by Michael D. Anestis, M.S.
We have addressed anorexia nervosa (AN) several times on Psychotherapy Brown Bag. Up to now, our focus has been on describing the nature of the disorder itself and what treatments are available. Today, however, I would like to shift focus to an entirely different area: pro-anorexia websites. Also known as pro-ana websites, these web pages promote AN as an alternative lifestyle rather than a mental illness. At first glance, this might seem like a legitimate perspective - after all, homosexuality was once labeled a mental illness, so the field of clinical psychology is certainly not immune to making errors in classification. For a variety of reasons, however, I believe this comparison is entirely invalid and that pro-ana websites serve a destructive role for individuals struggling with AN.
Pro-ana websites present AN as an alternative lifestyle through a variety of methods. Although hundreds of sites exist, many of which differ from one another in substantial ways, there are certain themes and areas of content that appear regularly across sites (Bardone-Cone & Cass, 2007). Many of the sites promote a view of AN as akin to a religion, presenting "Ana's Creed" (e.g., "I will be thin, at all costs, it is the most important thing; nothing else matters.") and the "Thin Commandments" (e.g., "Being thin is more important than being healthy."). As Clarke (2008) argued, this helps to create a sense of community amongst individuals viewing the site by developing a set of rules to follow and promoting the idea that anorexia is a common, healthy shared pursuit amongst members. Individuals with AN are often isolated due to the nature of their illness. They tend to avoid interactions that might involve eating and, quite often, become estranged from peers. The potential social capital available through membership in an online community promoting the very lifestyle that led to social isolation can thus be quite alluring. Pro-ana websites thus fill a niche, capitalizing on vulnerability and preying upon the distorted cognitions of individuals struggling with AN.
Readers of pro-ana websites are thus met with content that promotes the idea that individuals have the innate right to self-starve and that pathologizing the behavior is unfair. There is validity to the idea that labeling something that is simply different from the norm can be harmful. This, however, is not the goal of mental illness diagnoses in general or AN in particular. The DSM-IV-TR requires that symptoms cause distress and/or dysfunction in order for a syndrome to be classified as a mental illness. Individuals with AN can, at times, feel empowered by the sense of control inherent in chronic dietary restriction. Driven by perfectionism, individuals with AN can develop a sense of pride in their ability to persist in the presence of chronic, significant pain and the desire to eat. Finding like-minded individuals who share in their beliefs can therefore be highly reinforcing. In the case of AN, while distress is thus often not an issue, dysfunction is undeniable. As mentioned in an earlier PBB article, AN has one of the highest early mortality rates of any mental illness (Sullivan, 1995), with most of these deaths due to suicide and the side effects of nutritional deficits (Crisp, Callender, Halek, & Hsu, 1992). Clinicians and researchers are not aiming to marginalize an alternative lifestyle they simply do not understand. They are attempting to reduce early mortality rates in a population that appears to be driven by distorted cognitions and perceptions of their own bodies. Pro-ana websites, on the other hand, reinforce the behavior and perpetuate false beliefs.
In addition to the overlapping theme of "alternative lifestyle," pro-ana websites also often share particular content. "Thinspiration" models - images of thin women, often celebrities - are posted in an effort to provide readers with prototypes to which they can aspire. Additionally, most pro-ana websites include a section of "tips and tricks." This section provides insights to readers on ways to resist hunger, lose weight, hide weight loss, and deceive family and peers regarding eating behaviors. For a variety of reasons, the "tips and tricks" section of these sites is particularly dangerous. Pro-ana websites are not regulated and, as such, the information provided as safety measures is often full of misinformation capable of causing fatal physiological consequences. Also, by teaching individuals to better deceive friends, family, and clinicians, the websites serve as an obstacle to early symptom reduction. There is some evidence that early detection and treatment is a strong prognostic indicator (Herzog, Rathner, & Vandereycken, 1992) and, as such, by obstructing treatment, pro-ana websites may serve as a risk factor for a more dangerous course.
