Andy Warhol Was a Hoarder (13 page)

Cultural pressure alone, however, does not cause eating disorders. Millions of people are subject to skinny fashion obsessions and unobtainable standards of “beauty” every day—but only about one percent will become anorexic, and 2 percent will develop bulimia over a lifetime. As scientists explore the psychological and biological roots of eating disorders, they are beginning to unravel a slew of contributing factors. Like other mental illnesses, eating disorders are triggered by a complex interplay of individual
psychological characteristics, genes (probably hundreds), and environment. Studies have found that eating disorders are at least 50 percent “heritable,” which means that you are more likely to develop an eating disorder if it runs in your DNA. Diana, it turns out, was not the only one in her family to suffer: Her sister Sarah battled anorexia in her 20s, at the very time that she was dating Prince Charles.

The significant influence of genes negates the oft-held judgment that people with eating disorders are solely responsible for their illnesses—that they make a decision to starve themselves or overeat. The reality is far more complex. “No one would choose to have an eating disorder,” says researcher Bulik, who is conducting a global study to identify the genes involved in anorexia. “We need to emphasize the genetic and biological piece more, in order to dismiss old myths that eating disorders are somehow a choice.”

Although anorexia and bulimia manifest differently, they share some key characteristics. A significant number of people experience “diagnostic flux,” says Bulik, meaning they cross over from one disorder to the other, suffering from anorexia at one point in time and binge eating and purging at another. Eating disorders are far more common in women than in men; data suggest that the hormonal shifts associated with puberty may play a role in female vulnerability, says Marsha Marcus, a professor of psychiatry and psychology at the University of Pittsburgh School of Medicine. Anorexia and bulimia are also strongly associated with other mental health disorders. As many as 50 to 70 percent of patients with bulimia will suffer from depression at some point in their illness, and many will struggle with different forms of anxiety as well.

In many cases, mood disorders come first and are a pathway to illness. Once anorexia or bulimia set in, underlying symptoms of depression and anxiety can be perpetuated and even exacerbated.
Diana openly discussed her ongoing feelings of frustration, inadequacy, sadness, and fear—all symptoms of both depression and anxiety. It wasn't just the turmoil going on within the walls of the palace that challenged her. After her many visits to sick and dying people around the world—work she savored—she was often unable to soothe herself, and resorted to eating. “I'd come home and it would be very difficult to know how to comfort myself having been comforting lots of other people, so it would be a regular pattern to jump into the fridge,” she said.

People with bulimia—officially classified as a mental health disorder in 1980—are especially likely to struggle with impulsivity, often resorting to risky behaviors without considering the consequences. This is evident in their inability to stop eating during a binge, but can also manifest as alcohol abuse, drug abuse, shoplifting, promiscuity, and self-injury. Princess Diana resorted to hurting herself multiple times; in interviews, she admitted to throwing herself down the stairs while pregnant with William, running around with a lemon knife with serrated edges, and intentionally cutting her arms and legs.

Patients may resort to cutting as a form of self-punishment or as a physical release of internal misery. Diana depicted her behavior as an attempt to make her anguish known and to be rescued from it. Unlike people with anorexia, who tend to look sick and skeletal, individuals suffering from bulimia can appear perfectly healthy from the outside. Diana did—and yet she wanted those around her to know what was happening below the surface. “You have so much pain inside yourself that you try and hurt yourself on the outside because you want help,” she said. “So yes, I did inflict upon myself. I didn't like myself. I was ashamed because I couldn't cope with the pressures.” One night, feeling rebuffed by her husband, whom she accused of being dismissive and abandoning her
when she was most desperate, “I picked up his penknife off his dressing table and scratched myself heavily down my chest and both thighs.”

Bulimia and self-injury together are associated with borderline personality disorder, a diagnosis that has been floated for Diana, who shared numerous characteristics of the disorder with Marilyn Monroe. Sally Bedell Smith makes an argument for a borderline diagnosis in her biography, citing Diana's mood swings, her feelings of emptiness, her impulsivity, and her struggle to find her identity. Diana openly acknowledged her experiences specifically with bulimia and self-injury, and both can exist independently of other diagnoses. At the same time, it is true that they can be features of other conditions or deeply intertwined with them. All of this underscores how difficult it can be to parse out diagnoses in every area of mental health, where behaviors and symptoms constantly bump up against each other, overlap, and merge.

In the case of bulimia, researchers are examining how one of these symptoms—impulsivity—manifests in the brains of patients. In one intriguing study, Rachel Marsh and colleagues at Columbia University scanned the brains of 20 women with bulimia and 20 without while they completed a task on a computer screen that required them to choose the direction of an arrow. In one version of the exercise, the arrows were situated on the logical side of the screen (left-pointing arrows on the left; right-pointing arrows on the right). In another version, the arrows appeared on opposite sides (left-pointing arrows on the right; right-pointing arrows on the left), making the exercise more challenging and requiring patients to think before they acted. The women with bulimia responded to the difficult task faster and also made more mistakes, suggesting that they had greater impulsivity. The scientists discovered that the frontostriatal circuits in the brain—areas responsible
for mediating self-regulation and impulse control—were underactive in the women with bulimia. These regions of the brain may actually be smaller in people with bulimia, too, perhaps contributing to patients' inability to control their behavior. Although these findings are preliminary, they raise the tantalizing possibility that the brains of people struggling with bulimia are structurally different—either because the individuals were born that way, or because the illness changed their brains over time.

