Anorexia Nervosa (from Rogue Habits)

Note: This is the third chapter of the current draft of my latest book, Rogue Habits. Like some other theorists, I believe anorexia to be one of many examples of such habits – habits that have escaped behavioral immunity, our normal means of keeping them from getting out of hand.

Click here for PDF

———-

No one will take me seriously. I know I am fat. Everyone says I’m just saying that to get attention, and they tell me I’m crazy… I guess they think I will outgrow it. I have tried to stop but can’t. – Anorectic pre-teen
1

Anorexia Nervosa certainly stands out among the eating disorders. It is dramatic, mystifying, and very dangerous. The first part of the term, anorexia, means simply that it involves a loss of appetite. The second part, nervosa, means “nervous” in Latin. It implies that the loss of appetite is a psychiatric or psychological issue. This contrasts it with other forms of appetite loss, for example those caused by physical illness.

The terms anorexia and nervosa are both technically accurate, as far as they go. But neither one explains the disorder. It is much more complicated than a simple loss of appetite. And I will stress that it is not caused entirely by psychological or psychiatric issues. But there is indeed a distinct psychological component to this kind of anorexia. 2

Distorted perception

Shani Raviv, in her book Being Ana 3, writes eloquently of her personal struggle with anorexia.

I had been starving myself on and off for about six years and by that stage lanugo, the tiny white hairs found on newborns, was growing all over my arms. My chest was so flat it looked as though I had a mastectomy. My stomach was concave and hard like a steel soap dish. And every bone in my body pushed hard against my taut skin, making it seem like my joint bones wanted to blast out of their sockets. I was all angles and no shape. All bones and no flesh. 4

By this stage of Ana’s illness her perception of her own body had diverged dramatically from others’ perception of her. And her thinking had changed in ways that supported her continued self-starvation. She had come to automatically edit out of her experience any ideas, information, or feedback that might have served as motivation for change and recovery. Ana ignored comments by friends and family that she was too thin, and was harming herself. Nor did she become concerned when she vomited up “black pellets that looked like rat shit or coffee grounds,” something she later learned was the result of internal bleeding. 5

Anorexia is a miserable way to live. Yet to the sufferer it seems inescapable. In her book Ana shares her experience with those who have not lived it, and so cannot understand the behavior of the anorectic.

I once wrote that if anorexia could be summed up into one line of text on a blank page, the sentence would read: “I don’t want to be me.” What a sad, hopeless attitude to carry through life. Still, I have yet to meet an anorexic who isn’t isolated in her agonizing suffering, who isn’t locked in a psychic hell of negative mind talk, who isn’t consumed 24/7 with the obsession of thinness and the frightening, insatiable compulsion to starve and over-exercise. And the confounding inability to stop. 6

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association. This manual lists the criteria U.S. professionals traditionally use to make mental health diagnoses. DSM 5, the newest edition, took effect in January 2014. It lists three characteristics of anorexia.

First, the individual does not eat enough to maintain “minimally normal” weight. Second, there is an intense fear of gaining weight or getting fat. Third, there is a disturbance in the way body shape or weight are experienced, undue influence of body weight or shape on self-esteem, or lack of recognition of the seriousness of current low body weight. 7 The individual often experiences herself 8 as fat or bloated, though objectively she may appear skeletal.

This last characteristic is central to the perpetuation of the pattern. It is primarily the distortion of perception and thinking that keeps the sufferer from appreciating, accepting, and acting upon the need for change.

A grave problem

Anorexia is the deadliest of all psychiatric diagnoses. 9 It is easily the most dangerous of the eating disorders, and is in fact the leading cause of death in young females 15 through 24 years old. 10 11 Around ten percent of sufferers die from the disorder within 10 years of diagnosis. 12 Of those who die, about one in five are suicides. 13 In anorexia, denial and perceptual distortion prevent the victim from fully comprehending that she is approaching death’s door. Irresistible compulsion prevents her from interrupting the cycle. The survivors are split between those who recover to some degree, and those who continue to struggle. Even among survivors the incidence of serious health problems is high. 14

