Anorexia Nervosa Research Paper

Sexual abuse in patients with Anorexia and Bulimia.
An attempt to order from the Modular-transformational approach.

The increasing incidence of anorexia / bulimia in the past thirty years and the difficulties for successful treatment are a challenge to the professional community dedicated to their attention. Both psychiatrists and psychoanalysts have redoubled efforts to understanding and intervention in order to give an appropriate response to what is considered an epidemic and a type of pathology characteristic of the present age ( Lucas , 1991 ) .

It is our intent in this paper to make a series of remarks on certain questions about the disorder , from which we believe that it is possible to take stock of the state of the matter and propose a theoretical and clinical management .
Is it a psychosomatic illness , of a behavioral disorder , a distortion of body image or a narcissistic balance deregulation ? Is the disorder anorexia / bulimia reaching epidemic character now has the same causes as those cases that psychiatry has documented for over a century and the history of psychiatry Hipocraticum back to Corpus ? ? Case of a syndrome that can support various causes nonetheless delimit a specific structure and dynamics symptom? Can anorexia / bulimia in adolescence is always preceded by a period of infantile anorexia ? Is it a specific disorder of the female gender ? Is there any similarity between the " epidemic " of last century hysteria and anorexia / bulimia today?

An examination of these questions , the first thing that stands out is a challenge to conceptions simplificantes attempting a unification - either early psychogenesis of the mother- daughter or a disorder autoperceptiva discrimination sensations of hunger - leading to the creation of an imaginary psychopathological identity as is " " anorectic or "the " bulimic singular . The clinic sample, on the contrary, a diversity and uniqueness of underlying configurations have in common only the deep narcissistic vulnerability of the period of puberty and adolescence female imbalance that rebalancing is an illusion in the fetishization of her culture delgadezque offers .

Often , puberty and adolescence female explicadan through reductionist conceptions as regression to preoedipal or reactivation stages oedipal and / or processes of separation / individuation in infancy incomplete without highlighting the complexity and scope of the problematic adolescence unpublished opens , with special feature in the present era . Risks to self-preservation that enactment of sexuality have to bodily integrity of women to the imperatives of sexuality early and active, ie , antagonism and conflict between sexual motivation and self-preservation , the risks of early and massive loss of attachment relation - processing necessary but essential in maintenance over the life cycle - by increasing motivation narcissistic statement about androgyny or standardized masculinization of female identity , conflict between narcissistic desires intrasystemic of excellence in self goals and ambitions and imperatives of perfectionism ideals of body image and physical beauty .

Whatever the nature of anxiety - triggered loss of the primary attachment references , sexual challenges , ideally ego collapse , always possible to appeal to female adolescent body perfectionism resource through the search and maintain this thinness as universal narcissistic defense of compensation offered by the values of the culture.

Like hysteria, disorder anorexia / bulimia is part of the body, but in this case without matter but with destructuring effects and destructive to the personality and life of the patient , thus requiring a first tour of the aspects epidemiological and psychiatric , and then get into the review of its structural / dynamic are those that allow us to understand and address forms of treatment that are specific to each case.

Topics for discussion will include: conceptual definition of anorexia / bulimia , the current epidemic ; syndrome and specificity causal correlation between the symptom and intrapsychic structure , value of the history of infantile anorexia ; conceptions of the causal role of mother 's body image and female puberty , treatment of symptoms of anorexia / bulimia and adolescent women.

Conceptual definition of anorexia / bulimia

We believe that the various proposals that have been given to the conceptual definition of the table: psychosomatic illness ( Deutsch, 1940 ; Blitzer, 1961 Sperling, in Wilson , 1983 ; Strauss, 1987 ) , eating disorders ( DSM -IV ) , pathology weight or weight phobia (Crisp , 1970 ; Kalucy 1977, Hall, 1986 ) , narcissistic balance deregulation ( Jeammet , 1991 ) refer to different levels of analysis of the table:

1. - The motivation that triggers the disorder : motivational setting establishes the pursuit of thinness for stabilization Self narcissistic balance , that motivation to become dominant over the other motivational systems , and sometimes exclusive , adverse effects personality.

