November 2008


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! 

How do you feel when somebody betrays your trust?  Hurt? Angry?  Furious?  Do you want revenge? Do you want them to suffer every bit as you have; more if possible?  Well, imagine how volcanic, how vengeful you might feel if that person had compromised and then killed the woman that you loved.  You would want them to die slowly and painfully.    Nothing less would suffice. 


James Bond, in his latest reincarnation, as personified by the actor, Daniel Craig, is such a dangerous man.  He has lost the suave insouciance of Sean Connery, the lounge-lizard innuendo of Roger Moore.  Craig is edgy, vulnerable, driven and lethal.  To my mind, this makes the character more credible, more understandable.   


Craig’s Bond is a sociopath, somebody so damaged, so lacking in trust, so defended that he can only function in a paranoid-schizoid mode.  He doesn’t bother to try to understand, to negotiate, to compromise.  His world is sharply demarcated into the good and the bad.  The good are tolerated and exploited. The bad are exterminated.   


In Casino Royale, he falls in love with Vesper Lynd, but she is blackmailed into betraying him and then killed.  Out for revenge, he hunts down the shadowy group responsible for her death.  With single minded efficient fury, he indulges in a spate of indiscriminate killing. 


A link to a bank account in Haiti puts Bond on the scent of  Dominic Green, whose chilling arrogance and sinuous manipulation, make him one of the most sinister Bond adversaries. Green plans to destabilise the Bolivian government, install a corrupt dictator and take control of the biggest reservoir of fresh water in the world.   In an environmentally challenged world, control of water may mean global domination.  Bond’s plots always seem to keep up to date.


But Bond’s psychology is too dangerous to be let out into the world without a minder.  He operates at the level of a toddler with the body of prize fighter and guns to match.  He is lethal.  Only the head of MI6,  M (for mother?), played with toughest of tough love by Judi Dench, has any hope of controlling him.  Bond respects her, but not her office. 


 “When you can’t tell your friends from your enemies it’s time to go,” she growls as she grounds him by removing access to his credit cards and blocking his passports.


But Bond cannot be contained by such means.


Of course, Quantum of Solace has the usual Bond caberet of terror: visceral violence, death-cheating stunts involving motorbikes, speedboats, jet fighters and expensive cars, spectacular pyrotechnics, impossible survival, ruthless villains and high level political duplicity -nobody does it better than the new 007.  But director Marc Foster has stripped away the frills to produce a film of raw, brutal, bare-knuckle intensity.


There are no gadgets.  Q has retired; so has Miss Moneypenny. MI6 is less gentleman’s club and more high-tech mission control room.  There is hardly any sex. Craig’s Bond has less time to play. He is no longer the sophisticate who enjoys his martini shaken but not stirred.  That belonged to another age. He is more of a terrorist, a man with a mission and a licence to kill; too psychopathic to be comfortable for long in a cocktail party or a lady’s boudoir without unleashing his destructive rage.  Nevertheless his combination of hardness and vulnerability is fatally attractive to women.


Bond’s women are no longer Playboy babes.  Camille, whose dusky beauty is exceeded only by her ruthless courage, will do anything to get heir revenge.  She works undercover and set herself up as Green’s lover to get close to the would-be president who killed her father and raped her mother. Bond is tender with herr in the face of extreme danger but there is no sex.    


He also demonstrates affection for his friend (symbolic father), Renee Mathis,  the retired Italian secret service agent he persuades to accompany him to South America, cradling him in his arms as he dies, but then tossing his body in the rubbish skip. ‘He wouldn’t care,’  he tells Camille.  


This combination of affection and ruthlessness reveal Bond as a needy, vulnerable man, who defends himself strenuously against compromise and exploitation.  Craig’s tight unsmiling lips and the wariness around the eyes fit the part perfectly.  I doubt there is a better actor for bottling rage.  


As the narrative, crashes and explodes its way to its inevitable conclusion, Bond leaves Green to die in the middle of the desert with just a can of motor oil to drink. 


Camille kills President Medrano while Green’s operations centre explodes around her, but this gives her little satisfaction. Her pain and loss cannot be expunged by killing the perpetrator, but it helps. 


Then cut to a town in Russia where Bond meets his girl friend’s killer, and despite his killing frenzy and the trail of bodies in Italy, Austria and South America, he does not assassinate him.  Meeting M outside the hotel, he acknowledges in the futility of another death, his love for Vesper, and so realises what it is to be human. 


