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Anorexia Nervosa
Recovery from Anorexia: Why the Rules *Do* Apply to You
Anorexia and the illusion of individualism
Posted August 12, 2014
Anorexia is full of paradoxes. People suffering from anorexia starve themselves yet feel nausea at the thought of eating, are fascinated and repulsed by watching others eat, compare themselves constantly with other people while being profoundly self-absorbed, combine apparent invincibility with obvious weakness, treat hunger as the definitive proof of control and the ultimate danger of losing every last vestige of it. These paradoxes aren’t inexplicable mysteries; most derive directly from the feedback loops that are established in starvation between mind and body. Nonetheless, they’re certainly arresting as psychophysiological phenomena. And one that strikes me particularly often and forcefully in messages and comments from readers is the paradoxical prevalence of the assertion of uniqueness: everyone (my past self included) thinks they’re the only one who doesn’t fit the mould.
The most common, and the most pernicious, context for this kind of conviction is the progression of recovery: because of such-and-such in my past or present, my future will not pan out the way it’s meant to / the way the doctors tell me it will. ‘Because I was overweight before the onset of my anorexia’, for instance, ‘I don’t think weight gain will stop at a healthy level for me’. Or, ‘because I’ve regained so much weight so quickly despite having added hardly anything to my diet, I must be on track to get morbidly obese’. Or, ‘I was always small as a teenager, so I think my natural BMI is only about 18-19’. Or, ‘because I’m not very severely underweight, I don’t think overshoot needs to happen for me’. Or, ‘because I’ve been so ill for so long, I’ve ruined my metabolism and it’s never going to normalise’. The danger comes because this kind of reasoning tends to result in the conclusion: real recovery is too much of a risk. (In practice, this belief reduces to either ‘I’ll end up overweight again if I’m not careful’ or ‘I don’t need to gain much/any more’. And both of these in turn reduce to the same action: eating less than is needed to really recover.) To this extent, the conviction of specialness just one of anorexia’s many clever tricks to keep one trapped.
Given the kind of illness anorexia is, it isn’t surprising that issues of bodyweight and metabolism take centre stage in this habit of thought. But worries about metabolic normalisation or the plateauing of weight gain are just one thread of the broader fabric that is the illusion of individualism, a fabric crucial to the phenomenology of anorexia. One way that anorexia sustains itself psychologically in (as far as I can tell) the majority of cases is through the illusion either that anorexia (or starvation) makes one special, or that because one is special/different one has to starve oneself – or an unscrutinised combination of the two.
There’s a bit of truth to both: risk factors for anorexia include perfectionism, low self-esteem, depression, anxiety, and a history of abuse, so sufferers may be in some senses ‘different’ before they develop anorexia. And from the other side too, anorexia does in a certain sense make you special: at least, it makes you abnormal. In anorexia, after all, one survives on less food than is adequate to maintain a healthy bodyweight and optimal physical functioning – in practice, on less than other people might think is possible. In anorexia, one feels hunger but doesn’t act on it except very selectively – more selectively than other people might think lastingly possible. And positive value judgements are very easily attached to both these abnormalities. Indeed, one of the trickiest things about recovery is that because the Western social norm is now overweight, thinness – even extreme thinness – has social cachet, so rejecting illness means relinquishing that too. But in a far more profound sense, of course, anorexia strips you of specialness, of difference, of individuality: it reduces you both to a pale imitation of who you used to be, and to a dreary likeness of all the other men and women who starve themselves as you do, without quite knowing why.
The moment of realising this reality often comes quite early on, because anorexia is often characterised by high levels of self-insight. And the realisation can be potent, painful, and revelatory. But anorexia is also usually characterised by a long-lasting gulf between insight and action on that insight: that is, the revelation is often not enough to galvanise change. I began to grasp the agonising banality of what I was doing on the day I was first diagnosed with anorexia, aged 17, at the end of my first session with a child psychiatrist, together with my parents:
It wasn’t as bad as I’d feared. He asked lots about our family relationships, about the origins and development of the problem, about how I felt – at the worst times and now – about my weight… everything really. And he listened and seemed to care […]. One thing that stands out from this morning – when the guy said, ‘I’m in no doubt that you are suffering from anorexia nervosa.’ No one had ever said it so calmly, categorically, irrefutably. In some ways it was a relief, but it scared me that he was obviously so familiar with all the symptoms I was describing – it made them more normal and therefore took away one of my strongest weapons against them. (20 May 1999)
I felt relief because I was understood, but I also felt fear because that understanding robbed me of the illusion of uniqueness. There was no heroism in fighting all those symptoms of a starving mind and body if the fight was one that whole dreary battalions of other pitiful adolescents were fighting at the same time; whether or not I survived, there was no glory at all in being just like them. This must be one of the most powerful effects of being diagnosed with any mental illness: forcing you to acknowledge that you are part of a group - whether that shared identity feels a release or a trap or both at once. You are forced to accept that how your mind is working or not working isn’t just you, but can be classified in terms of a shared and predictable set of psychophysiological features. You fall into a diagnostic category. In anorexia in particular, because of all the sociocultural currents that eddy around thinness and self-denial, the jolt of coming to realise this can be quite abrupt.
