Eating disorders and dissociation
Written by Natalia Seijo
Psychologist specialized in Eating Disorders
Dissociation is often present in Eating Disorders (ED) at different levels and, if not properly diagnosed, may complicate treatment. This article presents a general review of eating disorders, explaining their origins and most significant peculiarities. Many of the difficulties faced by professionals when working with these disorders are pointed out, in order to develop an appropriate treatment plan. Understanding the relationship between ED and dissociation is crucial, given that treatment may often become complicated by the underlying dissociation of the personality.
Dissociation in eating disorders (ED) was initially recognized by Pierre Janet (1907/1965), who was the first author to specifically study the relationship between traumatic experiences and dissociation in different mental disorders, including ED.
Janet (1965) stated that dissociation is a major psychosomatic response to overwhelming trauma. Memories and ideas associated with trauma may become separate from conscious awareness, resulting in a dissociative organization of mind and a variety of dissociative symptoms (Janet, 1907; Van der Kolk & Van der Hart, 1989).
In ED, dissociative eating activity can be seen at a somatic level, such as when clients with Anorexia Nervosa (AN) embody their eating disorder through body changes such as weight and shape variations, and, due to this, in changes in bodily functions and the cessation of the menstruation cycle. These take place during the development of their illness and as a result of starvation. Also in Binge Eating Disorder (BED) and Bulimia Nervosa (BN), the body changes as a result of binging and purging.
Dissociation can be perceived through these patients’ poor insight in regarding their body as being a part of themselves. In EDs, some parts are dissociated from the body, but in severe cases such as AN or BED, it is difficult to find parts that do not reject the body and want to be part of it. The body is the enemy and this is the reason why they dissociate from it. An example of this is when clients say things such as: “I don’t feel like the body is me, it’s like a carcass in which I live,” “I’m trapped inside this body; I want to get out of it and I can’t,” or “The real me is [the person] who is inside this body in which I am locked up.”
Another way of identifying dissociation is through the rejection clients develop toward their body, thus responding to the self-harming behaviours that lead them to the double meaning of “being”: on the one hand, being able to feel their own body and, on the other, channelling the emotion of rage they feel against it.
After Janet, interest in the concept of dissociation in ED disappeared for over half a century. In 1979, the British psychiatrist Russell identified the presence of dissociative parts in clients with BN. Torem (1986) stresses the importance of a systematic exploration of dissociative symptoms and ego states in clients with ED.
The importance of recognizing dissociation becomes clear, given the frequency with which it presents. In binge eating and during the binge-purge cycle, in which clients describe dissociative parts, quite often clients talk about how they feel completely disconnected when they binge and purge.
Authors such as Everill, Waller, and Macdonald (1995) find the presence of dissociative symptomatology in bulimia is indicative of a history of early experiences of abuse or significant loss, which links the presence of dissociation to trauma, as Janet had done before.
Many of these studies on the presence of dissociation in eating disorders focus on abuse in childhood as the basis for these disorders. However, neglect, excessive parental control, role reversal, emotional abuse, or abuse of power may precipitate ED and dissociation.
Within these causes are also included a type of traumatization that is often overlooked and is closely associated with ED: the so-called “hidden traumas.” These refer to the silent, everyday traumas which are invisible: children can be traumatized by medical treatments, child-rearing practices, and circumstances considered to be normal, including the failure to develop a secure attachment to the primary caregiver. It is possible to be born into and grow up in a loving, caring family and have a seemingly normal childhood, and still be traumatized. (Robin Carr-Morse, Meredith Wiley, 2012) For this reason, recognizing this type of traumatization is crucial for professionals working with these disorders, since it facilitates the understanding of the functioning of these clients’ internal worlds and helps increase treatment effectiveness.
Treatment with an ED structure has to be done from the outside in, that is, working through the outermost layers to reach the innermost ones. These layers contain parts and different defences that come out when the therapist tries to delve inside.
Types of Dissociation
Dissociation of the personality in EDs is usually present in different degrees and can manifest in various ways. Depending on the degree of dissociation, its severity varies from the less pathological to the more pathological. The latter may present with the first and most common type of dissociation.
Somatic dissociation: This is the most common type of dissociation in eating disorders. The body is perceived as strange and not felt as their own. Instead, it is felt as an enemy against whom they must fight, or as anesthetized parts that may be felt as foreign at a biological level: “I feel my legs melting sideways into the chair,” “After eating, I feel my body starting to swell up from the neck down to my toes.” These perceptions and sensations, which are experienced as real, reflect depersonalisation or derealisation symptoms due to the anguish they generate.
