“How Can I Have my Cake and Eat it?” A Contemporary Dissociation-Based Self-State Model of Anorexia and Binge-Eating Disorder

Abstract

The extant, contemporary psychoanalytic literature suggests that pathological dissociation is at the heart of most psychiatric disorders, ranging from personality disorders to affective and psychotic disorders. This chapter will begin by situating Janet’s contributions to the splitting of consciousness, and then discuss dissociation, and the resultant splintering of the self, as a ubiquitous response to early relational trauma. Specific dissociated self-states as they appear in anorexia and binge-eating disorder will be put forward, using detailed clinical vignettes to describe the paradoxical functions of these self-states, and the way they structure the eating-disordered patient’s relationship to food, eating, and their body. Treatment implications as they pertain to relational psychoanalytic technique will be considered.

1. Introduction

The psychoanalytic paradigm shift from a classic drive model to a relational model as it emerged in the 1980s saw an upsurge of interest away from intrapsychic conflict to the way in which traumatic interpersonal experiences structure the developing mind. The move from a one-person psychology to a two-person constructivist psychology [1], along with developments in trauma and attachment theory, have thus seen contemporary psychoanalysis develop into a psychology of trauma that, after a century of practice informed by Freud’s topographical model of the mind, [2] is finding its way back to his early research with Breuer into the splitting of consciousness [3]. In their studies on hysteria, Freud and Breuer documented their difficulties in the treatment of patients suffering the consequences of psychic trauma, and remained mystified by the role of hypnoid states in the genesis of hysterical symptoms at the turn of the 19th century. As a result of the relational turn in psychoanalysis, the 1980s saw a reintegration of dissociative phenomena, hypnoid states, and other identity disturbances into the theory and technique of contemporary psychoanalysis. Despite this progression, dissociation as a concept worthy of cementing itself into the psychoanalytic canon remains a work in progress.

In this chapter, Janet’s pioneering contributions into the splitting of consciousness will be examined. What contemporary relational psychoanalysts refer to as self-states, [4, 5, 6] Janet saw as unformulated, inaccessible systems of experience that are split off from the self and act as autonomous psychic entities [7]. As such, symptoms found in those with eating disorders represent revivifications of unthinkable parts of the self that remain unreachable and hypnoidally severed from normal perception and cognition. Using detailed clinical vignettes, dissociated self-state configurations will be discussed as they appear in patients with anorexia nervosa and binge-eating disorder. These self-states maintain the patient’s intractable, pathological relation to food and eating in order to protect the self from disavowed experiences that are shameful, bad, or “not-me.”

2. Janet on trauma and splitting

For Janet [8, 9], the origin of hysteria had its roots in the patient’s “normal” consciousness being segregated from consciousness that is contained in the hypnoid state. This hypnoid state, carrying reminiscences of early psychic trauma, functions as an isolated island with its own actions, drives, perceptions, and feelings. Pathological changes in perception and consciousness, or dissociative symptoms, therefore occur as a result of an extraction process where trauma becomes unlinked from personal consciousness and remains alive and active in the symptom, or altered state of consciousness, that has now developed a mind of its own. The symptom, in Janet’s dissociation model, is thus conceptualized as a split-off cluster of bodily-based feelings, sensations, perceptions, and actions, where dissociation is maintained by amnesia for the sequestered traumatic event.

Whereas Freud and Breuer’s studies focused mainly on unbearable affect, and the conversion thereof into bodily symptomatology, Janet described a specific alteration in consciousness where the mind becomes split from the psyche-soma. In his research on psychological automatisms, Janet found that hysterical patients had a psychical weakness that narrowed their field of consciousness, so that certain phenomena would not be perceived or attended to. As a result, these phenomena developed independently and formed a second psychical system, the unconscious. The fixed ideas found in this unconscious were dissociated aspects of the self that had the tendency to re-emerge as automatisms, which hold the thoughts, feelings, and sensations that are not representable or accessible to the conscious self [10]. Nemiah ([11], p. 54) described these as,

“fantasies, memories, impulses and feelings [that are] unacceptable to the self, so frightening, saddening, painful or disgusting that they are forcefully excluded from conscious awareness … nonetheless capable … of producing derivative, ego-alien symptoms.”

The narrowing of consciousness responsible for the psychical weakness postulated by Janet thus occurs when an idea, or a constellation of thoughts linked to a traumatic event, splinters off and takes on a life of its own outside of the nexus of the normal personality. These split-off pockets, or automatisms, are not accessible to each other nor can they be accessed voluntarily or consciously by the self. Symptoms can thus be seen as revivifications of dissociated parts of the self along with the traumatic reminiscences that are encysted within these parts. The ongoing process of relegating traumatic experiences to segregated parts of the self where they cannot be assimilated or symbolized linguistically forecloses the illusion of unitary selfhood and gives way to a fractured kaleidoscope of discontinuous self-states that are not authorized to exist in relation to one’s overarching experience of “I” [12, 13]. In other words, the ability to integrate versions of oneself into a cohesive sense of self – a self that gives the illusion of one – is impaired when there is a surplus of trauma-related vehement emotion [7, 14] and an associated narrowing of the field of consciousness, resulting in the dissociation of those versions of oneself from the main center of consciousness (the “I”).

