In this short article I will briefly give an opinion1 on Eating Disorders (E.D.) in adolescence that I elaborated from my experience with patients affected by E.D., treated mainly in analytical group psychotherapy.2.
Then I will relate on a session in which young patients told some fairy tales. In these tales one can trace significant aspects of their difficult individuation path.
It is with extreme frequency that young individuals suffer from E.D., especially girls3 even if they are expressed in explicit way with a certain difficulty, due to feelings of shame or absence of illness awareness.
One must refer to literature for the nosographic (ICD-10, DSM-IV Classification), epidemiologic, clinic and therapeutic aspects.
The datum frequently reported is that on 100 girls of age 15-25, 10 suffer from an E.D.; out of these 2 from a severe E.D.(more precisely, about 0,5 from nervous anorexia and 1,5 from bulimia ).
As it is known4 E.D. include: Anorexia Nervosa (A.N)., Bulimia Nervosa (B.N). and Eating Disorders Not Otherwise Specified (EDNOS). This last group also includes B.E.D5 (Binge Eating Disorder). Rarer forms are verifiable in the age of growth taking into account the differential diagnosis for very young patients6.
Classifications of the DSM IV and ICD-10 exclude the psicogenic obesity which is also closely linked to E.D.. In fact it is often the starting point and some times the final stage. They both share the same "negative body image"7 and the necessity of the multidisciplinary approach. Working and writing specifically on E.D. in adolescence I.Bruch , with clinic farsightedness places in the same area, even if on opposite poles, E.D.( in particular A.N.) and what she defines as " growing age obesity". To one extreme therefore there is A.N., in which the maximum of the alimentary restriction leads to a weight loss with life risk ("quoad vitam") among the highest in psychiatric diseases. To the other extreme the " growing age obesity" that is a psychogenic overeating condition, often due to BED, with a serious health risk ("quoad valitudinem"). Bruch claims that both these two conditions are opposite but similar ways to escape that the adolescence evolutive challenge taking refuge in the more controllable body and food areas ; this condition of “ anaesthesia" of the adolescence process is compared to the story of the " Sleeping Beauty”". At the age of fifteen she is exploring a prohibited wing of the castle when she is pricked by the sharp needle of a wool-winder and enters into a long long sleep.
Adolescence and Eating Disorders
The adolescence, as it is well known, is the nodal point for the development of E.D.. In fact it is the critical period in which various factors converge: the process of individuation of the self, the elaboration of the idealized infantile Self (including the idealized body image ), the experience of comparison with peers, a more autonomous self-experimentation and separation from the family, the mental integration of the adult "sexualized" body and the definition of gender identification.8.
This remarkable psychic torment is one of the reasons why E.D. really begin in adolescence.
As it is well known E.D. have a multifactor origin. Biological, psychic and environmental factors are closely intertwined.
In fact to the psychic and relational ones, in adolescence, important biological factors are added. In particular the hypotalamic-hypophisal-gonadic axis activation supports the physiological processes of somatic growth and sexual development; this causes an increase in food intake in order to satisfy the energetic and anabolic needs.
In fact two “para-physiogical “ phenomena, at the limits of physiology , meet in this phase and in predisposed cases contribute to the developmentof E.D.: the increase in appetite and "dieting”:
The increase in appetite and puberty weight increase of the girl at around 12 years of age, due to hormonal growth, stimulates the somatic growth processes and modifies the fat distribution placing it in typically female areas (pelvi, thighs…). These phenomena scare the girl and cause her to experience a worrying loss of self-control.
dieting: this constitutes a form of compensation for the former phenomenon: the girl regains a feeling of self-esteem and power. She starts to control her alimentation and actively checks on her weight and body shape.
The two phenomena favour both transitory and partial E.D. which are so common at this age, as well as “structured”E.D’s. In my opinion this latter outcome occurs when the paraphysiological phenomena can come together with a particular inadequate structuring of the Self (and of the family relationship context). Having said that each situation is different from another and therefore that any schematization is only a theoretical-clinical point of reference, the analytical work does however show that often such a deficit was generated from a particular “transgenerational field”9 and following a predisposed infantile phase.
In summary the hypothesis on the E.D. genesis expressed in this work is the following:
In a transgenerational field and after a predisposed infantile phase a deficient Self is generated unable to face the development tasks of adolescence. The increase in appetite and weight contribute10 to the start of dieting, which in turn leads to alimentation restriction or loss of control (which will then take structure in the E.D. symptoms.) The deficient experience of oneself is projected and “put into practice” in the body image and generates the experience of the “negative body image”: the image of one’s body is experienced as “faulty” and one tries to “magically repair” it with alimentation control. When this is “almighty” it leads to a life-threatening restriction (A.N), when it fails it leads to “eating binges” with attempts of compensation by means of vomiting, laxatives etc….(B.N.) and also without compensation ( B.E.D).
The analytical work with these patients highlights a highly varied transition from one form to another. The fixed continuity in the same nosographic pattern is therefore becoming more the exception than the rule.
The “transgenerational field” and the predisposed infantile phase
Analytical work often shows us that the parents of the child have suffered from alimentary problems themselves and that they had suffered from lack of care from their own parents.
Literature also highlights weight and alimentary troubles and diabetes in parents, ancestors and relatives as predisposal factors of E.D..
The food and body image culture they received in their family is handed down to the son from birth. It can be a hyper-evaluation of food as a “good object” that with “almightiness” cures all “negative internal objects”. This means the syntonization and mirroring of affections remains lacking while overeating and being overweight becomes the family reference model. On the other hand a phobic approach to food and weight increase (”to be fat”) means from an early age the development of an anxious control over calorie intake and weight increase.
So from the earliest stages the mother-child relationship is altered in the sense that the mother, incorrectly recognizing her own or her child’s emotions11, uses food as a “calming” factor for every emotional situation. This leads to a progressive inactivity of the physiological circuits of hunger and satiety perception.
Due to family “transgenerational” psychopathologies the parents often inherit a narcissistic fragility with super-ego, perfectionist and compulsive-obsessive aspects. Their personalities are often scarcely reflected and permanently hypercritical and depreciating.
