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The Starved Self

The Golden Cage: The Enigma of Anorexia Nervosa

by Hilde Bruch
Harvard University Press, 168 pp., $8.95

The Best Little Girl in the World

by Steven Levenkron
Contemporary Books, 196 pp., $8.95

They float in slow motion, the young girls, across fields of spring flowers, advertising hair spray and deodorants. Girlhood means white muslin and lace, innocence and purity; jeunes filles en fleur, milkmaids in sprigged cotton from Laura Ashley, dreaming. Here is one of their dreams:

On my way from the convent, I stopped outside the hospital. A woman who had just given birth was being lifted off a stretcher. I was horrified by her swollen and distended stomach. I heard them say that she had been brought to the hospital because her belly was still full of urine.

Virginity (female virginity, a boy cannot really be a virgin) has almost everywhere been revered: an emblem of uncorruptedness, unfleshliness, as mythical as the unicorn who can only be tamed by a virgin, and yet powerfully moving. The myth has been briskly and only recently destroyed. But it survives, in demonically twisted form, in one place: among girls who themselves reject corruption, fleshliness, sexuality, who sacrifice health and sometimes their lives to a terrified passion for purity—the starving girls, trapped somewhere between the convent and the hospital, dreaming nightmares about the horrors of swollen, dirty, female flesh.

Though anorexia is a modern illness (all these books are short on statistics, but Hilde Bruch quotes a recent assessment of one case per 200 girls, in an English middle-class environment), it has a history. Descriptions of something resembling it come from as far back as the seventeenth century, but the most recognizable accounts date from the late nineteenth century. Lasègue, in Paris in 1873, published a paper “On hysterical anorexia.” His description is classic:

After a few months, the patient finally arrives at a state that can rightly be called one of hysterical anorexia. The family is in a turmoil. Persuasion and threats only produce greater obstinacy. The patient’s mental horizon and interests keep shrinking, and hypochondriacal ideas or delusions often intervene. The physician has lost his authority; medicaments have no effects, except for laxatives, which counteract the constipation. The patients claim that they have never felt better; they complain of nothing, do not realize that they are ill and have no wish to be cured. This description would, however, be incomplete without reference to their home life. Both the patient and her family form a tightly knit whole, and we obtain a false picture of the disease if we limit our observations to the patients alone.

A year later William Gull in London described the syndrome in similar terms. This was the great age of the hysterias, and much subsequent discussion centered around the relative role of hysteria, neurasthenia, or insanity; but it was not doubted that anorexia was a mental rather than a physical illness.* Freud’s definition was “melancholia of the sexually immature”; later psychoanalytical work has probed into its origins. Pierre Janet, one of the neglected giants of nineteenth-century psychiatry, gave an acute description of an anorexic patient, “Nadia,” describing her illness in terms of a horror of the body, of the fleshiness of womanhood.

Bruch’s book is subtitled “The Enigma of Anorexia Nervosa”; why do those who discuss or write about anorexia so often find themselves faced by a core of mystery in the illness? Anyone can understand exasperation with the ludicrous, disobedient body that can seem an enemy rather than ally to a self trapped somewhere inside it; revenge on the carnal, especially revenge through fasting, is nothing new. And it is easy to grasp how tightly connected with emotion is our most elementary function, that of taking in the world as nourishment: how sadness makes us choke over “swallowing” things, or gobble insatiably. But the starving girls’ illness, in its typical form, is enigmatic because, while they are sane and quite different from psychotics, their thinking, self-perception, and phobic fear are all characterized by insane rejection of fact. Anorexia—lack of appetite—is the wrong word for the illness: literally the an-orectic is the melancholic who “has no appetite for life.” The girls described in these books, on the contrary, are characterized by fierce ambition to succeed in their project of self-starvation; by a paradoxical, feverish energy; by extreme terror of having any flesh on their bodies; and in particular by flat denial of the truth—that they are thin, ill, and hungry.

We can rely on the accuracy of these writers’ accounts of symptoms, but must take on trust their picture of the “typical” patient and parents. Certainly they come to remarkably similar conclusions (though both Self-Starvation and Bruch’s earlier book Eating Disorders, from which The Golden Cage is derived, make clear that there are also borderline cases where anorexia is only a secondary symptom). Steven Levenkron’s novel (he has specialized in treating anorexics) will do as a fictional summary, stilted though it is, of what the other books spell out in clinical detail. His anorexic heroine is presented as the odd one out in an averagely unhappy family: father growls into his whisky, mother covers exasperation with sweetness and martyrdom; sister gets attention by being the “bad girl,” brother by being the apple of everyone’s eye. Francesca is docile, shy, lonely, and almost invisible in the family hurly-burly. When weight phobia grips her she secretly renames herself: the thin girl is going to be a new, realler self. The obsession escalates and takes over, family panic rises; the girl is hospitalized. No gruesome detail of forced feeding and near-terminal symptoms is spared. Recovery is promised through a sympathetic therapist and some work with the family, which shows up, as we have guessed, that Francesca from now on needs some attention and respect from them.

