TWO

Just How Toxic the Triangle Is

THE TOXIC TRIANGLE of yo-yo eating, heavy drinking, and depressive symptoms reflects a complete breakdown of effective coping and the takeover of self-focused coping. Rather than doing something about the problems that are upsetting them, women who fall into the toxic triangle hold their concerns in their minds and their bodies. They ruminate on their troubles and concentrate on their bodies—focusing on how their bodies feel, trying to change those feelings, or attempting to control their bodies—rather than taking action to overcome the true sources of their distress.

Self-focused coping shuts out effective help from others. Family members and friends grow confused by the shifting picture of “the problem” that a woman presents—one day she’s depressed, another day she’s drinking, another day she’s binge eating. They may try to help her with one problem, just to have another pop up. Family members become overwhelmed, frustrated, defeated, even pull away. If a woman consults a physician or therapist, he or she is also likely to focus only on one of her problems, likely her worst one, but ignore the others.

Jill, the account executive we met in chapter 1, was occasionally confronted by her family members about her behaviors. As is often the case, her family tended to focus on her eating habits and her drinking, because they were the most visible signs of the toxic triangle. Another reason family members focus on a woman’s heavy drinking is because it carries a social stigma that can reflect on the family.

Jill’s sister, Sarah, was the one who most often said something to her about her behaviors. “You drink too much,” Sarah would say as the two of them were clearing away dishes after Sunday dinner with their parents, and Jill was sipping her third glass of wine that evening. “You’re going to ruin your career and your health. And you need to eat more and stop worrying so much about being skinny.”

Jill could easily blow off Sarah’s comments. Jill’s job provided much more money and prestige than Sarah’s job as a part-time manager of a clothing store ever would. Sarah had always battled her weight and had been even more self-conscious about her shape than Jill was. So, rather than taking Sarah’s comments seriously, Jill just ignored them as the product of sisterly envy and bossiness. Sometimes, if she was annoyed enough at Sarah, Jill accused her of jealousy. Most of the time, though, she just said, “Mind your own business,” and diverted the subject to something else.

Our Eyes Shut Tight

Because women take it upon themselves to manage stress by managing their thoughts and bodies, rather than taking out stress on others, their suffering is easy to ignore. You can see this in the amount of attention and money spent on the externalizing mental health problems that males more often suffer—such as antisocial behavior and attention deficit hyperactivity disorder—compared to the self-focused mental health problems that females more often suffer. The externalizing disorders that men and boys suffer wreak havoc on society in the form of property damage and violent attacks on others. In response, we spend millions of dollars trying to treat men and boys and contain these behaviors.

Because the quieter problems of girls and women don’t bother other people nearly as much, they are not dealt with. Even when it comes to alcohol abuse, women tend to be quiet. Compared to men, many women are “gentle drinkers.” When they are inebriated, women don’t tend to become as loud and obnoxious as men, if only because even inebriated women generally attempt to project an aura of traditional “feminine” submissiveness (whereas men may feel freer to fulfill traditional “masculine” behaviors of confrontation and bravado). Physicians don’t regularly ask women about their alcohol use, so don’t get the opportunity to notice trouble. Friends of a woman who drinks too much are often drinking heavily themselves, so they have no motivation to confront her about her drinking. The ease with which men’s antisocial drunkenness is seen as a problem allows society to remain ignorant of women’s less obvious, more “quiet” forms of drunkenness.

A factor leading us to ignore depression and eating disorders in women is the belief that this is “just how women are.” We expect women to be moody or sullen, so when they are, we write it off as part of their character, or just a hormonal phase. No big deal, she’ll snap out of it eventually, pay her no mind. If she talks constantly about her weight or what she’s eaten, well, that’s the way women are. If you’re a guy, just ignore her. If you’re a woman, you’re likely to be similarly concerned about your weight, and fall easily into an intense conversation about carbs and fat grams and calorie burn.

