пʼятниця, 29 жовтня 2010 р.

A Day in the Life of an Anorexic: An Aide to Those Who Can't Identify

Anorexia is a very hard for people to understand. Many see it as a harmful lifestyle choice. The truth is, it is a mental disorder and not any more a choice than depression or schizophrenia is. Some wonder, what is it like to go through a day in the life of an anorexic? The answer may be a bit tough for some to take.

But let's imagine...You wake up in the morning and your stomach growls. You take a shower and when you get out you catch a glimpse of yourself in the mirror. You wind up wasting 10 to 20 minutes staring, pinching fat here and there, sucking in your stomach, imagining what you'll look like 5, 10, 20 pounds less.

Before getting dressed, you weigh yourself. You must weigh yourself naked because you are afraid that anything, even your socks, will add weight to the scale. You step on and off about 3 times until you are satisfied you are given an accurate number. If the number is higher than yesterday by even a tenth of a pound, you will feel like you want to die. If it is lower, you are momentarily happy but you remind yourself you have a lot further to go.

You get dressed and go down to the kitchen, take a look at everything there is available to you, but you stop yourself from having a bite of anything. You tell yourself that the feeling of a hunger is a good one, that you need to keep strong because giving in would be giving up on yourself.

You go through the day thinking about food. You go to work or school, you socialize and smile, but in your head you are thinking only about food. How much you want it, the reasons you can't have it, how you are going to avoid this meal and cut the calories on that meal.

You've given yourself a maximum daily allowance of calories, a number that is probably 5 to 10 times below what your normal intake should be. If you manage to stay under, it is a good day. If you go over, even by 10 or 20 calories, you are disgusted with yourself. So disgusted that you feel you could scream.

You spend your time online looking at pictures of models and researching every tip in the book. How to dress to look thinner, what foods will fill you up quicker, what exercises will tone which muscles.

You over exercise on very little energy because of the lack of nutrients in your system. You feel like you are going to faint, but you push yourself anyway. That voice in your head is telling you than being thin is worth it.

You start to have a mental list of your "safe" foods. You fear certain foods to a point that if you are faced with them, you feel like you might cry. In fact, you probably will. You can't eat out with friends anymore because you can't stand not knowing all the calories in your food and they can't stand watching you suffer.

It will hurt to sit because you will feel your bones grinding against the chair. You will find your hair falling out more than usual. You will risk early onset of osteoporosis and possibly a heart attack.

You spend your night lying in bed, planning what you are going to let yourself eat the next day and you can't sleep until you have figured it out.

You have your moments throughout the day where you fight with yourself. Where you want to just force yourself to eat. The times when you realize what you are doing to yourself and you are nothing but scared.

 But the anorexia becomes a voice so strong and powerful that you feel like the real you has been forced into some back corner of your mind, struggling to be heard. You don't know what to do or who to turn to because you feel like no one understands.

 You finally get yourself to sleep, not knowing whether you will wake up in the morning. The next day, you go through it all over again. So please, before you pass any judgments on someone dealing with this terrible disease, understand the suffering they go through on a daily basis.

And if you know someone who is suffering from any eating disorder, get help as soon as possible.





http://www.associatedcontent.com/article/242904/a_day_in_the_life_of_an_anorexic_an_pg2.html?cat=5

вівторок, 26 жовтня 2010 р.

