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Listed below are articles written by Doctors, Therapists, Nutritionists, and others who have worked in the field related to Eating Disorders Awareness and Treatment. If you have an article you'd like to submit, please contact us to make arrangements to place it on the site with proper credit and referring information.


SELF-MEDICATION, TRAUMATIC REENACTMENT, AND SOMATIC EXPRESSION IN BULIMIC AND SELF-MUTILATING BEHAVIOR

by: Sharon Klayman Farber, Ph.D., B.C.D.

ABSTRACT: A psychoanalytic framework provided direction for research on the association between binge-purging (bulimic) and self-mutilating behaviors, comparing them for similarities and differences. The similarities in the multiple functions and psychosomatic processes served by these behaviors are presented, as well as the phenomenon of symptom substitution. Both behaviors tend to be practiced by those with severe personality and dissociative disorders and posttraumatic stress disorder. Both serve ego-compensatory needs in the absence of the adequate ability to regulate and modulate emotions, moods, and tensions. They may serve as compensatory attempts to differentiate self and object, define and differentiate body boundaries, master severe childhood trauma by means of psychophysiological addictive reenactments, and to express emotion.

KEY WORDS: bulimia; self-mutilation; addiction; trauma; symptom substitution.

People who binge and purge and those who self-mutilate embody the theme of the 1995 conference, Mind, Memories, and Metaphors. Paradoxically, these apparently self-destructive behaviors have the capacity to alleviate psychic pain in some individuals, and serve other restorative, redemptive, cleansing and healing functions (Farber, 1995a). Lacking the ability to use metaphor or symbol to express emotion or unspeakable pain, their acts of self-harm may serve to narrate that which their minds cannot remember and their words cannot say. The author has come to know this from her years of clinical practice and from her research on the association between binge-purge behavior and self-mutilating behavior, a study which compares binge-purging behavior and self-mutilating behavior for similarities and differences (Farber, 1995a). The similarities in the multiple psychic functions and psychosomatic processes served by these behaviors will be presented, along with their implications for assessment, engagement, and countertransference.

DEFINITIONS: Binging is the consumption of large amounts of food, usually in a concentrated period of time. Purging is the deliberate concrete attempt to undo the binge, usually by self-induced vomiting and/or laxative abuse, enemas, or diuretic abuse. Excessive exercise and long stays in a sauna may function as variants. Self-mutilation is the infliction of injury to ones body resulting in tissue damage or alteration. It occurs primarily among the mentally retarded, psychotic patients, prisoners, and in personality disordered patients (Favazza, 1987; Simeon, Stanley, Frances, Mann, Winchel, and Stanley, 1992; Walsh and Rosen, 1988; Winchel and Stanley, 1991). A variant of self-mutilation is body modification, a passive form in which an individual engages another to mutilate his body, as in the increasingly popular practices of tattooing, body piercing, decorative scarification, and branding (Juno and Vale, 1989).

THE ASSOCIATION BETWEEN BINGE-PURGE BEHAVIOR AND SELF-MUTILATING BEHAVIOR

A strikingly strong association between these behaviors has been found in numerous studies. In several studies of patients who were identified as self-mutilators, 57% to 93.3% of self-mutilators studied were found to have concurrent dysorectic symptoms (Coid, Allolio, and Rees,1983; Rosenthal, Rinzler, Walsh and Klausner,1972; Simpson and Porter,1981; Walsh,1987; Yaryura-Tobias and Neziroglu,1978; Yaryura-Tobias, Neziroglu, and Kaplan, 1995). In studies of bulimic patients, 8.9% to 26.6% of bulimics patients reported concurrent self-mutilating symptoms (Garfinkel, Moldofsky, and Garner,1980; Turnbull, Freeman, Barry, and Henderson,1989; Welbourne and Purgold, 1984; Yellowlees, 1985).

