The Noisy Water Review

Anorexia Nervosa: Starvation and Sacrifice of the ‘Self’

Jordan Gardner

Abstract

Anorexia Nervosa is a complicated psychiatric disorder, for which effective, long-term, treatment has yet to be found, based upon numbers that reflect alarming relapse and mortality rates. Although anorexia has been diagnosed and treated for years, the numbers do not reflect positive outcomes or promise for many suffering, which is a significant issue. The purpose of this essay is to understand why modern treatment methods are ineffective for treating people suffering with anorexia long-term, and if the answer to successful treatment lies within the roots of the disorder. Some research has indicated attachment style may play a large role in development of anorexia, and if more research were to be done in this area perhaps we could determine whether or not this is useful in creating successful long-term treatment, or management, of anorexia.

Introduction

For the purpose of lending a different perspective on how modern treatment of anorexia nervosa is flawed, and more often than not, ineffective for many who suffer, this essay will include a bit of personal experience and anecdotal evidence. As someone who has endured life with the disorder, gone to treatment, relapsed, then had to regain weight—on my own, once more. I hope my experiences with both anorexia and treatment, will provide insight into areas of the disorder modern treatment neglects, and potentially offer a slightly different approach on how clinicians could go about effectively treating anorexia long-term.

In the context of this essay, it is important I specify a few things. First, I will be referring to the anorexic as “her” and “she” throughout the paper. It is also necessary that I clarify my stance on “recovery” from anorexia, and whether or not I believe a “full recovery” is possible. As a diagnosed anorexic, I will be honest and admit: I do not think there will be ever a day where not one disordered thought won't cross my mind. I may not be under 100 pounds, or running myself into the ground, but the invisible war between mind and mirror wages on. Some days it will be easier to ignore, but other days it will be tempting to resort to old habits again. In any case, I will never be able to go back to how life was before anorexia. I will not be able to forget that I once looked in the mirror and truly, honestly, believed I was fat, and there will always be a nagging voice in the back of my mind quietly reminding me how many calories are in a serving of chips. Thus, in my personal opinion, “full recovery” from anorexia, if not impossible, is an unrealistic, and potentially damaging goal when reality does not match idealistic recovery. I prefer to use the term “managing” as a more realistic way to describe overcoming an eating disorder, as it will always be lurking among shadows in the recesses of my mind to some degree. However, I do believe that with future research and trials, there is promise for those suffering in successfully managing a life outside of their illness.

The Disorder

Anorexia Nervosa is a psychiatric condition that currently boasts the highest mortality rate—of all psychiatric, or mental, illnesses—yet remains relatively shrouded in mystery to psychologists, clinicians and researchers alike. Contrary to popular belief, eating disorders are not simply a fad diet, trendy lifestyle, or “just for attention;” they are a coping mechanism, and a way to control and escape. Any eating disorder has the potential to be life threatening, but anorexia is deemed exceptionally so. One reason the mortality rate is so high is because people suffering with long-term, or chronic, anorexia often end up committing suicide. Though we have come a long way in recognizing that anorexia is more complex than first thought, and often times, not about food at all.

Eating disorders are a subject that have been misunderstood and stereotyped for ages, and only within more recent years have we really begun to decipher the hidden motives that feed these disorders. Unfortunately, anorexia is not always easy to identify, and notoriously difficult to treat, especially over the long-term, as relapse rates are high. And sadly, more people suffer with anorexia than statistics report, because not everyone who has an eating disorder seeks treatment, therefore not all people with eating disorders can be accounted for. In many cases, people suffering with anorexia will also not seek treatment for reasons such as cost, availability, or simply because it would be an “inconvenience.” It can also sometimes be more harmful than helpful, in certain situations. But more importantly, of those who receive treatment and still ended up relapsing, why was treatment ineffective? Can treatment be improved upon so that it is more beneficial in improving overall quality of life in the long-term to those suffering? Is relapse potentially preventable, or are some things simply the “nature of the disorder?” These are questions that currently have no real answers, but if research were to focus on what lies at the root of anorexia, and shift course of treatment to more directly address those issues, then perhaps effective long-term treatment for anorexia is on the horizon.