In stark contrast, because we don’t expect women to have alcohol problems, we remain oblivious to the problem’s pervasiveness. A broad conspiracy of silence and denial surrounding women’s drinking problems exists among friends, family members, and physicians.

As most of us now recognize, large corporations profit from women’s preoccupations with their bodies. Women, more than men, spend billions of dollars every year on products and services to reduce their weight and control their eating, including expensive weight-loss programs, pills to curb appetite, health club memberships, and surgeries to remove fat.

The alcohol industry needs women. The overall rate of alcohol consumption has declined in recent decades, leaving the liquor and wine industries eager to promote drinking as a good thing for women. Advertisements depict women drinkers as sexy and young, having a great time, attracting handsome men. Savvy beverage industry executives have helped their companies make billions off wine coolers and spritzers specifically invented to be light and sweet enough to appeal to women. The same executives have made sure that the public is exposed to countless media stories about the health benefits of drinking. Of course, what we are not told is that many of those supposed benefits may only be true for men, and that even moderate levels of drinking raise a woman’s risk of developing numerous deadly disorders and diseases.

When it comes to depression, the pharmaceutical companies are only too happy to trumpet the high rate of depression in women, who make up over two-thirds of the market for antidepressant drugs. These drugs have been lifesavers for many women, but they don’t “cure” depression—they only keep the symptoms of depression at bay. Antidepressants don’t address the social and psychological forces that push women into depression, disordered eating, and alcohol problems. They don’t help us understand and confront women’s tendency to cope with situations by self-focusing. They do allow us to respond to women who are trapped in the toxic triangle with the simple phrase “go take your pills.”

These multibillion-dollar industries are not the single cause of the toxic triangle, but they help to create a culture of expectations for women and how they will relate to their bodies and minds. These expectations are like a drumbeat in the background—after a while, you don’t even consciously hear it, but you are nonetheless walking in step with the beat.

Documenting the Damage

It’s not just family and friends who have ignored the toxic triangle in women. Clinicians and researchers focus on one component of the triangle at a time, rather than documenting the long-term effects on women’s lives of combinations of depression, disordered eating, and heavy drinking.

Fortunately, this gap in the research is beginning to be filled. One critically important research project, run by psychologists Peter Lewinsohn, Paul Rohde, John Seeley, and Ruth Striegel-Moore, followed over a thousand young adolescents in the general community in Oregon over several years, reporting on the ebb and flow of symptoms of depression, eating disorders, and drinking problems. They found that those adolescents who had a combination of two or three of these problems were much more likely than those who had only one to have trouble in school, to fight with their parents, to attempt suicide, and generally to function poorly in many areas of their lives.1 It seems that adolescents who fall into one branch of the toxic triangle can break free of it or contain its damage to some extent. In contrast, those who reach the place where two or three components of the triangle intersect can become immobilized, unable to do everyday schoolwork or to take comfort from friends. They may use extreme measures—even suicide attempts—to try to escape the toxic triangle.

Psychologist Eric Stice of the University of Texas at Austin has specifically focused on the combination of binge-eating behaviors and depressive symptoms, identifying two types of binge eating. One type, which I’ll call the dieting type, is connected to excessive attempts at losing weight. Women with the dieting type are greatly concerned about their body shapes and sizes, and try their best to maintain a strict low-calorie diet, while frequently falling off the wagon and engaging in binge eating. These women often use vomiting or exercise to try to purge themselves of the food or the weight that bingeing puts on their bodies. In the other type of binge eating, the depressive type, women are equally concerned about their weight and body sizes but are also plagued by feelings of depression and low self-esteem, so they often eat to quell these feelings.