Favazza, DeRosear, and Conterio (1989) found that 50% of female habitual self-mutilators had at some time in the past concurrent dysorectic symptoms, of which 35% had binge-purge symptoms. Based on these findings they contend that individuals with eating disordered behavior, especially bulimic behavior, are at high risk for self-mutilation. They and others (Battegay, 1991; Favazza and Rosenthal, 1990; Welbourne and Purgold, 1984; Wilson, 1983, 1985, 1986, 1988, 1989) have noted the substitution of self-mutilating behavior for bulimic behavior and vice versa. Wilson (1983, 1985, 1986, 1988, 1989) explains the phenomenon of symptom substitution in the bulimic by suggesting that if symptoms are cleared before there has been sufficient change in the underlying neurosis and object relations, the bulimic ego functioning may be replaced by bulimic equivalents, such as self-destructive acting out; another addictive disorder, another psychosomatic symptom, neurotic symptom formation, or severe regressive symptom formation. Thus, it can be readily understood that psychopharmacological treatment, behavior modification, or the wish to please the therapist without sufficient attention to ego and object relations considerations may result in the precipitous relief of bulimic symptoms that may well compromise the patient's sense of well-being, upsetting an already fragile equilibrium.

Heller (1990) compared bulimics, self-mutilators, and bulimic mutilators in regard to their level of object relations and symptom choice, and found empirically that the symptoms are differing manifestations of a similar illness. She found that most of these women could be described as functioning in the borderline range. In a theoretical research article, Cross (1993) compared bulimia with delicate self-cutting, one of numerous forms of self-mutilation, in relation to the dynamics of female body image and feminine development, and postulated that they were quite alike as concrete bodily externalizations of similar psychological problems and emotional experiences. Miller (1994) has found clinically that various kinds of self-destructive behavior, including alcoholism, drug abuse, anorexia, bulimia, and self-mutilation are all part of a cluster of behaviors and problematic relationships common to women who were abused, violated, or neglected as children.

Favazza (1987) suggested that self-mutilation and eating disorders may be two different manifestations of the same problem, not elaborating further. However he contends that all mutilation of the skin, including the communal self-mutilating ritualistic practices of various cultures worldwide, as well as pathological self-mutilation, is deeply embedded in elemental experiences of healing, religion, and social amity. This author would extend Favazza's concept to include bulimic behavior as well, believing that both self-mutilating behavior and bulimic behavior and perhaps other forms of self-harm are rooted in primitive experiences of emotional healing and social amity. Those who harm themselves in these ways seem to experience themselves, if only briefly, as being resurrected from the ashes of destruction, quite like the mythical phoenix that burnt itself to ashes and rose from those same ashes of destruction.

THE SCOPE OF THE PROBLEM

These problems are reported primarily in women, and have their onset typically in adolescence or preadolescence. The incidence of both forms of self-harm has been on the increase in the past few decades. In borderline personalities the symptoms of eating disorders and self?mutilation frequently occur, often along with drug or alcohol abuse, suicide attempts, and hypersexuality. Clusters of these symptoms are commonly regarded as presumptive of a diagnosis of borderline personality organization (Kernberg, 1975; Walsh and Rosen, 1988; Kroll, 1988, 1994; Goldstein, 1990). In fact, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association, 1994) lists as diagnostic criteria for Borderline Personality Disorder "impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating" and "recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior." Lacey (1993) proposed the existence of a syndrome, Impulsive Personality Disorder, based on finding a core group of bulimic women characterized by numerous self-damaging and addictive behaviors, specifically substance abuse, overdosing, self-mutilation, and stealing, as well as a history of sexual abuse. These acts may well characterize a group of women in the same way that getting repeatedly involved in bar room brawls serves for their male counterparts.

Both binge-purge and self-mutilating behaviors have been found to be associated with a history of childhood physical and sexual abuse, with disturbances of mood, body image and gender identity, as well as with contagion and other group phenomena (Farber, 1995a). Both behaviors are associated with serious medical illness or complications in circular and interacting ways that seem to illuminate further the complex nature of psychosomatic processes, particularly in their association with trauma. Disordered eating and self-mutilating behavior, often in conjunction with dissociative states and substance abuse, seem to be behaviors commonly used by survivors of trauma to cope with and adapt to the aftereffects of sexual or physical abuse, traumatic loss and separation, and the trauma of intrusive medical or surgical procedures in childhood (Farber, 1995a).

