Anorexia nervosa and social contagion: Clinical implications

During adolescence, female friendship cliques can develop an unhealthy focus on body image, dieting and extreme weight loss (Eisenberg and NeumarkSztainer, 2010; Fletcher et al., 2011; Paxton et al., 1999). These peer group processes contribute to the prevalence of eating problems amongst young women in westernised cultures (Becker, 2004; Becker et al., 2011). Community studies provide robust evidence for peer influence as a significant mediator in harmful eating practices amongst young women (Fletcher et al., 2011; Quiles Marcos et al., 2013). Social pressures regarding body weight and shape make recovery from eating problems much more difficult (Murray et al., 1995). Anthropological studies describe how peer influence intensifies within inpatient wards, residential units and day hospitals, which can become ‘proana’, with patients actively promoting the practices of anorexia nervosa (Warin, 2006, 2010). The power of the peer group becomes greater as young people are aggregated into homogeneous groups in tertiary care. Mutual peer influence serves to intensify ‘deviant’ eating practices in a process termed peer contagion (Dishion and Tipsord, 2011). Social media and online networks greatly increase the ability of peer groups formed in tertiary care to remain in contact within larger informal pro-ana communities. There is scant literature on the clinical management of peer contagion in eating disorders (Vandereycken, 2011). This contrasts with the study of delinquency where empirical studies of peer contagion are advancing (Dishion and Tipsord, 2011). Further research is required into the peer system, especially during the adolescent phase of development when peer dynamics are crucial. Up to this point, the peer group has been a relatively neglected topic in the clinical treatment of eating disorders. The peer sub-system could usefully be added to the current discussion on the essential components of early intervention alongside individual, parent, family and multi-family therapy (Hay, 2012; Murray et al., 2012). Peer influence might play a role in the course of each of these forms of early intervention. Equally, later in the progression of the disorder, social media and online networks of pro-ana peers can influence the course of tertiary treatment. It is well recognised that the cultural context for this peer influence is the high status of thinness as sanctioned, desired and valued by western culture. It is the currency of cultural practices around food and bodies as understood by groups of young women that carry power (Warin, 2006). Moral values attributed to thinness are firmly embedded in the habitus of young people: their everyday, taken-for-granted practices. Young people (and young women in particular) learn from an early age that their bodies require constant surveillance, modification and improvement. Weight and food are the main focus of this attention, and they are important markers of competition and connection within female peer groups. Under the guide (and guise) of ‘healthy living’, attention to one’s body demonstrates a moral virtue that should be suitably rewarded. Within female peer groups, this cultural value is transmitted through a variety of processes including friends modelling dieting practices, body size comparisons, teasing about weight and ‘fat talk’ to encourage weight loss. Imitation and peer modelling tend to play the most important role (Quiles Marcos et al., 2013). Within the peer group, nothing is more contagious than a behavioural example from a popular and influential friend. Eating disorder behaviours can begin within these adolescent peer networks where friends routinely congratulate one another on weight loss or demanding physical exercise routines. Young people actively and competitively pursue crafted, thin bodies, which bestow unprecedented levels of symbolic capital in the contemporary peer group. By succeeding where many others fail (at dieting, self-discipline and thinness), the progression towards an eating disorder offers the appeal of a new adolescent identity and social distinction in the group. ‘Anorexia’ is not something a young person catches or a force that Anorexia nervosa and social contagion: Clinical implications