President of the National Center on Addiction and Substance Abuse at Columbia University and former U.S. Secretary of Health, Education and Welfare
Anatomy of Anorexiaby Steven Levenkron
"Invaluable to clinicians, parents, teenagers, and adults who are struggling with anorexia." Lynn E. Ponton, M.D.Anatomy of Anorexia is a tremendous tool for families: now more than ever, early diagnosis and treatment, and family participation, are crucial in helping the anorexic. Preeminent therapist Steven Levenkron demystifies this life-threatening disease and shows how the millions of girls and women who are afflicted with anorexia can be helpedand can look forward to rich and productive lives. "The nation’s premier expert in treating anorexia has written the nation’s premier book for parents, relatives, and friends of young women afflicted with this life-threatening disease."Joseph A. Califano Jr., president of the National Center on Addiction and Substance Abuse at Columbia University and former U.S. Secretary of Health, Education, and Welfare "[Levenkron’s] insights, descriptions of family relationships, and treatment recommendations for therapists create a rich, deep, and most helpful guide for a community of people whose lives are deeply and painfully affected by this persistent illness."Samuel C. Klagsbrun, M.D.
Clinical Professor of Psychiatry, New York University School of Medicine
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Obviously, not all girls and women exposed to our cultural emphasis on thinness develop eating disorders. A large majority of them remain healthy. We are reassured when we can name one or two factors that will determine whether or not someone will develop anorexia. Although realistically we cannot identify the factors that tilt the balance in favor of illness or health, we do know that the years between puberty and young adulthoodages eleven to twenty-twoare the most vulnerable for the onset of anorexia nervosa.
In his classic work Childhood and Society (1950), Erik Erikson describes the two major personality struggles in adolescence as "identity versus role diffusion" and "intimacy versus isolation." The classification is very useful in understanding why some adolescents fail to negotiate their adolescence without developing psychological disorders, while others succeed. Erikson also tells us that long before the child ever encounters these struggles, as an infant he or she faces only one battle: "trust versus mistrust."
So, while we can't find one catch-all as a criterion for determining susceptibility to anorexia nervosa, we can use three of Erikson's "eight stages of life":
Trust: Dependency and attachment
Identity: Emerging from successful trust and intimacy
Intimacy: Connection with others
When small children develop a sense of trust, and later asense of intimacy or closeness to others, and a sense of self or identity, they are not vulnerable to becoming "creatures of the culture" in its most extreme form as exemplified by the media: magazines, movies, and so on. But individuals who are seduced by popular trends allow these trends to define much of their identity.
Trust is the primary building block for identity and intimacy. Basic trust is, of course, developed during infancy, when children learn that the caretakers they depend on are safe, consistent, and dependable. This translates into "I am safe because I am fed and changed, held and rocked." It may later take the form of "I am safe because I am in someone's arms, on someone's lap," or "I see those familiar feet and legs nearby." How often we've been amused by a toddler's eager grip of the wrong jean-clad leg, in a crowded store, much to the surprise of the strangerand the toddler.
Many situations can interfere with the development of basic trust. Some of them may be familial: illness or even the death of the mother soon after childbirth; chronic illness of another family member that uses up the family's nurturance; divorce, leaving the child with a parent suffering from feelings of abandonment; loss of the original caretaker or nanny; or a primary caretaker who doesn't behave lovingly toward the child. Inherited and biological tendencies in a child involving depression and anxiety in the child's nervous system can also interfere with the consistent flow of nurturing and structuring behavior, effectively drowning out all the goodwill, love, and energy of the parent determined to raise the child securely.
If, for whatever reason, the development of childhood trust, dependency, and attachment fails, the child must reassure herself, regulate her own anxiety, and invent a false premature independence grounded in the self-assurance of a child by a child. Children who are forced to parent or nurture themselves are the children who do not trust adults because they were not shown the comfort of a consistent nurturing flow.
