By Yael Latzer, DSc, and Zipora Hochdorf, PhD
Reprinted from Eating Disorders Review
July/August 2005 Volume 16, Number 4
©2005 Gürze Books
Anorexia nervosa (AN) usually follows a prolonged course, with morbidity and high mortality.1 According to the DSM-IV,2 one of the diagnostic characteristics of AN is denial. These patients tend to view their low weight as an accomplishment rather than as an affliction and as a result have little motivation for change. Their drive for thinness is considered egosyntonic.3,4 Thus, one should raise the question, What kind of dialogue do AN patients have with life and death?
Various authors have dealt with this issue. Some refer to the denial of AN patients from a psychodynamic perspective, claiming that these patients play with the idea of death like a child in a game, pretending that they can disappear through death and return in a mystical way.5,6
Other authors relate to the dialogue of AN with life and death from an interpersonal theory perspective.7,8,9 According to this viewpoint, AN patients are not attracted to death so much as they are seeking control over their life and a sense of identity. The symptoms represent a latent suicidal act as a result of feeling depressed for not achieving such control and thereby serve as a way to achieve false control.
Lifton described the AN patient as an individual who is too afraid to live fully, yet too afraid to die.10 The paradox is imprinted in the psychopathology of an AN patient in that she refuses to eat in order to have a meaningful life and to fight against death, as if she is “dying to live.” Dally and colleagues. also referred to the close link between eating and death imagery, claiming that the aversion to food among AN patients reflects “a horror of eating” rather than a fear of gaining weight per se.11 Similarly, Strober argued that rather than being a flirtation with death, AN actually represents the struggle to exist within the narrowest parameter.12 Roea and co-workers relate to the illness itself as giving the meaning of life, rather than as being a threat.13 As such, the AN symptoms serve as a source of life in a sea of misery, and provide meaning to an otherwise meaningless life.
This theoretical point of view is in line with recent empirical findings. Bachar and colleagues used the differentiation between the attraction to and repulsion by life and the attraction to and repulsion by death as independent factors in order to clarify the perceptions of life and death among ED patients.14 They found that AN patients are characterized by a rejection of life rather than a contemplation of death or an attraction to it.
This point of view is also in accordance with the attachment theory. According to this theory, AN patients do not dare express their interests or needs, but rather feel insecurely attached to others by dependency or avoidance. They lack confidence in the world and the ability to cope with negative emotions. Rather than relying on human beings to fulfill their secure base needs, they resent food and in doing so fulfill those needs.
The Drive to Attachment
Bowlby postulated a drive that is separate from and more powerful than hunger in its effect on the mother-child relationship: namely, the drive toward attachment.15-17 Adult attachment representations are believed to be internalized working models of infantile drives and associated behaviors. Since Bowlby developed the attachment theory, there has been some suggestive evidence linking Hilde Bruch’s theory of abnormal mother-child interactions and eating disorders with insecure attachment styles later in life.7 Results of several recent studies support this link and find that attachment processes are abnormal among persons with eating disorders. This is particularly true in reference to these patients’ insecure attachment styles.18-20
Thus, one may assume that those insecure feelings may lead to a low sense of mastery and self-worth, to hopelessness and helplessness, and as a result to a repulsion to life. As such, AN symptoms may create a false sense of security by providing control over a seemingly meaningless life. This conceptualization is in line with recent empirical findings.21
The association between attachment style and the sense of meaning in life might shed further light on family issues and AN. According to this conceptualization, the question arises as to how clinicians may assist AN patients in feeling secure enough to be attached to life without needing the symptoms, that is, to be attracted to life from a real base of security rather than a false one.
The clinical implications of this theoretical conceptualization may suggest that creating an internal sense of security and a security-based environment should be the focal point of the therapeutic relationship, rather than focusing the attention and dialogue on death and/or food preoccupation.
In light of the importance of familial factors in the etiology of ED, family therapy may be a critical aspect of treating AN patients and helping them to develop a sense of internal security and autonomy of the self. Family therapy is recommended as a framework for changing family attachment styles through exposure of the beliefs and rules that dictate and influence family functioning, as well as through the introduction of new ways of interacting that promote family stability and a securely based environment. New emotional experiences that occur as a result of transformed interactions with attachment figures may be a powerful way to affect intrapsychic and interpersonal change.22 Sexson, Glanville, and Kaslow recommended modifications of interpersonal communication with adolescents, particularly those that address attachment issues within the context of various constellations of family members.23
The desired change may be achieved by giving parents access to round-the-clock acceptance, support, and containment during the first three months of treatment (during which time the parents also receive instruction regarding the feeding of their children). This viewpoint is based on the assumption that if the parents themselves feel a sense of safe communication with the therapist, they will be able to transmit this feeling to their children. When the parents feel that they are contained and supported, rather than guilt-ridden and insecure, they may become more aware of their own strengths and abilities and feel better equipped to take more initiative with their child. In addition, warm and empathic interactions with the therapist may act as a “healing experience” for the parents themselves, thereby helping them achieve a more secure attachment style.24-27
This approach is in line with the Emotionally Focused Therapy (EFT) model, which addresses attachment issues in the therapeutic process by shifting negative cycles to cycles characterized by affiliation and trust, thereby fostering the creation of a secure attachment bond.22,28 Hopefully, with this approach AN patients will start to feel secure enough in life to become attached to it once more.
