Starving to death and the anorexic frame of mind

Abstract

Because some forms of self-starvation such as hunger striking are exempt from attributions of pathology, and due to incomplete understanding of its etiology, anorexia nervosa (AN) is and must presently be defined by psychological criteria as well as behavioral and bodily measures. Although opaque, typical motivational frames of mind in AN lack the apparent cognitive and volitional dysfunction usually indicating disorder. In contrast to other conditions that exhibit more evident dysfunction, this distinguishes AN from the perspective of medical epistemology: the opacity of AN motivation jeopardizing the epistemic warrant for assigning it to the category of a mental disorder (and so influencing decisions over diagnosis and recovery). This seems to invite non-medical approaches to its prevention and care.

Keywords

Anorexia nervosa disorder epistemology. hunger strikers motivation phenotype

Introduction

Some clinical syndromes comprising apparently voluntary self-harm or self-neglect involve behavior that, in other contexts, would not be judged apt for medical attention. The contextual when, where, and why of their being appropriately subject to diagnosis apparently involve cultural norms and individual motivation, in addition to bodily and behavioral factors. This observation is explored here in relation to anorexia nervosa (AN), a disorder that is sometimes fatal, incompletely understood, and often unresponsive to treatment.¹^,² On the face of it, AN is a clear case of pathology. Its bodily effects are visible for all to see and physically dangerous, and it seems to transgress the social norms of most cultures.³ Yet little about this condition can be taken at face value.

Present day psychiatry generally acknowledges that the behavior of the politically motivated hunger striker or those choosing altruistic self-sacrifice in settings of food shortage, does not necessarily indicate pathology. The same will be true of the 17th-century nun whose self-starvation is undertaken for religious reasons.⁴ According to the particularities of the setting and case and the values of observers and subjects, the behavior of these self-starvers will be judged understandable, if regrettable, to be expected and tolerated as appropriate or even honorable.

These forms of self-starvation are exempt from attributions of pathology to the extent that the person's psychological motivation is intelligible and accords with societal norms. But applied to anorexia, such psychological criteria are insufficient, it is argued here, because the question of its intelligibility imposes unsupportable weight on the individual's motivation when it is understood as a composite whole (here, the individual's “frame of mind”). Despite all the evidence at our disposal, the motivation remains opaque. And with its phenotypical description thus incomplete, the ascription of pathology to the general category of anorexia remains unwarranted.

The present analysis must not be confused with the view sometimes promoted in social media that AN is an appealing “lifestyle choice.” I do not doubt that AN is a seriously dangerous phenomenon. My doubt is whether it is best seen as pathology, apt for medical analysis and treatment. The characterization of AN as a disorder presents this distinctive challenge for two reasons: (1) the diagnosis is not defined in exclusively behavioral and bodily terms; and (2) individuals diagnosed with anorexia, at least at the mild end of the spectrum, typically fail to exhibit obvious volitional or cognitive incapacities (near death from starvation, any person undergoes physiological and cognitive deterioration).

This article is divided into three parts. Part 1 introduces the diagnostic criteria for AN, the concept of motivation, the language employed in this discussion, and possible analogies offered for cases such as those of hunger strikers being exempt from medical intervention. Part 2 presents selected data from first person accounts and sorts the data into hypotheses and findings that rest on apparently measurable assertions open to disconfirmation (A-type hypotheses), and those that are not measurable and open to disconfirmation (B-type hypotheses). Sections raise interpretive problems with data for A-type hypotheses and introduce further interpretive issues with data for B-type hypotheses, using illustrative claims about anorexic self-identity. Part 3 summarizes the opacity earlier noted in the data, explaining its epistemic implications, and addresses methodological limitations and political implications of the discussion. A brief concluding section sketches some implications of accepting that AN cannot pathologized as easily as can most other psychiatric conditions.

