Bulimics and anorexics

Bulimics and anorexics-Children of fear and anger

On Health and Religion. This article is provided by the Health and Temperance Department of the General Conference of Seventh-day Adventists.

Francine Rasco, M. D., is a staff psychiatrist and director of the Psychiatric Unit as well as director for the Eating Disorders Program at Harding Hospital, Worthington, Ohio.


Perhaps you have seen them without even recognizing them, those children of fear and anger, as I have labeled those who suffer from bulimia or from anorexia nervosa.

Mr. and Mrs. B have decided to consult their minister because they have noted that large quantities of food regularly disappear from the kitchen. Someone has also been taking money from Mrs. B's purse, and she is almost certain it happens at home. They sometimes find telltale traces of vomitus in the bathroom when no one at home is known to be ill. They are worried, confused, and angry at their daughter Beth because she is evidently behaving in a way that disgusts them and that they do not understand. After the minister agrees to talk with Beth, her parents badger her into seeing him.

Beth is an attractive, neatly dressed 16-year-old. However, her observant minister notes that she has sores at the comer of her mouth (from a nutritional deficiency owing to vomiting and laxative abuse), mild swelling at the far side of her cheeks (swollen parotid glands from vomiting), and a callus on the back of her hand caused by the friction of her front teeth when she induces vomiting. (Others may use a spoon or the end of a toothbrush.) She covers her anxiety and anger about seeing the minister with a bright smile and light, social manner. Soon, however, his kind but direct questioning about her possible disorder produces a depressed and guilty facial expression. She reveals that in addition to binge eating and then vomiting and fasting, she has also been abusing laxatives. She is suffering from the eating disorder called bulimia.

Before we see how the minister proceeds with bulimic Beth, let us consider the parallel situation with another member of his congregation, Annette A, who returned a month ago from her first term at college much thinner than when she left in the fall. Her parents explained to the minister that they became alarmed by her appearance at Christmas and insisted that she return home after the first term so that she could be medically evaluated. Their family physician has informed them that no physical problem has caused her emaciation but that she has an eating disorder called anorexia nervosa and should be admitted to the psychiatric unit of a hospital for treatment.

Mr. and Mrs. A are skeptical of psychiatry. They are ashamed at the thought of their daughter being admitted to a psychiatric unit. They are consulting their minister to see whether there might be an alternative. They admit that Annette "eats like a bird," but she does not seem totally indifferent to food because she often cooks rich desserts for the rest of the family, even though she does not eat them herself.

They think their physician has been trying to frighten them by saying that Annette might die without adequate treatment. She seems so active and unconcerned that they cannot believe this and wonder whether she would come to her senses after a few sessions with the minister. When Annette comes to see him, he is shocked by her gaunt appearance and puzzled by her lack of concern. Instead of being worried about herself, she actually seems rather smug, as if her behavior has made her superior to others. The minister notes that her clothing is at least two sizes too large for her, as if she has a distorted idea of her size. Indeed, as he talks with her about her parents and the physician's concern, he learns that she thinks she looks fat even now!

The pastor can help

The minister's job is not an easy one in either case. Although both sets of parents profess concern for their children, they may resist seeking definitive treatment because of their unconscious fear that Beth or Annette will slip from their control through therapy. As is typical of many parents of bulimics, Beth's parents are very concerned about appearances and may resist hospitalization because of what their relatives or neighbors might think. Being rather needy, they may also resent the expense. Mr. and Mrs. A, on the other hand, have enormous difficulty recognizing any signs of distress in their family and will tend to deny the seriousness of Annette's condition, perhaps even to the point that the minister will wonder whether they unconsciously want her to die.

Beth will probably be more willing to seek treatment than Annette because she recognizes that her eating pattern is bizarre. Annette sees nothing wrong with her eating pattern. Although she claims that she looks fat, she secretly believes that others are envious of her superior control of her food intake.

However, since the families of Annette and Beth are likely to trust their minister of longstanding more than a psychiatrist previously unknown to them, the minister may be quite helpful in convincing them of the need for treatment. Depending on the severity of their problems, bulimics and anorexics may need psychiatric hospitalization, but some can be helped on an outpatient basis. Unless their physical condition clearly indicates a need for hospitalization (e.g., electrolyte imbalance in the vomiting bulimic or emaciation and malnutrition in the anorexic), a psychiatrist should determine whether outpatient or inpatient treatment is indicated.

