There is one finding about anorexia which seems to me more crucial to treating it successfully than anything else. It is a counterintuitive insight, but one that seems – like all the best facts – completely obvious once one knows it. It is this: that for someone with anorexia, regaining weight is the prerequisite for mental recovery, rather than vice versa. Put another way: you can’t make a person with anorexia want to put on weight until he or she has begun to do so. Put yet another way: the mind may make the body sick, but only the body can help the mind be well again.
This is not a new finding. More than seventy years ago, the so-called Minnesota Starvation Experiment, led by Dr Ancel Keys, showed how 36 robustly healthy young men all acquired eating disorders simply as a consequence of losing weight. The experiment was designed to increase understanding of human starvation, and to help guide the famine relief efforts of the Allies after the end of the war. The participants were all conscientious objectors, and pamphlets outlining preliminary results were used by many aid workers in Europe and Asia in early 1946. During the 6-month semi-starvation period, during which the volunteers’ intake was reduced to about 1560 calories a day and physical activities were also strictly controlled, they experienced severe psychological problems such as hysteria and depression, self-mutilation and hypochondria, and specifically eating-disorder-like symptoms: psychological ones such as preoccupation with food, reduction in sexual interest, social withdrawal or irritability and anger, vicarious pleasure in watching others eat, hoarding food, lack of concentration; and physical effects like oedema in the extremities, due to the large amounts of water consumed in the attempt to fill the stomach.
As starvation progressed, the number of men who toyed with their food increased. They made what under normal conditions would be weird and distasteful concoctions [. . .]. Those who ate in the common dining room smuggled out bits of food and consumed them on their bunks in a long-drawn-out ritual [. . .]. Toward the end of starvation some of the men would dawdle for almost two hours after a meal which previously they would have consumed in a matter of minutes [. . .]. Cookbooks, menus, and information bulletins on food production became intensely interesting to many of the men who previously had little or no interest in dietetics or agriculture. The volunteers often reported that they got a vivid vicarious pleasure from watching other persons eat or from just smelling food. (Keys et al., 1950, The Biology of Human Starvation, pp. 832-834)
During the refeeding stage of the experiment (3 months), the participants were divided into four groups, each receiving a diet of a different energy level and specific protein and vitamin levels. Many of the men lost control of their appetites and ate ‘more or less continuously’. Those who did lose control in this way reported feelings of self-deprecation, disgust, and self-criticism for having done so. After about eight months of refeeding, most men reported that their eating habits had normalised, although binge-eating continued to be a problem for a few. Participants did not, after the end of the study, eat and eat until they were obese: in general, they regained their original weight plus about 10% in the rehabilitation phase, and their weight then gradually declined towards the pre-experiment levels during the the follow-up period.
These men were chosen for their robust physical and mental health, and within a few months of a calorie-restricted diet they were, in physical and psychological terms, suffering from variously extreme forms of the symptoms associated with anorexia nervosa. To the body, it makes no difference whether starvation is self-induced or forced: when food is scarce, all mental and physical processes become directed towards the search for food, and all other human characteristics – sociability, sex drive, other interests – are subordinate to the fight for survival.
Numerous factors contribute to the start of an eating disorder, including genetic predispositions, upbringing, social experiences, and cultural expectations, but it is not necessary to unpick all these complex influences for recovery to occur. Understanding of possible causes can happen later (and will never be total). The most urgent requirement at the start of treatment of anorexia is that weight be regained.
Current therapeutic treatments for anorexia work best when they incorporate this insight. The form of cognitive behavioural therapy which helped me to recover insisted on the importance of reaching a BMI at which the body can come out of starvation mode. My therapist drew a line at 19 on the graph of my weight gain, a line I never believed, at the start, that I would reach, and certainly never believed would change anything, even if I did. But as my weight came closer to that line, the obsessiveness, the inflexibility of thought, the physical effects of starvation, and all else that had been predicted to diminish, did so.
Christopher Fairburn’s Cognitive Behavior Therapy and Eating Disorders (2008, Chapter 11) describes how some of the effects of being underweight contribute to maintaining the eating disorder: being preoccupied with food and eating, becoming socially withdrawn and losing interest in other things. Becoming indecisive, feeling a heightened need for routine and predictability, and feeling heightened sensations of fullness after eating, all help create vicious circles in which the only way to avoid mental or physical discomfort in the short term is by keeping on starving, but the only way to escape these problems in the long term is to regain weight.
