When Stephanie G. looks in the mirror, she sees the perfect image of an aspiring young professional. She is educated, intelligent, determined. Pretty, petite, and powerful. She recognizes the persistence in her striking hazel eyes that flash green when she is angry, often intimidating others—in college, her sorority sisters nicknamed her Bonaparte. At 24, Stephanie (not her real name) says, "I work for a hotel management company, where I've been tagged as an up-and-comer. I'm making more money than my mother. I'm completely happy. Everything is great—except for this one small thing." The one small thing is instantly apparent to anyone else looking at Stephanie, who at 100 pounds seems to be made up of nothing more than sinewy muscle and sharply angled bone.
Stephanie has a tremendously difficult time eating. "My optimum weight is 115 pounds," she says, "but right now, I'm trying not to go below 100, which is hard because my perspective for food is all wrong. What I think of as a full meal other people think is just a snack." Stephanie freely admits that she is anorexic. She has been in counseling for the last year trying to overcome the stringent eating guidelines she has imposed upon herself.
Anorexia. The name of this disorder stems from the Greek word orexis, and means a loss of appetite. The first case was published in 1694 when Richard Morton, a fellow of the College of Physicians in London, wrote about a 20-year-old woman who was "like a skeleton only clad with skin." Morton believed that her sadness literally ate away at her, and she died two years later. Instances of this pathological thinness have been reported throughout the centuries. During the Middle Ages, women who wanted to show their devotion to God would starve themselves, sacrificing their earthly roles as nurturer and the earthy pleasures of eating. These female mystics also wore hair shirts, bound their flesh with ropes, rubbed lice into self-inflicted wounds, and thrust nettles into their breasts. These saints and ascetics are now called "holy anorexics."
In the 1700s, it was commonly believed to be a woman's disease, mixed up with "nymphomania," "hysteria," and "wandering womb disease." (Though there are male anorexics today, mostly athletes like wrestlers and gymnasts, the majority of sufferers are female.) In 1874, the malady received its official name, anorexia nervosa, meaning nervous loss of appetite, from William Gull, physician to Queen Victoria. The German term, Pubertätsmagersucht, meaning an adolescent desire for leanness, may be more accurate.
Like most anorexics, Stephanie is aware of her disease. She knows exactly when the strict eating behaviors began. A few years ago, she endured several difficult job experiences, from a boss she describes as a tyrant and "just plain mean." She says, "I would walk around on egg shells all day, then go to the gym and run. I'd go home and eat popcorn and just go to bed because I had no energy." Eventually, she quit her job and moved back in with her parents: "I had nothing else to do, so I made these elaborate low-fat meals for my family and worked out like a fanatic."
Gerard Hoefling, a Ph.D. candidate at Penn State who has just completed a study of anorexic behavior, says that Stephanie clearly fits the anorexic profile. She is highly motivated, competent, and competitive; she comes from an upper-middle-class family; and she has a strong need to feel that she is in total control. It is a control so overwhelming that those of us who succumb to the seduction of chocolate, the sweet lure of butter, or the homey call of turkey roasting in the oven simply can't understand it. "I don't have cravings anymore," says Stephanie. "My body doesn't feel hunger." This, too, says Hoefling, is typical. "But what most people don't realize about anorexia," says Hoefling, "is that it's a disorder with powerful roots within the family." And it is this aspect—anorexia as a relational disorder rather than as an eating disorder—that Hoefling has focused on.
"Everyone working in this field has a pet theory," he says. "Some say anorexia is caused by serotonin levels in the brain, by media images, by society's expectation of women, or by the relationship between the parents. All of these things probably contribute, but you can't overlook the importance of interpersonal relationships, how the anorexics perceive themselves in the eyes of others." Using a research model called a multivariate study, Hoefling was able to focus on a small sample of five young women (three anorexic and two non-anorexic), to collect answers to hundreds of questions about their emotional interactions with family and friends. Says Hoefling, "Working with these women has been great. They always show up on time, they call when they're going to be late, and they are eager to please. Anorexics are perfect research participants." However, the anorexic quest for perfection can cause a great deal of pain.
