A Hunger Artist

Winning the battle against anorexia.

What Anorexics Really Feel About Food

What’s really going on when people suffering from anorexia refuse to eat? It isn’t usually as simple as not experiencing hunger, and a profound enjoyment of food is often also part of the illness. So what are the mechanisms driving the destructive and sometimes deadly abnormalities in how feeling hunger and liking food relate to wanting food and eating it? Read More

To put is simply, It isn't

To put is simply, It isn't really the anorexia, it is the nervosa. I have seen many women who stopped the suicidal anorexic behavior. What remained, was their significant and angry character problems, which then need to be dealt with in psychotherapy.

Anorexia and nervosa

Thanks for this insight from your clinical perspective. From what I've read on the subject, it seems clear that other psychological problems often predate and are comorbid with anorexia, but this is by no means always the case, and even when it is, these traits are almost always exacerbated by semi-starvation, and improve again (if only partially) with full weight restoration.

As far as my own experience goes, I was full of anger and irritability and impatience while I was ill, and so wrapped up in my own preoccupations that I had no time to empathise with anyone else, and this state of being was almost entirely brought about by malnutrition (which started simply with teenage dieting). Everyone who'd known me well before I became ill said it was 'like having the old Emily back' once I recovered.

That isn't to say that my CBT didn't leave gaps that needed addressing afterwards, in particular (just to confirm the old cliché) regarding my relationship with my mother, but in general being underweight makes everything worse - even if it usually seems helpful to sufferers because it flattens everything emotionally, and provides an illusory set of coping mechanisms.

In general it's important, I think, not to neglect the significance of the feedback between the psychology and the physiology.

Emily

Thank you for your thoughtful

Thank you for your thoughtful response. We do not really differ. You are certainly correct that anorexia nervosa is an adaptation with a life of its own, and its consequence does distort reality. I would add that its not an old cliche regarding the import of the relationship with one's mother. In my experience, the major issue does come from problems in emotional nurture which gets translated into physical nurture where one controls and denies the need for emotional nurture that isn't forthcoming, on the substitue level of food. The anger is actually about the emotional deprivation.

Mothers etc.

Thank you, yes, I’m sure you’re right about the cliché being a cliché for a reason, i.e. that filial relationships do play a key role in many eating disorders – and probably with mothers more than fathers, because of the sociocultural pressures to thinness etc. that act more on women than on men. Food may thus start as a substitute, though then it rapidly becomes the centre of things due to the physical-psychological feedback loops that get initiated. In my case, I found that physical and cognitive-behavioural recovery brought the difficulties with my mother sharply to light – because we could no longer bond about my illness – but also gave me the strength to start to address them. That’s still an ongoing process, as we continue to get used to each other without the anorexic dynamic in place, but at least what we have now isn’t based on my sickness. And my anger at her is pretty much gone, which is a definite improvement...

Mothers

I don't think there is objective evidence that the cliche about mothers is a cliche for a reason. People who develop eating disorders don't have any pattern of relationship with their parents any different from the general population. For example, a survey was taken several years ago of a large number of randomly selected eating disorder sufferers. They were asked about their relationship with their parents using an instrument known as the Parental Bonding Instrument (PBI). The conclusion of the study was that the eating disorder sufferers produced widely varied results, and the data, as the authors concluded, "did not support hypotheses which suggest that eating disordered patients have had a childhood characterized by any particular pattern of parental relationship." Palmer, Eating-disordered patients remember their parents: A study using the parental-bonding instrument, Vol 7 International Journal of Eating Disorders, pp 101-06 (1988) Therefore, I think it is reasonable to conclude that the cliche about mothers of eating disorder patients is really nothing more than a cliche and a myth.

It is certaily true that

It is certaily true that anorexia nervosa has a life of its own, and it requires special measures that have been extremely well described by Emily T. Troscianko in her blog. And it is extremely hard to reach people when they are deep into it. Anorexia is ultimately suicidal behavior and the body dysmorphia is functionally deluded. This does not come from nowhere. It is not just a function of deepening a bad habit. It is a character adaptation like all problematic character adaptations to a problematic environment. In every single patient I have treated, anorexia has been an adaptation to emotional deprivation. To grapple with the real issues is an essential component of the treatment. I'm not impressed by the Parental Bonding Instrument.

