ArticlePDF Available

Looking for the origins of anorexia nervosa in adolescence - A new treatment approach

Authors:
  • private practice

Abstract

Anorexia nervosa is an eating disorder, which affects particularly adolescents. The media coverage of feminine thinness is demonstrated as a token of beauty, with diet as a tool to achieve this. However, diets are not enough to explain the numerous cases. This disease is the symptom of a psychological disorder and looking for the origin must coincide with psychotherapeutic treatment. Multifactorial explanations seem dominate within our female patients. For most female patients, family problems and past experience with sexual assault explain this transition to anorexia. It is demonstrated throughout this paper how and why anorexia nervosa is used as a tool for identification and personalization in the assumption of autonomy and independence, and how and why anorexia becomes a defensive response to aggression. We give a clinical confirmation of the diverse origins of anorexia nervosa and of the impact of sexual abuse. This paper proposes a new therapeutic approach to patients with anorexia nervosa, in which the eating disorder is a symptom of an emotional disorder, often triggered by sexual assault or emotional deprivation.
1
Looking for the Origins of Anorexia Nervosa in Adolescence.
- A New Treatment Approach
Dr S. Matt Lacoste
Psychologist in Private Practice
Dr.matt.lacoste@gmail.com
Keywords: Anorexia nervosa; Family; Sexual assault; Psychological treatment; Cases
Study.
2
Looking for the origins of anorexia nervosa in adolescence.
- A new treatment approach -
Abstract:
Anorexia nervosa is an eating disorder, which affects particularly adolescents. The
media coverage of feminine thinness is demonstrated as a token of beauty, with diet as a tool
to achieve this. However, diets are not enough to explain the numerous cases. This disease is
the symptom of a psychological disorder and looking for the origin must coincide with
psychotherapeutic treatment. Multifactorial explanations seem dominate within our female
patients. For most female patients, family problems and past experience with sexual assault
explain this transition to anorexia. It is demonstrated throughout this paper how and why
anorexia nervosa is used as a tool for identification and personalization in the assumption of
autonomy and independence, and how and why anorexia becomes a defensive response to
aggression. We give a clinical confirmation of the diverse origins of anorexia nervosa and of
the impact of sexual abuse. This paper proposes a new therapeutic approach to patients with
anorexia nervosa, in which the eating disorder is a symptom of an emotional disorder, often
triggered by sexual assault or emotional deprivation.
Keywords: Anorexia nervosa; Family; Sexual assault; Psychological treatment; Case
Study.
3
Looking for the origins of anorexia nervosa in adolescence.
- A new treatment approach -
Introduction:
Anorexia Nervosa is an “eating disorder with more or less systematized refusal to eat,
acting as a reply form to psychic conflicts (Larousse Dictionary of Psychology, 2000).
People with anorexia nervosa (90% are women) have a distorted body image that causes
them to see themselves as overweight even if they are dangerously thin. In their lifetime
1
0.5% to 3.7% of females suffer from anorexia nervosa. It is the third most common chronic
illness among adolescents
2
after obesity and asthma. Populations most deeply impacted by
anorexia nervosa include women in the age ranges 13-14 years old and the 18-20 years old.
Studies continue to support this research, noting that 95% of those who have eating disorders
are between ages of 12 and 25
3
. Anorexia nervosa is a full disease which impact around
1.5% of French women of 15 to 35 years old. Additionally in the United States of America,
studies estimate that 1% of adolescents and 0.5 to 3.7% of women suffer from anorexia
nervosa.
While women of all social classes are impacted from anorexia nervosa, it can be
noted that matriarchal families seem to be over represented (Marcelli & Braconnier, 2004).
These subjects tend to deny that their eating behavior is problematic and we estimate that
only one third of these people have received a treatment. Of these 30%, the percentage of
people recovered completely is low (Herzog; Nussbaum & Marmor, 1996). Four years after
the anorexic period we count 44% of patients with good recovery, but seven and half years
1
National Institute of Mental Health (1994).
2
Public Health Service’s Office in Women’s Health – Eating Disorders information Sheet (2000).
3
Substance Abuse and Mental Health Services Administration US Department of Health and Human
Services.
4
after, this number decreases to 33% (Herzog et al., 1999). A majority of studies find that
only 11% to 40% find recovery and 1 out of 2 anorexia nervosa subjects relapse.
In accordance with Botha’s observations (2012), traditional understandings and
approaches to diagnosis and treatment for anorexia nervosa seem to be unacceptable,
inappropriate and laden with social stigmatism. Societal stigma exacerbates these patients’
struggles, leaving them dishonored, disabled, powerless and possibly in a place of greater
distress.
These factors in mind, as psychologist who treats anorexia nervosa subjects, there are
many questions that elevate in regards to recovery, treatment, and long-term success for
these individuals. The family problematic and sexual abuse seem to be the mains origins of
the beginning of anorexia nervosa. The main idea is to understand the link between the
origin(s) of the disorder and its implementation. In this way, a therapeutic strategy appears.
Understanding the inner thoughts of these individuals is essential in understanding
why the recovery for this population is so challenging and why treatments are mostly
ineffective. With a bottom-up clinical analysis of four patient therapies, throughout this
paper we hope to answer to these questions.
Literature Review:
1- Adolescence and family: A family issue as anorexia nervosa origin.
Anorexia Nervosa and Bulimia are linked to multiples factors usually associated with
psychological, family, social and biological influences. These items intertwine and impact
each over, contributing to the initiation, the maintenance and to the exacerbation of eating
disorders (Rogé & Chabrol, 2007). Coinciding with this notion, Fairburn and Harrison
(2003) found a combination of genetic variables implicated anorexia nervosa development in
5
conjunction with environmental implications. Friends and family circle are connected to the
disorder de facto, by the causes, by the consequences or both. We could find three times
more anorexia nervosa subjects in the families whose parents have a history of this disorder
(Strober, Morrel, Burroughs, Salkin & Jacobs, 1985). This could confirm the genetic
dimension of eating disorders displaying during the 1990s’ (Bulik & al., 2000; Grice & al.,
2002). But, the heritability of liability to eating disorders as Bulimia nervosa is difficult to
prove (Fairburn, Cowen & Harrison, 1999). For Collier and Treasure (2004, p. 365),
“Increasingly, the consensus is that eating disorders are complex disorders consisting of both
genetic and social factors, with a developmental component strongly linked to adult illness”.
