Brave Girl Eating_ A Family's Struggle With Anorexia Part 8

Dr. Beth makes me feel like we're doing OK. So many of the doctors and therapists we've seen since this began have exuded some level of blame or anger or annoyance-toward us and toward Kitty. Even when their words are neutral-Anorexia is no one's fault, it's a biological illness-their body language, the look in their eyes, convey a subtle sense of criticism. It strikes me that both doctors and ordinary people project all kinds of judgments, feelings, and desires onto people with eating disorders. Since getting sick Kitty has been both admired and scorned for her perceived stubbornness, envied for her emaciation, belittled for her feelings. The praise she's received for her extreme thinness comes with a dollop of prurience, a sense that she's accomplished something both meaningful and shameful.

I don't believe anorexia is a response to environment, but I do wonder about its relationship with culture. Once you develop anorexia you become not just a person with an illness; you come to represent something here and now, in this time and place. You become the anorexic, your ident.i.ty inextricable from the illness. Other diseases have carried a sense of stigma and judgment over the years-cancer, for instance, which was rarely mentioned or discussed when I was growing up. People with cancer felt a sense of shame and isolation, as if they were to blame for their illness.

But the stigma of anorexia, bulimia, and other mental illnesses goes beyond that. Even the way we talk about them is different. People with eating disorders lose their ident.i.ty; they become anorexics anorexics or or bulimics bulimics. We conflate them with the disease, as if whoever they were before the illness disappears when they're diagnosed. Whereas there's no one word to define someone with cancer or heart disease. A patient with lymphoma isn't a lymphatic; he or she retains a sense of individual ident.i.ty. It's a small point, but it matters, because language shapes the way we think about the world. Calling someone "an anorexic" suggests that anorexia is all there is to her, that it is is her and always will be, that there is no extricating the person from the disease. her and always will be, that there is no extricating the person from the disease.

Sometimes, while Kitty is at school or asleep, I take out our photo alb.u.ms, filling my eyes with her face and body and essence before: Age eleven, standing in front of Lake Superior, pants rolled up, beside Emma, each of them holding up handfuls of rocks collected along the beach. Age three, on the dock of the house we rented in northern Wisconsin that summer, grinning beside her friend Cinda, a bulky orange life preserver around each of their necks. Age four, holding a newborn Emma, her blond hair falling protectively over the baby in her lap. Age nine, sitting at my mother-in-law's kitchen table, totally focused on a stack of homemade pancakes.

I won't mistake the disease for my daughter. I will remember Kitty as she was before anorexia and as she will be again when it's gone.

I know I'm hypersensitive about this. What I want is for people to treat Kitty as though she's not just another anorexic, one of the thousands who say the same things and look the same way and struggle with the same compulsions. I want people to see the girl beyond the disease, with her habits and charms and failings. Her Her idiosyncrasies, not anorexia's. idiosyncrasies, not anorexia's.

But Kitty seems to feel relief at meeting other kids with eating disorders. She comes home from Ms. Susan's first lunch group practically gushing. "No offense, but you guys don't know what it's like," she tells me. "Mom, they really get it."

I'm standing at the kitchen counter, scooping Haagen-Dazs into the milk-shake maker a friend sent over. "Honey, I'm so glad," I tell her.

Kitty leans against the doorjamb, staying outside the kitchen as I prepare her food. "They totally get it," she repeats. "I can be myself around them."

I want to ask, Which self? Which self? But I'm afraid of what she might say, or imply. I don't want her to take on the ident.i.ty of But I'm afraid of what she might say, or imply. I don't want her to take on the ident.i.ty of anorexic anorexic. Maybe it's inevitable. Maybe, in fact, it's already happened, and I'm trying to close the barn door after the horse has galloped off. Still, one of the reasons I look forward to our appointments with Dr. Beth is that she seems to see beyond the disease. She talks to my daughter as if Kitty is an ordinary teenager. She asks about school and friends, boyfriends and movies. She brings a feeling of joy into the exam room, the joy of ordinary life, which we all have been missing for months.

Over the next few days, Kitty brightens visibly. Maybe cutting back on the meds helped. Maybe it's the new lunch group. Or maybe it's the weight gain. She seems engaged with the world in a new way. Or, rather, an old way, one we haven't seen since last winter. She tells me she's going to join Latin Club; Latin's her favorite cla.s.s, because she loves the teacher.

