TRIGGER WARNING: DO NOT read if prone to eating disordered thinking.
Introduction
The Essentialist (Natural-Human) View of emotions maintains the idea that the mental and the physical (including where illness is concerned) are separate. In her book “How Emotions are Made,” Lisa Barrett argues under the Constructed Theory of Emotions that the mental mind and the physical body are connected, especially as the “fertilizer” or basis for illness. Eating Disorders, however, are seen as purely mental illnesses that involve the body only because the thought process of an eating disorder affects the body. That is, body and mind do not work together to ignite the eating disorder, but rather the mind is the ignition and the body suffers the larger effects.
Is it possible that an illness such as an eating disorder, according to Barret, is as body-oriented as it is mental? If this is true, would it be better to view and treat eating disorders as much physically (with the body) as we view and treat them mentally? In this blog post, I will argue that Barrett’s philosophy of emotions (in relation to illness) is correct in suggesting that illnesses like eating disorders are, in fact, equally as grounded in and ignited by the physical body as they are in the mind. As a result, I will also argue that treatments should be tailored to combat the body-oriented aspects of eating disorders (in addition to the purely psychiatric mind-oriented treatments that exist today) separate from simply recovering from malnutrition. Ultimately, I will use Barrett’s philosophy to disprove the idea that eating disorders are purely mental illnesses or, even worse, simply the result of a set of “poor choices” made about one’s diet. My examples will stem from real-life people who I have known and spoken to (in the past) about their experiences.
The Fertilizer
Sara was a young ballerina who loved dancing at a small studio in New York City. She worked very hard to be admitted to this particular ballet school, which was run by a world-famous former ballerina. This teacher, however, wanted all of her dancers to have a particular body type (extremely thin, with a hint of an underlying eating disorder) and did not hide this from her students. She would say that certain girls looked too “heavy” and that they needed to “lose weight,” while other girls with certain body types were given lead parts and more attention with others left dancing in the back. Soon, what started with Sara feeling bad about herself turned into a massive amount of calorie restriction and fast-paced weight loss. She would set a new “goal weight” to meet, and then she would set another, and another, and another. “How could you not eat for so long?” she was once asked. “Thinspo.”
“Thinspiration,” defined in the context of anorexia nervosa is “used in reference to something or someone that serves as motivation seeking to maintain a very low body weight.” It comes in many forms, including Instagram users, specific Pinterest and Tumblr word searches, and endless amounts of blogs on which individuals will report their “progress updates” and share “helpful tools” for others. When one searches for “thinspo,” what often pops up is a culmination of idealistic pictures of thin individuals and motivational quotes such as “Dear stomach, you’re bored. Not hungry. So shut up.” The most popular is a quote from Kate Moss who once said, “Nothing tastes as good as skinny feels.” Soon, with the constant enthrallment of thinspiration, the eating disorder will be in full swing, and it was for Sara. “I remember looking at a blog that told me to think about anorexia as a person named ‘Anna’ living inside me. It told me to think about my hunger as a sign of success: a sign of the hard work Anna was doing to make me thin. That was all that mattered.”
In her book, Barrett explains the essentialist view which maintains the idea that the mental and the physical are separate. An example she uses is that we go to a psychiatrist for mental matters, while we see a neurologist for brain matters. Essentialists argue that emotion concepts may be out of your control at first, but we can change them by changing our perceptions (for example, see bias training or the way Sara looked at thinspiration to frame her emotion concepts). In the way eating disorders are developed (using Sara’s story as an example), the Essentialist would say that an eating disorder is a purely mental illness: Sara experienced a bad framing of negative emotions towards concepts of her own body and food, and locked them in her mind with thinspiration. As a result, her restrictive actions resulted from her own mental thoughts, feelings, and perceptions, so it would be wrong to believe that eating disorders are an illness that starts in the body. They may affect the body, but they do not start there.
While the essentialist view may be the way eating disorders are perceived and treated (as purely “mental” illnesses) as of now, Barrett’s constructionist view of emotion challenges this theory. In her book, she argues that major illnesses are “constructed in the same way as emotion… they are rooted in a chronically unbalanced body budget and unbridled inflammation” (Barrett, 203). This process functions as follows: everyone has their own body budget. The body budget becomes imbalanced when, for instance, much energy has been executed yet the person has not eaten for a while. When the person eats, the person rebalances his or her budget. This happens on a minute scale all the time.