Some families of anorexics are more open to hospitalization on a medical unit than on a psychiatric one, but the patient needs more than just medical management of her eating disorder. Otherwise, she will relapse again and again, regardless of how many times she is admitted to a medical unit.

Not just any psychiatric unit will do, either. These patients need a psychiatrist and hospital staff that are experienced and skilled in the treatment of their particular disorder. Some psychologists are also quite skilled in these areas but would require backup by a psychiatrist because of the possible physical complications and the need for medication, .such as an antidepressant.

Specific, effective treatment approaches are now available, which are greatly improving the outlook for patients with eating disorders, but not everyone knows how to implement them. A patient may have to go to a hospital outside her community or even outside her state to obtain adequate treatment. 

Needless to say, recovery from such disorders is well worth the effort. The minister can facilitate the treatment process by supporting the patient's family, who may feel very threatened, insecure, and angry during their family member's therapy, and will probably feel tempted to withdraw her prematurely from treatment.

Recognizing bulimics and anorexics

Bulimia and anorexia nervosa represent a plague of Western society and, unfortunately, appear to be increasing in prevalence, partly because of our society's idealization of the slender, even underweight, female figure that is more characteristic of an adolescent boy than of a mature woman. Other factors probably contribute to the increased prevalence of these disorders, but research has yet to identify them definitely.

At present 2 percent of American women and a little less than 1 percent of men are bulimic. Although anorexia nervosa is less common than bulimia, studies imply that about 1 percent of women in the high risk age group, 12 to 30 years, develop the disorder. Only 6 percent of anorexics are men. Up to 50 percent of anorexics may also have one or more bulimic phases. Depression often accompanies the eating disorders, affecting up to 60 percent of bulimics and 23 percent of anorexics. The mean age of onset for both disorders is 18, and most cases begin sometime between early adolescence and the late 20s. Because these disorders affect mainly women, I have used feminine pronouns in discussing them, but keep in mind that the problem is not limited to women.

One might easily miss a bulimic, for she will usually appear physically healthy and will be attractively dressed and groomed. One can easily detect an anorexic by her thinness, but until the later stages of the disorder you might still ascribe her appearance to natural causes or fashion consciousness.

Whatever their appearance, these individuals desperately need help, even if they themselves do not think so. Without help, and sometimes even with it, they are at best slaves to their compulsions. At the worst some may die early deaths from their disorders.

How can you recognize and help those in your congregation who suffer from these serious mental disorders?

Several criteria identify each of these disorders. No matter how thin she becomes, the anorexic retains an intense fear of becoming fat. She complains of feeling fat even when she looks as emaciated as a concentration camp victim. She steadfastly refuses to maintain her body weight above the lower limit of normal for her age and height. To be positively diagnosed as anorexic, she must have lost 25 percent of her original body weight or, if she is under 18, the weight she has lost plus the projected weight gain expected from growth charts should amount to the 25 percent. However, it is hoped that someone would suspect the problem before that point.

Bulimics also fear obesity, but the hallmark of their eating disorder is recurrent episodes of binge eating. Although she knows that her eating pattern is abnormal, the bulimic fears that she will not be able to stop eating voluntarily.

After a binge she becomes depressed and is plagued by guilt and self-hatred. The binges usually consist of the consumption of a large amount of easily digested, high caloric food in less than two hours. For instance, one of my patients would consume perhaps a gallon of ice cream, a dozen doughnuts, and a pound of candy. I have heard secondhand of even larger quantities of food being consumed. One atypical patient of mine preferred high-protein binges, such as an entire five-pound roast or a couple of large chickens.

The bulimic tends to indulge in these binges inconspicuously, often while alone. She will stop a binge for a variety of reasons such as abdominal pain, to sleep, interruption by others, or if her guilt becomes so intolerable that she begins to induce vomiting. Whereas the anorexic's eating pattern is a more consistently restrictive one, the bulimic's binges may alternate with desperate attempts to lose weight by dieting severely or fasting for a few days. She may also induce vomiting or use diuretics or large amounts of laxatives. I have personally known patients who vomited up to 30 times per day and/or used up to 50 over-the-counter laxatives per day. Only 5 percent abuse diuretics, but almost half abuse laxatives. As a result of the various attempts at weight control the bulimic's weight may fluctuate frequently by more than 10 pounds.

Families, friends, and medical personnel are likely to recognize a need for treatment before the affected individual does. Parents themselves are often overly concerned with weight and dieting. In fact, the onset of anorexia or bulimia frequently begins after a thoughtless remark by a relative regarding the girl's weight, such as "You've put on some extra pounds, haven't you?" or "Getting a little chunky, aren't you?"

