Our hypothesis posits that eating disorders are the result of deficiencies in mentalization. To explore this, we primarily relied on pertinent journals from databases such as Pub Med-NCBI and Google scholar. Upon meticulous examination of the primary literature, we found evidence supporting the notion that deficits in mentalization do play a role in the onset of eating disorders.
The study suggests that deficits in mentalization contribute to the development of eating disorders. These deficits result in emotional dysregulation, non-acceptance, loss of self, poor object relations, interoceptive awareness, and affect regulation capacities.
According to Fonagy, Bateman & Bateman (2011), mentalization is the process by which individuals interpret and understand their own mental states and those of others. Implicit mentalization refers to automatic and unconscious abilities to comprehend mental states, while explicit mentalization involves conscious and deliberate capacities for understanding.
Keywords: Mentalization, Object relat
...ions, Affect regulation, Eating disorders, Attachment, The self
Fonagy et al. (2011) suggest that mental states, such as beliefs, feelings, desires, reasons, and motives, are established in early childhood. They claim that if mentalization is lacking, it can lead to serious mental disorders and psychopathologies. These deficiencies hinder an individual's capacity for self-regulation, self-awareness, emotional consciousness, mindfulness practice, and self-reflection. Psychoanalytic studies indicate a strong connection between the process of mentalization and the emergence of eating disorders.
According to Robinson et al. (2014), the psychological, physical, and psychosocial functioning of individuals is impacted by the adoption of weight control and disturbed dietary behaviors in eating disorders. Bulimia nervosa, anorexia nervosa, and binge eating disorders are distinct types of eating disorders. Research indicates that individuals with impaired mentalizing capacities have a greater vulnerability to these eating pathologies.
In relation
to this matter, it is accurate to assume that the development of eating disorders can be caused by deficits in mentalization.
Background literature
According to Gander, Sevecke, ; Buchheim (2015), deficits in mentalization result in complex attachment issues that are crucial in the development of eating disorders. There are two types of attachment patterns: secure and insecure attachment patterns. Secure attachment patterns involve the provision of emotional availability and support.
Secure attachment allows children to internalize their interactions and experiences with others, leading to the development of internal working models. These models help children understand and predict the responsiveness, availability, feelings, and needs of their caregivers. By forming secure attachments, children also develop a sense of self-awareness and identity, seeing themselves as valuable and lovable individuals. On the other hand, insecure attachment patterns lack emotional support and availability, which hinders children's ability to comprehend their external experiences and interactions (Ward, Ramsay & Treasure, 2000).
Insecure attachment patterns pose challenges for individuals in understanding the thoughts and responsiveness of others, impeding the development of self-identity, self-concept, and self-awareness. Consequently, children experiencing insecure attachment struggle to comprehend their own emotions, sensations, beliefs, motives, and desires (Gander et al.).
(2015) suggests that insecure attachment patterns have a negative impact on the development of individual mindfulness, encompassing self-identity, self-awareness, and self-concept. Mindfulness entails comprehending present emotions or sensations without evaluating them based on past encounters. Insufficient individual mindfulness leads to a lack of awareness regarding satiety and hunger, ultimately resulting in unhealthy weight control habits and diets that contribute to the advancement of eating disorders. Insecure attachment patterns also undermine self-acceptance and
body image, hindering the growth of self-concept and self-awareness. Generally, body image refers to an individual's perception of their own physical appearance.
The relationship between body image and eating disorders is significant. Feeling unsatisfied with how one looks can cause people to try restrictive diets and exercise in hopes of altering their bodies. Ultimately, having a distorted body image can push individuals towards adopting unhealthy eating habits, making them more susceptible to different eating disorders like bulimia, anorexia, binge eating, or orthorexia. In a theoretical review done by Gander et al. (2015), the aim was to confirm that attachment and the development of eating disorders are interconnected.
According to a review, the majority of people with eating disorders exhibit insecure attachment patterns. This indicates that problems in mentalization are important in the development of these disorders. Merwin, Zucker, Lacy, and Elliot (2010) suggest that impaired interoceptive awareness is caused by deficiencies in mentalization. They argue that this lack of awareness contributes significantly to serious mental illnesses like eating disorders and personality disorders. Therefore, it is crucial to address inadequate interoceptive awareness during treatment for these conditions.
