Anorexia Nervosa and present-day culture

It is always difficult to establish the relationship between the psychopathological patterns of the individual and the social and cultural frame where he lives.

The interpretation of this relationship is risky in the case of Psychopathology, even when referring to neurotic patterns, which essentially seem to be close to the historical-hermeneutic dimensions of the human being. Firstly, because the analysis and comprehension of the symbolic level in human life is not easy: one only need have a look at the numerous trends of the present-day development of Ethics. Secondly, in current Psychiatry the risk is increased by its perverse drift towards an anti hermeneutic position, due to a dated neo-positivism, which claims to have eliminated what is subjective and even to exile the subject from his bosom, contrary to the present drift in the rest of sciences.

This is the reason why the task is at the time much more urgent … and more complicated. This risk may become temerity when we try to relate the individual psychological life to the present socio-cultural environment. On the one hand, we have not the necessary distance to objectify such an environment, since we are included in it, that is, we are insiders. On the other hand, our own epistemic perspective is subjected by this socio-cultural structure, from which our own consciousness has developed.

          With regard to anorexia, this relationship, despite what I have said, has always been present. The tendency to “ideal slimness” on the part of the adolescents involved has frequently been related with the “ideal of slimness” recently prevalent in our culture.  But all this brings about a new difficulty. Today it is well known that “obviousness” in science usually conceals enormous complexities in the intimate structure of the real.

          This conception of the ideal of slimness meets, from the very beginning, two strong objections in relation to the actual presentation of the frame. First, this pathology has appeared in times when the female ideal of beauty was very far from slimness. Thus, from the 19th century until World War II a plump female image was favoured.

          The other difficulty implied in that kind of interpretation is the real increasing presence of anorectic patterns in males. Men can only with difficulty covet an ideal body image of extreme slimness, precisely at present when body-building and film stars such as Schwarzenegger are in fashion.

          All this requires that we should deeply investigate the psychopathological structure of Anorexia; which is fundament of clinical and nosological aspects.

 

The nucleus of the psychopathological structure

          The principal objectified symptom of the anorexic consists of a bloody bitter struggle - a pursuit up to the border between life and death - against the body image of his self that he has. This fight - as we all know - takes place in the field of his food behaviour; that is, not eating, vomiting, anxious gobbling and so on. Other kinds of behaviour may appear as well, such as consuming digestives and laxatives, doing gymnastics, dressing loose black clothes and avoiding mirrors.

          All this has been considered an addiction to slimness; still, the appropriate word is thinness (Magersucht in German). This addiction aims at achieving an ideal body figure, never at one’s reach in reality precisely because of its ideal condition.

          This philia appears as a counter-phobic behaviour in that there is a phobic emotion due to the fatness, felt by the anorectic person, which makes him anxiously run away from that fatness by which he feels to be threatened with destruction, as in every phobia.

          What I have mentioned so far is well known. But when investigating phenomenologically the life experience and behaviour of these patients we find out that these adolescents have not the intention of being very thin, but rather of getting thinner and thinner all the time, of breaking out of their “voluminous” bodies, owing to the immediate presence of threat. But as running away from their own bodies is not possible, they can only try incessantly to reduce the spatial dimension of the threat by getting rid of volume.

          This attempt to reduce the threatening body fatness crystallizes, most often, into ideas of model corporal figures; these are catathymically perceived in a distorted way as mythical icons, a fetishist centre of all power. This distortion tends to an extreme idealization of other corporal figures, all them perceived as slim and attractive to the social community, at least with a high power over it, in extreme contrast with one’s own body, perceived as a repulsive, repugnant one.

 This ontological splitting is of an inverse Manichaean kind. It involves a body depersonalization, an alienation of the “dismorphophobic” type, where one’s own body becomes a separated thing from the self, who is no longer a naturally incarnate subject. His or her body is not subjetual corporeality. It is only an object, something in front of their eyes, whose only value could be an appearance design, as if it were just a tool to look at, with the dimension of a simple ´public-image`.

