Anorexic

Eavan Boland 1980

Author Biography

Poem Summary

Themes

Style

Historical Context

Critical Overview

Criticism

Sources

For Further Study

As the title of the poem suggests, “Anorexic” examines the troubling issue of self-inflicted starvation, a topic that some readers (and some poets) consider controversial and out of place in poetry. But that, Eavan Boland would say, is all the more reason to write about it.

Beginning with the publication of In Her Own Image in 1980, Boland began to explore and present in her work intimate subjects dealing with all aspects of a woman’s life, including her sexuality, her relationship with men, and her relationship with herself. In Her Own Image includes poems with such provocative titles as “Menses,” “Masturbation,” and “Mastectomy,” as well as “Anorexic.” These poems make public the highly personal thoughts and behaviors of women, and Boland’s strong feminist views are the driving force behind their creation. These poems have been both praised and condemned but often by readers who do not fully appreciate their motivations.

“Anorexic” relies heavily on irony to present Boland’s disdain for the long-held social practice of judging females by their look or weight. This poem, however, rather than being a straightforward account of a woman’s suffering, involves a cynical twist. The speaker imagines herself as the biblical Eve longing to disappear back into Adam’s body and become the rib from which she was created. By presenting the woman’s body as hideous, with its “sweat and fat and greed,” Boland ironically points out the female’s desperate desire for independence and an identity separate from an attachment to a man. By using the voice of a woman who believes in society’s conception of the perfect female and who is willing to waste away to become it, the poet exposes her outrage that such a conception exists.

Author Biography

Eavan Boland was born in Dublin, Ireland, on September 24, 1944. She was the youngest of five children in a fairly well-to-do and influential family. Her mother was an artist, and her father was a diplomat, serving as an assistant secretary in the Department of Foreign Affairs during World War II.

After the war, tension mounted between Ireland and England, and Ireland finally broke from the Commonwealth in 1948. Not long afterwards, Boland’s father was appointed ambassador to England, and he moved his family there. In 1956, he became the Irish ambassador to the United Nations and relocated the family again, this time to New York City.

Although her parents provided a good home for their children and were financially able to take care of their needs, their nomadic lifestyle left Boland feeling, at times, displaced and insecure. In 1959, when she was fifteen years old, Boland returned to Ireland.

Once there, Boland entered Holy Child Convent School. She studied and lived there until 1962 when she was accepted into Trinity College. In 1966, she graduated from Trinity with degrees in Latin and English. At both of these schools, Boland found the solitude, peace, and security that she had missed in her years spent in other countries. She began to write poetry. In 1962, she published her first collection, 23 Poems, at her own expense. Her following collections were picked up by publishing houses, and the second one, New Territory, won her the 1967 Irish Arts Council Macauley Fellowship.

To date, Boland has published twelve volumes of poetry. She has taught at various colleges and workshops in Ireland and the United States. Since 1995, she has directed the creative writing program at Stanford University in California.

Boland’s early poetry was heavily influenced by the physical and emotional environments in which she grew up. As a child living in England after World War II, she was witness to the devastation that the cities and countryside had endured, and she saw firsthand the destruction of both the people and the land. As an Irish child growing up in England, she felt the personal sting of prejudice and hatred that earmarked the relationship between the English and the Irish. As a result, much of her early poetry is political in nature, addressing issues of public and international significance. By 1980, however, with the publication of In Her Own Image, Boland’s work took a turn toward intensely personal subjects. “Anorexic” is a prime example of that turn.

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[This text has been suppressed due to author restrictions]

Poem Summary

Line 1

The first line of “Anorexic” shocks the reader with its bluntness and sets the tone for the entire poem. The word “heretic,” meaning something contrary to accepted beliefs, implies a religious theme, since it usually refers to something or someone that opposes the doctrines of Christianity. This subject will return later in the poem when the speaker alludes to Adam and Eve in discussing the relationship among men, women, and anorexia. The word “flesh” is noteworthy because it stresses how anorexia distorts its victims’ perception. The speaker does not say that fat or any other particular kind of flesh is “heretic”—rather, flesh in general is a sin.

Lines 2–3

These lines continue the sharp language and appalling sentiment as the speaker compares her body to a witch condemned to burn at the stake. The separation of the speaker’s mental self from her physical self is notable. In the third line, the speaker claims “I am burning it,” [italics mine] as though her body is a detached thing her mind can destroy at will. These lines also maintain the religious allusion and the idea of heresy, the sin for which many so-called witches lost their lives.

Lines 4–6

Line 4 not only confirms the speaker’s metaphorical act of burning her body, but also intensifies the description of it. Now she is not just “burning” it, but “torching” it. She also becomes more specific about the parts of her body that are on fire, calling attention to the physical features generally attributed to females—“curves and paps [nipples] and wiles.” The word “wiles” typically denotes something that entices or seduces, sometimes by trickery and deception. In this case, it likely refers to all parts of a woman’s body that men find enticing (the genitalia, in particular, since breasts are mentioned in the same line).

Media Adaptations

• A general search under Eavan Boland’s name on the Internet search engine “Yahoo” brings up hundreds of web pages that either feature or mention the poet. The page at http://mmc.arts.uwa.edu.au/chloe/outskirts/archive/VOL2/Feature3.html (January 2001) provides a thorough explanation and review of “Anorexic.”

Line 6 introduces another synonym for burning, as the female body parts “scorch” in their starvation. The last three words of this stanza, “my self denials,” sum up the position of the anorexic. The disease is based on denying food to the body, but it is notable that Boland does not hyphenate the word “self-denial” as in standard usage. By presenting “self” and “denial” as two separate words, the poet reiterates the idea of a complete division between the anorexic’s mind and her body.

Lines 7–9

In these lines, the speaker refers to her body in the third-person as “she” instead of “it,” as though her physical being is actually another woman, one she detests. She states that her body “meshed” her head “In the half-truths / Of her fevers,” implying that the body attempted to ensnare her mind and lie to it by claiming to hunger for sustenance. The fact that the anorexic calls the need for food a “half-truth” is evidence of her distorted mindset. Line 9 concludes with the word “renounced,” which can mean either “gave up” or “rejected.” Both work in this case since the speaker is both giving up and rejecting food.

Lines 10–11

These two lines are a clever juxtaposition of phrases, with line 10 having both a literal and a metaphorical meaning. The speaker has “renounced” food, which would include, literally, milk, honey, and anything for lunch. But “milk and honey” is also an allusion to God’s description in the Hebrew Bible of a beautiful, peaceful land— the country to which Moses was to lead the Israelites—so lush that it flowed with milk and honey. This line in the poem reiterates the religion and creation mythology allusions, and also implies that the anorexic willfully rejects all that is good, healthy, and plentiful. Contrasting this lofty allusion with “the taste of lunch” causes the poem to drop abruptly into harsh reality.

Lines 12–14

Line 12 presents the same sentiment as appears in lines 9 and 10 but with harsher language and more intensity. “I renounced / Milk and honey” has strengthened into “I vomited / Her hungers.” Likewise, the “witch” of line 2 has worsened to the “bitch” who “is burning.” Line 14 is the culmination of the speaker’s anger and self-hatred, and it occurs just before her emotional turning point.

Lines 15–17

These lines depict a more resigned, melancholy attitude on the part of the speaker. She appears to have become whole again, her mind and body reunited in lines 15 and 16, as she acknowledges, “I am starved and curveless / I am skin and bone” [italics mine]. Although she reverts to the third person again in line 17, claiming that the body “has learned her lesson,” this is the final time in which the third-person reference is made. This is a turning point for the poem and for the speaker, as both become softer and seem to slip into a weakened dream-like state. Just as the physical being loses energy and becomes lethargic as it wastes away in starvation, so do the tone of the anorexic speaker and the poem itself as they parallel the behavior of the disease.

Line 18

The speaker has already described her body as “skin and bone,” and now she is specific about the bone she is most like. “Thin as a rib” is a significant line, not only because it stresses how skinny an anorexic becomes, but also because it is thematically important, introducing man’s role in the woman’s struggle with self-identity and self-hatred. In the biblical story of Adam and Eve, God creates Eve by removing one of Adam’s ribs, forming the female body from it. The implication of the tale is that man came first, and that without man, woman would not exist. A woman is essentially a part of a man, and as such her role in life is secondary, or diminished, when compared to his. Line 18 of “Anorexic” is pertinent because the speaker is now becoming Eve, the perfect representation of women in general.

Lines 19–20

As the speaker sleeps, she dreams she is a rib, her stick-like body able to “probe” the way any long, thin object can.

Lines 21–22

The thing the speaker’s dreams probe is not a tangible thing, but “A claustrophobia / A sensuous enclosure.” These two items are an odd pair: one connotes a fearful emotional condition and the other a pleasant, comfortable haven. Claustrophobia is an abnormal fear of being in a tight or small space, and it seems as though the speaker has mixed feelings about where her dreams are taking her. At the same time as she tests, or “probe[s],” her fear, she also flirts with the pleasurable, even sexual, solace that being enclosed arouses in her. At this point in the poem, exactly what the “enclosure” is, is not clear. Its connection to the speaker’s identifying herself as a “rib,” however, soon becomes apparent.

Lines 23–26

These lines reveal what the claustrophobic and sensuous enclosure is: Adam’s ribcage. Just as Eve is presumed to represent woman in the poem, so Adam represents man. Here, he is portrayed in a peaceful, yet dominating, position. The speaker, in the form of a rib, recalls what it was like to be inside man’s chest, “How warm it was and wide.” She remembers lying next to his beating heart, the “warm drum,” and listening to the music of his breathing as he slept. This description is quite a turnaround from the anger and hostility that permeated the earlier part of the poem. The resignation in the speaker’s dream-voice implies the surrender of her existence as an individual human being, the giving up of womanhood to return to her origin within man.

Lines 27–29

In lines 27 and 28, the reader can almost hear the weak, nearly lifeless voice of the anorexic as she drifts into unconsciousness, waiting for death to end her battle with her physical self. The voice is feeble but hopeful that with “Only a little more” time, in “only a few more days,” she will succeed in killing her body, the “witch” she has been burning with starvation. The word “sinless” in line 29 is ironic in that it equates with “foodless.” Most people would assume that to starve the body is the real sin, but for the speaker, eating is the transgression.

Lines 30–32

Once the speaker’s body has died, she will be able to “slip / back into him again.” Notably, it is the “I” that will return to Adam’s body. It is the “I” who will feel as though she has “never been away,” has never become the healthy, fleshy, lustful woman whom the “I” turned into the third-person “she.”

Lines 33–34

Brevity and rhyme are conspicuous characteristics of these lines. Irony is also apparent. Something “caged” is not normally associated with growth, yet that is how the speaker sees her return to captivity within Adam. Her prison bars are actually the man’s ribcage, and only when she once again takes her place within it will she be able to “grow.”

Lines 35–36

The word “angular” in line 35 is a reference to the shape of a rib bone, but it may also imply a phallic symbol since the speaker has relinquished her femininity to reenter the male. This interpretation is reinforced by the inclusion of the word “holy,” which sustains the overall irony and cynicism of the poem. Society has not exalted the ribcage as a symbol of power, dominance, and holiness, but the male sex organ has often been afforded these attributes. Because of this, the speaker feels she can grow “past” the “pain” of being a lowly woman only by rejoining the godlike figure of man.

Lines 37–40

These lines present the speaker in her doting role as a rib lying next to the man’s heart, keeping it such good company that she will forget the past and her struggles as a woman. Line 40 reiterates the sense of claustrophobia that the speaker initially felt in her dream-like state and that seemed to disappear in her pleasurable musing on how comforting it would be to “slip / back into him again.” Calling attention again to the “small space” indicates that not all of her fear and discomfort has gone away.

