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Anorexia nervosa: Controversial aspects of therapy
Comprehensive Official
Journal
of the American
Psychiatry Psychopathological
Association
MAY / JUNE 1980
VOL. 21, NO. 3
Anorexia Nervosa: Controversial Aspects of Therapy Eugene
Piazza, Nina Piazza, and Nancy Rollins
A
BAFFLING ARRAY of data has been accumulated about the syndrome of anorexia nervosa since it was first described by Morton in 1689 and defined by Gull in 1874. The chronicity, resistance to treatment, and mortality associated with it have led to a succession of treatment modalities that have focused primarily on one or another level of dysfunction, defined here as the neuroendocrine, psychophysiological, intrapsychic, and intrafamilial (Fig. 1). At the neuroendocrine level, various drugs-hormones, insulin, thyroid, gonadal, and pituitary-adrenal, as well as antidepressants, antipsychotics and tranquilizers-have been used in therapy.‘-” Attention to neurological factors has included the use of anticonvulsant medications and appetite stimulants and depressants.A Electroconvulsive therapy and leucotomy have been reserved for the patient in life-threatening circumstances.“,‘; The psychophysiological level of dysfunction has been treated by focusing on nutritional needs: diets, supplemental feedings, oral or via nasogastric or gastrostomy tube or parenterally, intravenous and indwelling venous catheter.? Behavior modification methods using various reinforcers such as supplemental feedings, amount of activity, medication, and social privileges, have been used with increasing frequency in the past 10 yr.+“’ At the intrapsychic level of dysfunction, analysis, individual psychotherapy, relationship therapy, and milieu therapy have all been used in treating the syndrome.1’-‘3 Family therapy recently has focused attention on the intrafamilial level of dysfunction. Even the diagnostic criteria of anorexia nervosa have been controversial. In a recent paper, we noted the need for accepted diagnostic standards that should be neither too restrictive nor too inclusive, and have devised the following critera: a 20% weight loss or a weight loss of 20% or more of expected weight for height and age; amenorrhea in females; body image distortion; and a pervasive sense of inadequacy.
Eugene Piazza, M.D.: Associate in Psychiatp, Children’s Hospital Medical Center, Instructor in Psychiatq. Harvard Medical School: Nina Piazza, M.S.W., A.C.S.W.; Nancy Rollins. M.D., Associate in Psychiatry. Children’s Hospital Medical Center, Assistant Clinical Professor of Psychiatry, Harrrard Medical School. Address reprint requests to Dr. Eugene Piazza, Department of Psqchiatv. Children’s Hospital Medical Center, 300 Longwood Ar,enue. Boston, Mass. 02115. @ 1980 by Crane di Stratton. Inc. 0010-440X/80/2103-000~$02.00~0 Comprehensive
Psychiatry,
Vol. 21, No. 3 (May/June),
1980
177
PIAZZA,
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Therapeutic
Levels of Dysfunction in Anorexia Nervosa
PIAZZA,
AND
ROLLINS
Interventions
Diet Supplemental feedings
‘izogastric \
Nutritional
tubes
\ :~:~:$zz---
:zzl:n”,” Venous Catheter
/ -Behavior
Psychophysiologic-
Modification
Supplemental
\
feedings
Social privileges \
\ Psycho-Active Drugs and depressants
\
Family Therapy Casework with Parents Individual Psychotherapy Milieu Therapy
Neuro-Transmitters
Neuroendocrine-
/ \
Fig. 1.
Electra-Convulsive
\
Therapy
Leucotomy
Levels of dysfunction and therapeutic
interventions
in anorexia nervosa.
Despite the confusion of diagnostic criteria and the multiplicity of therapeutic approaches, recent outcome studies tend to indicate that the various approaches lead to similar results: two-thirds of the patients recover or are markedly improved, and a quarter to a third have a poor outcome. It is the thesis of this article that: (1) multiple levels of the organization of matter are involved in the predisposing, precipitating factors, and manifest symp-
ANOREXIA
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tomatology of anorexia nervosa and therefore in the therapeutic interventions needed, and (2) anorexia nervosa cannot be exclusively conceptualized as a small group systems phenomenon. DESCRIPTIVE
PSYCHOPATHOLOGY
Over the past 10 yr in our work with 84 patients hospitalized for weight loss due to failure to eat, there were 70 who met our Children’s Hospital Medical Center (CHMC) diagnostic criteria for anorexia, described earlier. In our review of the diagnostic features, we defined anorexia nervosa as a syndrome, a cluster of symptoms, and signs at both the physical and psychological levels with a characteristic psychopathology. l4 Most unique is the distorted body image that coexists with and is reinforced by anxiety-laden fantasies concerning the body. These fantasies may be expressed somatically, as a feeling of fullness, or emotionally as a fear of fatness. The deep-seated sense of inadequacy with depression is related to the body image distortion and to the perceptual difficulties in correctly reading body signals. The self-distrust involves the body sphere and other areas of life, including social perceptions and intellectual judgment. We noted that the major features of the syndrome are also characteristic to a lesser degree of normal adolescent development: moodiness, emotional iability, self-doubt, crash dieting, preoccupation with body size, and other forms of self-absorption. In several ways, our descriptive data supported a view of anorexia, at least in our young population, as a pathological deviation of adolescent development. Our data indicate the anorectic symptoms characteristically begin after the pubertal growth spurt and appearance of secondary sex characteristics. We wondered whether the period of rapid growth might be accompanied by a temporary normal instability of the body image that could act as a precipitating factor for the manifest syndrome. Furthermore, we found that the essential psychopathology exists in different types of personality organizations; different personality types experienced the central body distortions in dissimilar ways, depending on defensive style. Secretive, withholding, and hysterical types of patients were less likely to present the classical open acknowledgment of fear of fatness. Our observations of anorexia in other cultures highlight certain values shared by the developed countries of the world: competitiveness, overvaluation of achievement, and thinness as signs of competence seemed related to the onset of the disorder wherever it occurred. For us, however, it seemed that such factors would be powerless to produce such severe pathology unless a predisposing vulnerability and/or an enmeshed family system were also present. We come now to the question of physical and psychological vulnerability and its objective documentation in our patients. The mean height percentile for our group was 33.8, and 19 of the 70 (27%) were at or below the tenth percentile for height. This short stature group had a significantly higher percentage of secondary diagnoses and accounted for 3 of the 5 schizophrenics in the group of 70. These patients also had a significantly longer duration of weight loss before admission and a longer hospitalization (Tables 1 and 2). These findings point at
PIAZZA,
180 Table
PIAZZA,
AND ROLLINS
1. Comparison of Total Group Who Met Criteria for Anorexia Nervosa to Group of “Short Stature” Patients (i.e., Below 1Oth Percentile for Height) Total Group
Shot?Stature .95
Variable
Age at admission Height percentile at admission Males Females Previous high weight Weight at admission Weight at discharge Percent weight loss Age at menarche Expected weight for height and age High weight as percent of expected weight Admission weight as percent of expected weight Weight gain in hospital (AMA deleted) Age at onset of weight loss Males Females Duration of hospitalization (total) Proportion of weight gained in hospital Weight loss before admission Duration of hospitalization on PSU Age of onset of weight loss Admission percent weight loss from expected weight for height and age Duration of weight loss
R
Mean
70
14.6 yr
70 9 61 70 70 70 70 37
33.8 percentile 39.1 percentile 33.0 percentile 105.8 lb 72.3 lb 89.6 lb 31.1% 12.5 yr
70
Significant*
Confidence Interval
n
Mean
Difference
0
14.07-15.05
19
14.5yr
27.73-39.86 13.55-64.66 26.78-39.25 102.42-I 14.97 68.8-75.7 85.4-93.9 29.0-33.2 11.98-12.96
19 3 13 19 19 19 19 8
3.81 percentile 4.0 percentile 3.8 percentile 100.3 lb 62.0 lb 78.4 lb 30.7 % 12.6 yr
103.9 lb
98.3-109.5
19
79.7 lb
+
70
102.6 lb
98.6-106.5
19
112.9 lb
+
70
70.7 %
68.3-73.1
19
78.6 96
+
65
18.3 lb
16.0-21.3
18
17.1 lb
70 9
13.8 yr 13.0 yr
13.3-14.3 11.6-14.4
61
13.9 yr
13.4-14.3
19 3 16
13.6 yr 12.9 yr 13.7 yr
65
142 days
116.8-166.2
18
179 days
+
65
18.6 %
15.9-21.2
17
22.6 96
+
70
33.5 Ib
29.66-37.32
19
30.7 lb
65
124 days
101-146
18
142 days
70
13.8 yr
13.3-14.3
19
13.6
70 70
29 96 39.5 wk
27.1-31.8 33.6-45.4
19 19
22% 47.6 wk
+ +
*Criterion of significance: the mean of the “short stature” group is considered significant only if it falls outside confidence interval of larger group.