Part 1: Preliminaries

Etiology and psychological diagnostic criteria

Due to incomplete knowledge of its risk factors, the diagnostic criteria for AN rely on psychological in addition to behavioral and biological features. AN has long-recognized familial links, for example. But it is not a single-gene disorder; nor is polygenetic risk alone determinative (Breithaupt et al., 2018, p. 6). A combination of shared and distinctive environmental factors, including pre-natal, perinatal, and developmental pathways forged through gene–environment interactions, account for the remaining variance (Rozenstein et al., 2011; Steiger & Thaler, 2016; Toyokawa et al., 2012).⁵ These complex interactions have recently been amplified and explained by anthropological data revealing the multiple “cultural logics” within which disordered eating habits must also be understood (Eli & Warin, 2018). These features are part of the basis on which, in clinical settings, determinations of pathology are made. But so are the DSM (APA, 2013) and ICD (WHO, 2020) diagnostic classifications that are the immediate focus of what follows (See Radden 2021c).

The DSM-5 diagnostic criteria for AN include psychological features that form part of a disjunctive set: fear of becoming fat or persistent behavior that interferes with weight gain, as well as experiential disturbances of weight or shape or persistent lack of recognition of the seriousness of the low body weight (APA, 2013, pp. 338–339). That the hunger striker may well meet several of these psychological criteria illustrates the importance of motivation in the complex assignment of pathology.

Although this sort of challenge may apply to other disorders as well, AN is a special candidate for analysis because it is not typically associated with apparent disability. The person with AN is regularly described as reasoning without confusion and acting voluntarily; they give the appearance of being as knowingly and willingly engaged in their fasting as the hunger striker.⁶ (By comparison, addictive behavior may also give the appearance of being undertaken voluntarily. But the diagnostic criteria for addiction are regularly defined in exclusively behavioral terms, permitting the ascription of pathology without reference to motivation).

Motivation holistically understood as frame of mind

Individual motivation has been formed by and is also embedded within a broader life-world. But the focus of what follows is the criteria involving motivation found in diagnostic definitions. Understood in philosophical and normative traditions, motivation minimally involves a composite of a person's combined will and preferences, that is, their immediate wishes understood in relation to their values, goals, and ideals. Often implicit in such characterizations is the individual's self-identity, the self-constructed entity underlying and uniting these several agentic elements, as the subject to which they are ascribed (to illustrate, the political hunger striker's self-identity, often explicitly asserted, includes principles and goals for which it is worth risking a death by starvation). In what follows, “frame of mind” refers to this composite whole, including the organizing centrality of the agent's self-identity.

Within the context that includes her value system and priorities as they reflect her self-identity, the voluntary faster's seemingly irrational wish to starve herself is made coherent, if not acceptable, as an element of the composite, coherent whole. Illustrating this point, it has been pointed out that the person with anorexia “may accept the risks of dying through self-starvation since she claims that being thin is more important to her than life itself” (Szmukler, 2016, p. 138). This hypothetical account closely resembles actual responses, such as: “I am not suicidal. It's just that if I continue to live the way I want, I’m going to die, and so I say, so be it” (quoted in Goldman, 2017). Or, from a recent essay by a woman with anorexia:

As my … weight dropped, I didn’t find the prospect of dying nearly as terrifying as the thought of having to face a plate of food five times a day. I wanted to get well, just as long as it didn’t involve eating or gaining weight. (Quoted in Arnold, 2017)

Assertions like these are often difficult to interpret (at least by others). Answering a researcher's question about whether dying was a risk she was prepared to take, one patient may be understood to discount the risk of death, explaining: “It … was more that I just felt so awful about everything that sometimes I thought that it wouldn’t matter if I did die …” (quoted in Tan et al., 2007, p. 11; emphasis mine). But contrary or even contradictory interpretations also present themselves here: “There are more important things than dying” echoes the attitudes expressed above, while alternative interpretations “I care about nothing, not even death,” or “Everything is so awful that death couldn’t be more awful,” do not. Which of these captures the subject's motivation? Thus far, we cannot be sure. Death is rarely the goal of the AN patient, any more than it is that of the hunger striker, evidence suggests, and is merely a foreseeable outcome of fasting (Geppert, 2015; Giordano, 2005). Whether the prospect of that outcome is denied by the person with anorexia as some clinical lore attests (Geppert, 2015; Mountjoy et al., 2014), or is welcomed, regretted, or anticipated with indifference, may be an individual matter (Yager, 2015). Ambiguities such as these exemplify the interpretive challenges presented by this kind of material, to which we return in Part 3.

