ANOREXIA NERVOSA

The young woman reaches with bony fingers, draws a foreign cigarette from her case, and lights a match. She stretches her long legs across the floor, resting her weight on the tiny pelvis outlined by her jeans. The smoke dances slowly around her soft, beautiful face as she begins to talk about why she is so thin, about her anorexia nervosa.

"The egotism and vanity involved with anorexia is unbelievable," she says. "You spend hours a day examining yourself, looking at your body. Gaining one pound is a big thing." Unlike most anorexics, who deny there is anything wrong with them, she wants to talk about the strange disease she has for five years. But she doesn't want people to know who she is.

She is extremely skinny--not svelte, but unnaturally thin. She starved herself torturously to achieve and maintain her underweight state. She ignored the hunger pangs in her stomach and she denied to her family and friends that she was hungry, because she felt fat and wanted to be thin. When she got horribly skinny people got very worried but she thought she still needed to lose weight, and still she would not--or could not--eat. "It's this big secret," she says of the first stages of anorexia. "You're so guilty about it, but it's obvious that everybody knows about it. And you still think there's nothing wrong with you."

The textbook definition of anorexia nervosa is "a chronic illness principally affecting young girls after puberty. It is characterized by severe weight loss which is self-induced, amennorhea [loss of period], and a specific psychopathology." However, after a century of research on anorexia nervosa, this definition does not hold up well. The psychopathological basis for the disease is still not defined specifically enough to bring doctors who treat anorexia to a consenus on its cause. Furthermore, one in ten diagnosed anorexics is male.

A widely accepted definition of anorexia is not likely to emerge soon. Anorexic patients are perhaps too rare and too scattered to support large conclusive research studies; large hospitals admit only ten to twelve anorexic patients a year, people whose self-starvation has put their lives in danger, who have lost more than 20 per cent of their normal body weight.

Dr. Warren E.C. Wacker, director of the University Health Services, says UHS treats about eight anorexics a year, two of whom have to be hospitalized in Stillman Infirmary. Since most anorexics deny there is anything wrong with them and are generally brought to the doctor by their parents, Dr. Lauring Conant, an internist at UHS, says, there are probably more anorexic students at Harvard than UHS treats.

The most pervasive aspect of the disease is denial; anorexics' denial of their hunger, to themselves and to others, is extreme. They deny that they have any emotional or physical problems. While on ritualized and limited diets they are apt to suffer from digestive problems, but they deny they are ill and avoid seeing doctors who might force them to confront their self-starvation.

Anorexics have a distorted sense of their own body size, seeing themselves as much fatter than they actually are, and they have extreme goals for the size they consider ideal. They are obsessed with nutrition and food. They love to prepare meals, watch others eat, and work on nutrition projects for school. They go on eating binges occasionally, but will secretly induce vomiting afterwards. "One sub-group," Dr. George Tully, an endocrinologist at Massachusetts General Hospital, says, "will eat next to nothing for a long time, then gorge a jar of mayonnaise or pickle juice--very unappetizing-sounding orgies--and induce vomiting."

Generally anorexics are achievement-oriented, very intelligent, very depressed people. They are hyperactive, spending enormous amounts of time exercising to burn off calories, and they are very nervous. Most anorexics come from upper class or uppermiddle class homes where food is plentiful; few come from lower class homes, and anorexia is rarely reported in developing countries.

Anorexia is a mystery disease; doctors disagree over practically everything about it. The leading expert on it is Dr. Hilde Bruch, who has been observing anorexics for more than 35 years and has written a book on them. Bruch has developed a psychological composite portrait of the typical anorexic victim: they were, she says, model children who behaved with robot-like obedience because they doubted their abilities to stand up for and assert themselves. Their dieting usually began inexplicably, following trivial remarks about their appearance or upon a change of environment, like going to camp or college. In new situations, the anorexic feels embarassed about being chubby or not athletic enough, and begins dieting.

The dieting gets out of control, Bruch believes, because the anorexic expects it to bring about effectiveness and respect. Since no amount of weight loss can achieve these goals, the anorexic becomes frantic and pursues the diet with renewed fervor. The desire for control of one's life is replaced by the desire to control the body.

