• Tharushi Kaluarachchi

Mental illnesses do not exist independent of their social and historical context. Although it is generally accepted that sociocultural factors are key in the development of Anorexia Nervosa (AN), presently, it is bound by Western notions of disease as its criterion is focused on the obsession with thinness for women with the disorder. However with its evolution being mirrored in East-Asia, it has been hypothesised that an increased risk for eating disorders in those countries arises from a greater exposure to Western popular culture, diets and values. However this in itself does not explain the spread of the disorder as a more complex historical view is needed to explain its conception in East-Asia.

Being complex in aetiology, there is much debate centred on the motivation behind food refusal in being the most challenging factor to interpret (Keel & Klump, 2003). In Western countries, the promotion of thinness as the ideal female form today has forged a template for the diagnosis of AN as eating disorders have become more common among younger females with a period of icons of the American beauty becoming thinner during the late twentieth Century (Keel & Klump, 2003). As a result of this campaign, Lee (1995) claims that modern biomedical views of AN have attributed the avoidance of food purely to a fear of fatness while the sufferer becomes emaciated. The essential criteria for Anorexia Nervosa includes an intense fear of weight gain even with a significantly low weight (The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013). Hence it is insisted that the resolution of this fat phobia needs to presuppose recovery.

However this explanation is inadequate as East-Asian cultures have a historically unique evolution essentially apart from modern Western culture (Keel and Klump, 2003). Hence in East-Asian countries AN was previously noted to be unknown with the fear of fatness noted to be frequently absent among these rare anorexics. A culturally sensitive study of AN in Hong Kong revealed that although they bore a convincing resemblance to Western Anorectics in terms of physicality, a large portion, 59%, did not exhibit any fat phobia, instead rationalising their food refusal through bloating and oesophageal blockages (Lee, Ho & Hsu, 1993) . Hence these East-Asian Anorexics resulted to organic causes for self-starvation, endorsing the body as a social response to illness (Watters, 2010). Thus, an individual’s distress is culturally defined, as these bodily sensations indicate psychological distress carrying as much meaning and impact as a Western complaint of anxiety or depression (Lee, 1995).

Regarding a case study by Lee (1995), a thirty-one year old patient from Hong Kong began complaining of abdominal discomfort and reduced her food intake due to her boyfriend deserting her. Despite seeing doctors, her weight continued to decrease with her attributing it to abdominal problems, denying any fear of fatness or intentionally restricting diet. Clearly this patient did not fit the diagnostic criteria for AN according to the DSM due to the discrepancy between the biomedical explanation of fat phobia and the patient’s personal explanations (Watters, 2010). Aetiological explanations that were sought through Chinese herbalists attributed the self-starvation to imbalances with bodily organs being devoid of normal hunger sensations, yet was found to be ineffective in treatment. As a result, what was needed was a more local understanding of the personal and cultural forces at play instead of relying on a global template driven by the use of Western diagnostic categories as neither Western nor Eastern healing modalities were having an impact.

It is imperative to document that cultural forces are often mediated throughout history to mould the contextual factors which result in the mental illnesses of that time. Hence in pursuing an aetiological explanation for atypical Anorexics, hysteria is of particular interest as its symptoms tend to be shaped by the surrounding culture which is constantly changing in accordance with what is deemed to be female by society. (Shorter, 1986:1). Although the patient’s condition cannot be explained through modern conceptualisations of AN, the symptoms exhibited can be traced back to nineteenth century hysteria. This was an extremely popular form of illness manifesting in a variety of symptoms such as convulsive fits, paralysis and muscle contractions, which the patient believed was physical in origin and perceived as being beyond the control of their conscious mind (Shorter, 1986).

Lasègue (1873 as cited in Malson, 1998) presented hysterical anorexia as a form of hysteria caused by the ‘mental perverseness’ of the patient regarded as an illness of female nervousness. Lasègue (1873 as cited in Malson, 1998) constructs the typical patient to be a young woman who is mentally weak, aged fifteen to twenty years suffering from a personal trauma who is unable to voluntarily resist ascending to the illness. Hence in failing to differentiate between a typical patient and other young girls, he pathologized all young girls, depicting them as being incapable of controlling their symptoms. Hence his report inadvertently enabled a dialogue between the medical society and Victorian middle class females (Brumberg, 1985).