Anorexia Hypnosis Script

One of the few things experts agree on when it comes to anorexia is that the disorder itself is a paradox. While anorexia sufferers may feel in control their behaviour may be quite out of control. While they struggle to achieve happiness they often end up feeling despair. In her book The Golden Cage Hilde Bruch identified the patient's need to establish a feeling of control in her life as a central feature of anorexia. Focusing on controlling the body helps those who suffer from anorexia gain a much needed feeling of self-esteem. Exerting control over the body is a poor substitute for an ability to wield true control in life.
In the early 1900s Pierre Janet was perhaps the first to document his use of hypnotherapy to address anorexia based on the fact that hypnosis was effective in treating underlying problems of self confidence, low self esteem stress, and depression. These days Newsweek, Pediatric Nursing, and University of Maryland Medical Center are reporting how hypnosis has been a successful part of a program for anorexia treatment. Hypnosis has the potential to not only strengthen self-confidence but it can help those under stress learn to cope better. Reduced stress levels contribute to healthier eating habits, improved body image, and greater self-esteem.
A 1988 article in the International Journal of Eating Disorders noted three basic elements to successful hypnotherapeutic treatment for anorexia; body relaxation, reducing external sensory stimuli, and suggestions that inspire behavioural changes. Hypnotic World anorexia scripts include all these elements and more.
Because of the paradoxical nature of the disorder this anorexia hypnosis script uses a combination direct and indirect suggestions. Because of the need for control in this group, indirect and permissive suggestions are more effective. Indirect suggestions enhance rather than challenge the patient's need for control. This script also engages a sense of control through visualization of the metabolic "control room."
Clients are invited to "achieve a state of mastery over the most intricate functions of mind and body." Indirect therapeutic suggestions are also aimed at providing a safe and comfortable environment to enable the client to gain weight. Indirect suggestions also help to restructure the client's attitude toward food and help them complete any unfinished developmental tasks.
This anorexia hypnosis script also engages positive visualizations designed to associate food with pleasant memories to increase consumption. The metaphoric imagery of the control room offers clients a visual way to influence metabolic changes to increase the amount of fuel delivered to the organs. The idea of controlling micro functions like increased blood flow and desires for healthy food is an ideal way to redirect the client's focus on acquiring control. On a different scale imagery is also engaged in this anorexia hypnosis script to improve self-perception for example experiencing a body with "curves in just the right places."
Direct suggestions are aligned with maintaining a healthy body and increasing food intake. More general suggestions that inspire the client to feel better and better every day enhance their sense of effectiveness in the world helping them feel less out of control. This hypnosis script also uses positive post-hypnotic suggestions for healthy nutrition and positive self-image.
The script uses the direct access to the subconscious available during hypnosis to plant ideas designed to help clients overcome their resistance to change. The underlying emotional conflicts that contribute to the development of eating disorders are subjective. The general goal of this hypnosis script is to help patients develop feelings of control or even mastery over their thoughts and actions.
Given the high hypnotisability of most eating-disordered clients the use of hypnosis is very appropriate for counteracting anorexic symptoms, strengthening the ego, and restructuring cognitive behaviours. Hypnosis is an effective adjunct to any treatment program for anorexia enabling clients to experience success quickly and without complication. Each happy, successful client is a living breathing recommendation for your services and our scripts. 

пʼятниця, 22 жовтня 2010 р.

Anorexia and today's world

So it seems that neither most men nor most women find thinness beautiful or appealing in a direct, aesthetic way. For men it may represent indirectly their own status, through the rarity and social cachet of female thinness; for women it may represent something enviable: the different and self-controlled. But is this enough to sustain a physical ideal for long? Grim fascination and a status symbol seem a somewhat fragile basis for a whole cultural and physical obsession.
But does the anorexic care about any of this? She sees something fascinating in those as thin as or thinner than herself; she narrows her gaze to the single features that obsess her most (tummy, upper arms, thighs, whatever); she finds goals to aim for in catwalk cheekbones and means of attaining them in packaged-food nutritional information; once she starts trying to recover, the endless images of protruding breastbones and sunken eyes on society's most prized women don't make it easier. But while society may thus endorse certain anorexic habits, and facilitate others, and provide, in the early stages at least, positive feedback on the results, the physiological aspects of self-starvation remain untouched by social patterns. Although the incidence rates of anorexia are lower in third-world countries, it is by no means absent, and seems to be sharply rising (see, for example, Makino et al., 2004). Nonetheless, when I see an image of, say, Keira Knightley in a skimpy dress, I feel sick and confused that she should be celebrated for her looks, while starving women in less sickened nations would kill for all the food she rejects, and which we praise her for rejecting.

What is the attraction here?

But it's impossible to say to the family scraping a living from a drought-ridden field, we're no happier than you are (though it's true: Geoffrey Miller suggests that ‘all advertisements for non-essential goods should be required to carry the warning: "Caution: scientific research demonstrates that this product will increase your subjective well-being only in the short term, if at all, and will not increase your happiness set-point"'); it's impossible to dampen the human ambition for progress, for ease, for choice. And the closer we come to achieving total ease, infinite choice, and complete ‘modernity', the more glaring will its down-sides become: the obesity, the anorexia, the mental illness. And it is ironic that the West's millions of dieters are reacting against the general trend towards obesity, and that the fewer but growing number of anorexics manifest both this reaction against excess and fatness, and the mental illness that has invaded all sorts of spheres of life, from OCD to social phobia.

