I was in a gym last week and noticed an emaciated women running on a treadmill, who was so thin that individual muscles and bones were visible in her exposed flesh around her gym clothes. I wondered if, wearing my clinical hat, I should speak with the gym staff about her, given it was clear she either had a chronic disease that caused profound secondary weight loss, or she had an eating disorder, most likely anorexia nervosa. I have noted with concern when watching cycling races how thin elite professional cyclists are during long stage races, and was interested when reading the autobiography of one of the world’s best cyclists that they believed that both themselves and several of their cycling colleagues would probably satisfy the criteria for a full-blown eating disorder diagnosis, and that they had battled with food ingestion both during their career, and even after they had stopped being competitive. As a teenager I was sent to boarding school, and didn’t settle well into the strong routine and rules based environment that boarding schools require in order to function, and I stopped eating as a ‘silent protest’ to get attention to my dislike for my environment. I eventually cut my weight to almost zero body fat, and folk wondered if I had a bone fide eating disorder, though fortunately when my parents accepted that I could not continue at the boarding school in my state of refusing to eat and resultant massive weight loss, they took me out and put me into a day school, and almost immediately I started eating again, my weight normalized, and the problem was pretty much resolved for me. Seeing the lady on the treadmill, reading the book on the eating travails of the elite cyclist, and reflecting on my own weight reduction story of my youth, got me thinking about anorexia nervosa, what causes it, and why some folk both start to refuse to eat food, and continue to do so, even if it causes them to literally starve themselves to death in an environment of plenty, and with so many of their loved ones around them willing them to eat normally, put on weight, and live a ‘normal’ life as they apparently used to do.
The symptoms and signs of anorexia nervosa were first described in medical texts as early as in the 1600’s, and was termed anorexia nervosa in the late 1800’s. The term is Greek in origin, with ‘an’ describing negation and ‘orexis’ describing appetite – so literally a psychological negation of appetite. Its classical symptom is obviously food restriction resulting in rapid weight loss, and it can be accompanied by compulsive behavior such as excessive exercise (in order to use up calories and thereby lose weight), a paradoxical preoccupation with food, recipes, or cooking food for others which is not consumed by themselves, food rituals such as cutting food into small pieces and not eating it, refusing to eat around others or hiding and discarding food, and purging themselves with laxatives, diet pills, or self-induced vomiting in order to attenuate the effect of eating any food whatsoever, no matter how small the portion (to note these purging actions also occur in its ‘cousin’ disorder, bulimia nervosa, but there is usually not the marked food restriction in bulimia nervosa, and weight loss may not be evident in folk suffering from bulimia nervosa). There are a number of other signs which are diagnostic of anorexia nervosa, including low body mass index for one’s height or weight, amenorrhea in females, the development of lanugo (fine, soft hair growing over the face and body), intolerance to cold, halitosis (bad breath), orthostatic hypotension (low blood pressure when lying down), chronic fatigue, and changes in heart rate (either slowing down or speeding up). But, most of these may be related to the chronic and extreme weight loss, rather than to anorexia nervosa per se. Clinicians have to be very cautious before diagnosing anorexia nervosa to be sure to exclude a wide variety of clinical disorders that can lead to profound weight loss, including cancer, type 1 diabetes, thyroid hormone disorders, and a host of other clinical conditions. Anorexia nervosa is thought to occur in approximately 1-4 percent of females, and 0.5 percent of males, and often begins during the teenage or young adulthood years.
