| Contents | Preface | Acknowledgements | Chapter: | 1 | 2 | 3 | 4 | Conclusion | References |
Eating is normal, in that it is a human necessity; having an eating disorder is not. Sours (1980, p. 205) suggests that a form of anorexia was recognised as early as the eleventh century. The meaning attached to various religious practices involving self starvation is obviously contingent upon their historical, social, cultural and personal context. Over time, it is not possible to verify a homogeneity of symptoms and meanings. It is still worth asking questions. Did the Romans occasional use of vomitorium ever lead to the development of bulimia, as current mass binges and collective vomiting amongst college students do in a minority of cases (Hogan, 1992)? Is it possible to look through our 1990s eyes at the Holy women of the thirteenth and fourteenth centuries and try to equate their behaviour with the disease we term anorexia nervosa? There is no current consensus on what the eating disorders are or indeed if they are a valid clinical category at all. There is no consensus on how they are understood or how they should be treated. It is a complicated and confusing matter.
What is certain is that despite the lack of clarity, the numbers of women and men suffering from some type of eating problem continues to increase. This is suggested by the numbers of articles written about bulimia in the last 16 years. In the years from 1977-1986 there were approximately 600 articles written on the topic of bulimia. In the last six years, from 1987-1993, around 1,500 articles have been published in learned journals. A parallel development can be seen in the media coverage of eating disorders. Media definitions of eating disorders have undergone dramatic shifts of emphasis in the last ten years or so. Stories have to be newsworthy, so it was the extreme cases that were reported in the early days, anorexics and bulimics who died of their illnesses. The media presented these individuals behaviours as alien to their readers. Lists of what they ate, either very short or very long, were produced, and explanations of the disorders were given in strictly behavioural terms. They were both described as Slimmers Diseases. Diets that went wrong made some people want to binge. For others, diets that went right prevented them from being able to eat very much at all. The impression was sensationalist, that anorexics and bulimics had no control over what they ate and that their behaviour was outrageous, yet fascinating. They were described as individuals indulging in overt rituals of greed, on the one hand, and denial of need, on the other.
A variety of psychological myths grew up, that anorexia was about not wanting to grow up, whereas bulimia was about wanting to have your cake and eat it, but without putting on weight. There is a strong element of truth in both of these statements and the self-outing of stars such as Jane Fonda, Margaux Hemingway and Bonnie Langford encouraged a more understanding and in-depth portrayal of these disorders. This culminated in the widespread reporting of a speech given by Princess Diana, at the 1993 Eating Disorders Conference in London.
Obesity is rarely a matter for media interest - humour and pornography apart - but anorexia and bulimia are. Womens use and abuse of their bodies is infinitely interesting, and the extreme behaviour of some bulimics and anorexics has meant the picture presented by the media has remained split into two disorders, anorexia and bulimia. Cases of anorexia were reported in the media before cases of bulimia, and the number of books and articles on anorexia still outnumber those on bulimia. Bulimia, is thought to be a relation of anorexia, perhaps a close one, but there is an imagined line between the two which has to be looked at if either or both or these disorders is to be understood.
To locate current understandings of eating disorders it is ideally desirable to try to disentangle the myriad ways of conceptualising and treating these disorders that have grown up over time. The philosophical split into mind and body is present from the seventeenth century onwards, and one way to negotiate a route through the mass of material is to look at approaches that saw anorexia nervosa as a primarily physical disorder as distinct from those that saw it as primarily an emotional or mental disorder. The latter leads to the exploration of the conscious and unconscious meanings of the symptoms, the former to drug and behavioural models of treatment. In the United States and the United Kingdom there is an increasing tendency for hospital regimes to combine approaches, so that there is a psychodynamic component in treatment programmes, whether individual, family or group.
