By Natalie
In all of the Eating Disorders, the common theme is the (mis)use of food and eating behaviours as a way of coping with emotional stress. This misuse takes on different forms in the different disorders:
In Anorexia Nervosa, the sufferer shows a desperate fear of weight gain and a desire to be abnormally thin, and severely restricts her diet in an attempt to achieve this. Some sufferers also use excessive exercise and sometimes self-induced vomiting as a means of weight control. This behaviour leads to a wide variety of harmful physical and psychological consequences and can be life-threatening; in fact anorexia nervosa has the highest mortality rate of any psychological illness.
In Bulimia Nervosa, which may exist on its own or be combined with anorexia nervosa, the sufferer has bursts of massive overeating (bingeing) followed by `purging' behaviours aimed at limiting the weight gained (self-induced vomiting is the most common mechanism). Risks are similar to those of anorexia nervosa, with additional risks from frequent vomiting.
Compulsive Overeating shows similar overeating behaviour to bulimia nervosa, but without the purging episodes. Risks are generally those associated with obesity.
In all these disorders, the sufferer's quality of life suffers a major impact. Above all, the common theme to all eating disorders is emotional stress; the food itself is not the issue, but becomes a metaphor for the real, underlying problem.
There is a widespread, and totally wrong, public belief that the Eating Disorders, and especially anorexia nervosa, are a matter of immaturity and vanity, of wanting to conform to some cultural ideal of unnatural thinness. This is not so: although our society's idealised images may help to reinforce disordered behaviour to some extent, anorexia is really nothing to do with vanity or cosmetic dieting. Someone once described anorexia as `screaming with your mouth closed', which is a rather apt description: for some of us, unable to vocalise or express our pains and anxieties in a more constructive manner, eating-disordered behaviour becomes a surrogate mode of expression.
Above all, disordered eating is a coping mechanism: Just as some people may turn to self-injury, drugs, alcohol and the like when faced with intolerable pressures, for some of us our way of coping is by either starving, or bingeing and purging.
It is also a myth that anorexia nervosa strikes only teenage girls: It occurs in both sexes and across all ages. In some patients, the disease becomes chronic and ingrained, persisting for decades, and such people are often considered incurable by the medical profession.
There is a lot of talk of the `typical anorexic personality', and there does seem to be a lot of truth in this. Anorectics are typically over-sensitive, perfectionistic, rigid `black and white thinkers', and usually above average intelligence. People with these traits seem to be particularly prone to the development of anorexia when subjected to an emotional `trigger'.
Typical triggers are traumatic experiences of various sorts. These may range from being a victim of child abuse to the loss of a job or a loved person. Adolescents are often affected since that time is particularly full of emotional upheaval and life changes. Almost any form of emotional upset could form a trigger.
There is also a lot of new scientific evidence emerging that anorectics have a genetic predisposition to being `hyper-aroused' or excessively prone to stress and anxiety, and that by starving ourselves we are actually affecting our brain chemistry to numb out these anxious states.
In many cases, control may also be a major issue: people who have had their sense of control violated, for example by abuse, may come to feel that their eating and weight are the only features in their life over which they have control, and that control becomes a substitute for control over other aspects of their lives.
An enormous range of different treatments have been tried over the years, and all too often they have actually made matters worse. In this section, the comments and opinions about treatment methods are the author's, based on personal experience over the course of three decades.
There are, broadly, three categories of problems which treatment might need to address: the first is medical -- direct physical effects of starvation. The second is psychological -- addressing the emotional pains and problems that underlie the eating-disordered behaviour. The final (and most contentious) element is weight restoration -- re-feeding the underweight patient to return her to a more `normal' weight.
Medical treatment is necessary for patients whose starvation has already reached a level where physical problems are occurring. A full discussion of the different physical effects of eating disorders is outside the scope of this article, but much good information can be found via the Links page. Also, my life story, "Starved of Life", describes first-hand many of the consequences of severe starvation.
Medical treatment alone can only ever be a "patch-up" approach to preserve the life and health of the patient, and psychological treatment to address the eating disorder itself is indispensable if any real progress is to be made. Nonetheless, when a patient is admitted to hospital in a critical condition, medical treatment must necessarily take priority over anything else.
Some approaches to treatment concentrate dominantly (or only) upon weight restoration. These approaches, whose advocates usually cite obsolete or irrelevant studies to justify their methods, are based upon a notion that the disordered thinking of eating disorders is primarily an effect of malnutrition. This approach is clearly in flat contradiction to our modern understanding of the causes of eating disorders, but sadly there are still those who follow this approach. Many anorectics, myself included, have suffered enforced weight gain programs without adequate psychotherapeutic backup, and the results are always negative -- many an anorectic has "eaten her way out of hospital" only to relapse with a vengeance upon release.