How common is anorexia? A 2006 study estimated that about one percent of young females suffer from this disorder. 15 But a 2007 study suggests that percentage should be doubled to about one in fifty young women. 16 Women are eight times more likely to be diagnosed than are men. The pattern most commonly starts early, and gains momentum with age. Teen girls are five times more likely to become anorectic than are older women. But research indicates that incidence among 20- to 30-year-olds is increasing rapidly. 17

A portrait of desolation

Anorexia devastates the body. Most of the damage is caused directly by chronic nutrient deprivation. That is, by starvation. Even in its early stages anorexia causes the digestive system to largely shut down, interfering with normal assimilation of nutrients. This makes adequate nutrition even more difficult.

A recent study looked at anorectic women living at home. 18 These outpatients were as a group not as severely ill as hospitalized patients. Nevertheless the incidence of significant health problems was staggering. Almost 40 percent had anemia. Twenty percent of the group had abnormally low potassium levels, provoking abnormal heart rhythms and other problems. Forty percent showed slowed heartbeat. Researchers found bone density loss in 50 percent and frank osteoporosis in 35 percent. Thirty percent had actually suffered broken bones as a result.

Prolonged malnutrition leads, in particular, to low levels of the vital nutrients zinc, folate, and B vitamins. 19 The hair becomes thin and brittle due to chronic protein deficiency. The skin dries out, and is more easily bruised. Loss of warmth-retaining fat layers provokes growth of body hair called lanugo. This fine hair is the body’s last-ditch effort to retain warmth.

In the early stages, vitamin and mineral levels within the blood are close to normal. But levels of these nutrients are already dropping precipitously within the bodily tissues themselves. In later stages anorexia causes significant loss of heart and brain mass. It is not certain whether complete recovery from such trauma is possible, even with restoration of adequate diet.

Equal opportunity destroyer

There is a popular myth that anorexia is a disease of the privileged. But recent studies show it really occurs across all social classes. 20 21 That’s not to say it strikes at random, though. It occurs more frequently among persons who, for one reason or another, are especially concerned with their weight and/or their appearance. For example it is more often seen in performers, athletes, and those whose medical conditions require weight monitoring. 22 23 It is more common in cultures and in families that emphasize appearance. All these things suggest that any source of preoccupation with appearance can help kick-start this peculiarly malignant pattern.

Overemphasis is not the whole cause – just one of several predisposing factors. As with alcoholism, inherited factors account for half the risk of developing anorexia. 24 So the conditions behind anorexia parallel addiction, where both hereditary and environmental factors combine to create vulnerability. In fact several sources explicitly point to similarities between anorexia and drug addiction. 25 26 27

Addiction? It may not be obvious how something so damaging as anorexia could possibly be viewed that way. The conventional wisdom is that people engage in addictive behaviors because they are chasing something pleasant. And to outsiders anorexia seems about as pleasant as slamming your hand in a car door. But we need to be careful not to jump to conclusions. The truth is that all addictions are rooted in misery, and all are self-destructive in their later stages. 28

A deep mystery

It has in the past been convenient to blame this disorder on the sufferer’s parents. It is true that a childhood history of sexual, physical, or emotional abuse can predispose an individual towards anorexia. 29 And as I have said, parental overemphasis on weight or appearance can indeed bias a child toward eating disorders. But not all anorectics report a history of abuse, nor do all who are abused become anorectic. And most people don’t respond to an overemphasis on appearance by plunging into anorexia. So there must be more to the story.

A compilation of recent research hints that anorexia is started and maintained by a combination of things: hereditary disposition, family dynamics, nutritional deficits, social pressure, and below-average emotional intelligence. Neurotransmitters and endorphins are important – just as they are with alcoholism.