Even if it seems difficult to define a psychological profile of anorexic adolescents’
parents, studies show that anorexia nervosa is more common with distant parents who would
be inclined to neglect their child, to not show affection, and when communication with
children is volatile. Conversely, it is also found within families with overprotective parents
who would be possessive, pervasive and they encourage excessively the family cohesion.
These parents’ behaviors are typical of the parents of anorexic child. “Many authors
(Brusset, 1998; Jeammet, 1993) focus on failures in primary identification process
mother/daughter marked with a dependency where the ambivalence dominates. The nature of
the primary links would explain the frequent narcissistic breaches in these patients, and
breaches are responsible of wrong perceptions of self-image and of body” (Marcelli &
Braconnier, 2004, p. 153).
Shoebridge and Gowers (2000) found that the mothers of anorexia nervosa subjects
reported higher rates of near-exclusive child care, severe distress at first regular separation
and high maternal trait anxiety levels than the mothers of control subjects. They also showed
that families with anorexia nervosa case, had experienced a severe obstetric loss prior to
6
their daughter’s birth. This could confirm that overprotecting parents or high concern
parenting in infancy could be associated with the later development of anorexia nervosa.
If the earlier mother’s behaviors would have a negative impact on the adolescents’
eating behaviors, anorexia nervosa could be considered as bodily intersubjective. The eating
behavior and transformation of the subject’s body play a role in the family relationship.
Anorexia nervosa affects not only the subject’s relation to food but also her relation to others
(Legrand & Briend, 2015) and especially to her parents. The anorexia nervosa subject would
use as a tool her eating disorder and bodily shape to address others, to manifest her distress
or her desire, to put the others, and specially the parents, in a position to answer or to do
something for her distress (Legrand & Briend, 2015). The study of Rothschild-Yakar et al.
(2010) indicated that anorexia nervosa type patients presented significantly lower
mentalization levels and lower quality of current relationships with their parents compared
with non-eating disorder controls. When the verbal dialog seems to be difficult, the
adolescent would choose another communication tool. Additionally, the adolescent could
also try to take power from her parents by her eating behavior. Indeed, anorexia nervosa
subjects are obviously facing with paradoxical behaviors and thinking. The adolescent who
searches for more autonomy, claims with conflict more independence, addresses to her
parents to be taken care of by her eating disorder.
If sometimes, adolescents use anorexia nervosa to say something because it’s too
hard to use words, the therapy is the time to speak about their distress. Several researches
found a link between sexual abuse or rape and anorexia nervosa.
2- Anorexia nervosa and sexual abuse.
7
Even if it is always difficult to have accurate measure of sexual abuse rates, as
confirm Fallon, Collin-Vezina, King, and Joh-Carnella (2017) international trends from
recent meta-analysis has shown alarming rates of sexual abuse cases with 18 to 20 % for
females (Pereda, Guilera, Forns & Gomez-Benito, 2009). Additionally, we know that 70 to
75 % of child victims wait 5 years or more to report before disclosing the abuse (Hébert,
Tourigny, Cyr, McDuff & Joly, 2009). The interaction of different factors, with some can be
unconscious and difficult to identify, are generally at the origin of anorexia nervosa. Even if
it is sometimes possible to isolate a trigger event (e.g. injuring comment on physical
appearance, fight with parents, divorce of parents, romantic break-up); it is typically one
event too many more rather than an isolated explanation. By contrast, it would seem that
sexual assaults can be the (main) explanatory trigger of anorexia nervosa. Even if some
researches try to argue the link between sexual abuse and eating disorders (e.g. Smolak &
Murnen, 2002), several studies confirm the results in our patients in private practice. Favaro,
Tenconi and Santonastaso (2010) show that physical or sexual abuse of children result
significantly in anorexia nervosa during adolescence. Deep, Lilenfeld, Plotnicov, Pollice
and, Kaye (1999) found that 27% of anorexia nervosa subjects had antecedent of sexual
abuse compared to a rate of 7% in control women subjects and it could be more important
for bulimia nervosa patients (Casper & Lyubomirsky, 1997). According to the Center of
Disease Control and Prevention (2007), 1 in 4 of young people experienced verbal, physical
emotional or sexual abuse from a dating partner; 8% have been forced to have sexual
intercourse when they did not want and nearly 10% were hit, slapped or physically hurt by a
boyfriend or girlfriend within the 12 months prior taking the survey
4
. Sexual abuse has been
reported to occur in 30% to 65% of women with eating disorder compared to 10% to 30% in
rates of sexual abuse in the general population (Zerbe, 1992; Connors & Morse, 1993; Deep
4
CDCP Youth Risk Behavior Survey (2007)
8
& al., 1999; Daigneault, Collin-Vézina, Hébert, 2012). Faravelli; Giugni; Salvatori and
Ricca (2004) shown that 53% of rape victims reported current eating disorders symptoms
compared to 6% of control subjects. Thompson and Wonderlich (2004) found the same
results. Fischer, Stojek and Hartzell (2010, p.192) specify that a childhood emotional abuse
can be a predictor of current disorders symptoms. They explain this result by the hypothesis
“that an emotionally abusive environment does not teach adaptive emotion regulation skills,
and that the use of maladaptive emotion regulation skills results in eating disorders
symptoms”. The eating disorder can be a strategy of avoidance or regulation of emotion.
Lejonclou, Nilsson and Holmqvist (2014) confirm that for several traumas, the eating
disorders subjects had experienced a significantly larger number of potentially traumatizing
events, and they specify that the number of adverse childhood experiences and repeated
traumas were associated with eating disorders for adolescents and young women. All kind of
child sexual abuse is a traumatic experience and one of the major risk factor in the
development of mental health problems affecting both the current and future of victims
(Collin-Vézina, Daigneault & Hébert, 2013).
Lyubomirsky, Sousa and Casper (2001) specify that some personality traits like
dissociation can mediated the relationships between abnormal eating and sexual abuse. The
women with functional coping could avoid binge eating even in case of sexual abuse,
inversely the dissociation associated to others negative affects lead to the most important
eating disorders.
