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Anorexia nervosa: A developmental perspective

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Anorexia nervosa: A developmental perspective

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Content ANOREXIA NERVOSA: A DEVELOPMENTAL PERSPECTIVE
Copyright 2003
by
Robyn Marie Westbrook
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(EDUCATION - COUNSELING PSYCHOLOGY)
August 2003
Robyn Marie Westbrook
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UMI Number: 3116798
Copyright 2003 by
Westbrook, Robyn Marie
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UNIVERSITY OF SOUTHERN CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 90089-1695
This dissertation, written by
n V x l t T / S _______
under the direction o f h T : f dissertation committee, and
approved by all its members, has been presented to and
accepted by the D irector o f Graduate and Professional
Programs, in partial fulfillment o f the requirements fo r the
degree of
DOCTOR OF PHILOSOPHY
Director
Date A u g u st 1 2 . 2 0 0 3
Dissertation Committee
Chair
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TABLE OF CONTENTS
A B STR A C T....................................................................................................... v
CHAPTER
1. INTRODUCTION. ...........................................................................1
2. THE CASE OF SARA S. .............................. 4
Presenting Problem and History
Family History
Client’s History
Summary
3. WHAT IS ANOREXIA NERVOSA?................................ 33
The Historical Understanding of Anorexia
Definition of Anorexia Nervosa, Epidemiology, and Natural History
DSM-IV criteria
Subtypes of anorexia nervosa
Diagnostic criteria under dispute
Associate physical examination findings and general medical
conditions
Specific gender and culture features
Incidence
Prevalence
Onset and course
Outcome and prognostic factors
4. EXISTING THEORY...........................................................................56
5 Influences of Psychopathology in General
The Biomedical Model
The Psychological Model
Anorexia nervosa from a cognitive-behavioral point of view
Anorexia nervosa from a psychoanalytic/psychodynamic point
of view
Anorexia nervosa from a family systems point of view
Empirical studies
The Socio-Cultural Model
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iii
5. A NEW PERSPECTIVE OF ANOREXIA NERVOSA..................... 104
Brief Overview of Developmental Psychopathology
Developmental pathways
Risk and protective factors
Perspectives on the interface between normal and atypical
development
Resilience
The organizational perspective on development
6. GORDON’S DEVELOPMENTAL PERSPECTIVE..........................114
Gordon’s Normal Child Development Model
Physical development
Temperamental development
Cognitive development
Social development
Emotional development
Moral development
Psychosexual development
7. PROPOSED DEVELOPMENTAL UNDERSTANDING OF
ANOREXIA NERVOSA................................................................. 126
Criteria for Theory
Genetic Component
Learning Abnormal Relationship With Food, Eating,
Weight and Body
Psychological Experience
Resulting Neurotic Regressions in Different Areas of Development
Protective factors
8. PROPOSED TREATMENT OF ANOREXIA NERVOSA...............144
Client- Therapist Relationship
Issues Central to Therapy
Client’s Role in Her Own Therapy
Critique of Theory
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iv
9. CLINICAL APPLICATION OF RE-CONCEPTUALIZATION OF
Analysis of Case of Sara S.
Understanding Sara using developmental perspective
Genetic predisposition to anorexia
Learning within the family to have an abnormal relationship
with food, eating, weight, and body
Psychological experiences
Understanding the multiple neurotic regressions in Sara’s
development
Summary to the Case of Sara S.
ANOREXIA NERVOSA 154
10. CONCLUSION 176
11. REFERENCES 179
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V
ABSTRACT
Anorexia nervosa is a disorder with alarmingly high morbidity and mortality rates.
This dissertation examines current theory and proposes a new developmental
understanding of anorexia nervosa, based on Maureen Gordon’s model of normal
child development (2000). More specifically, it is proposed that anorexia nervosa
emerges as the result of the convergence of many risk factors. An individual who 1)
has genetic predispositions to anorexia, 2) learns within the family to have an
abnormal relationship with food, eating, weight and body, and 3) suffers particular
psychological experiences that culminate in a feeling of not deserving to exist, is
more likely to endure stagnation in the areas of social, emotional, temperamental,
physical and psychosexual development. This developmental stagnation renders the
individual incapable of navigating major transitional developmental periods that
require an increase in autonomy and independence. These developmental periods
include, but are not limited to puberty, beginning college or work, or moving away
from home. The anorexia nervosa arises as an articulation of this experience, as well
as an unconscious attempt to cope with, mask, normalize, or self-regulate
uncomfortable and unpleasant emotional experiences or states of multiple neurotic
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regressions in development. Application of the theory is demonstrated in a
constructed case history.
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1
CHAPTER ONE
THE INTRODUCTION
Anorexia nervosa is an enigmatic form of human suffering. It is fascinating because,
first, it centers on a necessary, commonplace activity of all human beings, the
consumption of food. Second, the behavior is self-inflicted. Third, despite the
heightened sociocultural attention, the disorder continues to have a high morbidity
and mortality rate. The etiology of anorexia nervosa is complex and multi
determined (Steinhausen, 2002). However, “the exact nature” of developmental,
social and biological processes “remains incompletely understood” (Kaye, Klump,
Frank & Strober, 2000, p. 299). Treatment is often difficult and, for many
individuals, ineffective. Based on a comprehensive study of outcome literature of
anorexia in the 20th century, Steinhausen (2002) emphasizes the “serious course and
outcome” of anorexia for “many of the affected individuals” (p. 1290) and states that
“advances in etiology and treatment may improve the course of patients with
anorexia nervosa in the future” (p. 1290). It is with this in mind that I propose the
use of a particular theoretical perspective to help understand the etiology of anorexia
nervosa.
My interest in trying to understand anorexia began in high school, when a friend fell
victim to the disorder. Years later, during my therapeutic training in counseling
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2
psychology, I found myself drawn to clinical cases of anorexia. I especially enjoyed
working with these individuals, and found the therapeutic experiences to be profound
and challenging. Based on my therapeutic experiences with these individuals, and
on my reading of the research literature, there appears a need for a better
understanding of the etiology of anorexia. I do not profess to have the answer, nor
do I believe that one answer exists. Rather, I would like to add to the dialogue of
paradigms that deal with anorexia nervosa, in hopes that some individual suffering
with this disorder may be better understood by her therapist and, consequently, have
a better chance at recovery.
Before examining existing theory and suggesting a new understanding of anorexia
nervosa, I will present a case study for analysis. Historically, psychology has sought
to understand psychopathology through case analysis (Freud, 1995; 1997;
Binswanger, 1958; Epston, 2000, 2001). In this tradition, the second chapter, The
Case of Sara, presents the fictitious story of a woman suffering from anorexia
nervosa. The third chapter will investigate how psychology defines and understands
anorexia, both historically and currently. This includes a historical contextualization
of anorexia, the current definition, epidemiology and natural history of anorexia.
The fourth chapter will examine existing theoretical perspectives of anorexia. The
fifth chapter will present a new perspective of anorexia. This will include a brief
overview of developmental psychopathology, which will include an exploration of
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developmental pathways, risk and protective factors, perspectives on the interface
between normal and atypical development, resilience and the organizational
perspective on development. The sixth chapter will present Maureen Gordon’s
(2000) developmental perspective of normal child development. Areas of focus will
be physical development, temperamental development, cognitive development,
social development, emotional development, moral development, and psychosexual
development. The seventh chapter presents my proposed developmental
understanding of anorexia. In addition to criteria for the theory, this chapter covers
the contributing factors to anorexia such as the genetic component, learning
abnormal relationship with food, eating, weight and body, and psychological
experiences. The resulting neurotic regressions in different areas of development are
explored, as well as protective factors. The eight chapter proposes treatment for
anorexia, including the client-therapist relationship, issues that are central to therapy,
and the client’s role in her own therapy. The ninth chapter is a clinical application of
the presented re-conceptualization of anorexia. It re-examines and analyzes the Case
of Sara using the proposed developmental perspective of anorexia. The tenth chapter
is the concluding chapter of the manuscript.
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CHAPTER TWO
THE CASE OF SARA S.
Sara is a fictitious character I constructed as an example of what
an individual struggling with anorexia might look like. Her
character and her life are a conglomeration of the many pieces
of different individuals with anorexia that I have come into
contact with over the years. Her case is not untypical nor is it
unusual. The case presentation allows for a humanization of ‘the
anorexic’, while also elucidating the difficulty of current theory
and treatment.
Presenting Problem and History
Sara is a 23-year-old, Caucasian female, who was just released from an impatient
hospitalization for anorexia nervosa, restricting type. She is medically stable. She
has intermittently struggled with anorexia nervosa for the last 10 years. In addition
to this hospitalization, she has undergone inpatient hospitalizations for anorexia at
ages 13 and 17. She currently resides with her parents and her 2-year-old brother.
She has been living at home for the past six months following graduation from
college.
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Family History
Sara is the first child in the family. Her 21-year-old sister is in college and does not
suffer from an eating disorder. Her parents have been married for 23 years, although
they have separated once, as a result of her mother’s substance abuse. Her mother
also struggles with anorexia, although has never undergone formal treatment for an
eating disorder.
Sara’s father, Seymour, grew up in an Irish Catholic, middle class home in the
Midwest. His mother was verbally abusive, controlling and rigid. She constantly
dieted and complained about being too heavy, although she was a thin woman. His
father died of a brain tumor when he was 7-years-old. His mother discouraged the
display of emotion and told Seymour to be strong and move on. Seymour would cry
in the closet at night. As he grew older, he became adept at hiding his feelings.
Seymour’s mother soon remarried a kind man who had difficulty providing for the
family. Seymour’s mother resented her husband’s modest means and constantly
belittled him. Despite her venomous rage, she was energetic, adventurous, and at
times, a very exciting mother. Seymour made excuses for her behavior and blamed
himself. Although he was a good student and well liked by his peers, Seymour
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believed he was inadequate. A high achiever, Seymour undertook many pursuits and
constantly sought his mother’s approval. She rarely acknowledged his successes. In
time, Seymour grew close to his step-father, who was nurturing, supportive and
complimentary of Seymour’s successes. His step-father was prone to depressive
episodes.
Seymour received a scholarship to a top university and went on to study law. As a
young successful lawyer, Seymour fell in love with Sara’s mother, Angela, and
married her when she became pregnant with Sara.
Sara’s mother, Angela, was also raised in the Midwest, in a lower middle class
home. Her father was a traveling salesman, who liked alcohol and women, and was
emotionally restricted. His work kept him away from his family for most of the year.
He was not close to Angela and when home, never showed her any affection or
praise. Angela’s mother immigrated to the states from Germany just prior to WWH.
Her marriage was one of convenience, rather than love. She was an angry woman,
who was distrustful of people. She and Angela were very close and interdependent.
She discouraged Angela from becoming close with anyone else. At times, she would
physically abuse Angela.
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Angela was a feisty child who grew into a rebellious teen. She defied her mother at
every given opportunity. After fights with her mother, Angela would restrict her
food intake. At 18, she left home and moved to Chicago. She supported herself as a
secretary for a legal firm. She used substances heavily and frequented nightclubs.
Although she had many superficial friends, she was not close to anyone. After a
couple months of dating a successful lawyer from the law firm where she worked,
Angela became pregnant. Seymour, the impregnating lawyer, who was mesmerized
by Angela’s vitality and charm, proposed marriage. They married shortly thereafter,
and bore their first child, Sara. 13 months later, they had a second daughter.
Seymour encouraged Angela to be a stay-at-home mother.
Client’s History
Sara’s prenatal and birth history is unremarkable. Her mother did not breastfeed. A
full time nanny was employed to help care for Sara. Sara obtained developmental
milestones, such as cooing and crawling in a timely manner. She was a very
affectionate baby who loved being cuddled. She was weary of new people and took
a long time to warm up to strangers. As long as her schedule was adhered to, Sara
was a relatively easy baby. When disruptions in her schedule occurred, such as no
bath before bed, Sara had difficulty. She would cry and reject the change. When
confronted with new tasks, Sara was curious but reserved. Although she would
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frustrate when she challenged by a task, she would not give up. Sara had a lot of
energy and was very physical. However, she did not engage in risky behaviors, such
as wandering off from her caregiver or climbing and jumping off things. She played
mostly at home and did not participate in child play groups or mommy and me
groups.
Angela found motherhood overwhelming and very demanding. She vacillated
between loving her role as mother, and resenting it. She felt needed by Sara all of
the time, which felt both good and bad. When she was in the mood to be a mother,
she enjoyed feeling needed, and would therefore be responsive. However, when
Angela did not feel like being a mother, Sara’s normal infantile neediness felt
overwhelming and excessive to Angela, and she would not be responsive to Sara’s
needs. For example, sometimes when Sara cried, Angela would be patient and
loving, and systematically try to figure out how to console Sara (ie; was Sara tired,
hungry, wanting a pacifier, hot, cold etc.). At other times, Angela would become
angry with Sara for crying, and aggressively try to placate her. This only served to
further upset Sara, and further anger Angela. Angela would pass Sara off to the
nanny to soothe Sara. Thus, Angela’s level of responsiveness to Sara was based on
her own needs, rather than the needs of the child.
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When Sara was thirteen-months-old, her sister, Lily was bom. The new addition to
the family was a shock to Sara. It took a while for Sara to accept Lily, but in time,
she grew very fond of her baby sister.
After her sister was bom, their mother, Angela, began dieting to lose her pregnancy
weight. She started up with amphetamines to aid her in the weight loss process.
Soon she was taking amphetamines during the day and sedatives at night to sleep.
Her behavior towards her children was erratic and more pronounced. Sometimes,
she would be loving and patient, and, at other times, for no apparent reason, she
would be irritated and express anger towards her children. Both children became
anxious. Sara displayed more depressive, withdrawn behaviors, while Lily became
frenetic.
By the time she entered preschool, Sara’s behavior was perfectionistic and rigid. She
stmggled to complete art projects because she would become stuck on one part of the
project. She had difficulty during activity transitions and resisted changes in the
schedule. During meals, she would align the food in patterns and eat in a systematic
way. Sara was shy with peers and tended to isolate. With familiar adults, Sara was
affectionate and endlessly sought their approval.
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At around this time, Sara started having problems sleeping at night. She would have
terrible nightmares, which she could not articulate. She woke her parents up every
night, terrified. At first, her mother was understanding and would walk her back to
her room and put her to sleep. As her night waking continued, her parents became
less understanding and would lock their door to discourage her from waking them
up. This did not deter Sara from waking, and her mother ended up spanking her,
which also proved unsuccessful. Eventually, Sara went into her sister’s room and
slept in her other bed, and stopped waking her parents.
During these years, her family did not challenge Sara’s temperamental qualities. Her
mother did not want to contend with the crying and tantrums, so she organized Sara’s
life to present the least amount of conflict for Sara. For example, a consistent
schedule was kept, she was not urged to finish tasks, and a highly structured
preschool and kindergarten were chosen.
In grade school, Sara’s homelife became more chaotic and abusive. Angela’s drug
use and food restricting behaviors escalated. She used amphetamines daily, which
also served as an appetite suppressant. Seymour was busy building up his own law
practice and was rarely able to be home. When he was home, he was very loving
with his daughters. However, when mother-daughter disputes arose, he deferred to
Angela. The number of disputes started to escalate.
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Sara’s sister, Lily was boisterous and oppositional to their mother. Consequently,
Lily received most of their mother’s wrath. Sara quietly watched the abuse and did
everything she could to please her mother. This was tricky because the substances
made her mother unpredictable. Different things would make her angry at different
times. Sara did anything she could to avoid conflict with her mother. Eventually,
she became quite adept at this. However, she was unable to stop her sister from
angering their mother.
Angela was always screaming at Lily, telling her how worthless and fat she was.
She ridiculed her in front of her friends, until she stopped having friends over. Her
abuse had escalated to the physical level. She would hit and slap Lily frequently.
On one occasion, Lily defied her mother in an Italian restaurant. Angela became
enraged, and, upon returning home, forced Lily to eat a bottle of hot chili pepper
chips. Sara watched helplessly and scared, as Lily screamed and cried. Finally, Sara
called her father to come home. He had to take Lily to the hospital, where they
pumped her stomach. On another occasion, Lily irritated her mother and was forced
to wear a dunce cap and sit on the comer. A neighbor called child protective
services, but no action was taken.
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During these years, Sara did everything she could to please her mother. She was
afraid of Angela and did not want to be the recipient of her rage. At the same time as
fearing her, Sara relished any attention from her mother. Sara admired her mother’s
beauty and wanted to look exactly like her when she grew up. Her mother would go
through periods where she was very close to Sara. Angela was glamorous and fun,
and Sara loved being with her. Sara adored her mother and wanted to spend as much
time with her as possible. Angela knew how to make Sara feel like she was the most
special little girl in the world. Additionally, Angela knew how to tell exciting stories
that would keep Sara on the edge of her seat, she knew how to help Sara place dress-
up, she knew how to garden and plant fruits and vegetables, and she knew how to get
dirty climbing trees and playing in the stream. They would also have special times
together alone, such as going to the movies or to dinner. Lily would be included in
the plan until her behavior deemed her punishable. Sara felt guilty about her sister
being left out, but enjoyed the time with and positive attention from her mother. She
later perceived herself as the favored child during this period.
Although Sara and her mother had a special relationship, Angela was inconsistent.
She would go through phases where she spent a lot of time with Sara, and then she
would stop. This would usually occur if Angela made a new, exciting friend, or
became involved in a new activity. Sara’s feelings would be hurt, but she would
make excuses for her mother and ignore her feelings. Sara spent time fantasizing
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about her mother being more like other moms. Sara desperately wanted her mother
to be outside after school, waiting to take her home. Instead, the nanny picked her
up every day. She wanted to feel proud of her on back-to-school night, rather than
feeling shameful because she rarely showed up. She wanted to feel free to bring
classmates home after school, rather than afraid her mother would be intoxicated.
Angela did not believe that Sara could think, feel or behave differently than Angela.
For example, if Angela was cold, she assumed Sara was cold. If she disliked fish,
she assumed Sara disliked fish. If she felt sad about something, she assumed Sara
felt the same way. Therefore, Angela made ill-informed assumptions about Sara’s
likes and dislikes. Sara was constantly told what she thought and felt. When Sara
expressed anything that differed from her mother, Angela ridiculed her.
Consequently, Sara altered herself to be similar to her mother. When she did have
different thoughts or feelings, she would not acknowledge them because somehow
she believed she would damage her mother.
Angela began confiding in Sara about her troubled marriage and her conflictual
friendships. She would justify and blame her substance use on her troubles. Sara
felt deeply sorry for Angela and wanted her mother to be happy. Sara would lie
awake at night feeling sickly sorry for her mother. Her stomach would ache. She
somehow felt responsible for her mother’s happiness. Sara thought if she could be
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the perfect daughter, Angela would feel better and not use as many substances.
However, no matter how perfect Sara tried to be, her mother continued using
substances. Because their father was often at work, Sara ended up being the one who
cared for Angela at the end of the night. Sara would undress her and put her in bed.
If she had engagements, Sara would cancel and make an excuse for her mother. She
would also make excuses when friends called, to protect her mother’s pride.
Sara worried tremendously about her mother. She feared that Angela’s substance
use would hurt her mother. She would do everything she could to deter her mother
from using, such as throwing pills out. Her mother had so many she never noticed.
Sara didn’t want to throw them all out because she was afraid of angering her
mother.
Sara’s worst fear was her mother dying. Her fear was pronounced and exaggerated,
and Sara thought about it obsessively. She prayed for her mother’s health because
she knew she could not endure her death. Sara’s sleep was adversely affected by her
worry for her mother. She would lie in bed awake at night, afraid for her mother’s
well-being. Sara had terrible nightmares that her mother would die or that everyone
on the planet would die, and that she would be left all by herself. She would wake
up terrified, heart pounding, not certain what was the dream and what was reality. In
order to make sure her dream was not real, she would have to see that her parents
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were alive. She no longer woke them up. She would creep into her parent’s room,
stand over their bed, and make sure their chests were rising and falling with each
breath. Only then could she go back to sleep.
Sara not only worried about her mother, but she also felt for her mother. When
Angela was unhappy or hurt, Sara would feel unhappy or hurt. She tended to feel
her feelings related to her mother more strongly than she felt for herself. Angela
thought her daughter’s ‘empathy’ was sweet, and would therefore encourage it.
Angela would endlessly complain about her weight and focus on the perfection of
Sara’s beautiful, thin, muscular body. She spent a lot of time in front of the mirror
criticizing her own body. She would pull on the flesh on parts of her body and call it
fat. She asked her daughters, almost on a daily basis, if she looked fat in what she
was wearing. Angela was prone to starving for days on end. When she did eat, she
ate strange things, such as salad with low-fat dressing with sweet-n-low. She would
expect her children to eat, while she sat at the table, not eating. She even joked that
by feeding them, she was feeding a part of herself. She also forced them to finish
their meals, even when they were full. In retrospect, Sara reported that in doing this,
her mother was trying not to pass on her own eating difficulties. Both sisters had a
heightened awareness of body weight, eating and dieting at an early age.
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During this grade school period, Sara began feeling a lot of diffuse anger. She never
allowed the anger to be directed outward. She reported feeling a tight, burning ball
in her stomach that made her “feel icky” and “hate” herself. She would look into the
mirror and repeat over and over again “I hate you. You are ugly”. Sara felt strong
feelings of shame about herself. Anything about herself seemed wrong and
embarrassing. She never wanted to be noticed or have attention. She often times
fantasized about being invisible. She tried not to take up space wherever she was.
Sara reported first ‘feeling fat’ in first grade, although her body weight was well
within the normal range. She said she did not want to take gymnastics because she
would have to wear a leotard and look fat. At around age ten, Sara reported feeling
trapped in her own skin. She felt certain areas of her body were fat and she wanted
to tear her skin off. After she ate, she felt as though she could “ooze out all over”.
She could not stand the feeling after eating of being full.
Her food restriction began around fifth grade. Her weight was normal, and she had
not yet begun puberty. She realized that the less food she had in her, the better she
felt. When she was full of food, she felt fat and uncomfortable. In certain parts of
her body that she considered fat, she felt what she described as little bugs crawling
under her flesh. Again, she wanted to rip the flesh off. When she restricted her food
intake, this feeling would go away. She reported enjoying the lightheadedness that
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resulted from starving. This seemed to dissipate her feelings of shame. Her weight
quickly dropped and her mother brought her to the pediatrician. She was told that
she had to gain some weight unless she wanted to be put in an eating disorder
hospital. Her mother was angry with Sara and irritated. Sara was fearful of her
mother and did not want to upset her. She complied and uncomfortably gained and
maintained the bare minimum of necessary weight. However, she stayed obsessed
with her body, her weight and her food intake.
Sara did very well academically in school. With the help of teachers, Sara learned to
finish tasks, rather than getting stuck along the way because of her perfectionism.
She loved school because it gave her a sense of structure and safety that she lacked at
home. She was excelling in all of her subjects and gaining academic praise. She
was well liked although she was not very close to her peers. Her sister, in the grade
behind Sara, did not do well in school, but was considered very popular. Sara envied
her sister’s social ease and lack of academic perfectionism.
When Sara was in junior high school, Angela’s relationship with her daughters
shifted. Her abuse of Lily subsided and they grew closer. Conversely, Angela’s
relationship with Sara became strained and difficult. Angela no longer seemed to
like Sara. Sara didn’t understand and blamed herself. The harder Sara tried to please
her mother, the less Angela seemed to like her. Angela was constantly drawing
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attention to Sara’s social un-ease and making fun of her. Every statement stung,
making Sara retreat inward and hate herself more. Sara spent a tremendous amount
of time doubting herself and her self-worth.
Angela’s substance abuse was again escalating. She was now using cocaine on a
regular basis. She showed up at school events clearly intoxicated. Sara’s junior high
school banned Angela from driving on school activities because her substance abuse
was well known. Sara was embarrassed and humiliated, and angry with her mother.
Her mother’s interest in being close to her daughter dissipated. She was rarely home
and spent little time with Sara. Sara started restricting her food intake again. This
time, her mother did not notice.
During eighth grade, Sara again lost weight. Her friends and teachers noticed. Her
father noticed but did not know what to do. When confronted by him, Sara promised
she would start eating better and assured him she was fine. He wanted to believe
her. Her teacher called home and spoke with Angela expressing concern for Sara.
Sara’s eating issues annoyed her mother. Angela thought Sara was just trying to get
attention. It was around this point that Sara also started expressing anger at her
mother for the substance use. Her anger was not well received. In fact, Angela
became increasingly verbally, and sometimes physically abusive to Sara. Angela
would constantly criticize Sara for her perfectionism and good-girl qualities. She
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would call her uptight and “little miss perfect”. Angela took every opportunity to
remind Sara how ungrateful she was and that she was alive only because Angela
brought her into this world. Angela also would tell Sara she was lucky to be living
in Angela’s home, using Angela’s things. Rather than fight back, Sara just retreated
further into herself. She focused on not eating and becoming a better person.
Fed up with the substance abuse, her father finally left her mother. The girls had
