WANTED—DISEASE VOLUNTEER: Seeking applicants to maintain weight at 15 percent or more below normal minimum while perceiving self as fat. Disease includes loss of menstrual cycle and constant obsession with food, eating, and thinness. Prefer adolescent females. Be prepared to be cold all the time, to have downy hair growth over the body including the face, to have slow heartbeat and body swelling. Muscle wasting will occur. Brain atrophy could occur in 80 percent of selectees. Unknown at this time whether this brain damage is reversible. Sleep may be disturbed. High likelihood of thinning of the skull bone, leading to skull fractures in possibly 15 percent of the cases. Unlikely that more than 18 out of 100 will die. Apply at your local high school.

ANOREXIA

Kara Nelson settled herself into her chair within the circle of women who met weekly to receive therapeutic support for recovery from overeating. She sighed and said, “Did you see that anorexic woman by the bus stop?” Two others nodded their heads. “I wish I had that problem,” Kara said.

The group unanimously agreed.

How many times has that statement been echoed by women who suffer from overeating and extra weight? The failure of our society to accept differences is tragically perpetuated in the self-image of the extraweighted and the drivenness of the anorexic.

So is that the whole point of anorexia—to be thin? Yes and no. Often, anorexic behavior is started as a solution to a problem. Then, as with other addictive diseases, it takes on its own life and perpetuates itself. Is anorexia, strictly speaking, an addiction? My answer: an unequivocal maybe.

RETREAT FROM MATURITY

Anorexia typically begins when, in response to the pressures in her life, a child acts on the thought, “My life would be better if I were thinner.” She begins to restrict her food. (Ninety-five percent of anorexia sufferers are female. Most begin restricting in adolescence.) Some anorexics are overweight prior to the slide into anorexia.

As the anorexic loses weight and gains attention for the weight loss, she may have her first feelings of success and accomplishment. In an overwhelming world that seems out of control, she finally has a heady feeling of being in control. She has the ultimate control over life and death: She can refuse to eat.

From the outside, we can see that she’s not in control at all, that the disease is controlling her, but one of the aspects that makes treatment of anorexia so difficult is that the sufferer’s own perceptions of being in control and needing to be thin are incredibly powerful.

It’s not unusual for anorexia to begin soon after a step into greater maturity—entering middle school, high school, or college. Anorexia frequently arises as girls enter adolescence. Puberty pushes children into sexual maturity. Anorexia is a retreat from that developmental crisis.

Anorexia makes the body childlike again. Menstruation stops or doesnʹt start, the body loses its sexual characteristics, and the figure becomes immature. Anorexia is one way to drop out of growing up. It’s a way to avoid being a sexual person.

Levenkron ¹ maintains that anorexia is a disorder of failed dependence. Dependency needs have not been met, so the child arrests her development. It’s a physical way of saying, “I haven’t had enough care. I refuse to continue the course of life until I get what I need.” If weight loss is severe enough, the child doesn’t even have to feed herself. Like an infant, a hospital takes over feeding her.

Interestingly, hospital treatment of anorexia usually includes pushing the child into maturity. Anorexics are presented with reality statements, chronological age-appropriate tasks, and behavioral training that rewards taking responsibility. Anorexic patients manipulate and resist these with the intense and subtle skill of any rebellious teenager.

I wonder what would happen if the child were allowed a few weeks of concentrated childhood, if the child (even if she’s 14 or 18) were rocked and cuddled and led gently by the hand. What would happen if the child could draw and play with toys and then gradually and gently be drawn though the developmental stages until her chronological age were reached? I wonder.

ESCAPE FROM FEELING

Anorexics generally have immature social skills and difficulty relating to others. This development may have been thwarted by parents who were controlling and who used the child to meet their own needs. One or both parents may be enmeshed with the child. She has tried hard to please them, has complied with their goals and ideas to the point that she doesn’t know what she thinks or wants for herself. She is a perfectionist and judges herself harshly, so regardless of how high her achievement is, she sees herself as falling short.

Anorexia is an engrossing escape from these problems and from any feelings of anger that may be buried beneath them. Anorexia gives her one focus and one goal. All the other challenges of life fade beyond the obsession with being thin.

Nearly all people with an eating disorder want to be thin and believe life would be better if this were true. Nearly all eating-disordered people are preoccupied with weight, food, and eating. The difference with an anorexic is the intensity of this obsession. It is all-encompassing.

