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Embodying the body in anorexia nervosa – a physiotherapeutic approach
Journal of Bodywork & Movement Therapies (2012) 16, 281e288
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PSYCHOMOTOR PHYSIOTHERAPY & EATING DISORDERS
Embodying the body in anorexia nervosa e a physiotherapeutic approach Liv-Jorunn Kolnes, Dr. scient Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Ulleval, P.O. Box 4956 Nydalen, 0424 Oslo, Norway Received 11 October 2011; received in revised form 13 December 2011; accepted 20 December 2011
KEYWORDS Anorexia nervosa; Norwegian psychomotor physiotherapy; Body awareness therapies; Body contact; Bodily stability; Embodiment
Summary Body dissatisfaction and disturbances in bodily sensations are prevailing qualities among patients with anorexia nervosa (AN). However, therapies addressing the body are typically marginalized within treatment programs for anorexia nervosa. The purpose of this article is to 1) describe common bodily symptoms and experiences of anorexia nervosa patients and discuss the accompanying physical and emotional impact, and 2) present physiotherapeutic approaches to help patients with anorexia nervosa. Recommendations are based on the author’s clinical observations and patient testimonials, in addition to the theory and methodology outlined by Norwegian Psychomotor Physiotherapy (NPMP), body awareness therapies, and current knowledge on bodily stability. It is the author’s experience that anorexia nervosa patients tend to have significant impairments in their body awareness, a restricted breathing pattern, significant muscular tension, poor postural stability, and they are frequently engaged in compulsive physical activity. A body awareness approach for these patients may contribute to novel ways of sensing and interpreting bodily signals, improving emotional awareness, experiencing the body and integrating the body as one’s own, i.e., becoming an embodied person. Embodying the body in patients with anorexia nervosa by utilizing approaches from NPMP and body awareness therapies, in addition to stability training principles, may help stabilize the body and the mind, and thus, constitute a beneficial addition to overall treatment for anorexia nervosa. ª 2011 Elsevier Ltd. All rights reserved.
Introduction Body dissatisfaction and disturbances in recognizing and identifying bodily sensations have been established as E-mail address: [email protected].
prevailing qualities among patients with anorexia nervosa (Bruch, 1962, 1988; Pollatos et al., 2008; Spoor et al., 2005). Hilde Bruch was a pioneer in the field of anorexia nervosa, emphasizing the necessity of understanding what is occurring within patients’ bodies, and assisting patients to become aware of impulses, feelings and sensations originating in the body (Bruch, 1973). Since her inaugural
1360-8592/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.12.005
282 research, however, sparse attention has been paid to body awareness and helping patients with anorexia nervosa evoke awareness of bodily feelings, impulses, and sensations (Close, 2000; Davison, 1988; Spoor et al., 2005; Thornborg, 2002; Thornborg and Mattson, 2010; Thornquist, 1994; Wallin et al., 2000). In-depth investigations describing bodily symptoms and experiences in anorexia nervosa, or the accompanying impairment, remain rare. Nevertheless, physiotherapists have a unique opportunity to improve body awareness among anorexia nervosa patients. The author, who is also the lead researcher and a specialist in Norwegian Psychomotor Physiotherapy working in a special unit for patients having eating disorders, has observed that patients with anorexia nervosa have significant impairments in their awareness of their bodies, an extremely constrained breathing pattern, significant muscular tension, poor postural stability, and are frequently obsessed with excessive exercise. As such, the concepts of ‘disembodied’ and ‘disconnected’ are relevant connotations for the anorectic body. Understanding how patients with anorexia nervosa attune themselves to their emotions, and to the broader social world, when they are so disconnected from their own bodies is an intriguing question. How do they make sense of themselves, and how do they manage to regulate emotions and tensions if they do not sense their own bodies, if they are disembodied? In the first section of this article, the theoretical framework of physiotherapy work with patients with anorexia nervosa is presented. In the second, clinical observations from the author’s practice are identified, and physiotherapeutic approaches for increasing body awareness and body contact are presented.
Conceptual and theoretical framework The theoretical and methodological guidelines outlined by the Norwegian Psychomotor Physiotherapy (NPMP), body awareness therapies, and current knowledge on bodily stability provide a solid foundation for clinical work with anorexia nervosa patients. These therapeutic approaches overlap and complement each other in meaningful ways. It is argued that exclusively relying upon a single theory or methodology fails to capture the complexity and seriousness of the anorexic symptomology.
Norwegian psychomotor physiotherapy The theory of Norwegian Psychomotor Physiotherapy (NPMP) is inspired by the contributions of the Austrian physician and psychoanalyst, Wilhelm Reich. Reich observed that the body had a significant role in expressing unresolved emotional conflicts and traumas, and that we tend to use the body to maintain various rigidities linked to unresolved emotions. He argued that the body could “speak” more honestly than the spoken word (Gilbert, 1999). The Norwegian Psychomotor Physiotherapy approach was developed by the physiotherapist Aadel Bulow-Hansen and psychiatrist Trygve Braatoey after the second world war, and have since then been further elaborated and modified by physiotherapists and researchers in the Nordic countries.
L.-J. Kolnes NPMP is based on the understanding that posture, respiration, muscle tension and body awareness are closely related to emotional and psychological strain (Thornquist and Bunkan, 1991). Two fundamental premises are that a person’s life and history are expressed through the body, and the body is a functionally integrated entity (Thornquist, 2010). The body is understood as the centre of experiences and knowledge through which we take in information and interact with the surroundings. Personal experiences and stories are imprinted in and reflected in our bodies, i.e., they become embodied. Our personal stories necessarily contribute to the meaning of bodily symptoms and dysfunctions. According to the NPMP theory, breathing and influences on the breathing pattern constitute a fundamental treatment component.1 There is a strong interaction between breathing, emotions, and the regulation of the emotions. Breathing is considered as a resonance field for emotional states and reactions. Constrained breathing is understood as a way of avoiding feelings. Living with enduring fear or anxiety, or under circumstances which imposed such feelings in the past, may result in the establishment of a consistent pattern of muscular tension and withheld breathing. As such, a pattern may manifest itself in the body, stress and strains will become embodied. A habitual pattern of rigid breathing can be seen as part of our emotional and social defence system when adjusting to the surroundings. A restricted breathing pattern may lead to rigidity in bodily expressions, functions, and movements, and also contribute to poor mental awareness (Bunkan, 2003; Ekerholt and Bergland, 2008), while free breathing is related to a positive self-image and mental health (Meurle-Hallberg, 2005). By carefully releasing and gradually allowing for verbal interpretation, free breathing may provide access to problematic emotions and painful memories. The NPMP examination includes a comprehensive history taking. The physical examination consists of observation and an evaluation of posture, respiration, muscles, functioning, and the ability to relax. Autonomic reactions to the examination are registered. Changes in the breathing pattern, emotional and autonomic reactions to the treatment provide important information about how to proceed with treatment, and on the extent to which the patient should relax or stabilize. Depending on individual findings, the treatment may have two main directions. In adaptive 1 Respiration is unique in that it is under both involuntary and voluntary functioning and control. Free breathing is characterized by a rhythmic interplay between inhalation and expiration. The diaphragm is our largest and our most important breathing muscle. When inhaling, the diaphragm descends and the abdominal content is pressed downward. In exhaling, the diaphragm is in itself passive, but is being pressed upwards by abdominal muscles. The movements related to the descending and relaxation of the diaphragm muscle, are considered to have a massaging effect on organs in the abdomen. Hence, breathing freely and satisfactorily facilitates circulation and the function of these organs, as well as the digestion by the abdominal organs (Mattsson and Mattsson, 2002). Thus, pain coming from the abdominal region and constipation may be influenced by the breathing pattern. Chaitow, Bradley and Gilbert’s Multidisciplinary approaches to breathing pattern disorders (2002) gives valuable contributions to clinicians engaged in and who wish to learn more about breathing-related disorders.