Two . - The pathogenesis : the lengths to which procedures are used for weight loss - induced vomiting , laxatives , diuretics , which generate a dynamic of self-centeredness , rituals and isolation.

Three . - The symptoms : weight loss , impaired judgment about body image , malnutrition leading to such loss as responsible body involvement and the risk of death .

So the various characterizations phenomenal effect on anorexia / bulimia appear as cutouts - components - all present in the box : a level of causation , procedures and consequences that constitute the disorder itself . But while all are understood, does not seem valid , strictly speaking, one of them erect as it takes over the ownership of the disorder and anorexia conceive / bulimia as a psychosomatic illness because there amenorrhea or hypothermia . Nor treatment center eating habits change regardless nacisista deep unbalance holding such a habit. This does not mean that during treatment disregards the need for hospital admission if risk of death , or the consequences restorative physical health status to gain weight back , but chaining clarify the causes factors and what the consequences.

What is the cause and what is the consequence ?

The psyche as a cause

If we consider the disorder as a psychosomatic illness is something of a psychic that affects the body , compromising some body so as to alter its normal physiology . But the core of the concept of psychosomatic illness is that the order that is happening is psychic , or unknown by the subject or as unspecific as stress or distress and, in turn , not detected organic cause justifying the ailment , which the considerársela undetermined and under empirical testing and statistics, are suspected to be related to the psychic . On the other hand , who suffers from hypertension and duodenal ulcer , go to the doctor looking for solutions. None of this happens in anorexia / bulimia and if they make their appearance hypothermia amenorrhea or the person in question knows that what he wants is not fat and if those are the associated consequences do not seem to worry her .

So if good nutrition is so affected , this is a direct consequence , clear , steely determination a psychic that is maintained throughout much of the course of the disorder as a determinant . If washing hands compulsive obsessive- compulsive involvement raises serious dermatological insomnia ideation or recurrent physical symptoms do not justify its conception as psychosomatic ailment .

It seems more appropriate, then, conceptually define anorexia / bulimia as they did in their early Lasègue ( hysterical neurosis , 1884 ) and Gull (anorexia nervosa , 1874 ) , as a mental illness . That is, linking rescue anorexia / bulimia with disorders of femininity and strong mental status .

The body as a cause

It is common in these disorders clinic the hyperfocus , both ideational and the discourse on issues related to weight - gained or lost -the concern over calories contained in food , in the type of food eaten , in the variation of mood in relation to intake and ease to feel angry and dysphoric . These characteristics of the psychoanalytic literature box has called in several ways: mental emptiness , reduction imaginary deficit phantasmatization capacity , difficulty in associating , the near impossibility of remembering ( Kestemberg , 1976 ) , and has been assigned a character causal . The poorer mental content , greater referral to the body of conflict.

For those who tend to regard psychosomatic disorder such as these traits are merely the expression of a constitutional defect in the ability to make the fantasies , called alexithymia by Sifneos box and Nemiah ( 1967 ) , who described in patients suffering from diseases organic have difficulty expressing emotions. They considered , in principle a neurological defect that would cause difficulties in symbolization and a greater tendency to resolve situations of tension throughout the body , and this is applied to anorexia / bulimia ( Zonis of Zukerfeld , 1996 ) .

Marty et al (1992 ) also use this idea as a key element in their conception of psychosomatic diseases : flaws in the constitution of the psychic apparatus , a weakness of the preconscious that by not providing representational link impede the processing of affect via psychic . Registration of bodily sensations would be found altered by conditions that can range from : 1 ) a body too narcisizado by the mother with a failure to recognize the corporate limits themselves and others, based on common expressions such as: " I feel full , stuck, invaded , drowned ", 2) a body poorly libidinized , semanticized not expressed through phrases like" I 'm empty , do not get to the bottom , I know my limit . "