There has been much research indicating that the neurotransmitter serotonin is important in eating disorders. Anorectics may be more sensitive to serotonin than others. Anorexia-prone individuals seem to respond to normal serotonin levels with over-arousal and anxiety. To illustrate, a study by Kaye et al deliberately lowered serotonin levels in a group of anorectics. This procedure normally produces depression. But anorectics actually felt better – both those that had recovered and those who were currently ill! Their anxiety diminished. This suggests that such clients could be self-controlling their anxiety through starvation. 30

A high percentage of anorectics seem to have under-developed emotional intelligence. That is, they have trouble clearly interpreting and talking about feelings – both their own feelings and the feelings of others. Questioning them may show that they aren’t capable of describing their feelings, and that they get confused when they try. 31 Some studies suggest that this kind of difficulty is ten times more common in anorectics than others. 32 Restricted capacity for dealing with feelings may set individuals up for chronically unresolved emotional issues. This in turn may lead them to act out feelings in an immature way, or to escape them through addictive kinds of behavior. 33

Here’s another key piece of information: as a group, anorectics can become depleted in the nutrient zinc. This is important because zinc deficiency is known to diminish appetite. Lowering zinc levels kills appetite in humans – and even in lab rats. It is possible that zinc deficiency may help start the pattern, and may make it easier to forgo eating as the disease intensifies. 34 35

Familiar ground

Here are some key similarities between anorectics and drug abusers:

The nature of anorexia is progressive and compulsive, just like addictions. 36
Sufferers experience perceptual-conceptual distortion of the destructive impact of their behavior, just like addicts. 37
Twelve to 18 percent of anorectics also abuse substances. 38
Anorectics resemble drug abusers on psychological testing. 39

Caroline Davis, PhD maintains that “current research documents a substantial lifetime comorbidity between the eating disorders and other forms of addiction.” 40 Julia Ross, a professional who works with anorectics, observes that most “actually get high on starvation.” 41 Hans Huebner is an MD who specializes in the treatment of eating disorders. Both Ross and Huebner are convinced that these clients have become hooked, enmeshed in a habit fueled by the natural endorphins released during starvation. 42 43

The downward path

Changes in perception are central to this disorder. Progressive distortion in the anorectic’s awareness, self-perception, and thinking support a pattern of behavior that would otherwise be unsupportable. But how can such an astonishing transformation of one’s experience come to be? What mechanisms are involved?

Huebner has detailed three phases in the development of anorexia. 44 Illustrating these phases with a concrete example will make things clearer. I will create a fictional teen named Kate for the illustration. Here’s a little background information on Kate.

Kate is attending high school, and lives with her parents. She has been anxious and mildly depressed for years. Her self-esteem isn’t very good. This certainly isn’t her fault. For one thing, her mother and father are both achievement-oriented and have high standards. They have at times been critical of Kate’s school performance. She tries hard to make good grades and please her parents, but she finds some subjects quite challenging. Unknown to Kate, she has an above average sensitivity to the serotonin circulating naturally within her body. Like her mother, she has a tendency to be anxious and compulsive. Again, this is partly because of her inherited brain chemistry.

Kate’s parents both come from a background of some poverty. So there has always been an emphasis on food in her home. Kate’s mother is an attractive woman who is invested in her appearance. Mother is slender, dresses well, and is proud of the way she looks. She is health-conscious too. She works out regularly, and she has for years been experimenting with various diets purported to be healthy. At the moment, mother is a vegetarian. From an early age Kate has been taught that food is not something to be wasted. Her parents have always insisted that she eat healthy foods, serve herself only what she needs, and finish everything she puts on her plate.

Mother has conveyed her health and appearance values to Kate. A couple of years earlier Kate became a few pounds overweight. Her mother expressed her disapproval in a concerned way, and urged her to pay more attention to her appearance.

The phases below mark Kate’s descent into the disorder of anorexia.

Phase One: Discovery. Kate’s disease process begins here. In this phase she first experiences the benefits of the behavior that will later become a compulsion.

Kate has an average physique now. But she has been a little depressed lately. She occasionally overeats to make herself feel better, but always feels guilty afterward. She is distressed to learn she has gained a couple of pounds. Kate does not doubt that she would be happier if she were thinner. She decides to go on a vegetarian diet like her mother. Over the next couple of months she does lose weight, and is proud of her achievement. She feels more in control of herself, and she gets positive feedback about her appearance from her family and friends. At the same time her vegetarian diet has resulted in an undetected zinc deficiency.

Phase Two: Incubation. In this phase the separate elements of the pattern are progressively shaped and adjusted to support the pattern as a whole.

