Final: Bulimia Nervosa from the Lens of Interpersonal and Attachment Theories SWOK 605 December 9, 2013 University of Southern California Todd Creager, LCSW Bulimia Nervosa Diagnostic Criteria Bulimia Nervosa (BN) is characterized by recurrent episodes of binge eating which is followed by a type of compensatory behavior by purging. Purging, as defined by the Merriam-Webster (2013) dictionary is an act of getting rid of something unwanted. This can be done by self-induced vomiting, ill-use of laxatives, diuretics, and/or other medications as well as fasting and/or excessive exercise.
Binge eating is the act of eating in a distinct period of time. The amount of food eaten is significantly larger than what most individuals would eat in the same period of time. When eating the individual usually feels a lack of control; one feels as if they cannot control what they eat or how much nor have control over stopping. An individual who participates in binging and purging generally does so in order to lose weight (American Psychiatric Association, 2013).
According to the DSM-5 there are three crucial features of BN; recurrent episodes of binge eating and compensatory behaviors in order to avoid eight gain as well as frequent self-evaluation that is markedly influenced to assess body shape and weight (American Psychiatric Association, 2013). Unlike Anorexia Nervosa (AN), were the weight loss and illness is evident by sight, many individuals with BN do not look like a person with an eating disorder (ED).
Even so someone with BN does share many common thoughts as someone with AN, despite looking relatively healthy; fear of gaining weight, desire to lose weight and an intense dissatisfaction with their bodies. Another aspect of BN is secrecy. There is a feeling of hame or disgust when binging and also when purging, depending on how one decides to purge. Binging and certain types of purging are often done in secret and the feelings of shame and disgust do not subside until after purging. After purging a person with BN will most often feel relieved (Spearing, 2001).
Purging is a way lessens ones ambivalence to eat even if for Just a little while. The obsessive thoughts about food and eating is a characteristic of BN that is a derivation for intense stress (Budd, 2007). statistics The National Association of Anorexia Nervosa and Associated Disorders (ANAD, 013) estimate that 24 million people of all ages and gender suffer from an ED in the United States. ED also have the highest mortality rate of any mental illness, 3. 9% of individuals with BN do not survive the illness.
Between the years of 1988 and 1993 the National Eating Disorder Association (NEDA, 2013) estimate that the number of women alone who suffer from BN has tripled and girls as young as 12 years old develop this mental illness. 1. 1 to 4. 2% of women suffer from BN in their lifetime, that being the statistic for women who meet the full criteria for diagnosis (Spearing, 2001); bout 5. 4% of men and women meet partial criteria for BN (Hoek and Hoeken, 2003). Men are less likely to seek treatment for BN due to the stigma of the disorder being a “woman’s disease,” nonetheless the ANAD estimate that 10-15% of men meet criteria for an ED.
According to Hoek and Hoeken (2003) women between the ages of 20 to 24 are at higher risk for developing BN; 82. 7 per 10,000 people a year in this population have BN. This statistic is not restricted to the stereotype that white women are more likely to have an eating disorder. In fact there is no significance difference in prevalence of BN among non-Hispanic whites, Hispanics, African Americans and Asians (Grabe and Hyde, 2006). BN is also not Just a mental illness found in adolescents and young adults. According to Hoek and Hoeken (2003) 1. 7 per 10,000 individuals over the age of 40, both men and women, suffer from BN.
The average estimated number out of 10,000 per year of individuals suffering with BN is 12, worldwide. Interpersonal Therapy Interpersonal therapy OPT) was developed by Gerald Klerman and Myrna Weissman with the New-Haven-Boston Collaborative Depression Project in the 1940s (Klerman, Weissman, Bruce and Eve, 1994). It was originally developed for treating depression, however in recent years it has been adapted to treat substance abuse, marital problems and ED. The application of IPT for BN is fairly similar in style and structure to that used for depression (Fairburn, 1994).
IPT for BN is a short term therapy consisting of three stages that span through 15 to 20 50 minute sessions. The first stage lasts for about four sessions in which an evaluation of the personal context in which BN began to manifest and how the illness has been maintained. The client’s uality of present-day interpersonal functioning is also assessed, as is the interpersonal circumstance of the client’s mental illness episodes. The first stage concludes with a focus point; which of the client’s current problems will be directly treated (Fairburn, 1994).
