, more will be done to help reduce the spread of all eating disorders and that those who are suffering are able to find a voice and speak out about their struggles.

BEAT, The Costs of Eating Disorders – Social, Health AND Economic Impacts report, UK: PwC, 2015
Treasure, Janet, Gráinne Smith and Anna Crane, Skills-based Learning for Caring for a Loved One with an Eating Disorder: The New Maudsley Method, New York: Routledge, 2007
Tucker, Nancy, The Time In Between: A Memoir of Hunger and Hope, London: Icon, 2015
Dauxerre, Victoire, Size Zero: My Life as a Disappearing Model, London: William Collins, 2017
Lock, James and Daniel Le Grange, Help Your Teenager Beat an Eating Disorder, New York: The Guilford Press, 2005
Kahn, Michael, Basic Freud: Psychoanalytic Thought for the 21st Century, New York: Perseus Books, 2002
Freeman, Christopher, Overcoming Anorexia Nervosa: A self-help guide using Cognitive Behavioural Techniques, London: Robinson, 2002
Barkham, Elizabeth, Anna Cave, Susan Harty, Annabel Jervis, Karren Smith, James Bailey and Esther O’Neil, Edexcel AS/A level Psychology, London: Pearson Education Limited, 2015
Gerhardt, Sue, Why Love Matters: how affection shapes a baby’s brain, London: Routledge, 2015
Woolf, Emma, The Ministry of Thin: How the pursuit of perfection got out of control, Chichester: Summersdale, 2013
Becker, Anne E., Rebecca A. Burwell, Stephen E. Gilman, David B. Herzog and Paul Hamburg, Eating behaviours and attitudes following prolonged exposure to television among ethnic Fijan adolescent girls, London: The Royal College of Psychiatrists

[2] BEAT, The Costs of Eating Disorders – Social, Health AND Economic Impacts report, UK: PwC, 2015
[3] Treasure, Janet, Gráinne Smith and Anna Crane, Skills-based Learning for Caring for a Loved One with an Eating Disorder: The New Maudsley Method, New York: Routledge, 2007 p19
[5] Tucker, Nancy, The Time In Between: A Memoir of Hunger and Hope, London: Icon, 2015 p191
[7] Dauxerre, Victoire, Size Zero: My Life as a Disappearing Model, London: William Collins, 2017
[10] Lock, James and Daniel Le Grange, Help Your Teenager Beat an Eating Disorder, New York: The Guilford Press, 2005, p67
[11] et al. = (and others)
[14] Kahn, Michael, Basic Freud: Psychoanalytic Thought for the 21st Century, New York: Perseus Books, 2002, p43
[15] Tucker, Nancy, The Time In Between: A Memoir of Hunger and Hope, London: Icon, 2015 p96

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