Stice and his colleagues have found that women with the depressive type of disordered eating pattern suffer even greater social and psychological consequences, over time, compared to women with the dieting type of disordered eating.2 Depressive eaters have more difficulties in their relationships with family and friends, are more likely to suffer significant psychiatric disorders such as anxiety disorders, and are less likely to respond well to treatment. One long-term study found that over a period of five years, women with the depressive type of eating problems were more likely to be diagnosed with major depression or an anxiety disorder, and were more likely to continue to engage in severe binge eating, compared to women who had the dietary type.3 Indeed, 80 percent of the women with the depressive type developed full-blown major depression over those five years. The lesson found here is that the intersection of depression and unhealthy eating patterns is more toxic for women than either of these problems alone. When heavy drinking is added to the mix, the combination is even more poisonous.

You Don’t Need a Diagnosis to Suffer

Recent research also reveals that the devastating effects of the toxic triangle do not come only to those women whose symptoms of depression, drinking, and unhealthy eating are severe enough to qualify for a psychiatric diagnosis. Problems in each of these three domains fall along a continuum, and even women who suffer only moderate symptoms can incur major damage to their health and well-being. Also, over time, moderate symptoms of depression, heavy drinking, and disordered eating tend to evolve into more severe symptoms, dragging women deeper and deeper into the triangle.

In the studies of adolescents in Oregon described earlier, researchers focused on what are called partial-syndrome eating disorders—behaviors that smack of anorexia or bulimia nervosa but don’t meet the full criteria for the diagnoses.4 Adolescents with partial-syndrome eating disorders may binge at least once a week, but not multiple times per week. They may be underweight, but not a full 15 percent underweight. They tend to be highly concerned with their weight and judge themselves on the basis of it. Nonetheless, their symptoms don’t add up to a full-blown eating disorder, just a partial one.

Adolescents with partial-syndrome eating disorders, the vast majority of whom were girls, were just as likely as those with full-blown eating disorders to experience multiple psychological problems, including anxiety disorders, substance abuse, depression, and attempted suicide, both as adolescents and in their twenties. In fact, almost 90 percent had a full-blown psychiatric disorder when they were in their early twenties. Those with partial-syndrome eating disorders also reported lower self-esteem, poorer social relationships, poorer physical health, and lower life satisfaction than those with no signs of an eating disorder. In addition, they were less likely to have earned a bachelor’s degree, and more likely to be unemployed. Jenny is a young woman with a partial-syndrome eating disorder, which is ruining her enjoyment of life as a new mother.

When she was pregnant with her first child at the age of twenty-four, Jenny put on 50 pounds. She felt like a beach ball, as big around as she was tall, even after the baby was born. Jenny had always had a sweet tooth, and if she got a box of chocolates or other sweets for a present, she was known to eat the entire box in one sitting. While she was pregnant, her food cravings were out of control. One day she ate half of a carrot cake. Another day she had a Big Mac and supersize fries for lunch, then an hour later had a Whopper and an ice-cream sundae for dessert. In the two years since the baby was born, her binge eating has slowed down only a little. While the baby is sleeping, she might eat a whole can of Pringles, or all of the leftover casserole from last night’s supper. Occasionally, Jenny will feel so disgusted with herself after bingeing that she’ll go into the bathroom and try to throw it all up. She’s successful only some of the time. A lot of the time, she just gags a lot and gives up, feeling even more ashamed and stupid.

Jenny is so embarrassed by her eating behaviors and her excess weight that she hasn’t wanted to go out in public much. She and the baby have been invited to play groups, but she has made excuses not to go. Jenny had a good career as an accountant before she stopped working during the pregnancy. She always intended to go back to work once the baby was toddling. But now she can’t imagine, with the way she looks, facing her old friends and the schoolchildren. She also has visions of getting caught bingeing in the employees’ lounge. Jenny feels she’s a failure, even though she is a great mother with a beautiful, healthy child.

Toxic to Our Relationships

The social isolation that Jenny is experiencing is greater than that of other young mothers, which is, unfortunately, common among women who are locked in the toxic triangle. You’re ashamed and embarrassed. Just having a conversation with another person can seem like a monumental task. You may not even answer the phone or e-mails, because you just don’t know what you would say to those who are trying to reach you.

