Yeager vividly described his observation:
Gluttony is neither a disease nor a simple habit. Like pneumonia, gluttony is heterogeneous and has various reasons. I think this concept is quite useful: gluttony is a habit or behavior pattern, rooted in personality, biological characteristics, and finally culture, and in this culture, gluttony seems to be increasing.
Understanding of psychodynamics
When considering the mental motivation of gluttony, therapists must remind themselves of the heterogeneity of gluttony. Those who help us understand gluttony from a dynamic perspective are actually very similar to blind people touching elephants. Every blind person has a different understanding of this behemoth from his own unique angle. As usual, the understanding of motivation orientation must be individualized. Gluttony may appear in patients with various characteristics, from mental patients, borderline patients to psychofunctional patients. Anorexia and gluttony are actually two sides of the same body. Anorexia patients have good self-strength and superego control, while bulimia patients may not be able to delay the release of their impulses because of their fragile ego and loose superego. Gluttony and vomiting are not independent impulsive problems. In fact, they may be accompanied by impulsive and self-destructive sexual relations, or by multiple drug abuse.
Some empirical studies show that some psychodynamic factors may be related to bulimia. In a multivariate genetic analysis, Kaendler and others found that family and environmental factors played a key role in the development of the disease. In a community case-control study including 102 bulimia patients and 204 healthy controls, parental rearing problems, sexual or physical abuse and negative self-evaluation are all related to the occurrence of the disease. Researchers believe that negative self-evaluation may distort girls' feelings about their appearance and lead to dieting. These empirical findings are also supported by psychoanalytic observation. Ricky and Hipparchus found that the emotional dialogue between bulimia patients and their parents was blocked, and patients had internal conflicts with their parents' identity, so there was a persistent conflict pattern in their own contradictory parts. These researchers believe that many gluttony patients feel that their boundaries are not respected and their privacy is improperly violated, just like sexual or psychological abuse. Ricky and Schipper have noticed that these patients often use anti-emotional and anti-customer-oriented defense methods, and they often feel contradictory superego requirements.
Scholars who study the origin of gluttony have found that parents and individual patients will have extensive troubles when facing separation. In the history of bulimia patients, a common theme is the lack of transitional objects, such as nipples or blankets, to help children psychologically separate from their mothers. This painful struggle about separation in the process of development is now staged again with the body itself as the transitional object. Eating food symbolizes the desire to be integrated with the mother, while discharging food is to be separated from the mother. Like the mothers of anorexia patients, parents of bulimia patients often regard their children as an extension of themselves, and these children are recognized by their parents as objects of self. Every member of the family depends on other members to maintain self-cohesion. Although this pattern is also a feature of anorexic families, there is a more obvious special pattern in the families of bulimic patients to deal with unacceptable "bad" traits. In the family system of bulimia, everyone strongly needs to regard themselves as "completely good". Parents' innate unacceptable qualities are often projected on overeating children, so children are regarded as the repository of all "bad qualities". Through the unconscious recognition of these projections, the patient becomes the carrier of greed and impulse of the whole family, and the resulting dynamic balance is to keep the focus on this "sick" child, while the internal or mutual conflict between parents is invisible.
The observation of mental motivation on the separation difficulty of overeating patients can be confirmed by empirical research. The responses of 40 patients with eating disorders and 40 women with normal diet as control group to subconscious or conscious stimuli were compared. In each group, the subjects were presented with the following conscious or conscious forms of giving up stimulation or controlling stimulation respectively. After the abandonment stimulus appeared, the patients with eating disorders ate significantly more cookies than the control group. Researchers believe that gluttony is actually an unconscious defense against the fear of being abandoned.
In many cases, gluttony patients are therefore surrounded by the object-relationship mechanism of injection and projection. Eating and spitting may directly reflect the injection and projection of aggressive or "bad" injectables. In many cases, this process of division is further manifested by patients. She may regard protein as "good" food and keep it. Carbohydrate or junk food is regarded as "bad" food, and the purpose of eating a lot is only to spit it out again. On the surface, this strategy to deal with attacks is convincing-spit out bad things and make patients feel good. However, the remaining feeling of "good" is unstable, because it comes from the division, denial and projection of aggression, not from the integration of bad and good.
Matters needing attention in treatment
The most important principle of treating overeating is to tailor the treatment plan for patients. A complete treatment plan should also consider the combined mental disorders, such as depression, personality disorder and drug abuse. The "production line treatment plan" which treats patients with bulimia equally cannot identify and understand the inherent heterogeneity of the population of bulimia patients, so it can only help some patients. About one third of the relatively healthy gluttony patients responded well to short-term cognitive behavioral therapy and mental health education, and the time-limited treatment method responded well. Support groups such as Gluttony Anonymous (hereinafter referred to as OA) may be enough to support these patients without other treatment.
