Trauma and anorexia nervosa etiology

Trauma and anorexia nervosa etiology


Abram Sebastian Salim *







































* Retired Associate Professor of the Department of Mental Health
Faculty of Medicine, Federal University of Minas Gerais
* Psychoanalyst Psychoanalytic Society of Rio de Janeiro

Abstracts

The author uses as method his clinical practice as a psychoanalyst and psychiatrist for over a decade, coupled with studies on post-traumatic stress disorders, experimental psychology and neurobiology.
He suggests in this paper that AN etiology is due to a traumatic experience felt by the victim with feeling of death and needs a special predisposition, developed by a previous occurrence of another trauma during the fetal or perinatal age with the same characteristic.
These traumas triggered neurobiological innate and reflex responses of the body to prolong life and to auto appeasement the anguish of death present, like the return to the initial basis of human metabolism and auto generation of sensorial perceptions using body elements as fingers and the skin. The victim remains fixed to them for the rest of life.
Psychoanalytic psychotherapy is essential in the treatment, although the proposed etiology is neurobiological. It allows the analysis of the severe superego of the anorexic patient that grows up with difficulties since the birth and becomes victim of criticisms of others that internalizes. It happens a damage to future affective, social and professional life.
His positive clinical results suggests the continuation of these studies.





























Keywords: nervous anorexia; etiology; trauma; death anxiety; implicit memory; psychoanalytical psychotherapy.
Introduction
Nervous Anorexia (NA) is an eating disorder of varying severity. Its etiology has been studied by experts in various fields without conclusive result.
There are several hypotheses to explain it such as genetic1, religious2, hormonal3, neurologic4, socio-cultural5 and psychogenic6. These assumptions generate different diagnostic and therapeutic approaches that form a patchwork quilt, but without seams, do not unite. Each specialist focuses within its own framework.
The NA has several clinical manifestations, sometimes enigmatic and paradoxical as: the patient refuses to eat when it is clear their malnutrition; he sees himself fat in the mirror, when he is emaciated. That is, he is not aware of the seriousness of his condition, although walk to death.
In this paper, I emphasize that there are patients with clinical features of NA transient, very common in medical and psychological care. They are not diagnosed and are treated as depression.
My goal is to present a traumatic etiologic hypothesis of a neurobiological nature, whether physical or psychological trauma, requiring it to be experienced by the victim with feelings of death and the need of a predisposition formed by a previous fetal or perinatal trauma, registered in implicit memory, to which the victim of traumatic recurrence returns instinctively. This trauma activates two innate and reflex responses of the body: one to try to maintain life; another, to alleviate the distress of this death feeling.
The first seeks to reduce the absorption and oxygen consumption by the cells of
the body in a minimum to maintain the vital functions7. For auto appeasement of the anguish of death, the patient develops a phylogenetic production of auto sensory sensations produced with by the body with its elements as tongue, fingers, feet, saliva, feces, urine and other on its sensory surfaces such as skin and mucosas8, already present in fetal period, as shown in work done with ultrasound fetal9. These elements accompany us throughout life and are represented in latter ages by the biting of nails, push the car keys in the hands, straighten the hair, etc.
I believe that psychoanalytic psychotherapy is central to treatment, due to the maintenance of the therapeutic setting that allows the reconnection between the neural structures of the hypothalamus with that one of the cortex10, as well as the restoration of personal trust in the external medium. This hypothesis constitutes a new paradox, since this paper proposes a neurobiological etiology.
The application of these studies in my clinical practice has resulted in significant improvement in symptoms and patient adherence to treatment.