In our non-exhaustive literature review, family and sexual abuse seem to be two
important origins of a disordered eating behavior and can be associated in the development
of the disorder. What about our patients? Do they confirm these explanations? And how we
can clinically explain these processes?
9
Method:
This article draws a new approach in the anorexia nervosa treatment and in patient
monitoring. Through a case study, the main goal of this paper is to wonder about the origin
of anorexia nervosa as well as the adolescence specificity linked to this eating disorders.
This paper mainly use 4 outpatient cases that were treated with success in our private
practice as clinical psychologist. We have selected these cases to cover different ages and
histories of the anorexia nervosa, and because these women explained with their own words
how and why the anorexia nervosa became for them an answer, a coping strategy. They also
well represented the majority (67%) of our patients.
Mrs. C. (48 years old) suffered with anorexic eating behavior since childhood. Raped
at 22 years old, this assault intensified or escalated the eating disorders. The therapy will
reveal parents’ sexual and emotional abuse since a young age. Now, she’s married, mother,
and she’s a female entrepreneur who put a lot of time and energy in her job.
Ms. E. (25 years old) was in her 4th year of graduate studies but struggling a burn-out
about her studies. The anorexia nervosa began 7 years before, she was an inpatient facility to
address this crisis and her endangered health. The numerous inpatient weeks did not give
satisfactory outcomes. The relapses were systematic. She came the first time with her mother
who spoke more than Ms. E. about her health and about the importance of her studies and
graduation in 16 months.
Ms. D. is 17 years old, bright teenager with good results at school. She was living
with the anorexia nervosa for almost two years. She has an older sister (24 years old) who is
married and recent mother of triplets. Ms. D.’s parents consider her older sister to be a role
10
model and often compare them. Ms. D. lived with her parents. They were overprotective but
since the triplets were born, they only focused on the “new babies.
Ms. S. (16 years old) develops an anorexia nervosa 2 years ago. Ms. S. has to
regularly help her mother to prepare family meals. During the psychotherapy, Ms. S. will
reveal she was raped at 14 years old by one of her classmates, who is also a neighbor.
Data Analysis and Discussion:
We introduce a case study of four female patients voluntarily engaged in a
therapeutic process. The therapeutic monitoring was organized with one or two weekly
therapeutic consultation outpatient sessions. The patients were fully with the disease or in the
latter stages of recovery, and their comments collected will be confronted with our literature
review and discussed.
1- Adolescence and family in our cases.
This is a fact that cultural and media pressures to be thin contribute particularly to
increase the number of eating disorders subjects (Fallon, Katzman & Wooley, 1994). This
explanation is confirmed by Ms. E. (25 yrs.) when she explains I felt round, I was 117
pounds for 5.2 feet, so I went on a diet and gradually I could not swallow anything and I fell
to 81.5 pounds”. But going further in our conversations, the family issue came to emerge in
the explanation of the disorder origin: When I eat, I feel fat and guilty because it costs
money to my parents. […] Today I’m desperately ill, I do not want to fight anymore. I have
enough of life especially when I see that I hurt my parents”. A normal diet is often a mask
developed by the person to hide from the others (and from oneself sometimes) the anorexia
11
nervosa process which is going on. Anorexia nervosa is addressed to others, inviting or
rejecting them. Ms. E. seems to manifest an alimentary communication by stripping food
from its nutritional matter in order to make it of an element of language, Ms. E. would
materialize her hunger in her body which is transformed to address it to her parents (Legrand
& Taramasco, 2016). These authors explain that the subject eat, she eat nothing. This
“nothing” she eats has not gotten a nutritional value but a symbolic one. The food or the
meal is a communication system, and in this way anorexia nervosa is a food communication.
When she eats nothing, the anorexic subject removes the nutritious matter of food to keep
the language part only.
Conflicts are numerous during adolescence, they come from parents, family, friends,
loves, teachers, studies. They can be internal to the subject herself who does not accept her
body and the transformations related to adolescence. Body changes are sometimes marked
during puberty and girls can, by anorexia nervosa, attempt to regain power over this body
that no longer suits them and no longer meets their expectations.
Ms. E. (25 yrs.) put her anxiety into words for others to understand, I don’t like
when there are people at home and this is worsened if it was not planned. At others’ home
it’s just bearable. The more people that are there, the more I fear”. But this distinction
between home (family home) and among friends does show us an underlying family problem
explaining the disorder and the discontent facing this other? She fears this invader who is
going to introduce himself into her family cocoon plus to observe and to note her thinness.
Maybe, these “foreign family people” could endanger her attempt to take the power on her
parents. Anorexia nervosa subjects can maintain the disordered eating behavior and their
thinness to preserve the family circle or the family unit (Selvini-Palazzoli, 1986) because
anorexia nervosa creates a reason to be helpful, to be together.
12
The children or the teenager can use anorexia nervosa to avoid growing up. By
remaining a child, the person retains the carelessness of childhood and keeps the parenting
focus. Like that, Ms. E. (25 yrs.) confides, I live at my parents’ home, they shake me all the
time. They are unhappy, my father is often angry. I feel guilty. They often tell me “you are
almost an adult, it’s time you took responsibility for your actions!”. Becoming an adult is
often perceived as a loss, as a nightmare to face problems, constraints, obligations of life; it’s
becoming responsible for yourself (and others). Eat your soup, you will grow upcan take
some teenagers into major anxiety. By not eating, could it not represented for these children
the symbolism of the fetal period when the umbilical cord ensured that role for them?
Ms. D. (17 yrs.) explained this, my sister had just had triplets, I struggled with that.
Until that time I was the youngest of the family and I used to get all attention. Suddenly all
the attention focused on them and the only thing I had left was my diet. And every time I felt
alone, I consoled myself by losing a pound. […] Finally, they paid attention to me, they
started to take care of me, they did not leave me alone anymore. […] This is a part of me, I
would like to stop, I don’t want to die but it’s very hard and I don’t know how I can do it.
