The interaction of hunger and food intake involves structures at various somatic levels: energetic, humoral, nervous. Movement, muscle work, heat transfer from the body and any form of activity are carried out under the condition of energy balance and thereby thanks to food intake. The state and activation of energy depots such as glycogen reserves and adipose tissue are also influenced by adrenaline, acetylcholine and, finally, blood sugar levels. This in turn is regulated at the level of the central nervous system through the hypothalamic centers and their connections with the olfactory brain and cerebral cortex. The influences of the situation and the personality itself also take part in this somatic regulation.
Comparative studies of animal behavior show that eating requires a special environment: absence of danger, convenience, good relations with the “company of eaters,” a harmonious environment. Pets also need safety when eating. For example, dogs are very sensitive to the situation: in the presence of a stranger or when an attempt is made to take away even a piece of food from them, their mood for food can easily turn into aggression.
The act of eating - sucking, biting, chewing, swallowing, etc. is a set of processes with high affective intensity. Since childhood, they are associated with a joyful feeling of satisfaction and saturation. Many other affects can be expressed in eating behavior and deviations in the act of eating, up to refusal of it: love, protest, rage.
For a person, from the moment he first touches his mother’s breast, eating is an act of uniting the child and the mother, the child and the family, the child and the environment. In the future, eating is facilitated by the presence of company at the table, an atmosphere of frankness and sincerity. Eating together brings people together. If in the East people eat together, then they will not be enemies in the future. Friendship and love are cemented by eating together.
The presence of companions improves appetite, and even children who are indifferent to food become good eaters when they come to the group; incentives and rewards also improve their appetite. A study of animal behavior showed the same patterns. A well-fed chicken begins to peck again if it is locked together with hungry chickens.
However, food intake occurs not only at the elementary level of psychosomatic needs and emotions. Appetite is more than just hunger; human food culture is highly developed, but it is easily destroyed. Sitting at the table has made this culture more sophisticated and humane. Forming habits and creating personal values also matter when eating. In different cultures we see a choice of certain directions of tastes, which vary in accordance with one or another acquired experience.
When a person is freed from the dominance of elementary physical needs, and thanks to the food intake necessary to sustain life, the feeling of hunger has turned into appetite, it becomes possible to use this to express cultural and religious characteristics, as well as for personal self-expression. But refusing food can also become a manifestation of asceticism and overcoming oneself. Eating can be suppressed as a base, animal instinct, just as through the culture of feasting it becomes refined and human. But there is also a pronounced feeling of shame associated with eating, which reaches the level of shame in the sexual sphere. Since childhood, food intake has been burdened with special significance; it can be used to express interpersonal and internal conflicts.
Eating disorders such as anorexia, bulimia and obesity deserve special attention due to their prevalence and significance in psychosomatics. Since many questions regarding these types of eating behaviors remain open, they should be carefully distinguished from purely somatic or endocrine diseases. Given the often absent awareness of the disease and the still vain search for primary somatic causes, one can doubt that we are talking at all about disorders that are usually regarded as a disease. Historically, body weight has been valued differently in different cultures. However, the supra-individual typical mental and somatic data available in eating disorders and the possibility of developing health-threatening consequences make it inevitable to classify these characteristic changes in eating behavior and the corresponding body structure as painful. There is no doubt that in the presence of internal mental and situational conflicts, the diagnosis and treatment of these disorders are within the competence of psychosomatic psychotherapists.
The term “anorexia” defines a painful condition that occurs during puberty (almost exclusively in girls), associated with the desire to lose weight, become elegant and remain that way. In the chronic course, there is a local fear, which can be called phobic, of normal food, weight gain and achieving the average levels necessary to maintain health. Primary somatic or hormonal disorders are usually not detected. This disorder is based on an adolescent developmental conflict without awareness of the latter and a realistic attitude towards one’s own somatic state.
Symptoms. The following symptoms are characteristic of this disorder.
A. With so-called fasting anorexia, the focus is on limiting the quantity and calorie content of food. All high-calorie foods, primarily fats and sweets, are rejected. Vegetables, lemons, unripe apples, etc. are preferred. Eating with family is usually rejected; women eat little by little alone and outside of school hours. Increasingly bizarre eating habits arise, and those around us usually overlook or underestimate the consequences of this avoidance of food. Even if the girls seem to be eating at the table, they manage to put their food away somewhere under any pretext.
A 23-year-old patient was admitted to the clinic due to excessive thinness (35 kg). She emphasized that she acted of her own free will and only on the condition that she would regulate her food intake herself. She was on bed rest and, although staff made sure she ate every meal, after 10 days she had lost another 2kg. When she was taken from the room for examination to the doctor and her nightstand was checked, they found the entire lunch there, wrapped in a package. Undoubtedly, she threw all her food into the toilet at night.
B. Some patients achieve low body weight and maintain it through vomiting. This is always done secretly, most often immediately after eating. Women, under a plausible pretext, go to the toilet and empty their stomachs with amazing ease.
B. The next way to reduce body weight is to take laxatives, which is motivated by an unbearable feeling of fullness in the stomach and often actual constipation. Many women come to the hospital with a large number of laxatives that they hide. As potassium levels decrease due to loss of fluids and salts, this can cause further harm to health. Patients report a feeling of relief when, after taking laxatives, the perceived as alien feeling of fullness in the stomach is eliminated. They talk about achieving cleanliness, neatness and good physical well-being in this way.
It remains unclear to outside observers how people with anorexia lose their rational attitude towards food, body weight and their appearance. Even extreme weight loss is considered beneficial by patients. Many people say that they find the feeling of fullness and even a full stomach unbearable. They want to quickly achieve thinness and grace, which, in their opinion, makes their appearance more attractive and leads them to an “etheric” and “spiritual” existence in higher “higher” spheres of life. They always feel like they are still taking in too much food and are still at risk of overeating.
A 20-year-old anorexic patient with a height of 175 cm had a body weight of 38 kg. During her lunch break, she quickly went to the nearby swimming pool. In a swimsuit, she was truly “skin and bones”, swam throughout the entire session, not paying attention to other swimmers, and then returned to her workplace.
For patients with anorexia, a complete lack of awareness of mental and physical illness is very typical; they don't complain about any conflicts. The physical and mental state is synchronous with one’s own “I”; in the center of consciousness are refusal to eat, achieving grace, losing weight and maintaining this thinness. Restriction in food and its results in the form of graceful figure and weight loss are perceived with satisfaction, as a triumph.
If a breakthrough occurs in an increasingly suppressed feeling of hunger with a secret nightly meal from the nightstand or refrigerator, then this is experienced as a defeat, which, if possible, is kept secret and overcome by vomiting or taking laxatives.
In European history, people seeking to lose weight have been known for a long time, but it was not considered a disease. Characteristic descriptions of starving women date back to the early Middle Ages; The fasting of these women was given religious significance and they were seen as living in holiness. Even in our time, only severe cases of the disease lead to observation and treatment by specialists and in specialized clinics. Therefore, there is a large discrepancy between morbidity rates (primarily mild forms) and morbidity, which is determined by the number of cases of treatment.
A study using a questionnaire among schoolgirls and students aged 15 to 25 years found that the incidence of anorexic episodes was between 2 and 4% per 100,000 women, and other estimates put it higher. It should be noted that high rates of morbidity, especially in the last two decades, can be regarded as signs of an increase in the incidence of the disease. Those who get sick first of all are representatives of the wealthy population (in terms of education and standard of living).
Pubertal anorexia is more common in economically developed countries.
Cases of anorexia among young men are rare, but very common. The diagnosis is made on the basis of characteristic eating behavior, the presence of the ideal of “grace,” motor hyperactivity and bizarre, but synchronous with one’s “I” behavior.
A 17-year-old boy was hospitalized in a therapeutic clinic due to the fact that in 6 months, with a height of 168 cm, his body weight decreased to 31 kg. The patient complained of a feeling of pressure in the stomach and lightheadedness, worsening after eating. After excluding organic diseases, the patient showed external readiness to carry out the course of weight restoration that was offered to him. But in 3 weeks he lost another 1.5 kg. Upon inspection of his bedside table, all the food he had been given over the past week was found in plastic bags. He hid all the food there secretly from other patients. In a detailed conversation with the doctor, the patient reported his desire to be slim. His ideal is a gymnast with a completely flat figure. In recent weeks, in order to remain graceful, he secretly ran through the forest and climbed mountains every day. He categorically rejected contacts with women. The patient reported that his model was his father, who suffered from peptic ulcers and was very prone to asceticism. When the patient was prescribed strict bed rest and his clothes were taken away, he chose to escape from the hospital. He walked in hospital pajamas along busy streets, bought a coat and boots at a store and drove 30 km to his parents, refusing to return to the hospital. When examined 4 years later, he reported that he was interning in the police. He is still slim and looks athletic. He did not receive any treatment after being discharged from the hospital. He doesn't have a girlfriend, but he is completely immersed in his police work. In his spare time, he is engaged in rescue work in extreme situations. So, recently, by jumping into cold water, he saved people from a boat that was threatening to sink in the Kama.
There are usually no sudden changes in fate or trauma for the disease to occur. Rather, we are talking about new tasks that arise during physical maturation and psychosocial development. There are so-called threshold situations that young women expect in order to break off their childhood relationship with their parents and leave their father’s house, enter into new relationships with people of their age and get used to their new role as a woman, i.e. face sexual problems. What is easy and self-evident for other women in their quest for independence seems unattainable for them.
Situationally, the occurrence of anorexia seems to be associated with the physical maturation of a woman and the perception of the female role in puberty, which are experienced as alien and excessive and manifest themselves primarily emotionally, and not in the form of normal sexual ‘attraction to a partner. A permissive situation is described as a situation in which sexual intimacy is, as it were, imposed on a young woman from the outside or she herself determines its necessity, often under the pressure of the surrounding world. Women suffering from anorexia are often plump before the onset of the disease, have normal body weight from birth, and often develop normal “pubertal fat.” They usually start menstruating 14 months earlier than the average for this age group and their sisters. Earlier sexual maturation, as evidenced by age at menarche, has been complemented in recent decades by an earlier average age at sexual debut, leading young women to expect early sexual intercourse.
