Garner, D.M. and Garfinkel, P.E. (1997). Handbook of Treatment for Eating Disorders (2nd Ed.).New York, NY, Guilford Press
Chapter 1 – history of anorexia nervosa
-Firstly documented in the
1600’s – thought of as a medical thing
-with time, more realization
that is psychological
-->many
approaches had the idea that isolating girl from her natural surroundings
will help alleviate her anorexia
-except in early 1900’s where
there is a focus on pituitary gland, the main focus is increasingly
psychological elements to the exclusion of medical reasoning behind
anorexia
-most treatment plans in early
1900s were behavioral
Bruch/crisp/Russell
-breakthrough
-Bruch -spoke
about the anorexia being a struggle for autonomy/competence/self-respect
-->parents
didn’t allow the girl to develop her autonomy enough
results in:
distorted body image
introceptive problems
(can’t read body right)
feeling of ineffectiveness
– feeling of loss of control-girl feels that her body is her mom’s
and wants to separate from it
-therapy (Bruch): teach girl
ways of expressing herself/correct misperceptions
-->beginning of cognitive therapy used
today
crisp
-girl fears psycho-biological maturity: this is girl’s way to maintain
pre-pubertal body-shape/hormone level/experience
-at first, theorists spoke
about the asceticism -->later spoke about the fears of b/c
fat
Russell: main
problem is the fear of b/c fat
Bulimics:
-many anorectics binge eat
(bulimics)
more social/sexual
activity
more impulsive
more depression
purge their food
more (some claim that that is main factor and not the actual binge-eating
chapter 2
– history of bulimia nervosa
-coined in 1979
-b/f 40s, no documented cases
-probably
a new developed faulty adaptation
must have 3 criteria:
episodic over-eating
vomiting/laxative
abuse
fear of fatness
-at first was very close to
anorexia but distanced w/ time
-cultural expectancy to be
thin made this disease increase!
-when discussing bulimia, people
sometimes forget to include the 3rd factor – fear of fatness!
Note: it seems like
Bulimia developed from anorexia nervosa and now warrants its own categorization
Nemiah: anorexia is
not a loss of appetite, but problem in the eating mechanisms, so you
can have a range of problems along the anorexia-bulimia axis
bulimia –meaning
simply episodic over-eating) has been recognized since antiquity. This
is not relevant to the important historical issues regarding the origins
or newness the syndrome Bulimia nervosa
Bulimia nervosa
is a distinctive disorder that was identified in late 1970s but presumably
started somewhere b/w 1940s-60.
First, it was associated
w/ anorexia nervosa but gradually it b/c partially separated
Description of bulimia
nervosa must have facilitated the recognition iof the characteristic
phenomenon by clinicians, but this only provides a partial explanation
for the sudden rise in the disorder
The modern “cult
of thinness” has exerted powerful and harmful effects on young women
and has determined the frequency/clinical form/psychological content
of both anorexia and bulimia nervosa.
Additional etiological
factors are responsibly for the differences b/w the 2 disorders
Chapter 3:
Anorexia
nervosa
restricting type
binge-eating/purging
type (self-induces vomiting/laxatives/diuretic/enemas)
refusal to maintain
body-weight at or above minimally normal weight for age/height (underweight)
fear of gaining
weight or b/c fat, even though person is underweight
disturbance in body
shape/weight. Influence of body weight on self-evaluation. Denial of
current weight’s dangers
in postmenarcheal
females – missed at least 3 cycles
bulimia nervosa
a) recurring episodes of binge
eating which has:
eating in short
period huge amounts of food
lack of control
over eating during episode
b) compensatory b/h to avoid
weight gain: vomiting, laxatives, enemas/other medication, fasting,
excessive exercise
c) on average twice a week
for at least 3 months
d) self-evaluation is unduly
infl. by body shape and weight
e) not exclusive during anorexia
nervosa
purging type:
taking out the food – i.e. vomiting/laxatives/diuretics/enemas
non-purging type:
other compensatory b/h – i.e. fasting/excessive exercise
EDNOS
– eating disorders non-other specified:
-example:
still menarching
compensatory b/h
les than twice per week
body weight still
normal, despite purging
-despite nominal differences,
there are similarities b/w them all
-people might change diagnosis
w/ time, but their general problem remains!
-if you look for connection
b/w weight and life-events, you’ll get a clear picture of what’s
infl. the person
-->i.e.
binge-eater – person who got teased for being overweight or parents
w/ negative feedback about appearance
-after seeing the weight history,
see the body-concept
-does she feel fat? What is
her perceived ideal weight?
