When Joyce, a 23-year-old bulimic, came to our center for a treatment consultation, she explained her situation this way: "I have a nice apartment, a good job, a terrific boyfriend. Everything would be going okay if it wasn't for the binging and vomiting. I've tried to make myself stop but I can't. If you could just help me get rid of the bulimia, I'd be okay. I'm worried it's going to ruin my health."Joyce was upset and confused by her eating disorder. Why was she binging, even though it was so offensive to her? Was she lacking in willpower or strength of character? When they learned of Joyce's eating disorder, her parents were also confused. Joyce seemed to have everything going for her. What was wrong? Joyce herself did not know. AD she knew was that she could not stop binging and did not want to be fat. She would relieve this awful fullness by vomiting. For Joyce, the reasons she was compelled to binge and vomit were as unknown to her as they were to those observing her.
WHAT'S GOING ON INSIDE?
An eating disorder is not merely a problem with food or weight. It is an attempt to use food intake and weight control to solve unseen emotional conflicts or difficulties that in fact have little to do with either food or weight. An eating disorder is never simply a matter of self-control. Healthier eating habits or stronger willpower is not the missing ingredients that will make the problem disappear.
Anorexia, bulimia, and compulsive overeating never exist in a vacuum. These disorders do not occur in an otherwise satisfied, productive, and emotionally healthy person. At first, this may be a very hard concept to accept. Often, people hope for something like a surgical procedure that will "cut out" the behavior the way a surgeon removes the offending tissues or organ. However, it is a destructive myth that the only problem is the eating behavior.
After years of failed efforts to stop binging and vomiting on her own, Joyce joined a support group to help her resist her strong urges to binge. After several months in this group and when she was feeling less isolated and frightened, Joyce was able to pay attention to the connection between her eating and her feelings of anxiety and discomfort:
"I have this perpetual knot in my stomach. I was never even aware of it before. It comes from worrying about 'them.' I don't know who 'they' are-but I'm worried they will see me for what
I really am, not the mature adult, but the insecure kid, It seems that when I'm feeling the most shaky about myself is when I binge."
No amount of praise or material reward could convince Joyce of her value for long. She was driven to prove herself all the time, monitoring her words and behavior in nearly all circumstances. Her self-consciousness was ever present. The more anxious or self-doubting she became, the harder she would work to prove herself. Binging and vomiting helped her feel some relief from her vigilance; it was an attempt to make herself feel better.
Jill, a 17-year-old anorexic, describes her experience:
"When I was starving myself, all I felt was that I had to. There was no rhyme or reason to it.
You could not have convinced me it had anything to do with something emotional or psychological. It took time for me to see how frightened I was and how I had to feel in absolute control. It seems strange now, even a little pathetic, but my eating was all I could control: I felt I was more powerful than anyone when I wasn't eating. What a peculiar way to feel competent."
Is She Trying to Hurt Herself?
"8ut it's so destructive. Is she trying to hurt herself?." Joyce's mother wanted to know. The question is a common one. Eating disorders are destructive. They take a great toll, emotionally and physically. But this is not by design. Only when you understand the ways in which an eating disorder is someone's attempt to feel better about herself or to help her function in a world that feels intimidating can you see that the destructiveness is a by-product of the problem, not an intent. In fact, the self-destructiveness of compulsive overeating and bulimia causes the individual great anguish and is often a motivator to stop.
"Tell me again about the side effects and risks of death," requested a bulimic patient. "Maybe if I can really focus on how I am hutting myself, I can finally stop."
With another patient, it took years of intensive therapy for her to see and accept that her weight was part of a solution to an emotional problem.
"I always thought the weight was the obstacle. It was what kept me from a happy life. Indeed, at 280 pounds, I and everyone else thought I was just out to kill myself--a slow suicide. It is only recently that I've begun to see that my deeper terror is that of feeling close to people.
I built a natural barrier. No wonder every time I lost weight I ran right back to food."
In anorexia the destructiveness is flatly denied. Even on the brink of death, the anorexic sees her starving as essential to her sense of competence and self-esteem. It feels necessary to life, even as it kills.
