Anorexia and bulimia — these are everyday words for many of us. They are written about in women’s magazines, they are spoken about in television talk shows… but what really lies behind these medical terms is known only to those who have encountered them in real life. The picture is truly horrific: a third of those with anorexia, mostly young girls, die from hunger and destruction of their internal organs. Many who survive become disabled, and the psyche changes irreversibly. The task of Dr. Claudia Elsig from Calda Clinic is to understand the causes of the disease and return a patient with eating disorders to a normal life.
— Dr. Elsig, there is a general opinion that anorexia and bulimia are female diseases. Is it true?
— Yes, it is. It’s mainly women who suffer from these diseases. According to the statistics, 1.1% of women in Germany are sufferers. But also 0.3% of men suffer from anorexia: that is, every fourth sufferer is a man. With regards to bulimia, these figures are 0.3% and 0.1%, respectively. In the United States, the ratio is approximately 1:3 among adolescents aged 13 to 18 years, and yet more often than not we talk about women.
— Why is this?
— I think, first of all, it’s about the basic personality of a person. What do they do when there is a problem in their life? For some, it’s enough just to change their hairstyle or take a break. Others fall into depression and sink into their fears. Some start drinking or turn to drugs, and some develop eating disorders. The male psyche is different from the female one. Therefore, men with life problems are more likely to succumb to addictions or become aggressive towards others, while women destroy themselves through starvation…
I believe that society itself and the modern ideals of beauty are responsible for this. Women are much more exposed to media pressure in terms of appearance than men — and this is the result. However, the stronger sex has recently resorted to the plastic surgeon’s knife more often and undergone liposuction — in a word, started monitoring their appearance.
— In addition to the desire of young girls to follow these imposed standards of beauty, what other factors lead to anorexia and bulimia?
— Social pressure. Quite often, the root cause lies in the family. Many patients with eating disorders tell us of conflicts with relatives and rows during family meals. There are families where a certain amount of food is put on a plate for a child and he or she must eat it. In 18–19% of cases, the disease is a consequence of post-traumatic syndrome.
Girls who are subjected to excessive control at home are in the risk group. Each of their steps, each of their actions, is strictly regulated. The only sphere of life in which they are without parental control and in which they can establish their own rules is food.
Psychogenic overeating is closely related to feelings such as loneliness and inferiority. Love, tenderness, and empathy are replaced with food. Over the years of my medical practice, I have met many patients who have had eating disorders because of sexual abuse in childhood. Therefore, the main target of therapy is the hidden problem, not just the anorexia or bulimia itself.
— Tragic stories about death from anorexia of models and actresses quite often appear in the press. Is the disease really so dangerous? Or do only the most egregious cases appear in the pages of magazines?
— This is an extremely serious mental illness that ends in the death of one third of girls who suffer from it. They literally dwindle. They become so thin so that the heart and other internal organs can no longer perform their functions. For many, we are not talking about a full recovery if the situation is neglected. To be more precise, a doctor can lead a patient into a state in which it is possible to lead a normal life. But in the most difficult cases, mental changes may remain forever.
— Is it true that anorexia begins with a diet, with a desire to lose weight and, incredible as it may seem, to eat right?
— It’s possible, especially for girls of school age. They are often prone to peer pressure; they want to be «school stars» and they become an object of derision due to their excess weight. And after that, they start to starve themselves. During the diet, endorphins are activated, a state of euphoria arises and, over time, a dependence on it develops. A new «menu» becomes desirable and they continue to drink only juice, or kefir, or eat only apples…
Their ability to be objective about their appearance is lost. They look in the mirror and they think that their thighs are too thick or there are folds on their stomach…Gradually, they begin to see themselves as fat regardless of the real picture. They notice nothing except their «excess weight», even if others warn them that they are unhealthily thin. I believe that in this case, first of all, it is necessary to investigate the personality of the patient in order to understand what has led to the anorexia. After all, other girls also stick to diets, but do not become ill.
— At what point does the natural desire for a young woman to lose weight become a disease?
— If attempts to lose weight begin to interfere with a normal way of life, this is a clear symptom of the disease and a signal to the sufferer to seek qualified help. Often the patients themselves say that it has become a problem for them. The disease begins to have a social impact on the patients’ life long before the situation gets out of control and becomes dangerous.
— When ordinary people are on a diet or starve themselves, they still feel hungry. What happens to anorexic patients that they can bring themselves the point of death by starvation? Are they capable of such unnatural self-control?
— It’s not about self-control. Those suffering from anorexia do not feel hungry, because changes occur in the satiation center in the brain. And for those prone to overeating, on the contrary, the feeling of saturation disappears. They can eat non-stop. Only during treatment can we restore the normal operation of these parts of the brain. Patients must again learn to feel hungry or satisfied.
For those suffering from anorexia, food is disgusting, it makes you put on weight. Butter and other high-calorie foods really horrify them. We compile a ‘red list’ of food products with these patients, in which we list in detail all that they have denied themselves, and during the treatment we re-integrate it into their diet. First, we get them used to the smell, then we get them to touch the food with their tongue — they taste it and remember the feeling… this is a long process, during which we try to free the patient from the fear of eating. A food disorder cannot be treated in a few hours or days. The process usually takes 1–2 years, with weekly visits to the doctor.
