Anorexia Nervosa is a mental health condition not just the desire to be slim. It can endure for a lifetime and there are people who manage to escape from it. if you are interested as a carer or student please also read our article
Phases of Restrictive Eating Disorders which is also on our information pages.
Anorexia. Trying to get better is much much harder than staying in the illness.
When it enters the life of a family it changes everything, not only for the sufferer but for those around them. Anorexia is a need, akin to a compulsion, to achieve a low body weight by avoiding food – or avoiding certain foods that are believed to be fattening. It is maintained by the sufferer believing that they are fat no matter how thin they are.
What also keeps people stuck is a deep fear of change and terror of being at a normal weight as well as feeling special and in control. Anorexia has costs but it also has benefits. This is what makes it an “illness of contradictions”.
Most people would be worried by low weight or emaciation but people with anorexia seem proud of their bony appearance. They may insist, despite the concern and alarm of others, that they are perfectly OK. This sense of being able to survive with very little food can persist even when they are in a dangerous state of health and even at risk of losing life.
Anorexia needs to be understood in order for us to help someone to overcome it. It is described as an illness which is an “attempt to feel better on the inside by focusing on what is on the outside” (citing McCabe 2003 in Whitehead 2007). While this may be true of all people who place great importance on controlling their weight, in anorexia, no matter how much the outside is controlled, it never seems to be enough.
The Story Of An Anorexic Girl
I’m 15 years old. have an older sister; she is smart and good at everything and it’s hard to live up to her. I am close to my mother, she’s a housewife, and my father is a businessman. They get along okay I think, they’re not very demonstrative.
I’ve always done well at school; I suppose the teachers would call me an ideal pupil – not much trouble. I’m aiming for A’s in my GCSEs, because I’m expected to go to University. Everyone says it should be a doddle for me but I don’t have their confidence in myself. God, it would be terrible if I somehow failed!
It all started when I was 13 and started putting on a bit of weight and it didn’t feel right. When the gym teacher remarked that I was looking a little podgy I thought right! that’s it! and decided to diet there and then. I cut down on the sweets and stopped eating breakfast. It was a great feeling when those first few pounds came off and soon I was throwing away my lunch as well, I wasn’t really hungry.
I guess I was always rather shy and not as popular as I wanted to be, so it was nice when people began to notice that I had lost weight – “you look really good” they’d say and “when are you going to stop?”. I suppose you could say that I enjoyed the attention, and later their concern. Fighting my hunger pangs at first was not too easy but when I started doing aerobics it took the edge off my appetite. Now, if I don’t exercise I feel anxious and fat.
I don’t honestly remember the point at which I started to be afraid of food. Everything I eat bloats me out and I’m terrified of gaining weight. So long as I am losing I know I’m safe. Of course people are starting to nag me now and I have become quite clever at pushing food around on my plate or hiding it in a napkin on my lap. Most of the time I pretend that I have eaten somewhere else.
I’m 40 kg now, but strange, when I look in the mirror I just see an enormous blob and my stomach feels huge. My Mum cries a lot now and I am sorry about that, she’s threatening to take me to the doctor but I am certainly not going to let them make me fat again. They can’t make me eat.
I am afraid to admit to myself that I am starving all the time and I’d love to let go and sink my teeth into some bread and butter. But when I manage to resist and I have won, I feel totally in control. Believe me, I’m happy just the way I am and I wish that people would just leave me alone.
What Is Anorexia Nervosa
The word ANOREXIA means “appetite loss of nervous origins”. It is not the same as the loss of appetite that comes from overeating, from illness, or from emotional stress. Some people find that they cannot eat when they are afraid or depressed but this is not anorexia nervosa. Some people cannot eat when they have damage to areas of the brain which are associated with eating. A person may have a mental delusion that food is contaminated and as a result they stop eating and lose a lot of weight, but this is not anorexia nervosa either. Anorexia Nervosa is a condition of weight loss which is not secondary to a physical condition and not just a variant of depression, anxiety or OCD – although anorexia contains features of all of these psychological conditions.
Nor does anorexia imply lack of hunger. Many sufferers have intense hunger and yet are able to master it in a way we do not fully understand. They might do all sorts of things to distract themselves, like chewing gum, sucking stones and pretending that they have eaten somewhere else.
So anorexia is perhaps incorrectly named. Its main feature is a deep fear of food and eating, which is as strong as any of the more common phobias such as fear of heights or fear of flying – both of which are irrational but terrifying to some people none the less.
Anorexia is also a disturbed perception of body size and shape, associated with a fanatical desperation to avoid being fat. Now, in this day and age few people want to be overweight and many people say that they would rather lose a limb than be fat. So, some of these opinions are normal. But the strength of conviction in a skeletal person of being “really fat”, and the desperation to avoid having the slightest bit of fat on the body; this is what separates the person with anorexia from those of us who would simply like to be thinner but it is not such a matter of life and death.
