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Mental health

The unsustainable lightness

The interpretation of anorexia as part of one`s identity extends treatment possibilities

MARCOS GARUTIThey spend hours in front of cake-shops and pride themselves on the fact that they prove to themselves and to others that they can resist the desire to eat and even resist hunger. When they get thin to the point of losing their capacity to move, they go secretly to the emergency department at the hospital but do not give up their right not to eat. If they accept half a pear on the insistence of the hospital team they may then spend hours jumping up and down in the room to burn off the unwanted calories and show that they are the ones that give the orders.

It is not easy to treat someone who has anorexia, an eating disorder characterized by the obsession to lose weight and by an aversion to food. The weight they gain after weeks in hospital rapidly disappears. A psychiatrist and a psychologist from the Federal University of São Paulo (Unifesp) have found one of the reasons that explains why people with this problem strongly resist the possibility of being looked after: anorexia may be part of the identity of these people, most of whom are adolescents and young adult women. In Brazil, some 1.1 million women and 120,000 men over 15 weigh much less than the minimum recommended for their age and height and fast to lose even more weight.

“Eating, which could be the solution for the excessive weight loss, may sound like a threat to the very identity of these people”, says Sérgio Blay, a professor from Unifesp. Blay and Cybele Espíndola saw that people who suffer from anorexia recognize that not eating is harmful and leads to solitude and social isolation, but it also offers them control over their body, power, beauty and a feeling of being different, even superior to other people. Based on these findings they created a proposal for treatment, still being completed, which considers anorexia as one of the pillars of identity. It then tries to expand the interests of the patients to include things other than food and make those who have this problem admit it. Normally people suffering from anorexia refuse to admit they have lost too much weight and only think about how to escape from being hungry. “Unlike other psychic disturbances, this is a singular world in which the illness has a marked symbolic character”, comments Cybele.

With this same purpose of understanding the symbolic dimension of anorexia, during almost the whole of 2003 Rúbia Carla Giordani monitored eight adolescents and women from 16 to 25 with this problem who were, or who had been, undergoing treatment in hospitals in Curitiba – treatment consists essentially in weight-gain diets, psychological accompaniment and the use of psychotropic drugs, generally antidepressants. The interviews (the transcriptions of which covered 400 pages), the day to day observations of these people and the conversations with the doctors, psychologists and nurses who treated them led to similar conclusions.

“These women prided themselves on feeling hungry and not eating”, says Rúbia, who teaches nutrition and is a member of the research group in health psychology at the Federal University of Paraná (UFPR). She discovered that these anorexia sufferers spent hours in supermarkets reading food labels to memorize how many calories a glass of milk or a cookie has. “Girls with anorexia have a morbid fear of getting fat and dedicate themselves obsessively to controlling their body image”, she says. “The body occupies a central position in the lives of those who suffer from anorexia and functions as the basis for any type of social experience.”

Through this study, which was published in 2006 in Psicologia & Sociedade [Psychology & Society] journal and detailed in one of the chapters of the book Olhares e questões sobre a saúde, a doença e a morte [Considerations and questions about health, illness and death] (José Rasia e Rúbia Carla Giordani, published by UFPR, 2007) , Rúbia saw that anorexia was a problem that can extend beyond the highest social classes and affect the poorest people also: the income of the families of those she interviewed varied from 1 to 33 minimum salaries.

Listening to these women, the researcher from UFPR found out about the three development stages of this eating disorder. The first stage is marked by discretion and not even family members notice that someone in the family is becoming anorexic. According to Rúbia, this eating disorder may begin with a diet that eliminates sweets, fat and food in general that has more calories. It may later evolve to bizarre and ritualistic behavior, expressed by an option for colors, geometric shapes and combinations of food – all still very discreet.

MARCOS GARUTIIn the beginning these people do everything possible to show they are living a normal life, even if they are already getting a lot thinner as a result of fasting and excessive exercising. “Parents and friends also don’t detect any abnormal behavior”, says the researcher. The next stage consists in selecting and restricting food even more: people with anorexia may induce vomiting or take laxatives or diuretics. They lock themselves in the bathroom to rid themselves in secret of what they have eaten, but in time they end up being found out.

The third stage is one of hostility. “Educated and well-behaved girls, until then with good marks at school, begin to become rebellious and confront the medical team and the nutritionists”, says Rúbia. “A central aspect of anorexia is denial of the illness, however serious it is.”

In two articles recently published in the journal Psychopathology and another in the Annals of Clinical Psychiatry, Blay and Cybelle argue that recognition of the illness, reconciliation of the anorexia sufferer with themselves and the reconstruction of identity might contribute to the treatment. “The reconstruction of family relations and contact with friends now become much more important as part of the treatment”, says Cybele. Blay adds “Even spirituality, or looking after domestic animals, may extend the universe of activities and create situations that are no longer food-centered.”

