by Harvey Widroe, M.D.
American Reporter Correspondent
July 7, 2007
EAT OR DIE, Part IV: GAMES THAT ANOREXICS - AND PROFESSIONALS - PLAY
ORINDA, Calif. -- In just one year Debbie, all of 17, had watched her young life plummet down hill in every conceivable dimension. She felt isolated from her family and friends. She no longer cared about boys, and they no longer even talked to her.
Once a good student, she hadn't made it through her senior year of high school. To Debbie - her body, now weighing less than 90 pounds - she still looked and felt like a fat blob. While she obsessed about eating, she wondered that she no longer felt hungry. Yet, even in the absence of feelings of hunger, she looked forward to what had become ritualized bouts of food stuffing and self induced vomiting.
Eating disorders afflict thousands of young women, a few young men, and others who have survived to maturity but are still suffering. As with Debbie, the course of their illness often brings them close to death and sometimes nudges them over the precipice.
Anorexics and bulimics seem to frustrate our best efforts time after time. Can we help them? It requires a team of specialists - a primary doctor or internist, a dietician, a therapist, and a psychiatrist - each bringing a specific dimension of expertise along with a spirit of therapeutic zeal.
Debbie knew her physical health had deteriorated. She had little physical energy or endurance. Her body felt slow and achy. Exercise was a distant memory of the two-hour-a-day workouts she used to endure while trying to burn off calories. Her family doctor told her repeatedly that she was falling apart, that her muscles had wasted, and that her calcium deficient bones were now brittle and subject to breakage almost without injury. But it was electrolyte imbalance that posed the greatest danger for sudden death. Sodium or potassium levels either too high or too low could produce a fatal cardiac arrest.
It became more difficult for Debbie to resist some of the demands of her mother and doctors. She no longer had the energy required for head-to-head confrontation. Finally she gave in to the idea of seeing a diet counselor on a regular basis. To Debbie's surprise the diet counselor was a nice person, someone who didn't nag or scold. The counselor worked out a fairly simple plan that covered what she was to eat, taking account of her preferences along with some healthy additions.
Debbie was to keep a written record of what she actually ate and to report back each week. She was instructed to stop weighing herself at home. When the dietician would weigh her during each office visit, Debbie was asked not to look at the scale reading, lest she use any apparent increase in weight as an added impetus to eat less and vomit more.
To any normal person Debbie's food program looked like what we should eat if we were on a severe weight loss diet. There wasn't anything that might be construed as fattening, certainly nothing we would need to eat if we wanted to gain weight; no ice cream, hamburgers and fries, fried chicken, chocolate cake, or banana cream pie. Debbie's diet was full of fruits and vegetables with a smattering of high-protein foods added as an apparent after thought.
Debbie and her food counselor each had a very different view of the diet plan. The nutritionist described the carbohydrates as "healthy carbs" or "simple carbs," to create the illusion that if they were burned off quickly there was no prospect they could become fat. The dietician's patter was a sales trick, worthy of any sharp Las Vegas stage show magician or car salesperson.
The diet counselor had repeated this line so often that she almost believed the sales pitch herself. But her real goal was simple - to set up an eating plan Debbie could accept, and which, if followed, would insure survival. How to completely stop Debbie from stuffing and vomiting was considered beyond the dietician's skill level. Better leave that to the therapists and psychiatrists, she thought.
The counselor's only bag of tricks was to repeatedly tell Debbie that if she ate everything as prescribed she wouldn't get fat, and might regain some energy. She tried to be supportive of Debbie's reported efforts and results. Their weekly meetings were intended to monitor her progress and to tinker with the details of the eating program. Once she had elicited Debbie's trust and cooperation, the nutritionist hoped to sneak in a few more calories.
Debbie's secret interpretation of the food plan was that if she just ate a little less than prescribed, and occasionally omitted a bout of vomiting to make her parents get off her back, she might still be able to lose weight without endangering herself. To ensure that the dietician wouldn't get too excited about her real weight, Debbie - thinking the dietician was properly fooled - drank a few extra glasses of water before each office appointment.
Despite the mutual duplicity, the diet counselor was very helpful. Setting up an eating plan made Debbie less frantic and confused each time she ate anything. And finally, Debbie grew more aware than ever that something was seriously wrong. She really didn't want to die, at least not now, so most of the time she did follow the agreed upon eating plan.
The diet counselor talked to the therapist fairly often, partly to give the therapist more information she could use in her work with Debbie and partly to measure how well or poorly Debbie was doing.
While Debbie might fool anyone weighing her by loading up with water, she couldn't fake her electrolyte levels. Actually, the diluting effect of water loading would tend to amplify any electrolyte abnormalities, a fact not entirely lost on Debbie. Her internist ordered regular weekly blood tests and cardiograms to be done "stat" each time her electrolytes were reported significantly abnormal. To avoid emergency room visits, intravenous fluids and possible hospitalization, Debbie felt somewhat constrained to limit the extra fluid consumption intended to deceive anyone weighing her.
Clearly Debbie's condition was growing more serious. Significantly more help would be required to improve her odds, or that of any deteriorating eating disorder sufferer like her, to stay alive.
Next, we will look at the role of the therapist in the treatment of eating disorders.
Harvey Widroe, a longtime practicing psychiatrist, is the author of the recently published, "The Smart Dieter's Cheating Guide: Eat and Watch Pounds Melt Away," with Ron Kenner (Outskirts Press).