According to the National Eating Disorder Awareness website, or NEDA, 20 million women and 10 million men in the United States suffer from a “clinically significant” eating disorder at some point in their life. Though anorexia may not be so obvious, as it thrives off secrecy, the statistics reveal a serious problem. Diagnoses of eating disorders are becoming increasingly common in our physical appearance-obsessed society, especially among youth, due to a variety of both biological and environmental factors. The reasons behind one becoming an anorexic are often misunderstood, and though each disorder is as unique as each individual, there is definitely a common thread shared among disordered individuals. Because anorexia still remains a complex subject, with the help of modern medical technology we have been able to expand upon what limited knowledge we had of the disorder. For example, brain chemistry research of the past two decades has given us a new perspective on both origins, and treatment of anorexia, and shows us there is still much to be learned (Rumney 75). Past research suggests there does not appear to be a sole, overarching cause for development of an eating disorder, but rather, multiple contributing factors that come together to form a deadly “perfect storm.”

In the book Dying to Please: Anorexia, Treatment and Recovery, author Avis Rumney, an eating disorder specialist, therapist, and “recovered” anorexic, offers a thorough understanding of many potential causes and attributes of anorexia, in addition to providing information on different types of therapies and treatment options. She includes a personal touch through offering her perspective on dealing with anorexia, and what she found helpful in managing her symptoms during recovery. The first half of the book is primarily about the disorder itself, such as giving an in-depth explanation to a question so many people do not understand: why a person afflicted with anorexia engages in the disorder, or chooses to starve.

Avis Rumney asserts the idea of “self-annihilation in service of self-preservation” and introduces this concept in the first chapter, defining it with a quote from Rand and Asay Rosenberg, authors of Body, Self and Soul: Sustaining Integration, who define Self as: “a non-verbal sense of well-being, continuity, and identity in the body, plus the verbal structure and cognitive process one learns” (12). Rumney suggests that the Self the anorexic tries so desperately to hide are her real emotions, or her “True Self,” fearing that exposure will mean invasion, usurpation and annihilation. So instead of looking inwards when she seeks comfort and security, she finds solace in her mask of compliance, strict defiance, rigid self-control and endless self-deprivation. Essentially, it is because she lacks the coherent, developed, sense of Self, that was supposed to be constructed during the first several years of emotional and physiological experiences of development, that lies at the root of anorexia.

Causes and Contributing Factors

It should be no surprise that environmental factors have a tremendous impact on later psychology, especially in the early years of childhood, when the brain is going through so much growth and development. But there truly are numerous factors that contribute to someone developing anorexia, such as psychological aspects, family dynamics, spiritual hunger, cultural milieu, and triggering events, to name a few. And according to Simona Giordano, author of Understanding eating disorders: conceptual and ethical issues in the treatment of anorexia and bulimia nervosa, “Gene variations do seem to be associated with the disorder. However, these alone cannot explain why eating disorders occur. In conclusion, despite the importance of genetic/neuro-physiological factors, it cannot be claimed that they are purely ‘determined’ behaviour” (Giordano 265). This is interesting, because it means that although a link between genetics and eating disorders has been observed, genetics is still only one of many contributing factors of anorexia. Avis Rumney believes certain personality traits such as perfectionism, competitiveness, and emotional sensitivity may be precursors for anorexia, especially when coupled with other attributes, like unresolved grief, and immature sexuality.

Rumney additionally talks about how an anorexic encounters issues with loss and grief relating to beginning and ending eating. She fears if she begins to eat, she won’t be able to stop, and once she has begun to eat she is also wracked with guilt and grief because she has let her guard down, succumbing to her desire of food, and her lost sense of control. Initially, an anorexic may feel a surge of control every time she denies her hunger; but there comes a point when fear takes over her rational mind, and she will no longer feel in control, food will ultimately control her. The anorexic then becomes trapped; a prisoner to her mind and thoughts, and as long as she remains prisoner, her fears will control everything.

Control is a key aspect of someone suffering with anorexia. The main way an anorexic exerts power, or control, is over self-discipline through her food choices. With food, she tries to control her intake. She hoards and saves food to control the presence (to her, the very existence) of food. Food becomes much more than a form of sustenance; it is something that she can hang onto that protects her from the void” (Rumney 47). The “void” Rumney is referring to is that sense of Self the anorexic is lacking; she has no solid core of Self, and instead feels excruciating emptiness (47). Food then becomes a tool used to fill the void.

In those suffering with anorexia, it is not uncommon for other psychiatric conditions to coexist alongside the eating disorder. Some of the conditions commonly associated with anorexia include anxiety, depression, and obsessive compulsive disorder, though there are certainly more. Like many others, I frequently fought with depression, but long before I was diagnosed with anorexia. Some anorexics develop depression as a symptomatic side effect of the eating disorder, because they become so wrapped up in the world of to-eat-or-not-to-eat that they neglect normal social behaviours, opting instead for isolation, as food consumes every aspect of their lives. As a result, many of those who suffer with eating disorders often feel estranged, or cut off from the world around them.