Harshbarger, Ahlers-Schmidt, Mayans, Mayans, and Hawkins (2009) conducted a study of the content of pro-ana websites in an effort to provide clinicians with a better sense of the material that appears on these web pages. The most common theme across sites was instructions on ways to reduce caloric intake. The second most common theme was ways to distract from hunger, followed by tricks for deceiving others and methods for burning calories. Harshbarger and colleagues' primary goal was to provide clinicians with a basic understanding of the nature of pro-ana websites while also motivating them to educate themselves further. By better understanding the resources to which clients are turning, clinicians can be better prepared to face therapeutic obstacles and to anticipate areas of resistance.
In one of the few studies to experimentally examine the impact of pro-ana websites, Bardone-Cone and Cass (2007) divided a sample of female undergraduates into three conditions. In the first condition, students viewed a pro-ana website designed by the authors after careful examination of actual pro-ana sites. In the second condition, students viewed a female fashion website. In the third condition, students viewed a website devoted to home decor. The authors found that students in the pro-ana website condition reported greater levels of negative affect, lower levels of social self-esteem, and lower levels of appearance self-efficacy than did students who viewed either of the other two websites. Additionally, individuals in the pro-ana website condition viewed themselves as heavier and reported that they were more likely to exercise, think about their weight, and compare themselves to others than were individuals in the other two conditions. This study had several limitations, including the use of a non-clinical undergraduate population, but it also provided compelling initial findings that pro-ana websites can have deleterious effects on viewers.
So, given the apparent harmful nature of pro-ana websites, what can be done to remedy this situation? The answer, unfortunately, is unclear. Banning such sites, in addition to raising ethical issues relative to the first amendment, would be unlikely to actually diminish the existence of pro-ana communities. New sites would likely develop despite laws and, regardless, pro-ana individuals promote their beliefs in non-web-based methods as well (e.g., ana bracelets; Norris, Boydell, Pinhas, & Katzman, 2006), an approach that would likely become more prominent in the absence of websites. The most effective approach might be a combination of factors, most of which are based on education and dissemination. The efforts of Harshbarger and colleagues (2009) to educate clinicians is a strong start. Further efforts to provide accurate, up-to-date information to both clinicians and the general public are necessary as well. Additionally, the general public needs to be provided with readily available information on the most effective interventions for AN so as to increase the prevalence of smart consumers who actively shop for the best care as early as possible. Given the ego-syntonic nature of AN, it is unlikely that pro-ana websites will ever fully disappear. Their impact, however, can be mitigated through the creation of an equally prominent campaign advertising effective care and accurate information regarding the effects of AN. Such campaigns should include celebrities, researchers, clinicians, AN survivors, and anyone else who can provide a unique and compelling perspective based upon accurate, data-driven information.
As an internet service provider aimed at promoting scientifically-based information on clinical psychology, the authors of Psychotherapy Brown Bag are acutely aware of the impact of the internet on information acquisition. While we hold ourselves accountable for the information we write - citing empirical studies and making those citations available through our references page for readers interested in fact checking or learning more on particular topics, other sites choose not to do so, presenting themselves instead as experts who should simply be trusted. Our hope is that, in the future, this type of assumption will become less common amongst internet consumers as the dangers of misinformation become better understood. In the meantime, I hope that you will provide your thoughts on whether pro-ana websites are problematic and, if so, what can be done to effectively diminish their impact.
If you would like to learn more about anorexia nervosa, we recommend the following products, all of which are available through our online store:
DVD:
- NOVA: Dying to Be Thin
Books:
- Eating with Your Anorexic: How My Child Recovered Through Family-Based Treatment and Yours Can Too
- Treatment Manual for Anorexia Nervosa: A Family-Based Approach
- Eating Disorders
- Eating Disorders Review: Part 1
- Eating Disorders Review: Part 2
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
Subscribe in a reader
