Traumatic experience and anorexia nervosa etiology
Sebastian
Abraham Salim *
* Psychoanalyst
of the Psychoanalytic Society of Rio de Janeiro
* Member of
the Brazilian Psychiatric Association
* Associate
Professor, Department of Mental Health FMUFMG
Abstracts
The
etiology of anorexia nervosa is indefinite. In this clinical-conceptual manuscript
research, the author suggests an original hypothesis including
interdisciplinary studies between his clinical practice as psychoanalyst and
psychiatrist over a decade, experimental psychology and neurobiology.
He
suggests that anorexia nervosa etiology is due to a traumatic experience felt
by the patient with feeling of death. It is necessary a special predisposition,
developed by a previous occurrence of another premature traumatic experience with
the same sense of death.
These
experiences trigger neurobiological innate and reflex responses of the body to maintain
life and to auto appease the anguish of death that follows the traumatic
experience. The first one consists in a partial return of body metabolism to its
initial state, when the oxygen used by the cell was minimum for the vital
cellular functions. The second is an auto generation of sensorial experiences
using own body elements as fingers, urine and others in contact with the skin
and others sensorial surfaces. There happens a disconnection between cortical
and hypothalamic circuits.
Though this is a neurobiological hypothesis, the author consider
psychoanalytic psychotherapy as central to treatment, due to the maintenance of
the therapeutic setting. It allows the reconnection of the neural circuits, for
the restoration of personal trust with other people and for the interpretative
work of the habitual severe superego.
The
author thinks that his positive clinical results with these references suggest
the continuation of these studies
Keywords: nervous anorexia; etiology; traumatic
experience; implicit memory; psychoanalytical psychotherapy.
Introduction
Anorexia nervosa is an eating disorder of varying severity. Experts in
various fields do not present conclusive results about its etiology.
There are several hypotheses to explain it such as genetic 1,
religious 2, hormonal 3, neurologic 4,
socio-cultural 5 and psychogenic 6. These assumptions
generate different therapeutic approaches. Each specialist focuses within its
own framework.
The author aims to present an etiological hypothesis of biological
nature linked to a traumatic experience felt by the patient with feeling of
death as defined in DSM-IV 7. He emphasizes the need of
predisposition raised by a previous fetal or perinatal trauma with the same
sense.
These experiences trigger neurobiological innate and reflex responses of
the body to maintain life and to auto appease the anguish of death that follows
the traumatic experience. The first one consists in a partial return of body metabolism
to its initial state, when the oxygen used by the cell to operate her vital functions
is minimum 8. The second is an auto generation of sensorial experiences
using own body elements as fingers, urine and others in contact with the skin
and others sensorial surfaces 9. There happens a disconnection
between cortical and hypothalamic circuits 10. Both may go on throughout
life.
The traumatic experience may occur since the fetal period, as shown in the
work done with ultrasound fetal studies 11.
The author considers the symptoms of anorexia as biological concomitant
of traumatic experience and therefore they do not have mental representation.
There are not repressed elements, neither sexual nor aggressive, as psychoanalysts’
believes 6.
Although this is a neurobiological hypothesis, the author consider psychoanalytic
psychotherapy as central to treatment, due to the maintenance of the
therapeutic setting that allows the reconnection between the neural circuits of
the hypothalamus with those of the cortex 10. It is also important
for the restoration of personal trust with other people and allows an
interpretative work of the habitual severe superego.
The application of these studies in my clinical practice has resulted in
significant improvement of the anorexic patient and her adherence to treatment.
Method
The method used by the author is a combination of his many years of clinical
practice as psychiatrist and psychoanalyst and interdisciplinary studies on post-traumatic
stress disorder, experimental psychology and neurobiology.
He follows the reference of the DSM-IV 7 to diagnose anorexia:
A - A commitment of the anorexic patient to maintain body weight at
least 85% below normal body weight for age and height, accompanied by an
intense fear of gaining weight even though emaciated.
