9 Slices
Medium 9781855753839

CHAPTER TWO

Marilyn Lawrence Karnac Books ePub

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.

See All Chapters
Medium 9781855753839

CHAPTER SIX

Marilyn Lawrence Karnac Books ePub

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.

See All Chapters
Medium 9781855753839

CHAPTER EIGHT

Marilyn Lawrence Karnac Books ePub

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.

See All Chapters
Medium 9781855753839

CHAPTER SEVEN

Marilyn Lawrence Karnac Books ePub

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.

See All Chapters
Medium 9781855753839

CHAPTER FOUR

Marilyn Lawrence Karnac Books ePub

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.

See All Chapters

See All Slices