She originally saw thinness as a solution to the problems of her life. At first, she restricted food in order to improve life. Gradually this goal changed. Thinness became her life. Life became thinness. The disease took on a life of its own.

We look at this child with twigs for legs who’s complaining about the fat on her thighs. She spends hours in front of the mirror measuring her belly. She sees her body in such a distorted way, we find it unbelievable. How can she think she’s fat?

She has long lists of “bad foods” and a very short list of acceptable foods. Her intake for a day may be a lettuce leaf and a can of diet pop. Another day she may eat an apple and half a carrot.

Overeaters will hide food and lie about the amount they’ve eaten. Anorexics will hide their lack of eating and say that they’ve eaten when they haven’t. They’ll tell their parents they ate somewhere else so they can skip dinner. Or they may have dinner but nothing else the rest of the day to make up for it. They may move food around on the plate and actually eat very little or use sleight of hand to dispose of food into a napkin or a dog’s mouth, a deadly game.

Are they hungry? Some are. Some aren’t. In a supermarket I observed a pencil-sized woman staring at a snack display. She picked up a small bag of peanuts, held it, then put it back. She took a bag of crackers. She put it back. She took a candy bar, then put it back. After ten minutes of this painful longing, she went to a cooler, got a diet pop, and left the store.

Overeaters can’t tell when they’re full. Anorexics can’t tell when they’re hungry. Experiments have shown they have the same gastric sensations that normal people call hunger, but these are not interpreted as hunger.

STRESS AND HUNGER

So what kind of disease is this? Is it emotional? Is it physical? By now you probably know me well enough to predict that I don’t believe humans are so easily dissected.

As with most diseases, anorexia has both physical and psychological components. In chapter 2 you read that mild stress increases appetite due to the release of dynorphin. Severe stress, however, activates the sympathetic nervous system, which depresses appetite. Ordinarily, a period of high stress is followed by rebound appetite, due in part to a need to replenish nutrients depleted by the stress.

In rat studies, certain chemical chain reactions produce continued suppression of appetite, especially associated with certain types of severe stress.²

If a rat is stressed and can’t escape it, if it’s a prisoner of the stress, its appetite is suppressed. It also loses appetite when it is exercised to exhaustion. Interesting, wouldn’t you say? If a child feels herself trapped in an enmeshed relationship with her mother or father and has no skills to help her separate, if she’s been controlled to the point of having no sense of herself, how can she be on her own? How can she escape? Also, we commonly find that anorexics exercise compulsively.

THE TWO SIDES OF BETA-ENDORPHIN

So what is the chemical chain reaction? Chemically stimulated anorexia can occur through several mechanisms.³ I’ll summarize them for you. In chapter 2 you read that beta-endorphin stimulates appetite and promotes cravings for sweets, fats, and carbohydrates. Anorexia routinely results when beta-endorphin is suppressed or blocked. Beta-endorphin synthesis and release can be blocked by the release of certain hormones from the pituitary (in the brain) and adrenal (above the kidneys) glands. This works especially well in combination with a lack of turnover of norepinephrine in the hypothalamus. The hypothalamus, remember, is where eating is regulated.

Translation? Certain chemicals and hormones released by stress can override the appetite-producing effects of beta-endorphin and dynorphin, and cause decreased appetite. These naturally occurring body chemicals function as opiate blockers.

But wait, let me confuse the issue a bit more. Certain opiate helpers, that is, chemicals that promote opiate activity in the body, can also decrease appetite.⁴ When certain opiates are in excess, decreased eating and weight loss result.

Some theorists say that dieting/starving releases brain opiates and produces a high that, in some people, overrides the pain of hunger.⁵

Am I contradicting myself? Didn’t I say, in chapter 2, that eating sugar was an attempt to make up for inadequate endorphin functioning?

Let me get myself out of this quagmire. Let’s say you arrived from the planet Centauri Alpha Five and I was showing you my neighborhood. We’d walk to the corner and I’d say, “This traffic light causes the cars to stop.”

You’d smile and chatter with your companion Centaurians. Then I’d say, “This traffic light causes cars to go.”

You might smile politely because Centaurians have very good manners, but you’d be confused. I contradicted myself. How can the very same light cause traffic to both stop and go?

You watch the traffic light yourself. Your eyes don’t receive earth colors so to you the whole setup is a pleasant shade of puce.

