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The Anorexic Mind

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Eating disorders vary in severity from developmental difficulties in adolescence which may be transitory, to serious and chronic mental illnesses. The Anorexic Mind offers a coherent approach to these difficult and demanding problems, always underlining the point that while many of the manifestations are physical, eating disorders have their origins as well as their solutions, in the mind. While anorexia nervosa may be considered the central syndrome in eating disorders, this book also considers how it links and differs from bulimia nervosa, the more common, related disorder. In the process of the research on anorexia and bulimia, valuable insights have been gained into the very common problem of overeating.The author takes a developmental approach to eating disorders, and is very aware of the continuities between infantile, adolescent and adult experience. Our earliest relationship is a feeding relationship and feeding difficulties early in life are not rare. The view taken in The Anorexic Mind is that feeding difficulties indicate and reflect relationship difficulties whether they occur in infancy, adolescence or adulthood. Most eating disorders apparently begin at adolescence, though if a careful history can be obtained, it is often clear that there have been relationship difficulties at earlier stages of development.If eating disorders are understood as reflections of relationship difficulties, the author believes that they are best treated within a therapeutic relationship. Examples are given of treatment by formal psychotherapy or psychoanalysis where early difficulties become visible and treatable within the transference relationship to the therapist. The most serious cases of anorexia and bulimia nervosa are treated within institutional settings, and many patients have a number of long admissions.Part of the Tavistock Clinic Series.

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CHAPTER ONE

ePub

This book represents an attempt to understand the states of mind that underlie the serious eating disorders of anorexia and bulimia. Compulsive overeating or binge-eating is also considered, particularly as it relates to anorexia.

The ideas in the book have developed through two distinct areas of professional practice. The first is my own direct clinical work as a psychoanalyst, treating adult patients who suffer from eating disorders. The second is as a learning resource to the staff who run specialist units caring for patients with eating disorders. In recent years I have worked with colleagues on the MA programme at the Tavistock Clinic, Working with People with Eating Disorders, and am greatly indebted to both students and colleagues for what we have managed to learn together.

The perspective of the book is psychoanalytic inasmuch as it assumes that mental functioning is unconscious as well as conscious and that, as human beings, we only very partially understand our own motivation. However, the book is not written exclusively for psychoanalysts—quite the contrary. An approach that helps practitioners to find meaning in the illnesses of their patients is likely to be helpful to mental health workers from a range of different backgrounds. Following many years of working with psychiatrists, nurses, dieticians, and others concerned with the specialist care of eating-disorder patients, it seems clear that the most difficult task for the professionals is to go on thinking about their patients. This is a group of patients with many features in common, but perhaps chief among these is a real difficulty in thinking about themselves and their own psychological predicament. Staff, too, can become caught up in the mechanics of treatment, focusing on target weights, the body mass index (BMI), the rules and regulations that govern the unit, and the setting in which they work, while at the same time failing to understand in psychological terms what it might be that the patients are reacting to. Faced with the constant pressure and challenge from the patients to give up thinking, it should not surprise us that sometimes we do just that. A psychoanalytic framework can provide a structure that can enable thinking to be recovered, even if the work itself seems a long way from psychoanalysis as we normally understand it.

 

CHAPTER TWO

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The manipulation of the size of the body by deliberately limiting food intake (or, indeed, by overeating) has probably been practised by certain sections of every civilized society. However, it is the tradition we call asceticism, often associated with religious fervour, that has become particularly associated with the eating disorders of anorexia and bulimia. Asceticism nearly always involves fasting, sometimes in extreme forms. Other forms of what we might now call “self-harm”, such as self-flagellation and self-cutting, have often formed a part of both Eastern and Western religious traditions.

Well-known examples would include the early Christian anchorites and anchoresses who practised extreme forms of self-denial, living in caves as desert hermits. Underlying these practices is a dualistic understanding of mind/soul and body. The body is viewed, like the external world, as essentially sinful. The mind/soul can achieve perfection only if the body can be subdued and overcome. The body is felt to be an enemy of the soul, which it attempts to keep trapped in sinful imperfection (Lawrence, 1979). These beliefs have been explicit and dominant in the Christian tradition at certain points in history, such as the Gnostic heresy in the early church and in the Catharism of the medieval period. However, I believe that this dualistic thinking is actually very prevalent, and all of us to a greater or lesser extent experience our bodies as separate from our minds. Very often the body is regarded as inferior to the mind. The body is essentially uncontrollable. This is especially apparent in adolescence and again in the course of the ageing process. In patients with eating disorders, the uncontrollable nature of the body cannot be accepted. In fact of course, the mind is also uncontrollable. If we are able to think, we have no control over what thoughts come into our minds. These extreme religious practices, although ostensibly aimed at controlling and subduing the body, are in fact also a means of controlling the mind, which becomes utterly dominated by the body and its sufferings and quite unable to think. Paradoxically, although the anorexic and the aesthete both regard their body as the enemy, both are able to think of little else. Another problem with the body is its mortality, whereas the soul is widely believed to live for ever. As we shall see, anorexic patients find the idea of death unacceptable and believe they are indeed immortal.

