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Aggression and Violent Behavior

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Looking for the origins of anorexia nervosa in adolescence - A new treatment approach

S. Matt Lacoste1

Univeristy of Toulouse, 5 Allée Antonio Machado, 31000 Toulouse, France

A R T I C L E I N F O

Keywords: Anorexia nervosa Family Sexual assault Psychological treatment Case study

A B S T R A C T

Anorexia nervosa is an eating disorder, which affects particularly adolescents. The media coverage of feminine thinness is demonstrated as a token of beauty, with diet as a tool to achieve this. However, diets are not enough to explain the numerous cases. This disease is the symptom of a psychological disorder and looking for the origin must coincide with psychotherapeutic treatment. Multifactorial explanations seem dominate within our female patients. For most female patients, family problems and past experience with sexual assault explain this tran- sition to anorexia. It is demonstrated throughout this paper how and why anorexia nervosa is used as a tool for identification and personalization in the assumption of autonomy and independence, and how and why anorexia becomes a defensive response to aggression. We give a clinical confirmation of the diverse origins of anorexia nervosa and of the impact of sexual abuse. This paper proposes a new therapeutic approach to patients with anorexia nervosa, in which the eating disorder is a symptom of an emotional disorder, often triggered by sexual assault or emotional deprivation.

1. Introduction

Anorexia Nervosa is an “eating disorder with more or less system- atized refusal to eat, acting as a reply form to psychic conflicts” (Bloch & al., 2000). People with anorexia nervosa (90% are women) have a distorted body image that causes them to see themselves as overweight even if they are dangerously thin. In their lifetime2 0.5% to 3.7% of females suffer from anorexia nervosa. It is the third most common chronic illness among adolescents3 after obesity and asthma. Populations most deeply impacted by anorexia nervosa include women in the age ranges 13–14 years old and the 18–20 years old. Studies continue to support this research, noting that 95% of those who have eating disorders are between ages of 12 and 25.4 Anorexia nervosa is a full disease which impact around 1.5% of French women of 15 to 35 years old. Additionally in the United States of America, studies es- timate that 1% of adolescents and 0.5 to 3.7% of women suffer from anorexia nervosa.

While women of all social classes are impacted from anorexia ner- vosa, it can be noted that matriarchal families seem to be over re- presented (Marcelli & Braconnier, 2004). These subjects tend to deny that their eating behavior is problematic and we estimate that only one

third of these people have received a treatment. Of these 30%, the percentage of people recovered completely is low (Herzog, Nussbaum, & Marmor, 1996). Four years after the anorexic period we count 44% of patients with good recovery, but seven and half years after, this number decreases to 33% (Herzog et al., 1999). A majority of studies find that only 11% to 40% find recovery and 1 out of 2 anorexia nervosa subjects relapse.

In accordance with Botha's (2012) observations, traditional under- standings and approaches to diagnosis and treatment for anorexia nervosa seem to be unacceptable, inappropriate and laden with social stigmatism. Societal stigma exacerbates these patients' struggles, leaving them dishonored, disabled, powerless and possibly in a place of greater distress.

These factors in mind, as psychologist who treats anorexia nervosa subjects, there are many questions that elevate in regards to recovery, treatment, and long-term success for these individuals. The family problematic and sexual abuse seem to be the mains origins of the be- ginning of anorexia nervosa. The main idea is to understand the link between the origin(s) of the disorder and its implementation. In this way, a therapeutic strategy appears.

Understanding the inner thoughts of these individuals is essential in

http://dx.doi.org/10.1016/j.avb.2017.07.006 Received 28 October 2016; Received in revised form 13 June 2017; Accepted 26 July 2017

1 Psychologist (Private Practice) - Assistant Professor of Psychology. E-mail address: [email protected].

2 National Institute of Mental Health (1994). 3 Public Health Service's Office in Women's Health – Eating Disorders information Sheet (2000). 4 Substance Abuse and Mental Health Services Administration – US Department of Health and Human Services.

Aggression and Violent Behavior 36 (2017) 76–80

Available online 03 August 2017 1359-1789/ © 2017 Elsevier Ltd. All rights reserved.