Under normal conditions, consciousness is a state of self-awareness where there is little or no impairment in the ability to remember experience that is linked to a specific self-state. In the absence of trauma, automatisms are bound together to the central self and “conjured up” voluntarily and willingly. Trauma, however, disrupts the self’s capacity for symbolization and integration. As a result, inaccessible experience becomes encysted in a somnabulistic state that holds the fixed idea, [9] which is defined as a complex of emotional experiences, perceptions of self and other, and images related to the original traumata [15]. Symptoms, or automatisms, thus arise out of a somnabulistic state, the nucleus where the disavowed versions of self, along with their feelings, thoughts, and sensations, become entombed and remain active.

3. Dissociation in eating disorders

Janet clearly elucidated how uncommunicable, indigestable shards of a shattered childhood become hubs around which other psychological traumata cohere to become distinct self-states that make themselves known through dissociative symptomatology. For the purpose of this chapter, dissociation is thus understood as an attempt to prevent the flooding of the individual’s current sense of “I” with other “Is” that are linked to historical experiences of relational trauma. These “Is” include affects, ideas, and sensations that are disavowed, due their intolerability, and their potential to threaten self-continuity. From this perspective, the symptoms that we consider anorectic or bulimic are seen as dissociative systems, sprouting from a mind that is home to multiple selves each with their own consciousness, their own truths, their own intentions, and their own relationship to food and the body [13, 15]. For the eating-disordered patient, the automatisms, more specifically, the acts of bingeing or starving, thus occur in an altered state of consciousness, the somnambulistic dimension, where the body becomes the stage onto which these dissociated complexes of mental life perform, communicate, and take control of the personality. Janet [9] used the word somnambulistic because it’s as if the anorectic, in her altered state of consciousness, becomes hypnotized by her starvation, just as the binge-eater becomes hypnotized by her urge to devour. These trance states represent the cleft of amnesia that separates the individual’s normal state of consciousness from another state of consciousness that now acts automatistically and independently under the instruction of the disowned self-state.

The disowned self-states, housing traumatic reminiscences, are therefore responsible for the binge, the purge, or the act of starvation in the eating-disordered patient. Inaccessible, unformulated, and disavowed, these distinct versions of self thus get enacted, and revivified, “through the body and bodily actions” ([16], p. 1). Their performative enactments on the body allow for the unspeakable to be spoken and the unthinkable to be acted out. Eating, in the binge state, or not eating, in the anorectic state, thus serves two purposes: 1) it happens without awareness, or in a state of narrowed consciousness, where the food stimulus diverts attention away from intolerable affect states such as rage, shame, and helplessness; and 2) it enables the patient to cross over into the split-off inaccessible self that is home to disowned longings and needs, or it enables the split-off self to intrude into the patient. For the binge eater who is in the grips of this split-off self-state, food is used as both a soothing ersatz-object for unmet needs, and a furious weapon that reinforces the organizing principle that such needs are too revolting, too big, and too dangerous to be expressed relationally. The anorectic, under the spell of the restrictive self-state, experiences food and eating as a noxious reminder of instinctual impulses and corporeal drives that cannot be predicted or controlled, and so the contaminable, corruptible body-self becomes disavowed at deadly costs.

For the eating-disordered patient, what constitutes the kind of trauma that necessitates sequestration into dissociated, hidden pockets of the mind that find concrete expression through automaton self-states and the body? What happens for the infant’s basic physiological needs, and their links to the psyche, to become eclipsed by the parent, so that the infant or child must fracture into distinct parts to secure some semblance of an “I”? More simply, what happens in the parent-infant dyad for the infant to sever its mind’s link to the body and its needs? During infancy, all bodily instincts, impulses, needs, and drives are routed through the other. Hearing the infant’s cries, the parent is interpellated by the infant’s hunger to responds to, nourish, and regulate this bodily need. Should the ghosts from the parent’s nursery [17] disrupt this process, schisms form in the infant’s psyche that dislodge and relocate the unmetabolizable affects, sensations, and ideations of these early relational feeding experiences. Since these early experiences are dissociated, they are splintered off into parts of the brain where there is no codification, consolidation, and storage of memory. An optimal regulatory attachment system is thus contingent on the parent’s ability to take up, digest, and rhythmically attune to [18] the infant’s physiological needs, so that she can return them in such a way that the infant experiences them as tolerable, digestible, and safe enough to take in as part of Me. As a transformational object, [19] she imbues the infant’s inchoate experiences with her own meaning. The spectral shards, or phantoms, of her own dissociated needs determine her ability to saturate the infant’s budding experiences with meaning that is, upon its return, ‘fit for consumption and digestion.’ Her ability to act as a good enough transformational object is thus dependent on whether her needs, desires, and wants (i.e. her body) are representable to her mind as legitimate, recognizable, and worthy of being owned. Through repeated interactions with the ghosts of the disowned in the parent’s mind, the infant experiences the containment of basic needs as an invasive ricochet of traumatic (indigestible) apparitions that entomb themselves as alien objects into the forsaken, unreachable pockets of its mind [20, 21]. For the anorectic, this alien object, which later morphs into the dissociated anorectic self-state, is related to an active dread of instinctual life and the embodied self, which keeps at bay other selves that seek to give expression to primal states of need, hunger, and desire which could not be routed through the parent. For the binge eater, this alien object, which takes on a life of its own as the bulimic self-state, is related to the dread of greed, wanting, and lust.

