Boundaries

I was in the gym. I went through my usual exercise routine, which involves quite a large amount of cardiovascular work. Then I wondered if I should do a short session on the rower, as well as what I would normally do. As someone who's recovered from an eating disorder, I always worry about falling back on bad habits. Over-exercising to compensate for binges was one such habit.

I spent several minutes wondering if it would be a sensible reaction to do a bit more exercise, since I'd eaten more than I normally would, or if that would be a minor form of purging.

The problem is, there's no way to draw a barrier between exercise and over-exercise. One more minute on a treadmill doesn't suddenly change something from a healthy pastime into a danger. While I'm certain I could have done ten minutes on a rowing machine without putting my body in any danger, I didn't. The reason I didn't (aside from the fact I was already tired from an hour and a half of other exercise) was that small things lead to big things.

That can be taken as a general statement about eating disorders. A person doesn't switch overnight from being normal to being disordered. Looking back on my life, I can't tell you when I developed mine. I know there was a time when I ate normally, though perhaps with a tendency to snack when I was upset. I know there was a time when I would binge and hate myself and hide food wrappers where my parents wouldn't see them, and try and skip every meal I could to make up for the binges. But, seven years later, I can't see how I moved from one to the other.

Everything involved with eating disorders is a mixture of grey areas and blurred boundaries.

I had a comment conversation with someone in a lifejournal group were we discussed the different categories of eating disorders and the fact that many sufferers are classified as EDNOS while suffering almost all the symptoms of anorexia or bulimia. They were left out of the category because of a "loophole." We came to the conclusion that the official definitions for anorexia and bulimia weren't quite right. I think the problem is they treat these illnesses in the same way as they might treat a virus. But you don't suddenly go from being healthy to being infected.

Let's look at the diagnostic criteria for anorexia nervosa. This is taken from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. A person must have all four of these before they can be considered anorexic.

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).

B. Intense fear of gaining weight or becoming fat, even though underweight.

C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

The definition is very clear cut. If your body weight is 86% of what's considered normal, you're not anorexic, even if you starve yourself, exercise, take diet pills, think you're fat and have every other possible behaviour pattern of an anorexic. The day you lose that extra pound, you suddenly shift from being EDNOS to being anorexic, without any change in behaviour.

Let's take a hypothetical person. She was extremely overweight and began showing some of the symptoms of anorexia. These symptoms grew from an occasional skipped meal to full starvation. She began exercising furiously. She tried taking laxatives and diet pills when her parents made her eat. She developed an obsession with how much she was eating and how many calories she was burning. She dropped pounds and pounds of weight in a dangerously short amount of time. Now this person is slightly below average weight for her height and has missed a period. She eats only when forced to and tries to throw it up again afterwards. She is clearly ill and disordered. But this hypothetical person doesn't class as anorexic, because her body weight isn't low enough.

The official diagnosis criteria don't take into account the weight she was when she started.

Let's consider another hypothetical person. She was a ballet dancer, who kept a low body weight by careful eating and plenty of exercise. She was athletic and healthy and made sure to eat the right balance of nutrients to give her energy for performances and practice. She was very aware of her body and how to treat it right, but maintained a body weight about 13% below what would be considered normal for her height. She was given a large role in a performance and this involved a lot of extra practice. She didn't eat much more to compensate for the extra exercise and so lost a few pounds over the course of a month or so and reached the 15% below normal limit that is required for anorexia. But she doesn't display any of the other symptoms and is quite happy to eat, albeit carefully.

I feel that the body weight shouldn't be given in such a fixed way for the diagnosis. There is nothing special about the number picked. They could have chosen a percentage either way, and it wouldn't change who has the disorder and who hasn't. While I agree that a definition of a disease such as anorexia nervosa ought to have weight as one of the factors considered, but it shouldn't be given as such a fixed boundary. Doctors ought to be asked to consider starting weight before giving prognosis. Besides, all definitions say that this is a mental illness, so why do the definitions focus so much on the physical aspects such as weight and menstruation?

The definitions are a little better for bulimia, but they're still very clear cut. You either have it or you don't, according to the definitions. I think the medical dictionaries need to be reassessed to take into account the huge grey areas around starting a disorder and the blurred boundaries between them.

The same problem applies outside the realm of disorders as well. Just take a look at one of those BMI charts. It divides into neat segments of healthy, underweight, overweight, etc. If you're on one of those lines, half a pound either way could be the difference between healthy and fat. Those clear boundaries aren't real and shouldn't be applied to a process with such gradual changes. But we apply them anyway.

We judge ourselves by labels slotting us into one category or another, when really we should look around and see that the walls between those categories are as flimsy as the paper the medical books are printed on. As soon as you leave the text book and enter real life, there are no lines that separate the healthy from those who need help.