Anorexia Nervosa
A Constructivist Grounded Theory Study of the Change Process Associated with Anorexia Nervosa – Restrictive.
Joyce Ring & Rosaleen McElvaney, School of Nursing, Psychotherapy and Community Health, Dublin City University
Summary Findings
This qualitative study sought to understand the experience of, and recovery from, Anorexia Nervosa – Restrictive (AN-R), as described by six women aged over 18 years who had been free of restrictive behaviours for over 12 months. Anorexia Nervosa is associated with an extremely emaciated body but also an aversity to putting on weight. Where this emaciation is mainly due to self-starvation it is termed Anorexia Nervosa – Restrictive (AN-R); when also accompanied by binging or purging behaviours it is called Anorexia Nervosa – Binge/Purge (AN – B/P). This study focussed on the restrictive form of anorexia (AN-R). Interviews were carried out between December 2019 and February 2020 using a Constructivist Grounded Theory methodology. In this summary, responses are collapsed into three themes for clarity and readability: Becoming Ensnared, Contrasting Care, and Suffering Recovery. Quotes, with pseudonyms, are provided below to illustrate the participants’ accounts.
Becoming Ensnared captures the feeling of being drawn into anorexia and the excruciatingly painful sense of increasing loss of control. Contrasting Care, reflects the person’s difficulties looking for, and receiving, help. Finally, Suffering Recovery illustrates how getting well is also a source of suffering in itself and that recovery comes about in a sequential but circular process with relapse being commonly experienced. The findings reflect that ultimately it is the person herself, with her own autonomy and agency, who brings about sustained recovery but that she needs psychotherapeutic support to do this.
These understandings are visualised as an underlying sequential process in the graphic below although they are experienced with much movement forwards and backwards.
Figure 1: Graphical representation of Summary Findings
Becoming Ensnared
This theme highlights that well intentioned weight loss quickly spiralled out of control as the person inadvertently fell deeper into AN-R. A number of factors appear to have contributed to this such as previous life experiences, looking outside herself for personal validation, experiencing emotional upheaval at a vulnerable time, believing that becoming thin would solve her problems and experiencing the effects of starvation such as a hyper-critical voice and sensory numbing.
The study suggests that the person’s life experiences, long before the onset of AN-R, profoundly influenced her sense of herself and how she felt in her body. Some participants recalled early childhood experiences of parents with psychiatric illness, active addictions or latent eating disorders which resulted in sexual, physical, emotional abuse or neglect. Clarisse stopped eating when she was 2 years old and her father moved out of the house. She recalled acute distress about spending weekends with him but did not understand what was happening:
I didn’t feel connected … my eating wasn’t great because I’d feel so sick … I wouldn’t be able to sleep, I’d get very tearful … it was just really, really hard … it’s like ‘what’s wrong with me’? (Clarisse, 23)
Because these experiences occurred at a very young age, participants developed a negative sense of self with a focus on their own perceived shortcomings. However, AN-R also affected some who felt socially accepted and popular:
I was the loudest … best at dancing, popular … never, ever had a bad relationship with food (Tamara, 26)
A common feature among participants was that each person’s sense of self was typically experienced by comparing herself to others or by looking outside herself for validation:
I was the person growing up that constantly sought validation off others. I wanted people to like me all the time, I wanted to be the best (Tamara, 26)
However, with the internal self-criticism the person had experienced since childhood, this interpersonal comparison typically had a negative outcome:
I had this perception that all the other girls were, kind of like, little pixies and I was like a farmer's daughter kind of build (Saibhdh, 25).