Anorexia is only diagnosed when body weight is very low – (BMI is less than 17.5 or 10% less than would be expected at their size and age). For avoidance of doubt, other distinguishing features must be present as well, such as a very inadequate diet caused by fear of eating and deep fear of fatness. Not all anorexics are willing to admit their fear of food. As one person said:
“I don’t eat carbohydrate or fat because it makes me bloated and I don’t eat meat because I love animals and I run just as much as other people do; it makes me feel good and I just happened to have lost 20 lbs”
Other features which are common in the typical anorexic sufferer may be any or all of the following:
- Excessive exercise
- Complaints about stomach pains
- Withdrawing from contact with other people
- Sleeping badly
- Running on empty
- Denying that there is a problem. This is one of the many strange features of the illness. Most people who are ill ask for help or admit that something is wrong. But people with anorexia say that they do not want interference and will do anything to avoid it unless they are forced to have professional attention
- Anger if people try to discuss the problem
- Doing strange rituals with food or other odd behaviour
- Obsessively inspecting images of slim celebrities
- Cutting out food groups like meat or carbohydrate – perhaps making the excuse that this is about healthy eating
- Feeling fat even at very low weights
- Convincing other people that there is nothing wrong with you
- Visiting pro anorexia websites
Some of these aspects of anorexia are caused by starvation rather than the anorexia itself. Taking excessive exercise as an example; we know that starving people are very restless – which might explain to some degree why some anorexics do 500 sit-ups every day or walk for miles on very little food. But exercise can also reduce feelings of anxiety which might have caused the illness in the first place. So the need to exercise is as much due to starvation as it is a need to burn off calories.
What Is Anorexia “About”?
There are thousands of books written by professionals and personal accounts written by sufferers which try to explain what having anorexia means. In all of these accounts, anorexia comes across as being an “adaptive” illness, which means that it is doing something useful for the sufferer:
- It can be the only way of expressing inner pain
- It can be a way to get attention when one has felt misheard or ignored
- Or a way of suppressing emotions that are too difficult to manage. This is a common explanation -since people who starve are not in touch with their emotions.
- It can be a way of bringing a fractured family together
- It can be the only way someone can feel in control – again a very common explanation since people with anorexia feel that their emotional survival is dependent on being “in control”
- Keeping to rigid food and exercise rules can be a way of managing anxiety which is usually being caused by something else
- It can be the only way someone knows to be perfect when they feel deeply imperfect in every other way
- It can be a way of avoiding sexual maturation in someone who feels they cannot cope
- It can serve the purpose of keeping the person with a poor sense of self close to home where they can be cared for
Feminist writers such as Susie Orbach and Naomi Woolfe have written about anorexia as a form of hunger strike, a way of managing societal pressures which teach women that they must be successful and at the same time conform to a slim and submissive female stereotype. Feminist writers regard these pressures as being political in their motivation to keep women “in their place”. All accounts of anorexia are thought – provoking and should be read by carers and professionals alike in an attempt to make their own sense of this condition.
Who Gets Anorexia ?
The answer is “mostly girls, dieters, and mostly in early adolescence”, although 1 in every 50 sufferers is male and children as young as 7 suffer too. Statistics tell us that for every 100,000 people in the community, we can expect that 19 will have anorexia. The average GP will have 1-2 anorexic patients in their practice. Untreated, anorexia can last for many years, although older people who show signs of the illness have usually suffered from an earlier episode some years ago.
While expert accounts of anorexia differ, they do teach us something about the inner world of someone with this condition – or the person most likely to get it. The illness is associated with low self esteem, high levels of perfectionism, problems coping with the uncertainty in life, and managing relationships with other people. The anorexic personality yearns for a simple uncomplicated life, free of mess and unpredictability.
There is no strong relationship between abuse in childhood or unhappy experiences and anorexia. But we do have the impression that the sufferer has been an overly sensitive child growing into a teenager who feels like a failure no matter how well he or she is doing; someone who feels out of step with everything that is going on in life.
Thus, while expert accounts of the illness vary, everyone agrees that what starts as a simple desire to feel better by losing a little weight, turns into something very different. We are not sure when exactly a normal diet turns into anorexia. Some authors believe that anorexia is present from birth, hiding within and only triggered at a time of stress.
It is common to blame dieting for causing anorexia but most dieters do not get the illness and cannot wait to start eating properly again when they have lost some weight.
The simple, clear rules of dieting seem to suit the personality of the person who will become anorexic. Dieting is one thing they can do really well and they can push themselves to do it better than everyone else. Keeping to the rules 100%, and more, helps them to feel secure and successful. They come to feel that their body is their biggest achievement. They may get approval from other people – at least at first, and the fear of food and eating replaces their true fears of life that belong elsewhere.
Is Anorexia Caused By The Media?
Stories of starving religious ascetics – or fasting saints as far back as the 11th century teach us that anorexia has been around for a very long time. In the 19th century, people flocked to the bedside of Sarah Jones, “The Beautiful Child” in Wales , who lived without apparently eating any food. We cannot claim with certainty that anorexia doesn’t exist in third world countries where there is barely enough food for survival and where fatness is valued as a sign of affluence.
There may well be cases of anorexia among indigenous populations which are misinterpreted as malnutrition.
Few people dispute that the first decade of the 21st century has seen an unparalleled pressure on women and men to be slim, together with a corresponding hatred of obesity. The media is awash with images of skeletal women who are wealthy and successful. In such a cultural climate we would expect the rates of anorexia to soar, both male and female, but this does not seem to have happened. So anorexia is more than a sign of our times.
Anorexia is associated with both cultural and personal factors and is sufficiently complex that we cannot be certain of the relative contribution made by any one of these factors in any single individual. For example, anorexia emerges within a background of certain family styles, where there is poor communication, family conflict or high pressures to succeed.
