Anorexia: Falling From a State of Grace
by Ken Rude

At some point a diet becomes an obsession, starvation, a terror of becoming fat. She may have started at a normal, healthy weight, and as she becomes thin, then Hollywood-thin, people tell her how good she looks. Many of her admirers wish they could become that slim. But the mirror lies to her. Staring back at her is a butterball.

Now she no longer gets compliments on her looks, because she's become gaunt, sick-looking. Her hair starts to fall out. She no longer has her period. Cuts and sores take a long time to heal. She's emaciated, exhausted, and looks abused. Friends and family are worried something's wrong and she needs help. She does need help, desperately. But anorexics are the last persons to seek help. And the fat slob still stares back from the mirror.

Anorexia can be such an unexpected disorder. So often the sufferer has come from a comfortable home and has a history of triumphs. Although there are plenty of exceptions, anorexics often are high achievers — academically gifted, or successful in sports, or cheerleaders, or young models. They seem to be riding along on just the right track.

Then a bizarre disorder pops up. Gradually it becomes clear that something much darker has been hidden behind that fortress of achievements.

In all families there's conflict. One parent doesn't like the other's friends. Someone drinks too much, or doesn't want sex often enough. Children learn defiance from television or school friends and begin to rebel against parental limits. Arguments become common. Even healthy families encounter strife. Much worse happens in other families, we know: we're bombarded daily with stories of broken, dysfunctional families, domestic tragedies and twisted young lives.

Some children of a certain temperament decide at a young age that it is her (or his) responsibility to "fix" the thing that is broken in the family. She will be so good that everyone will become happy, and the conflict will end. She becomes sensitive to everybody's moods; she grows up very nice. She pushes herself to excel in school and sports.

Everybody marvels at her, but she's bearing a hidden burden. Her mission is to fix what's gone wrong elsewhere in the family, but she can't. The actions of others never were her responsibility, although she doesn't understand that. Things don't get better, and she feels it's all her fault. She tried and failed. She wasn't good enough — she's no good at all. In fact, she's a horrible freak. She becomes consumed with guilt, failure and self-loathing. She doesn't deserve praise. She doesn't deserve any sort of pleasure. She doesn't even deserve food. She stops eating.

The above scenario is a common story among anorexics. There are, of course, many variants, and some who don't fit this picture. But it does illustrate the widely-shared anorexic trait of self-punishment. We frequently believe that anorexics are starving themselves towards an impossible ideal of physical beauty. In reality, they commonly seek not an ideal, but a voluntary hell.

I have so far referred to anorexics as female. Most are, but about 10 percent are male, and this number may be growing. The frequency of eating disorders — anorexia and bulimia — seems to be on the rise in the industrialized world. (They are rare in cultures where hunger and starvation are a realistic possibility.) They most often occur during the teenage years, and up to 3 percent of adolescents — one out of every 35 — are affected. Other mental disorders often accompany anorexia, most commonly depression and obsessive-compulsive disorder. Often, sexual abuse or another traumatic event may precede the onset of anorexia. The mortality rate is among the highest for any mental disorder. Various authorities put the death rate — from starvation, heart failure, suicide or other causes — at between 5 and 15 percent.

Anorexia is the restriction of food and/or excessive exercise intended to burn the body away. A related eating disorder is bulimia, characterized by self-induced vomiting or laxative abuse. Bulimics are also attempting to deprive themselves of the rewards of food. Their excessive purging subjects them to their own unique symptom cluster, which may include corroded teeth and esophageal damage from too much exposure to stomach acids in their vomit. Bulimics are also at high risk of sudden heart failure due to electrolyte imbalances. Their medical risks may be greater than those of anorexics, who merely starve themselves.

Our media culture, which touts impossible thinness as a female ideal, may be a big reason anorexia is on the increase. Young persons at risk for anorexia who strive to be perfect in every way are likely to try to become perfectly fat-free, too. There are a few signs that some image-makers are beginning to understand it's irresponsible to encourage abuse. A few fashion venues, for instance, are banning too-thin models from their runways. Those who hope for a saner society can only hope this is the start of a much larger trend.

Anorexia can be treated, but there is no universally-effective cure, and the recovery time can be several years. Long-term studies show a 50 to 70 percent recovery rate. Anorexics, like alcoholics, can never consider themselves fully cured. There is a high risk of relapse even after the sufferer has gained some weight and appears to have stabilized.

A multi-disciplinary approach is usually needed to treat anorexia. The original disturbance is in the mind, but the mind may be resistant to treatment when the body is severely undernourished. The most acutely starved sufferers need to be hospitalized in order to gain weight and be treated for other symptoms. Most will need two or more — sometimes many more — hospitalizations before they stabilize. Re-feeding usually happens slowly — starved bodies cannot handle sudden increases in feeding. It can take two weeks or longer for an anorexic to tolerate enough calories to begin gaining weight. On top of this, most anorexics will resist efforts to get them to eat. For them, weight gain can be a crisis.

A hospital stay of 10 to 12 weeks may be considered appropriate in most cases to stabilize health and instill the needed behavioral changes. Compare this to the 15 to 30 day hospitalizations permitted by most insurance companies in America, and it becomes clearer why treatment for eating disorders is a revolving door of hospital readmissions, and why many families report spending tens of thousands of dollars on outpatient care for anorexics. (New York families affected by eating disorders can now celebrate a rare piece of good news. In his last few days in office, former Governor George Pataki signed Timothy's Law, which mandates that health insurers in New York pay for mental health on a parity with what they cover for physical health concerns. It may be too soon to know how much this will benefit mental health in our state, but for now cautious optimism may be justified.)

The sufferer will likely spend up to several years in outpatient therapy. Treatments range from classic talk therapy to more behavioral approaches; there's no consensus on which approach is best. All may have something to offer the individual who may have a history of trauma, exhibits disordered thinking, and engages in self-destructive behaviors. The need is substantial enough that a number of practitioners in the Hudson Valley specialize in the treatment of eating disorders.

The anorexic in recovery will benefit from working with a nutritionist to devise and stick with an eating program. He or she will track daily food intake and supervise weight gain or loss, and may be the first one to spot a relapse. Families are also deeply affected by the individual's eating disorder. Members can be desperate to understand what's going on with the loved one whose life has taken such a frightening turn. The natural impulse is to demand that she just start eating, or to manipulate her into good behavior. These approaches aren't likely to be successful with someone whose thinking is disordered. Family therapy thus plays an important role in helping family members adjust to the illness, and in educating members about how they can effectively assist with the sufferer's recovery.

We are a have-it-all society that seems to be becoming a winner-take-all society. We're taught from the earliest years, in ways gentle and sometimes not so gentle, to fight our way to the top. If you make it, the rewards are huge. Money, fame, worship…perfection. We know they're perfect because their lives are so visible. Athletes, movie stars, rock stars, supermodels, politicians, religious leaders. Our society feeds on a steady diet of airbrushed glamour and polished virtue. Can we or our children hope to be like them?

But so many of them fall from grace. In the end, perfection is a gigantic illusion, the Santa Claus of our vanity. Yet we raise generations of young strivers, and we don't always do a good enough job of getting them to see beyond the illusions.

We want that world of perfection, where everything is possible. Where you can have it all and be impossibly thin and virtuous. We might do better instead to acknowledge and learn to live with our flaws. We're not whole without them. But that's not our society. We are the strong, and we project images of strength. And we hope that those hidden flaws won't someday precipitate our own fall from grace.