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• Indian J Psychol Med
• v.37(2); Apr-Jun 2015

Case Report on Anorexia Nervosa

Preeti srinivasa.

Consultant Psychiatrist, Spandana Nursing Home, Bangalore, Karnataka, India

M. Chandrashekar

Nikitha harish.

1 Psychiatric Rehabilitator, Spandana Health Care, Bangalore, Karnataka, India

Mahesh R. Gowda

Sumit durgoji.

2 DNB Resident, Spandana Nursing Home, Bangalore, Karnataka, India

Anorexia nervosa is an eating disorder characterized by excessive restriction on food intake and irrational fear of gaining weight, often accompanied by a distorted body self-perception. It is clinically diagnosed more frequently in females, with type and severity varying with each case. The current report is a case of a 25-year-old female, married for 5 years, educated up to 10 th standard, a homemaker, hailing from an upper social class Hindu (Marvadi) family, living with husband's family in Urban Bangalore; presented to our tertiary care centre with complaints of gradual loss of weight, recurrent episodes of vomiting, from a period of two years, menstrual irregularities from 1 year and amenorrhea since 6 months, with a probable precipitating factor being husband's critical comment on her weight. Diagnosis of atypical anorexia nervosa was made, with the body mass index (BMI) being 15.6. A multidisciplinary therapeutic approach was employed to facilitate remission. Through this case report the authors call for the attention of general practitioners and other medical practitioners to be aware of the symptomatology of eating disorders as most patients would overtly express somatic conditions similar to the reported case so as to facilitate early psychiatric intervention.

INTRODUCTION

Eating disorder is defined as a persistent disturbance of eating behavior or behavior intended to control weight, which significantly impairs physical health or psychosocial functioning, often turning out to be chronic psychiatric conditions.[ 1 ] Anorexia nervosa is an eating disorder as recognized by both ICD-10 and DSM-IV-TR. It is characterized by excessive restriction on food intake and irrational fear of gaining weight, often accompanied by a distorted body self-perception. It typically involves excessive weight loss and is usually found to occur more in females than in males.[ 2 ] An individual with anorexia nervosa may exhibit a number of signs and symptoms that may be present but not readily apparent. The type and severity may vary in each case.[ 3 , 4 , 5 ]

Clinically they may present with symptoms of

• Distorted body mass index range; of less than 17.5.[ 6 ]
• Amenorrhea.[ 6 ]
• Fearful of even the slightest weight gain.[ 6 ]
• Cooking elaborate dinners for others, but not eat the food themselves.[ 7 ]
• Hypotension orthostatic hypotension, bradycardia, or tachycardia.
• May frequently be in a sad, lethargic state.[ 8 ]
• Swollen joints, hair loss or thinning.[ 9 ]
• Constipation,[ 10 ] electrolyte imbalance.[ 11 ]
• Lanugo.[ 12 ]

The causes for Anorexia nervosa have been attributed to risk factors such as, family history, obesity, weight concerns, psychiatric comorbidity, and substance abuse.[ 13 , 14 , 15 , 16 ] Although anorexia nervosa is widely described in the Western literature, it is rather rare in nonwestern cultures. In India, the information regarding these disorders is very limited.[ 17 ] In most Indian clinical settings, patients chiefly present with refusal to eat, persistent vomiting, marked weight loss, amenorrhea, and other somatic symptoms, but rarely show over activity or disturbances in body image.[ 18 ] However, the management of the disorder does not markedly vary irrespective of the cultural and ethnic variations in the clinical picture. It calls for the involvement of a multidisciplinary approach.[ 19 ]

In this article, the authors report a case of atypical anorexia nervosa in an attempt to contribute to the Indian literature of eating disorders that currently lacks clinical reports on the same.

CASE REPORT

Case of Mrs S, a 25-year-old female, married for 5 years, educated up to 10th standard, currently a homemaker, hailing from an upper social class Hindu (Marvadi) family, living with husband's family in Urban Bangalore; presented to our tertiary care center with complaints of gradual loss of weight, recurrent episodes of vomiting, from a period of 2 years, menstrual irregularities from 1 year and amenorrhea since 6 months, with a probable precipitating factor being husband's critical comment about her weight. Patient was reported to be dull and inactive most of the times since her marriage able to carry out her activities of daily living adequately. With symptoms of weight loss and amenorrhea, she was evaluated by a physician. A series of investigations were conducted in the background of suspected tuberculosis, anemia for evaluation and abdominal tumors. However, all the investigations were well within normal limits except low hemoglobin.

She was further evaluated by a gastroenterologist; an intestinal biopsy was done to rule out malabsorption syndrome. Gynecological opinion was taken in the background of amenorrhea and infertility, and was advised endometrial biopsy. Endocrinologist was seen and investigations conducted were normal. Thus, no clear cut cause could be established to the loss of weight. The patient was referred to psychiatric consultation by her treating physician as she appeared less cheerful, dull, and inactive and decreased interest in sex.

During psychiatric interview it was difficult to establish rapport and Mrs S was uncooperative. With persistent probing, she expressed low mood, easy fatigability, apathy, decreased attention and concentration, bleak, and pessimistic ideas about future. No suicidal ideas or unusual perceptual experiences were reported. Attempt to establish the cause of above symptoms were futile.

Information was elicited by Mrs S’ husband, revealed an incident during their early days of marriage when he had casually remarked of her being slightly heavy near her flanks and thighs and that she would look more beautiful if she reduced it. Since then her intake of food decreased. She followed a change in the diet pattern with complete avoidance of all foods with high caloric value. She gradually began to skip breakfast and would have minimal lunch. She began to avoid eating in front of other family members. At times hide and eat, and/or would secretly go into the bathroom and induce vomiting.