When a budget imbalance becomes prolonged, however, your body starts pumping cortisol through your blood as a result of your body’s stress, releasing more cortisol than needed. Overproduction of cortisol then leads to inflammation in the body, thus impacting your whole body budget: “it affects your predictions, in particular, those that manage your body budget… you become consumed with fatigue and unpleasant feelings… [it] depletes your resources, causes wear and tear on your body, and eventually builds up more proinflammatory cytokines [cortisol]. When that happens you are really, truly in trouble” (202).
Why is a body in this state “really, truly in trouble?” Because, as Barrett argues, inflammation and a chronically misbalanced body budget “acts like a fertilizer for disease” (202). As science has already demonstrated, the immune system is the reason why far more illnesses occur in the first place. For instance, the person who is extremely exhausted, stressed, and weak will have a much higher chance of developing a cold than the more balanced person, simply because the more balanced person has a better prepared immune system to fight off that particular germ–this person’s immune system is not already overworking. Inflammation, in particular, has been shown to add to the likeliness of one developing disease: Barrett uses an example of cancer research that shows how, if one has been diagnosed with cancer, inflammation in the body will make tumors grow faster.
Barrett explains that today, with illnesses like anxiety and depression, scientists are finally moving away from the classical approach of assuming disorders are distinct (and, therefore, diagnosing them individually as the essentialist would) and are instead “focusing on a set of common ingredients that leave people vulnerable to these various disorders”: such as genetic factors, insomnia, and “damage to the interoceptive network of key hubs in the brain” (124). Barrett explains that the key hubs in your brain are your brain’s body-budgeting regions. “Through their massive connections, they broadcast predictions that alter what you see, hear, and otherwise perceive and do (because your everyday decisions are driven by your body-budgeting regions)” (124). When hubs are damaged, however, “you are in big trouble.” Information can no longer “pass efficiently between different networks in your brain via the major hubs in the interoceptive and control networks” (124). As a result, illnesses such as depression, panic disorder, and dyslexia develop.
With all of this scientific discovery, however, why have we not seen more of this applied to the research of eating disorders? Why are they still seen as a purely mental issue–even to doctors treating eating disorders? Are they so ingrained in the essentialist view? According to an article in the Journal of Eating Disorders (from the BMC Collection of Scientific Research Journals), “structural brain imaging studies have shown gray and white matter changes which generally normalize with recovery. Functional brain imaging studies have demonstrated alterations in fronto-striato-limbic circuits, suggesting aberrant cognitive control, reward, and emotion processes.” This suggests Anorexia Nervosa psychopathology emerge as a result of altered interactions between top-down and bottom-up circuits, possibly related to core disturbances in how the brain processes salient stimuli.” For clarification, top-down circuits are psychological interactions, whereas bottom-up circuits are physiological. This means that anorexia can be traced back to hub damage in both the psychological and physiological areas of the brain!
With all of this in mind, the cognitivist would look at Sara’s case and argue the following: Sara’s eating disorder developed as a result of BOTH an imbalanced body budget and an increase in negative emotion conceptions of body image (body dysmorphia). Sara’s ballet school environment was highly stressful and made her feel extremely insecure about her body. As a result of existing in this stressful environment every day, her body started producing more cortisol than needed due to chronic misbudgeting, causing inflammation in her body. This inflammation, paired with her restrictive eating habits (impairing her nutrition intake), massively imbalanced her body budget.
Also, in her mind, Sara became obsessed with the goal-based concept of “thinness.” According to Barrett, goal-based concepts are a system within our culture that help us “manage ourselves and each other.” In Sara’s case, she became a part of the online “culture” of eating disordered individuals who used a system of “thinspiration” (through blogging and social media usage) to help her manage and maintain her eating disordered actions. “Thin” was the goal-based concept, and her actions resulted. Ultimately, the combination of both these psychological concepts and her physiological imbalanced body budget combined as the perfect “fertilizer for disease”: anorexia nervosa.
The Growth
As I have articulated above in the constructionist view of emotion, the seeds of eating disorders are planted in both the body and the mind. It is important to recognize, however, that while the imbalanced body budget is maintained by the stressors of the individual’s environment (in addition to the irregular eating habits), a unique set of emotion concepts trains the eating disordered mind as well, “locking it” into eating disordered thoughts.
In a novel called “Letting Ana Go,” the main character goes from being a regular girl to a girl with a full-blown eating disorder. In the end, she tragically dies from the illness, despite the help her friends, family, and boyfriend tried to give her. In one scene, she writes “I stomped up to my room and started doing my exercise routine. I got really light-headed in the middle of it and couldn’t stop coughing just now. I actually coughed up some blood. It was sort of amazing. I think I’m so thin my body is digesting itself” (Anonymous, 274).