As they had experienced themselves they transfer to the daughter the job of living up to highly perfectionist ideals, both in social image and in academic performance. However her Self and her potential are not reflected and therefore the girl prematurely sees herself as “faulty”, “inadequate” and “devalued.”
In this context the young girl is confused and torn between both her needs and her parents’, and between her emotional and alimentary needs. The body experiences are muddled up with the psychic ones and the development of a healthy perception of hunger and satiety is compromised. As Bruch correctly underlined, these effects are not totally innate. They are “learnt” correctly in a facilitating relationship context.
Therefore at this point alimentation has lost its connection with biological aims, but has taken on the psychic function of emotional regulation and self-structuring.
The Self-deficit in E.D.
Bruch wonderfully described the deficient sense of the Self as: “…interior emptiness…hyper compliance…empty space which adapts to what others desire…social isolation…of not being able to live up to ones parents’ ideal of perfection…”
The Self-Psychology added to this a theoretical frame useful in its understanding with the description of the self-object functions and experiences (fusion, mirroring, antagonism etc…) necessary for the structuring of a Self which is healthy, authentic, recognized, capable of self-esteem and development, assertion and creativity.
S.Sands, in particular, studied the application of the psychology of the Self to E.D.’s. As previously stated, the future patients’ Self hasn’t had the possibility in the family to develop in the context of valid and mirroring self-object experiences. The deficient self-object relationships don’t allow the girl to feel positively “validated” and “confirmed” in her being and existing. She therefore feels the need to carry out particular “repairs” to her image in order to be “presentable” to others.
In this non facilitating relationship context the girl has blocked the development of the “nuclear project of the Self.” She has structured a substitute “adaptive” Self which is often “obliging” to parents’ expectations and highly idealized. The experiences of a respected, effective, autonomous, competent and authentic Self are compromised. The devalued Self, deprived of love, is lived, with variations from case to case, as “negative, empty, inadequate, inconsistent, ugly, different, alien, without rights, unpresentable, non-existent…etc.)
Progressively and prematurely a permanent lack of self-esteem dominates and pervades the idea of oneself. It is in this situation of vulnerability that she arrives to puberty. It must be underlined that this fragile self-esteem will remain as one of the more pervasive and constant nuclear feelings in E.D. to an extent that they represent one of the most important semiological criteria in the diagnostic evaluation.
E.D. in adolescence
However the development task in this phase needs sufficient self-esteem to confront oneself to others. It needs a reduction in the “symbiosis” with parental figures and a differentiation from them. A restructuring of oneself that integrates new body experiences, the identification of kind and the reshaping of the ideal Self.
It is necessary therefore to have a radical change of the self-objects scenario. This must move from the family area to the “laboratory” of ones peers and the world of other adults.
The confrontation with ones peers, requiring an exposure to other real, concrete and limited aspects of the Self seen as faulty, generates feelings of unbearable anxiety and depressive frustration.
The precarious “presentability” of oneself and the inadequate relational support of the family open the route to a possibility of a “retirement” from interpersonal rapports. The girl closes herself off from others and puts her psychophysical development into hibernation. She “stops” time and regressively substitutes the new adolescent-relational self-objects with the more reassuring world of the body and a relationship with food.
Moreover the first menstruation, weight increase, the reshaping of a more feminine and softer figure and the increase in appetite lead her to a situation of “alarm”. The body has now become the most critical area for her self-esteem. Mass-media models, comments by her parents, boys and friends “stress” her relationship with her body. The body image experienced as a representation of the Self is given dangerous “reparatory” functions of her psychic image.
If in all girls there is a tendency of body and weight control, in her it is all the more accentuated. The emerging sexuality heightens her feelings of inadequacy. She escapes from the dangerous “match” and tries to recover self-esteem and a positive image by playing her own “game” of diet control and the objective of reduced weight and thin appearance. In summary: the inhibition of the Self individuation associated with a non-perceptive state of hunger and satiety and the installation of the alexithymic condition cause a shifting of the psychic experience to the body area. The Self is realised in the body image. It becomes the representation of the total Self and therefore a “negative body image”. With the excess in weight the vulnerable Self is hidden and “protected”; instead with emaciation it is “repaired” with a “thin” appearance. This is positively idealized as “ethereal”, “delicate”, and “disembodied”. At the same time the binges try to make up for and calm the empty space but also to the other extreme to express an angry attack on the negative Self.
In time the “match” with food and the body can become an exciting and euphoric challenge. In A.N. cases in particular: peaks of exaltation and abysmal lows in self-esteem are reached, depending on the success or failure of these objectives. These are omnipresent in the thought of an A.N. case.
At this point one of the results is that the mind, so one directionally absorbed, will no longer be subject to intense, driven, emotional and relational anxieties of the adolescent experience. It will, on the other hand, be occupied obsessively and with a persecution complex of thoughts concerning body shape and food quantities and the fear of being unable to control them.
The adult and sexualized body is substituted by a “starving” or “binged” body.
In this titanic battle against vital developmental changes, alimentary habits and thoughts become a real pathological behavioural dependence, similar to substance abuse behaviour. Bulimia and anorexia become an irreplaceable companion, just as drugs are for the addict and are often perceived as their only real personality.
Various authors talk of “bulimic” or “anorexic personality” as an autogenous system which supplies those self-object and self-nursing experiences which are not supplied in the interpersonal field. One retires from the “interpersonal theatre” and takes refuge in a more controllable and less frustrating “body theatre”.
At this point the self-objects no longer belong to the “human world” but to the “non-human” one. The girl therefore unconsciously uses adolescent dieting, entering into a full time “structured” DCA in order to magically stop time and the entrance into a new vital cycle which strikes distress. The D.A. becomes her “faithful companion”, her “self-object” which magically “cures” and “looks after “ her Self too fragile to live among human “objects” resorting to old more controllable “objects”: Food and the fantasy of a perfect body
The evaluation and treatment of E.D. in adolescence requires attention to the prognosis and the type of cure.
In fact, as previously stated, the majority of E.D.’s are transitory and regress in time. Therefore when deciding and starting an analytic treatment one must examine the consistence and cohesion of the Self, the seriousness of the lack of self-esteem, the entity of non-perception of the body (feeling “fat”) and alexithymia, the rigidity of the ideal perfectionism, the shame in exposure to the interpersonal field especially among peers and finally to the gravity of the family psychopathology. In my experience group treatment can be very useful after an initial individual phase.