(2010) The study defines interoceptive awareness as the capacity to recognize and embrace one's emotional and physical experiences, while comprehending their emotional reactions. Insufficient mentalization leads to a deficiency in interoceptive awareness, leading to confusion regarding emotions. Individuals with low emotional clarity encounter challenges in regulating their emotions due to difficulty discerning between bodily sensations and emotions. For instance, those lacking emotional clarity may inaccurately perceive anxiety as hunger or satiety.
Developing eating disorders and disorderly eating habits is a result of maladaptive interpretations. Non-acceptance, caused by a lack of emotional clarity and
interoceptive awareness, plays a role in this. Merwin et al. (2010) state that negative and distorted body attitudes are evident in non-acceptance, leading individuals to modify their dietary patterns in pursuit of improving their body image.
According to Merwin et al. (2010), changing one's diet can result in the development of disordered eating habits, which ultimately contribute to the occurrence of eating disorders. The researchers propose that individuals who struggle with emotional clarity may find it difficult to distinguish between their own fantasies and distortions and accurately perceive external events due to emotional dysregulation. Despite understanding reality, these people often choose to disregard its significance (Shore & Porter, 1990).
Underweight individuals may develop a compulsive fixation on obesity, despite being underweight themselves. These individuals mistakenly believe that they are overweight and therefore feel driven to further reduce their calorie intake. Their inability to differentiate between internal distortion and valid external experiences is seen as a deficiency in mentalization.
In an effort to shed pounds, people who are underweight may develop disordered eating patterns that can lead to the onset of eating disorders. Merwin et al.
(2010) conducted a study in order to examine how interoceptive awareness is linked to eating disorders. The researchers employed experimental techniques to break down the level of interoceptive awareness among individuals with restrictive dietary practices. The findings showed that those with restrictive eating habits encountered emotional dysregulation.
These individuals lacked the ability to comprehend their emotions, feelings, and bodily sensations. Consequently, they faced difficulty distinguishing between hunger and fullness, which contributed to the formation of unhealthy eating habits. Additionally, the research revealed that those who followed strict diets possessed a limited awareness of their body's
internal cues. This resulted in negative attitudes towards body image and a persistent adherence to restrictive eating patterns with the aim of enhancing physical appearance.
According to Mauler, Hamm, Weike & Tuschen-Caffier (2006), mentalization involves both interpersonal and self-reflective elements. These elements allow individuals to differentiate between external reality and internal reality, as well as understand interpersonal relationships and emotional processes. In essence, these elements play a crucial role in shaping one's sense of self and personal agency. Mauler et al. (2006) suggest that deficiencies in mentalization impede affect regulation, which refers to the ability to manage and comprehend one's psychophysiological constructs (like emotions).
Affect regulation is crucial for individuals to build defenses and resistances against emotional experiences and other factors that may impede normal mental functioning. Ultimately, it enhances their capacity to regulate emotions. Concerning eating disorders, Mauler et al. (2006) suggest that individuals grappling with affect regulation are more prone to developing negative attitudes towards food cues, as well as sensations of hunger and satiety. For instance, a person may cultivate a pessimistic mindset towards feeling hungry, which can result in the adoption of unhealthy and disordered eating patterns contributing to the onset of eating disorders.
According to Mauler et al. (2006), individuals who have a negative mindset towards food cues may develop unhealthy strategies for managing their food intake, leading to the development of eating disorders. In their empirical study, they examined 156 female participants to explore the relationship between affect regulation and the emergence of eating disorders.
In the study, two groups were examined: women with bulimia and healthy individuals. The researchers evaluated the participants' ability to regulate their emotions and found that women with
bulimia displayed negative attitudes towards food cues.
The researchers found that women's eating disorder was primarily caused by this attitude. This same attitude also caused a decrease in their ability to regulate emotions. Insufficient emotional regulation skills resulted in negative attitudes towards food cues for women with bulimia, whereas unaffected women had positive attitudes towards food cues.
By avoiding ineffective dietary management strategies, the women reduced their chances of developing bulimia. Additionally, their normal affect regulation capacities allowed them to maintain positive attitudes towards food cues, thus preventing the onset of eating disorders.
People who struggle to regulate their emotions are at a higher risk of developing eating disorders. This is because they have difficulty understanding and controlling their emotional responses to food cues, hunger, and feeling full. Consequently, they may develop negative attitudes towards food and resort to restrictive diets as a means of managing these emotions. These unhealthy eating habits can ultimately result in the development of eating disorders. According to Weinberg (2006), mentalization plays a significant role in fostering healthy self-development.