The clinician explains to the client that even though focusing directly on the ED can have positive results there is a high likelihood of relapse. Alternatively the clinician and client work together to figure out when and why the client developed BN by looking at their past history in relation to past nterpersonal experiences such as major life events, the history of the eating problem, possible problems with self-esteem and depression and also how the client was functioning on an interpersonal level before and after the development of BN. elationships with family and friends, schooling, work, involvement in the community, dating/marriage, social life and anything else that involves interpersonal functioning and communication. Subsequently certain factors that maintain the ED are focused on and modified. The idea is to look at the underlying issue that caused the illness to occur. IPT is a medical based therapy that looks at the mental illness as any other illness.
Much like a smoker who is at risk for lung cancer, the issue is not that the smoker will get cancer, rather that he or she can try to prevent the onset of cancer by not smoking anymore; the underlying issue is smoking. If you apply this to BN the issue is not the direct act of binging and purging (that would be the cancer in the prior mentioned example) but the situation, feelings or event that precipitated the illness (much like smoking being the issue that can cause lung cancer). An illness can e cured if the root of the problem is found and addressed.
It is also explained to the client that BN is not uncommon and that many people go through a phase in life where they binge and purge and then eventually stop. The average length of time a person suffers from BN is a little over four years. It is a transitory behavior and behavior can be changed (Fairburn, 1993). During the next two phases of IPT the focus is transmitted to the identified factors in phase one. Through understanding one’s ED he or she can achieve change by modifying the identified factors that led to he client’s BN.
In most cases the underlying problem that leads a client to BN emerges from some type of interpersonal problem and frequently the problem is no longer relevant by the time the client comes to therapy. “Eating problems tend to disguise other difficulties and thereby give the misleading impression that all would be well were control over eating established (Fairburn, 1993 p. 361). ” IPT has two main goals; reduce symptomology and help the client deal with the people and situations connected with beginning of the symptoms in a healthier manner (Weissman et. al, 1994).
Blame is never put on the client but rather the illness itself. IPT is based on the concept that BN is triggered by an event that caused interpersonal problems. Four of the main problems that are often focused on are complicated grief, in which a person cannot deal with a loss in an appropriate manner. Role disputes or transitions causing the client to become unsure of their identity or interpersonal deficits. Interpersonal deficits are personal problems such as low self-esteem that can cause the client distress and stunt their ability to make connections with others in their social environment (Barlow, 2007).
Someone who is having trouble adjusting to new identity roles and changes in their life that cause stress, are difficult to control and cause social issues, may turn to EDS in pursuit of control and use that to fill a void and feel empowered (Budd, 2007). IPT is also time limited and focused which pushes the client to do work outside of therapy and be more concentrated on getting better. They are put into a sick role which allows them to understand BN as an illness that can be cured rather than a mental illness that will be stuck with them for life. IPT is also empirically grounded and diagnosis irected.
It is focused on the here and now in order for the client to recognize what is true for them in the moment and how that might be different than when they first developed BN. As well as this IPT focuses on interrelationships between mood and current life events and vice versa, thereby giving the client a better understanding of emotions and situations. All of this is geared towards making modifications and behavioral changes (Apple, 1999). According to Fairburn (1993) the therapist must make it clear to the client that they will have to continue working after the 20 essions due to the fact that behaviors do not Just go away.
On the other hand, if there is no improvement what so ever the client is not blamed, rather the client is told that the therapy failed, the client did not fail, and the client is encouraged to try something different (Barlow, 2007). In order to better understand IPT it is important to understand the theories that it is derived from. IPT is largely based on Harry Stack Sullivan’s departure from Sigmund Freud’s psychoanalytic theory. Sullivan’s interpersonal theory paved the way for John Bowlbys attachment theory and is a ignificant conceptual model of object relations theory.
Nevertheless, only interpersonal and attachment theories will be focused on in the following section. Theories Interpersonal Theory/Personality Theory Sullivan shifted the view of psychotherapy and mental illness more dramatically than any neo-Fruedian. He defined mental disorders as complications in interpersonal living or insufficient measures of appropriate interpersonal relations. He hypothesized that all humans are inherently the same. An individual develops a mental illness due to poor interpersonal relations as a child and thus grows up ithout the knowledge of how to behave “normal” and adhere to social norms.
Sullivan’s notion challenged the barriers between the definitions of normal and pathological (Evans Ill, 2006). According to him, everyone is born normal; it is their upbringing, teachings and environment that can create problems for an individual which many times result in mental illnesses. Sullivan states the following, “In most general terms, we are all much more simply human than otherwise; be we happy and successful, contented and detached, miserable and mentally disordered of whatever (Berzoff, Flanagan and Hertz, 2008 p. 275).
