EDs Behind Bars: Eating Disorders in Prisoners
Being imprisoned means being deprived of your personal freedoms. In an environment when almost every minutiae of your life is strictly controlled, and where a majority of inmates have some type of pre-existing psychiatric problem, all types of maladaptive behaviors can crop up. You yell, you fight. You’re belligerent. A large number of inmates engage in regular, repeated self-injury.
In women’s prisons in particular, researchers and clinicians have been starting to ask how many of these women have eating disorders. Some may arrive in prison with an eating disorder already present. Others may have had disordered eating or other psychopathology that escalates into a full-blown disorder. High rates of other mental health conditions in the general population, as well as women in particular, indicate that EDs are almost certainly a problem in female inmates. The problem is that this really hasn’t been studied at all.
I’m not joking.
Luckily, psychologist Sharon Farber has begun to try and tackle this problem in a review article in the new journal Advances in Eating Disorders: Theory, Research, and Practice. She did this by bringing together what little we do know about EDs in women’s prisons and providing a theoretical underpinning to this behavior.
What do we know about EDs in incarcerated women?
A study of 110 adult female prisoners in Germany found that 24.5% met current criteria for ADHD. The women with ADHD also had more co-occurring psychiatric conditions: 3.6 vs. 2.3. These women were also more likely to show traits of borderline personality disorder, abuse stimulant drugs, and show signs of EDs (Rosler et al., 2009). Given the known associations between borderline personality disorder, substance abuse, ADHD, and EDs, it’s not unreasonable to hypothesize that EDs are also elevated in these populations as well.
So what about EDs per se? Farber cites two studies (one was unpublished, the other I couldn’t seem to locate despite trying as it was an older study and didn’t appear in any online databases that I use) in which she notes that
The limited number of international studies that explored eating problems in female prisoners revealed high levels of restrictive and bulimic eating pathology, and unhealthier attitudes toward weight and shape than women in the general population.
In the unpublished study by Rasmussen, et al., the researchers asked 124 women who were receiving mental health services at a women’s prison in Oregon about their ED thoughts and behaviors. They found that 40% of these women showed signs of bulimia at the time of the research, and that 25.4% and 5.6% met key criteria for bulimia and anorexia, respectively, during their lifetime.
There have also been some limited studies on EDs in non-US prisons. A study of UK incarcerated women in the journal Eating Behaviors looked at the role of anger in disordered eating in this population (Milligan, Waller, & Andrews, 2002). The researchers distinguished between anger as a more fleeting emotion, and having an angry temperament, where the anger is generally present, although in fluctuating degrees. Those women that showed more signs of having an angry temperament also endorsed more signs of an eating disorder, as measured by the SCOFF questionnaire. They also had higher levels of anger suppression.
Conclude the authors:
At a global level, unhealthy eating was linked to state anger and anger suppression (as suggested by Milligan & Waller, 2000), while extremely pathological levels of eating were also associated with high levels of reactivity to criticism. At a more specific symptomatic level, loss of control over one’s eating (a bulimic feature) was associated with trait anger (mainly as a function of reactivity to criticism) and with externally directed anger. In contrast, drastic weight loss (a restrictive behaviour) was linked to state anger. These results provide further support for the notion that different facets of anger are associated with different aspects of eating psychopathology.
The view from the inside
Perhaps the most haunting view of EDs in women’s prisons is from a prison nurse, who had worked and provided care for 11 years (as quoted in the Farber article):
In my tenure, we have had signiﬁcant numbers of women with eating disorders. A small proportion of these women arrive in our prison with a history of an eating disorder or current eating disordered behaviors. These women are the minority, and in my experience do not get as sick as the women who develop new eating disorders in prison.
The most alarming ﬁnding is the rate of women developing new eating disorders while incarcerated. These are women who never binged, purged, restricted, or had signiﬁcant body image issues in their lives. They do have lots of other issues that put them at high risk for eating disorders (for example – trauma history, signiﬁcant addictions, Axis II diagnoses).
Because of the rates of eating disorders in all the women’s housing areas, prisoners are exposed to the culture of eating disorders. As I noted above, we are taking a generally mentally ill, addicted population and putting them in cells for 21 hours per day, feeding them too many calories per day and exposing them to other women with disordered eating. These are women who are sober for the ﬁrst time in years and they are hyperaware of their bodies and their perceived shortcomings. They are substituting an allowed substance (food) for their street drug of choice. The mentally ill women are often receiving psychiatric medicines regularly and given the signiﬁcant use of atypical antipsychotics and some of the sedating antidepressants, they often have weight gain as a side effect of their treatment. All this is a recipe for disaster!
And a disaster we have. The numbers of eating disordered women changes all the time, but we are probably close to 30% at any given time … . Most of our eating disordered women would fall into the Diagnostic and Statistical Manual of Mental Disorders Eating Disorders Not Otherwise Speciﬁed (DSM EDNOS) category.
Vomiting is the most common compensatory behavior we see. We have some binge eaters. We have compulsive exercisers (8–10 hour per day of hard exercise). We do see some women restrict, but it is often in combination with other disordered behaviors. Many inmates tell me that they were just ‘trying to get to 140 pound, then I couldn’t stop puking.’ They say ‘my roommate was puking – and I watched her get skinny while I packed on the pounds – so I started doing it too – now I can’t stop.’ They are remarkably insightful, telling me, ‘this is WAY more addicting than heroin!’
Clearly, the problem is there. We need to start by acknowledging it, and talking about it. Ideally, too, we’d treat these disorders, but (maybe this is my inner cynic talking) I’m not holding my breath there. It’s there, it’s happening, and it’s not going to go away.