Wednesday, July 2, 2008

free will and eating disorders

We've a number of eating-disordered patients on the unit at the moment.  Eating disorders have never been a particular interest of mine; yet as I work more closely with eating-disordered patients, I've come to realize their problems raise a number of interesting philosophical questions.

We've all had the experience of being of two minds.  We want something, yet we do not want it. One experiences this on a regular basis, yet it rarely disturbs the view of oneself as a single, integrated ego, a unified mind.  However, the problem is very severe in the eating-disordered.

How to want to be well but also not want to eat?  How to want one's life back, to know that the eating disorder has wrecked it, to understand that one flirts with death, yet be so petrified of food?  Even my patient Ms. G., weighing just 35 kilos and desperate to regain a normal life, was yet utterly unable to prevent herself from binging, vomiting, and binging again.  "Obviously I have free will," she wailed unprompted, "but somehow I can't stop doing it."

Our medical student was surprised at her intelligence, unable to credit her self-destructive behavior because "but she's so smart!"  But 'smart' has nothing at all to do with it; in fact, quite the opposite: anorexics may have higher than average IQs.

(This may be tied to the well-documented association between anorexia and the need for control.  Besides body weight, academic achievement is another area where due diligence generally yields the desired results, and thus appeals to the controlling anorexic personality.  In fact, Dura et al. note that 'perfectionistic striving' actually yields better academic results for anorexics than would be predicted by their IQs alone.)
This makes a degree of sense when one considers that a certain level of complexity is required in order to deny one's own basic drives so severely.  At the most straightforward level of functioning, one merely obeys one's basic drives - hunger, thirst, fear, desire - pursuing the most immediate means of gratification.  At a somewhat more sophisticated level, one may delay instant gratification for a bigger payoff later on, forgoing one candy now for two candies later.  Ultimately, one may come to value successively loftier intangibles above the basics: staying up late to finish that big paper; starving for one's art; giving one's life for one's country.

Well then, how to be cognitively impaired, like our patient Ms. S., and yet have an eating disorder?  Ms. S. had been impaired since birth, and she behaved for all the world like a sweet and coquettish child, grinning impishly at the team, asking for hugs, requesting praise for her accomplishments.

At first I could not believe someone functioning at this simple level was sophisticated enough to have an eating disorder.  I thought she must have an organic illness, a food sensitivity or irritable bowel.  And yet as we weaned her down to the most elemental and gastroenterically benign food supplements it became clear that the problem was not in her bowel, but in her head.  She played all of the typical eating-disorder games: saving food, dumping food, vomiting food, mixing and freezing and thawing and refusing it, drinking gallons of black coffee and diet soda, and on and on and on.  

Ultimately it became clear that at least one of the reasons for Ms. S.' eating patterns had, unsurprisingly, to do with control - a common theme among eating disordered patients.  In Ms. S'. case, though, it was more to do with control over her family than over her body.  Still living with her mother in her forties, Ms. S. yearned to go out and build her own life.  She found that refusing to eat allowed her to exert a measure of control over her large, loving, yet stifling family, all of whom rallied round her and raised a ruckus of attention over her malnourished status.  Which was, evidently, far preferable for Ms. S. than sitting quietly on the couch watching TV all day and being ignored by those with lives of their own.

I hadn't given Ms. S. nearly enough credit for the complex, multilayered psyche she evidently possessed.  Humans are deep creatures, even the simplest of us.  

Not too much can go wrong with a simple machine like an abacus or a bacterium.  But as you add more bits and parts and cogs and circuits and cells and networks, the number of ways things can go wrong explodes.  Ultimately you end up with personal computers and human beings, both of which are endlessly surprising and infuriating in the sheer number of things that can go wrong with them.  Hence computer wizards, and psychiatrists.


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