When the anorexic sets out to cut back on her eating, she seems no different from anyone else who is dieting, but there is a subtle difference. For the dieter, eating less is only one part of her life and she diets to achieve physical attractiveness and health. For the anorexic, dieting is her whole life and she diets to achieve mastery over self. As she diets and discovers that it gives her a sense of achievement, she is motivated to keep losing weight when others would have stopped.

Although the anorexic declares that she is not hungry, apart from periods of loss of appetite through depression or the effects of prolonged starvation, she is often very hungry. In fact she is fascinated by food and feels triumphant in not giving in to the sensation; when she does give in she is filled with self-disgust at her weakness. It is not the anorexic doesn’t like food but that she fears losing control.

The anorexic also has a fear of weighing more than a certain weight (which is below average for her age and height). When she looks in the mirror a distortedly large figure stares back at her, and her face, filled with horror, gives away how much she detests the sight. She examines herself with great precision. As her hands glide over her body and she feels angular bones, she is reassured, but it is still not good enough.

Not eating causes restlessness and the anorexic may develop frantic exercise programmes, pushing her body to physical extremes. Soon she begins to develop rituals dictating that things must be done in a certain order and at a certain time; there is intense self-hatred when she fails to keep the harsh rules she has imposed. The lower her weight, the more impaired the anorexic’s thinking becomes. Everything is seen in very black and white terms. She also loses much of her ability to be creative, expressive, imaginative, and to handle challenging situations.

As her weight drops, her drooping frame is no more than skin and bone. Shoulder blades and hip bones protrude. Her eyes are sunken and her skin pale. Her hands and feet feel perpetually cold and appear slightly purple due to poor circulation. On her arms, legs, back and face she may begin to develop a fine downy hair. She is frequently constipated, her skin is dry and her hair brittle. Her body is frail to hold. Her blood pressure is low and her heart rate slow. Over time her bones become like those of a much older person and she may develop osteoporosis.

Starvation causes irritability and selfishness and as the anorexic struggles with inner pain, and pushes against other people’s control, she undergoes a personality change but she fears that if she lets go she will be faced with a surge of indulgence and agonised feelings. When people try to convince her that she is not well she sees it as a threat.

Below The Water’s Surface

There is no single cause to an eating disorder. Significant areas include:

1. Emotional hunger
2. Sexuality
3. Trauma
4. Family background

1. EMOTIONAL HUNGER
Everyone has needs when they long to have met, but when neediness is intense this usually stems from having been deprived in some way as a child. Children require meaningful time and attention from their parents that is not interrupted by the parents’ needs, does not demand back, and is not filled with anxiety. If needs are not met, or needs are seen as bad, weak , childish or selfish, then the person can be left with an empty void which then often gets filled through addictive and/or behavioural responses.

For the anorexic, who can’t face the fact that she is still emotionally hungry, it becomes easier to pretend that she isn’t hungry, physically or emotionally. Needs are a sign of weakness and she wants to achieve self-sufficiency. Marilyn Lawrence and Mira Dana believe that what the anorexic sees reflected in the mirror is not just her body, but a symbolic part of herself. It is the needy, demanding, yearning part which she so desperately tries to kill by starving her body, but which screams out to her, ‘I want to be seen, noticed, listened to’. This may be the reason for her still seeing herself as enormous when really she is emaciated.

Love and nurturing
The need for love and nurture has become entangled with issues around food for many people with eating disorders. Lack of unconditional love as a child goes on affecting a person for as long as the deprivation is not faced and dealt with. In order to feel loved, a child needs not only to hear loving words, but to receive tenderness. The longing for love is also a longing for safety, protection and intimacy. Intimacy, for many sufferers, can feel frightening because it requires vulnerability. In early childhood, being vulnerable usually resulted in feeling abandoned and alone.

Some sufferers feel the intensity of the need for love as though they are still children. Many are longing for childhood needs to be met through the nurturing and validation by others and have not yet learnt the importance of nurture and validation by self. Hence eating disorders are more often than not responses to other people not fulfilling what the person sees as essential to their emotional well being.

When someone is in pain, food is a quick and easy form of being nurtured, but if it isn’t food that a person is longing for, then food will never satisfy.

Self worth and security
Unmet emotional need also affect self-worth and security. What we believe other people think of us often rules how we feel about ourselves and how we act towards others. The conclusions we come to about ourselves are formed at an early age. Significant adults, such as parents, older siblings and teachers become the “mirrors” in which young children see themselves.

People with a good self-esteem are comfortable with themselves. They accept themselves including their shortcomings. Their acceptance doesn’t stop them from making changes; it frees them to do so. They are able to have a balanced estimate of themselves. They can be fully in touch with their emotions, but not controlled by them.