A few days later, as I walk Kitty up the hill to school, I ask, "How was Latin Club yesterday?"

Silence. Then she says, "I didn't go."

"Why not?"

Her eyes fill with tears. "Because they serve brownies at the meetings," she says. "And I would want one, but I'd be afraid."

"Afraid of what?" I think I know the answer, but I want to hear what Kitty says. Sometimes she seems incredibly unaware of how she's feeling and acting. I wonder how she sees things in moments like this, when the demon has subsided below the surface.

"If I choose to eat something I don't have to, then I'm bad," she explains. If I choose to eat something I don't have to. If I choose to eat something I don't have to. Anorexia is a prison sentence for a crime you didn't commit, a crime that fills you nevertheless with guilt and dread. Anorexia is a prison sentence for a crime you didn't commit, a crime that fills you nevertheless with guilt and dread.

I look at Kitty, pride and sorrow welling up in my heart. Sorrow over the claustrophobic, obsessive world she inhabits, and pride at her astonishing candor. These dispatches from the land of anorexia take a kind of bravery few people understand.

"You could go to the meeting and not eat anything," I say, but she shakes her head, and I understand: Not yet.

The next day I get another lesson in just how hard things are for my daughter, when we go downtown to do errands. As we walk by a new Ben & Jerry's store, she says, "If I were required to have another snack today, I would want to have it in here."

I open my mouth to say "What?" and then close it again. I pick up on her cue. "You know, I've been reviewing your day's calories, and you need an extra snack this afternoon," I tell her.

I expect her to say no, despite the invitation she's extended. Instead, she pushes open the door and goes inside, where she spends five minutes deliberating about what to eat-not freaking out, not panicking, but deciding what she's in the mood for.

I have a good idea of how many calories Kitty's eating every day-between twenty-five hundred and three thousand-and so far today she's on track. I'm astounded by the fact that the harsh taskmaster that flays her with guilt and fear and misery could be rendered harmless by such a transparent charade.

But this charade only strengthens my instinct that Jamie and I are at war with the voice in Kitty's head, the one that tells her not to eat, that she's fat, that she's loathsome and worthless. We hear only a fraction of its awful words, but Kitty gets up with it in the morning and goes to sleep with it drumming in her ears. We sit in Ben & Jerry's and I watch her dip her wooden spoon again and again into a dish of frozen yogurt. Her face is open and unguarded and, yes, happy. I'm struck by the power of words-in this case, my words, which have rendered the voice in Kitty's head mute and harmless. For the moment.

And I am amazed and grateful that this is so. All my life I've heard people say that love is powerful. This is the first time I deeply, truly believe it. Love can overcome the demon-for the moment. I know it will come back, in ten minutes or an hour or a day. The demon's voice will roar in Kitty's ears and spew out of her mouth and nothing we say or do right then will make it stop. But there will be other moments like this one, when our voices drown its insidious refrain. More and more moments, I hope, until, like the Wicked Witch of the West, the demon melts away.

I know that time is a long way off. I know the trouble is still now and the happy ending is yet to come. Earlier today I saw my doctor for a physical. When she walked into the room, I surprised both of us by bursting into tears. It felt good to cry; these days I am mostly numb and disconnected. I can't afford to feel pain because once it starts it might never stop, and then what good would I be to anyone? There will be plenty of time to process all this later. After Kitty's recovered. When, When, not not if if.

In fairy tales there is often a cleansing ritual, a symbolic expunging of dangerous magic. I want there to be a ritual for us. I want to walk through the house with a bundle of burning sage, a braided candle, a stick of incense. I want to wipe away the confusion and misery and suffering. But for rituals to work, you have to believe in them. And I don't. I believe in the marriage between the mind and the body, thought and feeling. I believe in the body's need to be nourished and the mind's ambivalence about doing it. I can't afford to feel powerless and helpless; that's a luxury, that kind of thinking, and it won't help Kitty one bit.

That night I sit with Kitty as she gets ready for sleep. Six months ago she would say goodnight and close her door, and that was that. Since the anorexia, we've resurrected our old bedtime routines. Now she lies on her stomach and hikes up her pajama top, and I put my hand against her back. I can still see the knotted rope of her spine, but now the vertebrae are covered with smooth flesh. Three months ago, I hated feeling the rude skeleton protruding through her icy skin. The claws of her hands. Touching her left me bruised and anxious.