It’s not that women in the toxic triangle don’t want others’ support. In fact, they are often desperate for the love and understanding of family members and friends but, like Jenny, don’t know how to reach out for support. They become withdrawn, avoiding friends and family and turning down invitations for social outings. Symptoms of depression, or the fear that others disapprove of their eating or drinking habits, lead women embroiled in the toxic triangle to reject others’ overtures, preferring isolation to being intruded upon or controlled.

When they do connect, family members and friends don’t always respond effectively. While often intending to be supportive and understanding, they may not understand why a woman can’t “pull herself up by the bootstraps” and “snap out of it.” Frustrated at their own ineffective nagging, they pull away, or continue until she blows up at them.

Psychologist Thomas Joiner of Florida State University has identified a phenomenon that appears to contribute to some of the hostility and rejection that women in the toxic triangle experience in their relationships: excessive reassurance seeking. Women who constantly ask family members and friends for assurance that they are loved and that they are good people are engaging in this phenomenon. Never satisfied with the assurances they get, instead they pester others to the point of driving them away. Rachel, a forty-eight-year-old homemaker from the Bronx, often engages in excessive reassurance seeking in her interactions with her husband, Phil.

Phil never really gave Rachel good cause to doubt that he loved her. He was attentive and loving. He had been at her side when she had medical problems a few years ago, and when her mother died last year. He supported her decision to stay home to raise their two children, and was sincerely interested in what she and the kids did during the day while he was working at his law firm.

But still Rachel doubted, and these doubts had grown stronger in the last few months as another one of her depressive periods set in. How could he love her, when she was so boring? Surely he was just being nice when he asked about her day—he couldn’t really be interested, given how exciting his own work was. She had gained weight over the years and felt she was no longer attractive to him. She wondered what he would do if one of the young women lawyers in his firm expressed interest in him.

Rachel tried to keep these concerns to herself, but they leaked out, in little comments to Phil. When he came home in the evening and said, “How was your day?” she sometimes responded, “Oh, boring as usual, you wouldn’t be interested.” Then she would wait to see what his response was. Phil would usually say something like, “Sure I’m interested, tell me what you did.” Then Rachel would tell him a few incidents from the day, but label each one as “nothing” and “silly” as she went along. She listened intently for his response, wanting him to deny that her activities were nothing or silly, and becoming anxious and disappointed if he didn’t explicitly do so.

When Rachel mentioned that she felt fat or unattractive, Phil would usually respond that she was still his beautiful bride. She responded, “Oh, you have to say that, you’re stuck with me.” Phil felt frustrated and put off by this, but tried to stay calm. “I don’t have to say that, I mean it. I love you, and I love how you look.” But Rachel would not be satisfied: “You love me now, but will you always love me no matter what happens?”

Rachel set up all sorts of other tests of Phil’s love for her, and ploys to gain assurance of his devotion. If they disagreed with each other about something in the morning, Rachel would ruminate about it after Phil left for work. In her mind, she implicitly believed that if he hadn’t called to talk with her about the disagreement by 10 A.M., this meant he was really angry and their relationship was in trouble. Sometimes, if he hadn’t called or e-mailed her by 11 A.M., she’d call or e-mail him with a neutral message, just to see whether he’d mention that morning’s disagreement. If he didn’t respond almost immediately, Rachel took this as further evidence that he was angry with her, even though she knew he was probably just very busy. If he did respond to her message, but didn’t mention the disagreement and how sorry he was for it, Rachel would ruminate about this for the rest of the afternoon. By the time Phil got home in the evening, she was ripe with fear and anger, while he hadn’t thought about the disagreement all day because it had been so minor.

Excessive reassurance seeking and its opposite, self-isolation, are only two ways that women caught in the toxic triangle suffer damage to their close relationships. At the same time that women who seek assurance can be obsequious and deferential in an attempt to hold on to others, they can also be hostile and irritable as a reaction to the resentment they feel at their dependence. This resentment leaks out in small and large ways—snide remarks, snapping back unnecessarily, seeing ill will when none is meant. Interactions with spouses, family, and friends may be peppered with conflict and misunderstanding. They may even feel they have no influence over their children, or that their children do not love or respect them.