 

CHAPTER THREE

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Once they become established, eating disorders are notoriously difficult to treat. There is no single form of treatment that we can say categorically is effective in all or even most cases. The kind of treatment I discuss here is a form of psychotherapy, based on psychoanalytic principles, that I have found to be helpful to very many patients. The reasons I think that it is often helpful are twofold. The first is that this form of treatment seeks to understand the uniqueness of the individual. While I try to outline in succeeding chapters where the developmental difficulties may lie, each patient is different, and someone needs to take the time and effort to understand precisely what has gone wrong for this individual. This is what psychoanalytic psychotherapy aims to do. The second reason for the usefulness of this treatment lies in the fact that it is based on a relationship. In eating disorders, many relationships will have broken down and the patient will be more or less terrified of getting close to anyone. And yet this is precisely what she needs to do if she is to understand what has happened to her and begin to find a way forward in her development.

 

CHAPTER FOUR

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Psychoanalytic thinking about eating disorders took an important step forward when it began to be possible to think about symptoms as representing disturbances in relationships. This is very much in the tradition of Freud’s earliest formulations concerning hysterical and obsessional neuroses where the symptoms were considered as displacements of affects or ideas onto other ideas or onto parts of the body (as in hysterical conversion).

One very common example of such a dynamic in both anorexia and bulimia is a situation in which the patient is terrified of her own greed. She may deal with this by strictly and obsessionally limiting her food intake, so as to make sure she is not guilty of greediness. Or, as in the case of bulimia, she may from time to time indulge in greedy gorging, which will be followed by self-induced vomiting in an attempt to rectify the situation. Usually we will find a similar pattern in the individual’s relationships. She may be a highly dependent person by nature, but someone who at the same time is terrified of her own dependent feelings. She may equate dependency with weakness or helplessness and try her best to create a sense of her own emotional self-sufficiency, refusing all help and understanding from other people. She may, from time to time, allow herself to form highly dependant relationships, but will suddenly pull away, terrified that she will become a helpless baby if she allows herself to make emotional contact with another person. The anorexic or bulimic individual may remain consciously unaware of her relationship problems, focusing her attention instead on the way she enacts the relationship problem with her food. And, of course, being obsessed with one’s own body and food intake does mean that ideas about troubling relationships do recede, further bolstering the illusion of self-sufficiency. I want now to look at one very specific aspect of the object relationships found in anorexia and bulimia and the murderous phantasies involved in the attempts by the patients to control their internal worlds. Anorexia and bulimia are both violent, sometimes murderous symptoms, directed towards the self. I believe that there is also a great deal of deadly intent towards the objects as well.

 

CHAPTER FIVE

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There seems little doubt that the advent of an eating disorder in an adolescent girl signals, among other things, that there is a serious complication in her sexual development. In this chapter, I begin my exploration of aspects of sexual and emotional development that seem to be specific to girls. I suggest that a developmental failure in infancy has far-reaching consequences for the whole personality, and I link this with the familiar difficulties in symbolic thinking, which I go on to describe in chapter 6.

In anorexia, there is usually a marked aversion to all things sexual, which I have described in chapter 4. As well an expression of sexual anxiety, I have linked this with an intolerance of the existence of the sexuality of the parents. In bulimia, sexuality, in line with the eating symptoms, may be more varied, with periods of sexual acting out, often including risks of pregnancy. Such occurrences are invariably followed by guilt and shame, and one feels that although there may be sexual activity, it is not at all integrated into the emotional and social life of the young woman. In fact, like food, sexuality always seems something of a torment to the bulimic patient.

 

CHAPTER SIX

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Iam returning again to one of the central enigmas of eating disorders, the preponderance of female over male sufferers. I shall be picking up some of the issues and areas raised but not elaborated in previous chapters. In the first part of the chapter I shall consider two contemporary accounts that locate the origins of anorexia in intrusion or impingement of one sort or other. I suggest that what is actually being observed and described is an internal situation, an intrusive object, instated in the mind of the patient, which may or may not have antecedents in actual external experiences of intrusion.