The emergence of a plethora of understandings of bulimia and anorexia means there will not be the room to survey in depth the many different approaches, both physical and emotional. Family therapy has been used to good result, particularly with young anorexics, who have not had the illness for more than three years. Minuchin (1974) and Palazzoli (1978) have successfully pioneered two different family therapy models for working with these patients. Christopher Fairburns (1981, 1982) cognitive-behavioural approach to working with bulimics has also been successful, well documented and influential. The use of drug therapy is a much more contentious issue, as are hospitalisation and force feeding (Wilson et al. 1992). All of these approaches are dealing with the behaviour of the individual, as a member of a family system, or in relation to food. What is not being addressed is the meaning being given to the symptom itself, or to the individuals experience of life. My own approach is psychoanalytic. I have no doubt as to the efficacy, in terms of symptom reduction, or cessation of the approaches mentioned above. They do however focus on the symptom itself, whether from a personal or familial point of view. My interest lies in understanding the symptom in the context of these patients internal and external worlds. I think more than the symptom has to change; it is not just about wanting to get a person to eat, or to stop bingeing, but to understand what it means for them in the intricate and complex interactions of their internal world.
I wish to look at individual psychoanalytic approaches to working with eating disordered patients as they have emerged over time. I shall look at pre-Freudian, Freudian, and post-Freudian ways of understanding anorexia and bulimia. This approach has been elaborated and worked with by many ego psychologists in the United States. Simultaneously some of them have moved from an understanding of the Oedipal origin of these disorders (Greenacre, 1950, 1952; Fraiberg, 1972; Brenner, 1974; Hogan, 1985; Sperling, 1983) to an understanding of their pre-Oedipal origins (Jessner and Abse, 1960; Boris, 1984a, 1984b; Sperling, 1949, 1968; Sours, 1974; Palazzoli, 1978; Sprince, 1984; and Wilson 1992) and often (as Sperlings presence in both lists suggests) an appreciation of understanding different meanings within the same symptom complex. A Kleinian understanding of narcissistic disorders allows the two strands to coexist in a different way and has important implications for technique. The expression of surprisingly consistent technical difficulties which seem inherent in working with this group of patients led me to wonder about the nature of the connection between technique and theory, for example, the technical implications of adopting a deficit model of working with these patients, which tends to be more active and supportive, than a classically analytic one.
The importance of the absence of transitional space and transitional phenomena is noted directly in some clinical papers (Sprince, 1984, 1988) and indirectly in others (Boris 1984a, 1984b, 1988; Rizzuto, 1988, Birksted-Breen 1989). However, there is little theoretical that has been written about eating disorders and transitional phenomena. An exception to this is a paper by Alan Sugarman and Cheryl Kurash (1982), on The Body as a Transitional Object in Bulimia. In the United Kingdom there is little psychoanalytic literature on working with adults with eating disorders. The papers which are written are usually good and based on individual work with one or two patients (Sohn, 1985; Coles, 1988; Sprince 1988, Birksted-Breen, 1989; Maguire, 1989). I wish to add a new angle which does not invalidate other perspectives, but which I hope offers an additional lens through which to perceive a particular aspect of some bulimics behaviour. I wish to explore in detail the idea of the body as a transitional object, but in a very different way from Sugarman and Kurash. I shall also explore other aspects of the bulimic ritual as ways and means of creating, finding or refinding some kind of a transitional experience.
At the same time, I shall try to explore and elucidate the differences and similarities between restrictor anorexics, bulimic anorexics and normal weight bulimics. This sounds a simple task but it is not. Even within the Diagnostic and Statistical Manual III-R, of the American Psychiatric Association (1988) there are glaring ambiguities, and many psychotherapists working with anorexics and bulimics fail to define clearly the group to which they are referring. It does matter. What I shall show is that the symptom of the eating behaviour, whether eating too little, too much or alternating between the two, unifies understanding, but what splits it is the issue of weight - weight in the sense of closeness to death, whether consciously or unconsciously. This is what differentiates a number of normal weight bulimics from anorexics and anorexic bulimics. This may explain why, although the range of psychopathology can be very varied, there are striking similarities in the experience in the transference and countertransference relationship, aswell as clear differences between these groups.
