Pro- Eating Disorder Websites 1. Pro-Eating Disorder Websites: Their Current Use and Future Potential for Individuals with Mental Illness

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1 Pro- Eating Disorder Websites 1 Pro-Eating Disorder Websites: Their Current Use and Future Potential for Individuals with Mental Illness

2 Pro- Eating Disorder Websites 2 The development of the internet and the growth of cyber-communities has changed society in ways that we are only beginning to understand. The internet is often celebrated for providing opportunities for new types of communities to form. While many of these have positive impacts, there are also many dangerous or anti-social groups online. In particular, selfharm websites, which share information about self-harm or suicide methods and can contain shocking images to inspire self-harm, have gained a lot of attention. One study found that 60% of UK youth aged had seen suicide and self-harm content online, with youth reporting having seen graphic sexual, violent, and even terrorist content such as ISIS beheading videos on social media (Penfold, 2016). Most individuals still see the internet as a beneficial part of their lives, but for those who are at risk of mental illness this accessibility of information can be dangerous. This essay will examine the impact of pro-anorexia (pro-ana) websites, which are maintained by individuals with anorexia, a complex mental illness. These websites have been heavily criticized for glorifying mental illness and sharing tips to maintain and hide eating disorders, and many have called for their ban. Pro-ana websites can indeed be very harmful, but a more nuanced analysis is needed to understand the reasons why individuals create and use these websites, as this information could inform more effective interventions, on- and offline, for individuals with eating disorders. Anorexia is characterized by an intense drive to lose weight, the restriction of food, and purging in the form of fasting, excessive exercise, vomiting, or laxative use. Lifetime rates of anorexia are estimated to be 0.9% for women and 0.3% for men (Hudson, Hiripi, Pope & Kessler, 2007), although these are conservative rates and real prevalence, including subclinical anorexia, could be much higher. These statistics are especially worrying considering the many negative health effects of eating disorders. Anorexia has the highest mortality rate of all mental

3 Pro- Eating Disorder Websites 3 illnesses due both to the physical effects of food restriction, and a high prevalence of suicide. An estimated 10% of individuals diagnosed with anorexia will die within 10 years of the onset of the disorder (Sullivan, 2002). Although the outward symptoms required for diagnosis are related to attitudes towards food and weight, the illness is much more complicated than this, and treatment requires addressing underlying mental health issues such as a history of abuse, low self-esteem, depression or anxiety. Treatment is not widely accessible, is often not sought because of the stigmatized nature of the illness, and even when treatment is available, recovery rates are very low. One meta-analysis of 119 separate studies found that, in general, less than half of all patients suffering from anorexia will fully recover, a rate that has remained constant over the past few decades (Steinhausen, 2002). Individuals with anorexia persistently act in ways that harm their bodies, starving themselves and purging to the point where their bodies are dangerously thin and malnourished. To outsiders, this may seem like reckless attention-seeking behaviour, but to those suffering with anorexia, these behaviours are coping mechanisms for dealing with difficult thoughts and feelings, much like other forms of self-harm. The common misunderstanding that anorexia is a selfish choice made by those who care too much about appearance means that anorexic individuals often feel unable to reveal their experience to others, and instead go online to seek people who understand them. Pro-ana websites are generally maintained and used by anorexics themselves, and usually include thinspiration photo galleries and quotes aimed at encouraging weight loss, creative writing about eating disorders, forums where members interact, and most controversially, tips and tricks for maintaining eating disorders (Norris, Boydell, Pinhas & Katzman, 2006). Because experiencing anorexia is so isolating, the internet is an ideal venue for seeking support without losing face (Harschbarger, Ahlers-Schmidt, Mayans, Mayans & Hawkins, 2008). In general, self-

4 Pro- Eating Disorder Websites 4 harm websites have been shown to provide users with resources such as validation, sympathy and encouragement, and often act as a distraction from the desire to self-harm, helping users get through the day (Baker & Fortune, 2008; Harris & Roberts, 2013). Pro-ana bloggers maintain their websites to share their experiences, allowing for a cathartic release of emotions (Yeshua- Katz & Martins, 2013). One study found that 35.5% of eating disorder patients aged had visited pro-eating disorder (pro-ed) websites (Wilson, Peebles, Hardy & Litt, 2006). Considering that this study included participants who had sought treatment between 1997 and 2004, this percentage is very high. Because of the incredible growth of the internet since then, this percentage is likely much higher now. Clearly, understanding pro-ed websites is important to understanding the anorexic experience. Due to the controversial content found on many pro-ana websites, many have called for their ban. Experts have warned that pro-ana websites normalize illness ( Psychiatrists urge action, 2009), and self-harm websites in general have been criticized for allowing the contagion of self-harm behaviours from those who are mentally ill to at-risk outsiders, supposedly causing new cases of mental illness (Baker & Fortune, 2008). One study followed healthy female college students with no history of eating disorders who were exposed to pro-ed websites for 1.5 hours and found that in the following week, 84% reduced their caloric intake, 44% said that they would use tips from the website to lose weight, and three weeks later, 24% said they were still following tips they had found on the websites (Jett, Laporte, & Wachisn, 2010). Even among healthy women, viewing pro-ana websites lowers mood, self-esteem and body satisfaction ( Psychiatrists urge action, 2009). However, the fear of eating disorders being spread to healthy individuals through pro-ed websites seems somewhat exaggerated, as self-harm websites primarily attract individuals who