3.1 The anorectic self-state

Most patients with anorexia have a particular self-state arrangement where one or more self-states is organized around punishment and castigation of enjoyment, indulgence, pleasure, and excess. In the grips of this self-state, the anorexic feels like her appetite for life has been hijacked. It demands that refuge not be sought in the pleasures of the world, including food, but that it be sought in the comfort of abstinence, emptiness, and starvation. In her normal state of consciousness, the anorexic becomes a spectator to her act of starvation, performed over and over again behind a closed curtain that hides the utter dread of satiation and fullness. This is one of the fixed ideas [10] linked to the anorectic symptom: eating and nourishment are associated with the physiologic and psychic sensations, acts, and images of fullness and satiation, which must be controlled and dominated so that shame-filled states of need and hunger remain dissociated. Courtney, an adolescent patient who will be discussed in the following vignette, refers to her monstrous anorectic self-state as Ursula. Named after the famous sea witch, she is a relentless slave-driver that squelches happiness and pleasure and makes Courtney question everything she does. “She makes everything so hard,” Courtney tells me. “I’m always in two minds,” she adds, giving me a glimpse of her splintered psyche by poignantly capturing the anorexic’s split: on the one side, the mind of the scathing, critical torturer that demands strength and discipline, even in the face of death; and on the other, the crumbling, enfeebled self, squashed into a crevice of lifelessness that, under conditions of exhumation, would bleed vulnerability, need, and weakness. It is as a result of this dreaded exhumation of disavowed systems that Courtney clings to Ursula: “I’m scared that without her, what kind of person am I going to be?”

The anorectic self-state thus keeps the anorexic safe in the cage of its imprisonment, protecting her from the dangers that lurk in the world. As such, she is both cut off from the world and choked by it. Temptation becomes the anorexic’s biggest fear. It shatters her illusion that appetite, and the need for human relatedness that go along with it, can be self-contained and insular. The experience of eating becomes tarnished by this abusive self-state. Food, which should be regarded as essential, sustaining, and inviting, becomes associated with the obscene, the bad, and the unwanted. While the anorexic remains in the dark (i.e. dissociated) from the life-threatening effects of this torment, she is also desperate to cling on to this anguish for the escape that it affords her. In consequence, she fears the intensity of temptation, the fluttering burn of desire, and the irrevocable havoc that would ensue should she surrender and forego abstinence. When she finds herself succumbing to food, in a different state of consciousness to the anorectic self-state, who is this person nourishing her, tasting, sensing, desiring? It does not feel like her, it is not her.

The abusive anorectic self-state does not merely command restraint and asceticism, it also orders the death of the part of her, the needy child, who hungers after human connection. It is this anorectic self-state, with its sniggering voice and deadly intentions, that steals the show and directs the play in such a manner that the hungry, starved, emaciated little girl remains famished, dissociated, and quarantined. The little girl is essentially trapped in a dead, lifeless body, entombed by her chronic lack of fullness. Calories represent flesh, fat, and appetite. It is this appetite, along with the temptation to cede, that needs to be warded off, destroyed, controlled, and suffocated. The body is stripped into consistency, the mind unhooked from the gut, the psyche severed from the soma [22]. In this segregation of the body from the mind, biological mechanisms such as menstruation and bowel movements appear as intrusive, ego-alien burdens that threaten to obliterate the anorexic’s rigorous mastery over her own physiology. Moreover, physiological consequences of ingesting food force the anorexic to admit that she has a body; a body that can grow, impose, and take up space. The body exists in a war with her wish to prove that she has no needs, that she has no human hunger or thirst. The body, with its dangerous fleshiness and suspicious biological machinations, turns this wish on its head. Wary of the body, the anorectic self-state goes to great lengths to keep it in the dark; silent, and skeletal, not to be noticed, not to be spoken of. The fear for the anorexic therefore is not starvation. Starvation is her modus operandi, her survival. The real unconscious fear is that she will become aware of an instinctual underworld inside of her with specific versions of self that demand satiation and full-fill-ment. Thus, when the anorectic self-state looks into the mirror, she looks for the ghost that is successfully vanquishing the material self, cementing her ability to both destroy and protect: nothing goes in, and nothing comes out. There must be no needs, period.

Courtney

Courtney, an adolescent patient with a one-year history of anorexia, has been in analytic treatment for six months. As a result of the remission of her eating problem, she is able to explore the splintered underworld beneath, or responsible, for her symptom. She describes her dilemma in this way:

“For such a long time, ever since I was little even, I built up this persona that I was bigger than I was, untouchable, and now it’s broken, in pieces. And I don’t even have a reason for that. I used to pride myself on being ok. It made me feel brave and strong.”

“As if that’s all there should be to you,” I respond.

“I feel like I’m the baby these days, not my sister,” she says, associating to the disowned part of her that is kept at bay by the anorectic self-state.

“There must be something so unwanted about that baby, and its needs.”

“It’s nothing I ever wanted to be … weak and helpless. Sometimes I even feel physically sick.”

As she tells me about her strict physical training regimen, she becomes aware of how she splits herself off from her body, willing it into subservience: no hunger, no pain, no needs. The purpose of the anorectic self-state is clear: total dissociation from instinctual life and embodiment.

“It should just be quiet,” Courtney tells me of her body. “I’m always used to pushing through and never listening to my body. I forgot about my body.” This dissociative “forgetting” about the body is at the core of the anorexic’s dissociative organization, and the seemingly unbridgeable fissure between mind and body.

“I’ve never worked with my body, I’ve abused it, been against it.”

I reply, “And now that it’s forcing you to listen to it you may be feeling hateful towards it.”

