Death related themes in anorexia nervosa: a practical exploration

The Interpersonal-Psychological Theory of Suicide to Explain Suicidal Risk in Eating Disorders: A Mini-Review

Suicide is a major cause of death in Eating Disorders (EDs) and particularly in anorexia nervosa (AN). The aim of the present mini-review was to summarize the literature focusing on the interpersonal-psychological theory of suicide (IPTS) by Thomas E. Joiner, as applied to explain suicidal risk in EDs. PubMed database was used to search articles focused on IPTS in EDs; 10 studies were eventually included. The majority of the included studies reported data from the same sample, even though the hypotheses and analyses for each study were unique. The investigated suicidal outcomes were suicidal ideation (SI) (40%), non-suicidal self-injury (10%), suicide attempt (40%) and suicide (10%). In ED patients Perceived Burdensomeness (PB) may play an important role, especially regarding SI risk. ED patients may feel like a burden to their close ones, and actually some of the ED symptoms may be an expression of anger and hate against the self. Overall, currently available research has supported some IPTS derived predictions (i.e., ED symptoms may increase PB and thereby SI), but not others (i.e., the elevated suicide rate in AN may be due to higher acquired capability for suicide). Further research on IPTS tenets as well as on other theoretical perspectives and constructs (e.g., interoceptive awareness), hopefully with a longitudinal design and adequate follow-up duration, might allow a more thorough understanding of the complex topic of suicidal behavior in ED patients.

Death Anxiety, Perfectionism and Disordered Eating

Recently, death anxiety, or dread of death, has been proposed as a key transdiagnostic process underlying the anxiety disorders, depressive disorders, somatic disorders, and trauma and stressor-related disorders. In fact, it has been argued that death anxiety underlies all psychopathology, and is more fundamental than perfectionism, a process which was previously considered the root of mental illness. However, there has been a paucity of research examining the relationship between death anxiety and the eating disorders, although these conditions have been found to be strongly related to perfectionism. The present study therefore aimed to examine whether death anxiety is related to disordered eating, and whether death anxiety is a better predictor of disordered eating than perfectionism. A sample of 164 participants (132 female), average age 33.55 years (SD= 15.45 years), completed an online survey comprising background questions (age, sex, diagnosed psychiatric disorder), the Eating Attitudes Test — 26 item version (EAT-26), the Almost Perfect Scale — Revised (APS-R), the Rosenberg Self-Esteem Scale (RSES), and the Death Anxiety Scale (DAS). The findings of a hierarchical multiple regression analysis with EAT-26 as the dependent variable, age entered at Step 1, the RSES and APS-R entered at Step 2, and the DAS entered at Step 3 showed that only death anxiety and self-esteem were independent predictors of disordered eating at Step 3. A simultaneous multiple regression analysis was subsequently run with age and the APS-R alone as predictors of EAT-26 scores. This analysis showed that perfectionism was only a predictor of disordered eating when death anxiety and self-esteem were not included in the regression model. Death anxiety and self-esteem both appear to be important transdiagnostic processes.

Anorexia nervosa: towards an integrative neuroscience model

We reviewed the evidence for emotion-related disturbances in anorexia nervosa (AN) from behavioural, cognitive, biological and genetic domains of study. These domains were brought together within the framework of an integrative neuroscience model that emphasizes the role of emotion and feeling and their regulation, in brain organization. PsychInfo and Medline searches were performed to identify published peer-reviewed papers on AN within each domain. This review revealed evidence for 'Emotion', 'Thinking and Feeling' and 'Self-regulation' disturbances in AN that span non-conscious to conscious processes. An integrative neuroscience framework was then applied to develop a model of AN, from which hypotheses for empirical investigation are generated. We propose that AN reflects a core disturbance in emotion at the earliest time stage of information processing with subsequent effects on the later stages of thinking, feeling and self-regulation.

Rejection of life in anorexic and bulimic patients

OBJECTIVES

To investigate eating- disordered (ED) patients' attraction to life and death.

METHOD

Thirty-two anorexic and 37 bulimic patients were matched by age, sex, and socioeconomic status to 37 matched normal controls. Participants were administered the Eating Attitudes Test (EAT-26), the Beck Depression Inventory (BDI), the Multiattitude Suicidal Tendency Scale (MASS), and the Selflessness Scale.