Anorexia is also associated with personal character traits like being afraid to stand one’s ground or express an opinion for fear of alienating other people. Thus families and sufferers alike often worry that they are to blame for the illness. There is no single cause of anorexia, which is probably the result of a number of factors coming together and which include:
- Genetic factors: eating disorders, depression and addictions do run in families
- Perfectionism: is something we can be born with – no matter how well they do it is never enough
- High expectations to succeed which some people go along with (and others will rebel against!) Parents are often older and the growing child experiences them as demanding, placing too much emphasis on the child’s educational or athletic achievements. While the parents may feel genuinely loving as well, the child does not experience their expectations to be accompanied by value for him or her as a person who is OK despite being imperfect. The child of such parents feels that getting 99% in a test means being held accountable for not having got it all right.
- Being teased: about your looks or your shape
- Being exposed to dieting behaviour in the family such as a mother or sister
- Having a family which does not like feelings to be displayed
- Having an anxiety disorder
- Having a lifestyle in which there is too much pressure to be thin such as dancing or sport
- Learning not to attend to your own feelings because of family rules – and being too sensitive to the feelings of other people
- Believing that the most important thing is to please other people
- Having unwanted sexual experiences when you were young
- Having an obsessional personality. This is closely connected to being an anxious person. Having to do the same thing over and over again in order to feel safe.
So if you or a loved one has anorexia and want to make sense of your / their fears of food, you might like to share your feelings about this list with someone you can trust.
What Makes Anorexia Begin?
Anorexia usually begins in a young girl at the time of puberty; this is a time in which a normal girl will start to gain some weight. Psychotherapy teaches us that few girls welcome the changes of puberty and experience it as a time of feeling disempowered. Puberty, according to these accounts is a time when females must deny their own needs and attend to the needs of others, becoming in a sense like their mothers before them. Anorexia could be a way of denying one’s own powerful needs which are sensed to be undeserved and shameful. But of course, not all adolescent girls become anorexic.
Common sense tells us that puberty brings challenges to a sensitive child, who may fear that he or she is not up to the task of growing up. At this time of life we start to break away from our parents and our friends become important to our self esteem. We have to find our own identity. Will we be a “goth” this year or a “rock-chick”? Can we handle sexual challenges? We must start making our own decisions and mistakes.
Managing the demands of adolescence and maturation demands a certain degree of confidence together with ways to solve the problems of a chaotic and uncertain life. Someone who does not have that basic sense of self may retreat into the simple life of anorexia which freezes out much of ordinary life and provides an apparently safe refuge.
The person with anorexia surrenders his or her real embryonic autonomy to the rules of the anorexic life. But they appear to be independent by choosing or rejecting their own food, doing what the anorexia tells them to do, exercising how and when they like. It is an independence of a sort. The anorexic is both captive and master of their existence at the same time.
Childbirth, Menopause and Extreme Old Age
It is often said that there are many hidden sufferers of anorexia who are older. Older people are less likely to come to attention because they are independent enough to refuse treatment, brush off the concerns of other people or explain their weight loss as stress or depression. Some people who lose a great deal of weight in adult life will have had an earlier episode of anorexia, in which case we believe that the illness has never really gone away. But many older people have a first episode well after puberty and researchers believe that any period of hormonal change puts vulnerable people at risk.
“The year after our marriage I began calorie counting, cutting out some foods missing out meals and began speed walking. My weight then dropped to 7 stones, I felt utterly miserable with life but boosted by my weight loss and the control I had over refusing food. I worked as a Doctor’s receptionist at the time and a colleague, an older lady noticed what was happening and nurtured me out of the cycle I was in. To my delight I became pregnant……”
“My husband spent a lot of time away from home and began working 7 days a week as well. I began eating less and less, was extremely physically active during the day, going to the gym 3 evenings a week and then discovered laxatives. I felt fantastic; I could go all day with just eating an apple or a grapefruit and drinking lots of coffee. A customer asked me if I was competing in the thinnest woman in the world competition. My weight down to 5 stones 9 lbs.
There are many anecdotal reports of elderly people who refuse to eat. Worried carers and clinicians explain their behaviour in terms of digestive disorders, hidden illness or rebelliousness which may be attention seeking. The author has friends who have bribed and cajoled an elderly emaciated parent into eating a little more.
There are many digestive, physical and emotional consequences of ageing which complicates the picture. However, by applying the criterion of extreme concern about fatness, we can identify some old age food restrictors as anorexic. It is not certain why anorexia can set in at such a late age. One explanation is that digestive changes can make a person feel fat and bloated when they eat, which triggers of concerns about weight gain alongside emotional changes of depression and helplessness. The anorexia of old age is known as Anorexia Tardive.
Only a very careful exploration of the history of someone with anorexia may uncover an event, or series of events that have come before the illness, often quite a while before. Typical findings are of loss of a loved grandparent or pet, divorcing parents or having a friend who lost a lot of weight herself.
Most experts subscribe to a dual pathway for the emergence of anorexia. The first pathway are factors involved in the development of an insecure self with low self worth and poor emotional resilience. The parallel pathway contains events that have made someone sensitive about their shape and weight. When something brings these two pathways together, anorexia or another kind of eating disorder might set in.