I try to explain that the light contains both red and green colors and the green color tells cars to go and the red color tells cars to stop. Finally you detect that the top light always make cars stop and the bottom light always makes cars go and we’re happy with each other until we come to the light that is sideways with the colors all in a row.

Using color graphics, beta-endorphin has been found to be divided into two fractions.⁶ We could say some beta-endorphins are greenish and others reddish. Obese individuals have an excess of greenish endorphins and insufficient reddish ones. Lean individuals have the opposite configuration. Yet we have a long way to go before we understand the exact chemical processes that produce overeating and anorexia. We are like the color-blind Centaurians encountering a light that is sideways.

For example, since a third of anorexics start out overweight, did starving change the balance of endorphins in the brain? Is starving itself a stress that produces a chemical imbalance that perpetuates a stress reaction? I don’t know. We’re only at the beginning of an understanding of the chemical mechanisms that perpetuate anorexia.

THE OBSESSION

What about psychological dependence? Does the individual become dependent on anorexia? Probably. The obsession with thinness is an effective escape from feelings, other problems, and the process of living.

By the time anorexia becomes entrenched, it seems to have moved itself out of the category of an addictive disease and more closely resembles an obsessional disorder.

What can be done? Throughout this book, I’ve inserted warnings that the plan contained here is not for anorexics. I’m making a presumption about my readers. I’m assuming you have the capacity to take responsibility for structuring your recovery, the ability to ask for help when a suggestion is too hard to do alone, and you want to change badly enough to push on when old ghosts whisper that you might as well quit. I’m assuming that you are seeking to improve your wellness.

Few anorexics want a change. The self-help book that would interest an anorexic is one that would tell her how to be thinner. My goals are opposite those of an anorexic. I’m promoting wellness, she’s wanting thinness.

What can be done? In most cases, recovery from anorexia is not a do-it-yourself project. Anorexia harms thinking ability and recovery from anything requires a clear head. Generally, professional help is advisable.

TREATMENT

If I had my druthers, I’d fix the parents. Since that is frequently not an option, the next alternative is long-term treatment with a specialist in anorexia or long-term inpatient treatment in an eating-disorders unit. Hospitalization allows for refeeding so she can be brought out of a starved state. Plus, a team approach is helpful because she has lots of people to rebel against and a chance of finding one person on the team with whom she can bond.

Steven Levenkron has had good results using a nurturant-authoritative approach to therapy.⁷ Anorexia is different enough from compulsive eating and bulimia to need a practitioner who has specific experience and training in anorexia.

Frankly, the success rate with anorexics is very low. Cognitive therapeutic approaches don’t begin to heal the lost little girl inside. Besides, an anorexic’s thinking ability is not too great. Starving people don’t think clearly. In addition, prolonged starving causes brain damage. A rise in a body chemical called cortisol causes brain atrophy similar to Cushing’s syndrome.⁸ Other brain damage occurs because important chemicals become depleted.

The biggest complication to recovery from anorexia is her own powerful resistance to it. Against her will, she must be fed so she can think, and if the starvation has been severe enough, she may never regain full mental capacity. As with most diseases, the prognosis improves if she is treated early, before her brain and heart tissues are eaten away.

If I saw signs of anorexia in my own child, I would not wait until her life was threatened. I’d take action immediately. I’d put my family into family-systems therapy, myself into personal therapy so my own needs were getting met, I’d get her an appointment with a specialist in anorexia following the nurturant-authoritative approach, and I’d put her under medical supervision so her nutritional needs were being met.

If these programs weren’t enough to stop her starving, I’d find an inpatient treatment program that used the nurturant-authoritative model and had a strong family program.

Is this costly? Of course! Will insurance pay for it? Typically, most insurance policies don’t cover the anorexic until she’s in danger of dying. By this time, brain and heart damage may have already occurred.

It is possible to find good insurance coverage. Anorexia is prevalent enough that if I had a ten-year-old daughter, I’d shop for an insurance company that provided coverage for long-term treatment of anorexia and bulimia in both inpatient and outpatient settings, and that covered long-term individual and family therapy with a free choice of practitioners.

The hard news is that an anorexic, bulimic, or compulsive eater in the family is a screaming sign that the whole family needs help. As with most crises, anorexia can be an opportunity as well as a challenge. It can be the pivot upon which the entire family turns itself toward health and growth.

