Anorexia

Anorexia (pronounced an-uh-rek-see-uh)

(1) In clinical medicine, loss of appetite and inability to eat.

(2) In psychiatry, as anorexia nervosa, a defined eating disorder characterized by fear of becoming fat and refusal of food, leading to debility and even death.

(3) A widely-used (though clinically incorrect) short name for anorexia nervosa.

1590–1600: From the New Latin, from the Ancient Greek ἀνορεξία (anorexía), the construct being ἀν (an) (without) + ὄρεξις (órexis) (appetite; desire).  In both the Greek and Latin, it translated literally as "a nervous loss of appetite".  Órexis (appetite, desire) is from oregein (to desire, stretch out) and was cognate with the Latin regere (to keep straight, guide, rule).  Although adopted as a metaphorical device to describe even inanimate objects, anorexia is most often (wrongly) used as verbal shorthand for the clinical condition anorexia nervosa.  The former is the relatively rare condition in which appetite is lost for no apparent reason; the latter the more common eating disorder related to most cases to body image.  Interestingly, within the English-speaking world, there are no variant pronunciations.  Anorexia & anorexiant are nouns, anorexic is a noun & adjective and anorexically is an adverb; the noun plural is anorexics

Anorexia Nervosa and the DSM

A classic pro-ana image.

The pro-ana community has created its own sub-set of standard photographic angles, rather as used car sites typically feature certain images such as the interior, the odometer, the engine etc.  Among the most popular images posted on "thinspiration" pages are those which show bone definition through skin and, reflecting the superior contrast possible, there's a tendency use grayscale, usually converted from color originals.  The favored body parts include the spine, hip bones, clavicles (collar bones) and the shoulder blades.  Although documented since antiquity, the condition in its modern form wasn't noted in western medical literature until an 1873 paper presented to the Royal College of Physicians (RCP) called “Anorexia Hysterica”, a description of a loss of appetite without an apparent gastric cause.  That same year, a similar condition was mentioned in a French publication, also called “l’anorexie hystérique”, and described food refusal combined with hyperactivity.  Although the author of the earlier work had within a year changed the descriptor to “Anorexia Nervosa”, the implication in all these papers was of an affliction exclusively female, something very much implied in “l’anorexie hystérique”, hysteria then a mainstream diagnosis and one thought inherently "a condition of women".

A slight Lindsay Lohan (during "thin phase") demonstrates the "anorexic look" which is something distinct from the clinically defined condition "anorexia nervosa" although there's obviously sometimes overlap.

After its acceptance as a psychogenic disorder in the late nineteenth century, anorexia nervosa (AN) was the first eating disorder placed in the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM).  In the first edition (DSM-I (1952)), it was considered a psycho-physiological reaction (a neurotic illness).  In the DSM-II (1968), it was listed with special symptoms & feeding disturbances, which also included pica and rumination.  In DSM-III (1980), eating disorders were classified under disorders of childhood or adolescence, perhaps, at least in part, contributing to the under-diagnosis of later-onset cases.  At that time, the American Psychiatric Association (APA) created two specific categories that formally recognized the diagnosis of eating disorders: AN and binge eating (called bulimia in DSM-III and bulimia nervosa (BN; the obsessive regurgitation of food) in both the revised DSM-III (1987) and DSM-IV (1994).  In the DSM-IV, all other clinically significant eating disorder symptoms were absorbed by the residual categories of eating disorder not otherwise specified (EDNOS) and binge-eating disorder (BED), noting the disorders were the subjects for further research.  Subsequently, When the DSM-IV was revised (2000), eating disorders moved to an independent section.  The DSM-5 (2013) chapter for eating disorders added to the alphabet soup.  In addition to pica, AN, BN and BED, DSM-5 added  avoidant/restrictive food intake disorder (ARFID) and other specified feeding or eating disorder (OSFED), the latter including some other peculiar pathological eating patterns, like atypical AN (where all other criteria for AN are met, but weight is in the normal range).

Logo of the Butterfly Foundation for Eating Disorders.

Strikingly, although there are Western countries in which anorexia kills more people than road trauma, even within among mental health clinicians there appears to be some reticence in dealing with patients.  Despite it being a mental health condition with a high fatality rate, there seems still a perception the root cause is “mere vanity” and something of a self-indulgent among young, white, middle class females who spend too much time on TikTok and Instagram middle; essentially, they’re often thought exemplars of the “worried well”.  The problem is acknowledged by some specialists who claim because of these perceptions within the mental health community; treatment regimes have in recent decades shown few advances.  Among psychiatrists and psychologists the notion of anorexia being a “self-inflicted problem of the privileged” is not universal but critics do say that despite the disturbing death toll (some studies claiming a fifth of patients die within 20 years), there is still some tendency to trivialise the condition.  In Australia, the Butterfly Foundation is a national charity offering services to those affected by eating disorders and body image issues, the coverage not limited to sufferers but available also to friends, families and support communities.  Although Anorexia Nervosa is the best known of the eating conditions, Butterfly Foundation functions as a kind of clearing house for all, listing the most frequently diagnosed as:

Anorexia Nervosa is characterised by restrictive eating that leads to a person being unable to maintain what is considered to be a normal and healthy weight. People experiencing Anorexia Nervosa possess an intense fear of gaining weight or becoming overweight, no matter their current weight and appearance.