When people have a low self-worth they often suffer from depression. They see themselves negatively; life negatively (demanding and unfair); the future negatively (without hope). Other long-term effects include stress, guilt, anger, jealousy, loneliness, lack of intimacy, feelings of failure, and a distorted picture of God. Eating disorders are one way in which people compensate for their poor self-worth. Other ways can be through excessive shyness, drawing attention to themselves, putting themselves down, boasting, always having to be right, suspicion and criticism, rigid thinking, aggression and overwork.

Many eating disorder sufferers do not have a strong sense of self-worth and security, and the eating disorder is used to fill the gap.

The anorexic’s body size represents the way she feels about herself. She views herself as so small and insignificant that if she existed in a normal body she would rattle around. Not eating is both a visible way of explaining to the world that she is a ‘nobody’ and, at the same time, a desperate attempt to regain some worth through rigid self control. Her worth will go up and down depending on how ‘good’ she has been, and how she looks.

2. SEXUALITY
Whichever eating disorder a person goes on to develop, there can be an element of being unsure about how to handle sexuality, and food and weight are used as a means of expressing this confusion.

Anorexics are very critical of their bodies. At puberty they may examine their changing shape, and, in shock, think, ‘Help! I’m fat. I must get rid of it.’ Some see this as the need to be slim whilst others equate weight gain with sexual expectation from others. Puberty often scares a sufferer because changes are happening to her over which she has no control. These changes are often taking place at the same time as the need for control becomes all-important in her life. Her fear drives her to take a drastic a measure such as starvation.

Anorexia is sometimes associated with a fear of growing up and sexual maturity. The pre-anorexic child is said to be behind her peers in terms of social and emotional adjustment, and it is not uncommon for her to feel ashamed of the bodily changes taking place at puberty. The idea of getting rid of the signs of sexual development, such as fat around the hips, and putting an end to menstruation, which is a monthly reminder of adult responsibility and leaves her feeling dirty, can be appealing.

Sexual abuse
A fairly high percentage of victims of sexual abuse go on to develop an eating disorder.

The home of an abused child can set her up for abuse. There is distance in relating. Two of the factors which are essential to a happy home would have been absent: the sense of being enjoyed for who she is rather than for what she does, and the opportunity to develop separateness from the other members of the family. The child might have carried adult burdens; have been led to believe that certain feelings are wrong, crazy, or non-existent. The atmosphere in the home might have been demanding, conservative, or rule bound; the highest value being loyalty to protect the family. The child would, to some extent, have felt empty, committed to pleasing people, and would have not had clear boundaries.

Feeling hungry for emotional attention, the child may take whatever is offered and find herself a victim of abuse.

The effects of sexual abuse are many. The person can feel guilty, dirty, rejected, disgusted and different. The survivor often believes that it was her own desire to be cared for, wanted, hugged and loved which led to the abuse. She ‘feels deceived by her body; the body is the enemy, and were it not for the body there never would have been a problem’. The most powerful emotions that are carried around are shame, anger and powerlessness. The child who is abused feels powerless, and she continues to do so as an adult. She believes that she does not have choices and that she cannot change her circumstances. She doesn’t value herself enough to choose to walk away from situations where people treat her badly, and as a result she very easily finds herself in ongoing abusive situations.

Eating disorders serve as a function to in response to sexual abuse by:

Creating protection
By becoming obsessed with food and by forming a relationship with food where it, rather than people, brings comfort, the survivor has a greater chance of protecting herself from being wounded by others. For the anorexic, changing her body to being unattractive to the opposite sex also limits her chance of being involved in an unwanted sexual relationship.

Dealing with feelings
Rage, guilt, shame and pain must be deadened and eating disorders provide a way to lessen painful emotions. In addition to the eating disorder, self-harm often becomes a way of dealing with pain of helping to shift from one feeling to another. Cutting or burning is a means of making visible what is going on inside and overdoses can be attempts to ‘kill’ the pain.

Shifting the focus
For as long as the sufferer concentrates on food and weight, she can shift the focus from the devastation of the abuse. By concentrating on the behaviour of the eating disorder, the pain of what happened to her does not need to be faced. For someone afraid to feel the full impact of abuse, the concept of the focus being directed elsewhere is very attractive.

Neutralising dirt
Many people who have been abused feel dirty, and eating disorders serve the function f neutralising this feeling. Purging and starving both create a sense of cleansing, and eating disorders are often accompanied by obsessive compulsive behaviour focused around cleanliness and tidiness.

Establishing control
Any form of abuse puts the person in a powerless position. Eating disorders become one way of gaining a feeling of control through what she does to her body. The anorexic needs to take control of her body and try to get rid of the terrible flaw she feel exists.

3. Trauma
Many people with eating disorders have gone through trauma prior to the eating disorder. It is not uncommon for them to be a 2 year gap between the trauma occurring and the eating disorder developing. Traumas might include: separation/abandonment, bullying, physical, emotional and sexual abuse, death of a close relative, separation/divorce of parents, disability, witnessing an assult, violence etc.