With the tip of my index finger I trace letters against the warm skin of her back: I. L. O. V. E. Y. O. U. We started this ritual when she was learning to read, when putting letters together into words was a magic act she never tired of.

After a while I get up. "Don't go," says Kitty. "Don't leave me all alone."

"I won't," I say, easing myself down on the bed again. "You know I won't."

By the third week of September, Kitty's weight has plateaued. Jamie and I confer with Ms. Susan and raise her calories to thirty-five hundred a day. That's a lot of food. of September, Kitty's weight has plateaued. Jamie and I confer with Ms. Susan and raise her calories to thirty-five hundred a day. That's a lot of food.

Eating large amounts upsets Kitty's stomach-eating any amount seems to upset her stomach, actually-so we try to reduce the volume and make sure everything she eats is calorie efficient. Our kitchen becomes High-Calorie Central; Paula Deen is my new literary muse. We go through so many sticks of b.u.t.ter that I dream about unwrapping them in my sleep, peeling back the translucent paper, dropping them one by one into an enormous metal bowl.

Which leaves Kitty with a meal plan something like this: Breakfast: a large bowl of nutty granola mixed with vanilla yogurt and raspberry jamSnack: a high-calorie protein barLunch: a large sesame bagel slathered with 3 to 4 tablespoons of almond b.u.t.ter; chips; a piece of fruitSnack: a milk shake made with 2 cups of Haagen-Dazs ice cream and a little milkDinner: a large serving of whatever we're having; bread and b.u.t.ter; milkSnack: three or four pieces of toast, b.u.t.tered and sprinkled with cinnamon sugar; or a large (4 to a pan instead of 12) pumpkin chocolate chip or banana nut m.u.f.fin One of the challenges in refeeding Kitty is the fact that she feels no hunger. So she says, and I believe it. It's still there-coming out in her continuous and obsessive thoughts about food, her need to plan every bite-but her brain and her body have become disconnected when it comes to eating, which makes sense in a way. If starvation is a function of, say, famine or war, if there's no food available, then constant hunger pangs would be a pointless torment. Loss of appet.i.te, in that case, is both a blessing and a self-defense mechanism.

Hunger is a function of a complex set of chemical interactions we don't yet understand, involving hormones like ghrelin, which is produced in the stomach and makes its way to the brain, rising before a meal to trigger eating. People with acute anorexia have high levels of ghrelin. Another hormone connected with hunger is leptin, made by fat cells, which tells the brain you've eaten enough, shutting down hunger. People who have lost weight have low levels of leptin, which pushes them to eat more.

We need hunger in the same way we need pain: a stimulus that makes us behave in ways that preserve ourselves and our species. Without hunger, eating is a ch.o.r.e dictated by the clock, a literally unpalatable task to check off a list. Eating without hunger can feel punitive, the introduction of foreign matter into a body that does not welcome it. It's easy to forget to eat without the relentless goad of stomach pangs, when food doesn't look or smell good.

And hunger does more than just get us to the table. It determines, in part, how we metabolize what we eat. In the late 1970s, Swedish researchers fed two groups of women-one Swedish and one Thai-a spicy Thai meal. The Swedish women absorbed only about half as much iron from the meal as the Thai women. When the meal was mushed up and served as a paste, the Thai women absorbed 70 percent less iron than they had before-from the same food.*

The researchers concluded that when we eat a meal that's unfamiliar or unappetizing, we don't get as much nutrition out of it as we otherwise might. Why? Because some of the digestive and metabolic processes don't take place in the gut. The smells, looks, and sensory gestalt of a meal we're looking forward to trigger a series of processes in the brain, which in turn tells the salivary glands to kick into high gear, producing more saliva, and the stomach to secrete more gastric juices, both of which help digest the food.

Maybe this explains, in part, why it's so hard for Kitty to gain weight. Maybe refeeding is not just a matter of calories in, calories out; maybe the antic.i.p.ation and experience of eating helps determine how much of the meal Kitty's body hangs on to. In which case this process is going to take a long time.

