In fact, the very name anorexia nervosa is ironic. The literal Latin translation is “nervous loss of appetite.” But people with anorexia don’t truly lose their appetites. They may be disconnected from the physiological sensation of hunger, but they are deeply, profoundly hungry. That’s why they draw out their meager meals for hours, savoring every scrap they allow themselves. It’s why they douse their food with mustard and salt and other condiments to sharpen the taste of what they’re eating. It’s why they read cookbooks like other people read pornography, why they plan elaborate menus they know they will not eat, why they stand longingly in front of bakery windows but never go inside.
Hunger is hardwired into us, physically and psychologically, and for good reasons. The drive for food must be insistent enough to propel us to seek it out three times a day. In twenty-first-century America, many of us have only to go to the kitchen, the grocery store, a restaurant to fill our bellies. But for most of the long story of human evolution, satisfying hunger has been a drawn-out and often perilous process.
Accounts of people with little or no appetites, who do not eat or have strong aversions to food, go back to at least the first century A.D., when the Roman physician Galen described people “who refuse food and do not take anything” and who “are called by the Greeks anorektous or asitous.” The Greek physician Alexander of Tralles, who practiced medicine in the sixth century, believed that anorexia developed from an imbalance of what classical philosophers called “humors” people with anorexia, in this view, had too many “cold humors” and needed herbs like cinnamon, pepper, and vinegar to restore balance and bring back appetite.
This perspective on anorexia persisted into the seventeenth century, when an English dictionary described it as “a queesinesse of stomack.” Lack of appetite, it was thought, must stem from physical disturbances—stomach problems, “humors,” and other bodily ailments. And in fact, a loss of appetite alone can be a symptom of all sorts of physical illnesses, from cancer to gallbladder problems.
In the Middle Ages, the culture around not eating shifted from physiology to spirituality. Religious women like Catherine of Siena, Beatrice of Nazareth, and Margaret of Cortona became known for fasting or eating almost nothing for years; some undoubtedly died from malnutrition. Their behavior was seen as a holy endeavor, a kind of reaching toward a state that transcended the body. Many of these women were later beatified by the church, and their starvation acquired a new name: anorexia mirabilis, a loss of appetite that was miraculously inspired. If they were good enough, holy enough, they were set free from the physical necessity of eating, lifted into an idealized state where food was irrelevant—or so the notion went.
Historians adamantly distinguish the self-starvation of these medieval women from later forms of anorexia. They argue that we don’t know enough about what inspired women in the Middle Ages to starve themselves and what kept them on that path. They say it would be naive to think that shared physical symptoms like an aversion to food, extreme thinness, and loss of menstruation derive from the same illness. They say that anorexia mirabilis and anorexia nervosa are two completely different disorders that originate in completely different ways.
To support this notion, medieval scholar Caroline Walker Bynum argues that fasting saints did much more than fast; they castigated themselves in all sorts of ways. Catherine of Siena, for instance, whipped and scalded herself and regularly slept on a bed of thorns.
I don’t buy it. The roads to anorexia mirabilis and anorexia nervosa may indeed start in different spots, and those spots may be defined in terms of the culture: in medieval times, young girls aspired to saintliness the way girls today aspire to thinness. But those roads quickly converge on the same highway to hell. Catherine of Siena, for instance, died at age thirty-three after years of subsisting on a daily handful of herbs; when forced to eat other food, she reportedly put twigs down her throat to make herself vomit it up.
Sounds like anorexia with a side of bulimia to me.
The difference in terminology underscores the idea of anorexia as a relatively new disease, an affliction of modern times. The first two medical descriptions of anorexia nervosa were published nearly simultaneously in 1873, one by a highly respected British doctor and one by a French neurologist. Sir William Withey Gull practiced medicine in London and was on close terms with Queen Victoria and the royal family. He spoke and wrote about an illness that affected mainly upper-class adolescent girls who suffered from diseased mental states and, as he put it, “perversion of the will.” Charles Lasègue was a neurologist in Paris when he described what he called l’anorexie hysterique as a “hysteria of the gastric center.”
