Entrapment in Eating Disorders
I believe people become anorexic for two main reasons. First, they gain something from being ill—the control and focus they need. Then there is the addictive side, followed by the mental turmoil that is so difficult to break out of no matter how desperately you want to.
—Sara, “Starving out of Shame,” in Anorexics on Anorexia
Eating disorders are a case study in the interface between the scientific and the human sides of psychiatry. As suggested throughout this book, these “sides” are not warring but complementary.
In trying to bring out the role of human interpretation of anorexia nervosa and bulimia nervosa (here shortened to anorexia and bulimia), I will contrast such interpretation with two brief and clear scientific accounts by respected leading researchers.
The first is the textbook account given by Janet Treasure and Ulrike Schmidt.1 They point out that the classification of eating disorders has “a degree of fluidity” and that many guidelines for managing them are not firmly evidence-based. They report that evidence about causes of anorexia is often poor—the evidence is better for bulimia—and that genetic mechanisms account for more than 50 percent of the variance in the risk of developing an eating disorder. Parental problems such as alcoholism, depression, and drug abuse are more strongly linked to bulimia than to anorexia. Cognitive and behavioral therapy for bulimia is at least moderately effective in about 70 percent of cases.
The second account, by Christopher G. Fairburn, discusses the therapeutic techniques and the theoretical approach behind this degree of success.2 He says the core pathology of these disorders is cognitive: “This psychopathology is the over-evaluation of shape and weight and their control … people with eating disorders judge their self-worth largely, or even exclusively, in terms of their shape and weight and their ability to control them.” He discusses ways of reducing the importance attached to these things relative to other things in life.
It is hard to disagree that the self-evaluation of people with these disorders gives exaggerated emphasis to weight and to the ability to control it. In this way the “core pathology” is obviously partly cognitive. But perhaps the core could be extended to include the emotionally charged responses that bulk large in first-person accounts. For a deeper understanding of where the exaggerated emphasis on shape, weight, and control come from, we may need a better idea of how people with anorexia or bulimia feel about themselves and their lives.
Treasure and Schmidt also discuss “clinical conceptualizations” of anorexia: “Bruch developed a psychodynamic hypothesis centred on insecure attachment and the lack of attunement between the infant and the caretaker. Family models emphasise either causal or maintaining factors risk. The Maudsley model is a manualised form of family treatment evolving from the evidence implicating expressed emotion as a key factor in maintenance. Cognitive behavioural formulations for anorexia nervosa have also been described. Neurodevelopmental models have also been translated into treatment models including trait management.”3
Treasure and Schmidt suggest thinking of bulimia in terms of this sequence:
EARLY EXPERIENCES (e.g., parenting, loss) → CORE BELIEFS → “HOT” COGNITIONS → INTOLERABLE EMOTIONAL STATES → “ESCAPE”/BLOCKING BEHAVIORS (binge eating, comfort eating).
They indicate that the “escape”/blocking behaviors feed back to influence both core beliefs and intolerable emotional states.4
Both the clinical conceptualizations of anorexia and the temporal or causal flow given for bulimia are at a striking level of abstraction. The sequential account gives no details about the particular “core beliefs,” “hot cognitions,” and “intolerable emotional states” found in bulimia.
The Waller and Kennerley article on which the Treasure and Schmidt account is based includes a flowchart, giving a typical illustration of its actual content.
It starts with a TRIGGER (Colleague says “You look really well.”)
This leads to IMMEDIATE INTERPRETATION (“He thinks I look fat.”)
This leads to SCHEMA ACTIVATED
Felt sense: ugliness.
Physiological responses: nausea, adrenaline.
Cognitive responses: negative images of self in past and future; confirmation to self that “I am unlovable.”
Emotional responses: fear, self-repugnance.
This leads to PROBLEM REACTION (High levels of distress; drive to eat or exit.)