Acknowledgment: We would like to acknowledge and thank Galia Golan for her valuable assistance.
- Le Grange, D. Family therapy for adolescent anorexia nervosa. J Clin Psychol 1999; 5: 727.
- Statistical and Diagnostic Manual of Mental Disorders (DSM-IV). Washington, DC: American Psychiatric Association, 1994.
- Garfinkel PE, Garner, D M. Anorexia nervosa: A Multidimensional Perspective. New York: Brunner-Mazel, 1982.
- Yager J, Landsverk J, Edelstein, CK, Jarvik M. A 20-month follow-up study of 628 women with eating disorders: A course of associated symptoms and related clinical features. Int J Eat Disord 1988; 4:503.
- Jackson CC, Davidson G P. The anorectic patient as a survivor: The denial of death and death themes in the literature on anorexia nervosa. Int J Eat Disord 1986, 5: 821.
- Sours J. Starving to Death in a Sea of Objects: The Anorexia Nervosa Syndrome. New York: Jason Aronson, 1980.
- Bruch H. Eating Disorders: Obesity, anorexia nervosa, and the person within. New York: Basic Books, 1973.
- Bruch, H. The Golden Cage: The Enigma of Anorexia Nervosa. New York: Vintage Books, 1979.
- Russell J, Halasz G, Beumont PJ. Death related themes in anorexia nervosa: A practical exploration. Journal of Adolescence, 1989: 13, 311.
- Lifton R. Death in life: The Survivors of Hiroshima. London: Wiedenfeld & Nicolson., 1969.
- Dally P, Gomez J, Isaacs A. Anorexia Nervosa. London: William Heinemann Medical Books, 1979.
- Strober, M. Disorders of the self in anorexia nervosa: An organisemic-developmental paradigm. In C.L. Johnson (Ed.), Psychodynamic Treatment of Anorexia Nervosa and Bulimia (pp 354-373). New York: The Guilford Press, 1991.
- Roea D, Rott S, Fenining S. Narrowing the insight in anorexia as an ambivalent relation to recovery. Sichot: The Israeli Journal of Psychotherapy 2003; 17: 247 [Hebrew].
- Bachar E, Latzer Y, Gur E, Bonne O et al. Rejection of life in anorexic and bulimic patients. Int J Eat Disord 2002; 31:43-48.
- Bowlby J. Attachment and loss: Vol. 1. Attachment. New York: Basic Books, 1969.
- Bowlby J. Attachment and loss: Vol. 2. Separation: Anxiety and Anger. New York: Basic Books, 1973.
- Bowlby J. Attachment and Loss: Vol. 3. Loss. New York: Basic Books, 1980.
- Latzer Y, Hochdorf Z, Bachar E, Canetti L. Attachment style and family functioning as discriminating factors in eating disorders. Contemporary Family Therapy 2002; 24:581.
- Ward A, Ramsay R, Turnbull ,. Benedettini M, et al. Attachment in eating disorders: past in present. In J Eat Disord 2000;27:279.
- Ward A, Gowars S.Attachment and childhood development. In: J Treasure, U Schmidt, E Van Furth (eds). Handbook of Eating Disorders. John Wiley & Sons, Chichester, Great Britain, pp 20-103), 2003.
- Hochdorf Z, Latzer Y, Canetti L, Bachar E. Attachment styles and attraction to death: Diversities among eating disorders patients. Am J Fam Ther 2005; 33:237.
- Johnson S M, Maddeaux C, Blouin J. Emotionally focused family therapy for bulimia: changing attachment patterns. Psychotherapy 1998;35:238.
- Sexson SB, Glanville D, Kaslow N J. Attachment and depression: Implications for family therapy. Child and Adolescent Psychiatric Clinics of North America 2001; 10: 465.
- Byng-Hall, J. (1995). Creating a secure family base: Some implications of attachment theory for family therapy. Family Process, 34, 45-58.
- Byng-Hall J, Stevenson-Hinde J. Attachment relationships with a family system. Infant Mental Health Journal 1991; 12: 187.
- Dallos R (2001). ANT attachment narrative therapy: Narrative and attachment theory approaches in systemic family therapy with Eating Disorders. Journal of Family Psychotherapy 2001; 12: 43.
- Liddle H, Schwartz S J. Attachment and family therapy: The clinical utility of adolescent – family attachment research. Family Process 2002; 41: 455.
- Mihikin J W, Johnson S M. Telling tales: disquisitions in emotionally focused therapy. Journal of Family Psychotherapy 2002; 11:75.