Sir William Gull (1873) who shortly succeeded Lasègue drew the conclusion subsequent to observing similarities across a number of cases, due to the consistent absence of gastric dysfunction which he used as evidence to attribute the loss of appetite to a morbid mental state. Hence Gull defined the loss of appetite as Anorexia Nervosa with the motive for self-starvation being as a result of mental wilfulness differentiated form hysteria which had an organic cause (Gull, 1873).

In constructing a weak minded, young nervous girl, Gull (1873) and Lasègue (1873) presented AN to be viewed as a characteristic or archetype of all young women (Malson, 1998). The ensuing public debate established AN as a distinct disease entity reifying it as a common female disorder which was typified by an aversion to eating food with the patient reporting abdominal pains (Mackenzie, 1888 as cited in Malson, 1998). Yet, as found with the case of atypical East-Asian anorexics, it was repeatedly asserted that careful examinations found no sign of any organic causes that could be attributed to the disorder (Marshall, 1895 as cited in Malson, 1998). Hence a phobia of gaining weight is not the reason for extreme self-starvation, as gastric discomfort was legitimized by physicians, instead attributing anorectic patients’ starvation as the wish not to eat or loss of appetite with the behaviour being as destructive as patients today with anorexia nervosa (Shorter, 1985 as cited in Lee, 1995). Hence non-fat phobia anorexia displays no particular cultural features as it was found in early conceptions of hysteria and atypical anorexics in East-Asia.

Oppenheim (1991 as cited in Watters, 2010) documents the influence of hysteria in Victorian culture in the early twentieth century that led to the rise of the disorder as it was mentioned in not only medical literature but also in popular magazines and newspapers that were easily accessible to lay people. Hysteria was encountered everywhere in the public, seen in an ad in Modern Mechanix – Physical Culture that promoted devices such as body braces to remedy “female weakness, backache, stomach trouble…the result of incorrect posture, misplaced organs” (Stop Suffering, 1934). Further an ad in Photoplay generalised woman as having “no control of herself” with “constant headache, backache and dizzy spells” prescribing tablets that would give women back their youth, beauty and health (These Hysterical Woman, 1932). Hence this reification of disease by medical professionals and consequently the media can have an unconscious yet powerful effect on people as the psychosomatic symptoms of anorexia nervosa were shaped by their beliefs of what constitutes a disease (Shorter, 1986 as cited in Watters, 2010). Shorter (1986) claims that as these expectations change, it targets a specific population and provides patients with a model of how to behave and which symptoms to present. Hence as seen with hysteria, this rapid increase in incidence of a pattern of symptoms coming into vogue through a public interest in medical discourse presents with a problem of incidences of diseases rising (Shorter, 1986). As a result the illness manifested in the population at large and the incidence of the disease drastically rose as self-starvation which was once a rare symptom became common. Shorter (1994:268 as cited in Malt, 1996) postulated that the medical society stimulated the eating disorder behaviour as it influences patients’ ways of communicating their distress to be more recognized and accepted as it offers a person who can no longer cope with their situation to be free of blame through a non-stigmatic label corresponding to medical diagnostics. Hence this rise in hysteria symptoms in early nineteenth century can be matched with atypical anorexics in East-Asian countries in the late twentieth century, with the speculation that the lack of public awareness in East-Asia correlated with the rarity of the disorder, as distressed individuals were less likely to select AN as the illness of choice (Watters, 2010).

In the late 1990’s the cultural and individual differences in diagnosis became blurred as the influence of the Western diagnostic manual grew and wouldn’t be confirmed as AN unless the patient fulfilled the DSM criteria which presents a large problem in treating them (Watters, 2010). Although increasing industrialisation and fraying of traditional forms of family occurred in the 1990’s, this Westernisation is inadequate in describing the rise in the incidence of eating disorders in Asian countries (Pike & Borovy, 2004). This clash between traditional and modernism formed a belief system suspended between East-Asian and Western conceptions at the point where modern attitudes have fragmented families yet not enough to overturn the traditional familism (Chan & Lee, 1995).

