Perfectionism + Eating Disorders
When I sat down to write The Perfectionist’s Guide to Losing Control, I wrote and I wrote and I couldn’t stop writing.
I knew I was writing outside the scope of one book. I also knew that I didn’t want to invite a conversation about perfectionism without including certain topics.
There was perfectionism and eating disorders, the history of perfectionism in psychological literature, the intersection of socially prescribed perfectionism and white supremacy, the problems plaguing perfectionism research…
I shared my dilemma with my editor, who so brilliantly told me, “If something doesn’t fit in a chapter but you still want it in the book, you can always put it in the author’s note.” I thought, oh, okay.
It felt simple.
It did not turn out to be simple.
My author’s note grew into a book of its own. Just this rambling, wild, rage-filled, hope-filled, research-filled, crowded, endless, sweaty, hungry but not for anything in the pantry, impossible document.
The truth is there’s no way to fit everything in your mind into a book. Like all of us do in one way or another, I tried to wait out the truth. Like all of us learn in one way or another, that doesn’t work.
Maybe, if you’re lucky, you figure out how to put one percent of what you’re trying to say to paper. Then, if you’re stubborn, you publish a long ass author’s note online.
I began my author’s note in my book and kept it at three pages, with a note inviting readers to continue reading it on my website; you can find the full continuation here. Below is the part about eating disorders.
PERFECTIONISM + EATING DISORDERS
Ok. Here we go.
It was the last five minutes of our session. Camilla was excited; she’d just started using a new diet app and had already lost three pounds. While describing the features of the app, Camilla interrupted herself, “Can I just show you?”
“Sure,” I said, and sat down next to her on the couch. I almost never do that, sit down next to clients on the couch; I can count on one hand how many times it’s happened throughout my entire career. In replaying this session over and over in my mind months later, it’s this detail that haunts me the most. I don’t know why.
Camilla was wearing a sundress with blue jays on it. We’d talked about her dress that day; she was proud of herself for wearing it because it showed her knees.
Camilla was self-conscious about her body in general. She saw herself as fat and therefore less-than. She thought her knees especially broadcasted her fatness.
I was recommended to Camilla through her friend Lucy, who was also a client of mine. Three days after that blue jay dress session, Lucy called me to tell me that Camilla had died of a brain aneurysm. It was a beautiful spring afternoon. I was shocked. My first thought was, but this day is too beautiful for tragedy.
Several months after Camilla’s death, I got an email addressed from her. It was early morning, before dawn. As pitch black as New York City gets. Upon seeing her name in my inbox, my stomach dropped through every apartment below mine. I suddenly remembered everything about the way Camilla looked – her eyes, the dimple on her chin, where she parted her hair. The clarity of the memory scared me.
I clicked on Camilla’s full name. The email was from Camilla’s dad. He was closing out her gmail account and had found a string of messages between Camilla and myself about appointment scheduling. Unaware that I’d already been informed, he was writing to notify me that she had died.
The email was short, two or three sentences. He wrote that he didn’t know she was in therapy, then something like, “I understand that you’re not at liberty to discuss the particulars, but could you please tell me if my daughter was happy that last week?”
Reading his question was, for me, an internal collapse. An unknowable amount of time passed. I just sat there at my desk. At some point, I hit ‘reply’ and went about the somber task of responding to this grieving man’s email.
I think it was when I clicked ‘send.’ Or maybe it didn’t fully hit until a few days later? It doesn’t matter when. Something happened after I sent that email. Something deeply uncomfortable. I felt a violence stirring inside of me. An escalating rage which prompted me to put myself in supervision.
Supervision is a type of therapy for therapists which is focused on the dynamics playing out with their clients. I told my supervisor on that first session, “If you tell me I’m forestalling my grief by fixating on anger because my anger is more accessible than my sadness, with respect, I’m going to find another supervisor. This is not that. This is something else.”
My supervisor told me that we don’t get to skip around in therapy. That we needed to “give voice to the rage, and let the rage tell us why it’s here.”
I hated everything she was saying. Her words were all a diminishment; cartoonish, dismissive. I hoped I didn’t sound like her when I spoke to my clients, while also being sure that I must. Therapists can be so aggravating sometimes.
