Eretz Acheret

Those closely acquainted with anorexia, who understand what it demands and entails of doctors, therapists, relatives and especially of the patient herself, will not be surprised to read about the connection between the disease and measuring – endless, obsessive measuring. In this sense, the term “anorexia” is misleading. Literally, it means “lack of appetite,” but the essence of the disease is entirely different, both physiologically as well as psychologically. The German term is more accurate – in German, the disease is known as Magersucht – “an obsession with being thin.” This obsession, on both the philosophical and practical level, means reducing the human essence simply to numbers. In the acute anorectic state, all those things that appear to us to be most unquantifiable, especially in simple terms – such as our identity, our self-esteem, our hopes and fears, our feelings, the essence of our lives – all these are flattened into an exclusively quantitative essence, whose value can be gauged with staggering simplicity using basic units of measure: calories and kilograms.
Unlike the prevalent claim in the popular media, anorexia nervosa, as a clinical entity, is not a modern phenomenon. As early as 1689, an English physician named Morton described what is today considered the first recorded case of anorexia nervosa. His account is an amazingly precise description of the symptoms and behavior of an 18-year-old girl under his care for months, up until her death. The professional literature reports a phenomenon known as “holy anorexia” or anorexia mirabilis (literally “a miraculous lack of appetite”) in the Middle Ages, when women starved themselves to death to signify religious devotion and achieve asceticism.

Exaggerated importance of quantitative measures

If until the 1970s anorexia nervosa was considered a rare phenomenon, according to the current estimates (see how easily I made the transition to quantifying the phenomenon on a statistical level…), anorexia is a disease prevalent among more than one percent (!) of the population. If in the past, the “classic” anorectic was characterized as being a young, intelligent, white woman belonging to the upper-middle­­-class, with a tendency to perfectionism, today anorexia can be found among all socio-economic classes, all races, ages and levels of intelligence. The gender asymmetry is the only one that remains unchanged: then, as today, the vast majority of those suffering from the disease are women.

Consequently, although anorexia is not a modern disease, it is certainly a modern pandemic. A pandemic is an epidemic on a global scale, and this one, which is not biological – although contagious on various levels – is a mirror of its time. This explains why the compulsion to measure that is so typical of the disease is not at all surprising.

Where anorexia is involved, the consuming preoccupation with quantification is characteristic not only of the anorectic herself. Further in this article, I will devote a few words to the tendency among the professionals (one that is anything but therapeutic) to exaggerate the importance of numeric measures, which is so characteristic of the professionals in charge of caring for these patients. Modern society has a predilection to quantify everything, a phenomenon whose most extreme expression is the emphasis – even dependence – on numbers by professionals that treat anorexia. But the most distinct – and in my opinion also the most interesting – feature of anorexia is the willingness – or rather the passion – of the patient to quantify herself. However, this is not a reflection of an overly enthusiastic embracing of Western criteria of beauty, but rather an internalization of asceticism and suffering as an ideology. Being thin is no longer “merely” a symbol of beauty, which may be one of the reasons that its pursuit persists without limits, long after the patient’s external appearance has become genuinely horrific. Thinness is perceived as an index of strength, resolve, control or the purification of both the body and the soul. The patient is very judgmental in relation to the self, total and unforgiving in her severity and dichotomy. Thin means good and worthy; fat means evil, miserable and weak of character. There are no concessions, no compromises, no mitigating circumstances. And most important, there is no such thing as being “too thin.” The thinner the better. The motto for anorectics is: “I am thin, therefore I am.” But because the patient never sees herself as thin enough, as the disease progresses, the motto transforms into “The less I exist (at least on the physical level), the more worthy I am to exist.” Paradoxically, the only way for the girl suffering from anorexia to obtain the right to exist is through her uncompromising pursuit of self-reduction, a quest that is liable to end in victory, which in this case means death.

The fear of gaining weight

I have already noted the tendency to ascribe exaggerated importance to quantitative measures, a characteristic that is typical not only of the patients of the disease, but also of the professionals that treat the disorder. By way of illustration, I will present here the criteria for the clinical diagnosis of anorexia nervosa, as they are listed in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition) from 1994:

A refusal to maintain body weight at or above a minimally normal weight for age and height, i.e. the weight of the anorectic is at least 15 percent lower than the desired weight. This index is often translated into a body mass index (BMI) lower than 18.
An intense fear of gaining weight or becoming fat, even though underweight.
A disturbance in the way in which one’s body weight or shape is experienced, an undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
In women: amenorrhea, i.e. the absence of at least three consecutive menstrual cycles.