After repeated sessions, the patient opened up to the clinician. When questioned about her purging behavior, she reported of being unable to tolerate the guilt associated with eating excessively. Patient was re-evaluated and probed about her eating habits. Premorbid personality assessment revealed an over concern about physical appearance, inspired by skinny models. She reported of wanting to impress her husband with her beauty as he was fond of thin looking girls. She recalled that her husband would repeatedly compare her with thin looking girls on television and magazines. She eventually developed a morbid fear of looking fat and ugly, began eating a handful of fennel seeds to facilitate digestion. She would use soap water enema and would occasionally use laxatives. Her weight dropped from 59 to 30 kg.

During clinical examination, her weight was 30 kg in relation to her height being 5.4 ft and a BMI of 15.6. She had lanugo hair on her face and looked emaciated. Vitals were stable and systemic examination was normal. Her thyroid function was normal, serum electrolytes were normal, her hemoglobin was 8 gm/dl. Clinical depression was ruled out and a diagnosis of atypical anorexia nervosa was made (according to ICD-10). The general health questionnaire (GHQ) and the eating disorder examination questionnaire (EDE-Q) were administered. She was admitted for inpatient care and started immediately on IV fluids. Initially she developed facial edema that gradually reduced with fluid redistribution. A multidisciplinary team approach was employed. Psycho education with regard to the disorder was given. Nutritional rehabilitation was planned, where she was asked to maintain a dairy about her intake of food. She was encouraged to eat food with high caloric value.

Post sessions with the family, husband was involved in the therapeutic process and was asked to keep a watch on her purging behavior. The patient was simultaneously given Cyproheptadine and low dose Olanzapine. Her weight gain after 1 week was 2 kg. Mrs S gradually became cooperative for treatment process. Supportive psychotherapy was planned that provided a maximum understanding of the patient perspective. Techniques of insight-oriented psychotherapy and cognitive behavioral therapy were structured to address the cognitive distortions. She was subsequently discharged and a follow up for every 2 weeks was done. Her weight gain at the end of 1 month was 4 kg. At the end of 6 months, there was a weight gain of 15 kg. At the end of 1 year, there was a relapse in symptoms with patient reported of decreased intake of food and purging tendencies. The symptoms were addressed through Psychotherapy only. Mrs S’ symptoms remitted. At the end of 2 years, her weight was 55 kg with no fresh complaints.

Though the cases of anorexia nervosa are reported greatly in the grey literatures of the western countries, the number of clinical cases in India is on the rise. The age of onset for most cases ranges between 12 to 20 years.[ 20 ] Most cases are brought to clinical attention only when there are severe somatic complaints.[ 18 ] In this case, Mrs S was taken to the physician by her husband with symptoms of weight loss and amenorrhea. Multiple specialist opinions were taken to ascertain the cause of symptomatology. With no clear cut causal factor, the case as referred for psychiatric evaluation. The clinical picture led to the diagnosis of anorexia nervosa. There were no other potentially fatal medical consequences as the case was referred at the earliest by the physician. By reporting the particular case, the authors call for the attention of general practitioners and other medical practitioners to be aware of the symptomatology of eating disorders as most patients would overtly express somatic conditions similar to the reported case. Such awareness would have called for an earlier psychiatric intervention and curbed other unnecessary investigations.

Ethical considerations

• The confidentiality of the identity of the patient has been ensured.
• The patient has been informed of the publication of the case.
• The case report is in the best interest of the community and to create awareness among mental and general health professionals.
• A copy of the article has been submitted to the ethical committee for clearance.

ACKNOWLEDGMENT

The authors thank Dr. M. Srinivasa, Director Spandana Nursing Home for his valuable guidance. We thank Dr. S. Kanchana for her clinical guidance and Mr. H. D. Harish for his ardent support. We also thank the treating team and the nursing staff at the Spandana Health Care for their minute yet valuable support.

Source of Support: Nil

Conflict of Interest: None.

Antonella: ‘A Stranger in the Family’—A Case Study of Eating Disorders Across Cultures

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The story of Antonella illustrates the way in which cultural and other values impact on the presentation and treatment of eating disorders. Displaced from her European home culture to live in Canada, Antonella presents with an eating disorder and a fluctuating tableau of anxiety and mood symptoms linked to her lack of a sense of identity. These arose against a background of her adoption as a foundling child in Italy and her attachment problems with her adoptive family generating chronically unfixed and unstable identities, resulting in her cross-cultural marriage as both flight and refuge followed by intense conflicts. Her predicament is resolved only when after an extended period in cultural family therapy she establishes a deep cross-species identification by becoming a breeder of husky dogs. The wider implications of Antonella’s story for understanding the relationship between cultural values and mental health are briefly considered.

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Overlaps and Disjunctures: A Cultural Case Study of a British Indian Young Woman’s Experiences of Bulimia Nervosa

René girard and the mimetic nature of eating disorders, the rise of eating disorders in asia: a review.

• Eating disorders
• Anorexia multiforme
• Cultural values
• Uniqueness of the individual
• Role of animals
• Cross-species identification
• Cultural family therapy

1 Introduction

Eating disorders are a potentially fruitful area of study for understanding the links between values—in particular cultural values—and mental distress and disorder. Eating disorders show widely different prevalence rates across cultures, and much attention has been given to theories linking these differences with variations in cultural values. In particular, the cultural value placed on ‘fashionable slimness’ in the industrialised world has for some time been identified with the greater prevalence of eating disorders among women in Western societies [ 1 ]. Consistently with this view, the growing prevalence of eating disorders in other parts of the world does seem to be correlated with increasing industrialisation [ 2 , 3 ]. In my review of cultural distribution and historical evolution of eating disorders , I was so struck by its protean nature and its variability of clinical presentations of anorexia nervosa that I renamed this predicament ‘anorexia multiforme’ [ 4 , 5 ].

The story of Antonella that follows illustrates the potential importance of contemporary theories linking cultural values with eating disorders though also some of their limitations.

2 Case Narrative: Antonella’s Story

Ottawa in the early 1990s. Antonella Trevisan, a 24-year-old woman, was referred to me by an Italian psychiatrist and family therapist, Dr. Claudio Angelo, who had treated her in Italy [ 6 ] . When Antonella came to Canada to live with a man she had met through her work, Dr. Angelo referred her to me. Antonella’s presenting problems concerned two areas of her life: her eating problems, which emerged after her emigration from Italy, and her relationship with her partner in Canada.