What I uncovered was a righteous rage; it’s still inside of me. I was and am enraged that in the final days of this extraordinary woman’s life, she spent one of her last precious mornings on Earth looking at her body in the mirror that hung on the back of her bedroom door, trying to decide if that pretty blue jay dress she was wearing made her look more or less fat.
I was and am enraged that while riding the 4 train to my office, she used more mental energy wondering how much of her thighs would show as she debated sitting down instead of standing up.
I was and am enraged that in the last time I would see this person alive, she paid me hundreds of dollars to announce to me her conclusion of all this mental energy, which was that her blue jay dress did make her look fat, and she would wear it anyway. She was excited and proud of herself for wearing it anyway. Her smile when she told me – that became the second most replayed detail of that session.
Camilla’s smile was a victorious one – deep down she knew there was no way to win the contest, but she was gleefully distracted with the satisfaction of having won a round.
I think about Camilla more than therapists are supposed to think about their clients. I think about all my clients more than therapists are supposed to think about their clients.
I miss her.
Everyone who knew Camilla will miss her for the rest of their lives. No one who knew Camilla cared about her knees.
On the opening page of this book, I write that the stories within it have been fictionalized beyond recognition, that they’re “amalgamations of amalgamations.” I worry that I haven’t changed enough in this story. I really did work with a woman who had the world at her feet. She was young, ambitious, charismatic, and unaware that she was about to die. Her loved ones really did reach out to me after her death by sending me an email through her gmail account. I really did sit down next to her on the couch that day. She really did smile that victorious smile.
Sadly, maddeningly, what allows me to share this story is the ubiquity of it. “Camilla” could be any one of my clients at certain points in their life. Camilla could be me in my own therapy at certain points in my life. To say that she spoke of her body in therapy is to say that she was a woman; it reveals nothing.
Camilla didn’t have an eating disorder per se, but she maintained an ever-present, silent awareness of whether the type and quantity of food she was eating moved her closer to or farther away from achieving the cultural beauty standard. In other words, Camilla didn’t encounter food without also encountering a framework of consequences.
Consequence wasn’t the exclusive framework within which Camilla’s thoughts about food operated, but the notion of “good food / bad food / good amount / bad amount” endured. Surpassing habituation, by the time Camilla reached womanhood, the deep-seated neurological connection between food and consequence could be considered congenital.
How could you let her talk about her body so much when there were so many other areas of her life that longed for her attention?
That was my reflex reaction when I thought about my last session with Camilla. I felt angry with myself, deeply disappointed in myself. My conscious response to thinking about my last session with Camilla, however, eclipsed my emotional reactivity: Women have to talk about their bodies, lest they fall into the weeping brook. That’s why I was so full of rage, because I understood the truth.
If you’re a woman and you have a healthy relationship with your body and food, you’ve done a whole hell of a lot of personal work. Years. Decades. Every woman reading this knows exactly what I mean.
I’ve spent so much session time with so many Camillas talking about their bodies. What’s expected of their body. What they think and feel about their body. What their goals are for their body. What their goals are for their relationship with their body. What’s been done to their body by themselves. What’s been done to their body by others. All this mandatory talking about our bodies at the expense of talking about our lives.
Let’s address the cultural beauty standard which the Camilla in all of us is so well-versed.
In a gag gift of a fact, in 2015, American retail giant JCrew began offering clothes in a size triple zero. Not a size zero, which is immediately absurd. Not a size “double zero,” which makes double less sense. But a size “triple zero.” Zero zero zero. This fashion industry practice, known as ‘vanity sizing’ does not occur in men’s fashion.
Men’s clothes are not available in a size zero, double zero, triple zero, quadruple zero, or any version of zero. When men buys pants, the appropriate fit is determined by applying a metric known as “inches” (pronounced: in – chez). Inches are a globally agreed upon standard of measurement which hold a static rate of conversion to metric units.
In addition to living in a world where an international brand that outfits both men and women can casually offer a size triple zero exclusively to women without so much as a raised eyebrow, we also live in a world where women of color are grievously underrepresented across all mainstream media. Eurocentric beauty standards (thin body type, light-skin, small nose, light eyes, and long, straight, soft hair) dominate, particularly across advertising. When Eurocentric beauty standards are abandoned in advertising, it's not a reflection of our emancipation from said beauty standards; it’s a campaign strategy.
