Brave Girl Eating_ A Family's Struggle With Anorexia Part 5

On our last eighteen-hundred-calorie day, I get a call from an acquaintance, Mary, who has a daughter Kitty's age; they took dance cla.s.ses together for a couple of years. She's calling to say that she spotted us the week before in a store and was shocked at Kitty's appearance. "I didn't recognize her," she says. She didn't want to approach us, so she called one of our neighbors, Delia, whom she also knows, and Delia told her that Kitty has anorexia.

And what am I supposed to say? "Yes, I know my daughter looks like a walking skeleton"? I haven't even talked to Delia about it. Anything she knows comes secondhand at best. How dare she spread this kind of news?

I hang up as soon as I can and go out on the porch to glare at Delia's house. I'm ready to storm across the street and tell her off, but Jamie stops me. "She cares about Kitty," he says.

"Well, it doesn't feel that way to me," I snap. "It's none of her business."

Jamie gives me the look, the one he's been giving me for the eighteen years we've been married: kind, steady, rea.s.suring. Usually it calms me down. But not today.

We've told a few close friends what's going on, but we haven't broadcast the news of Kitty's anorexia. For one thing, it's her life, her illness, and she's made it clear that she wants as few people to know as possible. For another thing, both Jamie and I also feel a sense of stigma and shame. People judge you when your child has an eating disorder, rightly or wrongly. Which is why I react so strongly to this bit of gossip.

I know I'm being defensive. But I can't let myself feel anger toward the demon, because right now the demon inhabits Kitty, and that would mean getting mad at her. And I'm not mad at her, not really. Sometimes I feel feel angry-when she's been sitting in front of a plate of chicken stir-fry for forty-five minutes, for example, picking out all the cashews. But it's not her flinging the nuts off her plate in disgust. I have to remember: that's not Kitty. angry-when she's been sitting in front of a plate of chicken stir-fry for forty-five minutes, for example, picking out all the cashews. But it's not her flinging the nuts off her plate in disgust. I have to remember: that's not Kitty.

That night, we eat a late dinner; the temperature has been in the nineties for days now, but eat we must. Kitty uses a baby spoon to scoop up tiny bites of mashed squash (into which I've mixed b.u.t.ter and honey). One minute she's fine, or what pa.s.ses for fine these days: she's not crying and she's eating. Then she looks up from her plate and I can literally see her flip from Kitty to Not-Kitty. I feel a jolt of adrenaline. And sure enough, when she opens her mouth, the demon's voice emerges, spewing its usual litany of self-loathing and rage.

"Why don't you take your plate onto the porch?" Jamie asks Emma. We've been trying to protect her from the worst of the poison. Emma gets up from the table, but before she can make it out the door, Not-Kitty says, "I just want to go to sleep and never wake up."

Emma freezes. Jamie and I look at each other. My heart turns over in my chest-literally, that's what it feels like, a heaviness revolving under my breastbone.

Not-Kitty says it again, louder this time: "I want to go to sleep and never wake up! I don't want to be alive anymore!"

Emma drops her plate and bolts from the kitchen as Not-Kitty begins to shout. I grab a bottle of Propel from the refrigerator, put a straw in it, and plunk it in front of my daughter. "Drink," I hiss, and run after Emma.

I find her downstairs, crying hysterically at the bottom of the laundry chute. When the tornado sirens sound and we head for the bas.e.m.e.nt, this is where Emma goes to feel safe. I put my hand on her back and she rears up out of the pile of dirty clothes, furious. "Don't touch me!" she shouts. "I hate you! It's your your fault Kitty is sick!" fault Kitty is sick!"

Her words smack the breath out of me. I try to suck in a lungful of air, but something inside me is paralyzed. Maybe I'm having a heart attack. Maybe the stress is killing me, right here in a pile of rumpled underwear. Don't air your dirty laundry, Don't air your dirty laundry, my mother used to say. my mother used to say. Don't be so quick to tell everyone your business Don't be so quick to tell everyone your business. This, then, will be my punishment for failing both my daughters.

