Home > International Dictionary of Psychoanalysis > Anorexia Nervosa

The term "anorexia nervosa" was coined by William Gull in 1873. Although the term has existed for little more than a century, the clinical description of the syndrome is much older. Among other works, we can find a description in Avicenna in the eleventh century, and we have no difficulty recognizing it in Richard Morton's 1694 account of "nervous consumption." The first complete description in terms identical to those of Gull can be found in an article written by Dr. Louis Victor Marcé in 1860.

The classic clinical picture of anorexia brings together three factors: weight loss of more than 10 percent, amenorrhea, and the absence of a manifest melancholic or delusional mental disturbance. But the emphasis has changed from these classic symptoms to more specific symptoms, such as a confused body image, denial of being thin, desperate desire to be thin, and fear of putting on weight. Also, two major types of anorexia nervosa have been distinguished: purely restrictive forms and forms associated with bulimic episodes accompanied by weight monitoring, self-induced vomiting, and excessive use of laxatives and diuretics. Anorexia nervosa frequently occurs during adolescence, especially among females (ten girls for every one boy). It affects between 1 and 2 percent of the female adolescent population.

Without ever dealing specifically with eating disorders, Freud did in fact establish all of the perspectives—hysteria, melancholia, and "actual" neurosis—around which the pathological manifestations of anorexia can be understood metapsychologically. As a hysteria, anorexia involves a double polarity: oral fixations of the libido serve as a point of regression, and sexual fantasies become oral and are then repressed. As a melancholia, anorexia involves melancholy over the issue of object loss and a loss of instinctual needs. Freud speaks of an anesthesia that leads to melancholic thinking, which opens up a research path related to the next perspective. As an "actual" neurosis, anorexia poses a threefold question about the importance of the current situation, of somatic and infrarepresentational factors, and of the inadequacy of the ego and capacities for working matters out.

Melanie Klein and her students have stressed the importance of archaic fantasies of sadistic devouring, destruction, and poisoning in anorexia. Psychoanalysts dealing specifically with eating disorders initially considered them to be primarily a symptom and took little interest in the organization of the personality. But because of the complexity of cases and the frequent severity of the evolution of the disorder, the pathology of the personality assumed a growing importance in their work. The Göttingen symposium, organized by J. E. Meyer and H. Feldmann (1965), recognized anorexia nervosa as having a specific structure and viewed it not so much as an attempt toward compromise formation but rather as an attempt to deal with psychotic failures in the organization of the ego by reestablishing the mother-child unit.

Evelyne Kestemberg et al. (1974) have provided a remarkable description of the specific modes of the regression and instinctual organization in anorexia. This organization is characterized by recourse to a primary erogenous masochism in which pleasure is linked directly to a refusal to satisfy a need. Pleasure does not accompany the feeling of having something inside oneself; rather, anorexia eroticizes not satisfying a vital need. Similarly, relationships become dominated by pleasure in their being not satisfied. The hedonization of refusal becomes the guardian of the feeling of being or existing in one's own right, corporeal activity and the body being thus liberated from all external holds. The most complete form of this hedonization of refusal is "hunger orgasm."

Different studies stress the importance of the dependence/autonomy conflict and the fundamental vulnerability of anorexics. This vulnerability is associated with powerful passive desires and, as a consequence, a constant fear of intrusion, particularly an invasion of the body by the object on which these desires depend. To pose the problem in terms that highlight the paradox of anorexia: anorexics destroy themselves to prove their own existence. The destructive effect is not sought after for its own sake, and in this respect anorexia is not a suicidal behavior, although it can be seen as the result of unleashing aggression and turning against the self an incorporation fantasy of an object experienced as destructive for the self. Anorexia is the consequence of using a physiological need indispensable for survival to preserve a feeling of autonomy. In doing so—and this is the second paradox—anorexics find themselves in fact more dependent on an environment from which they sought to free themselves. By making refusal the instrument of their liberation, they alienate themselves from the object of the refusal, which they can neither lose nor interiorize.

The anorexia-bulimia tandem leads to questions about whether a problem of dependence underlies other behaviors grouped under the label "addictive behaviors": drug addiction, alcoholism, pathological gambling, and shopping, as well as abuse of psychotropic drugs and kleptomania. The fragile narcissistic bases of such addicts makes their object relations difficult to manage, because these object relations become too exciting and too dangerous. Addiction to products or behavioral practices offers addicts a need-satisfying relational substitute that is always accessible and which they believe they can control, while in fact they fall into its grip.

The eating disorder represents a substitute for the object whose loss could plunge these patients into a collapse. This attempt to find a substitute object in addictive behavior represents a perverse organization of a relationship to the object in which the object is not recognized as having its own desires and differences, but is acknowledged only for purposes of narcissistic reassurance. An analogy exists among these patients' relationship with food, their relationship with their own bodies, and their object relations, as well as their modes of emotional investment in general.

Family-therapy approaches illustrate the sensitivity of these patients to the influences of their environment. These eating disorders can be seen as existing at an intersection between individual psychology, family interactions, the body in its most biological aspect, and society in general. An essentially mental disorder may thus have grave somatic consequences, and these consequences may in turn affect the anorexic's psychic state and thus contribute to maintaining the disorder.

Addictive behaviors raise questions about the type of society in which we live, particularly with the increase in the frequency of these disorders accompanying the increase in consumerism in our societies.

PHILIPPE JEAMMET

See also: Adolescence; Autistic capsule/nucleus; Bulimia; Flower Doll: Essays in Child Psychotherapy; Kestemberg-Hassin, Evelyne.