Inadequate nutrition also has a direct influence on mood, and energy level, which only serves to fuel an anorexic’s desire to hide away and disappear. The anorexic effectively does so when she “regresses into an immature, safe, less complicated pre-puberty state, single-mindedly pursuing starvation” where responsibilities and conflicts of adult womanhood can be avoided (Rumney 54). Many of the fears fueling anorexia are related to the anorexic lacking a secure attachment to the mother, or caregiver, and sense of Self. In effort to avoid all horrible consequences of failure, the anorexic seeks to reject, humiliate, or deny herself before anyone else has the chance, especially her mother. For the hunger, cold, and exhaustion she experiences are not as painful to her as the terrifying threat of rejection, the specter of failing to meet her mother’s expectations and being denied her mother’s love (38).

Few studies have been done which illustrate the importance of the maternal bond and attachment style, and its connections to manifestation of anorexia, but the few that have been done show intriguing results. One interesting piece of information studies exploring the brain and neuroendocrine systems have found is that anorexics seem to have deficiencies relating to oxytocin functioning. According to Strathearn, a study done by Baskerville and Douglas which focused on maternal neglect and attachment style discovered that two neuroendocrine systems critically involved in maternal caregiving behaviour are the oxytocinergic and dopaminergic systems. Another study, done by Ferguson’s team, found the oxytocinergic system to be important in the formation of social and spatial memories, affiliative behaviour and emotion regulation. And a study conducted by McClure and his colleagues indicates the dopaminergic system is involved in reinforcement stimulus-reward learning, and in decision-making based on future predicted reward (1058). A more recent study illustrates anorexic test subjects to have oxytocin receptor (OXTR) variations from those of healthy subjects, though it is not clear whether this is because of environmental adversity or a consequence of the illness (Kim 1). These results are exceptionally interesting, because previous studies showed oxytocin and dopamine to play a role in symptoms of anorexia, and these subsequent studies further back up those claims that there is a connection between early attachment, neuroendocrine functionality, and eating disorder pathology.

According to Rumney, “by the age of two, the normal child asserts herself and begins to develop a sense of herself as a separate being with limits and boundaries that are fostered and reinforced by her parents” (36). However, the future anorexic refrains from this self-assertion, and continues to conform to her mother’s ideals. In doing so, she avoids establishing her sense of Self, and continues to behave in accordance with her exaggerated view of what she believes her mother expects. Of course, it is not just early interpersonal interactions that shape the adolescent’s sense of Self, including her capacity to handle painful feelings, but the continuous repetition of psychological events in various forms during infancy and their entrenchment in childhood and preadolescence (45).

Nuances in the early interaction between mother and child affect the kind of attachment that the child develops, and if there are disruptions in the attachment process, the child will likely face difficulties later in life. The four types of attachment are categorized as: secure, insecure, disorganized, and ambivalent. Although attachment style is one of the many elements that contribute to anorexia, “insecure attachment can impair a child’s development of Self and can contribute to the Self deficits that are common to anorexia” (45). Rumney says, “the capacity for healthy attachment gets passed down from one generation to the next. When the child who lacks a solid attachment becomes a parent to the next generation, she often unconsciously repeats her own parent’s attachment style,” which means that although attachment style is not necessarily genetic, it exists in families and is passed down like a genetic mutation would (13). In fact, Rumney says “some traits in families are inherited by the anorexic, such as a proclivity towards perfectionism; others, such as attachment styles, have doubtless been passed down through the family culture for generations” (21).

In discussing how attachment plays into core feelings associated with anorexia, Rumney suggests that, a deficit in nurturance is one issue that can contribute to the later development of anorexia, as the infant anorexic-to-be lacks a sturdy foundation from which to develop a sense of her own importance—she does not believe she is inherently all right, thus her development of self-worth is impaired, or in extreme cases, seemingly non-existent (36). This is significant because, as Rumney states, “the infant gradually learns to deny her own needs, physical and emotional,” which is a key aspect of anorexia and the struggle for control (36). The anorexic receives subliminal, or outright, messages from her caregiver that eventually become ingrained in her thoughts at an early age, and ultimately lead to manifestation of the disorder later in life.

