The Golden Cage

The Enigma of Anorexia Nervosa, With a New Foreword by Catherine Steiner-Adair, Ed.D.

Hilde Bruch M.D., Hilde Bruch

• Publisher: Harvard University Press
• Year: 2001
• Print ISBN: 9780674005846
• eBook ISBN: 9780674253025
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

First published more than twenty years ago, with almost 150,000 copies sold, The Golden Cage is still the classic book on anorexia nervosa, for patients, parents, mental health trainees, and senior therapists alike. Writing in direct, jargon-free style, often quoting her patients' descriptions of their own experience of illness and recovery, Bruch describes the relentless pursuit of thinness and the search for superiority in self-denial that characterizes anorexia nervosa. She emphasizes the importance of early diagnosis and offers guidance on danger signs. Little-known when this groundbreaking book was first published, eating disorders have become all too familiar. Sympathetic and astute, The Golden Cage now speaks to a new generation.

1

THE HUNGER DISEASE

“It is such a terrible disease because you watch your child deliberately hurting herself, and obviously suffering, and yet you are unable to help her. Another tragedy is that it affects the whole family, for we live in an atmosphere of constant fear and tension. It is heartbreaking to see Alma caught in the vise of this disease and unable to get out of it. Her reason tells her that she wants to get well and lead a normal life, but she cannot overcome the fear of gaining weight. Her thinness has become her pride and joy and the main object of her life.”

These sentences are taken from the letter of a distressed mother who asked for help for her twenty-year-old daughter who had been sick with anorexia nervosa for five years. At fifteen Alma had been healthy and well-developed, had menstruated at age twelve, was five feet six inches tall, and weighed one hundred twenty pounds. At that time her mother urged her to change to a school with higher academic standing, a change she resisted; her father suggested that she should watch her weight, an idea that she took up with great eagerness, and she began a rigid diet. She lost rapidly and her menses ceased. That she could be thin gave her a sense of pride, power, and accomplishment. She also began a frantic exercise program, would swim by the mile, play tennis for hours, or do calisthenics to the point of exhaustion. Whatever low point her weight reached, Alma feared that she might become “too fat” if she regained as little as an ounce. There were many efforts to make her gain weight, which she would lose immediately, and she had been below seventy pounds most of the time. There was also a marked change in her character and behavior. Formerly sweet, obedient, and considerate, she became more and more demanding, obstinate, irritable, and arrogant. There was constant arguing, not only about what she should eat but about all other activities as well.

When she came for consultation she looked like a walking skeleton, scantily dressed in shorts and a halter, with her legs sticking out like broomsticks, every rib showing, and her shoulder blades standing up like little wings. Her mother mentioned, “When I put my arms around her I feel nothing but bones, like a frightened little bird.” Alma’s arms and legs were covered with soft hair, her complexion had a yellowish tint, and her dry hair hung down in strings. Most striking was the face—hollow like that of a shriveled-up old woman with a wasting disease, sunken eyes, a sharply pointed nose on which the juncture between bone and cartilage was visible. When she spoke or smiled—and she was quite cheerful—one could see every movement of the muscles around her mouth and eyes, like an animated anatomical representation of the skull. Alma insisted that she looked fine and that there was nothing wrong with her being so skinny. “I enjoy having this disease and I want it. I cannot convince myself that I am sick and that there is anything from which I have to recover.”

Anorexia nervosa is a puzzling disease, full of contradictions and paradoxes. These youngsters willingly undergo the ordeal of starvation, even to the point of death. Fear of hunger is so universal that undergoing it voluntarily often arouses admiration, awe, and curiosity in others, and publicity seekers and protesters have exploited this. There is something exhibitionistic about anorexia, though few girls will admit it at first. During therapy many will confess that this cruel dieting was a way of drawing attention to themselves, that they had not felt sure that anybody really cared for them. Young anorexic patients will say unabashedly, “If I eat, my mother doesn’t love me anymore.”

Except for insisting that they eat “a lot,” they are reluctant to tell what they really do eat. When pressed for information the answers are sometimes amazing. A fourteen-year-old said defiantly, “Of course, I had breakfast; I ate my Cheerio.” A twenty-two-year-old explained, “When I say I overeat, it may not be what you think. I feel I’m gorging myself when I eat more than one cracker with peanut butter.” Esther went into detail to describe how well she ate but that she carefully avoided extra calories. “I won’t even lick a postage stamp—one never knows about calories.” Parents usually complain about how painful and exasperating it is to see a child refuse to eat. However, in recent years I have heard quite a few mothers agree with the anorexic child, that she ate quite well and they did not understand why she weighed so little. Invariably these women were preoccupied with their own weight and in a way envied their child the will power of existing on token amounts.