Ms. D. was also fighting against this ambivalence of adolescence. This constant quest of
other people’s look, express what the anorexia subject wants more than anything but what
she cannot say Take care of me! (Jeammet, 2010). Ms. S. (16 yrs.) can blame too sustained
attention of her mother and at the same time she maintains this concern by her eating
behavior, My mother always bothers me so that I eat, she bugs me! Eating, this is not fun, it
became an order”. Therefore, her anorexia nervosa would become an opposition to her
mother to access some independence, typical of adolescence. At the same time, her eating
behavior is a tool to maintain her mother role like nurturing, and to see her as a child. Thus,
anorexia nervosa is the “perfect” strategy which answers in the same time to two opposite
goals, and answers to the internal conflict of adolescence (not more a child, not yet an adult).
13
This is another example of the paradoxical relationship between the anorexic subject
and others. The social (parental) relationships are frightening and necessary in the same
time, frightening because necessary (Jeammet, 2010). This ambivalence often appears with
Ms. S. as well when she describes herself. Our one on one allowed her to express the limits
of her behavior, and help to move beyond her disorder, I feel that there is a combination of
two girls in me: one very ugly and one very beautiful. I think I’m fat and thin […] I would
like to be perfect to please myself but I consider myself too thin now and I’m afraid to go to
the beach”. Ms. S. confirms here that her fine body bears the traces of her internal trouble
and in the same time, her obvious thinness express her uniqueness in the space where others
can see these traces and respond (Legrand & Taramasco, 2016). Relationships with parents
are often relationships of dependence. However, anorexia nervosa of the teenager tries to
reverse the roles because family becomes dependent of the adolescent and of her relation to
the food. This hold ensures the success of an illusory control of the affective and family
sphere. Conflicts with parents become inevitable which reinforce the anorexia behavior. For
Legrand and Briend (2015) anorexia nervosa subjects struggle with this paradoxical behavior
because they fail to negotiate the difference between needs and desires. Desires are often
insatiable and whether the parents satisfy the needs, they cannot fulfill the unfulfillable
desire.
For that matter, Ms. E. (25 yrs.) confided that her cousin is doing the same, we were
brought together. My mother’s side is considered quite beefy. My aunt, my uncle, my
grandfather are overweight. For my uncle, it’s the same, he was an anorexic subject”. Did
Ms. E. confirm a genetic role in the explanation of the anorexia nervosa or did she describe a
family who cultivate an environment which fosters the development of anorexia nervosa?
Was she fighting against a family relationship because she felt a subjugation of her
14
subjectiveness? That fear can be a reject of the other, or a call to the other, or both together
(Legrand & Taramasco, 2016).
The eating disordered behaviors often lead to a hostage of the family which is
undergoing a major anxiety regenerated at each mealtime. The circle, particularly parents,
tend to act and behave according to the wishes and moods of the adolescent hoping she’s
going to nourish herself. Thereby if a balance of power can be built, the adolescent takes the
power on the destabilized and distressed parents, by submitting this disorder living in a
permanent anxiety about each possible future deviant. By playing on the feeling of guilt and
on the protective parenthood sprout, the anorexic subject undermines the identity of parents
and put their social positioning and their attitudes in doubt. Indeed, at the end of the therapy,
Ms. D.’s mother said, I do not think that we could turn the page. There will always be this
pall hanging over us at least as long as she lives at home. We will have a little anxiety to
know if she’s eating all her meals. Me, I will wonder this, anyway”.
After analysis, Mrs. C. (48 yrs.) also verbalized that she ate during her childhood and
adolescence at the level of the perceived parental love. Developing a sense of abandonment,
of lack of affection and of reject from her parents, she expressed her feeling of these
perceived deficiencies, in the eating deficiencies. She experienced a correspondence between
the misery intensity and the anorexia nervosa. Mrs. C. cumulated a harmful family
environment, sexual abuse and rape.
2- Anorexia nervosa and sexual abuse in our cases.
Our practice confirms a large rate of young girls or women with anorexia nervosa
symptoms who were sexual abuse or rape victims (67 % of our anorexia nervosa patients).
15
Cannot this physical attack, still in that whole power of the mind over the body, expresses
itself as well in these young girls who have suffered sexual assaults? Because of the bodily
damage and the stolen privacy, it seems logical that the lack of interest for sexuality is
described as a symptom of anorexia nervosa. Even if the sexual abuse and rape victims are
not suffering of eating disorder, within our cases, sexual assault can be cause of anorexia
nervosa and the weight loss. Ms. S. (16 yrs.) explained that she fell in anorexia nervosa after
she was victim of rape. She said anything to anybody before her psychotherapy, after the
rape by my neighbor, I felt dirty, ashamed and guiltier than victim. I did not like the life
anymore, I no longer felt hungry, I did not want to do anything. But I kept the secret and live
like a robot, a scared robot”. The rape was clearly the triggering event, but Ms S. connected
the family problematic when she said In addition, my mother always wants me to help her
to prepare meals, I hate that, it makes me even more disgusted”. With the secret of the rape
wrote on her body but invisible for the other and with a specific problematic about food in
her family, Ms. S. seemed to use the anorexia nervosa to express her pain and to reveal her
secret in order to wean herself off it. The conflicts with her parents became regular, but it
was a paradoxical rebellion, remained under the wraps at the beginning, the secret wanted to
be visible to all by her gaunt body. Again, we understand how anorexia nervosa is
communication, it is a patient and stubborn building of a body of which his vulnerability is a
cry for protection (Legrand & Taramasco, 2016).
The desexualization that results would have the goal to protect the young girl who
hopes with that she’s not going to create the desire of a man anymore. Kestemberg,
Kestemberg and Decobert (1972) describe this paradox of the anorexic subject who is
struggling with an idealized body (for its thinness), object of desire in one hand and a real
body, object of denial in the other hand. Is it the paradox of the anorexic subject or the one
of the girl sexually assaulted?
16
Mrs. C. (48 yrs.) explain a posteriori that anorexia nervosa led me to drive my
femininity off myself and to break the mind and the body connection”. The bodily sensations
disappear and this becomes a survival strategy against the sexual assault. Because of the
rape, libido and desire disappear and this feeling is reinforced by the anorexia nervosa and its
physiological consequences. Towards the forced use of her body, the goal is to safeguarding
her mind, her soul, her Self, I, while doing the division between the body and the mind.