According to Weinberg (2006), mentalization is crucial for children's development as it enables them to internalize responses, fostering self-awareness and self-identity. Through mentalizing, individuals acquire autonomy and self-control, which enhances a sense of consistency, control, coherence, and accountability for their actions and decisions. However, the absence of mentalization can undermine one's sense of self.
Impaired mentalization capacities prevent individuals from developing various aspects of the self, including self-agency, self-awareness, self-direction, self-concept, and self-identity. As a result, they suffer a loss of the self. Typically, the self is considered the internal core that molds one's personality and essence. This loss entails prioritizing external factors and undervaluing internal
factors.
The focus on external appearance, specifically weight and beauty, is frequently observed when individuals lose their sense of self. This loss of identity is closely linked to the development of eating disorders, as attention becomes diverted from inner qualities. Individuals who have undergone this loss become preoccupied with their weight and resort to unhealthy eating habits in order to attain and maintain their desired body weight (Weinberg, 2006).
Overweight individuals who lose confidence in themselves may feel the need to lose weight, leading them to adopt unhealthy eating strategies. These strategies ultimately lead to the development of eating disorders (Ruangsri, 2009). Mentalization is crucial for forming human relationships as it allows individuals to understand the thoughts and emotions of others, making it easier to establish connections. According to object relations theory, humans are primarily driven by a desire for interpersonal connections. Ruangsri (2009) argues that deficiencies in mentalization can hinder the development of healthy object relation abilities.
Object relations refer to the internalized relationships between significant others (objects) and the self, characterized by the mental representation of the self in relation to the object, the object in relation to the self, and the relationship established between the self and the object. According to Ruangsri (2009), impaired object relations are linked to the development of eating disorders and disorganization of the self. Individuals with impaired object relation capacities are less likely to self-regulate.
People with eating disorders often struggle to differentiate their own desires and needs from those of others. Additionally, they may experience a fear of deterioration, leading them to prioritize the wishes and wants of others in an effort to form connections. The development of eating disorders
can be attributed to impaired object relation capacities in two ways.
Individuals with poor object relation capacities lack the ability to understand and interpret their feelings. Instead, they focus mainly on the desires and wants of others (Heesacker ; Neimeyer, 1990). Consequently, they seek alternative ways to regulate their basic affects. Often, these individuals resort to using their bodies as a means of managing their emotions. In many cases, they adopt disorderly eating habits in order to achieve their desired physical appearance. These disorderly eating tendencies gradually lead to the development of eating disorders. Additionally, impaired object relations hinder symbolization, which further contributes to the development of eating disorders.
According to Ruangsri (2009), individuals who have impaired object relations frequently struggle with symbolization. In particular, a child's mother is viewed as the main object, and those who fail to internalize this relationship often struggle with symbolization or finding a replacement for the primary object. This is especially relevant in the context of eating disorders, where individuals with impaired object relation capacities tend to perceive food as the primary object rather than a substitute.
As an illustration, some individuals resort to starvation as a means of disconnecting from the main focus. In general, food is associated with an unsuccessful relationship between a mother and child. Hence, individuals choose to deny themselves food in order to exert authority over these difficult relations. Over time, these inclinations eventually lead to the emergence of eating disorders.
Preferred Therapist Characteristics in Treatment of Anorexia Nervosa: The Patient’s Perspective.
Anorexia nervosa is a psychological disorder characterized by excessive weight loss and self-starvation, resulting from deficits in the development of the psychological
self, as explained by Hilde Bruch. There are two types of anorexia: the restricting type, where weight loss is achieved through fasting, dieting, and vigorous exercises, and the purging type, where weight loss is achieved through vomiting or using laxatives and diuretics. Research shows that approximately 90-95% of individuals with this disorder are female adolescents. Anorexia nervosa is the most common psychiatric diagnosis among women, with high mortality rates compared to other mental health conditions.
In America, approximately 0.5 – 1% of women suffer from anorexia nervosa. This disorder is influenced by multiple factors that impact the human body. Some symptoms include an intense preoccupation with weight, a fear of gaining weight, and constant efforts to prevent weight gain. These individuals also struggle with inadequate food intake, resulting in significant weight loss. Additionally, low self-esteem can lead to stress and depression, which in turn can contribute to further weight loss. Ultimately, these individuals may struggle to accept and appreciate their current circumstances. Life is filled with various challenges that can make it difficult for someone to cope.