Even more puzzling than voluntary starvation is the claim of not suffering hunger. On the contrary, some emphatically state that they enjoy the feeling of hunger, that it makes them feel good to have a flat and empty stomach; and feeling hungry makes them feel thinner. It is exceedingly difficult to get objective statements about how anorexics feel. They really are confused about their sensations because starvation has a disorganizing effect on general functioning and psychological reactions. Chronic malnutrition is accompanied by biochemical changes which, though thus far inadequately studied, influence thinking, feeling, and behavior to an enormous degree.

Whatever their inner feelings, or however inaccurately they interpret or report them, anorexics do not suffer from lack of appetite, but from the panicky fear of gaining weight. In order to avoid the most dreaded fate, that of becoming “fat,” they brainwash themselves (this expression is used by nearly everyone) to change their feelings. Those who experience hunger train themselves to consider it pleasant and desirable. Being able to stand it, and seeing themselves getting thinner and thinner, gives them so much pride that they are willing to tolerate anything. Whatever suffering is involved, the fear of not exercising control over their enormous interest in food is even greater. Food refusal, or not permitting themselves to eat as a kind of self-punishment, is a defense against the original fear—that of eating too much, of not having control, of giving in to their biological urges.

By controlling their eating, some feel for the first time that there is a core to their personality and that they are in touch with their feelings. Others look upon this self-sacrifice as some sort of initiation rite. Some are aware of the complexity of noneating. Betty explained that losing weight was giving her power, that each pound lost was like a treasure that added to her power. This accumulation of power was giving her another kind of “weight,” the right to be recognized as an individual, and also the right to permit herself to indulge her gluttonous self. She was losing weight rapidly and was preoccupied with food and eating. This Betty condemned as greed and gluttony, to which she would give in only under special circumstances. While hospitalized she was grateful that she was forced to eat. “By losing weight, accumulating empty pounds, I would give myself permission to be nurtured, to be cared for, to be recognized.” At the same time, she was continuously measuring herself in comparison with other anorexics, whether she was eating too much or gaining too fast.

Just as amazing, even awe-inspiring to the onlooker, is the iron determination with which anorexics pursue their goal of ultimate thinness, not only through food restriction but also through exhausting exercise. Most had been interested in sports before the illness and had taken part in the athletic activities of their group, but now the exercising becomes solitary, solely a way of burning off calories or showing endurance. In spite of the weakness associated with such a severe weight loss, they will drive themselves to unbelievable feats to demonstrate that they live by the ideal of “mind over body.” Cora took up swimming, increasing the number of laps from day to day, finally spending five to six hours at it. In addition she would play tennis for several hours, run instead of walking whenever possible, and became an expert in fencing. She also worked many hours on her school assignments to achieve the highest grades. She kept busy for twenty-one hours, reducing her sleeping time to three hours. When first seen she denied it, but much later she admitted that she also felt terribly hungry all the time. But she took so much pride in enduring it that she came to enjoy the sensation.

Much later she described how during this time of severe starvation all her sensory experiences were heightened, particularly sight and hearing. She felt better at night than during the daytime when there was too much light and noise around her. She kept up her day’s activities like going to school and pursuing sports, and then would study during the night when it was nice, cool, and quiet. In many ways these girls treat themselves as if they were slave laborers, who are denied all pleasures and indulgences and are fed a minimum of food and driven to work to the point of physical exhaustion. A male patient (aged twenty-three), to test his ability to exercise discipline, started an anorexic regime during the last year of college. When he began to feel weak and realized that his body was deteriorating, he increased the number of miles of jogging to reassure himself that he was not lazy.

With all this exaggerated activity and frightening loss of weight, the youngsters themselves declare that there is nothing wrong with them, they feel fine, they like the way they look, they would feel guilty and hate themselves if they were to gain as much as an ounce. The inability to “see” themselves realistically or to react to the weakness of severe malnutrition is characteristic for true anorexia nervosa; it is one more puzzling feature of the illness. Weight loss occurs in many organic conditions, and also with a variety of psychiatric and psychological conditions. But such patients will complain of the loss, or are indifferent to it; they definitely do not take pride in it, as the true anorexic does. One more enigma: on the one hand they declare they do not see how thin they are, and deny the existence of even severe emaciation, but at the same time they take extraordinary pride in it and consider it their supreme achievement.