5 Pro- Eating Disorder Websites 5 are already experiencing mental illness. For example, 90.5% of self-harm website users reported only visiting these websites after beginning to self-harm (Harris & Roberts, 2013), and pro-ed website visitors were found to have higher levels of body dissatisfaction and disordered eating than the general public (Harper, Sperry & Thompson, 2008). Although body dissatisfaction and disordered eating among healthy individuals may be worsened by pro-ed website use, the group most harmed by pro-ed websites are eating disorder patients themselves, whose recovery can be jeopardized by adhering to the pro-ed philosophy. A significant 70.8% of pro-ed website users in one study reported using the websites to maintain motivation for continued weight loss, which was the main reason for visiting the websites. It is very concerning that 96% of these pro-ed website users reported learning new weight loss or purging techniques, which could potentially be life-threatening (Wilson et al., 2006). The tips and tricks sections of pro-ana websites teach viewers how to restrict calories, self-distract to avoid hunger, and conceal symptoms to deceive others such as parents, healthcare providers or therapists (Harschbarger et al., 2008). These tools of deception, but also the catharsis of sharing experiences online, allow those suffering with eating disorders to hide symptoms and feel just well enough to avoid seeking treatment, thus prolonging their illness. In fact, pro-ed website users were found to live with their illness for longer and be hospitalized more often than non-website users (Wilson et al., 2006). Thus, pro-ed websites do not usually create eating disorders in individuals with no prior body-image issues, but primarily worsen problems for individuals already struggling with food and body-image issues. Unfortunately, because mainstream Western culture already encourages body insecurity, many people are vulnerable to pro-ed messaging. In our society people are taught from a young age to scrutinize their own appearance and food intake. Many parts of our

6 Pro- Eating Disorder Websites 6 culture lay the groundwork for unhealthy relationships with food and our bodies, so simply censoring pro-ed websites is not enough to prevent eating disorders. Pro-eating disorder and self-harm websites are just the tip of the iceberg of mental health issues in our society. They may exacerbate existing problems, but they are not shown to cause mental illness alone. Instead, they are a sign that mental illness is not being addressed properly in our society. Pro-eating disorder websites are criticized for going against mainstream psychiatric treatment, but perhaps we should ask why this is the case. Why don t these users seek treatment? It seems that many individuals find current treatment options so inaccessible, ineffective, or undesirable that they would rather look for help on the internet (Baker & Fortune, 2008). The stigma of mental illness, especially eating disorders, and the underfunding of mental health services mean that many feel uncomfortable seeking help, or do not feel that their problem is bad enough to deserve treatment. Somewhat paradoxically, given the harm that self-harm and pro-ed websites can cause, online resources may be crucial for helping people with mental illnesses such as eating disorders. Although the internet has proven to be dangerous for pro-ed website users, these people can perhaps best be reached through the internet to prevent self-harm and suicide. With the stigma that is tied to these illnesses, many people initially only feel comfortable getting help online, where they can avoid the anxiety associated with disclosing their problems in person (Durkee, Hadlaczky, Westerlund & Carly, 2011). These websites where individuals thinking about selfharm gather together may represent an important opportunity for crisis intervention (Mitchell, Wells, Priebe, & Ybarra, 2014). Online intervention could be very effective as those who first engage in online discussions with a clinical therapist have been found to be three times more

7 Pro- Eating Disorder Websites 7 likely to come for an in-person clinical evaluation and enter treatment than those who do not have this online interaction first (Durkee et al., 2011). Furthermore, censorship, although well-intentioned, is not a practical or effective solution. Ferreday (2003) questions our motivations for banning pro-ana websites, suggesting that a part of the motivation for banning pro-ana material can be attributed to the discomfort viewers feel when seeing mainstream skinny culture used to promote anorexia, but of course so much of our culture already promotes body insecurity. Magazines and health websites often promote similar ideas to what is seen on pro-ed websites, with a heavy focus on dieting and the perfection of the body, but it is uncomfortable to see these mainstream ideals taken to the extreme. Banning pro-ed websites will not solve the problem, considering that even wellintentioned eating disorder information can result in at-risk individuals picking up new techniques to losing weight (Sharpe, Musiat, Knapton & Schmidt, 2011) and that any kind of news coverage of eating disorders, especially of celebrity eating disorders, creates a rise in interest for pro-ed resources (Lewis, Klauninger & Marcincinova, 2016). Perhaps instead of banning pro-ed websites and further stigmatizing those who suffer with mental illness, we should try to provide better methods for support online, since this seems to be an effective way to reach vulnerable and isolated individuals. Although pro-ed websites can create harm, banning them does not address the deeper issues of why so many individuals initially develop a mental illness or how stigma prevents individuals from seeking help. Much research has focused on understanding pro-ed website users and why they go online for support, and this information is very useful for identifying gaps in current treatment options. Understanding pro-ed websites is crucial to understanding the current anorexic experience, and it is important that clinicians, as well as friends and family of eating disorder patients, are aware

