Pro-ana and pro-mia sites, for those of you who are not aware, are websites that generally promote anorexia nervosa and/or bulimia nervosa “lifestyles”.
They are so toxic and influential that even those nowhere near the restrictive eating disorder spectrum will subsequently rate much higher in body dissatisfaction and have a much greater desire to lose weight after viewing these sites [A.M. Bardone-Cone et al., 2007].
Now before you go racing away from this post to do a Google search, just bear with me a while longer…
The individuals who run these sites and the active participants actually don’t experience quite the same negative affect as passive viewers. However, there are far more passive viewers to these sites than active users, so the overall impact is still very dangerous.
Active users are almost all diagnosed patients of these conditions and feel that the community of health care providers and family are hostile agents towards their efforts to find sanctuary within their condition.
I’m going to get back to this concept of “sanctuary” near the end of this post.
Just so I’m clear, when I speak of anorexia and bulimia as chronic conditions I mean it in a medical sense. Chronicity does not necessarily involve permanent activity of the condition. It can mean occasional severe flares with long periods of remission or permanent remission; it could involve a long period of active symptoms with intermittent periods of remission; it could involve life-long mild symptoms being present; it could involve progressive debilitation; or it could involve a long period of progressive debilitation followed by spontaneous remission.
If We Had “Pro” sites for Other Chronic Conditions as a Comparison
If you went to a pro-asthma site, or a pro-diabetes site on the web, what would you expect to find?
That very comparative question is at the heart of why there is such confusion over on-line communities supposedly creating “sanctuaries” for those living with eating disorders.
Obviously a pro-asthma site that has a vibrant community won’t have members spending much time at all trying to find ways to reinforce their symptoms. They would find it strange to view their struggle to breathe as transcendent, or purposeful in any way. They don’t think in terms of “when I’m ready to recover”.
They will be looking to manage, moderate and minimize symptoms using both pharmaceutical and non-pharmaceutical options. They will also appreciate a community of co-sufferers who provide them with tips to help alleviate symptoms, and offer understanding and empathy for when the symptoms can still be tough to manage and may not go into complete remission.
So why would a pro-ana site meld the concept of reinforcing symptoms, not being “ready to recover”, viewing the rejection of medical intervention as a mark of heroic independence, with aspects of communal understanding and empathy over the severe reduction in quality of life and unrelenting misery that their anorectic (or bulimic) symptoms impose on them?
Teenagers with Chronic Conditions
The answer is in the demographic. It is not straightforward to identify the demographic involved in active use of the pro-ana and pro-mia sites on-line (because these are all electronically created and unverifiable identities), but it appears that it is girls in their early to late teens [Fox et al. 2005]. It is possible to indirectly confirm the demographic using language behaviors and lifestyle details that are revealed in the posts.
Most of the current scholarly review on the popularity and use of pro-ana and pro-mia sites is veering into the psychosocial weeds (in my humble opinion).
It seems so difficult for the professional community to stay on topic when it comes to chronic conditions that effect mental functions.
Rather than looking around to see whether there are any equivalent examples in medical experience, we race off to discuss the feelings of powerlessness of western white women (the predominant users of these sites), the desire to stay a child, the fear of adulthood, etc.
And there are plenty of equivalent experiences for teens with chronic medical conditions.
That is not to say that the psychosocial influences for these young girls and women are irrelevant, simply that they may only enhance the central reason for participation and not exclusively define it.
So while I’ve just gone to great lengths to point out that you will never see a pro-asthma or pro-diabetes site that would embrace the symptoms as a “lifestyle”, I can tell you that a sub-section of their populations are affected by magical thinking that really isn’t much different than what we’re seeing all over the pro-ana and pro-mia sites.
In fact, many a parent with an asthmatic or diabetic teen will be able to attest to their son or daughter’s refusal to take their medication and risk their lives in the process.
Paradoxically, many teens with chronic conditions deny the existence of their medical conditions in a misplaced and intense desire to be normal or fit in.
Often teenagers with asthma or insulin-dependent diabetes have had their conditions since they were very young. The management of those conditions has slowly transferred from being directed by their parents to becoming the individual’s responsibility with oversight from the parents.