Kate had originally planned to diet only until she lost a few pounds. But her first experiment went very well. She feels victorious, so she sets a new weight loss goal. She reduces her food intake further. Kate’s new “diet” doesn’t provide enough calories to maintain her weight, or enough nutrients to maintain her health. Within a few days her body switches into “starvation mode.” This is a way of feeling and behaving for which all humans are genetically pre-programmed. One part of this mode is the release of endorphins. So Kate’s endorphins kick in. As a result her depression and anxiety lift appreciably. As the body’s own version of morphine, the endorphins even make Kate feel a little bit “high.” It’s true that her new regimen is tough at first, but her new zinc deficiency helps suppress her appetite, making it easier to control her early food cravings.

In the early part of incubation the experience of reward is prominent. Kate finds her weight loss immediately gratifying. Her friends tell her she looks good. For the first time in a long time she feels in control of her weight. And because so much emphasis has been placed on weight, she feels in control of her life too. Her depression and anxiety have been dispelled. She likes the way this experiment is going.

The hook is set. Kate thinks about her severe calorie restriction as a “diet,” but in truth it is self-starvation. Her nutritional intake plunges. Her GI tract slows down with the starvation, reducing her ability to absorb essential nutrients from the little she does eat. Her existing store of nutrients begins to be used up. In particular zinc, tryptophan, and B-vitamin supplies are depleted. As her dietary tryptophan levels diminish Kate’s serotonin levels fall as well. Serotonin deficiency would cause most people to feel depressed and anxious – but not Kate. She’s oversensitive to that neurotransmitter anyway. And as her zinc deficiency gets worse, she finds it easier to eat less.

Incubation continues. Kate’s growing nutritional deficiencies begin to cloud her thinking. Her natural tendency towards compulsive behavior is worsened by her poor nutritional status. Her compulsivity contributes to her impulse to repeat the pattern of self-deprivation she has entered.

As is typical of all starving people, Kate develops a preoccupation with food. She begins to engage in compulsive behavior related to the handling and preparation of food – shopping, cooking, preparing meals – but only for others. She herself eats very little. Treatment professionals call this kind of behavior “vicarious eating.” it is a substitute for actual eating. For victims of famine a preoccupation with food is an adaptive response, since it keeps them focused on nourishment. But this preoccupation doesn’t help Kate. She is threatened by these constant thoughts of food, as it seems she is being tempted to eat and become fat. Her food obsession becomes so disruptive and intrusive that it disturbs her.

As her eating disorder incubates Kate creatively develops means of staving off the looming threat of indulgence and weight gain. She discovers more and more ways to avoid eating, despite her frequent thoughts of food. During this stage it is common for the anorectic to take up an aggressive program of exercise. “Accelerated motor activity” is a natural human response to starvation due to any cause. Increased activity is adaptive for famine victims, since it prevents them from simply “lying down to die.”

But Kate isn’t a famine victim. The impulse toward activity doesn’t help her. The same value system that supports thinness also supports “healthy” physical fitness. While she is still physically able to do so, Kate takes pride in pressing herself to her limits with exercise. Unfortunately, she doesn’t take in enough calories to offset the extra expenditure of energy. So the activity accelerates her weight loss.

The reality of the disorder becomes clearer when Kate decides to ease up on her weight loss, and is surprised to find she can no longer control the process. The process of incubation has adjusted her body, her habits, her perception, and her thinking in such a way that she is caught up in a circular pattern. That pattern has begun to perpetuate itself. Kate has dug herself into a hole, and finds she can’t simply step out again.

For one thing, she has come to firmly believe that her “dieting” is healthy. Her belief is that it is transforming her into a superior human being. For another, she has reached a point where her perception of her own body and her own health status is diverging from that of others around her. She perceives herself as healthy and attractive; others see her as way too skinny.

Importantly, Kate has become physically and psychologically dependent upon the release of endorphins within her system. In her book The Diet Cure Julia Ross explains that “Anorexia triggers the same kind of powerful high that opiates like heroin give to drug users. Why would we think that? When anorectics are given drugs that prevent opiates from affecting them, they go into a sudden withdrawal, just as heroin users do.” 45 46 Just like an addict, Kate now centers her life around her gratifying behavior. Just like an addict, she progressively withdraws her attention and energy from other activities, and funnels them into her anorectic ways.

