Anorexia is a disease of the mind, a disorder of perception, a form of mental illness. It has devastating consequences on the body. Treatment of the body may save lives in the acute phase of the illness but it will recur if the thought disorder is not treated with equal clinical significance. The most important prognostic factors in recovering from anorexia, or in recovery from any form of eating disorder and in relapse prevention, are psychological insight and a real wish to recover.
The likelihood of recovery is much improved in eating disorder treatment when the underlying depression is relieved by learning new coping skills rather than by drug treatment. Healthy attitudes towards normal body weight and shape, as diagnosed on medical charts and assessed on tests for basic metabolic rate (bmr) are seen as recovery develops and mental health is restored.
Feeling good about one’s self at a normal healthy weight is the ultimate goal of recovery. Towards this end, support is most effective from eating disorder groups such as Overeaters Anonymous (which also cares for sufferers from anorexia or bulimia) rather than from psychiatric help. The sufferers see themselves reflected in the mirror of the other group members: they learn from them and are encouraged by them.
In anorexia there is an absolute conviction that the body is obese – even grotesquely so – even when it is seen by doctors and other people as being normal or even underweight.
The truthful answer to the question, ‘Can’t you see how dangerously thin you are?’ is ‘No – I can’t’. Persuasion comes up against the firm resistance ‘I’m dangerously fat’ – because that is what is truly believed.
The psychological challenge is therefore in helping the sufferers from anorexia and bulimia and compulsive overeating to see their perception deficit. Cognitive approaches – rational and sensible though they may be – are ineffective. The patient is not rational and sensible. That part of the mind is dysfunctional as far as the eating disorder patient is concerned.
Therefore the effective approach towards recovery from the weight loss or weight gain or vomiting and purging in Anorexia nervosa, Bulimia nervosa and binge-eating disorder, as with any other compulsive disorder, has to be emotional rather than intellectual.
An anorexic patient feels fat and feels compelled to take off all weight that is believed to be excessive. To this end, starving and purging are seen as dire necessities rather than as being potentially catastrophic.
Someone who is skeletally thin is envied rather than pitied. Nourishing food is seen as an enemy rather than as a friend.
For parents or nurses to cut food up small, and stand over the sufferer while it is eaten, is totally counter-productive. Any body weight that is gained will be quickly lost again when the supervision is withdrawn.
Laxatives are used by sufferers in order to achieve a sense of inner emptiness. Excessive exercise – even clenching and unclenching the buttocks while sitting in a chair or lying in a hospital bed – is seen as a vital necessity in order to burn off the hated calories and shrink the despised body.
Forced vomiting tends to be referred to as ‘bulimia’ but many people – teenagers especially – do that in times of stress and when trying to achieve perceived social norms in terms of body weight and shape. Sufferers from anorexia may binge excessively and then starve dramatically. This illustrates that there is only one generic eating disorder. It can take various forms – anorexia, bulimia, compulsive overeating – at different times. But the underlying psychological condition remains the same: food – or its absence – is used in some way to change the mood.
Therefore eating disorders are essentially mood disorders and that is where treatment has to be focused. This does not imply that the sufferer has been abused or abandoned in childhood or that external circumstances are the cause of internal distress. It simply means that there is a disordered mood, possibly caused by genetically inherited defects in the limbic systems in the mood centres of the brain.
These are not in the cerebral cortices – the thinking part of the brain. The perceptual deficit is not caused by lack of intelligence. Sufferers from anorexia are often highly intelligent and often know a very great deal about nutrition, vitamins and trace elements and calorie counts. They will often volunteer to help in the kitchen and may express a desire to become professional dieticians. They may choose to wear chunky clothes, not so much in order to disguise their thin-ness as to confirm to themselves – and others – that they need a larger size than they actually do.
Effective treatment – other than life-saving restoration of body mass – can be mediated only by those who have suffered similar compulsions. They now work The Twelve Step programme – first formulated by Alcoholics Anonymous but subsequently adapted by Overeaters Anonymous – that welcomes sufferers from any form of eating disorder. Professional counselling from someone with a similar background, and with personal adherence to the Twelve Step programme, will often be helpful and may save years of avoidable suffering and diminish fearful risks.