eating

This week on the blog, we are hosting a guest post by Carolyn Smith, MA, a third-year PhD student in medical anthropology at Case Western Reserve University. Carolyn studies the intersections of mental health, eating, and the body, blending biological and cultural approaches. This blog post complements our July 2015 issue on autism, which you can read more about in the links provided at the end of the guest post.

In Autism spectrum disorders: Toward a gendered embodiment model, Cheslack-Postava and Jordan-Young[1] argue the importance of gender theory in understanding the preponderance of male cases with autism spectrum disorders (ASD) in the United States. In addition to evidence of autism as sex-linked, the authors argue that there is evidence as well for biases in diagnosing autism, and that social environment likely plays a role in male susceptibility. The literature on anorexia nervosa offers a parallel argument: anorexia nervosa, like autism, is often described in terms of biological risk factors[2] yet it remains a socially charged, deeply gendered diagnosis. In the USA and other societies with thin female beauty ideals, for instance, anorexia nervosa is most widely attributed to women.[3]

Both anorexia nervosa and ASD are recognized by the American Psychological Association (APA) and have specific criteria. While these categorizations are justifiably scrutinized by medical anthropologists, here I use the APA criteria as a cultural document that reflect what conditions that biomedical practitioners in the United States are cataloguing when they demarcate mental conditions. Anorexia nervosa is an eating disorder characterized as one of the most fatal mental illnesses in the United States.[4] Diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) includes restrictive eating and an intense fear of gaining weight/persistent behaviors to prevent weight gain. [5] One key criterion for anorexia is being of low body weight with the absence of any other pathology. The inclusion criteria have changed over the years, as have social ideas about the disorder and who suffers from it. Meanwhile, autism is classified as a neurodevelopmental disorder with social deficits and rigid behaviors.[6] The understandings of autism, like anorexia nervosa, have also changed over time in the United States.

Yet gendered categories for these conditions persist. In the realm of psychiatric health, autism is assumed to be a male disorder, and anorexia nervosa, a woman’s diagnosis. This simple categorization overlooks the extent to which anorexia and autism are demonstrably comorbid in studies carried out in the USA and the UK.[7] [8] [9] One study from the UK, in fact, found that anorexics, restrictive-type were five times more likely than the general population to score as high on the Autism Questionnaire as someone with an ASD. ⁹ This finding offers no simple cause-and-effect explanation for how the two disorders are linked. However, this new data suggests that the body, the mind, gender roles, and dieting behaviors may be entwined in ways that resonate with cultural beliefs and categories.

There are competing theories about the etiologies of anorexia as well as autism, each with gendered overtones that do not reflect the findings of associations between the two psychiatric conditions. One theory of autism is that it is linked to a “hypermasculinized” brain.[10] Meanwhile, in a 2012 article for Psychology Today, Maestripieri argues that anorexia may be due to a “hyperfeminine” brain. The two conditions, it seems, appear to be “oppositional.”[11] However, these theories do not capture the wide diversity of cultural perspectives within the USA or UK, meaning there may be unique gendered understandings of psychiatric disorders between social groups that are not accounted for in existing research. In either case, what is clear is that cultural categories of psychiatric conditions in the US and UK may be missing how patients (of any gender, from numerous cultural backgrounds) live and seek care with either condition.

These gendered categories become even more complex for individuals diagnosed as both autistic and anorexic. The comorbidity of ASD and anorexia is complicated by the fact that restrictive dieting in anorexia may lead to cognitive impairment, which subsequently causes behaviors that might be confused with cognitive patterns on the autism spectrum. However, people with anorexia do report having autistic traits prior to the onset of their eating disorder, and people recovering from anorexia appear more often than non-anorexics to fall along the autism spectrum. ^6,7 Thus, the two illnesses co-produce one another in ways that cross traditional gender lines (autism as male, anorexia as female) while also making it difficult, if not impossible, to isolate each condition from the other. Here medical anthropologists can offer valuable perspectives from the view of patients, who may describe their eating patterns and body image in terms that span and challenge existing diagnostic divisions.