That is why, in terms of their personal structure and internal maturation, women with anorexia are not ready for their maturity. More than other girls, they experience physical maturation, primarily menstruation and the growth of mammary glands, as their preparation for playing the female role, considering it, however, alien and excessive for themselves. This often leads to ambivalence regarding their puberty in women (less often in men), manifested in the desire to lead an ascetic lifestyle, characteristic of the puberty period, with young people internally and externally distancing themselves from gender roles and from endogenously arising needs and intensively looking for other activities .
Experience shows that it is least of all one’s own sexual fantasies or specific desires that would lead to conflict situations. Data on sexual dreams and early or intense masturbatory activity among anorexics are sparse. The anorexic reaction and chronic development lead a woman to an image of gender neutrality that is not interesting to anyone. Sexual problems take a back seat to the idea of losing weight.
The pathogenic influence lies in these seemingly everyday and banal situations, which cause emotional and empathic restrictions and thereby the increased vulnerability characteristic of puberty. This means that it is in the original personality that one should look for the decisive significance of the causal factor in the form of a corresponding predisposition.
Hereditary factors have to be considered due to the increasing incidence of anorexia and personality traits in some families. When observing twins with anorexia, impressive results were obtained. 13 pairs of twins with anorexia nervosa were described (6 own observations and 7 observations of other authors. This indicates the participation of a hereditary component in the appearance of anorexia nervosa.
Personal predisposition manifests itself in anorexia by special differentiation in the intellectual sphere and vulnerability in the emotional sphere. The increase in intellectual quotient, which reaches 128, is obvious, as noted by all researchers. Sensitivity and insufficient contact in the anamnesis are also noteworthy, although the girls do not attract attention to themselves in any way. In the language of the theory of neuroses, women with anorexia more often exhibit schizoid personality traits: in 28% of cases in women with anorexia nervosa and in 9% of cases in other patients who turned to a psychotherapist. In many cases, autistic attitudes and social isolation are detected even before the onset of the disease. It is necessary to take into account psychosomatic connections in the sense that the factors of the original personality in adolescence, under the influence of somatic maturation and psychosocial development, enter into a crisis, which causes a painful process with a tendency to become chronic, and sometimes even leads to death. It may also be fair to assume that there are specific families of people with anorexia. Such families are described as being particularly closely knit.
The course of this disease is difficult to predict; it often leads to the death of patients, but in this age group one can detect a number of variants of normal mental processing. As already mentioned, pubertal asceticism is a normal phenomenon, even if it is pronounced. This is explained by the transfer of one’s own impulses to other persons, which is characteristic of adolescents (A. Freud). In this case, a repression or shift of the sexual conflict situation into the oral sphere and regression to early presexual levels are detected.
If family doctors describe the family environment in patients with anorexia as very closely related, with the child’s strong desire for independence and with the achievement of individuation as a goal, i.e. willingness to exercise and defend one's desires and rights, combined with a sense of responsibility towards other people, i.e. remaining within the family, this reflects the normal theme of the puberty group and characterizes the problems of adolescence as a whole.
The patient, 21 years old, a student, was brought to the clinic by her mother on the referral of the therapist who treated her. She lost weight over the course of two years (from 55 to 38 kg); now, with a height of 168 cm, her body weight is 42 kg. Due to a tendency to constipation, the patient takes laxatives.
Left alone with the doctor, the patient reported that she had problems with nutrition. It is difficult for her to eat because she is afraid of possible vomiting. After eating, she induces vomiting on her own; The patient did not want to say how often this happens, but recently the vomiting has become more intense. According to the patient, this disorder developed on the eve of her adulthood. The freedom that allowed her to do whatever she wanted was unexpected for her. During a ski trip in winter, she met a man who later visited her only once. She now fell in love again with a 28-year-old bank employee, who then had a conflict with her father and was probably trying to turn her against her father. It became easier for her when in 2014 she moved to her aunt in another city and helped her with the housework there. She recovered (up to 48 kg), and her menstruation returned. Now she is studying at university and lives far from her parents.
Her family is dominated by her father, who comes from a family of employees and holds a high position in the company. He is very strict, works a lot, is extremely punctual and clean, conservative, and does not know how to give in. He expected active activity from his daughter. All members of my father’s family are inflexible and unemotional people. The mother, with whom the patient has a good relationship, comes from a large family from a small town, worked as a teacher of the Tatar language, but in the family she showed herself to be a dependent, weak person. The patient herself had few friends, was always calm, willingly played with animals, and was a successful student at school. She always wanted to do something practical. She started menstruating at age 12. During the conversation, the patient gives the impression of being depressed, but communicative and open, insecure and anxious. The illness began in the normal situation of leaving the parental home, with which she was closely connected, although this connection was ambivalent. Her fears are focused on the need to live independently, to find herself as a woman.
For some patients with anorexia, the situation causing the disease seems banal and ordinary, as does the further development of the condition during treatment and in later life.
The patient is 17 years old, a good student, a lively, intelligent girl, with a height of 162 cm, after two years of food restriction and taking laxatives due to severe constipation, but without vomiting, she lost weight from 42 to 32.5 kg. Over these two years, menstruation became shorter and more scanty, and then stopped completely. The patient’s father, a 37-year-old employee of Russian Railways, goes in for sports himself and involves his children in this. The mother is not independent, sacrifices everything for the sake of the children, without identifying her needs. The patient is the second of five children, born a year after her sister and a year before her brother. Her attitude towards her younger sisters is curious: she finds that her 11-year-old sister is a loser, and her 10-year-old sister eats too much and is too fat. The patient torments everyone in the family with this topic, scolds her sister at the table, eats nothing herself, and complains of a feeling of fullness in her stomach after only a small meal. She had few contacts outside the family and had no conflicts. During a 3-month inpatient treatment with careful monitoring of food intake, and then during outpatient treatment (individual therapy, gestalt therapy, kinesitherapy, intensive and then supportive individual therapy), her conflict was revealed: in her younger sister she found and defended herself . She was disappointed in her father and was jealous of his younger sister, whom her father preferred. In her suffering, she completely identified herself with her mother. (Family conflict issues were discussed twice in conversations with parents, but only the mother accepted this; she subsequently attended counseling sessions, and her position in the family was somewhat strengthened.) After treatment, the patient recovered to 52-54 kg, menstruation was restored after a year and became regular. Constipation and constant detachment in relation to friends and the doctor persisted for the longest time. In her dreams and drawings there was a pronounced tendency towards the formation of an Oedipus complex due to disappointment in her father. In the end, disappointment and even anger were processed by her. But she became less active at school, marked things down in her notebook, and began spending more money on herself. Relationships with her peers were more important to her than relationships with her doctor, and after 2 years she interrupted treatment. Talking a year later about what helped her the most, she said: “It was very important for me when new patients were admitted to the hospital and I, as the more experienced one, could help them. It strengthened my self-awareness. Of course, without treatment this would not be possible. But hospital treatment was only one type of practice for me. After it, I tried at home everything that they taught me in the hospital. I would not have achieved this with outpatient treatment alone.”
Flow.
Pubertal anorexia with pronounced symptoms is a serious progressive disease. Mortality (depending on the selection of patients and the quality of follow-up) ranges from 8 to 12%. Death occurs due to cachexia, hypokalemia, circulatory failure, pneumonia, infections, or due to refusal of food for suicidal purposes. If left untreated, in approximately 40% of cases the disease enters the chronic phase. But the majority of patients with an improvement in their condition remain still preoccupied with the topics of food and body weight. Many of them exhibit bizarre, fanatical and autistic personality traits, and some live in ascetic communities. They marry less often than women with other eating disorders, such as bulimia and obesity, and significantly less often than healthy women.
In some cases, almost normal family relationships can be established. As for individual variants of the disease, the prognosis is more favorable in those patients who become ill between the ages of 10 and 15 years, and less favorable in patients from an older age group; In patients with bulimic components, the prognosis is also more favorable than in patients with purely ascetic forms. Women with hysterical and depressive personality traits have a relatively better prognosis than patients with an expression of schizoid personality structure. During the treatment process, readiness to establish a psychotherapeutic relationship and the ability to analyze past and possible upcoming conflicts are among favorable prognostic criteria. An early age of onset of the disease, bulimic elements and awareness of conflicts, generally assessed as prognostically favorable criteria, are not always decisive, as the course of the disease in the next patient shows.
A 23-year-old female patient, a medical student, reported herself to the helpline (“Talk about losing weight”). On examination, she was described as “a small, dark-haired, generally pleasant woman in a loose pullover, animated, with dark eyes and a large head of hair. The patient smiles in a friendly manner, tries to give the impression of being open and friendly, but is somewhat depressed. Behind her openness there was a deep concern and loneliness. Only when she left did I notice her fragility and her very thin figure hidden under her wide clothes.”
The disease began at the age of 11 years, when the patient was in sixth grade at school. Then for the first time she lost weight to 37 kg (she simply did not eat anything). “Maybe I wanted to be noticed, but what else could I come up with?” At this time, her only friend left with her parents from their small town. The difficult years of loneliness came. Even in kindergarten and elementary school, the girl pretended to have stomach pains in order to attract attention. She became more and more timid and withdrawn. When she turned 12, her parents were very worried because they discovered some kind of “gang” at school in which their daughter willingly spent time. But when she went to university, she was faced with the troubling problem of meeting people. She gradually lost weight (up to 37 kg), sometimes vomiting spontaneously. When the patient was dissatisfied with something, she might vomit repeatedly during the day, and then she would eat everything again. Currently she has a friend, who, however, has many acquaintances. Therefore, the patient feels that she is only a burden to her friend. Friendly relationships with men are problematic for her. She cannot come to terms with her role as a woman, finds flirting and coquetry ridiculous, but at the same time passionately desires to have a male friend.