The studies in São Paulo and Curitiba provide a profile that, amongst mental disturbances, is peculiar to nervous anorexia and expand treatment possibilities for a problem that is not only current, nor restricted to adolescents, models and ballerinas. In 1893 Freud wrote about a woman who had developed anorexia after the birth of her first child and two years later about another, whom he insisted should drink water (she only drank milk) and stop throwing food out of the window. She told him right away that his recommendation would fail when she replied: “I’ll do it because you’re ordering me to, but right now I can tell you that this is going to end badly because it’s against my nature and my father was like me”. For Freud and other psychoanalysts the absence of menstruation for three successive months, one of the signs of anorexia, may represent a denial of femininity and the constant hunger is a way of feeling pleasure in the body.

Seduction and lies
“The main enemy of treatment for anorexia is the patient herself, who will employ all possible measures to get around the treatment”, says psychiatrist Táki Cordás, coordinator of the Bulimia and Eating Disorders Outpatients Clinic (Ambulim) at the Institute of Psychiatry at the Clínicas Hospital, the University of São Paulo (USP). He also remembers a letter he received years ago from a woman with anorexia whom he treated and who left the hospital. “She wrote something like this: ‘Don’t be taken in by us; don’t believe what we say. We’re lying. You need to learn to be strict'”, he recalled. “She committed suicide a few months later and I learned that we can’t be flexible and give in to the requests of patients who are not prepared to look after themselves, even though they feel themselves to be all powerful.”

More serious cases of anorexia may be fatal, like that of a 21 year old model, 1.74 meters [5 ft. 8 inches] tall and weighing 40 kg, who died in November 2006 because of renal complications caused by anorexia. The need to be thin in order to show off the clothes they wear on the catwalks means that models only have from 10% to 15% body fat; the level considered healthy varies from 22% to 26%.

Extreme situations, warns Blay, demand energetic measures, like admission to hospital, an emphasis on recovering weight and monitoring by a multidisciplinary team, with doctors, nurses, psychologists and social assistants. Often the treatment is very difficult because anorexia is frequently associated with other problems, like depression, obsessive-compulsive disturbance, bipolar mood disturbance, paranoid states and social phobia.

Under Blay’s guidance, for the first two years of her PhD studies, Cybele examined 3,415 scientific articles about anorexia that were published between 1990 and 2005. She organized the facts about this area and selected the studies that allowed anorexia sufferers to express themselves by means of a technique called metasynthesis, which collects qualitative data like interview statements, unlike the more normally adopted approach, meta-analysis, which is used to group quantitative data like the effectiveness of treatment. Her work is continuing with a survey of hospital outpatient clinics, private consultations and fitness centers in Fortaleza, where she was born, and São Paulo. She intends interviewing 30 people who have anorexia, were treated and have had no symptoms of this eating disorder for at least five years. She did not have to look very hard. In January this year, Cybele asked a physical education teacher in a fitness center if she knew anyone who had had anorexia and was astonished with the reply she got: “I had it”.

The 14 interviews she has done so far have indicated that the symptoms may have disappeared but the preoccupation with having an idealized and generally wasted body persists, often tempered with anxiety and depression. “It seems to be very difficult to rid oneself totally of dependence on the positive aspects of the illness, like power and security”, she says. One of the women she interviewed said he did physical exercise every day to maintain her weight and still weighed herself every day. Another recognized that the anorexia she had suffered from had resulted in serious personal problems: “There’s no way your life is going well when you have this problem; there needs to be something that’s not going right”.

This work throws some light on the meanings but not the causes of this illness, the origin of which may be genetic or organic, in addition, of course, to personal conflicts. Cordás gets concerned when she sees more people, mainly among a group that was previously risk-free, such as children, men and women over 40, with what she calls an “anorexic head”, worried about losing weight to the point of dieting or taking laxatives to excess. Television programs and magazines, especially those directed at adolescents, reinforce the pressure for the search for bodies that are thinner than Barbie’s. “For those who have anorexia”, observes Blay, “TV brings back the worst possible sensations, because it reminds them that they’ve not yet reached where they want to be”.

The project
Systematic review and the metasynthesis of qualitative studies in eating disorders (nº 07/50739-1); Modality Direct PhD scholarship – Fapesp; Coordinators Cybele Ribeiro Espíndola and Sergio Luis Blay – Unifesp; Investment R$ 74,998.17

Scientific articles
ESPÍNDOLA, C. R. e BLAY, S.L. Anorexia nervosa treatment from the patient perspective: a metasynthesis of qualitative studiesAnn Clin Psychiatry. 2009 21(1), p. 38-48
ESPÍNDOLA, C. R. e BLAY, S. L. Anorexia nervosa’s meaning to patients: a qualitative synthesisPsychopathology. 2009; 42(2), p. 69-80.
GIORDANI, R. C. F. A autoimagem corporal na anorexia nervosa: uma abordagem sociológicaPsicologia & Sociedade, 2006, 18 (2): p. 81-88.[Bodily self-image in anorexia nervosa: a sociological approach]