Before even discussing the holidays, there is a critical piece of the anorexia nervosa puzzle that needs to be discussed. It is often discounted, though it bears heavily upon potential therapeutic outcomes. This piece is the role that unrelenting anxiety plays in anorexia and the ways in which pathological fear influences the course of the illness.
Anxiety is a normal component of the human experience. For people with anorexia, however, anxiety takes on a new dimension. Individuals with anorexia experience extreme, pathological fear about their body, their weight, food, and calories every moment of every waking hour.
It is the sheer intensity of this anxiety that explains, at least in part, the restrictive eating behaviors that are hallmarks of anorexia. Put simply, patients feel better when they restrict because restricting food helps them to soothe their omnipresent anxiety. As physically painful as it is, self-starvation provides a welcome relief when the only alternative is living life awash in overwhelming anxiety and fear.
Anorexia and Family Dynamics
To this corrosive blend of anxiety and fear, life circumstances can add another factor: familial and social pressure. While motivated fundamentally by concern, many family members and friends of people with anorexia simply do not comprehend why anyone would inflict such punishment upon his or her own body. This lack of understanding and concern can sometimes manifest as judgement and condemnation, which can make social settings extremely difficult for the individual with anorexia to navigate.
Frustration is the emotion most frequently conveyed to me by the parents and family members of my patients when it comes to their loved ones’ food restriction. Mothers, fathers, and even siblings relay how the bafflement they initially felt upon observing their family member’s refusal to eat food slowly evolved into frustration. Many also describe how this frustration, inspired first and foremost by concern for their loved one’s well-being, eventually gives way to anger.
As a parent, I can absolutely understand this emotion. I understand how easy it can be for some parents to arrive at the conclusion that their child’s unrelenting food restriction is meant as a deliberate act intended to challenge parental authority. However, the reality is that the individual with anorexia is restricting food—and engaging in behaviors that to others may seem infuriating—to soothe his or her severe anxiety.
Being around friends and family who don’t comprehend the severity of one’s anxiety and who may express judgement and condemnation during the celebration of the holidays can amplify the anxiety experienced by someone with anorexia. This, in turn, may trigger compulsions to address this fear in ever more intensive ways, through more extreme forms of restriction. With the focus on food during the holidays, the situation is made all the worse for someone struggling with an eating disorder.
Holiday Tips for Friends and Family Members of Those Suffering from Anorexia
Don’t take their behaviors personally. Keep in mind that your loved one’s behaviors are motivated by a need to soothe their intense, overwhelming anxiety. Whatever behaviors of theirs that you find odd, bear in mind: it is not meant as an affront to you or others.
Don’t make food the sole star of the event. Holidays are often a culinary showcase and offer the opportunity to indulge in numerous delights. Don’t be afraid to spread your table with treats and delicacies, and don’t be afraid to partake yourself. But don’t make everything about food. Try to place an emphasis on the more important, social aspects of holiday celebrations, spending time with friends and family.
Be permissive about participating—or not participating—in games and activities. In addition to shining a spotlight on his or her disorder which will cause humiliation and shame, attempts at coercion will likely only result in the patient disengaging further. This can easily snowball into an argument and ruin an evening and intensify the patient’s anxiety and fear.
And if someone chooses not to participate, leave the door open for them to change their mind. If the response to an activity is initially no, let the individual know that if they change their mind they are free to join. This helps defuse tension and allows the person the freedom to reconsider without added pressure.
Celebrate spending time with your loved one; don’t try to “fix” them at a holiday event. It may be very difficult for parents and other family members to cast aside their worries about their loved one’s anorexia, particularly when the anorexia is right in front of them at a holiday event. A party, however, is not the place to try and “fix” someone struggling with anorexia, nor an appropriate time to try and coax the patient to eat or go to therapy. During the holidays, try to leave aside the worries and just enjoy spending time with everyone.
During the holidays, try to concentrate on the intangible aspects of holiday events that matter: spending time with loved ones, celebrating the season, and enjoying each other’s company. It may be difficult but try to put your worries on the back burner during holiday events. Chances are that your loved one with anorexia very much needs a reprieve from judgment, and from constant reminders of the imperative to get into treatment. Helping to make the holidays a supportive and enjoyable time may help in building the support and understanding they need to find further strength to help address their eating disorder.
James Greenblatt, MD, is a functional psychiatrist and a leading expert in treating eating disorders, Chief Medical Officer at Walden Behavior Care in Waltham, MA, and author of the Answers to Anorexia (FriesenPress, 2nd edition September 24, 2021).