Embodying the body in anorexia nervosa treatment, the aim is to change the person’s physical and emotional habitual patterns of reaction. In supportive treatment, the focus is on stabilizing the individual, allowing for a better connection to oneself. The aim of the treatment is to address bodily dysfunction and to facilitate a process of change through massage, movements, and exercises. An important principle in treatment is to build the body from the bottom up. To create and support the ability to stand firmly on the floor, the treatment typically begins with the legs. A solid platform is a prerequisite for free respiration, balance, and movement. Patient verbal reflections over bodily sensations, the identification of any physical changes, or changes in the patient’s relationships to others, comprise central components of NPMP treatment. The therapist facilitates this verbal reflection and helps the patient to establish a sense of coherence. Indications for psychomotor physiotherapy include strain and functional disturbances in the musculoskeletal system, as well as various psychiatric disorders. The treatment process may take months or even years. In order to be a qualified practioner in NPMP, the physiotherapist is required to take courses in the Advanced Programme for Mental Healthcare (2e3 years).
Body awareness therapies Body awareness therapies includes body-oriented, physiotherapeutic approaches aimed at building awareness of how the body is used, behavior, and interaction with oneself and others (Gyllensten et al., 2003a). Roxendal (1985) has defined body awareness as “the perception of bodily sensations, impulses, feelings, and reactions that originate in the body”. The treatment aims to integrate the body in the total experience of the self, to reestablish body awareness and body control (Roxendal, 1995), as well as to achieve a more developed contact with emotions and affect (Gyllensten et al., 2003b). The exercises are easily managed and focus on the here-andnow, helping the patient to recognize and observe without interfering and judging. Specific aims of body awareness therapies are to increase freedom in muscle tension, normalize posture and balance, improve movement and breathing, and promote mental awareness. The movements are based on movements from daily life, and are performed in standing, walking, sitting and laying positions. Grounding, improving the postural line, and the coordination and centering of movements are central aspects of the treatment. As in NPMP, body awareness therapies espouses the notion that breathing is closely interrelated with emotions. Body awareness therapies are frequently used by physiotherapists in Nordic countries for the rehabilitation of patients in psychiatric settings (Gyllensten et al., 2009, 2003a, 2010; Roxendal, 1985), patients with prolonged musculoskeletal pain (Grahn, 1999; Grahn et al., 1998) and fibromyalgia (Gustavsson et al., 2002; Gard, 2005). Research has shown that improving body awareness is important for a more positive experience of body and self, and improvement of health-related quality of life (MeurleHallberg, 2005). The notion that bodily sensitivity and
283 emotions are interrelated is also consistent with research showing that individuals who perceive their bodily signals with a high degree of sensitivity experience their emotions more intensely (Damasio, 1999; Pollatos et al., 2008).
Bodily stability Body awareness and body contact are inevitably connected to bodily stability, and its related muscular, neuromuscular, and proprioceptive2 systems. Bodily stability and good alignment depend on an interplay between muscular, neuromuscular, and breathing processes. Restricted breathing, combined with muscular stiffness and rigidity, have a major adverse impact on bodily stability. Balance and neuromuscular control in the entire body, including the under-extremities, are essential to stability and to establish a solid platform from the bottom up. This section will focus on stabilizing the trunk. Control and stability of the trunk in relation to body awareness and respiration, has not been previously described among patients with anorexia nervosa. Control and stability of the trunk are closely connected to activity in muscles such as the diaphragm (Hodges et al., 1997), tranversus abdominis (Hodges et al., 1999), multifidus (MacDonald et al., 2006) and pelvic floor muscles (Hodges et al., 2002). Reduced postural stability of these muscles may impair the mechanical support of the spine, and negatively affect strength and flexibility in spinal movement. Respiration is essential to the proper functioning of these muscles (Smith et al., 2006). Over the past decades, an ongoing debate has existed regarding which muscles are important trunk stabilizers. Similarly, debate surrounds the optimal training method to improve stability in the trunk by using the neuromuscular control system. There seems to be agreement among clinicians and researchers alike that enhancing motor patterns that incorporate many muscles, rather than a few, is appropriate when training for stability. Further, it is important to activate deep local muscles in the trunk, in conjunction with global muscles, to achieve control and stability (Kavcic et al., 2004; van Dieen et al., 2003). In order to activate local trunk muscles, it is of fundamental importance that the back and pelvis are in neutral positions. Free breathing and relaxation skills are essential to achieve neutral positions and stability in the trunk (Stuge, 2007). Functional muscle strategies are difficult if there is rigidity during stability training efforts, and this is done with a restricted breathing pattern, or reliance on mainly global muscle groups. This knowledge is important if the aim is to enhance body contact and body awareness for patients with anorexia nervosa. Obsessive training of muscles that are strong, and avoiding weak or unused muscles, will have an adverse effect on motor control and contact with local muscles (Stuge, 2007). 2 Proprioception can be defined as a neuromuscular process that involves both afferent input and efferent signals that allows the body to maintain stability and orientation during both static and dynamic activities, i.e. awareness of position or movement (Laskowski et al., 1997).
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Bodily characteristics and physiotherapeutic approaches Patients with anorexia nervosa display a complex and multifaceted clinical picture. In addition to body dissatisfaction and a disturbed body image, anorexia nervosa is associated with anxiety, compulsiveness, depression, impaired mentalization and difficulties with emotional expression and the regulation of emotions (Jordan et al., 2008; O’Brien and Vincent, 2003; Ska ˚rderud, 2007). A whole range of somatic symptoms and complications following long-standing and serious malnourishment have been documented (Frostad, 2004; Nicholls et al., 2000). Clinical findings from the author’s practice with inpatient treatment reveal that impaired body awareness and body contact, a restricted breathing pattern, postural disturbances, and muscular tension are characteristic of anorexia nervosa. Moreover, patients with anorexia nervosa convey a compulsive physical activity style and the inability to relax. This section further describes these clinical characteristics and recommended physiotherapeutic treatment modalities for patients with anorexia nervosa. The overall aim of physiotherapeutic treatment is to 1) help patients establish contact with their own body and bodily sensations, and 2) to increase body awareness and ownership of their bodies, or to become embodied. ‘Embodiment’ refers in this context to the body as a sentient subject and a subjective modality of being. In this sense, embodiment pertains to the sense of being in contact with the body and bodily sensations, as well as a genuine feeling of owning one’s own body and being in control of one’s own bodily functions. Prior to the initiation of treatment, the patient receives a comprehensive examination. Team collaborators are consulted to determine whether adaptive or supportive physiotherapeutic treatment is recommended. Recent admissions with extremely low weight are typically not assigned to physiotherapy until medically stabilized. The treatment can be administered in either an individual or group setting. Some patients find it difficult to participate in a group setting. Therefore, patients are initially offered individual physiotherapy, with the aim of joining the group at a later stage. Even small increments of increased bodily awareness can be frightening for some patients. It is of crucial importance to create a safe atmosphere and a trusting relation between the therapist and the patient. A maximum of six to eight patients is generally an optimal size for group therapy (as in Skattebo et al. (1989)). Emotions which are activated by the physiotherapeutic treatment are reflected upon during or at the end of the group session. Or alternatively, emotions can be further explored in individual psychotherapeutic treatment. For a bodily approach to be meaningful and to ensure continuity of care, it is of crucial importance that physiotherapy is integrated into the multi-disciplinary treatment at the unit.