After the assault, anorexia nervosa would be the extension of this strategy. This contribute to
the euphoric time explanation and to the feeling that everything becomes cerebral as explains
Mrs. C. (48 yrs.), anorexia nervosa causes this phenomenon of rising up, the body forget
itself and just the mind exists. It’s very exhilarating but very dangerous, I felt I could reach
death”. The fight then ensued between the mind and the body sometimes to the point of
living a marked dissociation between the two dimensions of the person. The subject is in
denial of her thinness and of health gravity especially because this thinness gives a well-
being and a control feeling.
The body of the victim is soiled and therefore rejected, the person does exist only
with her cognitive skills. What is the use to give food to this body which can cause a credible
or perceived attack? Why being physically enviable if it results in becoming a victim of such
tragic and violent consequences? Our analysis confirms the Fallon et al.’s study (1994)
which shown that the sexual abuse victims adopt a restricting eating behavior because they
refuse to see their bodies developed with secondary sexual characteristics during or after
puberty, or because they want to recover some control on their body.
Conclusion and therapeutic prospects.
17
As some studies try to identify the risk populations (Favaro & al., 2010), it seems
difficult to bring out definite predictor factors. The person is unable to express or manage
other than that food deprivation, Sometimes I’m hungry between meals, but I prohibited it
myself” (Ms. E., 25 yrs.). We define anorexia nervosa as the symptom and not as the
problem. This perspective will determine the approach and the treatment by the clinical
psychologist.
Following Legrand and Briend (2015), psychotherapies could progress if they avoid
the dichotomy to focus on the symptoms or to focus on the social and familial environment.
Indeed, anorexia nervosa treatment procedures are often focused on the patients eating
behavior and any weight gain or loss. It is often forgotten to research the triggers of the
anorexia nervosa for the subject. Is it not because psychotherapies do not treat the origin of
anorexia nervosa that this disorder has got this high relapse rate?
Even if we don’t deny the biological and neurophysiological implications of the
anorexia nervosa, we consider anorexia nervosa as the expression of a psychic conflict
experienced by the person in an opposition posture. This is a symptom masking a
discomfort, a trauma, an emotional deprivation, an emotional disorder, an identity disorder,
an emotional shock or an internal social conflict. Anorexia nervosa is rooted in this
emotionally fragile people or with difficult life experiences. Often, anorexia nervosa is the
physical expression allowing the nonverbal expression of a generally important
psychological disorder. By the thinness of their body and the visibility of their eating
disorder, patients show that a problem exists but they can decide whether they will put words
on the real problem (family issue, sexual assault, etc.) or they will stay on struggling only on
anorexia nervosa and keep the mask on the origin of their anorexia nervosa. This eating
disorder is a tool that patients use to have the control, by this way they control their relative,
18
I need help but I will say why only if and when I want”. Thus, our efficient approach is to
focus on the “why”. Respond to this question is to provide another tool than the anorexia
nervosa to speak about the origin(s) of the symptom, and therefore treat all the problem’s
consequences by the psychotherapy.
The psychotherapy (inpatient or outpatient) remains the crucial element in the
anorexia nervosa treatment. The psychiatric protocols with an excessive focus on weight
gain are, for us, incomplete and ineffective. The subject builds her personality and exists by
means of her thinness. If the psychotherapist’s work is focused on the thinness and on to
recover weight, he will reinforce the empowerment of the disease. Albert Einstein explained
that we cannot solve problems by using the same thinking we used when we created them. As
well for Sullivan, Bulik, Fear and Pickering (1998, p.945), this kind of therapy “neglects the
detection and treatment of associated psychological features and comorbidity”. These
authors also note a very high lifetime prevalence of several anxiety disorders. This proves
that the problem is not resolved and that the anorexia nervosa was a psychological
expression of this problem.
For Jeammet (1991) the kind, the quality, the consistency and the duration of the
anorexic subject treatment and accompaniment determine the quality of the disorder
recovery with the establishment of a social, family and sexual life and an eating behavior
close of the “normalcy”. We see in our psychological practices, how much it’s important for
the patient to establish a strong link with the clinician. We can construct, with this link, a
dynamic of work for that healing journey. For this pathway, we mainly use two engines
simultaneously: the first is to answer to the question of the why? (Why the patient fell in
anorexia nervosa?), and the second is to set goals for short, mid and long-term. The
psychotherapy needs to be focused on the patient in a holistic approach. We come back to
19
Rogers (1957), in the therapeutic relationship he turned to interpersonal qualities of the
therapist, namely empathy, unconditional positive regard and congruence. Thus, focused on
the patient, the therapist may provide the necessary conditions for realizing the healing
processes and create the ability to bond or develop attachments in future relationships.
The rates of relapse have to alert us to the emergency of improving the treatment for
anorexia nervosa. The anorexia disorder being generally the symptom, research of the one or
the several causes must be the major goal of an efficient psychotherapy.
References
Botha, D. (2012). No labels: Men in relationship with anorexia, Mooshine Media Editor.
Brusset, B. (1998). Psychopathologie de l’anorexie mentale, Paris : Dunod.
Bulik, C.M., Sullivan, P.F., Wade, J.J., & al. (2000). Twin studies of eating disorders: A
review. International Journal of Eating Disorders, 27, 1-20.
Casper, R.C., & Lyubomirsky, S. (1997). Individual psychopathology relative to reports of
unwanted sexual experiences as predictor of a bulimic eating pattern, International Journal
of Eating Disorders, 21, 229-236.
Collier, D.A., & Treasure, J.L. (2004). The etiology of eating disorders. British Journal of
Psychiatry, 185, 363-365.
Collin-Vézina, D., Daigneault, I., & Hébert, M. (2013). Lessons learned from child sexual
abuse research: prevalence, outcomes and preventive strategies, Child and Adolescent
Psychiatry and Mental Health, Vol. 7(1), 22-30, DOI: 10.1186/1753-2000-7-22
Connors, M.E., & Morse, W. (1993). Sexual abuse in the eating disorders: A review.
International Journal of eating Disorders, 13(1), 1-11.