“It’s not going along with me anymore,” she decries. Once a target for Courtney’s cruelty and abuse, her body-state [16] existed as a separate entity with a severed link to her mind and her overall self-experience. Now, there is betrayal and disruption, as her body emerges out of the amnestic shadows of her partitioned alien world, tentatively closing the chasm between psyche and soma. Where there was dissociation, there is now antagonism, or conflict, as Stern would say [4].

“I hate the fact that I am succumbing to it; it almost just happens now.” “Succumbing … like an either-or battle; winner or loser,” I reply.

“And it’s hard because I’m sort of realizing it’s not just a bad thing. When I was one-minded about things it was easier. That gap in between, I can’t see it. It scares me.”

Sometimes, Courtney and I will play with the word “suffering”, a word that connotes a system of sensations, feelings, and thoughts that is anathema to her ongoing experience of herself.

“When you suffer you become a stranger to yourself,” I tell her.

In my reverie, I start to wonder about an effortless, painless intermingling between Courtney’s body and her mother’s body during early nursing experiences. I wonder whether her mother was able to mold her body, her sensations, and her responses, to her infant’s interpellations.

“I feel like if I was more like her I wouldn’t be having these issues, which I’m not, which sometimes is annoying but other times I’m grateful. For me, experiencing each moment, or the details in the moment, is something she (mother) misses. She almost moves too quickly through life. And I’m not like that.”

“It must be hard for you to know which side you want to be on,” I say, as I point to the powerful identification that Courtney has with the part of her mother that is unable to stop, taste, and savor. “I shall not relish, and I shall not allow you to relish me, my milk … life,” is the message from her mother’s unconscious enigma that may have been intromitted into Courtney’s mind [23].

“Sometimes you really want to be in a moment but it’s hard because there’s also a very powerful force that takes you out of it.”

“Yes,” she confirms, “sometimes I appreciate these moments, especially lately, but it’s also easier to remove it.” She falls into a long silence, and I wonder whether we are in a moment, or in some kind of dead space.

This latter part of this vignette portrays the face of the kind of relational trauma that befalls the anorexic. We have to wonder about Courtney’s mother’s ability to attune to and “stay with the details” of her infant’s cries, her hunger, her needs for embodied, affected soothing, touch, and regulation. Misattunement to these earliest of bodily needs, instincts, and drives, which could be defined as a kind of attunement determined by the parent’s dissociation from her own enlivened stirrings, leads to intolerable affect in the infant that cannot be integrated into the mind where they form part of a coherent sense of “I”/“Me”; instead, instinctual life becomes extracted from body awareness and the functioning of the psyche-soma [22]; the sensations, ideas, and affects around these needs split off into discrete dissociated self-states that then take on lives of their own. Courtney’s needs are housed in the parts of herself that are unrecognizable to her established anorectic persona, and when they break through, she feels bereft, confused, and anxious.

“I only have me and my army. I don’t need people.”

With this anorectic “army” self-state to protect her from her needs, the fragile parts of her become the “enemy to be extinguished.”

“The struggling is not me … something I hide deep down hoping that no one will ever find. It’s who I am but I can’t live with who I am.”

I repeatedly empathize with her dilemma: “It’s hard to break free and explore these struggling parts. If you did, you wouldn’t be able to live with it, and another part of you would perhaps even punish you for it.” At other times, I frame her psychic impasse in this way, “There’s a constant battle between defending the army, and looking at the damage she’s done”.

“I start eating myself up about it,” she tells me. She describes the anorectic army self, at once her protector and destroyer, as “the person I wish I was if I wasn’t human. I can’t negotiate with her. In a way she just wants what’s best for me, to try my hardest, to have no excuses, I just can’t live up to that.”

Courtney wonders whether her “mind” will ever allow her to be happy. I tell her that Ursula, the slave-driving army sergeant, and her would have to get along. “That won’t happen, because then I’d have to acknowledge that she’s me, or in me. I’ve got myself hurting me! It’s like an abusive relationship, the weaker you are the stronger the other part gets and it just thrives.”

We circle over and over again around the theme of Courtney’s abuser self being both the defensive scaffolding that protects against intolerable, indigestible not-me states, [24] and the torturer that paradoxically ensures life, and death, at its own hands, and no one else’s. “Ursula is the one keeping me alive,” Courtney tells me, “without her drive I would have killed myself a long time ago.”

“You’re at a loss,” I tell her, “How do you get rid of something that is your skeleton, your structure, your army, but that also haunts you mercilessly on the inside.”

It is this skeleton, her trusted, faithful military operator, who vitiates the human inside of her.

“I’m human, I wish I wasn’t,” she tells me. “Being human … you can’t control everything.”

“Like if you can’t control something, you’d find something underneath, like a want?”

“I felt bad for being admitted to the clinic. If I take off the pressure, where do I go, where does that leave me? I don’t want to be that kind of person. Even when I fell apart I kept on pushing.”

“Falling apart means you’re not able to cope, which is a no-go,” I echo.

“It’s like food. I shouldn’t want the nice things. I don’t deserve it. I’ve set such rigid boundaries for myself and I don’t want to take these away because if I do I don’t know what I’ll be left with.”

“It’s frightening, and it’s also frightening to know that the parts of you that want and need things have other ways of reminding you that they are there.”

“But I don’t want that,” she avows, before she takes a tentative step to stand in the space [5] between her budding desire, and the disavowal thereof. “I actually don’t know what I want. I’ve been pushing away the parts of me that want and need for so long. I allow myself to relax for one day and my mind goes wild and aflurry with anxiety and panic.”