Impaired body awareness and body contact The concept body contact is a relevant and informative concept, as it encompasses the process of establishing contact with both the motor and sensory dimensions of the
L.-J. Kolnes body, and the sensations and emotions in the body. The widely described and complex concept of body image3 mainly includes perceptual (i.e. body size estimation and body size distortion) and attitudinal components tapping various cognitive and behavioral dimensions (Reas and Grilo, 2004). It is suggested here, however, that the term ‘body image’ does not fully capture the experienced aspects of bodily sensations and connectedness. Therefore, the terms body awareness and body contact are preferred in this context. In the author’s experience, patients with anorexia nervosa often demonstrate confusion surrounding bodily sensations and states, a lack of contact with the body, and an inability to describe bodily experiences. Many patients demonstrate a limited understanding of how they carry their bodies, be that in walking, standing, sitting or lying down positions. They tend to lack contact with muscle groups that are essential in daily life movements and that keep the body in an upright position. Patients often report the inability to feel their own feet, or have the sensation they are standing on their feet. These observations are consistent with research findings showing that patients with anorexia nervosa exhibit reductions in body contact and the capacity to perceive bodily signals, as well as a lack of ability to understand and respond to these signals (Bruch, 1962, 1988; Pollatos et al., 2008; Thornborg and Mattson, 2010; Winberg et al., 1997). Patients with anorexia nervosa have a tendency to distance or dissociate themselves from their own body. Some patients even claim that they have no body, and that they only exist (as a person) in their head. On the contrary, after attending a body awareness group, one patient claimed that “I feel contact between my brain and my body. I feel that I use all my senses when doing the movements in the body awareness group, and I experience that my senses are coordinated.” Another patient stated, “It is strange, because during the whole day at the unit, I try to avoid feeling and relating to my body. While in the body awareness group, we are encouraged to be aware of the body and its reactions. I relax and can feel my body in a positive way. I can feel my breath is getting deeper, and I manage to let tension go, and this is a good feeling. At the same time, it’s like I feel my body too strongly.”. Becoming aware of and connected to her body was a contradictory experience for this patient. While it felt good to be relaxed and to have positive bodily experiences and feelings, it frightened her to feel her body too intensely, and to become too connected to her body. Other patients have reported that exercises like standing on their feet while trying to recognize their center of gravity, or noticing the changes in respiration patterns which vary with different positions, elicit strong feelings. The body is experienced as too real, too open, too visible, and too detectable, especially in standing positions. Some patients find it less provocative to do movements in sitting positions or while lying down on the floor. Exploring the interplay of patients’ often 3 For an overview regarding the confusion over the concept “body image” and “body schema,” see Shaun Gallagher’s “How the body shapes the mind” by Oxford University Press, 2005. Even though many studies have addressed the confusion and conceptual difficulties related to these concepts, no precise definitions have been universally accepted.
Embodying the body in anorexia nervosa contradictory perceptions of the body as disconnected, or unreal, to sensing the body as too real, represents a unique opportunity to focus on the body and move forward in the course of recovery. Establishing contact with the feet and thereby creating a solid platform for the body is always introduced at an early stage. Having attended body awareness group sessions for several months, one patient said, “I have better contact with my own body, I can appreciate my own body and bodily functions, and I feel more contact with the ground. I get more grounded, to put it that way.” Working around the center of gravity in a standing position affects breathing and muscular tension. In directing full attention to what is going on within the body, including changes in breathing, the exercises facilitate concentration and focus upon the present moment.
Constrained breathing The author has observed that a constrained breathing pattern is nearly universal in patients with anorexia nervosa. The pattern of breathing is characterized as being highly costal, and the respiration movement is frequently reduced. The breathing rhythm is often distorted, in that both the inspiration and the expiration phase is shortened. Additionally, the expiration phase is often extremely tense, almost blocked. This has consequences for the regulation of breathing, affecting the rhythm and depth of the inspiration phase. When the expiration phase is tense, it is difficult to accomplish free and deep inspiration. Patients frequently state that they are unaware of their breathing, or that they have a sense of withholding their breath. Restricted breathing pattern in patients with anorexia nervosa may be understood as part of their emotional defence system. Constrained breathing inhibit emotional regulation and expression, as well as bodily expressions, functions, and movements. Normalizing the breathing can bring a variety of emotional, mental and physiological functions into better balance, and may help patients respond to general treatment demands and give them more coping strategies in their struggle against anorexia. While working with these patients, it is useful to ask them to try to observe their breath. After attending body awareness group sessions for several weeks, one of the patients stated that she had become “more aware of my breathing, and how even the tiniest changes in posture and relaxation liberates the breath.” Other patients reported that being physically relaxed stimulated thinking and reflection, they could think and feel more clearly. The relaxation of breathing is always done carefully and over time, since it is important that the patient is comfortable with the pace. Loosening up a patient’s breathing pattern may contribute to increased relaxation, less muscular tension, and to a sense of owning the body in a new and positive way. In general, patients with anorexia nervosa are psychologically vulnerable to change, especially changes that are body-related. In some patients, a constricted breathing pattern may serve the function of maintaining psychological stability. Withholding the breath may be the patient’s singlemost important coping strategy, keeping heror himself connected, and avoiding feelings which are
285 overwhelming. If releasing the respiration proceeds too rapidly and it is not tailored properly to the individual, undesirable experiences and reinforcement of symptoms (anxiety, depression, compulsiveness) may occur.
Muscular tension Increased muscular tension and muscular stiffness are routinely found throughout the body, being more pronounced in the legs, gluteals, the back and also under the soles of the feet. These are fundamental muscles for standing in an upright position. Muscles related to respiratory function and eating are also commonly afflicted by muscular tension. Muscular tension is strongly associated with restricted breathing, and may function to seal off painful thoughts and feelings, thereby shielding the patient. Muscular tension may also serve the function of being a defence mechanism against expressing vulnerability, longing, and grief (Fangel and Thornquist, 2009). Sometimes, a pattern of decreased muscle tension is observed. This is consistent with individuals who have been traumatized (Ekerholt et al., 2009). Reduced flexibility, lack of spontaneity, and increased autonomic symptoms are often seen in traumatized individuals. In this case, treatment should be long-standing and predictable, and the verification of sensations, emotions, experiences and reestablishing of body contact is essential (ibid.). To be able to connect to their bodies, some patients require more “advanced” challenges than traditional body awareness therapies and NPMP movements. These patients need to have the experience that they really use their bodies and obtain awareness of having a body, a body of which they can be in control. Exercises that improve bodily stability with the aim of establishing contact with and strengthening the stabilizing muscles of the trunk are particularly effective. Such exercises promote body connectedness, facilitate the ability to obtain a neutral position of the pelvis and deeper breathing, and generally create a stabilizing effect on the entire body. Stabilizing exercises are basically exercises which burn few calories. Some of the recommended activities are inspired by play. Clearly, this approach encourages the patients to open up, engage with other participants, and to simply have fun and enjoy themselves. Such experiences are generally perceived as positive ones by the patient, and may open the door for future positive experiences involving the body. Patient feedback indicates that the various movements and exercises stimulate feelings of wholeness and connectedness to the body. A certain degree of body connectedness, especially a connection to the muscles and breathing, are prerequisites to be able to regulate tension, to adjust movements, and for flexibility and desired physical changes to occur.
