NEWS AND VIEWS

1. MORE ON ANOREXIA NERVOSA

ANOREXIA NERVOSA; A SYNDROME OF THE AFFLUENT

SOCIETY by MARA SELVINI PALAZZOLI* (Translated from the
Italian by V. F. DiNicola)
My more than thirty years experience in the treatment of anorexia
nervosapatients permits me to make some socio-cultural observa-
tions which may be of interest. From 1938 to 1950, I worked as a
student and then as a resident in medicine at the Institute of Clinical
Medicine of the University of Milan. During the whole period of
World War II in Italy (1939-1945) there were dire food restrictions
and no pationts at all were hospitalized at the Clinic for anorexia.
Hospitalizations for anorexia started in 1948, concurrent with the
explosion of the Italian economic miracle and the advent of the afflu-
ent society. Within a few years there was an increase in anorexia
hospitalizations to the extent that, out of the 150 available beds
sometimes two were simultaneously occupied by such patients. It
seems possible to explain that unexpected ’invasion’ of anorexic

patients in the clinic on the basis of two factors: (1) at that time,
anorexia nervosa was still confused with Simmond’s disease (a pitui-
tary dysfunction) and, (2) due to the rarity of both diseases (Sim-
mond’s and anorexia nervosa), practitioners who had never encoun-
tered such cases tended to dispose of them by referral to the pres-
tigious University Institute for diagnosis and treatment. Unfortu-
nately, beyond accurate diagnosis, the Institute could do no better.
Thus my first encounter with anorexic patients was embarassing.
Their behaviour was a mystery and, with the frustration born of
the impotence of bio-medical therapy, I began to question my own
career as an internist. Having decided to resolve this mystery, I

gave up internal medicine and switched to psychiatry and psycho-

* As part of our exploration of the question whether anorexia nervosa may

be considered a culture bound syndrome (TPRR, 20(2):118, 1983), we
asked Dr. Selvini Palazzoli for her comments on the subject. As a pioneer
in both individual and family therapy of anorexia nervosa, her comments
are of great interest.

199
analysis. In November, 1950 I began psychotherapy with my first
anorexic patient. From then on I never lacked clientele because my
orthodox psychoanalytic colleagues almost always refused to treat
these cases which were very scary because of the risk of impending
death.
In 1963 I published a book, in Italian, devoted to anorexia nervosa
and its individual treatment (Selvini Palazzoli, 1963). Silvano Arieti,
who was then editorial consultant to Basic Books in New York, liked
my book very much but his insistence on an English translation was
not accepted by the editor because &dquo;it dealt with a rare disease of
interest to too few specialists.&dquo; After my book, I began to feel a
growing sense of dissatisfaction with individual treatment of anor-
exics because of the great expenditure of time and energy required
and because many questions remained unanswered on the basis of
the psychoanalytic model. I decided to find a more adequate model
and, in 1967, I founded the Centre for the Study of the Family and
opted with my colleagues to rigourously apply the systemic model
in family therapy.

THE ANOREXIC AND THE FAMILY

The notoriety that I had achieved as an individual therapist was a

great help in obtaining cases for my research on fammilies of anor-
exics. Each time I received referrals I described my new method
of treatment and requested the participation of the whole family.
The fact that we were treating anorexia facilitated our pioneering
work in family therapy: in the face of emaciation and potential death,
the parents were anguished and ready to try anything (this prompts
one to reflect on the enormous manipulative and blackmail power
that the anorexic has through her symptoms). Studying the char-
acteristics of the organization of relations in these families, we began
to grasp their commonalities, which may be reduced to two fun-
damental phenomena: the interactive pattern of the parental couple,
and the relations between parents and children (Selvini Palazzoli,
1970).
The couple relationship may be characterized as follows: every
conflict is denied; the surface impression is of an untroubled rela-
tionship between husband and wife; behind this facade of peace-at-
any-price however, each parent seethes with disappointment and
rancour about the other partner. Regarding relations with the chil-

dren, each parent appears fulfilled and satisfied as a parent in the

200
same measure as their dissatisfactions with each other, especially
as parents of offspring who will remain forever immature and
dependent.
In these families, precisely because of their dissatisfaction as a
couple, the birth of children takes on a crucial importance. The rais-
ing of offspring amplifies two common phenomena in Western cul-
ture, the obsessive primacy afforded the well-being of the child and
the subordination of the rights of the parents. Parents tend to retain
the role of super-competent parents of young children, liberally
offering advice and judgements on everything, friends, school, sports,
the right use of time; in short, on the smallest details of daily life.
Of course the passage of the child into adolescence normally demands
a complete reorganization of family relations. Adolescents no longer
want super-parents but people who can understand their critical
attitudes towards the values of the preceding generation, who can
grant them autonomous decisions, and allow them an increasing
amount of self-responsibility. This is the very adjustment that par-
ents of anorexics seem incapable of making. Both parents are
immovably arrested in an outdated position. One of them may decep-
tively appear more open than the other, but on enquiry it will be
found to be in word only, allowing himself or herself this attitude
knowing the other will impose restrictions.

