1 Department of Psychiatry, University of Perugia, Perugia (PG)
ABSTRACT
Anorexia Nervosa (AN) is an Eating Disorder (ED) characterized by a persistent alteration in eating behaviors, including limited food intake due to intense fear of weight gain, with excessive concerns regarding bodyshape and weight (APA 2013).
Fasting constitutes the main and most dramatic form of food restriction in these patients. At the same time, it represents a key gesture with a deep and symbolic value in the context of many religions, in which it assumes a catarchical value and distancing meaning from earthly desires.
INTRODUCTION
Anorexia Nervosa (AN) is defined, according to DSM-5 criteria, by the simultaneous presence of a restriction of energy intake, causing a significantly low weight, but also an intense fear of weight gain or the persistence of behaviors that interfere with the altered perception of weight and body image (APA 2013).
From the broader psychopathological perspective, AN can be described as a complex disorder in which fasting represents a vehicle for self-affirmation and omnipotent control over others. Moreover, the symptoms reveal the denial of sexuality in a body growing through adolescence; indeed, the body is perceived as distorted in this pathology, and a proper perception of reality can be altered (Sarteschi & Maggini 1989; Lalli 2002). Often the pre-morbid personality presents obsessive traits, showing anaffective and perfectionist tendencies, especially in the school environment, while at the same time displaying a strong sense of insecurity and helplessness. This results in the inclination to seek the approval of other people and family members (Sarteschi & Maggini 1989; Lalli 2002; Gabbard 2014).
Family members often project their preoccupations and their aspirations on the subject. This can create in patients with AN the perception of being an extension of their parents, and consequently a dependent attitude with them, leading to the onset of separation anxiety as well. (Gabbard 2014).
The unrealistic belief of being overweight, gastrointestinal disturbances, and food refusal are the first symptoms to appear. weight loss occurs only later, usually accompanied by motor hyperactivity or other compensatory mechanisms, making the condition evident to family members (Lalli 2002). At this point, as long as the food is out of the body, the subject with AN does not experience anxiety or distress; as long as the external environment (hated and experienced as hostile) is controlled, the disintegration of the Ego is prevented. An example of such control is the common finding of subjects with AN becoming interested in cooking and preparing meals for their family members (Lalli 2002).
It is estimated that only 5-10% of AN patients are male (Gabbard 2014). Although the psychopathological and clinical pattern basically overlaps with the women’s pattern, male patients often recieve the diagnosis of Unspecified ED or Avoidant/Restrictive Food Intake Disorder; on average they often use exercise as a compensatory mechanism, also presenting concerns about their body image more focused on muscularity (and Vigoressia) than thinness (Gabbard 2014, Timko et al. 2019).
Moreover, AN patients have a high prevalence of medical complications due to the consequences malnutrition and elimination behaviors. This condition reduces quality of life and impairs health status, configuring AN as a psychopathology with particularly high morbidity and mortality rates compared to other psychiatric disorders (Arcelus et al. 2011, Gravina et al. 2018; Westmoreland et al. 2016). Therefore, in the context of the dangerous mind-body perception in patients with AN, the necessity of organic risk stratification should be highlighted, considering not only the Body Mass Index (BMI), but also endocrinological and nutritional aspects (Hübel et al. 2019, Støving 2019; Winston 2012).
Four subtypes of ED patients have been identified based on comorbidity with personality disorders: a high-functioning subtype, with minimal personality disorders; an emotionally and behaviorally dysregulated subtype, with borderline and histrionic tendencies; an insecure-avoidant subtype, with anxious-depressive and social avoidance tendencies; and a restrictive-obsessive subtype, manifesting ananchastic tendencies and rigidity. Patients who can be framed in the restrictive-obsessive profile are those who most often show features that can be correlated with AN (Rotella et al. 2016). However, it has been found that the personality traits most associated with EDs starting in adolescence are those related to negative affectivity (e.g., emotional dysregulation, borderline tendencies, insecurity) and and the emotional detachment (e.g., inhibition, introversion, social alienation) (Dufresne et al. 2019). In addition, personality disorders referable to cluster C seem to be more prevalent for AN, unlike in subjects with bulimia nervosa which more often present cluster B traits: more generally, subjects who show restrictive behaviors tend to be more obsessive-compulsive or avoidant, subjects who develop binge eating and elimination behaviors more often have borderline features (Buzzichelli et al. 2018, Rotella et al. 2016).