According to Weissman et. al. (1994) Sullivan established a complete and reliable concept about the connections between psychiatric disorders and interpersonal relations for the developing child as well as for adults as they move through multiple transactions in life. An individual has two needs in life, security and satisfaction. If there is a conflict between the two then disturbances in emotion occur (Zastrow and Ashman, 2010). Sullivan depicted two areas the invoke anxiety in people; the tension of needs and the tension of anxiety.
The tension of needs refers to basic biological needs such as food, oxygen, water, leep, need for touch, dermal physiochemical regulation and the need for human contact. It is critical for a human to satisfy the tension of needs in order to properly function (Evans Ill, 2006). Someone who has an ED such as BN is continually attempting to find relief from this tension due to Humphery (1988) found that more often than not a person who develops BN comes from a family that did not satisfy the tension of needs when the individual was an infant or young child.
An individual with BN typically comes from a neglectful and unsupportive family and has a history of ejection, being blamed and overall lack of nurturance and understanding. The tension of anxiety is the removal of anxiety which leads to interpersonal security. If an infant is neglected he or she will grow up with no anxiety relief or sense of esteem and is prone to long term social adjustment problems. Steiger, Gauvin, Jabalpurwala, S?©guin and Stotland (1999) found this to be true in individuals who have BN.
The study ultimately links BN to self-disturbances, social conflict, fear of intimacy and mistrust of others. This can be attributed to ones inability to satisfy their own tension of anxiety. Personality in Sullivan’s interpersonal theory, also known as personality theory (PT) is not a sovereign entity, rather the persistent sequence of continuing interpersonal situations that typify humans. Personality manifests itself only during interpersonal exchanges or situations. There is another part of the personality called the self dynamism, better known as the self-system, which is used as a defensive mechanism.
The self-system grows out of experience, from learning what is acceptable and what is not and is used to protect one’s self- esteem, lower anxiety and find approval. The self is also regarded as separate from one’s personality (Holland, 1970). The self can also be mature or immature. According to Youniss (1982) the immature self has a heightened feeling of uniqueness, hides any deficits, is approval seeking and is unable to have intimate relationships. The mature self seeks mutual satisfaction with others instead of being overly selfish or giving.
The mature self is able to create balance between themselves and others. Another important aspect of PT is the good-me, the bad-me and the not- me identity. As an infant an individual gains a sense of who they are through nterpersonal experiences. If their experiences are good and result in approval and tenderness the self begins to develop the feeling of the good-me. If the infant experiences neglect, anxiety and disapproval the infant will develop the image of the bad-me. The not-me are aspects of the self that are not easily understood and divulges qualities the conscious finds repugnant.
An infant who’s caregivers did not satisfy their tensions will be more likely to have a self-image of the bad-me and/or not-me. Not-me aspects are habitually denied and blocked out in order to avoid anxiety. This is the root of many mental illnesses. This also causes many individuals to use selective inattention. That is, one picks and chooses what she or he wants to perceive in their environment in order to avoid anxiety and maintain emotional stability. According to Lipsitz (2009) the not-me identity leads to dissociative feelings, personality dysfunction, sublimation and obsessiveness.
A healthy human being who is brought up by caretakers who satisfied his or her needs until that individual is able to do so on their own characteristically develops a knowledge of the good-me and the ad-me. This allows a mentally stable person to understand both sides of themselves and thus conduct themselves accordingly in interpersonal interactions (Regan, 1990). Based on the aforesaid findings, found on page eight, about individuals with BN one can assume that a person suffering from this type of ED have immature self systems as well as a developed personification of the bad-me and not-me identity.
Someone with BN will have an immature self system due to not having a caregiver to role model or teach them right from wrong. People learn from experience and if parents o not punish and reward their children appropriately, or over punish and/or reward, the child will grow up without the basic knowledge of acceptable behaviors. Hiding the act of binging and purging as well as the reason behind doing so displays an immature self system. The bad-me identity develops from the person with BN not a form of self-harm and cause dissociated attempts to self-regulate everyday functioning (Farber, 2008).
The not-me identity causes one to dissociate from certain aspects in their environment and that is what BN causes one to do. The focus is on ood and losing weight, everything else comes second and during the act of binging one can become dissociated from everything else, at times even the act of eating itself; a person loses control and may not realize how much they are eating. That person is eating Just to eat. The same goes for purging for after a binge the main focus is getting rid of the food. The individual may not notice anything else going on around them until the stress of purging the food is gone.
Other characteristics that cause an individual with BN to develop a not-me identity is the disconnection and distance he or she may feel from other people. According to Budd (2007) that aforesaid is a classic indicator for BN. As is the lack to create close connections and the need to be socially acceptable. Women in the United States are made to feel as if they need to be thin due to the media and the pressure to maintain a certain physical appearance; there is a great deal of positive reinforcement for losing weight. It does not matter what race or ethnicity you are, as was mentioned before.
