They grow up confused in their concepts about their body and its functions and deficient in their sense of identity, autonomy and control…They misperceive or misinterpret their bodily sensations; they do not see themselves realistically, and they suffer from all-pervasive conviction of being ineffective, of having no control over their own life or their relations to others…The way they misuse the eating functions, their common fear of having no control over their eating, quite obviously means that the hunger awareness has developed in an inappropriate way. — Hilde Bruch, 1978, The Golden Cage, p. 39. (see side bar for link to book)

This quote from the great Hilde Bruch, a psychiatrist and pioneer in the field of eating disorders, points out the way that individuals with anorexia nervosa (AN) tend to have an inaccurate perception of themselves and an intense fear of being “found out” as a defective human being.  They latch on to the control over food and pursuit of thinness as “proof” of their goodness.  In order to accomplish this they must deny their own appetite, leading to a disconnect with the body where the signals for hunger and fullness start to be misinterpreted.  For example, a mere bite of food and the resulting sensation of it in the stomach may be misinterpreted as fullness, or hunger may be misinterpreted as nausea.  Both of these examples contribute to the inadequate nutritional intake seen in AN.  

She also speaks of the "misuse of eating functions."  This plays out in a number of ways.  Eating large amounts of high volume, low-calorie foods like vegetables; taking teeny tiny bites and chewing excessively; drinking large quantities of fluids to feel full without consuming calories; throwing up food (and maybe even convincing themselves this wasn’t intentional purging, but rather the body’s true rejection of food); abuse of laxatives — these are all examples of the many many ways people with AN may misuse the body’s eating functions.  

Numerous medical complications can result from this misuse.  Those who are malnourished and underweight are likely to develop delayed gastric emptying or even gastroparesis where food doesn’t move through the stomach into the rest of the GI tract at a normal rate.  This perpetuates the feelings of fullness despite the lack of adequate intake.  People who purge or abuse laxatives may encounter electrolyte imbalances that can cause cardiac arrest.  Fluid loading can also throw off electrolytes and put excessive strain on kidneys. Laxative abuse can also kill the colon, literally causing it to have to be removed and replaced with an external bag in which feces are collected and removed from the body.  

Let’s also not forget the medical complications associated with nutrient deficiencies.  Inadequate carbohydrate intake can result in a hypoglycemic coma and even death.  Inadequate protein intake impairs immunity and limits the body’s ability to repair itself.  Inadequate fat intake causes fat-soluble vitamins to pass through without being absorbed and hormone imbalances.  Vitamin and mineral deficiencies are too numerous to list, but can be extensive.  

When working with a patient with AN it is important that the treatment team help them to restore connection with the body and its appetite cues.  This will only be effective when the patient has been renourished and the medical consequences of malnutrition have been corrected, otherwise the appetite cues and digestive tract aren’t functioning properly to begin with.  The process of nutritional rehabilitation (sometimes called “refeeding”) can be quite painful and unpleasant both physically and emotionally, as the gut tends to be quite colicky as it is forced to handle increasing amounts of food without the maladaptive behaviors.  Emotionally the individual is usually ambivalent or even downright opposed to the process of gaining weight, as they have worked so hard to “accomplish” the tremendous feat of extreme thinness.  It’s like handing over their gold medal that they won in a sport that it turns out doesn’t even exist.  

But it is not all for naught.  The gift of the eating disorder and the treatment process is that the person gets the opportunity to examine their misperceptions and misinterpretations, not only of themselves, but of the world around them.  They need the neutral third party members of the treatment team to help them discover what their inaccurate beliefs and assumptions are, and the ways that operating their life based on these faulty assumptions has impaired their ability to live a fulfilling independent life.  In recovery they see the world through new lenses.