According to an object relations model as understood by Melanie Klein and her followers, knowing something of the different internal worlds of these patients is a prerequisite to understanding the nature of their eating disorders. Before moving into the sphere of the conscious and the unconscious phantasy life of bulimics and anorexics, I shall describe the current diagnostic categories in DSM-III-R to provide a framework of understanding and reference in which to move. To untangle the confusions by which the current categorisations are troubled, I shall give a brief overview of the historical emergence of these disorders and the relationships between them. I shall follow the two strands of the body and the mind, and, where appropriate, the conscious and unconscious understanding of the behaviour up to the present day.
Having surveyed the literature up to date, the primitive and powerful nature of the experience of disturbed eating will, I hope, also explain the interest in the particular problems of technique that come to the fore when treating these patients. I hope to provide a study of how particular theories affect technique, and how others do not. I will also consider how some of the experiences in the transference and countertransference work with these patients has not been delved into sufficiently. I hope to illustrate the common elements which are present and need attention and understanding in working with these individuals. Depending on the psychoanalytic approach of the individual, different ways of working may need to be thought about at different times in the treatment - how to give interpretations and how they are likely to be understood. I shall consider this in the chapter on technique.
Anorexia nervosa was included in The Diagnostic and Statistical Manual of Mental Disorders DSM-I (1952) as a psycho physiological reaction. In DSM-II (1968) it was under special symptoms - feeding disturbances. It was not until 1980 that bulimia was given an entry in the DSM. It joined anorexia, pica and rumination in the newly designated eating disorders section. Prior to this bulimia did not exist as a diagnostic category in its own right. Bulimic symptoms were listed as an occasional accompaniment to anorexia and psychogenic vomiting was a symptom often connected to other neurotic complexes and to psychotic ones (Parry Jones, 1991). As early as Robert Whytt (1767), whose detailed description of an anorexic boy included bingeing, the presence of bingeing, vomiting, diuretic and laxative taking has been visible at times amongst certain anorexics, Ellen West being one example (Binswanger, 1944). The creation of a separate bulimic category in DSM-III (1980) raises questions, both current and historical, about the nature of anorexia, of bulimia and the relationship between the two.
By stating that anorexics can suffer from bulimia, although bulimics cannot suffer from anorexia, the separating factor becomes that of weight. To be classified as anorexic patients have to be 15% below their normal weight. Bulimics do not. It is a defining symptom of anorexia and not of bulimia. Bulimia was recognised when it became apparent that individuals who had not had severe weight problems, who had been neither obese nor anorexic, were exhibiting bulimic symptoms. Little research has been done on this group, and the question of whether bulimia, as defined in DSM-III-R, represents a studiable and distinguishable group is still in dispute. Indeed writers and clinicians such as Sperling (1978), Stangler and Prinz (1980), Wilson (1983), Hilde Bruch (1985) and Wilson et al. (1992), refuse to recognise it is as being a separate syndrome from anorexia. They see bulimia as being part of the anorexic syndrome and so disown, by implication, the existence of normal weight bulimics. Anorexic bulimics are interestingly thought by Wilson to be the hardest group to treat, which implicitly puts his position into doubt. He describes them as the most difficult and refractory anorexic patients (Wilson, 1983, p. 170).
Before moving on to the specifics of DSM-III-R , I would like to describe a bulimic, an anorexic and an anorexic bulimic, as they might present in the consulting room. I am describing an extreme example of each sufferer. These descriptions are based on patients whom I have seen, and whose visual state is very striking. The symptoms described can be found in most self-help books about eating disorders, for example Marilyn Duker and Roger Slades Anorexia Nervosa and Bulimia: How to Help (1988). An anorexic is instantly spottable. She is usually extremely thin. She is starving. Her eyes are often sunken, her face cadaverous. Her facial bones look as though they are trying to break through her stretched and fragile looking skin. Her hands may be red and swollen and look too large for her body. Her gums may be receding and there may be a layer of baby like hair, lanugo, over her face and body. The thinness of her body, of bones lacking adequate lubrication and supporting muscles, makes one wonder whether movement itself is possible. Where can her energy come from and how can the pain be tolerated? Yet she might present herself as being well, as though this state of extreme thiness is not connected to her as a person at all, or if it is, it is a desired, not an unwanted state.
