This is a real illness, not a whim of spoiled rich girls. It’s been treated like it’s voluntary and wilful as opposed to what it is: a serious, life-threatening psychiatric and medical illness.
Diane Mickley MD
ANOREXIA NERVOSA IS AN INSCRUTABLE ILLNESS: baffling and frustrating to those who suffer it as it may be to those trying to help. Some mental illness dissolves the boundaries of the self, tearing the seams by which we hold ourselves together. Some foist on us delusions of being pursued, persecuted, contaminated – or their opposite: delusions of being powerful, grand and invulnerable. Some mental illness forces a retreat from the world, shutting down engagement in a destructive cloak of depression or catatonia. Anorexia is none of these things: a self-destructive, poisonous assault on the body and mind, a grim alliance between one of our most ancient instincts – to fast and even avoid food that we believe might harm us – and one of humanity’s newer preoccupations – the way we appear to ourselves and to others.
Effective mental health therapists are part-priest and part-conjuror: they find ways to re-invoke an individual’s boundaries, dissolve his or her delusions, and summon an authentic, engaged self from the shadow beneath which they’ve fallen. We no longer think of mental illness as a possession which descends on us, cast by powers beyond our control. Modern medical psychiatry looks at mental illness as a phenomenon of brain chemistry, but some languages still carry the sense that it comes from without as a kind of psychic weather. This perspective can be effective in neutralising any guilt or culpability a sufferer might feel – ancient physicians spoke of melancholia as something beyond our control, subject to the flux of humours, and some languages retain this sense today. There are languages in which to say ‘I’m depressed’ is to say ‘a sadness is on me’; in English we still speak of a depression as having ‘lifted’.
It seems irrational, in the twenty-first century, to think of anorexia as a malignant enchantment, yet culturally it’s the most plausible fit – a mood or conviction that brings misery and starvation, often arriving inexplicably and departing just as unaccountably. There may be warning signs: an unusual attitude to food before the illness came, a powerful determination to achieve goals, a destructive family dynamic, a traumatic experience, a perfectionist attention to detail, or any one of a number of other ‘risk factors’. Each could have played a part in initiating an obsession with restricting food, but that doesn’t explain why many people with odder attitudes to food, more destructive family dynamics, or greater perfectionism over details, never develop anorexia.
In some parts of the world shamans still use rituals to cast out malign spirits: as a family physician, in the modern West, anorexia can make me feel like a novice exorcist. Some of the anorexic patients I’ve known have succeeded, with or without help, to cast out the illness that was starving them; others found ways to make an uneasy truce with it. Some were defeated by their anorexia – it has the highest death rate of any mental illness. And it has been with us for centuries – St Catherine of Siena, who lived in the fourteenth century, was anorexic (‘I pray to God and will pray, that He will grace me in this matter of eating so that I may live like other creatures’). So was the seventeenth-century nun Veronica Giuliani, a tortured woman who would lick walls and eat spiders, but not the meals placed before her in the convent refectory. It’s not just a disorder of western culture: there are reports of anorexia from Nigeria, Hong Kong and South Africa, as well as among the Amish people (though one study from Fiji implied that television introduced anorexia to a community that had never known it).
Accounts from the Middle Ages, written by priests and abbesses charged with the care of anorexic nuns, betray feelings of bewilderment and impotence in the face of the illness that are comparable to those I’ve heard expressed by therapists in modern psychiatric clinics. Anorexia has been intimately, painfully and eloquently described by many men and women who have suffered it, and my perspective as a clinician is no substitute for those accounts.
SIMONE WAS A LAW STUDENT who hobbled into my office holding her stomach, complaining of overwhelming nausea and a light-headed sensation as if she was about to faint. I helped her onto the examination couch; the wings of her pelvic bones stretched the skin at her hips, and her ribs were a bowed washboard. Her abdomen was distended into a dome. ‘It must be gas,’ I thought to myself, ‘maybe she’s got a bowel obstruction.’ But the swelling felt dull beneath my tapping finger, as if there was little air or gas beneath the skin. Her temperature was normal, and her blood pressure was on the low side for someone suffering so much pain. Most people with an obstruction in the bowel can’t stop vomiting, but Simone didn’t even retch. When the bowel is blocked by a twist or a tumour, the intestine works harder to clear the obstruction: intestinal fluids trickle through the interconnecting caverns of the bowel making high-pitched, tinkling sounds. But when I put a stethoscope on Simone’s abdomen, it was silent.