Emma cries, her face contorted in grief and pain, and then I'm crying too, because I don't know what else to do. We kneel side by side and howl ourselves hoa.r.s.e.

Eventually Emma blows her nose and says, "I don't want to go to my sister's funeral."

I put my arms around her, and this time she doesn't pull away. "I don't either," I tell her, and hope my intention can magically keep the worst from happening.

chapter four

The Country of Mental Illness

If you're going through h.e.l.l, keep going.

-WINSTON C CHURCHILL

Anorexia is possibly the most misunderstood illness in America today. It's the punch line of a mean joke, a throwaway plot device in TV shows and movies about spoiled rich girls. Or else it's a fantasy weight-loss strategy; how many times have you heard (or said yourself) "Gee, I wouldn't mind a little anorexia"? most misunderstood illness in America today. It's the punch line of a mean joke, a throwaway plot device in TV shows and movies about spoiled rich girls. Or else it's a fantasy weight-loss strategy; how many times have you heard (or said yourself) "Gee, I wouldn't mind a little anorexia"?

The symptoms of anorexia nervosa are detailed in the Diagnostic and Statistical Manual of Mental Disorders, Diagnostic and Statistical Manual of Mental Disorders, known familiarly as known familiarly as DSM-IV, DSM-IV, the so-called bible of psychiatric illnesses. And the first item on the list of diagnostic symptoms is "a refusal to maintain body weight at or above a minimally normal weight for age and height." Notice the word the so-called bible of psychiatric illnesses. And the first item on the list of diagnostic symptoms is "a refusal to maintain body weight at or above a minimally normal weight for age and height." Notice the word refusal refusal rather than rather than inability inability. No wonder anorexia is so widely perceived as an illness of choice or lifestyle; the psychiatric profession defines it that way.*

In fact, the very name anorexia nervosa anorexia nervosa is ironic. The literal Latin translation is "nervous loss of appet.i.te." But people with anorexia don't truly lose their appet.i.tes. They may be disconnected from the physiological sensation of hunger, but they are deeply, profoundly hungry. That's why they draw out their meager meals for hours, savoring every sc.r.a.p they allow themselves. It's why they douse their food with mustard and salt and other condiments to sharpen the taste of what they're eating. It's why they read cookbooks like other people read p.o.r.nography, why they plan elaborate menus they know they will not eat, why they stand longingly in front of bakery windows but never go inside. is ironic. The literal Latin translation is "nervous loss of appet.i.te." But people with anorexia don't truly lose their appet.i.tes. They may be disconnected from the physiological sensation of hunger, but they are deeply, profoundly hungry. That's why they draw out their meager meals for hours, savoring every sc.r.a.p they allow themselves. It's why they douse their food with mustard and salt and other condiments to sharpen the taste of what they're eating. It's why they read cookbooks like other people read p.o.r.nography, why they plan elaborate menus they know they will not eat, why they stand longingly in front of bakery windows but never go inside.

Hunger is hardwired into us, physically and psychologically, and for good reasons. The drive for food must be insistent enough to propel us to seek it out three times a day. In twenty-first-century America, many of us have only to go to the kitchen, the grocery store, a restaurant to fill our bellies. But for most of the long story of human evolution, satisfying hunger has been a drawn-out and often perilous process.

Accounts of people with little or no appet.i.tes, who do not eat or have strong aversions to food, go back to at least the first century A.D A.D., when the Roman physician Galen described people "who refuse food and do not take anything" and who "are called by the Greeks anorektous anorektous or or asitous asitous." The Greek physician Alexander of Tralles, who practiced medicine in the sixth century, believed that anorexia developed from an imbalance of what cla.s.sical philosophers called "humors" people with anorexia, in this view, had too many "cold humors" and needed herbs like cinnamon, pepper, and vinegar to restore balance and bring back appet.i.te.