In every eating disorder, it is only when the person is able to find healthier means of taking care of herself and generating internal sources of self-esteem that she can give up the attempts at coping that have, ironically and tragically, led to further emotional and physical damage. Only by understanding the protective and adaptive functions of these behaviors can you begin to appreciate why it may be so hard for someone to just "give it up."
An Eating Disorder is an External Solution to Inner Turmoil
A focus on body size is a way to convert a worry about something inside to something outside. For example, if the concern, "Am 1 good enough?" becomes, "Am I thin enough?" the sufferer creates an external and measurable scale of her self-worth that offers her a less painful and more comprehensible way to cope with her fears.
Jennie, a 20-year-old overweight college student who was very pretty in spite of 60 excess pounds, describes the phenomenon this way:
"I wonder about why I can't lose the weight. Sometimes I think I stay fat because everything that is wrong in my life can be attributed to that. This way, if someone doesn't like me, I can always blame it on my weight."
Not as observable as Jennie's weight was her fragile self-esteem. With or without excess weight,
Jennie felt herself to be unlovable and undesirable. By focusing on the weight as the source of all discomfort, she could leave untouched the confusing and tumultuous feelings inside of her. She had an excuse for avoiding the social situations in which she felt timid and inept, and she could attribute any disappointment or hurt to her weight. Being 60 pounds lighter risked the hurts without the ready explanation.
Allison, a 15-year-old bulimic, describes what food does for her:
"I start to feel a terror, like a big, black cloud that creeps up. My thoughts start to race so fast
I don't know what they are. Then I go for the food. The food calms me, distracts me. Even though I'm eating frantically and I don't taste a bite, the terror subsides. Slowly, I'm back in a warm, familiar space where everything is blocked out but me and the food."
Betty, a 30-year-old bulimic, began to discover that the eating disorder was more about feeling secure than about food:
"It started to dawn on me that the binging and purging weren't entirely about my size and weight and then 1 noticed a certain pattern. When I was with a man, I was not binging. If someone was sleeping in my bed at night there was no urge to binge. It wasn't just that I couldn't binge because someone was there, but that the urge was gone! I noticed this when I started keeping a journal of my feelings and experiences, and it floored me! I feel so safe and secure with a man, almost any man, that I have no desire to eat. It's bizarre to me that
I can feel secure with a stranger."
An Eating Disorder b a Form of Substance Abuse
In Betty's case, she was able to substitute a man for the food in order to calm her anxiety. She experienced a man as a warm, soothing body rather than as a complex human being to interact with. In this way, a man was like a substance rather than a person. Therefore, be it a man or a binge, Betty was relying on an external substance to alleviate her inner distress. When used for emotional purposes, food functions similarly to a drug or alcohol: It provides escape.
As time goes on, food replaces people more and more in the world of the sufferer, and the isolation increases. Said one 19-year-old coed who would binge and vomit several times nightly:
"It got to be so that I would rather spend a Saturday night eating than with my friends. Being with people felt superficial. I was just killing time until I could go home and eat. I'd be carrying on a perfectly normal conversation, but in the back of my mind, all I'd be thinking about was all the food I could eat as soon as I left. I knew something was wrong. I hated that food was so important, but 1 was trapped. I couldn't get the thoughts of food out of my head and I didn't know any way out."
She May Also Be Depressed
Many people with eating disorders grapple with low moods, low energy levels, and feelings of despondency and sadness.
In some cases, the intensity of the mood and the seriousness of associated behaviors, such as severe sleep problems, lack of interest in life, and constant self-deprecating thoughts indicate the presence of a clinical depression.
Depression is usually associated with feelings of helplessness, ineffectiveness, loss of control, and or unexpressed anger. The relationship between feeling depressed and eating disorders is a complicated one. Because bulimics and compulsive overeaters often feel out of control, feeling depressed can be a frequent by-product of an eating disorder. After all, how would you feel if you repeatedly promised yourself to stop some destructive, disruptive behavior and failed over and over again?
In many people, depression and mood swings are the result of the disordered eating itself. Erratic and restrictive food intake can lead to internal chemical imbalances that can wreak havoc with mood.
When this is the case, the mood swings and depressed feelings will be alleviated by a normal diet.
But for some proportion of sufferers, the syndrome or illness of depression has preceded the eating disorder and may be physiologically based. The relationship between eating disorders and depression is the subject of much current research. Because the research is new, the results are not conclusive, but they indicate that some people seem to have depressions of a biological nature.