The sociocultural expectations cause many women to become overwhelmed by food causing obsessions and doubt about eating (Budd, 2007). Attachment Theory The theory of attachment stems from Bowlbys hypothesis that in order for a child to develop a healthy impression of themselves the caregiver must be attentive to the child’s needs and wants. If the parents do not treat the child well and fail to recognize the child in the appropriate manner than the child will not be able to develop a secure personality as they grow into adulthood.
In turn this causes an older individual to lack the ability to securely attach to another person simply for they do not know what a real connection to another human being looks and feels like (Bowlby, 2005). Poor parenting takes a toll on a person’s social functioning. Infants pursue an attachment figure (usually a caregiver or parent take on the role of attachment fgure) for support, comfort, or protection by using behaviors such as crying, smiling, clinging, following and even by using their arms and hands to signal to their attachment fgure the need for attention.
This is called proximity seeking behaviors. If the parents respond to these behaviors than the infant gains a sense of felt security and is able to move beyond their attachment figures and explore their surrounding environment. Infants are able to do explore and eventually detach due to their internal knowledge that they have a secure base to return to if need be. As a securely attached infant grows up he or she begins to form new attachments with friends, lovers, other adults and so on. Without the secure base an infant may become too afraid to explore and form new bonds (Bennet and Nelson, 2010).
Proper development, according to Cozolino (2010) requires the parents to allow the child to be dependent on them for a prolonged period of time. During this time the parents must provide nurturance, attentiveness and support while teaching them the ifference between right and wrong and ultimately becoming the model for appropriate social relations outside of the household. The most crucial time, according to Bowlby for creating attachment is during the four phases of attachment development; undiscriminating social responsiveness (O to 3 months), preferential months) and goal corrected partnership (24 to 30 months and up).
Bowlby accentuated the importance of the early phases, as he theorized that they accounted for the onset and organization of attachment behavior (Waters and Cummings, 2000). Mary Ainsworth is another key player in the development of attachment theory. She studied infants in order to determine their attachment style in an experiment called the Strange Situation. An infant will be playing in a room with his or her mother with another person. The type of attachment the child displayed depends on how the infant reacted to the mothers leaving and returning.
Ainsworth differentiated secure from insecure attachment through these reactions and further more found two different types of insecure attachment; avoidant and ambivalent/ resistant (Shilkret and Shilkret, 2008). Avoidant attachment is when one prefers distance in relationships, while resistant attachment is the opposite. It is the need to ave others very close in relationships (Eggert, Levendosky and Klump, 2007) Later another style of attachment was recognized by Mary Main; disorganized attachment, which is when one has no reliable pattern of response and seems to show a sense of disorientation.
Bowlby and Ainsworth proposed that the earliest attachment style formed and internal working model for a developing individual. This internal model determine interpersonal expectations and behaviors in social situations (Shilkret and Shilkret, 2008). According to Lipsitz (2009) Bowlbys theory stated that early disturbances in attachment are the cause of emotional complications. He went on to define that all anxiety derived from anxiety about separation. If a person does not have a healthy attachment style then that person may experience a great deal more anxiety which also can affect how individuals approach and negotiate relationships.
Attachment styles determine how one thinks and behaves and the internal working model is determined by the success or failure of early attachment experiences; these help regulate the quality of later adult relationships. According to Bennet and Nelson (2010) adults internalize their experiences of interpersonal relations; that is the working model. It is called so due to its ability to change in accordance to new experiences and attachments. It is possible for an insecure attachment to become secure at a later time in life and vice versa, however it is best if an adult has grown up with security.
It is crucial to pay attention to the differences between family dynamics in different ethnicities and cultures. Although there is no obvious difference in what type of person may develop BN (Grabe and Hyde, 2006) there is a difference in how families interact. It is important to have an understanding of differences in acceptable behaviors in other cultures. What may be typical of an all American family may be completely different than someone who originates from a different socio- economic or ethnical/cultural background.
In understanding these differences one can be more open to understanding attachment styles across multiple cultures (Shilkret and Shilkret, 2008). Insecure attachment has been associated with low self- esteem, lower academic success, and psychopathology, including BN. Research shows that individuals with an eating disorders are more likely to be insecurely styles it was found that 96% of adults with an eating disorder show insecure attachment. Similar results have been found examining individuals who displayed partial criteria for a disordered eating diagnosis (Eggert, Levendosky and Klump, 2007).