Just as young children prefer simple primary colors and learn to appreciate subtle earth colors only as they grow up, so does the mistrusting child prefer black or white viewpoints; there is no room for shades of gray. This often results in the mistrusting child becoming a perfectionist, succeeding without feeling pride, the "A" student who feels like a "C" student. Self-esteem seems unattainable. The child is often inconsolable about losses or defeats experienced by any member of the family. More often than not, the child displays obsessive or perfectionist behavior.
Some of these traits, such as perfectionist behavior, may disguise themselves as gifts to parents. They may see the child as independent, not needing much support in a family overburdened by other problems. A successful child who often does well in school and is socially outgoing does not appear worrisome.
As this child reaches puberty, she may interpret her developing breasts and her menstrual periods as signaling the end of an incomplete childhood. She may feel that she must turn away from her family to complete that childhood and seek some sort of an identity for herself. Most, if not all, adolescents, turn outside or rebel against some of their family values to assert their own independence. The child who has never successfully developed a healthy dependence in her early years has nowhere to go emotionally for fulfillment of her need to develop a sense of identity but to the larger culture and its messages to girls and women. Most of those messages are about being thin and ridding oneself of unnecessary and unwanted fat. She, of all her peers, becomes the ultimate devotee of this cultural message. Glance at any issue of a women's service magazine; look at the figures of popular models, and the female television and film stars, and you'll see quite slender women with prematurely lined faces, indicating that their weight is unhealthily low. Messages stressing normal weight as attractive and healthy are drowned out by the barrage of "the Thin Message."
The girl who doesn't get anorexia nervosa as a child has developed a healthy use of dependency and trusts her parents to moderate the extreme impulses that all adolescents experience. She is not to be seduced by the bizarre messages our culture sends out to adolescents in terms of dress styles, sexual behavior, and other demands in the area of antisocial characteristics and unrealistic roles for women.
The girl who is not able to reach out to her parents for refuge from these often-frightening cultural demands is left to her own devices when choosing her particular route to identity and security. A child who becomes anorexic is using her body to express her need for perfectionism.
However, not all anorexia nervosa cases occur at puberty. Puberty is only the first of many "separating points" that may cause some sort of crisis in girls. Other identifiable crisis junctures can happen during the junior year of high school (when exploring the option of leaving home for college), during the senior year of high school (when preparing to leave home), during the freshman year of college (when girls are living out of the home), upon graduation from college (moving further from the dependence of family life), and at other profound positive or negative life-changing moments that may occur in a young woman's lifemarriage, childbirth, incest, or the loss of a best friend. These "separating points" refer to separation from a previous, less mature level of dependency, which has been unfulfilling, so that the person is unable to move on toward more independence. This derails the negotiation of Erikson's key crises off:
1. Basic trust vs. mistrust
2. Identity vs. role diffusion
3. Intimacy vs. isolation (or obsessiveness)
In the chapters that follow, the development of identity and intimacy will be discussed with regard to fostering or preventing the development of anorexia nervosa. When an individual is overwhelmed by relational or circumstantial changes in her life, she will either rely on the storehouse of strength and support built up in the past and turn to others for support, or she will turn inward, away from realistic solutions and toward psychological symptoms and disorders. Tragically, anorexia nervosa has become prominent among the disorders of "choice" our culture offers.
WHO INVENTS US?
Children begin life as wordless anthropologists. They study their adults' world and react to it as if it were the only truth. They dare not disbelieve their caretakerswhether parents, a nanny, an aunt, older sister, or sometimes (but rarely) a father, grandfather, stepfather, or uncle. These caretakers either look children in the eye or they don't; they are glad to see them or they are not; they seem interested in children or not; they touch them softly or harshly; they speak softly or harshly or rarely. Grown-ups are content or discontented. They are cheery sometimes, always, or never.
Children believe that adults command them. They, the children, feel responsible for their parents' attitudes toward them. If children behave well, they will be loved; if they don't, they won't. In a child's eyes, grown-ups are never wrong. Children know who they are by the manner in which adults react to them. Sometimes, children help adults to get along with each other. Sometimes, children have to cheer and support adults. They do a good job and grown-ups love them for it. Sometimes, adults love children just for being who they are. Sometimes, adults love children for what they do for them. Although children encounter many different types of adults, one thing is constant: children study adults closely to know who they themselves are.
