It's Nobody's Fault (37 page)

J
ustine, 15, was warm, friendly, smart, and polite—one of the pleasantest young people I’ve ever met. The first time I saw her, Justine weighed 90 pounds. She was almost a skeleton, so thin that her collarbone and even the bone on her forehead stuck out. Her parents said they were almost afraid to touch her. A year earlier Justine’s weight was 130, which was perfectly fine for her five-foot, five-inch frame. But then she started starving herself. She ate practically nothing, and the more her parents pleaded with her or scolded her or threatened her with punishment, the more determined she became to avoid even a scrap of food. She eventually got so weak that her parents brought her to our emergency room. Her blood pressure and pulse were alarmingly low, and she had fine white hair, just like a newborn baby’s, growing on her arms and back.

By the time she reached her seventeenth birthday, Trudy—another lovely, personable girl—was bingeing and purging for nearly six hours a day. That was three years ago. Today, at 20, she’s down to only a half-hour a day and well on her way to recovery. Still, she’s preoccupied with taking in and getting rid of large quantities of food. Trudy says that when she walks into her house, she feels as if she’s walking into a giant refrigerator. When she opens the front door, all she can think about is food, food, food.

The two most common eating disorders among adolescents, nearly all of them girls, are anorexia nervosa and bulimia nervosa. The peak age of onset for anorexia is 14, during the transition between childhood and adolescence. Bulimia’s age of onset is 19, so it is associated with the transition from adolescence to young adulthood. Because the two eating disorders are so different, I’ll take them one at a time.

Anorexia nervosa—commonly referred to as anorexia—is, quite simply, self-imposed starvation. The girl who is officially diagnosed with anorexia—more than 90 percent of these patients are female—will weigh at least 15 percent less than she should, according to the growth charts. However, the true hallmark of anorexia is
body image distortion;
no matter how much weight they lose, these girls still see themselves as fat, and being fat is what they fear most. Even 90-pound Justine, with the protruding forehead and clavicles, thought she looked fat. “Look how the fat just hangs off my arms,” she’d say to her mother. About 1 percent of the school population will be diagnosed with anorexia, and some studies show that the number is growing. In the last 35 years the incidence of anorexia has increased some 30 percent every five years.

As I already said, the age of onset for anorexia is around 14, but it may take as long as a year after the symptoms begin for parents and their child to make their way to a child and adolescent psychiatrist’s office. Often the parents will try to work with a child themselves for a while, assuming that a refusal to eat is just part of their daughter’s rebellious teens. A neighbor, a minister, or a family friend might get involved before the pediatrician is consulted. When parents do finally get to a pediatrician’s office, most doctors are quick to diagnose anorexia and refer these children to a child and adolescent psychiatrist.

By the time we see these girls, there are nearly always some secondary physical symptoms to deal with, among them low blood pressure, low pulse, and dizziness when they stand up. Their estrogen, progesterone,
and cortisol levels will probably be abnormal. They will have stopped having menstrual periods. They may have baby-fine white hair on their arms, back, and neck. In all likelihood they will be anxious about their sexuality. Some girls with anorexia have boyfriends, but they are almost never sexually active. These girls are often afraid of sex and sometimes fearful of growing up. They are not ready for parties or the drugs, alcohol, and sex that are often to be found there. Many of these girls want to stay prepubescent, childlike. The typical youngster with anorexia is the good little girl who studies hard and tries her best to please everyone.

Adolescents with anorexia will be obsessive in their thoughts, always thinking, “I can’t believe how much I ate! Look how fat I am,” and compulsive in their actions, incorporating food-related rituals that annoy and exasperate their friends and family. They cut their food into little slices and push them around the plate for a half-hour, never actually eating anything. They hide food in their rooms, not to eat it but just to make sure it’s available. When they prepare their own meals, they make a huge, time-consuming production out of even the smallest concoction. They know everything there is to know about calories and weight reduction. Girls with anorexia have very poor self-esteem. Because their interests are so restricted—they’re focused entirely on food—they usually don’t have many close friends.

A diagnosis of anorexia requires a comprehensive history, including an examination of the course of the symptoms and observation of the family. In taking the history we get full details from these girls on their food intake, their eating behaviors, and their thoughts about and attitudes toward food. A thorough physical examination by a pediatrician or family practitioner, including a complete blood workup and an electrocardiogram, are essential; kids with anorexia may have medical complications that have to be addressed immediately.

THE BRAIN CHEMISTRY Parents have taken a lot of heat over anorexia—people blame mothers and fathers for their child’s eating disorders—but it is undeserved. There is no scientific evidence that faulty parenting or dysfunctional families cause anorexia, or bulimia either. Those theories tossed around about how forcing children to clean their plates or not allowing them to have a piece of candy between meals when they were toddlers leads to eating disorders later have no basis in fact.
The widely believed theory that a girl starves herself because she has a fear of physical and emotional maturity or that she’s rebelling against her parents is still hotly debated.

Family and twin studies offer evidence to support a genetic component attached to anorexia. The families of girls with anorexia seem to have a higher than average incidence of weight problems, physical illness, depression, and alcoholism.

One biological theory that needs further study suggests that adolescents with anorexia have a physiological response to dieting that is different from that of the rest of the world. Most people feel discomfort when their calories are restricted; girls with anorexia are different. Weight loss makes them feel successful, disciplined; they aren’t sensitive to the usual discomfort associated with dieting. As the girls begin to starve, there is a release of opioids (brain chemicals that long-distance runners also produce), which give them a “high.” Restricting calorie intake brings genuine pleasure, and a vicious circle has begun.

