Anorexic and bulimic states of mind in the psycho-analytic treatment of anorexic/bulimic patients and psychotic patients

SUMMARY

This paper discusses the relationship of bulimic and anorexic states of mind, and their interchangeability as manifested in the transference. The anorexic making bulimic-like greedy demands upon his/her objects. The bulimic showing all the qualities manifestly presented by the anorexic, an appetiteless approach to possibilities and peculiar searches in a non-specific fashion for satisfaction. Clinical material for discussion is presented from the analysis of three patients — one of whom was psychotic.

The paper attempts to show how in the transference in the true anorexic and bulimic, attacks are directed towards the awareness of the meaningful and intended specificity and function of all objects, so that any specific function can be mis-directed or nullified by the patient. The paper shows how some of these characteristics can appear as well in the treatment of borderline cases and affect the countertransference of the therapist.     

Early psychic disturbances in anorexic and bulimic patients as reflected in the psychoanalytic process

This presentation aims at demonstrating the emergence of a basic disturbance in the analytic material of anorexic and bulimic patients, namely, the unconscious attempt to restore the lost union with the feeding mother which is both relentlessly sought and equally feared. Food is used unconsciously to represent and control intra-psychically both the object and the affects belonging to that relationship in such a way as to avoid terror of fusion or dissolution of the self.     

Personality disorders, depression, and coping styles in Argentinean bulimic patients

This study investigates the coping styles of bulimic patients with personality disorders (PDs) and the effects of the level of depression on the relations between PDs and coping. The sample consisted of 75 Argentinean bulimic outpatients engaged in treatment. Patients completed the SCID II (Structural Interview for DSM IV-Personality Disorders), COPE (Coping Inventory), and the SCL-90-R (Symptom Checklist-90-Revised). No differences in the coping styles of bulimic patients with or without a PD were found. However, when three specific PDs were considered-Avoidant, Obsessive-Compulsive, or Borderline PDs-clear differences in the coping styles of the bulimics were found. However, the differences disappeared when depression was controlled. Regarding the severity of the three specific PDs, coping styles were only found to be associated with the Avoidant PD. Depression showed to affect the relations between coping styles and two specific PDs-Avoidant and Borderline PDs-in bulimic patients.     

An analysis of social anxiety in anorexic,bulimic, social phobic,and control women

Responses to the Social Phobia and Anxiety Inventory (SPAI) were examined in 23 women with anorexia nervosa, 54 women with bulimia nervosa, 50 female college undergraduates, and 43 social phobic women. Results indicated that women with anorexia nervosa and bulimia nervosa scored comparably high to social phobic women on measures of social anxiety and that these fears were not limited to fears of eating or drinking in public. This study suggests that fears of negative evaluation in women with eating disorders may generalize beyond the fears of scrutiny of body shape and size to more traditional social situations.     

What anorexic and bulimic patients have to tell: the analysis of patterns of unconscious conflict expressed in stories about everyday events

The development of European associations for counselling and psychotherapy raises questions about the challenge of producing pan-European statements of professional ethics. This article explores the range of ethical predispositions associated with different cultures to be found in Europe before examining how the European Association for Counselling and European Association for Psychotherapy have responded to this diversity. Recently produced ethical statements are examined in some detail. Both are found to be compatible with some of the culturally endorsed ethical predispositions to the exclusion of others. the article concludes by suggesting some of the issues that need to be considered in constructing a truly European ethic for counselling and psychotherapy.     

Body weight and bulimia as discriminators of psychological characteristics among anorexic, bulimic, and obese women

Bulimic women from underweight (n = 20), normal-weight (n = 31), and overweight (n = 22) categories were compared with restrictor anorexics (n = 20), normal controls (n = 31), and obese subjects (n = 22). Each subject was administered the Minnesota Multiphasic Personality Inventory, the Internal-External Locus of Control Scale, the Rosenberg Self-Esteem Scale, and the Semantic Differential Potency Scale. Bulimic women in all 3 weight categories exhibited greater psychopathology, more external locus of control, lower self-esteem, and lower sense of personal effectiveness than nonbulimic women at similar weight levels. The highest psychopathology, lowest self-esteem, and most external locus of control were found among the underweight bulimic women. Significant differences between bulimic women of different weight levels suggest the need for some modification of treatment approaches depending on the bulimic women's weight level.     

Addictive personality traits in bulimic patients

Forty-five female patients attending for treatment for bulimia nervosa completed the EPQ and an Impulsiveness Inventory (I₇). An Addiction score, derived from items on the EPQ, was obtained confirming that this group of bulimic patients score almost as high as drug addicts and certainly well above the normal range. On individual personality scales, the bulimic Ss scored higher than normals on N, P, Imp and Emp, but lower on E, Vent and Social Desirability.     