By contrast, the development of a restrictive eating disorder usually coincides with increased independence and responsibility as a young boy or girl enters the tween/teen years.
And therein lies the slight but critical difference in the relationship the teen has with their condition during these years of development.
For the asthmatic, or diabetic, the management of their condition is synonymous with parental control and the denial of the condition is a misplaced attempt to achieve the ever more critical acceptance of peers.
For the anorexic or bulimic, the enhancement of their condition is synonymous with separation from parental control and an identification with the condition is a misplaced attempt to achieve the ever more critical acceptance of peers.
Now, that sounds suspiciously like psychosocial explanations, doesn’t it?
So before I make a liar out of myself, let’s investigate how the teenage brain runs the show.
Teenage Risk Assessments
There has been a lot of fMRI investigation into how teenage brains work. The differences in brain activity between adult and teen brains suggested that teen brains are “under construction”.
The most quoted study reinforcing this concept was one that asked teens and adults various questions while their brains were being scanned for relative activity. When you ask the following question: “Would you stick your hand in a vat of acid?” adults laughed and immediately answered “No.” Teens briefly considered the question and answered “No” as well.
However, the consideration of the question appears to be processed in distinctly different areas of the brain. The adults generally processed the question in the basal ganglia, an area that manages automated day-to-day behaviors. The teens however processed the question in the frontal lobes, suggesting that it required cognitive consideration, rather than automated response.
But we have to be careful with adopting findings from what Cordelia Fine calls “blobology” (the study of brain scans where we are measuring relative blood flows and taking huge leaps of faith that a blob of color suggests much more than just increased blood flow).
Are teens unable to create an automated response when thinking of dipping their hands in a vat of acid? Does this mean that they really cannot process risks without contemplating them in a cognitive sense? Maybe not.
“A few researchers began to view recent brain and genetic findings in a brighter, more flattering light, one distinctly colored by evolutionary theory. The resulting account of the adolescent brain—call it the adaptive-adolescent story—casts the teen less as a rough draft than as an exquisitely sensitive, highly adaptable creature wired almost perfectly for the job of moving from the safety of home into the complicated world outside.” [D. Dobbs, National Geographic, Oct. 2011]
Specifically teens can assess risks as competently as adults, but the risk-seeking behaviors of 14-17 year-olds appear to originate from their over-estimating the rewards of taking a risk when compared to adults.
“The teen brain is similarly attuned to oxytocin, another neural hormone, which (among other things) makes social connections in particular more rewarding. The neural networks and dynamics associated with general reward and social interactions overlap heavily. Engage one, and you often engage the other. Engage them during adolescence, and you light a fire.” [ibid.]
So not only is the teen over-estimating the rewards to be reached through a particular risk, but she is experiencing tremendous neural cross-over in taking those risks in conjunction with reinforcing new social connections.
Great, so I’ve managed to wade my way out of the psychosocial bog and into the evolutionary biological swamp. Progress.
Back to Denial vs. Identification with Chronic Conditions During the Teen Years
As I mentioned, what may define the attraction of pro-ana and pro-mia sites for young girls and teens dealing with those chronic conditions is that the appearance of the condition has coincided with brain development that seeks more rewards and new peer connections.
Conversely, what attracts a teen asthmatic or diabetic to stop taking medication and managing their condition is that the chronic condition pre-dates their new teen brain that now seeks more rewards and new peer connections.
Ask any teen asthmatic in an emergency room how they managed to ‘forget’ their inhaler, and (with some prodding) he will admit to just wanting to be like the other kids and be “normal”.
Either way, these are hair-pulling nightmare behaviors for parents to have to live through.
Whether a teen embraces her condition as a mark of independence, or denies her condition as a mark of independence, the outcome is life threatening and therefore harrowing to watch as a loved-one.
With the exception of on-line communities, real-life interactions with peers usually mean that either the denial or embracing of these chronic conditions actually leads to peer alienation—which is one of the major pressures on the teen to stop denying or embracing and start managing and functioning.
Human beings experience peer exclusion in the same way as they experience physical threat or threat to the food supply. As social primates, our inclusion in the peer group assures our survival.
Evolutionary Value of Reward-Seeking, Peer-Focused Teens
Myelination of the nerves in the frontal lobes happens between ages 16-25 (ish). Myelination enhances the speed of conductance and it also inhibits the growth of new branches and axons.