Hoefling is a big guy -barrel-chested and tall. His easy laugh resonates like a kettledrum. He's in his mid-40s, has salt-and-pepper hair and mustache, more salt than pepper, and startling Mediterranean-blue eyes. Though he has the stance and stature of an ex-Marine, his politics definitely lean to the left. He's a firm believer in social programs: before returning to graduate school he had worked at Job Corps in Hazelton, and at the state unemployment office in Nanticoke. That was where he was reunited with Jane, a high school friend.
"Back then, in the late '60s and early '70s, dieting was considered pretty normal. The Twiggy look was the in thing, and nobody thought twice about the dangers of being too thin," says Hoefling. "Jane was a cheerleader, very pretty, very popular, and pre-anorexic, though she wouldn't have admitted it at the time."
By the time Hoefling and Jane were reunited and began a romantic relationship in 1992, Jane had been battling anorexia for 20 years. He says, "She knew that I knew about her being ill. She was teaching in a Montessori school and continuing therapy. Every day she had to confront her fears and anxieties. A variation in just a few pounds would have an effect on her spirit and mood. She would become avoidant and depressed. Her daily struggle made me acutely aware of this disease."
As Hoefling reads a transcript of the interview with Stephanie, in which she says, "I have to be the strong one, the perfect one, the one who absolutely cannot mess up," he says, almost to himself, "God, she sounds so much like Jane."
Hoefling says that Jane was one of the most determined people he'd ever met. When she contracted anorexic-related pneumonia in 1995, he believed she would beat it, just as she had managed to keep a few steps ahead of her "desire for leanness" for the last two decades. But the infection ravaged her already compromised immune system. Her body just wasn't strong enough to keep fighting, and she passed away at the age of 41. Later that year, Hoefling started graduate school at Penn State specifically to study the disease that took the life of the woman he loved.
"The most poignant thing about women with this disease is how hard they try to please and how intensely they feel that they fail. In their daily normal events, these women don't expect to be trusted. They have a heightened sense of being judged all of the time," says Hoefling. "Pervasive across the anorexic experience is the feeling that 'nothing I do is good enough,' and there's a certain sadness about that."
The average age of onset of anorexia is between 13 and 20. The women in Hoefling's study, both the anorexics and non-anorexics, were all considered to be "late adolescent," in their late teens or early 20s. As Hoefling writes in his thesis, "All were bright, articulate, dependable, warm, cheerful, caring individuals. All were highly successful college students who maintained very active lives of community service, dance, athletics, and a rich social life. Each maintained ties with parents, siblings, and extended family members. Each moved easily among a circle of friends."
While the exterior worlds of these women looks similar, the interior landscape of a woman who enjoys eating and a woman who can reward herself only with hunger reveal great disparities. Although the anorexic women have just as many social contacts as their non-anorexic counterparts, they never feel completely accepted by anyone.
"The non-anorexic women reported an emotional experience with daily life that can best be characterized as in equilibrium. For these individuals, daily dimensions of frustration, stress, repression, and anxiety are held in check by the counterbalancing effects of connectedness, autonomy, reciprocal affection, and support," writes Hoefling. "Thus the quality of interpersonal relationships, whether real or perceived, may be at the core of the pathology."
Hoefling says that in anorexic families there is usually a great deal of contact between the parents and children, what sociologists call "enmeshment." However, this contact may not necessarily be healthy, despite the best of parental intentions. "The parents tend to be hyper-vigilant," says Hoefling. "The child has a runny nose and everyone runs for a tissue. My corny phrase, 'when mothering becomes smothering,' is a common aspect of anorexic families."
Another important factor that is often overlooked is that anorexic behaviors are often set in place long before a woman actually begins starving herself. When Stephanie was growing up, she said she hated her father. They were constantly fighting. "He would read my notes, listen in on my phone calls," she says. "All he wanted was to know what was going on in my life, and all I wanted was to be left alone."