Anorexia is as necessary a consequence of an over-developed society as dieting is: it combines the taboo of mental illness with society's highest prize, and therefore it induces a sort of mild schizophrenia in the rest of society, who condemn it with one breath and wish they might emulate it with the next.

Anorexia and today's world

Still, not everyone turns to anorexia to perfect their bodies - indeed, anorexia is usually about other things as well: about control, or emotional sedation, or other things to which body-image is only an obvious focal point. Most people respond to the excess of cheap, easily available food with anxiety and with dieting, or with plastic surgery. Plastic surgery is the obvious quick fix to body anxieties, but not everyone (yet) has the courage or the cash to undertake it. The cheaper if slower, safer if less dramatic options are exercise and dieting - the latter in particular a commercial paradise: estimates of the annual US revenue from the dieting industry range between $40 billion and $100 billion (see Laura Cummings on how all dieting products are predicated on their failure). Dieting is a much more efficient way, in the short term, of losing body fat than exercise alone: you can eat in two minutes a blueberry muffin that will take you 35 minutes to ‘burn off'. The trouble is that dieting never works in the long run: self-deprivation induces desire, which makes ‘relapse' more and more likely; and each time weight gain happens, loss and gain get easier - each time, instability increases, and the cause of the initial overeating may of course never have been addressed, and if not will surely persist.
The sheer number of people on diets and ‘failing' at them means that those who are perceived to have ‘succeeded' attain an almost mythical status: they can resist despite (in many cases because of) the excess all around; their bodies testify to their perfect resistance. The apparently clearest example of such people are anorexics. But while anorexia may seem the epitome of the successful diet, it is in fact the antithesis of the diet: the point becomes the process not the end-point; breaking the rules is not forbidden, but impossible (otherwise it becomes a different eating disorder: binge-eating or bulimia); society's approval is less meaningful than internal compulsion. The great sanction of all obsession, health (note the rise in the ‘healthy eating disorder' ‘orthorexia') is no longer relevant, and sickness becomes undeniable.

I'm not entirely sure whether non-anorexics are in general truly horrified by the sight of a successful anorexic, and how much this horror is usually mixed with a fascination mixed more or less with envy. I think that especially amongst women, there is almost always some jealousy born of insecurity. When I was ill, I knew that I made people awkward, I was told of many instances of guests writing to my mother after they'd left and saying how ill I looked, and asking her, pointlessly, whether she wasn't terribly worried; but I remember, too, how at the very height of my emaciation (see the 'before' photo of me here), when my mother and her partner held a ‘house-cooling' party in the house of my teenage years, a friend of theirs, a painter, told me how striking I looked, and how she'd love to paint my portrait sometime. She was thin and odd-looking herself, and nothing ever came of it, but still, throughout it all there were enough instances of admiration to make those of simple horror far from the rule. My mother talked in the radio interview we gave recently about going on shopping trips with me, and how despite rationally disapproving of and fearing my excessive thinness, she couldn't help thinking, and saying, when we tried similar things on, how much better they looked on me. Fashionable clothes are designed for the very thin, and difference from the norm is always appealing too.

This isn't quite true, though: the obviously abnormal in other ways - the albino, the blind man, the woman who can't walk - are rarely considered attractive. But fat has become far more offputting to people than extreme thinness, whether or not it springs from illness, mental or physical (the Daily Mail, covering the story of Cheryl Cole's malaria, includes a gloatingly glamorous photo entitled ‘Weight loss: Mrs Cole looked incredibly thin at the Glamour Women Of The Year Awards on June 8'). Thinness is good because fatness carries with it numerous moral and character judgements concerning greed, gluttony, and lack of self-control, and thinness means the opposite of all these, however superficially.

Of course, not all very thin people are anorexics, but there is, today, in the West, no need to be malnourished in a way that results in thinness. Highly calorific food is cheaper than ‘healthier' food, so today's Western poor are often the fattest: whilst a Gallup survey for the first quarter of 2010 shows 26.7% of American adults to be obese, the difference between the highest earners and the lowest income brackets in obesity rates is precisely 10%. And it isn't the richer who are fatter: the lowest earners averaging 31.7% obesity and the highest earners 21.7%. Everything has turned topsy-turvy.