Disturbances in posture and postural control When dysfunction occurs in one system, it can negatively impact other bodily functions. When breathing is withheld and/or highly costal, respiratory muscles are constantly being over-activated. The author has observed that the head is pulled forward, and the shoulders are hunched up and pulled forward. Additionally, a common observation is increased
286 sway in the lower back, and the pelvis is tilted forward simultaneously as the back is overextended, resulting in a misalignment of the entire body. This may cause pain in the adjacent muscles of the back and pelvis. The possibility for free and deep breathing is inhibited in this position. Holding in both the back and the abdomen bears resemblance to postures typical of wearing a corset, historically used by women of the higher classes in late 1800s and early 1900s to control the shape of the trunk. The bodily adjustments secondary to muscular tension and restrictive breathing have significant implications for movement and can cause muscleand headaches. Typically, patients lack rotation in the upper body in gait, and walking is impaired. Clinical experiences here have shown that patients with anorexia nervosa tend to have problems stabilizing their back and pelvis in a neutral position. Normal bodily axes are consequently disrupted. Despite the tendency to overexercise and do large numbers of sit-ups, yet paradoxically they lack control and stability of the trunk in daily activities.4 Consequently, it is essential to help them establish contact with their pelvis, and to find a neutral position in which contact with local muscles is facilitated and global muscles can relax. These observations support the findings of Winberg, Persson and Thorssell (1997) who found that patients with eating disorders have reduced contact with the center of the body and difficulties performing isolated movements in their pelvis. Prerequisites for postural control are muscle strength and normal bodily axes. Accordingly, the initial step in achieving balance is to normalize the bodily axes. As such, movements from Norwegian Psychomotor Physiotherapy and body awareness therapies are particularly suitable for increasing postural control in patients with anorexia nervosa.
Compulsive physical activity Compulsive and excessive physical activity5 are prominent and prevalent features in the etiology and maintenance of 4
A common distinction used to classify the role of different trunk muscles is that intersegmental, or “local” muscles, are hypothesized to function primarily as stabilizers and multisegmental, or “global” muscles, are hypothesized to function primarily as moment producers (Bergmark, 1989.) 5 There is an ongoing debate in the literature regarding “unhealthy exercise”, and which concepts to use to describe the symptom. Numerous concepts are common, including excessive exercise, excessive physical activity, compulsive physical activity, hyperactivity, high level activity, physical overactivity, obsessive training, exercise dependency, increased physical activity, and so on. Definitions appear to fall into two main dimensions: a quantitative dimension (“excessive”) and a qualitative dimension (“compulsive”). On the quantitative dimension, exercise is considered excessive when duration, frequency and intensity exceeds what is required for physical health and increases the risk for injuries (Davies and Fox, 1993). On the qualitative dimension, exercise becomes compulsive when the exercise schedule is characterized by rigidity, is prioritized over other activities to maintain the exercise pattern, and feelings of guilt and anxiety arise if exercise sessions are missed (Adkins and Keel, 2005). In my experience, the compulsive quality, rather than the excessive quantity of exercise, is a more clinically useful characterization of exercise related to eating disorders.
L.-J. Kolnes eating disorders (Beumont et al., 1994; Bratland-Sanda et al., 2010; Bruch, 1962; Davies et al., 1997). Prevalence estimates of excessive exercise among inpatients diagnosed with a clinical eating disorder range between 33% and 100% (Katz, 1996). A greater proportion of patients with anorexia nervosa engage in unhealthy physical activity than patients diagnosed with bulimia nervosa (Brewerton et al., 1995; Davies et al., 1997), and excessive exercise is most pronounced in the restrictive type of anorexia (Dalle Grave et al., 2008). These research findings are supported by this author’s observations. Routine activities often become compulsive in nature, as patients turn daily activities into an opportunity to exercise. For example, walking often resembles jogging, and patients may stand in usually sedentary-type situations such as doing homework or watching TV. Compulsively engaging in physical activity may serve various functions, including affect regulation, burning calories, self-punishment, or acquiring permission to eat and relax (Penas-Lledo et al., 2002). Compulsive exercise is seen as a significant predictor of poor treatment outcome (Strober et al., 1997) and is clinically important in the treatment of anorexia nervosa. Supervised physical activity programs designed to modify physical overactivity may be carefully included in treatment. With regards to the key physiotherapeutic clinical observations described above, it is argued that physiotherapeutic methods designed to enhance body awareness, free breathing, and balanced muscle tension and posture, should precede the introduction of traditional physical activity strategies.
Summary The purpose of this article was to describe bodily symptoms and experiences in patients with anorexia nervosa, and to present and discuss a physiotherapeutic treatment approach with the aim of enhancing body awareness and embodiment in patients with anorexia nervosa. Clinical recommendations are based on the author’s clinical observations and patient testimonials, in addition to the theories and methodology outlined by Norwegian Psychomotor Physiotherapy, body awareness therapies, and general knowledge on bodily stability. In the author’s experience, patients with anorexia nervosa are characterized by having impaired body awareness and poor body contact, a constrained breathing pattern, extensive muscular tension, lack of postural stability and they engage extensively in compulsive physical activity. Physiotherapeutic theory and treatment provides important insight in helping anorexia nervosa patients with these challenges. A body awareness approach may contribute to novel ways of sensing and interpreting bodily signals, to experience the body in a more differentiated way and integrating the body as one’s own, in becoming an embodied person. Since increased body awareness and a free breathing pattern can improve emotional awareness, physiotherapeutic methods may provide a gateway to unexplored feelings, associations, and experiences. Improved body contact and bodily stability also seems to stimulate physical and mental vitality, increased pleasure in movements, and create new associations with physical
Embodying the body in anorexia nervosa activity that do not exclusively center around weight. Body awareness oriented therapies should therefore precede the introduction of physical activity and exercise programs, in order to prevent a training regime which maintains the mechanical and obsessive nature of physical activity characteristic of patients with anorexia nervosa. Embodying the body in patients with anorexia nervosa may help stabilize the body and the mind, and to discover unknown resources within the patients. Body awareness and body contact needs to first be established for the patients to be able to attune themselves to their emotions and minds, as well as to the surrounding world. Clearly, the body deserves more attention in treatment programs for eating disorders. Further research is needed to expand our knowledge in this growing field.
Acknowledgements The author would like to acknowledge psychologist Deborah Reas, PhD and Øyvind Rø, MD, PhD, Research Director at the Regional Department for Eating Disorders, Oslo University Hospital, and physiotherapist Eline Thornquist, professor at the University College of Bergen, for their support and valuable contributions to this paper.