-more willing to give info
about the dieting than the purging
-eating disordered seem to
be extremely unreliable in interviews
-there are some structured
interviews (CEDRI, EDE, IDED, SIAB)
-self-reports can’t give
diagnosis, but they can give hue and severity of symptomatology
-->i.e. the distorted self-image/where
the focus of body distortion is/etc.
summery:
in order to diagnose, you need
self-report/clinical interview/eating diaries
chapter 5
choice treatments:
anorexia:
family therapy: help family allow girl to go through developmental stages
bulimia:
cognitive-behavioral:
fix the underlying
assumptions leading up to Bulimia
self-monitoring
warped body-imaged
Chapter 11
– self-psychology perspective of Eating disorders
Psychodynamic explanations:
Drive-conflict
model - Freud: patients conflicted about sexuality. Id/ego/superego
are in conflict. The symptoms represent symbolic expression of sexual
or aggressive aims and defenses against the aims. The drive-conflict
is a good model for neurotics, but nor for borderline/psychotic people
Object relations
theory – Mahler: child moves from infantile autism-->symbiosis-->separation-individuation-->object
constancy. Move from mind’s biological aims to mental representations
of self/objects -->deal w/ psychic representations of
self/others
Theories of self-psychology:
immature/deficient structures are the problem. Self-vitalization/enhancement
through human connections = more important than insight. W/o this, person
will have painful self-states (devitalization (emptiness/numbness/going
through the motions/not really living)
Kohut –
for separation, you need to have internalize some mental functions –‘self-object
functions:’–provide your own cohesiveness/soothing/vitalization/narcissistic
equilibrium (sense of security and well-being)/SE regulation/tension
regulation. At first, those functions are provided by external caregiver.
Later, given to transitional object (i.e. blanket). The child totally
controls the transitional object which soothes him. transitional object
is perceived to be external, but experienced as part of the self.
Kohut: self-object
is an intra-psychic object/function that references to function initially
done by external caregiver. ‘Good enough’ mothering (Winnicot) leads
to self-objects developing
if the self-object
not fully internalized, the caretaker is seen as part of the self, and
not an independent person
When caregiving
is responsive to needs and don’t frustrate them too much, the baby
will acquire his internal ability to regulate SE/self-cohesion/tension.
There are 3 pathways leading to this:
mirroring
child’s archaic (but developmentally normal) sense of grandiosity
idealization
of an idealized object
twinship
– the validation that one gets when someone is like me and reflects
me
-->giving mirroring/idealization/twinship
allows kid to internalize self-objects tools
-other self-object
needs include need for validation and self-delineation
-if caregiver is unable
to give vitalization/cohesion/SE&tension regulation –then a disorder
of the self will result. Thus a person who provides self-object needs
is essential for this person
-thus, self is not
about conflicts but about impaired capacity to vitalize oneself
example: Mary,
13 year old girl, had no ability to express, or experience her own emotions
– turned to parents to express the. Saw her therapist as omnipotent
protector(same w/ dad) – when puberty was reached, she b/c anorexic.
– in order to stop sexuality that threatened maintaining dad’s self-object
functioning
drive conflict
-anorexia is supposed
to defend against sadistically oral/sexual fantasies
object relations
model:
selvini Palazolli:
problem w/ oral
incorporative stage -->impedes separation-individuation
oral incorporation
of maternal, bad, over-controlling self-object
mother introject
is equated w/ anorectic’s body so adolescent tries to undo the feminization
of body
Materson
introjects of anorexic
=hostile/rejecting/withdrawing in response to attempts at separation
supportive introject
is only activated when regressed
thus, 2 introjects:
inadequate/guilty/empty/bad
passive/compliant/good
distorted self-objects
support symbiosis and hinder separation-individuation
Sours:
defects in ego/self.
Poor differentiation
b/w self and other
Poor self objects
-therapy must work at understanding
the fixated/deviated/atypical development of the ego
Common defenses
denial
negation
disavowal
split
omnipotence
Palazzoli/Materson/Sours:
distortions in representation of body/self/object
Sugarman/Kurash: anorectic
has defective ego –no object constancy. The adolescent doesn’t assume
mom’s nurture when mom’s absent -->bulimia.
-the bulimic speaks through
body -->affect
regulation of maternal representation is never integrated
application of self-psychology:
development
girls are socialized
to be less external/exhibitionist
don’t get as much
mirroring as boys, but the usual focus is on external appearances/physical
when parents are
too self-absorbed, they give too little affirming
when those kinds
of parents are overwhelmed, the kid thinks it is his fault (and become
the complying girl). Girl never internalizes well-functioning self-objects.
Must call external ones in stress. Eventually (i.e. puberty) the girl
feels out of control (i.e. her body/drives/etc.) and this is especially
worrying for those w/o internal self-regulatory objects!
The bulimics dynamics
has more tension b/w her will and parent’s shaky equilibrium
restorative function
of symptoms:
attempts to restore
cohesion/vitality.