The toxic triangle can also erode intimacy by ruining women’s sex lives. Even moderate amounts of alcohol can make it difficult for women to become fully aroused or have an orgasm. Women who drink heavily can experience difficulty becoming aroused even when they are fully sober. Depression also kills sexual arousal and desire. You’re just not interested in sex anymore, and when you do have sex, you don’t enjoy it as much. And if you take antidepressants to try to overcome the depression, one of the major side effects may rob you of your sexual desire and arousal.

Women who end up in the toxic triangle seem to be magnets for interpersonal stress.5 They are more likely to marry men with psychological problems, including alcohol and drug problems and personality disorders, and they are then more likely to endure separations and divorces from their spouses. Their children are more likely to have problems in school or in their relationships with other children. Their friendships tend to be with those who have psychological problems, including depression, alcohol abuse, and eating disorders, only compounding the difficulty of escaping the toxic triangle. Indeed, these friendships may reinforce each woman’s unhealthy behaviors.

This is how a self-perpetuating cycle gets set up. Women who are vulnerable to the toxic triangle often find themselves locked in highly stressful family environments that include conflict in their marriages, husbands who have serious psychological problems, and children who are troubled. These stressors make them feel more depressed and out of control, which only feeds their symptoms. The symptoms themselves can create more stressors by worsening conflict with others and making it even harder to function as mothers, partners, and friends to others.

When Toxic Becomes Deadly

The conflict that arises from a life lived inside the toxic triangle can be much more severe than ordinary marital or parental discord. Particularly for women who are drinking heavily, the conflict that arises can become violent and dangerous. One large study of 1,160 women found that over half of the serious sexual assaults experienced by women involved alcohol; in almost all these cases, the man who perpetrated the assault had been drinking; in the majority of cases, both the man and the woman had been drinking.6 When husbands drink, or husbands and wives drink together, they are more likely to get into arguments, and even physical fights.7

We tend to think of alcohol-related violence as happening to poor, uneducated women who live in desperate areas. The reality is that much of the violence connected to alcohol happens to middle-class or upper-class women living in lovely homes with their seemingly nice families. Alcohol’s unique ability to unleash simmering problems between a woman and her husband or partner often escalates, with him getting rough and her fighting back. Unfortunately, she’s much more likely to get hurt than he is.

This was the pattern of interaction between Sandy and Bill, forty-year-old Polish-Americans living in New York. Their marriage had been in trouble for years. Most of their fights were over finances—Bill thought Sandy spent too much money on clothes, and she thought his endless “improvements” to the house were unnecessary expenses. They also fought about their two teenage children, who, they feared, were experimenting with drugs as well as alcohol. These fights were usually just loud shouting matches that ended with one or both of them retreating to the bedroom and slamming the door. Often, though, these fights would erupt after Sandy and Bill had had quite a bit to drink. When she was sober, Sandy tried to watch what she said during a fight so as not to immediately “push Bill’s buttons” and send him into a rage. When she drank too much, however, Sandy went right for those buttons and pushed as hard as she could. Most of the time, Bill would stomp off in a rage, jumping into his car and careening down the street, to be gone the rest of the night.

Occasionally, a shoving match would emerge during one of these fights. Sometimes it wasn’t really clear who started the physical contact between them, but it was always clear that Sandy got the rougher treatment. Bill was 50 pounds heavier so his shoves could send Sandy, who was only 5 foot 3 and 120 pounds, hurling across the floor. She might get right up and start punching on him, but he could pin her arms behind her back with little effort. More than once, Sandy woke up the next morning after one of these fights with bruises and cuts. About a month ago, on a rainy Friday night, she broke her arm in a hard landing after one of Bill’s rough shoves that this time sent her tumbling down a flight of stairs.