As University of Leeds professor of Cultural Geography and author Dr. David Bell states, “It’s important to remember that marketing is not a conspiracy. When advertising works successfully it confirms the stories we already believe.” (16) We live in a racist, misogynistic world. What we believe as a culture is that women and people of color are inferior. We teach this belief through a variety of methods.
The internalization of the cultural beauty standard - its seeping into our psyche, occurs early. As girls learn to walk and talk, they learn what’s considered beautiful and what’s not.
In an effort to raise awareness about unrealistic media images and their negative impact upon young girls, the South Shore Eating Disorders Collaborative (SSEDC) created a fact sheet about Barbie. I don’t need to tell you that Barbie is a doll targeted to young girls because the eponymous brand enjoys a 99% global recognition rate. A hundred Barbie dolls are sold every minute. Barbie consistently ranks as one of the most popular toys. (17)
A few points from the SSEDC’s Barbie fact sheet:
If Barbie were a real woman, she’d have to walk on all fours due to her proportions and she’d fit the weight criteria for Anorexia.
“Slumber Party Barbie” was introduced in 1965 and came with a bathroom scale permanently set at 110 pounds with a book entitled “How to Lose Weight.” The directions inside stated simply, “Don’t Eat.”
The target market for Barbie doll sales is young girls aged 3-12; a girl usually has her first Barbie by age 3. (18)
Do some Barbies feature women of color and diverse body types? Yes, but these representations are always “othered.” For example, in 2016, following plummeting sales, Barbie began to offer a special line of dolls called “Fashionistas,” with different body types, skin color, and hair texture, designed to celebrate diversity. (19) Fashionistas are a separate line.
As a parent I’m in toy stores quite a bit; I have yet to see a Fashionista doll in any of them. But it’s fine, right, because you can buy Fashionistas online. Just like how women’s clothing companies offer size zero in store but rarely keep anything above a size 10 on the rack – that’s fine too, right, because you can just shop online.
As writer Shannon Ashley notes, whenever you buy a Barbie playset, the default doll is white. The pictures in the Barbie dreamhouse and camper are predominantly white. If you walk through the Barbie section of a toy store, you will see the same Eurocentric Barbie almost identical to its 1959 original version. (20) In fact, that’s the current name of the default Barbie’s body type, “original.”
This “original” body type label lies in contrast to existing body type classifications for Barbie in the “alternative” category, such as “curvy.” The “original” body type label also lies in contrast to more accurate label descriptions, such as “thin,” “dangerously thin,” or “FYI this doll fits the weight criteria for Anorexia.”
The message is clear: light skin and thin is the beauty standard, “alternative” options are available somewhere online.
To review, one of the most popular toys in the world is a doll of an adult woman who fits the weight criteria for Anorexia. Size triple zero is neither a typo nor a marketing accident. Whiteness is still the default skin-tone not just across mainstream media, but in every sector, including the toys children play with during the peak of their brain development.
At this point, I’d like to request that we skip the detailed critique of diet-culture itself and just agree that it’s ruinous.
I assume we can agree that conflating body size with health, worth, happiness, and/or using body size as a primary metric of success is – for the sake of argument, let’s call it ‘not good.’
I assume we can also agree that the seventy-one billion dollar diet-industry is chiefly a money printing machine and, considering that ninety-five percent of diets fail, it’s a scam. (21)
Do some diets help a diminutive percentage of people a diminutive percentage of the time? Sure. That’s not a redemption. Let’s continue.
A reflexive association between food and consequence is ever-present in the psyche of American women. That’s not to say the association necessarily dictates choices around food, but it is present. Whether we listen to her or not, there’s a Camila inside each of us.
In addition to the incessant broadcasting of – I don’t know what to call the shit show cacophony that is the beauty standard I just described – women also live with an ever-present awareness that they aren’t safe.
Actively working to avoid being assaulted, raped, and murdered is an everyday, screen-saver consideration for women.
During your morning run. Walking back to your car. On those perfect summer nights when the air smells like falling in love and the breeze makes it cool enough to sleep with the window open – but do you sleep with the window open? Of course you don’t; the reward of the breeze is not worth the risk of rape.
If you assumed you watched too much Law & Order SVU or listened to too many true crime podcasts and that’s why you’re hypervigilant about avoiding assault, rape, and murder – that’s not why.
Women are assaulted, raped, and murdered every day. Women’s bodies are under attack. That’s why.