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PSYCHOMOTOR PHYSIOTHERAPY & EATING DISORDERS
Embodying the body in anorexia nervosa e a physiotherapeutic approach Liv-Jorunn Kolnes, Dr. scient Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Ulleval, P.O. Box 4956 Nydalen, 0424 Oslo, Norway Received 11 October 2011; received in revised form 13 December 2011; accepted 20 December 2011
KEYWORDS Anorexia nervosa; Norwegian psychomotor physiotherapy; Body awareness therapies; Body contact; Bodily stability; Embodiment
Summary Body dissatisfaction and disturbances in bodily sensations are prevailing qualities among patients with anorexia nervosa (AN). However, therapies addressing the body are typically marginalized within treatment programs for anorexia nervosa. The purpose of this article is to 1) describe common bodily symptoms and experiences of anorexia nervosa patients and discuss the accompanying physical and emotional impact, and 2) present physiotherapeutic approaches to help patients with anorexia nervosa. Recommendations are based on the author’s clinical observations and patient testimonials, in addition to the theory and methodology outlined by Norwegian Psychomotor Physiotherapy (NPMP), body awareness therapies, and current knowledge on bodily stability. It is the author’s experience that anorexia nervosa patients tend to have significant impairments in their body awareness, a restricted breathing pattern, significant muscular tension, poor postural stability, and they are frequently engaged in compulsive physical activity. A body awareness approach for these patients may contribute to novel ways of sensing and interpreting bodily signals, improving emotional awareness, experiencing the body and integrating the body as one’s own, i.e., becoming an embodied person. Embodying the body in patients with anorexia nervosa by utilizing approaches from NPMP and body awareness therapies, in addition to stability training principles, may help stabilize the body and the mind, and thus, constitute a beneficial addition to overall treatment for anorexia nervosa. ª 2011 Elsevier Ltd. All rights reserved.
Introduction Body dissatisfaction and disturbances in recognizing and identifying bodily sensations have been established as E-mail address: [email protected].
prevailing qualities among patients with anorexia nervosa (Bruch, 1962, 1988; Pollatos et al., 2008; Spoor et al., 2005). Hilde Bruch was a pioneer in the field of anorexia nervosa, emphasizing the necessity of understanding what is occurring within patients’ bodies, and assisting patients to become aware of impulses, feelings and sensations originating in the body (Bruch, 1973). Since her inaugural
1360-8592/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jbmt.2011.12.005
282 research, however, sparse attention has been paid to body awareness and helping patients with anorexia nervosa evoke awareness of bodily feelings, impulses, and sensations (Close, 2000; Davison, 1988; Spoor et al., 2005; Thornborg, 2002; Thornborg and Mattson, 2010; Thornquist, 1994; Wallin et al., 2000). In-depth investigations describing bodily symptoms and experiences in anorexia nervosa, or the accompanying impairment, remain rare. Nevertheless, physiotherapists have a unique opportunity to improve body awareness among anorexia nervosa patients. The author, who is also the lead researcher and a specialist in Norwegian Psychomotor Physiotherapy working in a special unit for patients having eating disorders, has observed that patients with anorexia nervosa have significant impairments in their awareness of their bodies, an extremely constrained breathing pattern, significant muscular tension, poor postural stability, and are frequently obsessed with excessive exercise. As such, the concepts of ‘disembodied’ and ‘disconnected’ are relevant connotations for the anorectic body. Understanding how patients with anorexia nervosa attune themselves to their emotions, and to the broader social world, when they are so disconnected from their own bodies is an intriguing question. How do they make sense of themselves, and how do they manage to regulate emotions and tensions if they do not sense their own bodies, if they are disembodied? In the first section of this article, the theoretical framework of physiotherapy work with patients with anorexia nervosa is presented. In the second, clinical observations from the author’s practice are identified, and physiotherapeutic approaches for increasing body awareness and body contact are presented.
Conceptual and theoretical framework The theoretical and methodological guidelines outlined by the Norwegian Psychomotor Physiotherapy (NPMP), body awareness therapies, and current knowledge on bodily stability provide a solid foundation for clinical work with anorexia nervosa patients. These therapeutic approaches overlap and complement each other in meaningful ways. It is argued that exclusively relying upon a single theory or methodology fails to capture the complexity and seriousness of the anorexic symptomology.
Norwegian psychomotor physiotherapy The theory of Norwegian Psychomotor Physiotherapy (NPMP) is inspired by the contributions of the Austrian physician and psychoanalyst, Wilhelm Reich. Reich observed that the body had a significant role in expressing unresolved emotional conflicts and traumas, and that we tend to use the body to maintain various rigidities linked to unresolved emotions. He argued that the body could “speak” more honestly than the spoken word (Gilbert, 1999). The Norwegian Psychomotor Physiotherapy approach was developed by the physiotherapist Aadel Bulow-Hansen and psychiatrist Trygve Braatoey after the second world war, and have since then been further elaborated and modified by physiotherapists and researchers in the Nordic countries.
L.-J. Kolnes NPMP is based on the understanding that posture, respiration, muscle tension and body awareness are closely related to emotional and psychological strain (Thornquist and Bunkan, 1991). Two fundamental premises are that a person’s life and history are expressed through the body, and the body is a functionally integrated entity (Thornquist, 2010). The body is understood as the centre of experiences and knowledge through which we take in information and interact with the surroundings. Personal experiences and stories are imprinted in and reflected in our bodies, i.e., they become embodied. Our personal stories necessarily contribute to the meaning of bodily symptoms and dysfunctions. According to the NPMP theory, breathing and influences on the breathing pattern constitute a fundamental treatment component.1 There is a strong interaction between breathing, emotions, and the regulation of the emotions. Breathing is considered as a resonance field for emotional states and reactions. Constrained breathing is understood as a way of avoiding feelings. Living with enduring fear or anxiety, or under circumstances which imposed such feelings in the past, may result in the establishment of a consistent pattern of muscular tension and withheld breathing. As such, a pattern may manifest itself in the body, stress and strains will become embodied. A habitual pattern of rigid breathing can be seen as part of our emotional and social defence system when adjusting to the surroundings. A restricted breathing pattern may lead to rigidity in bodily expressions, functions, and movements, and also contribute to poor mental awareness (Bunkan, 2003; Ekerholt and Bergland, 2008), while free breathing is related to a positive self-image and mental health (Meurle-Hallberg, 2005). By carefully releasing and gradually allowing for verbal interpretation, free breathing may provide access to problematic emotions and painful memories. The NPMP examination includes a comprehensive history taking. The physical examination consists of observation and an evaluation of posture, respiration, muscles, functioning, and the ability to relax. Autonomic reactions to the examination are registered. Changes in the breathing pattern, emotional and autonomic reactions to the treatment provide important information about how to proceed with treatment, and on the extent to which the patient should relax or stabilize. Depending on individual findings, the treatment may have two main directions. In adaptive 1 Respiration is unique in that it is under both involuntary and voluntary functioning and control. Free breathing is characterized by a rhythmic interplay between inhalation and expiration. The diaphragm is our largest and our most important breathing muscle. When inhaling, the diaphragm descends and the abdominal content is pressed downward. In exhaling, the diaphragm is in itself passive, but is being pressed upwards by abdominal muscles. The movements related to the descending and relaxation of the diaphragm muscle, are considered to have a massaging effect on organs in the abdomen. Hence, breathing freely and satisfactorily facilitates circulation and the function of these organs, as well as the digestion by the abdominal organs (Mattsson and Mattsson, 2002). Thus, pain coming from the abdominal region and constipation may be influenced by the breathing pattern. Chaitow, Bradley and Gilbert’s Multidisciplinary approaches to breathing pattern disorders (2002) gives valuable contributions to clinicians engaged in and who wish to learn more about breathing-related disorders.