Method
The method used by me in this conceptual work is a combination of my twelve years clinical practice as psychiatrist and psychoanalyst, interdisciplinary studies, studies on post-traumatic stress disorder, experimental psychology and neurology.
I follow the references of the DSM-IV11 to diagnose NA:
A - A commitment of the anorexic patient to maintain body weight at least 85% below normal body weight for age and height, accompanied by an intense fear of gaining weight, even though emaciated.
B - A disorder in order to experience weight loss, as no notion of slimming and denial of the risk of weight loss. Also the perception of distorted body image, ie, the anorexic sees or thinks fat.
C - Women who have started their menstrual cycle have at least three consecutive periods of amenorrhea or menstruation appears only after administration of the hormone.
I included in this work, the transient cases of anorexia to post-traumatic patients, which are common in clinical practice of physicians and psychologists, already commented. Commonly they show loss of appetite, refusal of food, weight loss, libido loss, physical layout, different psychosomatic symptoms, phobias, daytime sleepiness, fears, anxiety and other symptoms. Appear after the occurrence of traumas experienced with subjective or objective risk of death that may happen with a surgery, a physical violence, a torture, a sexual abuse, a dear relative loss, a marital separation, a kidnapping, a forced period of overwork and other stress situations. These symptoms may be short-lived or become chronic.
This study is also based on the latest publications held in national and international journals.

The trauma and the relationship to the etiology of AN
Lay observations show that children, babies and pets develop NA, when left in the care of strangers or when radical changes in the environment happen. If they are not removed in time such circumstances, they may die of auto inanition.
A study12 shows that birth trauma can cause symptoms of neonatal immaturity at birth and cause high levels of eating disorders.
In my clinical experience, I notice that it is possible to get from the patient or their parents, history of fetal trauma. When this is not possible, the neurobiology shows13 that the traumatic event appears in dream and can be detected with the aid of the understanding of the functioning and purpose of implicit memory, as chaotic dreams of falling, freezing, death, tight passages, etc.
Another indication of early trauma is the observation of embarrassment, soon after birth, to establish a healthy relationship between the newborn and mother, with feeding difficulties, excessive sleepiness, presence of autism early signs, such as continuous suction of the finger, the backslider and listless look, a motor slowness and others that usually accompany a newborn for the end of his life.
Other studies14,15 show that rats and monkeys, when separated from their mothers from birth to ten days, and kept isolated for six months, when put back in contact with the matrix and with other rats or monkeys, showed up at all, strangers, sought isolating and maintaining in a state of diminished vitality, and this is an irreversible state. However, the same did not happen with the second control group, separate arrays of ten days after birth, because when rats and monkeys returned to living with them, socialized and soon recovered its vitality.
Experimental16 psychologists, working with rats have shown that they become hyperactive in front of an obstacle to take the food and, contrary to what is expected, they eat less when they reach it. The phenomenon is paradoxical: it was expected that rats were to eat more when they have access to food; however, there is a loss of appetite. The researchers have not found such a hypothesis to explain this phenomenon.
Another more recent study17 continued the experiment with rats and because of evidence has indicated a possible correlation between NA in human and rats. The author used a control group of rats that had free access to a cage with food, attached to a wheel rim with 33 cm in circumference, around which ran; and another group whose access to the cage could be closed certain hours of the day. After a few days, after alternating bouts of free access to food with restricted access in one-hour intervals, the mice lost weight and could die if they were not removed from these conditions. He also observed that, as they lost weight, became more accelerated and ate less when they returned to have free access to food. He comments that, although aware of this last element for over forty years, no one knows the cause. This phenomenon is paradoxical, because it is expected that these mice eat more as your weight decreases, but actually eat less than those used as control in the experiment. Experience has demonstrated that its weight loss is not associated with loss of calories per becomes more accelerated, but at an activity that includes a state of stress - or the expectation of having no access to food.
Another important contribution7 was made experiments on human bodies, to increase the number of hours for use in transplants. For this, the solution of H2S, which decreases oxygen consumption by the cell to carry out the vital functions, with a damping of life, which, according to the experimenters, is placed in a "state of suspended animation" was used. Through various evidences, these scientists were able to demonstrate that this process can happen in humans, being activated in adverse living conditions, repeating the phenomenon of hibernation with plants and animals, allowing their survival for decades.
There is convincing observations of humans who have undergone several hours without oxygen as in accidents such as burial by ice or land. These victims have reactivated the process of blocking mentioned the oxygen that is instinctively activated, demonstrating that the human body also had the flexibility to dampen cellular activity when in stress. Thus, these victims, like animals and plants, showed extraordinary resistance to environmental stresses such as excessive temperatures, oxygen deprivation and physical injuries. Thus, the researchers were able, with the use of solution of H2S, prolong the lifetime of various organs to be transplanted, performing an important achievement in science.

