Brave Girl Eating (11 page)

I know I'm being defensive. But I can't let myself feel anger toward the demon, because right now the demon inhabits Kitty, and
that would mean getting mad at her. And I'm not mad at her, not really. Sometimes I
feel
angry—when she's been sitting in front of a plate of chicken stir-fry for forty-five minutes, for example, picking out all the cashews. But it's not her flinging the nuts off her plate in disgust. I have to remember: that's not Kitty.

That night, we eat a late dinner; the temperature has been in the nineties for days now, but eat we must. Kitty uses a baby spoon to scoop up tiny bites of mashed squash (into which I've mixed butter and honey). One minute she's fine, or what passes for fine these days: she's not crying and she's eating. Then she looks up from her plate and I can literally see her flip from Kitty to Not-Kitty. I feel a jolt of adrenaline. And sure enough, when she opens her mouth, the demon's voice emerges, spewing its usual litany of self-loathing and rage.

“Why don't you take your plate onto the porch?” Jamie asks Emma. We've been trying to protect her from the worst of the poison. Emma gets up from the table, but before she can make it out the door, Not-Kitty says, “I just want to go to sleep and never wake up.”

Emma freezes. Jamie and I look at each other. My heart turns over in my chest—literally, that's what it feels like, a heaviness revolving under my breastbone.

Not-Kitty says it again, louder this time: “I want to go to sleep and never wake up! I don't want to be alive anymore!”

Emma drops her plate and bolts from the kitchen as Not-Kitty begins to shout. I grab a bottle of Propel from the refrigerator, put a straw in it, and plunk it in front of my daughter. “Drink,” I hiss, and run after Emma.

I find her downstairs, crying hysterically at the bottom of the laundry chute. When the tornado sirens sound and we head for the
basement, this is where Emma goes to feel safe. I put my hand on her back and she rears up out of the pile of dirty clothes, furious. “Don't touch me!” she shouts. “I hate you! It's
your
fault Kitty is sick!”

Her words smack the breath out of me. I try to suck in a lungful of air, but something inside me is paralyzed. Maybe I'm having a heart attack. Maybe the stress is killing me, right here in a pile of rumpled underwear.
Don't air your dirty laundry,
my mother used to say.
Don't be so quick to tell everyone your business
. This, then, will be my punishment for failing both my daughters.

Emma cries, her face contorted in grief and pain, and then I'm crying too, because I don't know what else to do. We kneel side by side and howl ourselves hoarse.

Eventually Emma blows her nose and says, “I don't want to go to my sister's funeral.”

I put my arms around her, and this time she doesn't pull away. “I don't either,” I tell her, and hope my intention can magically keep the worst from happening.

Anorexia is possibly the
most misunderstood illness in America today. It's the punch line of a mean joke, a throwaway plot device in TV shows and movies about spoiled rich girls. Or else it's a fantasy weight-loss strategy; how many times have you heard (or said yourself) “Gee, I wouldn't mind a little anorexia”?

The symptoms of anorexia nervosa are detailed in the
Diagnostic and Statistical Manual of Mental Disorders,
known familiarly as
DSM-IV,
the so-called bible of psychiatric illnesses. And the first item on the list of diagnostic symptoms is “a refusal to maintain body weight at or above a minimally normal weight for age and
height.” Notice the word
refusal
rather than
inability
. No wonder anorexia is so widely perceived as an illness of choice or lifestyle; the psychiatric profession defines it that way.
^*

In fact, the very name
anorexia nervosa
is ironic. The literal Latin translation is “nervous loss of appetite.” But people with anorexia don't truly lose their appetites. They may be disconnected from the physiological sensation of hunger, but they are deeply, profoundly hungry. That's why they draw out their meager meals for hours, savoring every scrap they allow themselves. It's why they douse their food with mustard and salt and other condiments to sharpen the taste of what they're eating. It's why they read cookbooks like other people read pornography, why they plan elaborate menus they know they will not eat, why they stand longingly in front of bakery windows but never go inside.

Hunger is hardwired into us, physically and psychologically, and for good reasons. The drive for food must be insistent enough to propel us to seek it out three times a day. In twenty-first-century America, many of us have only to go to the kitchen, the grocery store, a restaurant to fill our bellies. But for most of the long story of human evolution, satisfying hunger has been a drawn-out and often perilous process.

Accounts of people with little or no appetites, who do not eat or have strong aversions to food, go back to at least the first century
A.D
., when the Roman physician Galen described people “who refuse food and do not take anything” and who “are called by the Greeks
anorektous
or
asitous
.” The Greek physician Alexander of Tralles, who practiced medicine in the sixth century, believed that
anorexia developed from an imbalance of what classical philosophers called “humors” people with anorexia, in this view, had too many “cold humors” and needed herbs like cinnamon, pepper, and vinegar to restore balance and bring back appetite.