Since she has no
self-soothing mechanism, she turns to something that she can manage
which helps her keep her mind off painful internal conditions
Helps her have a
significant existence in the world: “I am anorexic!”
The temporary enlivening/vitalization
through exercise and diet comes at expense of maladaptation
meaning of patient’s
body
Bodies b/c battleground
for separation-individuation – they think that their body is a matter
of contention!
W/o body cohesion/integration,
they don’t worry about their health and body signals saying that body
is in bad health
Freud – “ego
is first and foremost a bodily ego”
The anorectic attempt
to control body stems from attempt to control something going out of
control. Body is seen as controlled by others, i.e. parents/peers/food
By the way,
interoceptive
deficits: b/c of those poor internal self-objects, they are out
of touch with their own experiences - feels internally devoid of self-objects
failure to integrate
body/cognitive/affective states into an integrated self
all of this adds
up to deficits in self-organization
needs
fantasies:
when kid is seen as compensation of a lost relative, there is over-
protectiveness from parents, or dictating how to live (according to
parent’s fantasies). The irony is that the parent doesn’t want to
lose the child and anorexia does lose the child!
anger
anorexia is revenge
(kind of anger), as well as an attempt to make parents respond to
her needs
so if child can’t
express his anger at over-control, she’ll behave it through the anorexia
pathology
guilt
the anorexic feels
guilty for living/taking up space/others’ rightful resources (whereas
she has no right to resources of her own) -->she has internalized
that she is to serve others. Guilt for separation drive
Friedman: 2 kinds
of guilt: “separation guilt” (experiencing her separation as destructive
to her mom) and “depletion guilt” (whatever I receive is at expense
of another person – even taking food is at the expense of someone
else)
So anorexia/bulimia
serves the girl by under the carpet saying no (when she can’t get
herself to really say it. The anorexia gives the girl an expressive
channel for anger as well as:
Soothing
Vitalization
Recognition
Validation
Self-definition
Specialness
Self-confirming
responsiveness
Sense of effectiveness
Differential dynamics b/w
anorectic and bulimic:
anorectic
says: If I become beyond needs, I won’t be traumatically injured by
others’ failing to meet my needs
bulimic says:
I will accept my needs - but this is still very archaic
-Therapist needs to show that
there is a difference b/w self-interest and selfishness
note: symbiosis is a
major theme in anorexia/bulimia
Psychotherapeutic Process
Stages of therapy:
beginning stage:
dealing with reluctance to be a patient
patient absolutely
doesn’t want to be there. Will run away as soon as possible. Thus
disavowal of illness must immediately be addressed
when patient shows
façade of self-sufficiency – gotta inquire about the other, painful
side
see if patient thinks
that she deserves help
see what myths patient
harbors about therapy
remember that anorexics
are
withdrawn
distrusting
terrified of intimacy
(i.e. being alone in office w/ someone else)
alexithemic (don’t
speak much) and thus must speak out and anticipate what she’s feeling
proudly independent
ashamed of longing/self-object
needs
performance oriented
– don’t see the point of conversation
is under duress,
explain to the patient that you’re there to help
identify concrete
goals and work together, so at least therapeutic alliance will start
middle stage:
establishing a self-object transference, and w/I this, needs are identified
2 main stages
emerge:
insight about fundamental
pathology of development (helps self-organization
experience of being
understood (allows for self-object of validation)
relapse/termination issues:
-sometimes in therapy you have
sudden, unexpected regressions. I.e. w/ anorexics, they break once in
a while realizing that they have to be self-reliant
-this is called ‘negative
therapeutic reaction’
therapist role
instead of criticizing
anorectic’s maladaptation, show her that you think that here were
good reasons for it – this ‘lends’ the patient the therapist’s
self-organization (i.e. relate to other person/self-regulation/care
and forgive one self/etc…) -->must encourage self-regulation
must remember that
anorexics suffered enough injuries and is trying to defend against them.
Therapist should encourage taking safe risks. I.e. manage the transference
and not interpreting it; filing the deficit
don’t analyze
unconscious, but rather strengthen self-objects
transference/counter-transference
transference
over-control over
life, including therapist
defeating hope
doesn’t relate
to others, including the therapist as a separate human
selflessness
thinks that therapist
is omnipotent
-common counter-transferences
are usually over/under-involvement
family involvement:
-they usually see the patient
as either:
controlling their
lives (when she’s just trying to get help)
use patient as their
own self-object
-family therapy helps see every
member of family as their own person. Often, w/o therapy of other members
of family, a symbiotic parent might get psychosis when child achieves
individuation. Dealing w/ family’s problems is essential to anorectic
treatment. if untreated, the family might undermine the anorexic’s
therapy