The world-leading experts on

The world-leading experts on eating disorders at Columbia University have written that, based on their research and experience, anorexia nervosa actually is an ingrained habit with a biological basis. It typically begins with innocent restriction of food intake. This can happen for any number of reasons, such as athletes in endurance and weight-classification sports seeking to meet a weight goal. Once starvation takes hold, however, changes occur in the brain that make it difficult to reverse the process, and the starvation tends to make sufferers depressed, anxious, and irritable. Most experts now are convinced that anorexia nervosa is not "an adaptation to emotional deprivation." I see no evidence that treatment of anorexia nervosa is a major part of Mr. Berezin's clinical practice.

Dear Anonymous Would you

Dear Anonymous
Would you kindly explain what the biological basis is? I'd be very interested. In my book, "Psychotherapy of Character, the Play of Conscoiusness in the Theater of the Brain" I do explain the biological basis.

Twin studies have shown

Twin studies have shown anorexia nervosa to have a high genetic component. Brain scans of anorexia patients show alterations in brain structure and function. Many research studies show altered hormonal states affecting mood and eating behavior. There are thousands of papers describing the biological basis of anorexia nervosa on www.pubmed.gov For the paper I referenced by Tim Walsh of Columbia University, go to www.ajp.psychiatryonline.org Scroll to the May 2013 issue for the free, full text paper, Walsh, The Enigmatic Persistence of Anorexia Nervosa. Much of the specific biological basis is not known at this time, but it's clear there is a strong biolgical component.

On the other hand, Mr. Berzin's theory of emotional deprivation is speculative and unproven. All treatments for anorexia nervosa that try to correct a hypothesized emotional deprivation have resulted in low rates of recovery. Treatments that target weight gain and restoration of normal eating patterns, on the other hand, have proven to be effective.

Taking the broad view

Thanks for the link to this paper. I like how it draws together of reflections on the neurobiology of reward and of action-outcome and stimulus-response learning, on conditional reinforcement, on the compulsiveness that results from semi-starvation, and on restriction as a behavioural response to negative affect. We clearly need to engage in this kind ambitiously wide-ranging discussion if we're to advance our understanding of how eating disorders take hold and tighten their grip.

As you say, though, there's plenty left to be investigated, and although genetics and biology are involved, they're clearly not the only factors; as Walsh notes about the frequent onset of eating disorders during adolescence, for example, 'Many psychiatric disorders emerge during this phase of life, undoubtedly reflecting a complex interplay of environmental, social, and internal factors (39). He acknowledges, too, that 'It is also important to emphasize that this proposal addresses only one facet of a complex disorder. For example, it does not directly address the difficult but critical issue of vulnerability: Why do only a very small number of individuals who begin to diet during adolescence go on to develop anorexia nervosa?' Environmental factors, including emotional ones, whether or not in the form of a specific emotional deprivation, must be part of the answer to this still tantalisingly open question. And correspondingly, treatment methods clearly need to be developed that resist both extremes and acknowledge the multiple contributing factors in onset and continuation.

A plea for the middle ground

There's clearly ample evidence of the power of dietary restriction and subsequent semi-starvation to act as the trigger for the development of an eating disorder. One of the main aims of this blog is to counter the myth that eating disorders like anorexia must start with profound psychological trauma or with a mysterious biological abnormality, and so to help clarify the dangers of 'ordinary dieting' as on a continuum with disordered eating.

But acknowledging the significance of physiology in the onset and development of eating disorders shouldn't mean that we neglect the emotional and interpersonal factors that may often contribute too. Identifying the flaw in one theoretical extreme doesn't force us to veer to the other extreme and so commit an equal if opposite error. If we're investigating the reasons why dietary restriction leads to full-blown eating disorders in some people and not others, nature and nurture both need to be taken into account, and familial relationships are a major aspect of the environmental factors that can be highly relevant in both illness and recovery.

Parental Bonding study

Thanks for this contribution; it's an interesting paper, but the conclusion you quote doesn't quite tell the whole story. The authors note that 'for three out of four cases the clinical groups showed significantly lower mean care scores', and the fact that they label these differences 'inconsistent' (presumably because of the high standard deviation) runs counter to the fact that they acknowledge that for neurotic patients, high protection and low care scores (i.e. what's found in these data) are the norm.

