How do eating disorders actually work

Eating disorders, bulimia, anorexia : Much too little

Berlin-Mitte, Gendarmenmarkt. A completely normal Monday afternoon in August: groups of tourists populate the area between the two domes, follow guide umbrellas, lie down on the concert hall stairs, listen to guide speeches. Around them: business activity. Creatives, managers, doers. Men in suits, women in costumes. Hurrying and busy, ambitious and disciplined. Successful. Slim. "All these perfect people," says Louise Kirschbaum * and shakes her head. "It's really tough sometimes." She is sitting in one of the numerous cafés that line Gendarmenmarkt. But not outside on the sidewalk, in the front row of the everyday spectacle, but inside, where it is cooler. Calmer. Hidden. "I always wanted to be like her," she says, and looks out the floor-to-ceiling café window again at the businessmen and women hurrying by. But because she never succeeded, because she never felt so perfect, she wanted to - go away.

Louise Kirschbaum is a delicate young woman, 21 years old, tall, graceful. She has braided her reddish blonde hair in a wreath, once around the back of the head, and pinned it at the nape of the neck with silver flower clips. She wears a long, silver-gray dress, cable knit pattern, thin straps, no sleeves. In front of her on the little table is a frappé and a little something to eat: two slices of wholemeal bread, coated with avocado cream and artfully garnished. So far she has only bitten off a small corner.

Because eating is still not easy for her, it's not something that happens to her on the side: Louise Kirschbaum suffered from eating disorders. She first had bulimia, then anorexia. Starved, although she was only skin and bones. Weaked her body until she could barely stand. "I mistook being thin for being happy," she says, smiling a little apologetically. "Today I know that this is nonsense." There are a good 18 months between the Louise Kirschbaum of the past and the Louise Kirschbaum of today. And - perhaps more importantly - just under 15 kilograms.

Slim equals beautiful equally successful. And above all: happy. Louise Kirschbaum is not the only one who believed in this calculation - and for whom it never worked out. "Almost half of the women are worried about their appearance, their figure and their weight," says Mazda Adli, chief physician at the private Fliedner Clinic in Berlin-Mitte. "What is even more worrying, however: Almost every third 15-year-old already shows disrupted eating behavior and thus an increased risk of developing an eating disorder."

In general, experts differentiate between two types of eating disorders: anorexia and bulimic disorders, which in addition to bulimia also include binge eating disorder (from English binge, which means binge). Both forms still mainly affect women: one in 100 suffers from anorexia, around four percent from a bulimic disorder. "Men are significantly less affected," says psychiatrist Adli. “But they are slowly catching up. Unfortunately."

While anorexic people almost completely refrain from eating, bulimic disorders often lead to food cravings. In order not to gain weight, those affected vomit the food again in the case of bulimia. In the case of binge eating disorder, this vomiting does not occur. However, the individual ailments cannot always be clearly differentiated from one another: They can also merge into one another or alternate. For example, one in five anorexic people will develop bulimia.

With Louise Kirschbaum it was exactly the other way around: she first developed bulimia, then anorexia. At the beginning of 2014 she therefore went to the Fliedner Clinic. Instead of the eight weeks initially envisaged, she attended the day clinic for five months. And she still comes regularly for outpatient therapy at the private clinic for psychiatry, psychotherapy and psychosomatic medicine on Gendarmenmarkt, run by the Protestant Theodor Fliedner Foundation. Because the way to healthy, conscious and also enjoyable eating is usually very long - well-practiced thought patterns and behaviors have to be resolved.

Because eating disorders are more as a pathological relationship to food intake. "Basically, they are disorders of the regulation of emotions," says chief physician Adli. This means: Since those affected cannot find any other way to deal with negative feelings, they try to master them with the help of food. When they feel bad, they eat - or they don't. "Both can become a reward stimulus in the brain," says Adli: While people with bulimic disorders calm down immediately through overeating, anorectic patients usually draw pleasure, strength and self-confidence from refusing to eat.