Anorexia and depression: depressive comorbidity in anorexic adolescents

Frequently, depression is a concomitant pathology in anorexia nervosa. To verify this, we carried out a comparative case/control study with 50 anorexic patients, restricting-type (ANP), 50 depressed patients (DP) and 50 non-patients (NP), aged between 13 and 16. We used the Rorschach Test and the Minnesota Multiphasic Personality Inventory (MMPI) and compared the results to parent's observations collected from the Achenbach Child Behavior Checklist (CBCL). Results showed two clearly different groups among participants: ANP with depression (36%) and ANP without depression (64%). This seems to indicate that depression is not a core element in anorexic disorders. However, we also observed a significant increase in the MMPI scale 2, which was probably related to starvation and weight loss. We confirmed the absence of general anxiety in the ANP group and obtained differences between depressive symptoms and those derived from coping deficit disorders. The discussion emphasizes the importance of using several tests to reduce bias in results and conclusions.     

Personality traits in patients with narcolepsy

Narcolepsy is a lifelong disorder with the main symptoms of sleep attacks and cataplexy. In this study 49 narcoleptic patients were investigated with a battery of personality inventories, covering the following personality dimensions: anxiety-neuroticism, extraversion and socialization. The results were compared with three groups: normal subject, psychiatric inpatients with anxiety and outpatients with psychosomatic complaints. The main aim was to evaluate a clinical impression of a high degree of extraversion in narcoleptic patients, which according to Eysenck's model could be related to a disturbance in the arousal regulation. Narcoleptic patients had higher anxiety-neuroticism scores than normal individuals, particularly in terms of Somatic Anxiety. They had unexpectedly low scores in some socialization scales, and were contrary to our hypothesis slightly lower in the extraversion variables, than the comparison groups. The high scores in anxiety-neuroticism personality scales may depend on an anxiety-provoking effect of central stimulant drugs and/or a lability of the autonomic regulation associated with the disorder. Further, the strain caused by the narcoleptic symptoms may result in high scores in anxiety-neuroticism scales and low scores in socialization scales, via social-learning mechanisms. However, there may also be a coupling between the genetics of narcolepsy and biologically based personality traits.     

Gender identity and bulimic eating behavior

From a social-psychological perspective, the disproportionate number of women compared to men affected by bulimia nervosa implies that gender (i.e., the social construction of sex) plays an important part in the etiology of this disorder. From this perspective it was hypothesized that the risk of developing bulimia depends, in part, on the composition of a woman's gender identity. Three questionnaire studies conducted in the United States and former West Germany tested competing hypotheses on the relationship between gender identity and bulimia. Respondents were predominantly middle class and Caucasian. Study 1 was conducted in West Germany and tested the hypothesis that bulimia is related to a hyperfeminine gender identity [M. Boskind-Lodahl (1976) Cinderella's stepsisters: A feminist perspective on anorexia nervosa and bulimia, Signs, Vol. 2, pp. 342–356]. Twenty-six bulimic women were compared to 26 nonbulimic women. Results from Study 1 indicated that bulimic women typically had a gender-typed identity, whereas nonbulimic controls tended to be androgynous. However, between-group differences were based on hypomasculinity rather than hyperfemininity on part of bulimic women. Study 2 and Study 3 explored the idea that masculinity positively contributes to general esteem and reduces the risk of bulimia nervosa. In Study 2, three competing theories of the optimal relationship between mental health and gender identity (congruence, androgyny, and masculinity) were related to bulimia and tested with structural equation modeling in a sample of 301 North American undergraduates. In Study 3, the findings of Study 2 were cross-validated in a sample of 464 West German high school students. The results indicate that masculinity had significant positive effects on eating behavior via esteem, whereas the effects of femininity were negligible.The research and preparation of this article were supported in part by a Fulbright scholarship, a predoctoral stipend from the University of Heidelberg, and a postdoctoral stipend from the Max Planck Institute for Human Development and Education.I thank the women who volunteered to participate in this research project as subjects. I gratefully acknowledge the support of the principals, especially Frau Ute Vater, and teachers of the Bunsen-, Feudenheim-, and Lessing-Gymnasium, who enabled Study 3.Thanks to Michael Marsiske, Ulrich Mayr, John R. Nesselroade, Kai Schnabel, Anna Stetsenko, and two anonymous reviewers for their comments on an earlier draft of this paper, and to Bettina Franzke for technical support. I also extend my thanks to Frank Faulbaum and Norbert Schwarz, without whom this research could not have been completed.     