About the family situation, the patient reported that her father, a school director, is completely absorbed in work, her mother is a teacher and also a deputy. Little by little she got used to the fact that her parents were always busy. The father easily falls into aggression and rage, but can also be friendly; he never noticed that his daughter was ill. Her parents were never strict, but she experienced it as neglect. The mother was warm-hearted and loving, but she had too little time for her daughter. Her two sisters, one and two years younger than her, have no complexes. The younger sister already had two male friends, goes to discos, the middle sister has had a boyfriend for two years, but she still has close ties with her father. Both sisters attended school and are now studying economics. The patient was always at the top of her class, worked hard, and was ambitious without overexerting herself. She had excellent achievements in various sports and was involved in professional sports.
Now she is busy with herself and cooking, she has bulimia attacks, frequent headaches, insomnia, sometimes she lies awake until 5 o’clock in the morning. She can no longer concentrate on her studies and does not maintain contact with students in the dormitory.
Individual depth psychotherapy was conducted. She was recommended to keep a diary in which she should note all her experiences, describe attacks of bulimia, etc. So, one day she was forced to eat and vomit when she was waiting for a friend, but she did not come. It was obvious that she was experiencing her complete isolation. She talked about her dream in which she soared on wings over Kazan, having a plan in front of her, and all the time she looked at the plan, and not at the city. After awakening, she felt annoyed that she lived according to the plan and did not see anything outside it, and she does not want to be controlled by circumstances. She also had the feeling that she was fooling others. She could hardly force herself to study, and went home on weekends and holidays; when her parents were not at home, she played the guitar alone and was disappointed when her parents were at home, since she could not have anything in common with them.
Finally, after 3 months of unsuccessful outpatient treatment, the patient agreed to be admitted to the hospital. There she received individual psychotherapy and, in addition, group psychotherapy and symboldrama; she lived in a therapeutic community. Body weight was not a significant problem for her. At the first visit, her body weight was about 43 kg and 3 months later, after a vegetarian diet, which she chose for herself, it remained the same. During the ongoing individual therapeutic treatment, deep trusting relationships with the psychotherapist were not established. Further treatment was carried out by a female therapist whom the patient knew from group therapy. In the group she showed herself to be friendly and open, but she did not have a sense of belonging to the group as part of it. And she did not have a close connection with her new psychotherapist, her body weight remained the same (43-44 kg), menstruation was irregular. A year later she left the university and returned home.
Three years later, in response to a written request, the patient’s mother reported that she died 2 months ago in a university clinic. After leaving Kazan, she looked for other methods of treatment from internists, logotherapists, and psychoanalysts, but quickly gave up everything. (Before treatment in 2015 in Kazan, she was treated for a year in different clinics, receiving behaviorally oriented and even religious treatment.) Then she decided to go to the south of the country, hoping to recover in a warm climate. There she developed a friendly relationship with a student studying anthroposophy, whom she greatly valued. But her somatic condition became worse, her body weight decreased to 26 kg, and the patient returned to Kazan, lived with her anthroposophical friend, and again attended lectures. Due to her increasingly deteriorating physical condition, she decided to go to a local clinic herself to “feed herself.” There she received a course of artificial feeding, visits were limited. A week later, she had to be transferred to an intensive care hospital, where she was diagnosed with severe metabolic disorders, “shock lungs,” and renal failure; she had to perform artificial respiration. Then there was an improvement for several weeks, after which pneumonia developed, from which the patient died. The mother wrote: “Of course, this was the only way out for her. She was so sensitive and learned and experienced so much through suffering. This is a difficult loss for us. She left behind many diaries in which she described in detail the cruel properties of this common disease and her desperate attempts to get rid of it: “From the point of view of reason, I understand my illness and can overcome it, but from the point of view of feelings, I am powerless.”
Of course, the patient, neither in the clinic, nor in everyday life, and even in communication with her parents, could not experience “from the standpoint of feelings” what she was looking for in life and what led her to the desire to lose weight. Perhaps the answer should be sought in her family situation: the rapid successive birth of two younger sisters, the constant employment of parents who did not pay enough attention to her. However, neither the father nor the mother, in the eyes of the researcher, seems cold and indifferent to their daughter. They were unable to provide a satisfactory explanation for why the patient developed differently from her younger sisters. The patient could not blame her parents, girlfriends and friends, or the psychotherapist for the lack of showing feelings of affection towards her.
In this regard, the natural question is whether we are talking about the initial inability to empathy as the main violation of the patient’s personality, which led to the development of the disease. “Inability to maintain relationships with partners and parents,” as well as “substantially impaired self-confidence in comparison with other people,” are cited as prognostically important factors at the time of the fullest development of the disease and thereafter. Many psychotherapists consider the criterion for discharging patients not to be an increase in body weight, but for the patient to become confident that he has one or two people who will help him later and with whom he can maintain contact. This condition is also the main target of subsequent outpatient therapy. The limited possibilities of such psychotherapeutic efforts are, unfortunately, visible in the example of the patient described above.
Patients usually make energetic attempts to attract the attention of the psychotherapist and staff with their childish helplessness and at the same time refinement and prudence. But all attempts to achieve real influence on them, to penetrate their personality, to establish a community are initially rejected by them. They consider treatment, especially inpatient treatment, which reveals their tricks in connection with the food ritual, as something completely unnecessary, since they do not consider themselves sick. If admission to the hospital is inevitable, they strive to determine the course of treatment themselves, achieve certain privileges, and, first of all, try to delay the moment of artificial feeding using a gastric tube. For medical staff, every new patient with anorexia is a new hope of having a patient in the department with whom there will be few problems, but this hope is invariably not justified.
Usually, after weeks or months, it becomes obvious that the body weight curve, despite the fact that the patient seems to be taking a lot of food, remains at the same level or even goes down, and then the patient’s tricks of refusing food, secret vomiting, and abuse of laxatives are revealed means, maneuvers involving deception during weighing, and later theft from the kitchen or complaints from nearby grocery stores; everything that exhausts the patience of doctors and medical personnel. The task of doctors and medical personnel is to actively work with the intact sphere of the patient’s personality and at the same time assess severe psychopathological disorders of his behavior, without falling into a state of irritation. There is always a danger that the next measure will remain ineffective, and relatives will despair of achieving an increase in body weight “at all costs,” even if there is not yet or no longer a threat to life, which only obliges more active intervention. An angry and hostile attitude on the part of nurses and doctors leads the patient to isolation and autistic isolation, which in severe cases increases
Just like establishing a relationship with a patient, it is difficult to find a common language with his parents, who find it difficult to agree with the recognition of their son or daughter as sick. There is a danger for psychotherapists and nurses of becoming “scapegoats” for mothers and fathers, and in our time, for grandparents. When multiple therapists are involved in a family therapy conversation, it increases the chances of shared responsibility in the eyes of individual family members; It becomes easier to understand why everyone, based on their experience and conditions of development, becomes what they are.
Treatment. It is impossible to unconditionally compare the results of treatment with different methods, since they are influenced by different prognoses for mild or severe reactions or for a chronic course of the disease. Treatment outcomes are likely to determine disease duration and quality of outcome as determined by research studies. In this case, both somatic data and psychosocial state and psychosocial development should be taken into account. Once achieved by a certain method, the success of treatment may not be repeated.
Hopes of finding the key to the mysterious field of anorexia through therapy based on etiological theories (behavioral therapy, systemic or psychoanalytic method) have not been realized in recent decades. Yet experiments with various therapeutic techniques have led to the pragmatic consensus described below, at least with regard to severe conditions requiring hospital treatment.
The 21-year-old student described above was initially admitted to the hospital for a trial, since she came from afar and it was necessary to resolve the issue of upcoming treatment costs. With the freedom she needed and was given, she lost 3 kg in 2 weeks (to 38.1 kg). She then agreed to a nutrition program with the goal of achieving a body weight of 50 kg. She was on bed rest, receiving 2,500 calories for 4 meals, maintaining contact with a trusted nurse and psychotherapist, receiving psychotherapy for 2 hours a week, and then, as her body weight increased, individual psychotherapy for 3 hours. She spent all the time in bed , then began to get up, eat with other patients, and went to the psychotherapist’s office.
In the first weeks, she had crises of protest with self-destructive actions: she burned her face with cigarettes, registered her weight gain with fear, and in the end it was established that she drank 1.5 liters of water before weighing herself. Then she was prescribed nutrition through a gastric tube, strict bed rest was resumed, and smoking was allowed only in the presence of a nurse. Although the patient now protested, these measures were retained as a condition of discharge. Then there was a sharp increase in body weight to 48 kg within 4 weeks. After this, she was allowed to eat with other patients, leave the department, first with accompanying people, and then alone, and after 4 months she was transferred to a day hospital, and she began training classes. The patient was discharged when the goal of increasing body weight to 50 kg was achieved.
The themes of psychotherapeutic treatment were an ambivalent attitude towards her idealized and rejected father, her labile state of health, uncertainty when approaching other people, and elements of extreme lability and resentment in relationships with other people. After psychotherapy lasting 2.5 years, the patient’s condition stabilized. The extremely valuable significance of the topic of food in her ideas did not respond well to therapy and retained its relevance for a long time. The patient herself noted that this topic constantly breaks into her consciousness and she herself is forced to destroy everything that has been achieved. Nevertheless, the patient’s life improved.
Family therapy has the most pronounced effect. It should be noted that only half of the patients after family therapy did not resort to other types of psychotherapy (individual, group, in mutual help groups). The data that the authors of the family therapy technique report to other therapists who refuse this treatment are astonishing. Avoiding contact with family members, previously practiced by psychoanalysts, is now considered erroneous. For family therapy, important information is that which facilitates contact with the family, familiarization with its problems and allows you to attract the help of the family for the treatment of patients with anorexia.
A number of behavioral therapists have moved from the former single-method approach of operant conditioning to integrated intervention. It involves the use of behavioral and educational techniques in the first stage, and treatment aimed at psychosocial problems in the second stage. With this combined approach, after 1–2 years, good results are observed in 55% of patients, satisfactory results in 25%.
Thus, it can be argued that anorexia can rightfully be classified as a psychosomatic disease. Forms and approaches to psychotherapeutic treatment are strictly individual and do not lend themselves to template prescriptions.