MARK

understanding why the recovery for this population is so challenging and why treatments are mostly ineffective. With a bottom-up clinical analysis of four patient therapies, throughout this paper we hope to answer to these questions.

2. Literature review

1- Adolescence and family: a family issue as anorexia nervosa origin.

Anorexia Nervosa and Bulimia are linked to multiples factors usually associated with psychological, family, social and biological in- fluences. These items intertwine and impact each over, contributing to the initiation, the maintenance and to the exacerbation of eating dis- orders (Rogé & Chabrol, 2007). Coinciding with this notion, Fairburn and Harrison (2003) found a combination of genetic variables im- plicated anorexia nervosa development in conjunction with environ- mental implications. Friends and family circle are connected to the disorder de facto, by the causes, by the consequences or both. We could find three times more anorexia nervosa subjects in the families whose parents have a history of this disorder (Strober, Morrel, Burroughs, Salkin, & Jacobs, 1985). This could confirm the genetic dimension of eating disorders displaying during the 1990s' (Bulik, Sullivan, Wade, & al., 2000; Grice, Halmi, Fichter, & al., 2002). But, the herit- ability of liability to eating disorders as Bulimia nervosa is difficult to prove (Fairburn, Cowen, & Harrison, 1999). For Collier and Treasure (2004, p. 365), “Increasingly, the consensus is that eating disorders are complex disorders consisting of both genetic and social factors, with a developmental component strongly linked to adult illness”.

Even if it seems difficult to define a psychological profile of anorexic adolescents' parents, studies show that anorexia nervosa is more common with distant parents who would be inclined to neglect their child, to not show affection, and when communication with children is volatile. Conversely, it is also found within families with overprotective parents who would be possessive, pervasive and they encourage ex- cessively the family cohesion. These parents' behaviors are typical of the parents of anorexic child. “Many authors (Brusset, 1998; Jeammet, 1993) focus on failures in primary identification process mother/ daughter marked with a dependency where the ambivalence dom- inates. The nature of the primary links would explain the frequent narcissistic breaches in these patients, and breaches are responsible of wrong perceptions of self-image and of body” (Marcelli & Braconnier, 2004, p. 153).

Shoebridge and Gowers (2000) found that the mothers of anorexia nervosa subjects reported higher rates of near-exclusive child care, se- vere distress at first regular separation and high maternal trait anxiety levels than the mothers of control subjects. They also showed that fa- milies with anorexia nervosa case, had experienced a severe obstetric loss prior to their daughter's birth. This could confirm that over- protecting parents or high concern parenting in infancy could be as- sociated with the later development of anorexia nervosa.

If the earlier mother's behaviors would have a negative impact on the adolescents' eating behaviors, anorexia nervosa could be considered as bodily intersubjective. The eating behavior and transformation of the subject's body play a role in the family relationship. Anorexia nervosa affects not only the subject's relation to food but also her relation to others (Legrand & Briend, 2015) and especially to her parents. The anorexia nervosa subject would use as a tool her eating disorder and bodily shape to address others, to manifest her distress or her desire, to put the others, and specially the parents, in a position to answer or to do something for her distress (Legrand & Briend, 2015). The study of Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, and Stein (2010) indicated that anorexia nervosa type patients presented significantly lower mentalization levels and lower quality of current relationships with their parents compared with non-eating disorder controls. When the verbal dialog seems to be difficult, the adolescent would choose another communication tool. Additionally, the adolescent could also try

to take power from her parents by her eating behavior. Indeed, anorexia nervosa subjects are obviously facing with paradoxical behaviors and thinking. The adolescent who searches for more autonomy, claims with conflict more independence, addresses to her parents to be taken care of by her eating disorder.

If sometimes, adolescents use anorexia nervosa to say something because it's too hard to use words, the therapy is the time to speak about their distress. Several researches found a link between sexual abuse or rape and anorexia nervosa.

2- Anorexia nervosa and sexual abuse.

