Summary:

“To the bone” is a movie primarily portraying the struggles of a girl diagnosed with Anorexia
Nervosa and her journey at a special treatment centre. The story begins with Ellen, the
protagonist, being suspended from a group treatment centre as she was a negative influence
to other patients. Her disorder had pushed her health to a critical condition where she needed
extreme intervention to survive. She lived with her step-family- mother and sister, who were
making constant efforts to get Ellen the help she needed. Her stepmother was able to book an
appointment with a renowned doctor in Los Angeles. After meeting with Dr. Beckham, Ellen
was put up for 6 weeks of in-patient admission at a cottage stay called the “Threshold”. This
centre housed patients diagnosed with various eating disorders like Anorexia, Bulimia and
Binge eating. Dr. Beckham had an unconventional approach to treatment which will be
further discussed later in the report. As the movie proceeds, it attempts a realistic illustration
of the biological, physical, emotional, and social effects of eating disorders. Ellen is unable to
make significant progress with her bodyweight, leading to further health complications. The
community at Threshold has positive as well as negative impact on her; her supportive
friends are at times able to help her increase her food intake and stop unhelpful behaviours.
Unfortunately, her emotional state and mindset stands in the way of recovery, eventually
leading to a near death experience. At the end of the movie, Ellen goes on a hike during
sunrise on an empty stomach which make her faint. She enters an altered state of
consciousness where she sees the life she could have lived if she recovered from the eating
disorder. This scene is metaphorically called “rock bottom”, after which she gains the
courage and motivation to work on herself towards recovery. She gains a newfound respect
for life and will to live a happy and healthy life.
Description and DSM criteria for Anorexia Nervosa:
Anorexia nervosa is an eating disorder characterized by an abnormally low body weight, a
distorted perception of weight and an intense fear of gaining weight. People with anorexia
define their self-esteem based on their weight and engage in controlling behaviours to prevent
weight gain. They usually severely restrict the amount of food they consume and control
calorie intake by vomiting, misusing laxatives or diuretics. They may engage in excessive
exercise. These extreme efforts significantly interfere with their personal and social lives,
along with severe health complications. Their distorted self-image tells them that no matter
how much weight they lose, they are not thin enough. The person is never satisfied and
continues to fear weight gain.
Symptoms:
The primary signs of anorexia are low body weight, distorted perception of body weight and
intense fear of weight gain. Additionally, the above-mentioned restrictive behaviours may
lead to a lack of nutrients, causing other physical symptoms, including severe loss of muscle
mass and bone density, fatigue, low blood count, hypothermia, upset stomach, unhealthy hair,
nails and skin, irregularity or absence of menstruation, infertility, lanugo (increased body
hair). The behavioural symptoms a person with anorexia may demonstrate are: Extreme
dieting, excessive concern with weight and body size, calorie counting, excessive exercising
induced vomiting, use of laxatives, frequent assessment of body weight and size, social
withdrawal and signs of depression. The person may associate food and eating with guilt.
They may seem unaware that anything is wrong or be unwilling to recognize their issues
around eating.
Causes:
Some risk factors have been identified that may increase a person’s susceptibility to anorexia
and other eating disorders. The social factors include past criticism or a history of bulling
about eating habits, weight, or body shape, a sense of pressure from society or their
profession to be skinny, and historical trauma such as sexual abuse or racism. Personality
factors that influence Eds (eating disorder) are low self-esteem, anxiety, and perfectionism.
Sometimes, anorexia nervosa stems from a need to gain control over an aspect of their life.
DSM Criteria:
The clinical description of Anorexia Nervosa as per DSM-V is given as:
A. Restriction of energy intake relative to requirements, leading to a significantly low
body weight in the context of age, sex, developmental trajectory, and physical health.
Significantly low weight is defined as a weight that is less than minimally normal or,
for children and adolescents, less than minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that
interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue
influence of body weight or shape on self-evaluation, or persistent lack of recognition
of the seriousness of the current low body weight.
There are two types in which anorexia manifests:
1. Restricting type: During the last three months, the individual has not engaged in
recurrent episodes of binge eating or purging behaviour (i.e. self-induced vomiting, or
the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in
which weight loss is accomplished primarily through dieting, fasting and/or excessive
exercise.
2. Binge-eating/purging type: During the last three months the individual has engaged in
recurrent episodes of binge eating or purging behaviour (i.e. self-induced vomiting, or
the misuse of laxatives, diuretics, or enemas).
The severity of the diagnosis is determined by the following criteria:
1. Mild: BMI more than 17
2. Moderate: BMI 16- 16.99
3. Severe: BMI 15-15.99
4. Extreme: BMI less than 15
Critical analysis of portrayal of the disorder:
The representation of behavioural symptoms, physical appearance, consequential health
issues, social influences and emotional dimensions are considerably accurate. Some of the
evident behavioural symptoms noted are the following:
 Eating habits: She is shown to obsessively give calorie estimates to every bite of food
she eats or sees. At every meal, she picks on her food and portions it to very small
 bites. Even when she goes on a date to a restaurant with great food that she enjoys,
she puts the food in her mouth only to spit it out after chewing it. She often replaces
her meals with juices and other drinks.
 Exercising: As a majority of ED (eating disorder) patients, Ellen is constantly trying
to burn off as much calories as she can through physical exercises. Whenever she gets
the chance, she runs long distances. At many points, her main appeal in social events
is that she gets to walk there or burn more calories. She is also shown doing sit-ups
multiple times a day, especially when she is stressed.
 Constant assessment of physical appearance: Ellen looks at herself in the mirror
several times a day. She also measures how fat her arm is using her thumb and index
finger. This behaviour is shown throughout the movie whenever she is distressed
about her weight to show preoccupation with the obsessive thought. In some scenes, it
almost seems like it is an instinctive habit that comes naturally to her.