Refusal to eat due to lack of appetite or under the influence of psychopathological disorders. Anorexia nervosa (anorexia nervosa) is a complete refusal to eat or a sharp restriction of food intake in order to lose weight or to prevent excess weight gain under the influence of overvalued or delusional ideas of the corresponding content. More common in girls. With anorexia, there is a pathological desire to lose weight, accompanied by a strong fear of obesity. The patient has a distorted perception of his physical shape and is worried about imaginary weight gain, even if this is not actually observed.
There are two types of behavior in anorexia nervosa: restrictive - the patient voluntarily limits food intake and does not eat to capacity; and purging - the patient overeats and then provokes vomiting or abuses laxatives, diuretics or enemas.
The causes of anorexia are divided into biological (genetic predisposition), psychological (family influence and internal conflicts), and social (environmental influence: expectations, imitation). Anorexia is considered to be a female disease that manifests itself in adolescence. About 90% of patients with anorexia are girls aged 12-24 years. The remaining 10% includes older women and men.
Signs of anorexia usually include: the patient’s denial of the problem, the patient’s constant feeling of being fat, eating disorders (eating while standing, breaking food into small pieces), sleep disturbances, isolation from society, as well as the patient’s panicky fear of gaining weight. Physical problems caused by anorexia include problems with the menstrual cycle, cardiac arrhythmia, constant weakness, and muscle spasms. As well as increased irritability, unreasonable anger, and feelings of resentment.
Anorexia occurs in several stages. The initial period is the formation of dissatisfaction with appearance, accompanied by noticeable weight loss. This is followed by an anorectic period - a decrease in body weight by 20-30%. At the same time, the patient actively convinces himself and others that he has no appetite and exhausts himself with great physical exertion. Due to a distorted perception of his body, the patient underestimates the degree of weight loss. The volume of fluid circulating in the body decreases, which causes hypotension and bradycardia. This condition is accompanied by chilliness, dry skin and alopecia. Another clinical sign is the cessation of the menstrual cycle in women and a decrease in libido and spermatogenesis in men. The function of the adrenal glands is also impaired, leading to adrenal insufficiency. The last period is cachectic - weight loss by 50% or more. In this case, protein-free edema occurs, the water-electrolyte balance is disturbed, and the level of potassium in the body sharply decreases. Electrolyte disturbances at this stage can lead to death. According to statistics, without treatment, the mortality rate of patients with anorexia nervosa is 5-10%.
Method of treatment- individual and family psychotherapy, in severe cases - hospitalization, drug therapy and force feeding.
Mental anorexia (anorexia psychica) - refusal to eat due to severe suppression of appetite in depressive and catatonic states or under the influence of delusional ideas of poisoning.
Anorexia (symptom) - The term "anorexia" is widely used to refer to decreased or loss of appetite. This symptom is very common: it occurs not only in mental illnesses, but also in many somatic diseases.
Eating disorders are becoming an epidemic, especially among young girls who want to emulate their celebrity idols. Anorexia nervosa is a serious complex disease, which, unfortunately, not everyone knows about.
There is no one to blame for anorexia. Anorexia does not mean that parents raised their child incorrectly. Cultural, genetic and personal factors interact closely with life events, which creates fertile ground for the emergence and development of psychological eating disorders.
There is nothing pleasant about anocresia. Many people who follow exhaustive diets recklessly declare that they dream of becoming anorexic. They see only the obvious manifestation of this disease - excessive thinness, but do not notice the full danger of this “fashionable” disease. People with anorexia are not at all proud of their ideal figure and do not feel incredibly beautiful; if you talk to such a person, you will learn a lot of new things about him - for example, that a girl whose weight is 55 kilograms and is one meter eighty tall considers herself fat, unattractive and unstylish. Patients with anorexia suffer from a never-ending feeling of their own imperfection, they are scared and driven into a corner by their fears.
You can’t just get rid of anorexia; it’s not a disease that reminds you of itself once a month. The consciousness of anorexics does not belong to them; they cannot control their feelings. Such people are literally obsessed with thoughts about weight, food, extra calories and body image. For many, the disease torments them even in their sleep—they are haunted by nightmares and obsessive dreams about food and nutrition. And in their sleep, poor sufferers continue to count calories and are horrified by the 100 grams gained. Anorexia is a terrible disease that snatches its victim from normal life and dooms him to loneliness. Anorexia is very difficult to cure. Sometimes it takes years to fight it.
Anorexia can be fatal. By the way, anorexia has the highest mortality rate among psychological diseases. If you or someone you know is experiencing symptoms of an eating disorder, act quickly and seek help from a doctor.
Specific symptoms of anorexia:
A patient with anorexia is primarily characterized by a reluctance to maintain a weight appropriate to his constitution, age and height. To be precise, a person's normal weight should be 85% or less of the weight that is considered standard for a person of his size, age and height.
As a rule, a victim of anorexia constantly feels an unrelenting fear of gaining weight and gaining weight, and this fear completely overshadows all other feelings and emotions. This fear does not take into account the real weight of a person, and does not let go of its victim even when she is on the verge of death from exhaustion. First of all, the causes of anorexia lie in low self-esteem, which is also one of the main symptoms of this serious disease. A patient with anorexia believes that his weight, body measurements and size are directly related to his sense of self and personal status. Victims of anorexia often deny the seriousness of their condition and cannot objectively assess their own weight.
Another symptom typical for women is menstrual irregularities and the absence of at least three menstrual periods in a row. Specifically, a woman is diagnosed with amenorrhea (absence of menstruation) if her period begins only after hormonal therapy (for example, estrogen administration).
There are two types of behavior in anorexia nervosa:
- Restrictive - the patient voluntarily limits food intake and does not eat to capacity, and then provokes vomiting.
- Purifying - the patient overeats and then induces vomiting or abuses laxatives, diuretics or enemas.
Unlike depression or panic attacks, anorexia nervosa is difficult to treat. There is no universal and effective cure for anorexia. First and foremost, doctors prescribe general medications that are used to treat any health problems, such as electrolysis abnormalities or heart rhythm problems.
Antidepressants: Many people with anorexia nervosa also suffer from depression, and some symptoms of these conditions can be treated with antidepressants. However, there is no data proving the effectiveness of antidepressants in the treatment of anorexia. Moreover, antidepressants can have various side effects that will only worsen the condition of patients. Studies have shown that treatment for anorexia is much more effective when patients reach a normal weight.
Tranquilizers: Short-term tranquilizers called benzodiazepines can help anorexics overcome their anxiety. These medications are addictive, so they should not be used to treat patients with drug or alcohol addiction.
Estrogen: women with anorexia are at increased risk of fissures; it is a result of osteoporosis. Lack of menstruation and low weight can trigger a condition close to early menopause. It is believed that taking estrogen may help some women replenish mineral deficiencies in their bones and prevent future cracks.
In cases where anorexia is accompanied by a serious illness, and also when the patient’s weight drops again and is less than 15% of normal weight, urgent hospitalization is necessary.
Anorexia is a mental illness in which there is a pathological desire to lose weight, accompanied by a strong fear of obesity.
Typically, patients suffering from anorexia achieve weight loss in two ways:
From Freud's point of view, during conversion a person does not become ill with something random, but in each specific symptom a symbolic representation of what his experiences were associated with. For example, he explained psychosomatic visual and hearing impairments by a reluctance to see and hear the environment.
By the way, I once observed a girl who suffered from terrible sore throats while she lived with her mother-in-law. Whether my colleague was right or wrong in asserting that this was her unconscious desire to yell at this very mother-in-law, but as soon as “mom” left for permanent residence in a neighboring state, not only the sore throats, but also the consequences of many years of taking antibiotics went away.
With the onset of a psychosomatic illness, a person, oddly enough, experiences relief.
This happens for three reasons:
Firstly, as mentioned above, unconscious conflict is facilitated.
Secondly, illness makes it possible to receive various bonuses from the role of a sick person (not going to hard work, bringing tea to bed, and in general everyone around you is sorry).
Thirdly, the sequence of further actions immediately becomes clear. The little eye can’t see - droplets are dripping, an ulcer with colitis appears - take almagels with diets, my heart is naughty - eat Validol.
The picture is ideal: the person seems to be in business - he is being treated, the internal conflict recedes into the background. But the disease is not going to go away at all. Taking medications and treatment gives a feeling of gaining control over one's own life, which was lost as a result of a traumatic situation.
Franz Alexander's theory (its traditional name is the “autonomic neurosis model”) is, in general, similar. The difference, perhaps, is that he places less emphasis on the symbolic meaning of individual symptoms, but rather appeals to other factors. For example, to genetic. Roughly speaking, Alexander professes the principle: “where it is thin, it breaks.” Some are characterized by a not very healthy cardiovascular system, while others have a problem area - the lungs. It is these organs that will suffer first, regardless of the content of the internal conflict. From Alexander’s point of view, illness does not even always weaken that same internal conflict, since it does not serve as an expression of emotions. For example, an increase in blood pressure in a state of rage does not weaken the rage, but is just a physiological symptom of this emotion. If a person is often in a state of rage, he may end up with chronic hypertension.
The debate about what is considered psychosomatic and what is not is not over yet. Some people are ready to consider everything psychosomatic except for labor fever and dropsy in the knee. Some people believe that psychosomatics is largely a myth, like the Placebo effect.
From the point of view of some authoritative experts from psychology and medicine, even such a terrible disease as cancer is psychosomatic. And, although there is a lot of evidence for this, neither official medicine, nor especially patients and their relatives are ready to accept this point of view - it is too terrible a diagnosis.
It is customary to treat psychosomatics as something frivolous. To something that a person can cope with himself, with one effort of will. Perhaps this is due to the fact that the term “psychosomatics” refers to ordinary simulation, which is fundamentally wrong.
Psychosomatic disease is a disease that is based on both physiological and psychological causes, but at the same time it is a disease with all the symptoms that requires medical intervention. Another thing is that the disease will not go away with traditional treatment alone, relapses will continue (in fact, relapse with adequate treatment is one of the hallmarks of psychosomatics), therefore the most correct approach to psychosomatic diseases is to work on the problem with a psychologist simultaneously with treatment.