What proportion of the population this involves is still unclear. In these cases, the eating disorder may be the attempt to alleviate or anesthetize against the depression to make it bearable. The eating disorder may well be someone's attempt at self-medication.
Sara spoke of her periods of extreme depression:
"These waves of lethargy and dullness would come over me. The day before. I'd be fine, but then I would wake up and feel such utter hopelessness and despair that there would be no point in going to work or seeing friends. What seemed to offer pleasure yesterday looked bleak and uninviting today. I couldn't move and I'd feel horrible about myself. I don't know what makes me feel like this. But once I do, it goes on for weeks and there is nothing I want to do but eat. And then it lifts--as mysteriously as it began--leaving me 10 to 20 pounds heavier."
Sara's depressions began years before the binging became a part of her life. She had a history of depressive episodes, but as a child, her depression manifested itself through sleep disturbances and crying spells. When Sara reached 11 or 12, she found that eating alone in her room seemed to comfort and calm her. Although she didn't know it, Sara's use of food was an attempt at medicating herself for depression that no one knew existed. What started out as a naive attempt to deal with her depressive state quickly developed into bulimia.
Among the people for whom depression is associated with bulimia, antidepressants can be a helpful aspect of treatment. In Chapter 6, we discuss the use of medication and its treatment implications.
An Eating Disorder is an Emotional Anesthetic
Whether or not she is clinically depressed, someone with an eating disorder always has a great deal of trouble acknowledging, accepting, and enduring many of her own feelings. Sometimes they are the more tender emotions like affection, longing, and dependence that cause problems.
Sometimes conflictual feelings are the difficult ones, like wanting to be grown-up and remain a child at the same time. Feelings can be, and often are, intense for the eating-disordered person, who fears being overwhelmed by them or, worse still, overwhelming others with them. The fear of her feelings then exacerbates the problem, leading the person to panic and rush to food.
Lyla, 25-years-old, ten years bulimic, and now in treatment, talks about her use of food in this way:
"Sometimes my head feels like it's going to explode. I can't stop thinking about how I should have done something differently or how I blew a relationship because of what I said. I feel like I'm going crazy with my thoughts. I can't stop it except by doing one thing--and that's eating. When I sit down with food, all I think about is how good it tastes. Then, even when it stops tasting good, I still eat because it puts me in a daze. I can stop thinking and just numb out. It's like there's a fog around me."
She Believes the Pain Will Never Go Away
A person with an eating disorder often believes that painful feelings will never go away on their own and nothing can be done to make them go away.
"When people tell me the pain will pass or time will help, it makes me laugh." said Carin, a 36- year-old bulimic with a fifteen-year history of the disorder. "These people can't be having the same feelings I'm having. When I'm depressed, it's like going into a deep, dark pit and you can't convince me there's a way out. There have been times in my life I can stay in that feeling for months. And eating is the only thing that distracts me. It is the only thing worth doing."
Carin's experience is a common one, particularly among bulimics. The fear that pain will last forever and that there is no way out makes the sufferer feel helpless and prevents her from finding solutions to alleviate the discomfort.
She Has Learned to Inhibit Feelings: "The Don'ts"
We have all been raised with "don'ts": don't do this, and don't say that. Among the most common
"don'ts" in the personal histories of people with eating disorders is don't be angry and don't be needy. Young girls who ultimately grow up to struggle with eating disorders are often those who took to the classic "good girl" model-sweet, charming, perfect little girls who are unchallenging of authority, pleasing to others, and not aggressive.
Unlike their male counterparts, young girls are often encouraged to be responsible caretakers, self-sufficient, and to watch out for other people's feelings. As a result, they tend to keep a good deal of their feelings, wishes, and needs private and secret--sometimes even secret from themselves.
Angry, aggressive feelings are seen as bad and unacceptable rather than the basis of healthy assertion. Because of this, young girls feel as though they are "bad" for having these feelings.
Girls who become eating disordered have often grown up believing that they should be undemanding of others. The good girl is the quiet, unseen girl who learns not to show what is bothering her. She learns her lessons well as we see in how she hides her emotions, even as her disorder progresses. She learns to feel good about herself through pleasing others, while her own "appetites" are suppressed. What other people want seems justified; what she wants is a sign of selfishness.