B - A disorder in order to experience weight loss, as no notion of
slimming and denial of the risk of weight loss. In addition, the perception of
distorted body image, i.e., the anorexic sees or thinks fat.
C - Women who have started their menstrual cycle have periods of
amenorrhoea and menstruation appears only after administration of hormones.
The author includes in this work, the transitory cases of anorexia met
in post-traumatic patients. Commonly they show loss of appetite, refusal of
food, loss of weight and libido, different psychosomatic symptoms, phobias,
daytime somnolence, fears, anxiety and other symptoms. They appear after the
occurrence of traumatic experiences as surgery, physical violence, torture,
sexual abuse, dear relative loss, marital separation, kidnapping, a forced
period of overwork and other stress situations. These symptoms may be
short-lived or become chronic. These patients commonly receive diagnose of
depression.
The traumatic experience
There are many kinds of traumatic experiences, from biological to
psychological and it may happen in any period of life, as shown.
It is possible to observe difficulties of the newborn, right after
birth, to establish a healthy relationship with the mother. It happens feeding
difficulties, excessive sleepiness, presence of autism early signs as
continuous suction of the finger and apathetic look, a motor slowness and
others that usually accompany the newborn for the end of the life 12.
These observations indicate that the traumatic experience may occur in
fetal period. In the clinical experience of the author, he observed that it is
possible to get from the patient or their parents history of fetal trauma. When
this is not possible, the neurobiology shows 13 that the traumatic
event appears in dream and can be detected with the aid of the understanding of
the functioning and purpose of implicit memory in preserve our life, as chaotic
dreams of falling, freezing, death, tight passages and others.
Another kind of traumatic experience is that one related to stress. In a
recent study 14 with rats, the author shows clearly this relation. He
used a group of rats as control group that had free access to a cage with food,
attached to a wheel rim with 33 cm in circumference, around which the rats ran
and another group whose access to the cage were closed certain hours of the
day. After few days of alternating sessions of free access to food with
restricted access in one-hour intervals, the mice lost, weight and could die,
if not removed from these conditions. The author observed that as they lost
weight, they run more quickly but ate less when they returned to have free
access to food. This phenomenon is paradoxical, because it expects that these
mice eat more as your weight decreases, but actually eat less than those used
as control in the experiment eat. Experience has demonstrated that the weight
loss is not associated with loss of calories per becomes more accelerated, but to
an activity that includes a state of stress - or the expectation of having no
access to food.
Another contribution 7 to the author’s hypothesis is an experiment
on human organs, to explain the biological defence to preserve life. It aims to
increase the number of hours for use of organs for transplants. He used solution
of H2S, which decreases oxygen consumption by the cell to carry out
the vital functions, with a damping of life to a "state of suspended
animation of life". He was able to demonstrate that this process can
happen in humans, activated in adverse living conditions, repeating the
phenomenon of hibernation with plants and animals, allowing them to survival
for decades.
Perhaps the same happens with humans, who have undergone several hours
without oxygen in accidents, such as burial by ice or land. These victims like
animals and plants, showed extraordinary resistance to environmental stresses
such as excessive temperatures, oxygen deprivation and physical injuries. The
researcher was well succeed to prolong the lifetime of various organs
transplanted, performing an important achievement in organs transplants.
As described the traumatic experience also trigger a body resource to
auto appease the victim.
Predisposition
Studies on posttraumatic stress 15 with victims of road
trauma, found that victims of serious accidents do not develop PTSD, and other
victims became sick after minor accidents. In the personal history of the latest
had always occurred earlier traumas.
Observations show that children, babies and animals develop anorexia when
left to strangers or happens radical change in the environment. If not moved in
time of such circumstances, they may die of auto inanition. However, this does
not occur with all of them.
Also a study 12 shows that birth trauma can cause symptoms of
neonatal immaturity at birth and source high levels of eating disorders and
others no.