The affect and behavior of people who harm themselves in these ways seem to have a contagious quality leading to epidemics of self-harm, especially in group settings such as hospitals, residential treatment, dormitories, gangs, and prisons. When they become patients, these individuals make extraordinary demands on health care professionals in terms of transference/ countertransference and management issues. The potentially life?threatening risks they take tend to evoke intense and primitive counter? transference responses of anxiety, avoidance, anger, and feelings of helplessness. It is often the determination of many health care professionals to stop or control their self?destructive behavior that may result in their being over-medicated, improperly diagnosed, and unnecessarily hospitalized. This determination to control them further frightens and alienates these people whose exquisitely fragile sense of themselves is greatly determined by the extent to which they can feel some control over their bodies and their lives. Some self-mutilating patients have reported being traumatized in hospital emergency rooms by the punitive and sadistic treatment they have received. Many have found that if they declare that their intention was suicidal, they will generally receive more humane medical treatment. When clinicians can appreciate and can help their patients to appreciate those aspects of these self-destructive behaviors that serve compensatory and adaptive needs, they are more likely to maintain the more constant sense of empathic connection with them that successful treatment requires.

Self-mutilation has begun to receive scientific attention just as eating disorders began to in the 1970's. It was stated almost three decades ago that self-mutilators are "the new chronic patients in mental hospitals, replacing schizophrenics" (Graff and Mallin, 1967, p.72). In 1994 the New York State Department of Mental Hygiene sponsored a statewide telecast on self-mutilation (Favazza, 1994), which was viewed simultaneously by the clinical staffs of several New York state psychiatric centers. In 1996 this author did a presentation (Farber, 1996) on these behaviors at the New York State Mental Health Association Conference, Sexual Abuse Survivors Diagnosed with Serious Mental Illnesses. Such presentations constitute a public acknowledgment that self-harm is a problem of major proportions in patients with serious mental illness.

Today increasingly more people are "coming out of the closet" about their self-mutilating behavior in much the same way that people began to "come out" about eating disorders in the 1970's. Eating disorders have received a lot of media attention, and self-mutilation has begun to receive similar attention in the past decade or two. For example, the Sunday Magazine section of the New York Times (Le Blanc, 1994) reported on a black adolescent girl, girlfriend of a gang leader in Brooklyn, who at times takes a blade and gently runs it down her arm, enjoying the sight and feel of the red drops oozing from the cut. Recently the New York Times reported that in Recife, Brazil where there is a growing population of street children, many girl prostitutes slash themselves with razor blades, saying they cut themselves in fits of despair or anger (Schemo, 1996). Alice Walker's Possessing the Secret of Joy Joy is about the ritual genital mutilation of a woman as a rite of passage to mark her as a woman of an African tribe. Having experienced this culturally accepted ritual as a severe trauma, she became severely disturbed and resorted to mutilating herself with razors, thus repeating and reenacting the trauma by actively inflicting on herself that to which she was forced to submit passively. The female protagonists in three modern novels (Cat's Eye by Margaret Atwood, Thicker than Water and Exposure, both by Katherine Harrison) have both disordered eating and self-mutilating behavior. Employee Assistance magazines have featured articles on self-injury as a hidden problem among women in the workplace (Golden and Walker-O'Keefe, 1988; Witherspoon, 1990). The appearance of these phenomena in modern literature and the media is indicative of a beginning cultural awareness of the existence of a syndrome of self-harm behaviors.

PSYCHOSOMATIC PROCESSES AND DISSOCIATION

Eating disorders are considered to be a paradigm for understanding psychosomatic processes (Kaufman and Heiman, 1964) . If we understand that all disease is psychosomatic and somatopsychic, in that psychological and somatic factors are always present to greater or lesser extent, and are active and intertwine at many levels throughout complex reverberating systems (Weiner and Fawzy, 1989), then we can also understand that both binge-purging and self-mutilating behavior can be found to have underlying psychosomatic processes. A number of years ago ego psychologist Gertrude Blanck said something on this subject which this author has chewed on, swallowed, digested, and metabolized. Many of the people very narcissistically involved with their bodies have a borderline level of ego organization who "live more in the body and less in the mind." The people who binge and purge and self-mutilate live more in the body and less in the mind. They live in dissociated states, the space that Winnicott (1949) said dissociates mind and body one from the other. Dissociation seems to be the dwelling place for binge-purging, self-mutilation, and other psychosomatic processes. The British often spell psychosomatic with a hyphen (psycho-somatic), which separates psyche from soma.That has the added value of visual appeal if the hyphen is thought of as representing the dissociated space.