Though there may be no empirical means to measure the extent to which ASD and anorexia overlap, existing theories about socialization may shed some light on how these two illnesses co-occur. There are numerous common traits between anorexia nervosa and ASD, including perfectionism, social withdrawal, and obsessive thinking.⁶Girls and women with anorexia appear to have other similar traits to boys and men with autism: systematizing, a fascination with details, and resistance to change. Anorexic individuals with these autistic traits, Baron-Cohen hypothesizes, could become fixated on the systemic relationships behind body weight, shape, and food intake.[12]Of course, this would depend on whether or not the person with autism was brought up in a cultural environment where food intake and body shape are viewed as something that can and should be regulated at all. Here is where socialization may play a crucial role in the development of anorexia nervosa out of behavioral patterns attributed most often to autism.

The comorbidity of ASD and anorexia nervosa presents an anthropologically complex case where discrete classifications of mental illness may not reflect the connectedness of the two conditions. Likewise, the gendering of each illness as dualistic male-autistic and female-anorexic overlooks the extent to which the conditions share behaviors, tendencies, and thought patterns. Though national clinical studies in the USA and the UK suggest a connection between autism and anorexia, cultural readings of gender, eating, and self-regulation amongst patients with comorbid cases might better illuminate how these conditions manifest on the local scale, and between cultural groups.

Additional Reading

Publications:

Jaffa, T., Davies, S., Auyeung, B., Allison, C., & Wheelwright, S. (2013). Do girls with anorexia nervosa have elevated autistic traits. Mol Autism, 4(1), 24.

Nilsson, E. W., Gillberg, C., Gillberg, I. C., & Raastam, M. (1999). Ten-year follow-up of adolescent-onset anorexia nervosa: personality disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 38(11), 1389-1395.

Oldershaw, A., Treasure, J., Hambrook, D., Tchanturia, K., & Schmidt, U. (2011). Is anorexia nervosa a version of autism spectrum disorders?. European Eating Disorders Review, 19(6), 462-474.

Websites:

ASD and Autism

https://www.psychologytoday.com/blog/games-primates-play/201208/the-extreme-female-brain

http://www.medicalnewstoday.com/articles/264666.php

https://books.google.com/books?hl=en&lr=&id=iPGFAgAAQBAJ&oi=fnd&pg=PR10&dq=malson+the+thin+woman&ots=sQPGnzOFN1&sig=ZSv8OMyuNAFQ3UgBOWZTEX5lHAg#v=onepage&q=malson%20the%20thin%20woman&f=false

CMP Special Issue Features: July 2015 Issue on Autism

https://culturemedicinepsychiatry.com/2015/07/08/special-issue-highlight-the-anthropology-of-autism-part-1/

https://culturemedicinepsychiatry.com/2015/07/22/special-issue-highlight-the-anthropology-of-autism-part-2/

https://culturemedicinepsychiatry.com/2015/08/05/autism-in-brazil-and-italy-two-cases-from-the-june-2015-special-issue/

References Cited

[1] Cheslack-Postava, K., & Jordan-Young, R. M. (2012). Autism spectrum disorders: toward a gendered embodiment model. Social science & medicine, 74(11), 1667-1674. “Our argument is fully biosocial, and our main points in advancing it are to articulate a model for autism, specifically for explaining the male-female disparities in prevalence, that does not exclude social environmental variables, and is therefore more biologically satisfying; and to demonstrate concrete mechanisms whereby autism may become more prevalent in males as a result of social structures and processes related to gender (p. 1673).”

[2] Bulik, C. M., Slof-Op’t Landt, M. C., van Furth, E. F., & Sullivan, P. F. (2007). The genetics of anorexia nervosa. Annu. Rev. Nutr., 27, 263-275.

[3] Malson, H. (2003). The thin woman: Feminism, post-structuralism and the social psychology of anorexia nervosa. Routledge.

[4] Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders: A Meta-analysis of 36 Studies. Arch Gen Psychiatry. 2011;68(7):724-731.

[5] IBD

[6] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.).

[7] Zucker, N. L., Losh, M., Bulik, C. M., LaBar, K. S., Piven, J., & Pelphrey, K. A. (2007). Anorexia nervosa and autism spectrum disorders: guided investigation of social cognitive endophenotypes. Psychological bulletin, 133(6), 976.