The reason that the frontal area of the brain is not heavily myelinated during the teen years is because it appears to be a survival trade-off. Teens need the neural flexibility so that they can become optimally attuned to the world in which they will live. And so in the interests of allowing the brain to easily lay down new branches and axons in the frontal area, the speed of conductance that comes with myelination has to be delayed for that to occur.
Laying down new branches and axons is how the brain adjusts to environmental inputs so that it is better designed to thrive in the environment in question.
Over-estimating the rewards of risky behaviors maximizes the brain’s exposure to novel environmental inputs. The peers are critical because they are the ones with which you will share your world and your strong connection to them ensures your ultimate survival.
On-Line Communities Can Short-Circuit Maturation
Now we get back to the “sanctuary” of denial in on-line communities that promote anorexia and bulimia.
While it is true that real-life interactions can involve girls reinforcing anorexic and bulimic behaviors together, usually the condition itself slowly isolates the girl from interacting with others much at all. That the world shrinks to the point where the patient is not interacting with the very peers that will help her to develop into adulthood is often the point at which she decides she wants “her life back” and she seeks help to recover or facilitate full remission.
For asthmatics and diabetics (and other teens with chronic conditions), they do eventually realize that if they take responsibility for managing their symptoms, they are actually able to fit in with peers much better than when they deny their symptoms and subsequently are rushed to emergency.
However the pro-ana and pro-mia websites add an insidious and very large roadblock to the maturation process as they create a sense of virtual peer support when the patient is actually too ill, weak or generally embarrassed to interact with in-person peer groups.
When active use of these sites is combined with the physiological impacts of starvation (or starvation/reactive eating/purging cycles), then the patient is essentially in neural suspension – inhibited from developing to adulthood both psychosocially and biologically.
The on-line community in this case functions similarly to how the body is affected by chewing gum. When we chew gum, the act of chewing indicates to the body that nourishment and energy are forthcoming. For a while the system is tricked into generating that sense of calm that comes with satiation. Then it gets wise to the trick and we are hungry and need real food.
For the period of time during which a patient interacts with her on-line peers, she is essentially chewing emotional gum.
Starvation is also brutal on brain function. Comprising only 4% of our total body mass and yet requiring 20% of the energy we take in, the brain simply cannot function with insufficient energy intake.
Combine that with the necessity in teens of having the brain bombarded with new experiences to lay down new neural nets, and an anorexic or bulimic teen is essentially placed in developmental suspension. There is nowhere near enough energy to get the brain to function normally let alone to develop to adulthood.
This suspension, found in anorexic and bulimic patients, has been misunderstood for decades to be a self-directed effort. Presumably the patient simply feared growing up and wanted to stay a child forever.
In fact, all this time we have confused correlation with causation. Starve anyone and they develop extreme anxieties, compulsions and phobias. Starve a teen on the verge of needing monstrous energy input to lay down neural nets in the frontal area of the brain, and the anxieties, compulsions, denial, rebellion and secretiveness can all appear to be consciously driven.
Our brain seems quite limited in its ability to identify its own level of impairment.
It’s quite interesting to watch hapless college students forced to stay awake and perform various cognitive and motor tasks. The interesting aspect is not that they start to really suck at the tasks the longer they are kept awake, but how oblivious they are of how badly they suck.
My own personal experience of being oblivious to impairment was when I had an asthma attack that required an emergency visit when I was young. I was absolutely convinced that the blood gas monitor finger cuff was going to hurt me. With the benefit of adequate oxygen, it’s a truly embarrassing and laughable admission now. But at the time that poor intern had to work very hard to convince me to put the thing on my finger! Essentially, panic and anxiety is a symptom of hypoxemia (low oxygen pressure in the blood).
I was shocked at how my mind completely seemed ‘to clear’ and the panic disappeared as soon as the ventolin mask was slapped on me and I could take a full breath in and out.
In fact if I had had my asthma attack before my time, say in the 1950s, the medical community would have assumed that my anxiety, panic and breathlessness was due to my desire to escape from my controlling mother and generally dysfunctional family relations. That’s right. Asthma once lived in the Diagnostic and Statistical Manual of Mental Illness (first edition).