their choice with which parent to live. Sara knew she didn’t want to live with her
mother who always made her feel badly about herself, but she was afraid of hurting
Angela’s feelings and abandoning her in a time of need. After being forced to
choose, Sara chose her father and Lily decided to live with their mother. Angela was
shocked Sara didn’t want to live with her. Furious with Sara’s disloyalty, Angela
threatened to kill her in a drunken rage. Sara was afraid of her mother but spoke
with her often because she felt guilty. They had conversations that usually ended
because Angela would become angry and abusive towards Sara. During this time,
Sara stopped actively restricting her food, but maintained her weight at a low point.
Her father began therapy and thought Sara might benefit from therapy as well.
Following Angela’s inpatient substance abuse hospitalization and six months sober,
Sara’s parents reconciled and moved back in together. Sara did not support her
parent’s reconciliation. Besides believing that her mother would not stay sober, she
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simply feared living with her mother again. She would have to, once again, live on
pins and needles, trying to please, and not infuriate her mother. This would be
especially difficult because her mother was angry and felt betrayed when Sara chose
to live with her father. Angela held grudges. While she knew she had made the right
choice, Sara also felt tremendous guilt. This guilt made her more vulnerable to her
mother’s insults.
When the family reunited, Sara and Angela’s relationship was very awkward and
strained. It was clear that a shift had taken place in their relationship. Although
Angela was on her best behavior, her underlying anger towards Sara could be
detected. Sara became more withdrawn and spent most of her time in her room. She
did not confide in friends about her homelife. Rather, she isolated from her friends,
focusing on schoolwork and weight loss. Her mother, father and sister appeared
happy with the reunion, which made Sara feel more alone and like an outsider.
After several months, Sara’s weight had plummeted to a dangerously low level and
her psychologist suggested an eating disorder inpatient hospitalization. Sara was
fifteen years old. Her inpatient program was cognitive-behaviorally oriented and
focused on eating, body issues, and weight gain. Her father visited often and tried to
be supportive. Her mother was angry and believed that Sara was simply attention
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seeking. Angela denied her own history of eating difficulties and blamed Sara for
her anorexia.
Sara hated being in the hospital, especially because it made her feel more alien in her
family and in the world. She had no intention of gaining the weight back in the
hospital. After refusing to eat, she was tube fed to restore nourishment. Sara almost
preferred being tube fed because she didn’t feel as full as when she was filled with
food. However, once she began gaining weight, she no longer preferred tube
feeding. Realizing that the only way to get out of the hospital was to gain weight,
Sara decided to gain the weight.
After being hospitalized for 8 weeks, Sara’s weight was restored and she was
released. She promised herself to maintain a weight to avoid hospitalization. Sara
maintained her weight at the lowest point acceptable to her doctors. She excelled in
school but struggled socially, especially once in high school. She was terribly shy
and unable to relax in social situations. She had a couple friends but rarely confided
anything of importance in them. When everyone was going out to parties and
experimenting with drinking, Sara chose to stay home. The few times she had been
out, she felt terribly uncomfortable and insecure, comparing herself and her behavior
to everyone else.
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While everyone in high school started dating and experimenting with sexuality, Sara
did not. She still felt uncomfortable in her body and was not in touch with feelings
of sexuality. She felt more alienated from her peers because she did not have an
interest in dating. Dating frightened her and sexuality disgusted her. She felt
something was terribly wrong with her, and didn’t want anyone to see it.
Her sister, Lily, who was very popular, was always going to parties and constantly
dating. Sara felt terribly inadequate in comparison to her sister. Their mother, who
had also been social, did not understand Sara’s behavior, and urged her to be more
like Lily. Angela did not value Sara’s intellectual interests and successes. Sara felt
increasingly isolated and different in her own family.
Sara had blamed a lot of her mother’s historic behavior on substances, and therefore
expected her mother would be different if she were sober. This was not the case.
Her mother had maintained sobriety for several years at this point, and was still often
abusive and cruel towards Sara. This realization was very painful for Sara.
Angela’s critique was constant and relentless, and Sara took every statement to heart.
Although she knew her mother could be mean, she gave credence to her mother’s
insults and felt worthless. She also felt she somehow deserved the abuse, because
she had betrayed and hurt her mother when her parents separated. She spent a lot of
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time thinking about her relationship with her mother and wished it were different.
Above all, she wished she were different.
With the encouragement of her teachers and psychologist, Sara applied to
universities on the East and West coasts, all far from home. Sara’s father was
supportive, but not very involved. Her mother, who had not attended college, did not
understand or value the importance and pressure of the application process.
After gaining acceptance to most schools, Sara chose to attend a prestigious college
on the East coast. Sara’s mother’s indifference deeply hurt Sara. As the months
brought Sara closer to her dream of attending an elite college, Sara’s difficulty with
eating increased. Her mother became increasingly concerned as she witnessed
Sara’s weight loss. Rather than expressing concern, her mother would draw
attention to what Sara wasn’t eating and what she should eat. Mealtime became a
battleground. By summertime, Sara’s weight had again plummeted. Again, she
needed hospitalization.
Although she worked hard to gain weight in inpatient treatment, her parents did not
want her starting college in the fall. Her doctors believed that staying home with her
family would be detrimental to her recovery, and, going to college could help her
sense of self, and therefore advocated for her going to college. Sara ended up going
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to college, promising to maintain her weight and health. She was also medicated
with a selective serotonin reuptake inhibitor (SSRI) to help control her obsessive
thinking in regards to weight and eating.
At first, Sara felt homesick and lonely. However, as the months passed, she grew
more comfortable and started to really like college and being away from home.
Living away from her family gave Sara a sense of independence and power she had
never experienced. She felt relieved that she did not have to interact with her mother
on a daily basis. They seemed to get along better having phone conversations
instead of living together. Sara was making new friends and enjoying it. She was
inspired by her classes and, for the first time, felt proud to be an academic type. She
experienced a new found freedom and sense of herself she had never felt. It was the
first time Sara felt hopeful about and looked forward to her future. Even though the
feeling was slight, she started to want things for herself in her future, such as an
interesting career and loving family.
Although Sara was enjoying college and was starting to develop a sense of self and
independence, she still struggled in certain areas. Sara constantly felt shameful even
though she wasn’t sure what she was shameful about. She had difficulty owning her
space. She would stand crouched in comers, careful not to take up too much room.
She also struggled with valuing her possessions. Once something became hers, it
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would lose any value. It was as though once she came into contact with something,
it became tainted. She constantly battled with her eating disorder, she avoided
romantic relationships altogether, and she had a deep, nagging feeling that she did
not deserve to exist, which affected all areas of her life.
Being alone, away from family for the first time, allowed Sara to eat what she
wanted without external pressure. If she wanted to starve, she didn’t have to contend
with complaining parents or doctors. Sara was aware she was on her own which
prompted her to take better care of herself. She did not want to descend into what
she considered ‘the hell of anorexia’ again. Therefore, Sara took great measures
(never before taken) to ensure her health. For the most part, she ate well and
abstained from restricting. When her mind would tell her to restrict, she would
disregard the suggestion and change topics of thinking. At times she felt gluttonous,
like she did not deserve to eat and be healthy. Again, she would ignore the
dangerous thinking and change topics of thought. When her mind would tell her she
was a fat pig, she would breathe and disregard the thought. When it became difficult
to change her thinking, she would recall how miserable she felt at home and how
happy she was at school. She didn’t want to do anything to jeopardize being at
school. These strategies seemed to work much of the time. Sara did restrict her food
when she was upset about something (ie; a grade, a fight with parents or friends).
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Then, it appeared the dangerous thoughts had more control over her and could affect
her eating behavior.
Dating was another area with which Sara struggled. She had never dated and was
terribly insecure about this fact. She knew she was heterosexual because she
developed small ‘crushes’ on guys she knew. However, she never took the ‘crush’
further. She had never been out with, or kissed a guy. She felt very awkward about
her sexuality. She was highly uncomfortable with the notion of being sexual. She
couldn’t articulate why sexuality made her so uncomfortable, except as to say it
seemed somehow ‘wrong’ to her. She reported having had sexual feelings for a
particular guy that made her so uncomfortable, she stopped her friendship with the
guy.
Even though Sara was an excellent student, she struggled with being unusually hard
on herself. She expected herself to perform perfectly. Scoring anything less than
perfect on academic assignments was very upsetting to Sara. She would cry, feel
defeated, and apply 120% of herself to the class. Scoring imperfectly made Sara feel
inadequate and unintelligent.
Another area Sara struggled with was friendship. She believed she was lucky to
have so many friends, as she was unable to value herself as a friend. She was
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making new friends more than ever before, but did not know how to trust them. She
was there for them, but did not know how to depend on them. She never asked for or
expected anything from her friends, and she never disclosed much of her intimate
self. In her innermost thoughts, she did not trust that they would still like her if they
really knew her.
Despite these areas of difficulty, Sara enjoyed college and did well. In fact, she was
happier than she had ever been for an extended period of time. She never wanted to
go home for school breaks. Summers were especially challenging because they were
so long. Sara and her mother’s relationship was extraordinarily painful for Sara, and
being in the same house amplified the difficulty. Sara became more argumentative
since going to college. She was always willing to engage in a fight with her mother.
She was very resentful of how her mother treated her in the past. Fights would bring
up strong feelings in Sara that she didn’t want to feel. She would feel “worthless and
icky and uncomfortable”. Again, she reported feeling uncontained in her body, like
she could “ooze out all over”. Ultimately, she wanted to “disappear”. Her food
intake decreased and she lost weight. However, once she returned to college
following summers, Sara was able to increase her food intake, and maintain weight
gain.
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In her second year of college, her mother called Sara, ecstatic, with a surprise. She
and Sara’s father were going to have another baby! Sara immediately became angry.
Her mother was 40-years-old, had already failed with her first two children, and did
not deserve to have another child. Furthermore, Sara felt this should have been a
family decision, a thought she shared with her mother. Her mother recognized that
this news was difficult for Sara, and tried to be sympathetic. When they got off the
phone, Sara cried. Several months later, Sara realized that she wanted to have a
better relationship with her mother and felt that somehow this new baby would stand
in the way.
Sara’s baby brother was bom during Sara’s third year of college. She flew home
before the due date so she could be there for the delivery. Watching Angela give
birth was a special experience that made Sara feel closer to her mother. Once the
baby was bom, Sara fell in love with her brother. He no longer felt like a threat.
During the following summer, Sara’s brother, Timmy, seemed to bring the family
closer together. Everyone loved spending time with Timmy. He became the new
focus of attention. Sara loved spending time with him and doted on him constantly.
Much to Sara’s relief, Angela’s mothering skills were markedly improved with this
child. Sara and Angela’s relationship seemed easier and less volatile on both sides.
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Sara’s senior year of college posed the typical developmental challenge of career
decisions. Sara had no idea what she wanted to do with her life. The prospect of not
being in school was very frightening. However, she did not want to go to graduate
school just to be in school. She kept thinking that clarity would come, but it didn’t.
Her anxiety grew as the months wore on. Most of her friends were planning on
attending medical school, law school, or graduate school of some sort. Upon
graduating, Sara had no plans, except to return home to figure her life out.
Once home, Sara spent much of her time with Timmy. He was able to get her mind
off the daunting task of deciding what to do with her life. Her father did not seem to
have any time to talk to her about possible career choices. Sara felt afraid, lost and
alone. She was fearful that she would fail at anything she tried. Therefore, she
didn’t want to try anything. The months passed and Sara grew more apathetic.
Conflicts with her mother started to occur more often and old feelings resurfaced.
The novelty of having a child in the family was no longer enough to mend the
mother-daughter relationship. Sara’s relationship with her mother became damaging
to Sara once again.
Her mother couldn’t understand Sara’s ‘lack of motivation’ in getting a job. Angela
was on her own at eighteen and able to take care of herself. Angela constantly
reminded Sara that she needed to get a job and be self-supporting. This only created
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more tension between mother and daughter. Sara was anxious as it was, and her
mother’s balking only exacerbated her anxiety.
Sara started to forget the strength and sense of self she had experienced while in
college. Her future became more blurry and harder to envision. Without being
aware, Sara began restricting her food intake again. Within a couple months, Sara
was caught up in the spiral of anorexia again. She no longer cared about her career
or her future. She just wanted to waste away, to disappear, not to be bothered.
Following fights with her mother or disagreements with her father, she would lie in
bed, numb, tracing the outline of her hipbones and ribcage, gaining a sense of
tranquility. Sometimes she would have brief moments where she was scared, like
when her heart skipped a beat, or when she started to black out in public. She would
eat, feel better and resort to her starving behavior.
Sara’s weight loss became noticeable and alarming. Her parents were devastated,
scared and angry that this was happening again. However, they expressed their
feelings differently. Her father expressed concern, while her mother expressed
anger. They took her back to her previous psychologist, who recommended a
medical evaluation. The medical doctor and psychologist agreed that inpatient
hospitalization would be necessary. Again, Sara was admitted into the eating
disorder unit in the local university hospital.
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Following twelve weeks of inpatient treatment, Sara’s weight and psychological state
were determined to be adequate for release. Sara moved back in with her parents.
She is currently interviewing psychologists for extended outpatient psychological
treatment.
Summary
Sara has intermittently struggled with anorexia for the last 10 years. Although she
has undergone three inpatient hospitalizations, outpatient therapy, and has been
medicated with SSRI’s, her treatment has not been successful. Like so many of her
anorexic contemporaries, Sara’s disorder continues to take her hostage time and
again.
Current theory, which informs the treatment of anorexia, is inadequate. In order to
help improve our understanding in this arena, psychologists have to re-examine
anorexia and its symptoms in a different light. Psychological theory and treatment
has typically viewed anorexia from the biomedical, the psychological and the
sociocultural perspectives. I suggest that our understanding of anorexia would be
broadened and strengthened through the use of a developmental perspective.
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Perhaps a therapist with a developmental perspective could better understand and
treat Sara, resulting in a full recovery from anorexia.
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CHAPTER THREE
WHAT IS ANOREXIA NERVOSA?
Before exploring and critiquing the theories that exist to explain and treat individuals
such as Sara, a thorough understanding of what anorexia is, is called for.
The Historical Understanding of Anorexia
The earliest report of anorexia nervosa in the medical literature was by a 17th
Century English physician by the name of Richard Morton (1689). He attempted to
distinguish anorexia nervosa from tuberculosis. In his London publication of the
Treatise of Consumption, he referred to the illness as “a nervous condition” caused
by “sadness and anxious cares”. In his publication he presented two case histories:
the seventeen-year-old daughter of Mr. Duke in St. Mary Axe and a sixteen-year-old
boy, the son of a Presbyterian minister.
Anorexia nervosa was later described as a clinical entity in the 19th century by Gull
(1868) in England and Lasegue (1873) in France. The Anglo-Saxon word anorexia
nervosa was coined by Gull. He first referred to the syndrome as apepsia hysterica,
and then fours years later changed apepsia to anorexia as he realized that food would
be digested if eaten. He later changed hysterica to nervosa, once he recognized that
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men, too, could be afflicted with the illness. Gull conceptualized anorexia nervosa
as a unified disease entity, different from starvation among the insane and unrelated
to organic causes such as other diseases. His disease afflicted young women
between the ages of sixteen and twenty-three. The etiology of the behavior (lack of
appetite) was considered nervous in origin. More specifically, he held a nonspecific
kind of energy or ‘morbid brain force’ responsible for transforming whatever arises
in the brain into somatic conditions in other organs (Gull, 1868). He considered the
anorexia state as a ‘morbid mental state’ that requires treatment similar to that of
patients with ‘unsound mind[s]’ (Gull, 1868). He later considered anorexia nervosa
a “perversion of the ego”.
Lasegue, a French neurologist, focused on the psychological factors in the control of
appetite. In his article, De Vanorexie hysterique, Lasegue maintained that the
anorexic’s family interactions are paramount in understanding the plight and
behavior of the individual afflicted with anorexia (Lasegue, 1873). Lasegue was the
first to make the assumption that anorexic behavior is a form of intrafamilial conflict.
In 1914, Simmonds, a pathologist, performed an autopsy on an emaciated woman
and found lesions in the anterior lobe of the pituitary gland. Malnutrition became
seen as an endocrine disturbance. The concept of what anorexia nervosa was shifted
and the assumption was made that its cause was of pituitary origin. In other words,
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anorexia nervosa’s cause was perceived as physiological rather than psychological.
This opinion dominated the field for next three decades (Brumberg, 1989).
Consequently, experiments were conducted in anorexia nervosa treatment in which
patients were injected with natural and synthetic hormones including insulin,
antuitrin and estrogen (Farquharson and Hyland, 1938; Meyer and Weinroth, 1957).
By the mid-1930’s physicians were growing skeptical of the role of endocrine
disturbance in the etiology of anorexia nervosa (Brumberg, 1989). Ryle, a British
practitioner and professor of medicine at Cambridge University, discredited the role
of endocrine disturbance and criticized the use of natural and synthetic hormones
(Ryle, 1936). According to Ryle, anorexia nervosa was a mind disturbance with
prolonged starvation and nothing more (Ryle, 1936). Consequently, psychological
factors became more important than biological factors in locating the etiology of
anorexia nervosa.
During the 1940’s and 1950’s psychoanalysis brought forth a new understanding of
anorexia nervosa. As early as the last decade of the nineteenth century, dynamic
psychiatrists were attempting to better understand the sources of nervous diseases by
focusing on the individual’s life story and underlying emotional world. Among the
most prolific in their field, Freud and Janet had profound impact on the
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understanding and treatment of anorexia nervosa (Brumberg, 1989). However, their
views did not become popularized until the mid twentieth century.
Freud was the first to posit the important conceptual question of what does the
anorexic’s lack of appetite mean (Brumberg, 1989). Attempting to find meaning in
the lack of appetite, Freud turned to his focus to the individual’s infantile past.
Appetite for food is the first object of longing and desire for an infant. Freud
conceptualized all appetites as expressions of libido. Therefore, it would stand to
reason that not eating would be representative of the absence or lack of libido. Freud
postulated that anorexics did not eat because they detested food and sex (the food
had some symbolic meaning which made it disgusting). His view of anorexia
nervosa as a neurotic behavior expressing repulsion for sex was based on his idea of
conversion hysteria. In other words, chronic emotional conflicts manifest in physical
symptomology.
Janet, a preeminent dynamic psychiatrist and director of the psychology laboratory at
Salpetriere Clinic in Paris, also viewed anorexia nervosa as an expression of
underlying emotional turmoil (Brumberg, 1989). Unlike Freud, Janet did not believe
anorexics had no appetite. Rather, Janet focused on the controlled, voluntary and
conscious refusal of food amidst feelings of real hunger. Janet believed that the
individual experiences a delusion or mental disturbance that develops into an
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obsession or idee fixe (Janet, 1907). He did not speculate on a cause or type of
obsession. Janet identified the emotional source of anorexia as an unhappy
relationship between a girl and her body based on bodily shame (Janet, 1907).
Both Freud and Janet were powerful influences on current thinking of anorexia
nervosa and treatment (Brumberg, 1989). They were the first theorists to link
anorexia nervosa with psychosexual development (Brumberg, 1989). By not eating,
anorexics can literally maintain a small, childlike appearance, and in doing so hinder
normal sexual and physical development. These ideas laid the foundation for later
theorists to focus on the anorexic’s fear of growing up and desire to stay a child.
In the 1960’s, the discovery of a ‘feeding center’ in the rat’s lateral hypothalamus
(Anand and Brobeck, 1951) resulted in a refocusing on organic factors (Russell,
1965). However, it was later discovered that many of the hypothalamic
abnormalities were secondary rather than primary, or resulting from anorexia rather
than causing anorexia.
In the 1970’s there was a shift in emphasis towards families as etiological agents
(Bruch, 1973; Minuchin, Rosman, and Baker, 1978; Palazzoli, 1974), with anorexic
families described as conflict avoidant, rigid and enmeshed (Minuchin et al., 1974).
According to Ward, Tiller, Treasure and Russell (2000), although many theories
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currently exist, the main emphasis in popular culture is on sociocultural aspects of
illness, with clear societal pressures on women to be thin, associated with a rapid
increase in the incidence of eating disorders. This framework is not effective,
however, at explaining the incidence of anorexia nervosa in men or the occurrence of
eating disorders in nonwestemized societies (Mumford, 1993). Nor does the model
address why one individual should be afflicted with the disorder, whereas another
with a similar set of sociocultural risk factors escapes (Ward et al., 2000).
More recently there is a growing interest among experts, in the biological theories.
This can be seen with the recent discovery of a candidate gene for satiety (Zhang,
Proenca, Maffei, Barone, Leopold and Friedman, 1994), with inquiry into
abnormalities of leptin secretion in the onset and maintenance of anorexia nervosa
(Ward et ah, 2000), with analysis of computed tomographic (CT) scans in ill patients
with anorexia nervosa (Ward et ah, 2000), with inquiry into a possible association
between anorexia nervosa and the -1438 A/G polymorphism in the 5-HT2A gene
(Collier, Arranz, Li, Mupita, Brown & Treasure, 1997; Enoch et al. 2001; Sorbi,
Nacmias, Tedde, Ricca, Mezzani & Rotella, 1998), and with recently found
“evidence for a susceptibility gene for anorexia nervosa on chromosome lp” (Grice,
Halmi, Fichter, Strober, Woodside, Treasure, Kaplan, Magistretti, Goldman, Bulik,
Kaye and Berrenttini, 2002, p. 787).
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Definition of Anorexia Nervosa, Epidemiology, and Natural History
In a relatively short amount of time, the classification and understanding of eating
disorders have undergone changes. Anorexia nervosa was the first identified eating
disorder, dating back to 1873 (Gull, 1873; Lasegue, 1873). In the 1970’s, anorexia
nervosa was the first eating disorder to be classified in the Diagnostic and Statistical
Manual of Mental Disorders (DSM) with specific diagnostic criteria. Bulimia
nervosa was recognized by Russell in 1979 as “an ominous variant of anorexia
nervosa” (Russell, 1979). Bulimia was identified as the second eating disorder in the
DSM-m.
Atypical eating disorders were included under bulimia in the DSM-III. The DSM-
III-R made another separate category “eating disorder not otherwise specified” to
expand and give greater specificity to atypical eating disorders. Currently, there has
been recognition of two new eating disorders, binge eating disorder and the night
eating syndrome. Their diagnostic status however is still being debated (Garfinkel,
2002).
I will focus on the classification and diagnosis of anorexia nervosa, the longest
established eating disorder. Garfinkel, a leading expert in the field of eating
disorders, reports that in 1970, Gerald Russell proposed operational criteria for
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anorexia nervosa that focused on signs and symptoms (Garfinkel, 2002).
Specifically, Russell emphasized a behavioral disturbance that leads to a marked loss
of body weight, a psychopathology as represented by a morbid fear of getting fat,
and an endocrine disorder expressed by amenorrhea in females and loss of sexual
interest and potency in males. Russell’s criteria have evolved into the criteria
currently used in the DSM-IV and the ICD-10. Discussion of the DSM-IV criteria
for anorexia nervosa follows.
DSM-IV Criteria for Anorexia Nervosa
A. Refusal to maintain body weight at or above a minimally normal weight for age
and height.
The excessive drive for thinness is typically considered central to anorexia nervosa.
This criterion requires individuals to be significantly underweight. The DSM
includes a suggested guideline for determination of what exactly is underweight.
The guideline is clinically useful, but “should not be interpreted rigidly” (Walsh &
Gamer, 1998, p. 26). If an individual meets all other criteria for anorexia nervosa,
but weighs less than 90% of expected weight, the clinician can make the anorexia
diagnosis. The ICM-10 diagnostic criteria for anorexia nervosa are more rigid and
strict in that they delineate a precise figure for being underweight. It requires an
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individual to have a body mass index equal to or less than 17.5 kg/m2 (WHO, 1993).
The need for inclusion of a weight criteria is undisputed, however, Garfinkel reports
that “views on the weight threshold necessary for diagnosis have varied and the
optimal level is not known” (Garfinkel, 2002, p. 156).
The second aspect of the DSM-IV’s criterion A is that the individual wants to be
underweight and consciously behaves in ways to avoid gaining weight. These
individuals often restrict food intake both in terms of calories and fat content.
Exercise is also a common way used to bum calories.
B. Intense fear of gaining weight or becoming fat, even though underweight.
Although individuals with anorexia are underweight, they are afraid they will
become substantially overweight. According to Walsh and Gamer (1998), the fear
of becoming fat is not based on fact. They state that most of these individuals “have
never been significantly overweight, and are not particularly likely to come from
families with obesity” (Walsh and Gamer, p. 26).
C. Disturbance in the way in which one’s body weight or shape is experienced,
undue influence of body weight on self-evaluation, or denial of the seriousness of the
current low body weight.
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This criterion requires a serious disturbance in the individual’s experience of her
body. The individual can view her entire body or parts of her body as being too
large, regardless of weight loss. These individuals often judge themselves in part
based on weight gain or loss. Weight gain can induce negative feelings, while
weight loss can induce positive feelings. Individuals with chronic anorexia may
deny the severity of the situation and deny the necessity of medical or psychological
intervention. These individuals may “grudgingly acknowledge that they may need to
gain weight, but are unwilling to take consistent steps to achieve this goal” (Walsh
and Gamer, 1998, p. 26).
D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three
consecutive menstrual cycles.
Based on individuals who have progressed normally through puberty and begun
menstruating, amenorrhea represents the loss of a normal physiological function.