Beside, in this age group, a simultaneous family approach is both useful and effective as indicated in literature.
Clinical Material
I relate on a group session in which we focused in particular on two fairy tales meaningful in the childhood and adolescence for two members of the group ( Isa and Caterina): “Nevina” 12 and “ The ugly duckling” ( these were read from their personal books but due to lack of space you can find the texts in the notes).
The former tale was read and told by Caterina (CA). She is 29, anorexic first and bulimic after with a borderline personality disorder and a past of drug abuse. The latter tale was read by Isa, a severe anorexic of a Binge eating/purging type. She was keen on classic dance but when at about twelve an instructor remarked she was a little overweight to be a dancer she abandoned her passion. Her physical aspiration was to be like the “Barbie doll”. She collected dozens of them and dreamed of becoming like her. Some years earlier she had a quarrel with her father to force him to accompany her to a party. That evening the car was involved in a tragic accident and the father died. From that day all the memories of the father were erased despite she was only ten at the time. For some time she was convinced her father hadn’t died but had simply moved to another city. One day at a party while observing her thighs she thought they were too large and from that moment she started to reduce her caloric intake. She became anorexic, her menstruations ceased, she became obsessed with her eating habits and her figure. It was sufficient to see a girl slimmer than her to be unwell for days. She couldn’t bear that somebody else was a doll. Only she was to be a “Barbie”. She took great care with her clothes and in particular had a thing about shoes; she dressed as if she were a perfect doll to be well appreciated when introduced to the world. Initially she successfully defeated hunger but slowly but surely hunger got the upper hand and so she started binge eating and vomiting. She has been in the analytic group for almost four years and has gradually become more cooperative.
This session took place in July 2007.
The other group members are:
-Vanni ( 24 yrs, bulimic)
-Eloisa (24 yrs, bulimic)
-Cecilia (28 yrs , anorexic)
-Gina ( 21 yrs, bulimic)
-Mary ( 21 yrs, bulimic)
-Renzo ( 17 yrs, bulimic)
( Analyst): do you remember that in the last session an interest in fairy tales from one’s childhood emerged? Do you remember any?’
CA : I don’t know why I have always liked this tale “nevina e Fiordaprile” (“Sweetsnowflake and Aprilflower”)…I have brought the book …Must I read it all? How embarrassing!
A.: go ahead…
CA: A princess called “Nevina” “ lived alone with her father…13
V. (Vanni). A myth came to mind this week which is very similar to my situation….Penelope’s situation in Odyssey weaving wool and than unweaving it to avoid marrying one of the Procys. This behaviour is both to keep her mind off that Ulysses may not return and also avoid facing the demands of the Procys. She could even stop this ritual (for example marrying one of the Procys or taking her own life) but she didn’t. He compares his situation to hers in the sense that he works out in the gym but then he cancels the good work by overeating14 and so the situation remains the same day after day.…
A : There is the feeling that the situation is going forward and backward…
Is there anything else?
Isa : my childhood tale was "the ugly duckling" but I can’t bring myself to read it because it makes me cry….I don’t know why.
Eleonora : (she volounteers and reads the tale):
“…It was so beautiful out on the country, it was summer …”15
….the episode of the farmer who gathers it strikes me, the series of unlucky events: it ends up in the milk, in flours, it’s a complete mess, it is forced to run away..”
Isa : I feel like crying all the same.
Cicely : there is a very banal film which in this period has made me think: it is “Pretty Woman”; first of all her job which is the complete opposite to mine but sometimes the opposites...
A. : they attract each other.
Cicely : no, they have something in common as someone so thin can do with someone so obese , that is to say food. After meeting Richard Gere she changed but in her job she already had class and beauty…nice clothes helped however it took somebody to believe in her to bring about the positive transformation that she carries forward in life. She remained true to herself in her simplicity…so she was alone and had to depend only on herself like me as I lost my parents….although it’s not a tale, it expresses a similarity to my situation….I had actually thought of the “ugly duck” too.
A : let’s sum up what we have come up with , impressions…feelings…
Isa : I am doing my best not to cry.
A. : you can cry if you want to.
Isa : the day I read the tale I broke down and cried ….the fact is that I would like to know why …I had thought of the” ugly duckling”’s theme which is banal: ugliness becoming beauty and being admired…but I think there mnay more expects that must be considered…and I’m trying to understand them.
A. : this is the reason why it is interesting to work on myths and tales: an energy which goes beyond a rational one and we are able to touch deep emotions.
Isa : as a child I avoided reading this book to avoid suffering
Eloisa :I think that one of the points which touches you is refusal…you are born and everybody refuses you and I can identify with this…
Isa : however this is not my story, I was desidered with strength. My mother performed miracles to have me: desired, desired! I do not remember my childhood well, I had a blackout which cancelled the first 10 years. Maybe the refusal came later.
Eloisa : maybe not the refusal of yourself but growing up you became to be in a certain way because a part of you was refused.
Analyst : eleonora seems to say that the feeling to be an ugly duckling or to be "defective" , “negative”, does not necessarily come from a true and real refusal but from the fact that parents look for something that doesn’t exist… in the tale the big suffering point was that the ugly duckling was not an ugly duckling but potentially a beautiful swan but nobody ever saw this potential.
Analyst : when the duckling is able to "disentangle” itself from the expectations of the parents there it is a turning point. It understands that it can be beautiful and happy even if it is not what parents would have wanted even when he looks for his path far from the parents and their expectations.
CA : there is a possibility of identity change when he meets the swans.
Analyst : it had to go against his nature, commiting a violence on himself but if one wants to manage to change scenario, and that is what we are trying to do here, one can find his true potential.
CA : identity change. It hadn’t really lived until he met the swans, all the time before seems wasted.
Eloisa : maybe it makes you cry because you are still looking for this identity … who am I?
Isa : it could be…
Analyst : there is the realization that to remain in the same scenario brings suffering but it is a hard struggle to move on to a new scenario even if this improves one’s value.
Analyst : No one has said anything about the other tale.
