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A girl with an eating disorder grows up. And then what?
In this groundbreaking book, science journalist Trisha Gura explodes the myth that those who suffer from eating disorders, including anorexia nervosa and bulimia nervosa, are primarily teenage girls. In truth, twenty-five to thirty million American women twenty-five and older suffer from serious food issues, from obsessions with calorie counting to compulsions to starve then overeat. These diseases often linger from ...
A girl with an eating disorder grows up. And then what?
In this groundbreaking book, science journalist Trisha Gura explodes the myth that those who suffer from eating disorders, including anorexia nervosa and bulimia nervosa, are primarily teenage girls. In truth, twenty-five to thirty million American women twenty-five and older suffer from serious food issues, from obsessions with calorie counting to compulsions to starve then overeat. These diseases often linger from adolescence or emerge anew in the lives of adult women in ways that we are only now starting to recognize.
Drawing on her own experience with anorexia, as well as the most up-to-date research and extensive interviews with clinicians and sufferers, Gura presents a startling, timely, and imperative investigation of eating disorders "all grown up," and offers hope through understanding.
The Myth of Recovery
The story begins with a teenager standing naked in front of the bathroom mirror. "Who am I?" she asks, turning in profile, dissecting the reflection of her breasts, hips, and belly. As she pinches flesh and frowns, a tape in her mind begins to play. It echoes the comments of her parents, the gossip of girlfriends, and the urges of boys who might want her. The one who does not want her, the boy she has a crush on, has just blown her off. Now, facing the mirror, she hears only rejection. She blames it on what she sees, her size-6 self.
She focuses on her stomach; it is bloated. The cruelty of premenstrual syndrome, PMS. In the hopes of soothing her sorrows, she has just eaten a pint of cookie dough ice cream. Stuffed and heartsick, she looks for another way to solve her problem. She thinks, If I were prettier, if I were a size 4, I would have gotten him. I would have gotten anyone that I had wanted. And I wouldn't be feeling so miserable right now.
What does she do? For her, the inevitable: she bends over the toilet and thrusts her finger to the back of her throat. She tickles at first. Then she jams. She reaches that special spot and heaves up pieces of herself, the ugliness spewing out.
Then she gets up, feeling ashamed, humiliated as only others like her can imagine. She will never tell anyone. Besides, I'll never do this again.
But she does. Three times a day, every day.
For how long?
Media accounts do not go that far. The tale typically endswith the girl in the mirror either dropping out of the story as it goes on to sensationalize the horrors of eating disorders. Or she tells someone and gets therapy. She gets better. And the reader celebrates the happy ending with her.
But is it really the end?
Not according to medical research. Many reports track the outcomes of girls who have been diagnosed with some type of eating disorder. Anorexia nervosa, bulimia nervosa, and binge eating disorder are all clinically defined according to criteria published in the fourth edition of the Diagnostic and Statistic Manual of Mental Disorders, the bible for practitioners. (See Appendix 3 on page 315.)
The DSM-IV says that a person with anorexia nervosa willfully loses weight to the point of emaciation. Such an individual is terrified of becoming fat, and the fear heightens as the weight drops. Some individuals with anorexia simply restrict what they eat, while others binge and purge, either through vomiting, using laxatives, or overexercising. Since nutritional starvation usually inhibits menstruation, failure to menstruate for at least three consecutive months is one of the defining criteria of anorexia.
Individuals with bulimia nervosa have a very different profile. According to DSM-IV, a person with bulimia is someone who eats large amounts of food in a short period of time and feels helpless to stop. Purging follows, either by self-induced vomiting or misuse of laxatives, diuretics, enemas, or other medications, along with fasting or excessive exercise. An individual does not have to vomit to be considered bulimic. She can exercise obsessively instead. But she must cycle through the binge-purge episodes, on average, at least twice a week for three months.
Binge eating disorder is defined as bingeing, as in bulimia nervosa, but without the compensatory purging or other behaviors. Individuals with BED tend to be obese and racked by low self-esteem. They may begin to binge either after years of unsuccessful dieting (starvation prompts the urge to binge) or these individuals may use food as a means to allay their self-rejection.
Classifying patients into groups and subgroups helps researchers pin down causes and doctors decide which treatment is best. DMS-IV also gives therapists a glossary of terms to convey information to one another about their patients. And in this day and age, establishing diagnoses is necessary for insurance coverage.
But diagnoses have their limitations. Strict criteria can convey a false sense of who is well and who is not. For example, a patient in therapy can progress enough so that she no longer fits into a disease category. She no longer displays the telltale symptoms of anorexia, bulimia, or binge eating disorder. The medical community may say she is better, but deep inside she knows that something is still wrong. Perhaps she even stops treatment because she has been led to believe there is no need for it. Worse, she may find down the road that she falls right back into the eating disorder, with all its fears and rituals.
What does DSM-IV, with its pages of precise definitions, say about that? Only that she does not fit in.
The Eating Problems that Don't Fit: Women Who Fall Under the Medical Radar
Dana, 40, cannot go a day without running. Every morning when the alarm goes off, she laces up. Rain, snow, or sleet, she runs outside because running inside on an indoor track or elliptical runner does not give her the same endorphin high as a forty-five-minute outdoor jaunt.
As a teenager, she suffered through both bulimia and drug abuse. Today, she has let go of both: no more bingeing and purging or smoking and snorting drugs. But she cannot let up on her exercise. She runs when she is fatigued, and even when she's injured. She has recently added a nightly twenty-minute workout on an indoor trainer. As for eating, she skips breakfast and lunch, saving her calorie quota until dinner. Even after starving all day, however, she still feels guilty about cooking herself a meal. Instead, she makes dinner for her two children—brown rice, vegetables, and tofurky (a tofu version of turkey)—and eats standing up, picking from her kids' plates.
What does Dana have? Bulimia? She does not throw up, but she does, in fact, purge through exercise. Does she binge? She says no. When asked to define the behavior, researchers can give only arbitrary answers: a "binger" is someone who eats between 2,000 and 10,000 calories in less than two hours. Because Dana does not eat that much within that time range, by definition, she does not binge. Therefore, she cannot have bulimia nervosa.Lying in Weight