Death and Suicide in Anorexia Nervosa

<Many authors have stressed that anorexics have a strong self-destructive urge; thus Boss (1955) speaks of suicide in "refractive doses" when referring to those patients who, in their innermost selves, refuse absolutely to live as beings of flesh and blood. "They are totally lost to the therapist: using their own method right to the end they allow themselves to evaporate and dissolve."

This highly suggestive interpretation of gradual suicide raises a number of questions. In the first place we must ask ourselves whether the desire for self-annihilation, the suicidal drive of these patients, is conscious, even though dissimulated, or unconscious. In the second place we must determine why, having discovered the apparently intolerable burdens of the flesh (the pressure of physical demands and the body's inevitable decay) they do not put an end to themselves there and then, instead of soldiering on at the price of atrocious sacrifices over many years. Let me try to answer these difficult questions by drawing on my own therapeutic experience.

From my direct contact with anorexic patients, and from reading their diaries and hearing the confessions of those I was able to cure, I am convinced that not one of them has ever had a conscious wish for annihilation by suicide...

Nosographically, too, I have never observed anorexics in the kind of depressive state that often leads to suicide, and, in fact, anorexia nervosa patients never deliberately end their lives by direct measures. This, we found, is also reflected in their Rorschach protocols. Moreover, their pathological picture does not even involve an unconscious suicidal wish: psychodynamic studies have shown that their "choice" of emaciation does not serve to remove or displace the real object of their conflict in the manner that common neurotic mechanisms do. It was precisely this bias on the part of many psychoanalysts that was responsible for the failure to cure such patients. Their wish to be thin is perfectly conscious, as is their struggle to keep control of their oral needs and the resulting sense of security, however precarious and unrealistic it may be. No authentic anorexic ever considers her symptom absurd or makes a real effort to eat copious meals; all of them consider their behavior perfectly justified (I am speaking of the prechronic phase, that is, of the phase before various clinical and therapeutic interventions persuade them to feign illness).

The true anorexic has a deep and lasting horror of obesity, completely untempered by introspection --- it reflects a deliberate decision that must never be renounced. The resulting struggle takes the form of alternate bouts of bulimia and the most stringent fasts, or of unbridled greed and total self-abnegation; but however often the patient succumbs to the demands of. the body, her mind is made up that the body can and must be subdued in the long run. But this type of acarnality is not a death wish --- quite the contrary. It is, essentially, an unrealistic tension and a rejection of existence qua living and dying in one's body. More precisely it is a rejection of death as a biological fact, and with it a rejection of aging, corpulence, and existential decay. In short, the anorexic turns her back on the existentially inevitable, on everything that is imposed by, and inherent in, her corporeality.

In two of my cases, the illness appeared quite suddenly after the death of someone they loved, and was preceded by a state of shock and of intense revulsion at the idea of such irreparable loss. In a third case (a probationary nurse) the illness started immediately after her first attendance at an autopsy, for which her rudimentary training had ill prepared her.

This patient, to whom I was the first to give a psychological examination although she had been chronically ill for ten years and had been hospitalized, had never once mentioned this unfortunate episode. It was only when she was given a Rorschach test that she suddenly "saw" an open abdomen and the exposed intestines in many Rorschach cards, thus reliving, and offering associations with, the traumatic experience of the autopsy. "I saw that open abdomen ... full of stinking bowels ... and I thought to myself ... there used to be a soul here ... and I rebelled!" This patient, who had reached the most extreme state of cachexia (height: 5'2"; weight: 50 lbs) but was still remarkably lively, looked highly skeptical when her doctor told her that she was close to death. She was firmly convinced that she had finally broken through the barrier of physical corruption.

In fact anorexics look upon their possible deaths as so many accidents, but never as something they themselves may be courting. We saw that anorexics, unlike certain psychotics, do not refuse food altogether but merely reduce their food intake to absurdly low levels. Their emaciated bodies are their guarantee that they are winning the fight against passive surrender to greed, so much so that whenever they lost weight for intercurrent reasons (fevers, dental complications, etc.) they pride themselves on this extra loss as yet another victory over their demanding bodies.

These patients play with death like children who think they can disappear by shamming dead. Incapable as they are of facing reality or even, as we shall see, of comprehending their own physical needs, they delude themselves into thinking that they can tamper with their bodies as they please. This I have observed with utter astonishment even in one of my patients who was a doctor, who, in theory at least, was fully familiar with her biological processes and nevertheless treated her own body in the most absurd and antiscientific, and sometimes even magical, way, thus ignoring the most elementary tenets of medical science.

All those who have observed patients in the terminal phase of the disease have been struck by their severe state of psychological regression and their divorce from biological reality. They are in no way depressed or sorry for themselves and do nothing to avert their impending death; but they also take no deliberate steps to hasten their end and show no signs of waiting or hoping for death. This attitude is maintained obstinately and persistently, until extreme organic exhaustion sets in. The accompanying mental state is one of emotional dullness and indifference reminiscent of that of patients debilitated by a long history of chronic organic disease. The suicide of Ellen West described by Binswanger (1959) was an exceptional case: to this unusually gifted woman, death was the mystical personification of salvation from an imprisoned existence, and hence an authentic choice, a dies festus. Ellen did not, as Boss (1955) would have put it, trade total suicide for a suicide in refracta dosi: to the last she tried bravely to preserve her existence through anorexia, but when, after fifteen years of torment, she came to appreciate the futility of her struggle, she tragically put an end to it.