The example is helpful. “He thinks I look fat” is less abstract than “hot cognitions.” But the flowchart stays very close to this immediate dubious or false interpretation of the colleague’s comment, and how that in turn triggers and reinforces preexisting thoughts and feelings about being unlovable. Nothing is said about reaching behind the self-repugnance to how it arose. The sequence is still abstract compared to the felt pressures that are so vivid when people tell their own stories. In their own accounts, matters of identity are prominent. Once again the abstract clinical account flattens the contours of the person’s inner landscape.
First-person accounts in turn have real weaknesses. They may contain mistakes, self-deception, or deliberate falsehoods. (Though I see no evidence of these in the passages to be quoted.) More interestingly, they may have distortions of selection and emphasis. And obviously it is worth investigating possible contributing factors (genetic, epigenetic, neurochemical, early environmental, or others), which the person is unlikely to know about. Equally obviously, the view from inside may also tell us a lot that the external perspective omits or sidelines. Probably no causal story fits everyone. But it is worth looking for recurring patterns even if they are not universal. The periodic table of the elements is not the best model for the messy human geography of psychiatry.
At the very least, the intuitive human interpretation of a few first-person accounts should throw up questions to be tested with larger numbers and control groups. With luck, this will get closer to the human reality behind the abstractions of “hot cognitions” or “intolerable emotional states.”
Although the illness made me extremely ill, I could not have coped with life without it.
—Kate, “Anorexic Anger,” in Anorexics on Anorexia
Many are drawn into eating disorders by problems and pressures. The diet regime offers some control over their lives. It replaces being overwhelmed with a needed feeling of achievement. But the sense of control can itself be addictive and the liberation a trap.
Accounts of experiences of anorexia or bulimia vary. People react differently to the same problems or similarly to different problems. One woman who had suffered terrible sexual abuse looked back on her anorexia as partly a strategy of escape: “I am certain that, to an extent, I was trying to get rid of my feminine characteristics. By reducing my body size I hoped I would no longer be seen as a sexual object that could be used and abused.”5 Another woman found that refusing to eat helped reduce her parents’ arguing: “The longer I did not eat the more attention my parents gave me and the less time they spent arguing. I felt happier because they were not so angry with each other all the time but I was worried that if I ate they would stop looking after me and would start arguing again.”6
One woman remembered family problems forced on her at 13. These included her father’s drunkenness and her mother’s affair and self-induced abortion. To support the family her mother had to go out to work: “I felt I had lost my innocence and childhood; I felt older but not wiser. I felt I had to be the mother figure. I did not want this. I think this was the start of my anorexia. I looked at myself and felt I wanted to be a child without these responsibilities.” Having lost a lot of weight, she saw anorexia as a protective friend: “At the time I felt great—full of life and in control of everything … Anorexia was my friend and sheltered me from my father’s coldness and drunkenness, away from my brother’s delinquency and away from my mother’s cosy confessions about the boss’s husband.”7
The idea of anorexia as a friend recurs. One woman had felt panic about exams and about leaving the security of school for the “real world” of looking for a job: “All I wanted to do was block out these new pressures, not to have to make any decisions and be able to concentrate on food, calories and exercising … Eventually I cut myself off from everyone; the only friend I had was Anorexia.”8 Another woman saw bulimia in a similar way: “I like to be alone and do my own thing, yet at the same time I get incredibly, uncomfortably lonely. An eating disorder became almost like a friend. As long as I have it, I don’t need anyone else … I’ve always had this sort of ‘something is missing’ type of feeling. Two things thus far have ever served to fill that void—having an eating disorder and love.”9
Like anorexia, bulimia can be seen as a solution to a problem. One woman grew up in a large extended family where life revolved round huge communal meals. Sharing food represented sharing love and affection, and she found the pressure to eat impossible to resist. “In those moments the debate in my head was usually whose feelings are first … Purging came as a way to please both. It was secretly rejecting what I didn’t want, without letting those around me know I didn’t want what they thought I should have.”10