The predisposition -------------------------------------------------------------------------------------------------
The predisposition to the development of NA has been related to genética1, but no concrete evidence has been found so far.
In citada17 experience with mice with broad access and restricted access to food, is considered the relationship of the state of auto inanition with age of the mice, the ambient temperature and the type of food. However the author highlights as most important element for the development of auto inanition the mouse, the occurrence of stress states resulting from failures in the period of motherhood. There are more experiences14, 15 emphasizing the importance of early trauma.
Studies on the tept18 made with victims of road trauma, found that victims of serious accidents do not develop PTSD, and other victims became sick after minor accidents. In the personal history of the latter had always occurred earlier traumas.
The relationship between prenatal trauma and autism spectrum disorders was marked by highlighting studies19 onset of symptoms in autism spectrum chronic course of NA. The study reveals impaired interpersonal processes and compares the phenotype of NA with autism spectrum disorders.
These interdisciplinary studies and my clinical practice suggests that the predisposition for the development of NA or transient transformation of NA is constantly generated by previous fetal or perinatal occurrence of a trauma with feelings of death, and the failure of the environment to help restore confidence of the continuity of life. These people live like they're in a fine line between life and death.
Traumatic recurrence can occur at any age, either with the baby, the child or young person, adult or senile. The victim runs reflexively, the same way back in search of the sleep state of life to which it became attached and becomes a fulcrum for survival when threatened. This response is similar to the mechanism of psychic regression in search of survival, described by Freud20 and illustrated by him as similar to the advancing armies, but leave behind him, points of support to which they can return if necessary.
Such studies allow hypothesize that the biological response to injury varies with the stage of maturation of the nervous system.
Another important contribution was made by neurobiologia21 with the study of implicit memory, showing that this works similarly to the Freudian unconscious. Responsible for acts performed automatically, geared for survival. Thus, unlike Freud22 so that the dream related to the performance of sexual desire suppressed from daytime waste, neurobiologia13 has shown that the dream is also a neuropsychological process by which a short daytime learning related survival is transformed into a learning long term (long term memory).
The knowledge that the body has a way of relating to the environment and innate reflex manner through existing records in implicit memory, independent of our cognition, often allows anticipate the existence of a traumatic event.

final Thoughts
The anorexic patient is difficult clinical management by fear to move in its objective and subjective delicate balance between life and death.
Due to the troubled relationship with her mother since birth by said failure usually grow without finding a means enabling environment to heal the disconnect-cortex and hypothalamus to restore confidence in the environment and the processes of separation and individuation of a baby normal6.
Consider the symptoms of NA as biological concomitants of trauma and therefore lack of mental representation, that is, have no psychological unconscious elements, whether sexual or aggressive, as advocate psicanálise6. Thus, it is unfounded to think they can hide a psychic conflict or will have a mental representation with the progress of psychoanalytic therapy, that is, objects are psychoanalytic interpretation.
We conclude that NB is an attempt to survive, although his approach bringer of death due to weight loss sought.





