Consultant Psychiatrist with a special interest in eating disorders
“Bulimia is very much on the increase. It is now considered to be the fastest growing neurosis in the western world and presents more frequently than anorexia. I sometimes wonder whether the anorectics of ten years ago are now coming with bulimia. The age of presentation is getting younger I am now seeing patients as young as eleven. We know from the literature that there is also an increase in the numbers of men presenting with anorexia and bulimia but I am not aware of it in my own practice.
“We have to ask why it is desirable to be thin. Why is such a value placed on it? Diana, Princess of Wales was a podgy teenager. Both she, and the Duchess of York aspired to, and succeeded, in being thin. There is enormous prejudice against overweight people, particularly women. Studies have shown that fat people are discriminated against in all areas of their lives and that being overweight is a serious social disadvantage. The obese are often perceived as being ugly, dirty, lazy, stupid, greedy and undisciplined. Thinness, on the other hand, is equated with success, control, attractiveness and other positive and alluring qualities.
“I sometimes wonder is it some kind of disgust at the excesses in our society? Weight seems to be the newest taboo. It used to be sex, now it is weight. There is shame, disgust, loathing at being seen to eat, almost as if one is being seen having sex. Children are reaching puberty earlier and earlier and becoming more sexually aware. Side by side with this is the anomaly that they never wanted so much to be thin while they have never been so rounded and well developed so early. Many of them have money so they can have everything they want, and they take no exercise. So when they become conscious of being fat, bulimia seems a seductively easy way out, much easier than dieting.
“I divide binge eating into three components. The first stage is one of restlessness and anxiety, familiar to any addict. They are unable to settle and want to take the feeling away They trade short term relief of anxiety, for the misery and shame that comes later. The first stage is exquisitely thrilling, sensual, pleasurable. There are no holds barred. They feel defiant and free. For bright, well brought up young women, who are possibly full of pent up rage, it is a liberation. The second stage is very relaxing, the food increases the flow of seretonin in the brain and is almost as good as valium tor inducing calm. The third stage is humiliating and punitive. ”
“In treating bulimia I try to encourage patients to get the thrill and relaxation they experience from food from other, more healthy pursuits. The cornerstone of treatment is stress and weight management. Teenage girls should be encouraged to value the benefit of relaxation in the maintenance of good mental health. They should make out a list of all the activities they had most enjoyable other than eating, and should then be encouraged to ‘binge’ on these activities when they feel stressed, instead of turning to food.
“I would see anorexia as a more severe, dangerous and abnormal condition than bulimia. It occurs when people have so little control that they can’t eat at all and it quite quickly seems to develop a power of its own. It begins with the person being weight conscious, then it becomes an obsession, then an illness. It has an anaesthetic, numbing effect. It detaches them from their own feelings. They are not easily upset, someone described anorexia to me as being like a cloud or blanket device:
“Anorectics enjoy no mental rest because any appetite that is denied tends to become more insistent. Although the word anorexia means loss of appetite’, most anorectics in fact have a voracious appetite – so voracious that the power of their hunger terrifies them. Every waking moment must be given over to the control of that hunger. It must be dampened down, blocked out, controlled in will alone.
“Anorectics have to be preoccupied with food at all times to guard against giving into temptation. They have a love-hate relationship with food. They long to be surrounded by it and delight in its sight and smell. Anorectics are often very competent cooks and have an encyclopedic knowledge of calories. They love ‘fattening up’ family and friends while abstaining themselves. This iron discipline makes them feel morally superior to those lesser mortals who happen to enjoy their food! Eventually this preoccupation with food becomes overwhelming and dominates all mental activity. Anorectics complain that this obsessive thinking is one of the most disabling and depressing features of the illness.
“In treating anorectics we have to find out what they are afraid of, what are their conflicts. They appear to be avoiding the pain of their current lives. They do not have sexual or aggressive feelings – in fact such feelings revolt them. Anorexia is very disciplined and controlled; to give it up can be seen as shameful. Sufferers are in a prison. Rules and regulations apply not only to eating, but to their whole lives. All spontaneity is denied to them – it is cold, controlled, punitive. I give them permission to come out and move into a more normal existence. We look at their lifestyle and how they can bring more pleasure and colour and joy into their lives. It is hard for them to do this on their own. They invest food with moral attributes – bad, wicked, evil. I try to induce the possibility of pleasure into their lives.
“Women with eating disorders have a very negative and critical view of themselves. Recent research shows that they experience a slightly higher incidence of sexual abuse, which might explain their deep loathing of their bodies. Massage can be particularly helpful. Not only is it wonderfully relaxing, but it gives them a positive and pleasurable experience of their bodies. They may be nineteen but they are living like sterile ninety year old nuns. Yet, sooner or later anorexia will break; the passion for it will be spent.
“It is hard to be cured of being weight conscious. Some bodies cannot defy the odds: unrealistic expectation cannot be achieved through endeavour. ‘When I achieve this then I can live,’ is the belief that sustains many anorectics. But their goals are beyond the capacity of their bodies. I don’t work with groups myself, but they can be hugely useful in helping people with eating disorders.
“Anorexia is painful for families, especially for mothers. It can be seen as a rejection of mothers. “I will not eat your food. I am turning away from your nurturing completely because it is so bad.” It is an illness which doesn’t solicit care like cancer would. It arouses hugely hostile feelings between mother and daughter because it is seen as wilful behaviour. Family therapy can be useful in these situations. I sometimes think that the punitive hospital regime, which used to be so common in treating anorectics, was a response to this perception of wilful, defiant and destructive behaviour. I am glad to say that all this is changing rapidly.
“By and large people with eating disorders have high stress levels. Psychotherapy or ‘talking therapy’ can be very useful in alleviating stress, when problems are openly discussed, new solutions can be found. Sufferers can learn to recognise that their eating disorder is often a way of distracting themselves from other worries. If these worries can be solved, they may not need to comfort themselves with food (bingeing) or by switching off their worries with starvation (anorexia). Psychotherapy helps to develop a greater understanding and tolerance of themselves”
[While believing that psychotherapy is appropriate for the treatment of orders, Dr. Leader feels there are definite indicators for psychiatric intervention. If a patient has not had a period for over a year; if she has lost more than two stone of her normal body weight; if she is clinicallly depressed and is failing to function in other aspects of her life; if the therapy is going nowhere.]