To Know Another Inside and Out: Linking Psychic and Somatic Experience in Eating Disorders

ABSTRACT

This article explores the role of the body in the psychoanalytic treatment of eating disorders from a relational and developmental perspective. Many who struggle with eating disorders and related issues have had early experiences that adversely affected the development of flexible, adaptive self-regulation, including the ability to experience affects as psychic states that can be safely shared in the context of a relationship. Because of their difficulty symbolizing and expressing feelings, patients with eating disorders often experience affects as somatic problems, for which they seek somatic solutions. Tuning in to patients’ bodily experience can open up pathways for accessing and, eventually, verbalizing and reflecting on internal states in the therapeutic relationship. As shown through a detailed case illustration, the therapist can discover and engage aspects of the intersubjective matrix that may not meet the eye by attending to his or her own bodily experiences and associations in and out of sessions.     

Exploring Mechanisms of Action in Exposure-Based Cognitive Behavioral Therapy for Eating Disorders: The Role of Eating-Related Fears and Body-Related Safety Behaviors

Evidence-based cognitive behavioral therapy for eating disorders includes a component of exposure therapy, which involves patients confronting feared eating and body-related stimuli while preventing safety behaviors. With recent research demonstrating that eating-related fears and safety behaviors are central to eating disorder pathology, there is increased emphasis on improving the efficacy of exposure therapy in eating disorders. Doing so will require a better understanding of important mechanisms of action in this treatment. The present study explored how changes during treatment in eating-related fears and avoidance as well as body-related safety behaviors influence overall treatment outcomes. Individuals with eating disorders (N = 71) receiving exposure-based treatment completed measures of global eating disorder severity at admission and discharge. Hypothesized mechanisms of action were also assessed at admission and discharge as well as at a 2-week time point after beginning treatment. Path modeling analyses showed that decreased eating-related cognitions (feared concerns about eating) and emotions (anxiety about eating) at the 2-week time point were prospectively predictive of lowered global eating disorder symptom severity at discharge. Additionally, reduced body checking and avoidance behaviors after 2 weeks of treatment were also associated with lower eating disorder severity at discharge. These findings highlight the importance of exposure-based therapy in eating disorders and the need to uniquely address eating-related fears and safety behaviors.     

A HISTORICAL OVERVIEW OF THE PSYCHODYNAMIC CONTRIBUTIONS TO THE UNDERSTANDING OF EATING DISORDERS

The objective of this paper is to give an historical overview of the development of psychodynamic theories and to acknowledge their contribution to the understanding of the aetiology of these complex disorders. Relevant psychodynamic and psychoanalytic papers on the historical development of eating disorders were identified through a search of (1) Medline and PsychoInfo, (2) the library of the London Institute of Psychoanalysis, (3) Psychoanalytic Electronic Publishing (PEP), and (4) a number of textbooks on eating disorders.

The search revealed a dearth of psychoanalytic historical perspectives about the aetiology of eating disorders in general. Overall most psychoanalytic publications were based on single case studies and concerned primarily with anorexia nervosa. No single model was identified, but a number of psychoanalytic ideas remain consistent throughout. Several psychoanalysts and contemporary psychodynamically‐informed authors refer to, apply and have further developed a number of these original ideas. This overview highlights the unique contributions of psychodynamic concepts towards a better understanding of the aetiology of eating disorders and how much they have influenced and informed modern thinking on the meaning of these complex conditions. A range of psychodynamic views has emerged and gradually evolved from concentrating solely on intra‐psychic factors to a more comprehensive multi‐modal model. This tendency has become a fertile ground for cross‐fertilization which, along with the bio‐social counterparts, remains the fundamental pillars on which modern understanding of eating disorders still rests.     

