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FEMALE STRESS SYMPTOMS: ANOREXIA NERVOSA

Donna cuts her food into many little pieces and moves them around her plate. She drinks her coffee and eats the lettuce in her salad, but will not swallow the meat she has put in her mouth. She coughs into her napkin to remove it. Donna is twenty years old, five feet four inches tall, and weighs eighty-seven pounds. Although she has abundant energy for physical activities, within two weeks her malnutrition will endanger her life. Even then she will not seek help voluntarily. She feels fat and wants no interference with her dieting.

Donna's syndrome is called anorexia nervosa, and it is one of the many stress-related symptoms that are more frequently found among women than among men.

Under the stress of increasingly adult responsibilities, sexual anxiety, or self-conscious concern about their appearance, young women may begin to control their eating and thereby gain a sense of control over their other impulses as well. Soon their appetite is altered, but their body image is not. As young women like Donna become more and more emaciated, their self-image lags behind, and they continue to see themselves as needing to diet.

Why is this disorder so much more common among women than among men? The answer is not clear, but it probably involves female physiology. Appetite changes often accompany the menstrual cycle, for example. Premenstrual cravings for sugars, chocolate, and rich or spicy foods are common. The food preferences that accompany pregnancy are legendary. (Pickles and ice cream, anyone?)

Even if women were not more physiologically predisposed to anorexia nervosa, cultural messages probably encourage women to manage stress symbolically through anorexia.

Cindy was the oldest of many children and felt like a surrogate mother to her brothers and sisters. A little more was always expected of her, and she tried her best to live up to all expectations. Her grades were excellent, her friends were "nice," and her family was proud. By the time she was a high-school senior, Cindy was anorexic.

If Cindy is thought of as having "swallowed" others' demands all her life, the stage is set for her not "swallowing" any more. By late adolescence, she was facing additional adult responsibilities. Not the openly defiant type to begin with, Cindy took control over herself in this passive way. Her rebellion was symbolic.

Theresa seemed to be using her anorexia to manage sexual anxieties. She actually delayed her own sexual development by keeping her body thin and childlike. Since her fat/muscle ratio was altered by dieting, even her menstruation was delayed. She dispelled her guilt over sexual impulses by denying her "appetites," and her fantasy fear of pregnancy was dispelled by a perpetually flat belly.

Although her mother thought Theresa would be tired from her constant dieting, she found instead that her daughter was overactive. Psychologists would suspect that Theresa's hyperactivity was yet one more attempt to manage unacceptable impulses, by keeping very busy.

There is no mystery as to how anorexia nervosa reflects an obsessional concern with appearance. Anorexics are often "approval junkies," trying to live on love and acceptance rather than food. If thin is in, they will want to be the thinnest. If fat means a lack of willpower, they will avoid being fat at all costs: by starvation, vomiting, enemas, and diuretics, to name a few.

At what point should family members worry about a dieting young woman? As soon as they see her dieting excessively without medical supervision, becoming obsessed with fasts, water diets, or fad-food diets. As soon as they suspect her body image is unrealistic. As soon as dieting interferes with her normal menstrual cycle. As soon as they find evidence of her using forced vomiting, enemas, or diuretics to control weight gain. Psychotherapy, family therapy, group therapy, and even hypnotherapy can all help if the problem is treated early enough. If allowed to become severe, anorexia is life-threatening. In fact, some reports say that up to 15 percent of severe anorexia patients die of malnutrition or related complications.

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