A more basic change in her personality asserts itself. Under the influence of the incubation process, the rational and logical part of Kate’s mind begins to lose ground to an irrational component whose only function is to continue her addiction-like pattern. The distorted thinking asserts itself more and more often, feeding her lies and undermining any movement toward adequate nutrition. It becomes increasingly difficult for Kate to differentiate between what is realistic and what is not.

Psychiatrist John Feighner and colleagues say that during this stage the anorectic progressively engages in “denial of illness, failure to recognize nutritional needs, a distorted, implacable attitude towards eating that overrides hunger, admonitions, reassurance and threats.” 47 Starving herself is gratifying, so she does it more and more – just like an addict.

It is during this stage that Kate’s distorted thinking and perception become glaringly obvious to others. Huebner would say that Kate “has acquired new values that are real and convincing to her… and she is willing to defend her behavior against anyone challenging it.” 48 Although others express shock and dismay at her emaciated appearance, she maintains that her weight is normal – or even that she is a little pudgy. Kate’s friends and family can’t grasp why she continues to do things that are so obviously self-destructive. They tell her she is being stupid, and beg her to stop. These admonitions simply irritate Kate. Even on those occasions when her denial falters under the onslaught of her declining health, Kate finds herself unable to abandon her compulsive behavioral pattern.

Kate is confused. Her strong intuitive sense is that she has discovered a precious secret that makes her physically and morally superior to others. She is living out a delusion of supremacy. She won’t give up her secret no matter how energetically others try to pry it from her. Perhaps it makes sense, then, that Kate begins to lie, to cheat, and to maintain secrets to continue her pattern despite others’ objections and expressions of concern.

Phase Three: Final Pattern: In this stage of the disorder Kate is no longer physically able to support the pattern that is consuming her, though she cannot stop it.

Kate is no longer coping as well as she has previously. Depression and anxiety return, and her body is too nutritionally bankrupt to manufacture the quantity of endorphins that would be necessary to mask these symptoms. Kate makes a last-ditch effort to release endorphins by exercising more, but finds she is too weak to sustain this. The muscles of her body have been largely consumed – the protein has been burned by the body as fuel just to keep her alive.

It would be reasonable to expect that Kate would finally start to come to grips with the destructive impact of her self-starvation. But in fact just the opposite happens. The anorectic pattern pattern expands in what looks like a last, desperate bid for survival. In response to Kate’s renewed experience of depression and anxiety it reasserts itself in even greater strength.

It is during this final stage that the parasitic nature of anorexia is fully unmasked. The disease-like nature of the process is quite obvious to everyone but Kate. The pattern is serving only itself. As if it were a cornered animal, it is seemingly determined to perpetuate itself even at the cost of Kate’s life. At this point all of Kate’s human responses to starvation – her preoccupation with food, her restlessness, her production of endorphins – are serving another master. As Huebner puts it, her responses “lose sight of the interest of the whole organism, and actually become selfish and destructive to life. It is if a guard dog becomes confused and protects the intruding burglar with the same determination and vengeance as he commonly protects his master.” 49

This “last gasp” of the malignant pattern cannot prevail, for the simple reason that Kate no longer has the resources to support it. She finally begins to glimpse the truth of her physical decimation through her mental fog. Even so, she remains conflicted. Kate struggles with the idea that she will have to apply herself to the feared and despised goal of weight gain.

The attentional and perceptual distortions associated with anorexia make it extremely resistant to correction. Logical or rational arguments typically have zero impact on the sufferer’s perception of herself, or on her willingness to change her eating patterns. Offering rational “proof” – that she is underweight, that her health has been seriously compromised, that she is in fact near death – is water off a duck’s back. Her self-image, her off-center ideas, her misleading self-talk, and her behavior continue unchanged.

