An Outsider’s Look on Anorexia

We are pleased to share Dr. Wendy Oliver-Pyatt’s blog post, “An Outsider’s Look on Anorexia,” recently featured on the Eating Disorder Coalition of Tennessee’s (EDCT) Topic Tuesday.

I recently encountered a lovely young man from Nigeria. He is 15 years old. When I showed him Oliver-Pyatt Centers buildings, and let him know we treat individuals with anorexia nervosa, he asked, “What do you do with them? How do you make them eat? Why don’t they eat?” To a teenager from Nigeria, who came to America looking for stability and a brighter future, the disorder made no sense. Why did these people not eat when food is available? Aren’t they thankful to have the food in the first place? 

I got to thinking about what a misunderstood condition anorexia nervosa really is. Anorexia Nervosa is a condition where the patient is, as Carolyn Costin puts it, “a canary in a coal mine.” In our society of abundance, why would people “choose” to starve themselves?

The answer is complex. Anorexia nervosa is perhaps the most vivid example of the interplay between biology and environment, where the impact of the environment directly and indirectly interacts with the biology of the brain. The pressures to restrict are like the toxic fumes of our society, taking down those who are most vulnerable to interpersonal pressure to connect and “succeed” interpersonally by conforming to the social mandate to be thin (or be shamed).

When you ask a patient, “why do you want to be thinner?” the answers can vary. But when you repeat the question and dig further and further, you often will fumble onto the common principal of the wish, we all share, which is to be loved and accepted.  This may seem petty, but let’s think about survival. Attachment and connection may be as critical to survival as food and shelter. What else does “being thinner” represent to a patient? Being thinner makes the world a little safer, gives the person more chance of being cared for, accepted and “held.” The pursuit of thinness itself becomes a guiding light, making no room for any other thoughts, feelings or needs. Maintaining the rigidity around food is a parallel process for maintaining a way of living that leaves no room for conflicting needs and desires. That is why it can be so beneficial to learn the language of the eating disorder, and discover how the eating disorder is functioning for the patient. Is it keeping all other thought and emotion at bay? Relieving the responsibility of another developmental milestone? Drawing in attachment figures in a way that makes the world feel safer? Reinforcing for the patient that they are not alone?

Winnicott said, “being sick provides immediate relief by legitimizing dependency.” The “sickness” of anorexia is at once a biological process of the brain being “hijacked” by the impact of starvation, while also functioning in so many ways socially and psychologically.

The toxic fumes of our society imbed into the psyche of the vulnerable. The restriction begins and then all hell breaks loose. The brain changes, the thoughts consume the person, literally debunking all rationale thinking about food, creating what I call a “pocket of psychosis.” 

I was struck by the question from our Nigerian friend and how confusing this disorder seemed to him. How can I explain the pressure to restrict to this young man? Would he ever understand the depth of the condition and what is at stake? I did not know the words to use to help him grasp the origins of this condition and also gravity. My struggle to describe this condition to a person from such a far away place, I think speaks to the cultural and environmental factors that contribute.

Today I write this blog, emphasizing the bio-psycho-social condition of anorexia nervosa. I honor all of those who struggle with this painful condition, where the person is trapped between hunger and competing thoughts and fears. Our friend from Nigeria arrived in the USA not long ago. It will take him some time to understand how a culture and a brain can interact to lead to the demise of those who are vulnerable. I hope the world will become a kinder place, where we can work together to reduce the factors (Carolyn’s “toxic fumes”) that place a person at risk, while simultaneously evolving into a society that insists we do more for those who are impacted.

– Wendy Oliver-Pyatt, MD, FAED, CEDS