Dissociative fantasy: This is a very common type of dissociation in eating disorders. In many cases, it goes unnoticed due to clients’ lack of awareness. This is a defence used as a safe place since childhood, when the real world is no longer safe. This fantasy usually disappears as people grow up. However, in clients with ED, this fantasy becomes part of their internal world and is utilised in daily life. Examples of this type of dissociation are the stories clients make up in their imagination to solve problems. They tend to change their perception of real life and go into their inner fantasy world where the experience will become different for them: “The other day, I returned to my world in which I was the heroine: everyone cheered me, I felt important, and all the characters recognized my victory." Therefore, one of the main therapeutic goals is to help patients differentiate reality from fantasy, since they tend to confuse both experiences. The function of this fantasy is often to cover unmet needs in real life (Seijo, 2012).
Body image distortion: This is psychoform dissociation, that is, of a mental nature. The client perceives her body in dimensions that are not real and idealises and fantasises about a body that usually does not match the real one. This type of dissociation is associated with the part of the rejected self, through which the client sees herself as having a rejected body from the past that she fears having again (Seijo, 2012).
Alexithymia: Difficulties regarding this type of dissociation are centred on discriminating and expressing feelings and differentiating emotional aspects. Clients have trouble describing their feelings and differentiating them from bodily sensations. This is a core deficiency in eating disorders. Different studies have found that 69% of clients with anorexia and 50% of those with bulimia suffer from alexithymia (Spina, Ortego, Ochoa de Alda, & Aleman, 2002).
Somatoform dissociation: This differs from somatic dissociation in that somatoform dissociation does not present a distorted perception of the body. In this type of dissociation, the client projects her discomfort on multiple physical symptoms, which generate poor quality of life. Examples of these symptoms would be: abdominal pain, nausea, dysmenorrhea, menstrual irregularities…
Depending on the degree of dissociation, different parts can be distinguished within the clients’ internal world. Treatment requires an effort to understand these different dissociative parts, their make-up and function.
These parts are commonly found in ED clients. Often, people who suffer from EDs are people without childhood experiences, little girls who never were (Seijo, 2000). They are people who have been treated as small adults since they can remember, being forced to take on responsibilities and face situations not appropriate for their age, overwhelming the internal world and creating confusion. This generates a part that does not evolve, giving way to behaviours that are childish, rigid, or frozen, more appropriate for a child than a teenager or an adult. The different dissociative parts are often present in the different EDs, mostly in AN, BED and BNNP.
These parts are described below:
The Little Girl Who Never Was is the most damaged part and the one that usually generates more defences. This part holds the belief, “I do not accept boundaries other than my own.” This is the part containing the pain and frustration of having to learn to do things on her own. She is the self-sufficient girl, who has been forced to grow up quickly and become an ‘adult’ in childhood, learning to self-regulate and self-control through food (Seijo, 2012).
The Little Girl Who Could Not Grow Up is the part who failed to go through an adequate maturational development and shows some behaviours not appropriate for the age of the client. Through the ED, she has found the attention she did not receive, and through food, a way of being seen. This is the state that holds the belief, “In this home, one needs to get sick in order to get some attention” (Seijo, 2012).
The Pathological Critic is the part communicating through continuous criticism. It is the inner critic that judges and blocks the patient’s self-esteem. This part filters reality away from the negative view of the self, so the ANP is not able to see the positive side. The main belief this part holds is “nothing is okay in me”. (Seijo, 2012)
The Rejected Self is the part containing the body image distortion. This part rejects another part from the past that represents a trigger for rejection. The mirror reflects back the image of this other part from the past and this is how the person keeps seeing herself in the present moment, even though the body is not the same body anymore. Depending on the client, this may be displayed at different levels: from a negative body image that affects normal functioning in the person’s daily life in which perspective is lost with regards to body dimensions of size and shape, to a body dysmorphic disorder in which the client is completely limited by the body or a part of it that is considered defective. (Seijo, 2010)
This part is associated with the self-image the ANP rejected in the past. She usually feels ashamed of it and does not want to be that girl ever again. This is the image that gets in the way of the real one and through which she usually sees herself. For this reason, she does not see the body as it really is, because she truly does not see it.