Course of Anorexia
At first, weight loss proceeds as any normal diet and the anorexic-to-be might enjoy the positive or admiring comments they get from others. But while most dieters cannot wait for the diet to end so that they can enjoy some of their favourite foods, what sets in is a hidden fear of food that is progressive, replacing the real small and large anxieties that are part and parcel of a normal life. We cannot be sure at what point this fear sets in and takes over, but it will show itself as a hardening of the diet, more foods are given up and anorexic behaviours such as compulsive weighing or exercising take over.
“What sets in is a more profound process that we do not even now fully understand, of fearing food inside, of feeling horrible when it is inside you, of only feeling safe when you are empty” (Dare)
Most of the fear-driven behaviours of anorexia take place in secret and must be hidden from other people. Sufferers pretend that they have eaten elsewhere; they throw away packed lunches; they exercise obsessively in their room; they find ways to remove food from their plate and hide it in their sleeves or pocket.
“This is what I do….I sprinkle some cereal in a bowl, and put a bit of milk in, and toss the spoon in and stir it around. Then I leave it on the side and my mum will think I have had my breakfast.”
Rituals: As weight is lost, other changes set in which may or may not be a direct effect of starvation. While emotions in general are numbed, anxiety may increase which adds to any fears which were probably in place before the illness set in. In order to manage this anxiety, people with anorexia starve more, exercise more, jump on the scales more, cut out more foods, hide themselves away more. In the short term this may help them feel safe. In the long term anxiety will increase.
Anorexic rituals look strange to people on the outside looking in, although they make perfect sense to a sufferer. There may be ways of eating food, such as eating fractions of portions of food at specific times of the day, – like one third of an apple – or eating the crusts around a sandwich but not any of the middle. A person might toy with food, cut it up into tiny pieces, take a bite from each small morsel or chew 500 times. He or she may drink copious amounts of water or diet drinks to keep hunger at bay because hunger is regarded as a sign of being weak and out of control. Sadly, some people with anorexic restrict water because it “makes me feel fat”, risking dehydration and collapse.
Feelings of safety in anorexia are so tenuous that a sufferer could become angry or even violent if a concerned parent or carer tries to cheat the illness by, for example, adding butter to a plate of vegetables.
Weighing and checking are common safety behaviours in anorexia and it is not unusual for a person to weigh themselves several times each day, making a huge deal of the smallest fluctuations on the scale. A shift of only half a pound in the wrong direction lead to panic and a heap of irrational thoughts.
“I have put on a great deal of weight (and it will carry on like this)”
“I am gaining weight, I must cut back”
“I am out of control (or greedy or weak willed)”
Compulsive Exercise: while seen as a way of boosting weight loss, activity is really just another way of burning off anxiety as well as burning off calories. Anorexics have the remarkable ability to run for miles while eating next to nothing. Being able to endure such feats of endurance “on empty” convinces the sufferer that they are perfectly well.
Activity is a feature of starvation as well as of anorexia. Rats that starve run around on their treadmills more than do rats that eat a normal diet, groom and then go off to sleep. People with anorexia find it hard to sleep; this combined with the restlessness of starvation may lead someone to use the small hours of the morning to go out for their run or do hundreds of press-ups or star jumps in their room. Since exercise is, like starvation, an activity which fills the brain with feel-good endorphins, people with anorexia develop an addiction-like relationship to all the behaviours which are doing them harm.
The Anorexic Voice
A hidden but universal experience in anorexia is the emergence of an “Anorexic Voice”. It might be a something that is heard inside a person’s head or even something that is heard from outside. At first the Voice suggests that the person will feel better if they just lose a little more weight. Then the Voice becomes louder and more critical. It may tell the person that he or she is weak for eating or for failing to lose weight. It may even threaten the person with consequences if they try to fight the illness.
Anorexics will not disclose to other people that the Voice is there; it has crept up on them very gradually and just feels like a normal part of their life. Many sufferers are surprised and relieved to know that other people with anorexia have this Voice and are controlled by it as well.
“Yes this voice is with me all the time, it’s inside my head screaming in my ear.”
“I can hear it outside me. it is like another person is in the room with me. I thought I was going mad.”
“I believed everything it told me.”
“Even now years after I got better, I still hear it from time to time.”
A usual aspect of early stages of anorexia is denial. Denial will convince the person that there is nothing wrong, no matter how emaciated or malnourished they have become. Feelings of control and a conviction that he or she is doing something well – perhaps for the first time in their life – trump any feelings of harm. A person may even deny their condition to themselves as well as others by hiding inside baggy clothes and avoiding mirrors. Denial may also be just another way of avoiding treatment which is viewed as “a conspiracy to “make me fat.” This is the one single feature of anorexia which causes such pain and concern to carers.
The factors that cause the anorexia are not the same as those that keep a person stuck in it. Anorexia can be maintained by many factors, including the Anorexic Voice which is present all the time. Some of these maintaining factors are listed here:
Digestive changes are a direct cause of starving. Even the smallest amount of food makes someone bloated and digestion is impaired. People complain of feeling swollen and uncomfortable after eating, and this convinces them that they have eaten far too much. So many concerned carers say “you would feel so much better if you ate just a little meal”. But the sufferer generally feels much worse.
Starvation dulls the emotions, which can be useful for someone who felt miserable and distressed when they were at a normal weight.
