Beyond encouraging the anorexic to eat, doctors differ widely in their methods of treatment. Anorexics, once they get to the hospital, are likely to be put through an array of psychotherapy, behavior modification and medication that by its very variety shows how little doctors really know about the disease.
When an anorexic enters the hospital, before any psychiatric treatment begins, doctors work to bring her out of physical danger. Then, some sort of longer-term treatment begins, to combat the patient's will to starve and to induce voluntary eating. Dr. Robert Masland of Children's Hospital says, "Most people like food too much, so they cannot stay on a starvation diet; anorexics can. All the patients who come in want to weigh 100 pounds. We're dealing with patients with a stubborn streak and strong will-power. In behavior modification we say, "If you're not good we'll stick the tube down your throat or not give you certain privileges.' Patients have an apt phrase for this--they say they'll eat their way out of the hospital--but that doesn't mean they're straightened out in the head. For the dangerous ones [20 per cent of anorexics], maybe we should develop a drug to stimulate the hypothalmus so they will eat and not feel guilty about it."
At Mass General Hospital, insulin injections are used to stimulate an appetite in anorexics. Dr. George Tully, an endocrinologist explains, "the insulin induces hypoglycemia. This makes the patient feel hungry and gives them a sweaty, mild headache which only eating can relieve." Ideally, a normal appetite will develop in the patient and she will not just eat to avoid the insulin's side effects. The insulin treatment is accompanied by psychiatric care.
Dr. Peter Sifneos, a psychiatrist at Beth Israel Hospital, describes a German treatment for anorexics as "most upsetting to many people, but it has the best results in pounds per weight. The Germans force the patient to stay in bed twenty-four hours a day and don't allow parents or any others to visit. During rounds the whole team--professors, residents, interns and nurses--all give the patient a Germanic lecture on wasting time, being undeserving and taking another person's bedspace, and they tube-feed the patient, through the nose and down to the stomach. As soon as the patient makes an effort to eat and gains weight, the negative lecture becomes positive: 'You are a deserving person. You are a good German.' And they have the best success rate. They say the patients all gain 25 pounds."
The efforts at getting anorexics to eat and gain weight are often frustrated by the patients' own drives to lose weight. Piazza says that anorexics describe "something bad inside them that has power over them--this is what they're fighting. The fight within them is between the part that wants to eat and the part that doesn't. The body is a battleground."
Masland explains, "You really can't trust these patients. You must know what they're eating, whether they're going to the bathroom to throw up or throw food away. After they've been doing it for so long they can deny it with a straight face. The manipulation and denial can be amazing."
One doctor relates his experience visiting an anorexic after lunch, which she normally ate unguarded. "You've been doing very well, the doctor said. "You've been finishing your frappes every time now." Then he glanced at the plant besides her bed and his smile vanished. The plant was dead. It had overdosed on chocolate frappes.
Tully says that "the success of behavior modification in restoring and maintaining a satisfactory appetite in anorexics depends on the age of the patient and if you can work out the underlying stress." Doctors agree that the older the patient at the onset of anorexia, the lower the chance of success with any kind of treatment. The mortality rate can be as high as 50 per cent in older patients.
As to the actual psychological roots of anorexia, there is a great deal of disagreement from hospital to hospital. Each institution compares its anorexic patients, studies their case histories, and occasionally prepares reports on them. Each has a pet theory about the causes of the disease. Each seems to look specifically for its own pet causes in new anorexic patients, so the theories only become reinforced.
At Children's Hospital, Masland and Piazza have found that their patients come from close-knit, economically comfortable homes and that they suffer from a "fear of growing up." Piazza says the families are usually "so close-knit that the child hasn't really been able to express herself, to feel autonomous. There is a desire to stay small, to be cared for by this close-knit family." Parents feel guilty because their child will not eat, and meals become battles. Therefore the therapy at Children's focuses on the entire family.
Masland says the anorexic sees weight gain at puberty as "a distortion and wants to deny her femininity." He says anorexics need "a good relationship with a psychiatrist so they'll develop a strong sexual identity, know who they are and where they're going."
Sifneos, at Beth Israel, says anorexia may have its roots in a mother's problems with breast-feeding or feeding in general, while at McLean's Hospital in Belmont a study showed anorexics have a pattern of keeping secrets from their mothers.
Dr. Jessica Osterheld practiced psychiatry at UHS for two and a half years, and personally saw three to six cases of anorexia a year. She sees the roots of the disease as being in the anorexic's battle for autonomy over her friends and parents. The disease is far more frequent in women than men, Osterheld says, because "our culture encourages anti-authoritarian behavior in males; there are other avenues where the male's autonomy can be fought out."
Dr. Lauring Conant, an internist at UHS, e0xplains that denial of the problems keeps patients from seeing a doctor. He has seen only two "full-blown" cases of anorexia in the past two years. "One of the terrifying things with this disease," Conant says, "is that they're on a dangerous crevice of 65 pounds and engage in vocational and avocational activities and get in trouble. Even though they may look like prisoners or war victims, they still engage in sports and you wonder how they can do it. Characteristically they are high achievers, intelligent students. Even in starvation, their cerebral activity strives on. I feel most helpless with this disease. The magnitude of self-denial is so great that it's hard to break through."
Conant says he thinks the anorexic's behavior is a "form of misdirected anger at everything from family to self." This is his clinical impression and he says other psychiatrists at UHS share it.
Tully, at Mass General Hospital, found that many anorexic patients are children of obese parents. "One pattern of anorexia is that one parent, usually the mother, is overweight and constantly dieting and compulsive about dieting and loses weight and gains it right back again. The mother's compulsive habits are forced on the children. The children start dieting wanting to be sexually attractive to males. What occurs so that they don't know when to stop I don't know."
George Schreiner '71, a medical student at Harvard and MIT, points out that "women are much more often the victim of sexual aggression. My hunch would be that when they are the victim they might shy away from sex. Men can't deny their sexuality by changing their appearance. They just look a little skinnier. Whereas girls who are too skinny can look like boys."
Schreiner does not believe that only women wish to deny their sexuality. He says, "If you regard severe impotence as an expression of fear of sexuality and denial of sexuality then I'm sure if anorexia is common at Radcliffe, impotence is rampant at Harvard."
It seems the theories will keep coming. Anorexia's increasing frequency among both males and females could mean that the results of future studies, based on a larger number of patients, will be more conclusive and more widely accepted. But future studies may only result in a few more casual theories spiralling off, and the development of a new theory to explain why anorexia is on the upswing.
The skinny young woman has been talking about her anorexia for about two hours, and she's gone through a lot of cigarettes. She said her anorexia was an attention-getting device. Because she was sickly-thin, everyone worried about her, and she had the concerned attention of parents and friends, especially male friends. She says, "You're attracted to men who will take care of you. Once they respond sexually, you find that hateful because they're intruding upon your freedom, so you run. It's very selfish--they want something but you don't want to give anything. It's a way of protecting myself--I've always found work very important. This lets me shut myself up and work and work and work."