Bulimia Nervosa is characterised by repeated episodes of binge eating, followed by compensatory behaviours, such a purging or excessive exercise. People experiencing Bulimia Nervosa often place an excessive emphasis on their body shape or weight.

Binge Eating Disorder is characterised by episodes of eating large amounts of food over very short periods of time, with no compensatory behaviours. People who experience binge eating often feel a loss of control during episodes of binge eating.

Unspecified Feeding or Eating Disorder (UFED) refers to disordered feeding or eating behaviour that causes clinically significant distress but which does not meet the full criteria for any of the other eating disorder categories. UFED is one of the most common eating disorders.

Other Specified Feeding and Eating Disorders (OSFED) may present with many symptoms of other eating disorders, but where the person doesn’t meet the full criteria for diagnosis of those eating disorders. OSFED is no less serious and with treatment, recovery is possible.

Disordered eating is a disturbed and unhealthy eating patterns. They can include restrictive dieting, compulsive eating or skipping meals. Disordered eating behaviours, and in particular dieting are the most common indicators of the development of an eating disorder.

Avoidant/Restrictive Food Intake Disorder (ARFID) involves significant aversion and avoidance of food and eating, and may include highly selective eating habits, disturbed feeding patterns, or both.

PICA is an eating disorder where people eat things that aren’t considered food. For example, they may eat dirt, chalk, soap, hair, laundry detergent, among other things.

Orthorexia isn’t currently recognised as an official eating disorder diagnosis, however there is growing recognition that this may be a distinct eating disorder. It involves an obsession with healthy, or “clean” eating. People will often obsess about the benefits of healthy foods, food quality, but not necessarily quantity of food.

Pro-ana

Pro-ana (pronounced pro-anna)

(1) Of or relating to the position anorexia is a legitimate lifestyle choice.

(2) The on-line community advocating this view.  The most uncompromisingly pure among the community actively deny anorexia nervosa is a clinical condition.

(3) A movement for the promotion of behaviors related to anorexia nervosa. 

(4) A member of this movement or one of the related communities.

Circa 1998-2001:  The construct is pro + ana.  Pro was from the Classical Latin prō (in favor of, on behalf of), from the Proto-Italic por-, from the primitive Indo-European pr- & pro.  Ana is a clipping of of anorexia (an(orexi)a), a phonetic diminutive of the 1957 scientific term anorexia nervosa, the construct being the Ancient Greek ἀν (an) (without) + ὄρεξις (órexis) (appetite, desire) + the Latin nervōsa (nervous).  The clipping of "anorexia" was created both as verbal shorthand and coded language (so the matters of diet and related matters could be discussed without the risk of "outsiders" understanding.  "Ana" was thus a form of personification and a "cover", the outsiders hopefully assuming a young lady named Anna was being spoken of.  Pro-ana is a noun; the noun plural is pro-anas.

Only a matter of time: Lonaniana.

Ana in this context is thus obviously unrelated to the suffix -ana (familiar in forms such as “Victoriana” (of the era of the rein of Victoria (1819–1901; Queen of the UK 1837-1901)), “Americana” (of matters specific to US culture, politics etc), Holmesiana (memorabilia or writings related to the fictional detective Sherlock Holmes created by Sir Arthur ConanDoyle (1859–1930)) etc) that became popular after being adopted in continental literature.  It was from the Latin -āna (neuter plural of –ānus (feminine -āna, neuter -ānum) and was applied to create formations meaning “of or pertaining to”.  In English the specific sense originally was “a collection of things that relate to a specific place, person etc”; the suffices -ic & -ica now fulfil a similar function.  All formations created by appending –ana are pluralia tantum (from the Latin plūrāle tantum (plural as such; plural only); the term describes a noun (either in certain or all its senses) that does not generally have a singular form.  In his A Dictionary of the English Language (1755), Samuel Johnson (1709-1784) defined the suffix thus: “Books so-called from the last syllables of their titles; as Scaligerara, Thuaniana; they are loose thoughts, or casual hints, dropped by eminent men, and collected by their friends.”  An early exemplar was Thraliana, something of a gallimaufry of diary entries, jokes, poems and anecdotes, complied between 1776-1809 by Dr Johnson's dear friend by Mrs Hester Thrale (1741-1821) although those wanting something meatier will more enjoy the two volume Addisoniana (1803), a two-volume biographical and anecdotal anthology of the writings and conversations of the English essayist politician Joseph Addison (1672-1719), compiled and edited by Sir Richard Phillips (1767–1840); it’s a fine relic of a troubled time.

Palindromic elements: A collection of material relating to pro-ana would properly be titled “Pro-anaiana”.

