Representation of Eating Disorders in To the Bone

To the Bone is a film about a young girl named Eli, or former known as Ellen, who is a 20 year old girl diagnosed with anorexia nervosa^[1]. The movie focuses on her struggles and challenges in dealing with anorexia and is primarily set in an inpatient home of which Dr. William Beckham supervises^[1]. The movie also highlights the struggles of other patients who suffer from other eating disorders (bulimia nervosa and binge eating disorder)^[1].

Various types of eating disorders are experienced by the characters in To the Bone, with a primary emphasis on anorexia. Overall, the eating disorders shown are at a severe level.

The film’s protagonist Ellen (later known as Eli), as well as multiple other characters, display both the core features of anorexia and common related warning signs or symptoms. According to the DSM-5, anorexia is characterized primarily by extremely low weight due to restricting food intake, strong dread of weight gain, and a distorted perception regarding personal weight or body shape^[2]. Ellen shows extreme and dangerously low weight, participates in excessive exercise, and persists in limiting what she eats to the extent of chewing and spitting out her entire meal at a restaurant. Ellen expresses that she feels anxious about eating, and she frequently uses her thumb and forefinger to measure the circumference of her arms, fearful that she may have gained in weight and size. This obsessive measuring of selected parts of the body can occur as a component of the disturbed perception of weight and shape present in anorexia^[3]. Another character with anorexia, Pearl, also feels distressed when she learns the number of calories that she has received through a feeding tube, expressing fear of weight gain despite her need of that caloric energy.

In addition to these core components of the disorder, several common associated features or warning signs are exemplified in the film. Such signs could be in altered behavioral or physical characteristics, and some of these could be more easily identified by friends and family members.

One behavior of anorexia that Ellen exhibits is wearing loose clothing. Though at first glance this may not seem related to disordered eating, dressing in layers or loose-fitting clothes constitutes a warning sign for anorexia,^[4] as such outfits hide weight loss and can help very thin individuals, who feel cold due to low levels of insulating body fat, to stay warm.

Additionally, Ellen shows obsessive attention to counting calories and hints at a preoccupation with thoughts of food. In a conversation with her sister, Ellen demonstrates that she has become able to simply look at a food and know its calorie count. She also recalls immediately the exact number of calories that are provided in a feeding tube when another girl in treatment experiences this. Later in the film, Ellen mentions that she sometimes draws pictures of food at night, when she is hungry and cannot sleep. Excessive preocupation with food is experienced by the majority of individuals who experience anorexia.^[5]

Another behavior that Ellen exhibits is excessive exercise. She has chronic bruises on her spine from completing sit-ups so frequently. One scene shows Ellen doing sit-ups in bed at night, in a way that seems compulsive. Both obsessive and compulsive symptoms are commonly associated with anorexia, and those behaviors which relate specifically to food might be worsened by the individual’s being in an undernourished state.^[6] In fact, weight gain by itself can improve symptoms of obsessive thoughts and depressive symptoms.^[7]

Depressive symptoms are also a common feature associated with anorexia,^[8] and Ellen exhibits a somewhat irritable attitude, appears socially withdrawn, and tends to express more negative than positive emotions throughout the film. She may also have some insomnia, given the examples above of her exercising or drawing food at night. Many depressive symptoms experienced by those with anorexia may occur as a result of being severely undernourished.^[9]

One more warning sign associated with anorexia is having a strong need for control.^[10][11] Ellen assures her sister--and herself--early in the film by saying that she has it all “under control.” Yet, this sense of control seems to really be more of an illusion; Ellen’s eating disorder seems to control her.

Physical warning signs of anorexia that the film features include amenorrhea, which is the atypical loss of menstruation, and lanugo, an increase of fine, soft body hair.^[12] Ellen’s experience of both of these is noted in the examination by her doctor.

Though the film focuses on characters with anorexia, one character, Anna, is described as having bulimia nervosa. The core features of bulimia include recurring episodes of binge eating, recurring purging behaviors to compensate for binges and stop potential weight gain, and an undue emphasis on body shape and weight in evaluating the self.^[13] The binging and purging must also occur on average once a week for at least three months.^[14]

Anna engages in the purging behavior of vomiting her food, as Ellen discovers the vomit hidden in bags under Anna’s bed. Anna may also utilize laxatives, since she offers to obtain some for Ellen. Anna additionally exercises secretly; she runs on the way back to the treatment center after her night out when she has been allowed to go see a movie. Self-induced vomiting, excessive exercise, and use of laxatives are all common compensatory behaviors, but misuse of other medications and fasting can also be employed.^[15] Anna also suggests that one of the actresses in the film was kind of fat, implying that she prioritizes having a low weight or slim shape as an important factor about a person, even for a celebrity commonly considered attractive. It is likely that she evaluates herself in this light as well.