Lines 41–43

These lines can be seen as two separate metaphors, both regarding creation, but one is based on religion and the other on sexual intimacy. The “fall” refers again to the biblical story of Adam and Eve, in which humankind falls from the grace of God by defying His orders and giving in to temptation. Although Eve is warned against eating fruit from the Tree of Knowledge, she is enticed to do so by a snake, and she entices Adam to do the same. In this sense, “the fall / into forked dark” relates to the forked tongue of the snake, and “python needs” is a direct reference to the fierce, deadly reptile. This metaphor maintains the theme of creation and religion within the poem, bringing it full circle from the frenzy of burning heretics to the longing of Eve to slip back into Adam and, finally, to the downfall she brings upon the human race.

But these lines also involve the creation of life through sexual bonding and, in this case, the speaker’s own creation as a woman. Although the poet presents the act metaphorically, the language is an example of Boland’s move toward explicit and graphic detail. In these lines, woman is created when she falls from her safe place next to man’s heart and into the “forked dark” of female genitalia, all at the urgency of the male’s sexual needs. Here, “python” is another phallic symbol, and once again it is attributed with power and desire.

Lines 44–46

The final three lines of “Anorexic” consist of a list of human features and characteristics, but the implication is that they are primarily the features of women. But while it is not far-fetched to relate “hips and breasts / and lips and heat” specifically to the female sex, one could reasonably argue that “sweat and fat and greed” apply equally to both sexes. Ending the poem on this ironic point simply reaffirms the speaker’s position taken in the beginning—the female body “is a witch” that has grown into a disgusting being with its “greed” for food and the real or imagined “fat” that results.

Themes

Self-Alienation

Anorexia nervosa is a disorder that occurs more often than most people think, yet it is odd in that it is self-inflicted. The “normal” human being would abhor the idea of giving himself or herself cancer, AIDS, or any other serious disease, but many of those same humans withhold proper nutrition from their own bodies for the sake of “dieting” or “getting into shape.” But there is a marked difference between individuals who carefully measure their fat grams and count calories and those who simply stop eating. “Anorexic” is not a poem about a woman who falls victim to a bad diet, but

Topics for Further Study

• Write an essay about a physical or psychological disorder that you believe is caused by social pressure. Explain the nature of the pressure, possible reasons for it, and who it affects most often.
• There have been news articles, books, and at least one popular rock song written about the 1972 massacre in Ireland referred to as “Bloody Sunday.” Research this event and write an essay describing what happened and why.
• Boland’s poem makes metaphorical use of the biblical story of Adam and Eve and is told from Eve’s perspective. Write a poem about an emotional stress that is common in males using the same metaphor and told from Adam’s perspective.
• Explain how Boland’s use of the “anti-lyric” affects the presentation of her poetry in In Her Own Image and how the poems would differ if written in traditional lyric style.

an examination of the overwhelming consequences of a female’s being so alienated from her own body that she wants to kill it.

From the outset of the work, with its angry tone and violent description, the speaker is engaged in a battle with her own physical being. The alienation from her body that she feels so strongly is stressed by her references to “it” and “her” and “she” instead of “me” or “mine” or “myself.” The “self denials” that “scorch” her feminine attributes—“her curves and paps and wiles”—are the result of self-hatred. She is incapable of loving or respecting herself as a woman, and the only solution she sees as viable is to destroy the part that makes her miserable. The “part,” unfortunately, happens to be her entire body.

Even when the speaker’s body has become so weakened by starvation that “she has learned her lesson” [italics mine] and fades into the “I” who sleeps and dreams, the self-alienation is still apparent. Now that the anorexic woman has gotten rid of her physical burden, she imagines that she is Eve and seeks to rejoin her identity with Adam, from whom she originated. By doing so, she can completely obliterate what little personal identity she had and can “grow / angular and holy” within the body of the man, reflecting his physical features. The theme of self-alienation is carried through to the end of the poem, as the speaker claims that closeness to Adam’s heart will make her “forget” that she had ever possessed the “hips and breasts / and lips” that made her a female. Instead of respecting those attributes as natural to womanhood, the victim of anorexia equates them with “sweat and fat and greed.”

Social Alienation

Boland’s poem addresses two types of alienation in its themes. Once the obvious subject of self-alienation has been examined, it is equally important to consider the possible causes of it. People who are separated from and disgusted by their own beings may only be reflecting the estrangement and hostility that society has directed toward them. In the case of anorexia, it is most often females, usually teenage girls, who become victims of the disorder. While there have been varying opinions on why teenage girls are more susceptible to this disorder, the most prevalent belief is the one behind the poem “Anorexic”—the pressure to meet cultural expectations, which are unreasonable and unattainable.

The speaker in this poem hates herself. More particularly, she hates her physical self, and so she starves her body to punish it for its perceived ugliness. The key word here is “perceived,” for the anorexic person distorts the reality that she sees in a mirror. It is society’s unattainable perception of the perfect woman that she tries to achieve, inevitably failing, but taking the effort to a deadly extreme. Such cultural standards serve only to alienate females from their own societies. If their flesh cannot be perfect, they reason, then their “Flesh is heretic”—a sin for which the body must burn. But their “heresy” is not a sin against God; rather, it is a transgression against a society that shows no tolerance for imperfect females. “Anorexic” does not directly implicate society, or even mention “society,” but the scenario of Eve returning as a rib to Adam’s body represents the idea of a female so alienated from her culture that she must destroy her actual self to become a part of it. She must return to “claustrophobia” and the “sensuous enclosure” to please the world. Otherwise, she would be a free, independent woman with whom she equates “sweat and fat and greed.”

Creation Mythology

“Anorexic” is neither a “religious” poem nor an “anti-religious” poem, yet its main premise involves the biblical story of Adam and Eve. The poet’s personal views on a supreme being do not enter this work because the creation myth is used to provide a comment on human society, not religious doctrine. The speaker, or “Eve,” is a symbol of woman and “Adam” is a symbol of both man and society. Adam’s role is one of a sleeping, powerful god whose heart is a “warm drum” and whose breath is a “song.” Eve is a “starved and curveless” “foodless” rib. She needs to be “caged” within Adam because on her own she cannot measure up to the expectations of her culture. Outside of Adam, she is only a conglomeration of “curves and paps and wiles,” “hips and breasts / and lips and heat”— but none of it good enough.

Style

The Anti-Lyric

In general, lyric poetry expresses subjective thoughts and feelings, often deeply personal and emotional ones. The lines are typically drawn out and include regular rhythmic and metrical schemes, giving the work a songlike quality. Before the publication of In Her Own Image in 1980, Boland’s work had been largely lyrical, and a major influence on her style was the renowned Irish poet William Butler Yeats. As her concerns over the plight of Irish women poets grew, and as she became more involved in the Irish Women’s Movement, Boland began to reject the “expected” lyrical poetry and to write what she termed the “anti-lyric.” In this style, her lines were very short and the stanzas pared down to pole-like columns. In Women Creating Women: Contemporary Irish Women Poets, author and editor Patricia Boyle Haberstroh discusses the poetic style of the collection containing Boland’s “Anorexic”:

Boland describes these poems as ‘anti-lyric,’ her response to the constraints she felt the lyric placed on her as a woman. . . . One of the first things we notice about this volume . . . is the loosening of stanzaic form. Short-line tercets, reminiscent of the American poet Sylvia Plath, appear in half of the poems. Other poems with four-, five-, or ten-line stanzas employ neither regular meter nor rhyme; two of the poems have no fixed stanza. While not unusual in contemporary poetry, this loosening of form represents a departure for Boland from those conventional models which had dominated her earlier volumes.

“Anorexic” is a “thin” anti-lyric poem consisting of fourteen stanzas, all but three made up of three lines. The first and fifth stanzas consist of a series of three short sentences, each one blunt and powerful in its message. When read aloud, “Flesh is heretic. / My body is a witch. / I am burning it,” has a flat tone, even while the words are horrific. A similar flatness of tone can be heard in “I am starved and curveless. / I am skin and bone. / She has learned her lesson.” The eleventh and twelfth stanzas are even briefer, each of the three lines containing only two or three words: “Caged so / I will grow / angular and holy” and “past pain / keeping his heart / such company.”

Boland’s anti-lyric is actually only “half-anti.” While she has chopped the usual flowing lines of lyric verse into blade-like images, she has still maintained—even heightened—the subjectivity and personal expression so prevalent in lyric poetry. The speaker is highly emotional in describing her desire to torch her own sensuous body, and she strongly expresses her anger in stating, “Now the bitch is burning.” The language throughout the poem is strongly suggestive and deeply personal, making it lyrical, but the poem is also presented in brief, pared-down lines, making it anti-lyrical.

Rhyme and Alliteration

“Anorexic” is primarily free verse, but it does contain some effective uses of rhyme and alliteration (like-sounding consonants and vowels). Even as the voice is harsh and the message controversial, the work is still “poetic” with such rhymes as “wiles” and “denials,” “wide” and “side,” and “so” and “grow,” as well as the near-rhymes of “needs,” “heat,” and “greed.” The use of alliteration is also impressive, from the abrupt like-consonant sounds of two words—“bitch” and “burning,” “sleeping side,” “past pain,” “forked dark”—to the more strategic and compelling repetition of the “w” sound carried out in “How warm it was and wide / once by a warm drum.” In spite of the fierce political and social protest so obvious in this poem, it still retains the grace and style of pure poetry.

Historical Context

The history of Boland’s home country is a long and troubled one, from the battles among Celtic tribes

Compare & Contrast

• 1972: British troops shoot and kill thirteen Roman Catholic protesters in Northern Ireland on a day that becomes known as “Bloody Sunday.”
  
  1998: The Good Friday Accord brings a dubious peace to Northern Ireland after twenty-two months of negotiations and three decades of violence.
• 1979: The Moral Majority is established and its leader, Jerry Falwell, encourages the effort to block the Equal Rights Amendment for women.
  
  1995: After a lengthy legal battle, Shannon Faulkner becomes the first woman admitted to the all-male Citadel College.
• 1983: Pop star Karen Carpenter dies at the age of 32 after an eight-year battle with anorexia nervosa. Although she tried to overcome the disorder for at least two years before her death, the detrimental effects of years of starvation end in heart failure on February 4 of this year.
  
  1999: A study of 471 college students published in the Fall issue of Adolescence finds that twenty percent of the females and ten percent of the males surveyed exhibited anorexic eating patterns. The findings suggest that more males are affected by the disorder than previously thought.

thousands of years ago to the raids on villages and monasteries by the Vikings around 795 A.D. to the takeover by British noblemen 400 years later. Ireland has struggled to maintain its independence since it was first founded, and the hostilities between it and Great Britain still exist today.

Although Boland spent much of her childhood and teenage years outside Ireland, she has lived there most of her adult life except while holding teaching positions in the United States. During the 1970s, when she was writing the poems that would be included in In Her Own Image, the country was struck by several terrorist attacks, including the 1976 murder of the British ambassador in Dublin. Even though Ireland, along with Great Britain, joined the European Economic Community (now the European Union) in 1973 to help balance its position in the world community, civil unrest continued to plague the nation and make lasting peace a dim prospect.

Equal rights movements in Ireland were inspired by similar movements all over the world, and many came into being during the 1960s and 1970s. Prior to the Irish Women’s Movement, which got into full swing in the 1970s, women already made up the majority of participants in other civil rights actions. As Irish historian Jan Cannavan notes on the web site, “Women’s Struggle Liberates Ireland/Ireland’s Struggle Liberates Women: Feminism and Irish Republicanism”:

In the late 1960s the Northern Ireland Civil Rights Association, inspired by the African-American Civil Rights Movement, waged a non-violent campaign to win equal rights for the Catholic nationalist people of the partitioned Six Counties. Women made up a large proportion of this movement but, except for Bernadette Devlin, the entire leadership was male.