20
Daigneault, I., Collin-Vézina, D., & Hébert, M. (2012). La prévalence et la prévention de
l’agression sexuelle envers les enfants et les adolescents, Cahier Recherche et Pratique, Vol.
2(1), 20-23.
Deep, A.L., Lilenfeld, L.R., Plotnicov, K.H., Pollice, C., & Kaye, W.H. (1999). Sexual
abuse in eating disorder subtypes and control women: The role of comorbid substance
dependence in bulimia nervosa. International Journal of Eating Disorders, 25(1), 1-10.
Fairburn, C.G., Cowen, P.J. & Harrison, P.J. (1999). Twin studies and the etiology of eating
disorders, International Journal of Eating Disorders, vol. 26(4), 349-358.
Fairburn, C.G., & Harrison, P. J. (2003). Eating disorders. Lancet, 361, 407-416.
Fallon, P., Katzman, M.A., & Wooley, S.C. (1994). Feminist perspectives on eating
disorders, New-York: Guilford Press.
Fallon, B., Collin-Vezina, D., King, B. & Joh-Carnella, N. (2017). Cinical differences and
outcomes of sexual abuse investigations by gender: Implications for policy and practice,
Journal of Child & Adolescent Trauma, 10, 77-86. DOI: 10.1007/s40653-016-0121-0.
Faravelli, C., Giugni, A., Salvatori, S., & Ricca, V. (2004). Psychopathology after rape.
American Journal of Psychiatry, 161, 1483-1485.
Favaro, A., Tenconi, E., & Santonastaso, P. (2010). The interaction between perinatal factors
and childhood abuse in the risk of developing anorexia nervosa. Psychological Medicine, 40,
657-665.
Fischer, S., Stojek, M., & Hartzell, E. (2010). Effects of multiple forms of childhood abuse
and adult sexual assault on current eating disorders symptoms. Eating Behaviors, 11, 190-
192.
Grice, D.E., Halmi, K.A., Fichter, M.M., & al. (2002). Evidence for a susceptibility gene for
anorexia nervosa on chromosome I. American Journal of Human Genetics, 70, 787-792.
21
Hébert, M., Tourigny, M., Cyr, M., McDuff, P. & Joly, J. (2009). Prevalence of childhood
sexual abuse and timing of disclosure in a representative sample of adults from the province
of Quebec, Canadian Journal of Psychiatry, 54, 631-636.
Herzog, D.B., Nussbaum, K.M., & Marmor, A.K. (1996). Comorbidity and outcome in
eating disorders. Psychiatric Clinics of North America, 19, 843-859.
Herzog, D.B., Dorer, D.J., Keel, P.K., Selwyn, S.E., Ekeblad, E.R., Flores, A.T.,
Greenwood, D.N., Burwell, R.A., & Keller, M.B. (1999). Recovery and relapse in anorexia
and bulimia nervosa: A 7.5 year follow-up study. Journal of the American Academy of Child
and Adolescence Psychiatry, 38 (7), 829-837.
Jeammet, P. (1991). Dysrégulation narcissiques et objectales dans la boulimie, In B.
Brusset, & C. Couvreur (Eds.), La Boulimie. Paris : PUF, pp. (81-104).
Jeammet, P. (1993). L’approche psychanalytique des troubles des conduites alimentaires.
Neuropsychiatrie de l’enfance et de l’adolescence, 41 (5-6), 235-244.
Jeammet, P. (2010). Anorexie, boulimie : les paradoxes de l’adolescence. Paris : Librairie
Arthème Fayard/Pluriel.
Kestemberg, E., Kestemberg, J., & Decobert, S. (1972). La faim et le corps. Paris : PUF.
Legrand, D. & Taramasco, C. (2016). Le paradoxe anorexique : quand le symptôme corporel
s’adresse à l’autre, L’Evolution Psychiatrique, vol. 81(2). DOI :
http://dx.doi.org/10.1016/j.evopsy.2014.09.003
Legrand, D. & Briend, F. (2015). Anorexia and bodily intersubjectivity, European
Psychologist, Vol. 20(1), 52-61. DOI: http://dx.doi.org/10.1027/1016-9040/a000208
Lejonclou, A., Nilsson, D. & Holmqvist, R. (2014). Variants of potentially traumatizing life
events in eating disorder patients, Psychological Trauma, Vol. 6(6), 661-667.
22
Lyubomirsky, S., Sousa, L., & Casper, R.C. (2001). What triggers abnormal eating in
bulimic and nonbulimic women? Psychology of women quarterly, 25, 223-232.
Marcelli, D., & Braconnier, A. (2004). Adolescence et psychopathologie. Liège : Ed.
Masson.
Pereda, N., Guilera, G., Forns, M. & Gòmez-Benito, J. (2009). The international
epidemiology of child sexual abuse: A continuation of Finkelhor (1994), Child Abuse &
Neglect, 33, 331-342.
Rogé, B., & Chabrol, H. (2007). Psychopathologie de l’enfant et de l’adolescent. Paris :
Belin.
Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic personality
change, Journal of Consulting Psychology, 21, 95-103.
Rothschild-Yakar, L., Levy-Shiff, R, Fridman-Balaban, R., Gur, E. & Stein, D. (2010)
Mentalization and relationships with parents as predictors of eating disordered behavior,
Journal of Nervous & Mental Disease, Vol. 198(7), 501-507. DOI:
10.1097/NMD.0b013e3181e526c8
Selvini-Palazzoli, M. (1986). Toward a general model of psychotic family games, Journal of
Marital and Family Therapy, vo. 12, 339-349.
Shoebridge, P. & Gowers, S.G. (2000). Parental high concern and adolescent-onset anorexia
nervosa, A case-control study to investigate direction of causality, British Journal of
Psychiatry, vol. 176, 132-137.
Smolak, L. & Murnen, S.K. (2002). A meta-analytic examination of the relationship between
child sexual abuse and eating disorders, International Journal of Eating Disorders, vol. 31(2),
136-150.
23
Strober, M., Morrel, W., Burroughs, J., Salkin, B., & Jacobs, C. (1985). A controlled family
study of anorexia nervosa. Journal of Psychiatry Research, 19 (2-3), 239-246.
