Healing Psychology, Part D – Anorexia Nervosa.

Anorexia nervosa is a dangerous eating disorder. It’s incredibly treacherous—in fact, it’s the leading cause of death in young women aged 15 to 24. The most mysterious thing about Anorexia is that the sufferer sees herself as “too fat,” even when she has starved herself to the point that she’s near death, and looks skeletal to others. How can we make sense of this bizarre and often fatal misperception? Some treatment professionals compare it to addiction. In fact, anorexia and addiction do have much in common—the most important commonality being the central role of denial.

Transcript

Part D - Anorexia Nervosa
This Episode of Healing Psychology is a reading of chapter three of my upcoming book, Reimaging Psychology.

Copyright © Thomas O. Whitehead, 2022   All rights reserved

[Introduction]

This podcast is Part D of the multi-part series “Healing Psychology.” This part is focused on the dangerous eating disorder Anorexia Nervosa. The most striking symptom of anorexia is the sufferer’s bizarre misperception of her own body. She sees herself as “fat” even when she’s so emaciated that she’s near death, and has a frankly skeletal appearance. The misperception of her body, as well as distortions in her reasoning, derail any attempt to interrupt the disorder. 

How can we understand the sufferer’s weirdly distorted, often fatal, misperception? One way is to compare anorexia to addiction, as many treatment professionals do. 

The connection will become clearer as we examine the details of each disorder. Addiction and anorexia can be understood as habits that have escaped the individual’s control to become self-sustaining. In essence, these habits have become parasites, sustaining themselves by misusing the resources of their hosts. Understanding anorexia as a parasitic habit is certainly not mainstream psychology. But you’re invited to listen … anyway.

[Reading]

• 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. [1]

 - Anorectic pre-teen

A great many self-maintaining behaviors have features similar to those of addiction. But most of these don’t involve any substance use. One good example is the stubbornly persistent eating disorder anorexia nervosa. [2] As with alcoholism, our current psychology doesn’t account for the mind-bendingly strange details of this malignant pattern.

Anorexia 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 appetite loss 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 descriptive, as far as they go. But neither one helps explain the disorder. It’s much more complicated than a simple loss of appetite. And I will stress that though few experts believe it to be caused entirely by psychological or psychiatric issues, there is indeed a distinct psychological component to this kind of anorexia. 

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 late 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 reflexively edit out of her experience any ideas, information, or feedback that might have motivated 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 evidence of internal bleeding. [5]

As with alcoholism, anorexia is organized around the experience of misery. As with alcoholism, the disorder creates misery, which the sufferer attempts to escape by further indulgence in the disordered habit. She [6] can conceive of no other path. 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. [7]

The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, lists the criteria U.S. professionals traditionally use to make mental health diagnoses. DSM 5, the newest edition, took effect in January 2014. The manual details 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 sufferers experience their body shape and weight, undue influence of body weight or shape on self-esteem, or lack of recognition of the seriousness of current low body weight. [8] The individual often experiences herself as fat or bloated, though she likely appears skeletal to others. 

This complex misperception reminds us of the perceptual/cognitive distortions so characteristic of alcoholism. Further, the distortion is central to the perpetuation of the malignant pattern. How? Paralleling alcoholic denial, it is the anorectic’s distortion of experience that keeps her 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. In fact, it is the leading cause of death in young females 15 through 24 years old. [10][11] Around ten percent of anorectics die from the disorder within ten years of diagnosis. [12] It’s a life of misery. Of those who die, about twenty percent are suicides. [13]

In anorexia, denial and perceptual distortion prevent the victim from fully appreciating that she is approaching death’s door. Irresistible compulsion stops her from interrupting the cycle. The survivors fall into two groups—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 the very next year, 2007, a study suggested the true percentage could be double that—about one in fifty young women. [16] There are eight times more women diagnosed than men. The pattern commonly starts early, and gains momentum with age. Teen girls are five times more likely to become anorectic than are older women. But research shows that incidence among 20- to 30-year-olds is burgeoning. [17]

A portrait of desolation

Anorexia devastates the body. Chronic nutrient deprivation—starvation—directly causes most of the damage. Even in its early stages, anorexia prompts the digestive system to 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] As a group these outpatients were not as severely ill as hospitalized patients. Even so, 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. 

Prolonged malnutrition leads, in particular, to low levels of the vital nutrients zinc, folate, and B vitamins. [19] The hair becomes thin and brittle because of 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 keep warmth. 