To live is the society of others is not to act out in revenge, it is to understand, to forgive, to negotiate, to tolerate difference and to temper frustration.  That is his quantum of solace.             



There’s just a day to go in the American elections and the result seems clear.  Barack Obama is six points ahead in the polls and is leading in all the key states.  He looks and sounds like the President already.  His mixed race and global understanding will give him real stature in the world.  His appointment will send out a strong signal of a wise and resurgent America.      


His opponent, by contrast, is looking increasingly like Mr McGoo – bumbling, out of touch and outshone by a much more charismatic, if somewhat flaky running mate, with whom he has ‘differences’.  ‘We’re both mavericks and mavericks don’t always agree.’  Well, that’s as may be, but it helps if the candidate and his running mate were singing from the same hymn sheet.  If ever there was a symbol of America in decline, McGoo is it. 


The republican candidates are being undermined by two unlikely figures.  Tina Fey gives such an amusing and convincing impression of Sarah Palin that it is difficult to one ends and the other begins.  Sarah is palin’ into Tina and they both have expensive wardrobes. 


And McGoo is too preoccupied by the privations of Joe the Plumber to sound very effective, especially when it turns out that  Joe is really Samuel J. Wurzelbacher and stands to gain by President Obama’s proposed tax cuts.  Joe the Plumber has spawned a host of republican friends,  Tito the Builder, Jack the Hunter, Ed the Dairyman, Christine the Florist, Bill the Bricklayer and Clare the Cook.  It just needs Noddy, Big Ears and Mr Plod the Policeman to turn up and we will have a full house but no president.


McGoo’s campaign has always been about make believe. Let’s stop the charades, get the election over and focus on the real threats.     

He was driving back from a business trip interstate, just 24 hours from Tulsa, Oklahoma, looking forward to getting back home to his wife and children, when a chance meeting in a roadway diner changed their lives forever.  Within hours, he had found the person he had been searching for all his life – or so he thought.  His conviction was so compelling that he knew he had to break all the connections of family, friends and community. He could never go home again.


But what of her?  Something in the way Gene Pitney sings it tells us that she had had this experience before.  She knew the territory.  So was he just ‘another roadside attraction’ or might he be more?  He certainly thought so.   


Somehow you just know it’s never going to work out, but it will probably change his life forever – and not for the best.


Falling in love is perhaps the most exciting but the most dangerous thing anybody ever does – so risky that many people don’t ever dare to do it.   At a bat of an eyelid, it can change the sense of who a person is.  Suddenly, family, home, occupation, friends, beliefs and attitudes count for nothing.  The only thing that matters is the object on one’s desire.   When the widowed Mrs Thrale fell in love for the first time in her life with the younger Signor Pozzi, who so closely resembled her own father, she gave up her salon, her friends, her numerous eminent acquaintances, even the great Dr Johnson.  She just disappeared.  They all thought she had gone mad.  Perhaps in a way, she had.  


Falling in love is analogous to rage, panic and melancholy in the way it takes over the  personality, arresting the capacity for rational thought, subsuming all meaning.  But it is also make believe, a wonderful delusion, the triumph of desire and hope over logic and reality. The enamorata seems to embody everything the love-stricken have ever wished for.   


The psychoanalyst, Adam Phillips, has said that some people need a delusion as powerful as ‘falling’ in love in order to escape the gravitational force of their mother and enter the all-embracing attraction of another heavenly body.  It takes an overwhelming complusion to disconnect them from the tenets of their identity.  But such power is dangerous. We know that other forms of personal disconnection; displacement, disillusion, retirement, unemployment, bereavement, can all too readily instigate mental illness.          


So is ‘falling in love’ a culturally acknowledged form of madness?  It certainly possesses all the features of obsessive-compulsive disorder and delusional psychosis and has the capacity to create severe anxiety and depression.  And the flashbacks, sleeplessness, anxiety, intrusive thoughts and preoccupations, characteristic of post-traumatic stress disorder (PTSD), occur as much in love as they do after abuse or disaster.      


Falling in love is so much more potent and dangerous if it is consummated with physical intimacy.  Just as the pain of natural childbirth and the act of breast feeding intensify the bond between mother and infant, so physical intimacy magnifies feelings of love.  My one-time colleague and friend, Kerstin Uvnas-Moberg,  Professor of Physiology at the Karolinka Institute has suggested how release of oxytocin from the posterior part of the pituitary gland through stimulation of the nipples and genitalia and during female orgasm consolidates the pair bond, eroding the defences and inducing deep feelings of trust. Recent research indicates that an analogous phenomenon occurs in the male.  So sexual intimacy can cause the participants to become more open, more vulnerable, more susceptible to the devastation of the personality brought about by betrayal or abandonment.  