          I think it is necessary to remember here that the evolution of all the corporal alienations of the dismorphophobic type is very hard.

          All those phobic fantasies are just “physiognomic materializations”, as happens with all phobias.

Underneath that crystallization of idealized images of extreme thinness, there is a necessity on the part of the anorectic person of getting rid of his corporal volume. As a matter of fact, the basic point is not a worry about having a nice figure. This is clear in the case of male anorexia. What anorectic females necessarily seek is “not to have a corporal volume at all” in order not to take up any space in the external world. Actually, it is not a dismorphophobia, it is a real morphophobia.

          The attempt not to fill any volume results in an antiexpansive or retroactive corporal space behaviour, sometimes by taking up the minimum possible space when sitting in a public transport, sometimes by trying not to go to any public spaces. With a stiff, constrained, retroactive, psychomotor behaviour, there is lack of any expressive gestures. In fact, the patient moves about in public spaces with apparent calmness, but his personal experience is of being locked in his own spatial capsule, in an intimate bubble, where he feels isolated from the rest.

          All this belongs to the anorexic’s counter-phobic behaviour. The apparent fatness phobia in anorexia is ultimately a phobia against the public manifestation of his own intimacy. It is in relation with “social phobias”, frequently noticed by many authors in these patients.

          It is also necessary to point out, in these patients, a frequent, justified “alexitimia”, hidden behind elusive language expressing their own affectivity from outside, as though it were somebody else’s affectivity or talking about their affects as if they were things.  Certainly, their verbal expression is always agile, intelligent and quick, and their dialogue is given the appearance of good communication, but it is always produced in a very rationalistic way; merely intellectual, away from any personal commitment, which is phobically avoided.

          An anorectic person experiences his own external manifestation of his self’s intimacy as being something obscene, like a degrading show of his personal core in the moral space of society. He feels himself exposed shamefully to the attentive sight of people.

        As it was pointed out long ago, “sight” plays a fundamental role in the anorectic world, especially in Sartre’s sense, the glance of others reificating the personal subject that oneself is. The anorectic world is an optical one.

          In fact, it is possible to say that the psychopathological core of anorexia is the patient’s impossibility of personal communication. Part of the symptomatic manifestation of this is the extreme care to keep their food behaviours out of the sight of others, since they are considered really intimate.

          Everybody with experience in psychotherapy with anorectic patients can remember the paradoxical contrast between the good verbal-intellectual-rational communication and the very big difficulties to accede to the deep personal level, not to mention the impossibility of having a normal habitual social corporal contact with them. The corporal expression of these patients is rare and merely formal.

          These last concepts bring us nearer to “thinness addiction”. Anorectic persons try to have a disembodied existence. They intend to have a disincarnate life, being only spiritual persons. That kind of existence can evolve to a rigid, rationalistic life without affections, eccentric at times, which has made some psychiatrists relate it to schizophrenic behaviour.

          In anorexia, as in every phobia, the menacing field (the distressing social existential world) is condensed in an object, which at any given moment holds all the destructive power belonging to the situational field. The phobic object becomes a malignant fetishist metonymy, with the power to organize all the field of life. This phobic object, being constructed with the imagination, is operative through its physiognomy, not through its real operative structure. And, as in every phobia, the anguish threat operates on the space structure, putting the subject at the reach of the menacing object.

          Anorexiants experience their own bodies as an alienated involuntary exposure of themselves, of their personal intimacy, at the reach of others’ repudiation. It is the protuberant volume of their own body that is felt disgusting and obscene.

          In more sexually repressive epochs than ours, anorectic adolescents used to desire not to have breasts and protuberant hips. This was interpreted as a fear of sexual relations and interrelated with those patients’ real desire of not becoming adults, the desire of remaining children. At present, anorectic adolescents have sexual relationships with the same high frequency as the others, but they continue showing a refusal to have bodily protuberances. They want to have a body with no apparent structure that forces them to stand out. Current patients have sexual interrelations without any special problems in many cases, but they have enormous problems to maintain erotic relationships full of affectivity and to get personally involved. 