In the early stages of anorexia, 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, the disorder causes significant loss of heart and brain mass. It is uncertain whether complete recovery from such catastrophic losses is possible, even with restoration of an adequate diet.  

An equal opportunity destroyer

There is a popular myth that anorexia is a disease of the privileged. But recent studies show it occurs across all social classes. [20] [21] That’s not to say it strikes at random, though. It occurs more frequently among persons who are unusually concerned with their weight and/or their appearance. For example, it is more often seen in performers, athletes, and people whose medical conditions require weight monitoring. [22] [23] It’s more common in cultures and in families that emphasize appearance. All these things suggest that any source of preoccupation with appearance or weight is a risk factor. 

Overemphasis on appearance is just one of several predisposing conditions, though. As with alcoholism, inherited factors account for half the risk of developing anorexia. [24] So, the conditions biasing toward anorexia do parallel addiction, where both hereditary and environmental influences combine to create vulnerability. In fact, several authorities point to the similarities between anorexia and drug addiction. [25] [26] [27]

Similar to addiction? It may not be obvious how something so damaging as anorexia could possibly be viewed that way. The conventional wisdom is that people who engage in addictive behaviors are chasing some pleasant experience. And to outsiders, anorexia seems about as pleasant as slamming your hand in a car door. But we shouldn’t jump to conclusions. As I have stressed, misery is at the root of addictions of all types. And all are harmful in their later stages. [28]

A deep mystery

It has in the past been convenient to blame this disorder on the sufferer’s parents. True, a childhood history of sexual, physical, or emotional abuse can predispose an individual towards anorexia. [29] And as already noted, parental overemphasis on weight or appearance can indeed bias a child toward an eating disorder. But not all anorectics report a history of abuse, nor do all abused children become anorectic. And it isn’t the norm to 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 starts and is maintained by a combination of things: hereditary disposition, family dynamics, nutritional deficits, social pressure, and below-average emotional intelligence. Neurotransmitters and endorphins are also important—just as they are with alcoholism. 

There has been much research showing that the neurotransmitter serotonin is important in eating disorders. Oddly, 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, in a study by Kaye et al. researchers deliberately lowered serotonin levels in a group of anorectics. Lowering serotonin often produces depression in normal subjects. But anorectics actually felt better—both those who had recovered, and those who were currently ill! Their anxiety diminished. This suggests that some of these individuals 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 get confused when they try. [31] Some studies indicate that low emotional intelligence is ten times more common in anorectics than others. [32] Limited skill in dealing with feelings may set them up for discomfort in social settings, as well as chronically unresolved emotional issues. This, in turn, may lead them to act out their unrecognized feelings immaturely, or to escape their discomfort through addictive kinds of behavior. [33]

As noted, anorectics tend to have low levels of 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 anorectic 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 concerning 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]

 It isn’t unusual for professionals to apply our understanding of addiction to anorexia. 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 believe their clients are enmeshed in an addictive habit fueled by the natural endorphins released during starvation. [42] [43]

The downward path

It’s essential to understand that, as with alcoholism, changes in perception are central to anorexia. Progressive distortion in the patient’s awareness, bodily self-image, and way of thinking support a malignant pattern of behavior that would not otherwise be supportable. But what causes the anorectic’s astonishing transformations of experience? 

Huebner has detailed three phases in the development of anorexia. [44] Illustrating these phases with a concrete example, as we did with alcoholism, will make things clearer. So, for purposes of illustration I will create a fictional teen named Kate. 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. One reason is that her mother and father are both achievement-oriented, and have high standards. They have been critical of Kate’s school performance. She tries hard to make good grades and please her parents, but she finds some subjects challenging. Unknown to Kate or her parents, 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, in her home there has always been an emphasis on food. Kate’s mother is an attractive woman 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. She taught Kate 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 on her plate. 

Mother has conveyed to Kate her values about health and appearance. A couple of years earlier, Kate had gained a few extra pounds. 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.

Here’s how it happens. Kate has an average physique now. She has been a little depressed lately, and occasionally overeats to make herself feel better, feeling guilty afterward. She is distressed to learn she has gained a few pounds. Kate has no doubt that she would be happier if she were thinner. She goes on a vegetarian diet like her mother. 

Over the next couple of months, she loses weight. She’s proud of her achievement. Now she feels more in control of herself, and she gets positive feedback about her appearance from her family and friends. At the same time, though, her new vegetarian diet is worsening an undetected zinc deficiency. 

