This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders.
The “Pro-Ana” Movement by Jennifer Hancock
Anorexia Nervosa is diagnosed when an individual restricts energy intake, which results in a significantly low weight, persistent behaviors displaying an intense fear of weight gain or becoming fat, and disturbances in perception of body image or shape, or a refusal to acknowledge current low weight is serious (American Psychiatric Association, 2013). Anorexia may be triggered by stressful life events, adolescent difficulties, or family history among first-degree relatives. In many cases, self-esteem depends on perceived body image and may contribute to anorexia, along with environmental factor like a cultural view of valuing thinness. Athletes and models, and others that rely on the size and shape of their body for professional or recreational activities are potentially at risk for developing disordered eating.
It is not unusual for individuals to internalize images or visual ideals viewed on the internet or television. Eventually, after repeated exposure, the attitudes of others have the potential to become our own unconscious beliefs. Marketing is a billion-dollar industry for this very reason. So what happens when the presented belief portrayed on media sites has the potential for pervasive ramifications for the viewer? As a society, are we trivializing issues with the “ideal” body image by media glamorization of unrealistic body images and contributing to disorders that pose serious or even fatal consequences? Commercials advertising diet pills, weight loss plans, and exercise programs flood the airwaves; advertisements continuously cross lines or propriety and promote individuals extremely underweight. Entertainment shows grip headlines with celebrity scandals of weight gain or loss. Social media, internet-based forums, and the movement to view anorexia as a lifestyle choice that should be maintained is yet another contributor to a negative body image that promotes serious consequences.
What is pro-ana? The pro-ana movement is a subculture that uses the premise of maintaining anorexia as a lifestyle choice, under the disguise of community support. Search pro-ana on the internet and you will find an abundance of websites claiming to offer the best tips and guaranteed success in perpetuating behaviors that maintain anorexia. Some claim pro-ana sites are a judgment-free sanctuary for individuals with anorexia to find comfort and support, yet further investigation reveals that these sites are most often comprised of tips and techniques on how one can escape detection of anorexia while sustaining a dangerously low body weight. Bloggers lure people in with buzzwords like “thinspiration” and “thinspo”, with an abundance of images depicting extremely thin and potentially underweight models. Many pro-ana websites include a body mass index (BMI) calculator, accompanied by charts to record caloric intake and exercise. You become “truly ana” when you follow the guidelines for anorexia, which most often includes a dangerously low body weight. Pro-eating disorder websites typically follow a similar content scheme, as determined in an examination by Borzekowski, Schenk, Wilson, & Peebles (2010). Of the pro-eating disorder websites reviewed, 91% contained content open to public viewing, with 79% displaying interactive material, 85% featured “thinspiration” images, and 83% provided recommendations for following an eating disorder regimen. Although recovery measures were integrated throughout some pro-eating disorder sites, only 38% included some type of information or links to recovery resources, 40% presented warnings of dangerous content, and 27% provided disclaimers of responsibility for dangerous behaviors that might ensure after viewing content. Reoccurring themes of the need for isolation apart from heavier individuals, along with control over weight to maintain an ordered life, perfection, and solidarity, appeared in several of the sites, as well (Borzekowski et. al, 2010).
Ana is revered as a religion with tag lines such as “salvation through starvation,” and ultimate set of rules that must be followed at all costs. The “thin” commandments include ten proclamations that establish ana loyalty (i.e. 1. If you aren’t thin, you aren’t attractive, 2. Being thin is more important than being healthy). These rules are encouraging the continuation of anorexia by extending the cycle of reinforcement and learning history, consequently creating a more difficult task in treatment altering the course of anorexia. One blog in particular provides suggestions for a plan designed to increase exercise and decrease calories until “ana’s standards” are met. With recommendations containing less than the caloric intake needed just to sustain organ function, individuals potentially face the risk of putting their bodies in starvation mode. For example, the ABC diet recommend by one pro-ana blog lasts for 30 days with caloric intake fluctuating from 100-500 calories and sporadic mandatory fast days during the diet timeline. Followers are instructed to always follow the rules and that “when the bones start to show it doesn’t mean you’re skinny, it means there’s more to lose.” Rules include specifics like never eating after 6:00, always avoid binging because of the caloric concern and not because of the associated health risks, and although weight loss pills are sometime endorsed, laxatives and vomiting are not.
The question remains whether these websites are perpetuating a dangerous illness and potentially increasing prevalence rates or if instead, providing a therapeutic community forum that fosters acceptance and understanding. In a seven-year study by researchers at Stanford University, an alarming 40% of patients aged 10-22 admitted to viewing pro-eating disorders sites, when interviewed. Of even greater concern are approximately 61% of viewers admitted to attempting purging and weight loss techniques listed on these sites. Additionally, younger patients were three times as likely to require hospitalization for an eating disorder, when compared to teenagers who did not view pro-eating disorder sites (Wilson, Peebles, Hardy, & Litt, 2006). Pro-ana sites pose the potential for reinforcement of maladaptive behaviors by claiming to provide support and understanding that individuals outside of the disorder cannot comprehend. Individuals that feel alone outside of the internet gain social support for participating in the disorder, instead of attempting treatment, eventually finding friendship and commonality among pro-ana followers. Sharing a common bond strengthens relationships and ultimately reinforces the anorexia lifestyle.
Deciding how to approach this problem is controversial as well. Italian legislature proposed a bill this summer that would fine pro-ana website authors $13,00-$67,00 and comes with up to one year in jail; however, opponents to this stance feel this would only push the ana subculture that much further underground and make detection even more difficult (Arnold, 2014). The concern of pro-ana sites eluding detection when pressured to abandon operation was illustrated in 2001, when Yahoo and MSN shutdown many overtly pro-anorexia or pro-bulimia websites, based on demands from several national health organizations and professionals. Unfortunately, this led to many groups going underground, disguising intent, or using different servers all together, making the sites harder to trace (Borzekowski et al., 2010).
The bottom line is that in the US, the First Amendment allows hosts of pro-ana sites to vocalize thoughts and recommendations, and violating those rights has the potential for creating a slippery slope. Opponents of the pro-eating disorder movement should instead establish initiatives, campaigns, and primary interventions that encourage an overall positive body image, regardless of shape and size. We should promote proactive teaching at an early age and with curriculum covering healthy nutrition, appropriate exercise, and how to locate support resources for those in need or at-risk. Anorexia by its very definition is a pervasive disorder with dire, if not fatal, consequences. Even when treatment is successful, most individuals are left with residual organ damage. Under the guise of support, many individuals professing themselves as pro-anorexia are instead perpetuating a serious disorder. By creating a societal culture of tolerance and health education, we can compete with the pro-ana subculture and move towards a goal of eliminating the movement altogether.