Physically, Kitty is making progress. Slow progress, but still. Mentally-that's another story. At Dr. Newbie's urging we start her on Zyprexa, a new-generation antipsychotic, and after two days she perks up, acting like herself again, with a certain alertness and outward-looking perspective that's been gone for months. She says she feels better too, that she still has all the anorexia thoughts but the guilt isn't as strong. Unfortunately, she develops a side effect called akathisia-jitteriness, agitation, and anxiety-and Dr. Newbie says we have to take her off the Zyprexa, that the anxiety will intensify to unbearable levels. When I tell Kitty, she protests, "But it makes the voice get quieter." The voice in her head, she means. The voice of the demon.

I'm frustrated enough to cry. This is the only medical intervention that's helped Kitty at all, and now she can't take it. No shortcuts; we'll have to do this the hard way.

When I look back even a month, though, I see how far Kitty's come. Dr. Beth agrees. At our weekly appointment, Kitty asks when she can stop trying to gain weight and go on a maintenance diet, and Dr. Beth says, "Now!" When she heads down the hall to get something, I follow her out.

"I thought Kitty had to gain another ten pounds or so to reach her target weight," I say.

"I think she can gain weight more slowly now," says Dr. Beth. "Maybe a quarter pound a week."

A quarter pound a week? I think about how long it took to get Kitty started gaining weight. I don't understand why Dr. Beth wants us to slow down now that she's actually got some momentum. Why go back to prolonging the misery?

"I've seen people overshoot their goal, and that wouldn't be good," she explains.

I want to ask, "Why not?" But I'm conscious, suddenly, of the fact that I weigh thirty pounds more than the charts say I should. Self Self-conscious. I don't want to hear Dr. Beth say, "Because I don't want her to be fat like you."

To be fair, I have no idea if that's what she's thinking. What I'm I'm thinking is, Wouldn't it be better for Kitty to be a little "over"-whatever that means-than to chance falling down the rabbit hole again? We know the risks of her weighing too little; what, exactly, are the risks of her weighing five pounds "extra"? thinking is, Wouldn't it be better for Kitty to be a little "over"-whatever that means-than to chance falling down the rabbit hole again? We know the risks of her weighing too little; what, exactly, are the risks of her weighing five pounds "extra"?

I don't say any of this, partly because I feel such self-consciousness. Instead, I tell Dr. Beth that I think Kitty heard the words "You don't have to gain any any more weight" and ask her to clarify. When we go back into the room, Dr. Beth tells Kitty she can up her activity level a bit and stay at the same calorie count. "So your weight gain will slow down," she says. This is still a mixed message; for the last month we've been telling Kitty that she's going to feel better when she's gained enough weight, that our goal is to get her there as quickly as is practical and possible. We've told her to hang on, that things are going to get better. Now she's hearing, more or less, this is it. This is as good as it's going to get. I see the ambivalence on her face: the anorexia thinks this is fabulous news-you can stay thin! The part of Kitty that's not thinking like an anorexic is not so sure this is a good idea. more weight" and ask her to clarify. When we go back into the room, Dr. Beth tells Kitty she can up her activity level a bit and stay at the same calorie count. "So your weight gain will slow down," she says. This is still a mixed message; for the last month we've been telling Kitty that she's going to feel better when she's gained enough weight, that our goal is to get her there as quickly as is practical and possible. We've told her to hang on, that things are going to get better. Now she's hearing, more or less, this is it. This is as good as it's going to get. I see the ambivalence on her face: the anorexia thinks this is fabulous news-you can stay thin! The part of Kitty that's not thinking like an anorexic is not so sure this is a good idea.

I'm with her.

This will happen again and again over the course of the next seven months: not just Dr. Beth but Dr. Newbie and every doctor we see will be quick to tell Kitty that she can back off, not gain any more weight, based on the numbers on the chart. No one asks whether she still has anorexic thoughts and feelings. No one asks us us what her behavior's like, how hard it is for her to eat. They tell her she's fine when we can see clearly that she's not. what her behavior's like, how hard it is for her to eat. They tell her she's fine when we can see clearly that she's not.

Once more I think of Daniel le Grange's comment about how anorexia seems to infect everyone around the sufferer too. And I can't help but wonder how much the current angst about obesity and the general culture of fatphobia affects doctors' att.i.tudes. Still, we're lucky to have our treatment team, even if I don't agree with everything they recommend. Today, for instance, toward the end of this appointment, Kitty asks if she can fast on Yom Kippur, two weeks away. I hold my breath, wondering what Dr. Beth will say.