8 Pro- Eating Disorder Websites 8 of the harmful information available online. However, more research should be focused towards both addressing the deeper problems of a mainstream culture that encourages unhealthy relationships with our bodies while stigmatizing mental illness, and developing positive online spaces where those suffering with a stigmatized illness can interact online in a healthier way. Perhaps this way we can finally raise recovery rates for an illness that has already caused far too many losses.

9 Pro- Eating Disorder Websites 9 References Baker, D. & Fortune, S. (2008). Understanding self-harm and suicide websites. The Journal of Crisis Intervention and Suicide Prevention, 29, Durkee, T., Hadlaczky, G., Westerlund, M., & Carli, V. (2011). Internet pathways in suicidality: A review of the evidence. International Journal of Environmental Research and Public Health, 8, Ferreday, D. (2003). Unspeakable bodies: Erasure, embodiment and the pro-ana community. International Journal of Cultural Studies, 6, Harper, K., Sperry, S., & Thompson, K. (2008). Viewership of pro-eating disorder websites: Association with body image and eating disturbances. International Journal of Eating Disorders, 41, Harris, I. M. & Roberts, L. M. (2013). Exploring the use and effects of deliberate self-harm websites: An internet-based study. Journal of Medical Internet Research, 15(12), 1-9. Harschbarger, J. L., Ahlers-Schmidt, C. R., Mayans, L., Mayans, D., & Hawkins, J. H. (2008). Pro-anorexia websites: What a clinician should know. International Journal of Eating Disorders, 42, Hudson, J. I., Hiripi, E., Pope, H. G. & Kessler, R. C. (2007). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), Jett, S., LaPorte, D. J., & Wanchisn, J. (2010). Impact of exposure to pro-eating disorder websites on eating behaviour in college women. European Eating Disorders Review, 18,

10 Pro- Eating Disorder Websites 10 Lewis, S. P., Klauninger, L. & Marcincinova, I. (2016). Pro-eating disorder search patterns: the possible influence of celebrity eating disorder stories in the media [Letter to the Editor]. Journal of Eating Disorders, 4(5), 1-5. Mitchell, K. J., Wells, M., Priebe, G., & Ybarra, M. L. (2014). Exposure to websites that encourage self-harm and suicide: Prevalence rates and association with actual thoughts of self-harm and thoughts of suicide in the United States. Journal of Adolescence, 37, Norris, M. L., Boydell, K. M., Pinhas, L. & Katzman, D. K. (2006). Ana and the internet: A review of pro-anorexia websites. International Journal of Eating Disorders, 39(6), Penfold, J. (2016). What effect is the digital world having on our young people? Mental Health Practice, 19(10), 8-9. Psychiatrists urge action to tackle 'pro-ana' websites danger. (2009). Mental Health Nursing (Online), 29(4), 4. Sharpe, H., Musiat, P., Knapton, O. & Schmidt, U. (2011). Pro-eating disorder websites: facts, fictions and fixes. Journal of Public Mental Health, 10, Steinhausen, H. C. (2002). The outcome of anorexia nervosa in the 20 th century. The American Journal of Psychiatry, 159, Sullivan, P. (2002). Course and outcome of anorexia nervosa and bulimia nervosa. In Fairburn, C. G. & Brownell, K. D. (Eds.). Eating Disorders and Obesity (pp ). New York, New York: Guilford.

11 Pro- Eating Disorder Websites 11 Wilson, J. L., Peebles, R., Hardy, K. K., & Litt, I. F. (2006). Surfing for thinness: A pilot study of pro-eating disorder web site usage in adolescents with eating disorders. Pediatrics, 118, Yeshua-Katz, D. & Martins, N. (2013). Communicating stigma: The pro-ana paradox. Health Communication, 28, pp

Eating Disorders. Eating Disorders. Anorexia Nervosa. Chapter 11. The main symptoms of anorexia nervosa are:

Eating Disorders. Eating Disorders. Anorexia Nervosa. Chapter 11. The main symptoms of anorexia nervosa are: Eating Disorders Chapter 11 Slides & Handouts by Karen Clay Rhines, Ph.D. Northampton Community College Comer, Abnormal Psychology, 8e Eating Disorders It has not always done so, but Western society today