Phase Two: Incubation. This is the phase where the disorder evolves into a malignancy. Variation and selection progressively shape the separate elements of the pattern so that they work together to support the pattern’s continuation. 

Here’s how this incubation phase might go for Kate. She had originally planned to diet only until she lost a few pounds. But her experiment proved very gratifying. She feels victorious, so she sets a new weight loss goal. She reduces her food intake further. Kate’s new “diet” isn’t really a diet at all. Not only does it fail to provide enough calories to maintain her weight, but it fails to provide enough nutrients to maintain her health. She’s literally starving herself.

Within a few days, Kate’s 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 “high.” It’s true that her new regimen is tough at first, but her worsening zinc deficiency suppresses her appetite, making it easier to control her food cravings.

The experience of reward is prominent during the early part of incubation. Kate finds her weight loss immediately gratifying. She gets support from others too. Her friends tell her she looks good. For the first time in a long time, she feels in control of her weight. And because her family places so much emphasis on weight, she feels in control of her life. The experience dispels her depression and anxiety. She likes the way this experiment is going. 

The hook is set. Kate thinks of her severe calorie restriction as a “diet,” but in truth its starvation. Her nutritional intake plunges. Her GI tract slows down, reducing her ability to absorb essential nutrients from the little she does eat. The deficiency depletes her existing store of nutrients—zinc, tryptophan, and B-vitamin supplies. As her dietary tryptophan levels fall, 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. 

Kate’s nutritional deficiencies begin to cloud her thinking. The confusion that accompanies her poor nutritional status exaggerates her natural tendency towards compulsive behavior. Her compulsivity heightens her impulse to repeat the gratifying pattern of self-deprivation she has entered.

As is typical of starving people everywhere, Kate develops a preoccupation with food. She engages 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 feels 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 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, whether or not voluntary. 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 encourages 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 nearly enough calories to offset the extra expenditure of energy. So, the activity speeds up her weight loss.

The reality becomes clearer when Kate decides to ease up on her obsessive dieting, only to find she can no longer control it. The process of incubation has adjusted her body, her habits, her perception, and her thinking to maintain the circular pattern. All the concepts and behaviors that would support normal eating and adequate nutrition have been “chipped away” by the incubation process. 

Habits naturally vary as they are repeated. Kate’s repeating her “diet” habit over and over and over has given it the opportunity to evolve into a form that supports its further repetition. Simply put, all this repetition has allowed Kate’s anorectic habit to evolve into a parasitic form. Now it’s perpetuating itself at Kate’s expense. Both the behavior itself, and her perception of the behavior, have been zombified. She has fallen into the hole she dug for herself, a hole so deep she can no longer simply step out of it.

Kate has come to believe that her “dieting” is actually healthy. Her impression is that her practices are transforming her into a superior human being. She has reached a point where her perception of her own body and her own health status has diverged sharply from that of others around her. She perceives herself as healthy and attractive; others see her as morbidly and grotesquely emaciated. 

Contributing to the addiction, Kate has become physically and psychologically adjusted to 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 get 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 the only behavior she finds gratifying. And just like an addict, she has progressively withdrawn her attention and energy from other activities, funneling them into her anorectic ways.

Further trouble comes in the form of an even more fundamental change in her personality—full-fledged denial. As her disorder incubates, the rational part of Kate’s mind loses ground to an irrational component, a part whose only function is to carry on her addiction-like pattern. The distorted pattern of 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 engages in “denial of illness, failure to recognize nutritional needs, a distorted, implacable attitude towards eating that overrides hunger, admonitions, reassurance and threats.” [47] Her habit has become her go-to relief from her misery, so she does it more and more—just like an addict. And denial strengthens to protect her precious habit.

As Huebner stresses, 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] Kate’s distorted thinking and perception become horrifyingly obvious—to everyone but her. 

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 fathom why she continues to do things that are so obviously self-destructive. They tell her she is being stupid, and they beg her to stop. These admonitions simply irritate Kate. Even on those occasions when her denial falters under the onslaught of her steeply declining health, Kate finds herself unable to abandon her compulsive behavior. 

Kate is confused. Her strong intuitive sense is that she has discovered a precious secret that makes her physically and morally superior to others. Why would she believe that? By this point in the evolution of her disorder, incubation has chipped away all her more realistic beliefs and attitudes, leaving only those that support continuation of the habit. She is living 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 in order to continue her pattern—despite others’ objections and expressions of concern.