There is much debate still about what causes anorexia nervosa. There has been an increased incidence of the diagnosis of anorexia nervosa in the last 50 or so years, and this increase has been correlated with increase in social pressures, particularly on females, but more recently on males too, for the ‘ultimate body’, with most cultures increasingly favouring a slender shape and the ‘size zero’ model, where clothes and fashion are displayed on waif-like models. This is theorized to put pressure on most folk to be thinner than what is possible for the vast majority of people. But, correlation is not causation, and the counter-argument to this social theory would be that 96% of women and 99.5% of men see similar fashion images and models and do not develop anorexia nervosa. There is a strong familial link to it, with twins and first degree relatives of someone diagnosed with anorexia nervosa having a significantly higher chance of developing the disorder. It has also been suggested that the prevalence of anorexia nervosa is higher in athletes doing sports that require weight control, such as gymnasts, runners and cyclists, and in those folk whose careers similarly require weight regulation, such as ballet dancers and jockeys. It has also been suggested that folk with gastrointestinal disorders such as inflammatory bowel disorder and coeliac disease may have a higher prevalence of anorexia nervosa, due to the increased requirement to be ‘aware’ of what food types are ingested if suffering from other of these challenging gastro-intestinal disorders, and indeed eating any food whatsoever may initiate their symptoms. There has been an increase in interest in ‘extreme’ diets such as the keto, carnivore, and vegan diets, amongst others, and it has been suggested that engaging with such diets may precipitate the development of anorexia nervosa, or indeed be a ‘mask’ for those with eating disorders to ‘hide’ behind as a label that would allow them to explain their weight loss and extreme thinness in a way that was more socially acceptable than telling those around them that they have anorexia nervosa, or allows folk suffering from the disorder to feel part of a group of similar food conscious folk.
Anorexia nervosa would be easy to diagnose, treat and manage if the disorder was as simple as that described in the paragraphs above. But, a major confounding issue is that a high percentage of folk who suffer from it deny having anything wrong with themselves, deny having an eating disorder, and some resist being treated to the point of requiring to be restrained and force-fed to keep them alive. It sounds terrible that folk have to be force fed against their wishes (and some doctors have an ethical problem doing so), but unfortunately anorexia nervosa has the highest mortality rate of any psychiatric or psychological disorder, around 10-12 times that of the general population, with the risk of committing suicide being 50 times higher. Anorexia nervosa sufferers literally starve themselves to death, or commit suicide while doing so, and there is a high recidivism rate, with only half of the folk who have it ‘recovering’ (if they ever do), with the rest relapsing or becoming chronic and a permanent ‘way of life’ until death intervenes. So something is clearly desperately ‘wrong’ in these folk, who either know about it and acknowledge it, know about it and don’t acknowledge it, or not know that they have the disorder and perceive themselves to be well – clearly the latter group being the most challenging to treat, though all three groups require major psychological assistance and intervention. Anorexia nervosa is classified under Feeding and Eating Disorders in the ‘bible’ / official manual of Psychological disorders (known as the Diagnostic and Statistical Manual of Mental Disorders – DSM5), but there is a high prevalence of other associated psychological disorders, including obsessive-compulsive disorder and obsessive compulsive personality disorder, anxiety disorder, and depression. An array of other psychological disorders have also been linked to anorexia nervosa, including borderline personality disorder, attention deficit hyperactivity disorder, autism spectrum disorders, and body dysmorphic disorders, and while some of these linked disorders require further research to understand their prevalence and linkage to anorexia disorder, it is thought that having these comorbidities worsens the prognosis for folk suffering with florid anorexia nervosa.