APPLICATION OF THEORY FOR UNDERSTANDING THE ASSOCIATION

Psychoanalytic theory provided much food for thought on informing the author's understanding of the association between these two behaviors. How can both binge?purging and self?mutilation be understood according to the principle of overdetermination, the idea that psychological symptoms are caused by more than one factor? How can these behaviors be understood as serving multiple functions (Waelder, 1936)? If we understand compromise formation to be that which solves an intrapsychic conflict among and between the ego, the id, the superego, the repetition compulsion, and the demands of the outside world, creating a psychic equilibrium (Brenner, 1982), then these behaviors be understood as representing similar compromise formations? How can the prevalence of these symptoms in the more severe pathologies be understood? What concepts could shed some light on the association?

Khantzian and Mack's (1983) concept that an impairment in self?care functions reflects a failure in ego function may provide a partial understanding. So might Walsh and Rosen's (1988) concept of body?alienation, "a pervasive pattern of disrespect, discomfort, and debasement of their physical selves (p.70)" that is indicative of an individual's feeling of being alienated from her own body, and which promotes a negative and/or distorted body image. A Deliberate Self?Harm Syndrome (DSH), featuring multiple episodes of deliberate physically self?damaging acts of low lethality had been proposed (Pattison and Kahan, 1983; Kahan and Pattison, 1984) for inclusion in the DSM III?R.

SELF-REGULATORY FUNCTIONS OF BINGE-PURGE AND SELF-MUTILATING BEHAVIOR

It occurred to the author that these acts of self-harm might be the attempts of desperate people to alleviate their psychic suffering by somehow interrupting or terminating a dysphoric mood or affect state, therefore serving to medicate a vulnerable self and ego structure. This concept found support in Edward Khantzian's publications on self-medication and addictive suffering (1985a, 1985b, 1987, 1989) and in a personal correspondence with him (personal communications, June 15, 1990; January 9, 1991). He views drug and alcohol addiction as failed attempts to maintain self?regulatory functioning, specifying how individuals try to differentially self?medicate with various kinds of drugs, settling on a "drug of choice" that corresponds to which affect state they want to stimulate or sedate. The drug is used in an attempt to gain relief from the dysphoria that occurs in those individuals whose ego defenses are not sufficient to adequately defend against affects and drives. Brisman and Siegel (1984) took a similar view of the relationship between bulimia and alcohol abuse, and found that bulimic behavior, much like alcoholic behavior, serves ego-compensatory needs in the absence of the ability to adequately regulate and modulate emotions, moods, and tensions. Similarly, others have viewed bulimia and other eating disorders as attempts at self-regulation of mood and affect (Brenner, 1983; Goodsitt, 1985; Schupak-Neuber, 1993). It seems that for those who chronically binge?purge and self?mutilate, these acts themselves serve as their "drug of choice", used in the service of regulating mood and affect.

If the behavioral sequence and affect states of both a binge-purger and a self-mutilator are examined before, during, and after the bulimic and self-mutilating episode, the use of the behavior to regulate intolerable mood, affect, dissociative, and hyperarousal states as well as the remarkable similarities between the two behavioral sequences can be heard. The following bulimic account was published in For Crying Out Loud ( Angel, 1992), a newsletter for women survivors of child sexual abuse. The theme of this particular issue was the use of food as a means for tolerating and surviving the aftereffects of severe abuse.