Language and imperfect analogies

If starving to death is not the intended goal of the behavior, then the terms “self-harming” and “self-starving” are each too freighted for our discussion, implying a misleading purposiveness. At risk of presuming the ascription of pathology at issue in the present analysis, “AN” is used here, with the understanding that it refers to persons with AN diagnoses. “Anorexia” and its cognates can avoid that presumption, in referring to the symptomatic behavior regardless of motivation, and so encompassing both the accurately diagnosed (AN), the mis-diagnosed, and the hunger striker. But “anorexia” and its cognates are often loosely used as equivalents of “AN.” To avoid these misapprehensions, “voluntary caloric restriction” (VCR) is sometimes used in what follows.

Other instances where behavior and psychological states are exempt from medical intervention, as the hunger striker's seem to be, can serve to clarify the reasoning underlying the present analysis. In discussion of the grief exclusion during revisions of the fifth edition of the DSM, it was argued that what would be evidence of depression in another context is distinguishable as “normal sadness,” i.e., normal responses to the particular context of bereavement (Wakefield, 2012; Wakefield & First, 2012). For a time, it is fitting and proper, as well as typical, to feel overwhelming and debilitating sadness when a loved one dies. Norms governing manic exuberance apparently function similarly. Brief periods of unusual energy, vitality, excitement, and spiritedness are exempt from pathologizing judgements in a range of contexts (personal luck, triumphs, and reprieves). Moreover, high-spirited and optimistic dispositions are accepted as within the normal temperamental range found in humans. Since these expressions of “normal happiness” apparently occupy a continuum with the hypomanic moods that usually augur full-blown and more recognizable manic episodes, distinguishing them is not always easy. Nonetheless, there is no suggestion that all such normal variations are pathological, and they are regularly accommodated by context-sensitive norms of appropriateness.

The apparently voluntary yet strangely motivated behavior of those diagnosed with AN differs from the previous cases in one obvious respect. Grieving sadness and appropriate exuberance and joy are normal and entirely understandable—the anorexic frame of mind appears to be neither. Granted, some parts of that frame of mind make a kind of sense. The AN patient's explicit values—autonomy and perfectionistic self-control for example—are entirely familiar and unexceptional, as has been noted (Giordano, 2020). And even the patient's seeming discounting of future death by starvation contains a certain plausibility if we remember that unlike many other disorders (cancer and heart disease, for example), AN does not show an inexorable course. At least until its very final stages, it is ostensibly reversible by the seemingly simple expedient of eating (for discussion of the implication of this anomalous feature, see Giordano, 2019; Radden, 2021a, 2021b). Still, these AN value priorities are puzzling. Unlike the priorities around normal sadness and exuberance, those priorities remain opaque.

While this opacity arguably disqualifies any analogy with those other states, it alerts us to important implications for medical epistemology. Because it is not intrinsically tied to attributions of disorder, the VCR of those diagnosed with AN must be located within its motivational framing for confirmation of its status as pathology. Opaque motivation thus imposes a kind of burden and challenge for medical epistemology. Not fully understanding the frame of mind of the person engaging in VCR, we lack the means of determining whether that person's behavior is appropriately judged pathological and subject to medical care and attention.

Part 2: The evidence

Hypotheses, theories, clinical and laboratory findings

A large, if inconclusive, literature attests to interest in the broader cultural context and narrower individual motivations associated with AN. There are theories and hypotheses, clinical and laboratory findings, and self-report, both informal and derived from in-depth research interviews. First-person descriptions by AN patients in memoir and autobiographical form abound, in print and online (see Cavazos-Rehg et al., 2019). Much (although not all) of this autobiographical material confirms the speculations, findings, and clinical lore from more formal sources.

The DSM diagnostic definition, introduced earlier, provides us with a basic summary of features associated with three psychological aspects of the AN frame of mind: fear of becoming fat; experiential disturbances of weight or shape; and persistent lack of recognition of the seriousness of the low body weight. In line with these features, many clinical findings and research initiatives are directed towards issues around weight, shape, and appearance, arbitrarily designated here as A-type hypotheses.