Dr Johnson’s notion of “loose thoughts, or casual hints, dropped by eminent men, and collected by their friends” is familiar also as “table talk”.  Table talk literally is conversation (especially if informal or gossipy) among a group seated together for a meal or other social activity.  The point about table talk is it’s held to represent an individual’s “true” thoughts in unvarnished form (ie not “sanitized” for public consumption and for that reason the table talk of the illustrious or infamous often attracts interest when assembled and published.  However, such collections rarely are true transcripts and even if not deliberately misleading in that what can appear can be a verbatim account of what was spoken and an accurate summary of views and opinion, much can be lost in the transcription.  Classic examples of the difficulties historians encounter in the absence of audio recordings are the several editions of Tischgespräche im Führerhauptquartier (Table Talks at the Führer's Headquarters), published between the 1950s and 1980s, containing what were alleged to be transcriptions of (mostly) monologues delivered by Adolf Hitler (1889-1945; Führer (leader) and German head of government 1933-1945 & head of state 1934-1945) to guests at his lunches or dinners between 1941-1944.  As well as being edited at the time they were written, Albert Speer (1905–1981; Nazi court architect 1934-1942; Nazi minister of armaments and war production 1942-1945) pointed out the printed copy omits so much of the repetition, pauses and linguistic stumbles that could make meals with Hitler “stiflingly boring” for “the regulars who’d heard it all, many times before”.

Etymologists are inclined insist the correct form can be only "pro-ana" and there are traditions in English which supports this but the community itself uses ana, pro ana and proana interchangeably, the most common form the short-form ana, following the practice with anorexia nervosa which is truncated to anorexia in all but formal academic or clinical work.  Over two-odd decades, pro-ana has also spawned words such as thinspiration (often clipped to thinspo) and thinology, used to describe specialized editorial content of the calling; the much less-used term pro-mia referring to bulimia nervosa.  Pro-anas are purists who maintain high-standards; those who aspire to the anahood but in some way fail are dismissed as wannarexics.

Lindsay Lohan wearing (non-ana) red wrist-string.

The ana's standard means of social identification is a simple, beaded red bracelet, the beading of some significance because variations of red bracelets, some as simple as a wrist-string, have long been used by many cultures, usually with some sort of link to the idea of a good-luck charm.  Famously, a חוט השני (the khutt hasheni, a thin scarlet or crimson string) is sometimes worn as Jewish folk custom as a way to seek protection from those misfortunes which may be aimed at one by the עין הרע (evil eye).  It's most associated with the Kabbalah sect and Kabbalic scholars say there's nothing in ancient Jewish texts about wrist-strings of any color and the "tradition" is a recent folk practice which seems to have begun in the north-eastern United States early in the twentieth century.  Anas thus need always to check for beading before reaching out.

Notes

Although at the time it never reached the critical-mass needed to coalesce into a movement, the pro-ana concept actually pre-dates the web.  Among the bulletin boards the nerdiest connected to with 1200 or 2400 baud modems in the 1980s and early 1990s were both anorexia support boards and those which celebrated the condition but, once the indexed www (world-wide-web) was "bolted-on" to the internet the spread was rapid and, by the mid-late 1990s, pro-ana was global.

Pro-ana content tends to be (1) victim stories, (2) images & clips where ribcages & shoulder blades are often seen and clavicles much admired and (3), lists of helpful tricks and techniques.  Politically, the accepted pro-ana world view is they are not suffering from an illness; ana is a human right, an essential part of their identity and just another lifestyle choice.  As pieces of design, the sites tend to use pre-defined templates and in that are unremarkable although the preponderance of monochromic (in gray-scale) imagery is noted.  The pro-ana sites began to attract wider attention early in the twenty-first century, the irony being that much of the criticism came from the very publications many suggest contribute to eating disorders.  Off and on since then, pressure from the public and anti-ana organizations has compelled many hosts to shut down pro-ana sites although these efforts are Sisyphean, the relocations usually quick.

Sixteen Pro Ana Tips & Tricks for Beginners

If followed with sustained rigor, what's in this list should result in weight-loss and the ability to maintain a lower mass.  If adhered to, there should be no need to resort to using the new generation of GLP (Glucagon-Like Peptide) receptor agonists which, while effective, are (1) expensive, (2) introduce often novel chemicals to the body and (3) don't in all cases mean weight loss will be sustained once the course of treatment stops.  The GLPs should be regarded (like the various surgical options available) as "last resorts" because D&E (diet & exercise) is the better path to follow and the pro-ana path, though demanding, is straight, narrow and well-lit.   

(1) Keep track of your calories.  Set an absolute number and NEVER exceed it while trying always, gradually, to lower the number.  Within the calorie limit, aim for a diet which is 75% leafy-green vegetables & legumes, 20% tart fruit and 5% nuts. Added sugar should be zero because enough is in the fruit but, if absolutely necessary, one daily barley-sugar boiled sweet (taken early) is OK (brush teeth immediately after; as well as good oral practice this will diminish the possibility of the appetite being stimulated).  This diet mix can at the margins be varied but must stay vegan.

(2) Drink lots of water; try to aim for seven litres a day but anything over five is OK.  Being hydrated is anyway healthy and drinking water before taking food helps fill your stomach faster so you’ll eat less.  Remember to not drink a lot of water at once; instead keep hydrated by drinking little amount after every few minutes.  Always drink it as cold as possible, it forces the burning of more calories to restore body temperature.  Unless operating in extreme conditions with high fluid loss, do not go over eight litres a day; water can in extreme case be toxic and death has been reported among those who have ingested around 20 litres (less may be fatal in certain individuals, especially those with a lower body mass, hence the 5-7 litre recommendation). 