Most of the actions of the Northern Ireland Civil Rights Association (NICRA) involved large marches and demonstrations against British rule. The British-backed police force known as the Royal Ulster Constabulary (RUC) was charged with keeping the marches from getting out of hand and with making arrests when demonstrating turned into rioting. Violent conflicts occurred weekly—if not daily—in Northern Ireland during the late 1960s and early 1970s. Arrests and indefinite internment led to more heated protests by Catholics who supported a Republican Ireland. They constantly found themselves at odds with Protestants who were loyal to the British crown, making trouble in Ireland as much a religious issue as a political one.

Boland was twenty-eight years old in 1972 when tension between Catholic youth and the British Army culminated in one of the worst civil rights movement clashes of the era. No longer able to control the rioting, the RUC had called upon the British Army for help as early as 1969. On January 30, 1972, the NICRA held a massive anti-internment march in Derry County that ended with 13 protesters shot dead by the British Army, most of the victims under the age of 25. This event became known around the world as Bloody Sunday, eventually eulogized in the song “Sunday, Bloody Sunday” by the popular Irish rock band U2. Both sides of the conflict accused the other of lying about the causes. Soldiers claimed they had been fired upon by protesters, as well as by members of the Irish Republican Army who were supposedly among the crowd. Protesters denied the charges. Although the army was exonerated of any wrong-doing in the inquiry that followed, only recently in 1998—nearly 30 years after the tragic event— British Prime Minister Tony Blair announced that there would be a new inquiry into Bloody Sunday.

Obviously, there are many parts of the world in which people of both sexes are subjected to violence, social unrest, harsh physical conditions, and severe emotional distress. Only a small minority turns to self-destructive behavior (such as becoming anorexic) as a means of coping. When Boland turned her poetic attention away from strict political protest and onto issues of feminism, she did so in the wake of a relatively weak women’s rights movement in Ireland. Today, not much has changed socially or politically for Irish women in comparison to their counterparts in the United States and other progressive nations around the world. Again according to Cannavan, in Ireland, contraceptives are not easy to come by and abortion is not only illegal but unconstitutional as well. Divorce is also illegal in many states and women are often at the mercy of unscrupulous armed soldiers on the streets. Given these conditions, one is not surprised that an inflaming and accusatory poem such as “Anorexic” found its way onto the pages of a very outspoken female Irish poet’s book.

Critical Overview

Before the publication of In Her Own Image in 1980, Boland’s poetry collections received some-what mediocre attention in Ireland’s poetic circles. The early works were in traditional lyric style, and they exhibited the strong influence of renowned Irish poet William Butler Yeats. Because these characteristics were common to the works of many younger Irish poets, Boland went largely unnoticed in the poetic world for over a decade. With the release of In Her Own Image, however, she sent shock waves throughout the male-dominated network of Irish writers, and the book was predictably condemned by her male counterparts. Women, also predictably, praised the collection for its daring, honest subject matter and its candid presentation. Regardless of the “worthiness” debate, there is no doubt that the collection containing “Anorexic” put Boland on the poetic map.

After 1980, many critics began reviewing Boland’s work in terms of “women’s writing.” Instead of concentrating on her ability as a poet, they became absorbed by her reputation as a feminist. Ironically, the work that appeared to be a breakthrough, not only for Boland, but also for Irish women poets in general, prompted some critics to further pigeonhole her creativity. The subjects of In Her Own Image were looked at by some reviewers more as an ostentatious display than as a bold step away from the accepted domain of female poets. The denouncement was not limited to Irish literary criticism.

In an article for the Michigan Quarterly, critic Brian Henry states that the poems in this collection

attempt to shock us with their content—domestic violence, breast cancer, anorexia, menstruation, masturbation. Because these subjects are common material for American poets, these poems carry the extra burden of convincing already skeptical readers. They seldom succeed.

In specific regard to “Anorexic,” Henry is a bit more tolerant, calling the poem a “dramatic monologue [that] is faithful to the complexity of this disease.” But the overall conclusion of the review reflects an opinion other critics have also voiced: “When Boland can transform her narrators from stock characters to fully realized women, the poems work as verbally taut performances. The too-close resemblances to [Sylvia] Plath’s staccato short-line speech acts, however, diminish these poems’ long-term significance.”

As it turns out, Boland’s long-term significance as a poet has not been so easy to dismiss, and In Her Own Image was followed by politically-charged collections and works that explored the intricacies of domestic life. Her first overall success in the United States came with the publication of Outside History in 1990, and the mainstream American attention helped her win popular acclaim in Ireland as well. Her work is now included in major anthologies and journals in both the United States and Ireland, and in 1997, she was awarded the Irish Literature Prize in poetry.

Criticism

Pamela Steed Hill

Hill has published widely in poetry journals and is the author of a collection entitled In Praise of Motels. In the following essay, she examines the role of female sexuality in Boland’s poem, contending that the poem relies as much on allusions to female sexuality as on the main story of Adam and Eve.

Anorexia nervosa is a complex disorder with causes that are not completely understood. But what is well documented is the effect on the body that results from the cycle of self-starvation and purging food, such as sallow skin, brittle bones, loss of hair, tooth decay, and, in some cases, heart failure. Females are most susceptible to anorexia, and it is usually adolescent girls or very young women who become victims of this disease. Most recent studies have pointed to a stressful family up-bringing as a possible cause for many girls to become anorexic. Research indicates that parents who hold their daughters to high or unreasonable expectations while at the same time discouraging their daughters’ independence, create an emotional burden that the young girls cannot resolve. Many turn to self-hatred and, eventually, self-destruction as a form of punishment for not being “good enough.”

Eavan Boland’s poem “Anorexic” offers a different reason for the existence of this disorder in the lives of women. Instead of placing the blame on parents, the poem points a finger at society in general and at men in particular. The poem is based on the premise that the culture in which a woman lives places undue expectations on her physical appearance, mandating that the “ideal” woman be beautiful and thin. The speaker in the poem is so deeply affected by social pressure that she wants to destroy her “inept” physical self and return spiritually to the inside of a man’s perfect body— metaphorically, Eve returning to Adam as the rib from which she came. What is especially interesting about the speaker’s obsession with self-annihilation is her focus on destroying the most intimate parts of her body, eradicating her sexuality and all the features particular to a healthy woman. As a result, “Anorexic” is a mixture of allusions to both female sexuality and to the biblical story of creation.

On the web site WM’s Story, an anonymous woman relates her battle with anorexia nervosa, beginning her story with these words:

Obsession. Hunger. Fraud. Vice. Crutch. Need. Weakness. Selfish. Milk-fed. Stupid. Fat. Worthless. Lazy. Sloth. Me. No matter which word you select, they were all my name at one point or another, yelled at me by that ferocious taskmaster that used to be my conscience.

This grave list of self-loathing words could easily come from the poem’s speaker, but she has created a list of her own: “hips and breasts / and lips and heat / and sweat and fat and greed.” The lists are similar, and both contain the word “fat,” but the anorexic woman in the poem aligns the sexual parts of a woman’s body (hips, breasts, and lips) with descriptive words that are both erotic (heat and sweat) and distasteful (fat and greed). She compares female voluptuousness to a sin—in this case, gluttony.

From the beginning of “Anorexic,” the speaker spells out the sinfulness of the flesh. Her own “is heretic” and her body “is a witch.” From this Puritanical imagery, she goes immediately into a list of the specific body parts that are most heretic, the sensual “curves and paps and wiles.” Why would she single out her most intimate features for “torching” with no mention of the more benign fingers, toes, legs, arms, and so forth? Why would she make a point of calling her body “curveless” after she has “vomited / her hungers” and announced that “the bitch is burning”? The answer most likely lies in the second half of the poem, which introduces man, who plays the dual role of savior and destroyer in the woman’s life.

The story of human creation through Adam and Eve appears in a variety of similar versions throughout the history of theology and mythology. Typically, it involves a benevolent creator, an opportunity for everlasting happiness, and a “fall” from that happiness through surrendering to temptation. But the study of religion or myth has little, if anything, to do with Boland’s “Anorexic.” Instead, this poem uses the familiar figures of Adam and Eve to symbolize the difference in society’s treatment of men and women. It is a difference, the poet contends, driven by a male-dominated power structure that allows men the freedom to be and to look however they naturally are. That same structure, however, sets up a standard for women to meet, especially when it comes to their personal appearances. In the poem, the speaker despises her own sexuality and the parts of her body that most represent it. As she slips into the identity of Eve, however, she calls Adam’s ribcage “a sensuous enclosure,” a pleasurable description from the same woman who abhors sensuousness within herself.

She thinks of his heart as a “warm drum,” his breath as a “song,” and his “sleeping side” as a comforting, safe haven in which she used to exist. Compare these engaging descriptions of the man’s physicality to the words the speaker uses to describe her own, and the contradiction is obvious. The point here is that society’s inequitable treatment of the two sexes is so all-encompassing that some women themselves begin to accept—even embrace—their lower position.

As the poem moves toward its end, the speaker, now Eve, becomes more and more entrenched in her quest to return to Adam’s body. And just as she had targeted the intimate parts of her own body to make suffer, she now alludes to the man’s sex organ to praise and to imitate. Back inside his ribcage, she “will grow / angular and holy.” Here, sexual imagery is directly associated with religious imagery. The phallic symbol, characterized as “angular,” is sacred, and the thinner, more “curveless” she becomes, the more she will resemble it. Eve’s need to lose herself inside the male body is evidence of how drastically social pressure has affected her. Her independence as a woman is so weakened that she wants to forfeit her own existence altogether. It is that existence that she refers to as “pain” in saying that she can grow “past pain” by sleeping next to Adam’s heart in the form of a rib. Her hope is that by doing so she can “forget / in a small space / the fall” from her secure, yet questionable, sanctuary.

References to the “fall” of humankind from the grace of God have been a very commonplace metaphor in writings of all kinds for hundreds of years. Its usage is trite in most instances, but in “Anorexic” the mixture of creation mythology and sexual imagery provides an interesting twist to an otherwise stale idea. Eve wants to forget that she was ever tempted by a snake, gave in, and, thereby plunged the human race into sin and suffering. She carries the guilt of introducing greed into the world, and her only salvation is to give up her “evil” womanhood and become a safe, benign bone in Adam’s body again. The “forked dark” and “python needs” conjure up frightening images of snakes and devils and people falling into bottomless pits. But the final three lines of the poem give new meaning to forked dark and needful pythons.

With the sexually-charged description of “heaving to hips and breasts / and lips and heat / and sweat,” the “forked dark” and “python” now become symbols of female and male genitalia. Once again, Boland reverts to sensuous imagery to

“The speaker in the poem is so deeply affected by social pressure that she wants to destroy her ‘inept’ physical self and return spiritually to the inside of a man’s perfect body— metaphorically, Eve returning to Adam as the rib from which she came.”

emphasize the desire to destroy what is most womanly, what is prominently female. Had the description ended with “sweat,” the connotation might not have been so negative. Taken out of context, it might read as an enticing or, at least, expected depiction of human sexuality. But the final two adjectives are “fat and greed”—doleful reminders that the anorexic speaker loathes the idea of intimate pleasure, especially from inside a body she abhors.