Research shows that one in four college women will be sexually assaulted by the time they’re seniors.* According to the BBC, solved murder case reports from March 2020 to March 2021 revealed that ninety-two percent of women who were murdered were murdered by men. Ninety percent of rape victims are female (inmate rape comprising much of the remaining percentage for men). (22, 23, 24) *As mentioned in the research section of the full author’s note, research is typically skewed towards samples of college students.
As was reported by the New York Times, in recent years, the estimated number of untested rape kits has hovered around four hundred thousand. (25) These grim statistics live alongside the fact that women’s right to decide what happens within their own bodies has been revoked. Abortion is illegal. The point that abortion is not yet illegal everywhere is no consolation.
Now, let’s return to eating disorders.
In a staggering display of gender disparity, the DSM reports that ninety-one percent of those suffering from Anorexia Nervosa are women. The same statistic repeats for those suffering from Bulimia Nervosa; ninety-one percent are women. While we can acknowledge that there are likely issues with boys and men disclosing their eating disorder issues (i.e. boys and men under-reporting eating disorder/body image issues for fear that doing so might seem anti-masculine), the reason for the under-reporting supports this argument in itself.
Despite our knowledge that women’s bodies are under attack in every way – physically, psychologically, legislatively – these social causation factors are given no etiological significance within diagnostic models of eating disorders.
In other words, we’re acting as if the status quo is healthy and women just go skipping along into eating disorders because they don’t feel pretty. We’re acting as if eating disorders befall upon the dysfunctional ones who aren’t able to internalize all the clear messages of love and safety that surround them.
We’re ignoring an obvious connection: the lack of control women have over their bodies in the physical world and the amount of compensatory control they attempt to generate in their psychological world.
We’re placing the locus of dysfunction within the individual woman instead of the collective culture. For example, as per the DSM, treatments for eating disorders are directed at correcting women’s “cognitive distortions,” and helping them lessen their “unnatural” obsession with their body.
This is a big fucking problem.
In clinical speak: we currently frame eating disorders through the lens of individual psychopathology as opposed to cultural psychopathology (or some combination of both individual and cultural psychopathology). When you do that – when you conceptualize any mental illness exclusively through individual psychopathology and tell someone who is not well that they have a disorder – you’re saying that the culture is in order. You’re saying that the culture is healthy, safe, supportive, and functional. You’re saying that the development of, in this instance, eating disorders in women is born from their failure to be healthy in a healthy environment. They’re disordered. They’re sick. They need treatment.
Where’s the accountability for our culture?
Our culture isn’t just unsafe for women, it’s actively predatory; the omission of this critical context in the etiology of eating disorders is negligent, at best.
The reality is that mental illness stems from a constellation of forces, including – and sometimes primarily – dysfunctional and disordered cultures. This is why we need names for cultural disorders - we need language catches - so that we can stop pathologizing (read: blaming) individuals and solve the actual problem.
Examples of language catches include terms like, “sexual harassment” and “date rape.” Until the 1970’s, when we coined those terms and integrated them into the cultural lexicon, it was near impossible for women to understand that when they felt uncomfortable and “off” at work because they were being sexually harassed, for example, their negative internal reactions and subsequent behaviors were not a result of them doing anything wrong. They weren’t being ‘too sensitive,’ or forgetting how to be ‘team players,’ or anything of the sort.
Experiencing a negative reaction to sexual harassment doesn’t mean anything is wrong with you; it’s in fact the opposite.
Sexual harassment is felt by the woman, but it doesn’t come from the woman.
The term “sexual harassment” is an important language catch because it serves to externalize the source of dysfunction so that women don’t internalize the dysfunction themselves (i.e. what’s wrong with me?). In other words, the calls not coming from inside the house. Nothing is wrong with the woman, something’s wrong with the work culture.
So often, the problem is not the person. The problem is that we live in a disordered culture which thrives on systemic oppression and therein needs women (and any oppressed group) to stay sick, silent, and suffering to sustain itself.
Eating disorders are one example of the patterned dysfunction that inevitably arises when people try to acculturate to a culture which is itself sick. I’m not suggesting that eating disorders are healthy by any means, but they are natural reactions. Again, natural does not mean healthy.
