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Controlling your weight: eating disorders as diseases CONTROLLING YOUR WEIGHT: EATING DISORDERS AS DISEASES
To some extent, it helps to think of anorexia and bulimia in the same way as any other illness, such as diabetes or asthma. One advantage of this approach, called the medical model, is that it helps reinforce the "no-fault" concept I described earlier. A person with asthma is not responsible for the condition, but is expected to participate actively in managing the problem.
The medical model follows certain logical steps: evaluating the patient and the problem, arriving at a proper diagnosis, designing a treatment plan, then carrying out that treatment. This approach takes each person's individuality into account and looks at all the forces that may be contributing to the disorder. It also lets the physician choose from many therapeutic strategies to find the ones that have the best chance of working.
Such an approach is vastly superior to one in which a doctor assumes from the beginning that all eating disorders result from one cause-for example, a defective sense of self-esteem. Such restrictive, simple-minded thinking can lead to one-dimensional therapy that fails to address the multifaceted-perhaps I should just say human-nature of the disorder. As the saying goes, if all you have is a hammer, then every problem is a nail. It is better if the physician takes into account the nuts and bolts of the problem as well.
The medical model has limits. For one thing, anorexia and bulimia are not really like pneumonia. Most people would agree that there is nothing good whatsoever about pneumonia, unless you happen to be the bacterium that goes around causing it. Similarly, there is very little "good" about psychiatric disorders such as schizophrenia or depression.
However, I believe there is something positive that exists in the strangely inverted world of eating disorders. That positive element concerns the patient's attempt to exert her willpower to solve what she perceives as a problem. Rather than lying back passively and falling victim to the raging psychological and social forces that swirl around and inside her, she has adopted an active, even aggressive stance. She is taking a decisive course of action to achieve a goal-a goal she is willing to risk her life to achieve. While her goal is unreachable and her method is harmful, I feel her basic impulse is good and worthy of respect: She is trying to deal with a difficult situation by taking control and finding something in her life that makes her feel successful, special, and proud. In a strange way, eating disorders express a very American kind of thinking: Pull yourself up by your bootstraps, get a hold of yourself, improve your life, set a goal and work hard to achieve it, distinguish yourself. However, the approach taken by the bulimic or the anorexic is too rigid, too extreme, and is completely out of harmony with the needs of the body and the mind. The strategy is doomed to fail. When it does, the patient will suffer guilt, despair, and a sense of worthlessness-the very feelings that precipitated the disorder in the first place.
My approach as a physician is to recognize the complexity of the problem and try to take into account the many psychological and social factors that affect a patient. I accept that she is trying to solve her crisis, and I will try to help her channel that energy in a healthier way. When this approach works, the patient changes her faulty patterns of thinking, alters her destructive eating behavior, and improves her relationships with other people. Ideally, she leaves treatment with the resources she needs to cope in healthy ways with the pressure to be thin, pressure that will undoubtedly continue over the years.
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