least in one subgroup to a predisposing vulnerability relating to long-standing nutritional problems, which in turn could be related to distortions in body perception, and early mother-child interaction difficulties. Although individual case histories yield convincing evidence of vulnerability, we were unable to document a statistical relationship between medical outcome and natal and neonatal histories of eating or mother-infant disturbances. What part do precipitating external factors play in the onset of anorexia? We found that loss through death or separation or a symbolic loss were associated with the onset of anorexia in 78% of 37 cases.
ANOREXIA
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NERVOSA
Table 2. Comparison of Total Group Who Met Criteria for Anorexia Nervosa to Group of “Short Stature” Patients (La. Below 10th Parcantlle for Height) “Short Stature”
Total Group Variable
”
Frequency 96
.95 Confidence Interval
Significant ”
Frequency %
Difference’
Proportion males Somatic complaints Preoccupation with food Vomiting
70 70 70 68
9 49 62 17
13 70 89 25
21-5 81-59 96-82 35-15
19 19 19 18
3 13 16 6
16 68 84 33
0 0 0 0
Secretive behavior with food
70
32
46
58-34
19
9
47
0
69
66
96
91-100
19
19
100
0
70 69 69
51 21 20
73 30 29
83-63 41-19 40-18
19 18 18
13 5 2
68 27 11
0 0 +
Depression Edema Cyanosis Excessive body hair
70 70 70 70
65 7 11 11
93 10 16 16
99-87 17-3 25-7 25-7
19 19 19 19
18 3 3 6
95 16 16 32
0 0 0 +
Presence of secondary psychiatric diagnosis Schizophrenia
70 70
32 5
46
58-34 13-l
19 19
12 3
63 16
+ +
Denial of physical or emotional illness Altered activity level Sensitivity to cold Bulimia, gorging
7
*Criterion of significance: the percent of “short stature” group is considered significantly different only if it falls outside the confidence interval of the larger group.
DEVELOPMENT
OF A TREATMENT PROGRAM HOSPITAL
AT CHILDREN’S
A treatment program for anorectic patients was developed at the Psychosomatic Unit of the Children’s Hospital Medical Center, addressing all four levels of dysfunction. The therapeutic program begins with an initial evaluation, including complete history and physical examination, with lab tests as indicated, and psychological testing. Milieu treatment evolved over a 3-4-yr period. Our first priority is the patient’s survival; this entails an evaluation of his/her nutritional state and reassurance that we will be diligent in caring for his/her nutritional needs and, at the same time, recognizing his/her fears that we will make her fat. Patients are weighed daily and vital signs are monitored until stable. When the patient has begun to gain weight and eating patterns are more normal, the pediatrician discusses with the patient normal value for height and weight, and then, with the patient’s participation, sets a weight goal with a 5--IO-lb range. Staff and patients eat together, staff members providing modeling as well as support during the mealtimes, while avoiding lengthy intellectualizing and obsessing about food and weight. Efforts are aimed at providing a corrective emotional experience to counter the withdrawn, isolated behavior and shallow relationships often seen at admission. As the nutritional state improves, the focus shifts to social rehabilitation. The patient is encouraged to participate in age-appropriate activities provided by specialists in arts, crafts, dance, music, and drama, and to attend the residential school. Each patient is provided a staff member (child-care worker or nurse)
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AND ROLLINS
with whom he or she has the opportunity to develop a special relationship. This staff person is responsible for coordinating plans for the patient and communicating the child’s progress at weekly team meetings. This treatment team is chaired by the psychiatric resident and includes the pediatrician, the individual psychotherapist, social worker, head nurse, and the “Special.” The “Special” is one of the most important staff persons during the child’s stay on the Unit. Indeed, at follow-up the relationship with the “Special” has often been singled out by the parents themselves as having been the most helpful aspect of hospitalization. Each child is also assigned a psychotherapist who sees him or her twice weekly. The team decides when the patient is able to be involved in milieu activities and attend the residential school. Psychoactive medications are prescribed when indicated: i.e., when depression and withdrawal are the overriding symptoms, antidepressants are used; if overwhelming anxiety interferes with the patient’s ability to utilize milieu activities or individual therapy, major tranquilizers are used. Fourteen of the 70 patients received psychoactive medications-10 were treated with antidepressants, 2 with antipsychotics, and 2 were on a combination of antidepressants and antipsychotic medications. The family is crucial both in our understanding of the anorectic patient and in formulating a treatment plan. In many cases, there is a strong, hostile, controlling, and guilt-instilling relationship between the patient and family. For this reason, initially, informal visits and planned family activities occur on the Unit and are attended by staff, providing an opportunity for later review of interactional patterns with the patient. As treatment progresses, the patient is allowed visits off the Unit, after which patient and staff review the visits, paying attention to areas of conflict resulting in stress. These visits are increased gradually to the point where the patient can spend entire weekends at home prior to discharge. Treatment of the family usually includes an early family diagnostic interview with the social worker and the individual therapist. This may lead to family therapy as the primary treatment modality. Most often, however, we find the combination of family and individual treatment appears to be the most effective. All parents are expected to attend a weekly parents’ group. Issues in parents’ group develop first when new parents share their anxieties about having a child admitted to the Psychosomatic Unit and their self-doubts and guilt over the illness. It is supportive to hear from other parents who are at different stages of treatment and can recall their own distress when their child was first admitted. The group process is also beneficial in dealing with the parents’ sense of bewilderment at having to relate to a large staff and to deal with their fear that their parental role has been usurped. DEVELOPING
A FAMILY
APPROACH
Since 1961, we have been impressed with the degree of preoccupation with food, eating, and weight in the families of anorectics,‘5 noting the “family neurosis . . . the neurotic compliance of environment.” l6
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By 1968, we described two stages in the treatment of anorexia nervosa. Stage 1 involved managing the acute anorexia (usually in the hospital), with a decisive
role played by the parents, whose emotional permission for the child to relate to our staff was of critical importance. Using Winicott’s concept of “holding,” I7 therapy was focused on providing emotional support for the parents so they could work out their anxiety and ambivalence; only then could they give permission to their child to accept hospitalization. as traditional psychoanalytical oriented psyStage 2 was conceived chotherapy, directed to intrapsychic conflicts of selected patients able and willing to participate in seif-expIoration.11 During the early 7Os, we introduced family treatment, using Minuchin’s concepts of pathological family structures. lx We retained individual psychotherapy for the anorectic child, finding the two concepts complementary rather than conflictual. In common with Minuchin, we observed the following features of “psychosomatic” families: overconcern and overprotectiveness around physical health; enmeshment of family members, especially the anorectic and one parent; submerged or unresolved intrafamily conflict; rigidity and resistance to change. Two pathological family structures most commonly seen were: a stable coalition between the anorectic and one parent, and a detouring of marital conflict through the anorectic child. However, in contrast to Minuchin, we found the critical psychopathology was often the unconscious repetition in the mother’s relationship with her anorectic daughter of her conflicted relationship with her own mother; i.e., the detouring through the anorectic child is of an intrapsychic conflict with one parent, not a marital conflict. We also were impressed with the inappropriate role definitions displayed by the anorectic children in their families, as peacemakers and as protectors of a vulnerable parent. This latter situation often resulted in a family coalition against the therapeutic team, and a conflict for the child who wished to be free of the inappropriate role, yet remain loyal to the afflicted parent. Other structural shifts were observed as therapy moved to a deeper level. For example, the anorectic’s seeming dependence on the mother in a stable. protective coalition not infrequently covered a strong Oedipal relationship with the father. When the anorectic symptoms abated, and the Oedipal attachment surfaced, the mother would react with anger, jealousy, and a guilty sense of bewilderment. It has not been uncommon in our experience for the parents to refuse to enter therapy for their marital problems when they finally surface. Family resistance combined with institutional resistance (e.g., traditional psychoanalytic orientation) to produce powerful and at times irrational barriers to the exclusive use of family therapy for anorexia nervosa in our setting. However, many of our observations of the physical and psychological state of our patients realistically did not fit with a redefinition of the anorectic symptomatology as exclusively a problem of family structure and interactional patterns. The patients were usually physically sick with depressed vital signs, and psychologically their communications were filled with ample evidence of distortions of body image, inability to interpret correctly body signals of cold.