Causes within the family

Parents of anorexics tend not to permit even normal aggression in their children and to deny the existence of aggression in general. Their hypermorality and overcontrol of their children, combined with the child's desire to please them, lead the child to repress emotions in general. For some of these families, fun for fun's sake is not allowed; everything has to have a noble purpose.

Such repression inevitably leads to adverse consequences, one of which is that, beneath overt reverence for their parents, the children feel themselves to be in the humiliating position of puppets whose strings are pulled by their parents. In short, these families are overprotective and rigid. They fail to recognize the anorexic child's individuality and deny any distress within the family.

Psychoanalysts deduce that these pat terns first become apparent in infancy when the child's aggressive drive is thwarted and when the parents overlook the child's cues about basic needs, which are then unmet. Moreover, the parents regard the child's progression through the stages of development as their own accomplishment rather than the child's.

The families of bulimics also tend to be rather rigid. The parents of both anorexics and bulimics tend to involve the affected child in their unresolved conflicts with each other. In addition, families of bulimics are quite competitive with their neighbors and among themselves. They place exaggerated emphasis on appearance and stress achievement without allowing the child the individuality that would make achievement possible.

The affected children of these types of families develop intense internal conflicts, for which they unconsciously attempt to compensate through their eating disorders. Psychoanalysts believe that anorexia nervosa represents a flight from the individual's own unconscious, insatiable, instinctual needs as well as from the female role. This is associated not only with frightening sexual issues but also with resistance to identifying with her mother as a woman because of unconscious rage toward her for not satisfactorily meeting her needs in infancy. I would add to this theory that the rage must also be related to thwarting of the child's natural drive toward autonomy.

Anorexic patients also tell me, and others, that the restriction of their nutritional intake represents a form of control that they alone can exert over themselves, often in defiance of parental pressure. However, in reality it represents a defense against their underlying lack of an intact sense of self, rather than true strength of character. This severe restriction also gives them a sense of moral superiority over others, which covers their intense fears and hostility.

The bulimic lacks the consistent control of the anorexic. Her gorging reflects a loss of this impulse control and not only is related to unsatisfied infantile yearnings for food, closeness, and security but also represents an aggressive discharge. Her deficient control is so threatening that the slightest weight gain often produces panic and a frantic return to exercising, laxatives, and starving.

Seeking help

The families of people with eating disorders are often churchgoers and pillars of society and might very well consult their minister before a physician. If a family contacts their minister about a bulimic, they might initially be seeking consultation regarding the eating disorder or one of the compulsive disorders sometimes associated with it that can be even more troubling to them morally. For instance, their child may be one of the 11 to 24 percent who steal compulsively, sometimes stealing money from family members to buy more food but also sometimes stealing objects from stores or friends, such as jewelry or clothing—a sign of their deep sense of deprivation and anger.

Perhaps the family will be concerned about chemical abuse, since 21 percent of bulimics misuse street drugs, and 18 percent use alcohol weekly or more often. Their poor impulse control can express itself even more directly and self-destructively, since 19 percent attempt suicide and 7 percent mutilate themselves by cutting, burning, or in other ways.

The minister can help, first by strengthening the patient's appreciation of her own spiritual side, which would help to moderate her exaggerated emphasis on appearance and to compensate for her severely impaired self-esteem.

The minister can also serve as a role model for the patient and her family by demonstrating comfort with the open expression of feelings and appreciation for the individuality of each family member, including the right of each individual to develop independent decision-making skills and to behave assertively. He or she can encourage the patient's reliance on her own thinking, feeling, and perception, rather than sole reliance on societal and parental standards.

The road to recovery from an eating disorder may be a long one involving multiple setbacks, but with adequate treatment the setbacks can become shorter and less severe. Also, the sooner treatment is begun, the better the prognosis. Many bulimics and anorexics go for years without definitive therapy or, especially in the case of bulimics, without any therapy at all. By his involvement and guidance into treatment an observant, interested, and understanding minister can help to shorten that misery and the unhappy effects on families.

Ministry reserves the right to approve, disapprove, and delete comments at our discretion and will not be able to respond to inquiries about these comments. Please ensure that your words are respectful, courteous, and relevant.

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Francine Rasco, M. D., is a staff psychiatrist and director of the Psychiatric Unit as well as director for the Eating Disorders Program at Harding Hospital, Worthington, Ohio.

July 1987

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