Follow-up research shows that the difficulty of many patients is that the stability of overeating symptoms is often only temporary. In the review of 88 cases of overeating, Kyle and Mitchell found that about 50% of women fully recovered after 5 to 10 years of onset; 20% patients continue to meet the diagnosis of bulimia; In addition, about 30% patients have repeated symptoms of overeating during the course of the disease. In a cognitive behavioral therapy study lasting 16 weeks, patients who completely quit overeating and vomiting were followed up for 4 months, and the researchers found that 44% of them had a relapse. A retrospective study on cognitive behavioral therapy for bulimia patients shows the difficulty of treating this pathological condition. At the end of the treatment, more than half of the patients who did not fully recover had an average persistent bulimia of 2.6 times per week and vomiting of 3.3 times per week.
Even though the dynamic method may not be suitable for all patients, most patients with gluttony may still get improvement from it; Among the patients who have not improved, two-thirds may have borderline personality disorder at the same time, and the rest may have other personality disorders or obvious depression. These patients may need long-term expressive supportive psychotherapy, and usually must be used in combination with psychotropic drugs. Many patients clearly expressed their aversion to behavioral therapy for overeating symptoms. Paying attention to pathological explicit behavior and ignoring its inner world may repeat the growing experience of patients getting along with their parents who value appearance over substance. Yeager said that about 50% of bulimia patients are not satisfied with the behavior change treatment they received, and some patients even feel that it is meaningless to keep a diet diary every day, because they think that their diet problems actually come from other more fundamental problems. Treatment that does not conform to patients' interests and beliefs is doomed to failure.
Bulimia can be life-threatening. In the past, it was found that the severe electrolyte imbalance caused by patients may be enough to stop the heart. Blood biochemical monitoring is an important part of outpatient treatment, and hospitalization is an important backup. Because many gluttony patients also have borderline personality disorder or major emotional disorder, when suicidal behavior or serious self-harm occurs, they may need hospitalization. In addition to controlling symptoms by locking the bathroom, planning a normal diet, providing mental health education support by nutritionists and encouraging diary writing, hospitals must implement a complete treatment plan according to personal considerations. Hospitalization can often provide the healer with an opportunity to better understand the internal object relationship of patients, thus making the diagnosis more detailed and the treatment plan more accurate:
Miss W is a 19-year-old college student with symptoms of bulimia and anorexia. She was hospitalized after "firing" her psychotherapist, and completely lost control of bulimia and vomiting. Her parents took her to the hospital. They were at a loss about her behavior and were desperate because they couldn't let her eat normally. In the first week of hospitalization, Miss W told her doctor that she was going to remain cold and distant because she didn't want to rely on doctors any more, but she was still disappointed. The patient refused to eat or join the group even though the regular diet and the treatment plan of group meeting were arranged. She insists on eating only when she wants to eat, and when she wants to eat. She pointed out to the doctor that her weight had not changed and there was no need to be particularly worried.
Because Miss W didn't cooperate at all, she gradually angered the nursing staff. When the patient became more stubborn and resistant, the staff insisted that she must abide by the structure of hospital treatment. During a ward discussion, the doctor observed that the patient successfully reproduced the situation of her family. By insisting that she should control her own food, she encouraged others to try to control her diet. On this basis, she felt that she was a victim of external control forces, just as she felt persecuted by her parents.
The doctor met with Miss W, and during the meeting, she pointed out that she was trying to anger the staff and repeated the situation at home. The doctor asked Miss W to think about what she could get from it. Miss W responded that she was not interested in the conversation at all. Three days later, she told the doctor that in order to commit suicide, she hid the medicine and sharp tools in a locked drawer in the ward. She said that because she really didn't want to die, she decided to tell the doctor about it. She also said that it is extremely difficult to communicate with the doctor about her feelings. Because she believes in her, she will become uncontrollable dependent and lose herself. She insists that relying on doctors will lead to exploitation and improper treatment according to her own needs, not her treatment needs.
These materials help the staff to understand the impedance of Miss W to the treatment structure. By refusing to cooperate, she tried to establish a sense of self independent of the needs and expectations of others. The risk of working with nurses and doctors is that she may become an extension of others again, just like at home. When this hidden anxiety surfaced, the staff allowed Miss W to express more opinions on her diet plan. She can cooperate with nurses and follow a mutually acceptable treatment plan.