PIAZZA,
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PIAZZA,
AND ROLLINS
fatigue, hunger, and sexual feelings, not to mention low self-esteem, chronic depression, fear of puberty, and timidity in peer relationships. These matters really were their business and had to be treated as intrapsychic issues. FAMILY
THERAPY
IS NOT ENOUGH
June was a 13+-yr-old girl readmitted for her fourth hospitalization for anorexia, nearly dead with a weight of 55.5 lb, pulse 36, and temperature 93.6. Her weight loss had begun a year before in a conscious effort to become thinner. At her third hospitalization, June was transferred from a medical ward to the Psychosomatic Unit where the primary focus was on family therapy. At this time the family system pathology could be formulated as a stable coalition between June and her father, who played with her an intense, nurturant maternal role with elements of angry despair. The family was closely knit with poor differentiation of members. The parents were in chronic disagreement regarding management of June’s eating, and in regard to the degree of autonomy permitted the children. June, more than her three older brothers and one younger sister, had grown up not making decisions for herself. Her special position in the family focused everyone’s attention on her. Family therapy was continued after hospitalization, the emphasis being on encouraging the parents to work together with father in a more dominant role. Ten days later, June was admitted for the fourth hospitalization, in the condition previously described. She was agitated, frightened, wishing to die, plagued by contradictory voices telling her both to eat and not to eat. In a supper interview with the whole family, it became clear that both parents unconsciously promoted June’s special place in the family by not serving her a plate of food, because, they said, the hospital had her on supplements; they then revealed how they had undermined the nutritional program by not requiring June to take her supplements on the home visits. June acted out her feeling of not belonging to the family by standing at the end of the table, apart from the family group. Individual therapy then allowed June to express her depression and uneasiness when she went home and her inability to admit these feelings because of her anguish and guilt over hurting her parents. Family therapy focused on helping the parents stand together and support hospital policies. June and her mother were brought closer, June telling mother things painful for her to hear, and mother reflecting on her habit of being overprotective and overcontrolling with June. Yet, these shifts were insufficient for June to relinquish her not eating, which insured her a special position as a sick child. Though she expressed anger and defiance in individual sessions, she did not give the impression of being a separate self with independent wishes, feelings, and plans. In short, June’s anorexia was not only a symptom of small group system pathology in the here and now. To understand the multiplicity of levels involved in this case, it is necessary to return to the concept of vulnerability. Indeed, June was special, right from birth. During her pregnancy with June, her mother had flu, vomiting, and weight loss, and hemorrhaged just before labor. June was born with a club foot and underdeveloped muscles of the leg, necessitating four hospitalizations between 4 and 15 mo, and immobilization in a leg cast until 2 yr. June was
ANOREXIA
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185
brought home from the last hospitalization on the day of paternal grandmother’s funeral, the grandmother having spent several years in a psychiatric hospital. One week later, June’s younger sister was born. Thus June approached puberty with a complex vulnerability: (I) possible genetic predisposition from mental illness in father’s family; (2) intrauterine trauma from mother’s hemorrhaging; (3) the congenital birth defect and its treatment; (4) alterations in the early mother-infant relationship; and (5) early displacement by a sister. The multiplicity of the levels of the disturbance suggests a multiple level approach to therapy would be needed. The history shows that family intervention was not enough. “GROWING
UP ABSURDLY”:
INTRAPSYCHIC
ISSUES
June’s case was presented in some detail to demonstrate the kind of clinical evidence leading us to the conclusion that predisposing vulnerability, intrapsychic conflict, and a developmental perspective must be added to family system considerations in formulating the pathology and appropriate therapeutic interventions in anorexia. One patient, after her anorexia was resolved, wrote of herself as seeming to have been self-sufficient, mature, and intelligent to others, but always feeling ugly, having low self-esteem, and being ‘*. . . a very secret person, growing up quite absurdly.” Our experience parallels that of Hilda Bruchiy wherein the prominent intrapsychic issues are control, fear of loss of control, first displaced to eating and weight, but ultimately found to apply to emotions and impulses in a broad sense, both libidinal and aggressive. As with many anorectics, this patient tried to control the rate of her own growth through self-starvation, preventing herself from growing up. Her low self-esteem and chronic depression were found, in therapy, to be linked to a lack of a sense of self and the issue of identity. These patients have a long-standing distrust of themselves and their capacity to process their perceptual experience, suggesting a disturbance in the formation and development of the “body ego,” the precursor of later ego development. In a child thus rendered vulnerable, the developmental phases of adolescence trigger the overt anorectic episode. The demands for individuation and independent functioning conflict with the ‘demands of a pathologically enmeshed family system. Another intrapsychic issue in late adolescence may be heterosexual intimacy with its requirement of further emotional separation from the primary love objects and stimulation of anxiety-laden fantasies about the body, linked with distortions of body perception. An additional issue for individual treatment has often been the relinquishing of unrealistic self-demands for healing marital conflict, parental depression, etc., once these inappropriate role definitions have been identified. This is both a family and an individual treatment issue. TOWARD
A MULTIDIMENSIONAL
SCHEMA
FOR ANOREXIA
NERVOSA
It will be recalled that our preliminary studies had led us to formulate anorexia nervosa as a developmental deviation, the decompensation becoming
186
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manifest at the preadolescent or early adolescent stage. A conceptual schema was developed for the pathogenesis of anorexia, including the developmental or epigenetic dimensions and the dimension of levels of organization of matter, as Fig. 2 shows. The relevant levels include the neuroendocrine, psychophysiological, intrapsychic, and social. The schema* calls for a latent phase, starting in infancy, and a precipitating symptomatic phase at adolescence. In the latent phase, faulty perception of interoceptive stimuli (hunger, fatigue, temperature, etc.) and disturbed body rhythms (hunger-satiation, sleep-wakefulness, physical activity level, and mood fluctuations) are together conceived as a basic disturbance in the “body ego,” the precursor of ego development. The determinants of this body ego disturbance in infancy probably operate on at least three levels: (I) Congenital neuroendocrine vulnerability. (2) Dyadic interpersonal relationship: an interaction between mother and infant characterized by excessive projective identification, as described by Hilda Bruch .lg The mothers’ projections impede their correct reading of signals from the infants, who in turn fail to learn how to read correctly the signals coming from their own bodies. This could lead to disturbances of basic body rhythms. (3) Family system disturbances: characteristic features include enmeshment, rigidity, overprotectiveness, and triangulation, as described by Minuchin.18 It is postulated that the faulty body ego in turn leads to or exists with other developing defects in the forming ego, including uncertainty regarding cognitive processes with distrust of intellectual judgment, lack of a firm sense of self, uncertainty in object relationships, and rigid or inadequate defenses. These body image distortions may become associated with fantasies and introjected good and bad objects. The symptomatic phase at preadolescence or adolescence is characterized by a heightening of the sense of inadequacy, increasing depression, more obvious distortion of the body image, and neuroendocrine disturbances. Precipitating factors again operate on many levels, including the neuroendocrine factors of pubescence; intrapsychic adolescent issues of independence, individuation, and sexuality; loss, with its impact on the patient and the family system; the requirements of a pathological family system conflicting with the developmental needs of the individual: and the impact of cultural values on the patient and family system. There is also a regressive reactivation of earlier problems, especially pathological splitting of good and bad internal and re-externalized images; this may lead to attempts to exorcise the bad internal mother image, leading to starvation, vomiting, and suicidal impulses. If such a multilevel formulation is useful in understanding the pathogenesis of anorexia nervosa, it can be seen that there are also multiple levels of intervention. Individual psychotherapy and the relationship with the “Special” on the Unit deal with the problems of self-definition and support the normal adolescent development. Depression is diminished, self-esteem is improved, and
* The thoughtful comments of two colleagues, John Coolidge, M.D., and Ethel Walsh, M&W., stimulated the development of this schema.