          This anorectic phobia to bodily manifestation in social space appears in the fight against one’s own expanded and exposed body, impossible to eliminate because it is just a physiognomic condensation of the menace of having bodily structure. This sense dynamics makes possible the comprehension of this fight against one’s own body appearance, sometimes to death.

          This dynamics against the incarnated condition of life makes anorexiants similar to hypochondriac patients. More than thirty years ago Alby referred to anorexia as a “hypochondria of appearance”, but there are more similarities between both pathologies.

          Like the hypochondriac, the anorectic person suffers an alienation of his own body, perceiving it as an external body, a foreign body that attacks him with the destructive intention of not to be identified by the members of society. The anorexic experiences his own body as growing against his will, in a rebellion that places him in the space of society, which repels, humiliates and erases him, identifying him with his repulsive appearance.

          Against that threatening situation, the anorexic tries to have a complete control above his corporeality, from the exterior of it. As a matter of fact, every control is external, in opposition to leading some process or one’s own life as an inner subject of behaviour and his natural condition of being incarnate.

          First, the anorexic tries to have the control over his weight and volume, but it is not enough; then he tries to manage all the structure of his bodily condition, to produce it - a very modernistic aspiration! The anorectic subject tries not only to transform his corporeality; he attempts to pro-duce it himself. “To produce it” has two meanings here. First, that of making himself into a pure “ideal I”, like a Kantian “transcendental I”, a spiritual entity without flesh, an image without a third dimension, as all images. (Every phobic structure implies the loss of the property of the third dimension, the alienation of profundity, the dimension of the reach relation with the world).

          Second, the anorexic tries to dominate all the productive process in his construction of his own corporeality. He wants to overpower his bodily enemy, to subject to his will the transactional exchange between the body and the surroundings. He tries to bring under control his instincts and physiologic needs, and to have the supremacy over the others. “When controlling his body, he feels powerful over the world”.

          This structure of sense commonly generates two kinds of behaviour in these patients: the corporal hyperactivity and the intellectualism, with extreme emphasis on their studies.

The corporal hyper-activism is not only in relation to the calorie consumption, but, more deeply, it is devoted to constructing a personal space so as not to be exposed to others, a private space. It is not an activity space permitting to carry out tasks; on the contrary, it is a spatial structure, heroically built up, in which to be included, an island as a support and protection for himself and for his body, off the mainland, that is to say, away from the hostile general space.

The over-grown intellectualism attempts to construct a “cognitive space” in which to live, a symbolic space under one’s own control, out of the actual exterior space, which is felt as a social enemy space.

          The anorexic tries to subject the entire environment to his power, which sometimes makes him look hysterical. This was already pointed out by those who first described anorexia, from Lasègue to Freud. Frequently, he shows a victim’s attitude.

          In some cases, the necessity of being out of the enemy power of social heteronomy produces instances of law transgression conduct, like “kleptomania”, as the exercising of the power of one’s own desires above the legal limits.

          The exercise of spatial power in anorexia has a double root. On the one hand, it is a counter-phobic behaviour as a necessity of controlling the threat field. On the other, it is the exercise of a vicarious personal power not put in praxis in the very personal dimension of life. The anorexiant feels he has no personal power, as he completely depends on the assessment of others. His dependence implies his panic of being rejected and abandoned.

          As a result of all this existential structure, anorexics feel that they are in a terrible solitude which they usually call “cosmic loneliness”. They feel they live in a desolate world, without a personal ground on which it is possible to rest and get enough strength to fulfil their own life.  As a result of these shortages, the basic “humour” in anorexia is the sense of abandonment, and the basic “mood” is the sense of desperation.  They are projects of persons feeling that they have not a place of their own in the world, that they are just personal nuclei isolated in their intimacy.