Adolescent attitudes toward body image and anorexic behavior

This study explored the relationship between anorexic behavior and selected dimensions of body image. Anorexic behavior was assessed by two scales, the Eating Attitudes Test (EAT 26) (Garner, Olmstead, Bohr, & Garfinkel, 1982) and the Eating Disorders Inventory (EDI) (Garner, Olmstead, & Polivy, 1983). Predictor variables, selected dimensions of body image, physical attractiveness, self-esteem, and physical effectiveness, were measured by scales adapted by Lerner and Karabenick (1974) and Lerner, Orlos, and Knapp (1976). Multiple regression techniques were used to determine how much of the tendency toward anorexic behavior can be predicted by selected dimensions of body image. The major focus of the analysis was to explore the contributions of each of the dimensions of body image to predicting tendencies toward anorexic behavior in adolescents. The research sample consisted of 169 high school students, aged 15 to 18, who were enrolled in health, physical education, or psychology classes in the spring of 1983. Results indicated that the dimension of self-esteem was the major factor in the prediction of anorexic behaviors as measured by the Eating Disorders Inventory.     

Personality and family functioning in families of depressed patients

In this cross-sectional study, the authors attempted to identify correlates of family functioning in 86 couples with a depressed member during the acute phase of the patient's depression. Demographic variables, psychiatric status, and personality traits of both the patient and spouse were investigated as potential predictors of family functioning. Regression analyses indicated that lower levels of personality pathology in the patient, higher levels of patient conscientiousness, and less psychological distress in the spouse were associated with healthier family functioning. Future research implications and clinical importance of these findings are discussed.     

Anorexia and the Trojan Horse: a reflexive review of written psychoanalytic encounters with anorexic patients

A selective and limited sample of clinical case studies of psychoanalytic psychotherapy with anorexic patients, focussing on the author/therapist’s experience of working with such patients, is examined. Patients’ depressive and often angry states of withdrawal, and projections, are frequently noted. A summary of more hopeful interactions, as selected from the literature reviewed, is offered. An understanding of anorexic defences is explored in relation to the ‘Trojan Horse’ mythology, in the sense that that which purports to be emotionally nourishing and sublime can be suspiciously viewed as seeking to enter and conquer, through subterfuge. Some existing challenges to traditional tenets of psychoanalytic clinical practice with anorexic patients are presented.     

Personality traits in eating-disordered patients with and without self-injurious behaviors

Although there is a high comorbidity of eating disorder and self-injurious behavior (SIB), no systematic research has focused on personality trait differences in patients with and without SIB. In this study, a Dutch adaptation of the NEO-FFI (Costa & McCrae, 1985, 1992) was completed by 178 female, eating-disordered (ED) patients of whom 46.5% showed at least 1 form of SIB (e.g., cutting, burning, hair pulling). A subsample of 41 patients also completed the NEO-PI-R. Compared to patients without SIB, ED patients with SIB scored significantly higher on the Neuroticism scale and significantly lower on the Extraversion scale; on subtraits (facet scores) they appeared to be more anxious, more willing to please and less cheerful, efficient and ambitious. Personality traits were not associated with frequency or form of SIB or subtype of ED (except for impulsiveness). We also did not find a significant interaction effect between ED subtype and presence/absence of SIB.     

Personality, cognitive appraisal and adjustment in chronic pain patients

This study investigated the relationship between clinical personality patterns and cognitive appraisal as well as their repercussions on adjustment to chronic pain in a sample of 91 patients. It was predicted that clinical personality patterns would be related to adjustment and cognitive appraisal processes, whereas cognitive appraisals would be related to anxiety, depression and levels of perceived pain. The instruments used were as follows: the Millon Clinical Multiaxial Inventory, the Cognitive Appraisal Questionnaire, the Hospital Anxiety and Depression Scale, and the McGill Pain Questionnaire. Multiple regression analyses, the Kruskal-Wallis test, and the Mann Whitney U-test were used to analyse the data obtained. The results show that certain clinical personality patterns were associated with poor adjustment to chronic pain. The use of cognitive appraisal of harm predicted higher anxiety levels and greater perceived pain in chronic pain patients. The use of cognitive appraisals of challenge predicted lower depression levels.     

Personality disorders in patients with burning mouth syndrome

Burning Mouth Syndrome (BMS) presents high rates of comorbid Axis I disorders while no controlled studies have addressed the question of Axis II comorbidities. The aim of the present study was to examine DSM-IV (APA, 1994) Axis II comorbidity in BMS patients and to control for the specificity of this association. Seventy BMS patients were compared to a nonpsychiatric population sample and to patients with other Somatoform Disorders for the presence of personality disorders (assessed with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders [SCID-II; First, Gibbon, Spitzer, & Williams, 1997). Prevalence rates were compared using the Pearson's chi square test. At least one personality disorder (PD) was found in 85.7%, 24.3%, and 88.6% of subjects in the three groups, respectively. When examining PD subgroups, significant differences emerged even between the BMS and the somatoform disorder group, with BMS patients showing more Cluster A and fewer Cluster B PDs. Our results suggest that BMS is associated with a specific pattern of Axis II comorbidity.