Most of the poems collected in In Her Own Image are highly emotional and border on extreme responses to women’s issues, both personal and social. “Anorexic” is no exception. The language is extreme, the sentiment is extreme, and the speaker’s actions are extreme. While one could argue that severe thoughts and behaviors are typical of anorexia victims, a case may also be made for the poem taking things too far. On one level, the poem aptly depicts the distorted mindset of an anorexic woman and does a good job portraying the emaciated effects of starvation. On a deeper level, however, the placement of blame on a society dominated by males appears overdone in the references to sexuality and the destruction of the physical features most commonly associated with sexual behavior. The obvious sarcasm displayed in the annihilation of the female body and the praise of the male body serves only to add unnecessary hysteria to the work. Because the poem relies so heavily on sexual imagery entwined with creation mythology, it is especially important to control the voice to keep the already volatile material from dissipating

What Do I Read Next?

• Lori Gottlieb’s Stick Figure: A Diary of My Former Self, published in 2000, is the candid story of the author’s struggle with anorexia, beginning when she was eleven years old. Based on her childhood diaries, the voice is uniquely first-person, sometimes childlike, sometimes adult, and always honest.
• When Nathaniel Hawthorne published The Scarlet Letter in 1850, he probably had no idea that the theme of his book would still be a central issue in the lives of many twenty-first-century women. The Scarlet Letter examines the social stigma associated with being a female adulterer—the Puritan community of the novel sentences the offender to wear a large red ‘A’ on her clothing as punishment. Male adulterers did not suffer the same humiliation.
• The 1997 collection entitled Anorexics on Anorexia, edited by Rosemary Shelley, provides excellent and chilling insight into the minds of anorexics by allowing victims of the disease to tell their own stories. It is helpful not only for those suffering the disease, but for their loved ones as well.
• Feminist scholar Naomi Wolf takes on the destructive social control of women by the cosmetic, diet, and plastic surgery industries in The Beauty Myth: How Images of Beauty Are Used Against Women, published in 1990. Wolf argues that products marketed to women set unrealistic, impossible standards that the “average” woman cannot attain.
• Eavan Boland’s New Territory, published in 1967, was her first professionally published collection. It reflects her youthfulness as a poet, as well as her serious attention to form. The poems are an interesting contrast to those in In Her Own Image.

into baseless emotion. “Anorexic” does not lose total control, but some expressions are over-reaching in the attempt to make a feminist statement. Describing the phallus as “holy” and the female body as everything from a “witch” to a “bitch,” for example, is overly obvious sarcasm. In spite of a few lapses, however, Boland’s poem achieves its purpose by calling attention to the power of social pressure. Exaggerated or not, the pressure to be thin can result in anorexia nervosa, and the disorder is sometimes fatal. The speaker in the poem may be overwrought in her reasoning, but her battle is very realistic.

Source: Pamela Steed Hill, Critical Essay on “Anorexic,” in Poetry for Students, The Gale Group, 2001.

Joyce Hart

Hart, a former college professor, is currently a freelance writer and copyeditor. In this essay, she analyzes Boland’s poem “Anorexic” in terms of politics, language, and feminist literary theory, with an emphasis on the thoughts of French theorist Helene Cixous.

One of Eavan Boland’s most challenging themes, not only in her poetry, but also in her professional life, is that of formulating an authentic identity. By first looking at this challenge in all its aspects, it will be easier to understand the underlying theme in her poem “Anorexic.”

In her professional life, Boland has fought for over thirty years the “intensely chauvinistic Irish literary community,” as Michael Glover comments in Independent on Sunday. In an interview with Eileen Battersby in The Irish Times, Boland states that in Ireland “There seems to be no difficulty in being perceived as a woman poet. The trouble appears to lie in being fully accepted as an Irish poet.” The traditional Irish poet is male, and it is the male poets who criticize Boland “for her concentration on the domestic” in her poetry, says Battersby. Boland adds that she thinks “there was a hidden struggle over subject matter going on in Irish poetry which I blundered into. I was aware that it was easier to have a political murder as the subject of an Irish poem than a baby or a washing machine.”

“‘Challenge,’” says Battersby, “is a word which appears frequently in [Boland’s] conversation. . . . Few major contemporary Irish writers have been as dismissively treated.” Boland adds that “we have a powerful tradition here [in Ireland] of the male poet. Irish poetry was male and bardic in ethos. Historically the woman is the passive object of poetry. We aren’t supposed to write poems, we are supposed to be in them.” Battersby continues, “‘Who is the poet?’ and how is that identity constructed are the questions [Boland] seems to be addressing, and what are the issues poetry should explore. . . .she has been marginalised by poets and readers far more prepared to see the heroism in a stolen kiss than to acknowledge the pain which accompanies a mother’s realisation that her child no longer needs her.” Boland adds to this comment by saying that “so many men. . . sneer at the suburban life and yet it is the very life their wives and their daughters have led and are leading. And not to see through its circumstances to its vision and power and importance seems to be both wrong and illogical.”

Irish poetry, with its lack of female voices and female subject matter, shows wide gaps or silences in the woman’s exploration of identity. For Boland, says Brian Henry in his article “The Woman as Icon, the Woman as Poet,” poetry “becomes a way to usurp those silences, to bring back from an immersion in the collective unconscious, like Dante from his journey, the language that can liberate an oppressed community.” That oppressed community is the subject of Boland’s poem “Anorexic.” It is the community of women, in particular, Irish women, that Boland feels has no voice. Like women who suffer from anorexia, the Irish woman has a distorted image of herself, an image fed to her by male poets who depend on women “as motifs in their poetry,” as Boland claims. “The women in their poems were often passive, decorative, raised to emblematic status.” Women in traditional Irish poetry are seen only as ornaments. This image matches the psychological image that has been identified in women who suffer from anorexia— women who strive for perfection and are anxious to please. In Irish literature, Boland states, in an Irish Literary Supplement interview with Nancy Means Wright and Dennis J. Hannan, “transaction between the male and the female . . . is an active-passive one . . . this community nominates women as the receptors of other people’s creativity and not as the initiators of their own.” Women are told that their creative “gift is dangerous to [their] tradition of womanhood.” If Boland’s “creative gift” is substituted for food (for anorexics), Boland’s poem takes on a broader meaning.

As stated above by Brian Henry, Boland is searching for a new language, one that will rise from the collective unconscious (a term coined by Carl Jung, referring to a subconscious, mythical awareness by which all human thought processes are connected). This language will hopefully free women. But what is this language? How does one learn to use it? And how does it differ from the language that now exists?

To find a language in which women might liberate themselves, one must first define the language

“To find a language in which women might liberate themselves, one must first define the language that confines them.”

that confines them. Both of these tasks have been undertaken by French feminist Hélène Cixous. Coincidently, Cixous is also associated with having stressed the relationship between feminine writing and the female body, a relationship that fits very well into an analysis of Boland’s “Anorexic.”

“What theorists like Cixous . . . are trying to do,” says Julie Jasken in her “Introduction to Hélène Cixous,” is to “answer the questions that many of us may have personally struggled with.” This questioning, Jasken proposes, might find the reasons that women’s voices are conspicuously absent in the two thousand-year-long European literary tradition. Cixous, as Jasken presents her, is looking at women’s rhetoric to find out if there is a distinct way that women think, speak, and write that is inhibited by the accepted and currently practiced mode of communication.

Cixous has also coined the phrase l’écriture féminine which pertains to writing that is located in and authorized by female experience. In other words, Cixous believes that some kinds of writing are specifically gender or biologically determined. Male writing is basically rational and linear, whereas female writing comes more naturally from the subconscious level and flows in a more circular or sensual pattern. (She does not propose, however, that l’écriture féminine can be written only by women.) But to understand Cixous (and to analyze Boland’s poetry) first it is necessary to understand Cixous’s background. And to understand that, it will be necessary to say a little about Jacques Lacan.

Lacan was a French psychoanalyst who based a part of his psychoanalytical thoughts on the ideas articulated in linguistics. Briefly, Lacan believed that from birth to adulthood, humans go through three stages, including the Symbolic stage, in which language is formed. It is also in the Symbolic stage that humans develop a concept of “I” or “self.” Another important Lacanian concept is that becoming a speaker in the Symbolic stage requires humans to obey the laws and rules of language. According to Lacan, these rules are paternal. Lacan refers to them as the “Law-of-the-Father” or the “Phallus.” The Phallus is the idea of the Father, the patriarchal order, and the position that rules language.

Accepting Lacan’s concept that Phallus rules language, Cixous argues that, if this is true, it explains why women find it difficult (if not impossible) to express their feelings and their female sexuality and pleasure in this patriarchal language. In order for women to express themselves according to the rules of the Phallus language, women must do so as the other, that is, in the role of women as defined by men: passive and lacking (as in lacking a penis). The only other option open to women in a phallocentric language is to write as a man. The positive side of this Lacanian concept, states Cixous, is that because women are “lacking,” they are also less anchored to the phallocentric language and its laws of order and are thus more easily able to communicate in a more fluid or flowing language. This flowing language is found in poetry. Women are more in touch with the imagination and the unconscious, and poetry is the best vehicle to express their imagination. The phallocentric structure of language protects those who occupy the privileged position (the masculine position), and this is why Cixous encourages women to forego logical structure and write from their bodies. The body, for Cixous, is inscribed by everything, every experience of life. “Life becomes text starting out from my body. I am already text,” writes Cixous in her article “Coming to Writing.” If women write from their bodies, they will expose the logical structure of the phallocentric language. And when it is exposed, it will be seen for what it is—a structure, not the truth. States Cixous in “The Laugh of the Medus,” “Woman must write her self: must write about women and bring women to writing, from which they have been driven away as violently as from their bodies.”

In her article in Colby Quarterly, Jody Allen-Randolph writes that Boland’s “Anorexic” is a study of the relationship between “female identity and victimization.” The alienation from the female body that Boland presents in this poem is “a symptom of the violence directed toward female identity.” Allen-Randolph also states that “Anorexic” shows how a male-dominated culture and the definitions that culture imposes can “impinge tragically upon women, shaping their ideas of themselves and their relation to their bodies.” For instance, Boland begins the second line of her poem with, “My body is a witch. / I am burning it.” With these words, the speaker has already begun to remove herself from her body. She has objectified her body as if it is an entity that is separate from her definition of her self. She does not identify herself with “her curves and paps and wiles.” These are the outward signs of woman, the sexual definitions that have been imposed on her—her so-called hourglass figure, the sexuality of her breasts (paps refer to nipples), and her alluring ways of trapping men (this is what is implied by the word “wiles”).

In the third stanza, the speaker is totally alienated from her body. She not only has objectified her body, she now refers to herself as “she.” It is in this stanza that Boland writes about how women sacrifice their pleasures, using the words “fevers,” “milk and honey,” and “the taste of lunch.” Boland continues with this theme in the next stanza, as she writes, “I vomited / her hungers.” As someone who is anorexic, the woman in this poem is now empty. She is devoid not only of food and pleasure, she is also devoid of all passion. In all but vague terms, she no longer exists. “Now the bitch is burning.” In this stage of the decomposition of self, the speaker has not only removed herself from her body and identity, but she now finds that which she has removed herself from is repulsive. In the last line of the fifth stanza, the speaker takes on a somewhat phallocentric role as lawmaker and judge as she states: “She has learned her lesson.”

This masculine role is defined even more specifically when Boland begins the sixth stanza with the description of the woman who is “thin as a rib.” This is a definite phallic symbol that by the end of the stanza is “probing,” an action associated with a penis, as the speaker enters “a claustrophobia / a sensuous enclosure / how warm it was and wide.” The speaker has now almost completely transformed into the masculine. It is a claustrophobic transformation, but, at the same time, the transformation entices the female with its warmth, the music of the heartbeat, and the song of the masculine breath. She has slipped inside, but she is not quite a part of the masculine. She must still rid herself of the final essence of female by returning to the biblical story of Adam and Eve, returning to the mythical origin of the creation of human beings, returning back so far that she no longer exists except “caged so,” as Adam’s rib where she will grow “holy / past pain.” Only as man will she regain the grace that she lost when she was a woman, the first woman, who enticed man to eat the forbidden fruit.

