Profile of an anorexic

Profile Of An Anorexic
Who is most at risk for anorexia?
In an elementary school classroom, I can sit in that classroom for half an hour and I can tell you who would be most at risk in that classroom. Typically, it'll be the top 3% of the girls in the class, academically, the most brightest, the child who turns in that perfect work. A lot of my patients will say when they were in elementary school that they would write something, and if there was one place where they made an error they'd have to start from the beginning and rewrite that whole page again. Somebody who's highly anxious, somebody who's very perfectionist, somebody who's a people pleaser, and somebody who hates conflict - those are the personalities that are most prone to anorexia.

At what age to people suffer from anorexia?
Two classic ages. One is just as a person enters puberty. And if you think about the way I describe an anorexic - somebody who likes exactness, who likes symmetry, someone who is very perfectionistic - when they go into puberty what happens for them is that body change that is going on feels very disconcerting to that person, because their body is changing, they are not in control. So they don't say "Okay I'm going to become anorexic today" they just, in response to the stress of the body changing, they stop eating and then they retreat the body back to the pre-puberty body. So that is one age, and then another age that they seem to be very high risk is around 16 and 17, so there are two ages that we see. Just around puberty, so it could be 12, 13, somewhere around there. And then there is around 16 and 17.

How are teen anorexics different from adult anorexics?
So with teens often times its about control, and its about changes in the body. It could be about feeling really overwhelmed, and not knowing how to negotiate into adulthood. So for teens that would be the piece - where they're struggling with launching themselves into adulthood. With an adult, its much more about issues related to control and loss of control. So that's the big difference between teens and adults. With teens its about "God this is overwhelming. This big bad world out here. I don't know how to handle it. I know what I can do. I can retreat into pre adolescence." Whereas with adults its much more about - there may have been some multiple losses that may have come about. A woman may have gone through a really difficult divorce or something like that. So, it may be that she's really lost her power in that. So its about loss of power and loss of control.

What are the signs that lead to an anorexia diagnosis?
They'll tend to be perfectionistic. They tend to be very competitive. They're very achievement-oriented. They like things a certain way. They're very detail-oriented, very conflict-avoidant. And they do not like to make others unhappy, so they're very much about people-pleasing.

What percentage of anorexics are male versus female?
One in seven out of a general population—out of a population of eating disorder sufferers—one out of seven of those people will be male. And if we look at a general population, the prevalence rates are anywhere from 12 to 16 percent for women. So for women the prevalence rates for eating disorders are from 12 to 16 percent, and for men, when we look at the prevalence rates for men, it's much more smaller percentagewise. Because out of those 12 to 16 percent of people with eating disorders—those are women with eating disorders. Then in the general prevalence rate, which is one percent of the population, out of that one percent of the population, if we just lump in all the people with eating disorders, it's a very small percent that tend to be men with eating disorders. But what's occurring is over the last five years or so, the prevalence is really increasing.

What triggers anorexia?
It's very important, when we look at the onset of anorexia, that we take a look at the role that dieting plays. We live in a culture where dieting is a very normalized behavior, and what often occurs is that when a person starts a diet, think about how many people around them will be saying, "Oh, you look so good! You look so good, you've lost some weight." For somebody who has that need for perfection, when they are receiving so many positive accolades from people around them about that little bit of weight they might have lost, and they have that drive for perfection, ambition, and that pursuit of excellence of "I'm going to be the best at any cost", then dieting is what I call "the gun". It really fires off the eating disorder.

Is anorexia just a rich white girl's disease?
Absolutely not. We see it across all socio-economic groups, and across all culturally ethnic groups. So it's definitely not just a rich white girl's disease. The media unfortunately is not discriminating against which family it's not going to go in to. You know, the mass media is there in every family and that pursuit of thinness, you know when we have shows such as America's Next Top Model, it's a show that's watched by so many people. The norms about thinness are crossing all socio-economic and cultural boundaries.

How do media images play into anorexia?
It was so interesting, when all the girls on “Friends” started to lose weight, we saw a huge group of girls that came in for treatment soon after that. Because as everybody was looking up to all of those stars, all the stars of that show. So when those women began to lose weight, then the women out here that are watching them, that are looking up to them, that are adoring them are feeling “Oh my God, if she thinks she's too fat, I think I'm too fat, I have to lose weight.” And so, over the course of a person dieting, out of a hundred people that could be on a diet at any given time, thirty-three of those hundred turn into anorexia bulimia. That's how huge a prevalence we end up having as a result of dieting. So the way media plays a role is if you have these top stars that are glamorizing these diets and you read “People” magazine and they give you the diet of the person. A lot of my patients will tell me is that “What I'm trying to do is, if she looks as good as she does and this is the diet that she followed to look as good as she does, then I'm going to follow that diet and within three months they're in my clinic needing to be treated for anorexia bulimia. So they play a role. The Olsen twins, when one needed to be treated, when that happened, we ended up having a huge increase in girls coming in for treatment. So what happens in the media directly affects our eating disorder clinics because we just see that impact that the media personalities have on the emerging sense of self of young women all over the world. The other part is that Fiji didn't have television. And five years after they got television in Fiji (this was a study that was done about ten years ago), five years after they got TV, they went from zero prevalence of eating disorders to twelve to fourteen percent within five years of “Baywatch” coming into their country. So when Western media came into Fiji, instantly within five years, it just took five years, for the eating disorder rates to get to the level that we have over here.