Overall, the film portrays a limited view of bulimia. Anna’s experience of binge eating is neither depicted nor even referenced, despite this being a core component of bulimia. The sense of being unable to control one’s eating during a binge is a significant problem experienced by individuals with bulimia^[16] that is not mentioned at all in the film, nor are physical warning signs that relate specifically to bulimia. Likewise, individuals with binge eating disorder are not given significant attention, even though this is the most common eating disorder in the United States.^[17]

The main protagonist of the movie is Ellen (Eli), a young white woman in her 20s^[1]. Other characters in the movie who have eating disorders were mostly white young women as well, such as the girl in the waiting room at a clinic that Ellen and her step-mother visited in the beginning of the movie as well as the girls in the in-patient home such as Anna, Pearl, and Tracy^[1]. However, there were other characters who did not conform to the same stereotype as Ellen. Examples include Megan, an older woman in her 30s who was expecting; Luke, a man with anorexia; and Kendra, a young African-American girl with binge eating disorder^[1].

Despite including individuals of different backgrounds, most of the people who have eating disorders in the film were predominantly young, white females, which can reinforce the image that only this demographic is significantly affected by eating disorders in real life. Research shows that this portrayal of young, white women with eating disorders is very common within the media^[18]. Although there are a limited number of studies that examine eating disorders in minority groups, some studies show that minorities experience eating disorders at a similar rate to that of whites^[19][20]. In the movie, there was only one individual who was noticeably a person of color that had an eating disorder, which does not represent the actual statistics.

Moreover, the individuals in the movie with eating disorders were disproportionately women and girls^[21]. This can reflect the current situation, as there is a higher occurrence of eating disorders among females than among males^[22]. However, many men do experience eating disorders, and the film could inaccurately suggest that this is extremely rare by including only one man. There is ambiguity with this portrayal^[23].

In addition, the movie includes a slightly older woman who was pregnant, Megan. Studies have shown that pregnant people can have eating disorders; however such populations are not typically represented in the media^[24]. In general, despite the movie's attempts to include different individuals, they typically play into the common eating disorder stereotypes. Therefore, the movie does an inadequate job including a diverse population to represent individuals with eating disorders.

In the film, Ellen and several other characters are shown receiving treatment for their respective eating disorders. The majority of individuals who are treated for anorexia nervosa are individuals who are under 18 years of age or are young adults. Ellen, being twenty years old, falls into this group, along with several other patients at Beckham's facility, such as Luke, Pearl, and Anna. The execption to this would be Megan, who is presumably older than most of the other patients.

Cognitive behavioral therapy (CBT) is effective in treating eating disorders.^[25] Family based treatment is shown to be effective in maintaining remission of eating disorders.^[26]Family involvement is important in treating severe anorexia nervosa, especially with improving health and maintaining recovery.^[27]Self-guided CBT therapy has shown to be an effective treatment in treating patients with bulimia and binge eating disorder.^[28]The average stay in an inpatient facility for anorexia nervosa is around 26 days^[29]. It is considered to be shorter than what is needed to gain weight healthily^[29]. The length and cost of inpatient treatment can vary by country^[30].

In the film, Beckham is shown conducting therapy sessions with Ellen to aid in her recovery. He conducted family sessions, bringing in Ellen's mother, half-sister, stepmother, and her mother's partner. Though the doctor conducts individual and family sessions, the treatment approach overall does not map on to a commonly used, well-established therapy plan. For example, in Dr. Beckham's treatment facility, patients are not required to follow any specific diet plan and are not given any education regarding nutrition. This relatively hands-off approach is unconventional, as patients at a severely low BMI have a strong need to gain weight at an appropriate, safe rate. Dr. Beckham mentions allowing patients to "hit bottom" to motivate them to participate in treatment, but this could actually be very dangerous.^[1]