Even if it is always difficult to have accurate measure of sexual abuse rates, as confirm Fallon, Collin-Vezina, King, and Joh-Carnella (2017) international trends from recent meta-analysis has shown alarming rates of sexual abuse cases with 18 to 20% for females (Pereda, Guilera, Forns, & Gòmez-Benito, 2009). Additionally, we know that 70 to 75% of child victims wait 5 years or more to report before disclosing the abuse (Hébert, Tourigny, Cyr, McDuff, & Joly, 2009). The interaction of different factors, with some can be unconscious and dif- ficult to identify, are generally at the origin of anorexia nervosa. Even if it is sometimes possible to isolate a trigger event (e.g. injuring comment on physical appearance, fight with parents, divorce of parents, romantic break-up); it is typically one event too many more rather than an iso- lated explanation. By contrast, it would seem that sexual assaults can be the (main) explanatory trigger of anorexia nervosa. Even if some re- searches try to argue the link between sexual abuse and eating disorders (e.g. Smolak & Murnen, 2002), several studies confirm the results in our patients in private practice. Favaro, Tenconi, and Santonastaso (2010) show that physical or sexual abuse of children result significantly in anorexia nervosa during adolescence. Deep, Lilenfeld, Plotnicov, Pollice, and Kaye (1999) found that 27% of anorexia nervosa subjects had antecedent of sexual abuse compared to a rate of 7% in control women subjects and it could be more important for bulimia nervosa patients (Casper & Lyubomirsky, 1997). According to the Center of Disease Control and Prevention (2007), 1 in 4 of young people ex- perienced verbal, physical emotional or sexual abuse from a dating partner; 8% have been forced to have sexual intercourse when they did not want and nearly 10% were hit, slapped or physically hurt by a boyfriend or girlfriend within the 12 months prior taking the survey.5

Sexual abuse has been reported to occur in 30% to 65% of women with eating disorder compared to 10% to 30% in rates of sexual abuse in the general population (Connors & Morse, 1993; Daigneault, Collin- Vézina, & Hébert, 2012; Deep et al., 1999; Zerbe, 1992). Faravelli, Giugni, Salvatori, and Ricca (2004) shown that 53% of rape victims reported current eating disorders symptoms compared to 6% of control subjects. Thompson and Wonderlich (2004) found the same results. Fischer, Stojek and Hartzell (2010, p.192) specify that a childhood emotional abuse can be a predictor of current disorders symptoms. They explain this result by the hypothesis “that an emotionally abusive environment does not teach adaptive emotion regulation skills, and that the use of maladaptive emotion regulation skills results in eating dis- orders symptoms”. The eating disorder can be a strategy of avoidance or regulation of emotion. Lejonclou, Nilsson, and Holmqvist (2014) con- firm that for several traumas, the eating disorders subjects had ex- perienced a significantly larger number of potentially traumatizing events, and they specify that the number of adverse childhood experi- ences and repeated traumas were associated with eating disorders for adolescents and young women. All kind of child sexual abuse is a traumatic experience and one of the major risk factor in the develop- ment of mental health problems affecting both the current and future of victims (Collin-Vézina, Daigneault, & Hébert, 2013).

Lyubomirsky, Sousa, and Casper (2001) specify that some

5 CDCP – Youth Risk Behavior Survey (2007).

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personality traits like dissociation can mediate the relationships be- tween abnormal eating and sexual abuse. The women with functional coping could avoid binge eating even in case of sexual abuse, inversely the dissociation associated to others negative affects lead to the most important eating disorders.

In our non-exhaustive literature review, family and sexual abuse seem to be two important origins of a disordered eating behavior and can be associated in the development of the disorder. What about our patients? Do they confirm these explanations? And how we can clini- cally explain these processes?

3. Method

This article draws a new approach in the anorexia nervosa treat- ment and in patient monitoring. Through a case study, the main goal of this paper is to wonder about the origin of anorexia nervosa as well as the adolescence specificity linked to these eating disorders.

This paper mainly uses 4 outpatient cases that were treated with success in our private practice as clinical psychologist. We have selected these cases to cover different ages and histories of the anorexia nervosa, and because these women explained with their own words how and why the anorexia nervosa became for them an answer, a coping strategy. They also well represented the majority (67%) of our patients.

