A Summary of
“Abandoning the Body: Trauma, Eating Disorders and Dissociation”
Presented by
Laura Weisberg, Ph.D.
October 1, 2005
By Dr. Joan Fox
“Hunger hurts, but
starving works when it costs too much to love.”
—Fiona Apple,
“Paper Bag”
One of the strengths of NESTTD, in my opinion, is that it provides a
comprehensive understanding of how adult survivors of trauma become adept at
creating compensatory strategies to self-regulate. Eating disorders incorporate
intricate strategies that use the body as a vehicle for attempting to regulate
or discharge tension.
In this workshop, Weisberg, an expert in eating disorders, provided research,
theory and clinical application showing the role that trauma plays as a risk
factor in eating disorders. Citing the research, Weisberg pointed out that
30-61 percent of eating disordered clients report a history of some form of
sexual abuse. Sexual abuse is associated with greater comorbidity (depression,
anxiety, OCD) and tends to be associated with other self-destructive behaviors
(substance abuse, mutilating). While a history of abuse doesn’t indicate the
actual severity of eating disorders, a history of trauma usually does suggest
more disturbed eating attitudes. The variables that mediate symptom severity
include interfamilial abuse, younger age at onset of the abuse, multiple
episodes of the abuse, use of force and/or fear, poor maternal relationship,
lack of parental reliability, and cognitive interpretation of the abuse.
Teasing out the relative roles of sexual, physical, and emotional abuse and
neglect, Weisberg cited research indicating that childhood emotional abuse plays
the greatest role in the development of eating disorders. Other forms of abuse
have greater effect when they occur in the context of an emotionally abusive
environment. Dissociation and anxiety play a direct mediating role between
emotional abuse and eating pathology. There tend to be higher levels of
dissociation in abused eating-disordered clients than in those who are nonabused.
Neurobiological changes (dopamine, serotonin and opioid) may account for
dissociation during the acute phases of eating disorders. Purging, for example,
might be one way that a client attempts to rid herself of intense emotions.
Feelings of panic might subside or reduce during eating.
As might be expected, effects of abuse on treatment outcomes for eating
disorders indicate complicating and perhaps lengthening the treatment. Comorbid
symptoms (such as depression, substance abuse, PTSD) might need to be addressed
as a prerequisite for stabilization and recovery.
The psychological functions of eating-disorder symptoms fit well into trauma
work conceptualizations of disregulation, attachment theory and negative
cognitions. Weisberg points out that the eating-disordered client has poor
affect tolerance, vacillates between hyperarousal and hypoarousal, uses food as
a means to avoid pain and memory, and tries to establish food as her primary
relationship. Eating disorders provide a means for reenactment of the trauma
while enabling avoidance of painful feelings such as shame and guilt. In
addition, eating provides a means for dissociating as well as a way out of
dissociating (for example, moving out of numbness into alertness).
Emotion can often be felt as physical threats, in part, due to how present
stresses are experienced as past trauma. Thus, present triggers that arouse the
sympathetic nervous system activate “emergency responses” (requiring emergency
measures of eating disorder symptoms), which then provide psychological and
physiological release (the parasympathetic nervous system). Over time, these
symptoms become compensatory strategies to self-regulate and self-medicate, and
to manage signals from somatic memory and physiologic arousal.
Eating-disorder symptoms have pervasive impacts on cognitive, emotional and
physical functioning. There is a preoccupation with food that makes
concentration difficult and slows the process of recovery. Also challenging to
treatment is the tendency for cognitive rigidity, increased need for order and
control, and increased vulnerability to flashbacks and dissociation. For many
clients, eating-disorder
symptoms are considered a solution and not a problem. So even in the face of
starvation and extreme risks to health and well-being, some people reject the
need to address the
eating disorder, which to them is a survival strategy.
Hospitalization is necessary as determined by a physician. Usually the criteria
involves weight loss below 25 percent of ideal body weight, electrolyte
imbalances, medical instability, or another sudden change in physical or mental
status. Hospitalization is often recommended when severe symptoms continue
despite an adequate trial of intensive outpatient treatment. Working as a team
with medical professionals functions best if the physician is knowledgeable and
willing to listen. The relationship between the client and the physician is
crucial: ideally, one in which the client feels listened to and safe rather than
controlled. Nutritionists are often behaviorally trained and can teach small,
negotiated steps for healthy eating. Psychopharmacology seeks to meet the needs
of clients when medications can be their most effective (sometimes after weight
is restored).
Weisberg provided two case examples of effective treatment. In both clinical
scenarios, she emphasized the relational context of healing. Eating-disordered
clients are hypervigilant to fears that the violation of the attachment bond
will be repeated; therefore safety, security, reliability and predictability of
the therapist are paramount. The therapist is, in effect, competing with the
eating disorder, which as stated, the client is often loath to give up.
Teaching the client to recognize physical cues in service of regulation is an
important step in helping her reconnect to her body. Having attended Janina
Fisher’s weeklong training this past summer on Sensorimotor Psychotherapy, I was
pleased to hear Weisberg’s emphasis on teaching how the body can be an ally
instead of an enemy.
Weisberg had much to offer with regard to how eating disorders serve an array of
functions as ways to cope with trauma symptoms, dissociation, and psychosocial
isolation, and to manage arousal and phobia about bodily sensations.
Unfortunately, her attempt to cover too much ground left little time for
discussion about the two case examples that used contrasting treatment
approaches in treating restricting eating disorders.
Shortly after attending this workshop, I came across a recent report by the
National Center on Addiction and Substance Abuse at Columbia University about
the benefits of eating meals together as a family. The study showed that when
families eat five or more meals together a week, 12- to 17-year-olds are less
likely to drink, smoke or use drugs and are more likely to have good grades and
a sense of well-being. Apparently, this simple ritual is a protective factor
for youngsters. Adult survivors of trauma and eating disorders use high-risk
behaviors as attempts to protect themselves by diminishing states of fear and
helplessness and substituting states of well-being. If only there had been true
protection for them!
Dr.
Joan Fox has a private clinical practice in Norwood, Massachusetts.