Phase Three: Final Pattern: In this phase of the disorder Kate’s behavior and beliefs are fully zombified. Though no longer physically capable of supporting the life-consuming pattern, she is powerless to stop it. 

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

Now, given the now obvious devastation, it would be reasonable to expect that Kate would finally come to grips with the destructive impact of her self-starvation. But what happens is just the opposite. The anorectic pattern expands in what looks like a last, desperate bid for continuation. 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 pattern is serving only itself. Like a cornered animal, it seems determined to stick around even at the price 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 being exploited by another master. As Huebner puts it, her acts “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]

But this “last gasp” of the malignant pattern cannot long prevail, because Kate no longer has the resources to support it. Now, through her mental fog, she glimpses the truth of her physical decimation. Even so, she remains conflicted. Kate struggles with the idea that she will have to apply herself to the despised goal of weight gain. 

As with alcoholism, it is the attentional and perceptual distortions associated with anorexia that make it so fiercely resistant to correction. Logical arguments typically have zero impact on the sufferer’s perception of herself, or on her willingness to change her eating patterns. Offering her rational “proof”—that she is underweight, that she has seriously compromised her health, 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 persist against all efforts to correct them. 

Huebner explicitly outlines the close parallel between addictive denial and anorectic denial. The similarity is striking. He writes the following about the beginning 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: although moral rigidity is often one of the factors predisposing toward anorexia, as the disease progresses the sufferer is, like the addict, prone to slipping into a devious, manipulative, dishonest personal style. 

This deceitfulness makes anorectics unpleasant to deal with, and is disheartening to professionals who are working hard to save their lives. As Huebner puts it, “anorectics are notorious for their ‘dishonest character’ and for lying, cheating, and misleading others.” He stresses that despite the best intentions of the anorectic, the power of the addiction-like pattern is often beyond their control, and it is the power of this pattern that spawns “devious behavior.” [51]

Though he doesn’t use the medical term incubation, [52] Huebner’s description makes it clear he believes the dishonesty and other typical anorectic behaviors evolve toward maintenance of the addictive pattern. They are essential components of the disease itself. These negative characteristics emerge over time with the progressive refinement of the addictive process, contributing to the sufferer’s loss of control. [53]

Some Commonalities

I have sketched out a grim picture of anorexia. Now we can formally 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. But for the present, we need to focus on similarities. Here are some of their common features. 

In both anorexia and alcoholism,

• A pattern that originates as a voluntary habit converts into an involuntary, self-replicating compulsion. 
• The ultimate pattern of behavior has many disease-like characteristics.
• A variety of concrete factors—heredity, models, experienced discomfort—make certain individuals more likely than others to fall into this behavioral pattern.
• A process of incubation progressively refines the elements of the pattern in a way that supports its continuation.
• An especially problematic feature—denial, or perceptual-conceptual distortion—inevitably arises during incubation.
• This distortion prevents the sufferer from fully or consistently appreciating the damage being caused by the process. Denial undercuts the motivation for change, in this way keeping the destructive pattern going.
• Sneakiness and dishonesty characterize the later stages of both disorders. The host’s abandonment of personal integrity protects the dysfunctional habit by alienating outsiders who threaten its continuation.

 The end product of both anorexia and alcoholism is a self-supporting behavioral loop, a malignant habit that reproduces itself at the expense of the sufferer. In each case, the perceptual distortion that we call denial is at center stage. Without this distortion and the resulting confusion, the destructive pattern could not possibly persist. 

Unexplainable

Anorexia and alcoholism are but two examples of a large and mystifying class of repetitive, stereotypical, pathological behavioral patterns. I refer to these malignant patterns with the interchangeable terms “behavioral parasites,” “behavioral viruses,” and “parasitic habits.” I use disease terms to emphasize that the patterns are habitual, disease-like, and have many of the formal characteristics of biological parasites, especially viruses. True substance addictions fit into this category, as do true behavioral addictions—for example addiction to pornography, social media, gaming, or gambling. 