When feelings and needs are buffed, suppressed, or held back, they may remain hidden or unexpressed but they do not go away. Underneath a facade of control, optimism, or silence exist many complicated experiences that cause the eating-disordered person much distress. The following are some of the feelings and issues that cause the most common problems:
Needs for Approval/Needs for Nurturance:
People with eating disorders tend to be more dependent than others. This is true even when it does not look that way. The eating-disordered woman relies more than most of us on other people's opinions and reflections of her to determine how she feels about herself. This is why eating-disordered people are terrified of criticism. Criticism not only means that something they do or say is not approved of by others, but it can be taken as a judgment about whether they are a good or bad person.
As Lilly, a 25-year-old recovering anorexic, told us, "If someone didn't like a dress I wore, it didn't just mean that they didn't like the dress-it meant they didn't like me." She had not yet learned how to give herself the support and validation she needed and thus she felt dependent on others to give her the approval that she could not give herself.
The eating-disordered person is not only in need of approval but inside she is "hungry" for care and affection as well. Often, she has been so attuned to everyone else's needs that her own have gotten overlooked.
Despite feelings of dependency, women with eating disorders do not want to rely on or need other people. Feeling dependent or needy leaves them feeling weak or like a failure, and is to be disowned and avoided at all costs.
For some women, there is an intense fear that others will be overwhelmed by their needs and leave them, or stop loving them, to avoid this, they try to be perfect inside and out. The strain is enormous.
Amy, a 17-year-old bulimic, recently began to see how this fear affected her life.
"I know it sounds crazy and isn't logical, but I genuinely feel that to be loved I must be perfect.
If a guy doesn't like me I'm sure it's because I'm not thin enough, or my hair isn't nice enough, or I'm not smart enough. Then I have to work out, study harder, look better. It never occurs to me to think, 'Do I like him?' All I can think about is that I'm not good enough."
The self-imposed demands of perfection and the tear of rejection that eating-disordered people experience interfere with the development of comfortable, intimate relationships. The dilemma is a difficult one. If someone cannot reach out and allow herself to need someone else, to be vulnerable to someone else, how can she really get to know that person and let herself be known?
An experience we have heard often is that the only time someone with an eating disorder lets someone else take care of her is when she is sick. At other times, she does not feel she deserves the care and cannot allow herself to be needy. In some cases, the inability to accept care is so extreme that even when she is legitimately sick she will deny it.
Feelings of Inadequacy:
When someone grows up believing she should be stronger, more mature, more capable than her years, she meets these expectations outwardly. But her emotional, maturational development does not keep pace, and, in fact, can be slowed up. This leads to the experience that one is outwardly grown-up while an unacknowledged "little girl" remains hidden.
It is the little girl deep within the eating-disordered person who is frightened, who suffers the feelings of inadequacy and fears being overwhelmed. The competent facade and the exterior of independence make it hard for the onlooker to believe how young, ungrownup, and incapable an eating disordered person feels inside.
Abby, a 28-year-old recovering bulimic, talks about these feelings:
"At work I keep thinking that, at any minute, I'm going to be found out. Everyone thinks I'm doing a good job but I feel like I'm getting away with something and at the next step, the next task or promotion, I'll blow it. I live in terror that they'll see through me, see I really cannot do the job. It's ludicrous; I do do the job--why am I haunted by these fears? I feel schizophrenic- capable outside and completely inept inside."
Tanya, a recovering anorexic, recalled how such feelings haunted her high school years.
"I struggled so hard to feel I could handle it all. So instead of getting 90 on the test, I had to get 100. The 90 would reveal how stupid I really was. I was terrified I would fall apart. One slipup and all would be lost. I'd be overwhelmed. I had terrible, terrible fantasies about disintegrating, blowing up into nothing. The more I could control, the more I could feel I was not going to disappear."
Said Jim, a compulsive overeater,
"When I'm at home alone, I get so lonely and it becomes a physical emptiness inside.
Planning what to eat becomes an activity. It's like planning who I'll spend time with. Food definitely is my best friend."
