Episode 219: Eating Disorders: Empathy, Alexithymia, Reflective Function (Blog A)
Liam Browning, David Puder, M.D.
Part A
Eating Disorders: Empathy, Alexithymia, Reflective Function
This article is Part A of the episode with Tom Wooldridge, PsyD. Find Part B here.
None of the authors or speakers have any conflicts of interest.
Family-Based Treatment (FBT) is a widely used approach for treating disordered eating in adolescents by restructuring the family system. It involves a phased approach where responsibility for eating is initially shifted from the patient to the parents or other family members to ensure adequate nutrition and weight restoration. As the patient reaches a healthy weight, control over eating is gradually returned to the patient, while new coping skills are taught to both the patient and family (Rienecke, 2017). In addition to FBT, other effective modalities include cognitive behavioral therapy (CBT), which focuses on changing distorted thoughts and behaviors, and dialectical behavior therapy (DBT), which teaches emotional regulation skills. Nutritional counseling and medical management are also crucial components of comprehensive treatment.
While Family-Based Treatment (FBT), cognitive behavioral therapy (CBT), and dialectical behavior therapy (DBT) have been effective in treating many patients, these approaches can potentially overlook the underlying personality structure and developmental issues contributing to the disorder. Behaviors like starvation or binging are often expressions of deep psychological pain that the individual has struggled to integrate into their personality in a meaningful way. From a developmental and attachment perspective, these symptoms act as a defense mechanism, delaying the integration of unresolved psychological pain from earlier developmental stages.
Oftentimes, the inability to work through this pain stems from alexithymia and poor reflective functioning, which prevent a patient from using words and expressing their psychological pain to enable healing.
In order to sense a patient's pain to begin to understand its origins, we need to be mindful of our countertransference. When working with these patients, particularly in those who are severely ill, the countertransference can be fear, terror, inadequacy, and desperation. We should recognize that these feelings can influence us to act with a sense of urgency and prevent us from slowing down to understand the inner life of the patient. However, not all patients will be ready to engage in psychoanalytic work, especially those who are severely starved and malnourished. In these cases, getting the patient to gain weight first is vital, and the psychoanalytic mindset can instead be used to coordinate the other members of the care team and to help process their countertransference.
The DSM-5 focuses on observable symptoms, describing anorexic or bulimic patients as homogenous groups. However, the underlying personality structure leading to these symptoms is unique to each individual and can be targeted in therapy. According to Thompson-Brenner et al. (2008), there are three types of personality pathology in adolescents with eating disorders:
High-functioning/Perfectionistic
Someone who is high achieving but may be sacrificing their self-care in pursuit of their idealistic achievements
Developmentally, this person often has a highly functioning, self-critical superego and can be a remnant of shame felt from harsh, critical parenting that is intolerant of weakness/failure.
Constricted/Overcontrolled
Someone who is overly rigid in their emotional expression
This is often the patient who has difficulty engaging in therapy, relying on the therapist to take the lead in sessions or over intellectualizing to constrict their emotions.
Emotionally Dysregulated/ Undercontrolled
Someone who has difficulty regulating their impulses and emotions
This patient can be seen as having a (in psychoanalytic terms) “borderline” structure and can struggle with interpersonal relationships.
Understanding these prototypes can facilitate a developmental relationship between the therapist and patient, in which the therapist can assist a patient in their psychological development. For example, if the patient appears to be more aligned with the high-functioning/perfectionistic, the therapist can probe the role of shame in their psychological development vs. looking at how to find emotions in a constricted/overcontrolled patient.
The underlying personality structure can influence the driving factors of a patient’s body dysmorphia. In a narcissistically organized patient, they may view their body in a more grandiose way or they could be a collapsed narcissist and their binging is a means of coping with their inability to be their idealized self.
Alexithymia And Reflective Functioning In Eating Disorders
Alexithymia, the difficulty in feeling emotions and putting them into words, can result from childhood trauma and attachment insecurity.
Patients with eating disorders are very likely to feel alexithymia, and the initial therapeutic work can be difficult to get off the ground.
These patients will describe feeling empty, yet will deny having a problem or believe their problem is related to their weight.
Alexithymia can be a result of poor reflective functioning and/or malnutrition.
Average reflective functioning score in inpatients with eating disorders is 2.8, compare that to borderline personality disorder patients who scored 2.7.