So there do seem to be significant differences here, just not in the direction predicted by the existing theories mentioned here. That doesn't at all mean that nothing is going on, though. The authors also acknowledge that while the construct validity of this measure seems supported, the external validity is 'difficult to establish', and it would seem that relying on the childhood memories of adults suffering from eating disorders raises a whole lot of questions about memory and other cognitive biases, as well as the usual self-report caveats. So maybe we need to think a bit more creatively about how to find out precisely what is going on here.

Ms. Troscianko claims that

Ms. Troscianko claims that parent-child relationships play a "key role" in the development of anorexia nervosa, and are a "major aspect." Similarly, Mr. Berezin contends that anorexia nervosa is an "adaptation" to a "problematic environment." There is no objective evidence, however, for these theories. To the contrary, converging evidence from multiple lines points in the opposite direction. One of those lines of evidence looks at siblings of people who suffer from anorexia nervosa. If the family environment plays a significant role in the genesis of AN, we would expect to see sisters and brothers of sufferers -- who grew up in the same famiy -- develop AN at rates greater than the general population. The best available evidence shows this is not the case. The only exception is that identical twins of sufferers have an elevated rate, due to the fact that they have the same genetic inheritance. For a good study on this issue, see Klump,
Genetic and Environmental Influences on Disordered Eating: An Adoption Study, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805262/

More on genetics and environment

Just to clarify, I said that filial relationships play a key role 'in many eating disorders', and are a major aspect among the multiple 'environment factors that can be highly relevant'. That is, what I'm saying is that this factor is *likely* to be relevant in *many* cases, not that it's always or necessarily key (however 'key' is operationally defined).

Thanks for the link to the adoption study, which is really interesting. I think it's important to clarify here exactly what evidence it offers and doesn't offer, however. Firstly, as the authors make absolutely clear in the concluding discussion section, 'while our findings rule out the main effects of shared environment, they do not rule out interactive effects that may be equally important and potent', e.g. the interaction of family conflict with a nonshared environmental factor like peer pressure. Secondly, this study uses late adolescent / early adult participants, and the authors cite data from two twin registries which provide evidence that shared environment accounts for around 50% of variance in disordered eating in girls before puberty.

The authors also give indications of the complexity of heritability estimates depending on a wide range of population and environment variables, citing for instance a study of female twins in Japan that suggests significant shared environmental influences on personality traits associated with eating disorders, but little genetic influence on these same traits. Studies on socioeconomic status and cultural differences also throw up a range of results in this regard.

These are just some of the complex questions raised and only very partially answered by this study. It would have been completely crazy for Klump and her colleagues to claim (borrowing your formulation) that their results show or even suggest that 'the family environment plays no significant role in the genesis of AN', and they do not do so. Their final sentence makes absolutely clear that how genetics and environment interact is what still needs much more investigation: 'While no psychiatric disorder is entirely "biologically based", we hope that our findings will contribute to increased recognition of the genetic basis for eating disorders and the ways in which genes may interact with environmental factors to create differential risk'. Denying the importance of either element in this interaction would make no sense at all.

Ms. Troscianko, You did say

Ms. Troscianko,
You did say that "filial relationships do play a key role in many eating disorders." However, as the proponent of that assertion, it is your burden of proof to support the claim, not mine to disprove it.
By analogy, if someone asserts that childhood vaccines "do play a key role in many cases of autism" where would the burden of proof lie? Would the proponent of that assertion be expected to offer evidence, or would the opponent? Would we normally assume the assertion is true unless it is proven to be false beyond a reasonable doubt by numerous scientific studies? Or would we reasonably be skeptical unless and until someone offered evidence that met high standards of scientific reliability?
So far, you have not offered proof for your opinion that filial relationships do play a key role in many eating disorders.
Personally, I am completely agnostic with regard to the cause of eating disorders. I don't think anyone knows.
The purpose of citing the Klump paper was not to show that I can disprove your assertion beyond a reasonable doubt. It was to show that some of the best-available scientific research at this time is offering important clues that the assertion that filial relationships play a key role is highly questionable. Some day some scientist may prove such a role. However, at this time, the assertion is speculative, not scientific.