Sullivan, P.F., Bulik, C.M., Fear, J.L., & Pickering, A. (1998). Outcome of anorexia
nervosa: A case-control study. American Journal of Psychiatry, 155(7), 939-946.
Thompson, K.M. & Wonderlich, S.A. (2004). Child sexual abuse and eating disorders, In
J.K. Thompson (Ed.) Handbook of eating disorders and obesity, Hoboken, NJ: John Wiley
& Sons, pp. 679-694.
Zerbe, K.J. (1992). Eating disorders in the 1990s: Clinical challenges and treatment
implications. Bulletin of Menninger Clinic, 56(2), 167-187.
... In practice, by contrast, debates about eating disorder treatment methods often involve statements to the effect that because one extreme of treatment is ineffective, the solution must be sought at the other extreme. For example, Lacoste (2017) states that "The psychiatric protocols with an excessive focus on weight gain are, for us, incomplete and ineffective" (2017, p. 80). He concludes that nutritional rehabilitation should be ignored in its entirety, and that instead, "research of the one or the several causes must be the major goal of an efficient psychotherapy" (p. ...
Article
Full-text available
Mainstream forms of psychiatric talk therapy and cognitive behavioral therapy (CBT) do not reliably generate lasting recovery for eating disorders. We discuss widespread assumptions regarding the nature of eating disorders as fundamentally psychological disorders and highlight the problems that underlie these notions, as well as related practical problems in the implementation of mainstream treatments. We then offer a theoretical and practical alternative: a dynamical systems model of eating disorders in which behavioral interventions are foregrounded as powerful mediators between psychological and physical states. We go on to present empirical evidence for behavioral modification specifically of eating speed in the treatment of eating disorders, and a hypothesis accounting for the etiology and progression, as well as the effective treatment, of the full spectrum of eating problems. A dynamical systems approach mandates that in any dietary and lifestyle change as profound as recovery from an eating disorder, acknowledgment must be made of the full range of pragmatic (psychological, cultural, social, etc.) factors involved. However, normalizing eating speed may be necessary if not sufficient for the development of a reliable treatment for the full spectrum of eating disorders, in its role as a mediator in the complex feedback loops that connect the biology and the psychology with the behaviors of eating.
... The beginning of AN is almost imperceptible, and the first signals may seem as a form of selfdiscipline and willpower that does not catch the attention of those around them. In addition, psychological aspects that contribute to the disorder, such as emotional problems, low self-esteem, tendency to extreme perfectionism, overvalued ideas of the body or body image, can go unnoticed (Lacoste, 2017). Furthermore, people who suffer from the disorder usually adopt a secret attitude, hiding eating disturbances and body shape; for example, using loose clothing, avoiding certain situations of exposure of their body (e.g. ...
Article
Full-text available
Parents are often the first to detect the initial signs of anorexia nervosa (AN) and take necessary measures to ensure that their children receive appropriate treatment. The evaluation of AN in adolescence is complicated by taking into account the tendency to minimize and deny the symptoms by adolescents, and the difficulty of parents in detecting the main symptoms. We compared the adolescent and parent scores on measures of disordered eating at initial presentation. The sample consisted of 62 adolescents diagnosed with AN, who attended an eating disorder children’s unit. Adolescents completed the Eating Attitudes Test (EAT-40) and their parents the Anorectic Behavior Observation Scale (ABOS). The questionnaire data were collected as part of the routine clinical practice and were obtained from clinical notes. The findings indicate no significant correlations between the EAT-40 and ABOS scores, or between AN subtypes according to parent observation of symptoms. There were significant differences between parents, with mothers reporting higher scores than fathers. This study highlights the importance of psychoeducation for parents on the early signs of AN, in order to improve recognition and diagnosis at initial assessment of their adolescent children in the early phases.
Article
Full-text available
Background The relationship between anorexia nervosa (AN) and family disturbance has been a subject of debate since its first description. What began as a clear view of the pathologically disturbed family causing AN has become ever more complex over the decades. Objective The aim of this review is to explore the literature to examine the changes and evolution of clinical opinion around family dysfunction and AN over the last 20 years. Methods A narrative review of heterogeneous studies in peer-reviewed publications sourced from the major databases, including PubMed and ScienceDirect, to illuminate the topic of family distress and AN by highlighting the conflicting and complementary ways it has been studied. Results This review has highlighted the complexity of the relationship between anorectic sufferers and their families. It has explored the literature about parental burden, emotions and cognitive mechanisms together with parental attitudes about weight and shape. It is clear that there is no consistent psycho-social pathology in families which has been shown to be causative. However, over the last twenty years, research has highlighted the distress and family dysfunction caused by having to look after an anoretic child with poor mentalisation skills, insecure attachment and emotion dysregulation. Conclusion The area has become clearer over the last 20 years; research suggests a bi-directional relationship between AN and family dysfunction, with difficult dynamics becoming entrenched within the family. This is best addressed, the consensus suggests, by specialist family therapy and carer skills interventions. Longitudinal research is needed to definitively answer the question with rigorous scientific certainty. EMB rating Level V. Level of evidence Level I: Evidence obtained from: at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies. Level II: Evidence obtained from well-designed controlled trials without randomization. Level III: Evidence obtained from well-designed cohort or case-control analytic studies. Level IV: Evidence obtained from with multiple time series analysis such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. Level V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.
Article
Full-text available
Although the detrimental impact of child sexual abuse is well documented, there is a dearth of literature on differential outcomes and on child protection services by gender. Using a representative dataset of child welfare investigations, this paper explores how boys and girls investigated by the child protection system for alleged sexual abuse (n = 4,261) compare on key clinical characteristics and on the likelihood of a transfer to ongoing services. These characteristics include sexual abuse type, associated physical and emotional harm, and caregiver and child functioning concerns. The results indicate that there are significant differences in child functioning concerns by gender, with investigations involving boys having a stronger association with aggressive behaviour, attention problems, academic difficulties, depression, and the presence of an intellectual disability. Paradoxically, although sexual abuse investigations involving boys are less likely to note emotional harm and be substantiated, they are more likely to be transferred to ongoing child welfare services.