(3) Place a full-length mirror in your bedroom and evaluate yourself on daily basis. This is one of the best ways to stay motivated and remember, you’re there to be critical as well as admire.  If you can arrange multiple mirrors to provide for a 360^o view that's even better because it makes it easier to focus on problem areas (these can persist even as overall weight is falling).  Hanging a thinspiration photograph next to the mirror is recommended. 

(4) Have small meals.  It’s easier for the body to burn three 100 calorie meals than one of 300 and lends your body the illusion you’re eating enough to keep the stomach full, whereas you’re eating less.  Always eat slowly and chew thoroughly, it will hasten the digestive process.  After every meal, brush teeth; again, this is good dental hygiene but with freshly brushed teeth, you'll be less inclined to eat. 

(5) Find an ana-buddy.  The pro-ana routine can be a harsh mistress so an ana-buddy with whom you can talk about your problems and diet related stuff can be helpful but only if they're a kindred spirit.  This works not only by keeping each other motivated but you'll find also you'll teach each other new tricks or exercise routines.  You both must be 100% committed to the system and such noble souls are rare so, if need be, replace them with someone wholly committed.  You're in a war with weight so be harsh and accept only allies who will help in the fight.

(6) With the aggressive pro-ana diet, it’s very important to take vitamin pills.  Research suggests that for most people on what is the orthodox "balanced diet", vitamin supplements are probably unnecessary (some researchers suggest they can even be counter-productive) but because pro-ana doesn't include certain food groups, a daily multi-vitamin is recommended and usually adequate so resist the temptation to take two and do so only if you become light-headed or faint with any frequency; you may need specific additional supplements.  The most publicized deficiency associated with pro-ana is iron and it may thus be necessary greatly to increase the intake of leafy greens like spinach or peas, broccoli & string beans; seeds high in iron include pumpkin, sesame, hemp and flaxseeds.  One's family physician can obtain the tests to determine specific deficiencies and these should be dealt with by adjustment to the diet.  Remember though that doctors are inclined to be dictatorial and the recommended technique to deal with their negativity is just to agree with whatever they say.  Try to appear sincere and be deferential; they like that.   

(7) Avoid butter and oils.  Treat them like sugar or drugs of dependency.

(8) Resist the temptation to smoke or vape.  While it's true some short-term weight loss often is achieved by smoking cigarettes, (1) in the medium-long term weigh-gain is the typical consequence, (2) the nicotine in cigarettes is addictive making it difficult to use tobacco as a short-term or occasional "quick-fix" and (3) it's a carcinogenic product which, on average, appears to reduce life-expectancy by around a decade.  Not enough is yet known about vapes but there are many reports of adverse outcomes, presumed to be a consequence of inhaling that many chemicals.       

(9) Sleep at least eight hours a day, preferably more.  Less sleep means tiredness and hunger and you can’t eat while asleep.

(10) Keep setting a target weight.  Because of fluid retention and other cyclical variations, it’s probably counter-production to set daily targets and a weekly goal is better although true obsessives will monitor at least once and maybe several times a day; this is not discouraged.  To stay motivated, hang on the wall thinspiration photographs of slender models to observe while weighing-in.  Many non-ana diet sites suggest avoiding weighing-in daily and clinically they may be right it achieves little but they just don't understand the nature of obsessions.  Record the weigh-ins so you can chart progress over weeks and months; this requires nothing more demanding than the most basic open-source spreadsheet but math nerds who enjoy such things can do it with pen & paper.  Although for most purposes pencils are better than pens, ink is permanent so it's harder to cheat.  You will be tempted to cheat but you must not; pro-ana does often demand you lie to others but you must never lie to yourself.

Example of a thinspiration photo: Model Lululeika Ravn Liep (b 1998), Cover magazine, February 2015.  Although the use of this image was condemned by the thought police, a true pro-anaite should think: “She could lose a few pounds.”

(11)  Do NOT drink any alcoholic beverages; for variety only soda-water or carbonated mineral water are acceptable.  Coffee and tea are good appetite suppressants so drink only black coffee or tea and NO milk or sugar.  Avoid caffeine drinks; either they’ll contain sugar or chemicals about which there exists no reliable research on how they affect the appetite.  Avoid the inherently sweet herbal teas; they do tend to stimulate the appetite in a way black tea and coffee don't.  Black tea and coffee are also useful in training the palette away from sweetness and towards the tart.  After a while, this will start to influence your choice of fruits and vegetables; as a general principle the darker and more bitter in taste, the better.  Care must of course be taken.  In its pure form, caffeine can be fatal in tiny quantities although in the form usually enjoyed (coffee), one would need to drink dozens of cups in a day to approach toxicity.  The French philosopher Voltaire (François-Marie Arouet; 1694–1778) (1694–1778), often at the Café de Procope in Paris, drank a reputed forty-odd cups a day, enjoying it so much he ignored the advice of his doctors to stop.  He lived to 84 but there’s no evidence the often attributed quotation: “It may be poison, but I have been drinking it for sixty-five years, and I am not dead yet” was his.  The more likely source is French author Bernard Le Bovier de Fontenelle (1657–1757) whose actual words were: “I think it must be [a slow poison], for I’ve been drinking it for eighty-five years and am not dead yet.”   Fontenelle died a month short of his hundredth birthday.  The sensible approach is to restrict yourself to one strong (ie short black and such) coffee at the start of the day and otherwise just have cups of weak (even decaffeinated) instant coffee; think of it not as a stimulant but a companion.

