Anorexia is strange in making people who suffer from it defend, glorify, and cherish it—at least some of the time. It’s hard to think of another illness where ambivalence about recovery is so universal and so profound. The ambivalence is not static, though. It shifts as the illness progresses and as time passes.
Anorexia is an illness from which full recovery is possible. (As opposed to, say, a condition which can typically only be managed, not recovered from, like schizophrenia, bipolar disorder, or blindness.) But it’s one of very few from which sufferers often spend a lot of their time not wanting to get better. In this it’s quite different from, say, depression, the anxiety disorders, or obsessive-compulsive disorder, which people tend to hate and long to be rid of. Many people with anorexia will even resist the term ‘sufferer’, because at least some of the time, suffering doesn’t feel like what they’re doing—and/or they won’t admit to themselves or others that it does.
Ambivalence has long been a focal point in eating disorder research, not least with the practical aim of reducing ‘treatment resistance’. Sometimes it’s been considered a relatively superficial factor, depending on things like phase of illness or quality of care. Sometimes it’s seen as a more fundamental part of all eating disorders, intimately bound up with sufferers’ characteristic confusions of illness and identity, for example. (See Eli, 2014 for an overview and references.) In this post I’ll tread a path between these two perspectives, suggesting that there’s nothing superficial about the ‘phase of illness’ factor: that the lifespan of anorexia involves two profound though usually gradual shifts, from the honeymoon period to the bargaining period, and from that to the phase of separation.
I’ll draw in particular on research just published in Transcultural Psychiatry, in a special issue ‘Anthropological perspectives on eating disorders’ edited by a colleague at Oxford, Karin Eli, and Megan Warin from the University of Adelaide. Anthropology is the study of humans and human behaviour and societies. This anthropological take on eating disorders centres on in-depth interviews and takes the nuances of individual experience and personal and cultural contexts more seriously than happens in most biomedical or psychiatric research.
This is the kind of research we need to help us understand better what helps eating disorders take hold, and what keeps people clinging to them and either refusing treatment, withdrawing from it, or relapsing after it. We need it in conjunction with larger-scale controlled experiments which get at cause and effect in ways other than self-report. Both matter, because while most experiments in this field neglect individual experience in the search for causal patterns, interview-based studies can risk taking participants’ retrospective narratives of cause and effect too much at face value. Each is an important corrective to the other (and we need more studies that combine the two methods in creative ways), but here I’m giving space to the personal voices. Please bear in mind, though, that humans are consummate storytellers in the widest sense of that word, and that what we can’t make sense of, we try to, and what we feel uncomfortable about, we try to justify. Still, the specific ways we explain and justify reveal a lot too.
The papers I’m drawing on here encompass the full range of eating disorders, and many of the points I’ll make in this post will apply beyond anorexia (not least because most people transition at some point from one diagnosis to another). Nonetheless, my main focus is on anorexia, where I feel most confident in commenting.
As I explored in this post, one of the metaphorical structures people often use to think and talk about their eating disorder is personification of the illness (a devil on the shoulder, a whispering voice, an invading identity). Having anorexia often does feel like having a dysfunctional relationship, and the dysfunction changes: usually, from mistaken infatuation to fearful collusion in abuse, and sometimes, finally, to still-fearful but determined escape from the relationship that gave you something but took far more from you.
To begin with, then, there’s the infatuation: the rose-tinted time when there’s more that feels good than feels bad. The bad stuff takes time to kick in, and to be noticed and accepted and understood, and by the time all that happens, the mental and physical habits of illness may have made anything that isn’t this illness too frightening to unequivocally long for.
Perhaps not everyone has a honeymoon with anorexia, but most people do. The real honeymoon may arguably sometimes be the period before anorexia could actually be diagnosed: before your weight has got critically low, before the thoughts and behaviours get too obsessive and too distorted and distorting. But unlike with marriage, the transition from honeymoon to ordinary life isn’t as clear as a flight home and back to work on Monday morning. Rather than ending, it mutates into a darker, more enduring version of the apparently happy beginning. Fragments of how it once felt cling on right into the depths of illness and even, often, far into recovery. These, combined with the dependencies those early gratifications helped entrench, keep determination to recover from ever feeling complete.