An interesting point that further goes along to illustrate importance of attachment in development of anorexia is a study conducted by psychologist and researcher Sylvia Brody. Although it was a rather small sample, Brody’s experiment consisted of following a number of girls from birth to age seven, with follow-up studies at ages eighteen and thirty. Out of the experiment, two 18-year-old subjects reported having been anorexic for a few years. When Brody went back to her observations, she discovered that the mothers of both girls in the study exhibited little capacity to emotionally invest in their infants. Thus, it can be said that “the parent-child relationship, and particularly the mother-child connection from infancy onward has major impact on a child’s development” (Rumney 54).

More research examining maternal attachment style as a significant part in the root of anorexia still needs to be carried out, as that is an area of study that has been somewhat ignored. I think it is especially important to look into it more closely because a lot of feelings associated with insecure attachment style are also associated with anorexia, such as suppression of feelings, loneliness, and emptiness, to name a few. Researchers and notable psychoanalyst Alan Sugarman have attributed the sense of emptiness and loss many anorexics experience to a serious depression, caused by under or over-involvement (Rumney 45). I have had personal experience in struggling with major depression, including suicidal thoughts—as well as anxiety—long before my eating issues had ever come to light.

In retrospect, I can see from the beginning the stars were aligned. Honestly, I am a bit surprised my anorexia became an issue when it did, and not sooner, since the underlying feelings and driving forces have seemingly been a part of my life as long as I can remember. My parents got a divorce when I was five, and my mom was a functional alcoholic for thirteen years following. I moved around almost every year as a kid, either to a new school or a new state, therefore was not able to form close friendships with my peers. I was also an extremely shy, sensitive, and anxious kid, which further kept me from engaging with my classmates and forming normal relationships. After constantly moving around all the time, I eventually stopped trying to even engage at all. From middle school to 9th grade, I was enrolled in an all-girls college prep school, the place where I first felt inklings of an eating disorder. I was in 8th grade when I had my first bitter taste of depression, back before my eating issues became a serious issue. In my opinion, I believe having depression before my anorexia significantly complicated my eating disorder, thus its treatment. When in residential treatment, the biggest problem I had was lacking the simple motivation to eat and recover.

I was involuntarily admitted to Center for Discovery, a residential treatment center in Washington, and taken out of school for 2 months during my senior year. At that time I was going through a tremendous amount of stress, and although I was deep in the throes of my disorder, I was utterly petrified at the prospect of not graduating the year I was supposed to due to my anorexia. I was so upset because I felt like either way I was going to “lose.” On top of leaving my life behind, going to treatment meant gaining weight, which meant undoing the hours of hard work, sweat and tears I spent on losing weight to begin with. I remember feeling like nobody was listening to me, and that the counselors, therapists, and doctors just wanted to make me fat and miserable. I felt like I was not allowed to do anything to try and change how I felt about myself, because the one thing I changed, and was successful at, ended up being bad and now it was going to be taken away when I put the weight back on.

This does not even take into account the depression aspect of treatment, and how persistent suicidal thoughts made it all the more difficult, because when I would feel overwhelmed or frustrated with treatment, my thoughts would immediately resort to death, and how that would be a more than welcome escape from this hell, and be the end of my anorexia. It was hard to eat the food and even consider recovering at the treatment center, because I had hardly any interest in life in general, especially one where I’d be “fat.” The only reason I completed the program was because I really had no other options, and I knew it would be my only chance at getting out of there fast.

According to the treatment center I went to, the average stay in residential varies, but can last anywhere from one month—if insurance decides to stop paying, which unfortunately, happens quite often—to 2 months, or in some cases, even longer. Most anorexics, however, who are severely underweight need a minimum of 8 weeks, and typically more, to successfully restore weight. The residential treatment center is a lot like an upscale prison where copious amounts of food are piled on your plate six times daily. Many patients admitted to treatment end up doing okay for the duration they are in treatment, just to get out quicker so they can get back to disordered behaviour again.

This is a big part of why I believe treatment is ineffective. The treatment environment to an anorexic is suffocating, and often times downright humiliating, and little focus is given to addressing underlying reasons for anorexia, because most of their focus is on weight normalization and medical stabilization. This is also why I believe relapse and mortality rates are high, because treatment does not focus on cultivating an overall improved quality of life and sense of well-being in the long-term.

When someone has an issue like depression, or anorexia, death can seem like the only true escape from an existence dominated by control, food and numbers. Since anorexia treatment is not profoundly effective, many of those who don’t perish due to a physical health related consequence often end up losing hope and retreat to an early grave through suicide. This is a difficult issue to address, because when someone is involuntarily hospitalized and they have no say in the matter, the rest of her already limited motivation for living might as well be thrown out the window, too. People suffering with anorexia are generally so distraught by the idea of gaining weight and changing their eating habits that they may view death as an easier, less painful, and permanent “fix” for their problems, than putting on the weight and changing. This is significant, because if a patient is unwilling to want to get better, putting them in treatment is a self-defeating purpose. They may do better temporarily, but at what costs?