A Meta-Analysis of the Dependency–Eating-Disorders Relationship: Strength, Specificity, and Temporal Stability

Meta-analysis of studies examining the dependency–eating-disorders relationship revealed that (1) there is a positive association between interpersonal dependency levels and eating disorder symptoms/diagnoses (r = .25); (2) this relationship is comparable in anorexic and bulimic participants; (3) although dependent personality disorder symptoms are elevated in eating-disordered participants, so are the symptoms of several other personality disorders; and (4) when eating disorder symptoms remit, dependency levels decrease. Conclusion: There is a statistically significant link between interpersonal dependency and eating disorders, but this relationship is modest in magnitude, nonspecific, and varies with eating disorder symptom levels. Clinical, empirical, and theoretical implications of these findings are discussed.     

Many Selves in One Body: Discussion of “The Entropic Body”

The discussion of Wooldridge’s paper (this issue) offers two theoretical ideas to conceptualize the psychodynamics and treatment of individuals with severe eating disorders. Multiple self-states posited by Philip Bromberg and others allows for an understanding of the often contradictory nature of eating disorder symptomatology. Pathological organizations and primitive anxieties, elaborated by Paul Williams, suggests that the deep psychotic layer of the personality must be reckoned with in order to help the patient. Wooldridge’s patient Sara is discussed from these two perspectives, and technical considerations are offered.     

The “Perseverant” Personality: A Preattachment Perspective on the Etiology and Evolution of Binge/Purge Eating Disorders

The author integrates “psycho-digestive” metaphor with contemporary relational perspectives and developmental research to propose a way of thinking about the etiology and evolution of binge/purge eating disorders—including “purging anorexia,” bulimia, and “yo-yo” binge/dieting—and the personality organization that may underlie them. Focusing on the unifying, cyclical nature of these disorders, the author hypothesizes that an early-developing, fear-based form of somatopsychic perseveration may be set in motion from the beginning of life when a nursing infant is unable to achieve a psychic connection with a physically present and feeding (m)other. Without intervention, such a preattachment failure in (m)other/infant synchrony would inevitably impact all subsequent development. The author proposes that it may also lay the foundation for a uniquely intertwined somatopsychic personality organization—what she calls a “perseverant” personality—that fosters the development of binge/purge eating disorders. A perseverant personality is defined as a solitary and circular mode of being, thinking, and relating that is organized around a sustained physiological and psychological reliance on the feeding as a mode of thought-processing and affect regulation.     

Eating Disorders Among Urban and Rural African American and European American Women

Abstract

It is alleged that eating disorders are nonexistent in African American women and that eating disorder symptomatology occurs predominantly among White middle class women (Kumanyika, Wilson, & Guilford-Davenport, 1993; Smolak & Striegel-Moore, 2001). This research attempted to identify differences in eating disorder symptomatology in African American and White American women. An eating disorder is a disability because it can damage the person physically, emotionally and socially. It can be undetected for years and society may reinforce the hidden disorder by being complimentary regarding the thin appearance of the person. The Eating Disorder Inventory (EDI) was used to measure psychological traits and symptom clusters associated with the understanding and treatment of eating disorders (Garner, 1990). Measures of self-esteem, depression and coping were also examined. Findings indicated differences between African American and White women on the Ineffectiveness scale of the EDI, differences between the urban/rural women on Ineffectiveness and Perfectionism, and differences in coping strategies and education among this sample group of women. Successful treatment usually involves psychotherapy and/or medication for depression.     

Assessing readiness for change in adolescents with eating disorders

The Readiness and Motivation Interview (RMI) is a semistructured interview measure of readiness and motivation to change that can be used for all eating disorder diagnoses. The RMI has demonstrated excellent psychometric properties and has both clinical and predictive utility in adult samples. This study examined the psychometric properties of the RMI in a younger population, namely, 12- to 18-year-old girls with eating disorders. Study participants (N = 65) completed the RMI and measures of convergent, discriminant, and criterion validity. Adolescents with eating disorders were able to conceptualize and articulate their readiness for change and to report the extent to which change efforts were for themselves versus for others. RMI readiness profiles across eating disorder symptom domains in adolescents were comparable to those in adults, with higher reported readiness to change binge eating than to change dietary restriction or compensatory strategies. Differences in internal consistency between adult and adolescent samples are discussed. Interviewing adolescents early in treatment about readiness may assist clinicians in forming an alliance with this difficult-to-engage population, while also providing valuable information for treatment planning.     