In the next sessions, Courtney expands on the anorexic’s self-imposed exile from the human, fleshy realm that demands interconnectedness and dependency. Again, she stresses the importance of the anorectic self-state in segregating her from experiences that seem anathema and alien to her overall sense of “I”.

“I don’t like putting my stuff on other people. It doesn’t make sense in my mind.”

I reflect her dilemma in the transference, “It seems so foreign that you could lay something on someone and have them carry it for you.” As I say these words, I feel anxious and alarmed. Courtney and I, suspended in the forbidden affect storm that is swirling between us.

“You just had a thought and it feels scary to share it.” She nods, “My chest feels so heavy … tight.”

“Like something wants to come out but it’s being restricted?”

“Maybe,” Courtney looks uncomfortable, struggling to take in the connection between the restrictive anorectic symptom, or self-state, and its necessity in restraining unregulatable affect related to our connection [13].

A few minutes go by.

“It’s my baggage, that’s where it ends,” she tells me, too calmly. Where is Ursula in this exchange, I wonder to myself.

“Speaking to someone makes it real,” I venture.

“Yes.”

I continue, “That there’s another person, another body, and that doesn’t compute. It shouldn’t be like that.”

“I’ve been having a persistent thought. I want to feel the pain, I want to feel it. I feel so lost and if I just … physical pain will make me feel human again.”

Something is broiling underneath her anesthetized shell. Courtney wants to feel something. A tendril of pain at her own hands, as opposed to the ferocious unstitching of the suture that would ensue if she felt with someone.

“Without the pain you’d feel too dead.”

“Too dead to die,” she responds, as she invites herself further to think about the function of her anorectic self-state. “She stopping me from things and that is destroying me because I’m floating around like a ghost. I’m not living like I want to.”

I share with her my association to The Living Dead. “I want to live and thrive,” says one-self-state; “it doesn’t seem like an option,” says another self-state.

“The idea that something could sprout inside of you seems unimaginable.”

In the next session, Courtney tells me about a picture she drew during an amnestic episode of daydreaming. It’s a drawing of two people in one body. A woman, peaceful, serene, plain, with wild hair, and inside of her, a screaming sprout (child); dark, shaded, and open-mouthed, her eyes squeezed shut in pain. “She’s scared,” she tells me of this child. “Is she hungry?” I ask tentatively. Courtney tells me that in one sense, the girl is not hungry for life, “she’s done”. In another sense, this girl has starved herself of the joys of living, “unable to taste any of it”, and “too exhausted to want it anymore.” “It’s almost like not wanting a future is easier. Wanting one I’ll have to fight for it,” she adds.

“If you want a future you will have to fight this raging screaming girl on the inside who will destroy you if you keep ignoring her.”

Courtney feels heard, “I almost walk over that part of me, and that then ends up making me not okay. Lately, through my panic attacks, I’ve been seeing how strong that part of me is and its making itself more known.”

“If she doesn’t she’ll go under and keep raging from the basement,” I tell her.

“Last week I gave myself two days of me-time. It’s like painting a new picture from scratch. Something I don’t know.” “Yeah,” I respond, “and I imagine if you spent too much time there you’d become unrecognizable to yourself.

In this vignette, Courtney has located one of the dissociated selves that has been splintered off from her consciousness by the anorectic self-state. It’s a child self-state that is in pain, frustrated and raging, in desperate need of safety, care, and holding. This version of Courtney shrieks, agape and hungry, from the cauldron of her interior, pounding her consciousness through panic attacks and anxiety with remnants, or reminiscences, of torturous, unmetabolizable desire.

Kelly

Kelly, a patient in her 40s who’d been battling severe anorexia since late adolescence, shared a dream just before she abruptly terminated therapy. She is with her mother and her father in her childhood home,

“My father’s heart stops beating. I shake him, he takes a breath, and comes back to life. I’m relieved, but he’s aged by twenty years. He looks like a dead person. My mom is just watching. He starts vomiting uncontrollably and having diarrhea. Everywhere. I think what if the cancer is back. I try to carry him to the bathroom. My little nieces and nephews keep getting in the way. I’m trying to explain to them that grandad is sick and I really need to get him to the bath. As I lay him down he starts bleeding. It starts spurting everywhere. He keeps apologizing, saying it’s disgusting. I tell him not to worry about it. I just need to get him to a bed.”

