some more thoughts on eating disorders

I'm not an expert in this, but I have some general thoughts from my own experience and what I've come across over the years. Personally, I perceive theories of eating disorders to change largely in the manner of fashions with the prevalent climate in psychology. Which is simply meant to say that the causation isn't pinpointed to anything specific. Obsessiveness and perfectionism loom large in the profile of most anoretics, and they take in thinness as a goal for organizing their lives, but the odd thing, the thing that makes the condition so destructive, is that they can never quite get where they want to go, they just keep striving for a partly illusory goal.

There are theories sometimes found carried forward from older books about perfectionistic parents, or early childhood abuse, but I find serious weaknesses with both of these theories. Perfectionism is probably as much inherited as learned, and notable trauma or abuse doesn't turn out to be a reliable marker of eating disorders in the general population, only in psychiatric populations, which are already a biased sample in many ways. I don't see a clear and simple causal pattern, there seems to be a web of individual tendencies and environmental conditions that foster the most destructive patterns.

Some general concepts I think are helpful:

1. Anorexia is classically characterized by restriction, that is, voluntarily not eating. And often by high activity levels. Many anorectics (though certainly not all) are young athletic girls, often dancers, skaters, or gymnasts, whose perfectionism and spartan diet and exercise habits are not recognized for a while because they are almost reasonable patterns for a dedicated athlete. The way anorexia is distinguished, even in this population, is by the distinctive distortion of body image and their pursuit of thinness as an end unto itself.

Anorectics tend look at their lean frame in the mirror and see flabby areas and imperfections, just as many of us do, but they see flab and fat to an almost comically exaggerated degree. They literally see themselves as fat even when skeletal. The distortion is sometimes measureable: a well-known exercise in therapy can serve as a diagnostic test as well. The person is asked to draw a lifesize outline of their body, and then is asked to step into it for comparison. Most of us draw something fairly close to our actual body outline. People with anorexia tend to draw their outline much larger than it really is.

The false perception of being fat and having an imperfect body is combined with seeing thinness as a central goal. "This problem would go away ... if only I could lose another 10 pounds ..." is like a mantra. "Just a few more pounds." Again, the refrain is not uncommon, it is the way it gets applied that makes it a serious problem. The pursuit of thinness becomes seen as the answer to almost everything. It's a little like taking the dedicated olympian's dream of a gold medal, and substituting the dream of ultimate thinness, but then having it forever pulled just out of reach. Anorectics seem like they are on a treadmill forever chasing the carrot dangling just out of their reach, until they die of exhaustion.

Once they have made restricting a lifestyle for a while, the meaning of "anorexia" (no appetite) kicks in, and they actually lose the desire to eat as well as pursuing thinness. That's where it becomes particularly easy for them to maintain, and particularly difficult to treat.

2. Bulimia tends to be associated with a pattern of indulging and then feeling guilty and purging (usually inducing vomiting). Bulimics and anorectics both seem to have a tendency to abuse laxatives and diuretics. It's distinguished by that pattern from the more consistent restricting pattern of anorectics.

3. Anorexia and bulimia are distinguished both because the behaviors are fairly distinct, and because treatments that are frequently effective for one are sometimes markedly less effective for treating the other.

4. Anorexia and bulimia both lie somewhere in the fuzzy middle in the traditional distinction of "psychological" and "biological" conditions. It's a peculiar kind of obsession. You don't find anorexia in cultures where most people are starving, or where thinness is not a widespread social ideal. It is clearly in part an internallization of ideals we are exposed to. However it is also different from other kinds of ideals in how much of our life it affects and how obsessively it affects these other areas. As with alcoholism, anorexia has tentacles reaching into every aspect of individual and social life. You do also find it along with many other problems, (high "comorbidity"), related to personality disorders, psychological trauma, and so on, although it isn't always clear what is cause and what is effect, or whether something else underlies multiple problems.

kind regards,

Todd

Replies:

Notes from a patient, by Hungry, 06/05/04 Re:Notes from a patient, by Valerie Kirby, Ph.D., 06/06/04 Thanks, Valerie -- finally quit therapy, by Hungry, 06/07/04 Re:Thanks, Valerie -- finally quit therapy, by Valerie Kirby, Ph.D., 06/08/04

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