Hilde Bruch was the first to call attention to the defects in self-perception and self-regulation of feelings of hunger in feeding tratornos , which today is one of the subscales of the Questionnaire of Eating Disorders ( EDI , Garner , Olmstead and Polivy , 1983 ) , entitled: " intraceptiva awareness " , which evaluates the degree of confidence to recognize and accurately identify the emotions and feelings of hunger and satiety . In his article entitled Hunger and Instinct ( 1969 ) Bruch endeavored to show that the self-perception of hunger is not completely innate , that the infant must experience and constantly repeat a sequence of events : the emission of signals, recognition by the adult , appropriate response and feel of final relief . Remarked that it is not guaranteed by the instinct is postnatal regulation . Went ahead a few decades to the current proposals on the importance of confirmatory responses , reinforcing or inhibitory , innate components from attachment figures for the proper development of self-perception and autoefectividad .

No doubt the importance of the sensitivity of the attachment figure for the regulation of the infant 's discriminative capacity between bodily sensations and emotional states , but it is necessary to note that this disturbance - in case there was a defect in the mother should to affect infants of both sexes , as indeed is observed in cases of infantile anorexia , which creates serious reservations to hold its ground in the anorexia / bulimia almost exclusively in women. In 1969 Bruch work includes obesity and eating disorder and, indeed, the continuity between childhood and adult obesity and its distribution partner in the two sexes to take account for defects of consciousness intraceptiva one early nondiscrimination basis . But while obesity is included among alimenario behavioral disorders , there are many factors that differentiate .

Given this impasse in determining cause of the obsession of these patients on mental contents about other authors consider food (Casper et al . , 1977 ; Garfinkel & Kaplan , 1985 ) that this is a direct effect of the famine as has been shown in studies of Keys et al . ( 1950 ) , at the University of Minnesota with 38 normal male volunteers. For 3 months they observed its standards of food and in the 6 months following intake was reduced by half , losing about 25 % of the original weight . The dietary restriction produced a series of changes that reproduced those observed in anorexia : spoke only of food , much of the interest lost by other issues and activities , were restless and irritable and it was very difficult to maintain a dialogue with them . At the end of the experience , a high percentage took between 8 months to a year to regain his normal life and 3% food restriction continued .

In turn, although many patients with bulimia appear physically good health may have psychological and physical correlates of semihambruna such as depression, irritability and obsessive tendencies .

So much of the psychic symptoms as -eg obsessive trend around issues related to food , dysthymic states , irritability , social isolation and mental emptying the need to correlate very closely with the effects a state of high metabolic imbalance that comes to regulating the mind . That is, although the symptom is usually ego - syntonic , and anorexic patients / bulimia are reluctant to treatment and want to control food intake, body effects in risk awaken psychic alarm systems as it highlights the experience of men who had no motivation to food deprivation to participate in a human experiment .

The continuum of anorexia / bulimia

Although specific clinical criteria adopted for the diagnosis of patients with eating disorders (DSM- IV) , symptoms frequently appear as a continuum between those of anorexia nervosa and bulimia nervosa the . Patients with anorexia may alternate between restrictive and bulimic periods in different stages of their evolution . And among the bulimic type of anorexia nervosa are those that are purged or vomit after a binge and vomit only not binge or purge . Preoccupation with weight and shape overvaluation and thinness are alike in anorexia and bulimia, and most patients have a combination of bulimic and anorexic behaviors ( Practice Guideline , Am J Psychiatry , 2000 ) .

Anorexia / bulimia and the current epidemic

The knowledge of this condition is very old and there are references of anorexia in Hippocrates , Galen and bulimia in the Talmud , as well as the practices of Teresa of Avila with an olive branch to induce vomiting ( Blinder , 1992 ; Reda , 1997). In the past century , we already have Lasègue publications ( 1873 ) Gull in the British Medical Journal ( 1874 ) , and photographs of Miss KR in Lancet ( Clinical Notes , 1888 ) . Subsequently found in psychiatric and psychoanalytic literature cases have laid the foundation of the proposed explanatory about the disorder , but always tried to isolated cases. It is only in the late 60s , and mainly from the 70 that is starting to show a significant increase in the incidence and epidemic begins to talk

What we see as the difference , besides the number , including anorexia / bulimia in the past and the present ? That adolescents with severe comorbidity are the least that most of them suffer from the symptom in a more or less isolated and it is on this latter population -already contained in any statistics because they are consultants in clinics or hospitals , or those that form the bulk of statistics hidden in private consultations - on which is based the idea of an epidemic in the present tense of anorexia / bulimia.