The best available research

The best available research evidence is that anorexia nervosa is a neurobiological disorder, not a problem of "emotional nurturance" between mother and daughter. The anger sometimes seen is typically the result of semi-starvation, not based on "emotional deprivation. See Minnesota Starvation study. Psychotherapies aimed at improving the emotional relationship between mother and daughter have not shown any measurable benefit in the treatment of anorexia nervosa. See Cochrane Collaboration review of all research studies on family therapy. The only known method of recovering from anorexia nervosa is 1) weight restoration and 2) resumption of normal patterns of eating.

If the mother-daughter

If the mother-daughter relationship were the cause of eating disorders, then you would expect treatment methods aimed at that relationship would be effective. In fact, however, the opposite is true. In a recently-published study, 70 patients with eating disorders were randomly assigned to either 2 years of weekly psychoanlytic psychotherapy, in which the mother-daughter relationship is central to treatment, or 20 sessions of CBT over 5 months. After two years, 44% in the CBT group were symptom-free, compared to only 15% of those who received psychoanalysis.
Poulsen, A Randomized Controlled Trial of Psychoanalytic Psychotherapy or Cognitive-Behavioral Therapy for Bulimia Nervosa, http://ajp.psychiatryonline.org/article.aspx?articleID=1785749 The psychoanalysis cost an average of $15,000 per sufferer. The CBT cost only $3,000.
If a therapist uses psychoanalysis on 100 patients, therefore, she can expect to gain more than $1 million in fees. This explains, in part, why psychotherapists favor using psychoanalysis. If the therapist is able to convince the patient that her mother is the problem, the therapist is in a postion to make much more money.

CBT versus psychoanalytic psychotherapy for bulimia and anorexia

It's good to see the results of this direct comparison, thanks. And the financial question you raise is certainly very important too. As I've tried to highlight in my responses to other comments in this thread, though, the fact that a therapeutic approach that largely neglects the physical side of treatment in favour of the emotional side works (much) less well than one that focuses on the core eating-disorder psychopathology simply doesn't indicate that emotional factors aren't involved. It seems fairly obvious that treatment based on the 'assumption that bulimic symptoms are rooted in a need to ward off inner feeling states and desires and in difficulties acknowledging and regulating such inner states' would be more effective if it were complemented by specific behavioural (dietary and other) guidance in order to directly address the bulimic behaviours alongside the emotional issues. Indeed, this is precisely what the authors themselves suggest in conclusion.

In addition, it's worth noting that there's much more substantial evidence to support the effectiveness of CBT in treating bulimia than anorexia (e.g. Murphy et al. 2010: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928448/), so it's important to bear in mind (even if it should be obvious) that different eating disorders may respond differently to different treatments. Even in this study, furthermore, the CBT group outcomes - just over 40% of patients free from binge-eating and purging behaviours, at 5 months and at 2 years, as opposed to 6% and 15% respectively for the psychoanalytic psychotherapy group - isn't exactly a resounding success. Relatively speaking it may be a fairly positive outcome, but surely our aim must be to do better than this in the future. And I can't imagine that that will happen unless we start doing rather more joined-up thinking when it comes to therapeutic methods.

Cochrane review; physiology, neurobiology, and other factors; and the Minnesota study

Many thanks for alerting me to the Cochrane review; I hadn't realised there was one on family therapy for eating disorders. The results clearly aren't promising for family therapy, but the main conclusion of the review appears to be that existing research is - as in so many areas of eating-disorder treatment - completely inadequate as a basis for confident conclusions about the relative merits of possible treatment options, with the few trials carried out marred by small sample sizes, potentially significant risks of bias, and highly variable reporting of key outcome measures.

In particular the authors highlight the lack of investigation of the impact of family therapy on family functioning, which one would have thought would be an obvious focus for all studies in this area. The most we can conclude from this review is therefore that more and better research on family-based as compared to other therapies is needed, and not in the slightest that familial factors are irrelevant to eating-disorder aetiology.