          This conviction makes them adolescents without the desire to develop their maturity to go into the adult world, feeling at the same time, paradoxically, extremely differentiated from others, that they have a particular personal kind of way of being. This contradiction between their own peculiarity, their feeling to be strange to their own society, and their necessity of being approved of by it, as egalitarian members of it but being accepted with their personal identity, places them in an unresolved conflict. They desire a personal adult world with an infantile dynamics, impossible to be actually wanted with a realistic will, which implies the effective dimensions of the world as it is. As a result, some of them can have the desire of finally being a full grown-up because what they suffer from most is not being able to get integrated with other adolescents.

          Behind their humour of total abandonment and their mood of desperation, anorexiants have the “temper” of complete uprooting, in relation with their desolated world. They feel detached from all human cohabitation structure, not belonging to any incarnate affective sphere. They feel their own inner sense structure not in tune with the sense structure of everybody else’s world.

          They feel a terrible affective emptiness, without the hope of an encounter with other personal intimacies and, at the same time, they feel as nest drop-outs, foreigners to the infantile world, with its unconditional bonds. They feel they have no place in a world lacking a receptive structure, empty and of course without any precise limits, feeling they themselves have no limits either.

This has been described by several authors as having a difficulty to clearly discriminate inner from outer objects. These relative indiscrimination concern only the spatial position, not the formal property of self, as is usual in psychotics.

          This lack of well defined limits is likely to be related to diffuse and contaminated roles in the original families of anorexics, as frequently pointed out by familial-systemic therapists.

          As everybody knows, the arising of this psychopathology takes place near the transition from childhood to adolescence and the emergence of the spontaneous capacity of exercising a criticism on the primary cognitive systems of identification. Very frequently, the precipitation of the pathology occurs in relation with family segregation, change of school or residence, all of which questions the social inclusion systems, with their identification by belonging to them. 

          They are children that seem to have had confused and conflictive identification-individualisation processes in childhood, with a difficulty to differentiate inner from outer, then to discriminate internal from external and lastly not distinguishing intimacy from interiority. It is the formal cause of having the life experience of alienation of their own intimacy when it is expressed in public space.

          I believe that this pathology is the most profound incarnation of phobic psychopathology, the one nearest to the self, in which the third dimension, the profundity, that constructs the space-volume has become alienated. Here it is one’s own corporeality, as volume in the world that is alienated, disappropriated or expropriated by oneself.  

 

Present-day culture

          I have to say here, to give our topic a framework, that today’s culture, the so-called “post-Modern Age”, is the last phase of the Modern Age, not forgetting it applies to western culture. And I am saying it in relation with the incidence and prevalence of this kind of pathology, Anorexia Nervosa. Epidemiology shows it predominantly in our culture, being hardly present in others, including groups like Afro-American people. Historical inquiries seem to conclude that A.N. did not appear until the end of eighteenth century, when the Modern Age had already developed all their formative forces over the western mentality and ways of life.

 

The Modern Age

          The core of The Modern Age is the development of “rationality” and the increase of “individuation”, or, to put it in other words, the emergence of the subject and his subjectivity.

          Rationality, linked to the scientific-technological development and “instrumental reasoning”, produced the so-called disenchantment of the world. It was the change from a theological and theocratic society to a secular and technocratic one. It further implied the disappearance of mythical and religious meta-stories, the narrations that gave sense to life and the world and made the latter into a familiar human being’s dwelling. As science explains the reality structure but is dumb as to its sense, the world subsequent to the Enlightenment lost its sense.

The source of the sense of life and the world was transferred from myth and religion to metaphysics and politics. The quest for religion-oriented “absolute sense” in metaphysics contributed to the “philosophical idealism” of the eighteenth and nineteenth centuries, and fostered the development of a hyper-rationalistic mentality, an intellectualistic attitude to life, and the increasing basic conception of an “ideological personality” in the western world, which was very well  studied by Matussek.

This change of life framework turned the old mediaeval fear of physical violence and the fear of God into a new fear, a psychological one, which has remained so far: the fear of the loss of social prestige.

The other axis of The Modern Age, from the Renaissance to our days, the development of subjetual individuality, has a very complex history and is only briefly showed here.