‘What have you had to eat in the last twenty-four hours?’ I asked, gently pressing my hand over the quadrants of her swollen abdomen.
‘Nothing unusual,’ she said, grimacing. Her eyes looked trapped and frightened, like a stowaway under an opening hatch. ‘A rice salad last night, and this morning a bit of toast.’
I slid a needle into her vein at the elbow, drew out a few tubes of blood for the lab, then gave her some anti-nausea medication and morphine. ‘You’re very dehydrated,’ I told her, ‘I’d like to arrange an ambulance to take you down to the hospital.’ She lay back on the couch and nodded. White, downy hair on her cheeks, illuminated by the overhead strip lights, made a ragged, tilted corona around her face. ‘Come and see me when you get out.’
It was a couple of weeks before she came back to see me, and her discharge letter held a surprise. ‘Acute gastric dilatation with foodstuffs,’ it said: ‘Therapeutic Procedure: Decompression gastrotomy.’ Simone had stitches down the front of her belly: the surgeons at the hospital had opened her up and found a stomach bulging with around six pints of half-chewed rice and melted ice cream. They’d piped it out with a tube, repaired the hole in her stomach, and stitched her up again.
The food restriction of anorexia leads to emaciation and malnutrition, while most men and women I’ve known with bulimia – whose eating disorder takes the form of self-induced vomiting or other purging – maintain a normal weight. But there’s a grey zone between the two, variants of anorexia that are haunted by the compulsions of bulimia. In ‘binge-purge anorexia’, sufferers survive years of semi-starvation only to binge as a response to some stressor, sometimes as rarely as once every few years. A stomach shrivelled through disuse can’t cope with the burden of a normal meal, so a binge stretches it perilously thin, and vomiting the foodstuffs out becomes impossible. It was clear that Simone had eaten so much food that her stomach, like her skin and bones, had been taken to breaking point.
I NEVER KNEW SIMONE’S PARENTS; on the couple of occasions I went to the home she shared with them, they weren’t there. Over the months, then years, that I was Simone’s doctor I found out more about her, and how anorexia nudged its way into her life. It took root like a spore in shadowed soil. She had always been slender and quiet, an only child, and the family was affluent: her mother was an academic who commuted between Edinburgh and Oxford, and her father a lawyer. They lived in a modern luxury apartment overlooking one of the city’s parks, with sleek designer furniture and wide, echoing rooms.
Some anorexia begins in imitation – it’s commoner among siblings of anorexic people and in pupils attending boarding schools – but in Simone’s case it began with a fear of contamination. She picked up an infective diarrhoea – a common enough illness – that left her for a few weeks with cramping abdominal pain every time she ate. At first she thought that she was being recurrently infected by intestinal parasites, then that she was being poisoned by new food intolerances. She began to manipulate her diet to exclude potential triggers. Alone for much of the time in an empty flat with her textbooks, she commenced an obsessional hygiene routine, and began to categorise and weigh her food into ‘good’ and ‘bad’. ‘Bad food’ insidiously became categorised in her mind as ‘too fattening’. Most of us when we are hungry become distracted, irritable and light-headed, but Simone had a paradoxical reaction – she felt clean, clear-headed and calm. At first, her studies improved. She felt a new level of control over life and her circumstances.
Gradually, Simone’s worries over being contaminated or poisoned by food began to give way to a horror of the sated feeling that comes with a normal meal. She approached her meals distrustfully, pushing food around the plate as if engaged in bomb disposal rather than nourishment. In the early days, she’d stand in front of the refrigerator for a quarter of an hour, agonising over what to eat before walking away empty-handed. Later she avoided the refrigerator altogether. She took up running, experimenting with how little she could eat and still manage to complete her favourite circuit of the park without feeling faint. The circuit lengthened; the fat that all of us need for health, to cushion our bones, muscles and organs, began to melt from her hips, cheeks, shoulders. Her bones thinned, her ankles swelled with fluid from malnutrition, and she felt cold all the time. Her family life had never been particularly harmonious but mealtimes with her parents, frantic with concern about how to make her eat, became a battleground. It was after a particularly violent argument with them that she’d gorged on the rice and ice cream that had brought her to my clinic.