Isa : the figure of “Nevina” with these features: she is diaphonous, transparent, untouchable, pale, fairhaired , ghost-ike
attracts me and my perennial dilemma is whether to follow this model or not…
CA : but “Nevina” cannot survive in spring and I chose this tale because these two worlds can never touch….I had also thought of bringing a story of Donald Duck……
Isa : it is sad the fact that they cannot be together…I was a little disappointed because I was expecting him to die in the arms of the prince or when he raised his eyes, she would change in to a star, swan…cloud…but she goes back home and that’s it.
Analyst : struck by the representation of these parts of oneself about which we talked; “Nevina” finds herself in a world similar to anorexia where emotions are cold and even if there is the desire for warmth the two worlds ( freezing-winter and warm-spring) are not compatible
; we are experiencing this in the therapy.: Nevina ( the “anorexic part”) necessarily dies in the moment in which life is reborn but this mourning cannot be accepted; one would like a combination which is not possible….
Cicely : the ugly duckling spent all its life thinking and thinking to be ugly because the other ones said so.
Analyst : …”all life” is a lapsus of yours…
Cicely : He had convinced himself. I think that who has this problem has a big insecurity. You convince yourself because the others says so. Even when it became beautiful it did not believe it. It hid its face behind its wing. It’s difficult to manage this even if they say that you are very beautiful as you passed all your life thinking to be ugly you have the impression not that they say it just to make you feel worse.
Analyst : in the tale there is the convergence of two movements: one is the search of a new positive identity and the other is the fear of change …
Cicely : but the beauty you find may not be the beauty you were looking for because the beauty we want must be absolutely perfect and therefore it’s frustrating….
Analyst : the message is not to search for that beauty which one pre-established, but maybe the beauty of the true self that can be even superior to physical beauty ….
Cicely : in the end however it does not have that arrogance which the other ones have when they are told that they are be beautiful. Having suffered it is easier to appreciate one’s beauty without pride….
Isa : I feel a little anomalous. The moment I was approaching this ideal I had so much energy and joy, that I didn’t want to go back. I had suffered so much to arrive there that I had to throw it in other people’s faces and the shyness disappeared
Cicely : I do not say shyness, it’s more not being convinced of having some worth
Isa: I had moments in which I thought I had not reached it but I was in fact approaching what was the illness’ peak, I had a sense of power when I understood that I could do….I had tried many times before, but I couldn’t succeed ….the fall came after….
Cicely : you and I see beauty in a different way: you in thinness, I now see it at this moment in which I am expressing myself . When I was so thin I did not like myself, I had lost my ideal. I am speaking about my present experience….
Eloisa : the duckling is happy because it became itself, that is a swan. You were looking for something you were not; you could be exalted, you could like it and that was all, but in fact it was an imposed ideal, how much of you was there in that?
Isa : anyway 20 kg more or 20 kg less …there is always the problem to understand who you are but it’s as though this outside packaging, the 20kg in less, has the same effect on others, giving you self-confidence.
Eloisa : you have a crutch with which you support yourself : “I am thin so I can allow to expose myself ”
Analysis : the idea that one can be oneself is interesting allow what is truly. When people see you can send you a positive image of yourself as you really are…
Cicely : everyone asks me " what have you done ? Have you got engaged ? "16 Also elderly people who have not seen me for a long time. I know that when you are wel, it is noticeable to others and your true self comes out. They have told me that I am full of life …I always laugh but I don’t recognize this in myself but it comes naturally …they are things I have never been told before, I am surprised as though I do not deserve it, it seems strange to me. In these moments I think" Maybe it’s really me" but a moment later something stupid happens and I think the oppositecontrary . There is this contrast; one day you feel well, and the day after you think you are worth anything
not avail nothing. It’s still difficult but before these moments didn’t exist at all …
A: What do you think of this work on the tales?
Cicely : It’s cool but one does not realize…you think it’s not relevant while instead…..
Analyst : and…. Instead…it moved important area for Isa moved…
Isabel : It’s a tale which has always made me suffer….
The aspects of the illness which emerged from this session are many and varied. It is not possible to touch on all of them due to a lack of space. However it was reported to show an example of the topics of the internal “scenario” of E.D. patients. These themes surfaced through the use of fairy tales, myths or other fantasy stories. In my opinion these are always useful to stimulate research in the analytical work.
Briefly we can hypothesize that:
· In the tale of “Nevina” – there is a representation of the anorexic-bulimic alexithmic problem (the emotionally “cold” and far from life part) of risking to die if one approaches life and emotions (the spring world of “April flower”) This is a reason why these people have difficulty in freeing themselves from the illness. Sands speaks of “bulimic” and “anorexic personality” to indicate the dominance of the pathological side of a personality.
· In the”Ugly Duckling” tale – it seems to be the story of an individual who sees himself as ugly due to a family that doesn’t recognize his “potential Self”. It is only an adventurous exploration which allows us to discover that his self was perceived as “ugly” because it didn’t correspond to the family group’s expectations. In a new context his self was appreciable and could restart its development process.
· In the story of Penelope’s “procrastinating” behaviour – the boy “projects” the infinite habits of compensation mechanisms and weight and alimentary phobias, which he uses to avoid confronting reality.
·In the film “Pretty Woman” – Cecilia describes the aspiration, desire and possibility of someone with a devalued self (J.Roberts, the “prostitute”) to be re-valued if one meets a positive “mirroring” figure (R.Gere) and thus expressing her potential.
Conclusions
E.D.’s are traceable to problems of the Self. These emerge in adolescence due to the difficulties which the vulnerable self encounters in its individuation process upon entering the new interpersonal scenario.
A positive transgenerational family history and a pre-adolescent history constitute a predisposed terrain in a phase where weight and alimentary changes occur physiologically.
Intervention in the adolescent phase is crucial. One of the most useful preventive interventions is that of DCA detection and treatment in the premature sub-clinical phase.
In E.D. the identification of the Self remains in a state of “retirement”, in a “non-human world.” It is seen as a self-cure for a Self too fragile to live among “human objects.”
The objective of the analytical cure is to substitute this “self-cure” with an “interpersonal cure” which should allow for the inhibited Self to reopen possibilities of reopening himself to the world of affection and people through therapeutic experiences of
human self-objects.
Bibliografia
Abraham S., Llewellyn-Jones D.(2001), Eating Disorders (Fifth edition),Oxford: University Press.