The eating disorder serves the purpose of coping with the trauma(s) but besides an eating disorder other disorders may also be present, such as:

• Post-traumatic Stress Disorder
• Borderline Personality Disorder
• Acute Stress Disorder
• Depression
• Dissociative Identity Disorder
• Obsessive Compulsive Disorder

One of the means of identifying whether there is unprocessed trauma in a person’s life is to consider what other patterns of behaviour and belief systems are in operation besides the eating disorder.

4. FAMILY BACKGROUND
The family background in and of itself is not the cause of an eating disorder, but aspects of the sufferer’s background may well contribute to the developing of an eating disorder.

The families of those with eating disorders provide well for their  children in terms of physical, material and educational needs, but the area often lacking is the meeting of emotional needs. Aspects of the family background which are relevant to eating disorders include:

• Communication
• Shame
• Boundaries
• Negative feelings

Communication
The child who goes on to develop an eating disorder uses behaviour rather than words to communicate needs and feelings, because generally non-direct communication has been role-modelled in the family.

Researchers who were sent into anorexic families reported that they felt uncomfortable when the whole family was together; they had to be careful not to ‘make waves’. Pre-anorexic children come across as needing their parents more, and being very aware of the conflicts and neglects. They are vulnerable, compliant and take criticism and ‘put downs’ very seriously.

Prior to the anorexia developing, the child has been seen as good, obedient and loveable, with few problems. Yet it is not uncommon for her to be feeling immense inner anguish. The child tends to feel that she is not good enough in that she does not live up to ‘expectations’ or that she could be in danger of leaving her parents’ love and consideration. But she conceals her discontent, behaving as if she were happy. She feels ‘undeserving’, ‘unworthy’ and ‘ungrateful’. She often complains that she has received too many privileges and feels burdened by having to live up to such ‘specialness’.

Shame
Shame, which is a feeling of being defective as a person, is often significant in eating disorder families. Maxine West, a psychologist, points out that in these families it is extremely important that members look and act appropriately. Many ‘rules’ exist… and a ‘front’ is created and outsiders see and interact with this ‘front’, not what with what is really happening in the family. This can affect the child’s sense of reality. Control is imperative to survival. Value and acceptance are based on performance and members are afraid of what the existence of a ‘problem’ says about them.

Boundaries
Each family has its own sense of boundaries and out of these a child begins to learn who she is as an individual and where she stands in relation to family members and outsiders. Marilyn Lawrence and Mira Dana indicate two extremes of boundary problems which occur in eating disorder families. In one type of family, privacy and being an individual are highly prized and it may be difficult for the member to feel close to each other, to share, or to truly relate. In another type of family, the need for privacy is experienced as rejection. It is considered that everything should be shared; everyone has to know all about everyone else. Even feelings are family property; it can be impossible for one member to be upset without upsetting the whole family.

Salvador Minuchin has found anorexic families to be over-involved, overprotective, not willing to change, and tending to avoid conflict. Palazolli indicates that the child, rather than the conflict between the parents, becomes the family problem. This focus on the child’s symptoms serves to express as well as avoid the unresolved conflicts existing between the parents. If conflict is not openly expressed, the child never learns how to resolve it, and will remain frightened of situations where even differing opinions are spoken. The anorexic’s goals become approval and love rather than knowledge or competence. She will develop an obsessional concern for perfection, resulting in low self-esteem. She will also suffer with extreme self-consciousness, making it difficult for her to form relationships outside the family and creating increased dependency on the approval of her parents.

Negative feelings
How negative feelings are handled in the family can be a part of the chain of events that lead to the developing of an eating disorder. Not dealing with emotions teaches the child that she must suppress how she really feels in order to be ‘acceptable’. The eating disorder family may find it hard to cope with certain feelings, such as anger, and the members are not encouraged to discuss how they feel. The parents may discount their children’s feelings by stating that whatever has happened can’t be that bad, or quell their emotions by inferring that children shouldn’t feel that way.

Members aren’t allowed to question the family rules or to voice thoughts or feelings that conflict with these rules. Disagreement is met with rejection. Children from this type of home don’t learn to communicate openly and directly. They don’t learn that one can disagree with someone else and still have the person’s respect and acceptance …  they become afraid to express themselves, until eventually they don’t have a clue as to who they are or how they feel. They learn to avoid conflict at any price, to swallow ‘unacceptable’ thoughts and feelings as not to upset others, and constantly to fear rejection.

The children can come away with the sense that they are not loved and accepted, or if they are, it is only if, or when, they perform. They can feel that they are not valuable or worthwhile. They often feel very alone and as though they do not really belong anywhere.

Adapted from the Waverley Abbey Insight Series: Eating Disorders by Helena Wilkinson