Mrs. C. (48 years old) suffered with anorexic eating behavior since childhood. Raped at 22 years old, this assault intensified or escalated the eating disorders. The therapy will reveal parents' sexual and emo- tional abuse since a young age. Now, she's married, mother, and she's a female entrepreneur who put a lot of time and energy in her job.

Ms. E. (25 years old) was in her 4th year of graduate studies but struggling a burn-out about her studies. The anorexia nervosa began 7 years before, she was an inpatient facility to address this crisis and her endangered health. The numerous inpatient weeks did not give sa- tisfactory outcomes. The relapses were systematic. She came the first time with her mother who spoke more than Ms. E. about her health and about the importance of her studies and graduation in 16 months.

Ms. D. is 17 years old, bright teenager with good results at school. She was living with the anorexia nervosa for almost two years. She has an older sister (24 years old) who is married and recent mother of tri- plets. Ms. D.'s parents consider her older sister to be a role model and often compare them. Ms. D. lived with her parents. They were over- protective but since the triplets were born, they only focused on the “new babies”.

Ms. S. (16 years old) develops an anorexia nervosa 2 years ago. Ms. S. has to regularly help her mother to prepare family meals. During the psychotherapy, Ms. S. will reveal she was raped at 14 years old by one of her classmates, who is also a neighbor.

4. Data analysis and discussion

We introduce a case study of four female patients voluntarily en- gaged in a therapeutic process. The therapeutic monitoring was orga- nized with one or two weekly therapeutic consultation outpatient ses- sions. The patients were fully with the disease or in the latter stages of recovery, and their comments collected will be confronted with our literature review and discussed.

1- Adolescence and family in our cases.

This is a fact that cultural and media pressures to be thin contribute particularly to increase the number of eating disorders subjects (Fallon, Katzman, & Wooley, 1994). This explanation is confirmed by Ms. E. (25 years) when she explains “I felt round, I was 117 pounds for 5.2 feet, so I went on a diet and gradually I could not swallow anything and I fell to 81.5 pounds”. But going further in our conversations, the family issue came to emerge in the explanation of the disorder origin: “When I eat, I feel fat and guilty because it costs money to my parents. […] Today I'm

desperately ill, I do not want to fight anymore. I have enough of life espe- cially when I see that I hurt my parents”. A normal diet is often a mask developed by the person to hide from the others (and from oneself sometimes) the anorexia nervosa process which is going on. Anorexia nervosa is addressed to others, inviting or rejecting them. Ms. E. seems to manifest an alimentary communication by stripping food from its nutritional matter in order to make it of an element of language, Ms. E. would materialize her hunger in her body which is transformed to address it to her parents (Legrand & Taramasco, 2016). These authors explain that the subject eat, she eat nothing. This “nothing” she eats has not gotten a nutritional value but a symbolic one. The food or the meal is a communication system, and in this way anorexia nervosa is a food communication. When she eats nothing, the anorexic subject removes the nutritious matter of food to keep the language part only.

Conflicts are numerous during adolescence, they come from parents, family, friends, loves, teachers, studies. They can be internal to the subject herself who does not accept her body and the transformations related to adolescence. Body changes are sometimes marked during puberty and girls can, by anorexia nervosa, attempt to regain power over this body that no longer suits them and no longer meets their expectations.

Ms. E. (25 years) put her anxiety into words for others to under- stand, “I don't like when there are people at home and this is worsened if it was not planned. At others' home it's just bearable. The more people that are there, the more I fear”. But this distinction between home (family home) and among friends does show us an underlying family problem ex- plaining the disorder and the discontent facing this other? She fears this invader who is going to introduce himself into her family cocoon plus to observe and to note her thinness. Maybe, these “foreign family people” could endanger her attempt to take the power on her parents. Anorexia nervosa subjects can maintain the disordered eating behavior and their thinness to preserve the family circle or the family unit (Selvini- Palazzoli, 1986) because anorexia nervosa creates a reason to be helpful, to be together.