It is important to make note of the fact that those diagnosed with eating disorders such as anorexia or bulimia will, in many cases, not be aware that they are ill. If they are aware, they are often proud when others demonstrate concern–it is seen as a sign of success. They also get excited about “accomplishments” that, for any other illness, would be seen as a bad sign (such as Anonymous’s coughing up of blood). Regardless of whether or not the disordered are aware, they will see those trying to help them as “jealous” individuals. But why is this? Why are their goal systems, their success and pride ratings, and their happiness levels based on such drastically unusual experiences? Because the psychological state of an eating disorder is drastically warped in comparison to that of a healthy, non-eating disordered individual. They have their own unique set of emotion concepts that they have trained their minds to see, which their malnutritioned bodies and damaged brain hubs cannot effectively recognize and rebalance. For further clarification, I will now take a look at the concept-building going on in an eating disordered mind.
Barrett argues that “Emotions are social reality. We construct instances of emotion in exactly the same manner as colors, falling trees, and money: using a conceptual system that is realized within the brain’s wiring. We transform sensory inputs from the body and the world, which are perceiver-independent, into an instance of (say) happiness in the context of a concept, “Happiness,” found in many human minds. The concept imposes new functions on these sensations, creating reality where there was none before: an experience or perception of emotion” (134). But how do emotions become social reality?
“First,” says Barrett, “you need a group of people to agree that a concept exists, such as ‘Flower’ or ‘Cash’ or ‘Happiness.’ This shared knowledge is called ‘collective intentionality’” (135). Barrett argues that humans are unique because our collective intentionality involves mental concepts: “we can look at a hammer, a chainsaw, and an ice pick and categorize them all as “Murder Weapons.” We can impose functions that would not otherwise exist, thereby inventing reality” (135). But how? Barrett explains that collective intentionality forms emotion categories through shared human understanding. She says, “To communicate to someone else that you feel angry, both of you need a shared understanding of “Anger.” If people agree that a particular constellation of facial changes and cardiovascular changes is anger in a given context, then it is so. You needn’t be explicitly aware of this agreement. You don’t even have to agree whether a particular instance is anger or not. You just have to agree in principle that anger exists within certain functions. At some point, people can transmit information about that concept among themselves so efficiently that anger seems inborn” (135).
For those living with an eating disorder, the basis upon which these individuals experience emotion is a result of collective intentionality. While certain cultures may “agree” that certain concepts exist, thus shaping their emotion concepts, the same happens in the eating disordered community–but largely online. Ever since the rise of social media (and idealistic photography as a result), eating disorder occurrences have shot up in numbers. Why? Because social media has served as the perfect platform on which the thinspiration eating disordered culture can exist. Let’s go back to Sara for a minute. When Sara was experiencing inflammation as a result of her stressful environment, she was also following certain Instagram influencers who all had a specific “aesthetic.” “They were all as thin as Barbie dolls with gorgeous long hair. Their collar bones would be visible and their jeans would look baggy. And they were in beautiful places: Paris, London, Venice… it was as if they were living that life because they were thin. It was all I ever wanted to look at on Instagram anymore.”
With thinness associated in the category of “ideal beauty,” how do eating disordered individuals begin to feel pride, success, and happiness when they know they have lost unhealthy amounts of weight or, in Anonymous’s case, coughed up blood? For most illnesses, this would instill fear… but why not for eating disorders? Barrett says, “You need an emotion concept in order to experience or perceive the associated emotion” (Barrett, 141). The existence of these accounts provides those emotion concepts for eating disorder-prone individuals. All of these users’ followers watch the accounts, in large part, to see these images and imagine themselves living this life and looking this way. A “concept,” is a population of diverse instances (thousands of images individuals scroll through?) that a person recalls under one labeling word, such as ‘thin.” Thus, by categorizing thinness concepts in the category of “ideal beauty,” they create a shared “reality” (as Barrett calls it) that the things they see in these photos are “ideal.” These accounts put a positive spin on this unhealthy body image and say “this is how great you will feel if you become thin,” thus instilling within individuals the equation of “thin” = emotions of happiness, confidence, pride, success, etc. Why? Because these photos instill the concepts necessary to “experience or perceive the associated emotion” which is, in this case, happiness, confidence, pride, and success.