Interestingly, their characterizations of the illness diverged from their recommended treatments. Gull believed that medicines were useless and that only food could cure the illness. He prescribed high-fat, high-protein meals, administered every two hours by a trained nurse, along with bed rest and a hot water bottle along the spine; he believed that the person who was ill needed someone outside herself to compel her to accept food. “The inclination of the patient must be in no way consulted,” he wrote. He thought a trained nurse was best because friends and family lacked the “moral authority” to insist that a young patient eat.
Lasègue’s treatment veered more toward the psychological. He was the first to suggest that anorexia stemmed from family conflicts over an adolescent girl’s transition to adulthood—a view that remains stubbornly entrenched today.
I think Gull had it right. When it comes to anorexia, food is medicine, and it’s a given that someone with anorexia will not willingly come to the table.
In her book Fasting Girls: The History of Anorexia Nervosa, Joan Jacobs Brumberg writes that Lasègue’s research “captured the unhappy rhythm of repeated offerings and refusals that signaled the breakdown of reciprocity between parents and their anorexic daughter. In this context anorexia nervosa can be seen for what it is: a striking dysfunction in the bourgeois family system.”
Like Hilde Bruch and so many other “experts” on anorexia, Brumberg mistakes effect for cause. Typically, by the time parents consult a doctor or therapist about a teen with anorexia, the family has become dysfunctional, no matter how competent it was to begin with. The pattern of insistence and resistance Brumberg describes is absolutely normal in the context of a child who is starving herself. Of course parents become edgy and upset, frantic to get their child to eat. And of course the child becomes terrified, hostile, and manipulative—anything to avoid eating.
But eating-disorders therapists don’t see a family before anorexia strikes. So they don’t know, they can’t know, the true rhythm and flow of a family’s previous life. Which means that they can’t establish cause and effect between family dynamics and eating disorders. There’s no way to predict who will develop an eating disorder, based on family dynamics or on any other criteria.
Somehow the medical and psychiatric professions have confused hindsight with understanding. There’s a saying in the scientific world: “Correlation does not equal causation.” Just because two things happen at the same time doesn’t mean that one causes the other. Maybe an unknown third variable causes them both. Maybe they coexist coincidentally. We know that anorexia changes family dynamics. But we don’t know whether those dynamics caused the anorexia in the first place.
Most years we take a vacation in August, but not this year. Just as well, because we’re not a beach family. Our vacations usually revolve around activities: kayaking in Lake Superior, skiing in the Porcupine Mountains, hiking in the Catskills. All of these would cost Kitty too many calories. Instead, we spend most of the month, when we’re not at work, watching movies and playing board games, which Kitty hates but Emma loves. Poor Emma, whose summer has been one big nonvacation. She’ll be glad to get back to school, I think.
In the second week of August, Jamie and I bump Kitty up to twenty-one hundred calories a day. For two days beforehand she frets and worries over the coming change, so muc
h so that Dr. Newbie prescribes a mild antianxiety medication—just in case, she tells us. Just in case of what? I think as I pay for it at the pharmacy. In case things get any worse? I allow myself a small sardonic laugh. But even as I walk out, bag in hand, I know there’s nothing to laugh about. Things can always get worse.
With the increase in calories, meal planning becomes more of a challenge. Eating large volumes of food is stressful for Kitty physically as well as emotionally. We add in a midmorning snack, to spread out the calories, but still she complains of bloating and stomachaches—common side effects of refeeding. Starvation affects the entire body in ways both profound and minute, and it will take a while for her metabolism and digestion to normalize. I’m hoping to minimize the unpleasant gastric consequences by cutting back on fruits and veggies, which are hard to digest and which in any case don’t contain enough calories, and feeding her smaller amounts of calorie-dense foods.