Amenorrhea, a common feature of anorexia nervosa, arises in part out of the loss of
body weight and fat. However, amenorrhea sometimes occurs before there is
significant weight loss, and sometimes does not occur with significant weight loss.
In addition, Garfinkel (2002) reports that it has been demonstrated in community
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samples that women who exhibit all other features of anorexia are still as ill as those
who meet full criteria. Consequently, this criterion is under dispute due to its value.
Although this criterion applies to females, it must be noted that similar changes
occur in males. As females with anorexia produce little estrogen, male counterparts
produce little testosterone. The ICD-10 includes males in the criteria as indicated by
their loss of sexual interest and potency (WHO, 1993).
Subtypes of Anorexia Nervosa
Once it has been determined that an individual meets the criteria for anorexia
nervosa, the clinician classifies the individual into either the restricting type or the
binge-eating purging type. Many differences have been noted between the type
groups. For example, Garfinkel (p. 157, 2002) reports that when compared with
non-binge eaters, regular binge eaters have “weighed more in childhood; have come
from heavier families, with more frequent familial obesity; more commonly use
extreme methods of weight control; more frequently display other impulsive
behavior, such as alcohol and drug abuse, stealing, and self-mutilation; display
different personality types: frequently borderline, narcissistic, or antisocial, a group
that discharges impulses through action”. Walsh and Gamer (1998) similarly report
that binge/purging anorexics are more likely to exhibit disturbances in impulse
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control. The DSM-IV asserts that binging/purging anorexics are “more likely to
have other impulse-control problems, to abuse alcohol or other drugs, to exhibit
more mood lability, and to be sexually active” (DSM-IV, 1994, p. 541). In
comparison to binge/purging anorexics, restricting anorexics are more likely to be
more obsessional and more socially awkward and isolated (Walsh and Gamer, 1998).
Diagnostic Criteria That Are Under Dispute
As indicated by Garfinkel (2002), certain diagnostic criteria of anorexia nervosa are
under dispute. Both Garfinkel et al. (1996) and Anderson (2002) have conducted
studies showing that amenorrhea is not necessarily present in patients with eating
disorders, which raises questions about the parameters of the category anorexia
nervosa. Additionally, Anderson (2001) deems the anorexia criteria of achieving
less than 85% of normal body weight “arbitrary” (Anderson, 2001, p. 3). He states
“It is, in fact, the decrement of weight from any stable set point to a substantially
lower weight that produces the starvation symptoms that are typical of anorexia
nervosa” (Anderson, 2001, p. 3). Both the amenorrhea criteria and the weight
criteria for satisfying the diagnosis of anorexia nervosa warrant further study.
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Associated Physical Examination Findings and General Medical Conditions
Many individuals with anorexia nervosa show a variety of physical disturbances as
the result of the semistarvation characteristic of this disorder. The DSM-IV cites the
following potential problems: leukopenia and mild anemia (hematological),
dehydration, hypercholesterolemia (chemistry), elevated liver function tests,
hypomagnesemia, hypozincemia, hypophosphatemia, hyperamylasemia. Vomiting
behavior and use of laxatives can lead to metabolic alkalosis,hypochloremia, and
hypokalemia. Sinus bradycardia is seen and less frequently, arrhythmias are
detected. When there are significant fluid and electrolyte disturbances, “diffuse
abnormalities, reflecting a metabolic encephalopathy” can be found (DSM-IV, p.
542). In brain imaging, “an increase in the ventricular-brain ratio secondary to
starvation is often seen” DSM-IV, p. 542). Resting energy expenditure is also “often
significantly reduced” (DSM-IV, 1994).
Additional physical examination findings, as reported by the DSM-IV, are caused by
starvation. Some of the findings include amenorrhea, constipation, abdominal pain,
cold intolerance, lethargy, excess energy, hypotension, hypothermia, dryness of the
skin, lanugo and bradycardia. The semistarvation (and purging) of anorexia nervosa
“can result in significant associated general medical conditions” such as “the
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development of normochromic normocytic anemia, impaired renal functioning,
cardiovascular problems, dental problems and osteoporosis” (DSM-IV, 1994).
Specific Gender and Culture Features
Field studies indicate that less than 10% of the cases of anorexia nervosa occur in
males (DSM-IV, 1994, p. 543). Diagnosis of anorexia in males may be sparse
perhaps due to biases in diagnosis, referral patterns and sampling procedures, as well
as its relative scarcity (Carlat and Carmargo, 1991). In an overview of eating
disorders in males, Andersen (2002) discusses the problem that “males with eating
disorders have at times been ignored, neglected, dismissed because of statistical
infrequence, or legislated out of existence by theoretical dogma (p. 188). The
diagnosis of anorexia nervosa can also be considered gender biased because “the
systematic marker of reproductive hormone abnormality (viz., loss of sexual appetite
secondary to lowered testosterone) develops in a gradual manner unlike the more
abrupt cessation of menses among females” (Andersen, 2002, p. 188).
In his overview of eating disorders in males, Andersen (2002) reports higher figures
of males afflicted with eating disorders. He reports findings of a community-based
epidemiological study of eating disorders where one male presented for every six
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females. Lower figures were found in clinic samples, where 10% to 20% of cases of
anorexia nervosa were male (Anderson, 2002).
It is interesting to note that in children, “boys have been reported to represent
between 20% - 25% of referrals” for anorexia nervosa (Bryant-Waugh and Lask,
2002, p. 211). Lask and Bryant-Waugh (1992) similarly report that in younger
samples, the proportion of young boys with eating disorders ranges from 20% - 30%.
It is not clear whether “there is a true age-related difference in the gender ratio, or
whether these younger boys are simply more likely to come to medical attention
(Bryant-Waugh and Lask, 2002, p. 211). The tentative data suggests that there is a
differential gender ratio, but further study is necessary.
The DSM-IV states that anorexia nervosa “appears to be far more prevalent in
industrialized societies”, appearing most commonly in “the United States, Canada,
Europe, Australia, Japan, New Zealand and South Africa” (DSM-IV, 1994, p. 542).
The DSM-IV acknowledges, “little systematic work has examined prevalence in
other cultures” (DSM-TV, 1994, p. 543). Striegel-Moore and Smolak (2002) state
that because “the most rigorous epidemiological studies of anorexia nervosa have
been conducted either in countries with relatively homogeneous Western
populations, or with samples selected to represent one ethnic group (white European
ancestry) and, frequently, only women, the distribution of these eating disorders
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among non-Westem populations, ethnic minority populations residing in Western
countries, and men is largely unknown” (p. 253).
Dorian and Garfinkel (1999) also suggest “there is currently a lack of clarity
regarding the characteristic features of these disorders in different cultures” (p. 189).
For example, although the fear of fat is considered central to anorexia nervosa,
anorexics in Hong Kong frequently do not exhibit the morbid fear of fat (Lee, Ho
and Hsu, 1993; Hsu and Lee, 1993). In a study by Lee, Lee and Leung (1998), they
confirm fat phobic and non-fat phobic subtypes of anorexia nervosa in the Chinese
population. However, whether these patients are concealing weight phobia, have an
atypical manifestation of anorexia or represent a true form of anorexia is not clear.
Further study is warranted.
Incidence
Incidence rates can be defined as “the number of new cases in the population per
year” (Hoek, 2002, p. 234). Incidence rates are formulated based on cases detected
in health care systems. Hoek (2002) states that results of incidence studies of
anorexia nervosa “suggest an increase in incidence of anorexia nervosa between
1930 and 1970” (Hoek, 2002, p. 234).
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Prevalence
According to the DSM-IV (1994) and Kaplan and Saddock (1998), prevalence
studies have found rates of anorexia nervosa between .5% -1% among females in
late adolescence and early adulthood. Kaplan and Saddock state that anorexia
“occurs 10 to 20 times more often in females than in males” (1998, p. 720), whereas
the DSM-IV maintains, “there are limited data concerning the prevalence of
[anorexia] in males” (DSM-IV, p. 543). The prevalence rate of young women with
some but not all symptoms of anorexia nervosa “is estimated to be close to 5%”
(Kaplan and Saddock, 1998).
Due to the increase in the number of patients receiving treatment in recent years,
some individuals suggest there is an epidemic (Klemchuk, Hutchinson and Frank,
1990; Meyer and Russell, 1998; Whitaker and Davis, 1989). However,
“epidemiological data are not confirming that there has indeed been an equivalent
increase in the number of cases in the general population” (Hoek, 2002, p. 233).
Onset and Course
The DSM-IV states “the mean age at onset for anorexia nervosa is 17 years, with
some data suggesting bimodal peaks at ages 14 and 18 years” (DSM-IV, 1994, p.
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542). However, evidence suggests that the age range of anorexia nervosa onset is
extending beyond the original 14-25 year age range. Using the few epidemiology
studies available, Lask and Bryant-Waugh (1992) note the increase in the numbers of
children under 14 years of age presenting for treatment of eating disorders, although
this number is low in comparison to other age groups. Rarely is the onset of anorexia
seen in females over the age of 40 years. Stressful life events are often associated
with late onset of anorexia nervosa.
The course of anorexia nervosa is variable. Some individuals recover without
treatment following a single episode, some individuals repeatedly recover and
relapse, some struggle with a deteriorating course, while some eventually die due to
complications of starvation. Kaplan and Saddock (1998), authors of the leading
textbook used in psychiatry, assert that although short-term response of patients to
hospitalization is good, in general “the prognosis is not good” (p. 725). The
American Psychiatric Association (2000) states, “the greatest excess of patient
mortality due to natural and unnatural causes is associated with eating disorders and
substance abuse” (p. 6).
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Outcome and Prognostic Factors
Outcome studies support the notion that the prognosis for anorexia nervosa is not
good. In 2002, Steinhausen analyzed 119 outcome studies on anorexia nervosa,
composed of 5,590 patients. Results suggest that anorexia nervosa has not lost “its
relatively poor prognosis in the 20th century” and “advances in etiology and
treatment may improve the course of patients with anorexia nervosa in the future”
(Steinhausen, 2002, p. 1284). Steinhausen’s analysis indicates that among the
surviving patients, on average, 46.9% attain a full recovery (from all essential
symptoms of anorexia nervosa), 33.5% have a fair outcome (improvement with some
residual symptoms), and 20.8% develop a chronic course of the disorder. The mean
crude mortality rate was reported at 5%. Favorable prognosis was associated with
longer duration of follow-up. Unfavorable prognostic factors included vomiting,
bulimia, and purgative abuse, chronicity of illness, and obsessive-compulsive
personality symptoms.
In 2000, the American Psychiatric Association published a “Practical guideline for
the treatment of patients with eating disorders”. Similar outcome figures were
reported. They state “the percentage of individuals with anorexia nervosa who fully
recover is modest” (p. 6). 44% reach a good outcome, 28% vacillate between good
and poor outcomes, 24% have a poor outcome and roughly 5% died. Furthermore,
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they state “mortality has been found to increase with length of follow-up, reaching
up to 20% among patients followed for more than 20 years” (p. 6).
Sullivan (1995) aggregated published crude mortality data from 42 studies of 3006
individuals diagnosed as having anorexia. He intended to estimate a mortality rate
over time associated with anorexia nervosa. He found an estimated rate of mortality
of .56% per year or 5.6% per decade. He further stated that “the aggregate annual
mortality rate associated with anorexia nervosa is more than 12 times higher than the
annual death rate due to all causes of death for females 15-24 years old in the general
population” and is “more than twice that of a national study group of female
psychiatric inpatients 10-39 years old” (p. 1074). The following discussion of some
recent, individual outcome studies will underscore these figures.
In a 21-year follow-up study of anorexia nervosa, Zipfel, Lowe, Reas, Deter and
Herzog (2000) found that “50.6% have achieved a full recovery, 10.4% still met full
diagnostic criteria for anorexia nervosa and 15.6% had died from causes related to
anorexia nervosa (p. 721). Additionally, they indicate that early identification and
intervention are important, as is targeting social and psychological symptoms. These
suggestions are based on findings that “a longer duration of illness before first
inpatient treatment, a low body-mass index and severe psychological problems” were
“risk factors for a poor outcome” (p. 722).
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In a 12-year follow-up outcome study of anorexia nervosa, Sullivan, Bulik, Fear and
Pickering (1998) found 10% of the subjects continued to meet the criteria for
anorexia nervosa. However, “even among those who no longer met these criteria,
relatively low body weight and cognitive features characteristic of anorexia nervosa
(perfectionism and cognitive restraint) persisted” (p. 155). Findings also reveal that
“the rates of lifetime comorbid major depression, alcohol dependence, and a number
of anxiety disorders were very high” among subjects. Investigators indicate the need
for therapeutic approaches to focus on “detection and treatment of associated
psychological features and comorbidity” rather than excessively focusing on “weight
gain” (p. 155).
In an 8-year follow-up study of anorexia nervosa, Casper and Jabine (1996) compare
outcomes for adolescent onset anorexia and adult onset anorexia. Findings reveal
“no significant differences in outcome for age at onset” (p. 499). Outcome was
considered good for 70% of adolescent onset and 42% of adult onset subjects.
Outcome was considered intermediate for 17% of adolescent onset and 21% of adult
onset subjects. Outcome was considered poor for 9% of adolescent onset and 21%
of adult onset subjects. 5.3% (4) of the subjects died; 2 from each onset group. 2
adolescent onset and 1 adult onset mortalities were due to complications of anorexia
and the remaining adult onset death was due to suicide. Findings also reveal that
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severity of illness was a poor prognostic indicator. Length of illness and food
restriction or bulimia as eating patterns was unrelated to outcome.
In a follow-up study of anorexia nervosa, Herpertz-Dahlmann, Wewetzer,
Henninghausen and Remschmidt (1996) found that after 7-years, 44% of anorexic
subjects “still fulfilled DSM-III-R criteria for some form of eating disorder
diagnosis, an 62% for some other psychiatric diagnosis” (p. 455). Additionally, the
results indicate “a similar course of adolescent anorexia nervosa to that of early-
adulthood onset in terms of global outcome and psychiatric morbidity” (p. 462).
In a German study, Fichter and Quadflieg (1999) investigate course and outcome of
patients with anorexia nervosa 2 and 6-years following the start of therapy, as
compared to similar individuals with bulimia nervosa and binge eating disorder.
They found that in comparison to samples with other eating disorders, “the 6-year
course of anorexia nervosa was less favorable” (p. 359). Anorexic patients “showed
a course of illness of high persistence” (p. 382). Although “treatment and time
reduced the severity of symptoms... many cases did not result in full remission” (p.
382). 34.7% of the anorexic sample had a good outcome, 38.6% had an intermediate
outcome, 20.8% had a poor outcome and 5.9% died.
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Ben-Tovim, Walker, Gilchrist Freeman et al. (2001) assessed outcome in eating
disorder subjects 5-years following their first assessment. Results “provide strong
support for separate identities for anorexia and bulimia” as there were “clear
differences in overall outcomes of these two groups and in the characteristics that
predicted those outcomes” (p. 1258). They found that 56% of the survivors from the
anorexic group did not meet criteria for any eating disorder, as opposed to 74% from
the bulimic group and 78% from the eating disorder not otherwise specified group.
However, these prior anorexic subjects obtained scores “indicating the continuation
of their illness and psychosocial difficulties” (p. 1258). These results are supported
by Rastam & Gillberg (1996), who found that although recovered in terms of weight
restoration, former anorexics still exhibited difficulties in social areas. More
specifically, “obsessive compulsive and avoidant personality disorders and empathy
disorders were very much more common in the anorexic than in the comparison
group” (p. 439).
Thus, anorexia nervosa, although rare, is a disorder with alarmingly high morbidity
and mortality rates. Why many individuals afflicted with anorexia nervosa do not
recover and die is an important question for psychologists. Perhaps it is due to the
insidious nature of anorexia. Perhaps individuals are not getting better because we
simply do not have a good enough understanding of the subtle nuances and
intricacies of anorexia.
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CHAPTER FOUR
EXISTING THEORY
Before examining the various theoretical understandings of anorexia nervosa, we
must first consider how psychology’s current model of psychopathology is
multidimensional and integrative.
Influences of Psychopathology in General
“Most scientists and clinicians believe that abnormal behavior results from various
influences”, including behavioral and cognitive, biological, emotional, social and
developmental influences (Barlow and Durand, 2001, p. 29). Behavioral and
cognitive influences “affect the learning and adaptation each of us experience
through life” (Barlow and Durand, 2001, p. 61). These influences can contribute to
psychological disorders, as well as affect and change brain functioning, brain
structure and genetic expression. Such influences include, but are not limited to,
classical conditioning, learned helplessness, social learning, prepared learning, and
implicit memory.
Biological influences of abnormal behavior are comprised of genetic and
neuroscience contributors. Psychologists attempt to understand how genes
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contribute to or are associated with psychological disorders. The diathesis-stress
model and the reciprocal gene-environment model are two theories that account for
the interaction of genetic and environmental effects. The diathesis-stress model
suggests that individuals “inherit certain vulnerabilities that make them susceptible
to a disorder when the right kind of stressor comes along” (Barlow and Durand,
2001, p. 61). The stress (or diathesis) can be biological, environmental, or both. The
environmental part of the equation can be either biological or psychological. The
reciprocal gene-environment model maintains that an “individual’s genetic
vulnerability toward a certain disorder may make it more likely that he or she will
experience the stressor that in turn triggers the genetic vulnerability and thus the
disorder” (Barlow and Durand, 2001, p. 61). Neuroscience also adds contributions
to the understanding of abnormal behavior. Neurotransmitters (such as serotonin,
gamma aminobutyric acid (GABA), norepinephrine, and dopamine), and
neuroendocrine activity levels interact and “modulate and regulate emotions and
behavior and contribute to psychological disorders” (Barlow and Durand, 2001, p.
61).
Emotions can have a major impact on the development of psychopathology, either
directly or indirectly. Furthermore, emotions can either contribute to
psychopathology or define psychopathology. An example of emotional contribution
to psychopathology is that the suppression of emotional responses can lead to
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increases in activity in the sympathetic nervous system, contributing to
psychopathology (Barlow and Durand, 2001). In terms of defining psychopathology,
mood, such as depression, can define the psychological disorder.
Influences of social, interpersonal and cultural factors are important in understanding
the development, expression and maintenance of psychopathology. These factors
affect the individual’s biological, as well as psychological world.
Finally, developmental influences are important in understanding pathology. What
we experience during “different periods of development may influence our
vulnerability to other types of stress or to differing psychological disorders” (Barlow
and Durand, 2001, p. 60). The principle of equifinality reminds us that there are
many paths to a particular outcome, and that we must attend to the different
pathways, rather than focusing solely on outcome.
Given these five general causal influences of psychopathology, different theories
accentuate different influences in psychopathology. In term of anorexia nervosa,
most theorists agree that it is a complex, multidimensional disorder that is not
unicausal in nature. Although experts may acknowledge the multi dimensionality of
the anorexia, “current explanations generally fit within one of three models: the
biomedical, the psychological, or the cultural” (Brumberg, 1988, p. 24). I will
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explore each of these models and show why a different approach to understand
anorexia is called for.
The Biomedical Model
Recently, “familial transmission of risk (for anorexia nervosa) has emerged as an
increasingly strong focus of research attention” (Strober, Freeman, Lanpert,
Diamond and Kaye, 2000, p. 393). Studies “strongly suggest that the familiality
observed in family studies is primarily due to genetic causes” (Grice et al. 2002).
In what appears the “largest case-control family study of eating disorders conducted
to date”, using first degree relatives of anorexia nervosa probands, Strober et. al.
(2000, p. 393) draws important conclusions. The comparison group families rarely
exhibited full or partial syndromes of anorexia nervosa. However, in anorexic
proband families, “full and partial syndromes of anorexia nervosa aggregated in
female relatives” (Strober et. al., 2000, p. 393). These researchers maintain that “1)
the age specific risk for anorexia nervosa in relatives of probands with anorexia
nervosa was 11.4 times as high as the risk in relatives of normal probands... and 2)
for relatives of anorexic probands, the age-corrected risk of partial anorexia nervosa
was 5.2 times that for relative of never-ill probands” (Strober et. al., 2000, p. 399).
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Another study found that “there may be a common familial vulnerability for
anorexia” (Lilenfeld, Kaye, Greeno, Merikangas, Plotnicov, Pollice, Rao, Strober,
Bulik & Nagy, 1998, p. 603). More specifically, their results “suggest a shared
familial transmission of anorexia nervosa and obsessive compulsive personality
disorder”, and that “obsessive personality traits may be a specific familial risk factor
for anorexia” (Lilenfeld et al., 1998, p. 608). Other studies have indicated that there
is an association of anorexia nervosa with traits of obsessive-compulsive personality
disorder as well (Jarry and Vaccarino, 1996). More specific eating disorder traits
like ‘body dissatisfaction’ and ‘drive for thinness’ are thought to have a significant
genetic component according to some theorists (Rutherford, McGuffin, Katz and
Murray, 1993).
Twin studies have shown higher concordance rates in monozygotic twins when
compared with dizygotic twins (Holland, Sicotte and Treasure, 1988; Holland, Hall,
Murray, Russell and Crisp, 1994; Maddox and Long, 1999; Ward, Tiller, Treasure
and Russell, 2000). More specifically, “concordance rates for monozygotic twins
with anorexia nervosa have been estimated to be 5% -ll% (Garfinkel and Gamer,
1982; Holland et al. 1984,1988; Wade et al. 2000)” (Grice et al. 2002).
Although concordance rates in monozygotic and dizygotic twins show differences,
the results regarding genetic and environmental causes of anorexia nervosa are
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guarded due to the study’s small sample size and the scarcity of anorexia nervosa in
the general population (Bulik, Sullivan, Wade and Kendler, 2000). In an analysis of
anorexia nervosa and major depression, heritability for anorexia was found to be
58% and a correlated genetic liability between anorexia and major depression was
found (Wade, Bulik and Kendler, in press).
Latest evidence suggests there is a genetic link to anorexia nervosa. In a
groundbreaking study, Grice, Halmi, Fichter, Strober, Woodside, Treasure, Kaplan,
Magistretti, Goldman, Bulik, Kaye and Berrenttini (2002) conducted the “first
genomewide linkage analysis of eating disorders” (p. 789). These researchers found
“evidence for a susceptibility gene for anorexia nervosa on chromosome Ip” (p.
787). This finding supports family and twin studies that suggest that biology plays
an important role in the etiology of anorexia nervosa.
There is inquiry as to a possible association between anorexia nervosa and the -1438
A/G polymorphism in the 5-HT2A gene (Collier, et al., 1997; Enoch et al., 2001;
Sorbi et al., 1998). In attempt to consolidate the findings of various studies, a meta
analysis was performed that reinforces the view “that the 5-HT2A gene is a
susceptibility gene for anorexia nervosa” (Collier, et al., 1999, p. 99). However, due
to the possibility that the associations may have occurred by chance and/or
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publication bias (positive findings first published), this finding must be interpreted
with caution.
Additional support for the biologic importance in anorexia nervosa comes from
serotonin studies, imaging studies and case reports based on organic lesions. Due to
serotonin’s involvement in appetite control, there has been inquiry into serotonin
levels as a vulnerability factor in anorexia nervosa. Kaye (1999) suggests that
“increased serotonin activity might cause increased satiety, which is often the
initiating symptom of anorexia nervosa” (p. 158). Kaye (1999) also states that
“increased serotonergic activity could also contribute to anxious, obsessive,
perfectionistic and harm avoidant types of behavior found in anorexia nervosa” (p.
158). According to Maddox and Long (1999), individuals with anorexia nervosa
often times have “decreased levels of plasma tryptophan (a serotonin precursor) and
serotonin’s major metabolite 5-HI A A as measured in the urine and cerebrospinal
fluid” (p. 380). Consequent to these findings, there was an increased interest in the
use of selective serotonin reuptake inhibitors (SSRI’s) for treatment of anorexia. In
low-weight anorexics, abnormalities of serotonergic functioning have been found
(see Brewerton, 1995, for review). In a sample of ‘recovered’ anorexics, results
suggested long-term abnormality of serotonergic functioning (Kaye, Gwirtzman and
George, 1991). However, more recent studies present conflicting results showing no
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difference between recovered subjects and controls (O’Dwyer, Lucey and Russell,
1996; Ward, Brown, Lightman, Campbell and Treasure, 1999).
Due to conflicting results, it is unlikely that abnormality of serotonin regulation is a
major vulnerability factor in anorexia nervosa. Additionally, the results of treatment
of malnourished and underweight anorexics with selective serotonin reuptake
inhibitors (SSRI’S) have not been effective (Kaye, 1999; Maddox and Long, 1999).
Research as to the involvement of other neurotransmitters, such as dopamine and
norepinephrine, with anorexia nervosa needs further development (Bailey, 1995;
Marken and Sommi, 1997).
Another avenue of inquiry regarding biologic vulnerability to anorexia nervosa is the
involvement of the newly discovered obese (ob) gene, and its product, the satiety
protein leptin. Leptin, which is secreted by fat cells, acts on the hypothalamus and is
thought to play an important role in the regulation of body fat stores. In male and
female subjects, there is a highly significant correlation between body mass index
(BMI) or percent body fat and plasma level (Maffei, Halaas, Ravussin, Pratley, Lee,
Zhang, Fei, Kim, Lallone, Ranganathan, Kern and Friedman, 1995). Ward, et al.,
(2000) suggests that abnormalities of leptin secretion may be involved in the onset
and maintenance of anorexia nervosa. Ward and her colleagues have found in
preliminary results that leptin secretion may be abnormal in a subgroup of actively
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anorexic patients, while levels in long-term recovered patients are normal (Ward, et
al., 2000). Although promising, these findings do not explicitly establish a causal
link between biological deviations and anorexia nervosa. This area lends itself to
future research and investigation.
Through the 1990’s imaging studies have demonstrated evidence of organic
involvement in anorexia nervosa. Ward et al., (2000) reports that computed
tomographic (CT) scans have consistently shown enlarged cerebral ventricles and
sulci in ill patients with anorexia nervosa. Most studies have shown at least a partial
recovery of the enlargements with recovery. However, there are minorities of brain-
atrophied scans that show no improvement despite several months of normal weight
(Ward et al., 2000). Other imaging studies, such as single-photon emission
computed tomography (SPECT) and positron emission tomography (PET), have
been inconclusive due to their conflicting results (Braun and Chouinard, 1992).
Future investigation is warranted.
Until recently, there have been many documented cases where organic lesions
present, and are sometimes diagnosed as anorexia nervosa, suggesting an organic
link. Ward, et al., (2000) reports that significant number of the lesions have been
identified in the hypothalamic area. The circadian pattern of eating is controlled by
the suprachiasmatic nucleus, while the paraventricular and ventromedial nuclei of the
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hypothalamus control energy balance. The lateral hypothalamus is involved in the
reinforcement system. Therefore, the hypothalamus has an important part in the
control of appetite. After illustrating several pertinent case reports, Ward et al.
(2000) support the notion that the organic factors act as aggravating rather than
initiating influences. Most anorexics will not present with such gross organic