RESULTS

ED patients scored significantly higher on the Selflessness Scale than normal controls. They are less attracted to and more repulsed by life than normal controls. In death variables, attraction to or repulsion by, no significant differences were found. These results were not influenced by depression. The higher the tendency of ED patients to ignore their needs and serve other's needs (high Selflessness scores), the higher their tendency to be attracted to death and to be less attracted to life.

DISCUSSION

ED patients, rather than dwelling on death, reject life. Theoretically, the findings support differentiation of death preoccupation to several components. Clinically, the findings might direct clinicians to help patients reduce their "self-guilt," that is, guilt of promoting their own interests.

Adverse life events and resilience

OBJECTIVE

Adverse life events are well-documented risk factors of psychopathology and psychological dysfunction in children and adolescents. Youth with good adjustment despite high levels of adverse life events are considered resilient. This study identifies factors that characterize resilience.

METHOD

Household probability samples of youth aged 9 through 17 years at four sites were used. Main and interaction effects of 11 factors were examined to assess their impact on youth adjustment.

RESULTS

Children at risk because of higher levels of adverse life events exhibited a greater degree of resilience when they had a higher IQ, better family functioning, closer parental monitoring, more adults in the household, and higher educational aspiration. The interaction between maternal psychopathology and adversity was significant, and the interaction between IQ and adversity approached significance.

CONCLUSION

Resilient youth received more guidance and supervision by their parents and lived in higher-functioning families. Other adults in the family probably complemented the parents in providing guidance and support to the youth and in enhancing youth adjustment. Higher educational aspirations might have provided high-risk youth with a sense of direction and hope. Although IQ had no impact in youth at low risk, youth at high risk who had a higher IQ might have coped better.

Paradox, persecution and the double game: psychotherapy in anorexia nervosa

OBJECTIVE

In anorexia nervosa, the interface between psychotherapy and effective physical management continues to arouse dissent. For this reason, theoretical underpinnings and their practical applications were explored.

METHOD

A selective review of the literature was based on the authors' clinical experience in hospital treatment settings.

RESULTS

The psychosomatic paradigm, the threat to life, the reward characteristics and the developmental trajectory of anorexia nervosa necessitate a particular form of integrated psychotherapy.

CONCLUSIONS

The approach is essentially that of self psychology but with an important departure which must be addressed in the therapeutic process. This is exemplifed in the paradox of persecution by refeeding and the curious double game that evolves.

Life event precipitants of adolescent anorexia nervosa

As part of a prospective outcome study, independent life events occurring in the year before onset in 35 consecutive cases of anorexia nervosa were recorded by a semi-structured interview with the subject and a parent. Negative impact and context were rated blind, using the case vignette method. Subjects with anorexia reported intermediate rates of negative life events between community and psychiatric controls. Chronic adversities were common. Negative life events were associated with depressive disorder in controls, but not in those with anorexia. Significant under-reporting of events may occur in this population.

Complications of bereavement as seen in infant anorexia and adolescent anorexia nervosa

In a certain number of cases, parents of infant and adolescent anorexics may exhibit complications of bereavement. Both infant and adolescent forms of anorexic symptoms constitute indeed two distinct pathologies. Sometimes, however, these two forms of anorexic symptoms share points in common, namely a psychopathological aspect. Making references to two clinical cases, the authors show that difficulties in the mourning process may in fact play a key role in the constitution of anorexic symptoms.

A study of the relation between eating disorder and death concern

The relationship between eating disorder and various components of death orientation (fear, anxiety, acceptance and concern) was examined, taking into account the level of depression in patient samples as well as elements of religiosity. The results were not able to support more than a very modest relationship between eating disorder and death orientation. Eating disorder patients could not be distinguished from other clinical controls, nor did anorexia nervosa patients differ from other eating disorder patients in this respect. Beck and Beck [20] depression scores were higher in the non eating disordered clinical sample than in the eating disorder group, and death concern was shown to be related to the severity of depression. Religiosity did not appear important when indices of religiosity were considered, but did emerge as an important factor in the "free information" provided by participants.

Themes of death: Helmut Thomä's "Anorexia nervosa" (1967)--a research note

In the recent literature on eating disorders, little attention is usually given to the possible role played by heightened death fears and anxieties and failed death transcendence in the dynamics of patients who suffer from anorexia and bulimia nervosa. For reasons that remain unclear, early texts and articles in the literature do address death themes, particularly as they are discernible from patients' dreams and nightmares. Thomä's 1967 text Anorexia Nervosa may be interpreted as giving further illustration to this thesis.