Women are constantly told that the way their body looks is their greatest currency in this life. That if they can achieve mastery over their appearance, they’ll be powerful, and that power will protect them from a world they know is predatory.
When women then seek to gain power by doubling down on their appearance and attempting to control the way their bodies appear (which is what culture directs them to do), we treat them like they’re crazy by telling them they have a disorder.
The therapy world has a phrase for this type of dynamic, it’s called “crazy making behavior.”
The question ahead of us is not whether we should change the lens through which we examine eating disorders, but how long will it take for us to see that we need to change the lens. The question ahead of us is also not ‘how do we fix the current diagnostic model;’ it is instead, how do we break it.
Social causation models seek to understand a person’s mental health through the larger social context of that person’s experience; they’re better models for examining the mental health of human beings because, simply put, human beings are social creatures. Our mental health depends on the support, safety, resources, and connections around us.
Mental health does not develop or progress in a vacuum. Mental health is not something that’s inside of you.
Social causation models are frameworks for mental illness that basically say, “Hey, we know you’re suffering but it’s not because anything is wrong with you. The calls not coming from inside the house. The problem isn’t you, it’s the culture you live in. The culture is dysfunctional. The culture is disordered. The distress you’re experiencing is a natural reaction and internalization of the external cultural dysfunction; under similar circumstances, anyone would experience the symptoms you’re experiencing.”
The absence of social causation models in the etiology of mental illnesses is a profound error of the mental health care system. Future generations will be unable to relate to our current myopia. Once corrected, this fundamental error will disrupt the systems that depend on it to survive (misogyny, white supremacy, racism, etc.).
Individual pathology is real and important to understand. What’s also important for us to understand is that cultural pathology is real, too.
The dismissal of primary social causation theories in the genesis of eating disorders is unintelligible. The DSM acknowledges research which confirms that risk factors for developing eating disorders include living in cultures within which thinness is valued. Childhood sexual and physical abuse are also recognized by the DSM as empirically sound risk factors for developing bulimia. Yet, the DSM ultimately concludes that what causes and perpetuates eating disorders remains “insufficiently understood.”
Etiological factors are what cause a disorder. Risk factors are things that increase the chance of developing a disorder. Stating that cultural standards for thinness and violence against women are risk factors for eating disorders but not etiological factors is a cop-out.
Considering primary social causation theories in mental illness diagnoses (as opposed to internalizing the source of dysfunction squarely on the individual) is not unprecedented. For example, PTSD is often contextualized within the experience of being a veteran and having gone to war. PTSD is recognized as a complex reaction to an external stressor: combat.
The pervasive threat and direct experience of harassment, sexual assault, rape, the revocation of fundamental rights, violence, murder – are those not external stressors that might generate reactionary responses, too?
Do you think it’s a coincidence that as a culture, we readily recognize that mental distress in men might not originate in them, and is instead a reaction to an external circumstance beyond their control? (PTSD, while diagnosed for a wide range of causes now, was originally conceptualized as a disorder specifically resulting from men’s experience in war.)
Reverse the gender context and the negligence of dismissing a primary social causation model for eating disorders becomes tiger-in-your-living-room obvious.
I want you to imagine that tomorrow, the cover of every newspaper around the world reads an all-caps headline that takes up the entire top half of the page: MUTANT MEN INVADE EARTH.
I want you to imagine that these mutant men, who are generally larger and physically stronger than “regular men” begin sexually assaulting one out of every four of the “regular men.” Ninety-two percent of the regular men who are murdered are murdered by the mutant men.
Please stop me when you disagree – behavioral, cognitive, emotional, physical, and interpersonal distress would immediately besiege the regular men. In the US, an unprecedented spike in purchase rates of firearms by the regular men would transpire. All hell would break lose. The regular men would go to war.
At least .4% of the regular men (the reported prevalence of women who struggle with Anorexia) would turn their attention to the physicality of their body in the midst of all this traumatic chaos.
As a coping mechanism to the obvious external crisis, some men might attempt to generate a sense of personal agency by controlling the way their bodies looked. At least .4% of the regular men, for example, might go to extremes to change the size of their body; they might start working out excessively or taking steroids, regardless of adverse impacts to their health.
The regular men may also become acutely and chronically aware of the way in which their bodies were interacting with the environments they found themselves in. They may begin to feel self-conscious about running with their shirts off on a jogging trail, for example.