Jim felt he was condemned to loneliness. His self-consciousness about his weight kept him from taking part in activities and events. He thought everyone would be as disgusted at the sight of him as he himself was.
Sometimes this loneliness is like a feeling of emptiness, as though there is nothing inside. Some people experience it as "a space . . . a void."
"I feel so lost," Maddie, a 21-year-old, said of her evenings. "I'll be fine as long as I'm busy, but as soon as I'm home alone, nothing seems to satisfy me. I feel empty, lost, with this sense of vague uneasiness. I try to read or work but I feel distracted, ungrounded. I want to be 'filled up.' I know my family is there and I can spend time with them, but that doesn't do it for me. Sometimes drugs or alcohol seem to take away that feeling. Other times, if I sleep with a guy, that might do it too. But always, whether it's food, drugs, guys, or booze, it's always temporary, leaving me feeling horrible about myself afterward, and empty still."
Loneliness, sometimes felt as boredom, is a common experience of all eating-disordered people.
This feeling can occur despite the presence of other people.
"It is so peculiar," said Jerry, a 23-year-old bulimic during a group therapy session, "how lonely I can feel even when I'm not alone. It's a chilling feeling, like I'm cut off, all by myself in this world. It scares me when I feel this."
These feelings are often intensified when people are, in fact, alone. Some people experience being alone as though they were abandoned or left behind. Thoughts of food or exercise can be company at such empty times.
Fears of People:
As lonely as they are, eating-disordered people are often more comfortable with food than they are with developing meaningful relationships. Eating-disordered people have great difficulty trusting people and relationships.
Some people fear losing themselves or their own identities in their attempts to please another person. Others fear that the other person will take over, dominating them and leaving them little room to be themselves.
Jody, a 26-year-oid compulsive overeater, had trouble letting others get near her for fear she would give up control just as she always had with her mother.
"She was always doing things for me. It could be anything from changing batteries in my radio to cleaning up my room. I guess she was just taking care of me, but I felt like she was controlling everything and I came to believe I couldn't take care of myself Now, I worry about this whenever I get close to anyone else. t like being taken care of, but I quickly feel controlled. I'm so confused about this that my relationships are always in turmoil."
Many recovered compulsive overeaters have to contend with the fear of getting close to people after they have lost weight. Sexual intimacy is one aspect of emotional relatedness that can be avoided through binging and weight gain.
Said Cindy, a 34-year-old compulsive overeater:
"I was afraid to let a man near me. At 200 pounds, it wasn't much of a worry. I wasn't even aware of my terror till I lost the weight and men began to notice me. Then, what I had been avoiding all these years hit me. What an eye-opener-even at 120 pounds I felt inadequate and unworthy. So it wasn't the weight after all, it was me."
Anger and Aggression:
As we said earlier in this chapter, girls often feel differently about their awn anger and aggression than boys. Anger and aggression are very natural feelings that are the bases of healthy assertion.
But with girls who grow up to develop eating disorders, angry, aggressive feelings are seen as bad and unacceptable. This often leads to difficulty managing these feelings.
Suzanne, 15-years-old, put it this way:
"I got the message loud and clear that my brothers are allowed to disagree, fight, and be aggressive. Me? I'm supposed to be polite and make sure I don't hurt anyone's feelings. I guess I learned that in spades. As soon as I feel myself to be demanding or angry, I feel terrible and selfish. With food, though, I can let this out. I tear at if and eat with my hands. If anyone ever saw me, they wouldn't believe I'm the same person. I'm in my own world and I don't care about anyone else. If they saw me they'd know how selfish 1 can be, how angry, how I don't really care about anyone; it would be a disaster. But at least when I'm binging, no one gets hurt-except, I guess, me."
A child or teenager in conflict about her natural feelings of anger and aggression grows up to be an adult with equal difficulties. Only the context of her conflict broadens.
Jennifer, a 30-year-old corporate executive, describes how the requirements of her work clash head-on with her discomfort asserting herself:
"lt's bizarre-here I am in charge of a whole department and I'm uncomfortable with the idea of offending anyone, making anyone mad at me. Whenever I have to assert myself, which is often at this job, I feel like I've done something wrong. Then, I go straight for the food. Somehow when I'm eating, I can forget about how badly it all makes me feel."