pathology, but they will suffer physical consequences of their disorder. The physical
consequences will manifest overtly as well as though less obvious ways such as
disturbances in the neuroendocrine, biochemical and immunological systems (Ward
et al., 2000).
As can be seen, there is great importance in understanding anorexia nervosa from a
biological perspective. There is compelling research that supports the biologic
viewpoint in the etiology of anorexia nervosa. However, the biologic explanation for
the etiology of anorexia nervosa is not sufficient by itself. What is needed, is theory
that incorporates the biologic perspective, in addition to psychological, social and
developmental considerations.
The Psychological Model
Cognitive-behavioral theory, psychoanalytic theory, and family systems theory are
the major camps of thought with psychological models of anorexia nervosa.
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Psychoanalytic theory and family systems theory focus on anorexia nervosa as a
pathological response to a developmental crisis.
Anorexia Nervosa from a Cognitive-Behavioral Point of View
Cognitive-behavioral theory focuses on what initiates and maintains symptoms of
psychopathology “rather than on remote etiological factors” (Vitousek, 2002, p.
308). Cognitive theorists assume that “maladaptive feelings and behaviors are
mediated by distorted or maladaptive thinking and that the primary aim of clinical
intervention is to alter these cognitive processes” (Gamer and Bemis, 1985, p. 116).
Vitousek maintains that in anorexia, “the core disturbance is a characteristic set of
beliefs associated with the desire to control eating and weight” (Vitousek, 2002, p.
308). The anorexic individual is thought to base her self-worth on the size and shape
of her body, influencing certain eating disorder behaviors. She also responds to
“eccentric reinforcement contingencies”, processes “information in accordance with
predictable cognitive biases” and is eventually “affected by the physiological and
psychological sequelae of starvation” (Vitousek, 2002, p. 309). The underlying idea
of her self worth being comprised of body size and shape is only strengthened by
these processes.
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In addition, food restriction and weight loss serve valuable functions for these
individuals. “A sense of specialness, moral certitude, competitiveness, and positive
identification with the disorder” result (Vitousek, 2002, 309).
Cognitive-behavioral theory has important contributions to the etiology and
treatment of anorexia nervosa, (which will be seen in later section of empirical
studies). However, this theory alone does not give credence to biologic contributors
to anorexia, as well as the dynamic and developmental influences important in the
etiology of anorexia nervosa.
Anorexia Nervosa from a Psychoanalytic/Psychodynamic Point of View
The primary derivatives of psychoanalytic theory are the drive-conflict model, the
self-psychological perspective, the ego psychological model, the interpersonal
perspective, and the object relations model.
Drive-Conflict Model.
Drive-conflict theorists believe that an internal conflict between the id, the ego and
the superego results in pathology. This view assumes a relative intactness of the
mind, rather than deficits in structure. Symptoms are seen as symbolic
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representations of sexual and/or aggressive aims and defenses against these aims.
The beginning of pathology is the intrapsychic conflict between biological aims
seeking discharge and social constraints against this discharge. Treatment consists
of insight and interpretation.
The earliest psychoanalytic understandings of anorexia nervosa focused primarily on
the “oral” aspect of the disorder and its symbolic significance. Freud interpreted
anorexia as “a neurotic behavior that expressed undeveloped or repressed sexuality”
(Brumberg, 1988, p. 214). Other theorists understood anorexia as a defense strategy
against sexualized oral fantasies, such as the unconscious wish to be impregnated by
the father (Lorande, 1943; Masserman, 1941; Moulton, 1942; Thoma, 1967; Waller,
Kaufman and Deutch, 1940). Other theorists viewed starvation as a defense against
ambivalent oral sadistic fantasies (Berlin, Boatman, Scheimo and Szurek, 1951;
Masserman, 1941).
A Self-Psychological Perspective.
Self-psychologists support the notion that the self, the “center of the individual’s
psychological universe”, has internal needs for “self-esteem, regulation of emotions,
calming, soothing and a feeling of continuity over time and space” (Bachar, 1998, p.
148). Other individuals that fulfill internal needs are referred to in self-psychology
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as selfobjects. Disorders of the self arise when the child is unable to rely on humans
to fulfill selfobject needs.
Self-psychologists focus on the “psychic incapacities or deficiencies and immature
or undeveloped psychic structure” of the individual (Goodsitt, 1997, p. 206). The
incapacity results in “painful experiential states of the mind or self-states of
devitalization (emptiness and numbness; a sense of going through the motions, not
feeling alive, not really living), dysphoria and tension” (Goodsitt, 1997, p. 206).
Symptoms are seen as “desperate or emergency measures to restore a sense of
vitalization, wholeness or effectiveness (Goodsitt, 1997, p. 206). Although the
symptoms may have symbolic meaning, the symbolic meaning is not considered the
source of the symptoms.
Advocates of self-psychology suggest that individuals are vulnerable to developing
an eating disorder when there are “chronic disturbances in empathy emanating from
the caretakers of the growing child” (Bachar, 1998, p. 149). They experience
“developmental failures in the provision of mirroring, idealizing, and validating
needs leading to deficits in capacities to maintain self-esteem, cohesion, and various
self-regulating functions” (Goodsitt, 1997, p. 209). Parents who are “self-absorbed,
anxious, needy, overwhelmed, depressed, or psychotic” do not provide the child with
“appropriate, affirming selfobject needs” (Goodsitt, 1997, p. 209). The child’s role
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becomes “maintaining others’ well-being”, and she turns off her own needs”
(Goodsitt, 1997, p. 209). Consequently, her own selfobject and self-regulatory
capacities for maturation are defeated. What is specific to eating disorders is the use
of “a new restorative system in which disordered eating patterns are used instead of
human beings in order to meet selfobject needs” (Bachar, 1998, p. 149). An
anorexic, in particular, is unable to depend on others to meet her selfobject needs, so
she ignores food. In doing so, she “fulfills selfobject needs” (Bachar, 1998, p. 149).
In such a situation, the child is unconsciously afraid of growing up because growing
up means “loss, loneliness, isolation, emptiness, helplessness, and coming apart”
(Goodsitt, 1997, p. 209). Consequently, the idea of “doing or being well or of
gaining weight is dreaded” (Goodsitt, 1997, p. 209). The emergence of the anorexic
symptoms conveys the “thwarted needs and wishes” (Goodsitt, 1997, p. 209). The
emaciation screams for attention to her needs and demands. The anorexic’s
expressed feeling of fat is really the result of feeling inadequate, ineffective and out
of control as the result of “the absence of reliable internal self-regulation” (Goodsitt,
1997, p. 209). Focusing on anorexia activity allows the individual to turn “off her
needs of others”, turn “inward to herself’, to have a “sense of predictability and
control”, and ultimately to narrow “down her world to something she feels she can
manage” (Goodsitt, 1997, p. 210).
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Ego Psychological Model.
In theorizing anorexia nervosa, the ego psychological model removed the focus from
the oral impregnation wish and placed importance on the role of ego weakness in the
anorexic patient (Eissler, 1943). The focus in this model shifted the unconscious
wish to a re-establishment of the mother-child unity (Meyer and Weinroth, 1957).
Advocates of this model believe there was a disturbance in the early feeding
experience that resulted in later oral disturbance symptomology. Additionally,
Meyer and Weinroth believe that beneath the obsessional behavior in anorexia
nervosa lies a psychotic ego organization.
Interpersonal Theory.
The interpersonal theory of anorexia nervosa put forth by Hilde Bruch (1973, 1978,
1987) focuses on the mother-child interaction disturbances as the root of the
anorexic’s ego deficiencies. She posited that from birth on there are two basic forms
of behavior; namely behavior initiated in the infant and behavior in response to
stimuli. Likewise, the mother’s behavior in relation to the child is either responsive
or stimulating. The behavior interaction between mother and child can be considered
either appropriate or inappropriate, depending on whether it supports the child’s
survival and development or distorts it. In order for a child to organize significant
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building blocks for the development of self-awareness and self-effectiveness, the
mother’s responses to the infant’s cues in the biological, intellectual, social and
emotional fields must be appropriate. If the mother does not confirm or reinforce the
child’s needs and impulses or her behavior has been contradictory or inaccurate, the
child will grow up confused when trying to differentiate between disturbances in the
biological field, and emotional and interpersonal experiences and will be likely to
“misinterpret deformities in his self-body concept as externally induced” (Bruch,
1973, p. 56). Consequently, the child will feel deficient in his or her sense of
separateness, suffering “diffuse ego boundaries”. The child will thus feel subject to
the influence of external forces.
Healthy development is therefore contingent upon experience of confirmation of
clues originating in the child and his or her responses to outside stimuli. How this
operates can be seen in the eating function. Bruch believed that the experience of
hunger is learned rather than innate. If the mother offers food in response to signals
from the infant indicating nutritional need, over time the child will develop the idea
of “hunger” as a sensation arising distinctly separate from other tensions or needs. If
the mother continuously responds inappropriately, such as by being neglectful or
indiscriminately permissive, then the child will experience confusion. When older,
the child will have difficulty distinguishing between hunger and satiation, and
nutritional need or some other discomfort or need. The child also may be perplexed
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and inaccurate in differentiating between various bodily sensations and emotional or
interpersonal experiences. The child may experience confusion as to whether
impulses arise inside the self or from outside. Additionally, the child may not feel
truly separated from others.
Bruch delineates three areas of disordered psychological functioning that are
characteristic to anorexia nervosa. The areas are as follows: 1) a disturbance in
interpretation of internal and external stimuli, with the most pronounced symptom
being the inaccuracy in the way hunger is experienced, 2) a severe disturbance of
delusional proportions in the body image and body concept, and 3) a paralyzing
sense of ineffectiveness, which permeates all thinking and activities. The dynamic
issues of the developmental impasse are considered to be the cause of the anorexia.
Bruch also views anorexia as a search for a self-respecting identity.
Object Relations Theories.
Object relations theorists believe that the core problem in anorexia is the
developmental failure in separation-individuation processes (Masterson, 1977;
Palazzoli, 1978; Sours, 1974,1980). More specifically, some theorists have honed in
on the symbiotic-like attachments between anorexic’s and their parents and the
arrested separation-individuation process (Masterson, 1977, 1978; Palazzoli, 1978;
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Johnson and Gonners, 1987). Theorists such as Mahler, Pine and Bergman (1975)
believe the separation-individuation process to be a marker of the psychological birth
of an individual where there is a separation and a relation to reality and the
experience of one’s own body and to the “principal representative of the world as the
infant experiences it, the primary love object” (Mahler, Pine and Bergman, 1975,
p.3). Anorexia nervosa results from chronically disturbed mother-child interaction
during the separation-individuation process.
Palazzoli (1978) explained anorexia nervosa in an object relations framework. In
attempting to separate and individuate from a “bad introject”, the body self becomes
fused with the “bad introject”. The anorexic then attempts to deal with the body as if
it had all the negative associations of the primary object as it was perceived. In
attempt to control the primary object, the anorexic controls her own body by
starvation.
Masterson (1977) who explains anorexia nervosa from an object relations standpoint,
shifts the problem of anorexia in terms of the borderline phenomena. He believed
anorexia nervosa is a defense against the deep depression that would result if
separation-individuation were attempted. He perceived the mother of the anorexic
patient as never having separated from her own mother. In order to maintain her
own emotional balance, the mother fosters her symbiotic relationship with her own
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child by withdrawing support when the child moves towards individuation-
separation. The child is rewarded for dependent, clinging behavior and punished for
attempting individuation-separation. Therefore, the child experiences both positive
and negative maternal introjects dependent upon the child’s behavior (Masterson,
1978).
Johnson and Conners (1987) believe that anorexia nervosa is a paranoid defense
whereby fat becomes the symbolic focus to protect them from parental intrusiveness.
Parents who have been overinvolved are experienced as intrusive by the child. The
child believes that any attempt to separate and individuate will result in punishment
by the parent. Therefore, the child resorts to focusing on body to gain a sense of
autonomy, control, and a sense of purpose and motivation. These authors represent
some of the ways the fundamental problem in anorexia can be located in the
developmental failure in separation-individuation processes.
Anorexia Nervosa from an Attachment Theory Point of View.
Advocates for attachment theory view anorexia as a disorder of disrupted early
childhood attachments. Bowlby, who defined the concept of attachment, emphasizes
the causal relationship between a child’s experiences with parents and the ensuing
capacity to make affectional bonds (Bowlby, 1973,1979). In order to be secure
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enough to develop the capacity to trust others, a child must have an available and
responsive attachment figure (Bowlby, 1979). The mothers of anorexics have been
represented as over-controlling or under-nurturing (Minuchin, 1978), and either
encouraging of dependency or unable to foster autonomy (Sours, 1974).
Consequently, the child does not have a secure home base from which to separate
(Sours, 1974).
The behaviors of anorexia can be seen as abnormal “care eliciting” behaviors, a
pattern of activity intended to evoke comforting responses from others (Henderson,
1974). The behaviors are abnormal in that they are intensifications of what falls
within the normal range of care-eliciting behaviors. However injurious, the behavior
usually does bring people closer.
The starving behavior of anorexics has also been viewed as not only an illness
brought about by childhood conflicts and developmental failures, but also as an
unconscious attempt to fix unfulfilled needs with early attachment figures (Chassler,
1994). The hope of the anorexic is to experience fulfillment from the attachment
figure and be able to ascertain a sense of security and confidence in order to develop
normally towards growth and self-reliance.
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The psychoanalytic/psychodynamic point of view is crucial in understanding the
etiology of anorexia nervosa, as will be later demonstrated by empirical studies.
However, this viewpoint only looks at the individual in a psychological context,
neglecting to value the biological contributors in the etiology of anorexia nervosa.
Anorexia Nervosa from a Family Systems Point of View
Family systems theorists emphasize the importance of the dynamics and interactions
within the families of anorexic individuals. The concepts of the psychosomatic
family and triangular relationships (Killian, 1994) among parents and symptomatic
children will be discussed.
The Psychosomatic Family.
Minuchin et. al. (1975) used structural family therapy with children suffering from
psychosomatic illnesses, such as anorexia. The notable characteristics that have been
found in psychosomatic families are enmeshment, rigidity, lack of conflict resolution
and overprotectiveness. Minuchin, Rosman and Baker (1978) believe that anorexic
families demonstrate these four characteristics.
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Triangular Relationships.
It has been reported that anorexic families often have parent-child coalitions and
blurred generational boundaries (Killian, 1994). Selvini-Palazzoli and Yiaro (1988)
and Selvini-Palazzoli, Cirillo, Selvini and Sorrentino (1989) proposed a six-stage
model for the anorexic family process that exemplifies the triangular relationships.
These families do not explicitly express their feelings, goals and intentions. Rather,
they engage in a covert game that is based on the perception of a privileged
transgenerational dyadic relationship in the family. In the first stage, the parents
both demand the other change. However, the demand is not expressed as an
individual need for the other parent to change. Rather, the demand is placed as an
expectation of the other parent as a parent, not a spouse. In the second stage, the
future anorexic becomes involved in the parental conflict. The child is often aligned
with the mother, becoming her confidante and helper. However, the child does not
respect the mother. During the third stage, the child often turns to the father, sharing
contempt for the mother. The fourth stage is characterized by the child feeling
neglected by her mother. The child attempts to differentiate herself by altering her ■
diet. The mother only reinforces the new eating behavior by trying to control it. In
the fifth stage, the daughter is disappointed by her father, who does not side with her
against his wife. In the last stage, the daughter recognizes that anorexia gives her
power and makes her feel privileged in the family, how she used to feel.
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It has also been suggested that the child with anorexia responds to the enmeshed and
over-involved family patterns by seeking proximity in the form of interpersonal
contacts (Minuchin, Rosman and Baker, 1978). Minuchin, et.al’s (1978) work
suggests that the child develops anorexia to receive rewards of love and approval by
being thin or needy. They also posit that such children are dependent upon parental
approval and develop an obsessive perfectionism, which is expressed through
thinness. In order to be the center of attention or to deflect parental conflict, the
child becomes anorexic. The anorexia communicates that the child is weak,
incompetent and need of family support.
The family systems point of view implicates the family in the etiology of anorexia.
This viewpoint can be helpful in that it allows for the examination of the family
system and it’s psychological underpinnings. However, this viewpoint ignores the
biological and contributions to the etiology of anorexia. Furthermore, the notion of
triangular relationships that is exemplified by the six-stage model (Selvini-Palazzoli
and Viaro, 1988; Selvini-Palazzoli, Cirillo, Selvini and Sorrentino, 1989) makes the
false assumption that a mother, father and children constitute a family. This
particular etiological model of anorexia does not address single parent families,
divorced families, or same-sexed parent families.
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In order to demonstrate the usefulness of the psychological theories, researchers have
conducted many studies examining the tenets of the different theories. What follows
is an overview of empirical data addressing the different psychological theoretical
approaches to understanding anorexia nervosa.
Empirical Studies
Cognitive-Behavioral Studies.
Cognitive theories of anorexia suggest that anorexics are extremely preoccupied with
thoughts of food, weight and body shape. According to Vitousek and Hollon (1990),
anorexics develop organized cognitive structures around issues related to anorexia,
such as weight. They also suggest that these schemata may play a role in supporting
maladaptive eating disorder behavior. Studies have tried to expose the content and
nature of these schemata through the use of self-report questionnaires. In anorexics,
these studies have typically found more negative thoughts related to eating, weight
and shape (Hermans, Pieters and Eelen, 1998).
For example, Cooper and Fairbum (1992) conducted a study to investigate self
statements while performing three behavioral tasks, looking at oneself in a full-
length mirror, weighing oneself, and eating a chocolate mint. The subjects consisted
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of one group of anorexics, one group of bulimics, two control groups of dieters and a
control group of non-dieters. Both eating disorder groups had more negative
thoughts related to eating, weight and shape than control groups. The anorexics
indicated greater concern regarding eating, as opposed to the bulimics who indicated
greater concern with weight and appearance.
Studies have also been conducted that attempt to move beyond self-report and use
preconscious processes, such as the selective processing of material related to food
and body size. The investigation of selective attention and memory for emotionally
relevant material has been useful in many studies. Many researchers have used a
modified version of the Stroop task, where anorexics are asked, as quickly as
possible, to name the colors within which a series of anorexia related words (e.g., fat,
diet) or neutral words (e.g., ocean, clock) are written. These studies indicate that
when compared to control groups, anorexics are inhibited when color naming the
anorexia related words (Ben-Tovim and Walker, 1991; Ben-Tovim, Walker, Fok and
Yap, 1989; Channon et al., 1988; Cooper and Fairbum, 1992a; Green, McKenna &
deSilva, 1993; Long, Hinton and Gillespie, 1994; Perpina, Helmsley, Treasure and
de Silva, 1993; Walker, Ben-Tovim, Jones and Bachok, 1992; Walker, Ben-Tovim,
Paddick and McNamara, 1995). The selective processing of eating, weight and
shape related information has been seen as evidence for the existence and use of
eating disordered schemata in anorexics (Vitousek and Hollon, 1990). Therefore,
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according to Hermans et al. (1998), it can be argued that the modified Stroop test
results suggest that food, body, weight and shape memory concepts are more
accessible and more easily primed.
In a study investigating implicit and explicit memory for shape, body weight, and
food-related words in anorexics, Hermans, Pieters and Eelen (1998) found a strong
explicit memory bias for anorexia-related words for anorexics. In other words,
anorexics show an explicit bias favoring anorexia-related stimulus material. These
results therefore indicate that anorexics “should display a selective memory for
anorexia related information, and thus indicate that information related to weight,
shape, and food is well embedded within the memory structures of patients with
anorexia” (Hermans, et al., 1996, p. 198).
Psvchodvnamic and Family Systems Studies.
Psychodynamic and family systems theorists both support the notion that eating
disorders are reflective of a “deeper, more pervasive problem in the family’s role
structure, affective expression, relationship dynamic, and style of interacting”
(Humphrey, 1989, p. 206). Empirical evidence supports this claim.
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Humphrey (1986) reported that anorexic and bulimic subjects found their parents to
be more blaming, rejecting and neglecting than control subjects. Although bulimics
reported deficits in parental nurturance and empathy, anorexics did not. In a study
based on observed family interactions, Humphrey (1987) found that when compared
to control families, bulimic and anorexic families were less helping, trusting,
nurturing, and approaching toward one another than were control families. Eating
disorder families were also found to be more belittling, appeasing, ignoring and
walling-off in comparison to control families. In another study based on observed
family interactions, Humphrey (1989) found that anorexic daughters “were more
deferring and submitting in relation to their mothers than were any other clinical or
control groups” (Humphrey, 1989, p. 211). Findings also describe a family in which
mother and father are both too nurturant and too neglectful. Being too nurturant
discourages the anorexic’s efforts to individuate, making her all the more dependent
on her parents. At the same time, the parents “ignore and negate her genuine self-
expressions and developmental needs” (Humphrey, 1989, p. 211). Humphrey further
speculates that the particular “pattern of parental control and negation of the
anorexic’s true, separate self leads to the development of her “false” self and to her
restrictive and destructive attitudes toward her body” (Humphrey, 1989, p. 211).
Sordelli, Fossati, Devoti, La Viola and Maffei (1996) found significant similarities
and differences in object relation patterns among anorexic and bulimic patients.
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Both groups shared the “common element of a loss of differentiation in the
description of their mothers and fathers” (Sordelli et al., 1996, p. 69). However,
while bulimics view their parents as both caring and overwhelming, anorexics
perceive their parents to be absolutely caring. Anorexics appear to present an image
of their parents as entirely good, which could be the result of idealized object
representations.
Swarr and Richards (1996) conducted a longitudinal study examining girls’
subjective experiences with both parents and the emergence of eating problems.
During the 7th, 8th, and 9th grades, girls who felt closer with their mothers indicated
fewer weight and eating concerns, and girls who spent more time with their mothers
indicated fewer eating problems two years later. During the 7th, 8th, and 9th grades,
girls who felt closer to their fathers reported fewer weight and eating concerns. Thus,
the findings support the notion that the relationship with parents is strongly related to
adolescent’s weight and eating concerns. Furthermore, the authors state “spending
time with their fathers served as a protective factor for those girls whose perceptions
of their pubertal timing as early may have placed them at greater risk for eating
problems.
Heesacker and Neimeyer (1990) conducted a study examining object relations and
social cognitive correlates of eating disorders. Results indicate that women with
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higher levels of eating disorder behavior show higher levels of object relations
disturbances, including insecure attachment in formative, parental relationships, and
social incompetence. Results also indicate that women with higher levels of eating
disorder behavior have “a rigid and overly constricted cognitive structure that results
in a unidimensional framework for construing self and others” (Heesacker and
Neimeyer, 1990, p. 427).
In examining the attachment patterns in eating disorders subjects, Ward, Ramsay,
Turnbull, Benedettini andTreasure (2000) found that eating disorder subjects scored
significantly higher than controls on most scales of the reciprocal attachment
questionnaire, most notably on compulsive care-seeking (anxious) and compulsive
self-reliance (avoidance). Findings demonstrate a “pull-push” dilemma in the
reciprocal attachment relationships of eating disordered subjects, with not only the
mother, but in other adult attachment relationships as well.
Salzman (1997) reviewed narrative data from the ambivalent attachment subgroup of
a larger attachment investigation. Unexpected findings indicate that 7 of the 11
ambivalent subjects had a history of clinically significant anorexia, and 9 of the 11
ambivalent subjects reported affective instability (distressingly intense feeling
states). Furthermore, the subjects who had experienced anorexia associated their
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disorder “with deep frustration at being cheated of a warm, steady source of love
from their mothers” (Salzman, 1997, p. 257).
Using an inpatient sample of women with eating disorders and a control group,
Kenny and Hart (1993) examined parental attachment. Findings suggest “the
presence of an affectively positive and emotionally supportive parental relationship,
in conjunction with parental fostering of autonomy, is inversely associated with
weight preoccupation, bulimic behavior, and feelings of ineffectiveness” (Kenny and
Hart, 1993, p. 521). The eating disorder women characterized their relationships with
their parents as more affectively negative and less supportive. They also described
themselves as less likely to solicit and receive support and comfort from their parents
in stressful times. These results concur with theorists who maintain that attachment
is “a central and healthy dimension of adolescent and adult life” and that
“characteristics of secure parental attachments are associated with adaptive
psychological functioning” (Kenny and Hart, 1993, p. 523).
Goldstein (1981) found that when compared to parents of pre-schizophrenic and non
anorexic hospitalized adolescents, parents of anorexics exhibited enmeshed and
conflict avoiding behavior. In contrast, in a study of adolescents and their families,
Lattimore, Wagner and Gowers (2000) found that anorexia dyads had more
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destructive communication than comparison dyads. These results do not lend
support to the notion that anorexic families are conflict avoidant.
Friedlander and Siegel (1990) investigated whether a link exists between separation-
individuation difficulties and a set of cognitions and behaviors that have been
established indicators of eating disorders. Their findings suggest that failing to
achieve a separate sense of identity plays a role in maintaining maladaptive patterns,
such as anorexia. More specifically, their results reveal that “reported dependency
conflicts and functional impairment, along with a generally diminished sense of
individuality, were strongly predictive of bulimic behaviors, the pursuit of thinness,
beliefs about personal ineffectiveness, interpersonal distrust, immaturity, and an
inability to discriminate emotions and sensations (notably hunger)” (Friedlander and
Siegal, 1990, p. 77). The results reflected both relationships with mothers and
fathers, although the results of reported difficulties with mother had a “more
complex empirical relation” (Friendlander and Siegal, 1990, p. 77).
Meyer and Russell (1998) tested the relationship between cognitive and behavioral
