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Four Reasons for Low Success Rates in Anorexia Treatment

Marya Hornbacher’s “Wasted: a Memoir of Anorexia and Bulimia” is a powerful record of her fluctuations between these two eating disorders. As she talks about her experiences, Marya frequently compares bulimia to anorexia, thereby delineating the major differences between them. Some of these major differences are related to whether the disorders evoke a sense of disgust, whether they cause a change in body mass, whether they acknowledge the existence of the body and the ways they affect the dynamics between losing and gaining control over life events. These four chief differences can help us understand why the success of anorexia nervosa treatment lags behind that of bulimia nervosa.

At the age of thirteen, Marya realized that the vomiting involved in bulimia disgusted her and that this feeling of disgust was the main factor pushing her away from bulimia, but closer to anorexia. Since anorexia can be defined as abstinence from eating, it cannot be associated with a feeling of disgust; unlike bulimia, it does not involve vomiting. Vomiting can trigger disgust not only through the automatic bodily feeling associated with this action, but also through other sensory experiences. Looking at the texture of vomit, coping with the sour bile taste left at your mouth, observing your teeth rot and the blood vessels in your eyeballs pop, and spending a long time in an environment, such as the bathroom, that is associated with excretion can also trigger disgust. These triggers are absent in anorexia. In anorexia, the only trigger that can cause disgust is the excessively thin body that makes many of the patient’s bones visible. However, the sight of human bones can only make a non-anoretic feel disgusted, since the anoretic who constantly sees herself in a concave mirror may not even notice the sight of her bones or may actually perceive this excessive thinness as being beautiful.

Marya’s association of Bulimia with disgust hints at an important factor that can explain why the relative success of bulimia treatment is higher. Even though the sequences of binge eating followed by vomiting relieves Marya, the disgust felt afterwards offsets a good portion of the initial rewarding feeling. The rewards of bulimia are less than that of anorexia. In order to understand the effect of these reward schemes on treatment, it can be useful to introduce an analogy from drug-use disorders. From a reward-schemes perspective, bulimia is related to anorexia as marijuana is related to cocaine. Since the rewards of bulimia are much less than the rewards of anorexia, bulimia is less addictive. Moreover, just like how a marijuana addict gradually moves up to a drug like cocaine with more rewards, a bulimic patient moves up to anorexia. The insufficient reward scheme of bulimia reduces the incentive of the bulimic patient to cling to bulimia. On the other hand, the lack of an offsetting factor, such as the feeling of disgust, makes anorexia more addictive.

On page 91 of “Wasted”, Marya emphasizes another significant difference between the two eating disorders: “Bulimics often vacillate between eating normally with other people and bingeing and purging in solitude, which keeps them at an average weight.” On the other hand, anoretics do not eat at all, which causes considerable weight loss. In comparison to anoretics, bulimics are more concerned about seeming normal to the people around them. Due to this concern they temporarily change their eating habits when eating with people. During their times of solitude, however, they return to their old habits.

Although camouflaging eating habits makes it more challenging to identify bulimics, the fact that this action prevents weight change can make bulimia easier to cure. Bulimics, like anoretics, enjoy control and are obsessed with being thin. The act of vomiting does allow the patient to exercise control, but bulimia does not make one thinner. Consequently, bulimia’s stabilizing the patient’s weight is a factor that prevents the rewards perceived by the patient from increasing. Even though bulimia does not allow the patient to gain weight, it fails to fulfill the ultimate objective of losing weight. On the other hand, anorexia fulfils this ultimate objective. Hence, anorexia leads to more rewards than does bulimia. Because the amount of rewards and the level of addiction are directly proportional, we would expect the anoretic patient to have a larger incentive to resist treatment.

A vital philosophical difference between anorexia and bulimia is that bulimia acknowledges the existence of the body, while anorexia denies it completely. (Hornbacher, 93) The impulse that triggers bingeing and the disgust felt after vomiting indicate that the body is “inescapable”. (Hornbacher, 93) On the other hand, such bodily impulses and emotions are absent in anorexia. There is no bingeing and no feeling, only resistance against the body’s most fundamental need. As time passes and the anoretic patient realizes that her resistance against her body is sustainable, she finds herself immersed in the delusion that “she can escape the flesh”. (Hornbacher, 93) After Marya left for boarding school, this delusion caused her to feel that the Marya she knew was disappearing.

How does this philosophical difference between the two eating disorders explain the low levels of success of anorexia treatment? First of all, being delusional about your ability to escape your body makes it more difficult for the anoretic patient to accept her illness. Since she has complete control over her body and she has been able to live for a long time without eating, why would she believe that she is sick? Bulimic patients would not pose this rhetorical question due to the constant irritation caused by the imbalances in their bodily impulses. Secondly, even if the anoretic patient accepts her illness, she would not have an incentive to have treatment. The worst that can happen is that anorexia might lead to death. In denial of her body, the anoretic patient does not fear death.

The fourth major difference stressed by Marya is related to the dynamics between losing and gaining control. She characterizes bulimia as a sequence of vacillations between loss of control and control. Binge eating demonstrates loss of control, while throwing up demonstrates control. On the other hand, anorexia is a state of total control. There is no bingeing, only an inexhaustible resistance against the body’s most fundamental need.

Perceiving an eating disorder as your means of control is dangerous, because this perception leads to your denial of your disease. Marya’s control-related reasoning proves this point: “The convenience in having an eating disorder is that you believe, by definition, that your eating disorder cannot get out of control, because it is control. It is, you believe, your only means of control, so how could it possibly control you?” (Hornbacher, 66) This type of reasoning can lead to long periods of denial. Since the level of control associated with anorexia is higher, we would expect anoretics to be in a more intense state of denial, compared to bulimics. Denial would make it impossible even to initiate treatment. In addition, comparing the reward schemes of the disorders, it can be concluded that patients perceive anorexia as being more rewarding due to the feeling of total control that it generates. A better reward scheme leads to a larger incentive to retain the disorder. In other words, the rewarding feeling of total control leads to an addiction to the habits that characterize anorexia.

In her book, Marya emphasizes four main differences between anorexia and bulimia that explain the relatively low success rate of anorexia treatment. These differences are related to the sense of disgust evoked by the disorders, the change in body mass caused by the disorders, the disorders’ acknowledging the existence of the body and the dynamics between losing and gaining control. Anorexia’s characteristics regarding the four differences either give the patient a larger incentive to retain the disorder or a larger incentive to deny her disorder. The facts that Anorexia does not evoke disgust, causes significant weight loss and allows the patient to feel in total control increase the rewards perceived by the patient, thereby giving her a larger incentive to retain the disorder. In addition, the delusion of escaping the body and feeling totally in control give the patient a larger incentive to deny their diagnosis. Reiterating our drug-abuse analogy, marijuana is to cocaine as bulimia is to anorexia. Anorexia is a far more dangerous and addictive next-step to be taken after bulimia.



Hornbacher, Marya. Wasted: a Memoir of Anorexia and Bulimia. New York: Harper         Perennial, 2006.