The urgency to keep the body as thin as possible is so great that anorexics will resort to any means, fair or foul, to keep their weight low. In an effort to remove unwanted food from the body, many resort to self-induced vomiting, enemas, or excessive use of laxatives or diuretics. All this may result in serious disturbances in the electrolyte balance which may play a role in cases with fatal outcome.

By whatever means and for whatever reasons the low weight is achieved, much of the typical behavior of an anorexic patient is related to the fact that she is a starving organism. In classical descriptions of anorexia nervosa the emphasis has been mainly on the physical consequences of the undernutrition, severe weight loss, skeletonlike appearance, anemia, dryness of skin, soft, fine body-hair growth, cessation of menses, low body temperature, and low basal metabolism. In recent years detailed studies have revealed many disturbances in neurological and endocrine functioning. Much effort has been spent on the question whether or not these neuroendocrine disturbances are the cause or the result of anorexia nervosa. It seems that all the disturbances described thus far can be explained as consequences of the malnutrition.

The behavior of anorexic patients resembles in many ways that of other people deprived of food. During the tragic years of World War Two whole populations were exposed to starvation, and much was learned about the psychological effects of famine. Anorexic patients are reluctant to speak about the hunger experience, at least at the beginning of treatment. Their peculiar eating behavior seems to be very similar to what has been observed in other starving people, except for their defiant denial of feeling hungry and the repeated sullen statement, “I do not need to eat.” Like other starving people they are eternally preoccupied with food and eating, will not talk about anything else, become excessively interested in cooking, often taking over the kitchen. However, they will not themselves eat but will force food on others.

Dora’s parents had been reluctant to admit that their brillant, admired daughter might be sick and in need of treatment. They finally came for help because her behavior interfered with the functioning of the family. She would get up early in the morning and prepare a huge breakfast and would not permit the younger children to leave for school until the very last morsel had been consumed. In another family the fifteen-year-old girl would begin baking cakes and cookies after she came home from school and would not permit her parents to go to bed until they had eaten every bite. What finally brought action was the mother’s concern with her own weight, that she was getting fat under the pressure from her daughter.

Dawdling over food and continuous thinking about it are not specific to anorexia nervosa. It is commonly observed during severe food shortages. People will “toy” with their food and make what under normal conditions would be considered weird and distasteful concoctions, markedly increasing the use of spices and salt. The same is observed in anorexic girls who may take vinegar as their drink, or put enormous amounts of mustard on their one lettuce leaf. As the starvation progresses, the desire for food does not diminish. Political prisoners have reported that only a few would eat the limited meals in a normal way. Eating was treated with great secrecy, and most developed methods to stretch the tiny amount over a long period, one using an hour and a half to two hours to eat one slice of bread. The prisoners spoke continuously about food, recipes, and favorite dishes, and indulged in fantasies about what they would eat when free.

What has been called “anorexic behavior,” as if it were specific to anorexia nervosa, such as obsessive, ruminative preoccupation with food, narcissistic self-absorption, infantile regression, is identical with what occurs during externally induced starvation. The telling difference is, of course, that the victim of starvation will eat whatever he can find. In contrast the anorexic is starving, in whatever distorted form this is experienced, in the midst of plenty, as if an internal dictator were preventing her from satisfying her needs or forcing her to reject food that is constantly offered and available. This gives to the anorexic’s preoccupation with food a peculiar bizarreness and frenzy.

In some, the hunger sensation becomes overpowering and they will eat—sometimes prodigious amounts, in spite of the urgent desire to stay slim, and then they throw up. It may start out with an occasional eating binge, about which they feel secretive and guilty, but then a definite routine develops. Overeating, always followed by vomiting, becomes the rule; the whole behavior will depend on the opportunity for vomiting, almost always in secret. I know of only one girl who did it openly at home—and this led to violent fighting. Finally, her father threatened to remove the doors from all bathrooms so that he could keep her from doing it. When there is no opportunity for vomiting, such as on vacation trips or visits with friends, they will go back to the starvation routine.

