Distribution
The rate of anorexia in the risk population is 0.5 percent–1 percent of all late adolescent girls and young adult women. The rate of bulimia in the same population is 1 percent to 3 percent.
Both anorexia and bulimia are much more prevalent in rich and industrialized societies with an abundance of food. Developing world immigrants to rich countries may develop the disorder in rates similar to local populations. Furthermore, in rich countries the disorder is more common in higher socioeconomic levels than in lower socioeconomic groups (Hsu, 1990). Research of the difference in distribution across socioeconomic levels was published in the Netherlands in 1998 (Hoek, 1998), indicating that the rate of bulimia is seven times higher in the Netherlands’ urban areas than in its rural areas. Hsu (1990) reports an interesting finding regarding the Arab Emirates: the rate of eating disorders in those emirates was increasing in direct relationship to improvement in quality of life and income level, up to seven times higher. His observations show a kind of social contagion within high school classes or cohorts where a case of anorexia was found – one case leads to additional cases. All those findings indicate the crucial influence of social, cultural and psychological factors on the rates of eating disorders. At the same time, certain genetic risk factors might increase the chances of an eating disorder to emerge. It is known that in families of anorexic or bulimic patients, the frequency of nutrition problems (ranging from obesity to anorexia), or of other mental illnesses is higher (APA, 1994). The genetic factor’s impact on the disorder’s course is yet to be explored, or its contribution, if at all, to the statistically explained variance of these disorders.
Traditionally, the common age for the onset of anorexia or bulimia had been adolescence or early adulthood, with the average onset age being 17. It was very rare to find such disorders before adolescence, or after 40, and some even suggested a bipolar curve of onset in age 14 or 18. However, in recent years it appears that the age range is expanding, as more prepubescent girls are being admitted to both inpatients and outpatient facilities, even at the age of nine or ten. The average onset age for bulimia is slightly older (more inclined toward late adolescence and early young adulthood). This phenomenon is also in line with the fact that at least in 50 percent of bulimia cases, the disorder emerged after the patient has already suffered from anorexia.
The duration of the disease is varied in both disorders. Some patients recover after a short period of time (several months), and some are drawn into the disease for years. Strober (1998) published a prolonged observation of anorexic patients over more than 15 years. He found that after six years of treatment, 65 percent of the patients were fully recovered and none of them relapsed back to the disease; another 12 percent were in partial recovery, and 10 percent of them relapsed; 13 percent were not recovered even after six years of treatment.
History of the Treatment of Anorexia
As early as the late seventeenth century, the medical literature saw a report of a disease matching the description of anorexia (Morton, 1694). Until the early 1930s, at least seven articles were published proposing that anorexia has physical origins and suggesting mineral salts and different kinds of baths as a cure. While Sigmund Freud pointed out the psychic origins of anorexia already in 1895 (Breuer & Freud, 1895; Freud, Bonaparte, Freud, & Kris, 1954), it wasn’t until the 1930s that the psychological origin of the disorder was acknowledged, and psychotherapy increasingly became the central route for treatment.
Psychoanalysis, undoubtedly the leading theory in the field of psychotherapy, has developed from the beginning of the twentieth century and to this day has three distinct models to understand pathology and normality of the human psyche. Like in any other science, each new psychoanalytic model encompasses its predecessors. Scholars and therapists treating anorexia (bulimia was defined as a distinctive syndrome only since the 1980s) were using the “lenses” and the “map” provided by the dominant model of the time. Thus, since the 1930s to early 1950s, scholars and professionals treating anorexia observed the disorder through the prism of the drive-defense model. According to this model, underlying the psychic life is a conflict between sexual and aggressive drives and a strict “super ego.” The “ego” exercises defense mechanisms to mediate between them. This model is effective in neurotic patients since their psychic structures are in order. However, anorexic patients do not appear to be driven by strong impulses. Sexuality seems to be the last thing on their mind. On the contrary, they seem to have annihilated drives. But since the therapists of the time had only the lenses and concepts of the drive-defense model, these concepts were applied to anorexia. Moulton (1942) and Waller, Kaufman, and Deutsch (1940) proposed that self-starvation is a defense from fantasies of oral impregnation. Masserman (1941) suggested that the pervasive refusal to eat is a defense from sadistic-cannibalistic oral fantasies. This model did not make a significant contribution to the treatment of anorexia both because of its theoretical presumptions and its interpretative and confrontative technique that was ill-fitted to treating these girls.
The drive-defense model contends that the tension between the sexual and aggressive drives on the one hand, and the strict super ego on the other hand, generates the neurotic symptoms. But the model fails to account for a major part of the anorexic and bulimic symptoms. The distorted body perception, the alienation from internal feelings and the paralyzing fear of self-realization indicate a more severe damage to the psychic structure than a conflict between structured psychic systems. As mentioned earlier, in many cases anorexic and bulimic patients exhibit avoidance of sexuality. But it ensues not out of fear or guilt because of the Oedipal complex, but the fear of growing up. Growing up means abandoning the girl’s position of special attunement to her parents, which we’ll later explore in detail. In the sixth chapter, we’ll see the case of an anorexic girl who was disappointed and discouraged by her father’s reaction to her growing up. She felt he was hoping for her to stay slim, small and angel-like and that her signs of sexual development made him sad because he did not want them to grow apart. He used a Hebrew expression that literally makes a comment about the size of her bottom, which both points out the sexual markers and disapproves of her exhibiting her presence, both physically and behaviorally. Whereas the neurotic patient feels guilty about the pleasure she derives from satisfying wishes she deems forbidden, the anorexic or bulimic patient feels guilty about feeling any form of pleasure. This is because of her inability to attend to herself, to care for herself and satisfy her own needs, characteristics which we’ll further elaborate in the next chapters. In the advanced phases of the treatment, after a stronger self is built, the patient may exhibit sexual preoccupations with Oedipal tones. At this point, the treatment would resemble a classic treatment of neurosis. Such early signs of Oedipal elements in the advanced phases of treatment can be found in Chapters 16 and 17.