THE CONSUMER SOCIETY AND THE FASHION OF THINNESS

All cultures have inherent contradictions. The culture of the affluent

society presents a highly interesting example of one such contra-
diction which in my view is related to anorexia nervosa: in propor-
tion, as food becomes abundant and available to everyone, so each
person is obliged to be thin. The demand for self-discipline in the
consumer society which prescribes an inverse relationship between
abundance of food and body weight is a cultural phenomenon rich
in social consequences. The fashion for thinness, which started in
the clothing industry which demanded models like Twiggy, has spread
through the media to all levels of the affluent society. Not a day
goes by without the appearance of new diets, books about nutrition,
products to acceleralte metabolism, and low calorie foods.
Having considered the relations typical of the anorexic family, we
can now hypothesize that the fashion for thinness is acting as a
trigger in this type of dysfunctional family organization. In other
201
words, the thin look reigning in Western culture has supplied anor-
exics the instrument to express covertly their relational distress.
This systemic hypothesis allows us to answer the questions that
the psychoanalytic model was not able to address convincingly: (1)
Why do only a small percentage of the enormous number of girls
who diet become anorexic? (2) Why is the incidence of anorexia ner-
vosa increasing in Western cultures? and, (3) Why do females con-
stitute the majority of anorexic patients?
Regarding the first question, the Western adolescent, conforming
to the dictates of fashion which commands the absence of fat, submits
to a weight reducing diet; sometimes they cannot put up with it and
give up; at other times, achieving the desired results, they interrupt
or cheat on their low calorie diets. The adolescent who becomes
anorexic usually starts a diet for the same reasons as other girls her
age. But as soon as she loses a certain amount of weight, her parents
decree that she has already lost too much weight and she must start
to feed herself. As super-parents, they take it as their duty to decide
the physical fitness of their daughter and when and how she must
eat. At this point the spiral is sparked that leads to the symptom
of self-starvation, since the adolescent has unexpectedly discovered
a foolproof way to bring her parents to their knees. This bursts into
a symmetrical escalation; the more the parents insist that she eat,

the less the daughter eats (not because she does not want to, she
says, but because she really cannot). It proceeds this way to the
dramatic 30 kilos, to physical and mental exhaustion, to tube feeding
and to hospitalization, and to the beginning of psychotherapy.
of the large number of girls who start to diet, only
Synthesizing:
a few unable to stop and starve themselves to emaciation. This
are

requires the specific organization of family relations described above

which, when sparked by a struggle for control, escalates into the
enactment of the anorexic scenario, a deadly family game with pre-
scribed moves for each member.
Why is the incidence of anorexia nervosa on the rise in Western
cultures? I feel the important factor is the influence of the mass
media through which the fashion for thinness has become extraor-
dinarily pervasive. The probability of triggering the emergence of
anorexic behaviour thus increases exponentially when this wide-
spread fashion interacts with the large number of families organized
in the way described. Furthermore, the abundance of food has now
reached the lower socio-economic classes and anorexia, once

202
restricted to the higher classes, now similarly affects the Italian
working class.
Why is anorexia nervosa much more common among females? The
imperative of the consumer society that prescribes an inverse rela-
tionship between abundant food supply and body weight is a socio-
cultural phenomenon which is difficult to explain. It is nonetheless
evident that this imperative besets women specifically. The feminine
image that fashion has prescribed is that of a slender body. That is
why girls and young women adopt en rnasse severe weight reducing
diets. It is a short step from this to the discovery that a silent hunger
strike is a powerful instrument of indictment of their parents. And
that it is very much more frequently girls who take this step is, in
my view, the result of the fact, the sexual revolution and feminism
notwithstanding, that they continue to be more controlled by par-
ents than boys.

TRANSCULTURAL ASPECTS

The most suggestive finding comes from the medical literature: in

the so-called Third World where food is scarce and insufficient, there
are no case reports of anorexia nervosa. Biological psychiatry, still
focussed on the concept of mental illness as a disturbance &dquo;inside
the skin&dquo;, cannot explain the absence of anorexia nervosa in such
cultures. Adopting the systemic model however, the explanation
becomes obvious. Once we accept that in human groups with a his-
tory, such as families, the relations between members in time become
organized according to patterns of behaviour that we call games,
then even the appearance of symptomatic behaviour can be con-
strued as a move in a game. In recent years, our work with families
has become based essentially on the game metaphor. By the term
gan2o, we mean a type o fie lational organizations of afamily in 7,vhich
each member occupies a specific position. When a family in the grip
of a dysfunctional game asks for help, our therapeutic task is to
collect adequate information to construct a map or model (LeMoigne,
1977) of the ongoing game and thereby make an intervention which
renders its continuation impossible. In the problem considered here,
the refusal of food by the anorexic is a move in a family game at a
certain moment of its evolution. It is also clear that such a move
can take place only if there is food and if it is offered. It would be

impossible to manipulate as a move in a game something that is not

offered or that is not there.