In the Renaissance the human being became conscious of his singularity as a subject, or rather, since Descartes, as a cognitive subject in front of the object. Furthermore, as the origin of culture: artists began to sign their masterpieces. In another dimension, the singular individual discovered himself as an autonomous subject out of and in front of the society. Lastly, this process brought about a great socio-political change, as illustrated by the American and French revolutions.

This consciousness of oneself as an original subject made the human being of the Modern Age increasingly attempt to attain freedom as a self-foundation.

This condition positively developed critical consciousness but, on the negative side, it generated personal existential guilt, a typical product of The Modern Age, since the individual’s fulfilment is felt as his own exclusive responsibility.

This autonomic liberty in the Modern Age brought about intimacy and the necessity to keep it out of the glance of others. There appears the difference between the private and the public, with the consequent modesty and sense of shame. Previously, in the Middle Age, or the promiscuous culture, as Le Roy Ladurie puts it, everything could be done in front of others, including sexual and excremental behaviours.

In the late Modern Age, all this cultural development has made possible the emergence of two contradictory characteristics of modern westerners: individualism and egalitarianism, as Renaut pointed out. That is, the conflictive simultaneity of both the sentiment of autonomic identity and the necessity of being approved of by society, which gives its individuals their own heteronomous identity.

Present people are broken apart by the conflict between their own free wills and their very limited capacity of doing, of leading their own lives. Many people feel helpless at the requirement fulfil themselves in life.

The modern instrumental reason really took the human being out of the enchantment, but at the same time took him out Nature, and out of reality, and placed him in a symbolic, abstract world, in a mental space of ideas, concepts, images, theories, models and virtual things. In Heidegger’s words: “the transformation of the world into an image characterizes the Modern Age”.

Modern man stays over reality, tries to subject it to his will, but remains out of it. He does not feel that Nature is his home. And, since a human being has the necessity to appropriate the power of outer reality to make his life, he has become almost powerless. Moreover, in today’s life it is the object, the instrument, that has the power over man, as Baudrillard makes clear.

Behind the superficial activism of life nowadays, the present human being is fundamentally a passive subject, an ontological paradox, described by Albert Schweitzer at the beginning of the last century.

Present culture (the post-Modern Age)

          This very present epoch, called “the age of void” by Lipovetsky, is in my opinion not the culmination of the Modern Age, or the “end of history”, as Fukuyama said, but a transition period. Of course it is impossible to clearly envisage the coming age. Anyway there are many symptoms of this epocal change including a new manner of perceiving reality (in the way of “General Theory of Systems”) beyond substantialism, and the transition from both the classic philosophic horizon of essential permanence and the modern creationist horizon into an emergent historical process (evolutionary processes).

          In the pertinent field of owner theme: The most obvious issue about the post-Modern Age usually pointed out is its extreme individualism, with its consequent egoism and narcissism. I think, with Clecack, that they are only sub-products of the present personalisation process, which nevertheless involves the increasing fear of depersonalisation. I remind here of the high awareness level of anorexiants’ own particular personality and, at a time, their suffering condition due to their impossible self-fulfilment. This conflictive situation provokes its corporal depersonalizing sub-products in their intention of body fabrication and, by means of this, the powerful control of their environment. This condition reminds one of Giddens’s words: “The Modern Age is sustained on an imaginary structure, the unlimited expansion of the rational domain”.  And the same famous British sociologist adds: “What could be regarded … as a narcissistic cult of bodily appearance is, in fact, an expression of a deeply preoccupation to construct and control the body”. And the German sociologist Bauman states: “Existence is modern insofar it is oriented by the urgency of design - the design of oneself”. 

          In this light, it is useful to remember Beck’s words about the fruits of “the dialectics of the Enlightenment: the anthropological opposition between rationalisation without a subject and an impotent subject”. This naturally leads “modern reflexivity to the purpose of foreseeing, of preventing everything, a divine desire of controlling the uncontrollable”. This is the origin of one’s own body’s fetishism in Anorexia.