What she says is just right: "That would not be a good idea for you, Kitty."

"But all my friends will fast, and I'll feel awful if I don't," says Kitty. "How about if I just eat lightly?"

"Nope," says Dr. Beth. Thank G.o.d.

In the end, the nagging sense of unease I have about Kitty's target weight is resolved in the best possible way: she begins to grow. By the end of September she's half an inch taller, which means her target weight goes up too. For the moment, anyway, we're back to straightforward refeeding. Spare no calories. Full steam ahead.

chapter seven

In Which We Take On the Insurance Company, and Lose

It wasn't simply that I chose not to eat; I was forbidden to. Even thinking about forbidden foods brought punishment. How dare you, this voice inside me would say. You greedy pig.

-ANONYMOUS ANOREXIA SUFFERER, quoted in an online "thinspiration" video

Every family deals with anorexia in its own way, just as each family deals with-well-everything in its own way. One of the long-standing arguments for the screwed-up-psychodynamics theory is that by the time families get to treatment with an anorexic teen, they tend to look rather similar: resistant child, angry/worried/overwrought parents. Lots of tension, especially around meals. Lots of frustration expressed on all sides, especially around meals and eating. Lots of criticism, also related to food and eating. anorexia in its own way, just as each family deals with-well-everything in its own way. One of the long-standing arguments for the screwed-up-psychodynamics theory is that by the time families get to treatment with an anorexic teen, they tend to look rather similar: resistant child, angry/worried/overwrought parents. Lots of tension, especially around meals. Lots of frustration expressed on all sides, especially around meals and eating. Lots of criticism, also related to food and eating.

But this h.o.m.ogeneity is superficial. There's no better way to see what a family's really made of than to go through the process of refeeding. Anorexia and its horrors can highlight every little crack in the mirror of a family's self-image; it can also take a hammer and smash the whole thing to bits.

In their 1994 book Helping Families Cope with Mental Illness, Helping Families Cope with Mental Illness, psychiatrist Harriet P. Lefley and professor of social work Mona Wasow write: psychiatrist Harriet P. Lefley and professor of social work Mona Wasow write: Families [struggling with mental illness]...must deal with disrupted household routines; time investments in negotiating the mental health, housing, social security, and sometimes the criminal justice systems; impaired relations with an unsympathetic outside world; financial burdens; psychological and career impact on other household members, and difficulties in finding alternatives to hospitalization.... Families must learn to cope both with the patient's behavior and with their own reactions; to balance the patient's needs against those of other family members; to perceive when expectations are too high and too low; and to know how and when to set limits. They must deal with unwarranted guilt feelings, learn to handle their anger, tolerate the suffering of people they love.*

I cringe at the label mental illness. Yet there's truth here. Janet Treasure, a psychiatrist at the Maudsley Hospital in London who specializes in treating eating disorders, says that caring for a child with anorexia is just as stressful as caring for a child with schizophrenia or other serious psychiatric disorders.

I believe it. Taking care of Kitty has been the hardest thing our family has ever gone through. Harder than both girls' colicky infancies. Harder than my bout with postpartum depression after Emma was born. Harder than surviving the ups and downs of the freelance world, or the week Emma spent in the hospital with Kawasaki disease.

It's harder because the range of emotions is so much greater, and because the literal exigencies of this process are so complex. There's the denial at the start, followed by dawning comprehension, shock, and horror. There's shame and self-blame, guilt and doubt. There's anger and frustration. And then there's the sheer exhaustion, physical and emotional, of battling a force you can't physically touch and don't understand.

I know families who put a child into residential care because they need a break, and I don't think badly of them for it. "For a year and a half, anorexia consumed our whole family," one mother tells me. "We had a bit of breathing room when she was away. Time to think." I can't imagine sending Kitty away and being able to relax. But I also can't imagine dealing with the demon every day for a year and a half.

And then again, the fallout isn't entirely negative. There's a growing movement toward involving families more in the mental health treatment for their children, whether they're dealing with bipolar disorder, eating disorders, depression, or autism. The days of experts "fixing" a child-or attempting to "fix" the child-are over. This isn't to say that families should go it alone without professional help. But part of the pleasure as well as the burden of being a parent is engaging with your kids, no matter what's going on with them. Caring for Kitty now-despite the demon-feels more satisfying than watching her starve and not being able to do anything about it.