When we met again after the hospital admission I referred Simone urgently to the local eating disorders clinic. The psychiatrists recommended citalopram, an antidepressant medication which they hoped would help reduce some of her anxieties around eating, and they arranged fortnightly meetings both with themselves and with a dietician. ‘They gave me sheets showing the minimum I have to eat to slowly bring up my weight,’ Simone told me at one of the early appointments. ‘I’m sticking to them, I really am.’ But her weight didn’t rise. Deception is an inextricable part of most eating disorders, and I found out later that she never took the citalopram as prescribed, and rarely ate as the dieticians advised. Her periods had stopped long before, but now her ankle swelling worsened, and downy hair grew even more thickly on her cheeks.* She dropped out of law school.
WHAT IS IT THAT CAUSES a healthy adolescent, whether male or female, to starve themselves until their bones soften, their teeth loosen, their hair falls out and their hearts weaken? Among the first to define it was a French physician, Charles Lasègue, who in 1873 gave a fairly sweeping summary of some of the characteristics he associated with the illness:
A young girl, between fifteen and twenty years of age, suffers from some emotion which she avows or conceals. Generally it relates to some real or imaginary marriage project, to a violence done to some sympathy, or to some more or less conscient desire. At other times, only conjectures can be offered concerning the occasional cause.
As to ideas about causes, the same could be said today: ‘only conjectures can be offered’. As a constellation of attitudes to food and body weight, anorexia transcends times and beliefs, but its triggers involve a pernicious synergy of culture, advertising, peer pressure, genetics, family relationships, storms of hormones and peculiarities of personality. It’s often precipitated by some stressful life event: a bereavement, challenge or change in role.
The journalist Katy Waldman, a recovered anorexic, wrote an eloquent, fearless essay about her illness which noted some of the contradictions at its heart. She pointed out that there’s a tendency among survivors to make a poetry of emaciation: anorexia becomes a choreographed performance that ultimately becomes a prison. She called for an end to the celebration of wan, delicate women in art and literature, and a rejection of destructive narratives that seek to amplify their appeal. The illness awakens a revulsion towards food and a healthy body weight that seems unassailable, perhaps because it is so closely associated with the primitive aspects of our humanity: nourishment, sexuality, body awareness. For adolescents, it provokes a retrogression of puberty, seeming at first to effect a transformation in reverse. ‘I starved,’ wrote Waldman, ‘to acquire that old classical capability: metamorphosis.’
If anorexia is, as Waldman proposes, a kind of dramatic performance, Simone and I tried to sneak in new stage directions. I wanted to exploit her formidable perfectionism and resolve to an alternative end: a healthy weight. We agreed together a list of foods she’d endeavour to eat at breakfast, lunch and dinner, tabulating their associated calories – she accepted that without a minimum intake her body would grow weaker, and her mind too. But none of my interventions seemed to hold; her revulsion at the feeling of a modest meal within her stomach remained strong, and her weight continued to fluctuate on the edge of what is compatible with life. Twice more she was admitted to hospital: once when the salt levels in her blood threatened to destabilise the rhythms of her heart, and once when she collapsed unconscious with low blood pressure. I asked her once, ‘Do you think there’s a part of you that would welcome death?’, and she took a long time in answering.
But the answer, when it came, was ‘no’, and after three years of our meetings, her breakthrough came. I can’t take any credit for the change: after numerous medications, dieticians, admissions to hospital and regular visits to the psychiatrists, one day she told me simply that she’d eaten a chocolate bar, and felt better. ‘It was that simple,’ she said, astonished by the obviousness of what she needed to do. ‘I had energy. I felt good. I was expecting that horrid feeling to come over me, that disgust, but it didn’t. And I had only the one – I didn’t gorge on them.’
‘What made the difference?’ I asked her.
‘No idea – it’s just that now when I feel nauseated at the idea of eating, I can see it as a sign that I’m not thinking straight, a sign that I actually have to eat.’
Over the subsequent months I charted the rise of Simone’s weight back into health. She returned to law school, moved out of her parents’ flat, started dating, and though she never lost her perfectionism, her dedicated attention to the ingredients of what she ate, her weight didn’t drop the way it had over those three years.
Much later, when the downy hair had gone from her cheeks, she had strength in her limbs and the rhythms of her hormones had returned, she came to see me about contraceptive pills. ‘Remember those awful years,’ she said and gave a short laugh, ‘the only good thing about them was that my periods stopped.’
‘Do you ever think about those years now?’ I asked her.
‘Sometimes,’ she replied. ‘It’s hazy though, as if I was under a spell. I wish I knew how it was broken.’