This perspective on anorexia persisted into the seventeenth century, when an English dictionary described it as "a queesinesse of stomack." Lack of appet.i.te, it was thought, must stem from physical disturbances-stomach problems, "humors," and other bodily ailments. And in fact, a loss of appet.i.te alone can be a symptom of all sorts of physical illnesses, from cancer to gallbladder problems.

In the Middle Ages, the culture around not eating shifted from physiology to spirituality. Religious women like Catherine of Siena, Beatrice of Nazareth, and Margaret of Cortona became known for fasting or eating almost nothing for years; some undoubtedly died from malnutrition. Their behavior was seen as a holy endeavor, a kind of reaching toward a state that transcended the body. Many of these women were later beatified by the church, and their starvation acquired a new name: anorexia mirabilis, anorexia mirabilis, a loss of appet.i.te that was miraculously inspired. If they were good enough, holy enough, they were set free from the physical necessity of eating, lifted into an idealized state where food was irrelevant-or so the notion went. a loss of appet.i.te that was miraculously inspired. If they were good enough, holy enough, they were set free from the physical necessity of eating, lifted into an idealized state where food was irrelevant-or so the notion went.

Historians adamantly distinguish the self-starvation of these medieval women from later forms of anorexia. They argue that we don't know enough about what inspired women in the Middle Ages to starve themselves and what kept them on that path. They say it would be naive to think that shared physical symptoms like an aversion to food, extreme thinness, and loss of menstruation derive from the same illness. They say that anorexia mirabilis and anorexia nervosa are two completely different disorders that originate in completely different ways.

To support this notion, medieval scholar Caroline Walker Bynum argues that fasting saints did much more than fast; they castigated themselves in all sorts of ways. Catherine of Siena, for instance, whipped and scalded herself and regularly slept on a bed of thorns.

I don't buy it. The roads to anorexia mirabilis and anorexia nervosa may indeed start in different spots, and those spots may be defined in terms of the culture: in medieval times, young girls aspired to saintliness the way girls today aspire to thinness. But those roads quickly converge on the same highway to h.e.l.l. Catherine of Siena, for instance, died at age thirty-three after years of subsisting on a daily handful of herbs; when forced to eat other food, she reportedly put twigs down her throat to make herself vomit it up.

Sounds like anorexia with a side of bulimia to me.

The difference in terminology underscores the idea of anorexia as a relatively new disease, an affliction of modern times. The first two medical descriptions of anorexia nervosa were published nearly simultaneously in 1873, one by a highly respected British doctor and one by a French neurologist. Sir William Withey Gull practiced medicine in London and was on close terms with Queen Victoria and the royal family. He spoke and wrote about an illness that affected mainly upper-cla.s.s adolescent girls who suffered from diseased mental states and, as he put it, "perversion of the will." Charles Lasegue was a neurologist in Paris when he described what he called l'anorexie hysterique l'anorexie hysterique as a "hysteria of the gastric center." as a "hysteria of the gastric center."

Interestingly, their characterizations of the illness diverged from their recommended treatments. Gull believed that medicines were useless and that only food could cure the illness. He prescribed high-fat, high-protein meals, administered every two hours by a trained nurse, along with bed rest and a hot water bottle along the spine; he believed that the person who was ill needed someone outside herself to compel her to accept food. "The inclination of the patient must be in no way consulted," he wrote. He thought a trained nurse was best because friends and family lacked the "moral authority" to insist that a young patient eat.

Lasegue's treatment veered more toward the psychological. He was the first to suggest that anorexia stemmed from family conflicts over an adolescent girl's transition to adulthood-a view that remains stubbornly entrenched today.

I think Gull had it right. When it comes to anorexia, food is medicine, and it's a given that someone with anorexia will not willingly come to the table.

In her book Fasting Girls: The History of Anorexia Nervosa, Fasting Girls: The History of Anorexia Nervosa, Joan Jacobs Brumberg writes that Lasegue's research "captured the unhappy rhythm of repeated offerings and refusals that signaled the breakdown of reciprocity between parents and their anorexic daughter. In this context anorexia nervosa can be seen for what it is: a striking dysfunction in the bourgeois family system." Joan Jacobs Brumberg writes that Lasegue's research "captured the unhappy rhythm of repeated offerings and refusals that signaled the breakdown of reciprocity between parents and their anorexic daughter. In this context anorexia nervosa can be seen for what it is: a striking dysfunction in the bourgeois family system."