In general, you can protect yourself from syphilis, and from nerves, and from psychosomatic disorders. If you find yourself thinking that getting sick would not be so bad, consult a psychologist to understand the situation, or try to find the irritant yourself and get rid of it, or, at worst, just rest.
Psychology of ill health - Why people get sick.
According to WHO, 70% of physical illnesses are due to psychological reasons. Doctors say: any disease first arises in the subconscious and only then manifests itself at the body level. That is, most of our ailments are associated with unresolved internal problems.
The main psychological causes of illnesses are anger, envy and guilt.
The fact that a person’s health depends on the state of his psyche has been known since ancient times. They began to talk directly about psychosomatics - various aspects of poor health and illnesses that arise under the influence of negative experiences - at the beginning of the last century, based on knowledge about psychoanalysis. And in the eighties of the twentieth century, a new interdisciplinary science even emerged in the United States - psychoneuroimmunology, the main thesis of which was the following: “The state of mind of people who can be cheerful or sad, experience guilt, resentment, and other experiences, affects the immune system.”
The main psychological causes that cause most body ailments are pickiness, anger, resentment and guilt, says Louise Hay, a well-known specialist in the treatment of psychosomatic diseases. Here's what she writes in her world-famous book Heal Your Body:
“To get rid of a disease forever, we must first get rid of its psychological cause. But since we often don’t know what the reason is, it’s difficult to determine where to start... I realized that there is a need for any of our ailments. Otherwise we wouldn't have it. Symptoms are purely external manifestations of the disease. We have to go deep and destroy its psychological cause. That is why will and discipline are powerless here - they only fight the external manifestations of the disease. This is the same as picking a weed without uprooting it...
If, for example, a person engages in criticism long enough, he often develops diseases such as arthritis. Anger causes illnesses that cause the body to boil, burn, and become infected. Long-buried resentment decomposes, devours the body and ultimately leads to the formation of tumors and the development of cancer. Feelings of guilt always force us to seek punishment and lead to pain. It’s much easier to throw these negative thoughts-stereotypes out of our heads even when we are healthy than to try to eradicate them after the onset of the disease, when you are in a panic and there is already a threat of falling under the surgeon’s knife.”
There are certain signals that the cause of the disease lies precisely in the field of psychology. First of all, this is a frequent recurrence of the disease: a person receives treatment according to the doctor’s recommendations, but as a result, the symptoms disappear for a short time and soon reappear. Adequate drug treatment in Israel gives the expected result.
In addition, there is a certain list of conditions, the cause of which is very often psychological problems, experts note.
This:
frequent and long-term respiratory diseases in a child: for example, children 3-6 years old begin to get sick often when they are sent to kindergarten - after all, for them this is the only opportunity to stay at home and receive the missing love and attention of their parents;
skin diseases, dermatitis: skin is a “contact boundary” called “me and the world around me,” “me and my family,” “me and other people,” etc.; therefore, skin problems indicate problems in contact with others;
asthma: this condition signals a fear of living to the fullest, breathing deeply; a person has some kind of fear that has not found a way out;
tics, stuttering: in addition to organic reasons, such phenomena can be generated by accumulated tension that a person cannot throw out;
sleep disorders: can be the consequences of emotional stress, fear and anxiety;
excess weight: in this way a person protects himself by creating a “protective layer” around himself.
In general, the range of disorders that can be caused by psychological factors is quite wide: these include visual impairment (a person does not want to see the world) and hearing (unwillingness to listen to quarrels, screaming), and problems with the digestive system (the inability to “digest” or survive some kind of food). or situation) and much more.
At the same time, the symptoms of psychological discomfort are strictly localized, doctors note. That is, from the picture of diseases one can judge quite accurately what problems a person should solve, what internal conflicts oppress him. Any organ, any part of the body symbolizes one or another side of life, one or another sphere. And disorder in this part indicates problems in the corresponding area. 
Table of psychological problems:
Organs and systems
Psychological reasons causing diseases
Typical diseases
Head
Heavy, obsessive thoughts, discrepancies between thoughts and actions
Headaches, migraines, brain tumors
Hair
Loneliness, desire for power, inability to use power, feeling of lack of freedom or fear of freedom
Alopecia, early gray hair, hair fragility
Eyes
Excessive commitment to one’s own views on the world, inability to correlate and adjust them in accordance with the changing picture
Farsightedness, myopia, conjunctivitis, styes, strabismus, glaucoma, etc.
Nose
Pride, narcissism, power
Runny nose, adenoids, nosebleeds
Ears
Reluctance to listen to other people’s opinions or, on the contrary, an excessive desire to listen to everyone’s opinion on your personal problems, lack of self-confidence. Inability to obey or, on the contrary, an eternally subordinate position
Otitis, deafness, tinitus
Mouth, throat
Problems with accepting information and situations
Sore throat, laryngitis, pharyngitis, stomatitis, herpes
Jaws
Difficulties with adaptation
Dislocation, osteoporosis
Gums
Problems with trust (distrust in yourself, in life, in God)
Periodontal disease
Teeth
Aggression (overt or suppressed)
Caries
Neck
Fear of communication, problems with communication
Hernias, limited vertebral mobility
Lungs, bronchi
Communication problems: lack of harmony between the desire to give and receive
Bronchitis, cough, asthma
Breast
Hyperprotection, excessive desire to take care of loved ones
Cysts, lumps, mastitis
Heart
Emotional problems (unsuccessful love, unrequited feelings, inability to establish deep contact with loved ones, etc.)
Angina pectoris, arrhythmia, atherosclerosis, hypertension, hypotension
Shoulders
Hyper-responsibility, the desire to hold everything on oneself, to carry an unbearable load
Joint pain, arthritis, arthrosis, calcium-phosphorus imbalance
Hands
Excessive activity or fear of any activity, desire for overprotection of loved ones, greed
Myalgia, arthritis, arthrosis, neuropathy
Palms
Difficulty understanding situations
Sweating, peeling, redness
Nails
Unprocessed aggression
Brittleness, hardening
Blood
Weakening of the will to live, vitality, vitality
Leukemia, anemia, thrombosis, bleeding
Stomach
Inability to adequately perceive, “digest” problems, insecurity
Ulcers, motion sickness, gastritis
Pancreas
Inability to find and choose a way to solve problems
Diabetes, pancreatitis
Liver
Difficulty assessing yourself and your problems and working through them
Hepatitis, fatty liver
Gallbladder
Unprocessed aggression
Cholelithiasis
Small intestine
Problems with analysis, processing, criticism
Dysbacteriosis, bloating, colitis
Colon
Inability to give, share (including responsibility), unite
Constipation, flatulence, hemorrhoids
Kidneys
Problems and fears associated with partnership
Kidney stones
Bladder
Constant tension, fear of relaxing
Urethritis, cystitis
Penis
Excessive power, guilt
Impotence and other sexual diseases
Testicles
Lack of masculinity, creativity, fear of being a creator
Cysts, inflammations, dropsy
Vagina
Staying in an eternally subordinate position, sacrifice, unconscious sexual deviations, rejection of one’s feminine principle
Vaginitis, sexually transmitted diseases
Pelvis
Excessive conservatism, resistance to progress, the movement of life
Joint deformity
Hips
Lack of balance between thoughts and actions
Neuropathy
Knees
Excessive humility or pride, selfishness
Joint diseases, meniscus destruction
Feet
Problems with internal stability and endurance
Arthritis, arthrosis
Leg joints
Moral instability, promiscuity
Arthritis, arthrosis, deformity, limited mobility
Bones
Lack of self-confidence, instability
Osteoporosis, osteochondrosis, decalcification, softening
Muscles
Problems with activity, mobility, internal flexibility
Tension, hardening, myalgia, atrophy
Leather
Difficulties in establishing contacts with people, vulnerability, disgust towards others, rejection of the environment
Rash, eczema, psoriasis
Connective tissue
Inability to take decisive action, lack of self-confidence
Collagenosis, scars
Nerves
Problems communicating your thoughts and feelings
Neuralgia, disorders, paralysis, paresis
In conclusion, I would like to note that most psychosomatic diseases are quite difficult to cope with on your own. Therefore, if you suffer from one or another ailment, and medicine has not been able to help you, consider contacting.
To start analyzing the “flights” with weight, nutrition, accepting yourself at a given weight and body, I recommend reading this article. Continuing the topic of such a science as psychosomatics.
Eating style is a reflection of a person’s emotional needs and state of mind. In the early days of our existence, eating is the main vital function. Satisfying hunger causes a feeling of security and well-being. During feeding, the child feels comfort from bodily distress. Skin contact with the mother's warm, soft body while feeding gives the baby the feeling of being loved. In addition, with his lips and tongue he feels the sucking of his mother’s breast as something pleasant. By sucking the thumb, the child tries to repeat this pleasant experience later. Thus, feelings of satiety, security and love remain inseparable in the infant's experience (Luban-Plozza et al., 2000).
There is a danger that infants will be left with developmental disorders if they are too early to be frustrated in their vital needs in a way that is incomprehensible to them. If such a child does eventually receive food, he often swallows hastily without feeling full. This type of behavior is the infant's response to an insecure, damaged relationship with the mother. It is assumed that in this way the basis is laid for the later development of tendencies towards capture, envy and jealousy.
Even more decisive than feeding method is the attitude of a mother to her child. This was already pointed out by 3. Freud. If the mother does not treat the child with love, if during feeding she is far from him in her thoughts or is in a hurry, this may result in the child developing aggressiveness towards her. The child often cannot react or overcome these aggressive impulses; he can only repress them. This leads to an ambivalent (* my note: instability, extreme) attitude towards the mother. Mutually opposite movements of feelings cause various vegetative reactions. On the one hand, the body is ready to eat. If the child unconsciously rejects the mother, this leads to a reverse nervous reaction, spasms, and vomiting. This may be the first psychosomatic manifestation of later neurotic development.
Thus, eating is not only closely related to the need for loving care, it is also a communicative process.
OBESITY
Personality picture
Obesity can be caused by parents when they systematically respond to any external expression of need by the child with an offer of food and make their expression of love for the child dependent on whether the child eats. These relational structures lead to a lack of self-strength, with the result that frustrations cannot be tolerated and worked through and must only be erased through “reinforcement” (Bruch, 1957).