indicators of eating disorders and elements of codependency, including exaggerated
caretaking and constricted emotion. Findings reveal that college women with higher
levels of eating disordered behavior and conflictual separation from parents
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displayed more exaggerated caretaking and tended to deny or refrain from expressing
their feelings.
Smolak and Levine (1993) examined whether there are differences between
anorexic-like and bulimic-like college women in their patterns of late adolescent
separation-individuation from parents. Anorexic-like were categorized as those
women who positively endorsed three or more symptoms of anorexia nervosa,
including refusal to maintain a healthy weight. Results indicate that anorexic-like
women had more conflictual dependence (such as excessive guilt, mistrust, and
resentment) on both parents in comparison to bulimic-like women and normal
college students.
Cole-Detke and Kobak (1996) based their study on the control theory model of Main
and Weston (1982) that connects an individual’s perception of attachment figure
availability to the development of “attachment strategies that regulate attention,
deployment and emotion” (Cole-Detke and Kobak, 1996, p. 282). This study
examined the relationship between attachment strategies and eating disorders.
Findings revealed that women who reported elevated levels of eating disorder
symptoms used deactivating strategies, the type of defense strategy that develops
when the attachment figure is perceived as ignoring or rejecting of attachment
signals” (Cole-Detke and Kobak, 1996, p. 282). Deactivating strategies include
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deactivating the attachment system in hopes of minimizing potential conflict with the
attachment figure. Subjects who reported eating disorder symptoms did not
cooperate in the interview, did not allow for access to attachment information, and
minimized feelings of anger and vulnerability.
Rowa, Kerig and Geller (2001) explored the relationship between anorexia and
boundary problems between parent and child. The boundary problems that were
used were enmeshment (lack of separation and individuation between parent and
child), role reversal-caregiver, role reversal-confidante (when the parent turns to
child for inappropriate emotional support), intrusiveness (parental overcontrol or
overinvolvement with child), and spousification (when martially dissatisfied parent
puts negative feelings for spouse on child). Findings revealed that women with
anorexia did report higher levels of boundary problems with both parents when
compared to a control group. However, parents of women with anorexia did not
concur that boundary problems were problematic within the family. In fact, when
compared to control mothers, mothers of anorexic women reported lower levels of
boundary problems within the family. They also found specific types of reported
boundary problems associated with mothers and fathers. Anorexic women reported
higher levels of enmeshment and role reversal-caregiver with mothers than did the
control women. With fathers, women with anorexia reported higher levels of
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intrusiveness, role-reversal-caregiver, enmeshment and spousification than did
control women.
Based on Minuchin, Rosman and Baker’s (1978) depiction of the “anorectic system”,
whereby loyalty and protection supercede autonomy and self-realization, Berghold
and Lock (2002) empirically explore guilt as the motivator behind this self-sacrifice.
They used a measure developed to assess guilt in the context of control-mastery
theory, a theory that maintains that normal development is impeded by certain kinds
of interpersonal guilt. Berghold and Lock (2002) found that anorexics displayed
significantly higher levels of self-hate guilt than comparisons. Self-hate guilt is
“closely related to shame and is an extreme and maladaptive self-evaluation that may
occur in compliance with harsh, punishing or neglectful parents” (Berghold and
Lock, 2002, p. 383).
As can be seen, empirical evidence supports the notion that anorexia nervosa is
representative of profound problems that permeate the family, the relationship
dynamics, the style of interacting and affective experience and expression.
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Comparison Studies.
Channon, de Silva, Helmsley and Perkins (1989) compared individual outpatient
cognitive-behavioral treatment with strictly behavioral treatment and an eclectic
treatment control group. Both 6 and 12-month follow-ups indicated that all groups
had gained weight and showed improvement in psychosocial functioning.
Using subjects who were older and had a poor prognosis, Treasure, Todd, Brolly,
Tiller, Nehmed and Denman (1995) compared educational behavioral treatment and
cognitive analytical therapy for adult anorexia. The subjects given cognitive
analytical therapy reported significantly greater subjective improvement although
differences in other outcome measures were not found. It must be noted that the
small sample size of this study limits the interpretation of these results.
Ball (1998) conducted a study comparing individual outpatient CBT with behavioral
family therapy (BFT). The findings indicate no difference in outcome between the
groups. 7 of the 25 patients prematurely terminated treatment. 78% of the
completing patients were rated as having a ‘good to intermediate’ outcome at six
months follow-up. However, the small sample size of this study limits the
interpretation of these results.
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Russel, Szmukler and Dare (1987) compared the effectiveness of family therapy
versus individual therapy with a group of anorexic patients. Their results showed
family therapy to be more effective with patients under 19 year of age, and
individual therapy to be more effective with patients over 19 years of age. It must be
noted that individual therapy was defined by Russel et al. as “the control therapy”,
that was “supportive, educational, and problem-centered” (Russel et al., 1987, p.
1049). They acknowledge the inequality between the two treatments and support
further research with more specific and systematically well-conceptualized therapies
for individual interventions.
Using anorexics ages 12 to 19, Robin, Siegel, Moye and Tice (1994) compared
family therapy and individual ego treatment. Both treatments were designed to be
equally credible from the viewpoint of both therapist and patient. Following one year
of therapy, all patients in both groups were menstruating. 82% from the family
therapy group and 50% from the ego treatment group met their target weight. It
must be noted that studies report that there tends to be a high rate of therapeutic
improvement with anorexics under the age of 19 years (Bachar et al., 1999).
Robin, Siegal, Moye, Gilroy, Dennis and Sikand (1999) conducted a controlled
comparison of behavioral family systems therapy (BFST) with ego-oriented
individual therapy (EOIT) for the treatment of adolescent anorexics, ranging in age
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from 11 years to 20 years. Findings reveal the BFST encouraged greater weight gain
and higher rates of menstruation return than did EOIT. Although both treatments
produced improvement in eating attitudes, depression, and eating related family
conflict, neither treatment changed ego functioning.
Bachar, Latzer, Kreitler and Berry (1999) conducted an investigation comparing a
psychoanalytic psychodynamic therapy, self psychological treatment (SPT) and
cognitive orientation treatment (COT) of anorexia and bulimia. Findings indicate
significant improvement following a year of self psychological treatment and slight
but nonsignificant improvement following a year of cognitive orientation treatment.
No changes were evident following the control/nutritional counseling only. More
specifically, at the end of therapy, 83% (5 of 6) of the SPT anorexic patients were no
longer diagnosable as anorexic. Both of the 2 anorexics treated with COT were still
diagnosable at the end of treatment. This study supports the idea that psychotherapy
that does not focus on eating behavior can lead to significant improvement of eating
disorder symptoms. Furthermore, this study “may support the longheld
psychoanalytic assumption that solving underlying problems can reduce overt
symptoms, even if the latter are not directly focused on in the session” (Bachar et al.,
1999. p. 125).
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The Socio-Cultural Model
There are a multitude of ways in which anorexia nervosa can be understood to be
created by and maintained within the socio-economic, cultural and political contexts
of contemporary Western culture. Advocates of this model shift the understanding
of anorexia nervosa from an individual pathology to a problem created by and
maintained within a socio-historically specific postmodern cultural context. These
theories focus on what it means to inhabit a woman’s body in contemporary Western
culture. Proponents of these theories believe that the medical model focuses on the
biologic aspects of the disorder, annihilating the experience of the self and
terminating any productive cultural analysis (Lester, 1997). Analysis of some of
these theories will elucidate this point.
Feminist theorists maintain that the medical model of anorexia nervosa is grossly
inadequate, especially in positing a disembodied self. Feminist theorists argue that
either there is a medicalization of anorexia whereby it is viewed as only a biologic
disturbance or abstract theories of the self are utilized which reinforce the Cartesian
duality of mind and body. The medical model of anorexia nervosa focuses either on
the body or the mind, without having an integrated, more holistic approach. More
specifically, the primary focus on the biologic aspects of illness neglects a more
inclusive ideology of time, space, culture and gender. Traditional psychotherapy
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theories of the self are ineffective in understanding anorexia nervosa because they
also interpret the human self outside of time, space, culture and gender, while
utilizing gendered, classed and raced criteria of health and what constitutes normality
(Broverman et al., 1970; Chesler, 1972; Nowacki and Poe, 1973; Orbach, 1978;
Gilligan, 1982; Kaplan, 1983; Caplan, 1985; Martin, 1987; Lester, 1997).
The idea of a “disembodied self’ has been critiqued by feminist theorists as being
impossible and dangerous. While proposing to be gender-neutral, these theories of
the self (and hence not a particular gender) are dangerous because they reiterate
traditional gender and cultural assumptions in a covert way. Feminist theorists view
these flaws as intrinsically located in the reification of the Cartesian duality of mind
and body. In Western philosophy the body is only the physical material, the non
self, which can be construed as animalistic, deceiving, that which entraps the self and
undermines it (Lester, 1997). The self is placed on a pedestal where it is the soul, the
spirit, the mind, the purest and closest to God or the ethereal. The body is regarded
as the depraved, the lowest and the impediment to self-realization (Bordo, 1993).
Feminist theorists have attempted to deconstruct the Cartesian mind-body split. In
terms of interpreting and understanding anorexia nervosa, these theorists view the
behavior as a passionate and complex form of social protest. Rather than locating
the dysfunction in the individual women afflicted with anorexia, these theorists find
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the dysfunction in the backbone of American culture. Therefore, the dysfunction is
not based in some personal psychological pathology. Rather, the anorexic woman is
only using her body to express in an extreme way what is culturally expected of
women; namely, to be weak, withered, silent, withdrawn and self-hating. Cultural
idealizations of women demand self-eradication, which forms the basis of the
anorexic’s behavior. She acts out the cultural idealization in a very literal way.
Other cultural theorists view anorexia in a different light, although they still find
anorexia’s culprit deeply embedded in the patriarchal gender ideologies and gender
power relations. Some view anorexics’ excessive control over their bodies as a
response to their powerlessness or lack of control over other aspects of their lives
(Lawrence, 1984). It has been viewed as a controlled body, representative of a pure,
independent and powerful subjectivity (Malson and Ussher, 1996a). Anorexics’ tiny
bodies have been seen as representative of women’s subordinated and ‘child-like’
social status (Chemin, 1983; Malson, 1998). Anorexia has been interpreted as the
rejection of traditional femininity (Orbach, 1993), or a ‘boyish’ subjectivity (Bordo,
1990). Conversely, it has also been viewed as an overconformity to contemporary
traditional femininity (Boskind-Lodahl, 1976).
Using the psychology of women perspective to understand anorexia, Steiner-Adair
(1986; 1991) “focuses on self in relation to others and on the reciprocal meaning that
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individuals have for each other” (Steiner-Adair, 1991, p. 229). Based on the research
of Gilligan (1990) and Brown (1989), Steiner-Adair rejects the theoretical stance that
encourages anorexics to separate or individuate as a therapeutic goal. Steiner-Adair
concurs with Brown’s research that during childhood, girls are confidant about their
emotions experienced surrounding relationships. At around 11 or 12 years of age,
girls experience a “developmental crisis of connection that centers around the loss of
the relational world as they come of age in a culture that does not value or
acknowledge relationships as the girls have known them to be” (Steiner-Adair, 1991,
p. 227). The cultural message idealizes relationships and implies that women are to
be valued based on their ability to be both all-caring and at the same time
independent. By age sixteen, some girls who may be afflicted with eating disorders,
are less confidant and articulate, and resort “underground” (Gilligan, 1988).
Based on this mapping of female development, Steiner-Adair identifies the central
problem of anorexia to be a seeming lack of relatedness, which stems from a
“starvation for an experience of closeness that is not fusion, and separateness that is
not detachment” (Steiner-Adair, 1991, p. 230). Anorexics fear connection will be
enmeshment and they will lose a separate sense of self. Therefore, their needs of
others are misconstrued as being dangerous and undesirable. Therapy, therefore
centers around the integration of connection, and the balancing of tension between
separateness and connection.
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Anorexia nervosa has been theorized to be a postmodern condition. More
specifically, anorexia can be seen as an expression of the postmodernist analysis of
the theme of the body and with ‘undermin[ing] or displacing] modernist
epistemology and the human subject on which it depends’ (Jagger, 1996, p. 192).
The critical element of this discourse is the deconstruction of all truths and all
identities, including the identity of woman (Spivak, 1976; Poovery, 1988; Riley,
1988; Jagger, 1992; Butler, 1993; Hall, 1996a, 1996b). Woman is no longer seen as
an essential, uniform identity that can be guaranteed by the body. Woman in effect
is under erasure, no longer located in a consistent identity beginning from the female
body or from the individual woman. The modem idea of a self-contained, unitary
identity is therefore displaced. This shift in the cultural politics of gender can be
understood to represent a shift in which “everyday lived subjectivities are constituted
as decentered, fragmented, multiple fictions which cannot be guaranteed by the
body, geographical location or anything else” (Malson, 1999, p. 142). Explication of
the ideas of three theorists will demonstrate the practical application of
postmodernism in anorexia nervosa.
In a qualitative study of semi-stmctured interviews of women diagnosed with
anorexia nervosa, Malson (1999) focused on the discursive construction of the
anorexic body as a body that appears to disappear. The particular construction of the
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anorexic body is associated with an identity that is profoundly problematic. In her
interviews, it became clear to Malson that the ‘self was represented by the research
participants as deeply flawed and absent. Malson did find that although the
participants represented themselves as not having an identity, the anorexia and the
anorexic body were discursively constructed as an identity for and by these women.
Because she believed the body is discursively constructed and the anorexic body
cannot guarantee its meaning, Malson focused on the discursive context rather than
the literal context of the physically disappearing body. The postmodern contexts in
which we live define the body as body image or body text that serves as a
‘background text’ for the consumer culture. She argues that anorexia is
representative of an entire feminine identity that is under erasure. In focusing on the
deconstruction of identity, she seeks to show that anorexic bodies and anorexic
subjectivities are not representative of individual pathology but are a “collectivity of
subjectivities, experiences and body-management practices located in and constituted
by a socio-historically specific ‘postmodern’ cultural context (Malson, 1999, p. 143).
Thus, anorexia nervosa is removed from the individual pathological context and
placed in a discursive context of expression of a widespread postmodern cultural
condition.
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Using Foucault’s (Foucault, 1986) notion of self technologies, Lester (1997)
proposed a theory for an embodied self and its expression in anorexia nervosa.
Foucault’s self technologies consist of the theory element and the practice element.
Theory is the expression of the self one wishes to utilize, while practice consists of
procedures, usually aimed at the body, which transform and mold the self along the
path of the desired attitude. Lester first looked at the theory of anorexia, or the self
that is being sought after, and then looked at the practice of anorexia, or the
‘anorexic’ behaviors that -culminate in the self-transformation.
Lester believed that slenderness represents competence, self-control and intelligence
in our society because it reflects the ability to rise above the need to eat and avoid the
“‘female’ excesses of appetite and sloppy overindulgence” (Lester, 1997, p. 486). It
communicates an ability to compete in a man’s world by squelching one’s female
nature. A thin body exudes self-restraint, control over and transcendence of the
flesh. Ultimately, Lester believed that “For the anorexic woman, thinness is
liberation” (Lester, 1997, p. 486). As for the practice, Lester posited that the body
becomes a metaphor for the self and the boundaries of the body become the
boundaries of the psychological self.
Refusal of food allows for a strengthening or solidification of the body boundary and
a redefinition of the self boundary. Lester views the anorexic’s hard body as a
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defense against invasion from the outside. Most crucial to her analysis however, is
her idea that it is a cultural, gendered invasion rather than a psychological invasion.
Also using the ideas of Foucault as a springboard, David Epston applies a narrative-
deconstructive approach to the treatment of anorexia. Therapy generates around a
story, where struggles against and liberation from anorexia are central to the plot.
Anorexia becomes regarded as a “thing or person” with which the individual has “a
complex and mutable relationship” (Epston and Roth, 2000, Engaging Young
Persons in Externalizing Conversations, p. 1). Between therapy sessions, he and the
client write letters, where the client’s story is encouraged to be molded and
remolded.
Epston views anorexia as improperly possessing “the moral authority to decide the
fate of a person- whether they are ‘worthy’ or ‘unworthy’ of life itself’ (Epston,
2000, Moral Duelling: Anorexia versus Anti-anorexia, p. 1). He and his colleagues,
referred to as the League, have “come to know anorexia as our sworn antagonist in
this life -or-death (or living a life versus living a living death) duels” (Epston, 2000,
Fighting Words, p. 10). He maintains that only through “violent hostilities and
raging vehemence” has anyone had “the ‘power’ required to disentangle themselves
from anorexia’s web of deceit” (Epston, 2000, Fighting Words, p. 10). His use of a
counter-approach is otherwise known as an anti-anorexic practice.
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Epston considers anti-anorexia as “any number of resistance movements, large or
small... connected by their opposition to Anorexia and the ‘concentration camps’ that
it has thrown up in so many people’s/families lives” (Epston, 2000, Fighting Words,
p. 13). It’s strength “comes in its counter-claims for the lives of women that it
articulates, circulates and spreads underground” (Epston, 2001, Can Anorexia
Swallow Up Your Anti-Anorexia?, p. 4). Epston’s use of anti-anorexia attempts to
externalize the problem from the person. What Epston refers to as a radical
externalizing conversation allows for “a) the historical tracing of the anorexic
occupation and b) the resistance to it” (Epston, 2000, Separating the Person From the
Problem, p. 2). Anti-anorexia allows one to hear “not only what anorexia has to say
but how it says it” (Epston, 2000, Fighting Words, p. 2). With the use of anti
anorexia, Epston attempts to “turn anorexia against itself’, in hopes of generating
“love of self and others, goodwill towards oneself and others” and confirmation of
“the innocence and tragedy of those seduced, betrayed and murdered by anorexia”
(Epston, 2000, Moral Duelling, p. 4).
In order to reach those struggling with anorexia and bulimia worldwide, Epston has
created the Anti-Anorexia Archive of Resistance website. He dedicates the website
to the memory of Ellen West. This website consists of a conglomeration of
transcribed therapy sessions, letters between therapist and client, and essays about
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narrative therapy and anorexia/anti-anorexia. Epston contends “the archive holds the
documents of those who have both known and defied such evil and reclaimed their
innocence” (Epston, 2000, The History of the Archives, p. 4). The archives are
intended to be “both a resource to and exemplary tales of a ‘counter practice’ (Anti
anorexia) to what I have been referring to as the social practice of anorexia” (Epston,
2000, The History of the Archives of Resistance, p. 1).
As can be seen, advocates of the socio-cultural model locate the etiology and
meaning of anorexia nervosa in a historical, cultural, gendered context. There are
many different theorists who propose different variations of a similar theme.
However, these theories are not effective at explaining the incidence of anorexia in
men or the occurrence of anorexia in nonwestemized societies (Mumford, 1993).
Furthermore, the socio-cultural model does not address why one individual should be
affected, whereas another with a similar set of sociocultural risk factors escapes
(Ward, et al. 2000). In fact, broad-based prevention programs that educate the public
about eating disorders and encourage resistance to the cultural obsession with
thinness have been unsuccessful, and some believe, may induce more harm than
good (Walsh and Devlin, 1998). Ultimately, this theoretical perspective is narrow in
that it denies the biological, psychological and developmental components of
anorexia nervosa.
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CHAPTER FIVE
A NEW PERSPECTIVE OF ANOREXIA NERVOSA
Having reviewed the multitude of biological, psychological and socio-cultural
theories that account for anorexia nervosa, it becomes clear that many of the theories
claim important contributions to the understanding of anorexia. However, a global
framework that allows for the simultaneous integration of all of these areas, coupled
with a means for determining how these areas operate through time is necessary.
Such a theoretical framework would allow for a more in-depth understanding of the
multiple systems and multiple pathways to anorexia. Hopefully, using a more
inclusive and expansive model would inform and improve existing treatment. Many
researchers consider the existing treatment for anorexia inadequate and encourage
the exploration of new treatment. These opinions are expressed in overviews,
literature reviews and outcome studies of anorexia nervosa. Such examples follow.
In an overview of eating disorders, Kaye, et al. (2000) maintain “the efficacy of
psychological treatments and pharmacotherapy has been more clearly established for
bulimia nervosa than for anorexia nervosa” (p. 299). They conclude “future research
should develop additional treatment approaches that may improve the efficacy of
currently available treatment techniques” (p. 306).
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In his data analyzed review of outcome studies, Steinhausen (2002) underscores the
“serious course and outcome” of anorexia for “many of the affected individuals” (p.
1290). He concludes “advances in etiology and treatment may improve the course of
patients with anorexia nervosa in the future” (p. 1284). In a summary of new studies
on eating disorders, Andersen (2001) states we are entering an era in which eating
disorders require “a new paradigm” (p. 516). Based on a review of outcome studies,
Hsu (1996) states “efforts to improve outcome are urgently needed” (p. 566).
In an outcome study of anorexic patients, Fassino, Daga, Amianto, Leombruni, et al.
(2001) indicates that for anorexia nervosa, “progress in therapy in the last 10 years
has been slow” (p. 201). They also refer to anorexia nervosa as “a severe disorder
that often responds poorly to treatment” (p. 201). Findings from another outcome
study of subjects with anorexia (Ben-Tovim, Walker, Gilchrist, Freeman et al., 2001)
“suggest that the efficacy of existing interventions is questionable” (p. 1255). In
Fichter and Quadflieg’s outcome study (1999), they state “the development of more
effective treatments will be important for improving the course of anorexia nervosa
in the future” (p. 382).
In a handbook for the treatment of eating disorders, Anderson, Bowers and Evans
(1997) hone in on a most important issue. They state that “since treatments logically
grow out of assumptions about the nature of a disorder, with etiological beliefs
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leading pari passu to treatment strategies, the clearest possible description of known
contributing factors is important for guiding effective treatment of anorexia nervosa”
(p. 328). Given the difficult nature of anorexia nervosa and its treatment, how we
contextualize our understanding of anorexia is paramount. Anorexia predominantly
emerges during adolescence. For this reason, attending to issues of this
developmental stage is important.
Many of the existing theories, namely the psychodynamic/analytic and family
systems theories, focus on anorexia nervosa as a pathological response to a
developmental crisis. In addition to the theories I have already covered, there are
several others that view anorexia in light of a developmental crisis. I will briefly
address these theories.
Strober (1980; 1991; 1997) delineates a developmental model of anorexia whereby
the individual’s 1) temperament and personality traits; 2) the psychological dynamics
of pubertal growth; and 3) the familial environment render her ill equipped at
handling the maturational changes and challenges of puberty. Anorexics have
heightened harm avoidance, low novelty seeking and reward dependence. Anorexics
are “significantly more self-doubting, submissive, deferential to authority, compliant
with outside demands, and stimulus-avoidant than their peers” (Strober, 1991, p.
366).
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The nature of puberty places demands on the individual, such as the increasing
instinctualization of behavior, a more intense affective experience, a shift from
relying on family and external structures for regulation of one’s behavior to relying
more on the self, a greater need for affiliation and intimacy, and physical changes in
the body. Although there is not evidence supporting one type of family environment,
certain features such as “limited tolerance of disharmonious affect or psychological
tension, emphasis on propriety and rule-mindedness, parental overdirection or subtle
discouragement of autonomous striving, and poor skills in conflict resolution”
(Strober, 1997, p. 234).
Because these individuals are dependent on their environmental structure for
reflection of self worth and security, and because they are not comfortable with
change and emotional arousal, puberty is a defeating challenge that leaves them with
an “unsteady and defective sense of self’ (Strober, 1991, p. 371). Anorexia arises as
an attempt to maintain unity of the self, against the backdrop of the everpresent
developmental changes that are conflictual with her basic nature. Strober contends
that anorexia “is an indefatigable struggle to exist” (Strober, 1991, p. 367).
Steiner-Adair (1990) proposed a model whereby adolescent girls who saw
themselves in “superwoman” terms, were more likely to be at risk for eating
disorders. Adolescent girls who reject the “superwoman” ideal and see it as
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detrimental to their developmental needs are less likely to be at risk for eating
disorders.
Levine and Smolak (1992) proposed a cumulative stress model. Adolescent girls
who adhere to notions of “superwoman” and have multiple stressors are more
vulnerable to eating disorders. More specifically, the combination and interaction of
pubertal weight gain, changes in opposite sex relationships and threats to
achievement status can encourage body dissatisfaction, distress, and perceived loss
of control. In a study, they found support for their model. They found that changes,
such as onset of menarche and onset of dating, in combination with academic
pressure, a slender body ideal, peer and family investment in thinness, best
determined adolescents with and without self reported disordered eating.
Although these theories attend to developmental crisis, they do not assume an
overarching, integrative developmental framework that examines the various areas of
development (including physical, temperamental, cognitive, social, emotional, moral,
and psychosexual) in the context of development’s inherent genetic predispositions,
it’s interactive qualities, it’s repetitive patterns, and it’s transactional processes.
Unfortunately, the current research in eating disorders “lacks a developmental
framework for integrating findings from sociocultural, biogenetic, personality,
family, and behavioral studies” (Attie and Brooks-Gunn, 1995, p. 332). I therefore
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propose the use of a developmental framework that would allow for a more
comprehensive, integrative, fluid understanding of the emergence of anorexia. To
begin with, I would like to give a brief overview of developmental psychopathology.
Brief Overview of Developmental Psychopathology
Developmental psychopathology was originally defined by Sroufe & Rutter (1984)
as “... the study of the origins and course of individual patterns of behavioral
maladaptation, whatever the age of onset, whatever the causes, whatever the
transformations in behavioral manifestation, and however complex the course of the