A third of people with anorexia develop bulimia within five years.11 Sometimes they slide because it makes binge eating possible again. “Why drive myself insane trying to find something to eat that I won’t feel guilty about when I could just eat whatever I wanted and then purge?”12
One frequent pattern of response starts with an eating disorder being welcomed as a way to block out pressures and stress: “I had needed to lose a little weight but it is obvious to me that I had problems and issues I needed to deal with and that dieting had provided me with something to focus on other than these problems.”13 Another woman said her bulimia “was clearer and safer to me than the chaos of my feelings and of relationships; or perhaps just clearer than trying to make sense of them.”14
Then there is the “high” about losing weight, with the morale-boosting sense of taking control of part of their lives: “The feeling of lightness—of happiness—and a fuzzy, airy kind of an energy, which seemed to be irreplaceable. This is the high—every addiction has one—something that makes you feel good, something that is worth the low, or so it seems … With each new shape I made for myself, I was more optimistic, more alert, more euphoric and more in charge.”15 And this can give the hope of taking charge of themselves more generally: “I had such will-power that I knew I would make the end of my course and manage to survive in the safety of my anorexic world.”16
The comforting feeling of being in control can make changes seem threatening: “I was just too ill mentally and I no longer wanted help. I was too deep into my Anorexia and the illness had completely taken me over. I felt in complete control and I did not want that taken away from me.”17 That fear of losing control is sometimes remembered as holding back efforts to escape: “Recovery took such a long time because by giving up my eating disorder I lost so much more as well—my ‘safe’ world of food and weight, the high I felt at being able to refuse food and the sense of power this gave me.”18
In this way the liberating sense of control can itself become an addiction. Some compare their experiences to other addictions: “I would certainly class much of my behaviour now as compulsive and ritualistic … I know that a lot of my problems occur through habit in the same way as alcoholism or drug addiction.”19 In recovery there can be the same need for total abstinence to avoid sliding back: “It is like being an alcoholic. With alcoholism, if you have this problem you can no longer drink, even a mouthful. With Anorexia you have to keep away from the scales and one missed meal can lead to a never-ending downward spiral of weight loss.”20
To experience fasting and weight loss as addictive brings awareness of being in a trap: “Anorexia can be addictive to an extent. You get addicted to the ‘fasting high’ and the regular weight loss but it is a horrible illness. I don’t believe that people become seriously underweight in order to feel slim and look good … It feels to me as if there is much more to it than that, and in many ways anorexics become trapped in the illness … a disease that spreads until it completely consumes every part of you.”21
Because one outcome of anorexia is death, the thought of being completely consumed can be the literal truth. One man used other powerful images for his entrapment and its possible outcome: “Anorexia for me was like being trapped in a prison where the prisoner is incarcerated in a deep pit and can see daylight above but has no way of reaching it. I was in a tunnel with no light at the end and a train travelling towards me.”22
Is anorexia compatible with a good human life? The rejection of any contrast between the two is sometimes found on “Pro Ana” websites. These reflect a range of opinions and purposes. Some aim simply to provide a space where people with anorexia can share and discuss problems with each other, when it is often hard to find others who will listen sympathetically. Other sites have a message. Some see eating disorders as terrible illness, urging (and advising about) escape and recovery. At the other end are some advocating anorexia as a lifestyle: “Volitional, proactive anorexia is not a disease or disorder … There are no victims here. It is a lifestyle that begins and ends with a particular faculty human beings seem in drastically short supply of today: the will … Contrary to popular misconception, anorexics possess the most iron-cored, indomitable wills of all. Our way is not that of the weak … If ever we completely tapped that potential in our midst … we could change the world. Maybe we could even rule it.”23
One of Doris Lessing’s books has the title Prisons We Choose to Live Inside. The Internet gives helpful access to supportive groups of like-minded people—which could also make it easier, almost without noticing, to live inside a self-built prison. Of course the quoted passage is very unusual. Neither the world-domination project nor the rhetoric of the iron will is likely to win many converts. Stripped of the heroics, though, it contains a thought worth pursuing: Is anorexia a lifestyle choice without victims?