While this has not half the vividness of the German psychiatrist Binswanger’s classic piece on an early case, “The Case of Ellen West,” or of some of the extracts from patients’ letters and diaries that Bruch and Selvini Palazzoli quote, in capsule fictionalized form it presents the classic syndrome on which they agree. The family background is shown as by no means a “bad home”: it is fenced in, insensitive, unwilling to face problems—in Lasègue’s words, “a tightly knit whole,” too tight for the anorexic’s sense of autonomy. The girl Francesca is hypersensitive and docile; secretly an ambitious perfectionist, yet hopelessly lacking the rudiments of confidence. She hates the crudity of her adolescent growth, and in particular her periods (they always stop during the illness). She is hyperactive, astonishingly in view of her desperate physical condition. And—the enigma again—though she longs for food and may have secret bouts of eating, the rest of the time she will defy and deny to the limit to ensure that no food goes into her. The denial quite simply displaces her reason: while the patient with a phobia about insects or elevators knows intellectually that his terror is not justified and would like to be free of it, the flesh-phobic anorexics apparently claim (to return to Lasègue) that “they have never felt better; they complain of nothing, do not realize they are ill and have no wish to be cured.” It is the encapsulation of a piece of madness within an otherwise sane—though fragile—personality that is the uncanny element in the illness.

The Golden Cage and Self-Starvation, each good in its own way, confirm this picture and each other. The Golden Cage is the shorter and simpler; like Selvini Palazzoli’s book it is written out of extensive experience with anorexics. It gives a concise and readable account of the antecedents, characteristics, and course of the illness (though more or less ignoring psychoanalytical theory about its origins), and uses much case history material.

Each book has special insights of its own. One of Bruch’s points, not generally made, is that some of the symptoms considered typically anorexic may be simply secondary effects of starvation. The suggestion makes the exponential character of the illness seem a little less mysterious: as she sees it, once the phobic obsession has taken root, its dizzy escalation is partly the result of the starved state (though anorexics force-fed often lose no time in restarting the cycle). At the same time, she points out, fasting has also long been known to induce a “high” which can be exhilarating. “Being hungry has the same effect as a drug,” wrote a fifteen-year-old;

You feel outside your body. You are truly beside yourself—and then you are in a different state of consciousness and you can undergo pain without reacting. That’s what I did with hunger. I knew it was there—I can recall and bring it to my consciousness—but at that time I did not feel pain.

Compare Selvini Palazzoli’s quotation from a Catholic theologian on the spiritual delusions of the fasting state:

The spirit becomes more sensitive; more far-seeing and more acute, and the conscience more quick and lively…. The awareness of spiritual power is increased and with it the danger of losing sight of what is assigned to each one of us, the limits of our finite existence, of our dignity and our abilities. Hence the dangers of pride, magic and spiritual intoxication….

The anorexic’s project, in one aspect, is one of pride and magic: ineffectual and afraid in most ways, she has found out almost by accident that she can achieve immense power from the fact that it is difficult to stop anyone starving herself. She eats up the desperation of everyone around her instead of food.

Bruch makes it clear, however, that the anorexic does suffer cruelly, both mentally and physically, beneath the exhilaration, but is unable to stop the machinery of denial and admit it. When she can she is already getting better.

I remember now how it felt at that time, and how I talked about it. It was not really lying because starving was what I wanted to do, but I remember feeling terribly uncomfortable…. I felt weak when I ran home, but I made myself run all the way. I used to be hungry and I couldn’t concentrate on things. I don’t remember any of the books I read when I was starving; I don’t remember the movies I saw at that time…. I never used to think about anything except food.

In her earlier book Bruch quotes an even more revealingly pitiful extract from the diary of an anorexic boy:

I feel now that suicide would be very easy but I am so obsessed with food that I couldn’t even eat a death meal for fear of being over-weight on death….

I look at recipes to find the one that will finally satisfy me….

I think of quick death to end it all, and then slow death to have your love while I am dying. Oh, mom and dad, help me….

So much runs through my mind, I feel like a ticker tape hours behind.

I don’t think I’ll have the power to fast any more. Food is so good. Now I’m worried I’ll surely gain weight. I think that it is terrible; it is just like mental spite work.

I want to save all my gaining for when I come home. Where I can be spoon fed by you and you only.

  1. *

    During the 1920s and 1930s, anorexia nervosa was frequently considered to be an endocrinological disorder. The authors under review, however, are representative of current thinking in treating the syndrome as entirely psychological.

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