2.1 Antonella’s Predicament

My initial psychiatric consultation (conducted in Italian) revealed the complexities of Antonella’s life. This was reflected in the difficulty of making an accurate diagnosis. Her food-related problems had some features of eating disorders , such as restriction of intake, the resulting weight loss, and a history of weight gain and being teased for it. What was missing was the ‘psychological engine’ of an eating disorder: a drive for thinness or a morbid fear of fatness. Her problem was perhaps better understood as a food-related anxiety arising from a ‘globus’ sensation (lump in the throat) and a learned avoidance response that generalized from one specific situation to eating in any context.

Although it was clear that her weight gain in late adolescence and the teasing and insults from her mother had sensitized her, other factors had to be considered. Antonella showed an exquisite rejection sensitivity that both arose from and was a metaphor for the circumstances of her birth and adoption. Her migration to Canada also seemed to generate anxieties and uncertainties, and there were hints of conflicts with her partner. Was she also re-enacting another, earlier trauma? In the first journey of her life, she was given up by her birth mother (or taken away?) and left on the steps of a foundry. In the first year of her life, Antonella had shown failure to thrive and developmental delays. And she had, at best, an insecure attachment to her adoptive family, predisposing her to lifelong insecurities.

2.2 A Therapeutic Buffet

After my assessment, we faced a choice: whether to treat the eating problem concretely, in purely behavioral terms, or more metaphorically, with some form of psychotherapy. Given the stabilization of her eating pattern and her weight and the larger context of her predicament, we negotiated to do psychotherapy. There were several components to her therapy. Starting with a psychiatric consultation, three types of therapy were negotiated, with Antonella sampling a kind of ‘therapeutic buffet’ over a period of some 2 years: individual therapy for Antonella, couple therapy for Antonella and Rick, and brief family therapy with Antonella’s adoptive family visiting from Italy.

The individual work with Antonella was at first exploratory, getting to know the complex bicultural world of the Italian Alps, how she experienced the move to Canada, examining her choices to move here and live with Rick. Sessions were conducted in a mix of Italian and English. At first, the Italian language was like a ‘transitional object’ in her acculturation process; slowly, as she gained confidence in her daily life, English began to dominate her sessions. Under stress, however, she would revert to Italian. I could follow her progress just by noting the balance of Italian and English in each session. This does not imply any superiority of English or language preferences; rather, it acknowledges the social realities of culture making its demands felt even in private encounters. This is the territory of sociolinguistics [ 7 , 8 ] . Like Italian, these individual sessions were a secure home base to which Antonella returned during times of stress or between other attempts to find solutions.

After some months in Canada and the stabilization of her eating problems, Antonella became more invested in examining her relationship to Rick. They had met through work while she was still in Italy. After communicating on the telephone, she daringly took him up on an offer to visit. During her holiday in Canada, a romance developed. After her return to Italy, Antonella made the extraordinary decision to emigrate, giving up an excellent position in industry, leaving her family for a country she did not know well. Rick is 22 years her senior and was only recently separated from his first wife.

In therapy she not only expressed ambivalence about her situation with Rick but enacted it. She asked for couple sessions to discuss some difficulties in their relationship. Beyond collecting basic information, couple sessions were unproductive. While Rick was frank about his physical attraction to her and his desire to have children, Antonella talked about their relationship in an oddly detached way. She could not quite articulate her concerns. As we got closer to examining the problems of their relationship, Antonella abruptly announced that they were planning their wedding. The conjoint sessions were put on hold as they dealt with the wedding arrangements.

Her parents did not approve of the marriage and boycotted the wedding. Her paternal aunt, however, agreed to come to Canada for the wedding. Since I was regarded by Antonella as part of her extended family support system, she brought her aunt to meet me. It gave me another view of Antonella’s family. Her aunt was warm and supportive of Antonella, trying to smooth over the family differences. A few months later, at Christmas time, her parents and sister visited, and Antonella brought them to meet me. To understand these family meetings, however, it is necessary to know Antonella’s early history.

2.3 A Foundling Child

Antonella was a foundling child. Abandoned on the steps of a foundry in Turin as a newborn, she was the subject of an investigation into the private medical clinics of Turin. This revealed that the staff of the clinic where she was born was ‘paid off to hide the circumstances of my birth.’ As a result, her date of birth could only be presumed because the clinic staff destroyed her birth records. She was taken into care by the state and, as her origins could not be established, she was put up for adoption.

Antonella has always tried to fill in this void of information with meaning that she draws from her own body. She questions me closely: ‘Just look at me. Don’t you think I look like a Japanese?’ She feels that her skin tone is different from other Italians, that her facial features and eyes have an ‘Asian’ cast. With a few, limited facts, and some speculation, she has constructed a personal myth: that she is the daughter of an Italian mother from a wealthy family (hence her hidden birth in a private clinic) and a Japanese father (hence her ‘Asian’ features). It is oddly reassuring to her, but also perhaps a source of her alienation from her family.

At about 6 months of age, Antonella was adopted into a family in the Italian Alps, near the border with Austria. This is a bicultural region where both Italian and German are spoken and services are available in both languages (much like Ottawa, which is bilingually English and French). Her father, Aldo, who is Italian, is a retired FIAT factory worker. Annalise, her mother, who is a homemaker, had an Italian father and an Austrian mother. About her family she said, ‘I had a wonderful childhood compared to what came afterwards.’ Years after her adoption, her parents had a natural child, Oriana, who is 15.

She describes her mother as the disciplinarian at home. Her mother, she said, was ‘tough, German.’ When she visited her Austrian grandmother, no playing was allowed in that strict home. Her own mother allowed her ‘no friends in the house,’ but her father ‘was my pal when I was a kid.’ Although she had a good relationship with her father, he became ‘colder’ when she turned 13. Her parents’ relationship is remembered as cordial, but she later learned that they had many marital problems. Mother told her that she married to get away from home, but in fact she was in love with someone else. Overall, the feeling is of a rigid family organization. Her father is clearly presented by Antonella as warmer and more sociable. She experiences her mother as being ‘tough’. But she is crying all the time, feeling betrayed by everybody.