BULIMIA

“I’d be bulimic myself if I didn’t hate to vomit!”

Overeaters sometimes feel so trapped by their bodies that even a disease as destructive as bulimia looks attractive to them. Judge for yourself whether the grass is truly greener.

Bulimics binge and then participate in some extreme measures to counteract the binge. Bulimic binges are similar to overeaters’ binges. Large quantities of sweet, high-calorie food can be consumed by an eater who feels out of control and unable to stop the binge. However, the pace is different. A bulimic eats quickly, often gobbling her food. If a bulimic is going to rid herself of it, she’s eating against the clock. She has to bring the food back up within a certain time or it will be too digested.

A bulimic may eat quite a bit more food than a compulsive eater during a binge. The food that is chosen has to be easily vomited. Bulimics become skilled at learning the combinations of food that can be vomited smoothly. Some bulimics binge rapidly, vomit once, and it’s over. Other bulimics binge and vomit several times in one episode. Bulimics may routinely vomit one or all meals each day.

Most food addicts and overeaters love restaurants. We love to go out to eat. Eating out is an anxiety for bulimics. Beyond the privacy of home, getting rid of food is more of a challenge. Someone could walk in during a purge. She could be caught. A husband or parent might get suspicious if she always disappears after meals. The need to purge her food gives the bulimic another obsession that requires planning, secrecy, and dishonesty.

Does this really sound like fun?

Bulimia has a certain notoriety because of purging. Does a person have to purge to be considered a bulimic? No. One way to be bulimic is to alternate binges with periods of strict dieting, fasting, or vigorous exercise.

Other bulimics use laxatives or diuretics. This is not a very effective weight-loss method. A diuretic simply rids the body of liquid. Laxatives carry digested food out more rapidly but the food value has already been extracted by the body. These are poor weight-loss measures but excellent ways to abuse the body. Fluids and electrolytes get way out of balance and can cause a person to tremble, feel queasy, sick, and weak—effective distractions from life’s problems.

So bulimics have this in common with anorexics—a compulsion that includes manipulating the natural processes of the body. Bulimia gives a person something she needs and then takes it away.

For some purging bulimics, the purge is an end in itself. They binge so that they can purge. They become addicted to purging, experiencing euphoria with being emptied.

Bulimics don’t stand out like anorexics and compulsive overeaters. Even though, like most disordered eaters, they are very concerned about their body shape and weight, they are usually of normal weight or slightly over- or underweight. Yet in a day they may consume many more calories than a compulsive overeater.

REJECTION OF OUR FEMALENESS

How does bulimia get started? With a diet. Numerous studies show that bingeing follows a period of food deprivation. Does dieting cause bingeing? Perhaps. It unquestionably increases the likelihood of bingeing. Food restriction produces a host of physiological responses—elevated motilin levels, unbalanced insulin levels, pancreatic polypeptide responses—that can cause an exaggerated response to palatable food. It also causes changes in the way a person thinks about food and hunger.⁹

While anorexia is a sign of problems with entering adolescence, bulimia is a sign of problems with leaving adolescence.¹⁰

The anorexic individual appears to stumble on the first steps of transition to adulthood—the development of sexuality and the transfer of energy and interest from the family to peers. The bulimic individual usually negotiates these early phases successfully, often becoming sexually and socially active, but falters later in the establishment of intimacy and authenticity in peer relationships and in the separation from her family. She seems to know the steps but cannot dance.¹¹

Why?

One strongly supported theory is that bulimia arises from a severe disturbance in body image.¹² The rise in the incidence of bulimia has been connected with vast changes in role expectations for women and the increasing preference for lean women. The young women of today are seen as the first generation to be raised from birth by mothers who reject their own bodies.

The female form has been synonymous with nurturing and producing, but the roles of mothering and nurturing have fallen on hard times. Motherhood is devalued, femininity has been mocked. Thinness can be a rejection of the roles associated with femaleness, an effort to achieve the more admired consequences of maleness.

BULIMIA AND ABUSE

A shocking percentage of bulimics have been victimized. In a well-conducted study, 66 percent of 172 female purging bulimics interviewed had been physically victimized: 23 percent raped, 29 percent sexually molested, 29 percent physically abused, and 23 percent battered.¹³ The study observed that bulimia fulfills certain functions:

1. Bingeing and purging leave one exhausted and relieved. It effectively numbs fear, rage, and pain.

2. Bulimia is a safer way to express anger if the victim is currently in an abusive relationship. (Eating-disordered people are very likely to turn anger against themselves rather than toward the people who have harmed them.)