The shapes of anorexia’s half-lives have commonalities between individuals as well as differences. Here are six common ways that anorexia makes you like falling ill, and staying that way.
1. Anorexia as anaesthetic: Making everything else matter less.
For many people this may be the key to how anorexia takes and keeps hold. If you’re hungry almost all the time; if you rarely think about anything but food, exercise, and your body; if your emotions are dampened down to a uniform depression—then the rest of the universe dwindles in the periphery. And because the universe is vast, incomprehensible, and meaningless, this can mean everything. Anorexia offers one solution to the ancient human question of how to bear the extent of the world’s horror and cruelty and idiocy. Some sufferers describe it as retreating into a numb and protective ‘bubble’, or erecting a ‘screen’, or inserting a delay, between you and reality (Eli, 2018). Others speak of it explicitly as an anaesthetic:
Abigail likened being in treatment to ‘having an anaesthetised limb cut off.’ She said, ‘it’s better to keep it anaesthetised so it doesn’t hurt. That’s why people continue to be anorexic, so they can remain anaesthetised.’ (Lavis, 2018, p. 460) [all the names given in the papers I quote are pseudonyms]
The anaesthetising happens through the neat dual mechanism of
- not eating enough (which brings first the distraction of hunger, then when extended long enough the change of normal hunger into something either more euphoric or just more gnawing) and
- constantly thinking about or performing rituals around food, exercise, and the body (which leaves no room for anything else).
Some people even describe deliberately letting their thoughts fill with food to make themselves frightened: they allow food to come ‘too close’ for comfort, and so anorexia ‘rises up’ all the more powerfully—and brings in its wake the desired numbness, zoning-out, or diffuse buzz (Lavis, 2018, p. 461).
Starving yourself is no better a solution than most other mind-and-body-altering habits (opiates, sports, religions) taken to extremes, since it shares their common structure: anaesthetising the embodied mind to what it cannot bear, or doesn’t believe it can bear. Self-medication is arguably where most addictions begin (Khantzian, 1985, 1997, 2017), and by definition it works for a while. But drugs always wear off, and if nothing meaningful changed while or after you were on them, and if you are taking them not to enhance your life but to endure it, you’ll need to keeping taking them, usually more of them, to get the same effect, and gradually you’ll end up replacing the pain you were trying to avoid with damage you can’t.
For some, the feeling of needlessness that anorexia may bring seems irresistible because of disempowerment in other realms. One woman who has suffered six years of alternating anorexia and bulimia compares her eating disorder with defiance of the father who beats her. Disconnecting from the world through hunger and ritual is, Dalia says, like approaching her father and saying, ‘hit me’.
You’re having a relationship with your eating disorder, you’re not having a relationship with the world and you don’t care about the world… you don’t need food, you’re not dependent on anything, and you don’t care about pain. My dad used to slap me, no big deal. I came to him—this is what I did to make it stop—I came to him and said, hit me. Why? Because if I had allowed him to hurt me and I would stand [by] and say to him, okay, I don’t care, hit me—[it’s] emotional disconnection, so he doesn’t reach his goal, he doesn’t control me. (Eli, 2018, p. 483)
For Dalia, seeking out the suffering of illness is like coming and asking to be hit: It lets you disconnect from the pain, by taking control of it. Whether through eating too little or through bingeing and vomiting, being ill is, for some people, a way of standing and saying to a society that oppresses and hurts you, I don’t care, I don’t need anything from you. The less you need, the less anyone can hurt you. Except, of course, that you continue to be hurt, even if it means less to you now.