2.4 A Family Visit from the Italian Alps

When her family finally came to visit, Antonella brought them to see me. At first, the session had the quality of a student introducing out-of-town parents to her college teacher. They were pleased that I spoke Italian and knew Dr. Angelo, who they trusted. I soon found that the Trevisans were hungry to tell their story. Instead of a social exchange of pleasantries, this meeting turned into the first session of an impromptu course of brief family therapy.

Present were Antonella’s parents, Aldo and Annalise, and her sister, Oriana. Annalise led the conversation. Relegating Aldo to a support role. Oriana alternated between disdain and agitation, punctuated by bored indifference. Annalise had much to complain about: her own troubled childhood, her sense of betrayal and abandonment, heightened by Antonella’s departure from the family and from Italy. I was struck by the parallel themes of abandonment in mother and daughter. Mother clearly needed to tell this story, so I tried to set the stage for the family to hear her, what narrative therapists call ‘recruiting an audience’ [ 9 ] . I used Antonella, who I knew best, as a barometer of the progress of the session, and by that indicator, believed it had gone well.

When I saw them again some 10 days later, I was stunned by the turn of events. Oriana had assaulted her parents. The father had bandages over his face and the mother had covered her bruises with heavy make-up and dark glasses. Annalise was very upset about Oriana, who was defiant and aggressive at home. For her part, Oriana defended herself by saying she had been provoked and hit by her mother. Worried by this dangerous escalation, I tried to open some space for a healthy standoff and renegotiation.

Somehow, the concern had shifted away from Antonella to Oriana. Antonella was off the hook, but I waited for an opening to deal with this. I first tried to explore the cultural attitudes to adolescence in Italy by asking how the Italian and the German subcultures in their area understood teenagers differently. What were Oriana’s concerns? Had they seen this outburst coming? The whole family participated in a kind of sociological overview of Italian adolescence, with me as their grateful audience. The parents demonstrated keen insight and empathy. Concerned about Oriana’s experience of the session, I made a concerted effort to draw her into it. Eventually, the tone of the session lightened. Knowing they would return to Italy soon, I explored whether they had considered family work. Since they had met a few times with Dr. Angelo over Antonella’s eating problems, they were comfortable seeing Dr. Angelo as a family to find ways to understand Oriana and her concerns and for Oriana to explore other, nonviolent ways to be heard in the family. I agreed to meet them again before their departure and to communicate with Dr. Angelo about their wishes. On their way out, I wondered aloud about the apparent switch in their focus from Antonella to Oriana. The parents reassured me that they were ready to let Antonella live her own life now.

When they returned to say goodbye, we had a brief session. Oriana and Antonella were oddly buoyant and at ease. The parents were relieved. Antonella had offered the possibility of Oriana returning to spend the summer in Canada with her. I tried to connect this back to the previous session, wondering how much the two sisters supported each other. I was delighted, I said emphatically, by the family’s apparent approval of Antonella’s marriage to Rick. It was striking that, even from a distance of thousands of miles away, Antonella was still a part of the Trevisan family. And Rick was still not in the room.

3 Discussion

In this section, I will consider the impact of cultural and other values on Antonella and those around her and then look briefly at the wider implications of her story for our understanding not only of eating disorders but of mental distress and disorders in general.

3.1 Antonella: Life Before Man

The key to understanding Antonella’s attachments was her passion for her Siberian huskies. In the language of values-based practice , it was above all her huskies that mattered or were important to her. And it is not hard to see why. From the beginning of her relationship with Rick, she used her interest in dogs as a way for them to be more socially active as a couple, getting them out of the house to go to dog shows, for example. As her interests expanded, she wanted to buy bitches for breeding and to set up a kennel. Rick was only reluctantly supportive in this. Nonetheless, they ended up buying a home in the country where she could establish a kennel. Her haggling with Rick over the dogs was quite instrumental on her part, representing her own choices and interests and a test of the extent to which Rick would support her.

Yet the importance to Antonella of her huskies rests I believe on deeper cultural factors, both negative and positive. As to negative factors , these are evident in the fact that from the first days of her life, Antonella was rejected by her birth parents, literally abandoned and exposed, and later adopted by what she experienced as a non-nurturing family. Positive cultural factors , on the other hand, are evident in the way that having thrown her net wider afield, she looked initially to Canada, and to Rick, for nurturance and for identity. Then, finding herself only partly satisfied, she turned to the nonhuman world for the constancy of affection she could not find with people. Her huskies gave her pleasure, a task, and an identity. She spent many sessions discussing their progress, showing me pictures of her dogs and their awards. As it happened, my secretary at the time was also a dog lover who raised Samoyed dogs (related to huskies) and the two of them exchanged stories of dog lore.

As to positive factors , again, is there something, too, in the mythology of Canada that helps us understand Antonella? Does Canada still hold a place in the European imagination as a ‘New World’ for radical departures and identity makeovers? Or does Canada specifically represent the ‘malevolent North,’ as Margaret Atwood [ 10 ] calls it in her exploration of Canadian fiction? Huskies are a Northern animal, close to the wolf in their origins and habits. Bypassing the human world, Antonella finds her identity within a new world through its animals. If people have failed her, then she will leave not only her own tribe (Italy), but skip the identification with Canada’s Native peoples, responding to the ‘call of the wild’ to identify with a ‘life before man’ (to use another of Atwood’s evocative phrases, [ 11 ]), finding companionship and solace with her dogs.

3.2 Wider Implications of Antonella’s Story

Antonella may seem on first inspection something of an outlier to the human tribe. Orphaned from her culture of origin, she finds her place not in another country but by identification with another and altogether wilder species, her husky dogs. Yet, understood through the lens of values-based practice Antonella’s story has, I believe, wider significance at a number of levels.