THE TREATMENT In some ways the biggest problem associated with treating adolescents with anorexia is that
adolescents with anorexia don’t want treatment.
They scream and cry and curse their parents for bringing them to psychiatrists’ offices, accusing them of not trusting and not loving them. Then they deny having a problem at all. (Their parents see them as sick, but they feel wonderful, because they’re thin!) Finally, they admit they have a problem but promise they’ll eat if they can just leave the hospital and go home. The tears, denial, and recrimination are all perfectly understandable, of course. These girls know that getting “better” means putting on weight, and that’s precisely what they don’t want.

Even so, it is essential that these girls get the treatment they need. Anorexia is a very serious disorder. If these girls don’t get better, they may die. Recent studies say that anywhere from 5 to 7 percent of all children with anorexia will die within 10 years. With treatment, about 70 percent will eventually have full medical, social, and psychiatric recovery. The sooner the disorder is treated, the more favorable the prognosis will be.

The best treatment for anorexia is cognitive behavioral therapy, often in combination with medication and family counseling. After an initial examination, including a thorough physical, children with anorexia will
need at least weekly sessions with a psychiatrist; many will need to come in twice a week. They also need weekly weigh-ins and other medical follow-ups. In the past, when dysfunctional families were thought to be the cause of eating disorders, family therapy alone often was the treatment of choice. Today we rely largely on cognitive behavioral therapy, which concentrates on changing the girl’s distorted perceptions about food and decreasing the significance of thinness in determining her self-worth. Family counseling can be very useful in helping parents and other close family members cope with a sick child.

Not all child and adolescent psychiatrists have experience with anorexia, and others aren’t really comfortable treating these kids. Parents shouldn’t be shy about getting answers to some important questions here, since finding the right physician is critical. “Do you treat kids with anorexia?” is the best place to start. “Do you believe in outpatient management?” “Do you use medication?” and “May I talk to you and be involved in the treatment?” are other questions to which a parent should receive an unqualified yes.

It’s not necessary to find an eating disorders specialist for the child with anorexia or to check her into an eating disorders clinic, although there are many good ones out there. It is necessary to find a good psychiatrist who is interested in the disorder and can do the therapy, prescribe medication, and follow the child for at least a year and a half. That’s about how long the outpatient therapy for anorexia will take, though severe cases will take longer, sometimes much longer. The worst case I’ve encountered took six years of treatment before the girl was completely well.

Many children being treated for anorexia will take some sort of medication, but the role of medicine is limited with this disorder. Antidepressants, specifically the SSRIs (selective serotonin reuptake inhibitors), such as Prozac, Zoloft, and Paxil, may help with the obsessive-compulsive symptoms and the depression that often accompany anorexia. Prozac has been effective in helping these girls maintain their weight gain and normalize their eating habits. The medicine needs to be taken for at least a year. Appetite stimulants are sometimes recommended; the one most often prescribed is Periactin, an antihistamine that has been helpful in increasing weight and maintaining weight gain. The MAOIs (monamine oxidase inhibitors), especially Nardil, have also helped girls put on weight.

Many of these girls hate taking pills, and not for the usual reason. They panic because they think the coating has too many calories. Others are terrified that the pills will make them eat, so I tell them—quite truthfully—that there is no pill that makes a person eat. “I wish there were a medicine that would make you eat, but there isn’t,” I say. “All this pill will do is help you not to worry so much about what you
do
eat.

When the medication and therapy described above don’t work, when there is no increase in weight and no improvement in the child’s overall health, hospitalization may be necessary. Hospital care offers a multidisciplinary approach to the disorder, involving dietitians, nurses, and psychologists as well as psychiatrists. Inpatient treatment can be done in any adolescent psychiatric unit or in special eating disorder units that combine both pediatric care and child and adolescent psychiatry.

The young women who have bulimia (again, some 90 percent of the patients are female) don’t starve themselves; they
binge
, they
purge
, they try to
fast
, and they have strange attitudes about food. Like girls with anorexia, they’re afraid of getting fat, but they don’t have a distorted body image. They don’t see themselves as fatter than they are. They’re afraid of food, but they can’t help taking in a huge amount of it—anywhere from 3,000 to 20,000 calories per binge. I’ve talked to girls who would eat several loaves of bread and boxes of cereal at home and then go from one fast food restaurant to another, consuming an enormous amount of food in a few hours. The frequency of the binges of someone with bulimia will vary greatly, from twice a week to several times a day. A binge may last from several minutes to several hours. Young women with bulimia describe having a lack of control during the binges; some describe it as an altered state of consciousness. Unlike girls with anorexia—who are preoccupied with their success at restricting their calorie intake—young people with bulimia are not very good at dieting. They often diet, but restricting calories makes them uncomfortable and usually leads to bingeing.

After bingeing usually comes purging (some people with bulimia binge but don’t purge), by vomiting or using laxatives—as many as 20 a day
—or both. Many use diuretics or diet pills. Some exercise for hours at a time. Not surprisingly, there are medical complications associated with bingeing and purging, among them low blood pressure, dehydration, low potassium and other metabolic problems, cavities, constipation, swollen cheek glands, and hormonal changes. The physical signs of bulimia are frequently pointed out by other health care professionals, especially dentists, who notice the enamel wear on a young woman’s teeth as a result of the acid in the vomitus.