American Psychiatric Association (2004), Practice Guidelines for the Treatment of Psychiatric Disorders,APA: Arlington, Virginia
Baranger W-M. (1990), La situazione psicoanalitica come campo bipersonale. Milano: Ed. R. Cortina
Bruch. H.(1973), Eating Disorders :Obesity, Anorexia Nervosa and the Person Within, New York: Basic Books.
Bruch. H.(1973), (1991),La bella addormentata: fuga dal cambiamento.In Greenspan I.S , Pollock., G.H.(1997), Adolescenza, Roma: Ed. Borla
Costin C. (1999), The Eating Disorder Sourcebook, Los Angels: Lowell House.
Cuzzolaro M.(2004), Anoressie e Bulimie, Bologna: Il Mulino
Garner D.M.,Garfinkel,P.E.(1997), Handbook of Treatment for Eating Disorders. New York: The Guilford Press.
Greenspan I.S., Pollock G.H.(1997), Adolescenza, Roma: Ed. Borla
Kaes R., Faimberg H., Enriquez M., Baranes J.-J. (1995), Trasmissione della Vita Psichica tra Generazioni. Roma: Ed. Borla
Kohut.H. (1994), How Does Analysis Cure? Hillsdale, NJ: The Analytic Press
Laufer M.-E.(1986), Adolescenza e Breakdown Evolutivo,Torino: Bollati Boringhieri.
Resnick S.(1976), Persona e Psicosi, Torino: Einaudi Ed.
Resnick S.(2001), Glaciazioni, Torino: Bollati Boringhieri..
Sands, S. (1989) Female Development and Eating Disorders. A self psychological perspective. In A. Goldberg (Ed.) Progress in Self Psychology Vol.5 (pp.75-104). New York: Analytic Press.
Searles, H. (1979). Countertransference and related subjects. New York: Internationa Universities Press.
Stolorow, R.D., Atwood, G.E.(1992).Context of Being: The Intersubjective Foundations of Psychological. Hillsdale, NJ: Analytic Press.
Winnicott, D.W. (1958) Trough Paediatrics to Psycho-Analysis Tavistock Publication, London.
Winnicott, D.W. (1965) The maturational process and the facilitating environment. New York: International Universities Press
Wolf. E. (1988). Treating the S elf. New York: Guiford Press).
1 influenced by psychoanalytic theories centred on Self and its developmental processes (Kohut, Winnicott,etc.,..).
2. they are adolescents or grown-ups who are analytically working at the adolescential phase of their trouble.
3 the male relationship: female is of 1:10-20
4 one commonly refers to the DSM IV-R classification
5 Binge Eating Disorder.
6 Rare forms of E.D.
Feeding Disorder of Infancy or Early Childhood
Pica
Rumination
FAED ("food avoidance emotional disorder"),
Selective Eating,
Functional Dysphagia
Pervasive Refusal Syndrome.
7 for “negative body image” see I. Bruch and M. Cuzzolaro.
8. the "sexualized body" of M.Laufer.
9 see Kaes R., Faimberg H., Enriquez M., Baranes J.-J, Baranger W-M. and other psychoanalytic authors who used the concept of “field” and “transgenerational”.
10 Contribute” as socio-cultural factors (advertising, fashion-world images etc.) strongly influence the adolescent’s physical role models.
11 The phenomenon of “alexitimia” described by Nemiah and Sifneos (1970)..
12 “Sweetsnowflake”
13 she continues reading the tale “Nevine e Fiordaprile”( Sweetsnowflake and Aprilflower “) : ".Nevina modelled it on little shapes taken from the stars and edelweiss’. When the cornucopia was full, obeying her father, she emptied it at the four horizon points a nd snow fell on the world.
Nevina was pale and transparent. She was as beautiful as the goddesses of the past. Her locks were faintly blond. Her face was of a blond imitated by the Polar Star. Her hands were of the whiteness of not yet still fallen snow. Her eyes were as sky blue as the glaciers .Nevina was sad.
In the hours of break, when the night was clear and starry, father January interrupted his work father to sleep in the immense flowing beard. In this moments Nevina lent on to the icy banisters, cupped her chin in her and dreaming stared at the distant horizon. An injured swallow , passing over the mountains towards sunny lands had fallen into her hands. Her hands had tried invane to comfort it. In agonized shudders the swallow had raved , longing for the sea, flowers, palmtrees and eternal spring. From that day on nevina dreamed of unknown lands. One night she decided to leave. She cautiously passed over the flowing beard of January and left the ice and eternal snow. She took the valley road and ended up amongst the fir trees. The gnomes when they saw her pass so delicately and fluorescent in the darkness of the forest interrupted the dances, straddled on the treebranches and stared at her all giggling curiously.
-Nevina !
-Nevina! Where are you going?
-Nevina, come and dance with us!
-Nevina,
And the little kind spirits crowded round her trying to stop her by tightly hugging her ankle and imprisoningt her light feet in ivy branches and dead fer.
Nevina smiled , deaf to their affectionate appeals. She removed a snowflake from the silver cornucopia and spraying it around her managed to free herself from her little playmates. Thus she continued as cautiously, quietly and lightly as the godesses of the past.
Arriving in the valley she was on the big road. The air was milder and a sense of panic overcame Nevina’s heart. To breathe she removed snowflake from the silver cornucopia and sprayed it around her thus regaining strength and breath in the suddenly icy air.
She carried on quickly and covered a great distance. At a junction she halted in ecstasy with dazzled eyes. In front of her there open up unknown space, an infinite blue plain. It was like another sky taken from the celestial vault and placed on earth, held and moved at the edges by invisible hands. Nevina pushed on stunned. The land around her changed: anemones,carnations, mimosas, violets, mignonettes, daffodils, hyacinths, jonquils, jasmines, tuberoses, until the eye could see. Form the hills to the sea , unstopped by the garden walls and hedges, the flowers overflowed like a river of petals from the houses and trees.
The olive trees stretched out their silver veils, the palmtrees towered straight, sublime as arrows hurled into the blue…”
Nevina turned her eyes on things never seen before. She forgot to spray the snowflakes tnen anguish repossessed her. She then took off a snowflake and an area of candid flakes and icy air formed around her regiving her breath. And the flowers, the olive trees, the palmtrees looked with astonishment at delicate little girl who flew past in a snow whirlwind and they shivered at her passing.
