She was exposed to toxic substances as a baby. She was too mature for her age. She was too smart for her school. She was not smart enough for her school. Her school was too rigid. Her school was too flexible. She did ballet as a child. She had a hormonal imbalance. She was just unbalanced. She was painfully immature. She wanted attention. She wanted to disappear. She was obsessed with sex. She had an aversion to sex. She wanted to be a boy. She wanted to be Kate Moss. She was part of the zeitgeist.
These are among the 75 explanations given by doctors, therapists and others to Hadley Freeman for her severe anorexia nervosa.
Freeman, the author of a riveting new memoir, “Good Girls: A Study and Story of Anorexia,” became sick during the 1990s, but over the last few years, the incidence of anorexia, which predominantly affects preteen and teenage girls, seems to have gone up. “During Covid, a lot of published data showed increases in eating disorders both inpatient and some outpatient as well,” Joanna Steinglass, the director of research at the Eating Disorders Research Clinic at Columbia University and the New York State Psychiatric Institute, told me. This increase was true not only in the United States, where Freeman was born, but also in other countries, including Britain, where Freeman was given her diagnosis and treated.
We’ve known about anorexia for a long time. The question is why it looks to be getting worse now.
Did the pandemic cause an increase? Can it be tied to social media? Is it related to the general increase in rates of depression and anxiety among girls?
When I was a teenager, the “dying to be thin” narrative predominated in the shadow of Karen Carpenter, the singer who died in 1983 of complications from the illness. At the time, a combination of parental (mostly maternal) missteps and a culture that glorified a model-thin physique were presumed largely culpable for the disorder. Ballet and gymnastics were looked at as risky endeavors; “perfectionist” tendencies were also a potential red flag.
The truth is, we still don’t know exactly what causes anorexia. But we have learned more in recent decades. Whereas anorexia was earlier viewed through the lens of individual and familial behaviors and cultural influences, it is increasingly understood, as with other psychiatric disorders like schizophrenia and depression, to involve a neurological element.
“Over the last 20 years, we have an increased understanding of the neurobiological basis of anorexia,” Steinglass told me. “Not that there isn’t a person there and behaviors — but there are brain mechanisms to all this.” Recent research shows, for example, that when anorexics decide what to eat, different parts of the brain are activated than in those of people without disordered eating. Other research indicates that metabolic features play a role.
There is also evidence suggesting a genetic component to the disorder, though the extent to which the cause might be a mix of genes and environment is still unknown. As one doctor at the Eating Disorders Research Unit at King’s College London tells Freeman in her book, “You need genetic soil and environmental triggers.”
Freeman is one of several authors of recent books addressing their experiences with anorexia. In her best-selling memoir, “I’m Glad My Mom Died,” Jennette McCurdy writes about having anorexia followed by a severe case of bulimia. In “Strangers to Ourselves: Unsettled Minds and the Stories That Make Us,” the journalist Rachel Aviv recounts her own hospitalization for anorexia at age 6.
For those predisposed to anorexia, a common element seems to be a “precipitant” or “trigger” incident. For Aviv, it occurred on Yom Kippur, when she realized she could say no to food. “The decision retained the religious energy from the holiday and carried an aura of martyrdom,” she writes. For McCurdy, it was her quietly anorexic mother instructing her in “caloric restriction” when she was an 11-year-old child actress desperate to forestall puberty and look younger and thinner to get roles. For Freeman, it was in gym class, seated next to a classmate with remarkably bony legs, who, looking at Freeman’s thighs said, “I wish I was normal like you.” That did it. As Freeman writes, “A black tunnel yawned open inside me and I tumbled down it.” Normal, she writes, was boring: “Normal was nothing.”
And so anorexia became Freeman’s identity. “In the ’90s when I was a teenager, there were other options: goth, skater, punk,” Freeman told me. “But I chose this.” Her descent into illness was swift and profound, requiring multiple hospitalizations.
Once ingrained, an anorexic identity can be inadvertently encouraged in group settings, such as hospital wards. While the goal was for girls to learn new behaviors from their doctors, in practice both Aviv and Freeman witnessed their fellow sufferers learning behaviors from one another, reinforcing and even intensifying their disordered eating. Not surprisingly, one 2016 study shows that girls who attend schools with more girls than boys and have highly educated parents are more likely to develop anorexia.
It is this evidence of social influence that leads some to point to social media as either a trigger of or a contributing factor toward exacerbating the disease. In January, one mother in Hastings-on-Hudson, N.Y., filed a lawsuit against Meta and TikTok, along with its parent company, ByteDance. According to a report about the complaint in The Rivertowns Enterprise, the apps began showing her daughter, who developed anorexia, posts related to eating disorders after she began following accounts related to exercise and diets. Interestingly, some eating disorder clinics now discourage patients from friending one another on social media because while the mutual support can be helpful, the tendency to compete and fall into old habits outweighs the benefit.
Not surprisingly, habits — how they form and how they can be broken — are one focus of current anorexia research. Not eating becomes its own ritual and trap. As Aviv notes in her book, “Eventually, an impulsive decision gathers momentum, becoming increasingly hard to reverse.” Freeman’s anorexia was abetted by her obsessive compulsive disorder. “Anorexia is super O.C.D. heavy, obsessively counting calories,” Freeman told me. “For me, the routine felt very reassuring, very soothing.” Starving yourself, she says, can become a way of self-soothing.
In her book, Freeman also notes some doctors see an intersection between anorexia and autism spectrum disorder, with a rigidity in thinking common to both. There may also be a genetic connection here. One 2022 Swedish study found that the children of mothers with eating disorders are “significantly associated with attention deficit hyperactivity disorder and autism spectrum disorder,” even after controlling for family histories of these conditions.
In all three books, a sense of powerlessness and the desire for control emerges as central features of the disorder. Often those feelings of powerlessness revolve around discomfort with puberty, sexuality and adulthood. (“I still wear board shorts to hide my ass, which is curvy and womanly and disgusts me for being those things,” McCurdy writes of her earlier mind-set. “I wish there was nothing sexual or suggestive about my body.”)
But Freeman is eager to dispel the idea that anorexia is simply about the desire to be thin. Instead, she says, the goal is to look ill, like a skeleton. It’s about courting death. Among psychiatric illnesses, anorexia is among the deadliest; both Freeman and Aviv’s books describe revisiting the cases of wardmates after their deaths.
“Anorexia is a way of telling people you’re unhappy without saying it because saying it looks entitled,” Freeman told me. “It’s a highly visible outward expression of saying something is very wrong here.”
Something is very wrong here. The statistics are alarming: A 2022 British study of 15,000 students found that girls were twice as likely as boys to suffer mental health problems. A 2019 Lancet Psychiatry study found that self-harm among teenage girls and young women had tripled between 2000 and 2014. The proportion of American girls who’ve had a major depressive episode in the last year increased 145 percent between 2010 and 2020. Nearly three in five teenage girls reported feeling “persistent sadness” in 2021, according to the Centers for Disease Control and Prevention, the highest ratio in a decade. Whichever susceptibilities they are born into and whatever pain they’re feeling in the world, girls clearly seem to be taking it out on themselves. We need to ask very seriously why.
