Anorexia nervosa – persistent and prolonged refusal to eat – is one of the most insidious and at the same time mysterious mental disorders. If I was asked for a metaphor for the illness, I would suggest the dragon from Evgeny Shvartz’s play of the same name. The townspeople would bring the dragon virgins as a sacrifice and he’d eat them. The victims of anorexia are also young girls as a rule, but unlike the virgins in the play, they take an active role in becoming victims and, in a sense, they eat themselves.
Anorexia begins like this. One day, which we can hardly call fine, a girl decides she needs to lose weight, that she has fat deposits on her waist or thighs and she has to get rid of them. Whether this decision has any basis in reality or not doesn’t matter. The dragon of anorexia is not choosy in this respect and has no principles. Skinny girls fall victim to him as readily as tubby ones, the only difference being that the former quickly shed weight to a catastrophically low level and the latter take longer to reach that point.
Once she has resolved to lose weight, an anorexic is decisive and single-minded. She sets herself a very rigorous diet, with no regard to nutritional requirements, and takes it to the point of starvation. Since a natural biological need for food still exists, and since family, and then doctors, put a lot of pressure on the girl and constantly urge her to take food, she will yield from time to time and eat a little more than usual. It quite often happens that immediately after eating she will make herself vomit. By the way, the stronger the pressure from the family, the more stubborn will be the girl’s resistance to attempts to get her to eat normally. Some victims also wear themselves out with intensive physical exercise. If the girl cannot be dissuaded from starving herself, and emergency measures, such as artificial feeding, are not taken in time, weight loss can reach a critical level, leading to irreversible change in the metabolism and death from emaciation.
There are many theories about the causes of anorexia, some of them are reasonably well grounded, but there is not a single one that is complete and exhaustive. According to a psychodynamic approach, refusal to eat in adolescence often reflects an unconscious protest against insufficient parental attention, especially from the mother, against the fact that the attention given the child was confined to satisfying its purely physical needs. From this type of mother’s perspective, the child should be warmly clothed and properly fed, but all the rest is of less importance. She has no interest in the child’s spiritual needs and inner world, and so there is no emotional contact. When a mother’s interest is limited to ensuring her daughter is fed (often in these cases too well fed) then we should not be surprised if in the end the daughter develops a revulsion against food, masking a revulsion against the mother. This mechanism can play a role in anorexia, but it is far from being present in every case and is not the basic cause.
As part of the psychodynamic approach, there have been studies of anorexics’ perception of reality and, first and foremost, their perception of their own bodies. In a number of cases, results have shown, girls somewhat overestimate their body weight and the thickness of the fat layers. As a result they develop a negative image of their own bodies. Their assessment of the volume and weight of other objects is not affected. Some researchers suggest that because of the distorted perception of their bodies, girls underestimate the amount of weight they have lost while dieting.
However, some recent in-depth studies have shown that overestimating body weight is far from universal amongst anorexics. Some have a fairly accurate idea, some even underestimate their weight. But even in those cases where there is an obvious tendency to overestimate, it is usually quite modest and cannot by itself explain markedly anorexic behaviour. For example, if a girl overestimates the size of her waist or hips by a couple of centimetres it cannot be the reason for the following kind of scene: a girl, so thin practically all her bones are showing, stands looking at herself critically in the mirror and states flatly: “No, still too fat”. A distortion of perception bordering on hallucination is probably the only explanation for such a phenomenon. You get the impression that a girl must have a very strong need in order to see herself in such a distorted way, or that some powerful emotional factors are at work which are, almost literally, clouding her vision.
Actually, in many studies anorexia is linked with emotional disorders. The main candidate for an explanation of anorexic behaviour is depression. There are a number of indicators of this illness in anorexia: lowered mood, broken sleep, hostility directed at the self, lowering of libido, alexithymia. Signs of depression quite often precede anorexia.
But along with the similarities, there are also serious differences. First of all, appetite is lowered in depression, but is preserved in anorexia. Goal-oriented active behaviour, especially connected to losing weight (physical exercise, elaborate stratagems to avoid eating), is preserved, unlike in depression. Academic achievement often remains high, whereas it falls in depression. Finally, in many cases of anorexia use of antidepressant medications does not bring an improvement, but a worsening of the condition.
So, anorexia cannot be explained by depression, despite a number of common characteristics. Naturally, the hypothesis has been advanced that both anorexia and depression may have a common basis in some more general mechanism, which manifests itself in rather different ways in these disorders. It has been claimed that “learned helplessness”, a concept familiar to us from an earlier chapter, is this common mechanism.
Indeed, recent research has indicated that children who later develop anorexia do show signs of helplessness in childhood and experience the conditions for its development. They often perceive family relationships as over-complicated and as not fulfilling their need for emotional contact. The adults who care for them are often over-protective, while at the same time lacking the capacity to solve real problems of life – a combination quite sufficient for a child to develop a feeling of helplessness. These children often have a negative assessment of their circumstances. Despite a good level of natural ability, they are often unsuccessful in solving problems which are important for them and so acquire experience of failure. This is very characteristic of anorexics. They need praise a lot, but at the same time often feel rejected by those same people whose positive attitude they need so much. They have low self-esteem and do not feel able to cope with difficulties.