First, Antonella’s story is significant for our understanding of the role of values – of what is important or matters to the individual concerned – in the presentation and treatment of eating disorders , and, by extension, of perhaps many other forms of mental distress and disorder. Specifically, her story provides at least one clear ‘proof of principle’ example supporting the role of cultural values.

As noted in my introduction, much attention has been given in the literature to the correlations between the uneven geographical distribution of eating disorders and cultural values. Correlations are of course no proof of causation. But in Antonella’s story at least the role of cultural values seems clearly evident. They were key to understanding her presenting problems. And this understanding in turn proved to be key to the cultural family therapy [ 12 ] through which these problems were, at least to the extent of her presenting eating disorder, resolved.

The cultural values involved, it is true, were not those of fashionable slimness so widely discussed in the literature. But this takes us to a second level at which Antonella’s story has wider significance. For it shows that to the extent that cultural values are important in eating disorders , their importance plays out at the level of individually unique persons. In this sense, social stresses and cultural values are played out in the body of the individual suffering with an eating disorder, making her body the ‘final frontier’ of psychiatric phenomenology [ 13 ]. Yes, there are no doubt valid cultural generalisations to be made about eating disorders and mental disorders of other kinds. And yes, these generalisations no doubt include generalisations about cultural values—about things that matter or are important to this or that group of people as a whole. Yet, this does not mean that we can ignore the values of the particular individual concerned. It has been truly said in values-based practice that as to their values, everyone is an ‘ n of 1’ [ 14 ]. Antonella, then, in the very idiosyncrasies of her story, reminds us of the idiosyncrasies of the stories of each and every one of us, whatever the culture or cultures to which we belong.

Antonella’s identification with animals , furthermore, to come to yet another level at which her story has wider significance, was a strongly positive factor in her recovery. As with other areas of mental health, it is with the negative impact of cultural values that the literature has been largely concerned: the pathogenetic influences of cultural values of slimness being a case in point in respect of eating disorders . Antonella’s story illustrates what has been clear for some time in the ‘recovery movement’, that positive values are often the very key to recovery. Not only that, but as Antonella’s passion for her husky dogs illustrates, the particular positive values concerned may, and importantly often are, individually unique.

Not, it is worth adding finally, that Antonella’s values were in this respect entirely unprecedented. Animals , after all, are widely valued, positively and negatively, and for many different reasons, in many cultures [ 11 ]. Their healing powers are indeed acknowledged. Just how far these powers depend on the kind of cross-species identification shown by Antonella, remains a matter for speculation. But, again, her story even in this respect is far from unique. Elsewhere, I have described the story of a white boy with what has become known as the ‘Grey Owl Syndrome’ , wishing to be native [ 12 , chapter 5 ]. Similarly, in Bear , Canadian novelist Marion Engel [ 15 ] portrays Lou, a woman who lives in the wilderness and befriends a bear. Lou seeks her identity from him: ‘Bear, make me comfortable in the world at last. Give me your skin’ [ 15 , p. 106]. After some time with the bear, the woman changes: ‘What had passed to her from him she did not know…. She felt not that she was at last human, but that she was at last clean’ [ 15 , p. 137]. It was perhaps to some similarly partial resolution that Antonella came.

4 Conclusions

Antonella’s story as set out above goes to the heart of the importance of cultural values in mental health. Her presenting eating disorder develops when, displaced from her culture of origin in Italy, and in effect rejected by her birth family, she finds healing only through cross-species identification with the wildness of husky dogs in her adoptive country of Canada. Although somewhat unusual in its specifics, her story illustrates the importance of cultural values at a number of levels in the presentation and management of eating and other forms of mental distress disorder.

And Antonella? I met her again in a gallery in Ottawa, rummaging through old prints. She was asking about prints of dogs; I was looking for old prints of Brazil where my father had made a second life. How was she, I asked? ‘Well …,’ she said hesitantly. Was that a healthy ‘well’ or the start of an explanation? ‘Me and Rick are splitting up,’ she said without ceremony, ‘but I still have the huskies.’ For each of us, the prints represented another world of connections.

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Acknowledgements

The story of Antonella was first published in reference [ 12 ] (pp. 214–220) and presented at the Advanced Studies Seminar of the Collaborating Centre for Values-based Practice in Health and Social Care at St Catherine’s College, Oxford in October 2019. The names and other details of the case have been altered to maintain confidentiality. Parts of the discussion are adapted from that publication and the Oxford seminar. I am grateful to the publishers for permission to reproduce these materials here and to Professor Fulford and the members of the Advanced Studies Seminar for their stimulating exchanges. The subheading to the discussion of Antonella’s story (‘Life before Man’) was inspired by Margaret Atwood’s novel, Life Before Man [ 11 ].

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Vincenzo Di Nicola

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Drozdstoy Stoyanov

St Catherine’s College, University of Oxford, Oxford, UK

Bill Fulford

Department of Psychological, Health & Territorial Sciences, “G. D’Annunzio” University, Chieti Scalo, Italy

Giovanni Stanghellini

Centre for Ethics and Philosophy of Health Sciences, University of Pretoria, Pretoria, South Africa

Werdie Van Staden

Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China

Michael TH Wong

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For a more extended treatment of the role of culture in eating disorders and family therapy see:

Di Nicola VF (1990a) Overview: Anorexia multiforme: Self-starvation in historical and cultural context. I: Self-starvation as a historical chameleon. Transcultural Psychiatric Research Review, 27(3): 165–196.

Di Nicola VF (1990b) Overview: Anorexia multiforme: Self-starvation in historical and cultural context. II: Anorexia nervosa as a culture-reactive syndrome. Transcultural Psychiatric Research Review, 27(4): 245–286.

Di Nicola, V (1997) A Stranger in the Family: Culture, Families, and Therapy . New York & London: W.W. Norton & Co.