Why does someone 'choose' to be anorexic?
I don't think anybody "chooses" to be anorexic; I believe that they are predisposed to developing an eating disorder and then certain factors kind of come together and fire off the anorexia; I have yet to meet a patient that says, "Dr. Kaikaya, I decided my life was not going the way I wanted it to go, so I decided to starve myself." That isn't what it is; it's an unconscious process that occurs for them, where they just start to feel a sense of a loss of control over issues; and then all of a sudden the appetite starts to get affected or they suddenly start to look at their body in a different way and they suddenly feel fat even though they may be either underweight or normal size. Most anorexics will tend to be underweight at the start of their eating disorder or even normal size.

What motivates an anorexic to continue his or her behaviors?
There's a huge physiological loop that we've not talked about here. As I mentioned, there could be a time period, which is typically before somebody has an onset of an eating disorder. They'll have a two year period where certain stressful events could have occurred in their life, and usually I look back about a year to two years. It could be that they moved home, or she might have lost her best friend, or she may have lost a pet, or there may be increased conflict between mom and dad, or maybe it's because of transitioning to middle school. There's a period of brewing that we talk about. In that process, when there may be a subtle depression that may be going on, what happens is that when she begins to restrict, or she starts to count calories, or whatever the behaviors are that she gets into, she suddenly starts to feel better. If she's starting to feel better, she'll want to do more of that. It becomes an adaptive mechanism. What motivates a person to accelerate into their anorexia is typically a physiological mechanism, and that's when they start to restrict, and they actually end up having increased levels of serotonin in their brain, which makes them feel better. Therefore, they will want to do more of the same. There's a cycle, a physiological loop, that occurs in the brain. The restricting increases the serotonin level, and for bulimics, the actual act of throwing up increases the serotonin level. They've got brain scans that show us that. You'll see changes in brain chemistry that result from starvation, and changes in brain chemistry that result from throwing up.

Is anorexia inherent, or is it caused by outside factors?
I think when we think about causes for anorexia, I think it's important for us to think about causes of anorexia and triggers. So, we often do what we call a pie chart here at the clinic, where we create a pie chart of all the factors that predispose the person towards developing the anorexia. And those factors can be obsessiveness, detail orientation, a vulnerable personality where they are very conflict avoidant, they may have a family history of eating disorders or alcoholism or substance abuse, they may have had major life changes, puberty may have been sort of difficult, so there's like 8 or 10 different factors that predispose a person towards developing anorexia. What we talk about is that what tends to fire off like thinking about those factors as loading up the gun and the piece that fires off the gun typically is issues around dieting and body image. And where those issues with dieting and body image come in are from media, it could be a well-meaning uncle made a comment "Oh my god, you've developed a bit of a paunch over here, what's going on? Are we getting fat?" So the girl could just be about to start her puberty and as it is she's feeling uneasy about her body changing and she's never even thought about her body as fat. But then somebody makes a comment, and we have studies abut the prevalence of teasing among people who develop, who tend to develop eating disorders that they've often been teased about their looks or their body image or something like that. So that teasing can be a factor that can trigger and predispose a person towards the anorexia.

What leads people to eating disorders instead of other addictive behaviors?
What occurs for a lot of people with eating disorders is they tend to come from families that tend to be very appearance conscious. My little girls, my women, whoever it is I'm working with, if you look at the majority of people with eating disorders they are amazingly attractive people. They're gorgeous, and so as little girls there's been a lot of credence paid to them about their looks. There's a lot of importance paid to their looks. What ends up happening is that as they're growing up, as we develop our sense of identity and who we are, for somebody who is predisposed to a eating disorder, what has actually occurred is that they have that slice of them, "That's who I am, depending on how I look" is large. There's a lot of emphasis on looks and appearance consciousness in these families as well as with these individuals. What's really interesting is that, because they're perfectionist, no matter how attractive they are, they don't see themselves as attractive because they could always be looking a little bit better, they could always have their ear pushed back or they could always be a little bit thinner over here, and they could always be a little bit taller. So there's that constant comparing because people who tend to be perfectionist, tend to compare themselves a lot with others. In treatment, some of the issues we really work on are really honoring themselves and not looking outside of themselves for their self-affirmation.

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