Sitting on a sofa in the lounge on the ferry, I wondered, too, about the anorexic lifestyle and modern life. Solitude, secrecy, immovable routine, are increasingly invalid ways of life in many spheres: the social butterfly, perpetually connected, is both the commonplace and the ideal - hence the rise, I suppose, of ‘pro-ana' websites and the rise of the competitive aspects of anorexia to an overt component of some forms of the illness. Does this mean that what I said about external approval mattering less to the anorexic than internal compulsion does not hold? Is the illness itself responding to cultural influences, not only in its prevalence but in its very essence? Perhaps in the early stages: sharing tips, comparing weight and shape, may be paramount, to begin with. But ultimately, starvation takes over. As severe and prolonged malnourishment sets in, everything else becomes less relevant: one is trapped with the solitary mental mantras of food eaten and to be eaten, trapped with the weakness, the cold, the obsessive checking and weighing behaviours, trapped within depression, within sickness.
It's interesting that most men don't find the anorexic - as commonly publicised in the form of the catwalk model - terribly attractive: men see (even if they don't articulate it to themselves) thinness as sickness of a sort, and therefore as absence of sexual availability, or the potential in evolutionary terms for a sexual, reproductive partner. A woman is rapidly assessed as ‘f***able' or not - and these androgynous creature are not. They are slightly frightening, inhuman-seeming, certainly unwomanly. The ‘glamour model', on the other hand, embodies the feminine, the fertile, the sexually available. The parts of her that represent this - breasts, bum, hips, lips - are accentuated (see another PT blogger on the appeal of breasts); the rest - waists, ankles, wrists, etc. - are diminished to accentuate the former still further. The ideal here also becomes naturally impossible: thin women injected with silicone breasts are common now. Yet those genetically gifted few who attain the ideal naturally are desired by men and admired/envied by women in a simpler (and evolutionarily more direct) way than very thin women are. Women know, after all, what extreme thinness means, how much of a destruction of life it entails, and most, whether through strength or weakness of will, decide to ‘choose life'.

Anorexia and today's world

I spent a fortnight on a Greek island last month with my boyfriend, and while I was there felt a splendid simplicity: the routines of breakfast on the terrace with the sun already hot, doing a little academic work, cycling to the beach for a swim, lunch in the shade, a nap on the sofa in the shuttered cool, another swim before sunset, and dinner on the terrace looking out over the sea, made life seem unimaginably calm and beautiful. Walking round half-naked, eating local produce, and entertaining myself with some Joseph Conrad and the beauty of the landscape, I was especially struck by the distance I felt from all the anxieties that modern society induces. Partly that was just the solitude: spending all day only with the person one loves creates a great contentment. But it was also the freedom from advertising, from overstocked supermarkets, from overworked people, from a crowded gym fostering exercise obsessions, from modern life.
Reflecting on modern society from a distance

In general I live quite secludedly, not watching television (except the occasional HBO drama) or reading magazines or exposing myself to much of the franticness that often passes for entertainment, but still I felt a great difference, being there. It made me reflect on the nature of this world that has grown up around us in the way it has, and on the ferry back from Naxos to mainland Greece, in between a mind-numbingly protracted game of battleships and a lunch of very un-Greek burger and chips, I had some thoughts about Western society and its relation to anorexia, and to eating disorders and obsessive mental disorders more generally.
The first thing that struck me was the many irreconcilable oppositions that structure our ideals of body and hence self. For both men and women, there are two extremes of physical perfection promoted to us as desirable: for women, the ‘fashion' ideal versus the ‘soft porn' ideal, that is stick thinness versus busty curves; for men, the ‘fashion' ideal versus the bodybuilding one (see Polly Vernon on how men are ‘subject to increasingly proscriptive and exaggerated notions on the physical ideal'). In each case, the fashion-dominant ideal is historically much newer, but holds increasing sway over the other. The woman's hourglass figure and the man's macho build are still powerful models, but androgynous emaciation seems to be ever more influential a template. Most human beings, of course, fall naturally somewhere in between these two types of ‘perfection': a woman may have curvaceous breasts, but also the wide hips that go with them; a man may have rippling pecs but also some fat round the waist.
                               Catwalk and glamour models: what lies in between?
 