developmental pattern may be (p. 18). Currently, developmental psychopathology
can be viewed as providing a framework that does not compete with existing theories
and facts, and allows an environment where “the contributions of separate disciplines
can be fully realized in the broader context of understanding individual functioning
and development” (Cicchetti and Cohen, 1995, p. 8). Core concepts in
developmental psychopathology include developmental pathways, risk factors,
perspectives on the interface between normal and atypical development, and
resilience (Cicchetti and Cohen, 1995). After addressing these core concepts, I will
give a brief overview of the organizational perspective on development.
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Developmental Pathways
Developmental psychopathologists contend 1) that there are many contributing
factors to disordered outcomes in any particular individual, 2) that individuals with
the disorder can have different contributors, 3) that there is heterogeneity in features
of a disorder among individuals with the disorder, and 4) that there are multiple
pathways to a particular expression of disordered behavior (Cicchetti and Cohen,
1995). The general systems theory (von Bertalanffy, 1968) principles of equifinality
and multifinality are therefore relevant. The principle of equifinality reminds us that
there are many developmental progressions that may result in a particular outcome or
disorder. The principle of multifinality refers to the notion that different outcomes
may result with the same particular process component. The different outcomes
depend on the interaction of the particular component with the other components it is
interacting with in the system.
Risk and Protective Factors
Examining factors that may contribute to adaptive or maladaptive functioning is a
core feature of developmental psychopathology. Sources of vulnerability can be
both external (intrafamilial, social-environmental) and internal (biological,
psychological) influences. They are considered vulnerability factors when they deter
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successful achievement of adaptation and competence, and encourage pathological
organization across all domains of development (Cicchetti and Cohen, 1995).
Conversely, protective factors merit examination as well. Protective factors
encourage successful and competent adaptation and development.
Perspectives on the Interface Between Normal and Atypical Development
Developmental psychopathologists focus their attention on high-risk and disordered
populations, as well as on normal populations. They have an understanding and
appreciation for normal development as well because such a perspective is intrinsic
to understanding psychopathology. Conversely, an understanding of
psychopathology sheds light on normal development. Developmental
psychopathologists are therefore also interested in at risk individuals who do not
develop a disorder. Thus, studying normal and atypical development concurrently
can be “mutually informative” (Cicchetti, 1990; Cicchetti, 1993, p. 476).
Resilience
Since the developmental influence has increased in the study of psychopathology,
there has been an increase in the interest of resilience (Cicchetti and Cohen, 1995;
Garmezy and Masten, 1994, Masten, Best, and Garmezy, 1990). Rather than being
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static, resilience is considered to be “a dynamic process” (Cicchetti and Cohen, 1995,
p. 12). Developmentalists are interested in studying the mechanisms and processes
whereby individuals with risk factors (biological and/or environmental disadvantage)
are able to avoid psychopathology and adapt effectively. In order to most effectively
study resilience, all domains of development must be concurrently examined. Only
then can a full picture of adaptation and resilience be ascertained. It must be
remembered that individuals labeled resilient also experience struggle and often
times need support. At times these individuals use atypical developmental pathways,
raising the question of “whether the use of alternative pathways to attaining
competence renders individuals more vulnerable to manifesting subsequent delays or
deviations in development” (Cicchetti and Cohen, 1995, p. 13).
The Organizational Perspective on Development
Many developmental psychopathologists adhere to the organizational perspective on
development. An organizational approach adheres to the core concepts of
developmental psychopathology discussed above. This type of approach attempts to
define the complicated interactions among cognitive, social, emotional, and
biological processes that together affect the individual’s developmental progress. An
individual’s developmental course is steered by the transactions between the
individual and his/her environment. Development progresses when new tasks or
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behaviors are qualitatively reorganized, and differentiate into patterns (Attie and
Brooks-Gunn, 1995). When new tasks emerge, old issues are not as important.
Every new issue or task requires integration into the individual’s adaptation to the
environment, and to the important stage related issues of the period (Cicchetti, 1993).
Further development relies on, builds on and incorporates past development.
Therefore, an “early failure to negotiate stage-salient developmental tasks is thought
to steer the ontogenetic course toward maladaption and incompetence” (Cicchetti,
1993, p. 481). Psychopathology is therefore considered to result when various
competencies at specific developmental transitions are not integrated (Attie and
Brooks-Gunn, 1995).
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CHAPTER SIX
GORDON’S DEVELOPMENTAL PERSPECTIVE
A current trend in psychology is to look at psychopathology as the result of
developmental failures (Achenbach, 1990; Cicchetti, 1990, 1993; Boyce, Frank,
Jensen, Kessler, Nelson and Steinberg, 1998; Rutter and Sroufe, 2000; Cicchetti and
Sroufe, 2000). However, as discussed earlier, current eating disorder research “lacks
a developmental framework for integrating findings from sociocultural, biogenetic,
personality, family, and behavioral studies” (Attie and Brooks-Gunn, 1995, p. 332).
I therefore propose the use of Gordon’s (2000) developmental framework that would
allow for a more comprehensive, integrative, fluid understanding of the emergence
of anorexia.
Maureen Fulchiero Gordon is a developmental psychiatrist who is not widely known
in psychology. However, that is not the case in psychiatry. She wrote the chapter on
normal child development in the book (Kaplan & Saddock) that is used for
psychiatry training for medical students across in the United States. In addition, she
is an Assistant Clinical Professor of Psychiatry and Biobehavioral Sciences at the
University of California, Los Angeles’ School of Medicine, where she teaches child
psychiatry fellows. I was exposed to her theoretical teachings through one of her
child psychiatry fellows. I found her work to be an important contribution to
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developmental psychology as well as developmental psychiatry. This is one of the
many reasons (which will be addressed) I chose her model as a template for the
reconceptualization of the emergence of anorexia.
Gordon’s (2000) transactional model of child development is a general model of
universal child development. She is not speculating on the particular developmental
impasses that contribute to or influence particular forms of psychopathology. More
specifically, her model does not account for, in any way, the development of
anorexia nervosa. Therefore, I consider the use of her model a skeleton or a scaffold.
I also believe her model is not applicable only to child development. Rather, her
model pertains to the entire lifespan, if viewed in that light. All of her areas of
development, as well as the sustaining structures of identity and family environment
extend across the entire life span.
I specifically chose Gordon’s model as a scaffold for several reasons. First, it allows
for a dynamic conceptualization of psychopathology. We can see how early
psychological experiences can affect all areas of development. With this model, I
can locate where the developmental disruptions occur that make an individual
susceptible to anorexia. Second, it allows for the confluence of nature and nurture
and how that supports development. Anorexia can be understood within a context of
physical, temperamental, cognitive, social, emotional, moral and psychosexual
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development. Third, it regards children as active forces in their own development.
Fourth, rather than focusing on one theorist (such as Piaget or Freud), this model
incorporates and utilizes the work of all major developmental theorists. In
describing all areas of development, Gordon (2000) bases her overview on the work
of geneticists, biologists, ethologists, cognitive developmentalists, social
developmentalists, sociocultural theorists, attachment theorists, social learning
theorists and psychoanalytic theorists. Each of the developmental periods can be
understood from various perspectives, depending on which theory one uses.
Gordon’s model gives the individual using the model, the liberty to view each
developmental area from whatever perspective he or she chooses. For example, one
could consider psychosexual development from a biological, cognitive-
developmental, social learning theory or psychoanalytic perspective.
Finally, I chose Gordon’s developmental model because it delineates developmental
progression in each of the 7 developmental areas, including physical, temperamental,
cognitive, social, emotional, moral, and psychosexual development. This enables the
practical identification of stagnation in each area. The use of Gordon’s model as a
scaffold will enable a paradigm shift in the understanding of anorexia nervosa.
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Gordon’s Normal Child Development Model
Gordon’s approach to understanding child development focuses on the period from
conception to the end of middle childhood. Certain requisite elements of
development are thematic and form the backbone of her model. These elements
include development’s “inherent genetic predispositions, its interactive qualities, its
repetitive patterns, and its transactional processes” (Gordon, 2000, p. 2534).
Children are considered “active participants in their move toward competence”
(Gordon, 2000, p. 2534). Gordon’s model is dynamic, interactive, multidimensional,
independent and interdependent, and in flux.
Gordon’s concept of normal development (progression), normal regression, and
neurotic regression is explained by her transactional, interactive model. Normal
development occurs in areas where regression is not taking place. Normal regression
occurs either as a precursor to a normal growth spurt (growing pains) or in reaction
to a single stressor. During normal regression, certain skills in a particular
developmental area do not function for a period of time. However, the infant or
child’s biologic and psychological identities, and their environmental and cultural
milieus “remain intact during periods of normal regression” (p. 2536). The a)
biologic and psychological identities, as well as the b) environmental and cultural
milieus act as structures “which frame the process of normal development” (p.
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2536). Neurotic regression occurs when continuous and/or major stressors separate
these two structures, thus, impeding the sustenance and continuation of development.
Consequently, certain skills are lost or impaired, ‘the child’s identity ceases to
interact successfully with the environment” and psychosocial isolation results” (p.
2536). As can be seen, neurotic regression disrupts the entire developmental
process.
Central to Gordon’s theory is the notion of developmental tutoring. This
transactional principle is the practice whereby children’s potential is inhibited or
stimulated through interaction with environment. This principle has considerable
implications for the role of childrearing, as well as the role of therapeutic
intervention in child development.
Gordon delineates seven independent and interdependent areas of child development:
physical, temperamental, cognitive, social, emotional, moral and psychosexual.
Each of these seven developmental components “operate in a dynamic,
multidimensional way to help infants and children to integrate their growing sense of
self identity with their environment” (Gordon, 2000, p. 2535). She maintains that a
child’s identity (genetic prints and the child’s perceived sense of self), and the family
environment (psychosocial and cultural milieu) together support the developmental
process. Development results when “various components of behavior, supported by
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the child’s identity and milieu, come together to form a completed set of
maturational skills in each of the seven developmental areas” (p. 2535). Using this
model, it becomes apparent that development in one area may continually affect past
or future growth in each of the other areas of development. A brief discussion of
each of the seven developmental areas follows.
Physical Development
Children’s physical development enables the perception and negotiation of their
external world. Growth is especially rapid in infancy and early childhood. Central
nervous system maturation allows for the acquisition of motor abilities, perceptual
abilities and pathways, and language. As in all seven areas of development,
“environmental factors interact with the organic to serve as tutors of growth”
(Gordon, 2000, p. 2537). Gordon maintains that growth can either be encouraged or
inhibited by nutrition, caregiving and stimulation.
In fact, “although the brain’s full supply of neurons is present at birth, critical neural
pathways that depend upon environmental stimulation for their maintenance and
development shape and reform the original morphology” (Gordon, 2000, p. 2538).
Although during the first 10 years of a child’s life “the nervous system most actively
interrelates with environmental stimuli”, It is during the first 3 years that the bulk of
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neural synapses are formed (Gordon, 2000, p. 2538). After the age of 10, the brain
actually destroys weakly formed synapses. During the time of active formation of
synapses, a child’s repeated experiences stimulate neural pathways”, which in turn
“interact with genetically controlled enzymes and other proteins to create neural
synapses” (p. 2539). These synapses form the parts of the brain that are responsible
for motor development, perceptual development and language. Conversely,
pathways that are understimulated “atrophy the parts of the brain that correspond to
unused pathways” (p. 2539). These findings accentuate and demonstrate the
importance of early childhood development and developmental tutoring.
Temperamental Development
The maturation of traits that allow a child to respond to new experiences is known as
temperamental development. Children are bom with specific temperamental traits
that can be stimulated or inhibited by the environment. Different temperaments can
have positive or negative connotations, influencing the child’s sociocultural growth.
In other words, how the child is perceived and received is often contingent upon
temperamental traits. For example, a verbal child is often seen as bright, while an
equally intelligent nonverbal child is cognitively underestimated. A deliberate and
goal directed child will excel in a traditional school, while an impulsive, non-goal
directed child may be mislabeled as unmotivated with attention problems. A verbal
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child is more likely than a nonverbal child to receive psychological treatment for
difficulties.
Temperament as an area in child development, has only existed since the 1970’s,
when Stella Chess and Alexander Thomas conducted the New York Longitudinal
Study. The identified dimensions of temperament include activity level,
distractibility, adaptability, attention span, intensity, threshold of responsiveness,
quality of mood, rhythmicity, and approach/withdrawal. Findings suggest that
“temperamental traits in children could be identified from infancy and at least
through adolescence” (Gordon, p. 2540). Their results support the notion that
“temperament has a genetic base but that such traits are significantly altered by
environmental factors, including family and sociocultural situations” (Gordon, p.
2540).
Cognitive Development
The development and maturation of mental activity is known as cognitive
development. The biological approach to cognitive development uses a biological
model that centers around schemas. Piaget, a biological cognitive theorist, delineates
four fixed stages, including the sensorimotor stage (birth- 2 years), the preoperational
stage (2 years- 7 years), the concrete operational stage (7 years-11 years) and the
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formal operational stage (11 years onward). The increasing ability to conceptualize
internal and external space defines cognitive maturity. Only when a child is capable
of hypothetical thought does language become an important tool. The sociocultural
approach uses a sociocultural basis for describing cognitive development. Vygotsky,
a sociocultural cognitive theorist, ignores a biological component to cognition. He
believes that children are bom with a basic instinctual cognition that is developed for
the first two years through environmental interaction. After the age of 2, children
cognitively mature by acquiring skills that create mental representations. It is
through language that cognitive maturation occurs. Children use language to interact
in social settings, thereby developing cognition. The internalization of dialogue
becomes private speech, which supports and encourages new learning.
Social Development
Social development is the process whereby an individual develops a sense of
him/herself and applies that information to the experience of other people. As the
child matures, she or he moves from being adult oriented to being peer oriented.
According to Gordon (2000), there are four phases of social development through
which children mature. The first phase involves the development of a sense of self,
otherwise known as the attachment period. The second phase occurs as the child
becomes self-reflective and gains a sense of self-understanding. In the third phase,
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the child translates his/her self-knowledge to other people. Finally, in the fourth
phase, the child is peer oriented and experiences true friendships. While different
theories better explain different phases of social development, all social development
theory includes identity formation as an integral, primary process in social
development.
Gordon (2000) cites certain social development theorists, such as John Bowlby and
Margaret Mahler, who have formulated theory that solely address identity formation,
and are therefore known as attachment theorists.
Emotional Development
Emotional development, the process whereby children acquire emotion, is comprised
of different elements. Children progress to a place where they are able to recognize
emotions and use them appropriately. When internal experience of emotion occurs,
they must learn to be responsive rather than reactive. They must also learn to use
their emotions in managing stress and anxiety, intrinsic experiences to being human.
Gordon (2000) proposes a model of emotional behavioral milestones. Her first
milestone, acquiring basic emotion, occurs when happiness, anger, sadness and fear
are “learned directly or inferred from facial expressions” (Gordon, p. 2546). The
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second milestone, the acquisition of self-conscious emotions, appears at the end of
the child’s second year. These emotions, including shame, envy, pride,
embarrassment and guilt, stem out of “injury to, or enhancement of, the sense of
self’ (Gordon, p. 2546). In the third stage, the child develops the capacity to
emotionally self-regulate, or adjust emotions to comfortable levels. This phase can
be detected as early as a couple of months and develop into middle childhood. The
final stage of true empathy, or the capacity to respond to other’s emotions, can also
be seen as early as the age of one, in elementary form. The progressed form of this
stage marks emotional maturation. Gordon (2000) maintains “empathy is a major
underlying theme that supports each of the stages of maturation” (Gordon, p. 2546).
Psvchosexual Development
Psychosexual development involves three stages whereby the individual comes to
recognize themselves and others in terms of gender. The stages include the
“development of a gender identity, the formation of a concept of behavior related to
their own gender identity (gender roles), and the formation of children’s attraction to
a particular gender.in others (gender relationships)” (Gordon, p. 2546). The four
significant theoretical contributors to the area of psychosexual development are
biological theory, cognitive-developmental theory, social learning theory and
psychoanalytic theory (Gordon, 2000).
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Moral Development
Moral maturation is the process through which children acquire internal standards
that lead their behavior. Gordon bases her overview of moral maturation on the
work of ethologists, cognitive developmentalists, social theorists, psychoanalytic
theorists and gender based theorists. Gordon reports that ethologists support the idea
of adaptive moral development, in that the principles are innate and inherited, and
further developed through socialization. She reports that cognitive
developmentalists believe that moral development is “an active process of acquiring
a moral sense through a set of cognitively derived constructions that operate in
conflictual situations” (Gordon, p. 2547). Gordon reports that social theorists
suggest that morality is learned through adult behavior and interaction with the child.
Gordon indicates that psychoanalytic theorists views conscience development as
superego growth, which occurs due to positive identification with parental values.
Gordon says that gender based theorists maintain that morality develops in a gender
specific course, with women’s development resulting in compassion and caring and
men’s development resulting in justice. Therefore, moral maturation can be
understood from these various perspectives.
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CHAPTER SEVEN
PROPOSED DEVELOPMENTAL UNDERSTANDING OF ANOREXIA
NERVOSA
Having explained Gordon’s developmental model of normal child development, we
have a context for normal child development, and conversely abnormal child
development. Only through knowledge of normal child development can one fully
appreciate and understand pathology. With this in mind, I would like to propose my
ideas of how individuals develop anorexia nervosa and then, according to Gordon’s
(2000) model, delineate the developmental insults that can lead to anorexia. Many of
my ideas are symbolic, and therefore could be considered psychodynamic in origin.
Before proposing my ideas, I will give a brief overview of my criteria for the theory.
Criteria for Theory
• Human nature is dynamic. This theory supports the notion of psychic determinism
(nothing happens by change, and that all mental phenomena have causal connection
to psychic events). Problems are caused by underlying unresolved past
developmental impasses.
• There is a conscious and unconscious mind.
• Change occurs as the result of working through developmental stages.
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• Individuals are active participants in their developmental processes
• Developmental stages are independent and interdependent.
• The theory is transactional (nature and nurture interplay). The theory considers
how the transactional interplay affects all areas of development.
• Normal development and abnormal development are important and inform one
another.
• Psychopathology arises as the result of neurotic regressions in the developmental
process.
• The primary caregiver - child relationship is essential is developmental process.
• The theory is applicable to psychological therapeutic treatment.
To begin with, I am ascribing to theory that can be considered phase theory. As
described by McAuliffe and Eriksen, 1999), developmental theories can be divided
into a) phase theories, that attend to the culturally expected tasks of developing and
growing old (Buehler, 1933; Havighurst, 1972; Super, 1963) and b) cognitive or as
Kegan (1982) suggested, constructive, stage theories, that come from Piaget’s (1963)
tradition of defining stages of knowing based on one’s experiences with the
environment and subsequent accommodations in knowing.
More specifically, I contend that anorexia nervosa emerges as the result of the
convergence of many risk factors. An individual who 1) has genetic predispositions
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to anorexia, 2) learns within the family to have an abnormal relationship with food,
eating, weight and body, and 3) suffers particular psychological experiences is more
likely to endure stagnation in different areas of development. This developmental
stagnation renders the individual incapable of navigating major transitional
developmental periods that require an increase in autonomy and independence.
These developmental periods include, but are not limited to puberty, beginning
college or work, or moving away from home. The anorexia nervosa arises as an
articulation of this experience, as well as an unconscious attempt to cope with, mask,
normalize, or self-regulate uncomfortable and unpleasant emotional experiences or
states of multiple neurotic regressions in development.
Genetic Component
Based on research that was reported earlier, it has been established that there is a
genetic component to anorexia nervosa (Garfinkel and Gamer, 1982; Holland et al.,
1984, 1988; Holland, et al., 1988; Holland, et al., 1994; Lilenfeld, et al., 1998;
Maddox & Long, 1999; Strober, et al., 2000; Ward, et al., 2000; Grice et al., 2002).
The exact nature of the genetic component is still under investigation. However,
based on family transmission and twin studies, it is known that individuals are more
susceptible to anorexia if they have relatives with anorexia or partial anorexia
(Garfinkel and Gamer, 1982; Holland et al., 1984, 1988; Holland, et al., 1988;
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Holland, et al., 1994; Lilenfeld, et al., 1998; Maddox and Long, 1999; Strober, et al.,
2000; Ward, et al., 2000; Grice et al., 2002). Furthermore, evidence suggests that
there is a susceptibility gene for anorexia on chromosome Ip (Grice, et al., 2002).
Finally, it has been documented that certain temperamental and personality traits
exist in anorexics before as well as after they are symptomatic (Casper, 1990;
Strober, 1980). These traits include “a disposition to avoid whatever is novel,
intense, or unfamiliar; to have nagging self-doubt and to ruminate; to shun intimate
ties with others, especially those outside her immediate family; and to persevere,
even in the absence of tangible reward” (Strober, 1997, p. 233).
Learning Abnormal Relationship With Food, Eating, Weight and Body
I propose that in the anorexic’s family, there is an unusual focus on food, weight and
eating. From a very early age, the future anorexic learns to have a distorted
relationship with food, eating, weight and body. This can result either from
watching family members have distorted relationships with eating, or from a child’s
own eating being controlled or critiqued. This behavior can manifest in many ways.
Family members may have their own eating disorder. Family members may engage
(and sometimes invite participation) in behaviors related to the idealization of being
thin and the degradation of not being thin (ie: guilt about eating, restricting, purging).
Family members may use food as a vehicle for controlling one another. Weight may
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be associated with one’s worth (strength, weakness, vulnerability, attractiveness etc.)
It must be noted that not all caregivers with eating disorders or odd eating behavior
produce a child with an eating disorder. However, I contend that it is one of the
familial contributing factors that, in conjunction with other factors, can predispose an
individual to anorexia.
Because our Western, socio-cultural environment favors and encourages thinness in
women, I suggest that female children are more likely to learn disturbed relationships
with food, eating, body and weight within the family. This would account for the
predominant female affliction of anorexia.
Research suggests that parents transmit sociocultural messages about weight and
dieting to their daughters (Benedikt, Wertheim, and Love, 1998). It has been found
that parental influence can shape a child’s eating from infancy, and an adoption of
the Western ideal of thinness can shape children’s early feeding practices (Birch,
1990; Klesges et al., 1993; Stein & Fairbum, 1989; Fahy and Treasure, 1989;
Pugliese et al., 1987). Pike and Rodin (1991) found that mother’s dieting and weight
concerns were associated with concerns of the daughter, and that mother’s
preference for a thinner daughter was associated with higher eating disordered scores
for the daughter. Hill et al. (1990) found an association between maternal and child
dieting.
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Two studies, one using children (Thelen and Cormier, 1995), and one using
undergraduates (Moreno and Thelen, 1993) found daughters with greater eating
concerns who had mothers who actively encouraged them to lose weight. Benedikt
et al. (1998) found a significant correlation between daughters who used moderate
weight-loss attempts and had body dissatisfaction and mothers who wanted the
daughter to be thinner and actively encouraged her weight loss. Daughter’s extreme
weight-loss behaviors (such as fasting, crash dieting, and skipping meals) was
predicted by mother’s own body dissatisfaction and her own reported use of fasting,
crash dieting, and skipping meals.
Psychological Experience
I propose that the child’s sense of self is damaged as a result of familial
relationships. I will use mother throughout the rest of the text to indicate primary
caregiver, although the father could occupy this role. The damage is incurred
throughout the entirety of childhood and adolescence. The mother is unable to
respond to the child in appropriate ways because she is not responding to the child as
a separate entity. The mother’s self is not whole and her boundaries are diffuse. She
metaphorically introjects herself into her child, who she unconsciously perceives as
an extension of herself. Because the mother’s sense of self is not whole, and the
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child is perceived as an extension of the mother, the mother looks to the child for
reflection of herself, in hopes of feeling complete.
When the child reflects the mother’s perceived and desired concept of her self, then
the mother fuses with the child, and experiences herself to be whole. However, this
is accomplished at the expense of the child. The child is denied the right to a
separate self. The only sense of self the child may hope for is that fused with the
mother. The state of fusion can be mistaken by the child as love.
If the child improperly reflects the mother’s perception of her self, then the mother
