Breaking the Skinny Standard: Anorexia on Screen

Akriti Sinha, MD

A television drama looks at eating disorders from the patient, physician, and family perspectives. What does it get right—and wrong?

Psychiatrists are called on to help patients with an array of stubborn mental health illnesses. Some of the most challenging to treat are also the deadliest: eating disorders. Characterized by a persistent disturbance of eating that impairs health and psychosocial functioning, these disorders include anorexia nervosa, avoidant/restrictive food intake disorder, binge eating disorder, bulimia nervosa, pica, and rumination disorder. Too often, their outcomes are tragic. Anorexia nervosa is associated with the highest mortality rate of all psychiatric disorders, with fatal outcomes observed in approximately 10% of cases, primarily from arrhythmia and suicide.1

Recently I watched the 2017 Netflix film To the Bone, a semi-autobiographical story about a 20-year-old named Ellen and her journey to recovery from anorexia nervosa. It is based on the experiences of Marti Noxon, the film’s director, and Lily Collins, the actress who plays Ellen. The film starts with a written warning of triggers, a warning that should be taken seriously by anyone likely to be upset or encouraged by the behavior.

In the film, Ellen is a cynical, artistic young woman whose anorexia has made her life unmanageable. Forced to see a new doctor by her nervous stepmother, she ends up in an inpatient rehab unlike any other she has been in before: A house with 7 young individuals supervised by a blunt house manager and an unconventional clinician—Dr Beckman, played by Keanu Reeves. The young patients are diverse, both demographically and in terms of their eating disorders. The housemates include a Black female with binge eating disorder, a White female with bulimia nervosa, a British white male with anorexia, and a pregnant White female with anorexia (who has a miscarriage). The movie’s diverse cast reflects the epidemiology of eating disorders, which affect individuals of various ages, sizes, socioeconomic statuses, gender identities, races, and cultural and ethnic backgrounds.

When we meet Ellen, her weight has fallen dangerously low; she exercises excessively, shows obsessive attention to counting calories, and hints at a preoccupation with thoughts of food, consistent with the diagnosis of anorexia nervosa. Another character with anorexia nervosa also feels distressed when she learns the number of calories that she has received through a feeding tube. Ellen wears loose clothing, which is a warning sign for anorexia, since loose outfits hide weight loss and can help the wearer stay warm.2 She reassures her sister and herself that she has it all under control, a common belief among patients with eating disorders.

Another character, Anna, has bulimia nervosa. She engages in the purging behavior of vomiting, uses laxatives, and exercises secretly. Anna’s experience of binge eating is not shown, despite binging being a core component of bulimia. Often, individuals with binge eating disorder are not given significant attention, even though this is the most common eating disorder in the United States.3

The movie also shows the exasperation of the patients’ families. Ellen’s stepmother and stepsister exemplify the fallacies that so many individuals have about eating disorders. “Why don’t you just eat?” Ellen’s sister asks in exasperation, while her stepmom gibes: “Do you think this is beautiful?” The pathogenesis of eating disorders is complex and attributable to a combination of genetic, environmental, and biological factors, including dysregulation of homeostatic drive and the self-regulation system of appetite.4 Like most mental illnesses, childhood adversity plays an important role. Ellen’s mother came out as gay when Ellen was 13 years old and now lives in Phoenix, running a horse therapy farm with her partner. We do not see the father; he seems to be physically and emotionally absent. The child with the eating disorder is often expressing dysfunction within the family system through her behaviors and symptoms, as Ellen exemplifies.

Ellen and her peers are shown in a residential group home in which they have a lot of say in their treatment. This may not be a realistic portrayal. Treatment of eating disorders generally involves an interdisciplinary team; this team includes a mental health clinician, dietitian, and a general medical clinician. Although Beckham conducts individual and family sessions, the treatment approach overall does not match with commonly used, well-established therapy plans like cognitive behavioral therapy, psychodynamic psychotherapy, or the Maudsley model of anorexia treatment for adults.5

Beckham has a tough tone: He calls Ellen’s attitude “childish and cowardly” and tells her, “You know how [to recover].” He makes statements such as, “Stop waiting for life to be easy. Stop hoping for somebody to save you....Face some hard facts and you could have an incredible life.” These ideas suggest that Ellen needs to simply use her willpower and decide to get better, which is not a realistic vision for recovery. For Ellen, it was not about eating, it was about deciding to choose life. To achieve long-term recovery, the focus needs to be redirected to the underlying emotional, cultural, psychological, and spiritual issues.

Several noteworthy scenes have stayed with me: The emotional scene when Ellen asks her mother to feed her like a baby; the thousands of emotions that trace across her face every time she steps on the scale to be weighed; and the way she constantly circles her upper arm with her middle finger and thumb (a practice known as body checking). At the end of her family therapy, Ellen states, “I’m sorry that I’m not a person anymore; that I’m a problem.” This is touching, because medical professionals and family can lose sight of the fact that their patients are individuals with feelings, not just diagnoses.

Noxon’s film does an incredible job of portraying the nuances of this complicated character living with an even more convoluted illness while also developing the world around her. To the Bone finds the humor in its material, the absurdity of real-life mixed in with real dangers. Collins, who has been honest about her own experiences with eating disorders, channels that struggle into a fine performance.

In 1983, when Karen Carpenter died of anorexia, the general public expressed shock that someone could starve themselves to death. In the 1990s, unfortunately, skinny was the overwhelming female beauty standard. Now some websites glamorize anorexia, advising readers on how to avoid eating, and some show so-called thinspiration pictures on Instagram. The more we talk about eating disorders as a serious mental illness, the more we can break down the walls of stigma that keep individuals from seeking the early intervention that improves prognosis.

Dr Sinha is chief resident physician of psychiatry at the University of Missouri–Columbia.

References

1. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry. 2011;68(7):724-731.

2. Warning signs and symptoms. National Eating Disorders Association. Accessed April 21, 2021.

3. Binge eating disorder. National Eating Disorders Association. Accessed April 21, 2021.

4. Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet. 2010;375(9714):583-593.

5. Zipfel S, Giel KE, Bulik CM, et al. Anorexia nervosa: aetiology, assessment, and treatment. Lancet Psychiatry. 2015;2(12):1099-1111.