The DSM-HI-R (Diagnostic and Statistical Manual of Mental Disorders) is more than just a psychiatric cookbook. No mere list of diagnostic criteria can describe the many ways a mental disorder affects people, while diagnosing by symptoms alone will not fully explain a condition. To enhance its usefulness, the manual describes some of the other features of anorexia nervosa.

For example, it notes the different ways weight loss can occur. One woman might rely on reduced food intake alone. Another might reduce intake but exercise excessively as well. Others use self-induced vomiting or laxatives or diuretics. The manual thus acknowledges that bulimia and anorexia may indeed coexist.

The compulsion to exercise is very common in anorexia. Even doctors a century ago recognized the symptom.

Many anorexics feel they have to run everywhere, that walking is just a missed opportunity to burn off more calories. Parents often tell me that their anorexic daughter “never stands still” or that she “always runs up the stairs” or that she “pedals her exercise bike until after midnight.”

Anorexics aren’t driven to exercise because they want to be physically fit. They simply want to burn off energy (and thus weight) in any way possible. Excessive exercise may also trigger some pleasurable changes in brain chemistry, producing effects such as the “runner’s high” that many joggers report. Thus anorexics may exercise to experience a neurochemical “reward.”

Besides exercise, other weight-loss methods include use of laxatives to stimulate bowel movements or diuretics to decrease water in the body. Anorexics frequently resort to such tricks to speed up the removal of food from the body.

The results can be disastrous. Many patients-some of whom use between thirty and a hundred laxative tablets a day-report cramps and abdominal pain. What’s more, the body, robbed of its ability to regulate elimination on its own, can become dependent on a laxative. I find that weaning patients from laxatives is one of the hardest tasks in treating eating disorders.

Laxatives and diuretics can produce severe dehydration and electrolyte imbalance. Electrolytes are chemicals such as sodium and potassium that help transmit electrical signals within the body. An insufficient supply of electrolytes puts tissues and organs, particularly the heart, at risk of failure. Patients who abuse laxatives and diuretics risk problems with their hearts and other organs, problems that in some cases lead to death. Ironically, laxatives don’t even help that much. A laxative abuser loses no more than 10 percent of available calories through this method, and most of the weight loss is merely “water weight” anyway, as I mentioned earlier.

Of course, the problem with starving yourself is that you’re always hungry. No matter how carefully you defend yourself against food, sooner or later you will have to eat something or die. Because the hunger can be overwhelming, eating even small amounts can trigger a binge.

For people with these disorders, eating anything, especially when it leads to a binge, represents loss of control. Vomiting restores control-at least until the next urge to eat comes along.

About half of all anorexics practice self-induced vomiting. I’ll have more to say about the physiological impact of vomiting in the discussion about bulimia in the next chapter.

By acknowledging these weight-loss practices, the DSM-III-R recognizes the differences between anorexics who attempt to starve themselves exclusively through reduced food intake (restricting anorexics) and those who reduce weight by extraordinary means (bulimic anorexics).

The manual goes on to describe some of the other common features of anorexia nervosa-for example, the “magic power” that food has over its victims.

Once I discovered that a patient named Debbie had stuffed whole packages of cookies, cheese, fruit, and candy into her underwear drawer in her hospital room. When I asked whether she was preparing for an eating binge, she replied, “Oh, no. I’m not going to eat that stuff. I just keep it there to show myself how much control I have over it. The more food I can lay my hands on, the greater the temptation to eat. And the more I can hold out and not eat, the stronger I feel.”

Like Debbie, many anorexics exhibit peculiar behavior connected to food. They imbue food with enormous, almost supernatural force. Some prepare elaborate meals for their families, but eat nothing themselves. Or they toy with the food on their plate, poking it around with their forks, and finally throwing the whole meal away.

Anorexics see their starvation not as a defect, but as something that makes them special. “Look at me,” they seem to say. “See how much control I have over my body.” Almost every one of my patients, at one time or another in the course of her illness, will feel something to the effect that “Not everyone can do this.”

Because they deny the problem, anorexics feel that therapy, or any attempt to intervene, constitutes a deadly threat, a plot to rob them of their “specialness.” Needless to say, such an attitude makes my job as their doctor much more difficult..


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