I was not designed to be a skinny kid. I was a round one. I don't know why I succumbed to anorexia nervosa. Maybe it was because I was a perfectionist? Because my mother got sick with depression? Because I found the speed at which I was growing up alarming and wanted to rein it all in?
Anorexia nervosa means "loss of appetite", which is a misnomer. I never lost my appetite. I ignored it - even though it complained loudly from the pit of an increasingly shrunken stomach.
It is an illness characterised by a distorted body image and subsequent abnormal eating patterns. After nearly four years, at the age of 17, I was exhausted by the lack of food and my strict, self-imposed eating regimen. I realised I wanted to be well more than I wanted to be thin. If that meant being 51kg and not 38kg, I'd take the risk. Even when you don't eat, you still grow up.
Gabrielle Tuscher, a Hong Kong child and adolescent psychologist and eating-disorder specialist, says anorexia is a complex mental health disorder driven by a number of factors including genetics, environmental influences and personality traits. "What drives one person's illness does not necessarily drive another's," she says.
Perfectionism and the need for control are usual symptoms in most anorexia sufferers, Tuscher says. "Where other aspects of their lives and self are out of control or emotionally overpowering, the body and food become a space for the sufferer to have structure and a false sense of safety and control.
"It allows the individual to halt feelings by focusing on another distraction [like food and the body], but ironically all the person does is feel. It is never about weight, your body or food - it only presents itself this way. The underlying factor, as with all eating disorders, is seeking an identity of self."
It's not just girls and young women that suffer; both genders are susceptible. "Because it's seen as a 'female disorder' many males suffering do so in silence and never seek help for fear of stigma," Tuscher says. Nor is it an illness that affects only the young; some people sustain their eating disorders into old age.
While this illness physically and visibly affects the body, anorexia is essentially driven by the brain. Tuscher describes the brain as "the organ that silently suffers the most and is also disregarded the most".
"In care, we do not address treatment recovery as weight recovery - it is brain recovery. Brain atrophy [a loss of neurons and the connections between them] occurs through starvation. When you starve, the brain starves as well. But for brain recovery to occur, which is what will sustain full recovery, the body obviously needs to be weight-restored."
A brain that is battling starvation will not be well enough to support a sufferer through recovery because, as Tuscher explains, "the brain matter literally breaks down and hence all perception is affected, even vision is distorted due to changes in living in such an anxious, starved state".
Once an individual recovers, a CAT scan shows that full recovery in the brain matter is possible, Tuscher says.
White matter - essentially the brain's subway that conducts, processes, and sends nerve signals - recovers faster than grey matter, the regions of the brain involved in muscle control, and sensory perception such as seeing and hearing, memory, emotions, speech, decision making, and self-control. The grey matter will still be lacking within the first year, Tuscher says. Within three years, though, all brain matter will be restored - as long as the individual is fully recovered.
Helping someone in their recovery is a delicate task. The cycle of denial and deceit, and frequently withdrawn and angry behaviour that is characteristic of any person with an eating disorder, can drive away those who care about them, leaving parents and friends bewildered and at a loss as to how to help.
Love and support are essential in rebuilding their self esteem and bringing them back to health. Although there is no single solution to the difficult situation an eating disorder can provoke, families and friends are the best allies a young person has. The most effective remedy is to have friends, family, professionals and counsellors working together.
Parents must give up control, says Tuscher. "This is not something they can fix, nor is it being done 'to them', though it may feel that way. The distress and frustration they feel is their sense of feeling unable to fix their child. They cannot. They need to recognise that this is a serious illness."
The parent's job is to support, love and nurture the child through the illness while the child does the work of getting well. Familial dysfunction plays a huge role in eating disorders. So recovery is also about ensuring the parental space is one of understanding and support, and is safe and never judgemental, Tuscher says.
Eating disorders are not about weight, nor their body or food. They just present that way in symptoms. Keep that in mind and focus on how the child is feeling.
ANOREXIA THROUGH A SURVIVOR'S EYES
Anna, now a surgeon in her late 40s, left Hong Kong to study medicine at university in the United Kingdom. She had developed anorexia in secondary school, and it grew worse at university. Fully recovered for two decades, she recounts her struggle with the illness.
"I became anorexic at 15, and suffered for nine years. I was very shy when I was young and struggled with low self esteem and anxiety. I was often told I was beautiful, sweet, perfect - and, yet, never felt good enough," she says. "At 15, my twin brother and my father died, and my world collapsed. They were my everything and I was left with a mother who barely saw me and focused all her attention on her perfect other child.
"I collapsed into the eating disorder and it overcame my entire being. I didn't care what happened to me. My life was gone. I dove head first into trying to claw back some level of control and [to] do everything I could not to feel. My weight plummeted to 35kg at 165cm, as I purged. I swallowed laxatives by the handful, cut my arms, my face, exercised relentlessly and did as much cocaine as I could manage. I think I just wanted to not wake up, to be with my dad and brother.
"My mother couldn't handle my illness, as she had lost so much already; I had to be the strong one for her. She never knew how to help me. My other brother had no patience or sympathy with my condition and said I was doing it on purpose. My friends were there but couldn't help me and slowly pulled away. So I was on my own.
"In the end I recognised I was sick and that life had to be something better than this. So I told myself I would try to get better; what was the worst that could happen? I made the decision to finally deal with my father and brother's deaths and all the grief and trauma. I decided to fight for me, to let go, to live and to heal. And I did. It was a painful process but worth it.
"People suffering with an eating disorder need help. Those in their lives need to educate themselves, to listen, to understand that an eating disorder is never about your body or what you do or don't eat. It's about having no sense of self. It's being trapped in abuse and trauma and change, with no self love and no self worth. It drives the sufferers who have no control over it. See beyond what we look like or don't look like. See us for our pain. Ask. Listen. Support. Don't judge. The more you shame us, the more we seek solace in our pain."
For information and support on eating disorders in Hong Kong, contact the Hong Kong Eating Disorders Association on 2850 4448 or email email@example.com.
This article was first published in South China Morning Post.