In my experience anorexic bulimics sometimes look a little healthier. This is often an illusion, a result of the swelling of the salivary glands which make the face, cheeks and neck bulge. This is a response to the bodys attempt to take nourishment from the moment food enters the mouth. The food does not remain in the body for long, and the salivary glands become more than usually sensitive to food in the mouth and attempt to get the maximum nourishment they can from this first site of digestion. A bulimic anorexic has a definite presence. There is a sense of having a person in the room, often a very angry, smelly, distrustful person, but a person. The feeling of being non-existent, of the absence, or severe retreat, withdrawal - of the self which is so pronounced an experience with anorexics - is not there with anorexic bulimics, whose unwanted, out of control, unheeded and messy self is forcefully present in the room.
A normal weight bulimic is unnoticeable by physical appearance alone. Some are dressed in a careful and feminine fashion, some in a more male and chaotic manner. Some are smart, some are scruffy. Many are good looking. Some look you in the eye, some do not. There is little to let you know they are bulimic unless they come to the session in the middle of a binge, in which case the feeling of being in a maelstrom is unavoidable. But physically, little is apparent. What might be visible, is tiny broken veins on the cheeks and depending on the severity of the disorder, the presence of calluses (Russell, 1979), grazes, or red marks on the hands, particularly the knuckles and sometimes the fingers. This is due to the action of the teeth against the hand when it is thrust into the mouth to induce vomiting. A normal weight bulimic may have swollen salivary glands, but in a average or above average weight individual this is not necessarily noticeable.
So differences are definitely apparent from the outside in, suggesting, according to a modern Kleinian approach, a difference in the underlying phantasies between the two (Klein, 1920, 1921; Isaacs, 1948). In DSM-III-R (1988) pica and rumination are seen as disconnected childhood disorders, whilst anorexia and bulimia are seen as connected eating disorders which occur during adolescence and early adulthood. Pica, the consumption of non food items is quite separate from anorexia and bulimia. Rumination, the chewing of regugitated food in the mouth is on occasion part of the anorexic or bulimic picture but rarely appears in the literature. Another form of eating disorder which as yet, has not made its way into the psychiatric textbooks is spitting where food is chewed, but not swallowed. It is spat out.
The current diagnostic criteria for anorexia are:
A. Refusal to maintain body weight over a minimal normal weight for age and height, e.g., weight loss leading to maintenance of body weight 15% below that expected; or failure to make expected weight gain during period of growth, leading to body weight 15% below that expected.
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which ones body weight, size, or shape is experienced, e.g., the person claims to feel fat even when emaciated, believes that one area of the body is too fat even when obviously underweight.
D. In females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea). (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration)
Bulimic symptoms of self-induced vomiting, the taking of laxatives and diuretics, are referred to in the general description. They are not diagnostic criteria, since not all anorexics suffer from them, but many do. The point is made that individuals can have both anorexia and bulimia. Other generally observed features of anorexic behaviour are excessive exercising, a wish to feed others, often with elaborate meals and the secret hoarding of food.
Women still make up the majority of anorexics, up to 95%. Anorexia can be fatal, and between 5 and 18% of sufferers die as a result of the illness.
The current diagnostic criteria for bulimia nervosa are:
A. Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time).
B. A feeling of lack of control over eating behaviour during the eating binges.
C. The person regularly engages in either self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain.
D. A minimum average of two binge eating episodes a week for at least three months.
E. Persistent over concern with body shape and weight
Bingeing is not described in the general category of anorexic behaviour, although it is implied. Bulimics are described as generally bingeing on easily consumed, high calorific food: The food is usually gobbled down quite rapidly, with little chewing (ibid., p. 67). Binges come to an end due to discomfort, sleep, interruptions or self-induced vomiting. (In practice this is usually when the available food has run out.) Sometimes vomiting is the desired goal: Although eating binges may be pleasurable, disparaging self-criticism and a depressed mood often follow... Often these people feel that their life is dominated by conflicts about eating (ibid., p. 67). Vomiting is listed as one of the ways is which food is dealt with, suggesting that individuals who binge and then exercise or diet to get rid of it are bulimic. For the purposes of my work I consider bulimics to be those who binge and vomit or take inappropriately large numbers of laxatives. Non-vomiters or laxative takers, I would view as being compulsive eaters or possibly sufferers of SED.