The events of the last few months have taught me a lot about our family's strengths and weaknesses. On the plus side, we've practiced attachment parenting from the start, and both Kitty and Emma seem to trust us. In times of trouble, they tend to turn toward the family rather than away. We know them, and each other, pretty well. We're a communicative family, and I think we do OK at expressing feelings and listening to one another. That was one of Hilde Bruch's critiques of "anorexigenic" families, families that produce (in her view) children who must resort to anorexia in order to express themselves. Bruch believed that families like ours shut down their children's true feelings and engender a kind of intimacy based on falseness and superficiality.

I'm ready to take the blame for anything I've done that might remotely have harmed either of my daughters. But on this point, I think Bruch was wrong. Both Kitty and Emma have been enthusiastically telling us how they feel and what they think from the time they learned to talk. For the most part, we've been listening. Not perfectly or all the time, but consistently and enough. More than many parents.

I sound defensive, I know. Like so many of my generation, I grew up in a household where children were supposed to be seen and not heard. My parents brushed off my feelings, telling me that if I just stopped thinking, everything would be all right. Maybe they didn't know what else to do; maybe that's what their their parents had said to them. But I grew up determined to parents had said to them. But I grew up determined to listen listen to my children, even if I didn't want to hear what they said. to my children, even if I didn't want to hear what they said.

Another of our family strengths is the fact that Jamie and I have very different temperaments. I'm quick-sometimes too quick-to take action and rush to conclusions; he's a think-about-it-from-all-angles kind of guy. I'm loquacious; he's more reserved. I like to-need to-talk things through, while he's more private. He processes situations slowly; I tend to leap first, ask questions later. I'm empathetic, sometimes overly so, while he maintains more of an emotional distance. At times these differences have proved problematic for us as a couple. But they've made us more resilient and resourceful parents. to-talk things through, while he's more private. He processes situations slowly; I tend to leap first, ask questions later. I'm empathetic, sometimes overly so, while he maintains more of an emotional distance. At times these differences have proved problematic for us as a couple. But they've made us more resilient and resourceful parents.

For instance, when we started this process of refeeding Kitty-only seven weeks ago?-I researched anorexia, came up with the plan to do family-based treatment, got things rolling. Jamie was slower to come to terms with what was happening. He got frustrated and angry more often than I did. "Why can't she just eat?" he would ask me in the privacy of our room. "I just can't understand this disease." I didn't understand it either, but I didn't need to. I was focused on the next step, and the next. What did we have to do today? Tomorrow?

Now, however, we've switched roles. I'm the one who often loses patience first, who paces or frets when the demon emerges. I'm restless, always in motion; I clean and tidy obsessively and still have too much anxious energy at the end of the day. Jamie can sit with Kitty indefinitely as she weeps or rages. He's the calm and steady presence these days. On one of Kitty's bad nights not long ago, Jamie took her upstairs while I stood in the middle of the kitchen, overcome. I picked up a dirty plate, to load it into the dishwasher, and instead hurled it at the floor, where it smashed in a satisfying spray. It was so satisfying, in fact, that I broke three more. The only thing that stopped me was remembering that Kitty needs big plates. She'd freak out if I served her food on small plates, because it would look like she was eating so much more.

Jamie would never have broken plates on the kitchen floor.

On the other hand, he's less a.s.sertive about what and how much Kitty eats. He's hesitant to push for more and often holds back instead of actually dishing out the food and requiring her to eat. The concept of counting calories in either direction is strange to him; that and his natural reticence make him hesitant to plunge in.

If Kitty gets well, all the struggles and suffering will have had a purpose, and the hardest thing we've ever done will also become the most important and most satisfying thing. And if Kitty doesn't get well?

I can't, I really can't imagine that.