          If every fetish is an apparently powerful object, the fetishism of one’s own body if just rooted in its appearance: it is one’s own image that becomes a fetish, the corporal image taken as an image in front of the eyes, as it were a really modern pseudo-reality. Baudrillard tells us: “Image, and information with it, is not assimilated today to any principle of truth or reality”, and goes on to say “As far as reality is concerned, we have been contented with that of image for a long time”.

As everybody knows we live in the “culture of image”. We live in an imaginary space without, to certain degree, a local volumetric reality, in emptiness in which, in Lipovetsky’s words, “the principle of reality has been changed by the principle of transparency”. Life has been dislocated, hyper communication and simultaneity make the fundamental distinction to the life between “here/there/ beyond there” disappear. Lipovetsky himself adds: “The body, like consciousness, turns into a floating space, a dislocated space in the hands of societal mobility”. As a result of this situation, the author concludes, there becomes necessary “the narcissistic inversion in the visible body”; precisely what occurs in A.N.

This “age of simulation”, as it was named by Baudrillard, is eliminating the painstaking differentiation between private and public space produced in the Modern Age. In this author’s words: contemporary man experiences “the total proximity, the absolute instantaneity of everything, the sensation that there is neither defence nor a possible withdrawal. It is the end of interiority and intimacy, the excessive exposition and transparency of the world (…). He can no longer produce the limits of his own being”. Here, it is pertinent to remember Heidegger’s words: “A limit is not the point where something stops … on the contrary; it is that from where the presence of something begins”.

          This is the psychopathological situation of an anorectic person. The patient cannot set up his own boundaries; distinguish his intimacy from public space, because he perceives the exterior, where he expresses his intimacy, as belonging to the others, as being the intimate space of others.

          Alain Touraine, one of the most clear-minded analysts of the Modern Age, tells us: “The world seems to have become flat, like a stage, (…) just the weakest possible mock acting”. And he adds: “The division between public life and private life, identified with the Modern Age, is now viewed as a primitive, surmounted form of the Modern Age”. “This post-Modern Age culture rejects, above all, profundity, the distance between signs and meaning”. The anorectic personality does not get distant from the social-public space, where signs prevail, and consequently does not take his own intimacy as the original source of sense. On the contrary, the anorexic phobically feels he is a prisoner in the social space of sense.

          In this situation, as Sennet says, “The capacity of being expressive is lost, because we try to identify our appearance with our profound being and because we link the problem of expression to that of its authenticity”. If we put this in relation with Touraine’s statement that “authenticity is today a social value (…) there is a search for authenticity, not at all for spontaneity”, we find here another possible relation with the difficulties in A.N. of being expressive of their intimacy, including their usual “alexitimia”.

          Furthermore, in our indiscernible exterior-interior space “we live - according to Baudrillard - in the ecstasy of communication, and this ecstasy is obscene (…). The obscenity begins (…) when everything becomes transparent and immediately visible”.

          Many of these sociological descriptions, and others we have not the time to deal here with, could pass for very good phenomenological descriptions of the existence and psychopathological structures in A.N. But, it is necessary to emphasize that, in this kind of patients, the root of the psychopathological situation is their conflict of identities. The conflict lies between their high differential consciousness of their personal identity and their equalitarian social identity, the identity of belonging to their community structures.

          Following Borne, “The Modern Age is defined as a decisive progress in the conscience of one’s self”. This is why “we look no more for glory, but for identity”, in Baudrillard’s words. And we should bear in mind that this age has given rise to “the passage of destiny from meta-social exteriority (God, Nature) to a socially produced destiny”, according to Anthony Giddens. But, this author continues: “in the later Modern Age (…) the self (…) have to be made reflexively”.

          In fact, nowadays the sentiment of one’s own personal, free, autonomous, independent identity is very high, but “the fight to obtain social recognition does not disappear; rather, it becomes privatized and is manifested in intimate circles”, as Lipovetsky says.

 

All these social conditions are, in my opinion, sparking off the presence of this pathology, A.N., in which the adolescent in search of himself could suffer this kind of alienation of the most intimate space, his own corporeality, with the sense that it obscenely invades the identifying space of society, which menaces him, phobically, with his elimination.