Like Hilde Bruch and so many other "experts" on anorexia, Brumberg mistakes effect for cause. Typically, by the time parents consult a doctor or therapist about a teen with anorexia, the family has become dysfunctional, no matter how competent it was to begin with. The pattern of insistence and resistance Brumberg describes is absolutely normal in the context of a child who is starving herself. Of course Of course parents become edgy and upset, frantic to get their child to eat. And parents become edgy and upset, frantic to get their child to eat. And of course of course the child becomes terrified, hostile, and manipulative-anything to avoid eating. the child becomes terrified, hostile, and manipulative-anything to avoid eating.

But eating-disorders therapists don't see a family before anorexia strikes. So they don't know, they can't can't know, the true rhythm and flow of a family's previous life. Which means that they can't establish cause and effect between family dynamics and eating disorders. There's no way to predict who will develop an eating disorder, based on family dynamics or on any other criteria. know, the true rhythm and flow of a family's previous life. Which means that they can't establish cause and effect between family dynamics and eating disorders. There's no way to predict who will develop an eating disorder, based on family dynamics or on any other criteria.

Somehow the medical and psychiatric professions have confused hindsight with understanding. There's a saying in the scientific world: "Correlation does not equal causation." Just because two things happen at the same time doesn't mean that one causes the other. Maybe an unknown third variable causes them both. Maybe they coexist coincidentally. We know that anorexia changes family dynamics. But we don't know whether those dynamics caused the anorexia in the first place.

Most years we take a vacation in August, but not this year. Just as well, because we're not a beach family. Our vacations usually revolve around activities: kayaking in Lake Superior, skiing in the Porcupine Mountains, hiking in the Catskills. All of these would cost Kitty too many calories. Instead, we spend most of the month, when we're not at work, watching movies and playing board games, which Kitty hates but Emma loves. Poor Emma, whose summer has been one big nonvacation. She'll be glad to get back to school, I think. a vacation in August, but not this year. Just as well, because we're not a beach family. Our vacations usually revolve around activities: kayaking in Lake Superior, skiing in the Porcupine Mountains, hiking in the Catskills. All of these would cost Kitty too many calories. Instead, we spend most of the month, when we're not at work, watching movies and playing board games, which Kitty hates but Emma loves. Poor Emma, whose summer has been one big nonvacation. She'll be glad to get back to school, I think.

In the second week of August, Jamie and I b.u.mp Kitty up to twenty-one hundred calories a day. For two days beforehand she frets and worries over the coming change, so much so that Dr. Newbie prescribes a mild antianxiety medication-just in case, she tells us. Just in case of what? Just in case of what? I think as I pay for it at the pharmacy. I think as I pay for it at the pharmacy. In case things get any worse? In case things get any worse? I allow myself a small sardonic laugh. But even as I walk out, bag in hand, I know there's nothing to laugh about. Things can always get worse. I allow myself a small sardonic laugh. But even as I walk out, bag in hand, I know there's nothing to laugh about. Things can always get worse.

With the increase in calories, meal planning becomes more of a challenge. Eating large volumes of food is stressful for Kitty physically as well as emotionally. We add in a midmorning snack, to spread out the calories, but still she complains of bloating and stomachaches-common side effects of refeeding. Starvation affects the entire body in ways both profound and minute, and it will take a while for her metabolism and digestion to normalize. I'm hoping to minimize the unpleasant gastric consequences by cutting back on fruits and veggies, which are hard to digest and which in any case don't contain enough calories, and feeding her smaller amounts of calorie-dense foods.