Nasser M and Di Nicola, V. (2001) Changing bodies, changing cultures: An intercultural dialogue on the body as the final frontier. In: Nasser M, Katzman M A, and Gordon R A, eds. Eating Disorders and Cultures in Transition . East Sussex, UK: Brunner-Routledge, pp. 171–193.

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Di Nicola, V. (2021). Antonella: ‘A Stranger in the Family’—A Case Study of Eating Disorders Across Cultures. In: Stoyanov, D., Fulford, B., Stanghellini, G., Van Staden, W., Wong, M.T. (eds) International Perspectives in Values-Based Mental Health Practice. Springer, Cham. https://doi.org/10.1007/978-3-030-47852-0_3

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• Published: 17 May 2024

Dismantling the myth of “all foods fit” in eating disorder treatment

• Timothy D. Brewerton 1 ,
• Kim Dennis 2 , 3 &
• David A. Wiss 4  

Journal of Eating Disorders volume  12 , Article number:  60 ( 2024 ) Cite this article

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We call for a reevaluation of the long-standing dogmatic nutritional principle that “all foods fit” for all cases of eating disorders (EDs) and its corollary, “there are no bad foods” (for anyone ever) during ED treatment. Based on accumulated scientific research, we challenge these ideologies as outdated, confusing, and potentially harmful to many patients. We review the evidence that indicates the folly of these assumptions and show there are a variety of exceptions to these rules, including (1) food allergies, sensitivities, and intolerances, (2) religious and spiritual preferences or doctrines, and (3) the ubiquitous emergence and widespread availability of ultra-processed foods leading to the potential development of addiction-like eating and a higher prevalence of various medical and psychiatric comorbidities, as well as higher mortality. This evidence supports a nutritional psychiatry approach that should be integrated into (rather than dissociated from) ED treatment research and practice.

The adage, “all foods fit,” has been an eating disorder (ED) treatment dogma for decades. In other words, there is an almost monolithic belief or proclamation within the ED field that “there are no bad foods” when it comes to the nutritional rehabilitation of all patients with all forms of EDs. Decades of clinical experience have demonstrated that this approach is helpful in addressing the restrictive dimension of ED pathology across phenotypes. However, for many individuals with EDs, eating symptoms extend beyond the domain of dietary restraint. The well-intentioned assertion that “all foods fit” persists in the anti-diet culture movement despite mounting evidence substantiating the association of ultra-processed foods with negative physical and mental health outcomes.

This essay calls into question these suppositions and proclaims that for many patients, they, at best, represent an incomplete truth and, at worst, stand to cause harm. When uniformly and rigidly applied to all patients, the age-old adage that “all foods fit” no longer serves the entire ED treatment community. This is most pressingly true for patients with EDs from communities historically marginalized and underrepresented in ED research, advocacy groups, training programs, and treatment settings. We will discuss why assumptions associated with “all foods fit” are outdated and incomplete concepts for some patients with EDs. These strong assumptions no longer align with the evidence base that has emerged over the last decade, which we as clinical scientists strive to translate to good clinical care.

“Food is medicine,” a shortened version of “Let thy food be thy medicine, and thy medicine be thy food,” has also been a related ED dogma for decades. This saying (often misattributed to Hippocrates), carries a lot of truth and heuristic value [ 1 ]. However, are all foods medicinal? Are there any “bad” or harmful medicines for any given patient? Of course, there are. Medicines are neither “good” nor “bad” unto themselves. It’s how they’re used or prescribed, for which problems, in which persons, at what times, and in what doses. The same medicine may help or harm an individual depending on many factors, and biopsychosocial-spiritual context is paramount.

The scientific literature clearly indicates that some foods “don’t fit” and are harmful, at least to some people under specific circumstances. An obvious example is a food allergy, which can cause various problems, including anaphylaxis, which has been increasing in prevalence and affects up to 20% of individuals in the population [ 2 , 3 ]. There are 14 identified food allergens: celery, cereals containing gluten (such as barley and oats), crustaceans (such as prawns, crabs, and lobsters), eggs, fish, lupin, milk, mollusks (such as mussels and oysters), mustard, peanuts, sesame, soybeans, sulfur dioxide and sulfites (at concentrations > ten parts per million) [ 4 ]. Food allergies are associated with high degrees of psychological distress and significantly reduced health-related quality of life [ 5 ]. In addition, recent studies suggest positive associations between EDs and food allergies, so this is an important area of inquiry in clinical evaluation and subsequent dietary management [ 6 ].

A related problem is food sensitivity, in which certain individuals develop various adverse effects, both acute and chronic, including neurobehavioral, gastrointestinal, metabolic, or teratogenic consequences, upon exposure to certain substances, such as gluten, food additives, Fermentable Oligo-, Di- and Mono-saccharides And Polyols (FODMAPs), and non-nutritive sweeteners [ 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. There are several examples of these phenomena relevant to the treatment of patients with EDs, including comorbid migraine headaches, irritable bowel syndrome, attention deficit hyperactivity disorder (ADHD), major depressive disorder, and anxiety disorders [ 12 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ], in which a nutritional psychiatry perspective can be highly influential [ 26 , 27 , 28 ].

While not eating can be a trigger for acute migraine headache, so can the ingestion of certain foods, such as those containing monosodium glutamate, sugar, alcohol, nitrites, gluten, cheese, chocolate, caffeine, and fermented, processed, and pickled foods [ 29 , 30 , 31 ]. However, not all foods will trigger migraine in every individual with migraines, and there is tremendous variation that needs to be individually evaluated [ 32 ]. For a patient with an ED, restrictive or not, and comorbid migraine, who routinely gets migraine headaches after consuming certain food types, they may need a meal plan that explicitly does not include or includes very little of those foods. Often, in ED treatment, patients expressing preferences to avoid these foods are assumed to be related to restrictive pathology rather than intuitive eating and adaptive dietary restraint. Nevertheless, dietary interventions have been successfully employed in the treatment of this common comorbidity that needs to be routinely considered in the comprehensive treatment of ED patients [ 13 , 30 , 33 ].