This sense of unacceptability often resulted in feeling that she was on the outside, was unacceptably different and did not fit in:
teenage was … so, so deeply full of shame and pain … this deep knowledge of not, not being cool or acceptable as a teenager amongst my peers (Amy, 50)
For the participants, the decline into AN-R was preceded by a series of events which caused emotional overwhelm. Family break-up was one source of upheaval:
my parents had broken up … I still wasn't speaking to my mum … my dad had started to drink more … I had no friends in school because I totally isolated myself … so I guess it was just like the perfect storm of s*** happening (Siabhdh, 25)
Other events that caused overwhelm centred on interpersonal issues such as struggling for social connection and reflecting negatively on herself in that scenario:
... when I went there (to college) … not being the best … being around girls who were thinner than me … who I felt were better looking than me, and then I started comparing myself to that environment (Tamara, 26)
As her critical self talk gets stronger, the person came to believe that the solution to all her problems lay in restricting her food and becoming thinner or smaller. This was her preferred best self:
fat, fat, fat was a feeling, fat wasn’t about fat. I’m, I’m taking up too much space, I’m too big … be small, be small, be small (Amy, 50)
Initially, weight loss was welcomed enthusiastically as it held the promise of correcting perceived personal shortcoming in comparison to others and satisfying deep desires to fit in:
Before I lost weight, any time I looked in the mirror I was … disgusted … repulsed (but) that feeling was getting less the smaller I was getting, so I was like - this is great (Sarah, 25)
Weight loss also brought feelings of superiority and pride as thin was equated with improved physical appearance, increased confidence and gaining access to social groups:
felt I looked good … I was successful (Amy, 50)
In this way, weight loss enabled a sense of feeling secure and being validated:
thin was ‘you're doing ok … you're safe’… it's like a safety thing (Saibhdh, 25)
However, believing that thinness was within her grasp created a desire for more:
I really liked losing weight, and I liked the number on the scales (Alison, 30)
While falling scales became a source of self validation for the person, self-criticism was always present. Because of this, the resultant weight loss was never enough and restriction became a relentless pursuit:
there was already this target, target, target so I, I think part of it … wasn’t attaining an end goal, it was living for a target (Amy, 50)
From the joy of the initial weight loss to the obvious need for help, the journey into physical dissemination was swift with the participant not being aware of how bad her obsession was becoming:
totally consumed with thoughts of food and exercise, I was suffering really badly, I was out of control even though I was totally controlling every aspect of my life (Alison, 30)
Without being challenged, critical thoughts developed into a hyper-critical voice before, in the extreme, resulting in a feeling of being possessed:
I thought like I was actually taken over by another person … I felt like I was going fully crazy (Sarah, 25)
The tyrannical nature of the voice, and its’ dominance in the person’s mind, was one of the most agonising aspects of AN-R. However, once the anorexic voice was experienced, it was trusted more than family or friends:
it’s so powerful … it’s a person that’s inside of you, and you’re so loyal to them … she is constantly talking … she’ll tell you what’s right, she’ll tell you what’s wrong (Tamara, 26)
Over time enslavement to the voice drove dysfunctional over-exercising even when the person was very ill and emaciated:
I was suffering really badly … if I ate another cracker … I’d have to briskly walk for 10 minutes (Alison, 30)
Isolation, especially from family, led to fewer validating experiences to challenge the voice so that the effects were cumulative and the pull of AN-R became more powerful. As it progressed, continuous restriction bestowed a sense of ‘numbness’ which the person particularly appreciated to counter the anorexic voice:
lovely numbness that anorexia gives you, you just don't have to think … and … it was incredibly appealing to not have to think (Saibhdh, 25)
Numbing also provided a coping mechanism so that overwhelming feelings were made more manageable:
100% coping mechanism … it was the only control I had … a brilliant distraction (Clarisse, 23)
However, over time normal fear and self-protection that alert the person to danger were also numbed, resulting in emotional detachment from the corporeal danger the person was experiencing:
I knew all the stuff … that I will literally start to eat my internal organs if I don’t put food in me, and, my hair coming out was really the first point where I thought ‘oh shit, I’ve got to eat, I have to eat more (Amy, 50)
Somewhere deep within herself, the person sensed that there was something wrong but felt powerless to stop her descent as her personality and her identity had fundamentally changed. Personal choice, agency, sensitivity, integrity and congruence were among the attributes which were overridden by indifference, isolation and disconnection:
I was like nasty, I wasn’t a nice person to be around … I would’ve sacrificed anything to be smaller … I was deceitful, I was constantly lying to my family … which is not me (Sarah, 25)
In the arena of her mind, the person was also aware of her isolation, loneliness and sadness:
the loneliness … is one of the worst things because you feel completely alone (Sarah, 25).
Ultimately, the final isolation was from herself as spiralling weight loss led the person to lose both her control and her choice.
Contrasting Care
Stopping the pressure the person experienced from family and friends was the main reason most participants gave for attending treatment. As such, in treatment the person was still in the throes of anorexia, fearful, anxious and conflicted about recovery:
it was kinda like a constant mental battle still, em, where it was just back and forth, back and forth, constantly in my head … the full anorexic like voice … yeah, constantly, constantly, yea, it was just exhausting, exhausting (Siabhdh, 25)
Unfortunately, the torment of this struggle was often misunderstood by medical professionals whose reactions often increased the person’s sense of fear and anxiety and negative beliefs about recovery:
I went to see a, a specialist … and she turned me away for being too sick … I went to another one … she said she couldn’t see me because of the clash of interests … I remember coming out of that … frightened and devastated (Amy, 50)
Treatment also echoed past experiences of not feeling seen or understood. Indeed, where feelings of shame, unacceptability, vulnerability or powerlessness were reinforced, it often led to a strengthening of the hold of AN-R in unintended ways, compromising the impact of treatment:
X treatment … was a shitshow … I had no counselling … asking me … personal … emotional questions with these two other people in the room … I felt like I was in a petri dish … I just felt so like exposed and like the whole (X treatment) thing … was a disaster... and that made my whole behaviours 10 times worse (Saibhdh, 25)
However, participants eventually found help from professionals who did understand AN-R and received the empathy, understanding and support they needed to find a way forward. By working with these professionals to develop a self-concept with a sense of worthiness and agency, participants were able to withstand the difficult battle of recovery:
I put all my trust in them, because I had just reached a point where I was ‘I cannot do this anymore’ … and yeah, it worked (Sarah, 25)
The therapy process was, by necessity, long term as the person had to negotiate managing triggers, stressors and relapse without settling back into previous behaviours. Often, the hope and expectation of the therapist that recovery was possible was the only light which gave the person a reason to believe.