-
-
I
I
I
4
Faulty Ego Development
Faulty perception of interoceptive stimuli (hunger, thirst, fatigue, temperature, sex, etc.)
T Loss --+
I
Larger social system Cultural values
Rigid or inadequate defenses
I
Disturbed body rhythms Hunger-Satiation Sleep-Wakefulness Physical activity level Mood
Family system Pathological enmeshment, rigidity, overprotectiveness
Family system X1requirements: Conflicts withintrapsychic developmental needs I
of anorexia nervose.
Factors
schema of pathogenesis
4
Levels of Precipitating
t Intrapsychic factors Adolescent issues lndividuation t-Independence Sexuality
4 Symptoms: Pervasive sense of inadequacy Depression; Distortion of body image Neuroendocrine instability
Uncertainty re cognitive processes Distrust of intellectual judgment
!
c---------,
level: defects of body awareness
Verbal level: defects in ego boundaries
Multidimensional
/ factors
Fig. 2.
Neuroendocrine Pubescence
Symptomatic phase Reactivation of early problems
Precipitating:
c---------
Preverbal
Factors
1 Faulty Ego Precursors
Dyadic interpersonal relationship Mother-infant interaction Excessive maternal projective identification
Lack of of self c-------j individuation
Faulty synthesis of internal and external stimuli
Uncertainty re object relations -sense
Latent phase
Predisposition:
Congenital Neuroendocrine Vulnerability
A
Levels of Predisposing
PIAZZA, PIAZZA, AND ROLLINS
188
emotions are allowed more honest expression. At the intrafamilial level, family visiting on the Psychosomatic Unit, home visiting, family therapy, casework with the parents, and the family implications of change in the anorectic patient may all operate to contribute to healthier functioning of the family system. It may be useful to assume that any treatment strengthening and supporting fulfillment of the tasks of adolescent development will increase the probability of a favorable outcome. From the developmental point of view, the strong relationship with the psychotherapist and/or the “Special,” the nutritional protocol, and the ward routines tend to recreate in the hospital the early mother-infant relationship: symbiotic fusion followed by a “weaning” process. In this context, the splitting mechanisms can be challenged, sadness and guilt over destructive wishes may be expressed, and feelings of depression over the relinquishing of infantile positions may be dealt with. At the intrafamilial level, the family conflict tends to be recreated between the anorectic child and the staff, especially the conflict between normal adolescent developmental needs and the needs of an unhealthy family system that discourages individuation and adolescent efforts at emancipation. In conclusion, many of the controversies concerning the treatment of anorexia nervosa become false issues when they are examined from this dual perspective of levels of organization and development. In particular, the issue of family versus individual psychotherapy no longer is relevant since a combination of both is needed in a flexible approach, with interventions at several different levels. This flexibiiity should include a willingness to try whatever approach best suits the patient’s needs and to combine and shift therapies when necessary. The capacity, particularly of the prepubertal or severe anorectic to “work through” a massive negative transference is frequently overestimated in our setting. Too frequently our patients are expected to be independent, committed to self-exploration and introspection: capacities they simply never have developed. Sometimes, it may be necessary to change therapists or even to drop individual therapy. The need for a strong, positive relationship may be underestimated, as is the capacity of nurses and child-care workers to function in this way. Structural family change is sought to free the symptomatic member for healthy development and individuation. After the acute anorexia, some patients may benefit from psychotherapy or even psychoanalysis. REFERENCES 1. Dally P, Sargant W: A new treatment of anorexia nervosa. Br Med J 1:1710-1772. 1960 2. Needleman H: Amitriptyline therapy in patients with anorexia nervosa, in Vigersky R (ed): Anorexia Nervosa. New York, Raven 1977 3. White JH, Schnaultz NL: Successful treatment of anorexia nervosa with imipramine. Dis Nerv Syst 38567-568, 1977 4. Green RS, Rau JH: Treatment of compulsive eating disturbances with anficonvulsanr medication. Am 3 Psychiatry 131:428-432, 1974
5. Crisp AH, Kalucy RS: The effect of leucotomy in intractable adolescent weight phobia. Postgrad Med J 49883-893, 1974 6. Dally P, Sargant W: Treatment and outcome of anorexia nervosa. Br Med 3 2:793-795, 1966 7. Maxmen JS, Siberfarb PM, Ferrell RB: Anorexia nervosa. JAMA 229:801-803, 1974 8. Blinder BJ, Freeman DM, Stunkard AJ: Behavior therapy of anorexia nervosa: Effectiveness of activity as a reinforcer of weight gain, Amer J Psychiatry 126:77-82, 1970
ANOREXIA
NERVOSA
9. Halmi KA, Powers P, Cunningham S: Treatment of anorexia nervosa with behavior modification. Arch Gen Psychiatry 32:93-96, 1975 10. Stunkard A: New therapies for the eating disorders. Arch Gen Psychiatry 26:391-398, I972 1I. Blackwell A, Rollins N: Treatment problems in adolescents with anorexia nervosa: Preliminary observations on the second phase. Acta Paedopsychiatr (Base0 35294-301, I968 12. Bruch H: Psychotherapy in anorexia nervosa, presented at the Milton S. Hershey Medical Center, 1977, Hershey, Pennsylvania 13. Sours JA: The anorexia nervosa syndrome. Int J Psychoanal 55:567-579, 1974 14. Rollins N, Piazza E: Diagnosis of
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anorexia nervosa: A critical reappraisal. J Am Acad Child Psychiatry 17:126-137, 1978 15. Sternberg NS: A Descriptive Study of Anorexia Nervosa. MS Thesis, Wellesley College, 1975 16. Bhtzer J, Rollins N, Blackwell A: Children who starve themselves: Anorexia nervosa. Psychosom Med 23:370-386, 1961 17. Winnicott DW: The Maturational Process and the Facilitating Environment. New York, International Universities, 1965 18. Minuchin S, Baker L, Rosman BL, et al: A conceptual model of psychosomatic illness in children. Arch Gen Psychiatry 32: 1031-1038, 1975 19. Bruch H: Eating Disorders: Obesity. Anorexia Nervosa, and the Person Within. New York: Basic Books, 1973
Journal
of the American
Psychiatry Psychopathological
Association
MAY / JUNE 1980
VOL. 21, NO. 3
Anorexia Nervosa: Controversial Aspects of Therapy Eugene
Piazza, Nina Piazza, and Nancy Rollins
A
BAFFLING ARRAY of data has been accumulated about the syndrome of anorexia nervosa since it was first described by Morton in 1689 and defined by Gull in 1874. The chronicity, resistance to treatment, and mortality associated with it have led to a succession of treatment modalities that have focused primarily on one or another level of dysfunction, defined here as the neuroendocrine, psychophysiological, intrapsychic, and intrafamilial (Fig. 1). At the neuroendocrine level, various drugs-hormones, insulin, thyroid, gonadal, and pituitary-adrenal, as well as antidepressants, antipsychotics and tranquilizers-have been used in therapy.‘-” Attention to neurological factors has included the use of anticonvulsant medications and appetite stimulants and depressants.A Electroconvulsive therapy and leucotomy have been reserved for the patient in life-threatening circumstances.“,‘; The psychophysiological level of dysfunction has been treated by focusing on nutritional needs: diets, supplemental feedings, oral or via nasogastric or gastrostomy tube or parenterally, intravenous and indwelling venous catheter.? Behavior modification methods using various reinforcers such as supplemental feedings, amount of activity, medication, and social privileges, have been used with increasing frequency in the past 10 yr.+“’ At the intrapsychic level of dysfunction, analysis, individual psychotherapy, relationship therapy, and milieu therapy have all been used in treating the syndrome.1’-‘3 Family therapy recently has focused attention on the intrafamilial level of dysfunction. Even the diagnostic criteria of anorexia nervosa have been controversial. In a recent paper, we noted the need for accepted diagnostic standards that should be neither too restrictive nor too inclusive, and have devised the following critera: a 20% weight loss or a weight loss of 20% or more of expected weight for height and age; amenorrhea in females; body image distortion; and a pervasive sense of inadequacy.