Of course, it should come as no surprise that the medical criteria for the diagnosis of anorexia are operational-quantitative. In medicine in general, and psychiatry in particular, it is not at all unusual to encounter similar symptoms, which can characterize completely different disorders. It is important to emphasize that the DSM does not claim to provide an exhaustive description of the disorder. Its aim is to set guidelines that can provide a general direction regarding the essence of the problem and its source, and to propose treatment if necessary. Unfortunately, many of the professionals staffing the hospital wards or treatment centers for anorexia relate to these guidelines literally and also play the quantifying game. Instead of fighting the disease, they find themselves caught up in a power struggle with the patient.

As someone who has personally experienced this, I can say that this approach of “measure for measure” is fundamentally wrong. On more than one occasion, I found myself involved in a war of kilograms with the doctor in charge of my case, while at the same time fighting a calorie war with the dietician assigned to me. I saw and experienced countless cases in which exaggerated importance was attached to measures, especially on the part of the medical team. It starts with the “therapeutic” concept of the “token economy,” whose disciples do not even bother to hide the measurement paradigm that they espouse: A gain in weight of 300 grams elicits permission to wear clothing brought from home instead of hospital pajamas; in return for a gain of one kilogram, the patient is allowed one telephone call; three kilograms earn one a visit from one’s parents.

This treatment method sends the patient a clear message: Your value is directly tied to your weight. And there is no one more willing to embrace this message than the anorectic! Fortunately, support for the “token economy” method has been decreasing in recent years. Sadly, the same cannot be said for other widespread practices on the part of the professional team, such as the counting of the spoonfuls of rice that need to be placed on the plate; the absurd counting of the number of step the patient takes, based on the absolute ban on physical activity; the daily weighing of the patient – morning and evening before and after visits to the bathroom, before and after every meal; bitter disputes over every single spoonful of cheese that remains on the plate, and the prohibition against leaving the table until the last crumb of food has been eaten (I once knew a patient that remained seated at the table until dawn); intense preoccupation with matters related to food and being thin throughout the psychological treatment (despite declarations by the medical team that the therapy would not even touch on these subjects), which results in the patient withdrawing into herself and refusing to discuss more important and meaningful subjects with the therapist – and I could go on and on.

Life beyond the scales

I realized each time anew the extent to which all of these things, which are thought to embody the “guiding therapeutic approach,” serve to bolster the already dominant anorectic perception instead of eradicating it. In view of the enormous dependence of the anorectic’s identity on the results of the measurements, and because she tends to evaluate herself in accordance with the number of kilograms that she has managed to drop or the number of calories she consumes, it is all the more vital to refrain as much as possible during treatment from feeding this obsession. The therapeutic emphasis should be placed on the essence of life beyond the scales: on one’s fears and hopes, on anger and forgiveness, on wishes and aspirations, on friendship and rivalry, on love and disappointment. Yes, the therapeutic discourse should focus on all those states or characteristics that are difficult to quantify, because they are difficult to quantify. This type of treatment means giving attention to the human being, while pointedly ignoring and consciously denying rigid criteria of any kind. This type of treatment means resisting the dichotomous and oppressive mindset that the anorectic has learned to internalize and implement so proficiently. In short, good treatment must send the message that a person’s worth is not measured in numbers. If one day the impossible should occur and the key to deciphering the code of the essence of our identities and self is found, I have no doubt that it will be something far more complex than a dimension such as the circumference of one’s hips or the number of calories one consumes in a day.

There is no easy way to conclude this article on a subject so close to me. I have chosen to do so with a text I wrote six years ago, a letter bidding farewell to the tyrant that was part of my life for 11 years:

“I am leaving you. You, who have been with me for eleven long years – in my teen years, the army, the university, work. You were the disease that I denied, the sickness that I ignored, and also – I openly confess – the disease I was often proud of, the disease that I identified myself with. Sometimes I hated you. Sometimes I admired you. You were my protector, my excuse for what I experienced at the time as the total failure of my life. I hated you because of the invalid’s life that was forced upon me because of you, but I also thanked you for the excuse that you provided me with for every avoidance, for every bad decision, and for every success that was less than perfect. I pinned all my fears of facing reality on you, and comforted myself with the appalling thinness that you demanded of me. As if it were a huge achievement, a supreme goal… as if it were the very meaning of my life.

Eleven years of fear, terror and intolerable pain were needed before I could rebel against you, before I was able once and for all to free myself of your chains. The despair that I feel at the thought of the lost years that I sacrificed on your altar, the anger – at you, at allowing myself to give in to you – all these things are still very fresh in my mind. But today, from the strategic position in which I now stand, I see a more complete reality: True, there were fronts where I lost the battles, and others, in which victory took a very high toll in blood. But ultimately, I refused to believe your discouraging voice of despair. I may have lost battles here and there, but in the war of my existence – the war over my very life – I prevailed.

By Dafi Konis | 14/01/2010