For example, A-type hypotheses include speculation about the distortion of body image in anorexia. In one research program, the relation between her experiences and the patient's strange convictions indicates an interactive loop, where atypical perception initiates misapprehensions about size and shape (such as “I am fat” said by an emaciated patient). Mistaken convictions about one's appearance, it is speculated, are prompted and maintained by defective inner perception (Gadsby, 2017; Gillett, 2009; Giordano, 2005). On this hypothesis, which has received some empirical support in the laboratory, how bodies are experienced (the body image or percept) rests on non-conscious representations (the body schema), that have become distorted in AN as the result of initial affective disturbance (Gadsby, 2017, 2020; Gadsby & Williams, 2018).

A second group of largely theoretical claims and findings, B-type hypotheses, includes the broader preoccupations of AN patients—issues of agency, perfectionistic self-control and autonomy, appearance norms, value priorities, meanings and metaphors, and matters of self-identity, often closely linked to gender expectations (see Bordo, 1993; Doris et al., 2015; Giordano, 2005, 2019, 2020; Gremillion, 2002, 2003; Hesse-Biber, 2007; Lavis, 2013; Lester, 2018; Luhrman, 2012; Morris, 2013; Orbach, 2005; Svenaeus, 2014; Warin, 2010; Widdows, 2019; Wolf et al., 2009). The loose division between A- and B-type hypotheses does not exhaust the research material on AN or the extensive theorizing as to its motivation. They were chosen primarily because both are so amply confirmed by the first-person sources which will be our particular focus.

Data for A-type hypotheses

The DSM's “experiential disturbances about weight and shape” sums up the content of assertions that are often the focus of A-type hypotheses. In their apparent openness to consensual validation, they reflect one kind of contrast with the material of B-type hypotheses. Accounts such as those of Gadsby and Williams (2018) hypothesize that forms of internal perception foster or perpetuate a kind of hallucinatory mis-perception of size, together with mistaken (and delusion-like) inferred size estimates contrary to the person's measured dimensions. Customarily, the convictions of AN patients about weight and shape have not been regarded as delusional so much as instances of “over-valued ideas,” following Wernicke's account of isolated, abnormal beliefs dominating the patient's life to a morbid degree (Gadsby, 2020; McKenna, 2017; Mountjoy et al., 2014; Steinglas, Eisen, et al., 2007; Veale & Lambrou, 2002). Without other features often accompanying delusional thought, I would note, anorexic ideas about bodily dimensions bear some similarity to one kind of delusions, those involving inferences from hallucinatory or mood-related symptoms.⁷ The typical absence of other incapacitating features explains why AN ideas have been more commonly seen as over-valued rather than delusional. But if the person experiences herself as fat through sensations, her inferential belief that she is fat is “delusional” in this particular respect (as sensation-grounded inferences).

Assumptions underlying such delusion-like misapprehensions in AN have been subject to potentially damaging critical analysis, suggesting that contrast between how the person looks to herself, and how she really is, may be unsustainable. Clinical, autobiographical, and research evidence consistently illustrates that AN patients do not experience their shape as others do. Although emaciated, they often report appearing (to themselves) heavy, fat, and large. But perception of body is a complex matter, affected by cognitive, affective, and optative responses, as has been pointed out: this means that “in the way they look at their body and perceive their body, people express not only what they see, but also how they think they look, how they feel they look, and how they want to look” (Giordano, 2005, p. 217). Moreover, adopting Merleau-Ponty's critique of “scientistic” approaches, Katherine Morris (2013) explains that purportedly empirical claims about the mismatch between how one perceives one’s own body and how it “really is” depend on underlying philosophical presuppositions that may be challenged: first, that how the body really is, is objectively describable and measurable, an assumption “privileging the measurable world over the experienced world”; and second, that “perceptual” and “affective” are distinct dimensions” (p. 604).

