A key finding from participant interviews was the experience of shame as a consequence of diagnostic crossover. Participants described the existence of a diagnostic hierarchy whereby certain EDs, and the individuals diagnosed with them, were perceived as “better” than others. Exploring what “better” means in this context led to a careful analysis of how character, self-image, and moral identity are experienced by individuals who undergo diagnostic crossover. In the following discussion, these findings are divided into three sections:
Better diagnosis, better person
Reading moral character through the body
Diagnostic crossover: identity in flux
The first section explores some of the ways in which participants viewed moral character as intertwined with diagnostic categories or labels and therefore experienced EDs as existing within a hierarchy of better and worse people. The second section examines how moral character is often “read” from one’s physical appearance and therefore explores the ways in which participants experienced moral identity in relation to the body. The final section explicitly considers participants’ experiences of diagnostic crossover and how the movement from one ED to another was experienced as an “identity crisis” and shameful moral failing. The discussion that follows explores shame in more detail by drawing on relevant philosophical literature.
Better diagnosis, better person
Anorexia is like the top one, you’re an exemplar of resilience and determination and you work hard, you don’t indulge, it’s incredibly puritanical […] I’m not really sure that I would ever have referred to myself as having anorexia as I didn’t feel [pause] I wasn’t good enough for that. [Hollie]
Hollie clearly identified AN as the best or even most desirable ED in a diagnostic hierarchy. For Hollie, those diagnosed with AN are “exemplar[s]” of a number of admirable character traits such as resilience and determination. Her description of herself as not “good enough” seemingly denotes both a moral standard and a skill set; she views herself as insufficiently good at restricting her food intake to qualify as “anorexic,” and this failure in part stems from the fact that she is not a good enough person and lacks the character traits necessary to successfully “work hard” to resist food.
Similarly, Natalie describes a hierarchy of ED diagnoses, suggesting that individuals with a “better” diagnosis, such as AN, are worth more than those with a “worse” diagnosis, like BN or BED:
There is the perception that AN is this extreme manifestation of will power, [and] will power is a positive quality, and hence you are from the outset imbuing that diagnosis with this strength, and therefore bingeing and bulimia are chaos, that’s negative, so from the very start that these labels are tied up with value judgments, […] I attach value to the different labels, like I think I was worth more as a person when I was anorexic than when I’m bulimic, I sort of think of it as a very hierarchical thing. [Natalie]
Whilst all participants identified “better” and “worse” EDs, associating these with better and worse character traits, Hollie explicitly uses moral language to suggest that the diagnostic hierarchy is grounded in judgments about moral character and virtue.
I thought there was something morally good about restricting. I thought it was piggish and disgusting that someone could eat lots like chocolate and not have control over their impulses. […] I can remember turning round to my family who are über-Catholic, and they’re also greedy, and I said with so much venom, “greed is also a sin, you think you’re a good Catholic but you’re not because you are greedy and that’s something I will not be.” [Hollie]
Hollie suggests that uncontrolled overeating is morally bad rather than just unhealthy, and therefore by restricting she guards against the moral stain of “greediness.” Indeed, she views herself as morally superior because of her ability to restrict her food intake and implies that she is an overall better kind of person than her family members who cannot always control their impulse for chocolate.
Importantly, participants suggested that the character traits associated with various diagnostic labels were not exercised only in relation to eating or weight control but extended into other areas of their lives, particularly their academic work.
If you have an ED that’s mainly about restricting, then it’s about perfectionism, so that’s normal here [at university], because we are all perfectionists, we like having good grades and working hard, whereas bingeing and purging doesn’t fit that because it’s a failure as opposed to something you’re proud of […], so now, yeah, it’s more a feeling of shame, like I’m not good enough to belong here. [Sarah]
I associated my thinness with success because when I was doing my GCSEs and I did really well, I was very thin […]. Anorexia requires this extreme resilience and determination and, well, it’s an ideal that is actually hammered home in school, you’re told to be diligent, and in work, the people who work the hardest do the best. [Hollie]
Sarah suggests that it is “normal” for university students to display traits like “perfectionism” which are associated with AN. Indeed, Hollie explains that such diligence is taught in schools as a way of encouraging academic success. In contrast, the BN identity entails character traits that make Sarah feel she doesn’t “belong” in a university environment, because she isn’t “good enough.” Here, the word “good” seemingly indicates both an academic and a moral standard to be met.
Reading Moral Character Through the Body
Central to the diagnostic hierarchy is the differentiation between EDs that involve low body weight—AN and its subtypes—and those that do not. Participants often described BN and BED as more shameful in part due to the physically larger body associated with this diagnosis, and expressed concern about the ways that others would form judgments about their character from their physical appearance.
Anorexia—they’re the sad skinny girls, but internally they’re … well you feel really quite strong, you’re able to despite everything, despite people shouting and crying, you continue to do this one thing. Bulimics are less in trouble and that’s the sad thing because if you have an ED that makes you thin, oh tragedy but oh interest. But if you have an ED that makes you fat, then you’re no different to the fifty-year-old women who use Weight Watchers and can’t do anything about their proclivity for cheese. You know? It’s just conflated with general laziness or being unaware or not caring. [Marianne]
Marianne focuses on the physical body in order to clearly differentiate between the “skinny girls” with AN and “eating disorders which make you fat.” Because the bulimic body is often physically unremarkable, Marianne describes BN as being in some ways indistinguishable from “normal” overeating. This image is presented as mundane, in contrast to Marianne’s portrayal of AN as interesting and tragic. By blurring the boundary between “eating disorders which make you fat” and “normal” overeating, Marianne, like Hollie, emphasizes the idea that BN is associated with a shameful flawed character. She suggests that any weight gain resulting from this disorder is seen to be the result of “general laziness” rather than pathology.
