Monday, July 02, 2007

Anorexia on NPR

A friend called over the weekend to say that she'd been listening to this interview with the author of Peony in Love when she heard interviewer Liane Hansen make a comment about anorexia that made her blood boil. The author was describing lovesick young girls in 17th-century China. Hansen's comment, which comes about 4.15 minutes into the interview:

"It is interesting, the lovesick young ladies that are affected by the opera, what happens to them in their lovesickness is they starve themselves. And that's so much like anorexia, where you have young women today, and young men, starving themselves because that is the only way that they have some control over their own body."

Dear Liane Hansen, you may be an expert on so many things, as your NPR bio indicates, but anorexia is not one of them. Your throwaway comment about anorexia was made out of ignorance rather than malice, I'm sure. But ignorant it was.

Most researchers today believe that anorexia is a biologically based brain disorder. It's not "about" control. It's not "about" bad parenting, any more than autism or schizophrenia are. In fact, it's not "about" anything at all except having the bad luck to be genetically predisposed and to live in a culture full of triggers.

You have a lot of influence, Liane Hansen. I hope you will take this opportunity to educate yourself about anorexia. This website and this website would be great places to start. Then give me a call--I'd love to talk.

19 comments:

carrie said...

Harriet,

My view of the anorexia-as-control thing is a little different twist. Would anything I think be any other way?

Anorexia is control...those with AN are controlling their *fear of food* not anything else. It's not the food that is being controlled. It is the fears of food itself, of eating, of weight, of exercising. Just like OCD.

When I washed my hands compulsively, I wasn't so much trying to control some random thing in my life as I was trying to control my quite bizarre fears about getting and/or transmitting AIDS. Same with restricting foods in AN.

There is a control element there. Just not in the way that most people think. And it's rather literal, than metaphorical. There will always be something in your life that is out of control (if you identify someone who can say otherwise, please send me their brain, intact, overnight UPS. I will reimburse you fully). You can almost *always* say that. Out of control feelings can cause stress...which can cause someone predisposed to AN to not eat enough or stir up some other neurological calmity...and there you have it.

It's not the control of food. It's the control of the FEAR of food.

Harriet Brown said...

Hi Carrie,

While I completely accept your feelings and your understanding of your illness, I think you've got to go back further. I believe the fear of food is a byproduct of the physiological process of restriction and starvation. I'm guessing that once it's entrenched it feels like its own animal, but it doesn't start out that way.

I think of it as analogous to panic disorder, which I developed at age 12. I lived with extreme anxiety and terror all through my adolescence and early 20s, and it became part of my identity as it developed. So I have all these ideas about what the fear represents to me, etc., but the bottom line is that the anxiety began as a physiological brain disorder that did not get treated.

And the reason I think it's crucial to make this distinction is that if you don't, you wind up with ignorant people mouthing off about anorexics needing to control their food or body because they feel they don't have control of anything else in their lives, and from there it's a very short step to "and they should be able to think their way out of anorexia."

In my perfect world, anorexia would NOT be considered a mental illness. It would be a physiological illness that can have psychological/cognitive effects--just like diabetes. Someone in a diabetic state can seem almost psychotic, but it's all because of blood sugar fluctuations.

Sorry to go on and on, but as you can see I feel passionately about this. :-)

Rachel said...

I don't disagree with the author's assertion that anorexia is ultimately about control. In fact, speaking from personal experience and subsequent academic research into the psychology of eating disorders, I believe a perceived lack of control to be precisely the root of many disorders. You can't control the events in your life, but you can control your food input and your weight. An eating disorder becomes a manner, by proxy, of coping.

Studies do show that some are genetically predisposed to developing a disorder like anorexia, but not all. And that genetic predisposition could just as easily manifest itself in compulsive disorder disorder (which often goes hand-in-hand with anorexia) or smoking or alcoholism or any other disease. It's a predisposition to the behavior, not necessarily the vice (food).

I do think the author espouses the same erroneous myth that even much of the medical field still believe today: that anorexia is a disease of the young. Many woman, like myself, develop adult-onset anorexia and other eating disorders. And for women who do develop the disease in adolescence, they don't somehow "outgrow" the disorder in adulthood.

In an interview I conducted with Trisha Gura, author of Lying in Weight, Trisha says she encountered a woman who first developed the disorder at age 68. Different life experiences, including marriage, adult responsibilities or the birth of a child for examples, can cause the disorder to flourish.

Harriet Brown said...

Hi Rachel,

True adult onset anorexia is very rare; in fact I don't believe it exists. I wrote a piece about it and in the process spent months looking for interview subjects who had developed anorexia as adults. Every single one of the women I talked to had some kind of eating disorder in adolescence. Many had never been formally diagnosed; some were subclinical. But not one of those I talked to suddenly developed an eating disorder after age 25. I've seen the research on this "anorexia tardive," as they call it, and it's pretty sloppy.

