Eating Disorders and the Patient’s State of Mind: Anxieties and Mental Wounds Experienced in Infancy

Dr. Tomomi Suzuki
 

An examination of the conflicts that exist in the minds of patients with eating disorders throughout their psychoanalytic psychotherapy.

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Eating disorders tend to develop in adolescence, and appear in more females than males. This set of diseases presents pathologies that derive from the fear of becoming fat, and includes anorexia and overeating followed by self-induced vomiting. Many people are interested in dieting nowadays, with magazines and the Internet running high-profile articles on this subject on a daily basis. Nevertheless, not everyone who diets develops eating disorders. What, then, is the state of mind of individuals who end up developing eating disorders?

States of mind associated with eating disorders
During adolescence, people attempt to separate themselves from their mothers and become independent. This elicits depressive anxieties of a type that they previously experienced during infancy. If they have not been able to feel secure about their relationships with others who play the role of a mother — as a container — in their stage of development, they cannot endure these depressive anxieties. Their mind becomes flooded with feelings of loss of confidence, the helplessness of being alone, intense sorrow, fears of not being able to withstand loss, a sense of emptiness, the fear and anxiety of self-destruction, and a sense of despair. Unless they can feel secure about their relationships with their mothers, they cannot express such anxieties straightforwardly. Even if they do, they cannot feel confident that others would accept such feelings: this in turn induces the fear of abandonment. This is why they try hard all by themselves and somehow make do, patching things up, at least temporarily.

Patients with eating disorders are unable to carry their mental pain by themselves, and cannot rely on the people around them carry it for them, either. They therefore use either food or their own body as their ‘anchor,’ and fulfill their sense of omnipotence by imposing abstinence on themselves and accomplishing the attainment of this goal. They try to gain confidence by obtaining a slim body. Since this does not lead to security or peace of mind in the true sense—the kind they can obtain between themselves and other people, chiefly with their mothers—they end up wanting to lose even more weight. Their only thoughts, all day long, are about losing weight; they become obsessed with food and calories, and about eating and not eating. This way, they can avoid confronting their anxieties, conflict, lack of confidence, and/or loneliness.

An eating disorder, therefore, is a signal which reveals that a person’s supply of defences has run out; it can also be said to be a woman’s first ever attempt to assert herself.

Food and the formation of the mind; and depressive anxieties 
How is food involved in the formation of a person’s mind and interpersonal relationships?

Immediately after human beings are born, their mind has no cohesive form. Although they perceive the phenomena of the world that unfold before their eyes, as well as their own sensations, they are unable to conceptualize them, or understand them systematically. However, their mind still tries to understand what those phenomena of the world and their own sensations are all about.

It is exactly when such workings of the mind are taking place that the infant encounters his mother’s nipple. He detects his mother’s nipple and sucks it, thereby having the experience with an object (a part-object) in the form of the mother’s breasts that provide the pleasantness of a full stomach and the warmth of the skin. This experience connects to obtaining trust in other people and in the self, and to gaining confidence.

This ideal world of love, however, comes to be established by eliminating the painful, bad world. This is what Melanie Klein referred to as the paranoid-schizoid world. For example, if an infant becomes hungry but cannot get hold of his mother’s breasts, he experiences breasts as things that cause him hunger, which is a terrible pain that ends up destroying the self. An infant, from immediately after birth to around 4 or 5 months old, has a mind that is divided into two parts: the good self where he can feel secure, and the bad self that is filled with aggression. The child uses a ‘splitting’ mechanism to separate the bad part from the good part. He then takes good objects into the good self, and projects the bad self into the bad object and excretes it. The self’s good part is strengthened to make it good. On the other hand, since the self’s destructive properties are added, the bad object increases its destructive aggressiveness, giving rise to a persecutory emotion that one is being attacked by this object. This view of the world eventually becomes a world view in which love and hatred are split into opposing halves, such as “rewarding virtue and punishing vice,” and “black and white.” Eating disorder patients live within this view of the world.  

The role of a mother as a ‘container’ (the alpha function) becomes involved here, and children move on to a period in life where their mind tries to maintain a certain unity. The alpha function is a term used by Wilfred Bion that refers to the complex process of changing an unbearable state of mind to something that can be endured; it also refers to the function of converting a physiological sensation into something that is psychologically meaningful. During this period, children begin recognizing that the ‘bad breasts’ towards which they had directed their aggression, and the ‘good breasts’ that provided them with satisfaction, are in fact the same set of breasts. Because of this, the mind of an infant is forced to carry out the work of enduring ambivalence, of leaving intact, love and hatred which are two emotions that had been held on to without being made to coexist. This therefore leads to the development of depressive anxieties within a depressive position. Those who suffer eating disorders remain unable to take on this depressive position.

The development and unfolding of eating disorders
How do patients end up developing eating disorders, and how do the symptoms unfold?