The distress experienced by at least .4% of the regular men would cause significant impairment to their occupational and social functioning. At least .4% of the regular men would do anything they could to their bodies to gain control over the external crisis, even if the control only existed in their minds.
There’s no world in which anyone would dare respond to the regular men’s preoccupation with their physicality by saying, “Gosh, we’re really seeing a spike in perfectionism here. Look at all these men who are trying so hard to be muscular and strong; they don’t realize how handsome they are inside and out. We need to teach them how to love themselves. Maybe we could start with some affirmations in the bathroom mirror?”
Nobody would tell the regular men that their body issues stemmed from poor self-worth. Nobody except the mutant men.
When assessing the mental health of the regular men, ignoring the etiological significance of a phenomenon in which one in four of those men are subjected to sexual assault – the absence of that statistic alone would be an impossibility.
In our mutant men example, social causation models would naturally, logically prevail. Etiological factors would be confidently declared: “Regular men are internalizing distress because of chronic violations to their physical and psychological safety.”
The regular men’s preoccupation with their bodies would not remain “insufficiently understood.”
It's natural and logical to assume social causation models when it comes to cultural phenomenon that adversely impact women, unless you live in a misogynistic culture.
In misogynistic cultures, sexual violence against women is normalized. We’re not taught to view the one in four statistic as a phenomenon. We’re taught to view the one in four statistic as a harsh reality of life, then we’re told not to make ourselves an easy target:
Take your earbuds out when you run or walk in public.
Have so much fun on that first date you’re going on this Saturday! Oh and safety first, be smart - don’t forget to text your friends every ounce of information you have about the person/time/location in case your date is a violent predator. Anyways, let us know how it goes!
Obviously don’t go to a bar and drink your own drink unless you’ve had eyes on that drink every literal second of the night.
Keep your keys grasped between your fingers when you walk to your car to make an attack claw out of your hand.
These Pinterest hacks for not getting raped and murdered are emblematic of the ways in which the onus is placed on victims (women) to avoid risk instead of on perpetrators (men) to stop perpetrating.
In addition to being unspeakably patronizing, these preventative measures are useless. Can you guess where most women are when they’re sexually assaulted? They’re sleeping, or doing some other everyday task, at home. Forty eight percent of women who are sexually assaulted are attacked in their own home. (24)
If the imaginary regular men’s bodies were under attack in the same way that real-life regular women’s bodies are under attack, the regular men would be expected and encouraged to express a righteous rage.
Regular men would feel 100% entitled to protect themselves from the mutant men by any means necessary. Expressions of said protective efforts and attendant rage would be both clinically and legally sanctioned as appropriate.
The regular men would in fact be assessed as pathologically unhealthy if they went about their day pretending as if none of this life-threatening chaos were occurring.
And yet, that’s exactly what we expect women to do.
Women are expected to absorb zero psychological impact while living in this one in four, triple zero, no rights to your own body world. We’re expected to stay healthy and functional under the most unhealthy and dysfunctional conditions.
Tell me again how women experience distorted relationships with their bodies because they have low self-esteem. Tell me again that if it weren’t for perfectionism, if women could just learn to be a little more “body-positive,” everything would be okay. Look me in the eye and tell me that self-love is the solution.
Colossal disconnects with regard to our clinical understanding of eating disorders don’t just present etiologically. A study published through the Harvard T.H. Chan school of public health reported that approximately nine percent of the US population will have an eating disorder in their lifetime. (26) Respectfully, that statistic is out of touch with reality. Disordered eating is rampant amongst women.
Consciously and unconsciously, women maintain awareness over the complex interplay between our bodies, the foods we eat, the way we look, and the dangers that surround us. That awareness can manifest as the desire to be thin.
Being thin is seen as a route to power (albeit a false one). Being thin can also be about the desire to become invisible, to disappear, to be unseen and thereby untouched.
Disordered eating is only about wanting to be thin on a surface level. On a deeper level, disordered eating is about wanting power, sensing that you don’t have power, then trying to substitute power for the next best thing: control.
It’s not that women want to be thin, it’s that women want to have power. That’s why, when women find their power, they let go of the need to be thin. Emphasis on their power. Internal power. Real power. Not power within a patriarchal structure, which is power-over, which is really just control.
As emphasized throughout The Perfectionist’s Guide to Losing Control, power and control are not the same thing.