(12) Wearing short clothes can be very motivating. Wear short or revealing clothes so when looking at yourself in the mirror it will be obvious there's still work to do, something often disguised by the garments never worn in public.  Wear in private clothes you'd never dare to wear in public and make it a goal to be able to wear them out without looking fat.    

(13) Drink the juice of a squeezed lemon in hot water first thing each morning and last thing each evening; it has the general effect of adding to the stomach acids which break up food.  Because of this acid, always brush teeth afterwards.

(14) If you have to eat in company (it can be unavoidable), wear baggy clothes with big pockets able to be lined with plastic bags.  Then, when no one is looking, you can dispose of food and people will think you eat normally.  It sounds a difficult thing surreptitiously to manage and to start with it will be but you’ll learn to adopt techniques like always sitting in a corner or at the end of the table and soon become an expert.  It's easier than it sounds.

(15) Exercise every day.  Gyms are optional because you can do even better with ana-specific routines such as running up stairs or hills, both of which have an extraordinary multiplier-effect on whatever distance is achieved.  Unlike gyms, it's also free; remember the goal is weight-loss, not abstractions such as muscle tone or fitness.  If possible, exercise in darkness to avoid sun exposure; if this is not possible (and there may be good reasons to restrict this to daylight hours) cover as much skin as possible with protective clothing and use the highest available SPF (sun protection factor) sun-block lotion, wear a wide brim hat and never forget the sunglasses.  Never use elevators and escalators; always take the stairs.  Wherever possible, replace travel by cars, trains and busses with walking or biking.  This is also good for the planet which is the only one we have.

(16) Eat ice; ice can be an alternative to a meal, it really works.  Shaved ice is best because it avoids dental damage; there are many things to consider when eating ice and curiously, sometimes it's advantageous to take more, sometimes less.  For a discussion on the mechanics of ice-eating: The eating of ice

Anorexia nervosa was included in the (1952) first edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) as a psycho-physiological reaction. The DSM-II (1968) moved it to Special Symptoms–Feeding Disturbances and in 1980, a new eating disorders section was created for the DSM-III.  The most significant structural change came in 1994 when in DSM-IV the condition was afforded its own section.  The DSM-5 (2013) relaxed some of the diagnostic criteria including, for the first time, rendering it all entirely gender-neutral, a gesture to conform with practices elsewhere rather than anything suggesting clinical experience was noting a greater gender-spread in the patient count.  Announcing DSM-5, the board noted it wished to reduce the number of patients in the former EDNOS (Eating Disorder Not Otherwise Specified) category, now reclassified as the OSFED (Other Specified Feeding or Eating Disorder) group.  Thus the psychiatrists staked their claim in this low-cal demarcation dispute by capturing the wannarexics.

Pagophagia

Pagophagia (pronounced pag-off-faghia)

(1) The excessive and constant eating of ice, often as part of extreme dieting.

(2) A craving to eat ice, sometimes associated with iron-deficiency anemia.

Pre 900: A compound word, the construct being págo(s) + -phagia.  Págos is from the Byzantine Greek, the perfective stem of ἔφαγον (éphagon) (I ate; I devoured), singular first-person aorist active indicative form (by suppletion) of ἐσθίω (esthíō) (I eat; I devour).  Phagia is from the Ancient Greek πάγος- (phag-) (stiff mass; frost; ice) from pēnunai, (to stick, stiffen), from the primitive Indo-European root pag.  It was used also in a derogatory, figurative sense to describe a cold, unfriendly person (in the sense of one metaphorically cold like ice).  The nouns pagophile & pagophily and the adjective pagophilic reference species which prefer (ie are adapted to) ice as a habitat.  Pagophagia is a noun and pagophagic is a noun & adjective; the noun plural is pagophagics.

Ice, diet and the DSM

Pagophagia (the excessive consumption of ice or iced drinks), is often regarded as a recent phenomenon and a novel manifestation of pica (a disorder characterized by craving and appetite for non-edible substances, such as ice, clay, chalk, dirt, or sand and named for the jay or magpie (pīca in Latin), based on the idea the birds will eat almost anything) but in texts from Classical Greece are warnings in the writings of both the physician Hippocrates (circa 460–circa 370 BC) and the polymath Aristotle (384–322 BC) concerning the dangers of the excessive intake of cold or iced water.  The cause of the death of Theophilus (Byzantine (Eastern Roman) Emperor 829-842) was officially dysentery but, based on the original texts of Byzantine historians and chroniclers of the era, modern researchers speculate the cause of death may have been related to Theophilus' pagophagia (snow eating), a long-time habit he indulged to relieve the symptoms of gastric inflammation.  In the medical literature, from the sixteenth century on, there are discussions and illustrative case histories about the detrimental effect of immoderate usage of cold water, ice and snow, frequently in the context of eating disorders, another range of conditions with a long history.