So just as a side note, we would do well to learn from the history and treatment of asthma and reserve judgment on whether anyone with anorexia or bulimia actually can desire a permanent childhood, or whether the possible fear of development is merely a symptom starvation on the brain itself.
In the sleep deprivation tests, subjects would routinely stop in mid-sentence, sway on their feet and then express complete disbelief that they had not finished their thought when told that it had happened.
This hazy sense of our impairment is one of the main reasons that so many public service announcements encourage those who intend to go out and party to pre-plan their safe rides home. Once impaired, you are very likely going to think you are capable of driving.
There is something to be said for using an external brain if you are currently practicing self-administered starvation. External brain is a term used to describe a suite of tools and aides that might often be used to support those with brain trauma or damage.
These tools can be used to circumvent impairment just as much as they can circumvent more permanent brain function limitations. And the impairment due to starvation only exists for the duration starvation and is reversed through the process of full remission or recovery.
I will cover off these tools in more detail in a subsequent post. For now, if you are starving, remind yourself regularly that feelings of panic, anxiety, suspicion and even paranoia are the result of starvation.
Suggestions for Active Pro-Ana and Pro-Mia Participants
As I mentioned at the beginning of the post, active participants have a more mixed experience than those who are passive viewers on the pro-ana and pro-mia sites. If you are an active participant in one of these kinds of sites, then it isn’t just about “thinspiration” and idealizing the emaciated and sick body.
You do feel understood on the site. You feel supported and accepted. You feel less alone.
Yet fundamentally the site on which you participate has trapped you in a no-win situation. While your on-line peers provide you with empathy and understanding and they are not harsh, dismissive and judgmental as perhaps your parents, other friends or health care professionals have been, it’s as if you live in The Truman Show (the movie with Jim Carrey from the 90s http://en.wikipedia.org/wiki/The_Truman_Show). You sense that your “sanctuary” is actually more like a prison.
You have to lie a lot, to a lot of people in the real world to live in the magical world of a pro-ana or pro-mia site. And lying is cognitively expensive, meaning you are depleting what little energy is available to your brain on pretend living in a world that your 3-dimensional self cannot actually reside in 24/7.
In that catch-22 world where you no longer have enough energy to allow for your own physical development, it seems inconceivable that you would ever desire or want a life beyond anorexia or bulimia at all. Your brain can’t conceive of its own healthy and healed existence because there is no energy to conjure that image up in the first place.
You have a way out of the prison – actually a couple of ways out.
One way is that you could choose to trust a person in your real life who will guide you through a recovery. Ideally choose someone with a well-nourished brain (not a fellow anorexic or bulimic).
You deserve empathy and understanding and while that may be difficult for your parents and friends to unfailingly provide, as they struggle with their own fears about losing you and your poor state of health, you can certainly demand it of your professional health care providers.
I have heard some absolute horror stories about the kinds of things that my colleagues have actually said to their anorexic or bulimic patients, not to mention the judgment and derision heaped upon the parents of anorexics and bulimics.
Despite your impaired state, you can still absolutely sense when someone really does care. Ask that person to help or ask them to help you find someone who can help.
The second way to out of the prison is to swap out the on-line community on which you depend. There are several pro-recovery sites available to you and the advantage of going that route is that your virtual existence is no longer a magical one when compared with your real existence. Both your virtual and real selves are looking to manage symptoms, seek remission/recovery, and neither deny nor idealize the chronic condition that you have developed.
For those who have seen the Truman Show, you will recall the scene where Truman reaches the edge of the dome of his fabricated and televised life and as he heads up the stairs to the door marked “Exit” the show’s producer tries to encourage him to stay via the public address system.
For those who have not seen the Truman Show, the basic premise is that a television producer has generated an entire world in which a child was born and raised to believe the world is real, but everyone around him is an actor in on the deception.
In point of fact the two escape routes I mention: trusting someone who cares and/or swapping out the on-line community to synchronize your real and virtual worlds only gets you to that “Exit” door.
Real escape is achieved through re-nourishment. In Truman’s case he chose the unknown real world over his familiar unreal world. Your choice is not much different.
You are going to love the real world.