Attention deficit hyperactivity disorder (ADHD) is another disorder commonly associated with EDs that may be affected by nutritional intake of specific substances, such as food color additives [ 34 , 35 , 36 , 37 ]. Of particular interest are several studies showing that a diet high in refined sugar and saturated fat can increase the risk of ADHD, whereas a diet characterized by higher consumption of whole fruits and vegetables may be protective against ADHD [ 38 ].

Apart from allergies and sensitivities, some individuals have food intolerances (e.g., lactose, gluten, onions, shallots, leeks, bell peppers, etc.), all of which can cause gastrointestinal distress and which have been associated with anxiety and depression [ 39 , 40 , 41 , 42 , 43 ].

Then, there are individual food preferences for religious, spiritual, and/or ethical reasons, such as those who are vegan, vegetarian, pescatarian, Kosher, etc [ 44 , 45 , 46 ]. . . These proclivities have only sometimes been respected by ED therapists and programs, and practices have evolved over time as it has been realized that more research is needed to decipher their effects on clinical course and outcomes [ 46 , 47 , 48 , 49 ].

What is particularly controversial of late is the issue of food addiction (FA) or ultra-processed food addiction (UPFA), which, despite its strong scientific foundation [ 50 , 51 ], remains highly controversial in ED circles [ 52 ]. Unfortunately, UPFA and its treatment often get conflated with caloric restriction and diet culture, which are not equivalent. In fact, there are studies currently examining flexible, calorically robust, and weight-neutral dietary interventions for patients with FA [ 53 ]. Ultra-processed foods (UPFs), which are now identified as NOVA-4 in the NOVA classification system [ 54 ], have been associated with a host of adverse health effects and increased mortality [ 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 ]. The NOVA classification system categorizes foods according to their degree of processing, and the NOVA-4 group includes foods with the highest degree of processing. Specifically, they include packaged formulations of industrial ingredients and substances derived from foods or else created in laboratories, and typically contain little or even no whole foods [ 66 ]. UPFs have been shown to promote binge eating [ 67 , 68 ] and higher body weights [ 69 , 70 , 71 , 72 ], as well as worsen depression [ 73 , 74 , 75 , 76 , 77 ], type-2 diabetes [ 78 , 79 ], cardiovascular disease [ 80 , 81 , 82 , 83 , 84 ], and chronic kidney disease [ 85 ]. In terms of mechanisms for this multitude of adverse effects, UPFs have been associated with stimulating inflammation, altering multiple neurobiological and endocrine pathways (e.g., insulin), and disrupting the microbiome [ 86 , 87 , 88 ]. The presence of UPFA has also been associated with a poorer treatment outcome for binge eating disorder [ 89 ], which is known to be highly comorbid with addiction-like eating [ 90 , 91 , 92 ].

The intake of UPFs accounts for the great majority of calories ingested in Westernized countries and is only increasing in availability and popularity as time goes on [ 93 ]. Estimates of the worldwide prevalence of FA/UPFA using the Yale Food Addiction Scale are on the order of 14% in non-clinical samples [ 94 ]. In addition to having high concentrations of refined sugars and oils, UPFs also contain potentially obesogenic endocrine-disrupting chemicals that have been added (or neo-formed during high heat processes) to foods and food packaging by the food industry for the last several decades [ 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 ]. Many have called out the crisis in food quality as a major public health problem [ 65 , 107 ], and its contribution to the ED field is substantial, albeit mostly unrecognized. Up to 80% of food advertising promotes UPF and drink products, with food companies often targeting communities of color [ 108 ]. The ED community disregarding the role of the food supply chain and systemic racism in food access further compounds the racial inequities marginalized communities face with regard to accessing culturally attuned, comprehensive ED care [ 109 ].

We contend that inattention to and outright avoidance of the adverse effects of the Western diet has been a gaping blind spot of ED research and practice and, therefore, draw attention to the dire need to address this [ 86 ]. Evidence-based treatment of EDs is a work in progress, and much research remains to be done to establish best practices, particularly for patients of color and for newer diagnostic categories like atypical anorexia nervosa. Outcomes are less than ideal, particularly in complex patients with multimorbidity, such as those with addiction-like eating [ 110 , 111 ].

We understand the resistance to any departure from an “all foods fit” philosophy. The toxic impact of diet culture, intensified by social media, and its impact on people with restrictive EDs of all body sizes is an important factor. A “one size fits all” mentality is simple and easy to implement, particularly in treatment centers where services are scaled, staff turnover may be high, and individualized nutritional approaches may be challenging to implement and manage in a therapeutic milieu. Maintaining the status quo self-serves ED programs, which then don’t have to individualize nutritional approaches and can avoid the clinical work of supporting patients who may be triggered by peers with different nourishment plans. This stance may avoid potential conflicts among patients with various types of EDs who have different nutritional needs. Patients with ED (and their care teams) are often competitive, prefer rigid rules, and have strong tendencies to compare treatment approaches, including meal plans, with each other or across programs.