This isn’t to say that for me, the diagnosis changed anything fundamentally or lastingly. I did manage to regain some weight, but only temporarily. And indeed I don’t think the realisation sank in properly till a year later, when one day I visited my psychiatrist again:
A lazy day – the one burst of activity was cycling to the hospital for my appointment with Dr S., who seemed much reassured by my weight and reports of post-dinner chocolate-eating. We had the shortest session yet – less than half an hour – and we’re to meet again in two months’ time. It’s reassuring to me too, to go there and compare my state to how I was eighteen months ago – I feel in control now, and it’s not an illusion anymore. What brought my relief home to me was the smallest thing – he opened the door to the ‘weighing room’ without knocking and there was another teenage girl in there on the scales, her doctor peering anxiously over her shoulder – and the utter ridiculousness of it all overwhelmed me: we all think we’re so new and special and important, we stupid anorexics, but we’re not, we’re among millions of women equally self-centred and short-sighted, and it’s not a clever thing to do. It doesn’t make you special. It makes you a tormented bony creature perched on a weighing scale. (21 June 2000)
Something about the visceral visuality of this moment affected me more violently than anything had before. This, I realised, was where an addiction to hunger really leads: not to any alluring airy ethereal realm beyond the bodily, but to a weighing room in which you’re just one in a long revolving cycle of emaciated girls who look like you, think like you, understand and fail to act like you.
This too, predictably enough, wasn’t enough to change anything for real either. But from then on, the double vision of seeing myself from the inside and the outside, at once or in quick succession, was a permanent feature of my illness, shifting in and out of focus: now here I am, adding another gram of low-fat margarine to make it exactly 25 g, making sure it’s never one more or less, and now there she is, that strange intensely focused skeleton wrapped in dressing gown and cardigan, devoting all her energies to margarine when she could be – well, I rarely got that far. Eventually I learnt to laugh at that strange creature, and that took away some of the power of her all-consuming obsessions, but that took years more, and meanwhile I stayed somewhere in between being in thrall to anorexia and accepting its complete banality.
Again, of course, as with everything in human health, we can't claim anything as simple as: anorexia flattens out individuality entirely. However depleted the mind and body become, the person with anorexia remains an individual, retains some residues of the character traits, physical characteristics, acquired habits of language and thought, that defined him or her before. And these variations mean that nothing can be predicted with complete confidence in illness or recovery – after all, all the statistical probabilities in the world can’t tell you with certainty how a given individual is going to act in even the simplest context, so how can we expect to predict anything with confidence in a context as complex as this?
On a broader scale, factors like sex, race, and social and educational background are bound to have effects on how anorexia takes hold and is recovered from. But the problem is that, as I’ve said, a rejection of similarity in favour of difference is part of the pathology of anorexia. This means that a reasonable therapeutic strategy may be to downplay or even deny the difference in favour of the similarities, in the spirit of countering one extreme with another and hoping we’ll end up somewhere near the complicated middle where reality lies.
On the one hand, this may be deeply offputting to sufferers who are perfectly aware of some of the complexities that must determine individual responses to, say, a given treatment method. But on the other hand, foregrounding individual variation only gives fodder to the insatiable hunger for difference that is part of the anorexic mindset. Ultimately, although the science of understanding and treating eating disorders still has a long way to go, its basis in randomisation and replication means that, just as with diseases more wholly of the body, it can contribute in invaluable ways to what sufferers themselves know about how to turn sickness into health.
In many respects, the mechanisms of illness and recovery are almost unsettlingly predictable. During my final course of treatment, the one that was at last successful, my therapist was able to draw the line on my weight chart that marked a BMI of 19 and tell me how my thinking would have changed once I reached that point, and was right, even though at the time I was just as sure that she was wrong as I was sure that I’d never, ever get there to find out. And the funny thing was that there was a striking difference, this time round, in my attitudes to normality and specialness.
During earlier phases of treatment I’d never felt normal. Sometimes I'd wanted to be: I just want to be normal, I want food not to matter any more (07.02.99). More often not: Maybe I’m just afraid of becoming normal. I want people to recognise that I have a problem. I’m sick of being thought of as infallible (15.03.99). But this last time, I felt much less preoccupied with normality and difference. If anything, it was the anorexic community rather than the world of the healthy that I was determined to distinguish myself from, by proving people wrong when they made it perfectly clear they didn’t think I’d manage it this time round either. Recovery from anorexia always involves some amount of pulling oneself up by one’s bootstraps: partially achieving, or simulating, a more recovered state in order to make it possible to get there. But maybe one sign that you’re really ready for recovery is that you stop thinking of anorexia as a source of individuality, or a fitting response to it.
When it comes to your own body and mind and your own recovery, it’s probably safest to assume that anorexia will always be looking for ways to trick you into deferring the day when you reject it; that’s how it survives. And asserting that you constitute the sole exception to the general rule is one of its favourite ploys. Whether you're only just beginning to contemplate recovery, wondering whether you dare let weight restoration carry on further still, or trying to summon the energy for another attempt after decades of not-quite-illness, be on the lookout for it, and remember that the sense of exception only proves the rule.
If you need more detailed ammunition against it, try my posts on the normalisation of metabolic rate with refeeding (Part I and Part II) and the one on (amongst other things) the temporary overshoot in bodyweight that may well be crucial (for basic physiological reasons) to full and lasting recovery. Whoever and wherever you are, your default assumption (which would need a shedload of ultra-hard-to-come-by evidence to dislodge it) should be that you too will get well again if you let yourself do what everyone else has ever done who has got really well again: eat long and consistently and generously - not to where anorexia is willing to go, but to where your body needs to go - and let doing so be part of the wider process of learning how to be kind to yourself again.
Above all - because you need to see this coming too - don’t let yourself think that once you understand the but-I'm-different trick, this understanding in itself makes you exempt. It doesn’t. Even when you learn the rule, you’re still subject to it; there is no privileged meta-level where you get to look down at all the other suckers and say ‘I surpass this’. Of all the little lies anorexia whispers to you, this is amongst the most monumental.
