All In Her Head

She didn't choose anorexia. I know that now, but that doesn't make it any easier to watch her starve herself, and fade away into nothing.

It's like a nightmare where you see the boogeyman and you know it's going to kill her so you warn her, but she can't see it, so she doesn't believe you, and then she dies.

But anorexia's a slow suicide. And although anorexia accounts for more deaths than any other type of mental illness, she says she's okay, she says she's healthy. Her brain has shrunk and she's losing her cognitive skills.

She's says she's not like other anorexics. She's in denial. She's moody and angry and depressed a lot of the time. She thinks her mind and body are just fine. But her heart has shrunk, too, and its resting rate has fallen to 49 beats per minute (60 to 80 beats per minute is considered healthy) and she's seen doctors for problems with her kidneys, stomach and other organs.

When she's sleeping, her heart rate will fall well below the "critical" rate of 45 beats per minute, and she may not wake up again.

It's difficult not to feel angry with her because she's hurting herself and all of the people who love her. But she's not just a skinny, stubborn, vain girl who won't eat. She's sick, with a mental illness, and she didn't choose this any more than someone chooses cancer.

A few days after Christmas, she is hospitalized. She's in treatment now, although most of the time she doesn't want to be there and she insists she can get better on her own. I try to tell her that no one looks forward to chemo, either. I don't know if she hears me or not. There are millions of other women – and men – like her in the US, walking skeletons, dying to be thin.

"Why won't she just eat the sandwich?" asks Dr. Cecily FitzGerald, an emergency physician who also treats patients with eating disorders. "She can no more eat that sandwich than you can eat that shoe.

"It's important to stress that it's not about the food, because parents, spouses, loved ones – they always feel it's just about the food. It's really not about the food."

The National Association of Anorexia and Associated Disorders says the problem has reached epidemic levels in America, and affects everyone – young and old, rich and poor, women and men of all races and ethnicities. Their statistics say seven million women and one million men are sick with an eating disorder. More than 85 percent of victims report the onset of their illness by age 20.

There are still a lot of misunderstandings about the disease, however, even among health professionals. Treatment is hard to find – few states have adequate programs or services to combat anorexia nervosa and bulimia – and it's also very expensive.

Inpatient treatment can cost about $30,000 a month, and outpatient treatment, including therapy and medical monitoring, can reach $100,000 per year or more.

"The treatment should be multi-disciplinary," FitzGerald says. "Therapy, a nutritionist, and a physician. Those are the minimum requirements – you can add to that physical therapy or art therapy. You can add as much as you see fit. But the bare-bones is the therapist/psychologist, a physician and a nutritionist."

Anorexia – as all eating disorders – is a complex disease. There's not one single, simple cause, although new research has revealed that anorexia and bulimia are inherited conditions – one needs to have a genetic predisposition for them.

"But that doesn't mean that everybody who has that gene does have, or will develop, an eating disorder," says Kirstin Lyon, a marriage and family therapist in Carmel Valley who is also a certified eating disorder specialist.

So-called environmental factors can also trigger, and worsen, the disease: our society's obsession with thinness, puberty, dieting, going away to college, a traumatic world event or a more personal one, like a breakup.