The movie pays great attention to detail when it comes to the physical appearance of Ellen.
Apart from her visibly low body weight, she has a sickly appearance with droopy wrinkly
eyelids, bloodshot eyes, dry and blackened skin, thin unhealthy hair, pale skin and bony face
structure. She wears baggy clothes probably to hide her insecurities and has a slouching
posture that seem to highlight her sickly appearance. Her crouching posture signifies weak
bone structure and minimal body fat percentage. She also has reddish-black bruises on her
upper back because of her habit of doing constant sit-ups. Other distinct physical and
biological symptoms of the disorder shown in the movie are:
 Fatigue: Due to low energy, she shows signs of extreme fatigue and even faints in a
particular scene. When she overexerts herself, she often needs to close her eyes for a
few seconds to get back her energy to continue with her activities.
 Lanugo: This is a unique symptom of EDs where the body is covered with excessive
soft downy hair. This happens as the body is trying to make up for the heat lost due to
less body fat. Ellen reveals this during her weekly assessments.
 Absence of menstruation: When the doctor enquires about her last menstruation, she
reports that it was more than a year ago.
 Intolerance of cold: Another reason she wears baggy full sleeved clothes is because
she constantly feels cold and shivers. She is shown rubbing her arms as an attempt to
keep herself warm.
The other inpatients at Threshold also show different presentations of the disorder. For
example, Megan was a 28-year-old lady who was pregnant during her admission. Later in the
story, she loses her baby to miscarriage after 12 weeks of pregnancy. This displays the
adverse effects of an eating disorder on pregnancy. Women with anorexia nervosa appear to
have higher rates of miscarriage, prematurity, and slower foetal growth. Other patients
showed behavioural symptoms of purging (self-induced vomiting), taking laxatives and binge
eating.
The emotional and psychological dimensions of the disorder are mainly concerned with
distorted body image, denial, mood fluctuations, and so on. Along with her intense fear of
weight gain and preoccupation with obsessive thoughts about food, the key emotion
displayed was denial. Even after repeatedly bring told that her condition was … she had
trouble accepting its severity. She states, “I’ve got it under control. Nothing bad is going to
happen to me” and “But I don’t feel unhealthy”. This indicates how patients of eating
disorders often refuse to acknowledge how adverse their situation is, no matter what they are
told.
According to her personal history, the risk factors contributing to her condition may be her
broken family structure, insecure attachment during infancy, sexual abuse, and history of
mental illness in the family. In the current setting of the movie, she lived with her stepmother
and stepsister. Her father was extremely uninvolved in her life and showed no concern for her
illness. When Ellen was younger, her biological mother came out as a lesbian. She was also
diagnosed with bipolar disorder and had frequent breakdowns which disrupted Ellen’s
childhood. In current setting, although she loved her dearly, her mother had a new life with
her lesbian partner taking up too much of her time to take care of Ellen. Ellen barely had a
happy childhood or a good relationship with her parents. She also spoke about her traumatic
experiences as a young teen who was a victim of sexual harassment.
The next element of the movie to be analysed is the social influences of the disorder. Ellen’s
condition caused several disruptions in not only her personal life, but also social life. She had
to drop out of college and cut her education short. There was a significant negative impact on
her relationships, especially with family: her father was unable to deal with her condition and
so he was uninvolved in her life, her stepmother was not able to build a proper relationship
with her because she only felt worry and concern for her, her sister loved her a lot but grew to
resent her as even her personal life was getting affected, her biological mother lived in fear of
her daughter’s death as the situation got more adverse. To sum it up, all her close family
members were too consumed by worry and resentment about her health to maintain healthy
positive relationships. Secondly, her flattened affect and mood disturbances made it difficult
to make friends. However, she was able to befriend other patients at the threshold as they
bonded over what they had in common- eating disorders. It was also interesting to note how
progress with respect to her illness was accompanied by an improved social life due to her
change in attitude. The importance of social support was well illustrated in the movie when
she was likely to be persuaded to eat more by her new friends at the treatment centre. Here
we can understand the positive impact of such a community filled with people going through
the same things.
Finally, the unconventional treatment style offered by Dr. Beckham deserves special
attention. The setting of the in-patient house aims to transfer control and motivation on to the
patient’s will. In other words, there are no fixed standards for improvement but a point-based
system, where points are given for good behaviour and daily chores, which can then be used
to move to higher “levels”. A higher level means an upgrade in privileges and freedom. This
system is known as the “token economy system” which aids in reinforcing desired
behaviours. The accommodation arrangement consists of twin or triple sharing rooms, with
no doors to maximise supervision. All electronic devices are collected along with any
medications or tools used in negative behaviours like laxatives or pills. Group therapy is
conducted two times a day where they discuss their struggles and victories. The moto of the
centre is “fault and blame have no place here, only how you want to move forward.”,
emphasising a future-oriented approach. To quote Dr. Beckham, “Stop waiting for life to be
easy and stop waiting for someone to save you”, indicating the patient holds total control over
their health and progress. Lastly, the most significant element of this treatment approach is
the policy of no food talk and number talk. Nobody discusses what they eat and how much
they eat. Talking in terms of numbers i.e., calories and weight is discouraged. In conclusion,
the power of change lies in the patient; they get to choose how they want to get better and are
only provided a supportive positive environment to do so.
Negative perspective and suggestions:
This movie has made an appreciable attempt at accurately depicting the life of a person with
an eating disorder. However, it gets considerable backlash from its viewers, the primary
concern being the triggering nature of the movie.

References:
https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-
20353591
https://my.clevelandclinic.org/health/diseases/9794-anorexia-nervosa
https://www.medicalnewstoday.com/articles/267432#treatment-and-recovery