The case of Ellen West referred by Binswanger in 1945 -one psychiatric cases described in more detail and has received more comments . It was a purging anorexic , bulimia with evolution of great pomp and symptoms that ended up committing suicide , was diagnosed as hysteria by a first analyst , single melancholy by Kraepelin , Bleuler and simple schizophrenia by Binswanger , psychopathic constitution progressive development another psychiatrist , and something like a endocrine endogenous psychosis Zutt endogenously (Chinchilla , 1994; Ruiz Lazarus , 1999).

If we compare the case of Ellen West with data from a recent work of Goldner et al . ( 1999 ) , dimensional evaluation of 136 cases, covering the full range of eating disorders , which describes three clusters : 18.4 % with high scores on psychopathic traits , neurotic and impulsive , diagnosed as borderline disorders , 49.3 % with some compulsive traits and interpersonal difficulties , and 32.4 % of persons who are no different from other considered normal by the control group . We are faced with the fact that in the current cases , that 18.4 % of severe pathology associated the presence of the disorder remain anorexic / bulimic in approximate proportion to what had been appearing to the present. The rest has to do with new factors that add even more questions to a disorder that continues catalogándose enigmatic .

Another fact to consider is the rarity of complete frames of anorexia / bulimia or covering all diagnostic criteria -0.5 to 1 % - against the increased number of partial or incomplete tables 5% -3 - (Walters & Kendler , 1995; Bunnell et al. 1990).

So the imperative of thinness can be regarded as the factor that differentiates anorexic / bulimic past the current , which leads to diversity of approach motivational configurations that may trigger the symptom

Syndrome and specificity causal

Given the clinical data showing such a wide frame - neurotic , psychotic and borderline in which anorexia / bulimia may be present , many authors consider anorexia / bulimia as a syndrome . The various causes are in order divided between the individual, family and cultural ( Risen, 1982 ; Selvini Palazzoli , 1999 ) . ? Case of a syndrome that can support various causes nonetheless delimit a specific structure and dynamics of the symptom ?

1. - Forms of narcissistic balance equilibration through current beauty aesthetic pattern

Clearly the start is from the beginning of a weight loss diet . In these cases, which are the majority of which are currently prevalent motivation narcissistic gain is expected to be obtained to improve the silhouette. The bulk of the current literature explains the prevalence of 10-1 of this disorder in women from the prevailing culture of thinness ( Garner et al . , 1983 )

They seek a state of mental well-being through interpersonal recognition of the beauty of their bodies , or the thinness of it that seems to be basically equivalent. While the goal unifies psychological condition which may leave vary over a wide range . At the clinic , we find from the girl who imitates her classmates at school who diet and that only a desire perfectionist moves as part of the profile described for Anorexia / Bulimia young model, with excellent academic record , beautiful and sociable , a little " chubby ", the teen not feeling very favored thinness physically expected granted the necessary attributes to access the other sex until you are failing in several areas in the company of diet illusory compensation for malaise.

So the motivation behind restrictive behavior is triggered from a net predominance of narcissistic system linked to a bodily attribute that functions both as a) a gender stereotype narcisizante ensuring mirroring b ) as an essential qualification for a activity: gymnasts , models , acrobats , climbers ( Nudel , 1989, Malina , 1983 ; Rowley, 1987 ) .