Eugene Piazza, M.D.: Associate in Psychiatp, Children’s Hospital Medical Center, Instructor in Psychiatq. Harvard Medical School: Nina Piazza, M.S.W., A.C.S.W.; Nancy Rollins. M.D., Associate in Psychiatry. Children’s Hospital Medical Center, Assistant Clinical Professor of Psychiatry, Harrrard Medical School. Address reprint requests to Dr. Eugene Piazza, Department of Psqchiatv. Children’s Hospital Medical Center, 300 Longwood Ar,enue. Boston, Mass. 02115. @ 1980 by Crane di Stratton. Inc. 0010-440X/80/2103-000~$02.00~0 Comprehensive
Psychiatry,
Vol. 21, No. 3 (May/June),
1980
177
PIAZZA,
178
Therapeutic
Levels of Dysfunction in Anorexia Nervosa
PIAZZA,
AND
ROLLINS
Interventions
Diet Supplemental feedings
‘izogastric \
Nutritional
tubes
\ :~:~:$zz---
:zzl:n”,” Venous Catheter
/ -Behavior
Psychophysiologic-
Modification
Supplemental
\
feedings
Social privileges \
\ Psycho-Active Drugs and depressants
\
Family Therapy Casework with Parents Individual Psychotherapy Milieu Therapy
Neuro-Transmitters
Neuroendocrine-
/ \
Fig. 1.
Electra-Convulsive
\
Therapy
Leucotomy
Levels of dysfunction and therapeutic
interventions
in anorexia nervosa.
Despite the confusion of diagnostic criteria and the multiplicity of therapeutic approaches, recent outcome studies tend to indicate that the various approaches lead to similar results: two-thirds of the patients recover or are markedly improved, and a quarter to a third have a poor outcome. It is the thesis of this article that: (1) multiple levels of the organization of matter are involved in the predisposing, precipitating factors, and manifest symp-
ANOREXIA
NEAVOSA
179
tomatology of anorexia nervosa and therefore in the therapeutic interventions needed, and (2) anorexia nervosa cannot be exclusively conceptualized as a small group systems phenomenon. DESCRIPTIVE
PSYCHOPATHOLOGY
Over the past 10 yr in our work with 84 patients hospitalized for weight loss due to failure to eat, there were 70 who met our Children’s Hospital Medical Center (CHMC) diagnostic criteria for anorexia, described earlier. In our review of the diagnostic features, we defined anorexia nervosa as a syndrome, a cluster of symptoms, and signs at both the physical and psychological levels with a characteristic psychopathology. l4 Most unique is the distorted body image that coexists with and is reinforced by anxiety-laden fantasies concerning the body. These fantasies may be expressed somatically, as a feeling of fullness, or emotionally as a fear of fatness. The deep-seated sense of inadequacy with depression is related to the body image distortion and to the perceptual difficulties in correctly reading body signals. The self-distrust involves the body sphere and other areas of life, including social perceptions and intellectual judgment. We noted that the major features of the syndrome are also characteristic to a lesser degree of normal adolescent development: moodiness, emotional iability, self-doubt, crash dieting, preoccupation with body size, and other forms of self-absorption. In several ways, our descriptive data supported a view of anorexia, at least in our young population, as a pathological deviation of adolescent development. Our data indicate the anorectic symptoms characteristically begin after the pubertal growth spurt and appearance of secondary sex characteristics. We wondered whether the period of rapid growth might be accompanied by a temporary normal instability of the body image that could act as a precipitating factor for the manifest syndrome. Furthermore, we found that the essential psychopathology exists in different types of personality organizations; different personality types experienced the central body distortions in dissimilar ways, depending on defensive style. Secretive, withholding, and hysterical types of patients were less likely to present the classical open acknowledgment of fear of fatness. Our observations of anorexia in other cultures highlight certain values shared by the developed countries of the world: competitiveness, overvaluation of achievement, and thinness as signs of competence seemed related to the onset of the disorder wherever it occurred. For us, however, it seemed that such factors would be powerless to produce such severe pathology unless a predisposing vulnerability and/or an enmeshed family system were also present. We come now to the question of physical and psychological vulnerability and its objective documentation in our patients. The mean height percentile for our group was 33.8, and 19 of the 70 (27%) were at or below the tenth percentile for height. This short stature group had a significantly higher percentage of secondary diagnoses and accounted for 3 of the 5 schizophrenics in the group of 70. These patients also had a significantly longer duration of weight loss before admission and a longer hospitalization (Tables 1 and 2). These findings point at
PIAZZA,
180 Table
PIAZZA,
AND ROLLINS
1. Comparison of Total Group Who Met Criteria for Anorexia Nervosa to Group of “Short Stature” Patients (i.e., Below 1Oth Percentile for Height) Total Group
Shot?Stature .95
Variable
Age at admission Height percentile at admission Males Females Previous high weight Weight at admission Weight at discharge Percent weight loss Age at menarche Expected weight for height and age High weight as percent of expected weight Admission weight as percent of expected weight Weight gain in hospital (AMA deleted) Age at onset of weight loss Males Females Duration of hospitalization (total) Proportion of weight gained in hospital Weight loss before admission Duration of hospitalization on PSU Age of onset of weight loss Admission percent weight loss from expected weight for height and age Duration of weight loss
R
Mean
70
14.6 yr
70 9 61 70 70 70 70 37
33.8 percentile 39.1 percentile 33.0 percentile 105.8 lb 72.3 lb 89.6 lb 31.1% 12.5 yr
70
Significant*
Confidence Interval
n
Mean
Difference
0
14.07-15.05
19
14.5yr
27.73-39.86 13.55-64.66 26.78-39.25 102.42-I 14.97 68.8-75.7 85.4-93.9 29.0-33.2 11.98-12.96
19 3 13 19 19 19 19 8
3.81 percentile 4.0 percentile 3.8 percentile 100.3 lb 62.0 lb 78.4 lb 30.7 % 12.6 yr
103.9 lb
98.3-109.5
19
79.7 lb
+
70
102.6 lb
98.6-106.5
19
112.9 lb
+
70
70.7 %
68.3-73.1
19
78.6 96
+
65
18.3 lb
16.0-21.3
18
17.1 lb
70 9
13.8 yr 13.0 yr
13.3-14.3 11.6-14.4
61
13.9 yr
13.4-14.3
19 3 16
13.6 yr 12.9 yr 13.7 yr
65
142 days
116.8-166.2
18
179 days
+
65
18.6 %
15.9-21.2
17
22.6 96
+
70
33.5 Ib
29.66-37.32
19
30.7 lb
65
124 days
101-146
18
142 days
70
13.8 yr
13.3-14.3
19
13.6
70 70
29 96 39.5 wk
27.1-31.8 33.6-45.4
19 19
22% 47.6 wk
+ +
*Criterion of significance: the mean of the “short stature” group is considered significant only if it falls outside confidence interval of larger group.