The author suggests that the predisposition for the development of anorexia
remains in the fact of a previous fetal or perinatal traumatic experience with
feeling of death. They come to the world as if they were in a fine line between
life and death. This is valid to cases of transitory anorexia.
They brought with them the biological defence described to maintain
alive. They run reflexively back in search of the initial metabolic rate where
the cellular oxygen for its vital function is minimum. The author call this
mechanism of ‘autistic retreat’ responsible for what he calls ‘the autistic
personality’. Really, there are studies 16 showing the onset of
symptoms of autism spectrum chronic course in anorexia.
In cases of life threatening in a posterior traumatic experience
independent of age, the body of the victim moves back to that initial state of
safety. This defence is similar to the mechanism of psychic regression in
search of survival described by Freud 17 and illustrated by him as
similar to the advancing armies that leave behind them, points of support to
which they can return if necessary.
Another important contribution made by a neurobiologist 18
with the study of implicit memory, show that this works similarly to the
Freudian unconscious. It is responsible for acts performed automatically, turned
for survival. Thus, unlike Freud 19 that postulated the etiology of dream
as result of sexual desire suppressed from daytime repression, neurobiology 13
has shown that the dream is also a neuropsychological process by which a short
daytime learning related survival is transformed into a learning long term
(long term memory).
The knowledge that the body has a way of relating to the environment and
innate reflex manner through existing records in implicit memory, independent
of our cognition, often allows anticipate the existence of a traumatic event.
Clinical cases
Case A
Julia is a beautiful woman, twenty-three years old, thin, always well
dressed, intellectual and divorced. At our first meeting three years ago, she
reported loss of weight since her adolescence, when she began to avoid solid
food and to measure the calories ingested in an obsessive way. Since then, when
she exceeded the food intake she had vomit and made use of laxative with high
intake of water. She ate only chocolate. Associated with this eating disorder, she
mentioned intolerance to prolonged contact with people, cold, heat or noise. She
elected social isolation and has a feeling of existential emptiness. It also
presents insomnia, indifference, fatigue, sleepiness daily, amenorrhoea,
constipation, bruxism, sweating, salivation, difficulty in concentration and
memory. She felt depressed without sadness.
She told me that when she was four years old, she was sexual abused by
an uncle for two years, keeping this fact only for her because she was afraid to
tell it for her father and mother. Hers symptoms became severe at the age of
fourteen, when was preparing to be a model because of her thin body and facial
beauty. She started with success and when she was seventeen years old was encouraged
by her family to take a course in another country. She remained there a year
and no longer supported the absence of the mother and of the boyfriend. After
returning, she married him and set up home with furniture from the mother’s
house, although the husband insisted on buying new furniture. After a few
months, they separate due to the development of food obsessive ritual,
menstrual dysfunction and extreme attachment and submission to the mother. The
ex-husband left the apartment but returned frequently, attending to her
requests.
One year later, she started to work as teacher. Soon after, she felt a compelling
need to sleep in the afternoon, a fact that embarrassed her daily life. The
food rituals accentuated, appeared panic attacks with fear of death and social
phobia. She made several psychiatric and psychological treatments with no
improvement. She became suspicious with any kind of treatment and only sought
me by indication of a friend, who had been my patient.
At the end of the meeting, I prescribed benzodiazepine at bedtime and
proposed psychotherapy with two weekly sessions, fifty minutes each.
One month later, she reported that it was difficult to continue to work as
teacher because the persons look at her in a strange way. Sometimes they avoided
her because she was few communicative. She felt insufficient for physical and
intellectual work but her mother insisted that she worked. She told me a dream
in which she was in bed and was not breathing. She tried to move and could not.
She felt powerless. She heard a voice saying to her: "They're sewing a new
shirt for you. It is very tight”. She woke up feeling bad.
The session ended with her telling that her dream indicated the current
physical state of failure, but brought hope of improvement with psychotherapy -
the voice announcing a new shirt.