Clinical cases
Patient with twenty-three, emaciated, clear color, good IQ, divorced. At first, query reported loss of weight since her teens, when she began to avoid solid food and measure the calories ingested obsessive way. Since then, when it exceeds the intake has vomiting, laxative use, diuretic and sharp intake of water. It feeds primarily chocolate. Associated with this eating disorder, the patient has intolerance to prolonged contact with people, to cold, heat and noise. Opts for social isolation and has a feeling of existential emptiness. It also presents insomnia, disinterest in life, fatigue, drowsiness daily, amenorrhea, constipation, bruxism, sweating, salivation, difficulty in concentration and memory. Feel a depression without sadness.
He told me that, at four years, was subjected to sexual abuse by his uncle for two years, keeping this fact only for them due to afraid to tell her father and mother. His symptoms began at the age of fourteen. Was preparing to be a model because of her emaciated body and facial beauty. Having been encouraged by his family to take a course for which he traveled abroad at seventeen. Remained there a year, packed the course. Then no longer had tolerated physical impairment, which started to damage it, added to the absence of the mother and boyfriend. After returning, he married and set up home with furniture from the mother, although the husband insisted on buying new furniture. After a few months apart due to food obsessive ritual that developed, menstrual dysfunction and extreme attachment and submission to the mother. The ex-husband left the apartment but returned frequently, attending to their requests. The patient began a job as a teacher. Then presented compelling need to sleep in the afternoon, a fact that embarrassed their daily lives. There was accentuation of food rituals, panic attacks with fear of death and social phobia. She made several psychiatric and psychological treatments with no improvement. Became skeptical and only sought me indication of a friend, who was my patient. At the end of the consultation, you prescribed a benzodiazepine at bedtime and proposed psychotherapy with two weekly sessions fifty minutes each.
At the beginning of treatment, she reported that it was difficult to continue the work and that people look at you differently and that, sometimes, avoided her because she was uncommunicative. She felt inadequate to physical effort and friction with people, but mother insisted that worked.
He told me a dream in which she was lying and was not breathing. He tried to move and could not. He felt powerless. Heard a voice saying to him: "They're sewing a new blouse for you. It is very tight. "Woke up with a dream, feeling bad.
I finished the session by telling him that his dream indicated the current physical state of failure, but brought hope of improvement with psychotherapy - the voice announcing a new blouse.
The patient comes regularly to appointments due to my empathy for their failure to family, social and professional life. Always dresses in black. Sometimes speaks of her ex-husband and attachment to mother and father. Occasionally mentions of temperature, but a lot of sense, trauma relating to sexual assault. Unwilling to return to those scenes - as with most post-trauma patients. He told me, even though her mother that the pregnancy was normal, but the delivery was laborious. Born with blood running down his head due to the forceps and her mother spent a month without being able to put her up due to infection of the points arising from the suture held. After progressed well, but at two years showed that only severe bronchial asthma disappeared eight years.
After six months, still confirming its state of failure and stress, reported a dream in which her car could not go on a small rise near her home and she tried to push him, but felt powerless.
After three years, the patient arrives and I notice most is stained and the timbre of the voice stronger. Tell me, for example, that his end out good week that was with her boyfriend with whom are living, picnicking, but it entered the water only once because it was cold, but was happy to wear costume bath. He also told me that he did not live, only existed, and all mechanical.
Now she is living without fear of vomiting and is planning a trip to the home of her boyfriend's parents. Not being carried by the tendency to always stay at least as it did to feed. Still in psychotherapy.
Another patient shows a weight loss of eleven pounds two years now, after the loss of her husband, two brothers and the output of the child from home, staying alone. His doctors have raised suspicion, to explain this weight loss, the existence of an undiagnosed cancer. She then underwent a complete workup to detect the possible presence of cancer, and now is being submitted for the second time, for colonoscopy, breast and brain scan for the sake of conscience of its clinical. This considers only the weight loss resistant to usual medical treatment and did not take into account his memory loss, his daytime sleepiness and other symptoms indicative of his post-traumatic stress. Because of loneliness and medical mistakes, it presents a framework equizoparanoide, which took their children to seek me.
Was prescribed antipsychotic (risperidone), benzodiazepine and antidepressant and began psychoanalytic psychotherapy once a week. She came and continues to come to the meeting accompanied by a relative due to the fear of going out alone at the street and your state weakness without leg strength. After a month, improved psychotic symptoms and risperidone was discontinued. Began to sleep better and their relatives informed me that he was much better at home, but without entering into details. In the initial sessions, kept her focused on physical complaints, but gradually was encouraged to talk about their losses and dreams. I think the patient would not be in Psychotherapy longer, because soon started talking about spacing of sessions. I was inclined not to continue it, because even still no appetite, lost weight and general weakness. However, I considered his continued presence at sessions, their attachment to my person and the positive manifestations of relatives. After six months, she began to show improvement in appetite, weight loss and sleep with the absence of any psychotic symptom.
Another patient presenting progressive weight loss comes seven months with loss of eight pounds, after the arrest of his son on charges of drug trafficking. At the beginning I did not understand why psychotherapy, but gradually was adhering to treatment because of the improvement occurred. Was used only as an aid benzodiazepine treatment.