least in one subgroup to a predisposing vulnerability relating to long-standing nutritional problems, which in turn could be related to distortions in body perception, and early mother-child interaction difficulties. Although individual case histories yield convincing evidence of vulnerability, we were unable to document a statistical relationship between medical outcome and natal and neonatal histories of eating or mother-infant disturbances. What part do precipitating external factors play in the onset of anorexia? We found that loss through death or separation or a symbolic loss were associated with the onset of anorexia in 78% of 37 cases.
ANOREXIA
181
NERVOSA
Table 2. Comparison of Total Group Who Met Criteria for Anorexia Nervosa to Group of “Short Stature” Patients (La. Below 10th Parcantlle for Height) “Short Stature”
Total Group Variable
”
Frequency 96
.95 Confidence Interval
Significant ”
Frequency %
Difference’
Proportion males Somatic complaints Preoccupation with food Vomiting
70 70 70 68
9 49 62 17
13 70 89 25
21-5 81-59 96-82 35-15
19 19 19 18
3 13 16 6
16 68 84 33
0 0 0 0
Secretive behavior with food
70
32
46
58-34
19
9
47
0
69
66
96
91-100
19
19
100
0
70 69 69
51 21 20
73 30 29
83-63 41-19 40-18
19 18 18
13 5 2
68 27 11
0 0 +
Depression Edema Cyanosis Excessive body hair
70 70 70 70
65 7 11 11
93 10 16 16
99-87 17-3 25-7 25-7
19 19 19 19
18 3 3 6
95 16 16 32
0 0 0 +
Presence of secondary psychiatric diagnosis Schizophrenia
70 70
32 5
46
58-34 13-l
19 19
12 3
63 16
+ +
Denial of physical or emotional illness Altered activity level Sensitivity to cold Bulimia, gorging
7
*Criterion of significance: the percent of “short stature” group is considered significantly different only if it falls outside the confidence interval of the larger group.
DEVELOPMENT
OF A TREATMENT PROGRAM HOSPITAL
AT CHILDREN’S
A treatment program for anorectic patients was developed at the Psychosomatic Unit of the Children’s Hospital Medical Center, addressing all four levels of dysfunction. The therapeutic program begins with an initial evaluation, including complete history and physical examination, with lab tests as indicated, and psychological testing. Milieu treatment evolved over a 3-4-yr period. Our first priority is the patient’s survival; this entails an evaluation of his/her nutritional state and reassurance that we will be diligent in caring for his/her nutritional needs and, at the same time, recognizing his/her fears that we will make her fat. Patients are weighed daily and vital signs are monitored until stable. When the patient has begun to gain weight and eating patterns are more normal, the pediatrician discusses with the patient normal value for height and weight, and then, with the patient’s participation, sets a weight goal with a 5--IO-lb range. Staff and patients eat together, staff members providing modeling as well as support during the mealtimes, while avoiding lengthy intellectualizing and obsessing about food and weight. Efforts are aimed at providing a corrective emotional experience to counter the withdrawn, isolated behavior and shallow relationships often seen at admission. As the nutritional state improves, the focus shifts to social rehabilitation. The patient is encouraged to participate in age-appropriate activities provided by specialists in arts, crafts, dance, music, and drama, and to attend the residential school. Each patient is provided a staff member (child-care worker or nurse)
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AND ROLLINS
with whom he or she has the opportunity to develop a special relationship. This staff person is responsible for coordinating plans for the patient and communicating the child’s progress at weekly team meetings. This treatment team is chaired by the psychiatric resident and includes the pediatrician, the individual psychotherapist, social worker, head nurse, and the “Special.” The “Special” is one of the most important staff persons during the child’s stay on the Unit. Indeed, at follow-up the relationship with the “Special” has often been singled out by the parents themselves as having been the most helpful aspect of hospitalization. Each child is also assigned a psychotherapist who sees him or her twice weekly. The team decides when the patient is able to be involved in milieu activities and attend the residential school. Psychoactive medications are prescribed when indicated: i.e., when depression and withdrawal are the overriding symptoms, antidepressants are used; if overwhelming anxiety interferes with the patient’s ability to utilize milieu activities or individual therapy, major tranquilizers are used. Fourteen of the 70 patients received psychoactive medications-10 were treated with antidepressants, 2 with antipsychotics, and 2 were on a combination of antidepressants and antipsychotic medications. The family is crucial both in our understanding of the anorectic patient and in formulating a treatment plan. In many cases, there is a strong, hostile, controlling, and guilt-instilling relationship between the patient and family. For this reason, initially, informal visits and planned family activities occur on the Unit and are attended by staff, providing an opportunity for later review of interactional patterns with the patient. As treatment progresses, the patient is allowed visits off the Unit, after which patient and staff review the visits, paying attention to areas of conflict resulting in stress. These visits are increased gradually to the point where the patient can spend entire weekends at home prior to discharge. Treatment of the family usually includes an early family diagnostic interview with the social worker and the individual therapist. This may lead to family therapy as the primary treatment modality. Most often, however, we find the combination of family and individual treatment appears to be the most effective. All parents are expected to attend a weekly parents’ group. Issues in parents’ group develop first when new parents share their anxieties about having a child admitted to the Psychosomatic Unit and their self-doubts and guilt over the illness. It is supportive to hear from other parents who are at different stages of treatment and can recall their own distress when their child was first admitted. The group process is also beneficial in dealing with the parents’ sense of bewilderment at having to relate to a large staff and to deal with their fear that their parental role has been usurped. DEVELOPING
A FAMILY
APPROACH
Since 1961, we have been impressed with the degree of preoccupation with food, eating, and weight in the families of anorectics,‘5 noting the “family neurosis . . . the neurotic compliance of environment.” l6
ANOREXIA
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183
By 1968, we described two stages in the treatment of anorexia nervosa. Stage 1 involved managing the acute anorexia (usually in the hospital), with a decisive
role played by the parents, whose emotional permission for the child to relate to our staff was of critical importance. Using Winicott’s concept of “holding,” I7 therapy was focused on providing emotional support for the parents so they could work out their anxiety and ambivalence; only then could they give permission to their child to accept hospitalization. as traditional psychoanalytical oriented psyStage 2 was conceived chotherapy, directed to intrapsychic conflicts of selected patients able and willing to participate in seif-expIoration.11 During the early 7Os, we introduced family treatment, using Minuchin’s concepts of pathological family structures. lx We retained individual psychotherapy for the anorectic child, finding the two concepts complementary rather than conflictual. In common with Minuchin, we observed the following features of “psychosomatic” families: overconcern and overprotectiveness around physical health; enmeshment of family members, especially the anorectic and one parent; submerged or unresolved intrafamily conflict; rigidity and resistance to change. Two pathological family structures most commonly seen were: a stable coalition between the anorectic and one parent, and a detouring of marital conflict through the anorectic child. However, in contrast to Minuchin, we found the critical psychopathology was often the unconscious repetition in the mother’s relationship with her anorectic daughter of her conflicted relationship with her own mother; i.e., the detouring through the anorectic child is of an intrapsychic conflict with one parent, not a marital conflict. We also were impressed with the inappropriate role definitions displayed by the anorectic children in their families, as peacemakers and as protectors of a vulnerable parent. This latter situation often resulted in a family coalition against the therapeutic team, and a conflict for the child who wished to be free of the inappropriate role, yet remain loyal to the afflicted parent. Other structural shifts were observed as therapy moved to a deeper level. For example, the anorectic’s seeming dependence on the mother in a stable. protective coalition not infrequently covered a strong Oedipal relationship with the father. When the anorectic symptoms abated, and the Oedipal attachment surfaced, the mother would react with anger, jealousy, and a guilty sense of bewilderment. It has not been uncommon in our experience for the parents to refuse to enter therapy for their marital problems when they finally surface. Family resistance combined with institutional resistance (e.g., traditional psychoanalytic orientation) to produce powerful and at times irrational barriers to the exclusive use of family therapy for anorexia nervosa in our setting. However, many of our observations of the physical and psychological state of our patients realistically did not fit with a redefinition of the anorectic symptomatology as exclusively a problem of family structure and interactional patterns. The patients were usually physically sick with depressed vital signs, and psychologically their communications were filled with ample evidence of distortions of body image, inability to interpret correctly body signals of cold.