This perspective on anorexia persisted into the seventeenth century, when an English dictionary described it as “a queesinesse of stomack.” Lack of appetite, it was thought, must stem from physical disturbances—stomach problems, “humors,” and other bodily ailments. And in fact, a loss of appetite alone can be a symptom of all sorts of physical illnesses, from cancer to gallbladder problems.

In the Middle Ages, the culture around not eating shifted from physiology to spirituality. Religious women like Catherine of Siena, Beatrice of Nazareth, and Margaret of Cortona became known for fasting or eating almost nothing for years; some undoubtedly died from malnutrition. Their behavior was seen as a holy endeavor, a kind of reaching toward a state that transcended the body. Many of these women were later beatified by the church, and their starvation acquired a new name:
anorexia mirabilis,
a loss of appetite that was miraculously inspired. If they were good enough, holy enough, they were set free from the physical necessity of eating, lifted into an idealized state where food was irrelevant—or so the notion went.

Historians adamantly distinguish the self-starvation of these medieval women from later forms of anorexia. They argue that we don't know enough about what inspired women in the Middle Ages to starve themselves and what kept them on that path. They say it would be naive to think that shared physical symptoms like an aversion to food, extreme thinness, and loss of menstruation derive from the same illness. They say that anorexia mirabilis and an
orexia nervosa are two completely different disorders that originate in completely different ways.

To support this notion, medieval scholar Caroline Walker Bynum argues that fasting saints did much more than fast; they castigated themselves in all sorts of ways. Catherine of Siena, for instance, whipped and scalded herself and regularly slept on a bed of thorns.

I don't buy it. The roads to anorexia mirabilis and anorexia nervosa may indeed start in different spots, and those spots may be defined in terms of the culture: in medieval times, young girls aspired to saintliness the way girls today aspire to thinness. But those roads quickly converge on the same highway to hell. Catherine of Siena, for instance, died at age thirty-three after years of subsisting on a daily handful of herbs; when forced to eat other food, she reportedly put twigs down her throat to make herself vomit it up.

Sounds like anorexia with a side of bulimia to me.

The difference in terminology underscores the idea of anorexia as a relatively new disease, an affliction of modern times. The first two medical descriptions of anorexia nervosa were published nearly simultaneously in 1873, one by a highly respected British doctor and one by a French neurologist. Sir William Withey Gull practiced medicine in London and was on close terms with Queen Victoria and the royal family. He spoke and wrote about an illness that affected mainly upper-class adolescent girls who suffered from diseased mental states and, as he put it, “perversion of the will.” Charles Lasègue was a neurologist in Paris when he described what he called
l'anorexie hysterique
as a “hysteria of the gastric center.”

Interestingly, their characterizations of the illness diverged from their recommended treatments. Gull believed that medicines were useless and that only food could cure the illness. He prescribed
high-fat, high-protein meals, administered every two hours by a trained nurse, along with bed rest and a hot water bottle along the spine; he believed that the person who was ill needed someone outside herself to compel her to accept food. “The inclination of the patient must be in no way consulted,” he wrote. He thought a trained nurse was best because friends and family lacked the “moral authority” to insist that a young patient eat.

Lasègue's treatment veered more toward the psychological. He was the first to suggest that anorexia stemmed from family conflicts over an adolescent girl's transition to adulthood—a view that remains stubbornly entrenched today.

I think Gull had it right. When it comes to anorexia, food is medicine, and it's a given that someone with anorexia will not willingly come to the table.

In her book
Fasting Girls: The History of Anorexia Nervosa,
Joan Jacobs Brumberg writes that Lasègue's research “captured the unhappy rhythm of repeated offerings and refusals that signaled the breakdown of reciprocity between parents and their anorexic daughter. In this context anorexia nervosa can be seen for what it is: a striking dysfunction in the bourgeois family system.”

Like Hilde Bruch and so many other “experts” on anorexia, Brumberg mistakes effect for cause. Typically, by the time parents consult a doctor or therapist about a teen with anorexia, the family has become dysfunctional, no matter how competent it was to begin with. The pattern of insistence and resistance Brumberg describes is absolutely normal in the context of a child who is starving herself.
Of course
parents become edgy and upset, frantic to get their child to eat. And
of course
the child becomes terrified, hostile, and manipulative—anything to avoid eating.

But eating-disorders therapists don't see a family before anorexia
strikes. So they don't know, they
can't
know, the true rhythm and flow of a family's previous life. Which means that they can't establish cause and effect between family dynamics and eating disorders. There's no way to predict who will develop an eating disorder, based on family dynamics or on any other criteria.

Somehow the medical and psychiatric professions have confused hindsight with understanding. There's a saying in the scientific world: “Correlation does not equal causation.” Just because two things happen at the same time doesn't mean that one causes the other. Maybe an unknown third variable causes them both. Maybe they coexist coincidentally. We know that anorexia changes family dynamics. But we don't know whether those dynamics caused the anorexia in the first place.