FASTING IN RELIGIONS
Fasting represents not only the rejection of food, but portrays in the subjective world an ancestral affirmation of a spiritual component. The rejection of food symbolizes the denial of a sinful reality, guilty of corrupting the immaculate interior purity. Not surprisingly, fasting constitutes in the religious sphere an act of purification and catharsis.
In Christianity, in particular, abstinence from food is linked to the season of Lent. The phrase pronounced by Jesus Christ “man shall not live by bread alone” is reported in both the Gospels of Matthew (Matt. 4:4) and Luke (Luke 4:4) and constitutes Jesus’ response to the devil’s temptation to turn the stones of the desert into bread, in order to satiate the hunger after 40 days and nights of fasting. This expression is emblematic of Christ’s role in the Gospels, in which he represents the Verb-becoming-a-person. Jesus does not give the rule, but constitutes its fulfillment. Indeed, the famous phrase is preceded by the expression “It is written” because it represents a quotation to the fifth book of the Torah (as well as the fifth book of the Old Testament, Deuteronomy), and to the words of Moses in reference to the 40 years of the Jewish people in the wilderness during the travel to the promised land (Deuteronomy 8,2; in recent English versions of Bible, the literal translation “The Lord your God has led you these fourty years in the wilderness […] to teach you that man shall not live by bread alone, but men live by everything that proceeds from the mouth of the Lord” has been replaced by the non-literal interpretation “The Lord your God has led you these fourty years in the wilderness […] to know what was in your heart (mind), whether you would keep His commandments or not”).
In Judaism, fasting is scheduled on various occasions; the best known and most practiced is the fast of Yom Kippur, which refers to the day Moses came down from Mount Sinai with the Tablets of the Law, and is mentioned four times in the Torah (Exodus 30:10; Leviticus 23:27-31 and 25:9; Numbers 29:7-11). It is the day when, according to tradition, God seals his agreement with the individual man, who assumes ethical responsibility to God for his actions and therefore will no longer respond to moral judgments built on the “idols” chosen by the specific individuals or communities. Indeed, in the Torah the scene of the Tablets of the Law is preceded by the story of the golden calf (Exodus 32): in the absence of divine rule (the tablets brought by Moses) Jewish people, led by Aaron, built a golden calf, which they began to worship as a divinity.
The theme of fasting also recurs in the Muslim religion, where sawm, the intermittent fasting kept in compliance with Allah’s law in the lunar month of Ramadan, is one of the five pillars of Islam (Arkan al-Islam) prescribed by Shari’a law. Fasting symbolically represents the reliance on the words of the Qur’an (and thus on Allah), the realization of how the spirituality expressed in observing the rule feeds the body as much as the food. The Quran states: “the month of Ramadan [is that] in whitch was revealed the Quran […]. So whoever sights [the new moon of] the month, let him fast it […]. Allah intend for you ease and does not intend for you hardship and [wants] for you to complete the period and glorify Allah fot that to which He has guided you” (Quran 2:185). Food deprivation is closely associated with divine rule, an affirmation of Islamic culture, rejection of external reality and self-abandonment in spiritual reality.
Buddhism emphasizes the component of fasting connected with self-discipline: the abstention from food is a practical exercise that is elevated, through rigor and austerity, to a vehicle for achieving Nirvana. In the Buddha’s vision desire represented the principle of evil, and the renunciation of a desire as basic as food expressed the abnegation of evil. Fasting is in Buddhist culture one of the dhutanga (sacrifices) that monks practice periodically to approach enlightenment. Through these renunciations moderation is teached as a progression to “liberation.”
Fasting, or upvas in Sanskrit, literally means “to be/live near” (to the divinity or highest Self), indicating a movement of union with the Absolute. In the Hindu sacred scriptures, through upvas the view of fasting as a denial of earthly needs in favor of spirituality is reaffirmed. Only through the control of earthly attributes, body and mind, liberation from the cycle of rebirth can be achieved.