But if you truly developed an e.d. in adulthood, I'd love to talk to you more about it offline. Maybe I can learn from you.

The studies I've seen on AN show that 70-85% of those who develop it are genetically predisposed. That's a pretty whopping big number. Are you familiar with the Minnesota Semi-Starvation Study? You'd find it interesting reading if not. It supports the idea that many of the psychological hallmarks of anorexia--anxiety,depression, OCD type symptoms, control issues--are actually consequences of long-term starvation.

Rachel said...

Harriet wrote: "...you wind up with ignorant people mouthing off about anorexics needing to control their food or body because they feel they don't have control of anything else in their lives, and from there it's a very short step to "and they should be able to think their way out of anorexia."

The problem with this theory is that if the disease is organic in nature, then one could just as easily use it as an excuse NOT to seek treatment at all.

We might have different interpretations of what "thinking their way out of anorexia" means, but speaking from my experiences in therapy, anorectics can learn to rethink their behaviors. It's called cognitive therapy - you replace the bad behavior with a healthier one.

For me, I had to learn that a fluctuating weight in one day or even a few days wasn't necessarily weight gain or loss, but hormones and/or water retention. I had to learn how to conquer my fears of "bad" foods and see food in a different light altogether. I had to learn that my self worth wasn't exponential to the digits on my scale.

Anorexia is a serious psychological disease, yes - recovery is a lifelong process. But it isn't a disease without the hope of managing the disorder.

Rachel said...

Harriet - I'd love to follow this up offline - it seems we're trailing each other's thoughts here. My email is Rachel (at) the-f-word.org.

I'd also recommend Trisha Gura's book and also Aimee Liu's new book called Gaining for more information on adult-onset eating disorders.

Laura Collins said...

Well, I logged on with a lament about how so many things I once loved - like Liane Hansen's voice - have to be re-labelled as clueless on an issue of such importance.

But what a fun conversation I find you are all having here!

There is a big difference between the idea that an ED is "used" or "chosen" TO CONTROL - as opposed to an illness that CONTROLS THE PATIENT.

To the patient the two would feel like the same thing.

I think it is disastrous for caregivers to buy into the idea that what the patient is doing is asserting control. Cruel, actually.

Harriet Brown said...

So well put, Laura.

Anyone who has watched someone they love go under with anorexia knows that this disease is not about control. There's no one in less control than someone with anorexia.

And I acknowledge that these would feel the same to someone experiencing it. That's what I was trying to get at in my earlier comments.

Anonymous said...

Why would a person not seek treatment for an organic disorder, whether it was a physical or psychiatric one? That makes no sense at all.

Harriet Brown said...

Because the nature of some disorders is that they're anosognosic--meaning that those who suffer from them don't recognize the fact that they have an illness. The image that comes to mind for me is from one of the original Star Trek episodes, the one with the jellyfish-like thing that glommed on to Spock's spine and brain, entwining so deeply with his muscles and cells that it could not be removed forcibly. Not a perfect analogy, but you get the idea.

Read Oliver Sacks for good examples of people with brain dysfunctions that were anosognosic. Read any pro-ana site online for an example of how anorexia is anosognosic.

carrie said...

Harriet,

I posted a fairly long response to this last night but it disappeared into cyberspace. Blech.

Anyway, to summarize:

The fears of anorexia are without a doubt generated and amplified by malnutrition. There are so many fears of food and fat in society that it is possible that a person with AN gets scared of becoming fat, or of eating fat, or of becoming unhealthy, that they begin to restrict their food intake and malnutrition sets in and these fears go through the roof.

See, the person with AN is scared stiff. These rituals around food (not eating certain food groups, eating at a certain time, not eating more than a set number of calories) are an attempt to help offset this fear. Which is easily confused as control of food.

I guess in a sense you could say that these were the same as my OCD rituals. That fear is so real, so intense, and so absolutely irrational, that you want it to go away. It's a compulsion. It really is. And those compulsions are kind of a way to make everything better.

Ohly it doesn't.

I guess that the you're-controlling-your-fear-of-food is really about that. Food isn't the issue. Fear is. That fear is organic in nature, and the sufferer feels compelled to do whatever necessary to tamp down that fear. And the fear is so damn real that you don't realize that you're sick. It's a natural response to the sufferer. In a sense.

Oh Lord. I think I'm going to post the rest of this on my blog.

Hopefully you get the point.

Anonymous said...