Whether or not it arises out of abuse, finding a way to care less is a widespread longing. In anorexia it is satisfied, temporarily and precariously, by:
- Hunger, or the or the dopamine-mediated ‘hunger high’ (Bergh and Södersten, 1996), drowning out other sensations and emotions
- The starvation-induced depression lowering mood, reducing mental and physical energy, and eroding your capacity for nuanced emotional responses
- The radical decrease in time and energy for things unrelated to food, the body, and exercise (and possibly work or study) thanks to obsessive-compulsive thoughts and rituals
- The near-impossibility of meaningful engagement with other people’s joys and pains thanks to (1)-(3)
2. Anorexia as Rosetta Stone: Giving you readymade meaning.
One important way the everything-not-mattering comes about is via the system anorexia provides for meaning-making and decision-making. Humans spend all their lives interpreting stuff, and the world is overwhelmingly complicated and unpredictable (it has, in a technical sense, high entropy) (Hirsh, Mar, & Peterson, 2012). Choosing, and negotiating, weighing up, and wavering between interpretive frameworks is something we expend a vast amount of energy on, whether in relationship gossip, sports commentary, politics, academic research, or religious belief. If you find a way to make one thing in the world more significant to you than anything else, with absolute reliability, then you massively reduce the unpredictability of your life: your interpretations and the actions that flow from them are always already pre-determined. And rigid routines accrete around these interpretive structures to make new sources of unpredictability less likely to emerge.
In entrenched anorexia, feeling hunger doesn’t mean asking the question should I eat?, it means ignore until the preset time I always eat. Getting a social invitation doesn’t mean asking the question should I go?, it means say no. And so on. Right up to the point where the obvious danger of dying or of living half-dead forever doesn’t mean should I recover?—until it does.
You may be unable or unwilling to articulate the (often metaphorical) meanings of anorexia for your life, but the unquestioned fact of having them can make up, for a surprisingly long time, for their inability to stand up to scrutiny once the questions start.
3. Anorexia as gold star: Giving you top marks in the little things.
For most people, to begin with, there are also simple practical payoffs to anorexia:
- Not spending anything much on food or drink or doing fun things saves you money
- Not doing fun things means more time for work or study
- Losing weight improves self-confidence as compliments and sometimes sexual attention reinforce the changes
In these respects, early or incipient anorexia is the thing that in small and initially satisfying ways cleanses your conscience. Spending less, working longer, and getting attention from other people who overvalue slimness don’t in themselves improve anything much. But they give you that private smugness of knowing you’re doing ‘better’ than other people, or than you used to.
More profoundly, the early phase of illness may give you the existential comfort of allowing yourself to believe you’re irreproachable. Particularly if you were ‘overweight’ as a child and maybe teased or bullied or criticised for it, thinness and the habits that create it might become a potent way of escaping attack—first by attracting compliments instead of condemnation, later by pulling you further away from where any of that can touch you.
Hunger itself, the sensation at the centre of it all, can quickly become tightly bound to the feeling of being beyond reproach. Eli interviews a woman, Hadas, whose father ‘waged war’ against his own weight gain, whose parents constantly pressured her to lose weight, and who complimented her on her weight loss when she first developed anorexia eight years ago, until it went clearly ‘too far’. Now in recovery from bulimia, she continues to experience hunger as something infused with positive meaning:
‘Hunger is a good sign’, she said. ‘I’m hungry. I’m ok. I’m empty’. When I asked her what there was in that emptiness, she responded,
‘I’m ok. No one can blame me that I ate. Here, I know. I’m empty, I’m ok. Like, my body’s empty. I didn’t eat. Like, it’s simply a proof. And no one can tell me anything, like, no one—I’m not what all of you think, I’m not the child who eats all day. I don’t eat and I’m—I’m not like all of you. You eat, like, you’re disgusting. I’m different. I’m, like, empty, I’m floating above the surface of the earth… I’m not contaminated with all sorts of disgusting foods.’ (Eli, 2018, p. 484)
The association of purity with hunger or dietary restriction is fed by the chain of (self-)oppression that perpetuates through that dripfeed of comments and criticisms, and it’s gleefully preyed on by the diet industry (or rather, by the countless individuals who constitute and collude with it). The ‘clean eating’ disguise is one its currently most popular, but its origins go far back to the rituals of saints and other world-fleers through the ages.
the boys are allowed to eat, they’re my age, but it’s forbidden to me, it’s forbidden to take another biscuit, because I’m—I’m a girl, I’m a woman. It’s shame, shame, shame. (Eli, 2018, p. 486)
For Mirah, bingeing and purging became a fully embodied form of rebellion against everything that tried to control her and make her smaller and more ashamed.