There are multiple ways in which this dream could be understood, but from a dissociative self-state model it, it expresses the cavernous split between Kelly’s psyche and soma. There is Kelly, in her normal state of consciousness (i.e. her usual sense of “I”), and her split-off body, projected into her father. As a result of this split, she can safely experience herself dying. Many professionals struggle to comprehend the anorexic’s lack of alarm, even nonchalance, in the face of their impending death. It is because their body does not belong to them. The anorectic self-state is there to ensure that things get held in; it’s a safeguard against the hemorrhaging that would occur if she spontaneously gave over to abandon. If it was not for the anorectic self-state, Kelly would have to find a way to be in her body. The terror of the out-of-control body would obliterate her mind, in the same way that her mother was too abolished, or frozen, to contain and mentalize her infant’s evacuative bodily functions. Her mother could not revel in the richness of her infant daughter’s body-state, instead, she was either repulsed by it, frozen, or driven to resist it by strangulating the body of its impulsiveness, its freedom, its naturalness. The dream is thus about the way in which the anorectic self-state revivifies and reenacts this infantile trauma, Kelly suffocating her body, and its evacuative richness (bleeding, defecating, vomiting) through starvation. I imagine the opposite of keeping the body in check in this way would be a kind of pouring, a spurting, a gushing. “What if I unleash a part of me that doesn’t have a limit?” Kelly once asked me. This dream is also about the potential unleashing of banished child selves, as represented by the nieces and nephews. These dissociated selves, with their infantile longings for care, nurturance, and freedom, will not surrender to death without a fight. They keep getting in the way of the anorectic self-state’s death grip until they can emerge from the shell of dissociation. Unfortunately, Kelly left therapy before we could move out of the specular dimension and “get in bed together”; in bed with her and all her dissociated selves. Just as Kelly in the dream, I became the one watching the patient die before my eyes, veering between momentary spurts of life and protracted states of lifelessness, keeping vigil over the tightening hold of her anorectic self and its repeated efforts to block her ordered rhythm from becoming a shared rhythm. Had she come back, I may have said something like this, “You’re coming to life through this dream, and I hope that this violent part of you lets you live long enough that we can make use of this.” With this interpretation I would have communicated to Kelly that her dream serves as the vehicle through which she, the dreamer, is awakening [25] and coming into her body, while also emphasizing that the resuscitation of this emergent dreaming self is under threat of the anorectic self-state’s deadly grip on imagination and corporeality.

In the next section of this chapter, there will be a discussion of the dissociative configuration of the binge-eater’s psyche. In the anorectic self-state, the self has no corporeality, there is total power over the self, which has been rid of its link to the body. As the commanding authority over the anorexic’s mind, the anorectic self-state leaves the patient unencumbered by the exigencies and stirrings of instinctual life, narrowing attention away from the flesh and away from the body. The binge-eater’s self, however, is not severed from her body, instead, the binge-eater lives in conflict with her body and its needs. Where anorexia is about the refusal of flesh, the binge acknowledges the body graphically: it hungers, it takes in, it rejects, it wants again [26]. The binge-eater’s need for food and nourishment gets associated with greed and excess; so disgusting and terrifying is this need that it gets pinned to a separate part of the binge-eater’s self, the bulimic self-state.

3.2 The bulimic self-state

When the haunted self of the anorexic succumbs to food, it’s seen as an admission of weakness and a desire for life’s pleasure [26]; when the corporeal self of the binge-eater succumbs to food, it’s seen as an admission of greed and a desire for more. In anorexia, there is no needing at all; for the binge eater, needing is disavowed until it erupts furiously through the bulimic self-state. It is this self-state that holds the binge-eater’s dissociated desire and passion.

As a result of the binge-eater’s lack of compassion for her needs, the fleshy body gets violently assaulted through junk food. In the binge, it is not the individual that demands the food, it is the body-as-dissociated-thing that objects to moderation and control. The fear for the binge-eater is of there being no restriction, of wanton hunger introducing itself in all its foreignness and vulgarity. She cannot bear the shame, and the fear, of wanting. This is not say that she lacks parts within her self-organization that are not fascinated and seduced by the voluptuousness of the body. These inquisitive, needy parts get stifled by the binge-eater’s normal self, whose enforced restrictions (e.g. diets, eating plans) attempt to still the clattering rumblings of excess that could spew from these curious, wanting selves.

For the binge-eater, food thus signifies an invitation to be seen by the self and others as wanting. It must be warded off in its sickening badness. Food is whining greed, and its intake must be controlled and regulated with vigilance. The bingeing self holds the “eeew factor” [27] in relation to the body: I am too much, too big. It is a self-state that is associated with ferocious wanting and voracious hunger in its rawest form, a yielding to appetites and loss of control which the normal self perceives as uncontrollable and bad. The surrender to food is an admission of bad neediness and a crude statement that the binge-eater’s body is also incarnated as a fleshy, sexual, corpus replete with verve and lust [28, 29].

For the binge eater, infantile experiences around appetite, need, and wanting could not be regulated or recognized by the caregiver, and thus were encoded as affectively threatening, unbearable, and overwhelming, so that they became frozen into a dissociated self-state that then took on “an imperious life of its own” ([13], p. 903). As Janet’s theory of the processing of traumatic experiences posited, knowledge, body sensations, and feelings around that which is intolerable are not forgotten, they live in frozen, fixed states alongside other configurations of consciousness, occasionally, sometimes violently, finding expression through food and the body. Thus, when the binge-eater binges, it’s as though her greed has suddenly catapulted her into her body from a recess of her mind very alien to her; and when this greed leaves her, her body feels like a dump, something immensely shameful and heavy and disgusting that she now lugs around with its excess heft and insufferable rapacity.

Romy

Romy, a patient with a binge-eating problem, who had just exited an abusive relationship, spoke of her inability to allow anyone to comfort her, adding, “I give so easily but I ask for nothing.”

“The binger in you has to steal her comfort, she knows you won’t give it to yourself,” I tell her.

