August 18, 2012

random heresy of the day

So, do anorexics want to be thin more than other people?

That may seem like a really obvious question but if your answer is "of course: look at them" let's chat. First of all, visible low weight is an end-stage symptom and patients may not appear thin even when floridly mentally ill. No amount of weight loss satisfies or relieves the desire: in fact the reverse is more common.

(Worth noting here that many patients don't even report being interested in weight loss before being tutored in the language of eating disorders during treatment. See "effort after meaning")

I'm willing to bet that while the desire to be thin is ubiquitous the difference between the anorexic and the non-anorexic isn't the depth of desire but a different way the brain processes disgust and restraint and reward. What seems to be the "reason" to lose weight may not be different than everyone else who starts dieting or purging, and may not be stronger. We get confused by the "success" and assume a greater motivation by dint of the results. Anorexia makes it possible to continue to refuse food and to continue exercising despite energy imbalance: that's not "available" for most people, thank goodness.

Treatment that focuses on that motivation, and advocacy on decreasing that motivation, what evidence do we have that it helps? I'm deeply skeptical. Feels like guarding the well while ignoring the river.

Now the corollary: do people with binge eating disorder want to be larger than other people? Funny: you're probably struggling more with that one.


7 comments:

  1. Rock on, I love this post. I am willing to bet that there are a lot of non-eating disordered people out there who want to be thin much more than I do (and I've had many an argument with my treatment team about goal weights, blah blah blah). My point is, in my experience, it was never about being thin, however the fear of eating/gaining weight led to that consequence. I guess it is also worth noting that in my brain, fear of weight gain and drive for thinness are really different. I'm not sure if that makes sense...

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  2. I think you are soooooo right on this one. I have long argued that "wanting to be thin" is a societal malaise and has become an expression of anxiety easily understandable (and misinterpreted) by those "listening" to what the patient is saying.

    At some point, perhaps the desire to be thin does become "real" because it is a way of communicating this anxiety that is actually "listened to" and "acted on". I also think that many professionals may have carried their own "prejudices" about fat phobia into the treatment room. They are hearing what is said rather than listening to the underlying message.

    I think Carrie Arnold and I agree that Catherine of Sienna wasn't freaking out about the size of her thighs.....

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  3. Excellent post, Laura.

    For my part, I was utterly shocked when I found out, after months of drastically restricting my intake, that I'd lost weight. I was 15, and I'd never in my life wished I were thinner. At the depth of my illness, I didn't think I looked any different (while, of course, everyone around me was terrified for my health) and it just hadn't occurred to me that the result of my avoidance of eating might be weight loss. Once I was diagnosed, I remember wishing I could gain 20 pounds overnight so that everybody would leave me alone and I wouldn't have to start eating again.

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  4. What do you mean on that motivation? The motivation to be thin? Yeah, is there actually treatment that focuses on that? That's not very smart.

    I do think there's value is questioning "Why do you want to be thin? What do you get from weight loss?" etc.. I think that discourse, while, in and of itself, is unlikely to make any major dents in recovery, is useful to gain a better understanding of the ED, for the patient, anyway.

    I think Saren was planning on doing a few posts on this topic/something relevant.

    The most potent motivation for me, personally, to change, always came from realizing what I could lose to being incredibly symptomatic. So, I can see how things like motivational interviewing may be beneficial (but for a subset of patients, of course).

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  5. What I would argue is that a person can have anorexia nervosa (AN) without desiring thinness.

    Never in my 28 year history of AN did I want to be thin, or thinner. I was thin before I developed AN and lost weight very rapidly during my relapses. But never did I want to lose so much weight or to become so thin. What I found was that ANXIETY (about many things in life...) would trigger a set of behaviours that led to weight loss. But weight loss (and thinness) were 'side-effects' of the behaviours.

    It was the behaviours that I became dependent upon; not their effects of my body image.

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  6. not only does some treatment focus on motivation, much diagnosis and therefore access to treatment does too. The widely used "eating attitudes tests" http://psychcentral.com/quizzes/eat.htm(yes, I realise the one here isn't a professional one and that sensitively used by a professional considering the individual the tests could be less of a problem) ask such questions as do you avoid foods with sugar in them, do you eat diet foods, are you pre-occupied with a desire to be thinner? Most people on a diet would score highly on such questions, it doesn't mean they have an eating disorder. My daughter, at her sickest, was genuinely unable to score more than 10 and, in the case of computerised tests like this, broke the programme because it was totally fixed on weight and shape concerns and bulimic behaviours and she didn't have weight and shape concerns and was utterly terrified of bulimic behaviours

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  7. Well, I continue to believe the "desire to be thin" symptom is largely culturally and iatrogenically imposed on an underlying disorder that employs "effort after meaning" to explain itself. The disorder itself neither requires nor does it always have that symptom.

    While I do think there is value in measuring that symptom for diagnostic purposes and for measuring symptom relief over time for the individual I believe this single symptom has been confused for cause and is conceived as meaningful at some deep level far beyond utility.

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