One morning in early October, when I collect the mail, I see an envelope from Kitty's school. I open it absently, thinking it's a progress report. Instead, Kitty's school picture stares up at me, taken the day she registered for school, nearly two months ago. It's shocking to come face-to-face once more with her huge, shadowed eyes, the exhaustion and despair written on her gaunt face. I slide the photo back into its envelope and bury it at the bottom of a dresser drawer. This is one school photo that's not going up on top of the piano. October, when I collect the mail, I see an envelope from Kitty's school. I open it absently, thinking it's a progress report. Instead, Kitty's school picture stares up at me, taken the day she registered for school, nearly two months ago. It's shocking to come face-to-face once more with her huge, shadowed eyes, the exhaustion and despair written on her gaunt face. I slide the photo back into its envelope and bury it at the bottom of a dresser drawer. This is one school photo that's not going up on top of the piano.

But I'm also encouraged by this glimpse of how much progress Kitty's made in the last six weeks, progress it's hard to see on a day-to-day basis. Before anorexia, I tended to think about time in chunks-this week, this month, this season. This day. Now time has telescoped down into the intervals between Kitty's meals and snacks. Each takes on its own character and rituals. Midmorning snack, for instance, which these days often comprises several slices of toast with cream cheese. Kitty arranges them on a large plate and methodically cuts them into squares with a knife and fork. She spears them, one at a time, and slowly chews them. It takes her twenty minutes to consume three slices of toast. Which feels like a long time when I'm sitting at the table with her, b.u.t.tering my own toast (I've learned the best way to keep her eating is to eat along with her), but which is only half the time it took her to eat the same snack two weeks ago.

Progress. I'll take it.

Each day has its rhythms, too. Eating seems easiest early in the day for Kitty, both physically and mentally. As the afternoon wears on she complains of stomachaches, indigestion. She bargains and pleads. The demon is far more apt to make an appearance between, say, five o'clock and bedtime than earlier in the day.

She's particularly resistant to the daily milk shake, asking why she can't have a smoothie instead. "Peaches and yogurt sounds delicious," she says, and I'm tempted, because it's such a pleasure to hear her say that any kind of food sounds delicious. But a peach smoothie is three hundred calories, tops, while a Haagen-Dazs milk shake is about a thousand. Kitty swears it's not the calories; she just prefers the taste of a smoothie, honest.

We tell her no, sorry, milk shakes are a must. I ask Dr. Beth to "prescribe" a daily milk shake, and that helps. A little.

For many kids, the descent into anorexia begins with restrictions that could be reasonable. Vegetarianism, for instance. I was a vegetarian for fifteen years; I'm certainly not wedded to the idea of eating meat. But I've heard too many stories about teens who go meatless (and often vegan) right as they're developing an eating disorder. Coincidence? I doubt it.

I'm convinced that Kitty's preference for smoothies over milk shakes comes from the anorexia, not from her natural tastes. But when, exactly, did the shift begin? I think again of the sixth-grade "wellness" cla.s.s that inspired her to cut out desserts. I bet other kids in that cla.s.s cut back on sugar for a day or two, but Kitty's probably the only one who stuck to her resolution for weeks and weeks. Was that the beginning?

Years ago, Walter Kaye discovered lower-than-normal levels of the neuropeptide galanin in the brains of people who'd recovered from anorexia. Galanin is a kind of amino acid made by the brain, and its role is to stimulate an appet.i.te for fat. Low levels of galanin likely lead to an aversion to eating fat. I wonder how long the subjects in his study had been recovered. Six months? A year? Ten years? I wonder if levels of galanin ever recover. Or is it possible that people who go on to develop anorexia make less galanin in their brains from the start?

Will Kitty's tastes change back, once she's recovered? Will she ever dig in to a plate of sesame chicken with the same innocent pleasure? Will the eating disorder rob her of her original appet.i.tes? Or is that loss part of growing up in this culture-acquiring guilt and anxiety over every bite we put into our mouths? So many women eat the way Kitty does, avoiding fat and calories; do they do it out of a wish to be thin, or true preference?

A few years ago, researchers identified a fat receptor protein known as CD36, found on the surface of human cells and throughout the body, including on the surface of the tongue. Recent research done by Nada Ab.u.mrad, a professor of medicine at Washington University School of Medicine in St. Louis, suggests that some people may naturally have higher levels of CD36, which may lead to a taste (and even a craving) for fat. Maybe people like Kitty who develop anorexia are born with lower levels of CD36. Maybe the disease process of anorexia alters levels of these fat receptors. Or maybe anorexia masks Kitty's true tastes.

Whatever the cause, what I want to know is simple: Will she ever again eat the way she used to?