Transdiagnostic Theory and Application of Family-Based Treatment for Youth with Eating Disorders

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.     

The dread to repeat: comments on the working-through process in psychoanalysis.

This paper focuses on the process of working through in psychoanalysis. Reemphasis of the centrality of the empathic listening perspective and discovery of the selfobject transferences made it necessary to reconceptualize various aspects of the analytic process from the perspective of psychoanalytic self psychology. With the help of a clinical vignette, the paper illustrates the manner in which archaic defense organizations and newly developing psychic structures find a compromise solution in a transference symptom. Such symptoms can serve as nodal points in the process of working through; they represent a transitional phase between the old automatic responses to narcissistic injury and an increased capacity to use signal anxiety. The psychopathology that became illuminated in this process can be described phenomenologically as a self-defeating personality disorder.     

Die Praxis der Konzentrativen Bewegungstherapie (KBT)

In a survey the 458 members of the German Association for Concentrative Movement Therapy (DAKBT) were asked in a questionnaire, to answer the question how the actual therapeutic practice of Concentrative Movement Therapy (KBT) in Germany looks like. They were asked about their therapeutic setting, the patients diagnoses and the duration of treatment. 67.5% of the questionnaires were sent back. 191 of those who answered, are working as professional psychotherapists, 62.8% of them with out-patients, 51.3% in hospitals, 17.8% in both therapeutic fields. Besides group psychotherapy most of them offer individual therapy, especially with out-patients. It is shown, that besides psychosomatic disorders (being a wellknown indication) KBT is also applied in a broad variety of other psychic disorders. Half of the outpatient treatments is finished within 50 meetings. Female patients and patients with personality or eating disorders show up a greater number of contacts in out-patient individual treatment. The results verify that in practice KBT is no longer confined to a supplementary group therapy.     

Development and validation of the Eating Disorder Diagnostic Scale: a brief self-report measure of anorexia, bulimia, and binge-eating disorder

This article describes the development and validation of a brief self-report scale for diagnosing anorexia nervosa, bulimia nervosa, and binge-eating disorder. Study 1 used a panel of eating-disorder experts and provided evidence for the content validity of this scale. Study 2 used data from female participants with and without eating disorders (N = 367) and suggested that the diagnoses from this scale possessed temporal reliability (mean kappa = .80) and criterion validity (with interview diagnoses; mean kappa = .83). In support of convergent validity, individuals with eating disorders identified by this scale showed elevations on validated measures of eating disturbances. The overall symptom composite also showed test-retest reliability (r = .87), internal consistency (mean alpha = .89), and convergent validity with extant eating-pathology scales. Results implied that this scale was reliable and valid in this investigation and that it may be useful for clinical and research applications.     

A Network Analysis Investigation of Disordered Eating Across Demographic and Developmental Subpopulations Using a National Epidemiological Sample of High School Students

Disordered eating (DE) poses a large societal burden, yet limited research has examined DE from a developmental epidemiological perspective. It is important to consider how demographics influence DE symptoms to inform prevention and early intervention programs across diverse subpopulations. Therefore, we conducted network analyses using a large nationally representative epidemiological sample of high school students (Youth Risk Behavior Survey, United States; n = 59,582) to identify the most important symptoms and symptom relationships among six DE behaviors. We compared networks by sex, grade, and race to identify differences in symptom networks. Dieting for weight loss was highly central across networks. Networks significantly differed across sex, grade, and race. Our results suggest that dieting for weight loss may be an early intervention target for eating disorders, regardless of demographic and developmental factors. In addition, sex, race, and age should be accounted for when researching and developing prevention programs for DE and eating disorders. Public health officials, as well as mental health professionals, should present a more balanced message about dieting and weight loss to high school students to prevent the detrimental impact of DE on physical and mental health. Notably, this study is the first large, nationwide epidemiological sample using DE symptoms in network analysis.     

