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Anorexia nervosa is a metabolic rendition of madness. The anorexic fights a battle between catabolic and anabolic forces upon his or her flesh and its supporting systems. The struggle derives from the opposition of love and hate, the affective registry of the drives. To grow up requires accepting responsibility for the ownership of desires both to create and to destroy. Attainment of some order of harmony between these conflicting goals is the major developmental task of adolescence.
For reasons still poorly understood, some people, usually but not always female, have a particular form of difficulty that predisposes them to enact this conflict upon the substance of their bodies. In the phrase of A. H. Crisp, they attempt to gain a "biological solution to an existential problem." The patient substitutes the commitment of her body into surrogate battle. Thereby she spares the problem-solving functions of her mind from the rigors of intrapsychic conflict. When anabolic forces prevail, the clinical picture is one of bulimia; when catabolic factors predominate, the condition of anorexia nervosa results. Neither outcome addresses the underlying causes for the developmental impasse.
This substitution of physical conflict for a mental one requires a denial of reality, i.e., that the patient view "thin" as "fat". Her distortion of personal body image is the delusion from which behavior is derived. Her belief and behavior rest upon denial in a mental exercise that is baffling and distressing for those concerned with the patient's welfare.