A noted feature of the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5 (2013)), was the more systematic approach taken to eating disorders, variable definitional criteria being defined for the range of behaviours within that general rubric.  What may have appeared strange was including the ice-eaters within the psychological disorder Pica which is characterized by the manifestation of appetite for non-nutritive substances including sharp objects (acuphagia), purified starch (amylophagia), burnt matches (cautopyreiophagia), dust (coniophagia), feces (coprophagia), sick (emetophagia), raw potatoes (geomelophagia), soil, clay or chalk (geophagia), glass (hyalophagia), stones (lithophagia), metal (metallophagia), musus (mucophagia), ice (pagophagia), lead (plumbophagia), hair, wool, and other fibres (trichophagia), urine (urophagia), blood (hematophagia (sometimes called vampirism)) and wood or derivates such as paper & cardboard (xylophagia).  DSM-5 also codified the criteria for behaviour to be classified pica.  They must (1) last beyond one (1) month beyond an age in infancy when eating such objects is not unusual, (2) not be culturally sanctioned practice and (3), in quantity or consequence, be of sufficient severity to demand clinical intervention.  Interestingly, when the text revision of DSM-5 (DSM-5-TR, 2022) was released, the sentence “individuals with atypical anorexia nervosa may experience many of the physiological complications associated with anorexia nervosa” was added to the description of the atypical anorexia nervosa example to clarify that the presence of physiological consequences during presentation does not mean that the diagnosis is the (typical) anorexia.  However, it must be remembered the DSM is a tool for the clinician and, while it can be a useful source document for the lay-reader, there are other publications better suited to those self-diagnosing or informally assessing others.  An individual for whom the only symptom of pica is abnormally high and persistent ice consumption doesn’t of necessity need to be subject to the treatment regime imposed on more undiscriminating consumers.

One of the reasons pagophagia is one of the more-researched and better-documented examples of pica is its strong association with iron deficiency anemia (the word in modern use unrelated to ischemia (local disturbance in blood circulation) which well into the twentieth century was sometimes a synonym), something which manifests especially in women as one of the consequences of the menstrual cycle.  The research has established there’s a high prevalence of pagophagia in patients with iron deficiency which tends to disappear once treated although the mechanism isn’t fully understood.  One theory is chewing ice temporarily increases alertness in those with iron-deficiency–related fatigue, possibly by improving cerebral blood flow or nerve conduction.  Pagophagia is thus unusual among the picas in that it’s a “red-flag symptom” in hematology whereas the others tend to be of interest to nutritionists and the psychiatric community.  The correlation is not absolute because not all pagophagics suffer an iron deficiency; for some it’s the pleasure or the crunch, the oral stimulation or merely a habit but if the craving is strong or compulsive, the usual recommendation is the use of supplements (ferritin, serum iron, transferrin saturation, hemoglobin).

One cube at a time.

The pro-ana community does recommend the eating of ice, not merely as a food substitute but because the body needs to burn energy both to melt the ice and subsequently restore the body to its correcting operating temperature.  With frozen water, this effect is greatest in negative calorie terms but the discount effect applies even to iced confections.  If a frozen confection is listed as containing a calorie content of 100 (25 grams of carbohydrate @ 4 calories per gram), this does not include the energy the body expends to melt the ice and the net consumption is actually around 72 calories.

All things in moderation: Lindsay Lohan enjoying ice-cream and (an allegedly virgin) iced mojito, Monaco 2015.

Pro-ana does NOT however approve of frozen confections, the preferred one litre of frozen water containing zero calories yet demanding of the body a burn of around 160 calories to process, the energy equivalent of running one mile (1.6 km).  The practical upper limit per day appears to be between 3-5 litres (.67 / .8-1.1 / 1.3 (US / Imperial) gallons) depending on the individual and it’s speculated a daily intake much over eight litres may approach toxicity, essentially because the localized symptoms would be similar to hypothermia and some organs fail optimally to work when body temperature drops too much.  Paradoxically, pro-ana also notes, ice shouldn’t be eaten when one is too hot.  After running, the body actually exerts energy through the active effort of dissipating excess heat and if one were to ingest large amounts of ice as one was cooling off, some of the heat generated would be neutralized by the coolness of the ice, minimizing some of the energy burning benefits.  There’s also the need to avoid dental damage; pro-ana recommending it be allowed to melt in the mouth or consumed as shaved ice.

Dysmorphia

Dysmorphia (pronounced dis-mor-fiah)

(1) In clinical anatomy, characterized by anatomical malformation.

(2) In general medicine, having or exhibiting an anatomical malformation.

(3) In psychology and psychiatry, the perception of anatomical malformation; any of various psychological disorders whose sufferers believe that their body is wrong or inadequate, such as anorexia, bulimia, and muscle dysmorphia (bigorexia).

(4) As Dismorphia astyocha, a butterfly in the family Pieridae, found in both Argentina & Brazil.

From Ancient Greek δυσμορφίᾱ (dusmorphíā) (misshapenness, ugliness), the construct being δυσ- (dus-) (hard, difficult, bad) + μορφή (morphḗ) (shape, form) + -ίᾱ (-íā).  The prefix dys- was from the New Latin dys-, from Ancient Greek δυσ- (dus-), (hard, difficult, bad”) and was used to convey the idea of being difficult, impaired, abnormal, or bad.  Morph was a back-formation from morpheme & morphism, attested since the 1950s, from the Ancient Greek μορφή (morphḗ) (shape, form) and related to the German Morph, from Morphem (although dating only from the 1940s).  It’s probably now most familiar in (1) formal grammar & linguistics as a physical form representing some morpheme in language (it exists as a recurrent distinctive sound or sequence of sounds), (2) in linguistics as an allomorph (one of a set of realizations that a morpheme can have in different contexts) and (3) in digital image processing where shapes are changed from one form to another with the use of specialized software, a popular type being that which wholly or (especially) partially blends two images.  The plural is dysmorphias and, in clinical use, the synonym is dysmorphosis.