The Hidden Self is a very common part in EDs, which develops at an early age and is associated with the belief, “I cannot show myself or stand out because if I do, I will get hurt.” It is a part that protects the internal dissociative world by hiding, not exposing or showing herself. Maybe when the person did this in the past others did not make her feel good, perhaps it was threatening or even dangerous. Staying in the shadows ends up being safer (Seijo, 2012).
As professionals, being aware of these dissociative parts makes it possible to build a line of work that focuses on how these clients’ internal worlds are structured, instead of focusing on working with food, which is just the tip of the iceberg.
Rosen and Petty (1994) indicated that any treatment of people with an ED should include a psychoeducational component, which would teach clients to recognise their dissociative capacity. Therefore, awareness of dissociative parts reassures clients because it organises and names the internal chaos they feel.
Once again, the client will be offered all the space and time she needs. This will be the golden rule in working with these disorders, given that it will generate enough trust in the therapeutic relationship and process. It must be repeated throughout treatment, since it is basic for achieving good results.
Eating disorders may generate different reactions in the therapist due to the slowness required in order to obtain good results, the time requirements, and the patience needed on the part of the therapist. Trusting the process itself, knowing that there will be moments in therapy when blockages will appear and therapy will not flow, will be a major resource for the therapist in making the entire process safer. The professional, by knowing that this is one more stage of treatment, will be able to work it out with the client to increase motivation (both the client’s and their own), helping to normalize a situation that often is at risk of therapeutic drop-out if the professional does not recognise and properly channel this.
Psychoeducation explaining the different parts that appear in EDs, including the part of the little girl who never was and the one who could not grow up, validates clients by feeling seen through the recognition they feel from the therapist. Feeling seen is one of their basic needs. Through this validation and their role as surrogate attachment figures, therapists create a client-therapist bond that helps elaborate part of the path to successful treatment.
Working through the outermost layers to reach the most internal ones helps us find the injured little girl and her vulnerability. We must take this into account and be cautious with the interventions applied at different stages of treatment in order to follow the three phases; stabilization, treatment with traumatic memories, and integration and transformation. The little girl’s vulnerability activates defences and may complicate the therapeutic work. The therapist should know that working through the different layers and phases will make defences and parts come out.
In order to understand the scheme of work with these disorders, the “artichoke” metaphor can be used, as it symbolically represents what the ED specialist must keep in mind. Like artichokes, the outer layers are the toughest, the most protective, so at this stage the work is to be done slowly through psychoeducation. This will be a constant in treatment, since in most cases these clients lacked a compassionate adult attachment figure who understood and explained what they did not understand.
In addition, identifying the most limiting beliefs and replacing them with others that are more appropriate is crucial, in order to facilitate regulation and organization of the internal world. Each part has a main belief and reacts accordingly. Once the ANP becomes aware of this belief, she will be more capable of recognizing the behaviours, thoughts, and emotions that go with it. This can be one of the first changes in the stabilization phase. Changing beliefs is an important step in working with EDs. How they act and react depends on this web of beliefs. Working with these beliefs means working with the youngest parts that contain them. It is not an easy job because once these eating reactions are established, they are maintained through learning processes (often by classical conditioning) and become very resistant to change (Van der Kolk, 1987). The therapist will have to work with defences and attachment because these younger parts trigger defences in order to protect the inner world from pain.
At this point in treatment, validating the client as often as possible will improve collaboration between parts. In turn, collaboration will bring compassion and understanding of the function of these parts as defences in the inner world. If clients can understand this, their attitude will change and the work will become easier. The goal will be to get the client to understand that the parts are herself and they are there because they were necessary in the past. We must provide psychoeducation and explain that perhaps the way in which the parts defend the inner world is not adequate nowadays, but it was appropriate in the past and probably this was the reason why the client survived. Being seen and recognised will generate surprise in the internal world. Feeling emotionally validated and accepted as she is, not for what she does or how she does it, but simply for herself, from the healthy belief of “It is ok to be who I am” had not happened before, and now she gets to be supported and healed.
This intervention works on healing mistrust and repairing attachment wounds.
Once the way for development of the first layers is prepared, the process continues from the outside in.
Name and describe the parts that make up the internal world, so they can all be identified and work can start with each one of them. The therapist should recognize and respect the client’s meaning of the ED, how dissociation works as a defence, and how the client can comply with the demands of the parts trying to avoid inner conflict.
