September 23, 2013
Eating disorders are more common than you might think. A recent study of more than 8,000 teen girls found that, taken together, the prevalence of anorexia nervosa, bulimia nervosa, and sub-threshold eating disorders ranged from 13% to 21%. Importantly, most of the girls in the study did not meet full criteria for anorexia nervosa (defined by clinicians as extremely low body weight, intense fear of weight gain, and body image disturbance). Moreover, neither do most of the boys who seek treatment at Massachusetts General Hospital’s Eating Disorders Clinical and Research Program.
Instead, these young people fall in the perilous gray area between anorexia nervosa and normal eating—a gray area that my co-author, Jenni Schaefer (www.jennischaefer.com), and I call Almost Anorexic. My own research suggests that individuals with almost anorexia typically struggle just as much with eating pathology, physical complications, and other mental health problems (e.g., anxiety, depression) as those with anorexia nervosa.
In fact, the purgatory of almost anorexia was all too familiar to a young woman we’ll call Emma.
Upon graduating from a prestigious Chicago arts college, 22-year-old Emma couldn’t wait to move to California with her boyfriend, Sean, who had just been accepted to law school. A shy and bookish Midwestern native, Emma saw her relocation as the perfect opportunity to reinvent herself. But within a few weeks, she found herself second-guessing the move. Despite her impeccable résumé, the recession meant fewer employment opportunities in her chosen field of photography. Back home, she had a close-knit group of girlfriends, but now she found it difficult to meet new people without the predictable structure of school. Trying to hide her disappointment from Sean, Emma took a part-time retail job at a Santa Monica boutique, and refocused her energies on setting up their new apartment.
Still on a student budget, she snatched up free but mismatched dinnerware online, and started eating from the only matching cup and bowl set. She didn’t realize how important this ritual had become until one morning, she bubbled up with irritation to see her cup, coffee-stained from Sean’s all-nighter, lying dirty in the sink. Exasperated, she skipped breakfast. With Sean spending more and more evenings at the law library, their romantic evenings spent cooking together dissipated into Emma microwaving steamed vegetables to eat alone in front of the television.
Though Emma considered herself lucky to be employed, she knew she didn’t fit in with the other salesgirls at the boutique. The more she told them about her dream of doing photo shoots for national magazines, the more they questioned her commitment to sales. The only thing they complimented was her dietary restraint, calling her “tiny Emma,” and marveling at her “super-healthy” lunches of carrot spears and hummus. Having never considered herself particularly thin, Emma stepped on the scale at home one night, and was surprised to see that she had lost five pounds from her 5’2” frame since leaving Chicago. The weight loss hadn’t been intentional, yet gaining recognition for something—anything—after weeks of unsuccessful job searching felt absolutely intoxicating to her. Determined to be worthy of her newfound “health nut” moniker, Emma added new rules to her daily regime. She began eliminating snacks, measuring portions, and pushing mealtimes to later in the day. When Sean took Emma out for Thai food to celebrate his acing his first midterm, Emma vetoed the first restaurant because it didn’t serve brown rice. Sean was impressed with her self-control, and happily identified a more health-conscious restaurant where Emma could avoid white carbohydrates.
A welcome side effect of Emma’s food restriction was the emotional numbness it provided. Although she had previously characterized herself as pensive and empathic—“crying at the drop of a hat,” her mom used to say—she felt increasingly anesthetized to her failed job search, and growing emotional distance from Sean.
Her preoccupation with food, on the other hand, was maddening. Her valiant mental efforts did nothing to push away negative thoughts about the minutiae of her diet that bombarded her every moment. Did I serve myself too many almonds at breakfast? I know I counted them twice. . . . Can I wait until 3pm to eat lunch? If I eat too early, what will I do if I get hungry again and it’s not time for dinner? Should I have just one square of chocolate with dinner tonight? If I have one, will I be able to stop? On some level, she worried that a number of her food rules were irrational—like eating even numbers of foods (eight raisins rather than seven, for example) and eating clockwise around her plate. But Emma felt compelled to follow them. And besides, her weight still fell in the normal range.
By the end of the fall, Emma didn’t feel very interested in much of anything—except maybe food. When Sean broke up with her after finals, she had the surreal sensation that she was watching a scene from a movie. She knew that she should feel sad, but she felt nothing. As he admitted guiltily that he had met another girl—someone more “fun”—she wondered absentmindedly whether she had put too much olive oil in their stir-fry earlier that evening.
Are You Or A Loved One Almost Anorexic?
Emma’s precipitous weight loss, preoccupation with food, and rigid dietary rules are clear symptoms of an eating disorder. However, because she never fell in the underweight category, she stands at the cusp of anorexia nervosa—in other words, Emma is almost anorexic.
If you see yourself (or your child) in Emma’s story, please know that full recovery is possible. Here are some questions to help you determine if you (or your child) might be struggling:
The more “yes” responses you provide, the more likely it is that your relationship with food is problematic. Research shows that the sooner people receive treatment, the more likely they are to recover. Many of the same techniques that are useful for the treatment of anorexia nervosa and bulimia nervosa (e.g., family-based treatment, cognitive-behavioral therapy, and others) can provide much-needed symptom relief.
Today, the real-life Emma is at a healthy weight. She bases her self-esteem on her caring personality, passion for photography, and interpersonal relationships—not the number on the scale.
You can also take a free and confidential eating disorder screening at www.almostanorexic.com.