Hans Huebner explicitly outlines the close parallel between addictive denial and anorectic denial. The similarity is striking. He writes the following about the early stages of his work with sufferers:

One of the principal tasks during this early phase of therapy is to help the anorectic understand the many distortions of her addicted mind, which become more evident as the addiction is being challenged… I call these defensive maneuvers “mental tricks” that the addicted mind plays on the anorectic to maintain the addiction… I give her a rule of thumb, the so-called bottom line rule: any thought and subsequent action that could cause her to lose weight, burn calories, or render taken-in calories useless by purging is caused by her addicted mind. In other words, no matter what the conscious intent of the anorectic’s thought or behavior, when the end result does not favor weight gain, the bottom line is that it was caused by her addicted mind. 50

Huebner points out a second astonishing parallel between anorexia and addiction: despite the fact that moral rigidity is often one of the predisposing factors, as the disease progresses the anorectic is likely to slip into a devious, manipulative, dishonest personal style – just like the addict.

This tendency makes anorectics unpleasant to deal with, and is disheartening to the professionals who are working hard to save their lives. Huebner notes that “Anorectics are notorious for their ‘dishonest character’ and for lying, cheating, and misleading others.” He stresses that generally these individuals tend toward high moral standards. Yet despite their best intentions, “the power of their endorphin dependence is often beyond their control, resulting in dishonesty and devious behavior.” 51

Though Huebner doesn’t use the term incubation, 52 it’s clear that in his view anorectic deviousness and other typical anorectic behaviors evolve for the specific purpose of maintaining the addictive pattern. They are essential components of the disease itself. They emerge as the elements of the addictive process are progressively refined over time, contributing to the sufferer’s loss of control over her own behavior. 53

Some Commonalities

I have sketched out a picture of anorexia, and we can now compare it to alcoholism. There are both similarities and differences. Obviously, one big difference is that alcoholism involves consumption of alcohol, where anorexia involves consumption of precious little of any sort. For present purposes we need to focus primarily upon the similarities between the two. Here are some of them.

In both anorexia and alcoholism,

A pattern that originates as a voluntary behavior converts into a habit, and finally ends up as an involuntary compulsion.
The final result has many of the characteristics of a disease.
A variety of concrete factors – heredity, models, experienced discomfort – make certain individuals more likely than others to enter into the behavioral pattern.
A process of incubation serves to progressively refine the elements of the behavioral pattern in such a way that they support its continuation.
A particularly problematic feature – perceptual-conceptual distortion – always arises during the course of incubation.
This distortion prevents the sufferer from fully or consistently appreciating the damage being caused. So it undercuts any motivation for change, and helps keep the destructive pattern going.

It can be seen that the end result of both processes is a self-supporting loop of behavior, an injurious habit that reproduces itself at the expense of the sufferer. In both cases the perceptual distortion that we commonly call denial plays a central role. Without this distortion, and the confusion it engenders, the destructive pattern could not persist.

Unexplainable

Anorexia and alcoholism are just examples of a large and mystifying class of repetitive, stereotypical, pathological behavioral patterns. I refer to these malignant patterns as “behavioral viruses,” applying this term to emphasize that the patterns are disease-like, and share many characteristics with biological viruses. True substance addictions fit into this category, as do true behavioral addictions – for example addiction to pornography or to gambling.

Those of us who are not personally involved in addictions are often tempted to pass judgment on the addict. To explain addictive behavior in terms of hedonism, selfishness, immorality, or personal irresponsibility seems to make sense. “He’d rather stay drunk all day long than deal with the ordinary stresses of living,” we tell ourselves. Or, “He’s quite selfish to put his family into debt with his gambling. What is he thinking?” Perhaps this is the only way we can comprehend such strange behavior.

The examples of anorexia and alcoholism illustrate that the behavior of the affected individual is not easily explainable in terms of ordinary human motivation. Obviously neither habit benefits the person engaging in the behavior. These habits are pathological. Looking beyond these specific examples, it becomes clear that this kind of dysfunctional behavior is quite common.

Coming chapters should make it clear that addictions and other repetitive, destructive patterns are forms of behavioral disease. Some of these patterns begin as a pleasurable activity. But this fact is misleading – a red herring. A pathological behavior can begin with a chase for pleasure, or as an escape from pain, or as part of a search for meaning in life, or with any one of a hundred other reasons to try something different for the first time.