The word dysmorphia first appeared in the Histories of the Greek historian Herodotus (circa 484–circa 425 BC) when he referred to the myth of the “ugliest girl in Sparta”.  Herodotus, even in his lifetime, was criticized for making an insufficient distinction between legend and historical fact but the veracity of much of his work, subject to forensic analysis by modern archeologists and archivists, has been established.  The story of the “ugliest girl in Sparta” however, Herodotus acknowledges as “a magical myth” in which a baby girl, born in Sparta, was terribly disfigured (which he described as dysmorphia (meaning “misshapenness” or “ugliness”).  Fortunately, she was from a well-connected family and her nanny suggested taking her to the shrine of Helen of Troy on hilltop of Therapne, and there pray for a cure.  There the nurse sat with the baby and while praying before the agalma (a carved image of Helen), from nowhere a apparition of Helen appeared and smiling, laid her hand upon the child’s head.  As the years passed, the disfigured infant would grow to become the most beautiful girl in the kingdom.

Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a mental disorder.  It’s defined as an individual’s obsession with the idea that some aspect of their appearance is severely flawed and warrants exceptional measures to hide or rectify the offending part(s).  In BDD's delusional variant, the flaw is imagined and if some minor imperfection exists, its importance is severely exaggerated.  Sufferers find the symptoms of BDD pervasive and intrusive, symptoms including excessive attention to the perceived defect, social avoidance, camouflaging with cosmetics or apparel, the seeking of verbal reassurances, avoiding mirrors, repetitively changing clothes or restricting eating.

Italian physician Enrico Morselli (1852-1929) in 1886 reported a disorder he termed dysmorphophobia, a term still sometimes used in European literature to describe BDD.  Use spiked in academic literature in the 1950s although it wasn’t until 1980, the American Psychiatric Association (APA) recognized the condition in the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III).  The APA classified it as a distinct somatoform condition (characterized by symptoms suggesting a physical disorder but for which there are no demonstrable organic findings or known physiological mechanisms) and in 1987 replaced dysmorphophobia with body dysmorphic disorder as the preferred descriptor.

With the 1994 publication of DSM-IV, the APA noted BDD was a preoccupation with an imagined or trivial defect in appearance, one causing social or occupational dysfunction, and not better explained as another disorder such as anorexia nervosa but in DSM-5 (2013), it was reclassified as an obsessive-Compulsive and Related Disorder, adding diagnostic criteria including repetitive behaviors and intrusive thoughts.  Although the World Health Organization's (WHO) current International Classification of Diseases (ICD-10 (1994)) described BDD as just another hypochondriacal disorder, the revised ICD-11 (2019) aligned for all functional purposes with the DSM-5.

The DSM-5 diagnostic criteria for BDD requires the following:

(1) A preoccupation with appearance: The individual must be preoccupied with one or more nonexistent or slight defects or flaws in their physical appearance and “Preoccupation” is usually defined as thinking about the perceived defects for (in aggregate) at least an hour a day.  A distressing or impairing preoccupation with real and obvious flaws in appearance (anything easily noticeable such as obesity) is not diagnosed as BDD, being instead classified with “Other Specified Obsessive-Compulsive and Related Disorders.”

(2) Repetitive behaviors: Repetitive and compulsive behaviors must manifest in response to the concern with appearance.  These compulsions can be behavioral and thus observed by others (such as either excessively standing before or avoid a looking-glass, frequent grooming, skin picking, reassurance seeking or repeatedly changing clothes.  Other BDD compulsions include mental acts, the most often diagnosed being an individual frequently comparing their appearance with that of other people.  The DSM-5 included the note for clinicians cautioning that subjects meeting all diagnostic criteria for BDD except this one are not diagnosed with BDD; they are diagnosed with “Other Specified Obsessive-Compulsive and Related Disorder.”

(3) Clinical significance: The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important aspects of functioning.  This criterion was included to differentiate the disorder BDD, which requires treatment, from more normal appearance concerns that typically do not need to be treated with medication or therapy.  This has been one of the more controversial revisions because of concerns it may exclude from helpful treatment some who have developed better coping mechanisms while still suffering from the underlying condition.

(4) Differentiation from an eating disorder: If the appearance preoccupations focus on being too fat or weighing too much, it may be that the appropriate diagnosis is an eating disorder and this applies especially if the subject’s only concern with their appearance focuses on excessive weight; provided the diagnostic criteria for an eating disorder are otherwise met, that should be the diagnosis, not BDD.  If not, BDD can be diagnosed, as concerns with fat or weight in a person of normal weight can be a symptom of BDD and it’s not uncommon for subjects to have both an eating disorder and BDD.