Louise Kirschbaum knows both mechanisms only too well. Even if she didn't want to see that she was sick for a long time. Instead, I thought that I was in a position to control the eating disorders - and not the other way around. She is probably one of those women who always give a lot of thought to their appearance, who want to be liked and accepted - and who develop pathological eating behavior as a result. "I've always been very fixated on my body," she says in the café on Gendarmenmarkt. "I wanted to make a good impression on the outside in order to cover up my internal deficits." About the fact that there was nothing good in her. About the fact that there was actually nothing to justify their existence. Louise Kirschbaum always hesitates when she talks about it. These thoughts and feelings may have been years ago - they are still excruciating. "My goal was at least not to attract negative attention, not to disturb with a presence." If she did not succeed, that voice came back in her head: that it was worthless, that it would disturb, that it should disappear.

At the same time she drew warmth from the food, filled the inner emptiness with food. During a stay abroad, she therefore began to concentrate primarily on food. After graduating from a German school in London, where she had moved with her family when she was nine years old from the southern German province, she decided to do a voluntary social year. She did it in a gray Czech border town, where she worked with former Nazi forced laborers. And was alone: ​​in a foreign country, but also with the disturbing stories that the old people, who had to toil in camps for the Nazis, told her. Alone with their feelings. "The food gave me a feeling of security," she says. "I didn't feel so empty and alone anymore."

But then it increased. Not much. But she liked herself less and less, felt more and more uncomfortable in her skin. In their situation. In your life. "That's why I started vomiting after I ate," she says. “I didn't mean to gain weight. I also wanted people around me to notice that I was unhappy. That I feel bad. I wanted my parents to tell my parents that I should break off the FSJ and come home. ”She would never have allowed herself to“ give up ”this alone. "I thought I could use bulimia and later also anorexia for myself, as a kind of protective shield." As a way to show: So far and no further. I can not anymore.

In addition, she wanted to resolve her inner pain, her inferiority complexes, through anorexia. "Many of those affected have impaired self-acceptance," says Mazda Adli from the Fliedner Clinic. They could not fulfill their inflated ideals and would therefore perceive themselves as a disruptive factor. "This is how they come to the thought: every ounce of mine in this world is one gram too much." A dangerous misconception. But Louise Kirschbaum also ate less and less. Wanted to make himself disappear. Like an installment suicide.

In the case of eating disorders, eating becomes a burden. "All thoughts revolve around food," says Adli. What have I already eaten? What else can i eat? How many calories was that? How do I get rid of them? There is no longer any space for enjoying food or enjoyment at all. And physical health also suffers. "The consequences of bulimic disorders include metabolic diseases and organ damage," says Adli. "When they have hunger pangs, those affected do not resort to healthy foods, but mostly to highly processed, high-calorie and fatty foods." Since bulimics then vomit the food they have eaten, they are usually of normal weight. Binge eaters, on the other hand, are usually very overweight: The energy balance, i.e. the ratio of calories consumed and reused, is extremely unbalanced.

Even with anorexia this balance is highly unbalanced. However, in the other direction: those affected consume far too few calories, not only eliminate high-calorie foods such as chocolate from their menu, but gradually almost all of them. Skip whole meals and often do excessive exercise. But even if they are already very emaciated, they still feel too fat. The reason for this is a body schema disorder, a misperception of one's own contours, says chief physician Adli: Where there is objectively only skin and bones, you can still see fat and curves. In therapy they would have to learn to correct this body image. "That is extremely exhausting for the patients."

However, it is also necessary. Because constant starvation naturally also brings health problems with it: the body needs energy to survive. If he does not receive this, he will gradually stop his functions. Anorexia can be fatal. Louise Kirschbaum also went hungry until her body was extremely weak. "I ate a slice of black bread with spinach in the morning," she says, looking at the plate in front of her on the small café table. She has still barely touched the two avocado breads. "After that, there was only salad for the rest of the day and maybe a reduced-calorie canned soup." She drank lots of water to stop her hunger. Or distracted yourself from counting calories using a mobile phone app. Almost two years ago, the literature student only weighed 44 kilograms - with a height of 1.75 meters. This corresponds to a body mass index (BMI) of around 14.4. Extreme underweight.