Two . - Another way to control anxiety

It has been argued that anorexia / bulimia belongs to the family of obsessive - compulsive disorder ( McElroy , 1994 ; Stein, 1993 ; Thiel , 1998 ) for its high morbidity and prevalence in the life cycle ( Fahy , 1993 ; Kasvikis , 1986; Rubenstein , 1992). Some authors like Noshirvani et al . ( 1991 ) , holding a divergent gender factor would explain the high incidence of anorexia / bulimia in women . We agree with these authors on the importance of gender equality in particular theming acquire control mechanisms on issues governed by the ego ideal . That is, is the relevance between different motivational systems that acquires a particular theme for each particular subject which selects the control system for surveillance , in this case , narcissism reduced to the ability to control body image . Double determination thus : first , a basic function of decreased defense anguish that is felt as uncontrollable and , on the other hand , wish-fulfillment of narcissistic motivational system . In anorexia / bulimia anxieties of which protects symptom obsesivización may be multiple, while weight control becomes the element that gives universal concretely manifest level underlying this diversity .

Three . - Symptom product of a conflict

a. - Oedipal Conflicts

They generate panic and rejection of sexuality

b . - Sexual Abuse

The reviews of research on sexual abuse show a potential link with pictures of anorexia / bulimia, a prevalence of bulimic symptoms ( Baldo , 1996 ; Connors, 1993 ; Everill , 1995 ; Eyre , 1991 ; Martinez Benlloch , 1999 ; Pope, 1991, Schwartz, 1996, Wiedermann , 1998). Body involvement obey a form of resolution symptomal and defensively to the chaos which is the emotional experience of sexual abuse and that can mean body erasure object of abuse, with consequent inhibition of sexuality or, in other cases, a intake compulsive activity in order to disappear as sex object other.

4. - Symptom exchange situations unbalance the attachment bond

Difficulties in processing attachment bond teen , either by the mere fact of change of life situation , which correspond to a kind of adolescent crisis ( Selvini Palazzoli 's included in a previous personality typology dependent , 1999 , p . 196 ) or changes of residence for purposes of study or work. These cases are usually a good prognosis, with partial or incomplete clinical picture , which we tend to call " anorexic reactions " ( O 'Kearney , 1996 ) .

May . - Symptom into a major pathology

Depressive states are considered as predisposing condition associated or consequence of a picture of anorexia / bulimia (Casper , 1998 ; Cabetas Hernandez, 1998 ) , and its manifestations are very similar : sleep disorders, social withdrawal , decreased sexual desire and lack of pleasure in activities , irritability , decreased appetite. So in some cases of panic disorders with severe panic symptoms associated with food restriction and also in moderately serious borderline disorders with significant degrees of anxiety and impulsivity. Periods of food restriction schizophrenic psychosis boxes are also described .

Chronicity factors

Many patients suffer from this table in a chronic recurrent hospitalizations decades , leading to suggest the existence of important maintenance factors both of a biological disorder and psychological. Changing nutritional patterns persists despite the normalization of intake as was found in the work of Keys in 1950 , and Garfinkel and Kaplan in 1985. In turn, although the initial motivation has not been narcissistic , once installed is a support table maintenance in culture idealizes format for current female identity : a thin body looking teenager who brings strong interpersonal narcissistic gain . Moreover, the proven ability to achieve and maintain a physical state that most women aspire gives them a self-assessment holding intrapsychic balance .

Correlation between symptoms and intrapsychic structure

Is there then any psychic structure stable and specific for anorexia / bulimia or should we consider his position as transnosographic and transestructural ( Jeammet , 1985 ) , or divide the picture in subtypes of psychopathology or characterology underlying (Johnson & Connors , 1988 ; Swift & Stern , 1982 ; Selvini Palazzoli , 1999 ) ?

We joined the holding Jeammet approach and Brusset (1991 ) to consider that can be applied in this case the knowledge gained for addictions : "Any mental structure can lead to addictive behavior ( visible or latent ) in certain affective or relational " ( p. 84). We could paraphrase the claim arguing that any emotional or relational state can lead to a woman or a man who does your physical appearance privileged support of his narcissism to anorexic behavior / bulimico . So the only hard core or indispensable condition for producing this symptom is the dimension of experience holding the narcissism of the subject: if it is the body and appearance , the gateway to the disorder is assured. Studies show that men who suffer from the symptoms of anorexia / bulimia are mostly gay or serious issues around male identity ( Carlat , et al . , 1997 ; Ruiz Lazarus, 1999 ) , data that agree our study of 153 adolescent males in the province of Valencia ( Benlloch Martinez et al . , 1999 ) .