The fact that we haven't found ways of effectively treating (or experimentally assessing the treatment of) issues relating to family functioning in eating disorders is absolutely not grounds for concluding there is no problem here that needs addressing. It's beyond question that eating disorders involve emotional and interpersonal factors, and although these are highly unlikely to manifest along the simplistic lines that, say, a psychoanalytic approach might predict, they do need to be taken seriously if we want to make progress in understanding and treating eating disorders with holistic effectiveness.

Of course weight restoration and re-establishment of normal eating patterns are absolutely necessary to recovery, but it also seems clear that these outcomes can't be achieved without improvement in other areas. Even the most behaviourally focused forms of treatment involve work on issues like obsessive or otherwise distorted thought patterns, body-dysmorphic perceptual distortions, low self-esteem, social isolation, and so on. There's always some amount of chicken-and-egg insofar as none of these elements can be improved without weight gain, but weight gain won't remain sustainable if these elements aren't improved. Effective therapy acknowledges these complexities and attempts to address them through sensitive negotiation of the interactions between physiology and psychology (including interpersonal factors, to which the family is often central). If all that were needed was simple weight restoration, drip-feeding followed by a transition to solid meals to bring about a return to the target weight would be all that were ever required, and would always be successful. On both counts, it isn't.

As for the neurobiological evidence, I'm not aware of any that convincingly demonstrates neural abnormalities that predate and outlast semi-starvation.

Finally, note that the participants in the Minnesota Starvation Study without exception (as far as I'm aware) responded positively to the permission to increase their intake again during the refeeding phase, and all the problems experienced during this phase involved overeating/binge-eating rather than any significant reluctance to eat more or regain weight. Thus, although many of the other symptoms were a strikingly close match with anorexia, these participants did not manifest an 'intense fear of gaining weight or becoming fat', or 'persistent behaviour that interferes with weight gain, even though at a significantly low weight'; they did not have anorexia. This study has dramatically advanced our understanding of restrictive eating disorders, but we should remember that the volunteers did not develop anorexia as a consequence of their participation.

Most families I know do not

Most families I know do not want a professional eating disorder psychotherapist becoming involved in "family functioning." Sadly, about 70% of eating disorder professionals have a personal history of severe mental illness. When these professionals become involved in family functioning, therefore,they tend to create chaos and confusion. They do more harm than good. The best available research studies are showing that parents are generally achieving excellent outcomes for their children and teenagers with very little, if any, involvement by professional psychotherapists.

I don't think anyone is saying that weight restoration alone cures anorexia nervosa. What is needed is 1) weight restoration plus 2) re-establishment of normal eating behaviors. The second part is key; otherwise, if restrictive eating patterns are allowed to continue, the suffer simply reverts to a dangerously low weight, with all the medical and psychological harm associated with low weight.

The studies are inconsistent with regard to whether neural abnormalities outlast starvation. The weight of the evidence, however, suggests that the neurobiological effects of starvation are reversible with full nutrition for several months.

It is true that in the Minnesota Starvation Study the participants did not develop anorexia nervosa. However, the significance of the study is that the men did experience terrible psychological distress during the refeeding phase. See, They Starved So That Others be Better Fed, http://jn.nutrition.org/content/135/6/1347.full.pdf+html This can help us appreciate how difficult recovery is for those who suffer from anorexia nervosa. At the same time the Minnesota Study indicates that starvation itself causes most, if not all, the psychological symptoms of anorexia nervosa, and that full nutrition for several months is absolutely essential for recovery.

Professionals' personal history, parent-child questions, and the Minnesota study

I don't know of any evidence for your claim that eating-disorder professionals with a personal history of mental illness are less effective professionally than those without - and research on this would certainly raise ethical complications. Are you aware of any? I'd also be interested to know what studies you're referring to when it comes to parental input in the context of children's mental health. Are you saying that parents always do better than professionals when there's a mental-health issue to be dealt with? I assume not. But if not, I'm not entirely sure what it is you're arguing, since the claim that parents do better than psychotherapists when there is no mental-health problem involved would be meaningless.

I agree with all you say about the interactions between the nutritional, physiological, psychological, and neural factors. And that the MSS is a simply invaluable resource as far as detailed evidence on all of this goes.