Why do violence and alcohol go together? Alcohol increases physiological arousal, and men are more likely than women to act on this through aggression, sometimes toward their women partners. Research also shows that men, more than women, tend to associate alcohol consumption with feelings of dominance and power. Intoxicated men may be more likely to see women who have been drinking as more vulnerable to domination or more socially deviant and therefore deserving of punishment. Intoxicated women, in turn, appear more likely to retaliate violently when attacked by their intoxicated male partners, leading to an escalation of violence. Perhaps not surprisingly, in most cases the woman is much more likely than the man to suffer significant harm in these encounters.

Toxic to Our Careers

The interpersonal effects of the toxic triangle are not restricted to women’s personal lives. Being withdrawn and socially isolated, and being irritable and excessively seeking reassurance, are behaviors that can wreak havoc on our careers.

Other symptoms of the toxic triangle make it very hard to perform well at work. It’s difficult to concentrate if you’re depressed, hungover, or preoccupied with food, and so you may read the same page of a report over and over but still not know what it said. Your memory may fail you, leading you to forget both small and important things. Making decisions seems impossible, so you may remain immobilized at the worst possible moment, when the situation calls for decisive action. As a result, you may have difficulty keeping up with your work, and the work that you do may suffer in quality.

One recent nationwide study focusing specifically on depression found that over half of depressed people said their work was moderately or severely affected by their depressive symptoms.8 On average, people with depression experienced 35 days of the previous year in which they were totally unable to work or carry out their normal activities. The other two components of the toxic triangle can effect their own damage. Women with eating disorders or drinking problems are more likely than women without these problems to be unemployed or underemployed. When the three branches of the toxic triangle join together, it can stop a career dead in its tracks, as was nearly the case with Catherine.

At the age of forty-three, Catherine was considered a successful businesswoman by most people who knew her. She had opened her shop on a busy street in Chicago eleven years ago, and after a rocky start, it had been thriving for the last few years. Catherine imported beautiful hand-embroidered clothes from Latin America, and the intricate and colorful designs on the clothes were a big hit. Catherine always wore one of the blouses or dresses from her collection when she was in the store, and her dark features and tall, slender body showed off the clothes stunningly.

For the last year, however, Catherine has had difficulty keeping up with her business. After a messy divorce from her husband, she felt drained of all energy. Most nights, she was up half the night, worrying about work, wondering how her marriage had gone so wrong, and questioning what her life meant. She would often binge eat when she had insomnia, and had gained 35 pounds. She could no longer fit into many of the blouses she had brought home from her store.

When Catherine went on her usual buying trip to Latin America in January, she had great difficulty deciding what she should buy. Several times she found herself standing in front of a collection of clothes, supposedly choosing those she would buy, immobilized with doubt and indecision. She returned to Chicago with half the number of items she usually bought, far less than she needed going into the summer season.

Back in Chicago, Catherine began to receive phone calls from her creditors asking for payments. Usually a prompt and reliable bill-payer, Catherine had completely forgotten about some bills and had actually lost others. Her good credit rating with her vendors and her bank was in jeopardy.

At the shop, Catherine often felt irritable and impatient with her employees. They seemed so uninterested in their work, and she suspected some of them of stealing merchandise. The truth was that Catherine’s negative and hostile demeanor had put a black cloud over everyone in the shop, bringing their own moods down and making everyone more grumpy. Catherine had lost a couple of her best employees in the last year, after she had snapped their heads off for nothing or indirectly accused them of cheating her.

Catherine had built a brilliant business based on her keen eye for fashion and her retail savvy. Her symptoms of depression—the problems concentrating and making decisions, the irritability, the immobilization—although understandable following her divorce, were jeopardizing all she had built for herself. Rather than acknowledging she needed help, Catherine turned to binge eating for short-term solace. Her weight gain only added to her problems, giving her more to worry about and hate herself for.