Loss of appetite, resulting in reduced food intake, can occur as a consequence of this. Eating disorder experts have highlighted that intensive treatment can significantly enhance the chances of a patient's recovery. Hence, gaining an understanding of the warning signs associated with anorexia nervosa is crucial for promoting treatment. Some of these warning signs include heightened weight loss, denial of hunger, consistent avoidance of food-related situations, withdrawal from social activities and friends, fear of weight gain, refusal to consume specific types of foods, preoccupation with particular foods, fixation on dieting and body weight, usage of diet pills, laxatives or diuretics
for weight loss, and engaging in compulsive exercises to burn calories.
Concerns about weight loss, dieting, and food control are typically prominent in individuals with anorexia nervosa. This disorder involves self-starvation, which deprives the body of essential nutrients and slows down bodily processes in order to conserve energy. As a result, serious medical consequences can occur, including dehydration that may lead to kidney failure, overall weakness resulting in fatigue and fainting, hair loss, low self-esteem, dissatisfaction with one's body, strained family relationships, difficulty expressing emotions, weakened muscles, reduced bone density leading to brittle bones, deficiencies in potassium, magnesium, and sodium, constipation and bloating, low blood pressure, abnormal slow heart rates increasing the risk of heart failure, and the growth of a layer of hair called lanugo all over the body in an attempt to keep warm.
Therefore, patients' satisfaction in the treatment of Anorexia Nervosa is associated with four factors: acceptance, vitality, challenge, and expertise. Additionally, patients' suggestions for treatment require therapists to exhibit a complex set of behaviors when interacting with them.
Discussion
After conducting a thorough analysis of relevant literature, it is apparent that there is a strong link between deficits in mentalization and the onset of eating disorders. The reviewed literature indicates that deficits in mentalization can contribute to the development of eating disorders in multiple ways.
Deficits in mentalization hinder the normal development of the self, thereby triggering eating disorders. Mentalization allows individuals to comprehend their own mental states and those of others, promoting the development of self-identity, self-concept, and self-awareness. Consequently, these factors play a crucial role in initiating the normal development of the self.
Deficits in mentalization hinder the development of self-identity, concept, and awareness,
leading to a lack of self. Those affected by this impaired development tend to prioritize their external appearances and neglect their inner selves. Consequently, they feel the need to enhance their external appearances, leading to the adoption of unhealthy eating patterns. These patterns contribute to the development of eating disorders. Additionally, deficits in mentalization disrupt the development of normal affect regulation capacities, further exacerbating eating disorders.
According to literature analysis, affect regulation is the ability to control emotions and other factors that impede mental functioning. Individuals with impaired affect regulation often develop negative attitudes towards food cues, satiety, and hunger, leading them to adopt dysfunctional eating strategies that can result in bulimia. Additionally, deficits in mentalization hinder the normal development of object relations capacities, which refers to people's abilities to foster human relationships. These deficits prevent individuals from understanding their own mental states and those of others (Ruangsri, 2009).
Impaired object relations capacities can hinder individuals from cultivating human relationships, causing them to prioritize the needs and wants of others at the expense of their own desires. This may lead them to engage in unhealthy eating behaviors, such as trying to alter their weight in order to fit in and feel accepted. Additionally, impaired object relations capacities can impair normal symbolization abilities, further contributing to the development of eating disorders.
Object relations capacities emerge during early childhood stages, with the mother playing a crucial role as the primary object. However, individuals who experience inadequate mother-child relationships often struggle to symbolize and form negative attitudes towards their primary object, the mother. Consequently, they tend to associate food with this primary object.
They develop negative attitudes towards food when they equate
it with the primary object. These negative attitudes are linked to a lack of proper symbolization capacities. Rather than seeing food as a substitute for the primary object, individuals see it as the primary object itself. These attitudes motivate them to develop dysfunctional eating habits, which in turn lead to eating pathologies.
Deficits in mentalization hinder the typical development of interoceptive awareness capacities, which, in turn, can lead to the emergence of eating pathologies. These capacities allow individuals to accurately comprehend and interpret their emotional responses, feelings, desires, and wants. Inadequate interoceptive awareness triggers emotional dysregulation, which denotes a lack of emotional clarity. Individuals lacking emotional clarity are at a heightened risk for developing eating disorders, as they struggle to distinguish between hunger and satiety and may erroneously perceive satiety as fear.