Dr. Beckham also seems to have an unusually harsh tone: he calls Ellen's attitude "childish and cowardly" and claims, "you know how [to recover]." He makes statements such as, "Stop waiting for life to be easy. Stop hoping for somebody to save you. ... Face some hard facts and you could have an incredible life." These ideas suggest that Ellen needs to simply use her will power or personal resolve and just decide to get better--this is not a realistic or helpful vision for recovery, as eating disorders are complex and multi-faceted in their causes and are not the product of such a straight-forward choice.^[1]

Treatment centers that specialize in eating disorders focus on anorexia nervosa and bulimia nervosa, as well as non-specified eating disorders.^[29]

Inpatient treatment facilities are recommended as a standard for the treatment of anorexia nervosa^[29]. It is recommended because it is able to ensure that patients can undergo medical monitoring and are able to gain weight safely^[29]. Hospitalization also serves as a means to treat any other co-occurring medical or psychiatric illnesses^[29]. Intensive care is recommended for pregnant women with anorexia in order to ensure healthy growth and development of the fetus^[25].

Facilities and treatment focus on the gaining of weight in patients. Patients should gain .5 to 1 kg during inpatient treatment, or .5 kg during outpatient treatment on a weekly basis.^[25] This is combined with routine physical monitoring of patients.^[25]

In the film, Ellen, along with the other patients present at Beckham's facility, are shown receiving routine weigh-ins in order to monitor their weight gain. The facility also encourages them to eat, in order to gain weight and thus return to a more "normal," healthy lifestyle. Megan, a pregnant patient at the facility, is shown to be at the facility, despite her history of being in prior treatment programs.

Costs of a facility are reliant on the length of stay and eating disorder. Inpatient facilities cost more than outpatient treatment^[29]. Inpatient costs constitute the expensive part of treatment.^[30] Costs for anorexia nervosa are higher than those of bulimia nervosa and non specified eating disorders due to the need for a longer stay^[29]. The cost of stay for a female patient at an inpatient facility, on average, is $12,432. The average cost for a male patient is $10,126.^[29] The costs of eating disorders are similar to those of schizophrenia, but they are less than those of obsessive compulsive disorder. This is due to eating disorders leading to other co-occurring medical issues, many of which may require medical interventions.^[29] Patient body mass index (BMI) can also affect hospitalization cost^[30]. Total cost can decrease for small increases in BMI^[30]. If the BMI is higher at admission, it means less time needed for rehabilitation and weight gain. The younger a patient is, the lower the hospitalization cost will be. Having a younger age also increases the length of inpatient stay, since the body is still undergoing growth and development while also having to restore to a normal weight^[30].

The film does not specify the costs of Beckham's facility, but given that it is an inpatient care facility, it would be expensive. Ellen, upon arrival, is shown to be extremely thin, and is older, which can lengthen her stay in the facility. The various other patients at the facility would have varying costs, since much of the information regarding many of their diagnoses and stays are unknown.

Resistance to treatment is known to occur. In the film, Ellen is shown to have received treatment from several treatment facilities prior to joining Beckham's inpatient facility, including one in which she was tube fed. This highlights her resistance to treatment. Involuntary feeding is done at a last resort in facilities^[25]. As seen in the film, Ellen refuses to eat and continues to lose weight despite being in the facility, leading her to be near the requirement to be tube fed. Another character, Pearl, is shown to be undergoing a tube feeding when Ellen arrives at the facility.

Males, compared to females, are less likely to seek treatment, and those who do seek treatment receive less treatment.^[29] The majority of individuals in treatment facilities are female^[30]. In the film, this is evident in Luke being the only male present in the facility.

However, eating disorders in males are not unheard of and there are online resources available including forums that allow men to create a support system and/or ask questions.

If you recognize the signs of an eating disorder in yourself or in a friend or family member, many resources exist to provide help:

• Helplines of the National Eating Disorder Association:

  * Call: 1-800-931-2237 
  * Chat: NEDA Click-to-Chat
  * Crisis Text Line: text "NEDA" to 741741

The NEDA phone line is available Monday-Thursday from 9AM to 9PM ET, and Friday from 9AM to 5PM ET. However, the online Chat and Text Line are more accessible.

