A disorder of eating or of values?

JM and DS were struggling to find a shared perspective on the management of patients with eating disorders. JM, a middle aged consultant, was educated in the West, in all-female schools and colleges, where dieting and body image disparagement are norms. She has worked for decades with patients who lose weight obsessively and who defend their behaviour as a lifestyle choice rather than an illness. She has seen full recoveries take many years to achieve and has also seen patients die or live spoiled lives as a result of their disorders or of iatrogenic damage.

DS, a male medical student planning a career as a surgeon, still feels scarred by memories of 10 days of severe, involuntary starvation in the tropical jungle. He recalls life in extremis, in a state of desperation and prayer, trying to eat inedible plants. He is horrified by the many months patients spend in the ward resisting renutrition.

A patient’s spontaneous account of her difficulties shed some light for both on the paradox. RML told us that each time she has relapsed into the depths of anorexia, she has been aware that losing weight takes over as the most important thing in her life—even more important than the people she loves most as a devoted mother and daughter. The awareness that this dreadful perversion of her values has occurred only adds to her anguish and self hatred.

Later, JM wondered whether DS, even at his most desperate, would have been able to eat again if he had known that, by doing so, he would sacrifice the thing that was of the greatest value to him—the life of a loved one, for instance. Understanding then flooded into the student’s face. “Ah then,” he said, “I would surely have starved to death.”