#19. Attachment and Anorexia Nervosa

A blog reader in her late 30s asked how attachment issues might be related to her recent symptoms of anorexia nervosa. As she has resolved painful memories of sexual trauma she has experienced more distress about relationships. She reports: “I just don’t think I matter to anyone. I realize this can’t be true and I don’t know why I don’t feel any sort of healthy reciprocated relationship, but I know I’m the common denominator. I feel very alone in life.” As her life has improved, she has begun to find satisfaction in controlling food and has lost significant weight.

In an excellent article, Delvecchio et al (2014) advance research on anorexia from correlations to seeking causative links between attachment problems and anorexia. In doing so, they point out that trauma goes beyond catastrophic events and includes unmet emotional needs. While major trauma is not uncommon in anorexia patients, it is more understandable as a response to issues around needs. In this post, I’ll share some clinical observations and further thoughts about causation. 

Trauma with a small “t”

The usual definition of trauma is as seen through the eyes of an adult. Through a child’s eyes, the landscape is quite different. Very early in development, children respond intensely to variations in attunement. They respond as if emotional needs are matters of life or death. Why? Because they are! Social interaction in our species is essential for survival. Positive early attachment experiences are what lead to the development of effective interpersonal skills. Problems as subtle as a mother’s trouble tuning in accurately to the emotions of her child can lead to avoidance of interaction rather than pleasure. The Entrenched Maladaptive Patterns (EMPs) we deal with as adult therapists are largely the inventions of children, and we need to view them through the eyes of the child at the time of their first appearance.

Traditional psychodynamic explanations of anorexia nervosa focus on sexuality. This may be true, but I suspect that explanation is more a result of looking at the behavior thorough the eyes of an adult. My guess is that the appearance of anorexia in early adolescence has more to do with the extra neediness that goes with moving towards the scary separateness of adult life. 

Layered avoidance EMPs

The earliest response of a child to a shortfall of attuned responses is to avoid engaging. This can be detected through Bowlby and Mary Ainsworth’s “Strange Situation” assessment between 12 and 18 months, observing how children respond to the return of their mother. A cool or anxious reception indicates insecure attachment. That pattern may continue throughout life, but a second layer of avoidance (EMP) develops a bit later and is more relevant to the reader’s question. 

Imagine a child who is chronically deprived of positive emotional interactions. The child can push the mother away for a few minutes, but the natural drive to relate soon overrides learned avoidance. The result will be frequent breakthrough’s of need and painful disappointments. Perhaps the child will learn to seek soothing from other sources such as thumb sucking or other body oriented activities. Together, these are less than satisfactory and I believe painful experiences are likely to continue. This calls for a more effective EMP.

Shame equals conscience

Around age 18 months, as Alan Schore describes it, the prefrontal cortex becomes myelinated and the conscience is born. It becomes operational at about three. The conscience can and often is used for social survival. One very common pattern is to stop the child from behaving in ways that will cause pain. What if neediness leads to pain? The conscience will then internalize a core value that neediness is shameful. From then on, any time neediness is experienced, or even anticipated, the conscience measures reality against the internal standard, and determines that feelings of shame are needed as a deterrent to any direct outward expression. This kind of deterrent can and does last a lifetime until a healthier set of values is internalized.

This is what appears to have happened to our reader, who says “I was not raised to be needy. My neediness has always given me anxiety and guilty feelings.” She has internalized standards saying that to be needy is “bad.” 

When faulty internalized standards are implicated, to me it means that the therapeutic work will be harder and will take longer. That is because the conscience is set up to be incorruptible, even when it is wrong. It will take focused work to change unhealthy standards like the one that neediness is bad. 

Interestingly the difficulty of changing standards is in contrast with the relative ease of her recovery from sexual trauma. Many therapies don’t seem to recognize the special difficulty of changing internal standards or “core values.” As I wrote in TIFT #9, the fact that relapse can take place when bad things happen suggests that these standards are permanently lodged in the brain. 

From neediness to food 

The reader quoted me in a 2015 blog entry: “In a further twist on the seeking of substitutes, Anorexia Nervosa (at the risk of oversimplifying) embodies the triumph of control over neediness, played out metaphorically in the realm of food. Thinness represents a victory against appetite so it can’t betray one into vulnerability.”

The mind is a “metaphor engine” and that is how need for food becomes the conscious equivalent of unthinkable and secret interpersonal neediness. Following that metaphorical equivalence, conquering the need for food gives a reassuring feeling of being in control of appetites in general.

My reader, unlike many anorexia patients, doesn’t have a strong internalized value against eating, but her unconscious does block feelings of hunger or satisfaction from food. Often anorexia patients do experience intense shame about eating, and that, once again, is an indicator that the conscience has internalized a standard that fat is bad and thin is good. Any failure to adhere to that standard will bring on a wave of shame or intense self-loathing.

Therapy for maladaptive values.

Step one in treatment is clarity that one’s internalized standard is unhealthy and wrong. Whether it’s a standard that fat is shameful or one against neediness, it helps a lot to realize that the usually wise and good Jimminy Cricket of our conscience can be misguided and not to be listened to. That clarity is hard to achieve but will help with the hard work to come.

The Antidote

Even if values are permanent, they can still be functionally replaced by healthier ones. Step two in treatment is to design an antidote to the poison that has become part of the self. That will be a new value to replace the faulty one. The antidote should be clear and powerful, formulated in partnership to reflect the needs and style of the patient.

Perhaps for our reader, the antidote might be, “neediness is what makes the (attachment) world go ‘round.” The simple truth is that human emotional needs constitute the “glue” that holds relationships together. We crave closeness because we have needs and needs are what pulls others to us. Someone who doesn’t have needs (or who has become unconsciously and automatically adept at hiding them) will fail to send out the signals that make others want to get close and those signals are what make us feel cozy and connected.

But words are not enough. Internalizing new standards requires action. It might be to eat, and then to process whatever shame is experienced. In our reader’s situation, it would be to engage in positive human interactions.

OMG, do you mean I’ll have to show needs? It is so automatic not to do so! A helpful strategy comes from Fonagy’s approach to attachment problems. He prescribes “mentalization,” meaning awareness (mostly nonverbal) of what the other person (and oneself) is feeling with regard to relationship. This concept has spawned “mentalization-based therapy” applied especially for borderline personality, but valid in many cases where attachment problems are at issue.

What this amounts to in practice, is to use the therapeutic relationship as an experiential laboratory. Patient and therapist pay attention to what each is experiencing and compare notes. Words are used to build awareness of what is really happening in the relationship. That’s how misperceptions like thinking that needs are a turn-off can be corrected. It’s a place for testing out theories like the reader’s belief that she doesn’t “matter to anyone.”

Risk is good but it can be risky 

This kind of close interaction can be a challenge for therapists as well. As the comments in my blog have too often shown, therapists, too, can be subject to difficulty with mentalization and attachment. They, too, can respond emotionally and unprofessionally. Patients will need to be careful to test out, starting with low-risk disclosure, how the therapist responds, and how “tuned in” the therapist can be. Does the therapist respond with accurate empathy? Can the therapist handle real questions about his/her responses? [Note to self and readers: Any thoughts about how patients can assess these risks would be an important topic for a future post and clinical research.]

 Just to make it clear, under good conditions, taking thoughtful risks of disclosure of one’s personal feelings is what makes accurate empathy happen and naturally leads to the formation of caring bonds between humans.

Jeffery Smith MD

As always, I would invite comments, and also, if you find these posts interesting, please tell your friends and colleagues.

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