When Sara goes onto a thinspiration blog, she sees phrases such as “I lost 10lbs this week…I’m so happy!” She also sees lists of “Goal-Reaching Plans,” and “Diets to try to be successful,” amongst all of the idealistic pictures. Barrett says, “the word ‘fear’ groups together diverse instances that have greatly varied movements, interoceptive sensations, and events in the world” (136). On thinspiration sites, a word such as ‘success’ groups together diverse instances of people posting about weight loss and idealistic images. Negative words become associated with contrasting instances as well. All of these associations train or “lock” in the mind certain concepts with emotions. Ultimately, the more prolonged and imbalanced the body budget, in addition to the emotion concept-locking the eating disordered individual does, the harder it is to get the internal meter back in balance.
The Drought
So, now that we know eating disorders are a result of the combination of body budget imbalance and unhealthy emotion concept construction (and hub damage), how do we help the body and mind get back on track? News Flash: It is extremely difficult.
The most common misconception about eating disorders is that they are a “choice”: That someone who chooses to restrict one’s calorie intake does so because it is only a “bad habit.” If that person wanted to break this habit, it could be done with the same effort it would take for a person to break their bad habit of watching too much television. In a slightly more serious capacity, doctors and specialists see eating disorders as mental disorders with physical effects: the disorder only affects the human body insofar as the person starts altering one’s dietary intake or exercise plan, either by too much or too little. As such, eating disorders are treated mostly in psychiatric settings where patients discuss their feelings and thoughts revolving around food and body dysmorphia thoughts. I will, however, talk about three approaches to treatment–the just stop, essentialist, and constructionist approaches–to arrive at the conclusion that the constructionist approach is best.
The Just Stop approach assumes that the eating disorder is a choice: the person wants attention, is only dieting too hard, has weird eating habits, and is absolutely in control. How could the person not be in control when he or she is already so in control of what he or she eats? For obvious reasons, this approach is barely even an approach at all because it fails to recognize eating disorders as actual illnesses and, rather, views them as more of a bad habit. Therefore, it cannot be successful.
The Essentialist approach is the most common approach today. It is almost impossible to find a treatment approach to eating disorders that does not involve a basis of psychiatric therapy developed on the grounds that eating disorders are purely a mental disorder that only affects the body. As I said above, the eating disordered mind is filled with a unique and harmful categorization of emotion conceptions that lead the individual to feel emotions of happiness and success in response to signs of unhealth: for example, feeling success as a result of looking slimmer in the mirror. To treat the eating disorder, the essentialist approach must alter those conceptions: to train the mind that carbs are actually good for you and that success means taking care of the body at a normal, healthy weight. It teaches individuals not to associate the concept of a carbohydrate with the emotion “fear.”
When I was seventeen, I realized that I had an unhealthy mindset toward food. I had been dancing pre-professionally and, as a result, had met with a nutritionist who encouraged me to not eat processed sugars, gluten, or dairy. Cutting all three of those food groups out of my diet for an entire year messed with my emotion concepts of food, and I knew I was being unhealthy because I had no energy to get through the day or my schoolwork. As a result, I participated in a two-week program at an eating disorder center (even though I had not been diagnosed with an eating disorder) that was meant to re-teach me what a “healthy” balance of the food groups is. After a year of thinking one way, I had entirely forgotten how to not approach food with those new concepts I had “locked” into my mind. The people I met there, the stories I heard, and the information I learned serve as the foundation of my knowledge for this post [Sara’s name, in addition to particular facts about her, has been changed from her original existence].
This particular program was made up of group and individual therapy sessions regarding food, body image, and self-confidence. While I was only going to be there for a short period of time, it was mostly made up of individuals who were transferring from inpatient eating disorder centers to a normal, happy, and healthy life. Some of them had been there for almost a year. Monday through Friday consisted of a regular school day. In the mornings, we reported what we ate for snack and dinner the night before (after we left the program). Then we ate a prepared breakfast (of which all food had to be consumed), had certain tailored discussions during the middle part of the day, we ate another prepared lunch, and we had a closing discussion.
Discussions were tailored around why certain food groups were healthy. Certain individuals were asked how they felt about the food and why they did or did not feel a particular way, and were taught to alter their perspective (rewiring their emotion concepts!). The entirety of the program was focused on constant rewiring, demonstrating the good things about food, the benefits of being healthy, and more. It was fascinating to hear these discussions and they became intense. One patient said she would prefer to eat in a particular, eating disordered way, rather than live supported by her parents. The therapists reframed this for her: they started describing to her what her life would be like. She would not be able to work at a day job (she would not have enough energy), she could not support herself, she could not achieve her dreams, have a phone or pay for entertainment… she could not have a life. Suddenly, the patient acknowledged to the group how important it was to stay on her path of recovery, as a result of this discussion. The reframing prevented her from losing track.