I turn to my collection of cookbooks; leafing through them is an exercise in cognitive dissonance. Nearly every recipe seems to emphasize how low-fat and/or low-cal it is. Like Alice in Through the Looking-Gla.s.s, Through the Looking-Gla.s.s, I have the curious sensation of looking through a mirror into an alternate universe. While the rest of America hunts for ways to cut down on calories, I'm searching desperately for ways to pack them in. I have the curious sensation of looking through a mirror into an alternate universe. While the rest of America hunts for ways to cut down on calories, I'm searching desperately for ways to pack them in.

Frustrated, I go online and wind up on Web sites aimed at families of cancer and cystic fibrosis patients. I print out recipes for macaroni and cheese, chicken and peanut stew, lasagna made with ricotta and bechamel sauce, guacamole. Kitty's still terrified of foods like these-creamy foods, sauces, and pasta. Foods with fat in them. Even if we wanted to, we couldn't get enough calories into her by serving only "safe" foods-grilled chicken breast, steamed vegetables, plain whole wheat bread. And we don't want to. On my single trip to a nutritionist, I learned that the brain is made up largely of fat. That both the brain and the body need need fat-not just any old calories but the right kinds of calories-to begin the slow process of healing from starvation. fat-not just any old calories but the right kinds of calories-to begin the slow process of healing from starvation.

And it's more than a physical thing. Instinct tells me that if we are ever to rout the demon completely, we'll have to break all its rules, flout its proscriptions. We'll have to tar and feather it and run it out of town. We can't appear to collude or appease it in any way; we need to win this war visibly as well as tactically. We're engaging in a kind of exposure therapy, slowly desensitizing Kitty to the things she fears. And there's nothing she fears more right now than fat, whether it's on her body or in her food.

One night, poking around online, I find a glimmer of evidence that we're on the right track. I come across a 1967 study done by a grad student at Northwestern named Aryeh Routtenberg, who discovered, more or less by accident, that rats given access to food for only an hour a day became more physically active, running on their wheels for hours. After a few days the rats ate less and less and ran more and more. Most of them died within ten days, starving and running themselves to death.

I sit back in my desk chair. So many of Kitty's behaviors are a.n.a.logous to the rats'. If we didn't stop her, she, too, would exercise more and more. She, too, would starve herself to death. This study doesn't shed light on what triggers someone like Kitty into restricting her food in the first place. But it does lay out a pattern of effects that looks all too familiar. The rats' refusal (or inability) to eat, their compulsive overexercising-even unto death-reflect a biological imperative. Their self-destructive behavior didn't derive from psychological "issues" or screwed-up family dynamics; it was, as Routtenberg later discovered, a function of neuroanatomy.

The brain works on three main systems of neurotransmitters: serotonin, dopamine, and norepinephrine. These chemicals leap the synapses among the brain's millions of neurons, creating and regulating processes that affect everything from movement to behavior to mood. Like the rest of the body, the brain exists in a complex and delicate balance; one little misfire can bring down a big chunk of the system. In this case, Routtenberg theorized, the rats' limited access to food and unlimited access to the running wheel interfered with the brain's dopamine system. Which makes sense, because among other things dopamine helps regulate physical movement (it's connected with the basal ganglia, a cl.u.s.ter of nuclei involved with motor functions), motivation, and reward.

Just as interesting was a 1971 follow-up study done at the Medical College of Wisconsin by Joseph Barboriak and Arthur Wilson. They duplicated Routtenberg's conditions, but divided rats into two groups. One group got the usual low-fat, high-carbohydrate laboratory chow; the other got a special high-fat mix with no carbohydrates. Both groups were fed the same total number of calories and, as in the earlier experiment, had access to the food for only an hour a day. The lab chow rats behaved just like the rats in the original study; they amped up their activity levels until they were running nearly all the time. Each rat lost about 20 percent of its body weight. At the end of the experiment, twelve out of fifteen had died.

The rats on the high-fat diet, by contrast, didn't go into exercise overdrive. Their activity levels rose, but only a little, and they didn't lose weight. Only one of the fifteen rats in the high-fat group died, and that one had increased its running more than most of the others.