Romy tells me that her unconscious turns into Freddy Krueger while she’s asleep. She uses this image to describe the revivifications of the horrors that are entombed in her mind; horrors that are forgotten, but find resuscitation during altered states of consciousness. As in Nightmare on Elm Street (1984), these echoes of tortured pain molest her mind and body during hypnoid states, unable to be pulled into the waking world where these phantoms can exist with the rest of her self-configuration. Just as Freddy Krueger represents the fear of an unseen threat, so the binge signifies the threat of monstrous greed and gory food-lust. This is the “unthought known” that Bollas speaks of, [19] haunting the binge-eater in this altered state of consciousness. Through the image of Freddy Krueger, she perceives the uncanny within the monster that is her bulimic self. The binge is thus driven by an ominous Freddy-like presence, the dissociated bulimic self, lurking in the shadows of the patient’s subterranean world (psyche) that, in a dream state (i.e. dissociated or hypnoid state) ravages the body. In this hypnoid Freddy Kreuger binge-state, Romy remains dissociated from the damage that this “rummaging” self-state inflicts upon her. “Rummaging” depicts the burrowing frenzy and chaotic disorderliness typical of her experience of herself during the binge. She eats as if she’d never seen food before. Only afterwards does Romy sit with the effects of this ““bad nightmare”, consoled, though, by that “comfortable lethargic feeling” that comforts her and lulls her to sleep. For the binge-eater, the fear is not merely around being overtaken by greed, the fear is also of emptiness, the indescribable state of hollow longing and barrenness that lies on the other side of greed.

Kirstie

Kirstie beautifully describes the dissociative, hypnoid mechanisms underlying her binge states:

“You feel like you’ve been defeated. You don’t have any intention or want to do it, but then physically you see it, you feel it. It angers me in a way because the rest of the day I’m angry that I couldn’t control it or stop it. It’s like you enter tunnel vision, and you lose ten minutes of your life.”

What angers Kirstie here is that her need to stay on top of things, representative of her deeper need to “schedule” her urges, wants, and desires, gets thrown off by the binge. For Kirstie, who plans meticulously when and how to be intimate with her husband, the binge is the thing that she cannot stop in its tracks, it’s the thing she does not see coming, it’s the thing that announces itself unplanned. Most importantly, she says, “it’s the thing that keeps coming back.” She uses the word “overpower” to explain how the fixed idea around food first dominates and then explodes into her mind. This bulimic self-state demands to be fattened up with the doughy sugariness and starchy goodness that she deprives herself of in non-hypnoid states of consciousness. Her body commands the sweet nourishment which her mind denies her. At family gatherings she never dishes dessert: “Everybody would look at me,” she tells me, “it’s such a negative connotation.” Here, she is inviting me to look at the part of herself that would feel phantom-like, searing pangs of shame if she caught herself indulging, wanting, treating. This is the binge-eater’s not-me self, [24] with its unspeakable needs, longings, and desires, that got banished to the dissociative realm. This self carries those hungers and cravings for human relatedness which could not find containment or digestion through her mother, due to the shame, self-loathing, and deprivation around her own oral needs. “My mother has forever been on a diet,” Kirstie avers.

It should not be surprising that Kirstie’s binge-eating happens on-the-go. As with Romy, the “Who” that binges does so in hiding. For this part of the patient, food, which stands for nurturance, comfort, and care, needs to be stolen, rummaged through, and devoured clandestinely. It’s not just the comfort and the goodness that is disavowed, it’s the uncontrollable nature of an impulse that is even more dreaded; the fact that something measured and planned could turn into something lustful, unrestrained, and wanton. The nameless dread [30] is that deprivation could turn into gusto, and that gusto could turn into enthusiasm for human relatedness.

The planning that goes into Kirstie’s prepared meals evaporates at the attack of the binge, “one strike that ruffles everything,” she declares in dismay. “That one messy binge really has the power to shake things up for you,” I tell her. Is Kirstie resisting the food that she prepared, or the version of herself that went into the planning of the food – a premeditating, depriving, scrupulous self? “The fear is that this thing won’t stop,” she tells me. “That there is this part of you that you can’t catch? This part that creeps up on you and then blasts ‘I’m here’?” I say. “The uncontrollable side,” she utters, “I hate myself for that.” Where the anorectic has no sense of what could bring her body to life, the binge eater is aware of what titillates her, but deprives herself of this due to the fear of greed. She shifts between states of wanting and rejecting, thus regulating food in the same way that she regulates her desires. Deprivation puts her at risk, as it increases the voltage with which her disowned selves, the greedy, needy, thirsty parts, flood her consciousness.

As seen in these case vignettes, binge eaters often use images of monsters or animals to describe their bulimic self-state. These images signify the split between worlds, where needs that are considered universally human become connoted as too primal, monstrous, and other to exist inside of them. Simply physiological urges to indulge in, for instance, sweet treats, or to give in to passionate love-making, are disavowed in their categorical not-me-ness. These unintegrated aspects of self get enacted with food [16]. It’s as if the binge eater were saying: “Were I to pander to my needs and urges, the good, conscientious, vigilant me would cease to exist. I’d get stuck in the festering badness of indulgence, which is not me. I know I’m hurting me by depriving myself, but I’m afraid that if I taste something else, something more, I’ll never let it go.”