Miss w seems to be making progress. However, on the morning of Christmas, when the doctor was preparing to open presents with his family at home, he received a phone call from the hospital. The hospital nurse called the doctor and told her that Miss W smuggled laxatives into the ward and ate a lot. She has diarrhea all morning. The nurse was worried that Miss W might need emergency treatment, so the doctor had to go back to the hospital to visit her. Two days later, when Miss W's physical condition was stable, her doctor confronted her with the empathy and hostility behind her diarrhea and said that perhaps Miss W just wanted to ruin the doctor's Christmas morning. Although the patient categorically denied this possibility, her doctor had to try to suppress his strong anger against Miss W, and she chose this time to take action. The doctor gradually realized that the act of urging diarrhea reduced the patient's aggression. Therefore, she could not understand that the doctor interpreted her behavior as a hostile display; Doctors are unconsciously regarded as patients' anger.
Although this case is a refractory patient with borderline personality disorder, this empathy-anti-empathy struggle is not uncommon for individual therapists to face bulimia patients. Therapists may find themselves repeatedly angered and accept the "bad" parts that patients try to eliminate. When the patient repeatedly vomits back to the therapist's efforts, the therapist may feel as if he has been "vomited all over". Repeated family patterns in hospital treatment or individual psychotherapy can help therapists understand the role of patients in the family system. Because overeating is often regarded as a part of maintaining family balance, family therapy or individual therapy is often necessary. If the family system is neglected, the therapist will run the risk that the patient's improvement will pose a serious threat to other family members, and the defensive response generated by this threat may destroy the patient's treatment or cause serious dysfunction of another family member. Therapists must respect the needs of family members for the persistent illness of gluttony patients, and must make parents feel "protected" and recognized, so as not to undermine the treatment of patients.
Many bulimia patients have a strong sense of contradiction, and too much care will destroy the balance of the family, so try to avoid receiving in-depth psychotherapy. They may feel that they have defects, and the risk that psychotherapy may cause is precisely to expose such defects. Using a diet diary and pointing out the correlation between certain eating patterns and emotional states may be a quite effective way to establish a therapeutic alliance with patients. Therapists hope to cure patients quickly, which is one of the common anti-empathy problems, because therapists may give too many explanations too early, leading to "overeating". As Ricky and Shepard reminded, patients may treat the explanations and noodles given by therapists in a gluttonous way, that is, they eat greedily without proper digestion. Although cognitive behavioral therapy has become the first choice for bulimia, psychodynamic therapy still has a place. In a well-designed comparative study of cognitive behavioral therapy and dynamic directional therapy, at first, the results of cognitive behavioral therapy group were better, and after long-term follow-up, the therapeutic effects of the two groups were almost the same.
Dynamic group psychotherapy is also an effective adjuvant therapy. More and more empirical documents have confirmed the efficacy of group psychotherapy on bulimia patients. In the review of 18 different studies on bulimia patients, yust Hyde and others think that the curative effect of outpatient group therapy should be viewed cautiously and optimistically. Group psychotherapy is considered to be effective in reducing the symptoms of overeating by an average of 70%. However, since most studies exclude dropout cases, these data may be questioned and exaggerated. Even though most groups have excluded patients with borderline personality disorder and other serious personality pathologies, the atresia rate is still high. Like individual therapists, group therapists seem to agree that only when epiphany and symptom control are taken into account can stable relief be achieved. In a randomized controlled study designed for bulimia patients, the study was used to compare psychoanalytic group therapy and mental health education therapy. Most of the patients in the two groups were able to meet the diagnostic criteria of eating disorders, and the number of bulimia patients decreased. In the group receiving analytical group therapy, most of these improvements continued at the sixth month and the 12 month of follow-up.
In a word, when bulimia patients can't get improvement from limited mental health education and cognitive behavioral therapy, it means receiving dynamic directional therapy. Generally speaking, family intervention in the form of support, health education or family therapy is also necessary. To control some symptoms, it is necessary to cooperate with other treatment methods, including short-term hospitalization, support groups such as OA and group psychotherapy, which can help patients control symptoms. Some individual psychotherapists also regard symptom control as part of the treatment process. A considerable proportion of bulimia patients may need psychotherapy under the condition of long-term hospitalization when they are complicated with serious personality pathology, suicidal tendency or life-threatening electrolyte imbalance. These patients tried to resist the therapist's efforts to rebuild their lives. Without long-term hospitalization, these patients seem to be on the road of self-destruction and eventually die.