With all these challenging psychopathology and comorbidity factors, three key issues appear to be fundamental to anorexia nervosa. The first is precipitatory factors, the second loss of interoceptive (body state) awareness, and the third perception of loss of control in folk with the disorder. It is thought that a stressful incident in one’s past life, or a change in circumstances for an individual already predisposed to develop the disorder, or by being in a sport which requires weight regulation, can precipitate the development of anorexia nervosa in a susceptible individual. Sadly, a number of folk who develop anorexia nervosa have a history of childhood trauma, including abuse, parental divorce, or a conflict-filled environment, and a study published last year found there was a twenty five percent incidence of sexual abuse during childhood reported as occurring before the onset of anorexia nervosa. Equally, a change of environment that is challenging, such as moving geographically, or going to boarding school, or the death of a parent or sibling or loved one, or being teased about one’s body shape in childhood or adolescence, may also be precipitatory factors. While difficult to prove direct linkage as a response to these psychologically ‘shattering’ events, what appears to happen as a result of these traumatic challenges is that a process of ‘disembodiment’ occurs (also described as ‘interoceptive loss’) where one’s body image is altered, or one does no longer ‘recognize’ one’s current body image, perhaps as a way of ‘denying’ the trauma that was done to it as would have occurred as a result of being sexually abused for instance. It has also been suggested that folk with anorexia nervosa undergoes a ‘loss of emotional self’, where one no longer recognizes ones emotions and feelings, in a similar way, and for similar reasons described above, as why one no longer recognizes one’s physical body. Lonnie Athens, one of my most admired Psychology researchers, has suggested that one cannot have too weak a sense of self, as one would not be able to have a stable sense of self-identity if so. However, he suggested that with a profound change, such as being the victim of a violent episode, divorce, loss of a job, or some other profound experience, for which the individual has no prior frames of reference or experience of, and which their current self-identity system (whatever this is) cannot provide interpretation of or makes sense of, resulting in changes to the sense of self similar to that found in folk with anorexia nervosa. In his model, the factors which set the sense of self in the brain become confused in a crisis for which there are no previous precedents to benchmark the current experience against. Because of this, the sense of self become fragmented, and replaced by a different sense of self, if the individual is able to make sense of what happened to them and ‘move on’ from what happened, but if not, remains permanently fragmented, and folk develop into a permanent state of sense of self ‘flux’, in which the individual is to a degree unrecognizable to themselves in a manner which becomes habituated.
The underpinning issue of all of these factors, and the ‘unfinished’ response to them, is a sense of loss of control. The individual who has suffered life trauma, and the resultant ‘shattering’ of their sense of self, no longer feels in control of their life and situation. One thing that can be controlled is their food intake, and in the case of folk who develop anorexia nervosa, they stop eating due to the desire either to control one factor in their existence which they can have complete control over, or actually do want to starve themselves to death, as a compensation or ‘way out’ of their current psychological ‘fragmentation’, and they stop eating as a way of enacting a prolonged suicide. For this reason (amongst several other reasons), folk with anorexia nervosa do not believe that they have an eating disorder, as by limiting their food intake, they feel that they are for the first time since whatever precipitated the development of the condition of anorexia nervosa, and are ‘controlling’ something in their own body, and it would be too psychologically draining for them to ‘lose’ what becomes in effect a control ‘mechanism’ that they feel completely ‘in control of’. At the same time, the individual may deny or ‘forget’ that they ever had any abuse or traumatic episode happen to them, as it is too threatening to their already damaged psyche to admit such, and as a mechanism of psychological denial, they ‘remove’ it from the conscious self to the nether world of their subconscious, where it continues to ‘trip them up’ and damage their lives until they confront it. So paradoxically, folk with anorexia nervosa can be all of completely out of control (from the context that they have been ‘ripped up’ psychologically by prior damaging events), in control (from the context of what they choose not to eat), and in some folk not aware of (due to protective psychological denial processes) their current physical state, sense of self, or underlying psychopathology. The distortions of body image, and dread of adding on even a pound of weight, are a result of these three ‘issues’ (amongst others) at play in their deep psyche and if this ‘lack of awareness’ is not addressed, the person with anorexia nervosa will literally starve themselves to death, as a method of maintaining control, or of negating the damage caused to them of whatever lead to the development of their condition. Therefore, in many cases, folk forget that anorexia nervosa can be a symptom of some deeper psychopathology, which may or not be ‘hidden’ from view, apart from it being a psychopathology in itself.