So something about the higher-fat diet protected the rats from running and from starving themselves to death. Barboriak and Wilson didn't speculate on cause and effect; they simply reported what happened. I want to know why, so I can keep Kitty safe from the same deadly cycle.

For now, I suppose, it's enough to know that fat is an important part of the equation. Knowing will help me resist both the demon's imprecations and Kitty's fear of eating fat.* It's so tempting to want to spare her suffering, to avoid some of the trauma. To feed her the foods she feels safest eating and hold off on the others until later. But I'm beginning to understand that there won't It's so tempting to want to spare her suffering, to avoid some of the trauma. To feed her the foods she feels safest eating and hold off on the others until later. But I'm beginning to understand that there won't be be a later if we give in to Kitty's terror, if we enable the demon in any way. There is no compromise possible. The stakes are too high and the process is too painful. a later if we give in to Kitty's terror, if we enable the demon in any way. There is no compromise possible. The stakes are too high and the process is too painful.

For instance: the next day I make one of our favorite meals, homemade pizza, which Kitty used to love. We've been keeping Kitty out of the kitchen during meal prep, but she sees the dough rising on the stove and falls apart instantly. "Oh my G.o.d, not pizza," she cries. "I already feel so fat, Mommy. My thighs are jiggling. Please don't make me eat it." She is keening now, there's no other word for it, crouching on the floor, rocking back and forth, arms wrapped around herself.

I feel like the worst parent in the universe. I am causing my child so much grief and fear and pain. My job is to protect her, not hurt her. I want to give up. I want to go back to the way things used to be, I think, before anorexia. B.A. Ha. We're all getting an education in eating disorders. An education we don't want and could live quite well without.

Then I think, If I feel this way, how must Kitty feel? I can take a walk, read a book, shut out the anorexia for a little while. But it's inside her. She can't get away, not for a second. And every minute she spends trapped with the demon must be h.e.l.l. Pure h.e.l.l. My child is going through h.e.l.l. I could sink down right now onto the floor beside her. I could howl and cry and tear out handfuls of my hair. That's what I feel like doing. But that would be self-indulgent. That would be abandoning my daughter.

In our family, as in all families, my husband and I have taken on certain roles. Jamie is the one who fixes things: the vacuum cleaner, the car, the computer, the broken chair. When someone gets a splinter, he's the one who pulls out the hydrogen peroxide and tweezers. My role is to figure things out. I'm the one who makes the plans, who asks the questions (sometimes obsessively) about what it all means and what we should do. I'm the one who calls people and goes online and tears through the library looking for answers to whatever the problem.

The point is, Kitty needs both of us now. Jamie's strengths and mine are complementary, and she needs every shred of power and steadiness and stubbornness we possess. No matter how much I feel like giving up, I can't. Jamie can't. There is no way we're abandoning her. No way in h.e.l.l is the demon going to win.

I slide down onto the floor beside her and put one hand on her back, to let her know I'm here. I sit beside her and I stay with her until she's all cried out. Until Not-Kitty is gone, and Kitty is, for the moment, wholly herself.

Impulsively, I say, "This is really hard on you, isn't it?"

Kitty hates the idea of anyone feeling sorry for her. Some of her biggest outbursts in these last few weeks have come in response to someone's expression of sympathy, or empathy. I brace myself for her reaction.

But instead of stiffening in anger, Kitty simply turns her face toward mine. She's always had beautiful eyes, my daughter, and they are still lovely, large and complex, the dark irises flecked with light. Now they look too big, out of proportion, like the oversized, pathos-filled eyes of puppies in flea-market paintings. I was raised to think thin is beautiful, that there's no such thing as too thin. I will never again believe it.

Kitty leans her cheek into my hand, a rare moment of connection in our newly adversarial relationship. Once upon a time she trusted me. Once upon a time Jamie and I were not the enemies. Now the feel of her skin against my palm tells me what we have to do next. Each time we've raised her calorie intake, Kitty has suffered, her anxiety and terror flaring out of control. It's as if we're peeling away a Band-Aid, inch by agonizing inch. Wouldn't it be kinder to rip it off in one go?