Eating disorders can lead to a host of devastating health consequences, including gastrointestinal issues, bone loss, heart abnormalities, hormonal and electrolyte disturbances, and, in the case of bulimia, a ruptured esophagus from forced vomiting. Death, by organ failure or suicide, is the gravest threat of all. The main treatment for bulimia is cognitive-behavioral therapy, which teaches patients how to change their thought patterns from negative (“I'm hopeless; I'm only going to be happy if I'm thin”) to positive (“I'm a good person; my weight has nothing to do with who I am”). The therapy also provides tools for recognizing triggers and stopping the bingeing and purging cycle. Patients often receive antidepressants to treat accompanying depression and anxiety, as well as nutritional counseling, which helps reestablish healthy eating patterns.

Diana's treatment varied widely. Early on in her marriage, she was distrustful of psychiatrists, and angered when she was prescribed tranquilizers to calm her down. “She knew in her heart that she did not need drugs; she needed rest, patience and understanding from those around her,” Andrew Morton writes in his biography. To de-stress, she tried hypnotherapy, acupuncture, and aromatherapy. It wasn't until well into her illness, as late as 1988, that she finally received the help she needed to treat her bulimia. An old friend, worried about Diana's health, had threatened to go public unless Diana confided in a doctor. It was the wake-up
call the princess needed, pushing her to seek treatment from Dr. Maurice Lipsedge, the same prominent London doctor who had successfully treated her sister Sarah for anorexia years earlier. Dr. Lipsedge provided weekly counseling sessions and helped build back her self-esteem, Diana said. By 1990, her bouts of bulimia occurred just once every three weeks, down from four times a day. Her progress was “a big ‘hooray' on my part,” she recalled. When she was interviewed in 1995, Diana said her bulimia had lasted “a long time,” but it was over. “I'm free of it now.”

By then, her anguish was well known. Morton's tell-all book,
Diana: Her True Story
, was published in June 1992 and was met with a flurry of curiosity, shock, and controversy. Initially described as a collection of accounts by Diana's friends (it was only later revealed that the princess herself was the source), the book sold millions of copies and turned Buckingham Palace upside down. Diana said she relayed information about her marriage, life stresses, bulimia, and suicide attempts because “I was so fed up with being seen as someone who was a basket-case.” As secrets were aired, royal watchers, historians, and the ever-present media speculated about the collapse of the marriage—and perhaps even the monarchy. The queen called 1992 her “annus horribilis.”

In November of that year, Charles and Diana visited South Korea on their last official foreign tour together. A photograph captured them looking in opposite directions during a commemorative service to honor British soldiers killed during the Korean War—a symbolic representation of the distance between them. One month later, the British prime minister delivered the news: Prince Charles and Princess Diana were “amicably” separating. Diana heard the public report of their separation while she was at an event away from the palace and found it “just very, very sad,” she said. “The fairy tale had come to an end.” Within a few
years, Diana and Charles would both admit to infidelity in separate television interviews beamed around the world; a final end to their marriage, once unthinkable, was now inevitable. In August 1996, one month after their 15th wedding anniversary, Charles and Diana were officially divorced.

D
IANA
'
S DECISION TO TALK OPENLY
about her bulimia allowed the world to peer through the gilded windows of Kensington Palace—and to appreciate the ubiquity of mental illness. “She was human, she was admitting to her frailties,” says Arianne Chernock, an expert in modern British history at Boston University. Just as First Lady Betty Ford's openness about her breast cancer diagnosis increased screenings, Diana's candidness seemed to spur people with bulimia to seek help. A study of eating disorder trends in the United Kingdom, published in the
British Journal of Psychiatry
in 2005, found that new cases of bulimia jumped dramatically in the 1990s—even as anorexia cases remained stable—and then dropped again after Diana's death in 1997. The authors speculated that intense press coverage of Diana's experience might have contributed to the increase by raising public awareness about symptoms. “Identification with a public figure's struggle with bulimia might have temporarily decreased the shame associated with the illness,” the study authors wrote, “and encouraged women to seek help for the first time.”

Diana left a deep and lasting imprint on history. Although there was concern early on that her illness and the demise of her marriage to Charles would stain the monarchy, Diana's outspokenness about what went wrong may have helped guide the next generation to make wise choices from the start, Chernock
theorizes. Prince William and Catherine Middleton did not marry until eight years after they started dating, giving them far more time to mature in their relationship. (Kate was 29 at their wedding in 2011; William turned 29 two months later.) Their long courtship also allowed them to become adept at managing the media. Indeed, as the queen celebrated her diamond jubilee in 2012, a record 69 percent of Britons said Britain would be worse off without a royal family—a level of support that Chernock believes must be credited in part to Diana. “The royal family is in such a stronger position now,” she says. “You can't separate the success of today from Diana's contributions.”

During her battle with bulimia and in the years following her recovery and her separation from Charles, Diana found solace in getting out of the palace and visiting with everyday people who had struggles of their own. Relaxed and friendly, she readily engaged in small talk and consoled others, even touching and hugging sick patients with AIDS at a time when most people stayed away out of fear. She could identify with those in crisis, she said, because she suffered herself. In her final interview before her tragic death in a car crash in Paris on August 31, 1997, she told the French newspaper
Le Monde
, “I am much closer to people at the bottom than to people at the top.”

After Diana died, the editor of the
British Medical Journal
published a two-paragraph remembrance highlighting Diana's work with sick children, her fight against land mines, the many health concerns she campaigned for—AIDS, leprosy, drug addiction—and her honesty about bulimia. The editor, Richard Smith, acknowledged that it was unusual for the publication to mourn a public figure outside of the medical profession. This time, he felt it was the right thing to do. “She seemed to speak so well to and for the vulnerable because of the difficulties in her own
life,” Smith wrote. “Her life was full of glamour and opportunity, but her gift was to create a very special life—and an inspiration to many—from adversity.” That recognition, a handful of words tucked away in an academic publication, could not compare to the pageantry of Diana's funeral at Westminster Abbey on September 6, 1997. In the end, though, it might have been the kind of tribute she would have appreciated most of all.