We posit that another major reason for the anti-FA stance of many in the ED field is that FA/UPFA is associated with obesity. This topic has become taboo in the ED field largely as a result of weight-based stigma that has harmed (and continues to harm) many patients with ED living in larger bodies navigating medical and mental health treatment settings [ 112 , 113 , 114 , 115 , 116 ]. Any suggestion of reducing or eliminating UPFs is often equated with caloric restriction or attempts to lose weight, which is viewed as anathema to a traditional ED treatment philosophy [ 117 ]. All too often, ED professionals do not acknowledge that there may be times when a patient’s desire to lose weight is not necessarily reflective of restrictive ED pathologies, such as when there is comorbid type II diabetes, pseudotumor cerebri, hypertension, heart disease, or severe osteoarthritis. In fact, there are definitely times when weight loss occurs as a result of improved eating behaviors and normalized eating in the course of ED treatment. There may be times when it is indicated and appropriate, even in patients who may have or have had EDs, to support rather than pathologize a patient’s desire to lose weight, for example, when the benefits of weight loss can reasonably be expected to outweigh the risks. Care must be taken to mitigate the risk of worsening disordered eating behaviors and cognitions and to ensure that patients are fully nourished. The importance of advocacy for body neutrality and weight-inclusive care is essential, especially for ED patients in larger bodies who have suffered great harm from implicit bias related to weight stigma. Ongoing advocacy is undoubtedly of critical importance, but we maintain that a balanced, culturally attuned, individualized, and scientifically sound approach is needed, given how highly contentious these issues are and the limitations of these data. For example, recent studies illustrate that weight loss can be achieved in patients in higher weight categories who are receiving appropriate medical supervision without exacerbating ED symptoms and behaviors [ 118 , 119 , 120 , 121 , 122 , 123 ]. In fact, in a recent systematic review of ED risk during behavioral weight management in adults with overweight or obesity, out of 14 studies that reported the prevalence of binge eating, all 14 studies reported a reduction in binge frequency [ 121 ]. In addition, in those studies that measured global ED symptoms, the majority of studies reported reductions in ED risk. As stated in the new guidelines for treating EDs in patients living in larger bodies, “The presence of an eating disorder should not delay and does not preclude treatment for other medical/psychological conditions” [ 117 ]. Nevertheless, future research on better meeting the needs of the increasing population of ED patients with higher weights will hopefully continue to open up more avenues of effective, weight-inclusive, comprehensive care [ 124 ].

Notwithstanding, if the ED treatment community doesn’t acknowledge the evolving nutritional science, the role of the food environment, and medical multimorbidity and integrate this biopsychosocial perspective into our practices, there is a great risk of inflicting harm on our patients, as well as losing our credibility as a field [ 86 ]. In our opinion, it is imperative that ED clinicians challenge any all-or-nothing thinking that they may have when it comes to the dogmatic nutritional approaches like “all foods fit” and instead make way for a more nuanced, scientifically sound approach that accounts for the myriad of complex comorbidities that ED patients may present with that may necessitate more fine-tuned nutritional prescriptions. We owe it to the 30–40% of patients who do not fully recover with current evidence-based, standard ED treatment approaches, not to mention the countless patients who have no access to clinical trials or treatment settings and of course, those who avoid ED care altogether for fear of being pathologized and poorly served by paternalistic ED treatment delivery models.

Data availability

No datasets were generated or analysed during the current study.

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T.B. wrote the initial draft, and all authors participated in the creation, preparation, and editing of the manuscript.

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Clinical implications

The ED dogma that “all foods fit” is outdated and potentially harmful to many. Evidence indicates several exceptions to this rule, including the following: (a) food allergies, sensitivities, intolerances, (b) religious/spiritual preferences (c) ultra-processed foods, which promote addiction-like eating, higher morbidity/mortality. This evidence should be integrated into (rather than dissociated from) ED treatment.

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Brewerton, T.D., Dennis, K. & Wiss, D.A. Dismantling the myth of “all foods fit” in eating disorder treatment. J Eat Disord 12 , 60 (2024). https://doi.org/10.1186/s40337-024-01017-9

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• About Adverse Childhood Experiences
• Risk and Protective Factors
• Program: Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action
• Adverse childhood experiences can have long-term impacts on health, opportunity and well-being.
• Adverse childhood experiences are common and some groups experience them more than others.

What are adverse childhood experiences?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). Examples include: 1

• Experiencing violence, abuse, or neglect.
• Witnessing violence in the home or community.
• Having a family member attempt or die by suicide.

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. Examples can include growing up in a household with: 1

• Substance use problems.
• Mental health problems.
• Instability due to parental separation.
• Instability due to household members being in jail or prison.

The examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and well-being. This can include not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination. 2 3 4 5 6

Quick facts and stats

ACEs are common. About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs. 7

Preventing ACEs could potentially reduce many health conditions. Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs. 1

Some people are at greater risk of experiencing one or more ACEs than others. While all children are at risk of ACEs, numerous studies show inequities in such experiences. These inequalities are linked to the historical, social, and economic environments in which some families live. 5 6 ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work. 7

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States. 8

ACEs can have lasting effects on health and well-being in childhood and life opportunities well into adulthood. 9 Life opportunities include things like education and job potential. These experiences can increase the risks of injury, sexually transmitted infections, and involvement in sex trafficking. They can also increase risks for maternal and child health problems including teen pregnancy, pregnancy complications, and fetal death. Also included are a range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide. 1 10 11 12 13 14 15 16 17

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress. Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children’s brain development, immune systems, and stress-response systems. These changes can affect children’s attention, decision-making, and learning. 18

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. 18 These effects can also be passed on to their own children. 19 20 21 Some children may face further exposure to toxic stress from historical and ongoing traumas. These historical and ongoing traumas refer to experiences of racial discrimination or the impacts of poverty resulting from limited educational and economic opportunities. 1 6

Adverse childhood experiences can be prevented. Certain factors may increase or decrease the risk of experiencing adverse childhood experiences.

Preventing adverse childhood experiences requires understanding and addressing the factors that put people at risk for or protect them from violence.

Creating safe, stable, nurturing relationships and environments for all children can prevent ACEs and help all children reach their full potential. We all have a role to play.

• Merrick MT, Ford DC, Ports KA, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019;68:999-1005. DOI: http://dx.doi.org/10.15585/mmwr.mm6844e1 .
• Cain KS, Meyer SC, Cummer E, Patel KK, Casacchia NJ, Montez K, Palakshappa D, Brown CL. Association of Food Insecurity with Mental Health Outcomes in Parents and Children. Science Direct. 2022; 22:7; 1105-1114. DOI: https://doi.org/10.1016/j.acap.2022.04.010 .
• Smith-Grant J, Kilmer G, Brener N, Robin L, Underwood M. Risk Behaviors and Experiences Among Youth Experiencing Homelessness—Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts. Journal of Community Health. 2022; 47: 324-333.
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Adverse Childhood Experiences (ACEs)

ACEs can have a tremendous impact on lifelong health and opportunity. CDC works to understand ACEs and prevent them.