203
 In non-Western societies food is often scarce. But there is also
another important fact the marginal position of the child in the
-

family. In those cultures there are still poor children who steal mar-
malade, while in our culture there are rich children who are begged
to eat it; it is only in the latter situation that it becomes natural to
play games with marmalade. In the first volume of his splendid social
history of France, Zeldin (1973) notes:
It isgenerally believed that the basic transformation of the
family has been the rise of children to the position of central
importance in the home, after centuries of neglect... The change
took place in the eighteenth century. Before that, there was
no social prestige to be derived from being a good parent, and
none to be lost by being a bad one.

The passage of the child to the position of prince of the household

has obliged parents to be and to seem to be, good parents. Such an
important social upheaval cannot but have transformed all the rela-
tional games (or symptoms) of the family, above all those of children
and adolescents.
From this consideration comes the third reflection that I consider
important. What is the fate of the biomedical concept of mental
illness as an illness of the individual? What could have happened
inside the skin of girls who have become anorexic in a westernized
Japan as opposed to the girls with healthy appetites of feudal Japan?
And what could ever occur inside the skins of those girls who will
become anorexic in Ethiopia when, in the future, even there hunger
will be routed and the houses will be filled with food? It is evident
to those who use a systemic model that the culture in which a symp-
tom develops has a determining effect upon the appearance of the
symptom itself; each specific culture furnishes a certain type of dis-
comfort the means to express itself. In the case of the affluent soci-
ety, Western and westernized, the anorexic skeleton is the living
image of an unfortunate encounter between economic well-being and
relational malaise.

REFERENCES

LE MOIGNE, J. L. 1977. La Theorie du Système Général- Théorie de la Mode-

lisation. Paris: Presses Universitaire de France.
SELVINI PALAZZOLI, M. 1963. L’Anoressia Mentale. Milano: Feltrinelli Edi-
tore. Translated as Self-Starvation. From Individual to Family Therapy
in the Treatment of Anorexia Nervosa. New York: Jason Aronson, 1978.

204
___ 1970. The families of patients with anorexia nervosa. In E. J. Anthony
and C. Koupernik, eds. The Child in his Family. Vol. 1. New York: Wiley-
Interscience, pp. 319-332.
ZELDIN, T. 1973. France 1848-1945. Oxford: Clarendon Press.

ANOREXIA NERVOSA AS A CULTURE BOUND SYNDROME

by LESLIE SWAPTZ. Mimeographed (1984) 20 pp.
Recent work has emphasized the importance of sociocultural factors
in the development of eating disorders (Leon & Finn, 1984). Writing
in this Review, Prince has raised the question of whether anorexia
nervosa is a culture-bound syndrome, found exclusively in Wester-
nized cultures (TPRR, 20(2), 1983: 118). Anorexia nervosa is a clus-
ter of symptoms, not a disease with specific etiology. Over-zealous
dieting alone cannot provide an adequate definition of anorexia ner-
vosa as a disease. In Western psychiatry the diagnosis of anorexia
nervosa depends on presumptive psychogenic causation as evi-
denced by a disturbance of body image, an intense fear of becoming
obese and a refusal to maintain &dquo;normal&dquo; weight. The self-starvation
of anorexia nervosa appears to be motivated behaviour with great
interpersonal significance. Patients are often caught up in power
struggles with both family and clinicians over eating. Data on the
prevalence of anorexia nervosa-like syndromes are scant and cases
from non-Western cultures, while superficially similar may well
involve different social and psychological mechanisms (TPRR, 21(4),
1984: 302).
In the present article, Swartz puts epidemiological questions aside
to develop a notion of culture-boundedness that resides in the impor-
tance of the meaning imparted to symptoms within a cultural sys-
tem. He suggests that anorexia nervosa is a socially constructed
entity arising from negotiation between physician and patient. As
such, it is inextricably bound to culture, notwithstanding the pos-
sible appearance of similar behaviours in other cultures.
Swartz follows Ritenbaugh and Cassidy’s (1982) definition of
culture-bound syndromes, which views as culture-bound any con-
stellation of symptoms which has been categorized as dysfunction
or disease by those within the culture and which either (1) sym-
bolizes core cultural meanings and behavioral norms or which cannot
be (2) diagnosed, (3) understood, or (4) treated apart from its cultural
context. Just one of these criteria is sufficient to justify the label
&dquo;culture-bound.&dquo; Psychological and social disorders in which prob-

205