Toxic to Our Health

Even if we could shield our relationships from the effects of the toxic triangle and keep trudging along in our careers despite our symptoms, our physical health can suffer. We have lots of information about what each of the three components of the toxic triangle does to our health—when two or three of these problems are present in a woman’s life, her physical health may be tragically damaged.

ONE DRINK TOO MANY

Thousands of women across the nation are unknowingly drinking themselves into early graves. Because women’s bodies do not metabolize alcohol as efficiently as men’s, and because women are simply smaller on average than men, alcohol has a more noxious effect on all key organ systems—including the heart, liver, and brain.9 Even mild levels of daily drinking—for instance, consuming just two or three glasses of white wine per night—may seriously increase women’s risk for breast cancer, and may lead to a number of reproductive health problems (such as infertility).10 More serious levels of drinking can literally eat a woman’s insides.

We’ve all heard in the media about the cardiac benefits from moderate drinking, and many women and men who have a drink or two per day do so thinking it makes for a healthy heart. What we don’t hear in the media is that the cardiac benefits of alcohol don’t apply to women, at least to young and middle-aged women. On the other hand, consuming as little as two drinks per day can begin to inflict serious harm on women’s hearts.11 Perhaps most frightening, the overall rate of alcohol-related mortality among heavy drinkers in our nation today is four times greater for women than for men. When it comes to alcohol-related deaths in America, every year we’re burying four times more heavy-drinking women than men.

Research shows, too, that alcohol more seriously affects women’s overall ability to function than it does men’s.12 After just a drink or two, many women begin to have trouble walking straight and thinking straight. As a result, women are more likely than men to be involved in car crashes and other accidents after drinking.

Lucy is a woman who, thankfully, became aware of the toxic effects alcohol was having on her body.

Lucy is a thirty-year-old single woman from Phoenix who works as a real estate agent. Her dark pretty features—beautiful brown eyes and long black hair—do nothing to mitigate her feelings of unattractiveness because she is 20 pounds overweight. She believes her weight is the main reason she doesn’t have a steady male friend. Lucy works hard at having a social life, going out for dinner most nights with friends and to parties most weekends. She’s one of those women who can hold her alcohol—or at least thinks she can—and so tends to have at least three glasses of wine many nights each week.

A few months ago, Lucy began to have dizzy spells for no apparent reason. Since she has almost always been on a diet, she attributed them to hunger. Even more worrisome was the increasing blurriness in her vision and her need to pee all the time. When she mentioned these symptoms to her physician, he ordered a fasting blood test, which suggested Lucy had developed moderate diabetes. Lucy thought this was absurd, given that she had no family history of diabetes and was so young. Nonetheless, the doctor gave her a diet to follow, and strongly recommended she stop drinking.

Lucy decided to follow the diet, which seemed like a good one for losing some weight, but refused to stop drinking. Her glasses of wine were too much a part of her social life, and she desperately worried that men would find her even less attractive if she was a teetotaler. In spite of the force of her denial, Lucy’s symptoms of diabetes were getting worse, and she even began to have severe dizzy spells while driving.

Lucy was fortunate that on a subsequent visit to her physician he stressed the toxic effects that alcohol was having on her body. She began to work with a psychologist who helped her feel better about her body and her life, which in turn gave her the emotional support she needed to stop drinking. Of course, as lucky as Lucy was to get the information and support she needed, many, if not most, women who develop alcohol-related diseases may never realize the harm they’re inflicting on their organs with every sip they take. Tragically, many women only realize what they’re doing when it’s too late.

DANGER: FOOD!

Whether you eat too much or too little, your physical health can be strongly affected by crazy eating patterns. Binge eating is strongly linked to obesity, and obesity can lead to diabetes, stroke, heart attacks, and other debilitating conditions. It’s estimated that health problems caused by obesity now cost the health care system $117 billion per year.

