"To say that I recovered during that time applies primarily to the clinical side of things. And to say that the more complicated, internal struggles vanished along with the preoccupation -- the daily battle with things like closeness, vulnerability, and anger -- would be a lie.
Am I rigid and ritualistic about food these days? No. But am I rigid about other things? Exercise? Work? My daily routines? Absolutely.
Anorexia is no longer what I am, but it is -- and I believe I can say this with acceptance, rather than regret -- a part of who I am."
-- Caroline Knapp The Phoenix Jan. 24, 1992
Anorexia nervosa is serious, but treatable. Even adults who have struggled with this eating disorder for years can get better. How well do they get? Do they recover completely? To address these questions, my Massachusetts General Hospital colleagues Eugene Beresin, M.D., Christopher Gordon, M.D. and I advertised in a local newspaper for women who once had anorexia and now considered themselves recovered. We interviewed them and determined that they were indeed healthy. Our goal was to understand these women from their own perspectives, and we admired the candor with which they told us their stories.
The women reported improved abilities to relax, live in the moment, and engage in the world around them. They talked about finding jobs, cultivating hobbies, and life on the home front. When asked what took the place of the anorexia, many highlighted newfound capacities for experiencing feelings. A number of the women pointed to self-confidence and people skills: "I could finally accept myself when friends got to see me as I really was, without acting, and that meant seeing all sides of me, the good and the bad."
This is not to suggest that individuals who reach a healthy weight and learn to eat balanced meals live "happily ever after." Our interviewees indicated that getting better was far more complicated than that. All of them experienced remnants of their anorexia.
Were there residual eating behaviors?
For years after returning to a healthy weight, many of the women continued to experience thoughts, such as "Today's snack was too fattening" or "If I eat a piece of birthday cake, I'll gain weight." This mindset was most likely to strike during periods of stress. One woman said, "It's not on the surface much of the time, but one difficult day on the job or with my family, [and] I tend to find myself going back to the thought process of anorexia, because I used to think this was safe." A number of the interviewees reported that it had been hard to change their apprehension about eating in social situations. On the bright side, the women felt that their food- and weight-related thoughts had become less and less disruptive.
Did body dissatisfaction persist?
Many experienced lingering problems with body image: "It took a very long time after recovery from anorexia nervosa to realize what I really looked like ... The fear of going from 70 to 200 pounds is very hard to change. The first bite is always the hardest. If you start, it feels like you will never stop." In other words, core features of the eating disorder -- fear of losing control, distrust of the body's ability for self-regulation and the tendency to think in extremes -- still intrude into the eating process.
Did the role of exercise change?
The majority of interviewees recalled that they had exercised too much when in the throes of anorexia. Although they now had healthy weights, many continued to spend a great deal of time at the gym and permitted nothing to interfere with their exercise schedules.
Did perfectionism continue?
Yes. Many of the individuals felt they needed the approval of others in order to feel better about themselves. To this end, they expected themselves to perform flawlessly in everything they did. Their eagerness to be the best lasted long after they had attained a healthy weight.
Is anorexia nervosa "history"?
All our interviewees felt that their journeys to recovery were long and hard. They believed that getting better involved not only weight gain and establishing healthy eating patterns but also self-regard, "knowing who you are, trusting your feelings and judgment, getting rid of rigid 'shoulds' and rules, all resulting in feeling free, safe and in control."
Our interviewees were all leading satisfying and productive lives despite residual effects of anorexia. Some said they had progressed beyond the point where their disorder would return. But others felt vulnerable to setbacks, likening their eating disorder to alcoholism, where recovery involves control and vigilance. Many women referred to themselves as "in recovery," reflecting the presence -- and the power -- of hope.
For more by Dr. David Herzog, click here.
For more on eating disorders, click here.
If you're struggling with an eating disorder, call the National Eating Disorders helpline at 1-800-931-2237.