[8] Nilsson, E. W., Gillberg, C., Gillberg, I. C., & Raastam, M. (1999). Ten-year follow-up of adolescent-onset anorexia nervosa: personality disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 38(11), 1389-1395.

[9] Baron-Cohen., Jaffa, T., Davies, S., Auyeung, B., Allison, C., & Wheelwright, S. (2013). Do girls with anorexia nervosa have elevated autistic traits. Mol Autism, 4(1), 24.

[10] Baron-Cohen, S. (2002). The extreme male brain theory of autism. Trends in cognitive sciences, 6(6), 248-254.

[11] Maestripieri, D. (2012 August 23). The Extreme Female Brain: Where eating disorders really come from. Psychology Today. Retrieved from https://www.psychologytoday.com “Therefore, just like Autism Spectrum Disorders may be the product of the combination of the extremely high systemizing and low empathizing tendencies that characterize the extreme male brain, eating disorders may be a manifestation of high negative evaluation anxiety that originates from the combination of the extremely high empathizing and low systemizing characteristics of the extreme female brain.”

[12] (2013 August 10). Anorexia and autism – are they related? Medical News Today. Retrieved from http://www.medicalnewstoday.com

In our “From the Archive” series, we revisit an article published in past issues of Culture, Medicine & Psychiatry. This week, we’re highlighting a piece on eating disorders in Japan, originally featured in our December 2004 issue.

Kathleen Pike and Amy Borovoy’s article “The Rise of Eating Disorders in Japan: Issues of Culture and Limitations of the Model of ‘Westernization'” makes a poignant case for the importance of context when examining eating disorders across the world. In this piece, they argue that studies of eating disorders abroad have often attributed the etiology of these illnesses to an increasing visibility and presence of Western beauty standards that accompany the spread of new technologies, medias, and communication tools. While Western beauty ideals have been problematically exported to the non-Western and developing worlds in other cases, Pike and Borovoy suggest that this model does not account for the experience of eating disorders in Japan.

Westernization and modernization, they note, are two distinct processes: and Japan, which has developed economically but retained many of its traditional social roles, exemplifies this difference. Modernization is the process of economic and technological development as a nation shifts from traditional to modern (often, mechanized). Westernization may be defined as the process of integrating the lifestyle, values, and experiences of Western cultures into the fabric of society, especially during periods of modernization and economic change.

Despite the drive for modernization, Japanese women are still expected to be homemakers and mothers rather than career women in the new economy. The Japanese have not adopted the individualistic and feministic sensibilities of the Western world, and the domestic burden– both caring for the home and children, and tending to older family members– squarely falls upon wives and mothers. This creates enormous stress for young women, who wish to extend their adolescent years and savor the freedom between childhood and their adult lives, as defined by marrying and becoming a homemaker. Modernization allows young Japanese women to obtain jobs, travel widely, and earn an education, but traditional social roles do not create a space for women to enjoy such a designated period of freedom without familial commitment. The inevitability of domestic life, then, is ever-present in the lives of women who yearn for fewer responsibilities– even if just for a time. This creates feelings of distress, unease, or unhappiness in many young women.

Pike and Borovoy observe that Japanese women do not reject food (anorexic behavior) or induce vomiting (bulimic behavior) out of a desire for thinness or due to fat phobia, as women with eating disorders almost universally experience in Western nations. Rather, Japanese women stress that they reject food because it worsens their digestive complaints, which are connected to the anxiety and stress they feel out of dissatisfaction with their social role (or lack thereof.) The tension between women’s expected social functions, and their desire to live and work in some other way, therefore spurs disordered eating within this broader frame of mental distress.

As we see, women’s experiences of Japanese eating disorders are entwined in the fabric of traditional social life, and not rooted exclusively in imported ideas of the body, independence, and individualism per the Western way of life. Indeed, the non-fat phobic symptomatology of eating disorders reflects the essential differences between Japanese women with eating disorders and their peers in Western nations. The study highlights the centrality of culture in studies of mental illness, and the way that these conditions emerge out of a local social world.

To find the full article online, click here: http://link.springer.com/article/10.1007/s11013-004-1066-6