As a result, Cummins, Simmons and Zane (2005) criticise DSM as a diagnostic tool as it requires endorsing specific symptoms, yet it presents as less relevant to East-Asian populations as they may exhibit a different pattern of symptom presentation. However Rogler (1992 as cited in Aderibigbe and Pandurangi, 1995) claim that when translating international instruments such as the DSM, they should be culturally sensitive to ensure an accurate assessment of symptoms as they should be described freely without any Westernised prejudice. Further, Aderibigbe and Pandurangi (1995) call for more flexibly structured diagnostic systems where the diagnostic inclusion and exclusion criteria is applied in the context of the local culture as diagnosis would be improved if there are alternate classifications of disorders that were more suitable to East-Asian countries.

Western conceptualisations often neglect the conception of AN in contemporary East-Asia is affected by the dominant cultural expectations for young woman as traditional notions of love, marriage and adulthood create a context which offers financial stability whilst simultaneously limiting their social lives (Pike & Borovy, 2004). As a result of this culture, Pike and Borovy (2004) suggest that eating disorders may reflect the individual’s distress in negotiating these constraints which still values women in their traditional roles of domesticity. This is contrasted with Western cultural valuation of women where the tension arises from a result of striving for achievement and autonomy in being required to negotiate the demands of competitive worlds with a devaluation of traditional dependency work (Pike & Borovy, 2004).

Western societal standards of beauty often overvalue size and weight, expressed through a general distorted body image and fat phobia of the population. Although this pursuit of thinness has been absorbed by East-Asian culture, it is not the central causing factor of East-Asian AN. Instead there is a need to recognise that this fear manifests as a loss of control, which is the more critical factor in developing AN (Lee, 2001 as cited in Pike & Borovy, 2004). This is where the culture acts as a guide for the individual by providing a range of symptoms to express distress as it provides a range of physical symptoms for the unconscious mind to physically express the psychological conflict (Shorter, 1986:1). Hence it is important that the aetiological model of AN integrates the local East-Asian culture and the universal need to express distress and global Westernisation.

The rise in incidence of fat phobia anorexics can be ascribed to the popularisation of the DSM essential criteria of a fear of fatness in Hong Kong through the media. Instances such as the death of a young anorexic girl, Charlene Hsu Chi-Ying sparked the attention of the media with newspaper headlines from local Chinese-language daily papers such as “Schoolgirl Falls Dead on Street: Thinner than a yellow Flower” (Watters, 2010). With little local professional knowledge, Western experts were quoted, ascribing her demise to weight loss and dieting (Watters, 2010). Hence this media attention not only generated public interest resulting in the rise of this disorder, but especially a rise in the Westernised form of AN in a different subpopulation, modelling DSM symptoms. A newspaper article in The Nation claimed that eating disorders were estimated to afflict “one in 100 young Japanese women” (Effron, 1997:14) similar to the incidence rate in the United States. The extent of Western acculturation in Asian countries can be seen as Effron claims that “a weight-loss craze has swept the developed countries of Asia, sending women…scurrying to exercise studios and slimming salons” (Effron, 1997:14 as appearance and figures became very important to young people.

Hence raising awareness of AN in Asian culture inadvertently became a double-edged sword as it could draw a susceptible reader in, with Shaw (2006) finding that adolescents tend to respond more to fashion images. Further, vulnerable adolescents who were dissatisfied with their body and perceived the pressure to fit in were adversely affected by exposure to images of thin models (Stice, Spangler and Agras, 2001). Therefore, there is a need to change the perception of AN portrayed in the media as it has become a culturally manipulated syndrome in East-Asian societies, leading to mimic anorexics as they regard the process of self-starvation with veneration rather than pain (Brumberg, 1985). Hence this proliferation of the promotion of starvation as glamorizing the disease for girls who seek it as an outlet of distress can encourage imitation. As a result, Psychiatry today in East-Asian cultures are treating the subpopulation affected by Western manifestations of AN which is inadequate as it dismisses the genuine atypical anorexics.

In summation, it is important to consider AN as cultural artefact which has been refined over time, as well as integrating a biomedical and personal subjective models. Hence there is no single adequate suggestion that media and advertising or society alone have increased the incidence of AN. It is rather that culture is a layered process of history and social expectations which put modern adolescents at a greater risk for developing the disease such that a deeper historical view, as pursued here, can be sought to explain how expectations of AN have changed. However, the mediation of factors such as media, which help form a dialogue between the disease and the public need to be controlled and take into account the local culture in order to aid in treating and restricting the rise of the incidence of AN in East-Asian countries.