Trosi, Massaroni and Cuzzolaro (2005) found that women with eating disorders responded to separation from loved ones in an extreme way due to high levels of separation anxiety during childhood. These findings lead to the hypothesis that due to childhood experiences a person with an insecure attachment may develop some sort of eating disorder. Further finding indicate that individuals who have AN or BN generally come from overprotective and/or rejecting unsupportive families. Trosi,
Massaroni and Cuzzolaro (2005) state the following: From the perspective of attachment theory, eating disorders are conceptualized as externalizing behaviors enacted to allow the diversion of attention away from attachment-related concerns, and toward the more external and more attainable goal of body change. Based on this model, persons with eating disorders are expected to have a high frequency of adverse early experiences with their attachment fgures, and a high prevalence of insecure attachment. Both these predictions have been repeatedly confirmed by studies of clinical and non-clinical populations.
The insecure attachment style has een also considered as a risk factor for the development of an eating disorder (p. 89). Farber (2007) further back up the claim that a person who has had adverse experiences as a child is much more likely to behave in behaviors such as BN. Farbor (2007) claims that eating disorders are a form of self-harm, used by people with low self-esteem who are seeking attention and approval. According to Farbor (2007) people become attached to pain and suffering due to living with some sort of pain all their life.
He states that even the smallest trauma in childhood, such as having a mother who was physically there but not emotionally, an cause one to become attached to pain. Someone with BN who is suffering who has an insecure attachment can be helped. The attachment to self-harming behaviors of binging and purging can be relinquished if a new safe and secure attachment is developed with someone. Changing someone’s attachment style from insecure to secure can actually rewire the brain and help the individual let go of their need for self-harm. The Brain Individuals with insecure attachment styles that do not have the ability to engage appropriately in an interpersonal relation tend to have had maladaptive developmental experiences. Thus their social brain functioning does not function like it would in a “normal” person. Brain serotonin is lower in individuals with BN. This abnormality is a contributing factor to depressive mood, low impulse control and obsessive behaviors and thoughts (Kaye and Weltzin, 1991). Seratonin is distributed throughout the whole brain from the raphe nucleus.
It plays an integral role in the mediation of mood and emotion, which is important to the social brain. Without serotonin one might become isolative and thus not able to form attachments or interpersonal connections (Cozolino, 2010). The main areas of the social brain are the orbital and medial prefrontal cortex (ompc) which allows one to understand the meaning of non-verbal communication. The cingulate cortex is what allows us to communicate. It is also responsible for social cooperation and empathy.
Someone who has developed BN due to lack of attachment or interpersonal problems may have an underdeveloped cingulate cortex, as may their caretakers from childhood. The anterior cingulate is also a crucial part of the social brain. It contains spindle neurons that connect and regulate the development of self-control and the ability to carefully work out difficult issues. These emerge after birth and experience-dependent. Based on all of the above theoretical information and information about BN it can be deduced that these spindle cells may be disorganized and under developed.
This happens when one is neglected at an early age which causes stress, which also affects the cells as does traumatic experiences (Cozolino, 2010). The somatosensory cortex process information about bodily experiences. BN, or any ED, is all about bodily experiences. For some there is the attachment to pain and for all who have BN there is the feeling of losing control nd then the satisfaction of control once the binged food is purged. The amygdala also plays a role in bodily experiences. It controls emotional and bodily pain.
The ompfc and amygdala are both shaped by experience and allow one to learn what is safe and what is not. It is also assumed that a person’s attachment schema is developed in this part of the brain. This would make a lot of sense since one learns how to connect to others and what is appropriate or not, as well as how to attach to another person from experience. Having bad childhood experiences predispositions a child to develop a mental illness (Cozolino, 2010). Decreased levels of plasma cholecystokinin, serotonergic and levels of activity and satiety in the brain are found in bulimics after a meal.
This is most likely due to the modulation by different organs sending varied neurochemical and neuroendocrine signals about appetite, energy and body weight. The hypothalamus is important to the process of interaction between nutrients, amines, neuropeptides and hormones. This system is what moderates metabolism and normal eating patterns. Modifying the neurochemical- neuroendocrine systems is linked with eating disorders such as BN (Leibowitz, 1992). Conclusion There is a lot more research that needs to be done on the effect BN has on the brain and on BN in general.
Research on duration of the illness and brain functioning as well as how the brain reacts to the toll BN takes on the body. It would also be important to better understand the connection between interpersonal difficulties, attachments styles and trauma on the brain and how that may result in a person developing an eating disorder. It also important to gather a better understanding of what causes individuals who have no history of trauma, interpersonal or developmental problems to develop an eating disorder. That is an area of EDS that has scarcely been looked at, let alone researched.
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