A beautiful youth, with a green an violet jerkin, appeared in front of Nevina. He stared at her with troubled eyes, barring her passage.
- Who are you?
- I am Nevina
-January’s daughter
-The you do not know that this is not your father’s kingdom? I am Fiordaprile and you are not allowed to pass on my lands. Go back to your glacier, for your good and mine.
- Nevina stared at the prince with such imploring and sweet eyes that Fiordaprile felt moved.
-Fiordaprile let me pass! I will not stay long.
I want to touch that blue, green, red a violet snow that you call flowers. I want to dip my fingers in that upside down sky that you call sea!
-Fiordaprile looked at her and smiled and then he nodded his head.
- Let’s go the. I will show you my kingdom.
They went on hand in hand, staring into each others eyes, ecstatic and happy. But as nevina went on a grey area obscured the blue sky and a swirl of Flakes covered the marvellous gardens. They came to a village in festivity where peasants were dancing under the almonds in blossom. Nevinaa wanted Fiordaprile to let her dance. They started dancing but the happy gang dispersed with a shudder, the music stopped and the air became freezing. From a grey sky, with almond smelling snow, iced snow petals fell. It was real snow that Nevina let off when passing. The two had to escape from the angry complaints of the company. At a safe distance they looked back and saw that the village was again celebrating under a clear, sunny sky.
-Nevina, I want to to marry you!
-Your subjects would not want a queen who lets off intense cold.
-It doesn’t matter. My will shall be done.
They continue further , holding hands, staring into each others eyes, without cares an happy…but suddenly Nevina stopped with an even more delicate paleness.
-Fiordaprile! Fiordaprile!....I have no more snow!
And she tried invane with her fingers the bottom of the cornucopia.
-Fiordaprile!....I feel like I am dying!...Take me to the border…Fiordaprile!....I can bear no more!....
Nevina doubled over, she felt faint.
Fiordaprile tried to hold her up, he took her in his arms and carried her towards the valley.
-Nevina!
Nevina!
Nevina did not reply. She became even more transparent. She took on the appearance of a transparent bubble about to disappear.
-Nevina! Answer me !
Fiordaprile covered her in his silk cloak to protect her from the burning sun. He ran on, arrived in the valley to entrust her to the cold northwind
However when he lifted the cloak Nevina was no longer there. Fiordaprile looked around lost, pale and shaking. Where was she? Had he lost her on the way ? He buried his head in his hands in desperation when suddenly his face lit up. He saw Nevina on the other side of the valley. She was smiling and waving goodbye.
The cold northwind , an old tutor of hers, was pushing her to snowy paths, towards the eternal ice, towards the inaccessible reign of her father January”. ( by Guido Gozzano)
14 Vanni compensates for his binge eatings or by obsessive restrictions of food or more often by working in the gymn (2-5 hours a day).
15 It was so beautiful out on the country, it was summer- the wheat fields were golden, the oats were green, and down among the green meadows the hay was stacked. There the stork minced about on his red legs, clacking away in Egyptian, which was the language his mother had taught him. Round about the field and meadow lands rose vast forests, in which deep lakes lay hidden. Yes, it was indeed lovely out there in the country.
In the midst of the sunshine there stood an old manor house that had a deep moat around it. From the walls of the manor right down to the water's edge great burdock leaves grew, and there were some so tall that little children could stand upright beneath the biggest of them. In this wilderness of leaves, which was as dense as the forests itself, a duck sat on her nest, hatching her ducklings. She was becoming somewhat weary, because sitting is such a dull business and scarcely anyone came to see her. The other ducks would much rather swim in the moat than waddle out and squat under the burdock leaf to gossip with her.
But at last the eggshells began to crack, one after another. "Peep, peep!" said the little things, as they came to life and poked out their heads.
"Quack, quack!" said the duck, and quick as quick can be they all waddled out to have a look at the green world under the leaves. Their mother let them look as much as they pleased, because green is good for the eyes.
"How wide the world is," said all the young ducks, for they certainly had much more room now than they had when they were in their eggshells.
"Do you think this is the whole world?" their mother asked. "Why it extends on and on, clear across to the other side of the garden and right on into the parson's field, though that is further than I have ever been. I do hope you are all hatched," she said as she got up. "No, not quite all. The biggest egg still lies here. How much longer is this going to take? I am really rather tired of it all," she said, but she settled back on her nest.
"Well, how goes it?" asked an old duck who came to pay her a call.
"It takes a long time with that one egg," said the duck on the nest. "It won't crack, but look at the others. They are the cutest little ducklings I've ever seen. They look exactly like their father, the wretch! He hasn't come to see me at all."
"Let's have a look at the egg that won't crack," the old duck said. "It's a turkey egg, and you can take my word for it. I was fooled like that once myself. What trouble and care I had with those turkey children, for I may as well tell you, they are afraid of the water. I simply could not get them into it. I quacked and snapped at them, but it wasn't a bit of use. Let me see the egg. Certainly, it's a turkey egg. Let it lie, and go teach your other children to swim."
"Oh, I'll sit a little longer. I've been at it so long already that I may as well sit here half the summer."
"Suit yourself," said the old duck, and away she waddled.
At last the big egg did crack. "Peep," said the young one, and out he tumbled, but he was so big and ugly.
The duck took a look at him. "That's a frightfully big duckling," she said. "He doesn't look the least like the others. Can he really be a turkey baby? Well, well! I'll soon find out. Into the water he shall go, even if I have to shove him in myself."
Next day the weather was perfectly splendid, and the sun shone down on all the green burdock leaves. The mother duck led her whole family down to the moat. Splash! she took to the water. "Quack, quack," said she, and one duckling after another plunged in. The water went over their heads, but they came up in a flash, and floated to perfection. Their legs worked automatically, and they were all there in the water. Even the big, ugly gray one was swimming along.
"Why, that's no turkey," she said. "See how nicely he uses his legs, and how straight he holds himself. He's my very own son after all, and quite good-looking if you look at him properly. Quack, quack come with me. I'll lead you out into the world and introduce you to the duck yard. But keep close to me so that you won't get stepped on, and watch out for the cat!"