Ali

Ali, whose father chose alcohol over his family, and whose housewife mother resented her passivity and dependence on her husband, had structured her self-configuration around the organizing principle that she would never need or ask for anything. In her association to the word indulgence, she spoke of an “unnecessary state of selfishness and excess”, even using the word “gluttony” to describe the disastrous consequences of heeding one’s wants and desires. As the wanting and needing self is disavowed, it can only find expression through the dissociated bulimic self-state. To protect herself from this self-state, she buttresses the version of herself that is founded on refusal, discipline, and restriction. She bans herself from going to the grocery store, hires a coach, logs every meal into a calorie tracker, and refuses her daughter’s cookies that were made for the school bake sale. This is the problem-solving conqueror inside of Ali who experiences a “high” over mastering the urge to binge. “I’ve got this down,” she professes proudly. Permission becomes the punishable offense. As the line between permission and indulgence breaks down, she finds herself in the wreckage of swimming in the abyss of her bodily cravings. In this abyss, it feels like she is drowning, the body holding the unmet, disowned needs engulfing her like the wave that rips at the person lost at sea. Ali uses the image of the wolf to describe this engulfing bulimic self-state. In the epicenter of this volcanic abyss, the wolf becomes insatiable: “What more do you want, I’m already giving you what you want,” she laments as she reflects on her experience during a binge. The compulsive monster-wolf prefers crunchy food; the sound, the sensations, and the biting regulate terrifying states of anger and frustration that would overwhelm her if her consciousness were not narrowed in on the food. In this state, she cannot afford herself the time to sit and eat slowly. Instead, food is guzzled, as if the wolf’s survival depends on it. “Don’t think you can deprive me any more,” the wolf might be saying. This wolf cannot chew. He devours, he attacks. He gives in to impulse without inhibition or restraint, something Ali cannot fathom doing in her normal state of consciousness. It is in this primal state that she dislodges herself from her emotions. “This is not a nurturing state,” she says, “it’s not a dainty reach for a biscuit.” In this attack, there is a level of aggression that is only accessible to her through the wolf. Why is it so hard for her to nurture herself? This is the purpose of the bulimic self-state, a violent assault on the person for harboring disowned wishes for non-food-related (i.e. human) nurturance and connection. The bulimic self is there to prove to the binge eater over and over again that no good comes of giving in to desire or want. The binge is “a happy birthday to me from me,” as Ali aptly put it; a foolproof strategy of one’s self-sufficiency, on the one hand, and a glaringly shameful reminder that one’s needs are too big to be digested with, and through, an Other.

4. Treatment implications

Psychoanalytic treatment of the anorexic and the binge-eater occurs in conditions that take seriously the multiplicity of the self. The analyst accepts that the treatment will become the meeting place for her patient’s dissociated selves. She knows that her patients do not have the ability to dream up their bodies in their minds, and that she will become the portal through which her patients begin to associate to their bodies. Her patients will eventually route their disowned needs and longings through her, but before this happens, she will analyze, over and over again, the reasons behind the anorectic self-state’s erosion of her patient’s body, and the purpose behind the bulimic self-state’s rerouting of desire away from the patient’s self. She may use language around food, eating, and bodily function to achieve this, elaborating the inscriptions made upon her patients’ bodies by violent, yet protective, self-states. She will respect the autonomy of the anorectic and bulimic self-state, working painstakingly, at times against the odds of life, to discover the versions of truth contained within these states [12, 13, 15]. She will have to pay particular attention to the way in which her body becomes the vehicle through which uncommunicable shards of her patients’ lives tussle for expression and articulation. Her bodily reactions, her dissociations, and the self-states inside of her that get called on by her patient at any given moment, will give her clues to her patients’ unformulated bodily and affective itchings. She will also take note of when, and how, her patients become ruptured by their increasing body awareness and the emerging needs that had been dissociatively demoted to angry, lost, unknown child selves. Sometimes these ruptures will occur in the treatment dyad, with the phantoms, or ghosts, carried by these child self-states clamoring for air time. Through enactments, the analyst will express the traumatic reminiscences of the unthinkable and the ‘unfeelable’ (unfillable), first to herself, and then to her patient, in the here and now. Every time the patient senses that the tendrils of connection to her analyst are deepening, it will feel like she has committed an unforgiveable violation, a violation which the anorectic or bulimic self-state will remedy through attack on the body. The pain, the restriction, the deadness, the hunger, the disgust, the shame, the forbidden lust, the dread of too much – all the affects that fuel the splintering of the patient’s self – will play out between her and her patient, so that ultimately she learns to live with her disowned parts in a state of mutual antagonism; with more tolerance, and less dissociation.

5. Conclusion

Multiple psychoanalytic theories have been proposed in the genesis of eating disorders, ranging from drive-conflict models to ego psychology and object relations theories. This chapter attempts to enrich the psychoanalytic conceptualizations of eating disorders by examining the dissociative structures that may underpin the eating-disordered individual’s behavior. Consequently, there has been a description of Janet’s pioneering ideas into the splitting of consciousness, where the automatism, or the symptom contained within a particular self-state, actively maintains separation between parts of the self that cannot be formulated, integrated, or held in tension. Through an extended, detailed clinical vignette, it has been demonstrated how the anorectic self-state entrenches the anorexic’s conviction that her embodied, corporeal self does not exist. As a result of this defensive disembodiment, she can walk alongside her corporeal self, as opposed to it being her, and teeter comfortably on the edges of death and bodily annihilation. The bulimic self-state, on the other hand, holds the binge-eater’s greed, desire, and lust. Wanting and needing, intolerable states which were denied a spot in the assembly room of the binge-eater’s mind, are relegated to monster or animal selves that, in titrated states of consciousness, express the insatiability and ravenous passion that remains unsymbolized and unformulated. Treatment considerations have been outlined for clinicians working from a contemporary relational psychoanalytic perspective, highlighting the inevitability of enactments in the intersubjective space in revivifying traumatic reminiscences that are kept at bay by particular self-states, and stretching the limits for mutual regulation of intolerable affect.