Before developing the disease, patients encounter the anxieties of adolescence in the same way as most people do. Intuitive drives, such as sexual and aggressive impulses, become active, and controlling these drives becomes a challenge. This is also a period of establishing identity, and the girls feel lost amid diverse sets of values. It is at that point that separation from their mothers inevitably begins, and depressive anxieties that originated in infancy are reactivated. Unable to endure these conditions, the girls feel hurt and isolated, and, in the hope of becoming an outstanding presence, they cling to the ways of making their body thin. They discover their raison d’être here: that they can lose weight to a degree that other people cannot match. As they become thin, their sex drive declines, and the pleasure of physical exercise is brought about. This also creates the positive advantage of being able to draw their mothers’ interest and concern, and being able to depend on them once again. The pattern of refusal of food becomes clearly evident.

Even if thinness progresses, it is accompanied by a sense of pleasure, so patients continue to diet, exercise, and study until late at night. They weigh themselves many times a day, instantly calculate the number of calories they absorb, and continue to experience an uplifting of emotions. They gain a feeling of triumph and a sense of omnipotence, for having been able to attain thinness and to thoroughly stick to their plan. “I am able to do what nobody else can.” Some patients ultimately die of malnutrition; in most cases, however, they cannot bear physiological hunger, and the urge to eat wells up from within. A battle then begins, inside the mind, between wanting to eat and knowing that if they eat, they will get fat. Once they do eat, they experience tremendous fear and disappointment. Somewhere in the back of their minds, however, they feel relieved that they have escaped the restraint they had imposed on themselves, of not eating food. Although this is a perception of the healthy self, the pathological self pushes the ‘healthy’ self towards thinness once again by whispering words such as “Terrible things will happen if you eat, you know. You’ll end up becoming fat, and nobody will ever take you seriously; your mother will abandon you unless you are thin; all you have left is despair.” Their pathological self warns them, “You’ve worked so desperately hard so far, but if you eat now, all your efforts will be wasted.” And so, they end up in a vicious cycle: returning to anorexia and hyperactivity, then starting to overeat again.

Or they may use a method of artificially remaining thin while continuing to overeat: they cause themselves to vomit after eating and abuse laxatives. After they vomit, they are stricken with a sense of emptiness and misery. However, they erase this sense of emptiness with a feeling of accomplishment and exhilaration, of having overcome the fear of becoming fat and maintained their slimness. Here, a tendency of perversion is added to their pathologies and , as a result , their symptoms become chronic.  

They begin abusing laxatives since they cannot stand seeing their stomach swell, and detest having food inside their stomach. Since they become uneasy unless they have completely emptied their bowels, they often end up using more and more laxatives.

Their impulse to overeat is a violent sensation, as if they feel forced to eat more and more; as a result, they become terrified by the fear of becoming fat forever. Even so, they end up eating. This brings about only despair, and the feeling that they are powerless; the feeling of depressive anxieties that they had eliminated may return once again. Because of this, they can no longer control their emotions, lose their temper, and become agitated. They scream and shout, “Please do something!” If, at this point, they decide to seek help from other people, they can connect other’s to a cure.

The road that leads to a cure begins as the patient seeks a variety of emotions in other people: emotions they no longer can process in terms of their actions and behaviors to lose weight, or, in other words, the sorrow, despair and helplessness of losing their ideal self. While being supported by other people, the patients endure the depressive emotions that accompany overeating, discard the wish for omnipotent control, and accept the reality of the self as it is. Following this course of sorrow leads them along the road to recovery. 

Understanding a patient’s mind while in childhood
A girl with anorexia nervosa said that she tried to be a good daughter because she wanted attention from her depressed mother. In a session, she reported a very anxious dream associating the dream with her birth from mother’s womb. After reporting this dream, she talked about her helpless feelings at the time of separating from her mother in various situations during her life. Occasionally, her therapist tried to contain her anxiety and lonely feelings and helped her to verbalize those emotions. 

We as therapists need to understand that the state of mind of patients with eating disorders that develop in adolescence is associated with depressive anxieties in infancy, and we must hold and ‘contain’ the sense of loneliness experienced during childhood which the patient has held on to up to this point. In the course of psychoanalytic therapy, when a patient’s emotional experiences during childhood emerge as transference, the key, I believe, lies in how a therapist can function as a ‘container.’

References
Agman, G., Gorge, A. (1999). Comment vivre avec une anorexique. Lyon: Edition Josette.  
Bion, W.R. (1962). Learning From Experience. London: Maresfield Reprints (1984).
Klein, M. (1958). 'On the development of mental functioning', in The Writings of Klein, Vol 5 (1975). London: The Hogath Press Ltd.
Klein, M. (1959). On adult world and its root in infancy, in The Writings of Klein, Vol 5 (1975). London: The Hogarth Press Ltd. 
Matuki, K. (2008). Psychoanlytic Understanding and Treatment of Eating Disorders. Tokyo: Shinyoushya.