Those who become binge eaters experience it in the beginning as the perfect solution. They can give in to the urgent desire for food, eat as much and as often as they want—and still lose weight. As a matter of fact, in some the weight loss is more rapid than in those who play it straight and just eat very little. Yet as time passes the pride in outwitting Nature gives way to the feeling of being helplessly in the grip of a demonic power that controls their life. Gorging on food is no longer a way of satisfying hunger, but a terrifying dominating compulsion. Once the binge eating-vomiting cycle is established, it is exceedingly difficult to interrupt. Binge eaters are also difficult candidates for psychotherapy. The whole illness is based on erroneous assumptions and misconceptions, and therapy aims at correcting the underlying psychological errors. The binge eating adds a component of deliberate deceit. Those who have given in to it tend to avoid facing issues openly in their therapeutic sessions. About 25 percent of anorexic youngsters go through the binge-eating syndrome, and many get stuck in it. Whenever they experience anxiety or tension, they run for the comfort of food and thus avoid exploring the deeper problems.

Much of the confusion about the pyschological background of anorexia nervosa has to do with the fact that the dramatic effect of hunger on the psychological functioning has until now been given little attention. Behavior during the acute state of starvation, or in long-lasting chronic starvation, reveals little, if anything, about the underlying psychological factors. What we can observe during severe emaciation reflects the psychic and physical consequences of starvation. In this state patients are not only unwilling to talk about what they feel, but they are actually not able to because they are almost in a toxic state. Meaningful information about their psychological plight can be expressed only after nutrition has improved and when they are far along in treatment.

Marked individual differences are observed in the severity of psychological changes due to hunger, depending on the pre-illness personality, the damaging effects of increasing isolation, and the severity of the starvation. Though anorexics are very reluctant to give direct information on the starvation experience, I have come to the conclusion that the effect on psychological functioning of low food intake is to a large extent responsible for the drawn-out course of the illness, sustaining it and making recognition and resolution of the precipitating psychological issues difficult, if not impossible.

The whole behavior may be so severely disturbed that it borders on psychotic disorganization. To give an example: Elsa was nineteen years old when she was seen in consultation, after she had been sick for over two years. She was five feet six inches tall, and her weight had dropped from one hundred eighteen to seventy-eight pounds. She had been twice hospitalized and treated by behavior modification (a method that rewards weight gain and punishes failure to do so), resulting in rapid increase in weight; after the second time she made a suicide attempt. She lost again and weighed only sixty-nine pounds when I saw her in consultation. She admitted that she was skinny, but considered the low weight the least of her troubles. She was frantic about her obsessive “food thoughts,” which came in “all shapes, sorts, and sizes.” “Sometimes I hear voices or feel things in my head, and sometimes I get frightening mental images.” The voices seemed to be in conflict, some telling her “eat, eat, eat,” and others, “don’t, don’t, don’t.” These food thoughts filled her mind so completely that they drowned out her former interests in various activities (she was gifted as an artist and had done editing and writing). Even more terrifying was the continuous fear of being “not human” and the terror of “ceasing to exist.” At times she felt “full of my mother—I feel she is in me—even if she isn’t there.”

She spoke about these sensations in a monotonous rapid voice and explained her mental state as the diet’s having taken control of her; she also felt that a terrific hyperactivity had control over her. She was frightened by the fact that the concept of the future was a big blank. Elsa accepted the explanation that many of her terrifying experiences were directly the result of the state of starvation. She was cooperative with the refeeding program while hospitalized on a medical service, and her weight rose to ninety-five pounds, with marked improvement in her appearance and behavior. She was an unusually pretty and well-built girl and accepted that one hundred ten pounds would be a desirable weight for her. Even more striking were the changes in her psychological attitude. The double-track thinking, the fear of nonexistence, the feeling of being literally intertwined with her mother, all had disappeared—on refeeding alone and without the use of psychotropic drugs. However, she had also been seen regularly in psychotherapeutic sessions. Although she felt better, she knew that the basic psychological problems had not been resolved, only scarcely touched on.

Even after this brief period she found it hard to describe what had been going on. She remembered most clearly that her sense of time and reality seemed to have disappeared. Now after the terror was gone, she was ready to talk about the concerns that had made her life so unsatisfactory. Few anorexics are quite as panicky about the mental changes c...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Dedication
• Foreword
• Preface
• 1. The Hunger Disease
• 2. Sparrow in a Cage
• 3. The Perfect Childhood
• 4. How It Starts
• 5. The Anorexic Stance
• 6. Weight Correction
• 7. Family Disengagement
• 8. Changing the Mind