Suffering Recovery
For participants, the gradual movement away from the compulsion and mental obsession of AN-R behaviours occurred very slowly. Initial weight gain, even if reluctantly endured, improved brain function and this allowed participants to reflect on their situation so that a process of change commenced:
when you start putting on weight like, obviously your brain starts to … physically develop more, and more positive voices were coming into my mind (Tamara, 26)
Through psychotherapy, the person was experiencing herself differently with glimpses of her past self and fleeting senses of freedom reminding her that her life could be different:
I was just “I can’t do this anymore”, I said “I should be going out with my friends”, it was that feeling of people seeing me as the sick person (Tamara, 26)
Overtime, the person developed a different relationship with anorexia. She began to see what she was losing because of it and this led to a deep desire for change:
I was so fed up of thinking about food all the time … I wanted to move on, I was really frustrated … my controlling behaviours took the whole day … they took my life away… I was clearly experiencing a lot of loss … of things I wanted to do with my life … I wanted to live (Alison, 30)
However, recovery from anorexia involved excruciating conflict and one of the main barriers was the terror that was bound up in gaining weight:
the thing that really remained the core difficulty for me was just doing the calorie increase … just that fear again of, and it was really like, I can't even describe it as a rational person now the kind of pure terror, it was real terror (Siabhdh, 25)
Initial weight gain left participants struggling to cope with acute physical discomfort and the internal conflict associated with their anorexia:
I was so uncomfortable I was just … bloated … had put on all this weight … felt this constant sense of … acute discomfort … that feeling of feeling like fat, but just, 10 times more … my eating disorder voice in my head was just screaming at me … I felt like I was doing wrong, like, I actually felt … a sense of like, unclean (Sarah, 25)
In addition, initial weight gain often caused adverse physical changes as the person’s body adjusted to recovery:
when I started eating again and it felt like the bitterest irony … got a really bad case of thrush … hair started falling out … migraines again … it was a real battle … refeeding oedema … it knocked me back several times (Amy, 50)
In this excruciating conflict, the physical discomfort of weight gain heightened the compulsion to restrict and increased the volume of the anorexic voice. In this way, recovery intensified the very symptoms it was supposed to address:
you go through … phases in recovery where you nearly look back with rose tinted glasses because it’s so challenging, recovery is so bloody hard … you go ‘(anorexia) wasn’t that bad’ (Sarah, 25)
Loss of identity as a thin person, with all that promised, also intensified the recovery struggle as did developing a new concept of self:
it was an identity thing for me … I had become that girl that was really, really, really, really thin and I think that part of it was “if I do start to put on weight, what would other people say? (Siabhdh, 25)
Social isolation, fear of failure, loss of perceived status and other perceived consequences also had to be tolerated in the process of recovery. However, these distressing torments had to be suffered ‘cold turkey’ as the numbing and distraction of AN-R were no longer available.
Sensing loss no matter which way she turned meant that the fight to disengage from anorexic behaviours was relentless with the pull towards restriction always present. Participants recalled recovery being experienced as a conflictual battle which continued for years. Efforts to eat properly were often followed by a form of relapse, before adjustment and further efforts to eat and so on:
…food … exercise … you’re still just constantly trying to control, control, control … I started to eat more but I was still controlling what I was eating rigidly (Tamara, 26).
Devastating to experience, the person had to draw deep on her own personal resources to progress further on the recovery path. Over time, continuous psychotherapy helped each person to look inside themselves for their self-evaluation and to develop self-compassion. Finding a way to manage their compulsions re-ignited their hope and self-belief. Participants in this study embraced their experience of anorexia as an integral part of who they are today and spoke about their recovery to inspire hope in those still suffering. Through recovery, they discovered their own, authentic selves and are now experiencing the freedom this brings:
the way I describe it to people is the word freedom … like when you wake up and … you’re going on your holidays … you have this sense of ‘like, I don’t have anything on’, freedom, I have this freedom, that’s how I would describe my turning point in recovery (Tamara, 26)
This study was conducted as part of Joyce’s M.Sc. in Psychotherapy in Dublin City University.
Joyce Ring, MSc in Psychotherapy graduate, DCU
https://joycering.com/
https://www.linkedin.com/in/joycering/
Dr. Rosaleen McElvaney, Assistant Professor in Psychotherapy, DCU
https://www.linkedin.com/in/rosaleen-mcelvaney-446a192a/
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