In planning a media workshop to present Glenn Gers’ independent film disFigured for the May 2009 American Psychiatric Association meeting in San Francisco, my co-presenters and I devoted special attention to the diagnosis and treatment of anorexia nervosa. (The content was originally prepared by Katherine Halmi, MD, and was presented at the workshop by James Mitchell, MD, when Dr Halmi was unable to attend.) The film deals with the problems of body image represented by opposite ends of the spectrum of eating disorders-obesity and anorexia.
In planning a media workshop to present Glenn Gers’ independent film disFIGURED for the May 2009 American Psychiatric Association meeting in San Francisco, my co-presenters and I devoted special attention to the diagnosis and treatment of anorexia nervosa. (The content was originally prepared by Katherine Halmi, MD, and was presented at the workshop by James Mitchell, MD, when Dr Halmi was unable to attend.) The film deals with the problems of body image represented by opposite ends of the spectrum of eating disorders-obesity and anorexia.
Obesity is not a psychiatric diagnosis, nor for that matter is dissatisfaction with one’s appearance; however, anorexia nervosa is a psychiatric diagnosis, and emotional and unconscious elements play an important role in both obesity and anorexia. Persons with an eating disorder can be quick to anger when their family or friends show interest and concern about their weight. They experience their own supersensitivity and hostility as coming from outside themselves, rather than from their own defensiveness and distorted perceptions. Fortunately, it is not necessary to have a specific diagnosis documented by DSM criteria in order to provide treatment.
In this discussion, I briefly review the issues depicted in disFIGURED that are associated with both obesity and anorexia and describe a model for a therapeutic approach.
Issues associated with overweight
People who are obese and unhappy with their appearance do not usually go to a psychiatrist. Instead they go to the gym or exercise classes, buy cookbooks, or buy into the latest diet regimen designed to reshape their bodies and remake their appearance. Those who are unhappy with their weight or appearance and recognize that they are doing something that is making themselves unhappy may see a psychiatrist.
Unhappiness with one’s appearance is not one of the usual reasons why patients seek psychiatric treatment. But, because the underlying causes of unhappiness may be depression and anxiety, psychodynamic issues may actually become prominent during psychotherapy. Unless there is some exploration of the reasons for the person’s unhappiness, treatment is likely to be limited to pharmacological agents, which may reduce the symptoms. This approach, of course, does nothing to resolve the underlying basis for the unhappiness.
If the individual is motivated to explore the possible reasons for the unhappiness-depression or anxiety-a dynamically oriented exploration can help ascertain what contributory or associated factors play a part in the patient’s obesity. What has the patient done to correct or ameliorate the condition? How can the patient improve or exceed current efforts to make the condition better?
A full range of therapeutically helpful approaches can be offered. These include educating the patient by providing factual information; helping to prioritize personal issues and/or motivations; and offering support, advice, and/or encouragement, as well as psychodynamically oriented therapy when indicated.
It is important to recognize that psychotherapeutic treatment is not based on any particular words, theories, pronouncements, or interpretations (whether structured, manual-based, or otherwise). Rather, psychotherapy rests on the establishment of a stable therapeutic relationship that will allow the patient to disclose his or her problems, issues, or symptoms in some initial, even superficial manner. Once a nonjudgmental and accepting relationship is established, the often secretive or hidden issues can be explored.
With anorexia, attention is focused on factors that contribute to distorted self-perception, thereby opening the door to psychotherapeutic interventions in addition to dietary and medical approaches. In anorexic patients, the patients’ determination to avoid food is not altered by the reality that their behavior is dangerous and perhaps life-threatening.
If previous therapy was unsuccessful, the patient’s psychic reality is unchanged and her ideas about self-perception have not been explored. Consequently, the patient and therapist need to explore the reasons why the patient felt that initial therapy had not been beneficial.
My major guide in trying to understand the use of psychotherapy with anorexic patients has been the work of Hilde Bruch, MD, who in 1978 published The Golden Cage: The Enigma of Anorexia Nervosa,1 which was based on data from more than 70 persons with anorexia. Bruch found that issues of control were the most common dynamic. Regardless of the specific details (eg, setting, age at onset, family dynamics), the usual scenario is that of a bright, often attractive, and intelligent young female, who for various reasons becomes intensely fearful of being controlled and of having no opportunity or ability to prevent being overwhelmed. She can, however, exercise control over what she eats or does not eat, no matter how difficult it seems initially, especially during the preadolescent phase when one’s figure and weight become subjects of interest, observation, and comment by almost everyone.
What may have begun as an effective means of coping with a temporary situation may develop into a habitual or overused continually “successful” mechanism. The initial satisfaction of being able to overcome her own natural impulses to eat or to endure hunger eventually progresses to attempts to control other emotions and feelings. The results are often life-threatening and even lethal when carried to extremes.
I am not advocating psychotherapy as the treatment of choice for patients with anorexia nervosa. Intellectual understanding of dynamic factors in anorexia is not synonymous with effective treatment of a patient who is damaging herself with life-threatening starvation. Rather, such understanding can help explain underlying psychological dynamic conflicts of such self-destructive behavior. disFIGURED is not a psychiatric documentary, a training film, or an infomercial. It does not offer, suggest, or recommend treatment (psychiatric or otherwise), for any condition or disorder (psychiatric or otherwise). However, it is a realistic depiction of the psychodynamics that persons with eating disorders experience and thus might be used as a tool to facilitate conversation in a therapeutic approach.
The fictional character, Darcy, as portrayed in the film disFIGURED, illustrates the psychodynamic features that may not be included or be as observable in typical case histories or clinical vignettes. In the movie, the final confrontational scene between the 2 main characters, Lydia (who is obese) and Darcy (who is anorexic), is particularly poignant and revealing-especially if you are a therapist attempting to maintain a therapeutic relationship with an anorexic patient. We see the dynamics of Darcy’s resistance to treatment and to change, which will have to be addressed and overcome if therapy has any realistic chance of success. Darcy has mastered all the rational and intellectual responses for any discussions she might have as long as she can maintain affective mastery by remaining distant and asserting control of her own emotions. When her friend Lydia says she wants to help her, Darcy shouts: “I won’t let you!” It is only when Darcy herself allows it that Darcy can consider entering a therapeutic relationship and, even then, she will have to feel that she can maintain some degree of “control.”
Therapeutic work with patients who are obese or anorexic may initially be confined to overcoming obstacles that prevent unguarded and open communication. The therapist’s first goal is to establish a working relationship with the patient that will allow exploration of experiences that have previously been too painful for the patient to share. The patient and therapist can explore the significance, connections, associations, patterns, and meanings for behaviors that the patient has not been able to understand without professional help. Once the underlying issues are revealed, the patient may be able to chart a new and healthier course.
1. Bruch H. The Golden Cage: The Enigma of Anorexia Nervosa.Cambridge, MA: Harvard University Press; 1978.