Embodying the body in anorexia nervosa treatment, the aim is to change the person’s physical and emotional habitual patterns of reaction. In supportive treatment, the focus is on stabilizing the individual, allowing for a better connection to oneself. The aim of the treatment is to address bodily dysfunction and to facilitate a process of change through massage, movements, and exercises. An important principle in treatment is to build the body from the bottom up. To create and support the ability to stand firmly on the floor, the treatment typically begins with the legs. A solid platform is a prerequisite for free respiration, balance, and movement. Patient verbal reflections over bodily sensations, the identification of any physical changes, or changes in the patient’s relationships to others, comprise central components of NPMP treatment. The therapist facilitates this verbal reflection and helps the patient to establish a sense of coherence. Indications for psychomotor physiotherapy include strain and functional disturbances in the musculoskeletal system, as well as various psychiatric disorders. The treatment process may take months or even years. In order to be a qualified practioner in NPMP, the physiotherapist is required to take courses in the Advanced Programme for Mental Healthcare (2e3 years).
Body awareness therapies Body awareness therapies includes body-oriented, physiotherapeutic approaches aimed at building awareness of how the body is used, behavior, and interaction with oneself and others (Gyllensten et al., 2003a). Roxendal (1985) has defined body awareness as “the perception of bodily sensations, impulses, feelings, and reactions that originate in the body”. The treatment aims to integrate the body in the total experience of the self, to reestablish body awareness and body control (Roxendal, 1995), as well as to achieve a more developed contact with emotions and affect (Gyllensten et al., 2003b). The exercises are easily managed and focus on the here-andnow, helping the patient to recognize and observe without interfering and judging. Specific aims of body awareness therapies are to increase freedom in muscle tension, normalize posture and balance, improve movement and breathing, and promote mental awareness. The movements are based on movements from daily life, and are performed in standing, walking, sitting and laying positions. Grounding, improving the postural line, and the coordination and centering of movements are central aspects of the treatment. As in NPMP, body awareness therapies espouses the notion that breathing is closely interrelated with emotions. Body awareness therapies are frequently used by physiotherapists in Nordic countries for the rehabilitation of patients in psychiatric settings (Gyllensten et al., 2009, 2003a, 2010; Roxendal, 1985), patients with prolonged musculoskeletal pain (Grahn, 1999; Grahn et al., 1998) and fibromyalgia (Gustavsson et al., 2002; Gard, 2005). Research has shown that improving body awareness is important for a more positive experience of body and self, and improvement of health-related quality of life (MeurleHallberg, 2005). The notion that bodily sensitivity and
283 emotions are interrelated is also consistent with research showing that individuals who perceive their bodily signals with a high degree of sensitivity experience their emotions more intensely (Damasio, 1999; Pollatos et al., 2008).
Bodily stability Body awareness and body contact are inevitably connected to bodily stability, and its related muscular, neuromuscular, and proprioceptive2 systems. Bodily stability and good alignment depend on an interplay between muscular, neuromuscular, and breathing processes. Restricted breathing, combined with muscular stiffness and rigidity, have a major adverse impact on bodily stability. Balance and neuromuscular control in the entire body, including the under-extremities, are essential to stability and to establish a solid platform from the bottom up. This section will focus on stabilizing the trunk. Control and stability of the trunk in relation to body awareness and respiration, has not been previously described among patients with anorexia nervosa. Control and stability of the trunk are closely connected to activity in muscles such as the diaphragm (Hodges et al., 1997), tranversus abdominis (Hodges et al., 1999), multifidus (MacDonald et al., 2006) and pelvic floor muscles (Hodges et al., 2002). Reduced postural stability of these muscles may impair the mechanical support of the spine, and negatively affect strength and flexibility in spinal movement. Respiration is essential to the proper functioning of these muscles (Smith et al., 2006). Over the past decades, an ongoing debate has existed regarding which muscles are important trunk stabilizers. Similarly, debate surrounds the optimal training method to improve stability in the trunk by using the neuromuscular control system. There seems to be agreement among clinicians and researchers alike that enhancing motor patterns that incorporate many muscles, rather than a few, is appropriate when training for stability. Further, it is important to activate deep local muscles in the trunk, in conjunction with global muscles, to achieve control and stability (Kavcic et al., 2004; van Dieen et al., 2003). In order to activate local trunk muscles, it is of fundamental importance that the back and pelvis are in neutral positions. Free breathing and relaxation skills are essential to achieve neutral positions and stability in the trunk (Stuge, 2007). Functional muscle strategies are difficult if there is rigidity during stability training efforts, and this is done with a restricted breathing pattern, or reliance on mainly global muscle groups. This knowledge is important if the aim is to enhance body contact and body awareness for patients with anorexia nervosa. Obsessive training of muscles that are strong, and avoiding weak or unused muscles, will have an adverse effect on motor control and contact with local muscles (Stuge, 2007). 2 Proprioception can be defined as a neuromuscular process that involves both afferent input and efferent signals that allows the body to maintain stability and orientation during both static and dynamic activities, i.e. awareness of position or movement (Laskowski et al., 1997).
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Bodily characteristics and physiotherapeutic approaches Patients with anorexia nervosa display a complex and multifaceted clinical picture. In addition to body dissatisfaction and a disturbed body image, anorexia nervosa is associated with anxiety, compulsiveness, depression, impaired mentalization and difficulties with emotional expression and the regulation of emotions (Jordan et al., 2008; O’Brien and Vincent, 2003; Ska ˚rderud, 2007). A whole range of somatic symptoms and complications following long-standing and serious malnourishment have been documented (Frostad, 2004; Nicholls et al., 2000). Clinical findings from the author’s practice with inpatient treatment reveal that impaired body awareness and body contact, a restricted breathing pattern, postural disturbances, and muscular tension are characteristic of anorexia nervosa. Moreover, patients with anorexia nervosa convey a compulsive physical activity style and the inability to relax. This section further describes these clinical characteristics and recommended physiotherapeutic treatment modalities for patients with anorexia nervosa. The overall aim of physiotherapeutic treatment is to 1) help patients establish contact with their own body and bodily sensations, and 2) to increase body awareness and ownership of their bodies, or to become embodied. ‘Embodiment’ refers in this context to the body as a sentient subject and a subjective modality of being. In this sense, embodiment pertains to the sense of being in contact with the body and bodily sensations, as well as a genuine feeling of owning one’s own body and being in control of one’s own bodily functions. Prior to the initiation of treatment, the patient receives a comprehensive examination. Team collaborators are consulted to determine whether adaptive or supportive physiotherapeutic treatment is recommended. Recent admissions with extremely low weight are typically not assigned to physiotherapy until medically stabilized. The treatment can be administered in either an individual or group setting. Some patients find it difficult to participate in a group setting. Therefore, patients are initially offered individual physiotherapy, with the aim of joining the group at a later stage. Even small increments of increased bodily awareness can be frightening for some patients. It is of crucial importance to create a safe atmosphere and a trusting relation between the therapist and the patient. A maximum of six to eight patients is generally an optimal size for group therapy (as in Skattebo et al. (1989)). Emotions which are activated by the physiotherapeutic treatment are reflected upon during or at the end of the group session. Or alternatively, emotions can be further explored in individual psychotherapeutic treatment. For a bodily approach to be meaningful and to ensure continuity of care, it is of crucial importance that physiotherapy is integrated into the multi-disciplinary treatment at the unit.