Article
Full-text available
L'agression sexuelle est un geste à caractère sexuel, avec ou sans contact physique, commis par un individu sans le consentement de la personne visée ou, dans certains cas, notamment dans celui des enfants, par une manipulation affective ou par du chantage. Il s'agit d'un acte visant à assujettir une autre personne à ses propres désirs par un abus de pouvoir, par l'utilisation de la force ou de la contrainte, ou sous la menace implicite ou explicite. Une agression sexuelle porte atteinte aux droits fondamentaux, notamment à l'intégrité physique et psychologique et à la sécurité de la personne 1. L'agression sexuelle des enfants et des adolescents constitue un problème de santé publique qui suscite incom-préhension et indignation. Bien que cette problématique reçoive une attention grandissante, deux questions cruciales restent en suspens : les données les plus récentes démontrent-elles une baisse du nombre de victimes d'agression sexuelle dans notre société? et les programmes de prévention ont-ils réussi à diminuer la vic-timisation sexuelle des enfants et des adolescents? Le présent article propose d'analyser l'état des connaissances sur ces deux thèmes qui, bien qu'imbriqués l'un dans l'autre, sont le plus sou-vent abordés en silo.
Article
Full-text available
The objective here is to conceive the relationship to alterity at stake in anorexia. If the subject who eats is confronted with what it is not and upon which it depends (food), then anorexia implies the refusal to surrender to such alterity. Likewise, the anorexic would not assume the alterity of the other subject for whom or against whom the act of eating is organized. It is the hypothesis that we defend here.Method It is by relying on Levinas’ philosophy that anorexia is better understood as a problematic of alterity. Indeed, what Levinas reveals is that the other subject is not another ‘myself’ but an inassimilable ‘other’. Confronted with clinical observations, this conception demonstrates its relevance for understanding the anorexic as a subject for whom inassimilable alterity is unbearable.ResultsEither the other is assimilated as the one the anorexic is not but wants to become; or the other is rejected as a radical alterity which the anorexic cannot assume as such. In both cases, it is to others that the anorexia is addressed; inviting and rejecting them.DiscussionIn the diversity of their manifestations, anorexics are animated by the same fight against a subjection of their subjectivity to the alterity of the other.Conclusion Engaged in such intersubjective problematic, the anorexic manifests an alimentary communication by stripping food from its nutritional matter in order to make of it an element of language; doing so, the anorexic materializes hunger in a body which is transformed to address it to others.
Article
Full-text available
Although child sexual abuse (CSA) is recognized as a serious violation of human well-being and of the law, no community has yet developed mechanisms that ensure that none of their youth will be sexually abused. CSA is, sadly, an international problem of great magnitude that can affect children of all ages, sexes, races, ethnicities, and socioeconomic classes. Upon invitation, this current publication aims at providing a brief overview of a few lessons we have learned from CSA scholarly research as to heighten awareness of mental health professionals on this utmost important and widespread social problem. This overview will focus on the prevalence of CSA, the associated mental health outcomes, and the preventive strategies to prevent CSA from happening in the first place.
Article
Objective Twin methodology has been used to delineate etiological factors in many medical disorders and behavioral traits including eating disorders. Although twin studies are powerful tools, their methodology can be arcane and their implications easily misinterpreted. Method The goals of this study are to (a) review the theoretical rationale for twin studies; (b) provide a framework for their interpretation and evaluation; (c) review extant twin studies on eating disorders; and (d) explore the implications for understanding etiological issues in eating disorders. Discussion On the basis of this review, it is not possible to draw firm conclusions regarding the precise contribution of genetic and environmental factors to anorexia nervosa. Twin studies confirm that bulimia nervosa is familial and reveal significant contributions of additive genetic effects and of unique environmental factors in liability to bulimia nervosa. The magnitude of the contribution of shared environment is less clear, but in the studies with the greatest statistical power, it appears to be less prominent than additive genetic factors. © 2000 by John Wiley & Sons, Inc. Int J Eat Disord 27: 1–20, 2000.
Article
One's experiences of hunger, food, eating, and the body are not only subjective but intersubjective: They involve one's relation to others. On the basis of this observation, what is proposed here is a conception of anorexia as bodily intersubjective: Anorexia would involve, via the manipulation of food and eating behavior, the transformation of the subject's body, as a way of impacting her relations to others. The anorexic subject would instrumentalize her eating behavior and bodily shape to address others, thereby putting them in a position to respond to her meaningfully, by manifesting their sensitivity to her desire. Importantly, in this view, anorexia is not positioned on the intersubjective scene by opposition to the bodily and alimentary scene; rather, what is proposed is that anorexic sufferance is intersubjective insofar as it is bodily. After some clinical observations describing how anorexia is bodily intersubjective in a concrete way, an overview allows for consideration of whether this conception of anorexia conflicts with or is supported by the main approaches that are currently influential in this field.
Article
Although many studies have found associations between trauma and eating disorders, it is important to study associations between the whole spectrum of potentially traumatic experiences and eating disorders. This study examined to what extent noninterpersonal traumas, interpersonal traumas, and adverse childhood circumstances were reported in a sample of patients with eating disorders, comparing this with ratings in a nonclinical group. Differences in trauma experiences between the different eating disorder diagnosis groups were assessed, and associations between trauma experiences and the reported severity of eating disturbance were analyzed. Fifty patients with eating disorders and a group of adolescent girls and young women (N = 245) without known psychological problems completed a self-report trauma-history questionnaire: the Linköping Youth Life Experience Scale. The eating disorder group also answered the Eating Disorder Examination Questionnaire. For several specific traumas, the eating disorder group had experienced a significantly larger number of potentially traumatizing events. With regard to the number of different traumas, the results were more equivocal; more experiences of adverse childhood circumstances and repeated traumas were reported in the eating disorder group, but more noninterpersonal traumas were reported in the nonclinical group. The number of adverse childhood experiences and repeated traumas was associated with the presence of eating disorders in outpatient adolescents and young women. The frequency and type of potentially traumatizing events need to be clearly assessed for these patients, placing particular focus on repeated traumas. Treatment may be improved through a focus on traumatic experiences in order to resolve the eating problems. (PsycINFO Database Record (c) 2014 APA, all rights reserved)