rejects and emotionally cuts off completely from the child, annihilating any sense of
self (even a fused sense of self) the child may have developed. Because the child is a
literal separate entity, she will vacillate between reflecting the ‘right’ and the
‘wrong’ self perceptions or representations of the mother. The mother respectively
fuses with or annihilates the child. Consequently, the child’s experience of selfhood
vacillates between that of fusion and nonexistence.
Any behaviors that support a separate self are experienced by the child as potentially
damaging to the mother. Consequently, the child experiences guilt over any self-
sustaining or enhancing behavior. Rather than aimed towards self-growth, self-
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enhancement and development, the child’s energy is directed towards protecting,
stabilizing and making the mother feel complete and happy.
It must be noted that the child has strong feelings for the mother. The historic fusion
creates an unhealthy bond between mother and child. The child has intense feelings
of love and responsibility for the mother. The mother’s state of being becomes more
important to the child than the child’s own state of being. This is in part due to the
mother’s use of the child as an extension of herself, as well as the mother’s
expressed inability to care for herself.
To complicate the mother-child relationship, not all of the mother’s behavior is
negative. Like any other abusive parent, this mother can have certain positive
parenting skills and love her child. This only makes the child less likely to
acknowledge the abuse and more likely to blame herself.
Because fusion is preferable to nonexistence, the child learns how to maintain an
open system of selfhood, whereby the mother can metaphorically enter (fuse) and
exit (reject) the child’s identity. It must be noted that the mother vacillates between
fusing and rejecting the child, contingent upon the child’s momentary behavior.
Because the child cannot always reflect what the mother perceives, fusion and
annihilation both occur throughout the years. The child is taught to maintain fluid
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boundaries and a metaphoric empty space within the self. In essence, the child is
tailored to be a hollow vessel for containment of the mother’s diffuse identity. Due
to the ever present threat of annihilation, the experience of annihilation and the lack
of a permitted separate identity, the child experiences the core feeling of not
deserving to exist.
The younger the child is, the easier the mother can freely enter and exit the child. As
the child grows older, fusion becomes more difficult because separation is
encouraged by development and societal mandates. The situation becomes
increasingly charged. The mother reacts with more vigorous attempts of fusion and
annihilation of the child, based on the threat of the child becoming too separate. The
increase in intensity creates in the child a more powerful feeling of not deserving to
exist. If the genetic risk factors and environmental factors are present in the child,
the feeling can be acted out in the emergence of anorexia nervosa.
One of the primary symptoms of anorexia nervosa is substantial weight loss. This
loss of body weight can represent feeling unworthy of existing. The weight loss can
be seen as a physical attempt to become essentially fragmented and ultimately
nonexistent. The goal of being fragmented or not existing results from both the
historic fusion and annihilation by the mother, as well as from the experience of
being an empty vessel for containment of the mother’s needs.
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The anorexia can be seen as the primal, nonverbal, visceral articulation of the core
belief that she does not deserve to exist. There is incongruence between her feeling
of not deserving to exist and the physicality and experience of her existence. Needs
signify existence. Having a separate existence conflicts with the messages imparted
by the mother to the child. The less need the child has, the less she has to recognize
that she exists. Starving, the primary symptom of anorexia, is therefore an attempt to
remedy this incongruence. The smaller she becomes, the less need she has, the
closer she is to literally disappearing, to entirely losing a self, ultimately, to not
existing. The anorexia also serves another purpose.
From a very early age, this child has been taught to exist and have open boundaries
in order to meet her mother’s needs. This way of relating has been generalized to the
other people in her life. Consequently, she becomes “full” of others’ needs. The
fullness of others’ needs has been translated from the emotional to the physical level.
Therefore, there is not physical space for her own needs. There is not room for more
flesh or food because she is filled up of other people and their needs. If she restricts
her food intake (starves), she will feel physically better because she will not be
stuffed. If she were to fulfill her own needs (i.e., eat) and have other’s needs within
her, she would feel gorged. As it is, she feels gluttonous taking up literal space in
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the universe. This psychologically accounts for the perceptual disturbance noted in
anorexia in regards to feelings of fullness and eating.
Anorexia can also serve to undermine any successes achieved by the individual.
Success is experienced by the individual as potentially damaging to the mother
(regardless of how the mother reacts to the success). However, anorexia makes the
success tolerable to the individual. Success is not as threatening because it cannot be
entirely experienced because it is mitigated by the ‘failure’ in being anorexic.
Anorexia is also a paradox. While attempting to make the self disappear, the
anorexia also serves as a protective measure. Starving the body and the ‘self’ can
also be seen as the anorexic’s coping mechanism in response to the historic neglect
of her needs. Starvation creates a perceived sense of safety for the anorexic.
Physical emaciation serves multiple purposes: it satisfies her desire to ‘need’ less, it
validates her unworthiness to ‘exist’, and, at the same time, it keeps her protected
from the needs of others. She is metaphorically hardened and less vulnerable to the
world outside herself. She creates a boundary to her self, which she has not been
allowed by her mother to have. The boundary is created in the use of her body. The
boundary of her body is stretched tightly over bone, making external entrance into
her self more difficult. She is more compact and solid and less invade-able. Her
developmental history of being invaded by the needs of others makes her ‘bone-
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hard’ boundary appear valuable. Thus, in a way, the intention of anorexia can also
be viewed as self-preservation. The disorder is paradoxical because it serves a self
destructive mechanism as well as a self-preserving mechanism. This could be
illustrative of the paradoxical messages by the mother- ‘I love you, but will not allow
you to have any needs; You therefore do not deserve to exist; I love you enough to
fuse with you, or I do not love you and will annihilate you’. I believe that the
paradoxical nature of this disorder is reflective of the paradoxical experience of
selfhood.
The child’s relationship with the father (other parent) can be characterized as
inadequate. The father is either absent, abusive or emotionally unavailable.
Ultimately, the relationship with the father is unable to provide the child with an
experience that could temper or moderate the psychological damage inflicted from
the relationship with the mother.
Resulting Neurotic Regressions in Different Areas of Development
An individual who develops anorexia nervosa would have experienced neurotic
regressions in certain developmental areas. These disruptions would, in turn,
adversely affect all developmental areas, based on Gordon’s (2000) model. I
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propose that the primary areas of disruption that can lead to anorexia are in social,
emotional, temperamental, physical and psychosexual development.
Social Development
Based on Gordon’s (2000) model and my theory, I contend that an individual with
anorexia nervosa is neurotically socially regressed. The mother/child and
father/child relationship encourages a faulty attachment. Therefore, an individual
with anorexia nervosa has never been allowed the opportunity to develop an
authentic sense of self. The expressed self has been one for use by other people.
Consequently, what appears to be a self is only illusory. The individual has no real
sense of who she is, what she likes/dislikes, what she wants, what drives her, or what
she feels.
Consequently, this individual is unable to proceed to the next 3 phases of social
maturation (phase 2: becoming self-reflective and gaining a sense of self-
understanding, phase 3: translate self-knowledge to others, and phase 4: become
peer-oriented and experience true friendship). Therefore, being stuck in the first
phase deprives the individual of a developed and understood self, as well as the
experience of true friendship and relatedness. According to Gordon’s model, being
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socially regressed would cause disruption or difficulty in all other developmental
areas.
Emotional Development
I consider an individual with anorexia nervosa to be neurotically emotionally
regressed. Based on Gordon’s emotional development stages, and my theory, such
an individual would experience disruption in the second stage of self-conscious
emotions. The proposed mother and father/child relationship would incur injury to,
rather than enhancement of, the sense of self. Emotions such as shame,
embarrassment and guilt would dominate. These emotions would exacerbate the
core belief that she does not deserve to exist. Additionally, emotional self-regulation
skills and empathy skills could not adequately develop. Internal experiences of
emotion would cause the individual to be reactive rather than responsive. The
restriction of food is a reactive experience to emotion. Lacking the development to
have empathy skills robs the individual of being truly connected to other people.
Because “empathy is a major underlying theme that supports each of the stages of
maturation” (Gordon, p. 2546), all other areas of development are secondarily
adversely affected by regressed emotional development.
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Temperamental Development
An individual with anorexia nervosa is usually bom with certain identifiable
temperamental traits, such as “a disposition to avoid whatever is novel, intense, or
unfamiliar; to have nagging self-doubt and to ruminate; to shun intimate ties with
others, especially those outside her immediate family; and to persevere, even in the
absence of tangible reward” (Strober, 1997, p. 233). Although these traits have a
genetic base, temperament is affected by environmental factors as well.
Temperament can be tutored in order to inhibit or stimulate traits. Thus, important
people in a child’s life can affect their temperamental development. I propose that in
individuals with anorexia, the identified temperamental traits that make an individual
vulnerable to anorexia have not been mediated by environmental factors.
Furthermore, I contend that in individuals with anorexia, often times there is
incongruence in fit between parental and child temperament. The way parental and
child temperaments fit together can influence the child’s continued temperamental
development. This interaction can also have implications for emotional growth as
well. Poor parent-child temperamental fits can result in less parental sensitivity and
negative interactions.
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Physical Development
I maintain that an individual with anorexia nervosa experiences neurotic regressions
in the area of physical development. According to Gordon (2000), inappropriate
caregiving can inhibit maximal physical growth, including maturation of motor,
perceptual and language skills. As already discussed, I contend that individuals with
anorexia have experienced what can be considered inappropriate caregiving, based
on the mother-child and father-child relationship. It therefore makes sense that some
of these motor, perceptual or language skills may be regressed in individuals with
anorexia. Perception is considered one of the inherent areas of disturbance in
anorexia nervosa (Bruch, 1973, 1977, 1987, 1988; Rosen, 1997). Enwright,
Butterfield and Berkowitz (1985) state “...anorexic patients have poor perceptions of
their internal states” (p. 559). Rosen (1997) states “ A discrepancy between actual
appearance and a patient’s mental image of herself suggests perceptual disturbance”
(p. 189). Bruch (1973) states that the “second outstanding characteristic” of anorexia
nervosa is “a disturbance in the accuracy of the perception of stimuli arising in the
body, with failure to recognize signs of nutritional need as the most pronounced
deficiency” (p. 252). Therefore, in individuals with anorexia, I contend that there are
regressions in central nervous system maturation.
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Psychosexual D evelopm ent
I contend that an individual with anorexia experiences neurotic regressions in the
area of psychosexual development. In the stage of developing gender roles, I
propose that an individual with anorexia is conflicted about what it means to be a
woman. Being and behaving as a woman may be associated with weakness and
vulnerability— something an anorexic abhors. If she feels she does not deserve to
exist, she may not want to be feminine, womanly. Instead, she strives to be
androgynous. If she believes she doesn’t deserve to exist, then she does not deserve
to be sexual, to have pleasure and feel attraction to another individual. Therefore,
she experiences neurotic regression in the stage of gender relationships as well.
Protective Factors
I believe there are protective factors for an individual who a) has genetic
predispositions to anorexia, b) learns within the family to have an abnormal
relationship with food, eating, weight and body, and c) suffers particular
psychological experiences (as described earlier). One protective factor is the child
having an important relationship with an adult, where healthy interactions, guidance,
love and support occurs. The adult can be the father or anyone else in the child’s life
that is deemed important by the child and the family. This relationship can provide a
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healthy alternative way of relating and being that can help temper the psychological
abuse the child is enduring. This relationship, depending on its intensity, could
allow the child to develop some sense of self that is healthy.
Another protective factor is the child’s biologic self being altered through ‘tutoring’.
Because the environment interacts with and influences the development of the
child’s biologic self, an environment that steers the child away from temperamental
qualities usual to anorexia could change the child’s biologic self. For example, a
child bom with the temperamental trait of avoiding whatever is novel, intense, or
unfamiliar, could have a family that strives to keep everything the same and avoid
change. This environment would nurture the temperament the child was bom with.
Conversely, the child could live in an environment where change was constantly
occurring and the family encouraged the child to be flexible and learn to adapt. This
situation would influence and change the child’s bom temperament. Thus, a child’s
bom temperament can be ‘tutored’ or influenced. Steering a child’s temperament
away from the traits common in anorexia could serve as a protective factor. Both of
these suggested protective factors could intervene and deter developmental
stagnation, which in turn could deter developing anorexia.
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CHAPTER EIGHT
PROPOSED TREATMENT OF ANOREXIA NERVOSA
My proposed theory, understood within the context of Gordon’s (2000) model of
child development, is applicable to psychological therapeutic intervention, once
medical stabilization of the anorexia is achieved. Medical stabilization requires the
client to be medically safe and cognitively able to participate in psychological
treatment. It is also suggested that the client be periodically medically monitored, as
well as referred for psychotropic medication evaluation.
Therapeutic psychological treatment is an un-doing of childhood experiences that
caused developmental stagnation. It is both dynamic and insight oriented. Therapy
aims to identify and rectify the developmental stagnations intrinsic to anorexia,
allowing for progression in all areas of development. More specifically, issues
specific to social, emotional, temperamental, physical and psychosexual
development are worked on. This is accomplished through a re-parenting process by
the therapist, which occurs over long-term therapy. Throughout therapy, the
therapist attempts to provide insight into the client’s unconscious processes by
examining patterns of behavior, both within the therapeutic relationship
(transference) and within outside relationships. The therapist’s interpretations focus
on the connection between relationships in childhood and current relationships.
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Examination of the client-therapist relationship, the issues central to therapy, and the
role of the client in her own treatment will follow.
Client-Therapist Relationship
The therapeutic relationship offers the client a type of re-parenting experience that
becomes the primary impetus for change. Re-parenting consists of the therapist being
unconditionally warm, being a role model, being there for the client’s needs (as
opposed to his/her own needs like the client’s parent), encouraging growth and
development in all areas.
The actual experience of being re-parented offers the client a new way of relating to
others, relating to oneself, and experiencing being in the world. The therapist acts as
a healthy parent would, giving the client the opportunity for experiencing healthy
parenting. This re-parenting is accomplished in part through transference. The
client unconsciously transfers feelings to the therapist that really stem from feelings
for and about significant relationships in the client’s past. The therapist helps the
client recognize how she interacts and feels, and how this can be rooted in childhood
experiences. This gives the therapist the opportunity to help the client work through
the conflicts and respond and interact differently.
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The therapeutic relationship is based on therapist always being truthful, especially
because so much of the client’s prior parenting experience was based on un-truths
(ie; the client’s needs as a child were not important). The therapist’s use of and
acknowledgement of this truth helps the client see the world in a nondistorted way.
Because so many beliefs imposed on the client were distortions of reality, the use of
truth as a therapeutic tool is necessary.
Issues Central to Therapy
Based on my theoretical formulation of the contributing factors of anorexia, three
main areas need to be addressed in therapy; namely, the biologic area, the
perceptual/cognitive behavioral area, and the psychological area.
With regard to the biological predisposing factors of anorexia, currently, only
temperament can be therapeutically influenced. The younger the client is, the more
malleable her temperament. The therapist can stimulate or inhibit particular traits.
For example, the therapist can continually encourage the client to engage in novel
experiences in different areas of her life. The therapist and client can discuss the
feelings associated with such a task and the attainment of the new experience.
Repeated experiences may help the client be less avoidant of that which is novel,
intense and unfamiliar. The therapist may work with the client to establish and build
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new friendships. Together, the client and therapist can explore the feelings
associated with the experience. The therapist may also encourage the client to be
less perfectionistic, and help her to know when to stop persevering. These are just
some ways that the therapist can work with the client to help modulate
temperamental qualities that encourage and uphold the anorexia.
Because anorexics’ have a perceptual disturbance, as well as erroneous beliefs about
food, body and weight, cognitive and behavioral strategies ought to be implemented
into the therapeutic process, in addition to insight oriented process work addressing
the origins of the disturbances.
To begin with, the therapist needs to educate the client about the symptoms and
affects of starvation, using the client’s own history in order to contextualize the
information. Additionally, the adaptive and maladaptive functions of anorexia need
to be explored and deconstructed. The therapist will need to constantly challenge the
client’s beliefs about food, body and weight. Weight gain and consistent eating
needs to be reframed as medicinal and necessary. The client should be encouraged
to eat “mechanically, according to set times and a predetermined plan” (Gamer,
Vitousek, Pike, 1997, p. 111). Meals ought to be discussed and planned in treatment
(or with a nutritionist that is in contact with the therapist). Phobic reactions to food
ought to be treated as phobias in a cognitive behavioral way. As therapy progresses,
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and the client recognizes that fat is not a feeling, she can challenge her own thoughts
about body, food and weight as they emerge. If the client recognizes feelings of
fullness of others, she can be encouraged to differentiate between being full of others
and being satiated with food. She can metaphorically and behaviorally stop taking in
other people’s needs, thus making more room for the food she needs to eat to
survive. These are some of the many cognitive and behavioral strategies that can be
helpful in working with the anorexic individual.
Based on my theoretical formulation of the contributing factors of anorexia, one of
the most important tasks of therapy is uncovering and exposing the psychological
trauma that occurred within the family. This process can be slow, depending on the
client’s ability to confront her past. This is accomplished through the use of the
therapeutic relationship and insight. There are certain areas of concurrent focus
following the uncovering and exposing phase.
One of the most important roles of the therapist is in helping the client to recognize
and embrace her natural bom right to exist. This is a slow process because on a core
level the anorexic client does not believe she deserves to exist. She has had years
and years of accumulated experiences (within the parental relationship) that reinforce
the belief that she does not deserve to exist. Besides continually voicing and
drawing attention to the client’s right to exist, the therapist uses the therapeutic
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relationship to reinforce the truth of and right to existence. The client exists in the
therapeutic relationship, in contrast to not existing in the parental relationship. The
therapist treats and relates to the client as an individual, fully human with needs,
wants, feelings, thoughts, and experiences. This discrepancy in experience for the
client is the most profound reflection and reinforcement of the truth of and right to
exist. Additionally, the therapist encourages client participation in her world, which
also serves to contradict the childhood experience of not deserving existence. These
repeated experiences of deserving to exist slowly impact the client and erode her
feelings of not deserving to exist. The therapist also helps the client identify how not
feeling worthy of existing relates to the anorexia. Not eating food reinforces feeling
unworthy of existing. Therefore, eating needs to be reframed as an action to support
deserving to exist. Again, this process is lengthy and dependent on repeated
experience and the client’s ability to find connection between eating and existing.
The client has been raised to take care of other people, and to metaphorically take
those people’s needs into herself. The therapist helps the client to determine when
she is taking care of other people and taking their needs into herself. The connection
is explored between anorexia and taking care of other people. The therapist helps the
client to identify how caretaking affects eating. For example, does she feel full when
attending to others’ needs? The client’s childhood experiences are related to current
functioning in terms of caretaking. The client is encouraged to relate to others in a
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different manner, where caretaking does not occur. The therapist helps the client to
either detach from or set healthy boundaries in caretaking relationships.
It is the therapist’s responsibility to help the client discover who she really is, as
opposed to who she has been for other people. Because much of the client’s
experience of herself was based on other people’s prescription, her conception of
herself needs to be bom and nurtured. This is achieved over time as the client
partakes in her life more actively. Who she is slowly materializes over time and
experience. The therapist encourages and supports this explorative process.
The client’s historic parental relationship has taught her that fusion with another
person is love. The therapist has three tasks related to this teaching. First, the
therapist helps the client experience a healthy relationship (the therapeutic
relationship) not based on fusion. Second, the therapist helps the client to relate to
people outside of the therapeutic relationship in a healthy, non-fusing manner.
Third, the therapist helps the client explore and reflect on what love really is.
With the use of truth (ie: ‘you almost died and irreversibly damaged your heart and
bones, so you must not have been safe’), the therapist helps the client challenge the
notion that thinness is equated with safety. Challenging includes exploration of how
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this fallacy arose. Because the client may continually revert to this false notion, the
challenging needs to be continuous.
The therapist must also explore the feelings associated with recovery from anorexia.
Feelings include the client’s visceral experience as well. Helping the client find
ways to tolerate eating and weight gain is important. Becoming ‘well’ and not
having the identity of an ‘anorexic’ is also important and warrants continuous
attention.
These areas of focus contribute to the relief of developmental stagnation. In the
social developmental area, therapy aims to help the client develop an authentic sense
of self in order to experience a developed and understood self, and to experience true
friendship and relatedness. In the emotional developmental area, therapy aims to
enhance one’s sense of self and eradicate shame, embarrassment and guilt as related
to one’s sense of self. Subsequently, the client can acquire emotional self regulation
skills and empathy skills, she can become responsive rather than reactive, and she
can truly connect with others. In the temperamental development area, therapy can
modulate the extreme traits and help the client to be more adaptive. In the physical
developmental area, repeated behaviors such as eating, will hopefully create and
strengthen neural pathways that inform future behavior. In the psychosexual
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developmental area, therapy aims to clarify the client’s formulation of gender roles
and encourage gender relationships.
Client’s Role in Her Own Therapy
Having delineated some of the main tasks of the therapist, it is crucial to remember
that the work is dependent on the client’s role in her own therapy. I contend that
above all, the client must possess willingness. She must be willing to engage and
stay in therapy, be self-reflective, take risks, work through difficult periods and be
open to change. She is half of the therapeutic relationship, and is therefore
responsible for progress in the therapeutic relationship and in her own progress. The
client must be respected and treated as an adult in control of her own life. She must
be empowered and given the responsibility for her own therapeutic gains.
Critique of Theory
The theoretical understanding of anorexia nervosa that I have presented is
susceptible to critique. Following are critiques of the theory I have presented on
anorexia.
• Researchers who advocate for a non-dynamic approach to understanding human
behavior and psychopathology would disagree with this theory. They would
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advocate for focusing on the problem and the resolution of the problem. They may
see this theory as parent blaming.
• Researchers who support the notion that anorexia is culturally determined would
not agree that it is transactional in origin.
• Researchers may think the translation of this theory into psychological treatment is
too complicated.
• This theory relies on a certain type of client for psychological treatment. The
client needs to be relatively educated, able to think abstractly, and possess the
capacity for insight. In addition, because treatment is long-term, the client would
have to have financial means to support treatment.
• This theory necessitates long-term psychological treatment and would not be
applicable to short-term therapy or time-limited therapy.
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CHAPTER NINE
CLINICAL APPLICATION OF RE-CONCEPTUALIZATION OF
ANOREXIA
In order to illustrate the applicability of the proposed theory, application of theory
must be demonstrated as plausible. As discussed earlier, psychology has
traditionally sought to understand psychopathology through the use of case analysis.
The Case of Sara was presented in the beginning of this text to illustrate and
humanize the plight of anorexia. Now that a re-conceptualization of anorexia has
been presented, we can understand Sara and her symptoms in a different light, which
could lead to improved treatment and possible relief of her symptomology. Before
proceeding to an analysis of Sara, I will briefly remind the reader of the Case of
Sara.
Sara is a 23-year-old woman who has intermittently struggled with anorexia for 10
years. She has undergone inpatient treatment for anorexia at ages 13,17 and 23, as
well as outpatient psychological treatment. Her father, Seymour, was loving but not
emotionally available for much of her childhood and adolescence. Her mother,
Angela, has a history of eating disorder behavior, as well as a substance abuse
problem. Sara has a sister, Lily, who is 13 months younger, and a 2-year-old
brother, Timmy. Growing up, Sara had a tumultuous, troubling relationship with her
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mother. She did not have an active, supportive peer network. Sara has always
excelled in school and recently graduated from a prestigious East coast college. She
was recently released from inpatient treatment for anorexia, and does not currently
have future plans.
As can be seen, Sara has undergone many treatments for anorexia that have
ultimately not been successful. Now that we have a way to reconceptualize anorexia
in a developmental framework, we can analyze Sara’s case from a different
perspective. What follows is her case analysis using the proposed theoretical
