Anorexia nervosa (AN) is a severe mental illness with a number of physical, psychological and social conditions. In spite of the severity of the disorder, we still lack empirical evidence to choose one treatment over another. The failure to show scientific evidence of effective treatment and prevention might rely on the complex psychological mechanisms involved in the disorder. To further improve our ability to help patients with AN, a better understanding of the specific mechanisms involved in the disorder is needed. A scarcely utilized source of knowledge in this respect is the patients themselves. On these ground, we explored two central psychological phenomena of AN as they are experienced and understood from the patients’ own perspective, namely body image disturbance and emotional regulation.
The three studies included in this dissertation presents results from a collaborative research project - “Anorexia nervosa: The patients’ experiences” - in which patients’ experiences are utilized as a source of knowledge to understand different psychological aspects of AN. The study was conducted in two different phases and with two different samples. First, a wide-angled and exploratory study was conducted on a sample of 18 patients. Next, a more focused study was conducted on a sample of 14 patients. The total sample included 32 women aged 19-39 with current or previous AN (DSM-IV). In both phases, qualitative data was collected through semi-structured in-depth interviews. The interviews were tape-recorded, transcribed, coded and analyzed using Grounded Theory methods.
The first paper explores the concept of body image disturbance as it is experienced in the daily life of patients with AN. We identified four phenotypes of body image disturbance - “Integration”, “Denial”, “Dissociation”, and “Delusion” - which differed according to whether the patients overestimated their own body size (“Subjective reality”), and whether they acknowledged the objective truth that they were underweight (“Objective reality”). The second paper explores which everyday situations and contexts AN patients themselves associate with self-perceived fluctuations in their body images. Four triggering contextual factors were identified; “Eating food”, “Body awareness”, “Emotional experiences” and “Interpersonal influences”. The third paper explores how patients with AN manage their basic negative emotions and how they relate these experiences to their eating disorder behaviours. The participants tended to inhibit expression of sadness and anger in interpersonal situations, and reported high levels of self-disgust, fear of becoming fat and anger towards themselves,. The results suggest that different emotions were managed by means of different eating disorder behaviours.
In sum, the present dissertation suggests close relationships between emotional regulation and body image disturbance, and between specific emotions and different eating disorder behaviours. Knowledge about how patients understand these aspects of their disorder may be an important addition to further the more specific development of treatment programs for AN. The main findings and implications of this dissertation are:
- Body image disturbance may be conceptualized as a failure to integrate subjective experiences of one’s own body appearance with an objective appraisal of the body.
- Severity of body image disturbances may range from integration to delusion.
- Body image disturbance may be regarded as a dynamic phenomenon that may vary across time and situations.
- Stability of body image disturbance may range from relatively stable to very unstable, uncertain and fluctuating body experiences.
- Body image disturbance seems to be triggered in a range of daily life contexts which share in common that they trigger affective arousal in the individual.
- There seems to be specific relationships between certain basic negative emotions and specific eating disorder behaviours.
The concept of body dissatisfaction seems to be too non-specific to apply to the severity and complexity of patients’ emotions towards their own body.