I agree with you, Harriet and Carrie. I was questioning Rachel's assertion that "The problem with this theory is that if the disease is organic in nature, then one could just as easily use it as an excuse NOT to seek treatment at all." Oftentimes people with AN do not seek treatment for the reasons H & C mention--it has nothing to do with whether sufferers consider the disease organic or not. Suggesting that acknowledging a biological basis to the disease will not make sufferers avoid treatment--they ALREADY do oftentimes--is off base IMO.

It is possible to address organic illnesses with therapy (cognitive redemiation therapy is helpful in treating schizophrenia in addition to medication for example.) If it a disease is acknowledged as organic it doesn't mean therapy won't help.

Harriet Brown said...

Carrie,

Believe me, I know that the person with AN is scared stiff. I watched my d live in abject terror for a whole year.

If fear of fat led to AN, 80% of American women would be AN. And the true number is more like 2%.

Here's what I think happens: People fall into AN in different ways. For many it's a diet that just goes a little too far. (People who are genetically susceptible to AN are *really good dieters.* Typically it's easy for them to lose weight and--more important--they feel less anxious and "better" when they do. Unlike, say, me, who feels cranky and stressed when I lose weight.)

Some teens take up a calorie-burning sport like cross-country or track and drop 20 or 30 pounds in a month. Some get sick and lose weight. However it starts, the losing weight part comes first. And sure, in our culture, some ridiculously high percentage of teenage girls diet, which presumes that they think they should lose weight, and that they think they're fat on some level.

Anyway, however it happens, the person who develops AN falls over the edge. Down the rabbit hole. Off the cliff. It's a mistake. I don't know a single sufferer who set out to become AN; it just happens. And once it does, a whole nasty cascade of stuff happens, as you know all too well.

Cognitive therapy can help in the recovery process, as an adjunct to weight restoration. Because the thing is, once these feelings kick in, you've got to deal with them. We feel things in our bodies and minds, however they start. But that doesn't mean those feelings caused the disease.

I'm a person who likes a fair amount of control in her life. You might call me an alpha female, in fact. :-) (At least that's what my family says, fondly. I hope.) And I've felt my share of fat fears, growing up with a constantly dieting mother and a tendency to be stocky myself. But look Ma, no AN, and no temptation toward it. I don't have the genes for it, thank God.

And anonymous, if you're still with me after that long rant, we're in agreement there. People get therapy for depression and anxiety, too, and it helps--usually in conjunction with medication that alters brain chemistry. But we're such complicated creatures, aren't we?

carrie said...

Harriet,

Right on.

I think about all the commercials for the antibacterial products. Most people like cleanliness, and a significant proportion of the people I know are pretty finicky about sanitizing things. They're NOT OCD. It's the same for people being exposed to dieting and weight loss and fat phobia and most of them not developing AN.

And actually, I think this is where the impaired set-shifting comes in. Your brain can't move on once it's fixated on those fears. So many woman are afraid of fat, but only a small percentage develop AN, as you said. Those with AN can't move away from the subject of weight loss. Others can. Also the black and white thinking that tends to characterize those with EDs.

I'm sorry I'm not making a whole lot of sense. I'm doing the internet equivalent of thinking out loud.

Carrie

Harriet Brown said...

You're making great sense. I think in 5 years we'll have a much better understanding of the neurobiology of not just AN but OCD, depression, anxiety, and a slew of other brain conditions. I can't wait.

Anonymous said...

How can you say anorexia isn't about control? You are the ignorant one as anorexia has alot to do with control and I do not believe it is genetic, this has to be the stupidest thing I've ever read on anorexia.
Not only control but other aspects play a part like anxiety and identity crises, but control is a huge part of it. Have you ever HAD anorexia, do you have any idea how nice the control feels? Or how it shields you from anxiety and things you don't want to deal with? I take that as an insult, to ignore the causes of anorexia like that is to demean it.
I don't want yo insult you, but I feel so insulted!

Anonymous said...

Both the counselors and parents who post here may have bias is their positions re AN or any ED. Counselors need it to continue to make money. Parents generally want it to stop (in case in makes them look like bad parents). But parents pay the counselors, so I'm guessing there is a conflict of interest in there somewhere.
People with EDs are control-focused, and that is likely due to both genetic and environmental factors. But dismissing one or the other is counterproductive if the goal is successful treatment of the sufferer.

Harriet said...

I can assure you that parents don't want it to stop because it makes them look like bad parents.

We want it to stop because it's torturing our children, whom we love deeply.

I think *your* point of view may be biased here.

EmilyRF said...

I am 41 and I have adult onset anorexia. It started in Feb of this year after I was attacked by an off-duty policeman. While for me the disorder didn't start out being about control, it is now. Control my food or let it possibly control me. That is my fear anyways. I am scared to death that if I started to allow myself to eat I would just eat everything and be completely out of control. I hate this disease! I hate the way it makes me feel, think, the pain it is causing my partner. Everything about it for the most part is bad!