I turn to my collection of cookbooks; leafing through them is an exercise in cognitive dissonance. Nearly every recipe seems to emphasize how low-fat and/or low-cal it is. Like Alice in Through the Looking-Glass, I have the curious sensation of looking through a mirror into an alternate universe. While the rest of America hunts for ways to cut down on calories, I’m searching desperately for ways to pack them in.
Frustrated, I go online and wind up on Web sites aimed at families of cancer and cystic fibrosis patients. I print out recipes for macaroni and cheese, chicken and peanut stew, lasagna made with ricotta and béchamel sauce, guacamole. Kitty’s still terrified of foods like these—creamy foods, sauces, and pasta. Foods with fat in them. Even if we wanted to, we couldn’t get enough calories into her by serving only “safe” foods—grilled chicken breast, steamed vegetables, plain whole wheat bread. And we don’t want to. On my single trip to a nutritionist, I learned that the brain is made up largely of fat. That both the brain and the body need fat—not just any old calories but the right kinds of calories—to begin the slow process of healing from starvation.
And it’s more than a physical thing. Instinct tells me that if we are ever to rout the demon completely, we’ll have to break all its rules, flout its proscriptions. We’ll have to tar and feather it and run it out of town. We can’t appear to collude or appease it in any way; we need to win this war visibly as well as tactically. We’re engaging in a kind of exposure therapy, slowly desensitizing Kitty to the things she fears. And there’s nothing she fears more right now than fat, whether it’s on her body or in her food.
One night, poking around online, I find a glimmer of evidence that we’re on the right track. I come across a 1967 study done by a grad student at Northwestern named Aryeh Routtenberg, who discovered, more or less by accident, that rats given access to food for only an hour a day became more physically active, running on their wheels for hours. After a few days the rats ate less and less and ran more and more. Most of them died within ten days, starving and running themselves to death.
I sit back in my desk chair. So many of Kitty’s behaviors are analogous to the rats’. If we didn’t stop her, she, too, would exercise more and more. She, too, would starve herself to death. This study doesn’t shed light on what triggers someone like Kitty into restricting her food in the first place. But it does lay out a pattern of effects that looks all too familiar. The rats’ refusal (or inability) to eat, their compulsive overexercising—even unto death—reflect a biological imperative. Their self-destructive behavior didn’t derive from psychological “issues” or screwed-up family dynamics; it was, as Routtenberg later discovered, a function of neuroanatomy.
The brain works on three main systems of neurotransmitters: serotonin, dopamine, and norepinephrine. These chemicals leap the synapses among the brain’s millions of neurons, creating and regulating processes that affect everything from movement to behavior to mood. Like the rest of the body, the brain exists in a complex and delicate balance; one little misfire can bring down a big chunk of the system. In this case, Routtenberg theorized, the rats’ limited access to food and unlimited access to the running wheel interfered with the brain’s dopamine system. Which makes sense, because among other things dopamine helps regulate physical movement (it’s connected with the basal ganglia, a cluster of nuclei involved with motor functions), motivation, and reward.
Just as interesting was a 1971 follow-up study done at the Medical College of Wisconsin by Joseph Barboriak and Arthur Wilson. They duplicated Routtenberg’s conditions, but divided rats into two groups. One group got the usual low-fat, high-carbohydrate laboratory chow; the other got a special high-fat mix with no carbohydrates. Both groups were fed the same total number of calories and, as in the earlier experiment, had access to the food for only an hour a day. The lab chow rats behaved just like the rats in the original study; they amped up their activity levels until they were running nearly all the time. Each rat lost about 20 percent of its body weight. At the end of the experiment, twelve out of fifteen had died.
The rats on the high-fat diet, by contrast, didn’t go into exercise overdrive. Their activity levels rose, but only a little, and they didn’t lose weight. Only one of the fifteen rats in the high-fat group died, and that one had increased its running more than most of the others.