"What if we raised your calories to three thousand now, in one fell swoop?" I ask Kitty, bracing myself for panic, rage, the demon's hissing.

But instead, she says slowly, "In some ways that would be easier." As soon as she says this her eyes cloud, she claps one hand over her mouth, and she begins to cry.

"What is it?" I ask, but I already know. She'll pay dearly for saying this, my brave and honest daughter. She'll suffer guilt and terror at the hands of the demon inside her for even this small defiance. I'm her mother; I'm supposed to be able to protect her. Instead, I have to make it all worse, at least for now.

I remember a picture book we used to read when Kitty was small that described a family who ran into obstacle after obstacle-a swamp, a bear, a mountain-on their way to a picnic. Each time, they tried silly tactics to avoid the obstacles, and each time they succeeded by confronting rather than evading them. Kitty and I used to chant the refrain together each time: "We can't go over it. We can't go under it. Oh, no, we have to go through it!"

It's the same with anorexia. We can't go under it, we can't go over it. Oh, no. We have to go through it.

The week after we start our higher-calorie regime, Kitty gains three pounds. I feel like dancing around the doctor's office, but I keep my face neutral. I stay in character as The Mother. start our higher-calorie regime, Kitty gains three pounds. I feel like dancing around the doctor's office, but I keep my face neutral. I stay in character as The Mother.

"I did good, right?" asks Kitty anxiously. "Did I do good?"

What do I say? It depends who's asking, Kitty or Not-Kitty. My daughter or the disease. Either way, my answer could provoke a meltdown. My instinct is to speak to my daughter, and deal with the demon if it shows up.

"Good," I say calmly. "You did really good."

I see the conflict in Kitty's eyes, guilt and relief and fear swirling together, and wait for one of them to win out. "OK," she says eventually. We move on.

For weeks now we've lived in a kind of bubble. We've seen few friends, kept no social engagements. I've barely gone to the office; I've done the essentials of my job at home, late at night, after Kitty and Emma are asleep. I'm usually too anxious to sleep, anyway. Our lives have narrowed to a few basic activities: shop, cook, eat, clean up, watch movies, do it all again. We're lucky, if you can call it that, that it's summer, when schedules are more forgiving. But school will be starting in two weeks. Fifth grade for Emma, and ninth for Kitty. If she goes.

That's the question: Should she start high school? Some of the answer depends on what happens in the next few weeks. Right now, Kitty stays close to home, literally and metaphorically. Can she handle the emotional demands of high school, or would it be cruel to send her? Would it be crueler to keep her home, setting her back in a way that will feel humiliating? Then there are the practical considerations, like the logistics of lunch and snack, which have to be eaten with one of us.

From the time Kitty was a toddler, she's been an intensely social person, always wanting playdates, always up for going places and seeing people. She's the kind of person who's reenergized by hanging out with friends. This year, though, she doesn't want to see her friends and she doesn't want to go to school. I know a lot of her anxiety is a by-product of both the anorexia and the refeeding process. But I can't help wonder if on some level she's always felt anxious about school, and just never told us. Does the illness give voice to feelings that have been hidden to her, or does everything get mixed up in its chop and churn?

Ms. Susan says it's not helpful to get tangled up in this kind of thinking. She says people in recovery from an eating disorder do best when they limit the stress they're under, and I believe her. On the other hand, to keep Kitty out of school entirely would create a different level of stress for her. She'd feel like a failure, a freak, a weirdo. And, to be honest, it would be good for all of us-including my relationship with my staff and my boss, who have been immensely patient-to have her out of the house for a few hours a day.

One late August afternoon Kitty sits in front of a milk shake and weeps with anxiety. This is her talking, the real her in her own voice, not the creepy distorted voice of the demon. And yet-and yet she's irrational. She stares at me, her face full of worry, and says, "I don't want to go to high school and have everyone look at me and say, 'Look at Kitty, she got so fat over the summer!'"