The children or the teenager can use anorexia nervosa to avoid growing up. By remaining a child, the person retains the carelessness of childhood and keeps the parenting focus. Like that, Ms. E. (25 years) confides, “I live at my parents' home, they shake me all the time. They are unhappy, my father is often angry. I feel guilty. They often tell me “you are almost an adult, it's time you took responsibility for your actions!”. Becoming an adult is often perceived as a loss, as a nightmare to face problems, constraints, obligations of life; it's becoming responsible for yourself (and others). “Eat your soup, you will grow up” can take some teenagers into major anxiety. By not eating, could it not represent for these children the symbolism of the fetal period when the umbilical cord ensured that role for them?

Ms. D. (17 years) explained this, “my sister had just had triplets, I struggled with that. Until that time I was the youngest of the family and I used to get all attention. Suddenly all the attention focused on them and the only thing I had left was my diet. And every time I felt alone, I consoled myself by losing a pound. […] Finally, they paid attention to me, they started to take care of me, they did not leave me alone anymore. […] This is a part of me, I would like to stop, I don't want to die but it's very hard and I don't know how I can do it.” Ms. D. was also fighting against this am- bivalence of adolescence. This constant quest of other people's look, express what the anorexia subject wants more than anything but what she cannot say Take care of me! (Jeammet, 2010). Ms. S. (16 years) can blame too sustained attention of her mother and at the same time she maintains this concern by her eating behavior, “My mother always bothers me so that I eat, she bugs me! Eating, this is not fun, it became an order”. Therefore, her anorexia nervosa would become an opposition to her mother to access some independence, typical of adolescence. At the same time, her eating behavior is a tool to maintain her mother role like nurturing, and to see her as a child. Thus, anorexia nervosa is the “perfect” strategy which answers in the same time to two opposite goals, and answers to the internal conflict of adolescence (not more a

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child, not yet an adult). This is another example of the paradoxical relationship between the

anorexic subject and others. The social (parental) relationships are frightening and necessary in the same time, frightening because ne- cessary (Jeammet, 2010). This ambivalence often appears with Ms. S. as well when she describes herself. Our one on one allowed her to express the limits of her behavior, and help to move beyond her disorder, “I feel that there is a combination of two girls in me: one very ugly and one very beautiful. I think I'm fat and thin […] I would like to be perfect to please myself but I consider myself too thin now and I'm afraid to go to the beach”. Ms. S. confirms here that her fine body bears the traces of her internal trouble and in the same time, her obvious thinness express her un- iqueness in the space where others can see these traces and respond (Legrand & Taramasco, 2016). Relationships with parents are often re- lationships of dependence. However, anorexia nervosa of the teenager tries to reverse the roles because family becomes dependent of the adolescent and of her relation to the food. This hold ensures the success of an illusory control of the affective and family sphere. Conflicts with parents become inevitable which reinforce the anorexia behavior. For Legrand and Briend (2015) anorexia nervosa subjects struggle with this paradoxical behavior because they fail to negotiate the difference be- tween needs and desires. Desires are often insatiable and whether the parents satisfy the needs, they cannot fulfill the unfulfillable desire.

For that matter, Ms. E. (25 years) confided that her “cousin is doing the same, we were brought together. My mother's side is considered quite beefy. My aunt, my uncle, my grandfather are overweight. For my uncle, it's the same, he was an anorexic subject”. Did Ms. E. confirm a genetic role in the explanation of the anorexia nervosa or did she describe a family who cultivate an environment which fosters the development of anor- exia nervosa? Was she fighting against a family relationship because she felt a subjugation of her subjectiveness? That fear can be a reject of the other, or a call to the other, or both together (Legrand & Taramasco, 2016).

