Anorexia nervosa is known to be a life threatening illness that is most prevalent in industrialized societies (American Psychiatric Association, 2000). Anorexia nervosa’s prevalence in industrialized society is estimated to be at .5% among women and one tenth of that .5% among men (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed.) text revision, 2000). This may not be an accurate account of the prevalence given the secretive nature of individuals with this disorder; in addition, many individuals engage in subclinical forms of anorexia that may not meet the criteria for anorexia nervosa, but that may resemble similar patterns of behavior. According to the American Psychiatric Asssociation, anorexia is most likely to begin between the ages of 13 and 18 years old; however, indications suggest that anorexia nervosa is showing an increased prevalence for beginning later in life as well (Woodside, & Garfinkel, 1992).
From medical perspective, anorexia nervosa is an eating disorder that is diagnosed by assessing that an individual is unable to maintain her or his weight above 85 percent of what is expected for height and weight (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed.) text revision, 2000). In addition, anorexia nervosa is defined as an eating disorder when the individual presents with an extreme fear of gaining weight even when the individual is below a healthy weight, a severe distortion of body image, an unwillingness to acknowledge the severity of the problem, and an intense focus on the body as a measure of self-worth. Finally, if an individual presents with the symptoms identified previously along with amenorrhea that occurs for more than three menstrual cycles and no other medical condition is causing the cessation of the menses, then she may be diagnosed with anorexia nervosa. In males, reproductive abnormalities may occur as a result of the weight loss as well (Andersen, 1999). Anorexia nervosa may be identified as either “restricting type” or “binge eating/purging type”. The restrictive anorexic does not engage in binge and purge behaviors where as the binging and purging type does engage in those behaviors in addition to meeting the criteria for the overall diagnosis of anorexia nervosa.
The earliest mention of anorexia nervosa occurred in the 1600’s, “Richard Morton (1689), a 17th Century English physician is credited with the earliest report in the medical literature with the publication in London of his Treatise of Consumption” (as cited in Chassler, 1994, p. 400). Chassler indicated that Morton referred to the illness using the word “wasted” when referring to a 17-year-old girl who did not present with signs of a medical illness other than lack of appetite, poor digestion, and fainting spells (p. 400). Through the ages, particularly the 13th through the 17th Centuries, self-starvation was associated with asceticism and was justified “in the name of sanctity” (Bemporad, 1996, p. 222). Bemporad suggests further that, “Indeed many such women were elevated to sainthood, receiving an official stamp of approval by the powerful church” (p. 222).
In the latter part of the 20th Century and the early part of the 21st Century, anorexia nervosa is understood to be the result of multiple factors. Both the media and western culture’s obsession with thinness play a part in the widespread development of this disorder across class, race, and culture (Bemporad, 1996). Anorexia has also been understood to result from dysfunctional dynamics in family systems. Selvini Palazzoli (1974) offered an in-depth exploration for involving and working through dynamics in the family system. The transmission of eating disorders from the mother or father to the daughter or son has become increasingly common (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed.) text revision, 2000). Personality characteristics such as a desire for perfectionism often coexist with anorexia nervosa, sometimes to the degree that an individual with anorexia nervosa may be diagnosed with obsessive-compulsive disorder (as cited in Mussell, Mitchell, & Binford, 2001).
Girls in western culture are encouraged to be thin and are viewed more positively by others if they engage in weight loss behaviors. Mussell, Mitchell, and Binford (2001) suggested that, “Those who achieve an unusually thin physique often receive praise for their beauty and self-control” (p. 9). This attitude and the negative messages that primarily girls and women, and less commonly boys and men, are bombarded with daily promote an environment that is conducive to eating disordered behavior. These factors, matched with an individual who is psychologically vulnerable because of an impaired capacity to manage stimulation and a damaged ability to regulate emotions within relational contexts, set the ground for the development of anorexia nervosa. The primitive nature of this disorder contributes to the difficulties that clinicians encounter when treating individuals with anorexia nervosa.
Anorexia nervosa presents many dangers for those who are diagnosed with this disorder. Physiologically, the disorder is life threatening. Currently the mortality rate for anorexia nervosa is suggested to be very high; it has been identified as the psychiatric disorder most likely resulting in death of young women (Birmingham, et. al., 2005). Many individuals with this disorder do not recover from this illness and many who do recover from anorexia nervosa go on to engage in other eating disordered behaviors (Crisp, et. al., 2006). Individuals with anorexia nervosa are at high risk to commit suicide even if they have recovered from the illness (Crisp, et. al., 2006). Deaths related to anorexia nervosa are underreported because they are often defined as suicide or malnutrition without acknowledgement of the presence of anorexia nervosa, making it difficult to clearly determine how common death occurs from this disorder (Crisp, et. al., 2004). Individuals with anorexia may die from an electrolyte imbalance as well as cardiac malfunctioning.
For individuals who engage in anorexic behavior and live with the disorder, many dangers exist in terms of chronic medical conditions. The lack of proper nourishment affects brain functioning, maintenance of healthy bone structure, reproductive system, circulation, heart functioning, metabolic functioning, and many other physiological responses. These problems are not always reversible with recovery; some of these issues last for an individual’s lifetime and may contribute to a shortened lifespan. In addition, to the physical dangers, the psychological components of this disorder contribute to difficulties with day-to-day, normal functioning. Anorexia nervosa may interfere with interpersonal relationships, career pursuits, and basic experiences of the self. Many individuals with anorexia nervosa suffer from low self-esteem and little sense of self at all, poor capacity to communicate effectively with others, and difficulty sensing internal experience because the focus is geared toward external stimulation (Skarderud, 2007).