In the second part of the chapter, I look at ways in which the very nature of femininity—the biological and psychological given of femaleness—might lend itself to fears and phantasies of intrusion. Finally, I shall propose that the intrusive internal object so prevalent in anorexia is often linked to intrusive aspects of the patient’s psychopathology and, in particular, her intrusiveness towards her parents and their relationship. I further suggest that a failure to internalize the two parents and the link between them leads to a concreteness in thinking, a difficulty in symbolization, in which aspects of the maternal function are equated with food and are renounced. Anorexia is understood as a disorder in which a failure to differentiate adequately from the mother leads to difficulties in mastering sexual anxieties of intrusion, which become concretely enacted in the refusal of food.

 

CHAPTER SEVEN

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A  patient dreamt of a scene where a condemned person, hooded, stood waiting for execution. There seemed to be a group or a society in charge of the business who kept changing their minds. At one moment the condemned person would be told they were to be freed, the next moment that the execution was to proceed. It was a cruel torture. The patient felt he was being forced by the people in charge to be the witness.

What the patient was “witnessing”, in the form of his dream, was a situation in which his “self” was held at the mercy of an organization, a society—in reality, other parts of his own mind.

In this chapter I examine the psychoanalytic idea of the death drive, with the aim of testing its applicability to clinical situations concerning patients with eating disorders. While Freud sees the death drive as an innate force, parallel with the life force or libido, others have taken the view that destructive and self-destructive impulses arise as a result of environmental influences. Sometimes these opposing views take on a philosophical tone, as though it is the attitude to life of those holding the views which is at issue. I am concerned in this chapter with finding ideas that are clinically useful and enable the clinician to think more effectively under the enormous pressure that the patient’s behaviour imposes.

 

CHAPTER EIGHT

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While all eating disorders need to be taken seriously, some patients do, in fact, turn out to be much more ill than others. The symptoms of anorexia nervosa are remarkably consistent from patient to patient, as are those of bulimia nervosa. Of course, the severity of the symptoms varies, but in general it is true to say that, without help, the symptoms of eating disorders will usually get worse. So the patient with moderately severe symptoms now may, without help, very well have very severe symptoms in a few months time. It can therefore be difficult to make a judgement as to the seriousness of the situation, the degree of risk, and the likely prognosis. The clinician needs as much knowledge and understanding as possible in order to carry out a full assessment—hence my reason for including this chapter towards the end of the book.

Body mass index is a kind of shorthand way of expressing how seriously underweight, and thus how physically vulnerable, a patient with anorexia nervosa is likely to be. BMI is a person’s weight (in kilograms) divided by his or her height (in metres) squared. A normal or average BMI is around 20, with 15 considered seriously underweight, 25–30 overweight, and 30+ obese. While such a calculation is a useful aid to diagnosis and prognosis, it cannot replace the judgement of a skilled and experienced clinician. The BMI tells us something about the state of the patient’s body, but it does not tell us anything at all about her mind. As we shall see, these two are related, but not necessarily in a direct way. For example, a patient without a dramatically low BMI may nonetheless present psychologically in a way that is very worrying and suggests that urgent treatment is required. Anorexic patients can be at their most psychologically vulnerable when they begin to put on weight. Although they may be less at risk of complications from starvation, the beginnings of weight gain can often herald the beginnings of serious depression and sometimes accompanying self-harm.

 

CHAPTER NINE

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An observation of mine—and one that is shared by colleagues—is that, over the past thirty years, the eating disorders population has slowly but dramatically changed. In general, the young people we see treated in specialist eating disorder units seem to be more disturbed, more seriously ill, and more difficult to treat than they were in the past.

Practically speaking, we see more dual-diagnosis patients, with self-harming behaviour such as cutting or drug abuse frequently going with a serious eating disorder. The nurses who work in inpatient units report more incidents of violent acting out and more cases of absconding. The cases are often ones that I would think of as forensic, with high levels of delinquent behaviour such as stealing, but also fire-setting and other forms of law breaking that involve police intervention. In terms of the severity of the eating disorder itself, my impression is that more patients today require nasogastric tube feeding. I certainly do not think that staff groups fall back on this course of action easily. I think it is an extreme measure, one that raises issues about the rights of the patient, and in my experience the staff also regard it in this way. The staff who work in specialist units are better educated and better trained than in the past, and some of them are very talented, so I do think that the patients are more difficult. It is not easy to account for this change, but it suggests to me that young people who are encountering serious difficulties are more likely today to show symptoms of an eating disorder as at least a part of the clinical picture than they might previously have done. This is a worrying development. It leads me to doubt the effectiveness of the educational initiatives that have been put in place.

 

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