There can be no doubt that the experience of failure and helplessness in solving important personal problems is characteristic of anorexics. But what is the connection between this feeling of helplessness and refusing to eat? In their fight against ‘excess weight’ these girls are far from helpless. Quite the reverse, they are positively heroic in the way they resist both their own appetites and the efforts of everyone around them to get them to eat. And so anorexia may be considered as a reaction of protest against the sense of helplessness, a reaction which has a defensive character. The supporters of this idea suggest that the cause of the helplessness is a loss of control over their lives. The less a person is able to control a situation, the more helpless he feels and the more pronounced his need to gain control over one sphere of activity at least. According to one of the leading proponents of explaining anorexia through the concept of helplessness, control over eating and weight becomes the sphere of activity called on to compensate for helplessness in the face of the rest of life. Refusing to take food becomes the first successful attempt to control something in the life of a young person who has not been able to take serious decisions about her life, to build the normal relationships with friends of both sexes which are so important. And so a resumption of normal eating under pressure from family, doctors or even her own appetite evokes the horrific prospect of losing control in this last sphere under her personal ownership, and this is why it is so difficult to get the patient to eat. Under this model, a weakening of control in any sphere of activity will lead to a more pronounced dissatisfaction of the patient with herself as a whole and her body in particular, compelling her to an even more steadfast refusal to eat.
Even this interesting theory has a number of internal contradictions, however. First of all, lack of control over a situation is far from being a decisive factor in helplessness, and full control will not necessarily eliminate it. As I noted in earlier chapters, if control is achieved without effort, or if after achieving full control further effort, search behaviour, isn’t needed, then control is no protection from the development of helplessness as a manifestation of renunciation of search and may even hasten its onset. The genuine opposite of helplessness is search behaviour. As long as it is a continuing process, search behaviour, even if not wholly successful, even if it doesn’t provide complete control, will prevent the development of “learned helplessness”. Consequently, the drive to win control (search activity) is more important than the fact of control itself.
On the other hand, it is very doubtful whether it is even possible to speak of real control over eating behaviour with regard to anorexics. Real control supposes feedback between behaviour and its result. Behaviour must be flexible, that is what real control means. Yet behaviour in anorexia is extremely rigid and does not depend on real results achieved – losing weight. There are many more grounds for believing that the entire behaviour of these girls is controlled by anorexia than for believing that they control their eating behaviour. What is more, there are reasons for supposing that they don’t even try to make achieving control over their food intake any easier. Today there are many aids to lowering appetite without exercising massive will power, but the girls do not usually make use of them. You have the impression that they take pleasure in overcoming the obstacles in the way of refusing food.
I believe that this the key to the illness. The main motive spurring them on to refuse food is an active struggle with obstacles, with the challenge from the girls’ own appetite and all the people trying to make them eat normally. The struggle generates search activity and, as usual, the process here is more important than the result. Helplessness is renunciation of search, capitulation, and capitulation in the face of the challenge which life makes in all the spheres of life important to them, gives special significance to this sphere in which they do not capitulate and remain active. Anorexia is a process of struggle on an everyday basis, of surmounting obstacles, an idiosyncratic form of search behaviour, and this is what is of value to anorexics. This prolonged, desperate struggle enables the restoration of self-esteem, lowered by previous capitulations. The fear of returning to normal eating patterns is not a fear of losing control, it is a fear of losing the challenge which makes life complete. Every morsel of food that remains uneaten is a victory, and the fiercer the fight to win that victory, the more valuable it is.
One recent experiment supports my conclusion. Researchers studied the action of real and imagined control over a situation on anorexics’ perception of the image of their own bodies. The subjects were set intellectual tasks of varying degrees of difficulty. Success in solving the tasks depended solely on their objective difficulty. At the same time, subjects were inclined to exaggerate their body weight when they were working on an objectively easy task which the experimenter had told them was difficult when setting it. When an objectively easy task is passed off as a hard one, a subject should experience a feeling of high control over the situation while working on it and great satisfaction with his success, since he coped easily with a ‘difficult’ task. (Remember, success in solving a task depended only on its actual, objective difficulty, not on how the experimenter described it.) However, this feeling of full control over a situation was accompanied by a worsening of the ‘body image’, which is the condition for the strengthening of anorexic behaviour. The girls exaggerated their body weight because, as my concept suggests, the challenge from this situation was less than expected and required less effort for success. At the same time, if the experimenter presented a difficult task objectively as difficult, the ‘body image’ did not get worse and, consequently, anorexic behaviour did not increase, since the real challenge matched expectation and required a mobilisation of effort.
Another kind of eating disorder, bulimia nervosa, is characterised by sudden fits of appetite, ‘ravenous’ hunger and consequent regular over-eating. Pleasure from eating, the ecstasy of feeling replete, temporarily compensates a chronic feeling of dissatisfaction with the self and with life. But after an eating binge, bulimics frequently experience excruciating displeasure with themselves, with their lack of restraint and induce vomiting.
Anorexia and bulimia are usually lumped together as eating disorders, but in reality they are quite opposite in the source of the symptoms. Anorexia, as I have stressed, is a regular victory over hunger pangs, an overcoming of appetite. With bulimia every episode of unrestrained gluttony is a defeat, a capitulation, and is perceived by the bulimic as a sign of a lack of will. As we have shown, renunciation of search is characteristic for this group, while anorexics display the same search activity as healthy people.
There is a practical conclusion from all this. For the treatment and prevention of anorexia we need to look for those activities and zones of interest in the patient’s life where search activity is still possible. These can become a genuine alternative to those completely inadequate and self-destructive tendencies which patients will turn to in order to continue starving themselves. Like schizophrenia’s positive symptoms, anorexia is incorrectly oriented search. In a person’s life there are many roads he has failed to notice. They are sufficiently difficult to represent a challenge and stimulate search behaviour, while at the same time not so difficult as to prolong the experience of capitulation (especially if there is psychological support). If we can help a person set out along one of these roads, the need for anorexia will disappear.