Emily

In a famous study at Stanford

In a famous study at Stanford and the University of Chicago, sixty randomly-selected pairs of parents were instructed to use their own skills and judgment to determine how their teenager would recover from anorexia nervosa. The results shocked many people who had been assuming that parents were generally incompetent. After two years, 49% of the teens were completely recovered from anorexia nervosa, compared to only 23% in an alternative group randomly assigned to the mainstream, therapist-led treatments. I am not aware of any study that has achieved a success rate in the treatment of anorexia nervosa as high as 49% after only two years. Most of the studies of treatments by professionals are showing a remission rate closer to 25% after two years.
This is the evidence I had in mind when I wrote, above, that parents are generally achieving excellent outcomes with little, if any, involvement by eating disorder professionals.
You can read the full text of the paper at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038846/
My personal experience is that most eating disorder therapists tend to dilute the effectiveness of parent-led treatment. That is one reason many parents are choosing not to involve professionals in the care of their kids with AN.

You ask if I'm aware of

You ask if I'm aware of evidence that eating disorder psychotherapists with personal history of mental illness are less effective professionally than those without. I am aware of evidence that more than 50% of eating disorder therapists have suffered clinical depression at one time or another. See Warren, A qualitative analysis of job burnout in eating disorder treatment providers, Eat Disord 2012; 20(3): 175-95 http://www.ncbi.nlm.nih.gov/pubmed/22519896 Many of these individuals clearly continue to suffer from clinical depression while they are treating clients for eating disorders. I think most people would agree that clinical depression tends to make people less effective in their occupation. Therefore, a psychotherapist with depression will be less effective than one without.
My own experience as a parent was that most of the psychotherapists who treated my daughter for anorexia nervosa were depressed and ineffective. They provided little benefit, and charged huge amounts of money. That's why our family terminated most of them and put together our own plan for how our teenager would recover. This approach worked well. After years of ineffective treatments by ineffective providers, my daughter recovered. She has been free of anorexia for about seven years.
I don't understand why you say that research in this area would raise ethical complications. What complications do you think would be raised?

I disagree with Mr. Berezin's

I disagree with Mr. Berezin's contention that anorexia nervosa represents "suicidal" behavior. Suicide is the intentional taking of one's own life. The vast majority of people who suffer from anorexia nervosa, however, don't take their own life. Most don't perceive themselves to be ill, and generally don't appreciate the medical harm resulting from semi-starvation. In fact, one of the main symptoms of the condition is the sufferer's misperception. She thinks she is fine, even when she is starving.

Anorexia and suicide

I agree that many sufferers from anorexia fail to appreciate, at least to begin with, the severity of their physical state, but unfortunately there is plenty of evidence for the association of anorexia with suicide. A 2007 paper (Fedorowizc et al.: http://www.ncbi.nlm.nih.gov/pubmed/17607699) summarises the existing evidence, including the fact that the two leading causes of death in anorexia (with a total mortality rate of about 5.6% per decade of illness) are medical complications and suicide, and the results of a 1997 meta-analysis (Harris and Barraclough: http://www.ncbi.nlm.nih.gov/pubmed/9229027) which found suicide risk for anorexia increased 23 times above expected levels, higher than for any mental illness including depression. Fedorowicz and colleagues found a stronger association with suicide attempt or suicidal ideation in bulimia than in anorexia, but there are clearly profound associations here that need to be taken seriously when assessing risk factors for mortality in anorexia.