    It starts with an image that flashes . . . fear immediately follows, the internal chanting "That didn't happen to me. It didn't happen." Panic starts to rise in my throat. I have to eat. I jump into my car and fly to the supermarket, grabbing things off the shelves. All I can think about is getting home again. My body trembles in anticipation. I begin the routine. I know it well. I start the rice pilaf on the stove and put one frozen pizza in the microwave, one in the oven. On the table I have all the makings for cheese subs, along with a bag of Doritos, jar of picante sauce and jalapeno cheese dip. There is a box of chocolates for dessert, which I start on. I can put the subs together while munching on Doritos and dip. I tell myself I'll have only two sandwiches, although . . . I know I'll eat all six. . . . Oh, there goes the timer on the stove. I spread my feast on the table before me. Oh God, I am so happy. There is nothing in this entire world that can make me more content than the food I love. I am a queen and these are my riches. I have all that I have ever needed or wanted in my life. I can't get enough. I begin to stuff the food in great gulps into my mouth: six subs, two pizzas, the pilaf and the rest, including a two-liter bottle of Diet Coke. I don't even know what it is that I'm eating anymore. Was that a chocolate? Or pizza? It doesn't matter. I can't stop. I gorge myself as though I'll never eat again.. . . I eat in a frenzy until every last bit is gone. Then I look in horror at the mess left on the table and realize what I've done.

    You've done it again, you fat cow. You're such a loser. The self-hatred sets in. Worse is the panic--all those calories. . . My hips are fatter than when I sat down to eat ten minutes ago. Or was it a half hour ago? An hour ago? How long has it been? I don't know. All I know is that I have to get rid of the food. How many times am I going to do this? Why can't I just stop? I will, but not now. I'll just get rid of it today, and I'll never do it again.

    I am an expert at this. No finger in the throat. . . No ipecac syrup. I just tighten my stomach muscles and on cue, it all starts to come out looking similar to the way it did when it went in. Relief. This means it hasn't begun digesting yet; the calories are not yet packing themselves onto my body. I kneel, my head hanging in the toilet bowl, heaving. The vomit splashes me in the face. I am so disgusted. I keep tightening my stomach muscles. The food keeps coming. My face and hair are speckled with tiny bits of vomit. I hate myself. I am so very tired of living my life in the toilet bowl. This is what you deserve, you fat cow. I flush the toilet. . . and begin . . . again. I flush six or seven times more before I'm through.

    Anything with cheese is hard to get up. It packs in so tightly, cutting off my air supply. I can't force it up. I can't push it back down. For a split second I know, I am going to die. This is how they will find me, my head immersed in vomit my disgrace. A life of struggling to survive, flushed down the toilet. It's what you deserve. The hateful voice continues to batter and abuse me. I finally force the cheese out. Relief. This time I did not die. I should stop now but there is still more food left. I'll just get that out, and then I'll stop. I'll never do it again. I rise to my feet, weak and covered in sweat and collapse onto the bed.

When that account is compared to the composite profile of a self-mutilator created by piecing together the clinical literature about self?mutilation before, during, and after the self-mutilating episode (Camper, Farber, Gerson, and Murphy, 1988; Camper, Farber, and Gerson, 1988), the similarities are apparent:

The episode may be triggered by a real or perceived loss, a disappointment in or a separation from an important person in the girl's life, perhaps a parent, friend, boyfriend, or therapist. As the behavior becomes more entrenched in her personality, even the slightest mishap may trigger it. She begins to experience a tension growing within her, often accompanied by diffuse feelings of anger, fear, and guilt, which increase in intensity and gradually and increasingly interfere with daily functioning. Over a period of time ranging from minutes to hours, a state of tension is reached that is intolerable. It is replaced by a dissociated state of consciousness described as feeling numb, empty, unreal, wooden, trancelike. At first this feels better than the excruciating tension, but soon it feels like a terrifying isolation from people and the real world. The girl goes where she can be alone, and in a seemingly controlled and planful fashion that may disguise the frenzied excitement she feels, she cuts, burns or bruises herself. The act usually requires a minimum of medical attention. It may be performed in front of a mirror, or is at least experienced as if she is watching herself in a mirror or on a film screen. With the sight of the wound or startling redness of the blood comes a sense of aliveness, of connection to reality, and a great sense of relief and well?being. The sight of the blood warms and blankets her in blissful satisfaction and comfort. She feels good, capable, and whole. Now she is ready to resume her usual daily activities at a level of functioning considerably greater than that which preceded the act.