Despite the simplicity of the approach , it creates difficulties for theoretical status in psychoanalysis , as it is then a defensive move rather than an intrapsychic defense mechanism and unconscious. A maneuver that has the power to change the identity because the body surface contributes a significant percentage to the organization of personality , especially in women.

Bleichmar , H. ( 1997 ) noted the need to differentiate - concealment defense mechanisms to consciousness - of defenses in the unconscious , between the repressed unconscious - deposit the contents of the repressed unconscious , and productive, creative . When a fantasy counteracts persecution by identifying a heroic character that makes deceptively powerful invulnerable , this procedure is not a mere concealment to the conscience of fear it generates attitudes , activities according to their new identity , a modification autoplastic product taking unconscious defensive identity ( p. 346).

The thin body beautiful is an offer within easy reach of any girl of our current culture to erect a defensive compensatory organizacción . Facing the displeasure unaware of any such experiences can be activated behavior patterns that produce immediate pleasure .

The most puzzling to an outside observer is what pleasure enclosing undergo so great deprivation , and hypotheses are put forward all kinds masochistic pleasure , eroticism of hunger , ( Kestemberg , 1976 , p . 187 ) phallic pleasure in the body erect and thin oral orgasm ( Kestemberg , 1976 , p . 159 ) ; Hogan argues that an anorexic enough to observe in the table to check his oral sadism " Slowly cut food into tiny particles , sorting them into the dish from highest to lowest . Each portion is dissected and turned into threads, which are crushed , squeezed , chewing , and finally swallowed a grimace . A meal can take an hour , during which each portion is mutilated . The aggression is rooted in orality. The anorexic has not developed a superego that will provide a guide to transform oral aggression "( in Wilson , 1983 , p . 135 ) .

Case in 90-95 % of women affected by this disorder , the only pleasure possible, though hidden , they attribute certain trends seem to be the sexual and narcissism that leads to vigorous levels of asceticism , renunciation and desires off and needs bordering on the impossible. This is the rule in mountaineers and climbers who undergo states of deprivation , physical suffering and risk their lives in pursuit of a rare narcissistic triumph for the rest of humanity , but nobody thinks to argue that these behaviors are orgasm expression of snow.

Can anorexia / bulimia in adolescence is always preceded by a period of infantile anorexia ?

A considerable number of authors in the psychoanalytic literature that support the approach of infantile
During the period in which Maria Angeles agoraphobia leaves school , the father asked for a month to accompany her , trying not to lose the year , and then has a picture of angina. The mother, leaves his job under pressure from her husband who induced to accept an early retirement. In the interview with the couple of parents, he fails to specify an address and the mother cries because he did not want to leave her job . Maria Angeles has a phobic and dependent personality , choose a career for which there is neither prepared nor trained and nobody realizes it ( The choice was made because he found out that his cousin was a civil engineer and that "image he found nice " ) . Faced with the anguish of chaos , in a world that is unpredictable , weight control becomes the possibility that the reinsurer .

Specificity of family psychopathology

Our experience is consistent with respect to both the diversity of the psychological makeup of the patients and their families also show a very wide and varied profile ( Halmi.1978 ; Kog , 1985 ; Dare, 1990 ) . Even the authors of the systemic approach had insisted that both characterize the family of anorexics seem to have abandoned the attempt to give unity as expressed in his last text Selvini Palazzoli et al . , ( 1999 ) : "There is no family of the anorexic " , and lean towards the treatment of " individual and personal dimension of the patient and their parents. " While the psychoanalytic tradition that has been implemented is the cure around the unique configuration of each patient 's inner world , and anorexia / bulimia is not an exception to this principle but on the contrary , however , we think what we do is possible to consider the specific treatment of the symptom.

