"She's been in a moody puberty phase, and she's just starting to push off from her mom." Jenny was trying to describe the emotional change she'd seen in her half-sister, who was in treatment after seven years of anorexia nervosa. "She said to me last night, 'I just wasn't programmed to disagree with my mother. It hurts so much to disagree with her.'" Jenny paused. "She's fighting so hard to become her own person."
Jenny's half-sister is now a freshman in college, but because of her eating disorder she has been in a state of arrested development, both physically and emotionally, since age eleven. At 61% of normal body weight, what she saw in the mirror was a child, and she behaved accordingly. She clung to her mother like a little girl, even sleeping with her. She feared displeasing or defying her mother, and she avoided taking responsibility for herself. Now, as she regains her weight and her health with treatment, this young woman must pick up emotionally where she left off when she began her spiral into anorexia. Five years late, she is finally beginning her adolescence.
While interviewing women with histories of anorexia and bulimia for my book Gaining: The Truth About Life After Eating Disorders, I realized that delayed maturity is not just typical but predictable -- if we think of these illnesses in terms of arrested development. Unfortunately, because the body tends to regain its natural form and function faster than the mind does, the gap between appearance and maturity can widen before it closes. Jenny's sister at 80% of her normal weight might now look eighteen, but she is actually just beginning to exercise the emotional muscles of a twelve-year-old. This gap can be confusing for family and friends who see before them a physically healthy young adult. They naturally wonder why she doesn't "act her age."
Part of the confusion may lie in the all-too-common misconception of eating disorders as a problem solely of eating behavior. Recent studies indicate that more than one third of patients with anorexia struggle with aspects of avoidant or dependent personality disorder. Almost 40 % of those diagnosed with bulimia may have borderline personalities. And obsessive compulsive personality traits are common with both anorexia and bulimia. Such links between eating and personality disorders may be key to understanding why emotional maturity so often lags behind physical recovery.
In his 2004 book Feeling Good: The Science of Well-Being, Washington University psychiatrist Robert Cloninger observed that successful treatment for personality disorders most often returns patients "to their usual or best level of adjustment before the crisis that brought them to therapy." Cloninger, who has spent decades studying personality formation, found that this pre-crisis level served as a kind of default setting. Even the most effective therapy could only return the patient to the point of maturity she'd reached before becoming ill; recovery meant resuming development from that earlier state. Cloninger's observation parallels the experience of patients recovering from eating disorders.
Another source of confusion is the false front that people with anorexia and bulimia typically erect when sick. These are illnesses built around secrecy. Calories are counted furtively. Fasting, bingeing, and purging are covert behaviors. And true emotions are hidden behind a mask of defiant will. Often, this act fools even the suffering individual herself - until she lets go of her obsession with food and begins to regain her physical health. Then, as the late essayist Caroline Knapp wrote of her own recovery, she faces "the post-anorexic riddle of identity, a sense of wild shapelessness."
Even thirty years later, I remember this wild groping for post-anorexic identity all too well. I also remember my family's bewildered impatience with me to grow up. After all, I was graduating from Yale. Despite my seven-year compulsion to hold my weight below ninety pounds, I'd consistently earned good grades and impressed my teachers. But I felt light years (literally!) behind my healthy classmates. I had spent so long wanting nothing that I now couldn't tell what I wanted. I had spent so long minimizing myself that I didn't even know how to inhabit my skin. How was I supposed to be?
These were the early 1970s, and like most of my anorexic classmates, I'd received no treatment or counseling for my eating disorder. I had no idea why I'd been so set on starving and isolating myself. I knew only that I was miserable and wanted to change. I began by imitating my peers, trying on their habits - including procrastination, all-nighters, promiscuity, casual drug use and drinking -- like so many different sets of clothes. At twenty, I felt like a middle school kid trying to conceal her immaturity from the upperclassmen.
It was a struggle not to pull back into the safety of my obsession with food and weight, where no one could see how I felt. It was frightening and humiliating to give up my established identity as a fragile waif when I had no idea what identity would take its place. But I sensed I needed to experiment.
"I think these girls are quite delayed," Harvard psychiatrist David Herzog agreed when I asked him about the emotional immaturity that so often is part of anorexia. "They've never been given the opportunity to experiment."
"Never been given or never given themselves?"
"A combination. They believe there's no room for wrong. For some reason, wrong is unbearable." Recovery, Herzog said, means experimenting with failure, misbehavior, and taboo. It means learning to be a little more "bad" and a little less perfect. "Whether it be swearing, whether it be listening to certain kinds of music, whatever."
Parents, friends, and therapists need to be patient and remember that weight gain is just the most obvious beginning of recovery. As I look back now, I realize that it took me about ten years to catch up with my true age. Only then did I feel mature enough to fully embrace a particular career, to marry, to have a child of my own. My weight was normal all this time, but the process of recovery was continuing psychologically in ways I was only partially aware of. Those around me made no connection between my sometimes erratic experimentation and my earlier eating disorder, but in fact, it was all directly connected. In retrospect I can see, I was making up for lost time.
* * *
AIMEE LIU is the author of Gaining: The Truth About Life After Eating Disorders, just out from Warner Books. She is also the author of Solitaire (1979), the first published memoir of anorexia.