As I have stressed, those of us who are not themselves involved in addictions often pass judgment on the addict. It is tempting to think of addictive behavior as “bad” behavior—to use terms like hedonism, selfishness, immorality, and personal irresponsibility. Perhaps that’s because we can’t come up with any other explanation for this craziness. “He’d rather stay drunk all day long than deal with the everyday stresses of living,” we tell ourselves. Or, “He’s quite selfish to put his family into debt with his gambling.” It seems these are the only ways we can comprehend such things, using our current psychology

As the examples of anorexia and alcoholism illustrate, psychology in its present form can’t satisfactorily explain the details of these behaviors. Neither of these habits benefits the person affected. While some such patterns begin as a pleasurable activity, this fact is completely misleading—a red herring. A pathological habit 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 of a thousand other reasons to begin doing something. The motivation for starting the pattern is not the same reason it persists to evolve into an addiction. 

That’s the remarkable thing about this entire class of behaviors. At their beginning, we can easily explain them in human terms. But in their ultimate form they are never completely explainable in terms of human motivation—just as the symptoms of our viral illnesses, for example sneezing, are never explainable in terms of what we want and need for ourselves. The behavior is caused by diseases—diseases with needs of their own that they fill by using us as their hosts.

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, so she sees herself as “too fat” even when her disorder has progressed to where she is so malnourished as to be skeletal in appearance, and near death. 
• Anorexia and addiction share many features, with the most glaring similarity being the perceptual/conceptual distortion clinicians call denial.
• In both anorexia and addiction, the result of incubation is a self-reproducing pattern with disease-like characteristics. As with alcoholism, we can best understand anorexia as a behavioral parasite.

[Post Episode]

Thank you for your interest in this episode, Healing Psychology Part E – Viruses. Additional information is available on the website, Whiteheadbooks dot com, where you can also find credits for the music tracks you heard.

The Healing Psychology series will continue with readings of additional chapters of the book. The title of Part F is “Viral Origins.” In Part F we’ll see if the experts can tell us where viruses come from. Their origin is important, because it helps us understand how our own habits can turn into something that’s virus-like.

Please join us!

__________________________

[1] Boskind-White M, White WC. Bulimia / Anorexia: The binge/purge cycle and self-starvation. WW Norton and Co, New York, 2001. Page 58.
[2] In the interest of simplicity, from this point forward we will refer to anorexia nervosa with the single word “anorexia”.
[3] Raviv S. Being Ana: A Memoir of Anorexia Nervosa. iUniverse.com (first edition), August 2010.
[4] Raviv S, 2010. Page 131.
[5] Raviv S, 2010. Page 129.
[6] 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.
[7] Raviv S. 2010. Page xiv.
[8] American Psychiatric Association, 2013. Page 171.
[9] 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.
[10] Sullivan PF. Mortality in anorexia nervosa. American Journal of Psychiatry, 1995, 152, 1073-1074.
[11] Barnill J, Taylor N. If You Think You Have an Eating Disorder. 1998, Dell Publishing Group.
[12] 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.
[13] 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.
[14] Patrick L, 2002. Page 185.
[15] Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Current Opinion in Psychiatry, 2006, 19, 4, 389-394. Page 389.
[16] 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.
[17] 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.
[18] 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.
[19] The statistics in this paragraph are from Spear BA, 2001.
[20] 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.
[21] 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.
[22] Spear BA, et al, 2001. Page 810.
[23] Patrick L, 2002.
[24] Tyre P, 2005.
[25] 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.
[26] Huebner HF. Endorphins, Eating Disorders, and Other Addictive Behaviors. WW Norton and Co, New York, 1993.
[27] Hornbacher M. Wasted: A memoir of anorexia and bulimia. 2014, Harper Perenniel. Page 5.
[28] 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.]
[29] 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.
[30] 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.
[31] Taylor GJ & Taylor HS. Alexithymia. Chapter in M. McCallum & W.E. Piper (eds), Psychological Mindedness: A contemporary understanding. Munich: Lawrence Erlbaum Associates. Page 29.
[32] 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.]
[33] 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.
[34] 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.
[35] 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.]
[36] Patrick L, 2002.
[37] Patrick L, 2002.
[38] Patrick L, 2002.
[39] 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.
[40] Davis C, 2001.
[41] 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.
[42] Ross J, 2000.                   
[43] Huebner HF, 1993. Page 20.
[44] 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 Huebner’s stages to match the already-named phases in the development of an addictive disorder.
[45] Ross J, 2000.
[46] 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.
[47] 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.
[48] Huebner HF, 1993. Page 35.
[49] Huebner HF, 1993. Page 44.
[50] Huebner HF, 1993. Pages 86-87.
[51] Huebner HF, 1993. Page 87.
[52] 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.
[53] Huebner HF, 1993. Pages 33-34.