Emotional Health

Eating Disorders, Then and Now

Eating disorders have become among the most prevalent psychiatric conditions over the last fifty years. They are also among the most dangerous, with a higher risk of fatality than any diagnostic category, even depression.

The National Association of Anorexia Nervosa and Associated Disorders (ANAD) estimates

  • At least 30 million people of all ages and genders suffer from an eating disorder in the U.S. 
  • Every 62 minutes at least one person dies as a direct result from an eating disorder.
  • Eating disorders have the highest mortality rate of any mental illness.
  • 13% of women over 50 engage in eating disorder behaviors.
  • In a large national study of college students, 3.5% sexual minority women and 2.1% of sexual minority men reported having an eating disorder.
  • 16% of transgender college students reported having an eating disorder.
  • In a study following active duty military personnel over time, 5.5% of women and 4% of men had an eating disorder at the beginning of the study, and within just a few years of continued service, 3.3% more women and 2.6% more men developed an eating disorder.
  • Eating disorders affect all races and ethnic groups.
  • Genetics, environmental factors, and personality traits all combine to create risk for an eating disorder.

While they were relatively rare in the early part of the 20th century, in the late 1960s they began to appear, and from there, the growth was exponential. I vividly recall a magazine article from the early 1970s investigating the mysterious “dieting disease.” One woman I know, who consulted with several top psychiatrists in New York during those years, confessed her obsession with her weight (which had dropped so much that she had been forced to take a leave from college), but all failed to recognize that she was suffering from anorexia nervosa. Now, of course, New York, a city in which the pressure to be perfect is ubiquitous, is a capital for the eating disordered.

In the early years of the epidemic, mental health professionals were dominated by an allegiance to classical Freudian psychology, and so they saw these problems through the lens of sexuality. Young girls and women that dieted themselves down to the size of boyish waifs were avoiding their natural feminine shape and desire, they suggested. This explanation ignored the fact that the onset is often precipitated by a separation. Further, many women with this diagnosis have boyfriends/partners and/or a fairly normal sexual history.

Vivian Hanson Meehan, ANAD’s founder, was a nurse at a hospital in Highland Park, Illinois. In the early 1970s, a family member was diagnosed with anorexia nervosa, but she was unable to find any information or resources on eating disorders to help, even though she herself was a medical professional. According to the experts Vivian consulted, “Anorexia Nervosa is so rare that there are probably no more than 2000 cases of Anorexia Nervosa in the United States – you are wasting your time.”

Things have changed significantly since then, but when I completed my Ph.D. thesis in 1980, it was the first one in the university’s history on the topic of eating disorders. In fact, I had to call in an outside consultant to sit on my thesis committee because none of the professors on our faculty had any familiarity with the topic. Now it is an essential part of mental health training almost everywhere.

I challenged the traditional understanding of eating disorders, presenting the argument that they could be best understood as a problem in the realm of “the self.” Issues such as self-esteem and its regulation were more central, I argued. Eating disorders, in my view, represented an attempt to regain control and agency over a self that felt empty, diffuse, and unreal.

The literature on this subject was scarce, and I corresponded directly to Heinz Kohut, the founder of self psychology, for his comments and advice on the application of his ideas in this area. Meanwhile, Hilde Bruch, a psychologist with extensive experience with these kinds of patients, developed similar ideas about their origins but without the benefit of Kohut’s theory to help structure her ideas.

What Bruch recognized was some commonalities in the psychopathology of eating disorder patients (EDs). She was particularly struck by a kind of family enmeshment she observed, especially between her patients and their mothers. Though she had been using family systems theory to try to understand these interactions, I proposed that Kohut’s Self Psychology was more useful for several reasons.

Self Psychology had offered the additional perspective of the psychodynamics underlying this enmeshment. Specifically, I argue that anorexics’ mothers used their daughters as narcissistic objects, failing to recognize or encourage their efforts to develop a separate, independent sense of self. They saw and treated their daughters as if they were a part of themselves. When their daughters began to develop and express independent urges, these mothers undermined them. And, significantly, they experienced the changes in their daughters’ bodies, including pubescence and adolescent weight gain, as if they were happening to them.

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