It’s worth noting that several studies indicate that eating disorders carry a genetic link; that they’re sometimes inherited. One study estimated that genetic factors comprise forty to sixty percent of the vulnerability factor for eating disorders. (27)
While conducting research for this book regarding genetic predispositions to eating disorders, I spoke with Dr. Rabbi Alexander, the Director of Psychiatric Services at the Princeton Center for Eating Disorders. Alexander noted that eating disorders (like Anorexia, for example), can present in much the same way as obsessive-compulsive disorder; instead of a focus on common themes in OCD (cleanliness, contamination, fear of harming someone, etc.) the theme and focus is food. Alexander added that a commonplace opinion in her field is that certain patterns of eating disorder symptomology are better understood as a type of obsessive-compulsive disorder, not as an eating disorder. OCD is known to be due in part to genetic factors.
“Comorbidity” refers to two disorders that show up alongside each other. Anorexia has a notable comorbidity rate with OCD. One study found that thirty-five to forty four percent of those with symptomology for anorexia also expressed symptomology for OCD. (28)
These statics echo the sentiment of many clinicians – that there are certain instances during which the problem should not be identified as Anorexia, it should be identified as OCD with a focus on food.
Another consideration for the genetic predisposition of eating disorders is epigenetic trauma, the empirically validated phenomenon wherein trauma and stress from one generation influences the likelihood of psychological distress presenting in subsequent generations. (29)
From the Greek roots an (without) and orexis (appetite), anorexia is a misnomer to begin with. Anorexia is not about losing your appetite; it’s about suppressing your appetite.
Those who suffer from anorexia do have an appetite – they’re literally starving. They’re starving for food, yes. But they’re also starving for safety. They’re starving for power. They’re starving for acknowledgment that they’re not crazy. They’re starving for connection to the truth.
Anorexia is a profound expression of grief and desperation, laced with pure ‘fuck you’ rage, all turned inward by a person who feels (because they are) deprived of basic personal agency.
To be unequivocally clear, once again, maladaptive perfectionism is a risk factor and maintenance factor for any and every expression of psychological dysfunction. Maladaptive perfectionism cannot exist in a neutral state; it will always be harmful to you.
There’s an overwhelming body of research which highlights the correlation between maladaptive perfectionism and eating disorders. I think of that correlation like this: eating disorders are like forest fires; the potential scale of destruction is disastrous. Maladaptive perfectionism is to an eating disorder what wind is to a forest fire; maladaptive perfectionism exacerbates an already dangerous situation, but it’s not the flames. This is a critical distinction because you don’t prevent forest fires by focusing on ways to make it less windy.
Also, to be clear, the next task at hand does not involve identifying whose fault this all is. It’s not the DSM’s fault for framing disordered eating as an individual disorder, for example. The DSM was never intended to be the exclusive authority and reference point for mental health. Those who contribute to the DSM don’t intend for the DSM to have the final word; it’s designed to offer one perspective – a framework of individual pathology. The field of mental health is using the DSM incorrectly.
This moment is also not about assigning blame to men, to me, to other psychotherapists, to health coaches, to the mental health care system, to diet companies, to Barbie, to JCrew, to yourself, to the generations that came before us (and sure as hell not our mothers). This moment is not about assigning blame to any one person or any one group or any one company or some combination of all the above.
The next task at hand involves acknowledging our collective crisis and responding to that crisis from a conscious, solutions-oriented place. That looks like understanding that the attack on women’s bodies is everybody’s problem; it hurts everyone, and everyone is responsible for contributing to the solution.
Responding to disordered eating from a conscious place also looks like recognizing, with piercing clarity, that to center the locus of dysfunction within the individual when it in fact rests within our dysfunctional culture – that is gaslighting in its finest hour.
Acknowledgment for the ways in which mental illness is exploited to perpetuate oppressive dynamics is not only owed to women, but to all people who are oppressed.
Perfectionism is not the root cause of eating disorders. The degree to which that statement is controversial runs in direct proportion to the degree to which society fails to understand the deep and simple need women righteously possess to feel physically and psychologically safe in their own bodies.
Katherine Morgan Schafler is an NYC-based psychotherapist, author, and speaker. For more of her work: get her book, follow her on Instagram, subscribe to her newsletter, or visit her site.