We humans are complex creatures, yet despite this complexity many of our behaviors are highly predictable. Most of us will normally choose pleasure over pain, leisure over work, attention over neglect, compassion over abuse, wealth over poverty, praise over criticism, success over failure. In like fashion, we will choose less pain over more pain, more pleasure over less pleasure, etc. Our natural unconditioned responses to many situations are often instinctive, and involve little conscious thought. Many of these instinctive responses are "programmed" into our brain to automatically provide the correct response to a wide variety of situations. These instinctive behaviors, much like software, have been written into our DNA over millions of years of human evolution.
Much of this behavior can be modulated by conscious thought and effort, and indeed, living in a civilized society requires that each of us learn to control and modify many of these instinctive responses. Through belief, training, conviction, accountabilty, discipline, we learn to control our natural urges and responses so that we can live harmoniously in society.
We instinctively avoid pain and suffering by developing a fear response to situations where we experienced pain or discomfort. When it comes to food selection, this fear response occurs with foods that cause us discomfort or pain. For most of us with healthy digestive tracts, eating is a pleasureable experience, and we eventually learn to enjoy a wide variety of foods. Some foods will not bring pleasure to us, and in fact may actually cause us pain and discomfort. Foods that cause nausea, diarrhea, stomach ache, bloating, gas, constipation, heartburn or any other malady, we generally learn to avoid. Some of this food avoidance happens consciously, some subconsciously. Some foods will give us immediate pleasure, only to cause us discomfort later. Here we often yeild to the temptation of immediate gratification, having to pay later with heartburn, gas, or diarrhea or nausea.
One very common trait of anorexic patients is that very few of them enjoy eating most foods. Most who have reached an advanced state of malnutrition have come to the point where no food brings them pleasure. Most have a history of being fussy eaters. Most have a hard time eating fatty or high-protein foods. Often therapists interpret this avoidance of fatty foods as confirmation of a "fat-phobia", a deliberate attempt to avoid calories.
Instead of jumping to the conclusion that this food avoidance is an effort to lose weight, it would be wiser to consider the possibility that the patient may be experiencing nausea, bloating, or pain as a result of eating these foods. The patient may or may not realize this. Generally, the therapist or attending physician assures the patient that any pain or discomfort is a result of NOT eating, and since no one seems to believe her anyway, the patient finds complaining about these symptoms useless. The patient may interpret this abdominal discomfort as the "anorexic voice" punishing her for eating too much.
For the bulimic patient, purging is always viewed by the therapist as an effort to lose weight. Perhaps it would be wiser to consider that the patient actually is experiencing nausea, and may feel better after vomiting. Vomiting is an extremely unpleasant experience, one that most of us instictively want to avoid. Yet, when we are nauseated, we often are relieved to vomit. Here we do not choose pleasure over pain, but we choose less pain over more pain. If we know for certain that we'll feel better after vomiting, we may not even wait for the vomit reflex to happen on its own, and induce vomiting ourselves.
The use of laxatives is very common among both bulimic and anorexic patients, which the therapist will normally interpret as an effort to rid the body of calories and to lose weight. It's amazing that no one seems to ask these patients if they really are constipated. Constipation is not a pleasant experience, and anyone would certainly choose to be regular over being blocked up. The bloating and gas that often go hand-in-hand with this constipation is annoying. Conversely, laxatives can cause cramping and diarrhea, so it is doubtful that anyone who is regular would choose to use laxatives. The therapist again assumes that the constipation is a result of becoming dependent on laxatives due to abuse. In my daughter's case, we tried every laxative available to clear up her constipation to no avail. In the end we found it was gallbladder disease causing the terrible constipation. Upon having her gallbladder removed, the constipation immediately resolved and her appetite returned.
If an ideal body shape is the goal of a patient's weight loss, then the status of having that body would come at the price of either dieting or exercising. There is no status in being severely malnourished, nor in having to be hospitalized for force feeding. Therefore there is no gratification to offset all the pain and misery endured. The therapist assumes that this sort of behavior can only be caused by an obsessive-compulsive disorder. It would be far more sensible to investigate physical illness as the root cause of the weight loss since it is unlikely that anyone would purposely choose to go through the pain and trauma of hospital refeeding rather than just eat on their own (unless they can't eat).
None of us enjoys humiliation. We try to avoid it. We tend to gravitate toward pursuits that we have an aptitude for. A 250 pound woman does not try out for the ballet troupe. A tone-deaf person doesn't audition for the solo part in the choir. To do so would result in humiliation. So the husky, muscular high-school boy is much more likely to try out for the football team than for long-distance running on the track team. In like fashion, a petite, skinny girl is far more likely to pursue ballet or long-distance running where her body-type will lend itself to acheiving success. Now if a majority of people with digestive tract disorders tend to be lighter rather than heavier, one could predict that these sports favoring lighter body-types would have a statistically higher prevalence of eating disorders. I recall my daughter's track coach telling me "your daughter has a genetic gift for running". At the time we didn't realize that her low weight and resulting high strength-to-weight ratio was a result of not only the training, but the anorexia from gallbladder disease.
The behaviors of what has come to be called Anorexia Nervosa are, I believe, highly predictable, instinctive responses when considered in the light of underlying illness. To assume these behaviors are a result of an obsessive-compulsive disorder or self-loathing is speculative at best, and contradicts human nature. In fact, these behaviors only make sense when the possibility of chronic disease is acknowledged. Therefore it is imperative to make every effort to determine if disease is present.