Emily, I find your comments

Emily,
I find your comments about anorexia very thoughtful and encompassing. I would like to mention several points. As I said before, once the process has taken hold it has a life of its own and needs to be dealt with as such. I have no argument there at all. I do not draw major conclusions from studies. I base what I have learned from clinical experience. I have treated every kind of character adaptation imaginable. Each one has a life of its own - gambling, alcoholism, drug abuse, overeating, sado-masochistic sexual practices, etc. Experts in each field have a narrow frame that addresses the particulars of the character solution. And they are correct as far as that goes. However, the real question of why certain individuals select one or another is a complicated question. I address this in my book, ‘”Psychotherapy of Character, the Play of Consciousness in the Theater of the Brain.” In short, each of us has a unique temperament which is a particular array of different attributes and is genetic, by which we process our environment all the way through our development. That environment is the actuality of responsiveness, deprivation, and abuse. Certain temperaments are drawn to certain of the problematic characterological solutions. The determining factor is the degree of problematic abuse or deprivation that our temperament has to digest. This is not a blame the mother thing. It describes the actuality of character formation. This is hard to present in shorthand, but developed more fully in the book.
Second, the subject of suicide in anorexia is complicated. It is not just a function of conscious intent, when the consequence of a behavior is death. I evaluated a patient in the hospital who had jumped from a fifth story window and lived. She said it was not a suicide attempt because she believed she was going to go up in her body to heaven. However, if one jumps out of a fifth story window, one is jumping to one’s death. Even though she believed her delusion, her behavior was specifically suicidal. She didn’t stand on the ground and go up to heaven. Her right hand did not know what her left hand was doing, but it was unerringly accurate as to its consequence. If anorexia is not dealt with, it results in death. The specific mechanisms of death may differ, but it will happen. It is intrinsically suicidal. Anorexia does not lead to flourishing and thriving. I agree that bulimia is different, (with a different temperament) and there is often more conscious suicidal ideation.
I can’t prove how central the formative issues are in Anorexia. And studies do not disprove it. But my clinical experience is clear. I don’t quite grasp why there is such hostility, pitting one idea against a caricature of another. We are all human and anorexia is no different from any of the other character adaptations.

Mr. Berezin's clinical

Mr. Berezin's clinical experience differs from that of other professionals. For example, there are many clinicians who specialize in the treatment of anorexia nervosa and have treated thousands of suffers. These specialists acknowledge that they don't see evidence of anorexia nervosa being the product of mother-daughter relationships or a problematic family environment.

I'm glad Mr. Berezin condedes he can't prove his theory. It actually does seem like a "blame the mother thing" to me.

I'm not "hostile" toward his theory. I just think it represents the old-fashioned theory of anorexia nervosa. It partially explains why treatments have historically been ineffective. Fortunately, the new models, such as Family Based Treatment (also known as the Maudsley model) are proving to be much more effective than the older ones.

Suicide and explanatory models

Belated thanks for your thoughtful reflections on these topics, Robert. What you say about the disjuncture between suicidal intent and behaviour is very telling, I think: in anorexia in particular, there seems often to be a complete disconnect between acting in a way incompatible with life, but nonetheless denying (to oneself as well as others) that what is being chosen is death. I suppose in theory there's no need for the trajectory of anorexia to be one of continual decline, but in practice of course it almost always is, both because metabolic rate tends to reduce as food intake does, helping cement the downwards spiral, and because the physical state deteriorates the longer one is underweight, even if intake and bodyweight remain constant.

More generally, I completely agree about the importance of getting away from counterproductive either/or models of mental illness that claim it's all genetics, all family, all physiology, or whatever. All these factors and more are clearly in play in all cases.

Emily

For me being hungry and the

For me being hungry and the denial/allowance of food still remains the absolute point in my anorexic experience - regardless of having a reasonable BMI. Added to this is the perverse pleasure of eating food from the bin, spoilt food, out of date food, leftover food etc...

Bodyweight and food waste

Yes, I think this is very common, and lots of people with anorexia do say that it isn’t really about the bodyweight for them, and much more about exerting control by resisting and then selectively acting on hunger. Though I think the potent kinds of associations that get established between thinness and a whole host of positive qualities, as I mentioned in this post, mean that weight/BMI is unlikely ever to be conceptually irrelevant. Though of course factors like a narrow focus on particular body parts can easily mean that overall BMI becomes less critical.

As for eating foods that others have rejected – yes, absolutely, this is just what I did too: hanging around the common room after everyone else had gone just to be able to rifle through the bin and see what they’d thrown away; never throwing anything away myself, however stale (though I did draw the line at mould, if it couldn’t be scraped off); offering to clear up so as to have the chance to ‘tidy up’ what people had left on their plates. It’s so interesting how powerful that simple biological mechanism of famine response remains, even in our complex societies of abundance.

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Emily T. Troscianko, Ph.D. is a research fellow at the University of Oxford, investigating what happens when we read fiction.

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