The very point of most of the pictures of the human body that we see published in magazines and on billboards is to induce a mixture of aspiration and self-loathing at the perfection imposed on the real-life model by makeup, camera angles, and airbrushing (see GQ editor Dylan Jones on the ubiquity of these procedures, with reference to Kate Winslet's thighs). The very contours of impossibly slim thighs or an implausibly flat tummy are designed to make us at once dream and despair, and lap up the impossibility because it's what we've come to believe we desire. Body dysmorphia is, of course, made more prevalent by such techniques, which create a gaping gulf between the people we see in photographs and those we see and are in the real world.

So insistent and insidious are the advertised ideals that it is almost impossible to accept, these days, that one's body is simply a certain shape and will remain that way - and that that is OK. Of course, physical self-improvement has a long history, from corsetry and wigs to lead skin whiteners and Chinese foot-binding, but the methods available are becoming more sophisticated and profoundly effective. Consumerist principles already dictate how we view our careers and our relationships (see Hara Estroff Marano on how ‘we firmly believe that freedom of choice will lead to fulfillment' and how ‘free-market values' ‘seep into our private lives'). In essence, if it doesn't completely satisfy me, I have the right to exchange it for a new one. And this model now extends also to our attitudes regarding our own flesh and blood: if my breasts are too small or my hips too large, I will have them altered to fit my current ideal - or the one which society has imposed on me (though that caveat usually goes unacknowledged).

The pathological nature of all these impulses to physical picking and choosing is that our bodies don't actually have to do anything any more. Once upon a time, men had to be strong to provide for their women, and women had to have breasts and hips to give birth and nurture their offspring, but today we can avoid the pain of childbirth with elective C-sections and stroll to the corner shop whenever we feel peckish. Now bodies just have to look a certain way, rather than needing to fulfill any physical function. My boyfriend has encouraged me to take up weight-lifting, and yesterday in the gym I got a thrill from squatting 55 kg; but it was an essentially superfluous achievement, something that would once have been useful but now is merely a source of pleasure.

I sometimes feel a gentle longing to see society pushed back into a state where the problem is finding enough food rather than resisting eating too much; where work means growing crops and milking cows rather than slumping over a PC with Facebook on the next Firefox tab. I know that nostalgia is a pernicious sort of illusion, and that a global-warming induced apocalypse wouldn't simply bring out the best in people, but I do believe it would do away with a great slew of the mental illnesses that are so rife these days. I remember first seeing Al Gore's An Inconvenient Truth at the cinema with my mother, when I was very ill, and being plunged into a great and lasting dread of the global disaster that it presented as inevitable, and crying myself to sleep at the thought of how badly I would cope once society did break down. My mother has always liked apocalyptic thinking - she made boxes of provisions in the cellar in preparation for the Millennium bug that was meant to make the West crumble; then the Millennium stores turned into bird-flu stores and then into global-warming stores. She always said how well I'd do in a crisis on a grand scale, because I was so used to hunger and going without - but I knew that my hunger was possible for me only because it was a choice, only because it was the exception, only because I could put an end to it at any moment I chose - but never did choose to.

I knew that if the world as we knew it ended and I was still anorexic, I'd be crippled by anger at myself, by regret and by the deepest imaginable sadness that I'd insisted on refusing to eat when there was enough. When I then did start to eat more again, a couple of years later, I cried too, because it felt so beautiful and so awful that any food I wanted was there, waiting for me, and that I could choose anything I wanted to make myself better again: an unholy privilege, to say no to food for so many years, and then to have it all there for the taking as soon as I got over that perversion born, at least in part, of over-privilege.


понеділок, 4 жовтня 2010 р.

Anorexia: The Body Neglected What, exactly, does anorexia nervosa do inside the human body? The heart and bones suffer the most.