So something about the higher-fat diet protected the rats from running and from starving themselves to death. Barboriak and Wilson didn’t speculate on cause and effect; they simply reported what happened. I want to know why, so I can keep Kitty safe from the same deadly cycle.
For now, I suppose, it’s enough to know that fat is an important part of the equation. Knowing will help me resist both the demon’s imprecations and Kitty’s fear of eating fat.* It’s so tempting to want to spare her suffering, to avoid some of the trauma. To feed her the foods she feels safest eating and hold off on the others until later. But I’m beginning to understand that there won’t be a later if we give in to Kitty’s terror, if we enable the demon in any way. There is no compromise possible. The stakes are too high and the process is too painful.
For instance: the next day I make one of our favorite meals, homemade pizza, which Kitty used to love. We’ve been keeping Kitty out of the kitchen during meal prep, but she sees the dough rising on the stove and falls apart instantly. “Oh my God, not pizza,” she cries. “I already feel so fat, Mommy. My thighs are jiggling. Please don’t make me eat it.” She is keening now, there’s no other word for it, crouching on the floor, rocking back and forth, arms wrapped around herself.
I feel like the worst parent in the universe. I am causing my child so much grief and fear and pain. My job is to protect her, not hurt her. I want to give up. I want to go back to the way things used to be, I think, before anorexia. B.A. Ha. We’re all getting an education in eating disorders. An education we don’t want and could live quite well without.
Then I think, If I feel this way, how must Kitty feel? I can take a walk, read a book, shut out the anorexia for a little while. But it’s inside her. She can’t get away, not for a second. And every minute she spends trapped with the demon must be hell. Pure hell. My child is going through hell. I could sink down right now onto the floor beside her. I could howl and cry and tear out handfuls of my hair. That’s what I feel like doing. But that would be self-indulgent. That would be abandoning my daughter.
In our family, as in all families, my husband and I have taken on certain roles. Jamie is the one who fixes things: the vacuum cleaner, the car, the computer, the broken chair. When someone gets a splinter, he’s the one who pulls out the hydrogen peroxide and tweezers. My role is to figure things out. I’m the one who makes the plans, who asks the questions (sometimes obsessively) about what it all means and what we should do. I’m the one who calls people and goes online and tears through the library looking for answers to whatever the problem.
The point is, Kitty needs both of us now. Jamie’s strengths and mine are complementary, and she needs every shred of power and steadiness and stubbornness we possess. No matter how much I f
eel like giving up, I can’t. Jamie can’t. There is no way we’re abandoning her. No way in hell is the demon going to win.
I slide down onto the floor beside her and put one hand on her back, to let her know I’m here. I sit beside her and I stay with her until she’s all cried out. Until Not-Kitty is gone, and Kitty is, for the moment, wholly herself.
Impulsively, I say, “This is really hard on you, isn’t it?”
Kitty hates the idea of anyone feeling sorry for her. Some of her biggest outbursts in these last few weeks have come in response to someone’s expression of sympathy, or empathy. I brace myself for her reaction.
But instead of stiffening in anger, Kitty simply turns her face toward mine. She’s always had beautiful eyes, my daughter, and they are still lovely, large and complex, the dark irises flecked with light. Now they look too big, out of proportion, like the oversized, pathos-filled eyes of puppies in flea-market paintings. I was raised to think thin is beautiful, that there’s no such thing as too thin. I will never again believe it.
Kitty leans her cheek into my hand, a rare moment of connection in our newly adversarial relationship. Once upon a time she trusted me. Once upon a time Jamie and I were not the enemies. Now the feel of her skin against my palm tells me what we have to do next. Each time we’ve raised her calorie intake, Kitty has suffered, her anxiety and terror flaring out of control. It’s as if we’re peeling away a Band-Aid, inch by agonizing inch. Wouldn’t it be kinder to rip it off in one go?
“What if we raised your calories to three thousand now, in one fell swoop?” I ask Kitty, bracing myself for panic, rage, the demon’s hissing.
Brave Girl Eating Page 10