In the last two stanzas, the speaker has completely denied herself an identity as a woman. Rather, she has diminished herself to the all-consuming role of keeping the man’s heart company so that she can “forget / in a small space / the fall.” Then, in the very last stanza, Boland introduces the words “python needs,” which could refer either to the snake in the Garden of Eden (the tempter), or to the phallic symbol of snake in general (man’s sexual needs). It could also be a reference to the mythical Greek god Apollo who slew Python, a large snakelike dragon. It is interesting to note that Apollo was the god of poetry as well as the god who made men aware of their guilt. It also could be that Boland refers to all three symbols and, by using Apollo, gives the last lines a deeper meaning, as man is made aware of his guilt in consuming woman, or worse pushing her into “the forked dark” where he heaves first to her “hips and breasts / and lips and heat” and then slowly descends, as if from heaven to hell, as the concepts move further away from a sexual act to sin, as he heaves to the “sweat and fat and greed.”

It is not that Boland commends this female act of self-debasement or annihilation. Rather, she is stating a fact and warning women to find their voice, their language, and their identity. She warns women to not give in to the temptation to withdraw into the phallocentric world where they will lose themselves.

Source: Joyce Hart, Critical Essay on “Anorexic,” in Poetry for Students, The Gale Group, 2001.

Sources

Allen-Randolph, Jody, “Ecriture Feminine and the Authorship of Self in Eavan Boland’s In Her Own Image,” in Colby Quarterly, Vol. 27, No. 1, March 1991, pp. 48–59.

Amazon, www.amazon.com, (June 2000).

Anorexia Nervosa, http://wellweb.com/INDEX/QANOREX.HTM (August 16, 2000).

Boland, Eavan, Collected Poems, Carcanet Press. “CAIN Project: Bloody Sunday,” http://cain.ulst.ac.uk/events/bsunday/bs.htm (October 27, 2000).

Cannavan, Jan, “Women’s Struggle Liberates Ireland / Ireland’s Struggle Liberates Women: Feminism and Irish Republicanism,” http://www.etext.org/Politics/INAC/irish. women (August 8, 2000).

Haberstroh, Patricia Boyle, “Eavan Boland,” in Women Creating Women: Contemporary Irish Women Poets, Syracuse University Press, pp. 59–90.

Henry, Brian, “The Woman as Icon, the Woman as Poet,” in Michigan Quarterly, Vol. XXXVI, No. 1, Winter 1997, pp. 188–202.

The History Channel, www.historychannel.com (August 10, 2000).

Irigaray/Cixious, http://social.chass.ncsu.edu/wyrick/debclass/irigar.htm (August 2000).

WM’s Story, http://www.angelfire.com/wy/anorexia/WMStory.html (August 16, 2000).

For Further Study

Boland, Eavan, Object Lessons, W. W. Norton, 1996.

Dedicated to her mother, whom she calls “the friend of my lifetime,” this is a prose work by Boland that includes autobiographical details as well as her thoughts on women poets in general and women poets in Ireland in particular.

Boland, Eavan, Outside History: Selected Poems, 1980–1990, W. W. Norton, 1991.

This collection provides a good look at Boland’s writing in the ten years following In Her Own Image. It is interesting to note the subtle changes in her style and subject matter and to understand how these changes helped her gain greater recognition as a poet.

Hoagland, Kathleen, ed., 1000 Years of Irish Poetry: The Gaelic and Anglo-Irish Poets from Pagan Times to the Present, Welcome Rain, 1999.

Over 800 pages long, this book is not likely to be read cover to cover, but the comprehensive collection of Irish poetry provides an excellent overview of works from that country.

MacLiammóir, Micheál, and Eavan Boland, W. B. Yeats and His World, Viking Press, 1972.

W. B. Yeats is generally considered to be the most important English-writing poet of his time (late nineteenth to early twentieth centuries), and his work had a great impact on Eavan Boland’s early poetry. This is an illustrated biography and an interesting look at Yeats from an Irish perspective.

Anorexia

As defined by the American Psychiatric Association's Diagnostic and Statistical Manual, fourth edition (DSM-IV;1994), anorexia nervosa is an eating disorder marked by four major symptoms. First, the patient must be less than 85 percent of ideal weight for age, height, and gender. Second, there must be a morbid fear of fat. Third, the person must believe himself or herself to be normal weight or even fat despite emaciation. Finally, the victim should be amenorrheic (i.e., have no menstrual periods) or, in the case of men, show abnormally low levels of testosterone. Anorexia nervosa is considerably more common in women than in men with 80 to 90 percent of the cases diagnosed in adolescence or adulthood being females. The gender difference is somewhat less pronounced in childhood cases, with girls being approximately five times more likely than boys to suffer from the disorder. Less than 1 percent of the postpubertal female population suffers from anorexia nervosa. It is more common among white than African-American girls and women.

Anorexia nervosa has two ages of peak onset: around age fourteen, and at about age eighteen. The frequency of adolescent onset has led theorists to suggest that the developmental transitions to adolescence and to adulthood present special risks for girls, making them more vulnerable than boys are not only to anorexia nervosa but also bulimia nervosa and depression. The combination of age and gender factors has also led theorists to suggest that cultural variables, such as the thin body ideal for females and the relative lack of power among women, contributes to the disorder. Finally, it is clear that anorexia nervosa typically starts in a pattern of either dieting or excessive exercise which itself is probably rooted in an attempt to achieve a particular body shape.

There are at least two paths that lead to the modern definition of anorexia nervosa. The first is self-starvation. The second is a history of defining adolescence and young adulthood as problematic for women. These historical trends meet in the eighteenth century to define anorexia nervosa.

Self-Starvation

Walter Vandereycken and Ron van Deth (1994) suggest that self-starvation is a pervasive phenomenon in human history. Given the cross-cultural and cross-historical presence of self-starvation, it is not surprising that it has many motivations. Perhaps the best-known motives are political and religious. For example, Mahatma Gandhi's lengthy hunger strikes in defiance of British domination of India in the 1930s are well known. Less dramatically, fasting is required of Roman Catholics on certain holy days during Lent and even today, devout Muslims participate in a month-long fast during Ramadan.

The link between religion and self-starvation has received the most attention from students of anorexia nervosa. The link between self-denial, including of food, and spirituality, dates at least as far back as the Egyptian pharaohs. During the fourth and fifth centuries c.e., men went into the Egyptian and Palestinian deserts to dedicate themselves to the worship of Jesus Christ. Self-starvation was part of this dedication. As religious practice was largely limited to men at this time, most of those engaging in religious selfstarvation were men.

Of greater interest in terms of anorexia nervosa is the medieval practice of self-starvation by women, including some young women, in the name of religious piety and purity. By the twelfth century, it was increasingly common for women to participate in religious life and to even be named as saints by the Catholic Church. Many women who ultimatimately became saints engaged in self-starvation, including St. Hedwig of Silesia in the thirteenth century and Catherine of Siena in the fourteenth century. By the time of Catherine of Siena, however, the Church became concerned about extreme fasting as an indicator of spirituality and a path to sainthood. Indeed, Catherine of Siena was told to pray that she would be able to eat again, but was unable to give up fasting.

While there is a long-standing link between self-starvation and piety, there is also a historical relationship between self-starvation and demonic possession or witchcraft. For example, Catherine of Siena ate something everyday so that she would not be labeled a witch. After the middle ages, numerous "fasting saints" were accused of witchcraft under the Inquisition. In some places, women could prove they were not witches if they weighed a sufficient amount on government-designated scales. Again, the relationship between self-starvation and religion was particularly pronounced for women.

The virtually simultaneous designation of self-starvation by women as pious and demonic raises interesting issues concerning the cultural meaning of women's bodies, issues that are still debated in terms of anorexia nervosa. In the calculus of the early twenty-first century, the ideal body type for women is thin. "Supermodels," actresses, and even singers are typically substantially below the weight of the average American woman. Research indicates that this image is so pervasive that even elementary school-age children are aware of it. Studies routinely find that 40 percent of girls in fourth and fifth grade wish they were thinner or worry about getting fat. Yet, if girls take this message too much to heart, dieting severely and actually becoming as thin as the models, they are considered "mentally ill."

Early Adolescent Girls and Illness

Anorexia nervosa is not the first disorder in history marked by unusual eating and amenorrhea that is found predominantly in adolescent or young adult women. According to Brett Silverstein and Deborah Perlick (1995), a paper by Hippocrates, known as On the Disease of Young Women, describes an anorexia nervosa-like disorder. This treatise suggests that the dramatic weight loss is caused by problematic menstrual cycles and recommends marriage and pregnancy as the best treatment.

Similarly, hysteria, a disorder made famous in Sigmund Freud's Anna O. case but that was also diagnosed earlier in the nineteenth century, was marked by loss of appetite, depression, and amenorrhea. Neurasthenia was another late nineteenth century "female disorder" involving disordered eating and amenorrhea.

Probably the best known of these disorders of adolescent girls is chlorosis. Chlorosis was made famous by Joan Jacob Brumberg's book Fasting Girls. Brumberg argues that chlorosis, like anorexia nervosa, was a disease of middle-class American girls who were fulfilling the expectations of their culture in an extreme manner. In both the nineteenth and twentieth centuries, such girls developed exaggerated behaviors concerning food. Chlorosis was a form of anemia, found only in girls, that was linked to both the onset of menstruation and physical attractiveness. Oddly, these ill girls were considered particularly attractive, just as the most "beautiful" women in the United States of the early twenty-first century have an anorexic appearance. Chlorotic girls, like those with anorexia nervosa, were likely trying to exercise some control over their own lives and, like anorexic girls, were considered to be suffering from a "nervous" or "psychological" disorder rather than from a primarily physical illness.

By the early twentieth century, chlorosis was no longer being diagnosed in the United States. While it is possible that improved nutrition led to the decline of this form of anemia, it is more likely that culture changes affected the expression of eating-related pathology among adolescent girls. The belief that women were fragile and physically weak generally declined as opportunities for women in jobs, education, and even politics increased. However these changes were not quickly or universally accepted, setting up a clash between images of the "traditional" and the "modern" young woman. Young girls received and internalized these conflicting messages about womanhood and may have sometimes felt unable to control their own destinies or to even know want they wanted to do. One thing they could control, however, was their own eating. This culture-based model resonates with current explanations of the causes of anorexia nervosa.

Anorexia Nervosa

Neither the "fasting saints" nor the "chlorotic girls" were anorexic in the sense that the term is used today. Their self-starvation and "nervous" illness reflected beliefs and women's roles during their historic periods. Although Richard Morton described a case of tuberculosis that resembled anorexia nervosa in 1694, current definitions of the disorder are routinely traced to the work of Sir William Withey Gull and Dr. R. Lasègue, in 1874 and 1873 respectively.

Both Lasègue and Gull describe cases marked by self-starvation and high levels of activity or restlessness. Both note that the problem is particularly pronounced in young women; indeed, Gull suggests that adolescent and young adult women are unusually susceptible to mental illness. Lasègue notes that these young women are pleased with their food restriction, do not wish to eat more, and do not believe that they are abnormally thin. Lasègue referred to this condition as hysterical anorexia while Gull used the term anorexia nervosa.