• How to approach a friend about your concerns:

  https://www.nationaleatingdisorders.org/learn/help/caregivers/talk 

• Find treatment in your area:

  https://www.nationaleatingdisorders.org/find-treatment/treatment-and-support-groups
  http://effectivechildtherapy.org/concerns-symptoms-disorders/disorders/eating-body-image-problems/

• Connect with a support group:

  https://www.eatingdisorderhope.com/recovery/support-groups

• Other helpful resources

1. ↑ ^{1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7} "To the Bone (film)". Wikipedia. 2017-10-15. https://en.wikipedia.orghttps://en.wikiversity.org/w/index.php?title=To_the_Bone_(film)&oldid=805525329. 
2. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
3. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
4. ↑ "Warning Signs and Symptoms". National Eating Disorders Association. Retrieved 2017-10-26.
5. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
6. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
7. ↑ Lock, James; Via, Maria C. La. "Practice Parameter for the Assessment and Treatment of Children and Adolescents With Eating Disorders". Journal of the American Academy of Child & Adolescent Psychiatry 54 (5): 412–425. doi:10.1016/j.jaac.2015.01.018. http://dx.doi.org/10.1016/j.jaac.2015.01.018. 
8. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
9. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
10. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
11. ↑ "Warning Signs and Symptoms". National Eating Disorders Association. Retrieved 2017-10-26.
12. ↑ "Warning Signs and Symptoms". National Eating Disorders Association. Retrieved 2017-10-26.
13. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
14. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
15. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
16. ↑ American Psychiatric Association; Association, American Psychiatric. Diagnostic and Statistical Manual of Mental Disorders | DSM Library (in en). doi:10.1176/appi.books.9780890425596. http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596. 
17. ↑ "Overview and Statistics". National Eating Disorders Association. Retrieved 2017-10-26.
18. ↑ O’Hara, Sarah K.; Smith, Katherine Clegg. "Presentation of eating disorders in the news media: What are the implications for patient diagnosis and treatment?". Patient Education and Counseling 68 (1): 43–51. doi:10.1016/j.pec.2007.04.006. https://doi.org/10.1016/j.pec.2007.04.006. 
19. ↑ "Eating Disorders and Minorities — NOVA | PBS". www.pbs.org. Retrieved 2017-10-26.
20. ↑ https://www.ndsu.edu/fileadmin/counseling/Eating_Disorders_in_Women_of_Color.pdf
21. ↑ Hudson, James I.; Hiripi, Eva; Pope, Harrison G.; Kessler, Ronald C.. "The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication". Biological Psychiatry 61 (3): 348–358. doi:10.1016/j.biopsych.2006.03.040. https://doi.org/10.1016/j.biopsych.2006.03.040. 
22. ↑ "NIMH » Search Results". www.nimh.nih.gov. Retrieved 2017-10-26.
23. ↑ Sweeting, H., P.H.D., Walker, L., M.S.C., MacLean, A., P.H.D., Patterson, C., M.S.C., Räisänen, U., MA, & Hunt, K., P.H.D. (2015). Prevalence of eating disorders in males: A review of rates reported in academic research and UK mass media.International Journal of Men's Health, 14(2), 86-92,96-101,105-112. doi:http://dx.doi.org/10.3149/jmh.1402.86
24. ↑ "UNC Chapel Hill Libraries". libproxy.lib.unc.edu. Retrieved 2017-10-26.
25. ↑ ^{25.0 25.1 25.2 25.3 25.4} Wilson, G. T., PhD, & Shafran, R., PhD. (2005). Eating disorders guidelines from NICE. The Lancet, 365(9453), 79-81. doi:https://doi.org/10.1016/S0140-6736(04)17669-1
26. ↑ doi: 10.1002/eat.22042
27. ↑ http://dx.doi.org/10.1136/eb-2014-101890
28. ↑ doi: 10.1177/1359105311402244
29. ↑ ^{29.00 29.01 29.02 29.03 29.04 29.05 29.06 29.07 29.08 29.09 29.10} Striegel-Moore, R. H. (05/2000). The international journal of eating disorders: One-year use and cost of inpatient and outpatient services among female and male patients with an eating disorder: Evidence from a national database of health insurance claims John Wiley & Sons Inc. doi:10.1002/(SICI)1098-108X(200005)27:4<381::AID-EAT2>3.0.CO;2-U
30. ↑ ^{30.0 30.1 30.2 30.3 30.4 30.5} Toulany, A. (04/2015). CMAJ open: Cost analysis of inpatient treatment of anorexia nervosa in adolescents: Hospital and caregiver perspectives. Canadian Medical Association. doi:10.9778/cmajo.20140086