Personality disorder cognitions in the eating disorders

The eating disorders are frequently found to be comorbid with Axis II cluster B and C personality disorders. It is important to identify the personality-level cognitions that typify these disorders. This study of a clinical group examines the personality disorder cognitions in the eating disorders. The cognitions that were most relevant to the eating disorder pathology were those relating to avoidant and obsessive-compulsive personality disorder. Other personality disorder cognitions were associated with comorbid psychopathology in largely clinically meaningful ways. These findings extend our understanding of the comorbidity of eating disorders and personality pathology, suggesting that some cases need to be assessed and formulated with such cognitions in mind. Treatment strategies are required that address both the eating and the personality pathology, while considering the impact of these cognitions on the therapeutic relationship.     

Changes in defensiveness and in affective distress following inpatient treatment of eating disorders: Rorschach comprehensive system and self-report measures

Conceptualizing eating disorders (EDs) as forming a coping mechanism against facing psychic pain, in this study, we examined the contribution of weight stabilization and ED behaviors to psychological outcomes of affective distress, defensiveness, and contact with inner/external reality among 2 subgroups of adolescent inpatients with (a) "restricting type" anorexia (AN-R) and (b) bingeing/purging type EDs (B/P). We administered Rorschach Comprehensive System (CS; Exner, 2003) and self-report measures at acute admission and on discharge. Data indicated that in both subgroups, stabilization of weight and disordered eating behaviors was accompanied by reduced explicit (self-reported) affective distress, yet by elevated implicit affective distress (D, SumShd). Subgroups' different Rorschach change trends indicated different dynamic processes in defensive style and contact with inner/external reality.     

The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder

Body dysmorphic disorder (BDD) and eating disorders are body image disorders that have long been hypothesized to be related to obsessive-compulsive disorder (OCD). Available data suggest that BDD and eating disorders are often comorbid with OCD. Data from a variety of domains suggest that both BDD and eating disorders have many similarities with OCD and seem related to OCD. However, these disorders also differ from OCD in some ways. Additional research is needed on the relationship of BDD and eating disorders to OCD, including studies that directly compare them to OCD in a variety of domains, including phenomenology, family history, neurobiology, and etiology.     

Fonagy and Freud. Psychological versus psychic reality

Peter Fonagy and Mary Target present their Playing with reality theory as a developmental theory centred on the concept of psychic reality. This paper compares Fonagy and Target's use of the concept of psychic reality with Freud's original concept. It is argued that the concept of psychic reality has been redefined from delineating a psychic reality stemming from the unconscious to denoting a kind of conscious or preconscious psychological reality characterized by an experience of equality between the internal and the external worlds. The theoretical discussion is illustrated by being applied to eating disorder pathology, which by Fonagy and colleagues is described as associated with thought processes characterized by psychic reality.     

Loneliness and eating disorders

This article examines the link between loneliness and eating disorders. This concept is evaluated through a systematic review of the literature that links loneliness and eating disorders and through a survey of themes connecting the 2 conditions. Eating disorders-including anorexia nervosa, bulimia nervosa, and eating disorders that are not otherwise specified, which include binge eating disorder-are challenging health issues. Each of these diagnoses specifically relates to loneliness. This negative emotion contributes to and fuels eating disorder symptoms. Negative interpersonal relationships, both real experiences and individuals' skewed perceptions, exacerbate eating disorders and feelings of loneliness. Characteristics that have been associated with loneliness clearly relate to eating disorders. Understanding this relationship is vital, so that we can appreciate our patients' struggles and work to target these intense emotions within the treatment setting. We need to be aware of the power of loneliness as it applies to individuals in general and specifically to those struggling with disordered eating.     

Group therapy for eating disorders: A step-wise approach

Group therapy is emerging as a favored treatment for eating disorders. Open-ended psychodynamic group therapy is an effective treatment for the underlying conflicts in eating-disordered patients, yet these groups are difficult to form. The authors suggest a specific sequence using time-limited psychoeducational groups initially for symptom control, then offering an open-ended group for patients who are ready to address deeper issues in a group therapy setting.