Idoneidad de interacciones entre facetas

. Developmental stressors of adolescence • Societal pressures Activation of attachment system Stress reaction (fight/flight) D isruption of m en talization PRECIPITATING FACTORS • Interpersonal crises

(peer group or family) • Loss

• Dieting

• Genetics and biology . Psychological factors • Family environment &

attachment

INDIVIDUAL PREDISPOSING FACTORS

Figure 5. Mentalization and the development of eating disorders

Individual predisposing factors

While space precludes a full consideration of all predisposing factors, certain risk factors stand out. Bruch (1974) was one of the first to draw attention to abnormal parent-child interactions amongst individuals with EDs. She suggested that mothers who impose their own conception of the infant daughter’s needs create a situation where the infant struggles to differentiate her own feelings and impulses from those of her mother. Empirical research on alexithymia supports Bruch’s hypothesis in that anorexics appear to have difficulty identifying and communicating feeling states (Rastam e ta l., 1997; Zonnevijlle-Bendek et al., 2002). Furthermore, reviews of the literature demonstrate strong links between insecure attachment and EDs, although researchers disagree whether attachment

style predicts ED sub-category (O'Kearney, 1996; Ward et al., 2000). Studies confirming a link (e.g. Candelori and Ciocca 1998, cited in Ward et al., 2000) suggest that restricting anorexic individuals tend to have a dismissing attachment style, whereas bulimics are preoccupied.

One possible explanation for these inconsistent findings is that another factor is mediating the relationship: mentalization. In a study at the Cassel Hospital, Fonagy and colleagues (1996) confirmed that ED clients had significantly lower RF than other Axis I disorders, sharing levels similar to borderline clients. Evidence of intergenerational transmission of attachment states of mind is provided by Ward et al. (2001) who studied mother-daughter pairs and found that RF was significantly lower in anorexic daughters and their mothers than psychiatric controls, with both sharing a dismissive attachment style. A study by Besser and Blatt (2007) proposed that the quality of the adolescent’s relationship with the same- sex parent appears to be crucial, as positive identifications provide protection against later development of problem behaviours.

It may be that apparently normal mothering obscures subtle conflicts between mother and daughter. It is suggested here that, like the mentalization-based account of BPD, unresolved loss or trauma in the mother may hinder her ability to sensitively mirror her infant, superimposing instead her own emotional state. As Bruch (1974) said, the developing child is therefore caught in a dilemma between depending on the mother to supply a sense of self and defending against the mother’s intrusiveness. Clues as to why the mother is unable to be emotionally available for her daughter are provided in a study by Shoebridge and Gowers (2000). They noted high rates of obstetric loss prior to the anorexic daughter’s birth accompanied by over-protective parenting style. Another study uncovered significantly more deaths among first-degree

relatives of teenagers with anorexia nervosa than controls (Nilsson et al., 1998). Ward et al. (2001) found that narratives of anorexic daughters and their mothers showed high idealization. This lends tentative support to the present hypothesis that the developing anorexic learns from her family to defensively turn away from negative emotions and actively inhibit mentalization.

In more toxic family environments characterised by abuse, the adolescent may internalise a torturing alien self, much like the borderline individual. Suppression of mentalization becomes so extreme that parts of the self become split-off. It is certainly the case that individuals with EDs report childhood sexual abuse more frequently than those without EDs, and women with bulimic behaviours have higher rates of childhood adversity than other EDs (Schmidt et a/., 1997a).

General predisposing factors

Incidence rates for EDs are highest during adolescence and early adulthood (Hoeken et al., 2005), suggesting that normal developmental changes may stress vulnerable individuals. Brain changes in adolescence may compromise mentalization and therefore increase vulnerability to ED. Choudhury (2006) found that children’s social perspective decreased as they moved into adolescence. Blakemore et al. (2007) compared adults to adolescents and found the latter had more difficulties with abstract intentional causality than physical causality. Normative pubertal changes like weight gain in girls and sexual maturation ensures adolescents are acutely aware of their bodies. Exposure to ‘thin ideal’ media-messages compounds adolescents’ concerns with their bodies (Harrison, 2000). When adolescents’ orientation to the concrete is combined with their

relatively undeveloped social cognition, it is understandable how dissatisfaction with the body may arise, and hence disordered eating.

Precipitating factors

Adolescents face increased demands for individuation as educational pressures mount, and peer relationships become more salient. Interpersonal crises associated with changing roles may be experienced by some adolescents as insurmountable challenges. Neuro-imaging studies suggest that stress or activation of the attachment system causes areas of the brain associated with mentalizing to be deactivated (Arnsten, 1998; Bartels & Zeki, 2004). Just as hyper-activation of the attachment system drives borderline individuals to seek proximity to the attachment figure who abused them, adolescents with eating disorders are caught in a dilemma, wanting to be close to their family yet angry over their attempts to control them.

It is how an individual experiences an event rather than its intrinsic severity that dictates the embracing of disordered eating as a coping mechanism. For example, a study comparing binge-eaters with non-binge eaters showed that there was no significant difference in reported levels of daily hassles, but binge-eaters rated these as more stressful (Crowther et al., 2001). The meaning of certain events may have implications for type of ED developed. Schmidt et al. (1997b) found that life events or difficulties that evoked sexual shame or disgust were more highly linked with development of AN than BN.