Family life plays the greatest role in Bruch's theory of who gets anorexia and why. "It is possible," she writes, "that the success, achievement, and appearance orientation of these families is in some way related to the patient's driving search for something that will earn him respect." Despite the apparent stability in the anorexic's home--very few come from broken homes--Bruch finds in the parents a deep disillusionment with each other. They are competing secretly to prove which is the better parent. The mother is likely to be an achievement-oriented woman, frustrated in her aspirations, very conscientious in her conception of motherhood, subservient to her husband without truly respecting him. The father, despite considerable social and financial success, feels second rate and is preoccupied with physical appearances. He admires fitness and beauty, and expects high achievements and good manners from his children.

Though the children have had a great deal of exposure to education, athletics and the arts, they were not enouraged to think independently or to express their own feelings. Instead of relying on their own inner resources or autonomous decisions, they behaved with complete compliance to authority. When puberty demanded independence of the obedient anorexic child, he turned, Bruch writes, "to indiscriminate negativism."

The male anorexia that Bruch observed was all prepubescent. She found the same desire for autonomy motivating these boys, and leading them to develop overambitious, hyperactive and perfectionist attitudes. Male anorexia, however, is overcome by the flood of hormones at puberty, which leads to new aggression and makes self-assertion possible.

Bruch sees the task of a therapist as being the rewarding of self-initiated efforts to eat by anorexics, and helping them to think for themselves and grow into individuals.

Beyond encouraging the anorexic to eat, doctors differ widely in their methods of treatment. Anorexics, once they get to the hospital, are likely to be put through an array of psychotherapy, behavior modification and medication that by its very variety shows how little doctors really know about the disease.

When an anorexic enters the hospital, before any psychiatric treatment begins, doctors work to bring her out of physical danger. Then, some sort of longer-term treatment begins, to combat the patient's will to starve and to induce voluntary eating. Dr. Robert Masland of Children's Hospital says, "Most people like food too much, so they cannot stay on a starvation diet; anorexics can. All the patients who come in want to weigh 100 pounds. We're dealing with patients with a stubborn streak and strong will-power. In behavior modification we say, "If you're not good we'll stick the tube down your throat or not give you certain privileges.' Patients have an apt phrase for this--they say they'll eat their way out of the hospital--but that doesn't mean they're straightened out in the head. For the dangerous ones [20 per cent of anorexics], maybe we should develop a drug to stimulate the hypothalmus so they will eat and not feel guilty about it."

At Mass General Hospital, insulin injections are used to stimulate an appetite in anorexics. Dr. George Tully, an endocrinologist explains, "the insulin induces hypoglycemia. This makes the patient feel hungry and gives them a sweaty, mild headache which only eating can relieve." Ideally, a normal appetite will develop in the patient and she will not just eat to avoid the insulin's side effects. The insulin treatment is accompanied by psychiatric care.

Dr. Peter Sifneos, a psychiatrist at Beth Israel Hospital, describes a German treatment for anorexics as "most upsetting to many people, but it has the best results in pounds per weight. The Germans force the patient to stay in bed twenty-four hours a day and don't allow parents or any others to visit. During rounds the whole team--professors, residents, interns and nurses--all give the patient a Germanic lecture on wasting time, being undeserving and taking another person's bedspace, and they tube-feed the patient, through the nose and down to the stomach. As soon as the patient makes an effort to eat and gains weight, the negative lecture becomes positive: 'You are a deserving person. You are a good German.' And they have the best success rate. They say the patients all gain 25 pounds."

The efforts at getting anorexics to eat and gain weight are often frustrated by the patients' own drives to lose weight. Piazza says that anorexics describe "something bad inside them that has power over them--this is what they're fighting. The fight within them is between the part that wants to eat and the part that doesn't. The body is a battleground."

Masland explains, "You really can't trust these patients. You must know what they're eating, whether they're going to the bathroom to throw up or throw food away. After they've been doing it for so long they can deny it with a straight face. The manipulation and denial can be amazing."

One doctor relates his experience visiting an anorexic after lunch, which she normally ate unguarded. "You've been doing very well, the doctor said. "You've been finishing your frappes every time now." Then he glanced at the plant besides her bed and his smile vanished. The plant was dead. It had overdosed on chocolate frappes.