All of these ‘entangled issues’ make anorexia nervosa extremely difficult to treat. If folk deny that they are sick, it becomes very difficult to treat them, as whatever one does, they will not ‘stick with’ the treatment offered. Admitting that they are sick, or that they have a mental illness, requires them to acknowledge the psychological damage underpinning their anorexia nervosa (with anorexia nervosa being a symptom itself), and that they have no control over their life, and indeed that their own ‘treatment’ they have chosen to ‘cure’ their underlying psychopathology such as sexual abuse or other issue, namely not eating, or controlling their eating patterns to an extreme degree, has been wrong. A large number of folk with anorexia nervosa want to be left alone, and find it difficult to cope with being diagnosed as having anorexia nervosa due to the requirement this would make on them to confront their underlying psychopathology, and indeed, sadly, being diagnosed as suffering with anorexia nervosa creates a stigma of its own, and may ‘label’ and define them for life as such, and this is yet another psychological challenge to accept in their challenged state (that they have both an eating disorder and also underlying psychopathology) for the folk suffering from it. Treatment of the disorder involves trying to restore the person to a functional weight, treating the underlying psychological disorders that led to the development of anorexia nervosa, and reducing behaviors and activities that result from the disorder becoming habituated (such as not eating in front of other folk, hiding food, as well as of course not eating at all most of the time). Psychotherapy, cognitive behavioral therapy and family-based therapy have all been used with varying degrees of success to treat folk with the disorder. However, given that eating is a basic requirement of life, each day is an ordeal from the context that eating is required to happen in order for life to continue, and at each meal there is thus a conflict and habitual cycle of negation that is very difficult to alter or attenuate. Force feeding has been used in extreme conditions, but there are of course ethical issues associated with this, such as the individual’s rights, though of course the debate is whether folk with anorexia nervosa are in a ‘right’ state of mind and / or can make decisions that are good for themselves, rather than being damaging for themselves (similar issues of treatment occur in folk with alcoholism or who self-harm, amongst others). In the end, as described above, it is a disorder that is extremely challenging to manage, with a high level of chronic morbidity and mortality, very much as if the folk with the disorder ‘want to die’, as challenging as it is to describe it as such, or as a clinician to understand it as such.
Anorexia nervosa, for the reasons described above, is one of the most challenging disorders clinicians, friends and families of people that have the disorder have to manage and live with. To all of us watching the lady in the gym last week it was clearly obvious that she had a severe case of anorexia nervosa, yet she appeared oblivious to this, and was indeed working hard in the gym to ‘maintain fitness’ (thought of course in this case the exercise may be both a symptom and vehicle of psychopathology itself). In many ways society advocates restrictive eating and thinness, and from this perspective, the lady in this example would be congratulated for doing this to such extremes. Yet, paradoxically, someone like this who appears to be so in control, is actually completely out of control, and even more strangely, in many cases is not aware of it. The ‘mirror’ / self-image assessment function in their brains, however it works in both health and disease, appears to warp and become convex, and to the anorexic, their body image is usually so ‘fragmented’ that they see big where they are indeed thin. Even more sadly, as a clinician seeing folk like this makes one wonder what traumatic event the individual has gone through to trigger their anorexia nervosa, and whether they hopefully are in counselling to try and help them get to terms with whatever issue is causing their ongoing self-harm. Sadly thought, this is so difficult to do, as control mechanisms are involved which have become extreme, and make them unable to ‘move on’ from a life spent in the shadows to one in the light. Sigmund Freud suggested that folk have both a life instinct (Eros) and a death instinct (Thanatos), and one’s Thanatos instinct compels us humans to engage in risky and destructive behaviours that can lead to our own personal death. Clearly, in folk suffering from anorexia nervosa, a trigger has changed their ‘behavioral setting’ from Eros to Thanatos, and once changed, the God of Death appears to be fairly resistant to change. Much research is needed in the field to help us understand the psychopathology underlying anorexia nervosa better, and how to treat, or at least manage the condition. Mirror, mirror, on the wall, am I the thinnest person of them all may be the mantra of this disorder, but sadly the mirror is telling a lie. Each time I put in the two spoons of sugar which I enjoy my tea, I thank my parents for removing me from boarding school, before a fast of defiance became overwhelmed by Thanatos, the God of Death, and before I too went down to the place where everything which seems real is not, and where once one is over the edge of the abyss, there is very little chance of ever coming back. Dying by starving oneself to death may paradoxically represent a victory to the individual that pushes themselves to their own death, but the fight between Eros and Thanatos in a loved one, when Thanatos wins, is surely one of the most tragic things a clinician, family member or loved one can ever watch from a distance and understand, or even begin to comprehend, without wanting to smash the distorted mirror, and by doing so rebuild the fragmented spirit underneath it, no matter how impossible in real life this is.