Patients with obesity often experience a very close attachment to the mother, dominance of the mother in the family, in which the father plays only a subordinate role (Petzold, Reindell, 1980). The mother, with her excessive care, delays motor development and readiness for social contact and fixes the child in a passive-receptive position (Brautigam, 1976).
Psychodynamically, increased calorie intake is explained as protection against negative, especially depressive emotions and fear.
It is not possible to describe any single type of patients. Patients exhibit traits of internal twitchiness, apathetic-gloomy despair and signs of flight into loneliness. The act of eating shifts - albeit temporarily - negative emotions into a depression-free phase.
Patients feel imperfect, vulnerable, and incompetent. Hyperphagia, decreased activity and, as a result, excess weight provide a certain protection against a deep feeling of insufficiency: having become massive and impressive, an obese person seems stronger and more protected. In some cases, there is a clear temporal connection between the appearance and intensification of food cravings and some kind of frustration.
By regressively equating the meanings of love and nutrition, an overweight person consoles himself with food for his lack of self-love.
The clinical follow-up method made it possible to identify a significant frequency of stress in personal and family relationships, i.e., the sphere of interpersonal interaction seems to be the most problematic for patients with obesity. They show increased sensitivity towards interpersonal conflicts.
In obese patients, a noticeable increase in stable personal anxiety was found, which is considered as a basal mental property that predisposes to increased sensitivity to stress. Situational (reactive) anxiety reaches a neurotic level in severity.
A distinctive feature of psychological defense in such patients is the predominance of the psychological defense mechanism of the type of reactive formations (hypercompensation). The substantive characteristics of this version of psychological defense assume that the individual prevents the awareness of unpleasant or unacceptable thoughts, feelings, and actions through the exaggerated development of opposite aspirations. There is, as it were, a transformation of internal impulses into their subjectively understood opposite. Immature protective mechanisms of psychological defense are also typical for patients, one of which is associated with aggression, transferring one’s own negative ideas to others (projection), and the other with a transition to infantile forms of response, limiting the possibilities of alternative behavior (regression).
It should be assumed that the factors that lead to obesity in one person do not necessarily affect another.
Psychologically, different constellations are also found. The most commonly cited causes of obesity are:
Frustration at the loss of a love object. For example, obesity can be caused, more often in women, by the death of a spouse, separation from a sexual partner, or even leaving the parental home (“boarding obesity”). It is generally accepted that the loss of a loved one can be accompanied by depression and at the same time an increase in appetite (“bite the bitter pill”). Children often react with increased appetite when the youngest child in the family is born.
General depression, anger, fear of loneliness and feelings of emptiness can lead to impulsive eating.
Situations requiring increased activity and increased stress(for example, preparing for exams, professional overload), awaken in many people increased oral needs, which lead to increased eating or smoking.
In all these “revealing situations,” food has the value of vicarious satisfaction. It serves to strengthen connections, security, eases pain, feelings of loss, disappointment, like a child who remembers from childhood that when he was in pain, illness or loss, he was given sweets to console him. Many obese people had similar experiences in childhood, which led them to unconscious forms of psychosomatic reactions.
For most obese patients, it is important that they have always been fat, and already in infancy and early childhood they were prone to being overweight. It is interesting that in frustrating and tough life situations, feeding and excess food can become a stress-regulating factor for both parents and their growing children. Obesity and food as a substitute for satisfaction are therefore not a problem for one person, but for the whole family.
These situational conditions must be associated with the characteristics of the patient’s personality and its processing.
In a psychodynamic interpretation, one can give preference to the concept of regression with fixation on oral gratification. Food is a substitute for absent maternal care and a defense against depression. For a child, food is more than just nutrition, it is self-affirmation, stress relief, and maternal support. Many obese patients have a strong dependence on their mother and fear of separation from her. Since 80% of parents of obese patients are also overweight, we can think about a predisposition factor, as well as particularly intense family ties and adherence to traditions, a relationship style where direct expressions of love are rejected, and their place is taken by oral habits and connections . Adopted children are less likely to be obese if their parents are obese than their siblings (Meyer, 1967).
Certain forms of early childhood development and family environment in children with a tendency to obesity are described. Mothers of such children show hyperprotection and over-attachment. Parents who allow everything and prohibit nothing, who cannot say “no,” compensate with this their remorse and the feeling that they are not giving enough to their children. Fathers in such families are weak and helpless (Bruch, 1973).
Oral spoiling is often motivated by parents getting rid of the feeling of guilt for their emotional alienation, for their indifference and internal rejection of the child. Feeding children is the only possible means of expressing affection for them, which parents are not able to show by talking, touching, or playing with them. Oral refusal is the result of different forms of behavior of both an overprotective and indifferent mother.
Psychotherapy
Weight loss courses, as a rule, turn out to be ineffective if it is not possible to induce the patient to change his instinctive-emotional behavior, in which hyperphagia and excess weight would cease to be necessary for him. The success of therapy in practice is so low because the balance of pleasure of the patient is ignored, for whom, in general, it is more acceptable and tolerable to maintain his excess weight than to deal with his problems. During dietary treatment, over 50% of patients demonstrate symptoms such as nervousness, irritability, increased fatigue, and a wide range of depressive symptoms, which can also manifest themselves in the form of diffuse fear.
The reasons for the frequent failure of psychotherapeutic treatment of obesity may be:
- An exclusively symptom-oriented approach with an explanation of organic and functional disorders is not only inadequate to the problem of a patient with obesity, but also often has the consequence that he ultimately feels not so much sick as unreasonable and emotionally rejected.
- Lack of a thorough analysis of behavior, its conditions and motivations in the treatment of behavioral disorders.
- Difficulties in overcoming sociological factors, for example, family or national habits of eating high-calorie foods. Patients do not comply with psychotherapist's orders much more often than one might think. It is this behavior of patients that irritates the therapist, especially because he assumes that a patient who does not follow instructions is not ready to cooperate. Many studies, however, show that the patient is often unable to understand or remember the therapist's instructions because they are too complex, but does not dare ask for clarification or repetition. How can a patient be motivated to cooperate and comply with therapeutic instructions? The most important thing is the patient's active participation in therapy. To do this, the psychotherapist must first find a bridge of contact with the patient. The better he can understand the patient, the easier it will be for him. He must determine how deeply personally affected the patient is by the loss that has become familiar to him, find opportunities to cope with the conflict and gain pleasure in other ways.
An individualized treatment plan must then be created taking into account personal and work circumstances. The patient should be given the opportunity to train and control unusual eating behavior.
Behavioral therapy
Most authors testify to the effectiveness of behavioral psychotherapy aimed at changing inappropriate behavioral stereotypes (Basler, Schwoon, 1977; Brownell, 1983; Stunkard, 1980).
The principle of losing weight is extremely simple - limit calorie intake, according to modern nutritional concepts, primarily fat (Ginsburg et al., 1997). The most difficult thing is to put this principle into practice. The behavioral psychotherapy program proposed by Uexkull (1990) includes five elements:
1. Written description of eating behavior. Patients should write down in detail what they ate, how much, at what time, where and with whom it happened, how they felt, and what they talked about. The first reaction of patients to this tedious and time-consuming procedure is grumbling and dissatisfaction. However, usually after two weeks they notice a significant positive effect from keeping such a diary. For example, one businessman who spends a lot of time on the road first began to analyze that he abuses food mainly only in the car, where he had large stocks of sweets, nuts, potato flakes, etc. Realizing this, he removed food items from the car and was able to After this you will lose a lot of weight.
2. Control of stimuli preceding the act of eating. It involves identifying and eliminating food-provoking stimuli: easily accessible supplies of high-calorie foods and sweets. The number of such products in the house must be limited and access to them made difficult. For those times when you can't resist the urge to eat something, keep low-calorie foods on hand, such as celery or raw carrots. The incentive to eat can also be a certain place or time of day. For example, many people eat while sitting in front of the TV. As in Pavlov's experiments on the development of a conditioned reflex in dogs, turning on the TV serves as a kind of conditioned stimulus associated with food. To reduce and control excessive conditioned stimuli, the patient is advised to eat in only one place, even if it is just one bite or sip. Most often this place is the kitchen. It is also advisable to create new incentives and enhance their exceptional impact. For example, the patient may be advised to use separate fine dishes, silver cutlery, and napkins of a striking color for meals. Patients are asked to use these utensils for even the most minor meals and snacks. Some patients even take their cutlery with them if they eat out.
3. Slowing down the eating process. Patients are taught the ability to independently control their food intake. To do this, they are asked to count every sip and bite while eating. After every third piece, you need to put the cutlery down until this piece is chewed and swallowed. Gradually the pauses lengthen, reaching first a minute, and then longer. It is better to start lengthening pauses at the end of meals, as then they are easier to bear. Over time, the pauses become longer, more frequent, and start earlier. Patients also learn to avoid all simultaneous activities during meals, such as reading a newspaper or watching a TV show. All attention should be focused on the process of eating and enjoying food. It is necessary to create a cozy, pleasant, calm and relaxed atmosphere around, and, of course, avoid talking at the table.
4. Increased concomitant activity. Patients are offered a system of formal incentives for changing their behavior and losing weight. Patients receive points for each achievement in changing and controlling their behavior: keeping a diary, counting sips and bites, pausing while eating, eating only in one place and from a certain utensil, etc. Additional points can be earned if, despite great temptation, they managed to find an alternative to food. Then all previous points can, for example, be doubled. The accumulated points are summed up and converted into material value with the help of family members. For children, this could be a trip to the cinema; for women, it could be freedom from housework. Points can also be converted into money.