Impaired body awareness and body contact The concept body contact is a relevant and informative concept, as it encompasses the process of establishing contact with both the motor and sensory dimensions of the
L.-J. Kolnes body, and the sensations and emotions in the body. The widely described and complex concept of body image3 mainly includes perceptual (i.e. body size estimation and body size distortion) and attitudinal components tapping various cognitive and behavioral dimensions (Reas and Grilo, 2004). It is suggested here, however, that the term ‘body image’ does not fully capture the experienced aspects of bodily sensations and connectedness. Therefore, the terms body awareness and body contact are preferred in this context. In the author’s experience, patients with anorexia nervosa often demonstrate confusion surrounding bodily sensations and states, a lack of contact with the body, and an inability to describe bodily experiences. Many patients demonstrate a limited understanding of how they carry their bodies, be that in walking, standing, sitting or lying down positions. They tend to lack contact with muscle groups that are essential in daily life movements and that keep the body in an upright position. Patients often report the inability to feel their own feet, or have the sensation they are standing on their feet. These observations are consistent with research findings showing that patients with anorexia nervosa exhibit reductions in body contact and the capacity to perceive bodily signals, as well as a lack of ability to understand and respond to these signals (Bruch, 1962, 1988; Pollatos et al., 2008; Thornborg and Mattson, 2010; Winberg et al., 1997). Patients with anorexia nervosa have a tendency to distance or dissociate themselves from their own body. Some patients even claim that they have no body, and that they only exist (as a person) in their head. On the contrary, after attending a body awareness group, one patient claimed that “I feel contact between my brain and my body. I feel that I use all my senses when doing the movements in the body awareness group, and I experience that my senses are coordinated.” Another patient stated, “It is strange, because during the whole day at the unit, I try to avoid feeling and relating to my body. While in the body awareness group, we are encouraged to be aware of the body and its reactions. I relax and can feel my body in a positive way. I can feel my breath is getting deeper, and I manage to let tension go, and this is a good feeling. At the same time, it’s like I feel my body too strongly.”. Becoming aware of and connected to her body was a contradictory experience for this patient. While it felt good to be relaxed and to have positive bodily experiences and feelings, it frightened her to feel her body too intensely, and to become too connected to her body. Other patients have reported that exercises like standing on their feet while trying to recognize their center of gravity, or noticing the changes in respiration patterns which vary with different positions, elicit strong feelings. The body is experienced as too real, too open, too visible, and too detectable, especially in standing positions. Some patients find it less provocative to do movements in sitting positions or while lying down on the floor. Exploring the interplay of patients’ often 3 For an overview regarding the confusion over the concept “body image” and “body schema,” see Shaun Gallagher’s “How the body shapes the mind” by Oxford University Press, 2005. Even though many studies have addressed the confusion and conceptual difficulties related to these concepts, no precise definitions have been universally accepted.
Embodying the body in anorexia nervosa contradictory perceptions of the body as disconnected, or unreal, to sensing the body as too real, represents a unique opportunity to focus on the body and move forward in the course of recovery. Establishing contact with the feet and thereby creating a solid platform for the body is always introduced at an early stage. Having attended body awareness group sessions for several months, one patient said, “I have better contact with my own body, I can appreciate my own body and bodily functions, and I feel more contact with the ground. I get more grounded, to put it that way.” Working around the center of gravity in a standing position affects breathing and muscular tension. In directing full attention to what is going on within the body, including changes in breathing, the exercises facilitate concentration and focus upon the present moment.
Constrained breathing The author has observed that a constrained breathing pattern is nearly universal in patients with anorexia nervosa. The pattern of breathing is characterized as being highly costal, and the respiration movement is frequently reduced. The breathing rhythm is often distorted, in that both the inspiration and the expiration phase is shortened. Additionally, the expiration phase is often extremely tense, almost blocked. This has consequences for the regulation of breathing, affecting the rhythm and depth of the inspiration phase. When the expiration phase is tense, it is difficult to accomplish free and deep inspiration. Patients frequently state that they are unaware of their breathing, or that they have a sense of withholding their breath. Restricted breathing pattern in patients with anorexia nervosa may be understood as part of their emotional defence system. Constrained breathing inhibit emotional regulation and expression, as well as bodily expressions, functions, and movements. Normalizing the breathing can bring a variety of emotional, mental and physiological functions into better balance, and may help patients respond to general treatment demands and give them more coping strategies in their struggle against anorexia. While working with these patients, it is useful to ask them to try to observe their breath. After attending body awareness group sessions for several weeks, one of the patients stated that she had become “more aware of my breathing, and how even the tiniest changes in posture and relaxation liberates the breath.” Other patients reported that being physically relaxed stimulated thinking and reflection, they could think and feel more clearly. The relaxation of breathing is always done carefully and over time, since it is important that the patient is comfortable with the pace. Loosening up a patient’s breathing pattern may contribute to increased relaxation, less muscular tension, and to a sense of owning the body in a new and positive way. In general, patients with anorexia nervosa are psychologically vulnerable to change, especially changes that are body-related. In some patients, a constricted breathing pattern may serve the function of maintaining psychological stability. Withholding the breath may be the patient’s singlemost important coping strategy, keeping heror himself connected, and avoiding feelings which are
285 overwhelming. If releasing the respiration proceeds too rapidly and it is not tailored properly to the individual, undesirable experiences and reinforcement of symptoms (anxiety, depression, compulsiveness) may occur.
Muscular tension Increased muscular tension and muscular stiffness are routinely found throughout the body, being more pronounced in the legs, gluteals, the back and also under the soles of the feet. These are fundamental muscles for standing in an upright position. Muscles related to respiratory function and eating are also commonly afflicted by muscular tension. Muscular tension is strongly associated with restricted breathing, and may function to seal off painful thoughts and feelings, thereby shielding the patient. Muscular tension may also serve the function of being a defence mechanism against expressing vulnerability, longing, and grief (Fangel and Thornquist, 2009). Sometimes, a pattern of decreased muscle tension is observed. This is consistent with individuals who have been traumatized (Ekerholt et al., 2009). Reduced flexibility, lack of spontaneity, and increased autonomic symptoms are often seen in traumatized individuals. In this case, treatment should be long-standing and predictable, and the verification of sensations, emotions, experiences and reestablishing of body contact is essential (ibid.). To be able to connect to their bodies, some patients require more “advanced” challenges than traditional body awareness therapies and NPMP movements. These patients need to have the experience that they really use their bodies and obtain awareness of having a body, a body of which they can be in control. Exercises that improve bodily stability with the aim of establishing contact with and strengthening the stabilizing muscles of the trunk are particularly effective. Such exercises promote body connectedness, facilitate the ability to obtain a neutral position of the pelvis and deeper breathing, and generally create a stabilizing effect on the entire body. Stabilizing exercises are basically exercises which burn few calories. Some of the recommended activities are inspired by play. Clearly, this approach encourages the patients to open up, engage with other participants, and to simply have fun and enjoy themselves. Such experiences are generally perceived as positive ones by the patient, and may open the door for future positive experiences involving the body. Patient feedback indicates that the various movements and exercises stimulate feelings of wholeness and connectedness to the body. A certain degree of body connectedness, especially a connection to the muscles and breathing, are prerequisites to be able to regulate tension, to adjust movements, and for flexibility and desired physical changes to occur.