There are specifiers to BDD and following diagnosis, the subject should be sub-classified using the two (DSM-5) BDD specifiers:

(1) Muscle dysmorphia: Muscle dysmorphia is the (predominately male) concern that the build of their body is too small or insufficiently muscular, something which not untypically manifests with preoccupations with other body areas; the muscle dysmorphia specifier should still be used in such cases.  Studies have shown that among those diagnosed with BDD, those with muscle dysmorphia suffer the highest rates of suicidality and substance use disorders, as well as poorer quality of life.  Accordingly, the DSM-5 notes their treatment regimes may require some modification.

(2) Insight specifier: This specifier indicates the degree (not directly frequency although this is a factor in the analysis) of a subject’s insight regarding their BDD beliefs (eg “I look ugly”; “I look deformed”), an expression of how convinced the subject is that their beliefs about the appearance of the disliked body parts is true.  The DSM-5 levels of insight are (2a) with good or fair insight, (2b) with poor insight and (3), with absent insight/delusional beliefs (which are to be diagnosed as BDD, not as a psychotic disorder.

BDD has often been misdiagnosed, most often as one of the following disorders:

(1) Obsessive Compulsive Disorder: If preoccupations and repetitive behaviors focus on appearance (including symmetry concerns), BDD should be diagnosed rather than OCD.

(2) Social anxiety disorder (social phobia): If social anxiety and social avoidance are due to embarrassment and shame about perceived appearance flaws, and diagnostic criteria for BDD are met, BDD should be diagnosed rather than social anxiety disorder (social phobia).

(3) Major depressive disorder: Unlike major depressive disorder, BDD is characterized by prominent preoccupation and excessive repetitive behaviors. BDD should be diagnosed in individuals with depression if diagnostic criteria for BDD are met.

(4) Trichotillomania (hair-pulling disorder): When hair tweezing, plucking, pulling, or other types of hair removal is intended to improve perceived defects in the appearance of body or facial hair, BDD should be diagnosed rather than trichotillomania (hair-pulling disorder).

(5) Excoriation (skin-picking disorder): When skin picking is intended to improve perceived defects in the appearance of one’s skin, BDD should be diagnosed rather than excoriation (skin-picking disorder).

(6) Agoraphobia: Avoidance of situations because of fears that others will see a person’s perceived appearance defects should count toward a diagnosis of BDD rather than agoraphobia.

(7) Generalized anxiety disorder: Unlike generalized anxiety disorder, anxiety and worry in BDD focus on perceived appearance flaws.

(8) Schizophrenia and schizoaffective disorder: BDD-related psychotic symptoms (ie delusional beliefs about appearance defects or BDD-related delusions of reference) reflect the presence of BDD rather than a psychotic disorder.

(9) Olfactory reference syndrome: Preoccupation with emitting a foul or unpleasant body odor is a symptom of olfactory reference syndrome, not BDD (although these two disorders have many similar characteristics).

(10) Eating disorder: If a normal-weight person is excessively concerned about being fat or their weight, meets other diagnostic criteria for BDD, and does not meet diagnostic criteria for an eating disorder, then BDD should be diagnosed.

(11) Dysmorphic concern: This is not a DSM diagnosis, but it is sometimes confused with BDD.  It focuses on appearance concerns but also includes concerns about body odor and non-appearance related somatic concerns, which are not BDD symptoms.

One aspect of the condition BDD is that it’s not uncommon for subjects to be reticent in revealing their concerns or BDD symptoms to a clinician because of embarrassment or being negatively judged as vain or too concerned with trivial matters.  Case notes do suggest there is a pattern of subjects hinting at their issues and clinicians should thus be encouraged to respond by explicitly asking about BDD symptoms.

Although the brand-name is, strangely, no longer used, in the late 1950s and early 1960s, Chubbettes was a fashion-house supplying “slenderizing designs… designed to make girls 6 to 16 look slimmer” and therefore become “as happy and self-assured as her slimmer schoolmates”.  With a target market including those with eating disorders or BDD as well as the naturally chubby, Chubbettes helpfully offered with its fashion catalog a free booklet, Pounds and Personality.  Intended for parents of a chubby girl and written by Dr Gladys Andrews of New York University’s School of Education, it was packed with helpful hints about “understanding her problems, talent development, shyness, tactless remarks & the “game” of dieting etc."  Chubettes’ clothing range was said to be “available, coast to coast at stores that care”; the parent company was L Gidding & Co Inc, 520 Eighth Avenue, New York City.

Times certainly have changed and with them the perception of body shapes.  Parents who would now regard young ladies of the type pictured in the Chubbette advertisements as being chubby might now be suspected of having Munchausen syndrome by proxy (MSbP).  In the mind of the girl herself, a similar perception wouldn't necessarily alone be enough for a diagnosis of BDD but might be considered in the context of other behaviors.  

Crooked Hillary Clinton, the Hamptons, August 2021.

Paradoxically, although in the early twenty-first century there’s a larger than ever market for what Chubbettes once served as a niche, the brand is long gone and a revival seems unlikely.  Many factors including more sedentary lifestyles and a higher consumption of processed food, the sugar content of which has risen alarmingly, means demand for more accommodating clothing will likely continue to increase but many manufacturers have stepped into the Chubbette void and customers enjoy a wide choice.