What Morris sees as the “crucial property of anorexics’ bodies that helps to motivate” their condition is not the value-neutral and motivationally inert perception presupposed in the assumption that the perceptual and affective are distinguishable dimensions. Instead, entailed in being apprehended, the anorexic's body proportions are apprehended as unacceptable. If taken to prove that so-called size distortion is “affective” rather than “perceptual,” this composite apprehension unwarrantedly presupposes that the perceptual and affective are separable (Morris, 2013, p. 605). Also emphasizing the inescapably affective and attitudinal aspect of the AN patient's frame of mind, some theorists have classified states of AN as passions—persisting affective states that “play a significant role in motivating, determining, and organizing a person's long-term behavior” (Charland et al., 2013, p. 354). Self-descriptions from in-depth interviews are cited to illustrate the enduring and organizing centrality of these affective states.

Such holism secures the inseparability of the belief-value combination making up the AN frame of mind. But even on their face, only some of the AN patient's ideas concern potentially measurable matters, as we saw. Whether the belief-value wholes making them up can be disambiguated, as the above critiques doubt, is one issue. However, many of the patient's convictions will always elude literal interpretation or consensual confirmation. Included among these are not only the abhorrence over bodily size and shape, and overriding value placed on self-control, autonomy, and perfectionistic bodily restraint, but also self-assessments, descriptions, and metaphorical and metaphysical assertions often expressive of, or alluding to, self-identity. And this second kind of content brings further interpretive difficulties for understanding the AN frame of mind.

Data for B-type hypotheses

Even if ostensibly measurable assertions such as “I am fat” were open to consensual validation, still much of the ideation that is the focus of B-type hypothesis theorizing, by contrast, is quite obviously ambiguous, opaque, and not measurable. Theoretical accounts have offered conjectures about AN motivation which, while plausible, are equally difficult to establish. But our attention here will be to claims from first-person data. Examples include: (i) expressions of value priorities; (ii) expressions of ideals; and (iii) claims that explicitly involve self-identity:

“As my … weight dropped, I didn’t find the prospect of dying nearly as terrifying as the thought of having to face a plate of food five times a day.”⁸

“The problem in your life is your body. It is defined and has a beginning and an end. The problem will be solved by shrinking the body. Contain yourself.”⁹

“I worry that people … don’t know the real me.”¹⁰

Inaccessibility to consensual confirmation (or disconfirmation) as a feature of much of the data making up these assertions is evident. “I am king of my body now … I am a pure person, magic, revealed as I disappear into my final fat-free smile” writes the author of Diary of an Anorexic.¹¹ In becoming an anorexic, it is observed, “I adopted the only strategy open to me … to preserve any sort of identity … to believe in myself as an individual being separate from both the family and the school.”¹² Or, “I wanted to be an anorectic. I was on a mission to be another sort of person, a person whose passions were ascetic rather than hedonistic … whose drive and ambition were focused and pure, whose body came second.”¹³

Unsurprisingly, given the developmental stage of many with AN, claims made about, and presupposing, the self and identity constructs are the explicit subject of much first-person material. And self-identity will be our primary focus, in part because AN patients’ self-identity has been explored in important research by Jacinta Tan and colleagues. Interviews of young women (and their parents) have yielded a wealth of material focused on the patient's self or self-identity as it affected her attitude towards treatment. Among these, a subgroup was identified of those who avowed they could not imagine themselves without their disorder (unable or unwilling to envision a separation of self from symptoms, this group is judged to possess self-identity that is not merely different, but defective (Tan et al., 2003)).

Quoted lines from these interviews include:

“I … worry that people don’t know … the real me”;

[Anorexia] is “part of me now”;

“I can see [anorexia] as a different side of me”;

[Anorexia] is “a horrible little part of me which is telling me stupid stuff”;

“If I knew that I could be happy [without anorexia] but it would be a completely different me … I don’t think I could be the person I want to be.”

Similar reports by AN patients in later work included:

… it is almost like having two bits of you that are you all the time. The bit of you that is really scared of food and everything that means and the rest of you that wants to be able to get on without it. I just feel like there's two voices in my head sometimes. (Quoted in Erler & Hope, 2014, p. 221).