The eating disordered behaviors often lead to a hostage of the fa- mily which is undergoing a major anxiety regenerated at each meal- time. The circle, particularly parents, tend to act and behave according to the wishes and moods of the adolescent hoping she's going to nourish herself. Thereby if a balance of power can be built, the adolescent takes the power on the destabilized and distressed parents, by submitting this disorder living in a permanent anxiety about each possible future de- viant. By playing on the feeling of guilt and on the protective parent- hood sprout, the anorexic subject undermines the identity of parents and put their social positioning and their attitudes in doubt. Indeed, at the end of the therapy, Ms. D.'s mother said, “I do not think that we could turn the page. There will always be this pall hanging over us at least as long as she lives at home. We will have a little anxiety to know if she's eating all her meals. Me, I will wonder this, anyway”.

After analysis, Mrs. C. (48 years) also verbalized that she ate during her childhood and adolescence at the level of the perceived parental love. Developing a sense of abandonment, of lack of affection and of reject from her parents, she expressed her feeling of these perceived deficiencies, in the eating deficiencies. She experienced a correspon- dence between the misery intensity and the anorexia nervosa. Mrs. C. cumulated a harmful family environment, sexual abuse and rape.

2- Anorexia nervosa and sexual abuse in our cases.

Our practice confirms a large rate of young girls or women with anorexia nervosa symptoms who were sexual abuse or rape victims (67% of our anorexia nervosa patients). Cannot this physical attack, still in that whole power of the mind over the body, expresses itself as well in these young girls who have suffered sexual assaults? Because of the bodily damage and the stolen privacy, it seems logical that the lack of interest for sexuality is described as a symptom of anorexia nervosa. Even if the sexual abuse and rape victims are not suffering of eating disorder, within our cases, sexual assault can be cause of anorexia

nervosa and the weight loss. Ms. S. (16 years) explained that she fell in anorexia nervosa after she was victim of rape. She said anything to anybody before her psychotherapy, “after the rape by my neighbor, I felt dirty, ashamed and guiltier than victim. I did not like the life anymore, I no longer felt hungry, I did not want to do anything. But I kept the secret and live like a robot, a scared robot”. The rape was clearly the triggering event, but Ms. S. connected the family problematic when she said “In addition, my mother always wants me to help her to prepare meals, I hate that, it makes me even more disgusted”. With the secret of the rape wrote on her body but invisible for the other and with a specific problematic about food in her family, Ms. S. seemed to use the anorexia nervosa to express her pain and to reveal her secret in order to wean herself off it. The conflicts with her parents became regular, but it was a paradoxical rebellion, remained under the wraps at the beginning, the secret wanted to be visible to all by her gaunt body. Again, we understand how anorexia nervosa is communication, it is a patient and stubborn building of a body of which his vulnerability is a cry for protection (Legrand & Taramasco, 2016).

The desexualization that results would have the goal to protect the young girl who hopes with that she's not going to create the desire of a man anymore. Kestemberg, Kestemberg, and Decobert (1972) describe this paradox of the anorexic subject who is struggling with an idealized body (for its thinness), object of desire in one hand and a real body, object of denial in the other hand. Is it the paradox of the anorexic subject or the one of the girl sexually assaulted?

Mrs. C. (48 years) explains a posteriori that anorexia nervosa “led me to drive my femininity off myself and to break the mind and the body connection”. The bodily sensations disappear and this becomes a sur- vival strategy against the sexual assault. Because of the rape, libido and desire disappear and this feeling is reinforced by the anorexia nervosa and its physiological consequences. Towards the forced use of her body, the goal is to safeguarding her mind, her soul, her Self, I, while doing the division between the body and the mind. After the assault, anorexia nervosa would be the extension of this strategy. This contribute to the euphoric time explanation and to the feeling that everything becomes cerebral as explains Mrs. C. (48 years), “anorexia nervosa causes this phenomenon of rising up, the body forget itself and just the mind exists. It's very exhilarating but very dangerous, I felt I could reach death”. The fight then ensued between the mind and the body sometimes to the point of living a marked dissociation between the two dimensions of the person. The subject is in denial of her thinness and of health gravity especially because this thinness gives a well-being and a control feeling.