5. Cognitive therapy. Patients are encouraged to argue with themselves. The therapist helps to find suitable counterarguments in the patient’s monologue. For example, if we are talking about losing weight, then in response to the statement: “It takes so long to lose weight,” the counter-argument could sound like this: “I’ve been losing weight, but now I’m learning to maintain the weight I’ve achieved.” Regarding the ability to lose weight, the doubt may be: “I’ve never succeeded in anything. Why should it happen now? Counterargument: “Everything has its beginning, and now an effective program will help me.” If we are talking about the goals of work, then in response to the objection: “I can’t stop sneaking pieces of food,” the counter-argument could be: “But this is unrealistic. I'll just try to do it less often." Regarding the thoughts that arise about food: “I constantly notice that I think about the fabulous taste of chocolate,” you can offer the following counterargument: “Stop! Such thoughts only frustrate me. It is better to think about how I am sunbathing on the beach” (or about any other activity that is especially pleasant for the patient). If excuses arise: “Everyone in my family is fat. “It’s hereditary for me,” a counter-argument could be: “This makes losing weight more difficult, but does not make it impossible. If I stick it out, I will succeed.”
Suggestive psychotherapy
It reinforces the attitude toward correct eating behavior and is most effective in patients with psychological defense of the regression type and hysterical personality traits.
At all stages of treatment, elements of neuro-linguistic programming are used as a modern direction of behavioral psychotherapy with a non-behaviorist orientation. NLP promotes “tuning” to the patient and increasing the effectiveness of interaction with him based on clinically detectable mental characteristics.
Methods of Gestalt therapy, transactional analysis, art therapy, psychodrama, body-oriented therapy, dance therapy and family psychotherapy are also successfully used.
Obesity Questionnaire
1. Do you have the impression that you often “eat yourself for something” or “the way to the heart leads through the stomach”? Do you have a “mouth full of worries” or do you think that “everything that fits into your mouth is useful”? Do other proverbs and catchphrases come to mind regarding your illness?
2. What does it mean to you that each person has his own balance to which he returns, despite any diet? That the diet can even become the cause of subsequent excess obesity, since if you refuse it, fat cells not only fill up, but also multiply? That weight problems cannot be solved by diet alone, without taking care of other causes at the same time?
3. Do you take your prescribed medications regularly? Do you know how these medications work, what you can expect from them, and what side effects are possible?
4. Do you have professional problems that you compensate for with food? What current abilities do they relate to?
5. What would your partner have to do for you to lose weight?
6. Does “food bind body and soul” for you or your partner?
7. Does a “subsidence” of needs and a “pushing aside” of the feeling of displeasure occur during eating, as happens in small children?
8. Do you eat in public the same way as others because you are embarrassed to ask for more or what you like best (courtesy)?
9. What would you do if we had a famine?
10. Do you hope that the problem of world hunger will be solved in the foreseeable future? What can you do about this?
11. Can you use part of the money you spend on food to satisfy your other needs or the needs of other people (for example, education, housing, leisure, travel, entertaining, donations)?
ANOREXIA NERVOSA
Personality picture
The term "anorexia" is defined occurring during puberty(*my note - adolescence) (almost exclusively in girls) a painful condition associated with the desire to lose weight, become elegant and remain so.
In the chronic course, there is a local fear, which can be called phobic, of normal food, weight gain and achieving the average levels necessary to maintain health. Primary somatic or hormonal disorders are usually not detected. This disorder is based on an adolescent developmental conflict without awareness of the latter and without a realistic attitude towards one’s own somatic state.
In terms of personality structure and internal maturation, women with anorexia are not prepared for their maturity. More than other girls, they experience physical maturation, primarily menstruation and the growth of the mammary glands, as their preparation for playing the female role, considering it alien and excessive for themselves. This often leads to ambivalence regarding their puberty in women (less often in men), manifested in the desire to lead an ascetic lifestyle, characteristic of the puberty period, with young people internally and externally distancing themselves from gender roles and from endogenously arising needs and intensively looking for other activities .
Personal predisposition manifests itself in anorexia by special differentiation in the intellectual sphere and vulnerability in the emotional sphere. Also noteworthy are the sensitivity and lack of communication traced in the anamnesis, although the girls do not attract attention to themselves in any way. In the language of the theory of neuroses, women with anorexia are more likely to exhibit schizoid personality traits. In many cases, autistic attitudes and social isolation are detected even before the onset of the disease. As the disease progresses, more and more difficult-to-perceive schizoid autistic symptoms, similar to delusions, predominate.
My personal experience. M, 22 years old, applied 3 years after being diagnosed with anorexia and partial withdrawal. The request was not related to anorexia, but had its roots there.
M, 22 years old.
The mother is an authoritarian, independent woman. A brilliant specialist in the field of linguistics.
The stepfather is much older than the mother; at the time of working with the client he was 60 years old.
AN (anorexia nervosa) developed from the age of 14, reaching its peak at the age of 15.
The client was aware that this was due to the high demands placed on her as the daughter of an “ideal mother.”
The provoking situation for disordered eating behavior is often the first erotic experience, which patients cannot process and experience as threatening; Strong sibling rivalry and fears of separation are also reported, which may be activated by the death of grandparents, divorce, or siblings leaving the parental nest.
On the one hand, patients direct self-destructive aggression against themselves, with which they punish themselves for impulses to part with their mother, perceived as “betrayal.” On the other hand, refusing food is an attempt to achieve loving care or, if this fails, a means of at least angering other family members, including the mother, and using eating behavior to establish control over them. And in fact, in many families of such patients, the patient's eating behavior is an all-consuming topic, causing predominantly negative reactions. In treatment, patients try to transfer this relationship scheme to clinical staff.
In anorexia nervosa, oral aggressiveness is not only suppressed. It is rather a question of denial of all oral urges, and the ego tries to establish itself and raise its value by rejecting all oral urges.
With anorexia nervosa, the idea “I must lose weight” becomes an integral component of the personality. This feature is found, however, only with symptoms caused by psychotic processes. In severe forms of anorexia nervosa, the ego does not fight against the ideas that suppress it. This explains the lack of awareness of the disease and the rejection of all help.
Anorexia nervosa is, however, not only a struggle against the maturation of female sexuality. It is also an attempt to defend against growing up in general, based on a feeling of powerlessness in the face of the increasing expectations of the adult world.
In addition to individual psychodynamics, the field of relationships in families sick. Family relationships are often defined by an atmosphere of perfectionism, vanity and a focus on social success. They are characterized by a family ideal of self-sacrifice with corresponding competition among family members.
For families with anorexia patients, such behavioral characteristics as viscosity, excessive care, conflict avoidance, rigidity and children's involvement in parental conflicts have been described.
In such a family, everyone strives to impose their own definition of relationships on the other, while the other, in turn, rejects the relationship imposed on himself. No one in the family is ready to openly take over leadership and make decisions on their own behalf. Open unions between two family members are unthinkable. Overlapping coalition generations are negated at the verbal level, even if they can be established at the non-verbal level. Behind the façade of marital consent and harmony lies deep mutual disappointment, which, however, is never openly admitted.
In general, in families, female authority is often noticeably dominant, be it mother or grandmother. Fathers are mostly outside the emotional field, as they are hidden or openly suppressed by mothers. This reduces their value as perceived by the family, to which they respond by further withdrawal, which gives mothers room to further develop their dominant positions.
Psychotherapy
Family therapy has the most pronounced effect.
Methods of Gestalt therapy, transactional analysis, art therapy, psychodrama, and dance therapy are also successfully used.
BULIMIA
Personality picture
Bulimia (bullish hunger) is referred to as compulsive eating/vomiting or eating/defecation (Drewnowski et al., 1994).
Like anorexia nervosa, bulimia occurs predominantly in women.
Leading symptoms the disease consists of:
- frequent occurrence of time-bound bouts of overeating;
- active weight control through frequent vomiting or use of laxatives.
Patients with bulimia are outwardly well: they have an ideal figure, they are successful and active. The excellent facade, however, hides extremely low self-esteem. They constantly ask themselves what others expect from them, whether they are behaving correctly. They strive for greater success and often confuse the love they seek with recognition
The personality structure of patients with bulimia is as ambiguous as with anorexia. In general, bulimia can be explained by the social contradictions in which modern Western women grow up. Exploring the historical conditions for the emergence of bulimia, he characterizes it conflict in mid and late adolescence, which has common features in all women with bulimia. This is, firstly, leaving the parental family and the task of developing one’s independence; secondly, a developmental problem in connection with rejection of one’s sexually mature body and conflict in connection with sexual identification.
At first impression, patients often appear strong, independent, purposeful, ambitious and self-possessed. This, however, is significantly different from their self-esteem, which is marked by feelings of inner emptiness, meaninglessness and a pessimistically depressive background as a consequence of patterns of thinking and behavior leading to feelings of helplessness, shame, guilt and ineffectiveness. The perception of oneself and the “I-ideal” diverge sharply, patients put this splitting into an outwardly good and poorly hidden picture.
They often come from families in which communication is impulsive and there is a significant potential for violence. The structure of relationships in families is marked by high conflict and impulsiveness, weak connections between each other, high levels of life stress and unsuccessful problem-solving behavior with a high level of expectations of social success.
In this situation, patients assume responsible tasks and parental functions early. One’s own fears of not being able to cope and being at the mercy of the arbitrariness and unreliability of parents are controlled and compensated for by caring behavior; the weak and dependent aspects of one's personality are held back and will eventually react in bouts of overeating and purging.
Emotional instability, impulsiveness with fear of loss of control.
Hunger is distortedly interpreted as a threat resulting from a loss of control, control over bodily functions is overgenerally equated with the ability to cope with problems. The bout of overeating itself has the function of reducing tension, integration, and comforting self-satisfaction, which, however, is short-lived.
This is perceived by the patient as a loss of control, radically questioning her autonomy and ability to cope with life. Vomiting is induced to maintain a constant body weight, which for the patient is a measure and indicator that self-control and self-determination have been regained. Feelings of shame and guilt in this regard often cause social and emotional regression, as well as splitting into outwardly presented prosperous and hidden poor self-esteem.
The discrepancy between perception and presentation of oneself can cause a feeling of internal emptiness and tension, which is activated in stressful triggering situations and re-starts the disease relay.