In addition to the re-framing, these programs require that patients temporarily pause all activities that activated the eating disorder: Sara had to unfollow many Instagram accounts and stop dancing, another patient, Samantha, could not model for a while, another one could not hang out with certain unhealthy friends, I had to eat normally balanced meals that included all food groups and forget about nutritionists… we all had something we needed to stop doing, but only until we recovered. In addition, patients were prohibited from shopping for clothes in stores (for the trigger of trying on clothes) in addition to purchasing them online (so as to not look at suggestive models). Once the patient has had a full, concept-reframed mental recovery, the theory is that one should be able to resume these activities with a healthy approach.
In contrast, I build off of Barrett’s philosophy to argue what the constructionist approach would be. As said above, Barrett argues that inflammation and a chronically misbalanced body budget “acts like a fertilizer for disease.” Whereas the essentialist would treat an eating disorder with mental reframing only (as a result of the essentialist perspective that eating disorders are only developed in the mind), the constructionist would aim to treat both the mind AND body, arguing that the essentialist treats only half of the disorder. As a result, the constructionist approach does everything the essentialist would do but adds more to treat the body.
The difference is in is the eliminate vs. pause treatment. While the essentialist’s treatment only pauses the occurrence of certain activities for the eating disordered, the constructionist would eliminate those activities entirely from the person’s life. Recall, from the beginning of this post, that inflammation and imbalance in the body budget occur because the body is in a stressful environment. The eating disordered individual was in an environment that made the individual’s body overpredict cortisol needs and, therefore, overproduce cortisol as a result of the continuous stress of the environment on the body. This overproduction led to inflammation in the body.
Therefore, even if the person takes a step back, reframes emotion concepts, and successfully rebalances the body budget, the essentialist treatment cannot guarantee that reentering the environment would not harm the individual again. The environment would, again, start compounding stress on the body, inflammation would occur, body budget imbalance would kick in again, and the person would not be strong enough to prevent from slipping back into the eating disordered frame of emotion concepts. In my life, I have seen individuals fail to treat their eating disorders time and time again. I believe it is because they always re-enter the stressful environment that first ignited it. In contrast, I have never allowed myself to cut back on any food groups ever since, and I have lived a perfectly colorful life in a great relationship with food.
As a result, I believe that the constructionist approach to eating disorder treatments would take both a mental and physical approach, acknowledging the fact that a person may have individual reactions to certain things that make the person stressed. Therefore, as most individuals avoid particular foods, each individual must avoid such an environment as one would avoid an allergy: it could trigger a subset of reactions that could lead to a full-blown eating disorder. For example, Sara must avoid ballet studios, Samantha should not model, and I should not go onto unhealthy online meal-plan platforms (like Juice Press)… ever. Even though a person may have loved ice cream growing up, the development of a dairy allergy is difficult, yet crucial to acknowledge.
Conclusion
In conclusion, Barrett’s philosophy of constructed emotion demonstrates that eating disorders are, indeed, as body-oriented as they are oriented in the mind. The key point, however, is that they develop in the body, in addition to just harming the body as a result of malnutrition. According to the constructionist view, the body budget can become imbalanced while the body becomes inflamed, making it the best “fertilizer” for diseases such as anorexia and bulimia to develop. Why? Because when the body is out of wack (in this case, due to a much too pressured and stressful environment), it cannot fight off aspects of an oncoming disease, such as the harmful emotion concepts developed in eating disorders.
As a result of Barrett’s constructionist philosophy, it would be better to view and treat eating disorders by focusing as much on the physiological developments of the disorder as we do on the psychological developments. While the current essentialist approach to treatment may be effective in helping an individual reframe one’s emotion concepts, this treatment is not lasting. Today, eating disorders almost always exist in the form of lifelong relapses because the essentialist view only treats one portion of the eating disorders: it does not perceive the body as a cause for eating disorder development at all. But if medicine could adapt to Barrett’s constructionist view of emotion in its treatment practices and, as a result, acknowledge the body’s stake in this nasty game, change may finally occur. We might be able to fully remove the body from the stressor environments that ignite the physiological aspect of the disease and, in so doing, finally achieve long-lasting recoveries for a significantly healthier population.
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