A psychological disorder

Last week, it was widely reported that the prevalence of extremely thin models in fashion and the pressure this can put on women to try to conform to such standards has led French legislators to propose a law that would prevent talent agencies from employing models with a body-mass index (BMI) under 18.

Calculated by dividing a person's height by their mass squared, the World Health Organization (WHO) considers a BMI between 18 and 25 to be "healthy."

The proposed law follows articles that appeared in the New York Post and the Daily Mail earlier this month, about 18-year-old Australian Christie Swadling, who dropped down to 30 kilograms due to a desire to look more like Victoria's Secret lingerie model Miranda Kerr.

Swadling is now an advocate for healthy living. She has documented her battle with anorexia in an online video that now has more than 630,000 views on YouTube, and is now charting her recovery on image-sharing site Instagram.

While a BMI below 18 does not necessarily mean that someone is anorexic, advocates of the proposed law argue that representations of very thin models in magazines and advertisements are a major factor leading to eating disorders.

Song agreed that media representations of thinness could lead to the cognitive biases - such a woman inferring that if she is not thin then she is not beautiful - that can underlie eating disorders like anorexia.

Other triggers, said Song, included breakups or dissolution of close social relationships over weight or body image issues.

"People who have low self-esteem, are overly perfectionist or tend to be somewhat obsessive in their personality are also more prone to eating disorders," he said. Mu said that she first started becoming obsessed with losing weight after breaking up with her then-boyfriend, two years ago.

"He said that I was too fat," said Mu. "So I realized that if I am thin enough, I won't be dumped again."

Mu currently has a BMI of 14, which under the WHO classification would be considered "very severely underweight."

While BMI by itself does not indicate an eating disorder, Song said that when a person had a low BMI, and still insisted on continuing to lose more weight, then it would usually be considered that the person was suffering from some sort of eating disorder.

As is typical of those who suffer from anorexia, Mu rejects suggestions there is anything wrong with her.

"I don't want to go to therapy. I am not ill. I just want to be thin," she said.

"People who have anorexia are often in denial that they have a disease and refuse to be treated," said Song.

"It's up to the patients' families to intervene first. If they're willing to talk to a psychologist, this can help start changing some of their cognitive biases."

Further complications

"Anorexia nervosa is very dangerous. It has the highest mortality rate of any mental illness," Song said. "Five to 20 percent of the people diagnosed with anorexia nervosa die from it, due to heart complications, organ failure or suicide."

Dr. Gilbert Shia, a general practitioner at Beijing-based international health clinic MedicGo, said that people who were anorexic were often affected by a number of physical ailments, including a weakened immune system, constipation, bloating and other stomach pains.

"People with anorexia can also suffer from severe fatigue, dizziness, heart palpitations and shortness of breath," Shia said.

In some cases, women with anorexia would stop menstruating, as has been the case with Mu, and it could even result in infertility, said Shia.

Anorexia is also associated with a number of comorbidities, such as mood disorders, impulse control and anxiety.

According to an article titled "Mortality in Anorexia Nervosa" that was published in the American Journal of Psychiatry, nearly 50 percent of people diagnosed with eating disorders also meet the criteria for clinical depression.

Song said that some anorexics also suffer from bulimia, another eating disorder in which a person binge-eats, and then rids oneself of the food eaten by deliberately inducing vomiting.

"Sometimes I get very hungry in the middle of the night, so I eat whatever I can find in the fridge," said Mu.

"[During those moments], my appetite is uncontrollable, and I'll eat something like three times the portion size that a grown man might in one meal."

"Afterward, I regret it, so I force myself to vomit the food out. I can't help it," said Mu.

Treatments

One of the common myths about eating disorders is that treatment or recovery is not possible, a claim that Song strongly rejected.

Song said that there were two common treatments that were often effective in helping those with anorexia or other eating disorders.

The first is cognitive behavioral therapy (CBT), which involves minimizing and altering a patient's negative thoughts about his or her own body image, and realigning the harmful behaviors associated with eating disorders.

The second, said Song, is Family-Based Treatment (FBT), also known as Maudsley Family Therapy. In FBT, the eating disorder patient's family plays an active role in encouraging them to eat, and focuses initially on weight restoration before addressing the psychological or mental issues that underlie the eating disorder.

"For adolescents with anorexia, attending the FBT with their parents has been proven to be the most effective. Around 80 percent of patients treated through FBT make a full recovery," Song said.

"For adults, CBT can help locate the reasons for their obsessive attitudes toward losing more weight, and confront them."

In terms of the physiological complications of anorexia, Shia said that in critical situations, those with eating disorders could be put on intravenous drip to rapidly deliver the nutrients their bodies were lacking.

But in the long term, the only solution for those with eating disorders is to start to eating more food, said Shia, coupled with increasing exercise.

Shia suggested that those recovering from an eating disorder like anorexia could start with stretch exercises, like yoga or Pilates, to build up their muscle strength and flexibility.