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Section 15
The Bulimic Self and Dissociation

Question 15 | Test | Table of Contents

(Note: As you know many clients who feel they are unlovable act out these feelings in an eating disorder. This article cross-correlates the relationship between the identification of your clients bulimic self and their dissociation with it.)

That many bulimic patients are expert at dissociation is well-known to clinicians; in fact, there is research evidence (e.g., Pettinatti et al., 1985) in support of the dissociative abilities of bulimics. Many portray their bingeing episodes as one might describe a trance state, drug trip, or delirium. Most become wholly identified with – “taken over” by – the bulimic self-state. No amount of cognitive persuasion or exhortation can stop them, because the bulimic self has been dissociated from the more reflective, observing self. The early needs must be expressed. To try to talk the bulimic self out of bingeing or purging is like telling a cat stalking a bird to stop its carnivorous pursuit. What the bulimic self is able to hear is, first, an acknowledgement of its deeper needs in the present, and then, later on, an explanation of its genetic roots.

I have found that many eating-disordered patients will report a history of dissociative abilities, particularly those, of course, who are in the “borderline” range of psychopathology and/or who have experienced the trauma of physical or sexual abuse. In fact, several of my bulimic patients have reported being “better” at dissociating spontaneously as children than they are now. One patient described how as a child she used to be able to “go numb” at will to find relief from her emotional pain, and how as she got older she began to lose this ability. During one session, she realized with a jolt that she was now using her bulimia and her drug use as external techniques to reach the same dissociative state she had been able to reach internally as a child.

The connection between bulimia and dissociation – a defense that serves to “compartmentalize and separate aspects of experience” (Spiegel & Cardena, 1990) – needs further clarification. My own (incomplete) understanding of the role of dissociation in bulimia is as follows. When the nuclear needs (and the affects surrounding them) are not responded to empathically because they somehow threaten the caregiver's narcissistic equilibrium, they are split off from the total self-structure and may then be organized into a separate sector of the personality. Then, I propose, when the individual later begins to experiment with bulimia, the biochemical effects of the binge-purge cycle create an altered state that serves to reinforce the already existing split in the psyche and further organize the dissociate needs into a “bulimic self.” The split-off state becomes associated with the bulimia, and the bulimic behavior becomes a way of voluntarily accessing this hidden self.

From those who use hypnosis to study multiple personality (e.g., Watkins & Watkins, 1988) comes increasing evidence that divisions within a personality are quite common and range along a continuum from normal adaptive differentiation at one end to multiple personality disorders at the other. My experience suggests that most bulimic patients subjectively experience internal splits to a lesser or greater degree. The extent of the organization of their early, dissociated needs into a distinct self-state varies, with those who have suffered the most traumatic breaches of empathy having the most distinct self-states. This observation is in line with mounting research evidence of a clear relationship between dissociative symptoms and childhood trauma.

(Adapted from Johnson, Craig L., Psychodynamic Treatment of Anorexia Nervosa and Bulimia, The Guilford Press, New York, 1991.)

Personal Reflection Exercise #4
The preceding section discussed the connection between bulimia and dissociation. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.
Reviewed 2023

Update
Dissociation and its biological and clinical associations in functional neurological disorder: systematic review and meta-analysis

Campbell, M. C., Smakowski, A., Rojas-Aguiluz, M., Goldstein, L. H., Cardeña, E., Nicholson, T. R., Reinders, A. A. T. S., & Pick, S. (2022). Dissociation and its biological and clinical associations in functional neurological disorder: systematic review and meta-analysis. BJPsych open, 9(1), e2. https://doi.org/10.1192/bjo.2022.597

Peer-Reviewed Journal Article References:
Brown, T. A., Forney, K. J., Klein, K. M., Grillot, C., & Keel, P. K. (2020). A 30-year longitudinal study of body weight, dieting, and eating pathology across women and men from late adolescence to later midlife. Journal of Abnormal Psychology, 129(4), 376–386.

Duffy, M. E., Lieberman, A., Wonderlich, S. A., Crosby, R. D., Mitchell, J. E., Crow, S. J., Peterson, C. B., Le Grange, D., Bardone-Cone, A. M., & Joiner, T. E. (2020). Identity problems and suicidal ideation severity among women with bulimic-spectrum pathology. Personality Disorders: Theory, Research, and Treatment.

Katznelson, H., Falkenström, F., Daniel, S. I. F., Lunn, S., Folke, S., Pedersen, S. H., & Poulsen, S. (2020). Reflective functioning, psychotherapeutic alliance, and outcome in two psychotherapies for bulimia nervosa. Psychotherapy, 57(2), 129–140.

QUESTION 15
According to Johnson what is it that most bulimic patients experience? To select and enter your answer go to Test.