I told my mom I was going on a diet when I was ten. Not that I was fat, but I wasn't slender, quite. "You could be so skinny," my mom told me.
I once forgot to eat for almost two weeks, subsisting only on Pepsi Light. "You're a rail!" my mother told me, grinning. At summer band practice later that day, I fainted. At left you see me from that summer. Not fat but no "rail," I was developing what felt like a heavy coffin of flesh, despite plenty of biking, running, swimming and weightlifting.
The thing was, I was all back. Not fat; just a hulking box of a pelvis. I weighed less than my big sister, but wore pants two sizes bigger. I got teased a little by some guys, and Mom, who had always been petite and genuinely beautiful (think Ava Gardner), seemed to take my appearance very personally. Once, she took a snapshot of my two sisters after telling me to get out of the picture. Being a rather rigid, perfectionistic teenager, I took it all to heart. Stupidly to heart. Even though I knew I had bones like a Neanderthal, I began fasting a lot more, increasing my daily mileage. And purging.
It never thinned the ankles nor shrank my flanks, made me taller, tightened my buns, ripped my abs*, made look like Cindy Crawford or any of that nonsense. But I did it, because . . . it was doing something. I just had this inner imperative, somehow. I did it until I stopped, by myself, around age 21.
I guess you could say I had an eating disorder, though I did not wind up in treatment, rot my teeth or kill myself that way. It did not get the better of me. But it does get the better of way too many sufferers, baffling their clinicians and families along the way. A father of a young girl who had starved herself almost to death told me one day, in tears, about physically pressing her into the back seat of the car on the way home from the hospital, to stop her from doing crunches. I wonder how she's doing these days, if she is still alive. Only 50–80% of eating-disordered people emerge on the far shore, cured. A whopping 18–20% of suffers are dead within 20 years; it is THE deadliest mental disorder, its mortality rate exceeding that of bipolar disorder.
I have been thinking about it lately, partly because I work with eating disordered women of all ages, and they are among the most frustrating and challenging of patients. I just got word of one's death a few days ago.
And then there's the cosmetic freak show splashed across billboards and screens, streaming around and through us . . . while another current urges us to live large, think positive and pick up one of those double down things at KFC on the way home. Finger-lickin' good!
Did you see the Daily Kos link the other day to the woman who constructed a life-sized Barbie doll to scale? It's easy—almost facile—to say that Barbie's impossible and heavily marketed proportions hold the key to why young women starve and purge themselves, but it's only a fraction of the story.
Eating disorders are a knot of factors having to do not only with mind, but also body and milieu.
Below you'll find my attempt to tease apart a few of the snarled strands. To paraphrase historian Stephen Ambrose, writing is how I learn, so if you're along for the discovery, thanks.
Definition
Half of all Americans know of someone who has an eating disorder. We saw the Monday night problem of the week movies, repeated the Karen Carpenter jokes, watched Amy Winehouse shrivel up and cut her flesh. From the National Institutes for Health, here is a summary:
Anorexia:
Anorexia nervosa is an eating disorder that involves an inability to stay at the minimum body weight considered healthy for the person's age and height.
Persons with this disorder may have an intense fear of weight gain, even when they are underweight. They may use extreme dieting, excessive exercise, or other methods to lose weight
Some of the risk factors:
- Being a perfectionist
- Feeling increasing concern about, or attention to, weight and shape
- Having eating and digestive problems during early childhood
- Having a mother or father with anorexia or addictions
- Having parents who are concerned about weight and weight loss
Bulimia:
Bulimia nervosa is an illness in which a person binges on food or has regular episodes of significant overeating and feels a loss of control. The affected person then uses various methods -- such as vomiting or laxative abuse -- to prevent weight gain.
Many (but not all) people with bulimia also have anorexia nervosa.
The article does not cite risk factors, but allows that many factors may contribute, including genetic ones.
Other eating disorders:
Some diabetics and thyroid patients misuse their respective hormones to promote weight loss, as well, and now Mayo is floating a new diagnosis of healthy eat disorder: orthorexia. That's when in the drive to get good food, the process of shopping, growing, picking, washing and preparing begins to own the person, hampering his daily life. While it is tempting to analyze the rise of writing about food-cum-medicine over the past 40 years, with the ebb and flow of good and bad macro- and micronutrients, I will stick with the two major eating disorders.
History
From ancient times through the Christian ascetics on to tortured anorectic souls like Lord Byron, eating disorders have been around for a long time, but it wasn't until about 150 years ago that they began to be looked at in a systematic approach.
In the 1860s, when tuberculosis was major cause of wasting and poor appetite, a physician named Gull described something he termed "hysterical apepsia," common among young women, which amounted to self-starvation. "Young women emaciated to the last degree." It was the first formal recognition of anorexia nervosa as a disorder arising from the psyche, rather than from a tangible disease process, such as cancer or consumption.
Of course, in those days, the term "hysteria" was ascribed to just about every phenomenon common to possessors of a uterus, and political, sociological and even artistic trends sought to shove Woman into her gilded cage, whether she liked it or not.
Really, truly. Women needed to be dealt with. As the post-enlightenment medical profession, composed of male practitioners, largely, struggled to name and order maladies, a broad class of disorders among women were shaded under a "because she has a, you know, hoo-hoo" umbrella. The uterus was literally thought to be the source of just about everything different, confusing and/or pathological in a woman.
Forgive me my hysterical feminist aside. That's for another article.
As psychology organized itself into a discipline in the late 1800s, case histories began to crop up around the turn of the twentieth century. Then anterior pituitary lesions were discovered (Simmond's disease, 1914) as a cause of wasting, and eating disorders per se were neglected until the 1940s, when psychoanalysis proved particularly unhelpful.
Then, in the 1970s, Hilde Bruch published a pivotal work, The Golden Cage: The Enigma of Anorexia Nervosa, at a time when eating disorders were exploding, particularly among young, affluent white women. She had spent decades working with these patients and contributed insight into the typical eating disordered person's profile. It paved the way for public discussion about the death of singer Karen Carpenter, and the bulimia of Princess Diana.
Brooke Shields, my contemporary, made us all feel like dumplings in the soup.
And eating disorders become even more prevalent, across broader demographics.
More to come
In part II, I'll be writing about the psychological strands of eating disorders and the relationship between eating disorders, personality disorders, and certain Axis I disorders such as ADHD.
In part III, I will discuss the biological threads, including heritability, hormonal influences, neurotransmitters, perinatal brain injury and more. Parts II and III are deeply intertwined, and writing about them as if mind and body were distinct will have been a tough exercise!
In part IV, I'll highlight environmental influences that include family dynamics, socioeconomic status, institutional influence and, of course, the Barbie Factor.
And in part V we'll look at treatment and bring it on home.
* in 1980, when I was going through this, "ripped abs" was not in the common lexicon, as it is today. It was buried in bodybuilding magazines. Before the mass marketing of "Buns of Steel," "Hardbodies," and heroin chic, standards of beauty and fitness were easier to bear and achieve.