Discussion of clinical material
Consider that improvements occurred in patients by recognizing its shortcomings for family life, personal and professional and the need to spare. As reaction formation, insisted on increasing your family, professional, social performance to prove sufficient, factors for aggravation of wear, failure and stress as a result of the internalization of external criticism.
Understanding the charges of his superego allowed me the interpretive work, so working with a third sujeito23para promote auto appeasement, not formulating charges. This item shows the importance of psychoanalytic treatment for this type of patient to identify the transfer of countertransference and death anxiety, paranoid-schizoid and depressive concepts. Can be avoided, so iatrogenic treatment.
The neurolobiologia24 has demonstrated that the maintenance of regularity and constancy of the setting of the psychoanalyst, provided by the technique of analytic psychotherapy, are elements that allow the restoration of sense of security for the resumption of physical and psychic processes of biological maturation. .
This paper is a preliminary communication. Suggest its continuation by its clinical results achieved, or relating to symptomatic improvement, or relating to the attachment of patients to treatment.

















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Bulik C, Landt M, Van Furth, E. & Sullivan P. The genetics of anorexia nervosa. Ann Rev Nutr 2007; 27: 263-275.
2. Procopius M. Marriott P. Intrauterine Hormonal Environments and Risk of
Developing Anorexia Nervosa. Arch Gen Psychiatry. 2007; 64 (12): 1402 -1407.
3. HK Walter, Julie LF, Martin P. New insights into symptoms and neurocircuit
function of anorexia nervosa. Nature Rev Neurosc. 2009; 10: 573-584.
4. McDougall J. Theaters of the body. Psychoanalytic approach to
Psychosomatic illness. New York-London: W. W. Norton & Company; 1989.
5. Blackstone and Morrison M, Roth MB. Hydrogen sulfide induces the Suspended
Animation-like state mice. Science. 2005; 308: 518-525.
6. F. Tustin Autistic barriers in neurotic patients. London: Karnac Books; 1986.
7. Piontelli A. From fetus to child. Rio de Janeiro: Imago Editora; 1992.
______. L' Observation des Jume aux dès avant la Naissance. In Le Baby
Danstous Etats Colloque Gypsy II. Paris: Editions Odile Jacob; In 1997.
8. Salim SA. Psychoanalysis today: trauma, disconnection and posttraumatic stress
disorder. Rev Soc Psychoanalytic RJ Brazil. 2005a; 4: 105-134.
9. DSM-IV. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition.
Washington: American Psychiatric Association; In 1994.
11. Levine P. Waking the tiger: healing the trauma. Berkeley, CA: North Atlantic
Press; In 1957.
12. Harlow H. The nature of love. Am J Psychol.1958; 13: 673-68.
13. RA Boakes. Self-starvation in the rat: running versus eating. Span J Psychol
2008; 10 (2): 251-257.
14. Scaer CR 18. The body bears the burden. New York: The Haworth Medical Press; In
2005.
15. Freud S. Regression. Complete Psychological Works of Sigmund Freud (vol.
XVI). Rio de Janeiro: Imago; 1976.
16. Kandel E. Biology and the future of psychoanalysis: a new intellectual framework
for psychiatry revisited. Rev Psiq Rio Grande do Sul in 2003; 25 (1): 139-165.