For Marianne, the character traits associated with AN are not only more admirable but also more unique and special. She implies that many people are overweight, and as such unawareness or laziness is not only morally bad but also commonplace and unremarkable. Yet the extreme willpower associated with AN is seen to mark the anorexic person out as special, and the physically emaciated body much more notable than the large body in a society where so many people are overweight.
For Ruth, weight gain as a result of transition to BN was experienced as shameful because she feared that other people would wrongly attribute negative character traits to her on the basis of her physical appearance.
It was becoming fat that felt so alien. […] in my head I’m a thin, small person. I’m organised, I’m controlling, I’m pretty neurotic actually [laughs] but I’m really, really aware of what I eat, you know? But I see this fat, lazy person in the mirror, and it is really shocking because like people will think I just don’t care, but I do, it’s like my body doesn’t reflect what’s going on in my head, and I’m so ashamed when I think about how, how others see me, what they think. [Ruth]
The misalignment of lived and biological body in AN is well documented; physically the body is light and emaciated, yet the person often experiences their body as cumbersome and fat (Keizer et al. 2013). As a result, the individual feels alienated from the body and seeks to control it—and through the body, to control her identity—by starvation (Svenaeus 2013). However, Ruth is describing is something different; diagnostic crossover from AN to BN entails weight gain, and she feels as though her now physically larger body misrepresents her character or personality. Ruth holds onto the character traits that she associates with AN and which she values—good organisation skills, being “controlling”—and a heightened awareness around what she eats. But she worries that those who see her physically larger body will infer that she overeats and will assume that she is “lazy” and doesn’t “care.” Thus, although Ruth discusses the physical symptoms of BN, she is centrally concerned with the kinds of personality traits that she feels symptoms such as weight gain represent or imply.
Diagnostic Crossover: Identity in Flux
The above has described participants’ accounts of a diagnostic hierarchy, rooted in the close association of ED diagnosis and moral character. Consequently, movement between diagnostic categories was experienced by participants as an “identity crisis” since they no longer knew how to understand their own moral character.
I think the transition to binge eating was terrifying […] because of the extent to which I felt like I didn’t recognise myself; it was like, “I don’t know what I’m doing”; I felt like I became a different person. [Natalie]
And I was so ashamed of what I’d become. Being anorexic was always a badge of honour when I was young, whereas being bulimic is a source of total shame and humiliation, especially after having been anorexic. I didn’t know you could be bulimic after anorexia, and I didn’t know what I had was bulimia, so I felt like I was the only person in the world this had happened to, like the worst anorexic ever. I didn’t know what to call myself. Just a fat girl with no will power. [Ruth]
These accounts clearly describe the sense of not recognizing oneself or one’s own behaviour. Ruth depicts BN in terms of its contrast with AN, simultaneously clinging to the AN identity —“the worst anorexic ever”—whilst accepting that this prior identity no longer fits her behaviours and appearance.
Similarly, Marianne discusses diagnostic crossover from the perspective of her former “anorexic” self:
… it’s weird to imagine your twelve or thirteen-year-old self allowing [diagnostic crossover] to happen. She’d be horrified. Absolutely. […] Who I was back then, would, would be horrified, and there was so much pride attached to the strength of that […] it still makes me feel quite ashamed, I think. [Marianne]
Marianne talks of her past self as a different person—“who I was back then”—and imagines the censure of the previous disciplined self. BN is shameful not just because of the bad character traits associated with it, but because it denotes a “fall from grace” whereby one loses the exemplary characteristics embodied by one’s former self.
Sarah powerfully describes this same experience:
Every moment that you’re not eating when someone else is, you’re taking pride from that moment. Even if everything else is going wrong, you still get to be the skinny one, it’s a safety plan for your self-esteem, constant accomplishment […] But then bingeing and purging, there isn’t a positive to it […] and you have to be alone, I think mainly the having to be alone part. You can’t really confide to anyone about it, or if you do you really have to risk that they will look at you and think you throw up and that’s disgusting. It’s a lack of understanding. I think a lot of people understand where anorexia comes from, it’s just an extreme diet, whereas this [BN] isn’t, it’s a lack of self-control. But it’s not like just saying, “Oh well stop, just have more self-control,” that doesn’t work, you’ve told yourself that many times. […] I was just very ashamed of putting on weight, ashamed of eating food, and also quite lonely. So, yeah, it was a bit miserable, and it just transformed completely from anorexia to bulimia. [Sarah]
Sarah describes the shame that accompanies “transformation” from AN to BN, and the overwhelming feelings of loss; loss of the self-control that used to be a source of pride and self-worth and the loss of friends that comes with increasing shame and isolation. Whilst restricting food can be done in the company of others, bingeing and purging must be done alone and in secret and then cannot be discussed for fear of judgment.
The accounts of participants presented here poignantly illustrate the impact of diagnostic crossover on moral identity. Since the character traits associated with AN are so closely tied to an individual’s sense of self-worth, diagnostic crossover results both in self-loathing and a certainty that others will also view one as worthy only of contempt and disgust. This leads to intense feelings of shame.