Effects on the family:
Having a child or loved one who appears to be deliberately starving to death is a horrific experience for carers. But it can unite parents or other family members in their concerns. There are many stories of divorced or warring couples who are forced to come together to co-operate in treatment or agree a plan of action. Carers usually disagree about what should be done, and it is common for one party to want to leave things alone and for another to enforce any kind of help. The person with anorexia will usually claim that they just want to be left alone, and yet there is some sort of satisfaction to be gained from being the focus of concern in respect of a deeper pain which has never been expressed.
Most people with anorexia feel special, powerful and different because of their ability to overcome hunger and master the body which is the site of their original discomfort. Anorexia also helps the sufferer to avoid other personal discomforts such as menstruation, sexual feelings – which might feel dangerous, and the “mess” of having too many choices in a disordered and chaotic world. It is said that the clear, simple rules of dieting suit the character of the anorexic.
The benefits of anorexia lead many sufferers to describe anorexia as “My Friend”, and we see this idea reflected in the content of pro-anorexia websites. People will often write very movingly of their special relationship with the illness. “Dear anorexia, my friend. You are there for me when no one else cared about me. You keep me safe and you help me to feel in control. Everyone is against me and everyone is on my back but I can always trust you to look after me.”
Is a powerful emotion, emerging as the illness progresses, after the “stage of denial” and maintaining the sufferer’s attachment to it. Anorexics are said to wear their illness as a badge of pride, seeking out the company of other people with the illness and harnessing the deeply competitive aspects of their characters in the service of seeing who can be the most successful anorexic in the group. One of the more dubious features of the pro-anorexia websites is the shaming comments directed toward people who give in to their appetite or even try to get well.
“Look how much food I have not eaten today!”
“So you are going to be a fat slob like everyone else”
The Anorexic Personality:
The benefits of anorexia provide a clue about the “typical” anorexic personality, described as risk -averse, behaviourally rigid and driven by a need for asceticism (purity) and simplicity in life. The anorexic personality is not able to multi task – (which adult life demands); pays exquisite attention to detail and is unable to shift perspective to see the “bigger picture” which is behind everything they do. Some eating disorder specialists view anorexia as an autistic spectrum disorder illness, since anorexia and autism have behavioural characteristics in common.
Anorexia Freezes Time & Personal Relationships:
This means that during the course of anorexia there is little if any physical or emotional development. The person who recovers has experienced events during the course of their illness but they will be in emotional terms at exactly the same mental age as they were when the illness sets in. There will be a great deal of catch up to do even after the grip of the illness is released.
Consequences Of Anorexia
Anorexia is a disorder of body perception. A conviction of fatness is at the heart of the illness and increases with the degree of weight loss. Some of these feelings can be explained by a delusional experience which we call “thought shape fusion thinking” – where a person believes that even thinking about forbidden foods will make them instantly fat. It is fruitless to try and convince a sufferer that they are wrong or to attempt to engage their rational intelligence. It is better to suggest something like this: “The Voice is insisting that you are fat. What does that voice sound like? What do you think?”
Perceptual disturbance of the body may be the result of physical starvation. Studies into the effects of dieting done by Ancel Keys in the 1950s with a group of 36 males showed that even in males a prolonged period of dieting leads to preoccupation with food, mood changes and distorted body perceptions.
The physical effects of anorexia are entirely related to the effects of starvation. There is lowered resistance to illness, physical weakness and sensitivity to heat and cold. Anorexic people bruise easily and may have circulation problems. As body weight falls to low levels, the anorexic may be covered with a fine downy hair and in cases of prolonged starvation there is impoverished circulation leading to discoloured rough skin and possible ulceration of legs and feet.
Starvation affects every system in the body, muscles, skeleton, digestion, organ development and functioning; in particular the heart and brain and the immune system.
Bone loss (osteoporosis) is the most immediate outcome. Adolescence is a time when new bone is laid down to form the adult skeleton. If this process is impaired, the bones remain weak for life. There may be shrinkage of the reproductive organs in men and women, and destruction of areas of the brain which are responsible for the production of hormones.
Without nutrients, hormones cannot be produced and the reproductive system goes into reverse. The most obvious and immediate sign of this is the loss of menstruation in women and nocturnal emissions in males. Fertility may be permanently impaired.
Notwithstanding, the human body is a resilient instrument and its powers of recovery even after prolonged periods of starving are remarkable. Women and men despite years of the illness have succeeded in having children and recover to live until a ripe old age.
Depression is a prime feature of starvation and we must not assume that depression has caused the anorexia. Some people do have a depressive illness that may have pre dated their anorexia, but only careful assessment will bring this to light. Studies of dieters consistently show the effects of food restraint on mood and wellbeing.
Rates of death are higher than in any other psychological illness with 1 in 5 long term sufferers succumbing either as a result of starving or as a result of depression and suicide. The risk of suicide is 57 times greater among anorexia sufferers, compared to people in the general population.
Starvation also impairs thinking, the ability to concentrate and the ability to think rationally. This makes it very hard for the sufferer to make sense of their condition and to use their emotional resources to combat it. Therapists believe that it is hard justified the use of therapies designed to force weight up as a first line treatment simply so that other forms of therapy can take effect. We do not expect the sufferer to take kindly to this approach since the nature of anorexia is to create a compulsion to avoid treatment or accept only a treatment which is not designed to work. This has led to a recent Government ruling describing anorexia as a mental illness which can in some cases lead to compulsory treatment. The debate about whether the anorexic can truly “choose” to die and should be free to die continues to rage.