The patient comes regularly to the sessions due to my empathy with her insufficiency
to deal with the family, social and professional life. Always she came to me dressed
in black. Sometimes speak of her ex-husband and attachment to mother and
father. Occasionally mentioned her sexual life. Unwilling to return to the
traumatic experiences, as happens with posttraumatic patients, she never
mention the sexual abuses by the uncle. She told me that her mother pregnancy
was normal, but the birth was laborious. Once, she made reference to her birth,
saying that was born with blood running down her head due to the forceps and
her mother spent a month without being able to take care of her due to
infection of her genitals parts related to the birth. She remember that when was
two years old, she had intense severe bronchial asthma that disappeared at the
age of eight years.
After three months of psychotherapy, she was still in state of failure
and stress and in a session, reported a dream in which her car could not go on
a small rise near her home and she tried to push it but felt powerless.
After one year, the patient arrives and I notice that she is more
colourful and the timbre of the voice stronger. She told me that her weekend was
good. She went with her new boyfriend with whom is living and entered the water
only once because it was cold, but was happy to wear costume bath. She also
told me that felt she did not live, only existed, and all mechanical.
One year later, she told me she is living without fear of vomiting and
is planning a trip to the home of her boyfriend's parents, not being carried by
the tendency to stay at least as she did to feed and to live. She remains in
psychotherapy.
Case B
Another patient shows a weight loss of eleven pounds since two years ago,
after the death of her husband, staying alone. Her doctor have raised
suspicion, to explain this weight loss, of the existence of an undiagnosed
cancer. She then underwent a complete check-up to exclude its presence and now she
was going again to submit a second battery of exams as colonoscopy and breast
and brain scan for the sake of conscience of her clinic. The doctress certainly
considered only the weight loss resistant to usual medical treatment and did
not take into account her memory loss, her daytime sleepiness and other
symptoms indicative of her posttraumatic stress. Because of loneliness and
medical mistakes, the patient presents squizoparanoide ideas. Her son brought
her to me. I prescribed antipsychotic (risperidone), benzodiazepine and
antidepressant. She began psychoanalytic psychotherapy twice a week, attending
regularly to the sessions accompanied by a relative for the fear of going out
alone at the street and your state of muscular weakness. After a month,
improved psychotic symptoms began to sleep better and their relatives informed
me that she was more active.
In the initial sessions, she kept her focused on physical complaints,
but gradually was encouraged to talk about their losses and dreams. The author think
the patient would not be in psychotherapy longer, because soon started talking
about reduce the sessions. This moment he remembered that these patients wants
soon as possible to come back for themselves. The author showed this for her
and she considered continuing. She became dependent of him as important for her
sake. After six months, she began to show improvement in appetite, weight loss
and sleep with the absence of any psychotic symptom.
Case C
Another patient presenting progressive weight loss comes seven months
with loss of eight pounds, after the arrest of his son on charges of drug
trafficking. At the beginning I did not understand why psychotherapy, but
gradually was adhering to treatment because of the improvement occurred. The
author used only as an aid benzodiazepine treatment.
Conclusion
The anorexic patient is a difficult clinical management because she worries
with her delicate balance between life and death. As consequence of the
troubled relationship with her mother since birth, she grows up without finding
an enabling environment to heal the disconnect cortex-hypothalamus circuits11.
The author emphasizes that psychoanalytic psychotherapy is the most
important element in her treatment. It has a constant setting maintained with usual
consistence. She needs an emphatic caretaker with sensibility to countertransference
phenomenon in order to achieve her appeasement and confidence in other people.
This patient usually presents an insufficiency for her family,
professional, social and affective relations that generates many criticisms.
She internalizes these and becomes an important factor for intensification of her
fears, failure and stress responsible by the burnout. We have to elaborate with
her the charges of her superego by an interpretive work.
The author concludes that anorexia is an organism attempt conducted by
the cerebral amygdala to survive, although it approaches the patients to death,
which is another paradox. The body becomes a “sufficient good mother”20.
This paper is a preliminary communication. The author suggests its
continuation due to his satisfactory clinical results.
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