Identify those events over the patient’s life that have left a mark on the client, not just in terms of “T” trauma but also analysing “t” trauma, especially those based on attachment trauma and the aforementioned hidden traumas. These memories are important targets to be reprocessed with EMDR, in order to help heal and rebalance the internal system through reorganizing and storing memories and the information contained in them in an adaptive way. This process aids in the recovery of cognitive abilities, which are depleted in many of these clients.
Working with dissociative parts implies working with the beliefs that accompany them, which in turn feed each one of these parts. Understanding and identifying these beliefs facilitates working with the parts and the foundation that sustains them. Some of the questions that give answers to these beliefs are: where did they learn “to be rejected,” “to feel inferior,” “to eat in order not to think,” “to vomit in order not to scream” and what does that say about them or the world.
This is particularly relevant with the most important parts, “the little girl who never was,” “the little girl who could not grow up,” and “the pathological critic,” because these are the different parts the girl had to dissociate in order to survive.
Jointly studying both the functions represented by each of the parts and the ANP self’s compassion toward them is crucial. The part who eats and the part who does not eat must be identified, along with how she hears her voice when sitting at the table, and if this is the voice of a capricious child or if this is the most rigid part of the girl. Questions such as the following should be asked: “What makes the child not want to grow up?,” “How does this part of you convince you to vomit?” (or not to eat, or binge…)
Helping the ANP become aware of her own parts, their function, and what they represent, little-by-little and at her own pace, giving her all the space she needs, will slowly encourage integration and increase awareness.
Defences that protect the parts and feelings of therapeutic blockage are common in these disorders. The work is done by giving space and a voice to those parts that usually have not been able to show themselves. A good example of this is the part I call the hidden self. When this part appears in therapy, it can present different defences. One of my clients described her hidden self as surrounded by a bubble. When we started to work on this bubble, she felt very angry and disconnected. We had to work very carefully to get closer, but what was most impressive is that we first had to work with the rejected self because it was the bubble itself. One day the client described how the bubble burst and inside was all the horrible abuse she had suffered as a child. At that point in therapy, the inner world was ready to handle the trauma.
As therapists working with EDs, becoming aware of when defences take place is crucial because they protect the different parts, as I explain in the artichoke metaphor I normally use to describe this.
Working with defences also includes working with anger, which is the most common emotion in ED, along with shame and sadness. Working with anger is essential in unblocking the internal world and making room for the expression of what needs to be relieved. The work can focus on somatic parts, helping them to express what is traumatic for them in words instead of symptoms. Because when they are not able to do so in words, this material cannot be brought out in a healthy and adaptive way.
Somatic parts can show themselves through posture, gestures, or physical symptoms. These parts are usually child parts, little girls who could not express their needs in the past and now collapse in the body. When we work with these parts the trauma comes up.
This step is done by increasing the client’s awareness by means of giving a voice to the manifesting symptoms. The work can be done in different ways: focusing on the symptom itself, processing a somatic memory through an EMDR target, or working in ways that help the processing and allow for the emergence of what lies behind each of the layers protecting the injured girl. This is the final therapeutic goal and what will repair the attachment trauma.
Once the parts start healing, grief must be taken into account, since it is a natural consequence of integration (Van der Hart, Nijenhuis, & Steele, 2006). This pertains to phase 3 of the general phase-oriented treatment model.
Each one of the parts has been there for a long time, and having to learn to live without the same thing that helped defend the internal world is a difficult experience for many clients, even though the effects of defending it like they used to were negative. After realizing one’s traumatic past, there is a need to grieve those experiences, including everything that was missed because of it and may still be missing.
Allowing for the development of grief and anticipating its possible effects normalises it and helps the client keep in mind how she will feel in the future. This way, the client will be able to avoid becoming confused and thinking that her internal reactions are due to possible relapses or setbacks in therapy.
This may seem contradictory to therapists. This experience will need help to be elaborated during the therapeutic process. A good way of doing this is to offer the client adequate explanations of what may come up throughout the process.
Recognizing and knowing how to work with dissociation and its different aspects and levels is basic in therapy with ED patients because it facilitates treatment and prevents chronicity, which is so common in these disorders.
The fact that professionals who work with these disorders can recognize dissociation is of great importance in order to guide an appropriate treatment.
In working with parts in these disorders, what must be taken into account is that all parts have a function. Keeping this in mind may prevent complications in treatment.
Special attention should be paid to prevent making interventions that could convey messages such as, “Remove that part,” “Take that part out,” or “Eliminate that part,” because the result of such interventions can have negative effects and interfere with improvement.
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