perspective discussed earlier in the text.
Analysis of Case of Sara S.
Sara can be considered a chronic anorexic, based on the duration and severity of her
anorexia. The treatment she has undergone has not been successful in preventing
future relapses into anorexia. Individuals like Sara, are difficult to treat and have a
poor prognosis. For this reason, many professionals are not optimistic about treating
such individuals. Furthermore, current theory is limited in its scope in helping
understand Sara from a developmental perspective. I propose the use of my
developmental theory, in conjunction with Gordon’s (2000) model of normal child
development, in helping to understand Sara and her experiences. I hope that Sara,
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and those individuals like her, may be better understood and, consequently, have
better chance at recovery.
Understanding Sara Using the Proposed Developmental Perspective
Sara had all of the risk factors that I suggest are implicated in the etiology of
anorexia. More specifically, Sara 1) had genetic predispositions to anorexia, 2)
learned within the family to have an abnormal relationship with food, eating, weight,
and body, and 3) suffered particular psychological experiences. These three risk
factors stagnated different developmental areas, which in turn, rendered Sara
incapable of navigating transitional periods requiring increased autonomy and
independence. Her anorexia emerged as an articulation of that experience, as well as
an unconscious attempt to cope with the state of multiple neurotic regressions in her
development. A closer analysis of the Case of Sara will support these claims.
Genetic Predisposition to Anorexia
Although it cannot be established whether Sara possessed the susceptibility gene for
anorexia, we can be certain that her likelihood to develop anorexia was increased,
based on the report that her mother (first degree relative) had anorexia nervosa, and
that her paternal grandmother had what could be considered a partial syndrome of
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anorexia (restricting food intake although thin, distorted perception of body image).
Based on the research supporting a genetic familial component to anorexia
(Garfinkel & Gamer, 1982; Holland et al„ 1984, 1988, 1994; Lilenfeld, et al., 1998;
Maddox & Long, 1999; Strober, et ah, 2000; Ward, et ah, 2000; Grice et ah, 2002),
Sara was genetically more susceptible to anorexia.
Sara also possessed the temperamental and personality traits that have been
documented to exist in anorexics (Casper, 1990; Strober, 1980). More specifically,
Sara avoided that which was novel, intense and unfamiliar, she was perfectionistic,
she was subject to ruminating and doubting herself, she did not have intimate
relationships where she revealed her innermost self, and she tended to persevere.
Furthermore, these traits were nurtured, rather than discouraged by her environment.
Sara was bom with a temperament that resisted novelty and unfamiliarity. As a
baby, she was weary of strangers and took a long time to warm up to new people.
She thrived with schedules and did not easily adapt to changes. She stayed away
from unfamiliar territory and did not engage in behavior that had a risk-taking
component. In preschool, Sara had difficulty with activity transitions, she resisted
schedule changes, and due to perfectionism, had difficulty completing tasks. Sara
was shy and isolative. In not challenging Sara’s temperamental qualities, her family
strengthened her existing temperament.
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As she matured, Sara’s temperamental qualities continued. She was still
perfectionistic, which worked to her benefit because she was a straight A student.
She was quite fond of school because everything was very structured and she knew
what to expect. If she studied hard, she would get an A. She felt most comfortable
knowing what to expect, and having an understanding of cause and effect. Despite
doing well in school, Sara’s self-doubt continued. She spent a lot of her time being
self-critical and self-loathing, as illustrated by her sitting in front of the mirror saying
how she hated herself and how ugly she was.
Her isolative behavior persisted into high school. She did not form close bonds with
her peers because she did not confide anything of importance in the friends she had.
She was terribly shy and insecure, both of which served as a deterrent to being
social. Her fear of sexuality made Sara feel more isolated. Her isolation was
exacerbated by Sara’s familial environmental experience. Sara’s shame of her
mother’s substance abuse, as well as her mother’s constant teasing about her social
skills, contributed to her isolative behavior.
Learning Within the Family to Have an Abnormal Relationship With Food, Eating,
Weight, and Body
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Sara learned within her family to have an abnormal relationship with food, eating,
weight, and body. Her mother was an anorexic, who exhibited her own abnormal
relationship with food, eating, weight, and body. In addition, Sara’s mother’s abuse
often involved food, eating, weight, and body, which distorted Sara’s relationship
with food, eating, weight, and body.
While Sara was growing up, her mother, Angela, constantly complained about her
own weight, idealized Sara’s body, and berated Lily’s body. Angela stood before the
mirror, examining and critiquing her own body, calling it fat. She constantly asked
her daughters if she looked fat. Angela rarely ate, and when she did, she ate odd
foods, such as salad with low-fat dressing and sweet-n-low. However, regardless of
what she ate, Angela forced Sara and Lily to finish their meals, even when they were
full. Sara learned that the ideal body type was that of a child, lean, muscular, and
undeveloped. An adult woman’s body was fat and undesirable. She also learned to
have an awareness of her own body in this context of fat versus the ideal, due to the
attention that was drawn to her body. Watching her mother’s eating habits instilled
in Angela how an adult woman with an undesirable body should eat, or rather not
eat. In being forced to eat while full, Sara was taught to ignore her own bodily signs
of hunger and satiety.
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When Sara was in grade school, she witnessed her Angela’s abuse of her sister, Lily,
surrounding issues of eating and weight. Her mother constantly berated Lily for
being what she considered fat. Once, as a punishment, Sara’s mother forced Lily to
eat a bottle of hot chili pepper chips. This resulted in an emergency room visit where
Lily’s stomach needed to be pumped. Thus, in addition to witnessing her mother’s
eating disorder, and being taught eating disordered ideals and behaviors, Sara learned
to associate abuse with issues of food, eating, weight, and body.
Psychological Experiences
When Sara was an infant, her needs were not met on a consistent basis. Her mother
responded to her own needs, rather than the needs elicited by Sara. Sara therefore
learned that her needs would not necessarily be met by her mother. The inconsistent
meeting of her needs further confused her. She had to try to decipher the meaning of
why and when her needs were met. Thus, rather than learning to attend to her own
internal cues, Sara had to attend to her mother’s cues, to determine when her needs
could be met. The implicit message was that Sara’s needs were not important.
Angela’s substance abuse that began again when Sara was thirteen months old,
further amplified the implicit message that Sara’s needs were not important.
Angela’s responsiveness became more erratic and intense due to substance abuse.
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For Sara, there was little sense in cause and effect. Her relationship with her mother
was entirely unpredictable. Sara’s emerging depressive and withdrawn behaviors
can be interpreted as a suppression of her needs.
During Sara’s grade school, Sara witnessed her mother’s blatant abuse of her sister,
Lily. Sara avoided the abuse by doing everything possible to placate her mother.
Again, Angela’s needs, not Sara’s needs, took precedence. Sara’s need for being
mothered was expressed in her admiration and adoration of her mother. When Sara
mimicked her mother’s likes, dislikes, and behaviors, Angela responded positively.
Conversely, when she expressed disparate likes, dislikes, and behaviors, Angela
would ridicule Sara. Sara was therefore strongly encouraged to alter herself to be
like her mother if she wanted approval and love. In this way, a fusion took place.
Angela was able to look to her daughter for reflection of herself. Sara was taught at
a young age to function as a reflection mechanism for her mother. In other words,
she learned to fuse with her mother.
Fusion eradicates boundaries. Fusion with her mother caused Sara to take in, or
ingest Angela’s needs and feelings. Consequently, Angela’s needs and feelings were
experienced by Sara, and Sara’s needs and feelings were not allowed to exist and
develop. The following examples support this claim.
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Sara felt responsible for her mother’s happiness. She became Angela’s caretaker and
protector. She believed that if she differed from how her mother wanted her to be,
she would somehow be hurting her mother. Sara spent a lot of time worrying about
her mother and feeling deeply sorry for her. In fact, Sara experienced feelings for
her mother (worry, feeling sorry for her) more strongly than feelings she felt for
herself. Sara’s concern, which interfered with her sleep, was so pronounced, that it
was experienced on a visceral level.
Sara’s ultimate fear of her mother’s death can be interpreted as a fear of her own
death or destruction. More specifically, her fear of her mother’s death can be seen
both as an articulation of the fear of the reality of what was occurring in Sara’s life,
as well as a fear of her own obliteration. A part of Sara was dying, in that her
authenticity of self had been taken over by her mother. She was not allowed to
acknowledge her loss of self to her mother, and therefore, it was expressed in the
form of being obsessively worried about her mother’s death. It can also be
interpreted that Sara feared that if her mother died, how could she (Sara) survive
because so much of her identity was really her mother.
Sara’s sleep problems started when she was in pre-school. They can be interpreted
primarily as the result of the fusion with her mother. Sara was taught to function
fused with her mother. However, sleeping is something Sara had to do alone.
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Because she was used to functioning fused, and sleep required her to function not
fused, sleeping alone became terrifying. When she was slightly older, she would
actually have nightmares that she was left alone on the planet. To dissipate her fear
and anxiety, she would have to observe her parents breathing to make sure they were
alive and she wasn’t alone on the planet.
During early grade school, the fusion and intrusiveness of Sara’s mother began to
manifest for Sara on a physical level. For example, Sara expresses feeling trapped in
her skin, and feeling a ‘tight, burning ball in her stomach that made her feel icky and
hate herself’. She describes feeling fat in first grade, and wants to tear off her skin.
She hates the feeling of being full and felt as though she could ‘ooze out all over’.
These feelings are arising because Sara feels full of her mother’s needs (tight burning
ball in stomach), which in turn, makes her feel icky and hate herself. She is
metaphorically full without eating. Therefore, there is not room for Sara’s needs,
such as eating food. When she does eat food, Sara feels as though she could ooze
out all over, because she is full of other’s needs (mother) and her own needs (food).
As early as first grade, Sara feels fat. However, fat is not really a feeling. Fat
conjures up notions such as excess, fleshy, bursting out of one’s seams, gluttonous,
and overly full. Fat is the representation that Sara uses to describe her feeling of
being full of other’s needs.
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Sara begins restricting her food intake prior to puberty, a developmental period
marked by an increase in autonomy and socialization. She recognized the correlation
between not eating and feeling better. By restricting her food intake, Sara was
simultaneously assuring empty space within herself for the intrusion of her mother,
while ensuring her physical comfort. She is actively suppressing her needs to
provide room for her mother’s needs. The age at which she began food restriction is
meaningful, because it proceeded puberty. Puberty is an important developmental
period transition, when an adolescent gains autonomy and separation from parents,
and increasingly becomes more peer-oriented. The threat of impending autonomy
and separation from her mother (characteristic of puberty) appears to be the impetus
for food restriction. Food restriction assures the room necessary for fusion with her
mother, and therefore, serves as a protective mechanism for their current
relationship.
The underlying intention of preserving the current parental relationship does not
work for Sara however, because her mother becomes angry and irritated at her
weight loss. To preserve homeostasis and placate her mother, Sara regains the lost
weight, although she remains obsessed with her body, weight, and food intake.
In junior high school, Sara’s relationship with her mother shifted. Sara no longer
reflected her mother’s perception of her self. This can be seen in Sara’s description
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that her mother no longer seemed to like her, and ridiculed her lack of social ease.
Angela had always been very sociable. Therefore, Sara’s non-social behavior was
glaringly different from Angela. No longer reflecting her mother’s perception of her
self, Sara was not providing an adequate breeding ground for fusion. Therefore,
Angela’s behavior became increasingly annihilating towards Sara.
Angela’s substance abuse was escalating, as was her annihilating behavior towards
Sara. Angela showed up intoxicated at school events, humiliating and embarrassing
Sara. She was banned from driving on school activities due to substance abuse.
These are additional examples of how Sara and her needs were nonexistent to
Angela.
The shift in Angela and Sara’s relationship preceded the next bout of Sara’s food
restriction and descent into anorexia. The homeostasis of fusion (preferable to
annihilation) no longer existed. Sara began to express anger towards her mother,
which can be interpreted as Sara attending to Sara’s needs, rather than her mother’s
needs. Consequently, Angela became increasingly abusive and annihilating.
Besides criticizing her constantly, Angela made it clear that Sara ‘was alive only
because Angela brought her into this world’. This explicitly implies that Sara does
not have the right to her own existence, and that Angela holds the power to create or
destroy Sara’s existence.
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Therefore, Sara’s food restriction at this point can be seen as the unconscious
articulation that she does not deserve to exist. Her mother, who had been much of
Sara’s identity, was now rejecting, ridiculing, and ultimately annihilating her. Her
weight loss can be seen as a physical attempt to dispose of need, to ultimately
disappear. Having weight on her and physically existing was incongruent with her
feelings of not deserving to exist. The anorexia serves the purpose of making her
physical existence or experience more congruent with her feeling of not deserving to
exist. While anorexic, Sara is physically wasting away into nonexistence, which
correlates with her feeling of not deserving to exist.
During this period, Sara’s father left her mother, as the result of her substance abuse.
Sara chose to live with her father, putting her needs before those of her mother.
Despite her life-affirming decision, Sara still experienced tremendous guilt about
hurting her mother’s feelings and abandoning her in a time of need. Sara’s active
food restriction subsided, although she maintained a low weight. This improvement
can be seen as the result of her father standing up to Angela and naming her behavior
as unacceptable. This measure perhaps gave Sara the strength to put her needs first
and fight to exist. While Sara is making a life affirming choice, her guilt for doing
so can be seen in her low weight maintenance.
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When her parents reunited, Sara became an outsider in her own family because she
was the only one unhappy about the reunion. Being an outsider in her own family
reawakened and fueled her unconscious feeling of not deserving to exist. Not
surprisingly, her food restriction and isolating behavior returned.
Within several months, Sara was hospitalized in an eating disorder inpatient unit.
Being hospitalized made her feel more of an outsider in her family and in the world.
Sara focused on gaining weight to get out, rather than focus on what the issues were
underlying the anorexia. With the help of the program, Sara gained her weight and
was released. However, the deeper, underlying issues were not addressed.
High school exaggerated Sara’s feelings of being an outsider. She was insecure and
uncomfortable, and chose not to have much of a social life. Instead, she stayed home
and studied all of the time. She believed her mother’s abusive criticisms and
doubted her worth. Her feelings of alienation were exaggerated by her fear of and
lack of interest in dating.
Sara’s next bout with anorexia occurred at a time preceding another major
developmental transition period. For Sara, attending college would require moving
away from home, and becoming far more independent and autonomous. Her
existence would become more tangible or real. It can be argued, that on an
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unconscious level, because Sara did not believe she deserved to exist, she certainly
did not deserve to attend an elite college. Restricting her food intake can be seen as
a sabotaging mechanism, as well as the articulation of her feeling of not deserving to
exist. Consequently, as the beginning of college approached, Sara’s food intake
became compromised, and once again, she became anorexic and needed
hospitalization.
This hospitalization experience can be seen as more constructive for Sara. Her
doctors were instrumental in helping Sara begin college. They advocated for
separation from her family and attendance of college. Additionally, after helping her
gain weight, they medicated her with a selective serotonin reuptake inhibitor (SSRI)
to help control her obsessive thinking. It can be interpreted that in having a more
positive hospitalization experience, Sara was able to feel she deserves to exist,
enough so to regain health and begin college.
College gave Sara the opportunity to begin building her own identity. Being away
from the abuse of her mother, in an environment where she was forced to meet her
own needs rather than rely on family, gave Sara the unique opportunity to experience
her developing self. She felt a sense of independence and power, and was proud of
her intellect. This is the first time Sara conceived of her future, indicating that she
had developed some sense of self to have a future. Sara begins to have hopes for
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herself, also indicating that she had enough of a self to want for. One can only
envision a future if there is an existing self to begin with, that could move forward
into that future. Consequently, during college, Sara maintained her health and
abstained from starving, for the most part.
Although she had more friends than in high school, Sara still struggled socially. She
had difficulty connecting on a deep level with anyone. She avoided dating and
sexuality altogether, and was unable to get close to her friends. She still feared that
she was worthless, and if people knew her, they would reject her. It can be
interpreted that her underlying feelings of not deserving to exist, and being worthless
interfered with her connections to other people.
Summers at home proved difficult for Sara. Sara’s developing self was not
progressed enough to sustain Angela’s annihilation. Consequently, Sara again
wanted to ‘disappear’. She again experienced the annihilation on the physical level.
This is evident in Sara’s feelings of being ‘worthless, icky and uncomfortable’, as
well as in her feeling ‘uncontained in her body, like she could “ooze out all over’” .
Graduating college marked the beginning of another developmental transition that
Sara was incapable of negotiating. This transition to adulthood, where one ideally
gains further autonomy and independence, can be daunting. Sara was unable to
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successfully make the transition for many reasons. First, Sara had perfected being a
student, and had done it most of her life. School provided order and structure to
Sara’s world. Cause and effect were clear. Sara’s first sense of an identity was that
of an academic. Therefore, graduating college takes away a major part of her
identity. Furthermore, Sara was confronted with choosing a career when she was a
perfectionist without a developed identity. This transition brings individuals into
adulthood more completely, which Sara was not developmentally prepared for.
In addition to these challenges, Sara moved back home into an abusive environment.
What sense of self she had established was at risk for being annihilated. Meeting her
own needs was nearly impossible while existing in the same space as her mother,
who’s needs always took precedence. Consequently, Sara abandoned herself and her
needs, lost her vision of a future, and began the descent into anorexia.
The anorexia allowed Sara to articulate her feeling of not deserving to exist. It
brought her closer to literally disappearing, to entirely losing a self, and ultimately,
to not existing. At the same time, the anorexia offered her a place where she could
seek refuge. She was protected from being violated by her mother’s annihilation and
needs. Her bone hard boundary that she created through starvation, made her less
vulnerable to the external world. This can be seen in the sense of tranquility Sara
gained by lying in bed numb, tracing the outline of her hipbones and ribcage.
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Understanding the Multiple Neurotic Regressions in Sara's Development (based on
Gordon’s (2000) model of normal child development)
Given Sara’s genetic predispositions to anorexia, her experience within the family
that taught her to have an abnormal relationship with food, eating, weight, and body,
and the particular psychological experiences she endured, different developmental
areas were stagnated. This, in turn, rendered Sara incapable of navigating certain
transitional developmental periods. Further analysis into the different areas of
developmental stagnation is warranted.
Social Development.
Sara’s relationship with her mother encouraged a faulty attachment. Consequently,
in the home Sara was not allowed to develop an authentic sense of self. College was
the first opportunity Sara had to develop an authentic sense of self, although it was
sabotaged and mitigated each time she returned home. Because Sara is stuck in this
first phase of social maturation, she is deprived of a developed and understood self,
as well as the experience of true friendship and relatedness.
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Emotional Development.
Based on Gordon’s (2000) emotional development stages, Sara experienced
disruption in the second stage of self-conscious emotions. More specifically, her
relationship with her mother caused injury to, rather than enhancement of, her sense
of self. Her dominating emotions, such as guilt, shame and embarrassment all fueled
her underlying belief of not deserving to exist. Due to her emotional stagnation, Sara
was not able to develop emotional self-regulation skills. Her internal experiences of
emotion caused Sara to be reactive and restrict her food, rather than be responsive to
her emotions. Because she lacked the development to have empathy skills, she was
never able to truly connect with other people.
Temperamental Development.
As I have already discussed, Sara was bom with identifiable temperamental traits
that made her vulnerable to anorexia, including avoidance of novel, intense, and
unfamiliar things, perfectionism, ruminating and self-doubting, perseverance, and
avoidance of intimate relationships. These traits were nurtured and strengthened,
rather than discouraged and weakened by her environment. Consequently, the
temperamental traits she was bom with continued to develop.
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Unfortunately, there was incongruence in fit between Sara’s and her mother’s
temperament. Angela’s temperament was active, distractible, adaptive, and
approaching. She eagerly embraced novel, intense, and unfamiliar things. She was
not a perfectionist, nor was she self-doubting. Conversely, Sara was not active, non-
distractible, non-adaptive, and withdrawn. This combination of temperaments can be
considered a poor-fit. This disparity contributed to Angela not being sensitive or
responsive to Sara, and to their negative interactions.
Physical Development.
Based on the mother-daughter relationship, I contend that Sara experienced
inappropriate caregiving. Inappropriate caregiving can inhibit maximal physical
growth, including maturation of motor, perceptual and language skills (Gordon,
2000). Therefore, I contend that Sara experienced regression in some of these areas.
More specifically, given the perceptual disturbances intrinsic to anorexia, Sara’s
experienced perceptual skill disturbance.
Psychosexual Development.
The case study does not include information about Sara’s formation of a concept of
behavior related to her gender role or identity. However, we can speculate that due
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to certain temperamental traits, her gender role formation was a conflictual process.
The sociocultural ideal of woman does not coincide with Sara’s behavior or her
desired perception of herself. More specifically, the notion of woman as vulnerable
and weak, and as relationship and connection oriented, is diametrically opposed to
who Sara is and who she wants to be. Sara strives to be strong and invulnerable.
She is not relationship oriented, nor is she even capable of connecting on a deep
level with others. These discrepancies most likely caused Sara disruption in her
gender role formation.
Sara’s development in the formation of gender relationships is also arrested. She has
never had a romantic relationship. If we suppose that she struggles with feeling
unworthy of existence, it would reason that she believes she does not deserve to feel
attraction to or pleasure with another human being. Overall, Sara has experienced
significant disruptions in her psychosexual development.
Summary to the Case of Sara S.
Sara presents for psychological treatment following her third inpatient
hospitalization for anorexia. Her most recent hospitalization helped restore her
weight, once again. Rather than simply addressing the symptoms of anorexia,
treatment of the underlying problems causing the anorexia is called for. I have
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proposed a case conceptualization that provides explanations for the etiology of
anorexia in a developmental framework. It is my hope that in this re
conceptualization, Sara is likely to be better understood. Treatment based on these
ideas would address the underlying issues that cause developmental stagnation that,
in turn, creates and maintains the anorexia.
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CHAPTER TEN
CONCLUSION
Anorexia nervosa remains one of the most difficult of mental disorders to treat, with
alarmingly high morbidity and mortality rates. Over the years, there have been a
plethora of theories put forth, all hoping to provide a better understanding of the self-
imposed, insidious, and lethal prison called anorexia. Unfortunately, current theory
has not incorporated an overarching, inclusive, integrative developmental framework
that could hopefully inform and improve treatment. In fact, developmental
psychopathology experts note that current research in eating disorders “lacks a
developmental framework for integrating findings from sociocultural, biogenetic,
personality, family, and behavioral studies” (Attie and Brooks-Gunn, 1995, p. 332).
It is for this reason, that I have put forth a new developmental theory of the etiology
of anorexia, that utilizes an established, transactional model of child development
(Gordon, 2000) as its skeleton.
Gordon’s (2000) child development model maintains that the child’s identity
(genetic prints and perceived sense of self) and family environment (social and
cultural milieu) together support and sustain the developmental process. Although
based on children, her model is applicable to development throughout the entire life
span.
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Given this model, I propose that a variety of insults stress these sustaining structures,
causing neurotic regressions in different areas of development, which in turn, causes
the anorexia. The insults that stress the sustaining structures include 1) genetic
predispositions to anorexia, 2) the familial experience of abnormal relationships with
food, eating, weight, and body, and 3) particular psychological experiences with the
primary caregiver. A combination of these stressors is likely to cause neurotic
regressions in social, emotional, temperamental, physical, and psychosexual
development. These developmental stagnations render the individual incapable of
navigating transitional developmental periods that require an increase in autonomy
and independence. The anorexia emerges as an articulation of this experience, as
well as an unconscious attempt to cope with the experience of multiple regressions in
development.
In order to illustrate the applicability and practicality of my theory, I created a
clinical example of anorexia, and formulated a case conceptualization using my
theory as a basis for analysis.
Finally, in presenting theory and demonstrating its applicability, it is my hope to
contribute a new conceptualization of anorexia that will add to the paradigms in
anorexia research. With this addition, I hope that researchers and clinicians gain a
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different and better understanding of individuals afflicted with anorexia, improving
treatment, and offering a more hopeful prognosis for these individuals.
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Asset Metadata

Creator Westbrook, Robyn Marie (author)

Core Title Anorexia nervosa: A developmental perspective

School Graduate School

Degree Doctor of Philosophy

Degree Program Education (Counseling Psychology)

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, public health,OAI-PMH Harvest,psychology, clinical,psychology, developmental

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Polkinghorne, Donald (committee chair), [illegible] (committee member), Trickett, Penelope K. (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-478049

Unique identifier UC11335103

Identifier 3116798.pdf (filename),usctheses-c16-478049 (legacy record id)

Legacy Identifier 3116798.pdf

Dmrecord 478049

Document Type Dissertation

Rights Westbrook, Robyn Marie

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

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