Thus they sallied into the duck yard, where all was in an uproar because two families were fighting over the head of an eel. But the cat got it, after all.
"You see, that's the way of the world." The mother duck licked her bill because she wanted the eel's head for herself. "Stir your legs. Bustle about, and mind that you bend your necks to that old duck over there. She's the noblest of us all, and has Spanish blood in her. That's why she's so fat. See that red rag around her leg? That's a wonderful thing, and the highest distinction a duck can get. It shows that they don't want to lose her, and that she's to have special attention from man and beast. Shake yourselves! Don't turn your toes in. A well-bred duckling turns his toes way out, just as his father and mother do-this way. So then! Now duck your necks and say quack!"
They did as she told them, but the other ducks around them looked on and said right out loud, "See here! Must we have this brood too, just as if there weren't enough of us already? And-fie! what an ugly-looking fellow that duckling is! We won't stand for him." One duck charged up and bit his neck.
"Let him alone," his mother said. "He isn't doing any harm."
"Possibly not," said the duck who bit him, "but he's too big and strange, and therefore he needs a good whacking."
"What nice-looking children you have, Mother," said the old duck with the rag around her leg. "They are all pretty except that one. He didn't come out so well. It's a pity you can't hatch him again."
"That can't be managed, your ladyship," said the mother. "He isn't so handsome, but he's as good as can be, and he swims just as well as the rest, or, I should say, even a little better than they do. I hope his looks will improve with age, and after a while he won't seem so big. He took too long in the egg, and that's why his figure isn't all that it should be." She pinched his neck and preened his feathers. "Moreover, he's a drake, so it won't matter so much. I think he will be quite strong, and I'm sure he will amount to something."
"The other ducklings are pretty enough," said the old duck. "Now make yourselves right at home, and if you find an eel's head you may bring it to me."
So they felt quite at home. But the poor duckling who had been the last one out of his egg, and who looked so ugly, was pecked and pushed about and made fun of by the ducks, and the chickens as well. "He's too big," said they all. The turkey gobbler, who thought himself an emperor because he was born wearing spurs, puffed up like a ship under full sail and bore down upon him, gobbling and gobbling until he was red in the face. The poor duckling did not know where he dared stand or where he dared walk. He was so sad because he was so desperately ugly, and because he was the laughing stock of the whole barnyard.
So it went on the first day, and after that things went from bad to worse. The poor duckling was chased and buffeted about by everyone. Even his own brothers and sisters abused him. "Oh," they would always say, "how we wish the cat would catch you, you ugly thing." And his mother said, "How I do wish you were miles away." The ducks nipped him, and the hens pecked him, and the girl who fed them kicked him with her foot.
So he ran away; and he flew over the fence. The little birds in the bushes darted up in a fright. "That's because I'm so ugly," he thought, and closed his eyes, but he ran on just the same until he reached the great marsh where the wild ducks lived. There he lay all night long, weary and disheartened.
When morning came, the wild ducks flew up to have a look at their new companion. "What sort of creature are you?" they asked, as the duckling turned in all directions, bowing his best to them all. "You are terribly ugly," they told him, "but that's nothing to us so long as you don't marry into our family."
Poor duckling! Marriage certainly had never entered his mind. All he wanted was for them to let him lie among the reeds and drink a little water from the marsh.
There he stayed for two whole days. Then he met two wild geese, or rather wild ganders-for they were males. They had not been out of the shell very long, and that's what made them so sure of themselves.
"Say there, comrade," they said, "you're so ugly that we have taken a fancy to you. Come with us and be a bird of passage. In another marsh near-by, there are some fetching wild geese, all nice young ladies who know how to quack. You are so ugly that you'll completely turn their heads."
Bing! Bang! Shots rang in the air, and these two ganders fell dead among the reeds. The water was red with their blood. Bing! Bang! the shots rang, and as whole flocks of wild geese flew up from the reeds another volley crashed. A great hunt was in progress. The hunters lay under cover all around the marsh, and some even perched on branches of trees that overhung the reeds. Blue smoke rose like clouds from the shade of the trees, and drifted far out over the water.
The bird dogs came splash, splash! through the swamp, bending down the reeds and the rushes on every side. This gave the poor duckling such a fright that he twisted his head about to hide it under his wing. But at that very moment a fearfully big dog appeared right beside him. His tongue lolled out of his mouth and his wicked eyes glared horribly. He opened his wide jaws, flashed his sharp teeth, and - splash, splash - on he went without touching the duckling.
"Thank heavens," he sighed, "I'm so ugly that the dog won't even bother to bite me."
He lay perfectly still, while the bullets splattered through the reeds as shot after shot was fired. It was late in the day before things became quiet again, and even then the poor duckling didn't dare move. He waited several hours before he ventured to look about him, and then he scurried away from that marsh as fast as he could go. He ran across field and meadows. The wind was so strong that he had to struggle to keep his feet.
Late in the evening he came to a miserable little hovel, so ramshackle that it did not know which way to tumble, and that was the only reason it still stood. The wind struck the duckling so hard that the poor little fellow had to sit down on his tail to withstand it. The storm blew stronger and stronger, but the duckling noticed that one hinge had come loose and the door hung so crooked that he could squeeze through the crack into the room, and that's just what he did.
Here lived an old woman with her cat and her hen. The cat, whom she called "Sonny," could arch his back, purr, and even make sparks, though for that you had to stroke his fur the wrong way. The hen had short little legs, so she was called "Chickey Shortleg." She laid good eggs, and the old woman loved her as if she had been her own child.
In the morning they were quick to notice the strange duckling. The cat began to purr, and the hen began to cluck.
"What on earth!" The old woman looked around, but she was short-sighted, and she mistook the duckling for a fat duck that had lost its way. "That was a good catch," she said. "Now I shall have duck eggs-unless it's a drake. We must try it out." So the duckling was tried out for three weeks, but not one egg did he lay.
In this house the cat was master and the hen was mistress. They always said, "We and the world," for they thought themselves half of the world, and much the better half at that. The duckling thought that there might be more than one way of thinking, but the hen would not hear of it.
"Can you lay eggs?" she asked
"No."
"Then be so good as to hold your tongue."
The cat asked, "Can you arch your back, purr, or make sparks?"