Although Gull and Lasègue considered anorexia to be a "nervous" disorder, both treated it medically. Gull in particular seemed to have remarkable success, at least by today's standards, in gradually re-feeding the girls. He reported that his clients recovered their eating habits, weight, and health. Lasègue had more pessimistic reports, noting that patients often went many years without recovering.

It is important to recognize that neither Gull nor Lasègue considered anything resembling a "drive for thinness" as key in the etiology of anorexia nervosa. This focus is a product of the twentieth century, probably instigated by the work of Hilde Bruch. Some practitioners are now questioning the wisdom of the twentieth and twenty-first century emphasis on the role of drive for thinness in anorexia nervosa. They note that in some Asian cultures, particularly Hong Kong and China, drive for thinness does not seem to be part of what otherwise looks like anorexia nervosa. Others note that Gull's success in using medically based treatments ought to encourage us to re-examine the efficacy of such an approach.

Historians have raised a number of issues concerning the emergence of modern anorexia nervosa, which was a trans-Atlantic phenomenon involving both the United States and Western Europe from the mid-nineteenth century onward. The basic issues involve sorting out the "real" disease from its specific historical cause–why the disease emerged when it did– and the fact that it appears so disproportionately in females. The first outcroppings of the modern disease occurred before thinness was widely fashionable, which has prompted consideration of the dynamic of loving, middle-class families in which some young women chose food refusal as a method of rebellion that could not be explicitly articulated. Obviously, the rise of concern for slenderness from about 1900 onward as a fashion standard particularly bearing on women, helped sustain the disease. But the incidence of anorexia was not constant through the twentieth century in the Western world, raising questions about causation and about fluctuations in medical attention. By the 1970s, societal and parental concern about anorexia was widespread, sometimes working against efforts to limit children's food intake in a period when the incidence of childhood obesity was rising more rapidly than anorexia nervosa.

In its current form, anorexia nervosa dates from the midnineteenth century. Yet, it grows out of a long history of self-starvation and female-specific pathologies. As such, it likely is a disorder that can tell us much about the role of young women in today's society and why they opt to wage war against their own bodies.

See also: Gendering; Girlhood.

bibliography

Andersen, Arnold E. 1985. Practical Comprehensive Treatment of Anorexia Nervosa and Bulimia. Baltimore, MD: The Johns Hopkins University Press.

Brumberg, Joan Jacobs. 1982. "Chlorotic Girls, 1870-1910: An Historical Perspective on Female Adolescence." Child Development 53: 1468-1474.

Brumberg, Joan Jacobs. 1988. Fasting Girls: The Emergence of Anorexia Nervosa. Cambridge, MA: Harvard University Press.

Silverstein, Brett and Deborah Perlick. 1995. The Cost of Competence: Why Inequality Causes Depression, Eating Disorders, and Illness in Women. New York: Oxford University Press.

Vandereycken, Walter and Ron van Deth. 1994. From Fasting Saints to Anorexic Girls: The History of Self-starvation. New York: New York University Press.

Linda Smolak

Anorexia nervosa

Definition

Anorexia nervosa is an eating disorder characterized by self-starvation, unrealistic fear of weight gain, and conspicuous distortion of body image.

Description

The term anorexia nervosa comes from two Latin words that mean "nervous inability to eat." Anorexics have the following characteristics in common:

• inability to maintain weight at or above what is normally expected for age or height
• intense fear of becoming fat
• distorted body image
• in females who have begun to menstruate, the absence of at least three menstrual periods in a row, a condition called amenorrhea

There are two subtypes of anorexia nervosa: a restricting type, characterized by strict dieting and exercise without binge eating; and a binge-eating/purging type, marked by episodes of compulsive eating with or without self-induced vomiting and/or the use of laxatives or enemas. A binge is defined as a time-limited (usually under two hours) episode of compulsive eating in which the individual consumes a significantly larger amount of food than most people would eat in similar circumstances.

Demographics

Anorexia nervosa was not officially classified as a psychiatric disorder until the third edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. It is, however, a growing problem in the early 2000s among adolescent females. Its incidence in the United States has doubled since 1970. The rise in the number of reported cases reflects a genuine increase in the number of persons affected by the disorder and not simply earlier or more accurate diagnosis. Estimates of the incidence of anorexia range between 0.5 percent and 1 percent of Caucasian female adolescents. Over 90 percent of patients diagnosed with the disorder as of 2001 are female. The peak age range for onset of the disorder is 14 to 18 years. In the 1970s and 1980s, anorexia was regarded as a disorder of upper- and middle-class women, but that generalization is as of 2004 also changing. Studies indicate that anorexia is increasingly common among females of all races and social classes in the United States.

Causes and symptoms

While the precise cause of the disease is not known, anorexia is a disorder that results from the interaction of cultural and interpersonal as well as biological factors.

Social influences

The rising incidence of anorexia is thought to reflect the present idealization of thinness as a badge of upper-class status as well as of female beauty. In addition, the increase in cases of anorexia includes "copycat" behavior, with some patients developing the disorder from imitating other girls.

The onset of anorexia in adolescence is attributed to a developmental crisis caused by girls' changing bodies coupled with society's overemphasis on female appearance. The increasing influence of the mass media in spreading and reinforcing gender stereotypes has also been noted.

Occupational goals

The risk of developing anorexia is higher among adolescents preparing for careers that require attention to weight and/or appearance. These high-risk groups include dancers, fashion models, professional athletes (including gymnasts, skaters, long-distance runners, and jockeys), and actresses.

Genetic and biological influences

Girls whose biological mothers or sisters have or have had anorexia nervosa appear to be at increased risk of developing the disorder.

Psychological factors

A number of theories have been advanced to explain the psychological aspects of the disorder. No single explanation covers all cases. Anorexia nervosa has been given the following interpretations:

• Overemphasis on control, autonomy, and independence: Some anorexics come from achievement-oriented families that stress physical fitness and dieting. Many anorexics are perfectionists who are driven about schoolwork and other matters in addition to weight control.
• Evidence of family dysfunction: In some families, a daughter's eating disorder serves as a distraction from marital discord or other family tensions.
• A rejection of female sexual maturity: This rejection is variously interpreted as a desire to remain a child or as a desire to resemble males.
• A reaction to sexual abuse or assault.
• A desire to appear as fragile and nonthreatening as possible: This hypothesis reflects the idea that female passivity and weakness are attractive to males.
• Inability to interpret the body's hunger signals accurately due to early experiences of inappropriate feeding.

Male anorexics

Although anorexia nervosa largely affects females, its incidence in the male population is rising in the early 2000s. Less is known about the causes of anorexia in males, but some risk factors are the same as for females. These include certain occupational goals and increasing media emphasis on external appearance in men. Homosexual males are under pressure to conform to an ideal body weight that is about 20 pounds lighter than the standard attractive weight for heterosexual males.

When to call the doctor

A healthcare professional should be contacted if a child or adolescent is suspected of having anorexia nervosa or displays early signs of the disorder, such as the following:

• fear of gaining weight
• distorted body image
• recent weight loss
• restrictive or abnormal eating patterns such as skipping meals or eliminating once-liked foods
• preoccupation with food and dieting
• compulsive exercising
• purging behaviors such as vomiting or using laxatives
• withdrawal from friends and family
• wearing baggy clothes to hide weight loss

Diagnosis

Diagnosis of anorexia nervosa is complicated by a number of factors. One is that the disorder varies somewhat in severity from patient to patient. A second factor is denial, which is regarded as an early sign of the disorder. Many anorexics deny that they are ill and are usually brought to treatment by a family member.

Anorexia nervosa is a serious public health problem not only because of its rising incidence, but also because it has one of the highest mortality rates of any psychiatric disorder. Moreover, the disorder may cause serious long-term health complications, including congestive heart failure, sudden death, growth retardation, dental problems, constipation , stomach rupture, swelling of the salivary glands, anemia and other abnormalities of the blood, loss of kidney function, and osteoporosis.

Most anorexics are diagnosed by pediatricians or family practitioners. Anorexics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea in female patients, and sometimes of abdominal pain , constipation, or lack of energy. The patient may feel chilly or have developed lanugo, a growth of downy body hair. If the patient has been self-inducing vomiting, she may have eroded tooth enamel or Russell's sign (scars on the back of the hand). The second step in diagnosis is measurement of the patient's weight loss. DSM-IV specifies a weight loss leading to a body weight 15 percent below normal, with some allowance for body build and weight history.

The doctor will need to rule out other physical conditions that can cause weight loss or vomiting after eating, including metabolic disorders, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome. Persons with this condition sometimes vomit after meals because the blood supply to the intestine is blocked. The doctor will usually order blood tests, an electrocardiogram, urinalysis, and bone densitometry (bone density test) in order to exclude other diseases and to assess the patient's nutritional status.

The doctor will also need to distinguish between anorexia and other psychiatric disorders, including depression, schizophrenia , social phobia, obsessive-compulsive disorder , and body dysmorphic disorder. Two diagnostic tests that are often used are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).

Treatment

Treatment of anorexia nervosa includes both short- and long-term measures and requires assessment by dietitians and psychiatrists as well as medical specialists. Therapy is often complicated by the patient's resistance or failure to carry out a treatment plan.

Hospital treatment

Hospitalization is recommended for anorexics with any of the following characteristics:

• weight of 40 percent or more below normal or weight loss over a three-month period of more than 30 lbs (13.6 kg)
• severely disturbed metabolism
• severe binging and purging
• signs of psychosis
• severe depression or risk of suicide
• family in crisis

Hospital treatment includes individual and group therapy as well as refeeding and monitoring of the patient's physical condition. Treatment usually requires two to four months in the hospital. In extreme cases, hospitalized patients may be force-fed through a tube inserted in the nose (nasogastric tube) or into a vein (hyperalimentation).

Outpatient treatment

Anorexics who are not severely malnourished can be treated by outpatient psychotherapy. The types of treatment recommended are supportive rather than insight-oriented and include behavioral approaches as well as individual or group therapy. Family therapy is often recommended when the patient's eating disorder is closely tied to family dysfunction. Self-help groups are often useful in helping anorexics find social support and encouragement. Psychotherapy with anorexics is a slow and difficult process; about 50 percent of patients continue to have serious psychiatric problems after their weight has stabilized.

Medications

Anorexics have been treated with a variety of medications, including antidepressants , antianxiety drugs, selective serotonin reuptake inhibitors, and lithium carbonate. The effectiveness of medications in treatment regimens is as of 2004 debated. However, at least one study of fluoxetine (Prozac) showed it helped the patient maintain weight gained while in the hospital.

Nutritional concerns

A key focus of treatment for anorexia nervosa is teaching the principles of healthy eating and improving disordered eating behaviors. A dietician or nutritionist plays an important role in forming a nutrition plan for the patient; such plans are individualized and ensure that the patient is consuming enough food to gain or maintain weight as needed and stabilize medically. The anorexic's weight and food intake are closely monitored to ensure that the plan is being followed.

Prognosis

Figures for long-term recovery vary from study to study, but reliable estimates are that 40 to 60 percent of anorexics make a good physical and social recovery, and 75 percent gain weight. The long-term mortality rate for anorexia is estimated at around 10 percent, although some studies give a lower figure of 3 to 4 percent. The most frequent causes of death associated with anorexia are starvation, electrolyte imbalance, heart failure, and suicide.

Prevention

Short of major long-term changes in the larger society, the best strategy for prevention of anorexia is the cultivation of healthy attitudes toward food, weight control, and beauty (or body image) within families. Early treatment such as counseling may help to prevent early signs of disordered eating from progressing into more serious behaviors.