Recovering anorexics experience predictable emotional changes against which they and their carers could be forewarned. Re-feeding releases a flood of emotions which have been blocked by starvation. The recovering anorexic may not feel happier for quite some time; they are angry, confused and overwhelmed by emotional experiences which they are unable to describe or manage.
“It is like being in the middle of a hurricane.”
“Now I am fat and I have got all these awful feelings as well.”
Effects On The Family
The parents of a child in the initial stages of anorexia may deny that anything is wrong, even when their child’s behaviour gives rise to concern among schoolmates or people who may not have seen the child for a while. This may be because the anorexic is expert at hiding how much weight he or she has really lost, or it may be due to a family tendency to shy away from drama and problems. Parents may be worried in case their child falls behind with their schoolwork or loses their place on a team. If the child appears to be keeping up, they do not want to rock the boat.
The family in which there is anorexia describes itself as a servant or slave to the illness. Family members argue about what to do, and confront or avoid the sufferer whose personality appears to have changed. Should we persuade, force or bribe someone to eat? They have probably tried everything inconsistently. They are bound to someone who must be taken care of and must be watched like a hawk but who resents the scrutiny, refuses to take care of him or herself and is probably lying and deceitful as well.
A mother who would not normally let her daughter run around the streets in the middle of the night may find herself unable to say “no” to the anorexic force. A family may not feel able to go on holiday, enjoy a normal outing because of issues with food, or even mix with people who are enjoying a normal way of life. Some members of the family, in particular the siblings of a young sufferer, find their needs are ignored. It is said that life with the illness is as stressful as life with someone with cancer or who is undergoing chemotherapy.
One myth of anorexia is that it is just a way of getting attention, and someone in the family who loses a lot of weight, or starts eating strangely will indeed become the focus of concern. But this way of getting attention is not consciously motivated, many sufferers say that they want to be left alone. All of this points to the paradoxical nature of the illness.
It helps someone be both independent and dependent – I take control of my own eating BUT I need to stay close to home.
It helps someone to get and at the same time to reject attention – I want to be ignored but I love people noticing how little I weigh.
It helps someone be strong and show their vulnerability at the same time. Look how strong I am. I won’t let you interfere with my food. Yet how weak and frail I look.
Families do not cause anorexia despite research showing that there are some common patterns in ways of relating that can be a risk factor for the illness. Having high expectations, expecting adult behaviour in a child, denying the expression of emotions – take toll on a growing child. But anorexia causes tremendous stress and disharmony with patterns of over-reacting, ranging from over protectiveness to outright denial. This must always be seen as the result of the anorexia rather than its cause.
Evolution Of Anorexia
Many people with anorexia have a short course; this is associated with milder problems and earlier onset.
About 1 in 3 will develop intransigent problems with low weight which can persist for years. Many of these sufferers will overeat at time and purge in order to prevent weight gain.
About 2 in 3 people will begin to eat after a time, but continue to have a problem relationship with food. They may turn into compulsive overeaters who struggle with their weight. They could develop bulimia nervosa, an illness in which a person binge eats and attempts to control their weight with harmful practices such as vomiting, taking laxatives or excessive exercise.
Some “recovered” anorexics become “orthorexic” which is viewed as an escape from anorexia while keeping some aspects of its features of food control. The typical orthorexic is not necessarily severely underweight, but has become addicted to healthy eating plans. They may exclude major food groups from their diet – such as carbohydrate – with the insistence that,
“I am allergic to wheat because it makes me bloated.”
Recovery & Turning Points
Recovery from anorexia is more likely in someone with a short course of the illness who did not lose weight very fast and who did not reach a dangerously low weight. Most people who recover describe a turning point in the illness. Each turning point is different:
- Someone might suddenly wake up and want to be free of the illness
- He or she sees their reflection in a mirror or photograph and realises how thin they are
- Some people describe a sudden wish to stop the suffering of their loved ones
- Some people fall in love and it becomes their incentive
- Other people have a glimpse of how their life could be different without the illness and sense the waste of what they are doing now
- For other people recovery comes more slowly and gradually with the help of loved ones, or caring, understanding professionals.
- “I think it was my nurse who really understood me and helped me to get over my fears”.
- “My daughter was constantly pleading with me to put some weight on but it was a photograph of me at our work Christmas party that made me realise how thin I had become”.
Early treatment, before too much weight has been lost, predicts better outcomes because length of illness is associated with a poorer prognosis. Getting the anorexic to accept help remains problematic. 95% deny that they need help and refuse treatment when they are first brought to medical attention. Most people who are obliged or forced to get help eventually admit that they are glad that they did, because a very small part of them knew they were ill.
Early treatments for anorexia were based on behavioural techniques. The sufferer would be placed on complete bed rest and allowed small privileges like going to the bathroom alone as reward for eating and/or weight gain. These treatments had mixed success and some people described this kind of therapy as invasive and unpleasant.
Anyhow, weight gain is only one of the goals of treatment. The “best outcomes” come from therapies which strengthen the individual, enabling him or her to live autonomously, face maturity, cope with needing to be in control of everything all the time, relate appropriately to other people and pursue a more meaningful life.