In the most concrete terms, parents need to help their children experience life, and this orientation begins when adults focus on the child. Frequent, loving eye contact from parent to child tells the child, on a nonverbal level, that the child is interesting and valuable to the parent. This leads to the development of self-esteem. In addition to eye contact, voice tone is the second cue to children about how they are regarded by the parent. The child looks for warmth, confidence, and authoritativeness in the tone of the parent's voice. As children grow older, they will interpret the words that accompany the eye contact and the voice tones to develop further ideas and feelings about how they are seen by their parents.
Children like to hear that they are pretty, interesting, clever, smart, and so on. Children are demonstrative; they hug and kiss adults, tell adults that they love them. These adults might be parents, older siblings, grandparents, guardians, or anyone children believe and trust. And children will be pleased, displeased, or confused by what they observe in adults. If children hear good things about themselves, they will feel good about themselves. If they hear bad things about themselves, they will feel bad about themselves. If, however, children hear good things about themselves but don't believe them, it won't help them feel better. Worse, if children don't hear anything about themselves, or even feel that their adult models are looking to them for support, they will become invisible. Invisible, because they are lacking the identity messages that are so crucial in forming a young personality, that "fill up" the child with a sense of self. A self contains character traits, habits, behaviors, in other words, a personality. Children who are not given this support are left "undescribed," and they replace their lack of identity the only way they know how: they construct a false one to fool those around them.
Identity formation is a gamble, to be sure. The "nature-nurture" debate will no doubt continue as new DNA information is interpreted and reinterpreted to determine whether character traits are genetically inherited or formed by families. Regardless, what is formed by families and family systems is the way that children relate to adultswhat children see, observe, and hear.
Family members are continually giving "identity messages" to each other. Children usually receive these messages from their parents, but older siblings may send them messages (often negative) as well. The younger child who goes to play with his older brother and has the older brother's bedroom door slammed in his face repeatedly learns he is unwanted, and in turn he processes this by thinking or perceiving that he is unlikable. These identity messages, if they are consistently repeated, form children's first sense of who they really are: their initial identity. If the messages are directly spoken to the child, it is a simple matter for the child to believe what is said. If the message has to be inferred (or invented) by the child, it will be negative. For example, if a child is never told that she is pretty, or smart, or isn't listened to attentively, she will always believe that she is ugly, or unfeminine, unintelligent, and boring. Parents should never assume that their children will believe that they possess positive attributes that parents have not frequently ascribed to them. There is an old (untrue) parental admonition that begins with "I don't have to tell you that you're pretty, smart, interesting, or for that matter that I love you." Children have no ability to infer an unstated positive parental thought about their appearance and/or their personality.
I recall an attractive nineteen-year-old in my office who described how ugly she felt she was: "My hips are too wide," "My nose is crooked," "I could use an undershirt instead of a bra." All of her comments were distortions about her face and body, but she felt they were real. She stated these remarks with intense self-contempt. She was not looking for reassurances. When her mother came to drive her home, I invited her into my consultation office. I asked her if she thought her daughter was plain-looking or pretty. She promptly replied: "Of course she's pretty. Why, she's beautiful!" I asked her if she ever told her daughter that she thought she was beautiful. She responded: "No, I never wanted her to get a swelled head."
Children are rarely, if ever, spoiled by compliments that are sincere. They need all the support that they can get, whether it's about their appearance, intelligence, character, or personality. That does not mean that by positively reinforcing our children, we give them unrealistic, grandiose ideas about themselves. It means that we must explicitly support the positive qualities they do have.
Most corporate supervisors' handbooks advise that before a supervisor criticizes a subordinate, that supervisor first states what the subordinate does well before executing the criticism. As parents are so frequently called upon to correct their children, they may not always have time for a positive review of the child's good qualities. That is why it is important to state them when an opportunity presents itself, so that the child will have a backlog of praise to be able to hear, tolerate, and withstand the criticism, rather than using it to confirm a general sense of being no good.