"You're not fat!" I say, but I might as well be speaking in tongues, because she can't hear or understand.

"I'm so fat, everyone will be talking about me," she insists.

I don't want to tell her the truth: that kids will will talk, but not about how fat she is. G.o.d. They'll be gossiping and speculating about the fact that she has an eating disorder. They will comment on how she looks, but it will be about how thin she is. And yes, some of them will say and do stupid, insensitive things. Not that teenagers have a corner on the insensitivity market-some of our acquaintances have made some appallingly hurtful comments. talk, but not about how fat she is. G.o.d. They'll be gossiping and speculating about the fact that she has an eating disorder. They will comment on how she looks, but it will be about how thin she is. And yes, some of them will say and do stupid, insensitive things. Not that teenagers have a corner on the insensitivity market-some of our acquaintances have made some appallingly hurtful comments.

Like the acquaintance I run into at the food co-op, who had us to dinner early last spring, before we realized Kitty was sick. Now she leans across the sweet corn and says, in a voice dripping with concern, "How is is Kitty?" Kitty?"

I don't know why it rubs me the wrong way. She means well, I tell myself. "She's doing all right," I say, and then, to shut down the conversation, "Thanks for asking."

She leans in closer. "You know, I could have told you she had anorexia," she confides.

What I want to say is "Then why didn't you?" Instead I grit my teeth and say, "How so?"

She smooths her glossy hair. "I noticed the way she cut all her food into tiny pieces and pushed it around her plate," she says, her voice low and intimate. She gives me a look of concern and adds, "She didn't eat a thing. Didn't you you notice?" notice?"

Now I feel like slapping her. No, punching her in the mouth. No, garroting her. Anything to make her stop talking. "I have to go," I say, leaving my basket on the floor. I manage to get out the door and into my car, where my rage quickly evaporates, leaving an acid bath of shame. Of course people know exactly what's going on. And of course they blame us. h.e.l.l, I I blame us. We're Kitty's parents; we're supposed to be in charge. We're supposed to protect her. blame us. We're Kitty's parents; we're supposed to be in charge. We're supposed to protect her.

What I didn't realize was that they would blame Kitty, too. That they would see her behavior as willful and manipulative. That they would ascribe to her a kind of devious intention, not just now but always. That they would recast her whole life in the light of anorexia, and judge her harshly for it. So while Kitty's completely deluded on one level, her emotional radar is working. She's right to be self-conscious; she's right to feel judged. Just not for being fat.

Later that night, for the first time in weeks, Kitty will not eat her bedtime snack. Jamie's reading to Emma downstairs while I sit with Kitty in her room. Her snack tonight is four pieces of toast, with b.u.t.ter and cinnamon sugar on them-a nursery meal, one that both my daughters have loved since they were small. Kitty takes one tiny bite and spits it out, and the demon is back, with its infantile, singsong voice and vicious words.

I've learned by now that there's no point in arguing. Words seem irrelevant, so much more fuel for the self-loathing and despair. Usually the demon runs down eventually, but not tonight. Not-Kitty rants on and on, possessed by a manic energy, pacing, practically leaping around her room. I take hold of her shoulders, both to comfort her and to stop her frantic motion. The toast lands on the floor, and I don't want to leave her to make another batch.

"Come on, Kitty, you can do this," I encourage, but she gives no sign of hearing me. Jamie opens the bedroom door, holding a bottle of Ensure, bless him. "OK, you don't have to eat tonight," I tell her. "Just drink this."

She knocks the bottle out of my hand, spraying its sticky contents all over herself, me, and the floor, and begins. .h.i.tting herself in the head with her closed fist.

Jamie grabs for her wrists. "Kitty! Stop it!" I shout. My words are tiny feathers in a blizzard of hail. I plead. I threaten. I tell her if she doesn't eat or drink the Ensure we'll take her back to the hospital for the feeding tube. She flails and shrieks, and even though I'm right up in her face I don't think she can hear me.