How can this be done?
Home or Hospital. Some of the decisions for anorexia will involve where treatment will take place, home or hospital or outpatient day care. For dangerously low weight people, or people who are severely depressed, a stay in hospital might be necessary. Ideally this sojourn will be brief and for emergencies only; we must be mindful of the need to prevent an individual from becoming institutionalised or addicted to medical services.
It has been said that the average course of anorexia is 7 years, thus from the outset sufferers, carers and professionals alike must not expect immediate results.
Even experts are divided about the correct treatment for anorexia, depending on their interpretation of the illness and what exactly its control implications are. Feminist thinkers believe, for example, that it is wrong to enforce feeding because it replicates political pressures to control women and render them powerless. Some psychotherapists, however, insist on the necessity for immediate weight gain in order to help the patient be accessible to talking therapy. A full account of the treatment(s) for anorexia are beyond the scope of this essay, but important components of therapy include the following:
Medical Input. Medical help is necessary at all stages of the illness to assess current risk and take appropriate medical action if necessary.
Motivational Therapy.Features of the illness which make it a desired or compulsive way of life can be addressed by using interventions which help the individual to understand the costs of the illness as well as its benefits. It has proved very useful to help the sufferer understand what was “missing” at the start of the illness which must be reclaimed, and for which anorexia has been the apparent solution.
Engagement. A crucial aspect of treatment is engagement, the patient with the therapist and the therapist with carers and other professionals. The good anorexia therapist needs to be patient and able to contain crises, fully understand the language and evolution of the illness, support the patients motivation and confront the anorexic Voice. Above all, the therapist must show interest in the sufferer rather than their weight.
Re-feeding and Re-nutrition. A dietician must be involved with the caveat that this is not the only professional involved. The level and type of help depends on the degree of weight loss, nutritional deficiencies and any medical emergencies which must be addressed. Re-feeding at very low weights can be dangerous due to the risk of a low phosphate emergency. Nutritional work must always go in parallel with psychological strengthening and treatment ideally continues well after someone has regained weight.
Force Feeding – or Enteral feeling. The powers of the Mental Health Act can be invoked if the person is at risk of death. This is a safe procedure and some patients prefer feeding through a nasal tube because they feel they cannot tolerate the required amounts orally. Complications are rare but can include pulmonary haemorrhage, empyema, oesophageal perforation and pneumonitis. (Fater 2005 ). The experience is invasive, stressful, frightening and has the potential, especially if restraint is involved, to mirror the dynamics in someone who has previously experienced abuse or trauma. The resistance to the tube is interpreted as a de facto expression of strong views, although in practice clinical experience teaches us that patients are ambivalent about enteral feeding and may tolerate the procedure well. There are guidelines for good practice with adults in such situations (see Goldman Birmingham and Smye in Handbook of Treatment for Eating Disorders Guilford Press 1997) but none for younger patients. Thankfully there appears to be no obvious association between resistance to tube feeding and eventual outcome. When asked to reflect on their experiences, young people in this study could be divided broadly into two camps, the first viewed the experience as horrible but necessary. Some patients even those viewing it as an ordeal were thankful and viewed it as a first step toward their recovery. (Lask et al 2001, International Journal of Eating Disorders)
“Now looking back, I simply couldn’t see the wood for the trees, for I didn’t then, want a life. However now three years further on, I’m really know I can see tube feeding is the only last resort with the person’s best interests in mind. Without the help of the tube I know I wouldn’t be here now.”
About 1 in 3 hate it now as they did then and did not find it helpful. But most patients, looking back, said they felt it would have been preferable not to get so ill in the first place. Parents regarded the experience as a regretful necessity. Sufferers would advise others in this situation as follows: “Try your hardest to eat because it is a horrible memory to have and at the end of the day it isn’t food that is the issue, it is only a symptom of what is really wrong. Try your hardest then to accept it if it does happen, no matter how much pain the anorexia is putting in your head and body. Just look inside your head and find yourself, the real you, and fight with all your might”.
Dealing with the over evaluation of shape and weight. This aspect of therapy will take time and patience. It will involve work on education, developing new life values and stopping checking behaviours such as weighing. By helping a person to stop doing some of these harmful behaviours we reduce their compulsivity.
Family work is deemed by NICE as definitely helpful for most young people (depending on family circumstances). In this context, family work means helping all carers to unite with helpful strategies that can be consistently applied to confront the anorexia, manage meal occasions and prevent typical anorexic behaviours like cooking for the family and making others eat. Members are taught how to limit unhelpful comments and criticisms that are associated with poorer treatment outcomes. Families in treatment may also benefit from getting the help, support and friendship of people in similar circumstances and by sharing ideas of what is helpful.
Emotions and trauma work – is also central to anorexia treatment. The individual with a history of bullying, abuse or neglect will need specific help, although this is needed for only a minority of people. The core problem of anorexia seems more about sensitivity and perfectionist beliefs. In every case however, therapy must enable the appropriate release and expression of bottled-up feelings – including shame – these feelings must be named and managed now and for the future. Various methods can be used for to aid emotional resilience, such as expressive therapies like art, and talking therapies such as person centered counselling. People with anorexia also need to learn that feeling fat is usually a sign of underlying feelings that are not being expressed.