— Is it possible to go into an anorexic phase through dieting at a more mature age?
— Grown-up women very rarely develop anorexia. Rather, it is a disease of the young and of adolescents. The average age of patients with bulimia is a little higher, 18–24 years old, although I have had patients aged over 30.
— And from the point of view of human physiology, why is bulimia so dangerous?
— With constant vomiting, the body loses its acidity and the potassium-sodium balance is upset. The stomach, intestines, heart, and all of the other organs suffer and this happens over a period of time.
Can you imagine how much a woman suffering from this disease can eat at a time?
— Not really. Probably a lot?
— It’s not just a lot! It’s a huge amount! Imagine a table filled with dishes for a family meal where visitors are expected. Bowls of salad, a huge dish of pasta with sauce, a basket of bread, chocolate bars, cakes, fruit, cheese, sweet drinks… all this is consumed by one person in 35–40 minutes! They eat until the body refuses any more food. And at the end of the meal, they drink mineral water with ice cream, as carbonic acid helps induce vomiting.
Bulimic patients can have up to 5–8 gorge attacks a day, if circumstances permit and no one is around, and at work they are unable to think of anything else other than food. They return home, put all the dishes on the table, consume them, and then comes the vomiting. Thus does the evening pass. Such women have, as a rule, no family – it’s simply impossible. They are mired in debt — huge amounts of money go on food!
— So those suffering from bulimia must be very fat. After all, they consume a huge amount of food.
— Not necessary. Some women compensate for their eating disorders with manic sport activity. They eat uncontrollably and then spend hours in exhausting workouts. So if one of your friends or relatives is too keen on the gym, this is a reason to sound the alarm.
— And how does the treatment work?
— The treatment takes at least 3 months. This is extremely intensive therapy: 4–8 consultations a week instead of one. In addition we have a psychologist, under whose supervision the patient will have to train to eat a normal meal every day.
Outpatient treatment is not accompanied by home treatment; the patients have to do a lot themselves. Do not forget that this is a long and complex process, as with any form of dependency. After 4–6 weeks, the therapist will come and see how the knowledge acquired is being used in practice – how you go shopping, how you eat only at the dinner table, not in bed or in front of the TV. He will make sure that you do not create large food reserves again. And here, above all, the patient’s motivation is necessary.
Much more difficult is the situation with girls who are not yet 18 years old. The parents bring them to the clinic. They pay bills and think that they’ve played their part. But we must involve the family in the process of treatment, too. We must find out what led to the anorexia and contributed to the development of the disease, and we must know what the atmosphere is like at home. Sometimes this is a very complex and even controversial issue. In addition, the doctor must find a balance in the provision of information. On one hand these are the girl’s parents, but on the other they might be the basic cause of the disease. Sometimes the impact on the family is as important for a successful outcome as working with the patients themselves.
— What is the difference between outpatient and inpatient treatment?
— As a rule, outpatient treatment lasts longer: at least 6–7 months. I always recommend taking breaks to practice at home what you have learned in the clinic. There is no need to meet more often than three times a week. Nevertheless, all of this is very individual. Motivation and life circumstances — all of this plays its part. For example, I had a patient who lived with her sick father; she helped him at home. But during her childhood he had raped her, which was the reason for her eating behavior. We knew that the treatment could not be 100% successful as long as she lived with him. But she could not abandon him because of her compassion for him and his illness, and she understood this; so you always need to look at specific circumstances.
What is the best form of treatment for patients from other countries? To spend 2–3 months in the clinic or visit the doctor regularly?
— Every case is different but, as a rule, I recommend an intensive course for 2–3 months for patients from abroad to see what is happening to them, how they change and how they feel. Maybe they should repeat it again in six months. Everything depends on their state of health and on the specific situation. We do not follow any standard programs. However, it is obligatory for foreign patients also that the therapist goes to their home and see how the treatment is being implemented at home to be convinced of its effectiveness.
— What else, besides professional medical help, allows you to quickly return the patient to a normal life?
— The higher the motivation, the better the social and family support, then the greater the chance of success. We integrate the maximum number of resources into the treatment: for example, family and friends. This approach significantly increases the likelihood of a successful outcome.
Claudia M. Elsig
Dr. Med., medical specialist in psychiatry and psychotherapy and CEO and Head of the Medical Overall Management in the Calda Clinic, graduated from the medical faculty of Zurich University in 1994. For more than 16 years she has been engaged in a private medical psychiatricpsychotherapeutic practice. 2010-2014 – Head of Special Consultation Hour Clinical Hypnosis, Psychiatric Private Clinic Sanatorium Kilchberg, Kilchberg/CH. 2011-2015 – Medical Director and Head of Psychiatry, The Kusnacht Practice AG, Küsnacht/CH. Dr. Claudia M. Elsig is the author of several educational and training works. She is a member of the Swiss Society for Psychiatry and Psychotherapy (SGPP), the Swiss Society for Behavioral and Cognitive Therapy (SGVT), the Swiss Medical Society for Hypnosis (SMSH), the German Society for Hypnosis and Hypnotherapy (DGH), the Swiss Society for EMDR (EMDR Switzerland), and the Swiss Society for Anti-Aging Medicine and Prevention (SSAAMP).