Resistance to change : the gain of the symptom

Construction of identity

Many of the teenagers today face the task of inventing its own model of femininity as the generational line breaks, or differs significantly from the previous one by the profound changes that have occurred in recent decades about the identity women. The break or change the models of femininity from their mothers redoubles the crisis of adolescence , so that conflicts of the mother- daughter joined those from the genus expansion . We must be present in the therapeutic relationship in patients with anorexia and bulimia this dimension is not regressive , and that conflicts with the mother and / or the other sex containing a claim to the absence or lack of responses from adults for new conflicts genealogy of femininity. It is at this point that the sex / gender of adult analyst as another generation may be questioned , but not holding capacity , empathy and relief attachment figure to accompany the patient on his journey of building an identity containing a female subject position of desire , leaving behind an illusory identity and autonomous morbid " anorexic " ( Frankenburg , 1984 ) .

Superego pathology : the " scruples " of thinness

Surveillance on gram and curves is the theme on which the narcissistic superego exerts these girls all its rigor , is observed a shift in moral strictness of forms and perfection and not in virtue of the soul but body measurements . The intolerance of minimum deviation with respect to desired followed by harsh criticism, self-devaluation , reproach and suffering far from helping to reduce energy redoubles autoexigencia for surveillance. If the poor representation of the search itself rebalancing generated through symptom narcissistic , cruelty or severity of critical consciousness that takes as its focus the eating behavior becomes a torment life permanently. Perfectionism , self-sacrificial tendency , asceticism , traits that are described , mainly in restrictive anorexia , are expressions of narcissistic superego is necessary to deconstruct in therapy. However, this task becomes a real battle transference / countertransference because these personalities in that while the incidence of gender ideals plays a central role , interpersonal relationships - parents, friends , therapist - lack both the narcissistic balance rebalancing as achieving self-imposed targets . Therefore, the condition that precipitates decompensation usually not a lost love or interpersonal conflict but the feeling of failure to reach a target domain , in the sense of autonomy and power to control their lives . In these patients only an analysis of narcissistic superego and its sacrificial - superego imperatives supposedly autonomous but subject to the dictates of the dictatorship of thinness , are able to introduce a gap of change. Narcissistic superego must differentiate in the most classical superego and moral imperatives have nothing to do with the obligation of the moral precepts compliance - caring for others , feelings of guilt , but with the imposition of goals that lead to the identification with grandiose self ( Bleichmar , 1997 ) .

Battle for autonomy in the transfer

So the technical challenge that arises is how to generate a therapeutic relationship in which the patient retains some degree of control over the relationship, by distance or other resources, and at the same time, create conditions that allow the recognition the deep need for emotional contact and self-understanding suffering ( Herscovici , 1993 ) .

It is quite common that the battle for autonomy begins with difficulties surrounding the frame - changing schedules and sessions , which are used effectively to test such a control condition on his part ( Stern , 1992 ) . The question is how much one is allowed to use for these purposes without forcing the patient to repair in an analyst role is being fulfilled. A real challenge for the impersonality contratranferencial , implicit devaluation of the importance of the analyst, can induce feelings of lack of interest or commitment not similar to those it has had on his experience as a child with his parents or , conversely , a battle and forcing that are felt as attempts to control it. With this in mind it is possible to avoid acting from the complementary countertransference , requiring instead a more vivid appreciation and recognition of the strength of the desire for control which is essential to the patient to keep his fragile self-cohesion .

Vulnerability Care Self

We must take into account in holding that suffer from a serious disorder of self-esteem , that this , in turn , is a dimension that is necessary to decompose and know what elements are taken into consideration because, in regard to the ability to accomplish a goal and drawn , seem to have a lot of confidence in themselves and develop strong features of perfectionism and compulsiveness (Gordon , 1989 ; Peñas Lledo , 1999 ) . They have also resources to carry out such as the multiple strategies to hide or get rid of the food and keep their symptoms secret.