For the growing child, then, those aspects of that child that are directly spoken about are believed (even when the child acts defiant and disbelieving). Those aspects of her that are not commented on are inferred by the child to be negative. No child ever thinks, "I'm smart, I'm interesting, I'm attractive. My parents just forgot to ever mention it."
Biological Depression and Anxiety
When a child is diagnosed by a trained professional as being clinically depressed or anxious, aside from contending with that child's lack of enthusiasm, unhappiness, excessive nervousness, fearfulness, and timidity, parents will need to understand that their child believes that he or she is different from other children, that his or her mind does not work the same way. For children, "different is inferior." If family dynamics are examined in psychological evaluation by professionals and seem healthythe family members are open and honest, the parents (if married) have a substantially caring relationship, no extraordinary emotional relationship problems are apparent to account for unhappiness or long-term frustration or feelings of natureand don't account for the depression or anxiety in a child, and especially if there is a history of family members showing symptoms of the same problems, then a diagnosis of "chemical," "biological," or "hereditary" causes is concluded. Sometimes this kind of diagnosis results in the suggestion that medication be used as part of treatment. Usually in these cases, which vary from individual to individual, especially with children, a combination of individual psychotherapy and medication is the treatment most effective in helping a child through depression. Separate psychotherapy with the child's parents addressing and coping with the depression, or joint family therapy including the child, may be recommended.
Hereditary and psychological anxiety, and depression, all affect a child's developing sense of identity. The child will discredit the good things said about her, regardless of how much trust she has in her parents. Her parents will need to compete with the depression or anxiety continuously in order to prevent additional disorders common with young women, such as eating disorders, obsessive-compulsive disorders, agoraphobia, and crippling feelings of inferiority along with extremely poor self-esteem. It's a vicious cycle: disorders have a negative impact on identity, and negative identity creates new disorders which further devalue self-esteem.
An example: Susie is an anxious child, who is hesitant to participate in sports activities at school. When other children tease her, she feels depressed and ashamed. She develops psychosomatic disorders and hypochondria in order to stay away from school. She begins to view herself as sickly and physically weaker than other children. Her family has a no-win choice in front of them: disregarding her complaints would mean they don't believe her, thus adding to an already negative identity inventory (that collection of ideas the child has about herself); believing her would only further convince Susie that her physical condition is real. She develops psychosomatic stomachaches, causing her family grave concern: the consequences could lead to food phobias and more attention to her problems by the family.
Susie now has enough attention from her family to compensate for the low esteem in which her schoolmates hold her. Any kind of attention may be preferable to low self-esteem. Her sense of identity is drawn from negative attention and feelings of inferiority, but she is accustomed to this familiar pattern of relationships. Like most people, when it comes to relationships, Susie seeks out the familiar ways in which she is treated and regarded by other members of her family, no matter how bad these may be, rather than the unfamiliar, which could be disorienting and uncomfortable.
Chemically caused disorders (disorders caused by malfunctioning amines between brain cellsserotonin, to name but one) can cause children to have bad feelings about themselves and to invent explanations for them. They may think of themselves as inferior, or mean, or stupid. They may then act out these character and personality traits to get the family to reflect on them, or to verify them. This won't be deliberate on the child's part, but will be an attempt to make sense out of his or her feelings. Not only is it a vicious cycle when chemical disorders spur on psychological disorders in the individual, but the cycle can infect the entire family system and set of relationships.
To return to our original example, if Susie now has developed what seems to be a digestive disorder initially caused by anxiety, which has led her to become hypochondriacal and develop stomach problems, her parents are "used to it" and behave with a combination of sympathy, suspicion, and resentment. Susie becomes accustomed to being treated this way. It is certainly an improvement from the way she is treated in school, and she learns how to manipulate the sympathy, negate the suspicion and resentment, in what becomes a daily pattern of which no one is consciously aware. Making the family "aware" of the situation is a more difficult process than simply pointing it out to them; one cannot make them understand their unconscious feelings and actions merely by telling them what these are. Susie and her family must be helped to believe in the interpretation for it to effect a change in how she feels about herself, which in turn can effect a change in her behavior.
