Painfully thin, emaciated, starving \u2013 these words come to mind when looking at photographs of malnourished children in third-world countries. But they\u2019re not the only ones suffering \u2013 and they\u2019re not suffering by choice. Anorexia, or specifically, anorexia nervosa, a mental disorder manifesting itself as an eating disorder, involves deliberate choice to avoid food, an obsessive fear of weight gain and a constant pursuit of thinness. And it seems most prevalent in Western countries, specifically America. But where did this obsession start and, more important, who is to blame for anorexia? Before we can look at the problem of who is to blame, it\u2019s important to set the stage about what anorexia nervosa is and the damage it can do. Anorexia Nervosa Diagnostic Criteria Not everyone who is thin is anorectic. Some individuals have naturally high metabolisms and burn calories more rapidly and completely than others. Some may look leaner due to a slight frame.\u00a0 True Anorexia Nervosa (AN), a psychological eating disorder that is life threatening, has four diagnostic characteristics and two subtypes: Diagnostic Criteria \tRefusal to maintain body weight at or above minimally normal weight for age and height (<85 percent of expected weight) \tIntense fear of gaining weight, being overweight or fat \u2013 even though underweight \tDisturbance in the way the individual experiences body weight or shape, denial of the seriousness of their low body weight \tAmenorrhea \u2013 for example, the absence of three consecutive cycles Subtypes \tRestricting type \u2013 The person has not regularly engaged in binge-eating or purging behavior during the current AN episode \tBinge-eating\/purging type \u2013 The person has regularly engaged in binge-eating or purging behavior during the current AN episode Anorexia is a Subversive Killer Statistics show that anorexia nervosa has the highest mortality rate of any psychiatric illness \u2013 about 6 percent of the general population per decade. Experts in the field say this is due to either malnutrition or suicide. According to a 2006 study funded by the National Institutes of Health (NIH), National Institute of Mental Health (NIMH), about 0.5 to 3.7 percent of women will develop anorexia nervosa over the course of their lifetime. About 0.5 percent of those with anorexia nervosa will die each year from the disease, according to the NIMH figures. In addition, the disorder is extraordinarily difficult to treat, with most treatments proving generally ineffective. It is said that anorexia nervosa is one of the most difficult psychiatric disorders to successfully treat. This is partly because of the scarce number of treatment facilities specializing in treating eating disorders, and partly due to the extremely ego-centric and ego-symptomatic nature of the disorder. Individuals with anorexia nervosa perceive their behaviors to be self-rewarding and positive. Furthermore, anorexia nervosa patients see the benefits of their behavior to far outweigh any consequences or risks \u2013 either physical or psychological. In short, they may see absolutely nothing wrong with what they\u2019re doing. While they may enter treatment because they are forced to by family members or loved ones, their heart isn\u2019t truly in it. Relapse is very common within a year or less following discharge from treatment, accounting for 30 to 50 percent of weight-restored patients. Some 20 percent of anorectics in treatment remain chronically ill, going in and out of hospitals, while less than 50 percent go on to complete recovery. Partial remission of anorexia nervosa symptoms occurs in about 30 percent of patients. But just restoring normal weight to an anorectic doesn\u2019t always get at the underlying psychological contributors to the disorder. These often persist for years and include moderate to elevated levels of anxiety, perfectionism and obsessive behaviors that are associated with anorexia. Is Genetics a Factor? Can we blame genetics and heredity for anorexia? While clinical observations point to an association between eating disorders, anorectic personality traits and other psychological disorders tending to cluster in families, and there has been some chromosome 1 linkage with restricting anorexia nervosa, such findings are preliminary. Other studies show high values of heritability in families, suggesting strong genetic predisposition. In addition, eating disorder symptoms such as dietary restraint, self-induced vomiting, and preoccupation with body image and weight \u2013 even in the absence of an eating disorder \u2013 appear to suggest that clustering of eating disorders in families is due predominantly to a number of genetic factors. This also suggests that anorexia nervosa is mediated by many genes. Personality Traits and Psychiatric Disorders in Anorectics Anorectics display elevated levels of anxiety, obsessive behaviors and perfectionism, as well as personality traits including rigidity, reduced expression of emotion and perfectionism. Obsessive-compulsive disorder (OCD) is 15 times more likely in an anorectic than in the general population. OCD is characterized by recurring compulsions and obsessions serious enough to impair an individual\u2019s life. Another form of OCD, although less severe, is obsessive-compulsive perfection disorder (OCPD), characterized by neatness, preoccupation with rules, perfectionism and rigidity. Major depression and anxiety also frequently occur in individuals suffering with anorexia nervosa. Some personality traits precede the onset of anorexia nervosa and include social introversion, need for exactness, order and symmetry, inflexible thinking, harm avoidance, perfectionism and low novelty-seeking, according to experts in the field. These personality traits also persist even after recovery. The co-occurrence of psychiatric conditions with anorexia nervosa is also linked with genetic evidence which again suggests that multiple genes are involved in predisposing individuals to a number of personality traits and psychiatric conditions, including anorexia nervosa. Serotonin and Dopamine \u2013 Are These the Culprits? Maybe genes and neurotransmitters are involved in