Unless they are understood to be entirely metaphorical—which they may well be—none of these descriptions is open to consensual confirmation. Rather, they are metaphysical posits and evaluations. Like the “pure, magical person” aspired to (from earlier quote) or the “real me” the patient worries others don’t know, the self-identity described is a construct, neither more or less accurate or plausible—merely more or less consistent with norms of self-description. The interest of Tan and her colleagues lies with correlating certain self-identities with treatment outcomes. Our interest, by contrast, is with the epistemic status of such claims, that—while no more opaque or difficult to interpret than such assertions associated with other mental disorders—play a more pivotal role.

Part 3: Epistemic analysis

Why anorexia nervosa presents a distinctive challenge

Because it is not intrinsically tied to attributions of disorder, the VCR of those diagnosed with AN must be located within its particular subject's individual motivation for a warranted judgement about its status as pathology. The central epistemic problem is that the opacity of that motivation compromises attempts to understand the AN frame of mind.

This is no everyday opacity—not because it is intrinsically more difficult to interpret but because of its epstemic implications. Words may of course mislead, distort, or obfuscate, intentionally or inadvertently; we may misunderstand, or misinterpret; this is the nature of linguistic communication, and complete understanding of the motivation and words of others will likely always elude observers. But the epistemic role played by these everyday communicative lacunae is different when it comes to assessing VCR. In this context, a failure to understand individual motivation must stand in the way of achieving informed and warranted judgements over its status as pathology.

Several different sources of this opacity were identified and illustrated in Part 2.¹⁴ Even ostensibly descriptive claims in A-type hypotheses were shown by Morris to be arguably misleading due to the holistic nature of introspective states of mind. B-type assertions were also shown to be ambiguous, or even polysemic in carrying multiple meanings, and issues of interpretation arose in two distinct analytic registers, including both whether or not, and in what way, metaphorical language might be intended.¹⁵

Methodology and epistemic norms

The first-person assertions on which this argument rests present their own methodological challenges. My aim in selecting quoted assertions was for representative claims, based on a review of the many available sources. Beyond questions of representation, the reliability of first-person report here must also be subject to scrutiny. Some might challenge their elusive privacy as first-person accounts, or their tacit meanings (Smith et al., 2014). But in terms of coherence and syntax these assertions are usually unexceptional. Moreover, as long as the defining phenotype of AN includes psychological features, we cannot make progress without them. Cultural ideas shape—and are shaped by—first-person experience, so no experience comes entirely unmediated. And today, complexity is added when we assess this material due to contradictory cultural ideas involved—particularly, the medical language and assumptions employed in clinical care, and powerful counternarratives rejecting those medical assumptions, fostered by now-ubiquitous online sources such as #proana sites and other forms of peer contagion in care settings (Vandereycken, 2011; Warin, 2010).

There are additional social and political reasons for the epistemic caution urged here as it relates to achieving assessments that are fair-minded and just. In the history of mental disorder, deficiency, and madness, misunderstanding has been commonplace, and mistaken assessments about patients’ decisional capacity—by turns both under-estimated and over-estimated—have been frequent. Those with any form of mental disorder are vulnerable to injustices associated with their status, suffering a “credibility deficit” due to the persistence of stigmatizing social attitudes (Crichton et al., 2017, p. 65). Multiplying these effects is the fact that people diagnosed with AN are predominantly females and are often very young. They are thus doubly vulnerable to social marginalization through interlocking systems of power (Crichton et al., 2017; Fricker, 2007; Hamilton, unpublished; Potter, 2019).¹⁶ This status calls for closer attention to the particularities surrounding these women's voices than they would otherwise receive—what is left unsaid, what is coded, and particularly what is ambiguous, allowing for alternative interpretations.¹⁷

Conclusion and implications

The foregoing discussion was intended as a contribution to medical epistemology, offering conclusions that are primarily skeptical. Due to careful work from medical anthropology in recent years, we understand some of the cultural contexts and more particular “cultural logics” within which the AN frame of mind is situated. But before attributing pathology to VCR we would still also need to fully understand the individual motivations involved in the sense presupposed here (a composite including immediate wishes, long-term goals, ideas, and ideals, and the way these are united within the person's self-identity). A rich supply of data, theoretical speculation, research, clinical findings, and personal narratives about AN is available to aid this inquiry, and a nuanced, multi-faceted, and complete analysis should be possible. Still, key aspects of the frame of mind associated with AN remain opaque, ambiguous, and open to interpretation, presenting an epistemic impediment.¹⁸