FASTING AS A SYMBOL
The psychopathology/religion combination in this work is an added perspective that can help to expand the vision of psychiatrists and psychotherapists about this clinical condition. The psychopathological scenario is expressed with symptoms that refer to deep archetypal meanings. In the AN, fasting constitutes a self-imposed and self-produced rule, but also self-referential. Divinity is replaced by the Ego, the myth of beauty, and recognition by the Other, which is used as a mirror for personal desires. Consciousness attempts to “displace” the Unconscious, rising itself to the role of the golden calf.
Moreover, restriction can institute the assertion of personal purity over the contamination of the world. As previously pointed out, the ED component in AN is associated with obsessive personality traits (Buzzichelli et al. 2018; Rotella et al. 2016).
Fasting as a self-imposed directive shows a clear infantile position, expressed through the rejection of the rules of the mother-environment (defined as parental, educational, social and cultural), perceived as despotic. The symptom symbolically displays a sense of annihilation that is perceived as externally imposed (the rule limits me, therefore the rule annihilates me).
Not coincidentally, in the female sex the AN deprives the subjects of the nutrients needed in adolescence for a proper development of sexual characters, resulting in androgynous-infantile physicality, and going to cancel the physical maturation of femininity and adult traits.
Indeed, fasting become an attempt to assert the personal childhood omnipotence against perceived constrictions. It shows a struggle against authority, with the typical traits of a phase of life that constitutes the bridge between childhood and adult maturity, attempting to develop a puerile core of a personal identity. This attempt is unsuccessful, nevertheless it manifests an (unconscious) expression of the need to develop themself as an independent individual.
Psychodynamic psychotherapy that respects the rules of an analytic setting can reconcile the need for autonomy with the norms of society. The setting can restore a positive valence to the rules, allowing the subjects to internalize them and promoting the process of Individuation.
References
American Psychiatric Association (APA), (2013) DSM-5. Diagnostic and Statistical Manual of Mental Disorders.
Arcelus J, Mitchell, A, J, Wales, J, Nielsen S, (2011) Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Archives of general psychiatry, 68(7), 724–731.
Buzzichelli S, Marzola E., Amianto F, Fassino S, Abbate-Daga G, (2018) Perfectionism and cognitive rigidity in anorexia nervosa: Is there an association? Eur Eat Disord Rev. 26(4):360-366.
Dufresne, L, Bussières, E, L, Bédard, A, Gingras N, Blanchette-Sarrasin A, Bégin PhD, C, (2020) Personality traits in adolescents with eating disorder: A meta-analytic review. The International journal of eating disorders, 53(2), 157–173.
Gabbard G, O, (2014) Psychodynamic Psychiatry in Clinical Practice, Fifth Edition
Gravina G, Milano W, Nebbiai G, Piccione C, Capasso A, (2018) Medical Complications in Anorexia and Bulimia Nervosa. Endocrine, Metabolic& Immune Disorders – Drug Targets, 18(5).
Hübel C, Yilmaz Z, Schaumberg K, E, Breithaupt L, Hunjan A, Horne E, García-González J, O’Reilly P, F, Bulik, C, M, Breen G, (2019) Body composition in anorexia nervosa: Meta-analysis and meta-regression of cross-sectional and longitudinal studies. The International journal of eating disorders, 52(11), 1205–1223.
Lalli N, (2002) Manuale di psichiatria e psicoterapia, Liguori Editore, Napoli.
Rotella F, Fioravanti G, Ricca V, (2016) Temperament and personality in eating disorders. Current opinion in psychiatry, 29(1), 77–83.
Sarteschi & Maggini (1989) Manuale di Psichiatria. Monduzzi Editoriale.
Støving R, K, (2019) MECHANISMS IN ENDOCRINOLOGY: Anorexia nervosa and endocrinology: a clinical update. European journal of endocrinology, 180(1), R9–R27.
Timko C, A, DeFilipp L, Dakanalis A, (2019) Sex Differences in Adolescent Anorexia and Bulimia Nervosa: Beyond the Signs and Symptoms. Current psychiatry reports, 21(1), 1.
Westmoreland P, Krantz M, J, Mehler P, S, (2016) Medical Complications of Anorexia Nervosa and Bulimia. Am J Med. 129(1):30-7.
Winston A, P, (2012) The clinical biochemistry of anorexia nervosa. Annals of clinicalbiochemistry, 49(Pt 2), 132–143.
