The Relentless Pursuit of Thinness


Back in the day I spent 6 months at the Clarke Institute training with Drs Garfinkel and Garner, on what was called the clinical investigation unit. We dealt with obscure or intractable conditions that often walked the interface between psychiatry and general medicine eg Tourette syndrome, psychomotor epilepsy, migraine tension headache and eating disorders mostly anorexic.

With Anorexia the majority of patients were young women, many of whom looked like denizens of Bergen-Belsen. Our job was to feed them to their ideal weights (sometimes with NG tubes) accompanied by appetite stimulants, motility agents and major tranquilizers. At that point there  was a risk of depression and suicide due to the breakdown of their anorexic coping strategies. There was no Prozac back then to take the edge off.

Upon reaching near ideal weight, the next step was to help them find better ways of managing their fat phobias and thinking distortions through cognitive and dynamic psychotherapy. But their resolve was as strong their obsessional defenses, and relapses were frequent. The underlying issues entered around maturation, autonomy, and sexuality. To be succinct they strove to remain child like to avoid facing these adult challenges. So they used the only weapon they had in the face of pressures from their often rigid, emotionally bankrupt, dysfunctional families of origin: starvation. As in 600 calories/day. Grapefruit and lots of water to feel full.

Part of my training involved intense 2x/week, supervised psychotherapy after stabilization. My assignment was Tiffany age 26, 5’4″, intelligent, attractive and introspective permanent university student. She never budged above 88 +/-2lbs. She was punctual, perfectionistic and asexual, though sexually active with her boyfriend. That was the only control she relinquished, though without any pleasure. In the two years I worked with her she was the anorexic prototype…mirror gazing, hyper exercising, laxative abuse, amenorrhea, hiding coins in her bra while being weighed, food dreams, cheese binges, and severe body image distortion to the point of psychosis.She did enjoy cooking for others. The pinnacle of her success was a flat/concave stomach.

Typical exchange:
“I feel fat”
“A  feeling isn’t necessarily accurate. Part of your illness is skewed perception”
” So I should trust you? Maybe you like plump women. So then your reality is perception as well”. Good comeback.

Her father was an emotionally distant banker and her mother a passive doting homemaker. Her brother was an introverted physics major. I asked what her family life was like. She said “you know Annie Hall? The scene where Woody Allen has dinner with her family? That’s them only not as much levity.”

At the end of the two years I began working in the far north. We had worked through her anxiety and feelings of abandonment, and she was able to identify emotional states. That is a common issue with anorexics termed alexithymia.  She made it to 92 lbs.

A major factor in perpetuating this illness is our societal expectations of women to be thin…This is culture bound as Latin American men and those of Mediterranean  origins prefer a more well rounded partner.

Studying playmate centrefold parameters from 1959 to 1978 it appeared men wanted women to look like men, or at least so it seemed.
30 years later these perceptions remain although there are attempts to counter this with ads showing women who are older and more rubenesque.

As for Tiffany I ran into her some years later. She had earned a degree in education, married and had one child. Her philosophy was: “I must fight my demons, they are illogical and irrational, yet they try to beat me each time they strike.”


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