Adolescents moving toward adulthood try on new personalities, personal styles, and social skills, as well as new clothes. Peer acceptance is crucial for many teenagers. The struggle for autonomy and control is paramount—and often painful. Hoefling says that Stephanie's experience with her father is not uncommon: "Her father's efforts were probably genuine, not cruel. But she was trying to gain some degree of control over her life, and all she could see was that he was being intrusive, not concerned."
Stephanie says that she and her parents now have a good relationship, and that they are supportive of her seeking treatment for her anorexia, but she also admits that family communication was lacking while she was growing up, another symptom of the anorexic family, according to Hoefling. He also thinks that the father-daughter relationship is significant and understudied. "Fathers are powerful in a daughter's life," he says. "I found that the anorexic women tended to have authoritarian fathers. One woman said, 'My father treats me like a business partner.' The non-anorexic women reported having a warm, confirming, validating, and reciprocal relationship with their fathers."
Another young woman, Diane B. (not her real name), now a 22-year-old college student, suffered from anorexia between the ages of 13 and 15. "My father would become obsessed with various projects and hobbies," she says. "He would also become obsessive about doing things with me like homework and sports. We had a definite connection because we saw the world in the same way, and he didn't have the same connection with my sister. Then he became severely depressed, and I got sick a few months later. This is a family disease. It is so difficult now explaining to my friends that I didn't want to look like a fashion model—I couldn't talk about my disease without talking about my father. The two are so intertwined."
Diane says that when she was growing up, she kept her father on a pedestal: "He was everything to me, so in control, so intelligent, so competent. And then he fell apart, and I started becoming obsessive about making lists of calories. I would go to the grocery store with my mother dressed in a heavy sweatshirt in the middle of summer and my fingers and lips blue because I was so cold all of the time. But I decided what to buy. I controlled their food, and I thought I was better than them because I had transcended the need for food.
"My dad's opinion was, 'She's an athlete with an eating problem. Give her a protein drink, and she'll gain weight.' It's hard to remember specific things from that period because I spent all of my time thinking about food, counting and recounting my calories. But I do remember one incident when I went shopping with my mom and sister for a bathing suit. I came out of the dressing room in a bikini, and my mother had to turn away to keep from crying because I looked like a skeleton. Soon after that, my mother took me to the doctor, and I was admitted to the ER."
The family both sustains and deprives the anorexic. Says Hoefling, "These young women are usually the perfect children. But they are constantly re-evaluating the self and are relationship-bound, both inside and outside of the family." In the next phase of his study, Hoefling will use larger samples and will evaluate emotional responses over a year's time. According to Hoefling, the study of this disease is still in its infancy, "and the public must understand that there is no magic bullet to cure anorexia. Seriously malnourished women can be hospitalized, others can receive non-psychotropic drugs, and everyone should be in therapy. The medical profession treats the symptoms, but doesn't look at the psychological links. This is a pathology that encompasses all realms of human experience. It's social, familial, psychological, and biological."
Hoefling insists that anorexia must be recognized as a disease that occurs over the life span of an individual. What concerns him most is that there is a high recidivism rate for anorexics, particularly if the anorexic begins treatment after leaving home. The mortality rate is high as well: 25 percent of those treated die.
For the food-loving segment of society, anorexia is unimaginable. The softness and fullness of flesh is reassuring. Breaking bread together is a fundamental ritual. Food is love. On the other hand, this tableau of feast and love is unimaginable to the anorexic. Though she is present among family and friends and appears to be involved, often too much involved, she never feels reciprocal affection. Says Hoefling, "These women place a great deal of attention on others' needs, so much so that it becomes dangerous. The self becomes erased. It's a cruel irony that these women are completely involved in the lives of others, and yet they feel totally isolated."
Gerard Hoefling is a Ph.D. candidate in human development and family studies in the College of Health and Human Development, S1-A Henderson Bldg., University Park, PA 16802; 814-865-2570; gdh108@psu.edu. His adviser is Sherry Corneal, Ph.D., assistant professor of individual and family studies, S110 Henderson Bldg.; 865-2646; ccc3@psu.edu.