"But she's not that skinny!"
This is a comment I've heard over and over, in the last five years, from well-meaning friends and neighbors. They've been talking about my daughter Kitty, who was diagnosed with anorexia at age 14, recovered, relapsed at age 18, and recovered again.
These friends and neighbors associate anorexia with being too skinny. And for good reason: Until now, one of the diagnostic criteria for anorexia nervosa has been an inability to maintain at least 85% of "ideal body weight," which of course is a mushy concept in itself.
That's changing with the next edition of the DSM-V, the diagnostic bible of psychiatric disorders. The committee in charge of looking at the criteria wisely decided that a cutoff of 85% hurt more people than it helped. It kept people from being diagnosed with anorexia if they weighed half a pound over the 85% cutoff. It also meant that the diagnosis of anorexia nervosa could come only late in the game, once a patient was deeply afflicted and affected. It made it impossible to officially catch, diagnose, and treat someone who hadn't quite tumbled down the rabbit hole yet. Because by the time someone has lost 15% of her ideal body weight, she's very, very ill. If anorexia were staged like cancer, we'd be talking Stage III. Or more.
Where the weight issue really gets confusing is when someone is in recovery. I'm thinking, with great sorrow, about a young woman from Iowa named Krista Phelps, who died last May from anorexia. Krista was a runner, a high school athlete who'd been diagnosed with anorexia ten months earlier. At the height of her illness, she'd lost about a quarter of her body weight.
Her parents got her treatment, and Krista gained weight—not back to her earlier healthy weight, but enough so that she was not in immediate danger. Or so the doctors thought.
In photographs taken shortly before she died, Krista Phelps looked OK. Not super skinny. Not skeletal. Not anorexic in the way we've come to associate with the disease. But she was still 20 pounds too light when she competed in a state track meet, placing sixth in the discus. Two days later, she collapsed and died from an electrolyte imbalance on a training run.
I didn't know Krista Phelps, but I know that when she died, she was still very much in the grip of the illness. I can guess that in her head as well as in life, she counted every calorie and ran more miles than she was supposed to, to get rid of as many as possible. I can guess that she was anxious, driven, haunted by obsessive thoughts about what she ate, what she looked like, whether and how much she ran.
But you couldn't have known that, looking at her—and by you I mean any one of us. You might have looked at her and seen just another athlete in top shape, without an ounce of fat on her body. You probably would have admired her physique, her strength, her determination and her athletic prowess. You would have had no inkling of the mental and emotional torment she was going through.
Part of the issue is that we are, all of us, used to looking at bodies—especially the bodies of women—through the distorting lens of our culture's emphasis on the unattainable thin ideal. When your eyes are accustomed to seeing images of young women who are five-eleven and weigh 110 pounds, it's hard not to see everyone else as "not that skinny." When you're used to seeing protruding hipbones and images where every lump, bump, and wrinkle has been Photoshopped out, it can be hard to recognize when someone's too thin.
When it comes to anorexia, physical recovery is only the first step. It takes time at a healthy weight for the brain to heal and the disease to recede and disappear.
Krista Phelps didn't get that time, sadly. What happened to her is a tragedy. No one should die from anorexia or bulimia. And no one should presume to judge someone else's health by looking at them.
Harriet Brown's new book, BRAVE GIRL EATING: A FAMILY'S STRUGGLE WITH ANOREXIA, will be published later this month by William Morrow.