the development of anorexia nervosa. Scientists using positron emission tomography (PET) and magnetic resonance imaging (MRI) are making strides in studying the pathobiology of anorexia nervosa. Serotonin \u2013 involved in regulating appetite and mood, and dopamine \u2013 primarily involved in modulating reward and motor activity \u2013 show great promise with respect to understanding anorexia nervosa pathogenesis. Dysfunction in 5-HT (5-hydroxytryptamine) in the serotonergic system, for example, can result in many of anorexia nervosa\u2019s elevated traits. Similarly, dopamine, another neurotransmitter, involved with harm avoidance, motor activity, feeding behaviors and reward, has been implicated with the pathobiology of anorexia nervosa. Despite some promising findings, however, further studies need to be conducted. Let\u2019s Blame the Media Genetics and heredity aside, what other factors exist that may contribute to a greater or lesser degree to the prevalence of anorexia in America? One needs to look no further than the most-photographed celebrities on magazine covers or those in television and the movies. In fact, the mania over being the \u201cright weight\u201d has reached into every nook and cranny of America over the past three decades or more. What started the rush to be thin? Go back to the mid-60s and the world\u2019s first supermodel Twiggy, a \u201cskinny kid with the face of an angel.\u201d Aptly named, as it turns out, due to her waif-like (read thin) appearance and innocent child\u2019s looks, Twiggy became an idol for millions of American girls. They wanted to be just like Twiggy, and the famous Twiggy boyish haircut was adopted by millions. And it wasn\u2019t just that.\u00a0 Girls (and women) started starving themselves to approximate the Twiggy look. Twiggy was the darling of photographers who captured her every move until she retired from modeling in 1970. But Twiggy was naturally thin, not an anorectic. How did we progress from an admiration of a certain personality to a trend toward skinniness in the extreme? Go back to Hollywood and, again, the media. It\u2019s common knowledge that the camera adds at least 10 pounds. Look at movie and television stars over the years and how their weights fluctuate up and down (along with hemlines, hair color and other cosmetic alterations). Think of some of the most obvious: Calista Flockhart (previously star of the TV show, Ally McBeal), whose painfully-thin appearance sparked rumors of an eating disorder; movie actress Christina Ricci, only 5-foot 1-inches tall, and incredibly thin; actress Mary-Kate Olsen (fraternal twin to Ashley) reported to have suffered from anorexia nervosa, and many more. This is not, however, meant to imply that any of these individuals is now or previously was an anorectic. It is simply to illustrate excessive media attention paid to highly-visible celebrities over every aspect of their lives, including weight loss and\/or gain. Pick up any tabloid and you\u2019ll find articles on who\u2019s wasting away, photographs of actresses and celebrities in their before and after (healthy and emaciated) stages, along with rampant rumors and wild speculation as to the causes \u2013 psychological or otherwise. Are they losing weight due to trauma, emotional distress, a new movie role, being dumped \u2013 or an eating disorder? What\u2019s more, it doesn\u2019t end with celebrities. Morning news and entertainment programs and other daytime (and nighttime) venues have taken to showing interviews with women (and they\u2019re almost always women) who have dieted to the extreme. Many of these women are so painfully thin that you wonder how they can move about without breaking a bone. Still, almost to a one, they think of themselves as fat. That\u2019s not beauty, that\u2019s a death sentence. Young girls, in particular, have doubts about their own self-image and self-worth. If their mother has an eating disorder problem, coupled with another psychological disorder or personality traits associated with anorexia nervosa, the young girl may have a more difficult time warding off an obsessive pursuit of weight loss. Taunts by other classmates and a daily dose of media coverage of the latest thin starlet and you have a recipe for unhealthy behavior which may or may not translate into an eating disorder. Combating the Hype While the underlying and contributing causes of anorexia are complex and subject to much more discussion and investigation, one way to lessen the impact of obsessive thinness is to reject the idea that \u201cYou can never be too thin.\u201d It\u2019s not likely that the beauty pendulum will swing back to the Rubenesque plumpness of centuries ago, nor is that a good idea. Too much weight is as bad as too little. But a healthy balance is required, balance in media coverage, balance in family and individual perception, and balance in eating habits. This will go a long way toward combating the hype. It may also prompt anorectic-prone individuals to re-examine their behaviors and seek help. Change in America\u2019s perception of what constitutes beauty to encompass all body types and proportions may also encourage family members and loved ones to recognize the signs and symptoms of anorexia in those closest to them \u2013 and to insist on treatment. Toward a Healthy Future According to the NIMH, \u201call eating disorders involve multiple biological, behavioral and societal factors that are not well understood.\u201d So, in the end, who is to blame for anorexia? Look around. There\u2019s plenty of blame to be shared, if blame is even the right word. Instead, as a society, we should focus more on helping re-establish priorities that include good nutrition, healthy self-image and self-esteem, and on finding and implementing effective treatment for individuals who suffer from anorexia. Individuals can and do come back from anorexia. It isn\u2019t easy, and it doesn\u2019t happen overnight. The personality traits that pre-dated onset of anorexia may linger for years after recovery. But with specialized treatment and counseling, a commitment to wellness on the part of the patient and the support of family and loved ones, the outcome can be favorable.