The object-relations model is the next layer in the development of psychoanalysis. This model is concerned with the modes of attachment between individuals. It contains the first model since a large part of such human attachment is about sexual and aggressive drives. But apart from the psychosexual developmental axis, Mahler (1968) has outlined an additional developmental axis based on her observations. The steps along this axis were not the stages of the psychosexual development, but stages of the psychological development allowing a child to gradually separate herself from her mother. Scholars and practitioners who used the object-relations model to treat anorexia – Masterson (1995); Sours (1980); Selvini-Palazzoli (1985) – described the strains of separation of the anorexic patients. The difficulties of separation according to this model are reflected in the anorexic patient in severe disgust of her mother’s figure. To avoid resembling her mother, for instance in her femininity, the anorexic girl mutilates her own body. By that she symbolically annihilates the internalized mother figure. The treatment technique in this model, like its preceding model, is interpretation that often acquires a confrontational tone. Interpretations and confrontations are adequate for treating an unsolved conflict better than for filling in and repairing deficiencies in the self. Goodsitt (1997), a self psychology scholar and practitioner, points out that neither in the case studies of the previously cited scholars nor in his own cases could he find evidence for confusion of the anorexic patient’s self-perception and the figure of her mother; and particularly not that such confusion is intermediated by oral fantasies.
The difficulty of the anorexic or bulimic patient to separate is only a part of the broader explanation provided by self psychology. Self psychology discusses not only the difficulty of separation, but also the difficulty of individuation, namely, reluctance to develop an independent individuum that is an independent center of initiative and promote its own interests.
Self psychology is the third layer of psychoanalysis. Kohut (1971) described an additional developmental axis: the narcissistic axis. Along this axis, narcissistically relying on others is not one single developmental stage from which the mature individual grows up and totally abandons this stage like in the object-relations axis. Kohut’s theory legitimizes this human need all through one’s life. The healthy development along this axis is moving from a total and desperate reliance on others to a flexible and mature reliance.
An optimal fostering environment allows the baby or the toddler an appropriate narcissistic reliance. This is reliance where the person on whom one relies is willing to give up his or her needs and viewpoint and act from the relying person’s perspective. By this he or she acts as a selfobject, a term we’ll discuss in detail in the next chapter. In such conditions, the child develops a strong and healthy self who is capable of exercising from within the soothing and regulation mechanism previously exercised from without, by the selfobject. This process advances while fluctuating between empathic-enough environment to optimal empathic failures. A girl developing an eating disorder does not believe she can rely on other people to fulfill her selfobject needs. Throughout her growing up years, a role reversal is taking place between parent and child: the parent is the one to narcissistically rely on the child rather than the other way around. When the parent thus relies on the child, namely, expects the child to attend to the parent and fulfills the parent’s needs (for example, needs of soothing, consolation and regulation of depressive feelings), rather than to act as having interests and perspective of her own, the child might feel as if she has no right to live her own life, and in this sense she is selfless, lacking a self. Such children, who devote themselves to the prosperity of their parents while negating their own internal needs and who do not believe that another person can fulfill their selfobject needs, tend to develop eating disorders (Goodsitt, 1985, 1997). When a girl feels selfless, she experiences self-guilt whenever she attempts to act for her own sake, since her role, as she perceives it, is to attend to her parents and fulfill their needs. Later on, in the transference process well-known in psychology, she would feel obliged to fulfill the needs of other significant people in her life. The reason for this is that independent thinking and feeling are experienced as betrayal of the person whose selfobject needs she must fulfill. She feels self-guilt about occupying a psychological space in the world, namely, self-expression, presence, will and opinion. She experiences all these as immoral, destructive and harmful to others. This self-guilt also accounts for her will not to occupy a physical space in the world, therefore not to eat. Eating means providing for the self and attending to internal sources of need, as opposed to attending to external duties (Goodsitt, 1985). Eating also reflects acknowledgment of her right to consider her own interests and prioritize herself over others. Eating thus becomes a selfish act for the anorexic or bulimic girl. The bulimic patient will purge what she ate because she experiences the binge as an indecent act of self-indulgence. The anorexic patient perceives eating itself as an unjustified act that expresses self-indulgence, betraying the role of serving as a selfobject for others.
These central characteristics of the eating-disordered patient, namely, self-guilt and self-deprecation, also generate what psychoanalytic literature terms “negative therapeutic reaction.” Recovery would lead to self-advancement and a sense of psychic presence, which as mentioned earlier she perceives as betrayal and as inappropriate stance.
The picture depicted of the anorexic or bulimic girl is a picture of a deficit in the sense of self. Only self psychology, which conceptualizes such deficit of the self, can explain feelings of lack of self-initiative, self-alienation, lack of enthusiasm and lack of vitality.
The self psychologically oriented therapist exercises a special therapeutic stance that emphasizes attunement to the needs of the self. In the next chapter, we’ll elaborate how the self psychology therapist revives in this manner the patient’s depleted and undeveloped self. T...