According to DSM-111-R, features which are at times associated with bulimia are drug taking, depression, and borderline personality disorder. It is stated that the usual course of the illness is chronic and intermittent, although the time span of these respective states is not described. Bulimia is not usually incapacitating. It can be if all day is spent bingeing, vomiting and taking laxatives. There are weight fluctuations, but these are rarely so extreme as to threaten life - although what may threaten life are cardiac arrhthymias as a result of an electrolyte imbalance.
The similarities and differences may be seen as falling into four categories: attitudes to eating, body image concerns, actual effects on the body and other psychological and emotional features. Anorexics eat little and fear losing control; bulimics do lose control. Both groups fear putting on weight and becoming fat, although anorexics are already thin. Anorexics have amenorrhea. Bulimics usually do not, although they misuse their bodies by self-induced vomiting or and by taking laxatives and diuretics. Anorexics have a high mortality rate; whereas bulimics are seldom in danger of losing their lives. The issue of life or death is explicitly more relevant for anorexics. Some anorexics suffer from obsessive-compulsive disorder. Bulimics may suffer from depression, addictions or borderline personality disorder, suggesting a greater breadth of psychological disturbance.
Comparing the different pictures of the symptoms described, anorexia and bulimia are not the same illness. A major anomaly is that bulimics, by definition, have to be within a normal weight range, and yet you can be both bulimic and anorexic at the same time, thus disregarding the relevance of one of the symptoms which differentiates between the two disorders. This is the confusion. The obvious answer would seem to be to create three rather than two groups so that the weight distinction can be preserved. Following this line of thought, there would be restrictor anorexics, bulimic anorexics and normal weight bulimics. From now on I shall use the term anorexics to refer to restrictor anorexics, anorexic bulimics or bulimic anorexics to refer to themselves and bulimics to refer to normal weight bulimics. I have decided not to use Marlene Boskind-White and William C. Whites term bulimarexia, first coined by them in 1975 (Boskind-White and White, 1987, pp. 19-20) to refer to bingers and purgers or Russells 1979 term bulimia nervosa. Neither term is used consistently in the literature, and although Boskind-White and White (1987) claim that Russells term is exactly equivalent to theirs, they do not have weight as a defining characteristic, whereas Russell does, and wants to use bulimia nervosa to describe anorexic bulimics, not normal weight bulimics. It is for ease of recognition and clarity that I have decided to use the terms outlined above.
It is clear that bulimics use their bodies in quite a different way from restrictor anorexics (those who do not have symptoms of bingeing and vomiting) and perhaps from anorexic bulimics, and this may reflect different unconscious phantasies, both in general and in particular. I want to look at the emergence of these disorders over time to further elucidate their relationship to each other, how the symptoms have been described and how they have been understood, before moving on to the implications for working psychotherapeutically with these patients.
The most obvious change and one that needs addressing immediately - is that anorexia is a misnomer. Etymologically, anorexia means absence of desire. Anorexia is not about not having an appetite. When Gull (1873) and Lasègue (1873) coined the term, the notion of starvation being undertaken voluntarily was an idea that was simply not considered. Anorexia was, at that time, understood as an illness where the appetite vanished. The desperate awareness and fear of hunger that anorexics experience was not recognised. It was kept secret by the sufferers and was not linked by their carers to the outbreak of bulimic symptoms.