3. Bulimia replays the pattern of abuse in her life.

4. Victims often feel as if they have little control over what happens to them. Bulimia is a desperate attempt to have control over one’s own body.

5. Abuse has violated boundaries. Bulimia could be an attempt to set boundaries.

For some, perhaps, bulimia is a way of acting out the past, when something that was put into the woman’s body is rejected and thrown out.

PSYCHOLOGICAL CONSEQUENCES

Like anorexia, bulimia can have severe consequences. Fifty percent of the patients studied at the Max Planck Institute in Munich exhibited symptoms of brain atrophy that may or may not be permanent.¹⁴ Blood studies showed that numerous body chemicals were out of balance. A rise in ketone bodies overnight, for example, showed that the glycogen reserve in the liver was being used up. Fatty tissues may be broken down to provide energy for the body but cannot be used in the brain. The glucose needed by the brain comes from protein and if the person is not eating enough, muscles and vital organs are used to provide energy requirements for the brain. The decrease in amino acids also meant that the brain was not getting the raw materials needed to replenish neurotransmitters. These and other imbalances cause decreased thinking ability.

Edwin Pike described the effect of bulimia on the heart:

Probably 40% of bulimics have mitral prolapse, caused by malnutrition. If they get malnourished enough, their cardiac volume goes down and their cardiac musculature doesn’t have enough energy to work efficiently, so basically the muscle kind of sags. If you have ever seen their chest x-rays, their hearts sort of fall into their chests, literally just hang there. The mitral valve ... keeps the blood from squirting backward. In the malnourished state, there is a functional mitral prolapse, and you want to get them renourished, so ... when they stand up, they don’t faint.¹⁵

Do you still think bulimia is a handy way to have your cake and get rid of it too?

What else can happen? Body electrolytes can get out of balance. A drop in potassium levels may produce cardiac arrhythmias that, untreated, can cause death. The body can get severely dehydrated. Tooth enamel erosion is common. The esophagus can tear and the stomach can rupture.

RECOVERY

Can bulimics use this book? The chapters on reducing stress and building support can benefit any human being. The chapters on fat prejudice and the letter to the family might also apply. However, bulimics should approach abstinence gingerly. Bulimics are notorious for having lists of bad foods and good foods, alternating between dieting with the good foods and bingeing on the bad foods. I’d rather see a bulimic build up her protein stores and chemical balance by eating and keeping down three hearty, healthy meals a day. “Get real,” you may say. “If she could do that, she wouldn’t have a problem.”

To follow such a simple dietary plan may require squadrons of support. I recommend a therapy group with a therapist who specializes in bulimia and overeating. Recovery requires attention to all the aspects that contributed to the development of bulimia and structures that promote a decline in the harmful, addictive behaviors. At the same time, she must be regaining physical health. Sometimes the damage is so severe, the body so depleted, or the addiction to purging so powerful that hospitalization is required in order to build up the body’s strength and stop the personal violence of purging.

Exercise for a bulimic can be dangerous if she’s exercising before nutrients have had a chance to rebuild her heart tissue. If a bulimic is purging, exercise can further complicate the electrolyte imbalance. It’s a good idea for a bulimic to have medical supervision before she begins exercising.

Bulimia is such a complicated disease that it’s a wonder sufferers have been able to recover by attending Twelve Step meetings such as Bulimics Anonymous, Overeaters Anonymous, and Eating Disorders Anonymous. Of course, alcoholism is no picnic, and millions have become sober through A.A.

Professional guidance can, however, provide a more structured path and speed recovery along known paths. The combination is dynamite—the expertise of an eating-disorders therapist or program and a Twelve Step program.

POSTSCRIPT

If you are one of the many overeaters who envied bulimics and anorexics, I hope you now have another perspective on the matter. Extra weight can be harmful, we all know this. Yet drastic measures to eliminate weight such as starving and purging can cause far greater damage that may not even be fixable.

If you have occasionally starved yourself or purged now and then, perhaps it’s now clearer that you were trading one harmful pattern for another. You deserve much more than to travel through a jungle of symptoms. You deserve full recovery from the whole syndrome of deprivation, self-violence, and obsession. Yes, you deserve abundance, support, purpose, health, and fullness.