Working with rigidity and information processing difficulties. Intrinsic character aspects of the illness such as fear of change or obsessive compulsive leanings can be addressed with flexibility work, teaching spontaneity and a range of other strategies.
Psychological and social strengthening. Therapy often ends when a person is physically out of danger but ideally would extend well beyond that point. It is in the psychological work that the usual and irrational anorexic beliefs about being bad, flawed and emotionally inhibited will be revealed. Self esteem work is paramount, as is stress management and relationship management skills. All the above are aspects of personal growth which are necessary if the person is to survive and thrive without the anorexia.
Relapse prevention. All eating disorders are potentially relapsing conditions and may recur at times of stress. Therapy involves preparing someone for the possibility of relapse and providing a whole range of skills to ensure that relapses are prevented or contained.
Anorexia in Males
The pursuit of obsessions becomes apparent in examining anorexia in the male who is striving to compromise his health and way of life by attempting to reach a never-ending goal of weight loss or muscle shaping. While this is normal in anorexic behaviour, there are several other factors which depict male anorexia as somewhat atypical.
In first examining anorexia in men we find that many usual factors are evident – signs and symptoms include low weight, preoccupation with dieting, loss of sexual drive and body discomforts. Diagnostic criteria are similar to anorexia in women – self induced starvation, fear of fatness due to loss of control of eating and disordered reproductive hormonal activity.
Male onset anorexia generally occurs older than in females with a usual risk of obesity before the illness.
The illness is often expressed differently at the beginning with females more likely to diet and men more likely to develop an excessive and obsessive interest in exercise or sport where dietary restraint is evident later on.
The three subgroups of male anorexia are early onset (pre teen) typical onset (teen) and adult onset. All three groups share features of obsession and perfectionism and low self esteem.
There is a myth of gender confusion among males with anorexia; dangerous – because the fear of being stereotyped prevents many males from seeking help. One young male, anorexic since the age of 14, plucked up the courage to see his GP, only to be told
“All young men are skinny and they don’t get anorexia”.
Most males are concerned with increased muscle definition and avoidance of flab even though they are less conscious of wanting to achieve an exact weight or iconic clothes size such as the “perfect 8″.
However, body insecurity and perceptual distortions are as common among gay men as in women in general. This is thus a significant issue which dominates male anorexics’ motives for self induced starvation. And the incidence of eating disorders generally is higher among homosexual men who show a preoccupation with appearance and a connection between appearance and self esteem similar to that of women.
Younger pre-pubertal anorexic males have greater than usual confusion about their sexual identity and may have been criticised by peers about their appearance, maleness or seeming lack of control as persons. Boys do not gain weight in puberty as females do and research among the few pre teen male anorexics suggest that a fear of becoming fat rather than fatness itself is the usual precipitant. This fear does not exist in a vacuum; there may be other personality variables such as obsessive compulsive disorder or anxiety disorder, which has been present from an early age and this is not so evident in girls.
Adult male anorexics have the same underlying “control with life / self worth” issues as do females. They show determination and eventually an obsession to cope with the stresses of life – e.g. divorce, or increased job responsibility through dieting, obsessive exercise and numerous other perfectionist practices which are also present in females. While anorexia in women is a quest for weight loss encouraged by (but not caused by) obsessive inspection of slim celebrity mages in the media, males aspire to the lean conditioned streamlined shape of the athlete, such as a cyclist or gymnast.
The adult men then develop the distorted idea that their anorexic behaviour will improve their appearance or slow down the ageing process, thus striving for life goals through misdirected means.
Males with anorexia show a gradual decline in their reproductive capacity as the illness progresses rather than the on-or-off of female reproduction.
In a recent study among GPs, a case of anorexia in a male under 10 years of age was generally misdiagnosed. The child presented with symptoms of “tummy ache” which is common in children with the illness. Careful questioning is needed to help the child confess the fears of weight gain which typify anorexia. Doctors need to be able to identify anorexia at these early ages and offer proper treatment to redirect the child toward a more realistic and appropriate way of managing their fears.
Anorexia in men is marginally more likely to evolve into bulimic forms in which control is undermined by binge eating and the adoption of dangerous weight control practices such as vomiting.
Treatment for male anorexia is exactly the same as described for females but many sufferers are “hidden” in the community and the apparent scarcity of the condition has not allowed us to pursue the research which could identify specific strategies that may be especially useful to males.
Conclusion : The Future
It is likely that cases of anorexia will continue to emerge in the community, in the same was as they have been doing since cases first started being recorded, and even if there is a sea change in cultural pressures impacting on how we experience our embodiment.
Many schools now offer eating disorder prevention programmes. These take varying forms. There are programmes which teach young students about eating disorders, those which focus on boosting self esteem and some which teach media literacy and convey anti-dieting messages. While attitudes and behaviour show short term changes these are not sustained. Some programmes actually intensify undesired behaviour in the long term and there is no evidence that they succeed in preventing anorexia or the other forms of eating distress.
If there is good news, perhaps it is that anorexia is not the hidden condition that it was in the last century. The internet is a good source of information for sufferers and carers. There are many more dedicated treatment services, a growing diversity of therapies that are available and dedicated eating disorder specialists whose research efforts will hopefully bear fruit in the future.
Source: Deanne Jade 2009