Quite aside from the danger to life and health posed by AN, and the observed lack of treatment effectiveness, this epistemic limitation suggests that seeking to approach this behavior in the general terms presupposed by the assignment of pathological status, we may need to find an alternative rationale. And due to the vulnerable intersectional identities of the majority of those diagnosed with this condition, the interpretation of their frame of mind must be a political as well as a medical matter, as has long been recognized (see Bordo, 1993; Gremillion, 2002; Lester, 2018).

This discussion was not intended to suggest that alternative reasons for pathologizing AN should not be sought or can never be found. Whether they need to be found, however, directs us to ask why such dangerous self-harming habits are pathologized in the first place. Overly medical presuppositions, and blindness to the possibility of achieving health consequences through non-clinical, even non-medical, means must be acknowledged here. Better health can be achieved in many ways, after all, through education; through legislation; through the regulation of social media; through private-sector engagement; through political action undertaken by groups of individuals; through art. Modest examples of such initiatives have included the fashion industry's agreement to avoid using emaciated models; school curricula focused on eating habits, the cultural meanings that attach to food intake, and the dangers of dieting; and efforts to educate parents, responsible for so many years of overseeing food intake and moral education around self-control, perfectionism, moderation, autonomy, and self-respect. Un-tried initiatives may include use of parental controls and warnings on social media sites to prevent “#pro-ana” contagion. This will not be easy, even with such obvious, and limited, approaches.¹⁹

Other analyses direct us towards prescriptions that are more ambitious and far-reaching—and if less realistic, then nonetheless closer to what would likely be required to achieve a significant impact on the prevalence of AN. Nothing less than fundamental change of social attitudes, structures, and institutions, including those around gender roles and expectations, and individualism itself, together with revision of long-held and familiar moral and aesthetic norms and guiding metaphors, could achieve this end, they imply.²⁰

Recognizing that, appearances aside, AN may not be as readily subject to pathologizing as other disorders has certain obvious implications. It suggests that rather than leaving this condition to clinical medicine, we would better direct some attention and resources towards its prevention through alternative—public health and more broadly societal—means.²¹

Footnotes

Acknowledgements

I am especially grateful for comments and extensive help from several anonymous reviewers for this journal. Earlier, members of Phaedra, Jane Roland Martin, Ann Diller, Susan Fransoza, Beebe Kipp Nelson, and especially Barbara Houston offered invaluable guidance, as did Simona Giordano, Serife Tekin, Jennifer Hawkins, Susan Hawthorne, Christopher Jay, Edith Croker, Mohammed Rashed, Sara Dellantonio, Luigi Pastore, and members of the Executive Council of the Association for the Advancement of Philosophy and Psychiatry. Audiences at Emmanuel College (Boston) and the Universities of Massachusetts (Boston), Trento (Italy), and York (UK) also provided indispensable critique.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Notes

ORCID iD

Jennifer Radden

Jennifer Radden, D.Phil., is a Professor emerita of Philosophy at the University of Massachusetts Boston, where she chaired the Philosophy Department between 2002 and 2007. Past President of the Association for the Advancement of Philosophy and Psychiatry, she has published extensively on mental health concepts, the history of medicine, and ethical and policy aspects of psychiatric theory and practice. Recent publications include ‘Public Mental Health and Prevention’ (2017); ‘Rethinking Disease in Psychiatry: Disease Models and the Medical Imaginary’ (2018); a co-edited volume (with Kelso Cratsley), Mental Health as Public Health: Interdisciplinary Perspectives on the Ethics of Prevention (Elsevier, 2019), and a group of 2021 papers on anorexia nervosa: ‘Food Refusal, Anorexia and Soft Paternalism: What's at Stake?’, ‘Forced Feeding for Anorexia: Soft or Hard Paternalism?’, and ‘Capturing the Anorexia Nervosa Phenotype: Conceptual and Normative Issues in ICD-11.’

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