PIAZZA,
184
PIAZZA,
AND ROLLINS
fatigue, hunger, and sexual feelings, not to mention low self-esteem, chronic depression, fear of puberty, and timidity in peer relationships. These matters really were their business and had to be treated as intrapsychic issues. FAMILY
THERAPY
IS NOT ENOUGH
June was a 13+-yr-old girl readmitted for her fourth hospitalization for anorexia, nearly dead with a weight of 55.5 lb, pulse 36, and temperature 93.6. Her weight loss had begun a year before in a conscious effort to become thinner. At her third hospitalization, June was transferred from a medical ward to the Psychosomatic Unit where the primary focus was on family therapy. At this time the family system pathology could be formulated as a stable coalition between June and her father, who played with her an intense, nurturant maternal role with elements of angry despair. The family was closely knit with poor differentiation of members. The parents were in chronic disagreement regarding management of June’s eating, and in regard to the degree of autonomy permitted the children. June, more than her three older brothers and one younger sister, had grown up not making decisions for herself. Her special position in the family focused everyone’s attention on her. Family therapy was continued after hospitalization, the emphasis being on encouraging the parents to work together with father in a more dominant role. Ten days later, June was admitted for the fourth hospitalization, in the condition previously described. She was agitated, frightened, wishing to die, plagued by contradictory voices telling her both to eat and not to eat. In a supper interview with the whole family, it became clear that both parents unconsciously promoted June’s special place in the family by not serving her a plate of food, because, they said, the hospital had her on supplements; they then revealed how they had undermined the nutritional program by not requiring June to take her supplements on the home visits. June acted out her feeling of not belonging to the family by standing at the end of the table, apart from the family group. Individual therapy then allowed June to express her depression and uneasiness when she went home and her inability to admit these feelings because of her anguish and guilt over hurting her parents. Family therapy focused on helping the parents stand together and support hospital policies. June and her mother were brought closer, June telling mother things painful for her to hear, and mother reflecting on her habit of being overprotective and overcontrolling with June. Yet, these shifts were insufficient for June to relinquish her not eating, which insured her a special position as a sick child. Though she expressed anger and defiance in individual sessions, she did not give the impression of being a separate self with independent wishes, feelings, and plans. In short, June’s anorexia was not only a symptom of small group system pathology in the here and now. To understand the multiplicity of levels involved in this case, it is necessary to return to the concept of vulnerability. Indeed, June was special, right from birth. During her pregnancy with June, her mother had flu, vomiting, and weight loss, and hemorrhaged just before labor. June was born with a club foot and underdeveloped muscles of the leg, necessitating four hospitalizations between 4 and 15 mo, and immobilization in a leg cast until 2 yr. June was
ANOREXIA
NERVOSA
185
brought home from the last hospitalization on the day of paternal grandmother’s funeral, the grandmother having spent several years in a psychiatric hospital. One week later, June’s younger sister was born. Thus June approached puberty with a complex vulnerability: (I) possible genetic predisposition from mental illness in father’s family; (2) intrauterine trauma from mother’s hemorrhaging; (3) the congenital birth defect and its treatment; (4) alterations in the early mother-infant relationship; and (5) early displacement by a sister. The multiplicity of the levels of the disturbance suggests a multiple level approach to therapy would be needed. The history shows that family intervention was not enough. “GROWING
UP ABSURDLY”:
INTRAPSYCHIC
ISSUES
June’s case was presented in some detail to demonstrate the kind of clinical evidence leading us to the conclusion that predisposing vulnerability, intrapsychic conflict, and a developmental perspective must be added to family system considerations in formulating the pathology and appropriate therapeutic interventions in anorexia. One patient, after her anorexia was resolved, wrote of herself as seeming to have been self-sufficient, mature, and intelligent to others, but always feeling ugly, having low self-esteem, and being ‘*. . . a very secret person, growing up quite absurdly.” Our experience parallels that of Hilda Bruchiy wherein the prominent intrapsychic issues are control, fear of loss of control, first displaced to eating and weight, but ultimately found to apply to emotions and impulses in a broad sense, both libidinal and aggressive. As with many anorectics, this patient tried to control the rate of her own growth through self-starvation, preventing herself from growing up. Her low self-esteem and chronic depression were found, in therapy, to be linked to a lack of a sense of self and the issue of identity. These patients have a long-standing distrust of themselves and their capacity to process their perceptual experience, suggesting a disturbance in the formation and development of the “body ego,” the precursor of later ego development. In a child thus rendered vulnerable, the developmental phases of adolescence trigger the overt anorectic episode. The demands for individuation and independent functioning conflict with the ‘demands of a pathologically enmeshed family system. Another intrapsychic issue in late adolescence may be heterosexual intimacy with its requirement of further emotional separation from the primary love objects and stimulation of anxiety-laden fantasies about the body, linked with distortions of body perception. An additional issue for individual treatment has often been the relinquishing of unrealistic self-demands for healing marital conflict, parental depression, etc., once these inappropriate role definitions have been identified. This is both a family and an individual treatment issue. TOWARD
A MULTIDIMENSIONAL
SCHEMA
FOR ANOREXIA
NERVOSA
It will be recalled that our preliminary studies had led us to formulate anorexia nervosa as a developmental deviation, the decompensation becoming
186
PIAZZA,
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manifest at the preadolescent or early adolescent stage. A conceptual schema was developed for the pathogenesis of anorexia, including the developmental or epigenetic dimensions and the dimension of levels of organization of matter, as Fig. 2 shows. The relevant levels include the neuroendocrine, psychophysiological, intrapsychic, and social. The schema* calls for a latent phase, starting in infancy, and a precipitating symptomatic phase at adolescence. In the latent phase, faulty perception of interoceptive stimuli (hunger, fatigue, temperature, etc.) and disturbed body rhythms (hunger-satiation, sleep-wakefulness, physical activity level, and mood fluctuations) are together conceived as a basic disturbance in the “body ego,” the precursor of ego development. The determinants of this body ego disturbance in infancy probably operate on at least three levels: (I) Congenital neuroendocrine vulnerability. (2) Dyadic interpersonal relationship: an interaction between mother and infant characterized by excessive projective identification, as described by Hilda Bruch .lg The mothers’ projections impede their correct reading of signals from the infants, who in turn fail to learn how to read correctly the signals coming from their own bodies. This could lead to disturbances of basic body rhythms. (3) Family system disturbances: characteristic features include enmeshment, rigidity, overprotectiveness, and triangulation, as described by Minuchin.18 It is postulated that the faulty body ego in turn leads to or exists with other developing defects in the forming ego, including uncertainty regarding cognitive processes with distrust of intellectual judgment, lack of a firm sense of self, uncertainty in object relationships, and rigid or inadequate defenses. These body image distortions may become associated with fantasies and introjected good and bad objects. The symptomatic phase at preadolescence or adolescence is characterized by a heightening of the sense of inadequacy, increasing depression, more obvious distortion of the body image, and neuroendocrine disturbances. Precipitating factors again operate on many levels, including the neuroendocrine factors of pubescence; intrapsychic adolescent issues of independence, individuation, and sexuality; loss, with its impact on the patient and the family system; the requirements of a pathological family system conflicting with the developmental needs of the individual: and the impact of cultural values on the patient and family system. There is also a regressive reactivation of earlier problems, especially pathological splitting of good and bad internal and re-externalized images; this may lead to attempts to exorcise the bad internal mother image, leading to starvation, vomiting, and suicidal impulses. If such a multilevel formulation is useful in understanding the pathogenesis of anorexia nervosa, it can be seen that there are also multiple levels of intervention. Individual psychotherapy and the relationship with the “Special” on the Unit deal with the problems of self-definition and support the normal adolescent development. Depression is diminished, self-esteem is improved, and
* The thoughtful comments of two colleagues, John Coolidge, M.D., and Ethel Walsh, M&W., stimulated the development of this schema.