No. The death rate, especially for anorexia, is high. One study puts the annual rate at 5.1 per 1,000 persons.24 Another study, of people with anorexia being served by an eating disorders service, suggests that anorexics have a tenfold increase in risk of early death.25 Those who die from anorexia are its victims. So are the devastated families of a daughter, sister, son, or brother either dead or still starving themselves. That there are victims is both true and central.
One possible reply to this is that anorexia is not a disorder but a lifestyle. People are not seen as psychiatrically disordered when they take up dangerous sports. There is one death for about every ten successful ascents of Mount Everest.26 Those who die (and their families) can be seen as victims of mountaineering. But our society values the freedom to take the risk more than avoiding the deaths. Why should choosing an anorexic lifestyle be treated differently?
One difference comes from the “entrapment” side of anorexia. There is not the same pattern of people being driven to climb Mount Everest to escape intolerable pressures and stress.
The other main contrast comes from the features of a good life that anorexia takes away. Chapter 20 suggested that strands in a good human life include being at peace with yourself and being to some extent in control. The first-person accounts do not give the impression of inner peace: “Then there is the addictive side, followed by the mental turmoil that is so difficult to break out of no matter how desperately you want to.”27 They also suggest that the promise of control is an illusion: “Then control took control and I was left with no control.”28 Relationships are another strand of the good life. But accounts of eating disorders suggest that they have disastrous impacts on relationships with family and friends. Another strand, creativity, is engulfed by the anorexic lifestyle. “It’s like a disease that spreads until it completely consumes every part of you.”29
Narrowness is a feature of some kinds of religion. Jeanette Winterson describes the effect of her adopted mother’s religion on her walk down the High Street. “We went past Woolworth’s—‘A den of vice.’ Past Marks and Spencer’s—‘The Jews killed Christ.’ Past the funeral parlour and the pie shop—‘They share an oven.’ Past the biscuit stall and its moonfaced owners—‘Incest.’ Past the pet parlour—‘Bestiality.’ Past the bank—‘Usury.’ Past the Citizens Advice Bureau—‘Communists.’ Past the day nursery—‘Unmarried mothers.’ Past the hairdresser’s—‘Vanity.’ ”30
The demanding narrowness of some versions of anorexia comes out in the rules advocated on some Pro Ana websites. One of them has “Ana’s Laws”:
Thin is beauty; therefore I must be thin, and remain thin, if I wish to be loved. Food is my ultimate enemy. I may look, and I may smell, but I may not touch!
I must think about food every second of every minute of every hour of every day … and ways to avoid eating it.
I must weigh myself, first thing, every morning, and keep that number in mind throughout the remainder of that day. Should that number be greater than it was the day before, I must fast that entire day.
I shall not be tempted by the enemy (food), and I shall not give in to temptation should it arise. Should I be in such a weakened state and I should cave, I will feel guilty and punish myself accordingly, for I have failed her.
I will be thin, at all costs. It is the most important thing; nothing else matters.
I will devote myself to Ana. She will be with me wherever I go, keeping me in line. No-one else matters; she is the only one who cares about me and who understands me. I will honor Her and make Her proud.31
It is easy to see other people’s mind-forged manacles. In a therapist’s response to the narrower versions of anorexia, one Socratic question might be: “How is your way of seeing things less stifling than Mrs. Winterson’s?”
There is a shriveling of personality and risks to health and life—this is why families, friends, and psychiatrists want to intervene. But offers of professional help are often refused. There is a broad consensus in medical ethics that a person who has the capacity to make the decision to refuse treatment must be left to die if that is what the person has chosen. To justify imposing a lifesaving intervention that has been refused, the person’s refusal must be shown to be the result of thinking so faulty or distorted as to show incapacity. Anorexic starvation can be linked to errors of judgment or reasoning, but these are usually too minor to undermine competence. The dilemma is stark. Must they really be left to die? Or are there other ways to question whether the decision to obey “Ana” is really theirs?