It was Jenny’s mother who asked me to see her.  I knew and respected her as a colleague. But when she tried to flatter me by telling me that she knew I was the only one who could sort Jenny out,  my heart sank!


Jenny had had anorexia for two years.  It started when she was studying for her ‘A’ levels.  She lost 3 stone in weight and had to defer her exams.  When I first saw her, her weight is just under six stone.  She knew how much she needed to eat to maintain it at a  level that would keep her at home but not threaten her life.  Her periods stopped a year previously and her body shape returned to that of a child. She was still living at home with her mother, whom she described as her best friend. Her father worked abroad. She had few friends and had not had a boy friend for 2 years. ‘There’s time enough for that when I’m better, ’ she told me.


Nevertheless, Jenny appeared quite unconcerned by her condition; it was her mother who is left to bear the burden of anxiety. 



‘Anorexia nervosa is a serious condition’,  explained Lisa Rudkin, Consultant Psychiatrist at the Seacroft Hospital in Leeds,  ‘Untreated, twenty per cent of young women will die and even when treated, the mortality is 10%’.   Although the fully established clinical illness affects less that 1% of the British population, food restriction and weight loss among young women is common in western societies.  Anorexia nervosa is at the end of a spectrum of eating behaviour   


So what causes anorexia nervosa?


Since the genetic revolution of the late 20th century,  psychiatrists have tended to see behavioural or psychological illness as hereditary.  Anorexia nervosa is no exception.  The high degree of concordance in first degree relatives and the much higher frequency in monozygotic (identical) twins versus dizygotic (non-identical twins) suggests a 50% heritability.  But this is misleading.  Twins and first degree relatives not only share a greater proportion of genes, they also share the same environment – the same influences on their behaviour.  Even identical twins separated shortly after birth share a womb and probably a breast or two.  Genes can only encode for certain chemical transmitters, that are never specific determinants for anorexia but may predispose to food restriction as well as other behaviours.  Such predisposition still requires an appropriate social environment ‘to bring it out.’


Anorexia is much more common in girls than boys.  The ratio is about 9:1. It starts in adolescence and may last for years, but often fades away in the twenties.  This strongly indicates that anorexia nervosa, in common with chronic fatigue syndrome and many cases of irritable bowel syndrome (IBS), is associated with changes and responsibilities associated with leaving home. 


Many regard it as the expression of a sickness in the family.   Rarely do you find a normal upbringing.  The parental relationship is often somewhat estranged, if not separated or divorced.  Classically mother is quite over-invested, anxious or and ambitious, while father is physically or emotionally absent, but there are other patterns.  Some therapists have noted a sense of rigidity in the family; an avoidance of conflict. Anorectic families are often intelligent, cultured and affluent, and the child is often the focus of parental ambition. Many anorexics feel they have to be special.  Love is conditional upon achievement.  The feel starved of recognition and real love. They have never been allowed to be themselves.  They are like the beautiful songbirds in The Gilded Cage (Hilde Bruch), admired as long as they perform.  


Anorexia nervosa, in common with chronic fatigue syndrome and IBS, often starts with the pressure of school examinations.  There is not only the pressure to succeed, but success brings with it the fear of adult responsibility and leaving home.  Their parents have always been there to advise them.  The thought of being alone can be truly terrifying.  It’s the classic conflict between desire and fear. They so desire to leave home but do not possess the confidence and experience to cope with independence and the  attendant obligations and demands of sexuality.       


Anorexia is such an apt solution.  It permits the budding adolescent to young woman to get off the parental treadmill, to escape into illness, where there is no pressure only care. Is there any more potent form of rebellion against parental control than refusing mothers food.  Hunger Strike (Susie Orbach) is a life saver;  it preserves the self against control by the authorities.  The body is co-opted as an instrument of resistance.


At the same time, anorexia causes a return to childhood, where adult responsibilities are avoided and sexuality is (hopefully) not an issue.  Secondary sexual characteristics regress, menstruation ceases and the emerging woman reassumes a child-like body shape.    


Psychoanalysts see the desire for food as similar to desire for romance or sex.  So anorexia represents both the fear and suppression of longing and desire.  It keeps a young woman away from the hazards of romantic attachments to their emergent identity.  In the middle ages, holy anorectics, such as St Catherine of Siena, developed anorexia as a sign of extreme piety.  They would eat nothing but the ‘host’.  Wilga Fortis developed anorexia associated with a hairy body when her father tried to forced her to marry a suitor she didn’t love.   


The fear of desire imposes strict controls.  Anorexia not only closes the body, it closes the mind as well.  It is associated with other expressions of restriction and control; constipation, obsessive-compulsive disorder, depression, exercise, hard work or study and sociophobia.  The focus on rituals, the rigid diet, the obsession with weight as a number, the compulsive exercise regimes are all part of the spectrum of autistic spectrum disorders, in which control is substituted as a defence against connection and engagement.  This is often a feature of male anorexics.   


Much attention has been paid to the effect of culture on anorexia.  The idealisation of the slim, tubular, androgynous physique, as perpetuated though the news and entertainment media, has became a focus of identification for many young women.  Feeling good for them is about being thin.  The introduction of television to Georgia, Czechoslovakia, and Fiji Islands, was associated with a sudden increase in the prevalence of eating disorders.        



Anorexia often fades when girls get into their twenties, but many anorexics retain the proclivity to restrict their eating at times of stress.  It often disappears when girls get married and have children, but some partners seem to collude in the eating disorder and can find it difficult as they gain weight, become hormonal and become truculent.  They are not the child they married. 


Treatment options are often limited to family therapy, drugs to relieve tension and refeeding, but is often resisted.  If anorexia is the preservation of the self at the expense of the body, then feeding an anorexic is like giving money to an artist in a garret.  It removes their identity, their purpose in life, while attempts to exercise control by cognitive behavioural therapy may only harden the resistance.  Family therapy can work when it calms the fears around family intrusion and exposes the futility of rebellion.        



My attempt at individual therapy was only marginally successful.  It lasted eight months. She gained some weight, went to college, but still continued to restrict her intake and she  remained over-dependant on her mother, who requested regular progress reports – of course!