On the opposite end of the spectrum, women who starve themselves also endanger their physical health. Prolonged starvation can lead to cardiovascular disease and heart failure, metabolic dysfunctions, dehydration, anemia, and susceptibility to bleeding, hypothermia, and a number of gastrointenstinal complications, including acute expansion of the stomach. The damage anorexia does to the immune system may make some anorectic women more vulnerable to severe illness.13

Although the death rate among women with bulimia nervosa is not as high as among those with anorexia nervosa, bulimia still has serious medical complications. One of the most deadly is an imbalance in the body’s electrolytes, which results from fluid loss following excessive and chronic vomiting, laxative abuse, and diuretic abuse. Electrolytes are biochemicals that help regulate the heart, and imbalances in electrolytes can lead to heart failure.

DEPRESSED HEALTH

It’s a little less obvious how depression affects physical health, but it does. For reasons we do not yet totally understand, people who are moderately to severely depressed have more illnesses than people who never get depressed.14 The range of illnesses includes colds, the flu, and also more severe illnesses, such as cardiovascular disease, stroke, and multiple sclerosis. For example, depressed people are significantly more likely to have complications following heart surgery or even multiple heart attacks. Likewise, liver disease, so often caused by alcohol abuse, does not respond as well to treatment in depressed patients.

It Never Seems to End

One reason the toxic triangle takes such a toll on physical health, careers, and interpersonal relationships is that the three health problems associated with the triangle tend to be chronic, lasting at least months and usually years. One study of 431 people with major depression that followed them an average of nine years found they had moderate to severe symptoms of depression 59 percent of the time and were symptom-free only 27 percent of the time.15 Alcohol abuse, anorexia, bulimia, and binge-eating disorder also tend to be chronic conditions. Long-term studies show that although symptoms of the disorders may wax and wane, over half of women with one of these disorders continue to have symptoms for at least five to ten years.16 Even if a woman escapes the toxic triangle free and clear for a time, she remains at high risk for relapse.

Women in the toxic triangle continue to have symptoms chronically, in part, because the majority of them never seek care, or wait for years after their symptoms have begun to do so.17 Often this is because they don’t have the money or insurance to pay for care, or because they are ashamed of their symptoms and don’t want anyone to know about them. Other women believe they should be able to get out of the toxic triangle on their own because the symptoms are just a phase that will pass with time and won’t affect their lives in the long run. This line of reasoning may be even more prevalent among women with moderate symptoms who often can keep going, dragging themselves through the day, never getting so impaired that friends or family push them into treatment.

Even as the more acute symptoms of the toxic triangle subside, some women seem to be left with lasting scars. Patterns of thought, self-image, social relationships, and academic and work lives are changed for the worse and can remain impaired for long periods after the symptoms have passed. Even if they don’t relapse into new episodes, women with previous episodes of depression, disordered eating, and/or heavy drinking tend to have other enduring problems. Their functioning on the job may remain below par. They’re not as interested in sex or don’t enjoy it as much as they did before they fell into the triangle. And persisting through this is a chronic conflict and dissatisfaction with their friends and families.18

The toxic triangle may be most likely to leave psychological and social scars if a woman initially finds herself there during adolescence, rather than during adulthood.19 A person’s sense of self—who she is and what she believes—is still being developed in adolescence, much more than it is in adulthood. Depression or obsession with how you look can retard the development of your sense of self, creating long-lasting effects. During adolescence, skills and abilities accumulate; symptoms that interfere with memory, attention, and learning, such as the symptoms of the toxic triangle, can damage adolescents’ achievement for the long term. Finally, adolescents are dependent on and connected with other people to a greater extent than are adults, so the hostility and irritability that goes hand in hand with the toxic triangle can significantly harm the social skills on which personal relationships depend.

Escaping from the toxic triangle requires that we first understand the journey into it—the social, psychological, and biological forces that pull us into this vortex and keep us trapped there. Only when we begin to see these forces at work in our own lives can we design strategies to bypass or conquer them and regain control over our health.