The BMI describes the ratio of height to weight. It is calculated by dividing the weight in kilograms by the size in meters squared. The result gives an indication of whether a person weighs too much, too little or exactly right: From a BMI of 25, one is considered overweight, the normal weight is a BMI between 24 and 18.5. Doctors call this underweight. Between Louise Kirschbaum and what is still considered normal weight, there was at least 13 kilograms in the winter of 2013. "I was so weak I could barely stand on my feet," she says. “When I went for a walk with my parents, I ran out of strength along the way. My father had to carry me home. ”That was the point at which she realized that things couldn't go on like this. That she needed help. Urgent.

Back in Berlin, she looked for therapy options - and decided on the Fliedner Clinic. According to its own information, this is the only facility in Berlin that offers day-clinic treatment of eating disorders. This means that those affected come to the clinic five days a week - from Monday to Friday - to take part in therapy and group sessions. They are at home in the evenings and on weekends. Usually, the therapy of eating disorders takes place on an inpatient basis in a clinic. "However, it was important to me to have a bit of normalcy and privacy during therapy," says Louise Kirschbaum. However, this was only possible because it is privately insured: Although the Fliedner Clinic also treats patients from statutory health insurances, these only cover the costs in exceptional cases.

The treatment itself is about more than just the patients' eating behavior - even if this is of course the focus with shopping, cooking and eating groups. In addition, however, patients also have to learn to deal with their emotions, to control them differently than by eating - and sometimes simply to endure them. In a second step, it would then be a matter of identifying certain situations and triggers that cause discomfort, avoiding them or at least resolving them positively, says psychiatrist Adli. This is usually a very lengthy and difficult process - also because eating disorders rarely occur alone. "Most of those affected also have other mental illnesses." These are personality disorders such as a borderline personality, obsessive-compulsive disorder or anxiety disorders, depression or addictions.

However, it is important Mazda Adli says that those affected seek treatment at all. “The environment is also important here.” Because far too often, relatives would notice an illness far too late. Relatives can also do something to prevent an eating disorder: "Positive appreciation is extremely important," says Adli. On the other hand, comments about the figure are completely inappropriate. "On the contrary, the parents themselves shouldn't be too strict with themselves, but rather set a good role model." This and show the children that emotions are part of life and that there are other ways of dealing with them than through that Eat.

Louise Kirschbaum had to painstakingly learn that again over the past few years. "I will probably never be completely satisfied with myself," she says. “There's always something.” She laughs. Then she leans back and looks back outside on the Gendarmenmarkt. "But I'm not so easily driven crazy anymore," she says, actually looking relaxed. "I now know that there is more to happiness than a slim body." It sounds convincing. A larger piece of the bread on the plate in front of her is now missing. * Name changed

You can read more about this in the magazine for medicine and health in Berlin "Tagesspiegel Gesund".

Further topics of the edition:Fact check. Exciting information about mind and soul; You have a tit. When is the psyche really sick ?; Brain research. What neuroscience can and cannot do; Psychosomatic. Body and mind are an inseparable unit; The path to healing. Outpatient, inpatient, rehab? The navigator shows the treatment route; Help in life crisis. Berlin addresses for emergencies. Medication. Effects, benefits and risks of psychotropic drugs; DEPRESSIONS: Get out of the bladder. The way back to life can succeed; Still live well! A victim reports from her everyday life; Winter depression. How artificial light helps against seasonal mood lows; BURNOUT: Illness with chic? Why burnout is just a fad for some; Shut down. A ski jumping legend talks about sport and illness; Burned out. A comedian tells about the dark side of success; ADDICTION: Life without drugs.Weaning is hard work; Children of addicts. A picture book deals with the effects of alcohol addiction on the family; Drug. What drugs are there and how they work; SCHIZOPHRENIA: Flood of stimuli. When the dopamine balance in the brain is out of joint; Family affair. Author Janine Berg-Peer on life with a schizophrenic daughter; MENTAL DISORDERS: Live fearlessly. A sick fear is curable; Doctor's letter. How obsessive-compulsive disorder is treated; SLEEP DISORDERS: Self-experiment. Slumbering in the laboratory; Dream research. What our nightly head cinema reveals; SERVICE: A comparison of clinics and doctors; Column. Helmut Schümann advises taking the psyche seriously

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