4. Anorexia as halo: Making you feel special.
The elusive feeling of being irreproachable bleeds into the territory of the fourth of anorexia’s apparent benefits, which is all about the sense of release or pleasure or safety that comes from specialness. Most of the post-industrial world is apparently fixated on weight loss as a solution to all life’s problems, or a convenient way of ignoring the actual problems. This means that losing too much weight, or being seen to lose weight ‘too easily’, guarantees a certain status. The kind of shame involved in saying you’re anorexic is a very different shame from that entailed by saying you’re bulimic, or obese, or an alcoholic: shot through, often, with something closer to the opposite. For some, there’s a feeling of ‘laying claim to a title’ in managing to eat little enough, become thin enough, become infertile enough, to attain the status of a diagnosis (Eli, 2014, p. 4). The hesitation between feeling that anorexia makes you special (because so many people don’t have it) and knowing that it makes you banal and predictable (because so many people do) can, as it did for me, come to a head at the moment when a diagnosis is first formally given.
When so much human energy is squandered on the anxiety of trivia, anorexia offers a way to exempt yourself. It’s a steel-clad reason not to need to engage in the meaningless fretting about the kinds of dresses you will or won’t look fat in, or the relative merits of the ice cream and the number on the scale in the morning, or the latest pseudo-scientific study of the health risks of chocolate-covered Brazil nuts. As I described earlier, you’re off in a different realm where the questions everyone else seems to torture themselves with never even get asked, where control over everything about your food and your body has unquestioned primacy, where other people can be distantly pitied or despised. At least until things get too visibly severe, you seem to have this one thing everyone appears to care about sorted—that thing crystallised in the appearance of a body with the ‘right’ amount of fat in the ‘right’ places. And, just as for them aspiring to that lets them pretend it’s a solution, so for you achieving it does.
Of course, none of this means you’re actually able to float high above the hoi polloi with Sartre or Kant, because your brain doesn’t work any better than the rest of your body, and your entrapment in trivia is actually far more profound than for the people who gossip about diets but then also forget about them. But they don’t know that, and you probably don’t care any more.
5. Anorexia as hunger strike: Letting you be other than what you’re expected to be.
Sometimes, those around us make us suffer in ways far worse than slow poisoning through shared insecurity. Anorexia can emerge as a way of resisting suffocating norms. For women and girls who suffer sexual abuse, self-starvation is an (often futile) way to try to make the body safer from male aggression in the future. For women trapped in repressive social environments where nothing is expected or permitted of them but marriage, childbirth, and motherhood, obstructing fertility can be one of the only acts of resistance available to them.
In this sense, anorexia may bring about a disintegration of identity, but because personal identity was so constricted and distorted long before its emergence, it’s also the potential for identity creation—whether in relation to other people with anorexia on treatment wards or more autonomously.
This logic isn’t limited to overtly abusive oppression, either: If the ordinary structures of our only available models for ordinary life feel more like a conveyor belt than an adventure, the cost of many kinds of painful leap off the production line may seem worth it. Adi, an Israeli woman who had bulimia for nearly a decade, describes the trap:
There’s a crowd like that, that invented a method, that invented stages in life… go to primary school, go to high school, serve in the military, get out of the military, start—make a trip abroad, get out of the trip abroad, start studying [in university], get out of the studies, marriage, family, ageing, divorcing, it’s like everything—is very very structured. (Eli, 2018, p. 482)
There are many more creative, happier, lastingly interesting ways of breaking free from constricting social, familial, and professional expectations—of being abnormal, in whatever culturally contingent ways you choose. But many of them are less accessible the more complete the constriction. Sometimes the apparent simplicity of refusing it all by refusing food is the only response that seems available.