To date, little empirically based research has been conducted on the benefits of particular treatments for anorexia nervosa (as cited by Skarderud, 2007). Some studies have been conducted to assess the effectiveness of cognitive techniques; these studies have not clearly demonstrated the benefits of cognitive therapy for the treatment of anorexia nervosa (Woolrich, Cooper, & Turner, 2006). Psychodynamic approaches are also currently being used to treat anorexia nervosa (Tobin, & Johnson, 1991). These approaches include object relational, self psychology, and interpersonal styles of therapy. The basis for most of these treatments is to assist the individual with anorexia to repair developmental deficits that originated in the early parental bonding and to repair the early misattunements through the use of metacommunications in the relational aspects of the therapeutic relationship (Tobin, & Johnson, 1991). These approaches work to address the underlying issues that may be contributing to the problems with anorexia through an experiential process within the reparative relationship of the transference (Stern, 1991).
Skarderud (2007) has introduced a form of individual therapy that seems to communicate more directly with the client’s unconscious experience than the use of metacommunications. The approach is called “mentalising”. The primary purpose of this modality is to encourage the client to put thoughts, feelings, and impulses into words in order to create meaning of personal and interpersonal experiences. The main idea in this treatment approach is that the individual with anorexia lacks the capacity to engage in symbolic expression and views her or his experiences through a concrete thinking capacity. While the individual may be intellectually intelligent, the underdeveloped capacity to mentalise experiences interferes with sensing one’s internal self, interpreting others’ communications, and tolerating a wide range of emotional expressions. The concrete approach to functioning is used as a protective mechanism to maintain a fragile self character structure. This approach addresses the preoedipal nature of anorexia by suggesting that an individual with anorexia nervosa develop the capacity to tolerate symbolic thinking and the ability to interpret internal and external experiences. The problem with this approach is that it may lack the depth of emotional communication that may be needed to work through the recalcitrant nature of the resistances associated with anorexia nervosa.
Family therapy has also been a common form of treatment for anorexia nervosa, pioneered initially by Selvini Palazzoli (1974). Selvini Palazzoli worked with families to assist the parents and the client to repair disruptions in the separation/individuation process by encouraging families to communicate more openly regarding the system’s dysfunctional dynamics. Minuchin (1978) also worked with families who had an anorexic family member utilizing his structural approach to reorganize family boundaries, roles, and power distribution. He viewed anorexic families as “psychosomatic families” who are characterized by high levels of enmeshment, poor boundaries regarding invasion of privacy, and difficulties tolerating conflict.
Family therapy has been a useful form of treatment particularly for anorexia nervosa that is identified as early onset (prior to age 19) and less chronic (Eisler, et. al., 1997). Family therapy is recommended for individuals who are currently still living in the home with the family. Including families in the process rather than only working with the individual may be critical to repairing the disruptions that have led a client to engage in anorexic behaviors. From a family system’s perspective, it may be difficult for one family member to change, especially in the case of anorexia since the disorder is deeply intertwined in the family dynamics, without all members shifting to some degree in order to support the client’s changes. The anorexia nervosa may be an expression of unspoken dysfunction within the family system and may require some element of family therapy to support the client’s ability to sustain the changes. In the case of anorexia nervosa, individual therapy, in conjunction with family therapy, may be an optimal approach.
REFERENCES
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed.) text revision. Washington, DC
Andersen, A. E. (1999). Males with eating disorders: Medical considerations. In P. S. Mehler
& A. E. Andersen (Eds.), Eating disorders: A guide to medical care and
complications (pp. 214-226). Baltimore: Johns Hopkins University Press
Bemporad, J. R. (1996). Self-starvation through the ages: Reflection on the pre-history of
anorexia nervosa. International Journal of Eating Disorders, 19(3), 217-237
Chassler, L. (1994). “In hunger I am king”- Understanding anorexia nervosa from a
psychoanalytic perspective: Theoretical and clinical implications. Clinical Social
Work Journal, 22(4), 397-415.
Crisp, A., & Contributors (2006). Death, survival., and recovery in anorexia nervosa: A 35
year study. European Eating Disorders Review, 14(3), 168-175
Eisler, I., Dare, C., Russell, G. F., Szmukler, G., le Grange, D., & Dodge, E. (1997). Family
and individual therapy in anorexia nervosa: A five year follow up.
Archives of General Psychiatry, 54(11), 1025-1030
Mussell, M. P., Mitchell, J. E., & Binford, R. B. (2001). Anorexia nervosa. In J. E. Mitchell
(Ed.), The outpatient treatment of eating disorders: A guide for therapists, dietitians,
and physicians (pp. 5- 25). Minneapolis: University of Minnesota Press
Skarderud, F. (2007). Eating one’s words: Part III mentalisation-based psychotherapy for
anorexia nervosa – an outline for a treatment and training manual. European
Eating Disorder Review, 15, 323-339.
Stern, S. (1991). Managing opposing currents: An interpersonal psychoanalytic technique for
the treatment of eating disorders. In C. L. Johnson (Ed.), Psychodynamic treatment of
anorexia nervosa and bulimia (pp. 86-109). New York: The Guilford Press.
Tobin, D. L., & Johnson, C. L. (1991). The integration of psychodynamic and behavior
therapy in the treatment of eating disorders: Clinical issues versus theoretical
mystique. In C. L. Johnson (Ed.), Psychodynamic treatment of anorexia nervosa and bulimia (pp. 374-398). New York: The Guilford Press
Woodside, D. B., & Garfinkel, P. E. (1992). Age of onset in eating disorders. International
Journal of Eating Disorders, 12(1), 73-81.
Woolrich, R. A., Cooper, M. J., & Turner, H. M. (2006). A preliminary study of negative
self-beliefs in anorexia nervosa: A detailed exploration of their content, origins, and
functional links to “not eating enough” and other characteristic behaviors. Cognitive
Therapy Research, 30, 735-748.