Fairburn also emphasises that while sufferers from anorexia will be convinced that their present state reflects their personality, in fact their personality is masked by the effects of being underweight and will emerge again only if weight is regained. People with anorexia sometimes fear that they will stop being ‘special’, or stop knowing who they are, if they regain weight, but of course there is nothing special about being severely underweight, and ‘who one is’ shrinks towards nothingness: as the months and years of undernutrition drag on, one becomes more and more the same as everyone else who is severely underweight, more and more defined by the same habits and traits that arose and then disappeared again in the brave men who participated in the Starvation Study. Much of your character remains hidden when the body is starved, but much of it is there waiting to be rediscovered when you start to eat again - and much else can be constructed afresh without harking back directly to what existed before anorexia (see my post on constructing a character after anorexia, here).
There are two facts of key importance to the sufferer who is aware of the bleakness of the way in which (s)he is living but cannot resolve to change:
1. If you regain weight, not only the physical qualities of your current state – being constantly cold and weak, having bad hair and skin, losing bone density and (for women) fertility – will disappear, but so will the ways in which you currently think and feel: poor (or dreamless) sleep and concentration, low mood and self-esteem, irritability, secretiveness, repetitive thought patterns with loss of flexibility and overview. Your body - which includes your brain - is starved, and your character and your thoughts are dominated by this starvation, and will cease to be so once you allow yourself to regain weight.
2. There is no point in waiting for the magical moment at which you decide, once and for all, that you want to start eating more again, or to regain weight. Your starved state is making you unable to think flexibly enough to fully comprehend the possibility of eating or living differently, or even the possibility of wanting to think about and enjoy things other than food; it has hidden from you who you really are, and made you believe you are nothing but the anorexia; it is making the smallest piece of food feel like too much. For these reasons you will never truly want to recover, but you have to seize all your feelings of despair, desperation, hope, recklessness, and curiosity in order to make yourself plunge into that first day and first meal of recovery. As long as you keep yourself going, keep eating, through the first difficult weeks, it will get easier and easier.
Recovery from anorexia is not easy, but it is simple. 'All' you need to do is eat, and keep eating till your BMI increases to the point that is right for you. This point is not determinable in advance with complete certainty, but as mentioned above (and expanded on in a separate post - see below), some amount of 'overshoot' will probably be important in achieving full recovery. If you regain weight, but stop before this point, the massive effort required will not be matched by equivalent gains in mental and physical health.
As the essential process of weight gain advances, there are the concomitant physical reactions and mental distress to cope with, but there are also mental changes – increases in the flexibility of thought, most notably – that make the physical changes ever easier to deal with. By the time your BMI is approaching the point you need to get to, so much will have changed that the number on the scales may not even mean much to you any more, and further progress may well be much easier. For me, I noticed vast improvements from around a BMI of 19, but my weight gain wasn't complete (my eternal hunger didn't finally leave me) until BMI 26. Stopping before then would have kept me in the holding pattern of depressed metabolic rate and heightened hunger, undereating to maintain a constant bodyweight, and preoccupation with food and body thanks to the combination of hunger and undereating.
For many people, this is as good as recovery gets, but it need not be. If you hold your nerve and continue until weight gain slows and stops of its own accord (because metabolic rate returns to normal), you will come out the other side: you will be a real person again, not just a starving creature.
This really can be done, one mouthful at a time. You’ll even begin, at some point, to enjoy it, and you will almost certainly never want to go back - and not just that, but you'll stop being able to quite believe that your life was ever reduced to such a narrow, dark-pale imitation of what it is beginning to be again now.
(**Update 2017: I've lightly edited this post to remove my previous prescriptiveness about the BMI at which initial improvement and then full recovery is possible. This is different for everyone, and it seems clear to me that much of the blame for the high proportion of sufferers who stay ill or soon relapse lies with the setting of generic target weights/BMIs in recovery. Not being able to name a number in advance is frightening, but also liberating: not living according to a number is part of what being over anorexia means. If you want to read more on the various key aspects of the picture I began to piece together in this post, please see subsequent posts on how and why to start recovery, how and why not stop halfway (including on the importance of temporary bodyweight overshoot), and changes to metabolic rate in starvation and recovery.**)
Fairburn, C.G. (2008). Cognitive behavior therapy and eating disorders. New York: Guilford. Google Books preview here.
Keys, A., Brožek, J., Henschel, A., Mickelsen, O., and Taylor, H.L. (1950). The biology of human starvation (2 vols). Minneapolis: University of Minnesota Press. Amazon preview here.