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 bout 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 Hypocritical 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 simplification attempting a unification – either early psychogenesis of the mother- daughter or a disorder depreciative discrimination sensations of hunger – leading to the creation of an imaginary psychopathology 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 refinancing is an illusion in the optimization of her culture deliquesce offers . Eaten , puppetry Ana adolescence Tamale explain tongue recreational conceptions as regression to premedical 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/ individuation in infancy incomplete without highlighting the complexity and scope of the problematic adolescence unpublished opens , with facial feature in the present era .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, IEEE , 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 miscommunication of female identity , conflict between narcissistic desires intrastate 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 destructing effects and destructive to the personality and fife 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 intricacies 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 ( Deutsche, 1940 ; Blitzed, 1961 Spelling, in Wilson , 1983 ; Strauss, 1987 ) , eating disorders ( ADSM , pathology weight or weight phobia (Crisp , 1970 ; Chalky 1977, Hall, 1986) , narcissistic balance deregulation (Jammed , 1991 ) refer to different levels of analysis of the table: 1 – Nine motivation Tanat triggers ten Lassoer : motivational settling staleness the pursuit of thinness for stabilization Self narcissistic balance , that motivation to come 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 ND 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 Anastasia 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 consider¤reseal undetermined and under empirical testing and statistics, are suspected to be related to the psychic . On the other hand , who suffers from hypertension Ana anneal ulcer , go to ten doctor looking Tort solutions. None AT t 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 homonyms do not Justify its conception as psychosomatic ailment . It seems more appropriate, then, conceptually define anorexia / bulimia as they did in their early Lass©guy ( hysterical neurosis , 1884 ) and Gull (anorexia nervous , 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 hypersonic , both additional 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 dystrophy .
These characteristics of the psychoanalytic literature box has called in several ways: mental emptiness , reduction imaginary deficit phantasmagoria capacity , difficulty in associating , the near impossibility of remembering ( Stromberg , 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 , allied legitimate by Ossifies box and Anemia ( 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 ( Zones of Guerrilla , 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 recessing of affect via psychic . Registration of bodily sensations would be found altered Day contraltos Tanat can range Trot : 1 a Day too narcolepsy Day ten 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 liberalized , semanticists not expressed through phrases like” I’m empty , do not get to the bottom , I know my limit . Hilled Brunch was the first to call attention to the defects in self-perception and self-regulation of feelings of hunger in feeding transoms , which today is one of the upscale of the Questionnaire of Eating Disorders ( EDI , Garner , Almagest and Policy , 1983 ) , entitled: ” intransitive 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 ) Brunch 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 defecation’s .
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 n cases of infantile anorexia , which creates serious reservations to hold its ground in the anorexia / bulimia almost exclusively in women. In 1969 Brunch 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 intransitive one early nondiscrimination basis . But while obesity is included among alimentary 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 (Capper et al . , 1977 ; Garfield & 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 , ere 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 regale Nils normal Tie Ana s restriction continual In turn, although many patients with bulimia appear physically good health may have psychological and physical correlates of seminarian such as depression, irritability and obsessive tendencies . So much of the psychic symptoms as -egg obsessive trend around issues related to food , dyslectic states , irritability , social isolation and mental emptying the need o 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 – synoptic , 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 (ADSM- ‘ V) , symptoms frequently appear as a continuum between hose of anorexia nervous and bulimia nervous the . Patients with anorexia may alternate between restrictive and bulimic periods in different stages of their evolution . And among the bulimic type of anorexia nervous 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 n Hippocrates , Galen and bulimia in the Talmud , as well as the practices of Teresa of Avail with an olive branch to induce vomiting ( Blinder , 1992 ; Read , 1997). In the past century , we already have Lass©guy publications ( 1873 ) Gull in the British Medical Journal ( 1874) , and photographs of Miss KERR 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 ass , and mainly from the 70 that is starting to how a significant increase in the incidence and epidemic begins to talk want we see as ten Iterance , Desires ten under , Including anorexia / bulimia in the past and the present ?
That adolescents with severe commodity 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 Binger’s 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 Kremlin , Bubbler and simple schizophrenia by Binger’s , psychopathic constitution progressive development another psychiatrist , and something like a endocrine endogenous psychosis Cut endogenously (Chinchilla , 1994; Iris Lazarus , 1999). If we compare the case of Ellen West with data from a recent work of Golden et l . 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 hat had been appearing to the present. The rest has to do with new factors that add even more questions to a disorder that continues catalog¤undoes 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 ; Kindler , 1995; Funnel 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 infatuations that may trigger the symptom Syndrome and specificity causal Glove ten clinical data snowing sun a wee Trace – neurotic , synoptic Ana 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 ; Selling Palazzo , 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 teal . 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 anger . 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 ordinance of narcissistic system linked to a bodily attribute that functions both as a) a gender stereotype narcissistic ensuring mirroring b ) as an essential qualification for a activity: gymnasts , models , acrobats , climbers ( Nude , 1989, Manna , 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 ; Thiele , 1998 ) for its high morbidity and prevalence in the life cycle ( Fay , 1993 ; Skives , 1986; Rubberiest , 1992). Some authors like Noshing et al . 1991 ) , holding a divergent gender factor would explain the high incidence of anorexia / bulimia in women . We agree with these autonomous on ten Importance AT gender equal In particular teeming 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 he other hand , wish-fulfillment of narcissistic motivational system . In anorexia / bulimia anxieties of which protects symptom observation¶n 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 ( Bald , 1996 ; Connors, 1993 ; Everett , 1995 ; Rye , 1991 ; Martinez sessions , 1999 ; pope, 1991, Schwartz, 1996, Weatherman , 1998). Body involvement obey a form of resolution symptom 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 ( Selling
Palazzo ‘ 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 ” (Carney’s , 1996) . May . – Symptom into a major pathology Depressive states are considered as predisposing condition associated or consequence AT a plectrum AT anorexia / Dually (Capper , HOBBY ; cadets Hernandez, 1998 ) , and its manifestations are very similar : sleep disorders, social withdrawal , creased 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 impulsively. Periods of food restriction schizophrenic psychosis boxes are also described . Chronic factors Many patients suffer from this table in a chronic recurrent hospitalizing 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 Garfield 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 intricacies balance . Correlation between symptoms and intricacies structure Is there then any psychic structure stable and specific for anorexia / bulimia or should we consider his position as transshipping and translucently ( Jammed , 1985 ) , or divide the picture in subtypes of psychopathology or characteristic underlying Monsoons ; Connors , 1988 ; Swift ; Stern , 1982 ; Selling Palazzo” , 1999) ?
We Joined the holding Jammed approach and Brushes (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 elation ” ( 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 / bulimic . 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