-
-
I
I
I
4
Faulty Ego Development
Faulty perception of interoceptive stimuli (hunger, thirst, fatigue, temperature, sex, etc.)
T Loss --+
I
Larger social system Cultural values
Rigid or inadequate defenses
I
Disturbed body rhythms Hunger-Satiation Sleep-Wakefulness Physical activity level Mood
Family system Pathological enmeshment, rigidity, overprotectiveness
Family system X1requirements: Conflicts withintrapsychic developmental needs I
of anorexia nervose.
Factors
schema of pathogenesis
4
Levels of Precipitating
t Intrapsychic factors Adolescent issues lndividuation t-Independence Sexuality
4 Symptoms: Pervasive sense of inadequacy Depression; Distortion of body image Neuroendocrine instability
Uncertainty re cognitive processes Distrust of intellectual judgment
!
c---------,
level: defects of body awareness
Verbal level: defects in ego boundaries
Multidimensional
/ factors
Fig. 2.
Neuroendocrine Pubescence
Symptomatic phase Reactivation of early problems
Precipitating:
c---------
Preverbal
Factors
1 Faulty Ego Precursors
Dyadic interpersonal relationship Mother-infant interaction Excessive maternal projective identification
Lack of of self c-------j individuation
Faulty synthesis of internal and external stimuli
Uncertainty re object relations -sense
Latent phase
Predisposition:
Congenital Neuroendocrine Vulnerability
A
Levels of Predisposing
PIAZZA, PIAZZA, AND ROLLINS
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emotions are allowed more honest expression. At the intrafamilial level, family visiting on the Psychosomatic Unit, home visiting, family therapy, casework with the parents, and the family implications of change in the anorectic patient may all operate to contribute to healthier functioning of the family system. It may be useful to assume that any treatment strengthening and supporting fulfillment of the tasks of adolescent development will increase the probability of a favorable outcome. From the developmental point of view, the strong relationship with the psychotherapist and/or the “Special,” the nutritional protocol, and the ward routines tend to recreate in the hospital the early mother-infant relationship: symbiotic fusion followed by a “weaning” process. In this context, the splitting mechanisms can be challenged, sadness and guilt over destructive wishes may be expressed, and feelings of depression over the relinquishing of infantile positions may be dealt with. At the intrafamilial level, the family conflict tends to be recreated between the anorectic child and the staff, especially the conflict between normal adolescent developmental needs and the needs of an unhealthy family system that discourages individuation and adolescent efforts at emancipation. In conclusion, many of the controversies concerning the treatment of anorexia nervosa become false issues when they are examined from this dual perspective of levels of organization and development. In particular, the issue of family versus individual psychotherapy no longer is relevant since a combination of both is needed in a flexible approach, with interventions at several different levels. This flexibiiity should include a willingness to try whatever approach best suits the patient’s needs and to combine and shift therapies when necessary. The capacity, particularly of the prepubertal or severe anorectic to “work through” a massive negative transference is frequently overestimated in our setting. Too frequently our patients are expected to be independent, committed to self-exploration and introspection: capacities they simply never have developed. Sometimes, it may be necessary to change therapists or even to drop individual therapy. The need for a strong, positive relationship may be underestimated, as is the capacity of nurses and child-care workers to function in this way. Structural family change is sought to free the symptomatic member for healthy development and individuation. After the acute anorexia, some patients may benefit from psychotherapy or even psychoanalysis. REFERENCES 1. Dally P, Sargant W: A new treatment of anorexia nervosa. Br Med J 1:1710-1772. 1960 2. Needleman H: Amitriptyline therapy in patients with anorexia nervosa, in Vigersky R (ed): Anorexia Nervosa. New York, Raven 1977 3. White JH, Schnaultz NL: Successful treatment of anorexia nervosa with imipramine. Dis Nerv Syst 38567-568, 1977 4. Green RS, Rau JH: Treatment of compulsive eating disturbances with anficonvulsanr medication. Am 3 Psychiatry 131:428-432, 1974
5. Crisp AH, Kalucy RS: The effect of leucotomy in intractable adolescent weight phobia. Postgrad Med J 49883-893, 1974 6. Dally P, Sargant W: Treatment and outcome of anorexia nervosa. Br Med 3 2:793-795, 1966 7. Maxmen JS, Siberfarb PM, Ferrell RB: Anorexia nervosa. JAMA 229:801-803, 1974 8. Blinder BJ, Freeman DM, Stunkard AJ: Behavior therapy of anorexia nervosa: Effectiveness of activity as a reinforcer of weight gain, Amer J Psychiatry 126:77-82, 1970
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9. Halmi KA, Powers P, Cunningham S: Treatment of anorexia nervosa with behavior modification. Arch Gen Psychiatry 32:93-96, 1975 10. Stunkard A: New therapies for the eating disorders. Arch Gen Psychiatry 26:391-398, I972 1I. Blackwell A, Rollins N: Treatment problems in adolescents with anorexia nervosa: Preliminary observations on the second phase. Acta Paedopsychiatr (Base0 35294-301, I968 12. Bruch H: Psychotherapy in anorexia nervosa, presented at the Milton S. Hershey Medical Center, 1977, Hershey, Pennsylvania 13. Sours JA: The anorexia nervosa syndrome. Int J Psychoanal 55:567-579, 1974 14. Rollins N, Piazza E: Diagnosis of
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anorexia nervosa: A critical reappraisal. J Am Acad Child Psychiatry 17:126-137, 1978 15. Sternberg NS: A Descriptive Study of Anorexia Nervosa. MS Thesis, Wellesley College, 1975 16. Bhtzer J, Rollins N, Blackwell A: Children who starve themselves: Anorexia nervosa. Psychosom Med 23:370-386, 1961 17. Winnicott DW: The Maturational Process and the Facilitating Environment. New York, International Universities, 1965 18. Minuchin S, Baker L, Rosman BL, et al: A conceptual model of psychosomatic illness in children. Arch Gen Psychiatry 32: 1031-1038, 1975 19. Bruch H: Eating Disorders: Obesity. Anorexia Nervosa, and the Person Within. New York: Basic Books, 1973