- The Washington Times - Tuesday, January 14, 2003

In a country in which the majority of adults are overweight, there are some adults and teenagers who fear and obsess over food, afraid of gaining weight. For some, the guilt they feel from actually enjoying nourishment can lead to acts of self-mutilation, marks of penance for "indulging."
Such people have what is officially termed an eating disorder, the best known of which is anorexia nervosa basically, the refusal to eat enough to stay healthy, although there may be other components involved, such as excessive exercising in order to stay thin.
Anorexia is both a physical and an emotional disease afflicting mainly women as many as one in 200 American women. Their suffering is so intense that one out of 100 of them die either through suicide or starvation, a ratio higher than that of any other mental illness. Of patients who enter an inpatient treatment facility, as many as 5 percent eventually die of medical complications caused by anorexia or suicide, according to Dr. Angela Guarda, director of the Johns Hopkins Eating Disorders Program.
One of the insidious aspects of the disease is sufferers' ability to often disguise the nature of their illness in a society that values rail-thin female figures. The profile of an anorexic as described by Stanford psychiatrist James Lock is "a perfectionist, an achiever a driven, anxious kid off-track in life but with a lot going for her."
That certainly applies to 15-year-old Emmalee Thompson, a bright, attractive Baltimore high school student, who these days can claim a victory of sorts over the disease by being able to admit that "at this point I would rather maintain weight than lose." It would also apply to petite blonde Cushla McKinney, 29, a New Zealand-born biomedical researcher with a doctorate at the National Institutes of Health in Bethesda, who says she finally is getting control of her life, and of the disease, for the first time in 13 years.
Both women last year were patients at Johns Hopkins, considered one of the region's best treatment centers and they continue to see therapists regularly. Both relapsed seriously at least once, insisting they didn't need help a denial syndrome common to anorexics, Dr. Guarda says. Miss Thompson, who now weighs 108 pounds, was down to a dangerous 85 pounds when she first began seeing a therapist. An accomplished dancer, she recently returned to school full time and will resume ballet lessons later this month.
Ms. McKinney was near death when her weight dwindled to 60 pounds last summer, nearly half her normal weight. She is now living with a colleague while she gets reaccustomed to the work routine in the lab. She is planning to start an eating disorders support group at NIH.
"I'm amazed that I feel happy and realize I have so much I want to do with my life," she says, reflecting on the time when she was often in constant motion in an attempt to keep off weight and was terrified of her emotional and physical appetites.
She calls the experience "the most lonely, terrifying isolating feeling. I was alone, trapped inside my head with all these thoughts and not being able to stop any of it. It is like being stuck inside a machine. I look out my eyes but I've got no control over what I'm doing."
"When I came [to Hopkins], I was strictly illogical," she says. "Every morning the first thing [the staff] asked was whether I was alive or not. They really didn't think I was going to make it. I never believed them. I thought I was fine. I thought there was nothing wrong with me … I was sure I was putting on 20 to 30 pounds a day. I was also actively very suicidal.
"Then one day I woke up on a Saturday morning and my brain was back. It had switched back on. It was an incredible experience. They had started me on a selective seratonin uptake inhibitor drug that deals with some of the compulsive components of the illness. Suddenly I was actively involved in doing things myself and using the program. I think it was the combination of medication and reaching a specific weight so my brain began to function properly."
Occupational and group therapy, she says, involves learning coping skills, "strategies and to deal with those thoughts in a constructive way. You retrain how to deal with food in the real world, how to deal with people in a more constructive way, how to balance life. Because most of us have extremely unbalanced lives, and, for a start, all the insight in the world doesn't help you if you can't get outside the behaviors."
Anorexia causes bone loss, kidney problems, and possible cardiac trouble and brain dysfunction. It also can affect a woman's fertility. An estimated 10 percent of anorexics and bulimics, a related disorder in which those affected binge on large quantities of food and then purge by inducing vomiting, are men.. And these men are less likely to seek treatment.
Health professionals agree the origins of the disease are various and complicated, that there is no single set of motivating factors, just as there is no single treatment method.
"People think if only you figure out why it will solve something," Dr. Guarda says. "It doesn't. First, you have to stop the behavior, because it reinforces itself and becomes a consuming passion. One theory is that it is parents' fault, but there is no evidence for that, although there may be risk factors that increase your chance of being vulnerable, such as a family history of eating disorder or a family who diets. We actually think now there are genetic vulnerabilities."
She says the risk of a eating disorder is seven times higher for someone who has a close relative affected.
Another characteristic, she points out, is ambivalence in seeking treatment, since many anorexics have difficulty admitting they have an illness.
"Most adult cases are chronic, those 18 and over," says Dr. Lock, a co-author of "Treatment Manual for Anorexia Nervosa: A Family-Based Approach," published by Guilford Press in 2001. "When people develop the illness at 13 or so, by 20 they have had it five years. The bad news is that no treatments have been shown [in controlled studies] to be [consistently] helpful with adults."
One unresolved question, he says, is why only some women acquire the disorder when so many women are exposed to socio-cultural pressures involving body image. His approach proposes making the family responsible for their child's progress and using food as medicine throughout treatment.
One thing Dr. Guarda is sure about is that adults are more difficult to treat, since the longer one has the disease the harder it is to recover.
"At least with adolescents, the family can help with treatment," she says. "With adults you don't have as much control."
The vagaries of health insurance make recovery even more problematic since most plans support limited inpatient stays, not long enough for recovery, in Ms. McKinney's opinion.
The Hopkins program, which is both an inpatient and an outpatient facility, claims to be able to successfully treat as many as 90 percent of patients with a combination of family, behavioral and occupational therapy, as well as the strict monitoring of meals and schedules. Relapse is frequent, however, and often several admissions are necessary for full recovery.
The clinic is located in a suite of rooms on the hospital's fourth floor, a cheerful setting with plenty of daylight that, in many respects, resembles a well-appointed camp. A kitchen occupies one end of the "family" room where the contents of meals are weighed in calories. Patients are expected to consume 3,500 calories a day over the course of the first 10 days, after which they can begin to choose for themselves from carefully selected food groups.
The program is unusual in including adolescents alongside adults, a decision Dr. Guarda defends on several grounds. One reason, she says is that older patients can act as role models, even in a negative way, by saying "You do not want to end up like me."
"A lot of 35-year-olds say 'I thought I could just dabble in this at your age, but just look at me now.' Teenagers think they are indestructible and there are no consequences to their behaviors. You put a bunch of teens with eating disorders together and they compete without understanding the consequences."

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