Given the risks of relinquishing our identity for love, is it any surprise ‘falling in love’  often ends in pain and tragedy?  As Alan Yentob demonstrated in last weeks ‘Imagine’,  the greatest love stories rarely end well.  There are complications – obligation, loyalty, commitment or duty that can never be relinquished, not even for one’s ‘true love’.  In Brief Encounter, Laura could never leave her kind steady husband and her two boys for Alec.  In Casablanca, Rick and Ilsa are caught up in the exigencies of war.  Juliet’s family are deadly enemies of Romeo’s. Abelard and Heloise have taken a holy vow of celibacy. Lolita is under-age. The timing’s not right and the drama is played out against a backdrop of impending disaster. The lovers exercise restraint, they make sacrifices, they try to preserve their relationship but the reality is too much and it doesn’t work out.   


Some are determined to not let anything stand in their way. They tempt fate, but fate has the last word. Elvira Madigan’s soldier lover is caught and shot as a deserter. Anna Karenina throws herself in front of a train. Romeo takes poison. Juliet stabs herself.  Abelard is castrated. Love has subsumed their identity that life as they knew it is no longer possible.  And the destruction can spread to involve others, sometimes whole nations.  It was love that brought down Camelot, started the Trojan wars, disenfranchised  England from the catholic faith and threatened to bring down the British monarchy twice in the last hundred years.   


But it doesn’t have to be so tragic.  Not everybody falls in love.  For many the fusion is much less explosive.  There is no instant attraction, no compulsion.  Trust develops over weeks or months as they find out about each other and generates the confidence to permit increasing levels of intimacy. They are in love but never out of control.  They adjust to their new relationship in a manner that is informed, caring, relaxed and more likely to lead to the kind of life-long commitment and attachment that provides a secure base for raising a family.       


Romantics also crave commitment, but at the same time, they dread it. The risk seems enormous. It’s that combination of desire and fear that gives falling in love such compelling frisson. With no basis in trust, they can only act on impulse and give themselves to someone they do not know. They are so insecure, they have possess – now!  There is no compromise, no negotiation. They cannot tolerate that the object of their desire might love or have loved another.  The fear can create difficulties – busy diaries, other relationships, dramatic dysjunctures. It has to be all or nothing.  Teetering on the existential edge between bliss and disaster, they sway first one way and then the other.  Is it on or is it off?  It’s such a close call. 


If they take the risk and invest their identity, the realisation that the object of their love is a mere projection can cause enormous disappointment.  Infuriated by the destruction of their dreams, those whom they loved to distraction, they come to hate to destruction. 


But if they fear the risk and back away, the futility of it all may cause a deep narcissistic wound and lead to serious depression.   


Trapped in purgatory between risk and obligation, desire and boredom, fear and meaninglessness, romantics all too readily succumb to mental and physical illness.  They have to escape.  If they need the thrilling ‘tumble into love’ to start a relationship, then they must generate sufficient hatred and anger to achieve escape velocity so they can resume the quest for their true love. But as Lionel Shriver so cleverly illustrated in ‘The Post Birthday World’, the love object is not that crucial for the romantic narcissist, they are just the mirror.  It’s the process that’s important. They are in love with being in love. They need the desire of another person to affirm their fragile identity. 


This repetitive, parabolic flight of romantic love is so regressive – a throwback to the delusional split existence of the infant, where things are either black or white, good or bad, and steady is just so boring. The wild excursions are so exhausting and demoralising and commitment so frightening, that lovers often come to yearn for the peace that comes with severance.        


Whether it’s the effect of early emotional deprivation, or the materialistic, thrill-seeking, narcissistic culture, an ever increasing number of people are romantics and risk takers.  They want it all and they want it now. There is no compromise.  They’re worth it!  This is bad news for the current generation, worse for the next. Love, for the insecure, the vain and the needy, is such a lottery.  It may work out, but the chances of scooping the jackpot are very low, while all the losers take home is depression, unworthiness, shame and guilt. 


Cinderella may have pulled her prince on the way to Tulsa but will she be able to hang on to him. Will she want to?     



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