Parental concerns

There are many strategies that parents can undertake to help encourage healthy attitudes toward weight, food, and exercise in their children. These include the following:

• teaching children the importance of healthy eating and exercise
• avoiding using food as a punishment or reward
• instilling healthy eating and exercise habits by example
• being a good role model by promoting healthy body image and encouraging children and adolescents to find role models in the media who do the same
• encouraging children or teens who wish to diet to talk to a healthcare professional about healthy strategies to lose weight

KEY TERMS

Amenorrhea —The absence or abnormal stoppage of menstrual periods.

Binge —A pattern of eating marked by episodes of rapid consumption of large amounts of food; usually food that is high in calories.

Body dysmorphic disorder —A psychiatric disorder marked by preoccupation with an imagined physical defect.

Hyperalimentation —A method of refeeding anorexics by infusing liquid nutrients and electrolytes directly into central veins through a catheter.

Lanugo —A soft, downy body hair that covers a normal fetus beginning in the fifth month and usually shed by the ninth month. Also refers to the fine, soft hair that develops on the chest and arms of anorexic women. Also called vellus hair.

Purging —The use of vomiting, diuretics, or laxatives to clear the stomach and intestines after a binge.

Russell's sign —A scraped or raw area on the patient's knuckles, caused by self-induced vomiting.

Superior mesenteric artery syndrome —A condition in which a person vomits after meals due to blockage of the blood supply to the intestine.

See also Binge eating disorder; Bulimia nervosa.

Resources

BOOKS

"Anorexia Nervosa." In The Merck Manual of Diagnosis and Therapy, 17th ed. Edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck & Co. Inc., 2004.

Knowles, Jarol B. "Eating Disorders." In Textbook of Primary Care Medicine, 3rd ed. Edited by John Noble. St. Louis: Mosby Inc., 2001.

Litt, Iris F. "Anorexia Nervosa and Bulimia." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman, Robert M. Kliegman, and Hal B. Jenson. Philadelphia: Saunders, 2004.

Smith, Delia. "The Eating Disorders." In Cecil Textbook of Medicine, 21st ed. Edited by Lee Goldman and J. Claude Bennett. Philadelphia: Saunders, 2000.

PERIODICALS

American Academy of Pediatrics Committee on Adolescence. "Identifying and Treating Eating Disorders." Pediatrics 111, no. 1 (January 1, 2003): 204–11.

Pritts, Sarah D., and Jeffrey Susman. "Diagnosis of Eating Disorders in Primary Care." American Family Physician 67, no. 2 (January 15, 2003): 297–304.

Rome, E. S. "Eating Disorders." Obstetrics and Gynecology Clinics of North America 30, no. 2 (June 1, 2003): 353–77.

Rosen, David S. "Eating Disorders in Children and Young Adolescents: Etiology, Classification, Clinical Features, and Treatment." Adolescent Medicine 14, no. 1 (February 1, 2003): 49–59.

——. "Eating Disorders in Adolescent Males." Adolescent Medicine 14, no. 3 (October 1, 2003): 677–89.

Sigman, Gary S. "Eating Disorders in Children and Adolescents." Pediatric Clinics of North America 50, no. 5 (October 2003): 1139–77.

ORGANIZATIONS

American Anorexia/Bulimia Association. 418 East 76th St., New York, NY 10021. Telephone: 212/734–1114.

National Association of Anorexia Nervosa and Associated Disorders. Web site: <www.anad.org>.

National Institute of Mental Health Eating Disorders Program. Building 10, Room 3S231. 9000 Rockville Pike, Bethesda, MD 20892. Telephone: 301/496–1891.

Rebecca J. Frey, PhD Stephanie Dionne Sherk

Anorexia nervosa

Definition

Anorexia nervosa is an eating disorder characterized by unrealistic fear of weight gain, self-starvation, and conspicuous distortion of body image. The name comes from two Latin words that mean "nervous inability to eat." In females who have begun to menstruate, anorexia nervosa is usually marked by amenorrhea, or skipping at least three menstrual periods in a row. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV (1994), defines two subtypes of anorexia nervosa—a restricting type, characterized by strict dieting and exercise without binge eating—and a binge-eating/purging type, marked by episodes of compulsive eating with or without self-induced vomiting and the use of laxatives or enemas. DSM-IV defines a binge as a time-limited (usually under two hours) episode of compulsive eating in which the individual consumes a significantly larger amount of food than most people would eat in similar circumstances.

Description

Anorexia nervosa was not officially classified as a psychiatric disorder until the third edition of DSM in 1980. It is, however, a growing problem among adolescent females and its incidence in the United States has doubled since 1970. The rise in the number of reported cases reflects a genuine increase in the number of persons affected by the disorder, not simply earlier or more accurate diagnosis. Estimates of the incidence of anorexia range between 0.5-1% of Caucasian female adolescents. Over 90% of patients diagnosed with the disorder as of 1998 were female. It was originally thought that only 5% of anorexics are male, but that estimate is being revised upward. The peak age range for onset of the disorder is 14-18 years, although there are patients who develop anorexia as late as their 40s. In the 1970s and 1980s, anorexia was regarded as a disorder of upper- and middle-class women, but that generalization is also changing. More recent studies indicate that anorexia is increasingly common among women of all races and social classes in the United States.

Anorexia nervosa is a serious public health problem not only because of its rising incidence, but also because it has one of the highest mortality rates of any psychiatric disorder. Moreover, the disorder may cause serious long-term health complications, including congestive heart failure, sudden death, growth retardation, dental problems, constipation , stomach rupture, swelling of the salivary glands, loss of kidney function, osteoporosis, anemia and other abnormalities of the blood.

Causes & symptoms

Anorexia is a disorder that results from the interaction of cultural and interpersonal as well as biological factors. While the precise cause of the disease is not known, it has been linked to the following:

Social influences

The rising incidence of anorexia is thought to reflect the present idealization of thinness as a badge of upper-class status as well as of female beauty. In addition, the increase in cases of anorexia includes "copycat" behavior, with some patients developing the disorder from imitating other girls.

The onset of anorexia in adolescence is attributed to a developmental crisis caused by girls' changing bodies coupled with society's overemphasis on women's looks. The increasing influence of the mass media in spreading and reinforcing gender stereotypes has also been noted.

Occupational goals

The risk of developing anorexia is higher among adolescents preparing for careers that require attention to weight and/or appearance. These high-risk groups include dancers, fashion models, professional athletes (including gymnasts, skaters, long-distance runners, and jockeys), and actresses.

Genetic and biological influences

Women whose biological mothers or sisters have the disorder appear to be at increased risk.

Psychological factors

A number of theories have been advanced to explain the psychological aspects of the disorder. No single explanation

covers all cases. Anorexia nervosa has been interpreted as:

• A rejection of female sexual maturity. This rejection is variously interpreted as a desire to remain a child, or as a desire to resemble men as closely as possible.
• A reaction to sexual abuse or assault.
• A desire to appear as fragile and non-threatening as possible. This hypothesis reflects the idea that female passivity and weakness are attractive to men.
• Overemphasis on control, autonomy, and independence. Some anorexics come from achievement-oriented families that stress physical fitness and dieting. Many anorexics are perfectionists and "driven" about schoolwork and other matters in addition to weight control.
• Evidence of family dysfunction. In some families, a daughter's eating disorder serves as a distraction from marital discord or other family tensions.
• Inability to interpret the body's hunger signals accurately due to early experiences of inappropriate feeding.

Male anorexics

Although anorexia nervosa is still considered a disorder that largely affects women, its incidence in the male population is rising. Less is known about the causes of anorexia in males, but some risk factors are the same as for females. These include certain occupational goals and increasing media emphasis on external appearance in men. Moreover, homosexual males are under pressure to conform to an ideal body weight that is about 20 pounds lighter than the standard "attractive" weight for heterosexual males.

Diagnosis

Diagnosis of anorexia nervosa is complicated by a number of factors. One is that the disorder varies somewhat in severity from patient to patient. A second factor is denial, which is regarded as an early sign of the disorder. Most anorexics deny that they are ill and are usually brought to treatment by a family member.

Anorexia is usually diagnosed by pediatricians or family practitioners. Anorexics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea (failure to menstruate) in females, and sometimes of abdominal pain , constipation, or lack of energy. The patient may feel chilly or have developed lanugo, a growth of downy body hair. If the patient has been vomiting, she may have eroded tooth enamel or Russell's sign (scars on the back of the hand). The second step in diagnosis is measurement of the patient's weight loss. DSM-IV specifies a weight loss leading to a body weight 15% below normal, with some allowance for body build and weight history.

The doctor will rule out other physical conditions that can cause weight loss or vomiting after eating, including metabolic disorders, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome. Persons with this condition sometimes vomit after meals because the blood supply to the intestine is blocked. The doctor will usually order blood tests, an electrocardiogram, urinalysis, and bone densitometry (bone density test) in order to exclude other diseases and to assess the patient's nutritional status.

The doctor will also need to distinguish between anorexia and other psychiatric disorders, including depression, schizophrenia , social phobia, obsessive-compulsive disorder , and body dysmorphic disorder. Two diagnostic tests that are often used are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).

Treatment

Alternative treatments should serve as complementary to a conventional treatment program. Alternative therapies for anorexia nervosa include diet and nutrition , herbal therapy, hydrotherapy, aromatherapy , Ayurveda, and mind/body medicine .

Nutritional therapy

A naturopath or nutritionist may recommend the following:

• avoiding sweets or baked goods
• following a nutritious and well-balanced diet (when patients resume eating normally)
• gaily multivitamin and mineral supplements
• zinc supplements. (Zinc is an important mineral needed by the body for normal hormonal activity and enzymatic function)

Herbal therapy

The following herbs may help reduce anxiety and depression which are often associated with this disorder:

• chamomile (Matricaria recutita )
• lemon balm (Melissa officinalis )
• linden (Tilia spp.) flowers

Aromatherapy

Essential oils of herbs such as bergamot, basil, chamomile, clary sage and lavender may help stimulate appetite, relax the body and fight depression. They can be diffused into the air, inhaled, massaged or put in bath water .

Relaxation techniques

Relaxation techniques such as yoga, meditation and t'ai chi can relax the body and release stress, anxiety and depression.

Hypnotherapy

Hypnotherapy may help resolve unconscious issues that contribute to anorexic behavior.

Other alternative treatments

Other alternative treatments that may be helpful include hydrotherapy, magnetic field therapy, acupuncture, biofeedback , Ayurveda and Chinese herbal medicine.

Allopathic treatment

Treatment of anorexia nervosa includes both short-term and long-term measures, and requires assessment by dietitians and psychiatrists as well as medical specialists. Therapy is often complicated by the patient's resistance or failure to carry out treatment plan.

Hospital treatment

Hospitalization is recommended for anorexics with any of the following characteristics:

• weight of 40% or more below normal, or weight loss over a three-month period of more than 30 pounds
• severely disturbed metabolism
• severe binging and purging
• signs of psychosis
• severe depression or risk of suicide
• family in crisis

Hospital treatment includes individual and group therapy as well as refeeding and monitoring of the patient's physical condition. Treatment usually requires two to four months in the hospital. In extreme cases, hospitalized patients may be force-fed through a tube inserted in the nose (nasogastric tube) or by over-feeding (hyperalimentation techniques).

Outpatient treatment

Anorexics who are not severely malnourished can be treated by outpatient psychotherapy . The types of treatment recommended are supportive rather than insight-oriented, and include behavioral approaches as well as individual or group therapy. Family therapy is often recommended when the patient's eating disorder is closely tied to family dysfunction. Self-help groups are often useful in helping anorexics find social support and encouragement. Psychotherapy with anorexics is a slow and difficult process; about 50% of patients continue to have serious psychiatric problems after their weight has stabilized.

