The stages of anorexia nervosa: Description
In this stage, the person isn't actually ill yet. Beginning to lose weight is associated with enjoyment or gain, and may be a choice, such as deciding to go on a diet. The person is actively engaging in weight loss strategies to be slim, and often just trying to be healthy and fit. She would be getting compliments at this stage and feeling good about it. There may be a precipitant to the weight loss, for example, a prior negative event or stress, which may even be as small as a negative remark about the person being plump.
| When I was losing weight, initially I wanted to lose 3 or 4 pounds, and that was it. But then I found a method, and I maintained it for a while, and then for no reason, I didn't start eating less but it just plummeted and plummeted, and it just kept going. 04P Interview 1 |
Stage 2: Getting Caught Up in Anorexia Nervosa
In Stage 2, life is becoming narrower and limited in scope for the person. Psychiatric symptoms may prove problematic, for example low mood. The person is still unable to want to be otherwise, feeling that this is definitely the way she wants to be, and also unable to acknowledge any problems. At the same time, the family and health professionals might be beginning to feel concerned. The person will have high levels of ambivalence about treatment. In this stage, sometimes deterioration of physical health can get serious enough that family and professionals may impose treatment.
Interviewer: I believe that your psychiatrist is of the opinion that you have anorexia nervosa. What do you think about that opinion? As I said before, it's quite hard to accept, most of the time I feel there are people looking at me, they think, how can she think there's something wrong with her, she just looks normal. Interviewer: What do you feel about your current weight and body shape? Don't like it, sometimes I feel like everyone's got it wrong, the dietician's got it wrong, I shouldn't put on more weight, I just feel I don't need to, I just feel I'm going to end up bigger than all my friends. 01P Interview 1
I thought that I could just lose half a stone and that would be it, and that was all I actually wanted to lose at that point and, and then - I think I had about a week of kind of cutting down what I was eating and after that point then it just became the most important thing in my life. It was like the focus and so I think possibly it was just channelling all of my worries and fears into, into one thing and therefore having the control over the food was just giving me some kind of sense of security and, and stability I suppose. And at the same time blocking out, I mean it doesn't make problems go away but at the same time it did feel like it was kind of blocking other things out because people just didn't know, people didn't bother me so much because they were a bit afraid in like “She's not eating, she's odd”, you know. And um, and then after a while it just got to a point when it was just, I couldn't even think about eating anything, so it was self-perpetuating as well. 03P Interview 2 |
Stage 3: Beginning to Struggle
In this stage, life is getting much more limited and difficult for the person, and feelings of distress begin and increase. There is declining physical and psychological health. The sufferer begins to discover her lack of control, and also her inability to choose to get better, realising for the first time this is a problem or illness. At this stage, the struggle against her own impulses and drives begins. At this stage, physical health may become enough of a problem that family and professionals may impose treatment, because the sufferer is not yet able to fight the illness.
You have to be very strict with yourself to keep being anorexic - it's hard - I mean you work at it. I think a lot of people, if they just let themselves go, would probably end up with bulimic tendencies, just eating loads and loads and loads. And then panicking about it but, yeah, it's just … (5 seconds) it's not something you have to work on as hard or have to keep working on, just keep yourself going. […] It is a tiring illness, you know, you have to keep pushing yourself. Interviewer: Right. But is it you who makes the choices to push yourself, or is it something you can't help? I'm sort of trying to understand that. They have been trying to tell me here [inpatient unit] for the past three months that it is something that I can control, so I'm going to be biased with that! Interviewer: So what have they been trying to tell you? Because they want me to believe that I can change it. Interviewer: That you can make a choice? Yeah. Interviewer: What do you think? Um, I believe there was a point when I could have done, but it's gone past that point. 10P Interview 2 |
Stage 4: Deciding to Fight Back
In this stage, the sufferer finally begins rejecting the illness, although this might need her to hit rock bottom physically or emotionally in order to do so. This rejection can be accompanied by deciding to accept treatment, often reluctantly and with a lot of effort, because this is a really difficult decision. At this stage, the sufferer is still not able to help or control herself in terms of eating. She has to wage a constant struggle against conflicting desires. There may be grieving for losses involved in rejecting anorexia nervosa.