 

Most years we take
a vacation in August, but not this year. Just as well, because we're not a beach family. Our vacations usually revolve around activities: kayaking in Lake Superior, skiing in the Porcupine Mountains, hiking in the Catskills. All of these would cost Kitty too many calories. Instead, we spend most of the month, when we're not at work, watching movies and playing board games, which Kitty hates but Emma loves. Poor Emma, whose summer has been one big nonvacation. She'll be glad to get back to school, I think.

In the second week of August, Jamie and I bump Kitty up to twenty-one hundred calories a day. For two days beforehand she frets and worries over the coming change, so much so that Dr. Newbie prescribes a mild antianxiety medication—just in case, she tells us.
Just in case of what?
I think as I pay for it at the pharmacy.
In case things get any worse?
I allow myself a small sardonic laugh.
But even as I walk out, bag in hand, I know there's nothing to laugh about. Things can always get worse.

With the increase in calories, meal planning becomes more of a challenge. Eating large volumes of food is stressful for Kitty physically as well as emotionally. We add in a midmorning snack, to spread out the calories, but still she complains of bloating and stomachaches—common side effects of refeeding. Starvation affects the entire body in ways both profound and minute, and it will take a while for her metabolism and digestion to normalize. I'm hoping to minimize the unpleasant gastric consequences by cutting back on fruits and veggies, which are hard to digest and which in any case don't contain enough calories, and feeding her smaller amounts of calorie-dense foods.

I turn to my collection of cookbooks; leafing through them is an exercise in cognitive dissonance. Nearly every recipe seems to emphasize how low-fat and/or low-cal it is. Like Alice in
Through the Looking-Glass,
I have the curious sensation of looking through a mirror into an alternate universe. While the rest of America hunts for ways to cut down on calories, I'm searching desperately for ways to pack them in.

Frustrated, I go online and wind up on Web sites aimed at families of cancer and cystic fibrosis patients. I print out recipes for macaroni and cheese, chicken and peanut stew, lasagna made with ricotta and béchamel sauce, guacamole. Kitty's still terrified of foods like these—creamy foods, sauces, and pasta. Foods with fat in them. Even if we wanted to, we couldn't get enough calories into her by serving only “safe” foods—grilled chicken breast, steamed vegetables, plain whole wheat bread. And we don't want to. On my single trip to a nutritionist, I learned that the brain is made up largely of fat. That both the brain and the body
need
fat—not just
any old calories but the right kinds of calories—to begin the slow process of healing from starvation.

And it's more than a physical thing. Instinct tells me that if we are ever to rout the demon completely, we'll have to break all its rules, flout its proscriptions. We'll have to tar and feather it and run it out of town. We can't appear to collude or appease it in any way; we need to win this war visibly as well as tactically. We're engaging in a kind of exposure therapy, slowly desensitizing Kitty to the things she fears. And there's nothing she fears more right now than fat, whether it's on her body or in her food.

One night, poking around online, I find a glimmer of evidence that we're on the right track. I come across a 1967 study done by a grad student at Northwestern named Aryeh Routtenberg, who discovered, more or less by accident, that rats given access to food for only an hour a day became more physically active, running on their wheels for hours. After a few days the rats ate less and less and ran more and more. Most of them died within ten days, starving and running themselves to death.

I sit back in my desk chair. So many of Kitty's behaviors are analogous to the rats'. If we didn't stop her, she, too, would exercise more and more. She, too, would starve herself to death. This study doesn't shed light on what triggers someone like Kitty into restricting her food in the first place. But it does lay out a pattern of effects that looks all too familiar. The rats' refusal (or inability) to eat, their compulsive overexercising—even unto death—reflect a biological imperative. Their self-destructive behavior didn't derive from psychological “issues” or screwed-up family dynamics; it was, as Routtenberg later discovered, a function of neuroanatomy.

The brain works on three main systems of neurotransmitters: serotonin, dopamine, and norepinephrine. These chemicals leap the
synapses among the brain's millions of neurons, creating and regulating processes that affect everything from movement to behavior to mood. Like the rest of the body, the brain exists in a complex and delicate balance; one little misfire can bring down a big chunk of the system. In this case, Routtenberg theorized, the rats' limited access to food and unlimited access to the running wheel interfered with the brain's dopamine system. Which makes sense, because among other things dopamine helps regulate physical movement (it's connected with the basal ganglia, a cluster of nuclei involved with motor functions), motivation, and reward.

Just as interesting was a 1971 follow-up study done at the Medical College of Wisconsin by Joseph Barboriak and Arthur Wilson. They duplicated Routtenberg's conditions, but divided rats into two groups. One group got the usual low-fat, high-carbohydrate laboratory chow; the other got a special high-fat mix with no carbohydrates. Both groups were fed the same total number of calories and, as in the earlier experiment, had access to the food for only an hour a day. The lab chow rats behaved just like the rats in the original study; they amped up their activity levels until they were running nearly all the time. Each rat lost about 20 percent of its body weight. At the end of the experiment, twelve out of fifteen had died.