Why Anorexia Is So Hard to Treat

Eating disorders are stubborn. Anorexia, in particular, can cling on in spite of the best up-to-date treatments. Only 46 percent of people diagnosed with anorexia go on to make a full recovery, and even with prompt, specialist attention, 40 percent of sufferers fail to recovery fully. [1] With the highest mortality rate of any psychiatric disorder in adolescence [2], a greater understanding of this common condition is urgently required.

How Common Explanations Fall Short

It is often said that eating disorders share features of addiction, and should be approached simply by disrupting and changing eating habits. Some now argue that genetic dispositions are key, and that identification would make way for better prevention. Some researchers focus on distortions of self-perception within certain areas of the brain.

These paths are all worth exploring—but at present, they amount to little more than re-descriptions of well-known facts: that relapse and persistence are common even when risks are recognized, that many people share with anorexics a desire to be thinner but only some suffer from the clinical condition of anorexia, and that those with anorexia harbor distorted views of their bodies.

Another explanation is that people who suffer from eating disorders—mostly young people, and predominately females—keep them secret until they are deeply embedded and all the more difficult to root out. Some parents describe their anorexic teen as “evasive” or “full of normal-sounding excuses for not eating this particular meal” or even “devious” in their efforts to avoid being weighed accurately. Their eating disorders are kept secret, it is said, because they are ashamed of them.

But having spent the last few years listening to and observing teens, I do not believe “shame” is a helpful explanation of their secrecy. While most teens are distressed by their parents’ concern, and on some level want to be the healthy person their parents want them to be, teens suffering from anorexia and bulimia often say, in effect, “What you call my eating disorder is not really a problem, but a solution to my problem.” Recovering from the condition is viewed as a threat, not a desirable outcome.

Interpreting Teens' Views of Anorexia

Though the term "anorexia" means “without appetite,” those with the condition often do feel hungry, but resisting that hunger is a source of pride.

One of the fifteen-year-olds I spoke to described her self-imposed starvation as “a strength." Hunger gave her a “high” because it demonstrated the power of her will. Another 15-year-old described bulimia (characterized by binge eating followed by purging, most commonly via vomiting, but sometimes via laxatives) as “a way of beating the system.” She was not as “strong” as her friend, but used “natural cunning” to deal with her “weakness” of eating, which she could do without gaining weight—or, as she put it, “getting fat.”

Adolescence is a time of acute self-consciousness. Psychologists refer to teens’ “looking-glass self” arising from a question they see as most urgent—“How do other people see me?”—in a context in which they feel that “I am always being judged.” This looking-glass self is not the image they see when they look in the mirror, but the image that others see when they look at the teen.

Teens' rapidly developing intellect alerts them to the complexity of others’ views, not easily grasped—so the uncertainty of what others see becomes, in the teen’s self-doubting mind, anxiety about what others see. Anorexia and bulimia become the means by which they “gain” protection against one of the most salient negative judgments, that is, “Your body is too fat.”

These teens are secretive about eating disorders not because they are ashamed, but because their greatest fear is of “being cured.” Social pressures on girls to look a certain way are seen as key generators of girl teens’ eating disorders, but ideals of beauty and desirability do not explain the special punitive force of being seen as “fat”—with teens of a normal weight often described, and describing themselves, as “too fat” or “getting fat.”

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The Special Power of Fatphobia

Fatphobia—a pathological fear of fatness—is only one aspect of insidious culture ideals about female beauty and desirability, but it has a very special reach. Bolstered by (often false) arguments about health, and emerging from any increase in weight, it is easily internalized by teens as they focus on how they are seen by others. It resonates with the notion that girls should be without appetites of their own, that restraint and self-denial are their purview, and that they are entitled to less physical and social space.

While few (if any) parents or professionals involved with teens have such views, at least explicitly, our teen girls are clearly absorbing them from somewhere. It is time to sift this fear of fatness out of the more general package of social pressures, so we can discover their source and our role in their distribution.

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