A clear example of the multiple facets of Self , and that together with the deep sense of powerlessness and low self esteem that confirm most authors ( Bruch , 1982 ) , however , is present a dimension of Self vigorous and fierce : chase higher aim to focus their identity. In the restrictive anorexia seen this dimension in its best practices nevertheless considering bulimic - anorexic patients appreciate that as " binges " very low intake volumes , also require a capacity for self-discipline to a purpose. In turn, after the self-reproaches bulimic access redoubled in order to strengthen the target.

Garner and Bemis ( 1982 ) have clearly demonstrated that these patients do not want to lose the fear of gaining weight because it helps them maintain their self-esteem. It is an antagonistic stance against any attempt to change that contratranferenciales creates enormous difficulties for patients because the world is divided into " anxious rescuers and bitter enemies " ( Jessner , 1960). Anorexics mainly received qualifiers such as "savages " ( Gull, 1874 ), " evil , manipulative and deceptive " . Perhaps these features lead to much clinical and oppose avoid psychotherapy. If the psychic work of patients has turned to the demo of its ability to sustain an effort that generates a high valuation , and the need for recognition by others, any deviation can be considered fatal and well worth further effort. Anorexic groups have been neglected by many therapists to see that enhanced the girls away from each other in their eagerness to be competed for change even more able to resist the impositions hospital .

So if it is necessary in any treatment plan to build standardized intake and provide information on the effects of malnutrition , this should be handled through interventions that recognize the threat assessment involving itself , the feeling loss of self-esteem to undergo an external requirement .

transference interpretations

The same applies to transference interpretations that can be considered a kind of intrusion, excessive control or humiliation. Bruch was the first to highlight the difficulty of these patients for any transference interpretation because it is perceived as a form of the therapist to have control over it, based on early experience have been a narcissistic object to their parents. Bruch modified his technique since the trend changing work interpretive toward mirroring and attunement positive way to drive the process of the patient to self-exploration and self-definition. Stern (1992) and Gedo ( 1979 ) recommend management nonverbal, interpreting the transference relationship and the interpretation of the conflicts in the external relations of the patient until the therapeutic alliance is consolidated .

The difficulty in establishing a therapeutic alliance more or less stable

For many of these patients the rivalry and competitiveness erode all relationships , especially with women , which is expressed specifically in the competition for thinness. This constitutes the core of its identity. But the thinness is a very precarious state : once reached all the compromises and comparison with other girls , or with one 's silhouette returns the mirror or contour ( in the tests used to assess the distortion of the scheme ) is a continuous method of assessing the ability to get a goal out of the ordinary , ie graceful exit in the competition.

Competitiveness can be so widespread that all women are valued according to the paramere . They often complain that doctors and therapists - both men and women - just want to " cebarlas " , " them like a pig ," and the woman analyst as " other woman" to which the patient has to be more thin , will reproached with rudeness and hostility bonus. The blame is partly a way to put the remote analyst and excruciating central concern is your self-worth , which is not known in extent and importance. Fight for your thinness in a desperate and lonely struggle against the world - his family , his / her friends , and her therapist. The distrust and reluctance is the rule and should be understood as the extreme sensitivity of the patient to defend the only that makes the rules for the formation of that identity and so lost longed pursued. Tolerating this distance and alliance deficit and infinite patience to wait for the moment of encounter , without blame or guilt on our part, are essential therapeutic tools . Bruch argues that the primary goal is to help these girls find their own meaning for themselves and a range that allows them to realize their moods and impulses.

How much can gain the immunity / therapist with respect to sociocultural pressure for thinness is another intersubjective situation may create a barrier for the formation of the alliance , as the patient may suspect that it will be understood and to share their most intimate secrets and procedures only find the echo of ridicule and rejection / analyst . You need to be very careful , if it is a woman therapist countertransference reactions , if , indeed , is concerned about its own weight. Patients seen not only its own weight but the female therapist who for their own troubles , you can try to look away that becomes the focus of evaluation.

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