For the eating-disordered person who wants exclusively to be a nice, pleasing person, the experience of anger and consequent aggression can be very disruptive.
Some people manage that experience by dissociating the anger from themselves.This means that they feel like they become someone else when they binge.
Said Lettie, a 19-year-old bulimic:
"lt's like there is this horrible, binging monster inside who takes over and I can't control it. When I'm binging, I'm like a different person. I'll be nasty and not care about others. Usually, I'm a very nice person-too nice. Usually, I'm the one who fakes care of everyone else first and my own needs and feelings come last."
Other people have described this aspect of themselves as being "an ogre," a "derelict," or "it's the dark side of me." One patient suggested she was more in need of an exorcist than a therapist.
It is the "monster" that represents much that feels bad, out of control, ugly, and distasteful about the sufferer. In the case of bulimics, this monster is undone by purging; in the case of anorexia, defeated by control. In either case, the feeling of being in a battle with oneself is a part of daily life.
Fears of Success:
For many women in our society, the possibility of success and the consequent feelings of competency can generate serious conflict. It can go against the grain of the role of caretaker and puts women in a position of authority which they may unconsciously undermine. Eating-disordered women are particularly vulnerable to such conflict. They feel guilty and undeserving when they taste success.
Lauren, 27-years-old, and a compulsive overeater, found that whenever she did well at her job as an advertising executive, she would go home and binge. As she explored her experience, it became clear that binging was a way to sabotage her success.
"At first I feel terrific, in charge, successful, and then I begin to feel uneasy, guilty somehow.
I feel like I'm defying the gods. This wasn't meant to be. I start to worry what others will think of my achievements, and humiliation creeps up on me. I'm sure they're going to be thinking
I don't deserve this."
The binging not only numbed Lauren's uncomfortable feelings, but silently undid the success she would achieve at work.
Rachel, a 16-year-old bulimic, also struggled with the disquieting effects of achievement, but differently:
"When I do really well on an exam or with a project at school and the teacher is really pleased, I feel really good for a while. Then, I begin to doubt it--my achievement and their opinion of it. I destroy it. I think they are just telling me that I did well because they feel sorry for me or because they are worried about me. I have to take it all away. Sometimes, I think if I really believed I did something well, the pressure to keep it up would kill me."
At these times, Rachel would come home from school and binge and vomit to calm her uneasiness.
"I'd go into panic thinking, 'Was I doing okay in school or not.'?' Part of me believed I was doing fine. Part of me doubted everything. It was the worst feeling--like I didn't know who I was. When I ate, though, all those feelings stopped and I could start over again-l could study, or watch TV, or talk with my family and I'd be fine. Before that, though, I felt like I was just 'losing it."'
Anxiety is a signal. It can be a very useful tool, alerting us to situations or events that make us feel vulnerable. And with this awareness we can marshal our coping skills.
For example, if the idea of an upcoming exam makes us anxious, the tension and uneasiness can be powerful motivators to study. Anxiety provides the opportunity to prepare for the event by anticipating the possible difficulties. Anxiety gives us the opportunity to act to protect ourselves in potentially difficult situations.
People with eating disorders have difficulty using anxiety as a signal to cope. Because they often feel themselves incapable of dealing with stress, the anxiety becomes a signal of impending doom, a flag that whatever is coming will be emotionally overwhelming. Anxiety is something to be gotten rid of, not listened to. Therefore, the experience of anxiety is often the trigger of a binge or of a tightening of controls and intensified restriction (in the case of anorexia). While these behaviors numb the anxiety, they do nothing to help the person prepare for or protect against the actual cause of the anxiety.
THE COMPLETE PICTURE
Because the symptoms of binging, vomiting, exercising, or starving can be so disruptive and frightening, it is easy to pay attention only to those behaviors. To do so, however, misses the point. The overt symptoms are just the tip of the iceberg. Beneath the surface lies a much larger piece of the picture-a complicated and complex world of feelings and experiences that are very much a part of the eating disorder. Both the visible and invisible parts need to be acknowledged in order to understand the disorders of bulimia, anorexia, and compulsive overeating.
(For further explanation or understanding, please read other chapters in this book, Surviving an
Eating Disorder, by Siegel, Brishman, and Weinshel.)