Thus, individuals may feel compelled to change their dietary habits. These changes can lead to the adoption of unhealthy eating habits, which in turn can result in the development of eating disorders. Additionally, deficits in mentalization can also contribute to the development of eating disorders by hindering the development of mindfulness. Mindfulness involves accurately interpreting and understanding one's emotions without being influenced by past experiences. Individuals who lack mindfulness are more prone to developing eating disorders as they struggle to recognize feelings of hunger and fullness.
The adoption of disorderly eating habits is triggered by maladaptive interpretations of emotional feelings and bodily sensations, leading to the development of eating disorders. According to a significant majority of primary literature, factors such as affect regulation, loss of self, insecure attachment, non-acceptance, emotional dysregulation, lack of interoceptive awareness, object relations, and symbolization capacities are primary causes of eating disorders.
However, genetic makeup, including certain genotypes such as the FTO gene, has also been classified as a primary trigger for eating disorders. Skarderud (2013) argues that eating disorders are rooted in people's genetic make-up and individuals born with certain genotypes, like the FTO gene, are more susceptible. The FTO gene encodes the alpha-ketoglutarate protein, also known as the obesity and fat mass protein.
According to Helder ; Collier (2010), individuals with the FTO gene carry the GG and GA genotypes, which make them more prone to eating disorders. It has been observed that the method of treatment administration plays a crucial role in bringing about therapeutic change. Conversely, having a comprehensive understanding of the four factors can enhance the overall treatment of patients with Anorexia nervosa by helping clinicians and doctors establish a solid therapeutic alliance with those affected by this eating disorder.
Having knowledge of the factors mentioned above is important for promoting understanding of anorexia nervosa. This includes understanding the challenges and difficulties faced by individuals with this disorder, the causes and effects of anorexia nervosa, measures that can be taken to reduce the problem, and how treatment can be effectively administered. Anorexia nervosa is a mental condition that is associated with a high risk of premature deaths in young men and women (Smith, 1999). Treating this disorder can be challenging as many patients may not recognize their illness and assume their bodies are functioning normally. Some individuals may have a biological predisposition to anorexia nervosa, making it difficult to treat. In order to facilitate recovery, it is important to create a therapeutic environment that aligns with the preferences of the patients, allowing clinicians to
administer treatment effectively. Clinicians and doctors should also consider how the treatment they provide satisfies or dissatisfies patients, as satisfaction with treatment is closely linked to the effectiveness of the treatment.
Various studies on treating eating disorders have shown that patients value a strong rapport with their therapist in order to create a supportive environment that encourages open communication about their relationship with food. For individuals with anorexia nervosa (AN), positive treatment experiences are often associated with therapists who are understanding, supportive, trustworthy, respectful, caring, and affectionate. These qualities facilitate easier treatment because patients feel comfortable discussing their desires and expectations. Conversely, negative experiences are linked to therapists who lack validation, show indifference, and overlook patient emotions. To address the desired characteristics in therapists treating AN, it is essential for therapists to integrate positive treatment approaches to address the growing number of individuals affected by this eating disorder.
On the other hand, eating disorders are closely linked to personality disorders. Many patients with anorexia struggle to seek treatment because it is a difficult decision to make and they have trouble accepting that anorexia is a part of their identity. However, there is potential to overcome and heal from anorexia by implementing various factors that will enhance the satisfaction of these patients. For instance, when it comes to acceptance as a factor in patient satisfaction, it is important for a patient to acknowledge that their pursuit of thinness is beyond their control and recognize the physical and emotional harm they have endured in their attempts to lose weight. By admitting that there is a problem with their weight loss, patients can begin to let go of the activities
and situations that contribute to their eating disorder. In the end, the patient will come to terms with their current situation and work diligently towards recovery. On the other hand, patients must also recognize the significance of vitality in promoting satisfaction and ultimately achieving good health.
When a person with AN (Anorexia Nervosa) embraces vitality in their life, they have the opportunity to live well and experience physical growth and development, which can help them cope with eating disorders that contribute to mental health problems. Over time, the patient will work hard to develop healthy eating habits that promote good overall health. However, if faced with challenges that affect patient satisfaction, it is important for the patient to challenge destructive mindsets by recognizing damaging thoughts. Examples of these thoughts include emotional reasoning, where a person believes that their feelings determine truth, as well as labeling themselves based on past mistakes or holding themselves to rigid rules about eating. By recognizing and identifying negative thoughts, the patient can develop a more balanced perspective.