Bulimics usually:
- perfectionists (strive to do everything perfectly);
- prone to sadness, depression, obsessive thoughts or actions;
- impulsive, chaotic, ready to take risks;
- have low and unstable self-esteem;
- are not satisfied with their own body;
- set unrealistic goals for themselves;
- fall into despair when these goals cannot be achieved;
- they also build personal relationships according to the “bulimic” pattern: ardent passion - abrupt break;
- have unpleasant childhood memories associated with eating (food as punishment, force feeding, scandals, etc.).
Psychotherapy
As with psychosomatic diseases in general, to select adequate treatment in each individual case of bulimia, one should take into account the characteristics of the patient - age, motivation, chronicity, ability for adequate self-esteem, physical and mental state, severity of personality disorder, alcohol abuse, risk of suicide, etc. .d.
Representatives of different schools report the effectiveness of almost any treatment - from classical psychoanalysis to family therapy, from behavioral therapy to Indian meditation, from feminist groups to inpatient or long-term outpatient therapy.
Comparative data on the indications and prognosis of various treatment methods can be presented as follows (Lacey, 1985; Fairburn et al., 1991; Fairburn et al., 1992; Ricca et al., 2000)
Outpatient treatment, in which the patient remains in his or her usual environment, is adequate for most sick women and is often sufficient.
The following steps must be included in any form of psychotherapy.
1. In one or more diagnostic conversations with the patient, her current eating behavior and general life situation are clarified, mostly chaotic and hidden from others and from herself, eating behavior in all its details - the number of meals, its quantity, preparation for food, situations , in which such behavior arose, and first of all the mood preceding it, and then the emotional background in the current life situation with its difficulties and conflicts and external and internal circumstances.
2. The patient is offered a new eating regimen in the form of a written program with clear regulation of the frequency and time of intake, quantity and type of food. To do this, all nutritional details are noted in a notebook that the patient keeps daily.
3. On a specially dedicated page of the notebook, the most important events of the day, mood and, above all, situations in which relapses of bulimia occur, with their dependence and connection with the emotional state, are described.
4. The development of the general life and conflict situation, as well as the symptoms of relapses of bulimia are discussed once a week in an individual half-hour conversation with a psychotherapist (woman or man). The nutrition and life plan for the next week is drawn up taking into account physiological needs. The patient weighs herself in the presence of her psychotherapist, who thus “documents” responsibility for her body weight and health status.
5. Next, group conversations with patients with bulimia are added.
This stage of treatment lasts more than 10 weeks; conversations are carried out in the afternoon or evening at the clinic individually or in groups or by combining these methods. The treatment tactics are such that after a 10-week intensive program it is necessary to conduct individual conversations with patients, first at small and then at increasingly large intervals of time (after several weeks, then months), but always within a fixed time frame. For patients, the fact that someone is constantly interested in them and will share responsibility with them if they report subsequent relapses is a great support. As numerous observations show, bulimic attacks can also occur during subsequent crisis situations.
Family therapy, as with anorexia nervosa, produces positive results.
Methods of Gestalt therapy, transactional analysis, art therapy, psychodrama, body-oriented therapy, and dance therapy are also successfully used.
Positive psychotherapy for appetite disorders
Anorexia nervosa and bulimia - the ability to get by with little money, the ability to share the hardships of world hunger.
Current conflict.
With psychogenic starvation, we are talking less about the disease of an individual person, but rather about the disease of the whole family, where the starving person becomes a carrier of the symptom. With his illness he expresses what the whole family suffers from, but no one can express it or dare only think about it. From this point of view, the patient is the strongest in his family circle, because he dares, putting his life at risk, to discover family problems and social injustice. What powers these weak and outwardly helpless people possess is manifested in the consistency with which they refuse to eat and express protest, as well as in their ambition, their activity and iron self-control. The latter, of course, often leads to the opposite actions: in order not to have to justify themselves to themselves because of their ravenous appetite (courtesy/sincerity), they often consume mountains of food and then throw it out of themselves.
Basic conflict.
Hungry families are usually those with a strong financial position. Typically, in these families or in one of the parents, neatness, neatness, politeness, achievement and, in relation to religion, obedience are highly valued. The attitude towards the body, sensuality and sexuality is, as a rule, one-sided, in the direction of “spirituality”, “dematerialization”. In this regard, they talk about “ascetic families.” There is no joy from the sensual, “instinctive” delights of life and tenderness. Love serves only achievement and well-being, there is no time for each other, there is no contact with the outside world. The dominant concepts here are: “time for business is time for fun,” “if you can do something, then you are something,” “everything on the table should be eaten,” and “what people say” (courtesy).
Current and basic concepts.
When children raised in such a family, gaining independence, leave their home, they inevitably find themselves in a conflict between what they have learned at home and their own desires and attitudes. The path to somatics does not mean “escape” for them, but rather a dramatic action, a visible rebellion against conventions and conformity through a demonstration of autonomy. Thus, symptoms can sometimes reflect family conflicts (a sense of injustice: “why me?”), and in other well-adapted families they can be understood as a reaction to social injustice (for example, world hunger). Physical evidence forces the family to respond in a positive way: to pose problems, to reconsider concepts. Thus, positive psychotherapy sees in psychogenic fasting not so much a painful lack of appetite or a strategy of avoiding food, but rather the ability, through fasting, to pay attention to something in oneself or around oneself.
Those suffering from anorexia, on the one hand, show by their example how small means can be used (asceticism and loneliness). On the other hand, they have the altruistic ability to cook for others and share the world's hunger with others.
Current ability: "justice".
Definition and Development: Justice is the ability to balance all interests in relation to oneself and others. What is perceived as unfair is treatment that is dictated by personal preferences and rejections or partial orientations instead of detailed reflections. The social aspect of this relevant ability is social justice.
Every person has a sense of justice. The way loved ones treat the child, how fair they are to him, his brothers and sisters and to each other, is reflected in the individual’s attitude towards fairness.
How they ask about it. Which of you values justice more, in what situations and towards whom? Do you consider your partner to be fair (to children, siblings, other people, to you personally)? How do you react if you are treated unfairly (at work, in
family)? Do you have or have you had problems due to injustice (someone was preferred to you)? Which of your parents emphasized justice to you or your siblings more?
Synonyms and disorders: proportionate, deserved, objective, impartial, unacceptable, unreasonable, in comparison with..., feel left out, infringed on one’s interests, confidence in one’s own justice.
Hypersensitivity, competition, struggle for power, feelings of weakness, injustice/retribution, revenge, individual and collective aggression, depression, retirement neuroses.
Features of behavior: justice without love sees only achievement and comparison; love without justice loses control over reality. Learn to combine justice and love. To address two at the same time is to treat one unfairly.
Self-restraint in food in many patients quite often leads to a feeling of hunger -. Although there is currently a tendency to distinguish between anorexia nervosa and as independent diseases, there is evidence (M.V. Korkina, M.A. Tsivilko) indicating that they are stages of the same disease. In many cases, self-restraint in food itself can be a very short-term condition, almost unnoticeable to others. Then it gives way to pronounced manifestations of bulimia, which come to the fore. In many patients the condition and coexist. Subsequently, a number of them take on the character of an obsessive attraction, which often develops against the background of hyperthymia, turning into a state. Affective fluctuations manifest themselves in anorexia nervosa (the first stage of the disease) and nervousness (the second stage of the disease) and are found in the form of depression, less often in the form of euphoria. The course of bulimia nervosa is long, 5 - 7 years, in some cases with incomplete remissions.
A single cause of anorexia nervosa and bulimia has not been established. Various factors are involved in the etiopathogenesis of the disease. Personal predisposition (premorbid accentuations) and family factors play an important role; many patients have a history of gastrointestinal diseases. Socio-environmental aspects can play a certain provoking role (the formation in society of the idea of special significance for a woman as a standard of external appearance and the “cult of thinness”). Of the character traits that are more common in patients with anorexia nervosa and bulimia, the most commonly noted are stubbornness, over-carefulness, and hyperactivity, which is combined with rigidity and excessive attachment to the mother. In many cases, during the development of the disease, disharmony of pubertal development plays a certain pathogenic role. Pathogenesis is determined by the multidimensional interaction of mental and somatic factors. In particular, the presence of dystrophy and exhaustion decompensates the mental state, which leads to the progression of the disease. Thus, psychosomatic connections reveal a multiplicity of variable forms of interaction, as a result of which various shades of the dynamics of the disease are discovered in the clinic.
There is no exact data on the epidemiology of anorexia nervosa and bulimia nervosa, but information is accumulating about a trend towards an increase in cases of the disease: one case per 200 schoolgirls under the age of 16 and one case per 100 schoolgirls over 16 years of age, one case per 50 students (A. Crisp, D. Reed). Many researchers note a special frequency of anorexia nervosa and bulimia among students of ballet schools, fashion models, students of theater schools - one case for 14 students of ballet schools and models, one case for 20 students of theater schools. As a rule, girls, teenagers and young girls get sick (5-25 times more often than boys, teenagers and young men).
With the development of dystrophy in cases of anorexia nervosa, inpatient treatment is necessary. Outpatient therapy is possible when secondary somatoendocrine disorders do not reach a pronounced degree and there is no threat to the patient’s life. First of all, regardless of the underlying cause and nosological form of anorexia nervosa, it is necessary to conduct a course of restorative treatment to restore the somatic state (vitamin therapy, cardiovascular medications with the simultaneous administration of a sufficient amount of fluid). Vitamin preparations such as carnitine and cobamamide are indicated. From the first days of treatment, patients are prescribed split 6-7 meals a day in small portions with bed rest after meals for at least 2 hours.
In the future, differentiation of therapy is carried out depending on the established nosological affiliation of anorexia nervosa and bulimia. For independent anorexia nervosa syndrome (borderline register of neuropsychiatric disorders), psychotherapy is indicated, its various variants are prescribed (phenazepam, lorafen, strezam, grandaxin), mild action (teralen, chlorprothixene, clopixol). Patients with schizophrenia are prescribed broad-spectrum antipsychotics and antidelusional drugs (triftazine, haloperidol, etaprazine, risperidone) in small doses with correctors. When the process stabilizes, treatment can be carried out on an outpatient basis. An important factor is occupational therapy, the inclusion of patients in the educational process for the purpose of complete rehabilitation.