Anorexia nervosa takes an enormous toll on the body. But that's not all. It has the highest death rate of any mental illness. Between 5% and 20% of people who develop the disease eventually die from it. The longer you have it, the more likely you will die from it. Even for those who survive, the disorder can damage almost every body system.
What happens exactly? Here's a look at what anorexia does to the human body.
The first victim of anorexia is often the bones. The disease usually develops in adolescence -- right at the time when young people are supposed to be putting down the critical bone mass that will sustain them through adulthood.
"There's a narrow window of time to accrue bone mass to last a lifetime," says Diane Mickley, MD, co-president of the National Eating Disorders Association and the founder and director of the Wilkins Center for Eating Disorders in Greenwich, Conn. "You're supposed to be pouring in bone, and you're losing it instead." Such bone loss can set in as soon as six months after anorexic behavior begins, and is one of the most irreversible complications of the disease.
But the most life-threatening damage is usually the havoc wreaked on the heart. As the body loses muscle mass, it loses heart muscle at a preferential rate -- so the heart gets smaller and weaker. "It gets worse at increasing your circulation in response to exercise, and your pulse and your blood pressure get lower," says Mickley. "The cardiac tolls are acute and significant, and set in quickly." Heart damage, which ultimately killed singer Karen Carpenter, is the most common reason for hospitalization in most people with anorexia.
Although the heart and the bones often take the brunt of the damage, anorexia is a multisystem disease. Virtually no part of the body escapes its effects. About half of all anorexics have low white-blood-cell counts, and about a third are anemic. Both conditions can lower the immune system's resistance to disease, leaving a person vulnerable to infections.

Anorexia Damage Starts Early

Even before a person with anorexia starts to look "too thin," these medical consequences have begun.
Many young women who begin eating a severely restricted diet stop menstruating well before serious weight loss sets in. Since so many people with anorexia are teenage girls and young women, this can have long-term consequences on their ability to bear children.
"In truly, fully recovered anorexics and bulimics, it looks like the rate, frequency and number of pregnancies is normal," says Mickley. "However, if you look at infertility clinics, and those patients in the clinics who have infrequent or absent periods, the majority of them appear to have occult eating disorders. They may think they're fully recovered, but they haven't gotten their weight up high enough."
Many women with anorexia would rather seek fertility treatment than treatment for their eating disorder, Mickley says. And even among women who have fully recovered from their anorexia and bulimia, there may be a slightly higher rate of miscarriages and caesarean sections. "There also may be up to a 30% higher incidence of postpartum depression as compared to other women," she says.

The Risks of Bulimia

Bulimia, which often goes hand in hand with anorexia, does its own unique health damage. Bulimics who purge by vomiting wreak havoc on their digestive tracts by chronically bathing them in stomach acid, which can lead to digestive disorders like reflux esophagitis.
"It feels like I've been drinking Draino," said one woman who posted to a forum on digestive diseases about the consequences of her lifelong anorexia and bulimia. Some reported cases suggest bulimia may have led to a condition called Barrett's esophagus, which may can lead to esophageal cancer.

Damage from Anorexia May Be Reversible

The good news: Many of these complications can be reversible -- if the person returns to a normal weight. "The real focus has to be on weight restoration if you want to reverse outcomes," says Rebecka Peebles, MD, a specialist in adolescent medicine at the Lucile Packard Children's Hospital in Palo Alto, Calif. "That's the most essential part of treatment. You can't wait around for it to happen. It really is an essential first step in treatment and recovery."
Unfortunately, say experts, too many people believe that anorexia is strictly a psychological disorder, and ignore its medical complications unless the patient becomes visibly, dangerously thin. "A lot of people -- parents, and even some doctors -- think that medical complications of anorexia only happen when you're so thin you're wasting away," says Peebles. "Practitioners need to understand that a good therapist is only part of the treatment for anorexia and other eating disorders, and that these patients need treatment from a medical doctor as well."
Studies have found that many people who need treatment for anorexia aren't getting it. In large part, this may be due to cost. Inpatient treatment can cost more than $30,000 per month, while outpatient treatment can run as much as $100,000 per year.
Melissa Román, a Miami woman who's been in recovery from anorexia for several years, pays $800 per month out of pocket for therapy sessions that insurance won't cover. According to the National Eating Disorders Coalition, health insurance companies pay for an average of 10 to 15 treatment sessions for people with eating disorders, when more long-term care -- as many as 40 sessions -- may be needed for true recovery.
"Access to care is a huge issue," says Mickley. "Eating disorders aren't staged the way cancer is, so we don't have the way to convince insurance companies that a low potassium level can be like a small metastasis. It's only recently that we've begun to understand the genetic and neurochemical basis of anorexia and say that this is a real illness, not a whim of spoiled rich girls. It's been treated like it's voluntary and willful as opposed to what it is: a serious, life-threatening psychiatric and medical illness."