When Susie's parents become angry, Susie feels badly about herself. When they see the effects of their anger upon her, they replace anger with guilt and kinder behavior. Susie reacts by feeling better about herself. But when Susie's parents realize that their forced kindness inhibits them from disciplining Susie, they feel resentful toward Susie, the source of their guilt and guilt-driven kindness. They become angry all over again. The parents are caught in a roller-coaster cycle of anger-guilt-resentment. Their daughter keeps herself protected from the hostile "dips" in their roller-coaster ride, makes them "pay" more by countering with higher inclines or guilty paybacks for their previously expressed anger or frustration. All of this moves Susie further and further away from peer friendships at school; since she is so involved with the developing system at home, she is less involved with developing appropriate friendships at school.
Susie's identity development is not invested in healthy social growth but in defensive behavior, in a passive-aggressive struggle with her parents. On a deeper level, she is ashamed of this and hates herself for it. So shame and self-hatred have become part of her identity.
This entire scenario I've described began with a chemical/biological/hereditary tendency toward excessive anxiety. Why would we not want Susie merely treated with medication that would make the anxiety go away? The two most obvious reasons are: (1) Susie would feel inferior taking pills just to be normal; and (2) before the emergence of anxiety can be identified, she has already developed negative psychological attitudes toward herself for being frightened and timid.
Nature Heredity vs. Nurture Family and Childhood Experience
Using Susie's history as an example, we are left with the old question, Which came first, the chicken or the egg? "Came first" is the key phrase here. Everyone interested in human personality development sooner or later becomes involved in the "nature-nurture" controversy. Are we merely a genetic map? Or are we the product of our upbringing? Without attempting an in-depth discussion of this question, I would like to suggest that there are probably clusters of inherited personality traits that still remain to be identified. Shy and withdrawn, quick-tempered and impatient, are among the most obvious. Two of these "primary clusters" will probably turn out to be related to levels of anxiety and depression. There are already different chemical processes and neuroreceptors identified as responsible for both anxiety and depression. At least a half dozen medications, all developed in the last few years, can be helpful to a high percentage of patients who take them. Educated guessing is still the method of prescribing which medication will help whom. No test of the central nervous system has yet been developed to determine which chemical process would best be treated by which drug. Many questions still remain to be answered: Can life experiences from infancy onward affect the brain's chemical development, and to what degree? Or is the chemical map complete the day an infant is born?
In addition to these complex questions there remains the most nagging question, Which came first, the nature or the nurture? If the answer turns out to be "nature/heredity," exaggerated or minimized by nurture, then we can develop a method of understanding that will combine medication used for the "nature/hereditary" piece of the problem and appropriate psychotherapy to deal with the "nurture/family development." The third part of the problem is the effects of the disease process in complicating and worsening the illness. This is the model I will use to explain the causes, mental and emotional processes, and treatments for anorexia nervosa. They may apply to other disorders as well.
Meet the Author
Steven Levenkron is a psychotherapist and the author of seven previous books, including Cutting and The Anatomy of Anorexia. He lives and practices in New York City.
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I have struggled with an eating disorder for some time and I am seeking therapy. This book was recommended for my family, but I decided to read it. I thought the book was excellent. I don't know how many times I just was unable to put my thoughts and feelings into words, but I found numerous quotes in his book that explain everything. I would definatly recommend this book. For those with an eating disorder it may bring a better understanding to what you do. For others involved (family, friends, etc) it may help you to better understand the eating disorder's 'logic' behind what he or she does.
This book represents an excellent resource for patients and their families, along with professionals who are beginning to work with those who struggle with this complex illness. Although its section on psychopharmacology is quite limited and a bit dated, he does an excellent job in giving one a sense of what the therapy is like and the issues involved from both the patient's and the therapist's vantage point. I would definitely recommend this book to anyone interested in or in some way involved with eating disorders.