The body of the victim is soiled and therefore rejected, the person does exist only with her cognitive skills. What is the use to give food to this body which can cause a credible or perceived attack? Why being physically enviable if it results in becoming a victim of such tragic and violent consequences? Our analysis confirms the Fallon et al.'s (1994) study which shown that the sexual abuse victims adopt a restricting eating behavior because they refuse to see their bodies developed with secondary sexual characteristics during or after puberty, or because they want to recover some control on their body.

5. Conclusion and therapeutic prospects

As some studies try to identify the risk populations (Favaro et al., 2010), it seems difficult to bring out definite predictor factors. The person is unable to express or manage other than that food deprivation, “Sometimes I'm hungry between meals, but I prohibited it myself” (Ms. E., 25 years). We define anorexia nervosa as the symptom and not as the problem. This perspective will determine the approach and the treat- ment by the clinical psychologist.

Following Legrand and Briend (2015), psychotherapies could pro- gress if they avoid the dichotomy to focus on the symptoms or to focus on the social and familial environment. Indeed, anorexia nervosa treatment procedures are often focused on the patient's eating behavior and any weight gain or loss. It is often forgotten to research the triggers

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of the anorexia nervosa for the subject. Is it not because psy- chotherapies do not treat the origin of anorexia nervosa that this dis- order has got this high relapse rate?

Even if we don't deny the biological and neurophysiological im- plications of the anorexia nervosa, we consider anorexia nervosa as the expression of a psychic conflict experienced by the person in an op- position posture. This is a symptom masking a discomfort, a trauma, an emotional deprivation, an emotional disorder, an identity disorder, an emotional shock or an internal social conflict. Anorexia nervosa is rooted in this emotionally fragile people or with difficult life experi- ences. Often, anorexia nervosa is the physical expression allowing the nonverbal expression of a generally important psychological disorder. By the thinness of their body and the visibility of their eating disorder, patients show that a problem exists but they can decide whether they will put words on the real problem (family issue, sexual assault, etc.) or they will stay on struggling only on anorexia nervosa and keep the mask on the origin of their anorexia nervosa. This eating disorder is a tool that patients use to have the control, by this way they control their relative, “I need help but I will say why only if and when I want”. Thus, our efficient approach is to focus on the “why”. Respond to this question is to provide another tool than the anorexia nervosa to speak about the origin(s) of the symptom, and therefore treat all the problem's con- sequences by the psychotherapy.

The psychotherapy (inpatient or outpatient) remains the crucial element in the anorexia nervosa treatment. The psychiatric protocols with an excessive focus on weight gain are, for us, incomplete and in- effective. The subject builds her personality and exists by means of her thinness. If the psychotherapist's work is focused on the thinness and on to recover weight, he will reinforce the empowerment of the disease. Albert Einstein explained that we cannot solve problems by using the same thinking we used when we created them. As well for Sullivan, Bulik, Fear and Pickering (1998, p.945), this kind of therapy “neglects the detec- tion and treatment of associated psychological features and co- morbidity”. These authors also note a very high lifetime prevalence of several anxiety disorders. This proves that the problem is not resolved and that the anorexia nervosa was a psychological expression of this problem.

For Jeammet (1991) the kind, the quality, the consistency and the duration of the anorexic subject treatment and accompaniment de- termine the quality of the disorder recovery with the establishment of a social, family and sexual life and an eating behavior close of the “normalcy”. We see in our psychological practices, how much it's im- portant for the patient to establish a strong link with the clinician. We can construct, with this link, a dynamic of work for that healing journey. For this pathway, we mainly use two engines simultaneously: the first is to answer to the question of the why? (Why the patient fell in anorexia nervosa?), and the second is to set goals for short, mid and long-term. The psychotherapy needs to be focused on the patient in a holistic approach. We come back to Rogers (1957), in the therapeutic relationship he turned to interpersonal qualities of the therapist, namely empathy, unconditional positive regard and congruence. Thus, focused on the patient, the therapist may provide the necessary con- ditions for realizing the healing processes and create the ability to bond or develop attachments in future relationships.

The rates of relapse have to alert us to the emergency of improving the treatment for anorexia nervosa. The anorexia disorder being gen- erally the symptom, research of the one or the several causes must be the major goal of an efficient psychotherapy.

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