Disturbances in posture and postural control When dysfunction occurs in one system, it can negatively impact other bodily functions. When breathing is withheld and/or highly costal, respiratory muscles are constantly being over-activated. The author has observed that the head is pulled forward, and the shoulders are hunched up and pulled forward. Additionally, a common observation is increased
286 sway in the lower back, and the pelvis is tilted forward simultaneously as the back is overextended, resulting in a misalignment of the entire body. This may cause pain in the adjacent muscles of the back and pelvis. The possibility for free and deep breathing is inhibited in this position. Holding in both the back and the abdomen bears resemblance to postures typical of wearing a corset, historically used by women of the higher classes in late 1800s and early 1900s to control the shape of the trunk. The bodily adjustments secondary to muscular tension and restrictive breathing have significant implications for movement and can cause muscleand headaches. Typically, patients lack rotation in the upper body in gait, and walking is impaired. Clinical experiences here have shown that patients with anorexia nervosa tend to have problems stabilizing their back and pelvis in a neutral position. Normal bodily axes are consequently disrupted. Despite the tendency to overexercise and do large numbers of sit-ups, yet paradoxically they lack control and stability of the trunk in daily activities.4 Consequently, it is essential to help them establish contact with their pelvis, and to find a neutral position in which contact with local muscles is facilitated and global muscles can relax. These observations support the findings of Winberg, Persson and Thorssell (1997) who found that patients with eating disorders have reduced contact with the center of the body and difficulties performing isolated movements in their pelvis. Prerequisites for postural control are muscle strength and normal bodily axes. Accordingly, the initial step in achieving balance is to normalize the bodily axes. As such, movements from Norwegian Psychomotor Physiotherapy and body awareness therapies are particularly suitable for increasing postural control in patients with anorexia nervosa.
Compulsive physical activity Compulsive and excessive physical activity5 are prominent and prevalent features in the etiology and maintenance of 4
A common distinction used to classify the role of different trunk muscles is that intersegmental, or “local” muscles, are hypothesized to function primarily as stabilizers and multisegmental, or “global” muscles, are hypothesized to function primarily as moment producers (Bergmark, 1989.) 5 There is an ongoing debate in the literature regarding “unhealthy exercise”, and which concepts to use to describe the symptom. Numerous concepts are common, including excessive exercise, excessive physical activity, compulsive physical activity, hyperactivity, high level activity, physical overactivity, obsessive training, exercise dependency, increased physical activity, and so on. Definitions appear to fall into two main dimensions: a quantitative dimension (“excessive”) and a qualitative dimension (“compulsive”). On the quantitative dimension, exercise is considered excessive when duration, frequency and intensity exceeds what is required for physical health and increases the risk for injuries (Davies and Fox, 1993). On the qualitative dimension, exercise becomes compulsive when the exercise schedule is characterized by rigidity, is prioritized over other activities to maintain the exercise pattern, and feelings of guilt and anxiety arise if exercise sessions are missed (Adkins and Keel, 2005). In my experience, the compulsive quality, rather than the excessive quantity of exercise, is a more clinically useful characterization of exercise related to eating disorders.
L.-J. Kolnes eating disorders (Beumont et al., 1994; Bratland-Sanda et al., 2010; Bruch, 1962; Davies et al., 1997). Prevalence estimates of excessive exercise among inpatients diagnosed with a clinical eating disorder range between 33% and 100% (Katz, 1996). A greater proportion of patients with anorexia nervosa engage in unhealthy physical activity than patients diagnosed with bulimia nervosa (Brewerton et al., 1995; Davies et al., 1997), and excessive exercise is most pronounced in the restrictive type of anorexia (Dalle Grave et al., 2008). These research findings are supported by this author’s observations. Routine activities often become compulsive in nature, as patients turn daily activities into an opportunity to exercise. For example, walking often resembles jogging, and patients may stand in usually sedentary-type situations such as doing homework or watching TV. Compulsively engaging in physical activity may serve various functions, including affect regulation, burning calories, self-punishment, or acquiring permission to eat and relax (Penas-Lledo et al., 2002). Compulsive exercise is seen as a significant predictor of poor treatment outcome (Strober et al., 1997) and is clinically important in the treatment of anorexia nervosa. Supervised physical activity programs designed to modify physical overactivity may be carefully included in treatment. With regards to the key physiotherapeutic clinical observations described above, it is argued that physiotherapeutic methods designed to enhance body awareness, free breathing, and balanced muscle tension and posture, should precede the introduction of traditional physical activity strategies.
Summary The purpose of this article was to describe bodily symptoms and experiences in patients with anorexia nervosa, and to present and discuss a physiotherapeutic treatment approach with the aim of enhancing body awareness and embodiment in patients with anorexia nervosa. Clinical recommendations are based on the author’s clinical observations and patient testimonials, in addition to the theories and methodology outlined by Norwegian Psychomotor Physiotherapy, body awareness therapies, and general knowledge on bodily stability. In the author’s experience, patients with anorexia nervosa are characterized by having impaired body awareness and poor body contact, a constrained breathing pattern, extensive muscular tension, lack of postural stability and they engage extensively in compulsive physical activity. Physiotherapeutic theory and treatment provides important insight in helping anorexia nervosa patients with these challenges. A body awareness approach may contribute to novel ways of sensing and interpreting bodily signals, to experience the body in a more differentiated way and integrating the body as one’s own, in becoming an embodied person. Since increased body awareness and a free breathing pattern can improve emotional awareness, physiotherapeutic methods may provide a gateway to unexplored feelings, associations, and experiences. Improved body contact and bodily stability also seems to stimulate physical and mental vitality, increased pleasure in movements, and create new associations with physical
Embodying the body in anorexia nervosa activity that do not exclusively center around weight. Body awareness oriented therapies should therefore precede the introduction of physical activity and exercise programs, in order to prevent a training regime which maintains the mechanical and obsessive nature of physical activity characteristic of patients with anorexia nervosa. Embodying the body in patients with anorexia nervosa may help stabilize the body and the mind, and to discover unknown resources within the patients. Body awareness and body contact needs to first be established for the patients to be able to attune themselves to their emotions and minds, as well as to the surrounding world. Clearly, the body deserves more attention in treatment programs for eating disorders. Further research is needed to expand our knowledge in this growing field.
Acknowledgements The author would like to acknowledge psychologist Deborah Reas, PhD and Øyvind Rø, MD, PhD, Research Director at the Regional Department for Eating Disorders, Oslo University Hospital, and physiotherapist Eline Thornquist, professor at the University College of Bergen, for their support and valuable contributions to this paper.
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