George Gilles de la Tourette (1895) understood the ravenous and terrifying nature of the hunger that his patients experienced, and by the 1940s this denial of hunger was increasingly connected to a fear of becoming fat. The unconscious understanding of the symptomology of anorexia and bulimia, from the late nineteenth century onwards, could certainly be understood in this context. It is but a small step from the wish to be thin to the fear of being fat. Pierre Janet (1929) tells us of a patient of Charcots who wore a rose ribbon around her waist which she would not untie. She was not to get any larger. The fear of becoming fat was seen as the motive for not eating, and not eating was thought of as being a defence against the terror of a gargantuan, destructive and overwhelming appetite. The emphasis on the fear of becoming fat by clinicians has added a vital piece of understanding to the anorexic jigsaw which remains firmly in place with the work of Wilson et al. (1985, 1992).
The term anorexia came to the minds of two men at much the same time. In 1868 William Withey Gull, an English surgeon and Charles Lasègue in France, were - unbeknownst to each other - both working with anorexics. They decided independently on the name of anorexia, after a number of others had been mooted and then discarded. Hysterical anorexia had been put forward by Lasègue but was then dropped when it became clear that not all anorexics had an hysterical character structure. Gull pointed out that hysteria was a diagnosis given only to women at that time, and not all anorexics were female.
The search for normal weight bulimics, according to DSM-III-R immediately runs into trouble but for very different reasons. The etymological route gives a fair description of one half of the bulimic picture but only half. Bulimia comes from the Greek words bous meaning ox and lipos meaning hunger. The historian of psychiatry, Parry-Jones commented:
The Oxford English Dictionary (1961), under the heading bulimy, provides four examples of the use of the term, from 1651 to 1780, with consistent presentation of the condition as a state of insatiability and dog-like appetite (1991, p. 130).
If bulimia is exclusively about ox-like hunger then compulsive eaters should be termed bulimic. In fact historical data on normal weight bulimics, who both binge and get rid of the food, has simply not been found. What is described in reported cases of bulimia, such as those described by Parry Jones (1991), tends to be behaviour which is closer to the psychotic end of the spectrum and is often shocking and exhibitionistic. What may be skewing the picture is the element of secrecy in bulimic behaviour. This is not mentioned in the DSM but is apparent from the presenting descriptions in the consulting room, because bulimic behaviour, excessive overeating and vomiting and/or laxative taking is usually done behind closed doors. Although, in the United States it has been noted as a passing phenomenon amongst groups of college students, the majority of whom do not go on to develop a formal eating disorder (Hogan, 1992). It also occurs in the United Kingdom in a number of private day schools for girls (Felton, 1994).
Historically, we are left with the development of anorexia nervosa as a syndrome which does in practice include a description and understanding of anorexic bulimics - who are very low weight and binge and vomit - although they are not separated out in the literature. Bulimic behaviour, as either part of, or separate from, anorexia has been described by Gull (1873), MacKensie (1888), Osler (1892), Soltman (1894), Abraham (1916), Stunkard, Grace and Woff (1955), Bruch (1962), Thoma (1967), Sperling (1978), Casper, Eckert, Halmi, Goldberg and Davis (1980), Wilson (1982), Wilson et al. (1988), and others. Clear distinctions between the two have not been made.
I shall look at the emergence of anorexia and, whenever possible, at normal weight bulimia (but the scarcity and lack of clarity in the material makes this difficult), and I shall consider four main themes. The first is the gradual emergence of an emotional and psychological mode of understanding anorexic and bulimic symptoms, in preference to a biological and physiological one. Secondly, I shall explore these meanings as understood psychoanalytically, giving particular attention to Freudian, post-Freudian and Kleinian approaches. Thirdly, I wish to explore Winnicotts ideas on transitional phenomena in relation to the body and the behaviour of an individual with bulimic symptoms. Finally, I shall look at the difficulties of working with these patients in the consulting room. I shall suggest that an understanding of Kleinian narcissism and the concept of transitional objects can perhaps point a way forward in the technique used with these individuals which might enable them to take in and digest both the therapeutic atmosphere and interpretations.
The Human Nature Review © Ian Pitchford and Robert M. Young - Last updated: 28 May, 2005 02:29 PM