Reflective function is scored on the Adult Attachment Interview and is defined as the ability to assess the mental states of oneself and others and describe the contributing factors to those mental states from development (see Episode 213).
Male Anorexia
It is often said that 10% of anorexics are male, but it is likely 25% or more.
Under recognition of male anorexia stems from conceptualizing anorexia as a “female” condition and lack of help-seeking from males due to shame.
Eating disorders in men may not always conform to the typical “thin” picture of anorexia as seen with females. Instead, they may be more preoccupied with having a lean, muscular physique, blurring the distinction between muscle dysmorphia and anorexia.
Young men with anorexia or muscle dysmorphia are likely to first present with a fixation on their physique and with an extremely rigid diet and exercise routine. Where at one point they may have enjoyed eating out with friends and family, they now restrict themselves to eating only lean meat or to a fixed number of calories and protein.
There is often a childhood history of being teased or bullied, sometimes for their weight, to which the defense is to become muscular.
Rough-and-Tumble Play
Rough-and-tumble play is a form of play between fathers and children that contributes to the development of a child’s self-regulation and ability to express their aggression.
Patients with anorexia are often clinically recognized as having difficulty separating from the family unit and expressing themselves as an individual. Puberty is a vital period of individuation and also coincides with the emergence of anorexic symptoms in many patients. These symptoms can further limit their independence and increase their reliance on the family.
In some instances, the father in these families often fails to step in and help the child with individuation and outward self-expression, a process that requires aggression directed away from the self. Fathers can facilitate this outward-focused aggression by playing in a way that requires the child to assert their dominance.
Father Hunger
Father hunger is the deep emotional need or longing that children feel when they lack a positive and nurturing relationship with their father. When these needs go unmet, it can lead to feelings of abandonment, low self-esteem, and difficulties in forming healthy relationships later in life. Father hunger can manifest in various ways, including a search for father figures, risky behaviors, or a constant pursuit of validation and approval. It can appear in therapy, in which the patient may seek that relationship with the therapist. These feelings can be used positively to help promote emotional development.
Mike Tyson, for example, is often discussed in the context of father hunger due to his tumultuous upbringing and the impact of the absence of a stable father figure in his life. Tyson sought out surrogate father figures to fill the void left by his biological father. The most significant of these was Cus D’Amato, the legendary boxing trainer who took Tyson under his wing when he was a troubled teenager. D’Amato provided Tyson with the discipline, guidance, and affection he craved, and his influence was pivotal in shaping Tyson’s aggression into a world-class boxer.
Father hunger is often observed in patients with eating disorders due to their difficulties in individuation, for which they seek guidance on how to separate from their family of origin and exercise agency.
Abjection
The abject refers to something that exists at the lowest rung of what is considered acceptable— something so far removed from the normal societal standards that it evokes a strong feeling of disgust or repulsion. In psychoanalytic theory, particularly in the work of Julia Kristeva, the abject is closely related to our primal fears and disgusts, such as our reaction to bodily fluids or decay, which ultimately ties back to our fear of mortality and existential dread. However, most people do not think about the abject very often.
People with eating disorders are more often in touch with the abject, and it is demonstrated in their beliefs about their bodies and food, such as “my thighs are disgusting,” “the fat on that steak is disgusting,” the feelings of disgust after binging, and purity after purging.
Probyn (2004) describes this experience:
“Like many, I spent much of my childhood feeling disgusting. However, any evidence of that time is scant. Of the series of photographs that document my childhood, there is an absence that occurs about the time that I was severely anorexic. The reason for the lack of previous documentation is simple: why or how could such a sight be documented? Even now my eyes turn in aversion from memories tinged with a mixture of shame, disgust, and guilt. At the same time, I do remember the splinters of pride that accompanied the disgust: pride at the beautifully prominent set of ribs, the pelvic bones that stood in stark relief, causing shadows to fall on a perfectly concave stomach. Looking back at my experience, I wonder at the forces of pride and shame doing battle in a body that knows itself to be disgusting” (p. 127).
In working with these feelings of abjection, we want to help patients identify these experiences and give voice to them. With improved reflective functioning and mentalization later in therapy, patients can begin to seek out experiences that give feelings of satisfaction with the body.
References:
Probyn, E. (2004) Carnal Appetites: Food Sex Identities. London: Routledge.