Tully says that "the success of behavior modification in restoring and maintaining a satisfactory appetite in anorexics depends on the age of the patient and if you can work out the underlying stress." Doctors agree that the older the patient at the onset of anorexia, the lower the chance of success with any kind of treatment. The mortality rate can be as high as 50 per cent in older patients.

As to the actual psychological roots of anorexia, there is a great deal of disagreement from hospital to hospital. Each institution compares its anorexic patients, studies their case histories, and occasionally prepares reports on them. Each has a pet theory about the causes of the disease. Each seems to look specifically for its own pet causes in new anorexic patients, so the theories only become reinforced.

At Children's Hospital, Masland and Piazza have found that their patients come from close-knit, economically comfortable homes and that they suffer from a "fear of growing up." Piazza says the families are usually "so close-knit that the child hasn't really been able to express herself, to feel autonomous. There is a desire to stay small, to be cared for by this close-knit family." Parents feel guilty because their child will not eat, and meals become battles. Therefore the therapy at Children's focuses on the entire family.

Masland says the anorexic sees weight gain at puberty as "a distortion and wants to deny her femininity." He says anorexics need "a good relationship with a psychiatrist so they'll develop a strong sexual identity, know who they are and where they're going."

Sifneos, at Beth Israel, says anorexia may have its roots in a mother's problems with breast-feeding or feeding in general, while at McLean's Hospital in Belmont a study showed anorexics have a pattern of keeping secrets from their mothers.

Dr. Jessica Osterheld practiced psychiatry at UHS for two and a half years, and personally saw three to six cases of anorexia a year. She sees the roots of the disease as being in the anorexic's battle for autonomy over her friends and parents. The disease is far more frequent in women than men, Osterheld says, because "our culture encourages anti-authoritarian behavior in males; there are other avenues where the male's autonomy can be fought out."

Dr. Lauring Conant, an internist at UHS, e0xplains that denial of the problems keeps patients from seeing a doctor. He has seen only two "full-blown" cases of anorexia in the past two years. "One of the terrifying things with this disease," Conant says, "is that they're on a dangerous crevice of 65 pounds and engage in vocational and avocational activities and get in trouble. Even though they may look like prisoners or war victims, they still engage in sports and you wonder how they can do it. Characteristically they are high achievers, intelligent students. Even in starvation, their cerebral activity strives on. I feel most helpless with this disease. The magnitude of self-denial is so great that it's hard to break through."

Conant says he thinks the anorexic's behavior is a "form of misdirected anger at everything from family to self." This is his clinical impression and he says other psychiatrists at UHS share it.

Tully, at Mass General Hospital, found that many anorexic patients are children of obese parents. "One pattern of anorexia is that one parent, usually the mother, is overweight and constantly dieting and compulsive about dieting and loses weight and gains it right back again. The mother's compulsive habits are forced on the children. The children start dieting wanting to be sexually attractive to males. What occurs so that they don't know when to stop I don't know."

George Schreiner '71, a medical student at Harvard and MIT, points out that "women are much more often the victim of sexual aggression. My hunch would be that when they are the victim they might shy away from sex. Men can't deny their sexuality by changing their appearance. They just look a little skinnier. Whereas girls who are too skinny can look like boys."

Schreiner does not believe that only women wish to deny their sexuality. He says, "If you regard severe impotence as an expression of fear of sexuality and denial of sexuality then I'm sure if anorexia is common at Radcliffe, impotence is rampant at Harvard."

It seems the theories will keep coming. Anorexia's increasing frequency among both males and females could mean that the results of future studies, based on a larger number of patients, will be more conclusive and more widely accepted. But future studies may only result in a few more casual theories spiralling off, and the development of a new theory to explain why anorexia is on the upswing.

The skinny young woman has been talking about her anorexia for about two hours, and she's gone through a lot of cigarettes. She said her anorexia was an attention-getting device. Because she was sickly-thin, everyone worried about her, and she had the concerned attention of parents and friends, especially male friends. She says, "You're attracted to men who will take care of you. Once they respond sexually, you find that hateful because they're intruding upon your freedom, so you run. It's very selfish--they want something but you don't want to give anything. It's a way of protecting myself--I've always found work very important. This lets me shut myself up and work and work and work."