Approaches that recognise that eating disorders are not really about food, and address the underlying emotional issues, are more likely to be successful, and are thankfully commoner today than they were, say, twenty years ago. A wide variety of psychological approaches can be applied, and to be effective a treatment program must tailor the approach to the patient, rather than trying to force the patient into a mould to fit a psychiatrist's "pet theories". Psychotherapeutic methods are discussed in more detail in the next section.
Many treatment methods, in my opinion, place undue emphasis on weight restoration. Certainly, it can be argued that an ideal outcome of anorexia treatment should be a patient who is well-adjusted and happy with a normal-sized body -- but the world is often very far from ideal. Surely it is more important to give the patient emotional peace while maintaining life and health. Weight restoration should not be forced upon the patient until she is ready for it: the emphasis should be on preserving life and enabling the patient to make progress psychologically; only then will weight gain be useful or productive. Applying compulsion or coercion to patients with control issues, some of whom may be abuse victims, cannot be useful or acceptable in a humane society.
To counter this argument, some treatment `professionals' would argue that anorectics in an acute state of malnutrition or at very low weight are not in sound mind (this argument is also used to support detention and compulsory treatment of anorectics under Section 3 of the Mental Health Act, something with which I disagree strongly). While it may be true that some anorectics may be in denial about their condition or its potential risks, this is far from universally true. For myself, I know very well what the risks are, I am certainly aware when I am in a poor state of health and extremely low weight, but I am practicing the one coping mechanism that is effective at bringing me peace of mind. To be told that I am "insane" and do not know my own mind is patronising, insulting and very destructive. If I had an effective way of achieving emotional peace without starving myself I would be able to accept weight gain; to enforce weight gain on a patient who cannot cope with it and becomes suicidal as a result, is totally unethical. This viewpoint is not in any way unique to me; I know many other anorectics, most of them veterans of many years of treatment like myself, who feel exactly the same way.
So, to summarise:
This section is not intended to be an exhaustive list of psychological approaches to anorexia, but lists some of the more popular techniques, along with my experiences of being on the receiving end of them.
Drug Treatment is often helpful in conjunction with "talking therapies", but should not be seen as a replacement for them. Treatment is usually with antidepressants and/or anxiolytics, to help control the depressive and anxious states associated with eating-disordered behaviour. Additionally, the drug fluoxetine (Prozac) has been found to be fairly effective at reducing the "urge to binge" in bulimia.
Other drug treatments have been tried, especially in the past, including appetite-stimulating medications and neuroleptics (major tranquillisers, to sedate the patient and enable forcible feeding). In my opinion these treatments are unsafe and unethical; some patients have died as a result of such interventions.
Supportive psychotherapy/counselling is a useful adjunct to other forms of treatment, but is seldom a solution in itself. It can help to provide emotional support for patients having to cope with weight gain and with "letting go" of the eating disorder in favour of less destructive coping mechanisms. It can also help in the development of such coping mechanisms, by giving patients the psychological tools necessary to cope more effectively with their problems.
Cognitive Behavioural Therapy can offer useful insights into the true underpinnings of the eating disorder, and by giving the patient the ability to analyse objectively why she does what she does, can be effective at bringing about behavioural change. Studies have shown that CBT is more beneficial in bulimia than in anorexia, though I would consider it a worthwhile approach for all eating disorders.
Behaviour Modification is a treatment strategy aimed at conditioning the patient against repeating the "disordered" behaviours, and is often used in conjunction with force-feeding. Typically, a newly-admitted patient might be confined to bed and denied all "privileges" such as visitors, phone calls, etc. She then has to "earn" these "privileges", which are made conditional upon weight gain and/or behaviour changes. I cannot emphasise enough how barbaric and harmful these methods are -- lives have been destroyed by their use, and any therapist or hospital practicing such techniques should be rigorously avoided.
A variety of other therapies may be used to help give the patient a more constructive way of expressing her emotions than by damaging her own body, and again many patients have found these helpful. In some ways eating disorders have much in common with self-injury (and indeed, many anorectics also cut themselves or self-injure in other ways), and therapies helpful for the latter are often beneficial in eating disorders too.
Although not strictly psychotherapeutic, nutritional education may be valuable too: teaching a patient about her body's nutritional needs, and about what can happen if those needs are not met, is helpful in some patients. Others, however, may be quite aware of the damage they are doing to themselves and either be indifferent to it, or actively seek that damage -- a form of self-injury.
Above all, it must be remembered that every patient is an individual, and that there is no "one size fits all" treatment. The treatment program must adapt to the patient's circumstances and needs; any program that tries instead to force the patient into a mould is doomed to failure.