6. Anorexia as partial suicide: Letting you live.
Where much of this culminates is in the fact that for some people, some of the time, anorexia feels like the only way to stay alive—at the same time as being the closest they can come to death. This paradox of seeking deathliness within life shares the same structure as self-harm: You hurt yourself enough to relieve the pain of living, to forestall the urge to harm yourself enough to die. Of course, they both tread a knife edge: Flirting with death to escape it sometimes ends up taking you right into its arms.
The notion of anorexia as ‘a quiet suicide’ (Eli, 2018, p. 487), or the thing that at once destroys and saves your life, is a crystallisation of most of the rest of its allure, from the anaesthetic to the resistance. Kinneret, who has spent much of her life in closed psychiatric wards amongst victims of abuse, and who like many of them has attempted suicide, describes the existential compromise that is anorexia:
There’s a life you don’t want to live, and there’s death, and there is, in the middle, one bubble which is life, but is not life in the world where you don’t want to live, and is not death. And it’s in between. On the one hand, you live a little, live this life of this world, [and] on the other hand, you’re going in the direction of annihilation—annihilating all the, all the bad things you’re sure are inside you. (Eli, 2018, p. 487)
If anorexia is about the processes of making live liveable precisely through its near-unliveability, then treatment needs to take seriously the coping mechanisms that are being dismantled, and acknowledge the possibility that replacements will need to be found. My recent posts on the Mando method (here and here) convey a pragmatic sense that if you take care of the eating behaviours, everything else will sort itself out. And the impressive solidity of their evidence base suggests there’s a lot of truth to it.
But for those who don’t recover successfully and lastingly with this method, and for all those who never get anywhere near accepting this kind of treatment for reasons like those I’ve explored here, other wider, deeper changes may need to be nurtured alongside the simple eating-behaviour ones. An eating disorder often induces and exacerbates psychiatric problems of other kinds (anxiety, low self-esteem, starvation-induced depression, obsessive-compulsive habits, etc.), but the claim that eating disorders are always just ‘dieting gone wrong’, and that persistent psychological difficulties never underlie them, is as false as the counterclaim that they are always mere symptoms of something more profoundly wrong. Sometimes the prior problem, where there is one, may be a diagnosable disorder in its own right: I have a friend who always used to say that her eating disorder was the only thing she’d found that made her depression bearable. (She finally decided the eating disorder was itself not bearable, and she’s now happily recovered from both.) But even if the preceding problems aren’t diagnosed disorders, they may remain substantial obstacles to real recovery if not taken seriously.
If the essence of living with anorexia is always some kind of deep compromise, compromise often becomes the structure of recovery: shifting the balance just a little away from dangerous underweight, but not enough to change anything else very profoundly. Many people get stuck in a partially weight-restored version of anorexia at some point in recovery, and most people find it almost worse than the depths of incontrovertible illness. The logic of anorexia is deadly, so survival with anorexia is always an in-between: in between death and recovery, somewhere in the muddy no-man’s-land of chronic damage control. But maybe when the compromise becomes too glaring—when you’re no longer thin enough to look obviously ill, when you start to feel glimmers of the interests and joys that pull you back towards life, when your mind works just clearly enough to see the inadequacies on all sides—the old allure loses its power.
This doesn’t mean the fear of change ever goes—not until you act and keep acting despite it. But most people, in the end, realise that although anorexia was something they once felt they needed and therefore wanted, at some point it has stopped being. Many even intuit this in the depths—or at the precarious height—of illness: saying ‘I want to keep my anorexia for now’, already putting an undefined time limit on it.
Whether finding that for now is over happens more often because the misery that prompted it has gone or lessened, or because the solution has stopped working, or whether it’s almost always some form of both, in the end, I don’t know.
Lacey, who had a difficult relationship with an alcoholic father, says that in the end, after years of anorexia, she woke up.
‘I think I’m … I’m too awake to it now for it to be as good as it was.’ As her ties to anorexia loosened she said, ‘I feel like I’m starting to taste other ways to live.’ (Lavis, 2018, p. 469)
When we awake from restless sleep and remember what it is to taste again, then it’s over.