It should be stressed that the reason for calling the end result pathological is not same as the reason the pattern started. The confusing thing about this entire class of behaviors is that in their initial form they are comprehensible in human terms. But in their final form they are unexplainable in terms of normal human motivation – just as the symptoms of occasional viral illnesses are unexplainable in terms of what we personally want and need.

Summary

Anorexia nervosa is an eating disorder that is highly physically destructive. It is the psychiatric disorder with the highest mortality.
Perhaps the most mysterious feature of anorexia is its capacity to distort the patient’s perception of her own body, with the result that she sees herself as “too fat” even when her disorder has progressed to the point that she is so malnourished as to be skeletal in appearance, and near death.
Anorexia shares certain features with addiction, most obviously the perceptual/conceptual distortion clinicians call denial.
In both anorexia and addiction the end result is a self-reproducing pattern with disease-like characteristics. Like alcoholism, anorexia can be understood as a behavioral virus.

Why would I choose to label alcoholism and anorexia “viruses?” To answer that question definitively, I must be clear about what a virus actually is. That’s the subject of the next chapter.

Notes and References

1 Boskind-White M, White WC. Bulimia / Anorexia: The binge/purge cycle and self-starvation. WW Norton and Co, New York, 2001. Page 58.
In the interest of simplicity, from this point forward we will refer to Anorexia Nervosa with the single word “anorexia”.
Raviv S. Being Ana: A Memoir of Anorexia Nervosa. iUniverse.com (first edition), August 2010.
Raviv S, 2010. Page 131.
Raviv S, 2010. Page 129.
Raviv S. 2010. Page xiv.
American Psychiatric Association, 2013. Page 171.
In this chapter we will often refer to anorectics as female. Males can be anorectic too, but the disorder is much more common among females.
Patrick L. Eating Disorders: A review of the literature with emphasis on medical complications and clinical nutrition. Alternative Medicine Review, 2002, 3, 184-202. Available online at http://www.altmedrev.com/publications/7/3/184.pdf. Accessed 9/25/16.
Sullivan PF. Mortality in anorexia nervosa. American Journal of Psychiatry, 1995, 152, 1073-1074.
Barnill J, Taylor N. If You Think You Have an Eating Disorder. 1998, Dell Publishing Group.
Sullivan PF. Course and outcome of anorexia nervosa and bulimia nervosa. Chapter in Fairburn CG, Brownell KD (eds), Eating Disorders and Obesity (second edition), 2002, New York, Guilford Press. Pages 226-232.
Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies. Archives of General Psychiatry, 2011, 68, 7, 724-731.
Patrick L, 2002. Page 185.
Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Current Opinion in Psychiatry, 2006, 19, 4, 389-394. Page 389.
Keski-Rahkonen A, et al. Epidemiology and course of anorexia nervosa in the community. American Journal of Psychiatry, 2007, 164, 8, 1259-1265. Article available online at http://www.ncbi.nlm.nih.gov/pubmed/17671290?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum.
Pawluck DE, Gorey KM. Secular trends in the incidence of anorexia nervosa: Integrative review of population-based studies. International Journal of Eating Disorders, 1998, 23, 4, 347-352. PubMed summary at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9561424&dopt=Citation.
Miller KK, et al. Medical findings in outpatients with anorexia. Archives of Internal Medicine, 2005, 165, 5, 561-566. PubMed abstract at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15767533&query_hl=1&itool=pubmed_docsum.
The statistics in this paragraph are from Spear BA, 2001.
Spear BA, et al. Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (EDNOS). Journal of the American Dietary Association, 2001, 101, 810-819. Page 810.
Tyre P. Fighting Anorexia: No one to blame. Article in Newsweek, 2005. Available online at http://www.newsweek.com/fighting-anorexia-no-one-blame-113855. Accessed 9/25/16.
Spear BA, et al, 2001. Page 810.