"No."
"Then keep your opinion to yourself when sensible people are talking."
The duckling sat in a corner, feeling most despondent. Then he remembered the fresh air and the sunlight. Such a desire to go swimming on the water possessed him that he could not help telling the hen about it.
"What on earth has come over you?" the hen cried. "You haven't a thing to do, and that's why you get such silly notions. Lay us an egg, or learn to purr, and you'll get over it."
"But it's so refreshing to float on the water," said the duckling, "so refreshing to feel it rise over your head as you dive to the bottom."
"Yes, it must be a great pleasure!" said the hen. "I think you must have gone crazy. Ask the cat, who's the wisest fellow I know, whether he likes to swim or dive down in the water. Of myself I say nothing. But ask the old woman, our mistress. There's no one on earth wiser than she is. Do you imagine she wants to go swimming and feel the water rise over her head?"
"You don't understand me," said the duckling.
"Well, if we don't, who would? Surely you don't think you are cleverer than the cat and the old woman-to say nothing of myself. Don't be so conceited, child. Just thank your Maker for all the kindness we have shown you. Didn't you get into this snug room, and fall in with people who can tell you what's what? But you are such a numbskull that it's no pleasure to have you around. Believe me, I tell you this for your own good. I say unpleasant truths, but that's the only way you can know who are your friends. Be sure now that you lay some eggs. See to it that you learn to purr or to make sparks."
"I think I'd better go out into the wide world," said the duckling.
"Suit yourself," said the hen.
So off went the duckling. He swam on the water, and dived down in it, but still he was slighted by every living creature because of his ugliness.
Autumn came on. The leaves in the forest turned yellow and brown. The wind took them and whirled them about. The heavens looked cold as the low clouds hung heavy with snow and hail. Perched on the fence, the raven screamed, "Caw, caw!" and trembled with cold. It made one shiver to think of it. Pity the poor little duckling!
One evening, just as the sun was setting in splendor, a great flock of large, handsome birds appeared out of the reeds. The duckling had never seen birds so beautiful. They were dazzling white, with long graceful necks. They were swans. They uttered a very strange cry as they unfurled their magnificent wings to fly from this cold land, away to warmer countries and to open waters. They went up so high, so very high, that the ugly little duckling felt a strange uneasiness come over him as he watched them. He went around and round in the water, like a wheel. He craned his neck to follow their course, and gave a cry so shrill and strange that he frightened himself. Oh! He could not forget them-those splendid, happy birds. When he could no longer see them he dived to the very bottom. and when he came up again he was quite beside himself. He did not know what birds they were or whither they were bound, yet he loved them more than anything he had ever loved before. It was not that he envied them, for how could he ever dare dream of wanting their marvelous beauty for himself? He would have been grateful if only the ducks would have tolerated him-the poor ugly creature.
The winter grew cold - so bitterly cold that the duckling had to swim to and fro in the water to keep it from freezing over. But every night the hole in which he swam kept getting smaller and smaller. Then it froze so hard that the duckling had to paddle continuously to keep the crackling ice from closing in upon him. At last, too tired to move, he was frozen fast in the ice.
Early that morning a farmer came by, and when he saw how things were he went out on the pond, broke away the ice with his wooden shoe, and carried the duckling home to his wife. There the duckling revived, but when the children wished to play with him he thought they meant to hurt him. Terrified, he fluttered into the milk pail, splashing the whole room with milk. The woman shrieked and threw up her hands as he flew into the butter tub, and then in and out of the meal barrel. Imagine what he looked like now! The woman screamed and lashed out at him with the fire tongs. The children tumbled over each other as they tried to catch him, and they laughed and they shouted. Luckily the door was open, and the duckling escaped through it into the bushes, where he lay down, in the newly fallen snow, as if in a daze.
But it would be too sad to tell of all the hardships and wretchedness he had to endure during this cruel winter. When the warm sun shone once more, the duckling was still alive among the reeds of the marsh. The larks began to sing again. It was beautiful springtime.
Then, quite suddenly, he lifted his wings. They swept through the air much more strongly than before, and their powerful strokes carried him far. Before he quite knew what was happening, he found himself in a great garden where apple trees bloomed. The lilacs filled the air with sweet scent and hung in clusters from long, green branches that bent over a winding stream. Oh, but it was lovely here in the freshness of spring!
From the thicket before him came three lovely white swans. They ruffled their feathers and swam lightly in the stream. The duckling recognized these noble creatures, and a strange feeling of sadness came upon him.
"I shall fly near these royal birds, and they will peck me to bits because I, who am so very ugly, dare to go near them. But I don't care. Better be killed by them than to be nipped by the ducks, pecked by the hens, kicked about by the hen-yard girl, or suffer such misery in winter."
So he flew into the water and swam toward the splendid swans. They saw him, and swept down upon him with their rustling feathers raised. "Kill me!" said the poor creature, and he bowed his head down over the water to wait for death. But what did he see there, mirrored in the clear stream? He beheld his own image, and it was no longer the reflection of a clumsy, dirty, gray bird, ugly and offensive. He himself was a swan! Being born in a duck yard does not matter, if only you are hatched from a swan's egg.
He felt quite glad that he had come through so much trouble and misfortune, for now he had a fuller understanding of his own good fortune, and of beauty when he met with it. The great swans swam all around him and stroked him with their bills.
Several little children came into the garden to throw grain and bits of bread upon the water. The smallest child cried, "Here's a new one," and the others rejoiced, "yes, a new one has come." They clapped their hands, danced around, and ran to bring their father and mother.
And they threw bread and cake upon the water, while they all agreed, "The new one is the most handsome of all. He's so young and so good-looking." The old swans bowed in his honor.
Then he felt very bashful, and tucked his head under his wing. He did not know what this was all about. He felt so very happy, but he wasn't at all proud, for a good heart never grows proud. He thought about how he had been persecuted and scorned, and now he heard them all call him the most beautiful of all beautiful birds. The lilacs dipped their clusters into the stream before him, and the sun shone so warm and so heartening. He rustled his feathers and held his slender neck high, as he cried out with full heart: "I never dreamed there could be so much happiness, when I was the ugly duckling." (by Hans Christian Andersen).
16 Cecily made progress in the femminine area and this became evident outside too.