All of anorexia’s solutions come with expiry dates. The hunger high tends to degenerate into chronic gnawing unpleasantness. The depression embeds itself to make life feel nearly unbearable. The obsessive-compulsive rituals brook ever less resistance. The money in the bank loses meaning (or is eaten away by the costs of illness). The friends you once had drift away. The compliments cease. The thinness is way past attractive. The specialness reveals itself as nothing more than the winning of a competition whose prize was misery. The utter predictability of anorexia is a greater terror than the universe’s unpredictability. And the universe stays how it always was, except now made just a little bit more miserable by your misery.
The time it takes to experience and acknowledge all this may be months or years or decades. Usually, unless the decline is very rapid, it’s more than months. At some point, you step at last from believing you’re in love to fearing to escape. That may not feel like progress, but it is.
That step does not flip a magic switch that eliminates the ambivalence; waiting for that makes many people wait till they’re dead. But it tips the balance slightly in favour of all the accumulated reasons against, away from those for. It creates the potential for the loops of feedback between mind and body to switch from vicious circles to self-perpetuating progress out of illness. And it’s the gradual, cumulative, tightrope nature of this progress of questioning and awakening that makes the mantra of early intervention questionable for anorexia, I think: Being ill for longer may make real recovery more likely, not less. For a few people, the high will be brief and the come-down swift. For most, it all takes longer and is muddier.
Some profound questions about definitions and interventions arise from all this, especially:
- How to pinpoint where illness really begins, or predict whether it’s going to: how to detect the differences between, for example, weight loss that’s done healthily and never leads to illness (indeed might improve health) versus the weight loss that is the start of an anorexic honeymoon. There are no hard-and-fast rules for telling the difference, for yourself or for others.
- How to decide (for example as a doctor, therapist, or family member) whether someone’s (proclaimed) reasons for having become ill justify their (equivocal) desire to stay ill. Everyone’s pain threshold is different—or at least, we can’t ever know that it isn’t. Who are you to say that someone else must be what you call miserable instead of what you call ill? Or, how much confidence do you have that after their illness will come happiness not more misery?
These are questions that apply beyond anorexia and eating disorders to the study and treatment of all addictions—and all life choices.
But if it’s you who are ill, or addicted, or halfway to either—keep questioning.
Keep asking yourself: How would it be if my life were otherwise? Keep exposing yourself to rich and varied prompts to imagine how it might be.
Remember that once it’s time for change, the thing you have to do first is very simple, and within your power: start eating more again, consistently, until things begin to loosen and shift.
Remember that you can bear more than you think you can, and that many pains are lessened or dissolved by stopping resisting them, and simply watching them be.
Remember that once you work your way free from this, you will have learned more about your body and yourself than most people ever have to, and that that knowledge will make you wiser, calmer, and happier than you dreamt possible.
And above all—if the honeymoon is for now still feeling glorious, remember that the marriage will destroy you if you don’t destroy it. The only question is when you’ll realise this, and how much will by then have been lost.
Bergh, C., and Södersten, P. (1996). Anorexia nervosa, self-starvation and the reward of stress. Nature Medicine, 2(1), 21-22. Direct PDF download here.
Eli, K. (2014). Between difference and belonging: configuring self and others in inpatient treatment for eating disorders. PloS ONE, 9(9), e105452. Open-access full text here.
Eli, K. (2018). Striving for liminality: Eating disorders and social suffering. Transcultural Psychiatry, 55(4), 475-494. Paywall-protected journal record here. Full-text preprint available via the ORA, the Oxford University Research Archive [the PT platform won’t accept the url, but a Google Scholar search will take you to it].
Khantzian, E. J. (1987). The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. American Journal of Psychiatry, 142(11), 1259-1264. Open-access full text here.
Khantzian, E. J. (1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4(5), 231-244. Direct PDF download here.
Khantzian, E. (2017). The theory of self-medication and addiction. Psychiatric Times, 34(2). Full text here.
Lavis, A. (2018). Not eating or tasting other ways to live: A qualitative analysis of ‘living through’ and desiring to maintain anorexia. Transcultural Psychiatry, 55(4), 454-474. Paywall-protected journal record here.