Medications

Anorexics have been treated with a variety of medications, including antidepressants, anti-anxiety drugs, selective serotonin reuptake inhibitors, and lithium carbonate. The effectiveness of medications in treatment regimens is still debated. However, at least one study of Prozac showed it helped the patient maintain weight gained while in the hospital.

Expected results

Figures for long-term recovery vary from study to study, but the most reliable estimates are that 40-60% of anorexics will make a good physical and social recovery, and 75% will gain weight. The long-term mortality rate for anorexia is estimated at around 10%, although some studies give a lower figure of 3-4%. The most frequent causes of death associated with anorexia are starvation, electrolyte imbalance, heart failure, and suicide.

Prevention

Short of major long-term changes in the larger society, the best strategy for prevention of anorexia is the cultivation of healthy attitudes toward food, weight control, and beauty (or body image) within families.

Resources

BOOKS

"Anorexia Nervosa." In Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: The American Psychiatric Association, 1994.

Baron, Robert B. "Nutrition." In Current Medical Diagnosis & Treatment edited by Lawrence M. Tierney, Jr., et al. Stamford, CT: Appleton & Lange, 1998.

The Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Fife, WA: Future Medicine Publishing, 1995.

Cassell, Dana K., with Felix E. F. Larocca. The Encyclopedia of Obesity and Eating Disorders. New York: Facts on File, Inc., 1994.

Herzog, David B. "Eating Disorders." In The New Harvard Guide to Psychiatry. Edited by Armand M. Nicholi, Jr., Cambridge, MA, and London, UK: The Belknap Press of Harvard University Press, 1988.

Kaplan, David W., and Kathleen A. Mammel. "Adolescence." In Current Pediatric Diagnosis & Treatment. Edited by William W. Hay, Jr., et al. Stamford, CT: Appleton & Lange, 1997.

Mitchell, James E. "Anorexia Nervosa: Medical and Physiological Aspects." In Handbook of Eating Disorders. Edited by Kelly D. Brownell and John P. Foreyt. New York: Basic Books, Inc., 1986.

The Medical Advisor: The Complete Guide to Alternative & Conventional Treatments. Richmond, VA: Time Life Education, 1997.

"Physical Conditions in Adolescence: Anorexia Nervosa." In The Merck Manual of Diagnosis and Therapy, vol. II. Edited by Robert Berkow, et al. Rahway, NJ: Merck Research Laboratories, 1992.

Pipher, Mary. Reviving Ophelia: Saving the Selves of Adolescent Girls. New York: Ballantine Books, 1994.

ORGANIZATIONS

American Anorexia/Bulimia Association. 418 East 76th St., New York, NY 10021. (212) 734-1114.

National Institute of Mental Health Eating Disorders Program, Building 10, Room 3S231. 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-1891.

OTHER

Eating Disorders Home Page. <http://ccwf.cc.utexas.edu:80/jackson/UTHealth/eating.html.>

Mai Tran

Anorexia Nervosa

Definition

Anorexia nervosa is an eating disorder characterized by unrealistic fear of weight gain, self-starvation, and conspicuous distortion of body image. The name comes from two Latin words that mean nervous inability to eat. In females who have begun to menstruate, anorexia nervosa is usually marked by amenorrhea, or skipping at least three menstrual periods in a row. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV (1994), defines two subtypes of anorexia nervosa-a restricting type, characterized by strict dieting and exercise without binge eating; and a binge-eating/purging type, marked by episodes of compulsive eating with or without self-induced vomiting and the use of laxatives or enemas. DSM-IV defines a binge as a time-limited (usually under two hours) episode of compulsive eating in which the individual consumes a significantly larger amount of food than most people would eat in similar circumstances.

Description

Anorexia nervosa was not officially classified as a psychiatric disorder until the third edition of DSM in 1980. It is, however, a growing problem among adolescent females. Its incidence in the United States has doubled since 1970. The rise in the number of reported cases reflects a genuine increase in the number of persons affected by the disorder, and not simply earlier or more accurate diagnosis. Estimates of the incidence of anorexia range between 0.5-1% of caucasian female adolescents. Over 90% of patients diagnosed with the disorder as of 1998 are female. It was originally thought that only 5% of anorexics are male, but that estimate is being revised upward. The peak age range for onset of the disorder is 14-18 years, although there are patients who develop anorexia as late as their 40s. In the 1970s and 1980s, anorexia was regarded as a disorder of upper- and middle-class women, but that generalization is also changing. More recent studies indicate that anorexia is increasingly common among women of all races and social classes in the United States.

Anorexia nervosa is a serious public health problem not only because of its rising incidence, but also because it has one of the highest mortality rates of any psychiatric disorder. Moreover, the disorder may cause serious long-term health complications, including congestive heart failure, sudden death, growth retardation, dental problems, constipation, stomach rupture, swelling of the salivary glands, anemia and other abnormalities of the blood, loss of kidney function, and osteoporosis.

Causes and symptoms

Anorexia is a disorder that results from the interaction of cultural and interpersonal as well as biological factors. While the precise cause of the disease is not known, it has been linked to the following:

Social influences

The rising incidence of anorexia is thought to reflect the present idealization of thinness as a badge of upper-class status as well as of female beauty. In addition, the increase in cases of anorexia includes "copycat" behavior, with some patients developing the disorder from imitating other girls.

The onset of anorexia in adolescence is attributed to a developmental crisis caused by girls' changing bodies coupled with society's overemphasis on women's looks. The increasing influence of the mass media in spreading and reinforcing gender stereotypes has also been noted.

Occupational goals

The risk of developing anorexia is higher among adolescents preparing for careers that require attention to weight and/or appearance. These high-risk groups include dancers, fashion models, professional athletes (including gymnasts, skaters, long-distance runners, and jockeys), and actresses.

KEY TERMS

Amenorrhea— Absence of the menses in a female who has begun to have menstrual periods.

Binge eating— A pattern of eating marked by episodes of rapid consumption of large amounts of food; usually food that is high in calories.

Body dysmorphic disorder— A psychiatric disorder marked by preoccupation with an imagined physical defect.

Hyperalimentation— A method of refeeding anorexics by infusing liquid nutrients and electrolytes directly into central veins through a catheter.

Lanugo— A soft, downy body hair that develops on the chest and arms of anorexic women.

Purging— The use of vomiting, diuretics, or laxatives to clear the stomach and intestines after a binge.

Russell's sign— Scraped or raw areas on the patient's knuckles, caused by self-induced vomiting.

Superior mesenteric artery syndrome— A condition in which a person vomits after meals due to blockage of the blood supply to the intestine.

Genetic and biological influences

Women whose biological mothers or sisters have the disorder appear to be at increased risk.

Psychological factors

A number of theories have been advanced to explain the psychological aspects of the disorder. No single explanation covers all cases. Anorexia nervosa has been interpreted as:

• A rejection of female sexual maturity. This rejection is variously interpreted as a desire to remain a child, or as a desire to resemble men as closely as possible.
• A reaction to sexual abuse or assault.
• A desire to appear as fragile and nonthreatening as possible. This hypothesis reflects the idea that female passivity and weakness are attractive to men.
• Overemphasis on control, autonomy, and independence. Some anorexics come from achievement-oriented families that stress physical fitness and dieting. Many anorexics are perfectionistic and "driven" about schoolwork and other matters in addition to weight control.
• Evidence of family dysfunction. In some families, a daughter's eating disorder serves as a distraction from marital discord or other family tensions.
• Inability to interpret the body's hunger signals accurately due to early experiences of inappropriate feeding.

Male anorexics

Although anorexia nervosa is still considered a disorder that largely affects women, its incidence in the male population is rising. Less is known about the causes of anorexia in males, but some risk factors are the same as for females. These include certain occupational goals and increasing media emphasis on external appearance in men. Moreover, homosexual males are under pressure to conform to an ideal body weight that is about 20 pounds lighter than the standard "attractive" weight for heterosexual males.

Diagnosis

Diagnosis of anorexia nervosa is complicated by a number of factors. One is that the disorder varies somewhat in severity from patient to patient. A second factor is denial, which is regarded as an early sign of the disorder. Most anorexics deny that they are ill and are usually brought to treatment by a family member.

Most anorexics are diagnosed by pediatricians or family practitioners. Anorexics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea (failure to menstruate) in females, and sometimes of abdominal pain, constipation, or lack of energy. The patient may feel chilly or have developed lanugo, a growth of downy body hair. If the patient has been vomiting, she may have eroded tooth enamel or Russell's sign (scars on the back of the hand). The second step in diagnosis is measurement of the patient's weight loss. DSM-IV specifies a weight loss leading to a body weight 15% below normal, with some allowance for body build and weight history.

The doctor will need to rule out other physical conditions that can cause weight loss or vomiting after eating, including metabolic disorders, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome. Persons with this condition sometimes vomit after meals because the blood supply to the intestine is blocked. The doctor will usually order blood tests, an electrocardiogram, urinalysis, and bone densitometry (bone density test ) in order to exclude other diseases and to assess the patient's nutritional status.

The doctor will also need to distinguish between anorexia and other psychiatric disorders, including depression, schizophrenia, social phobia, obsessive-compulsive disorder, and body dysmorphic disorder. Two diagnostic tests that are often used are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).

Treatment

Treatment of anorexia nervosa includes both short- and long-term measures, and requires assessment by dietitians and psychiatrists as well as medical specialists. Therapy is often complicated by the patient's resistance or failure to carry out treatment plan.

Hospital treatment

Hospitalization is recommended for anorexics with any of the following characteristics:

• weight of 40% or more below normal; or weight loss over a three-month period of more than 30 pounds
• severely disturbed metabolism
• severe binging and purging
• signs of psychosis
• severe depression or risk of suicide
• family in crisis

Hospital treatment includes individual and group therapy as well as refeeding and monitoring of the patient's physical condition. Treatment usually requires two to four months in the hospital. In extreme cases, hospitalized patients may be force-fed through a tube inserted in the nose (nasogastric tube) or by overfeeding (hyperalimentation techniques).

Outpatient treatment

Anorexics who are not severely malnourished can be treated by outpatient psychotherapy. The types of treatment recommended are supportive rather than insight-oriented, and include behavioral approaches as well as individual or group therapy. Family therapy is often recommended when the patient's eating disorder is closely tied to family dysfunction. Self-help groups are often useful in helping anorexics find social support and encouragement. Psychotherapy with anorexics is a slow and difficult process; about 50% of patients continue to have serious psychiatric problems after their weight has stabilized.

Medications

Anorexics have been treated with a variety of medications, including antidepressants, antianxiety drugs, selective serotonin reuptake inhibitors, and lithium carbonate. The effectiveness of medications in treatment regimens is still debated. However, at least one study of Prozac showed it helped the patient maintain weight gained while in the hospital.

Prognosis

Figures for long-term recovery vary from study to study, but the most reliable estimates are that 40-60% of anorexics will make a good physical and social recovery, and 75% will gain weight. The long-term mortality rate for anorexia is estimated at around 10%, although some studies give a lower figure of 3-4%. The most frequent causes of death associated with anorexia are starvation, electrolyte imbalance, heart failure, and suicide.

Prevention

Short of major long-term changes in the larger society, the best strategy for prevention of anorexia is the cultivation of healthy attitudes toward food, weight control, and beauty (or body image) within families.

Resources

BOOKS

Baron, Robert B. "Nutrition." In Current Medical Diagnosis and Treatment, 1998, edited by Stephen McPhee, et al., 37th ed. Stamford: Appleton & Lange, 1997.

ORGANIZATIONS

American Anorexia/Bulimia Association. 418 East 76th St., New York, NY 10021. (212) 734-1114.

National Institute of Mental Health Eating Disorders Program. Building 10, Room 3S231. 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-1891.