Patrick L, 2002.
Tyre P, 2005.
Davis C. Addiction and the Eating Disorders. Psychiatric Times, 2001, 18, 2. Available in full online at http://www.psychiatrictimes.com/articles/addiction-and-eating-disorders. Accessed 9/25/16.
Huebner HF. Endorphins, Eating Disorders, and Other Addictive Behaviors. WW Norton and Co, New York, 1993.
Hornbacher M. Wasted: A memoir of anorexia and bulimia. 2014, Harper Perenniel. Page 5.
Huebner writes, “Addicts do not become addicted for fun. Depression, social and personal demoralization, low self-esteem, as well as biological sensitivities existing since birth, are typical precursors of drug addiction.” [Huebner HF, 1993. Page 19.]
Wonderlich SA, Brewerton TD, Jocic Z, et al. Relationship of sexual abuse and eating disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 1997, 36, 1107-1115.
Kaye WH, et al. Anxiolytic effects of acute tryptophan depletion in anorexia nervosa. International Journal of Eating Disorders, 2003, 33, 3, 257-67. Discussion 268-270. Pubmed abstract online at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12655621&query_hl=5&itool=pubmed_docsum.
Taylor GJ & Taylor HS. Alexithymia. Chapter in M. McCallum & W.E. Piper (Eds), Psychological Mindedness: A contemporary understanding. Munich: Lawrence Erlbaum Associates. Page 29.
This difficulty in correctly interpreting and describing feelings in self and others, which goes by the awkward name “alexithymia,” is the opposite of emotional intelligence. It has been “consistently observed by clinicians, and demonstrated in research studies.” [Hatch A, Madden S, Kohn M, Clarke S, Touyz S. Anorexia nervosa: Toward an integrative neuroscience model. European Eating Disorders Review, 2010, 18, 3, 165-179. Page 169.]
Li CS, Sinha R (1 March 2006). Alexithymia and stress-induced brain activation in cocaine-dependent men and women. Journal of Psychiatry and Neuroscience , 2006, 31, 2, 115–121.
Shay NF, Mangian HF. Neurobiology of zinc-influenced eating behavior. Journal of Nutrition, 2000, 130, 1493S-1499S. Available online at http://jn.nutrition.org/content/130/5/1493S.full. Accessed 9/26/16.
The Institute of Medicine says “the requirement for dietary zinc may be as much as 50 percent greater for vegetarians and particularly for strict vegetarians whose major food staples are grains and legumes…” [Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. National Academies Press, Washington, 2001. Page 480.]
Patrick L, 2002.
Patrick L, 2002.
Patrick L, 2002.
Davis C. Addiction and the Eating Disorders. Psychiatric Times, 2001, 18, 2. Available in full online at http://www.psychiatrictimes.com/articles/addiction-and-eating-disorders. Accessed 10-3-16.
Davis C, 2001.
Ross J. Natural Treatment of Anorexia and Bulimia. Excerpted from her book, The Diet Cure. Penguin Books, 2000. Excerpted chapter available online at http://www.alternativementalhealth.com/articles/anorexia.htm. Accessed 10-3-16.
Ross J, 2000.
Huebner HF, 1993. Page 20.
Huebner HF, 1993. Pages 16-48. Huebner’s model is based on an understanding of anorexia as an addiction to the endorphins the body releases under the stress of starvation. He identifies three stages in the disorder: Early weight loss, Advanced weight loss, and Burn-out or depletion. For didactic purposes I have renamed them to match the three stages in the development of an addictive disorder.
Ross J, 2000.
The addiction model of Anorexia can provide valuable insights. Does this model accurately represent some cases of Anorexia Nervosa? Yes. Does it represent them all? Probably not. The body of knowledge in this area is as yet too incomplete to permit definitive answers.
Feighner JP, Robins E, Guze SB, Woodruff RA, Winokur G, Monroe R. Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry, 1972, 26, 1, 57-63. Page 61.
Huebner HF, 1993. Page 35.
Huebner HF, 1993. Page 44.
Huebner HF, 1993. Pages 86-87.
Huebner HF, 1993. Page 87.
In medicine, the term “incubation” refers to the development of an infection from the time the pathogen enters the body until signs or symptoms first appear.
Huebner HF, 1993. Pages 33-34.