I think people just think you're being silly, that annoys me, people think you're just being silly. And I think the most annoying comment is, “well, it's up to you”, it's like: “when you're in hospital and you can't just walk out, but it's up to you.” Yeah, it's up to you but it's a very strong illness and it's hard to fight, and I think people think it's just as easy as not letting yourself go out for that run, or just picking up your life again and getting on with it. 06P Interview 1
Interviewer: “Are there things you wish that professionals who treat anorexia should understand or should know?” “I think they should know that it's bloody hard. They don't necessarily always appreciate it. They know it's hard but they don't appreciate the fact that no matter what, you are making the effort. And they're just sitting there: “You're not making the effort”, blah, blah, blah.” Interviewer: “I see, right, OK yes. So it sounds like sometimes they might just look at what you are able to do and think you're not trying?” “Yeah, what they think you should be able to do, in their eyes.” 07P Interview 2 |
This is a broad stage with a lot of different variations. On the ‘tube map' it's like a railway siding that people can go into and get stuck at for a while. It basically involves adaptation to illness and adoption of a restricted coping lifestyle. Usually, the sufferer accepts a narrow scope of life as routine, and accepts symptoms, features of disorder or abnormal thinness as normal for her. It is not totally negative as she is often trying to get on with life in spite of illness. There can also be periodic short-lived optimism and improvement, but somehow it always comes back to this. She is often hating anorexia nervosa but unable to let go, but there is also a fear of treatment and inability to imagine recovery. The sufferer might identify completely with anorexia nervosa. There may be ending of active treatment – either hoping to do it alone, or giving up on recovery and only aiming for maintenance.
And the arguments I've then had with my parents about the fact that, you know, they'll say “well if you don't like it the way it is now, then why don't you change it?” Yeah, that's a fully sensible thing to say, but again I'm just, it's scary, it's scary to take that risk, to do something that I've not done for a long time. And I've almost forgotten how. I, I really feel, and so many people accuse me of, of making excuses when I say this, but I don't think it is one, I really feel that I've lost sight of number one what it is to, to be what a, you know, in quotations what a ‘normal 21 year old' is, and you know, to know things like what a portion size is, or how much a normal person would eat. And it's just become so totally distorted and just, anorexia has become normal for me, that it, it's difficult. And I, I don't want it, but when you're so used to something and it's not particularly affecting you at that moment in time, then why change it? You know I don't mean that in a lazy way or, or a way to make, to make it sound like I am making excuses, but risks are scary to take. 01P Interview 3
I don't see how you can be free from it completely, unless something's changed in your head, like physically changed. Because you can't, you still remember, don't you, and I don't see how you forget what's going on and have those same thoughts come back in. I can't kind of get my head round that. I don't see how that can completely go away. 06P Interview 4 |
Stage 5: Re-entering the Real World
Stage 5 is a very happy stage for most people. In this stage, the sufferer is regaining normal weight and health, and being discharged from inpatient or outpatient care. She is picking up the strands of normal life – work, schooling, independence, and social life, and looking well. However, she sometimes feeling shaky despite optimism. There are usually some remaining psychological features like rigidity, and often the sufferer usually still needs to be very careful about food. The sufferer still feels the influence of anorexia nervosa and often feels this will be a lifelong state.
Interviewer: So how would you say you are at the moment with respect to anorexia nervosa? I would say that I feel much better, um, but at the same time I do feel vulnerable. And I had a really stressful time during my [university] finals and that did actually play a huge part in what I was eating. And so I couldn't say that I was totally free of it and I don't think I probably will be able to say that for a while but I do feel a lot better. I just feel as if I understand it a whole lot more and therefore I can kind of be on the watch. And I think I made it my enemy instead of the world, because the world was my enemy when I was ill. 03P Interview 2 |
This is a stage which finds the sufferer becoming able to be relaxed with food. She is losing the ritualistic, obsessional mindset, and feels relaxed and does not need to think about food or control. She is finally able to be spontaneous and free, not rigid or rule-bound about diet or other things; and there is no sense of anorexia nervosa left in the self.
Interviewer: So what is recovery? Because then you're in a position to tell me because obviously it's not about the weight, because you've been a lovely weight pretty much since I've known you. Yeah that's true, so it's… (4 seconds) I think it's about finding, weight-wise certainly it's about finding something that's healthy and that you feel comfortable with and that you feel, and that actually you kind of tend to maintain it's like natural maintenance weight probably. […] I think having this kind of freedom that I have done has made me realise my true nature of eating I guess, in that I mean really now I will eat something just because I fancy it or because I want it, and so therefore – I just live on cheese – but the point being that I don't now look at calories on the back of things and when I go out for dinner I actually choose because I want the thing that I'm eating and not because it's not the most healthy or low-calorie thing on the menu and yet at times, you know, I can miss a meal, like, because I'm just not hungry and not then think at the next meal “oh well maybe I ought to!”, it's just like everything's in isolation, it's almost like how a normal person, well it is like how a normal person would eat. 03P Interview 4 |
Alternative ways to think about the stages of anorexia nervosa:
We don't think we've got it completely right or that these stages describe everyone or that everyone has to go through all of the stages. However, they do seem to be useful to some people. When we presented these stages at the workshops, this is what got the biggest buzz, and people had lots of comments as well as lots ways of modifying them. Click here to see what people suggested as alternative ways of thinking of the stages.
Photograph: The audience telling us about the way they see the stages of anorexia nervosa at the Edinburgh workshop