Residential treatment centers can charge upwards of a thousand dollars a day for care, which adds up quickly for someone who needs to be in a center for an extended period of time. And that’s not even taking into account the emotional tolls of treatment, such as creating additional anxiety and chaos in someone who already deals with enough internal chaos and anxiety on a daily basis. Most importantly, if anorexia treatment is designed to be a short term symptom fix, that does not actually address the roots of the issue, a short term fix is all it will ever be. This is why it is important that we go about treating disorders, such as anorexia, in an effective way with few set-backs and long-term health and happiness of the patient as the main goal in mind. If treatment were to take this approach, and focus on developing the anorexic’s sense of Self, then perhaps we would see the mortality rate decline somewhat, and relapse rates lessen.

Because eating disorders are a complicated matter of life or death, one cannot truly “live” with an eating disorder, as the eating disorder itself serves a purpose: to destroy. Concerning matters of eating disorders, life, and death, or rather—recovery and suicide—Giordano’s book discusses, in great length, how eating disorders are viewed as autonomous, or conscious, choices made by someone suffering in attempt to cope, and by interfering with a person's conscious choice it infringes upon her rights to make decisions regarding her health, since she is more than capable of making decisions in other areas of her everyday life. Giordano raises the controversial question of whether or not it is ethical to provide treatment for eating disorders, since a person is autonomously engaged in disordered behaviours for a perceived “good enough reason” that she is unwilling or resistant to change. Her final thoughts on the subject are “if we really want to understand eating disorders, and to understand what it is right to do with eating-disordered people, we do not need to focus on how people eat, but rather to look at what they believe, and more generally at what we all believe—at our morality” (Giordano 263).

Treating the Disorder

In general, when going about treatment of anorexia, severity of the illness must be taken into account. While all eating disorders are equally serious and potentially life threatening, more intensive treatment options, such as hospital inpatient or residential treatment, are more suited to extremely severe cases, where that amount of intensive care is appropriate, and sometimes even necessary. Of course, that is from a medical stability standpoint. From a mental and emotional well-being standpoint, treatment can be a tricky task. With many of the longer-term treatment options, that people with more severe illnesses generally go through, treatment can sometimes do more bad than good. It can be incredibly inconvenient if someone has to be taken out of school or a job due to their anorexia, which then causes further setbacks, and can make the disorder even stronger, since one of its main sources of fuel is loss of control, which happens when an anorexic has to go to treatment. Control is forfeited to the facility caregivers, and the anorexic’s priority is to rebel against recovering at all costs, until she is forced to realize her illusion of control is all it ever was, just an illusion.

As mentioned previously, Avis Rumney is a strong advocate of the concept of one’s Self and seems to firmly assert that maternal bonds formed during childhood have a lasting and important effect on a long-term general sense of well-being experienced in adolescence and adulthood. Based upon research, and personal anecdotal evidence, I think effective long-term treatment of anorexia is within reach if further studies on the importance of a secure mother-child attachment, as well as revising treatment to address the root of anorexia, which appears to lie within cultivating a coherent, secure, sense of Self in an anorexic who lacked that initial stability, due to early childhood experiences and attachment style passed down from the parents.

In conclusion, further addressing the effects an insecure attachment style has on development of anorexia would be an interesting area of focus in potential successful long-term treatment of anorexia, and eating disorders in general, since it would essentially mean successful treatment of the disorder can hopefully be achieved if treatment focuses on adjusting, or balancing, the anorexic’s weaknesses within her Self. Developing a sense of Self, as Rumney puts it, would give an anorexic the ability to live a secure, rich, and fulfilling life, without being anchored down by the disorder. In developing the anorexics Self, and creating the sense of security initially absent in the anorexics life and relationships, not only with people, but food as well, there is hope for an improved overall quality of life. By addressing what lies at the roots feeding symptoms of the disorder, anorexia can be managed long-term. This would be especially true if treatment takes a patient’s best interest into account, and is ultimately helpful, rather than harmful. If we approach treatment with a focus on rebuilding the anorexic’s shaky foundation of Self, we may find an effective strategy to treat anorexia without further setbacks or hang ups, which will hopefully result in lower relapse and mortality rates. Until treatment of anorexia is revised to accurately reflect what those suffering are truly starved of, the number of lives lost and consumed by the disorder continues to grow.

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