OTHER PSYCHIC FUNCTIONS SERVED BY BINGE-PURGE AND SELF-MUTILATING BEHAVIOR

For both the binge-purger and the self-mutilator, these acts seem to represent attempts compensatory attempts to serve transitional functions when deficits in self?object differentiation are present. A transitional object is an object the child uses when he is alone to comfort himself with the illusion that he is being held and comforted by his mother or caretaker (Winnicott, 1953). It is a "not me" object, not part of his body, although he may experience it as being part of himself, especially when falling asleep, and that precisely is its purpose.

The binge-purger or self-mutilator seizes upon the symptomatic behavior, immersing herself in the comfort it provides, much as the baby seizes upon his teddy bear or tattered blanket to soothe himself in the absence of the mother. The person turns to the behavior as toward a transitional object, but the behavior fails as a transitional object because it fails to promote separation-individuation processes (Mahler, Pine, and Bergmann, 1975). It fails to promote the differentiation of the boundaries between self and other, to further individuation, and to further the capacity for symbolic thinking. Instead, it functions as an addiction or a fetish, shoring up a defective sense of self for the brief time that the shoring up lasts, until it is time to do it again, and again, more severely and more frequently. It is much the same as how the alcoholic develops tolerance for the effect of the alcohol, progressing to drinking greater volume and with greater frequency. The bulimic binge-purge episodes may become more severe and more frequent. When even the escalated form of the behavior fails to do what it is supposed to do, another self-medicating behavior that is even more severe may be added to the repertoire. Thus, after even the most severe bulimic behavior no longer is strong enough self-medication, self-mutilating behavior may well be needed to supplement it. The self-mutilation may escalate from sporadic skin picking or hair pulling to more frequent and more severe self-mutilation such as self-cutting, self-burning, or repetitively and compulsively having ones body tattooed or pierced. When even the latter is not a sufficiently strong enough dose of self-medication, only suicide attempts may remain.

For both the binge-purger and the self-mutilator, these acts seem to represent an attempt to define and differentiate body boundaries. Freud said that the ego, first and foremost is a body ego (1923). The development of the self is basically a bodily experience in which the infantile psyche?soma (Winnicott,1949), via the ministrations of a good?enough mother, develops into an integrated psyche-soma. The mother's empathic mirroring and handling of the infant help define the body boundaries that distinguish the infant's outer surface from her internal body functions and needs, and later on, distinguishes between her own body and the mother's. Development of a distorted body image reflects a maternal empathic failure for which bodily focused symptoms may develop as compensatory efforts to repair early deficits and promote awareness of body boundaries and internal states.

The female child is especially prone to body image problems for reasons both anatomical and psychological (Krueger, 1989; Ritvo, 1988; Zakin, 1989). First, despite the difference in secondary sexual characteristics between the mother and the female child, the anatomical similarities between the two create a greater difficulty for the female child compared to the male child in distinguishing her physical separateness. Because much of her genitalia is hidden from her view, confounding her ability to perceive and experience its sensations, this serves to hinder the cognition of the whole genital . Second, the mother's tendency toward overly identifying with the child of the same sex is yet another factor that can serve as an impediment to self and object differentiation. Later in life, body image and gender identity is further compromised by the discrepancy between the reality of the female body's shape and size and the cultural expectation that women starve, carve, and liposuction themselves into images of starved asexual waifs. The author suggests that bulimia may be an attempt to differentiate and define the innermost part of the body (Krueger, 1989) by means of binging to induce sensations of distention and fullness and purging to produce violently painful diarrhea or vomiting. Just as intense or frequent urination or other urethral activity (Bass, 1994; Richards, 1992) can further define and differentiate the hidden and elusive female organ, the intense sensations of both binging and purging radiate from the lower gastrointestinal tract to the nearby inner genital in much the same way.

Severe binging and severe purging especially, often resulting in damage to internal body tissue (esophagitis, esophageal, intestinal, and rectal lacerations, internal bleeding, progressive muscle weakness), is a form of self-mutilation from the inside out. Self-mutilation, as well as excessive exercise or weight-lifting found often in bulimia, may be attempts to define the body surface (Krueger, 1989). If the skin is the psychic envelope, the body's container where the self resides (Anzieu, 1970, 1990), then having intact skin can be seen to represent an intact self (Grotstein, 1990, 1993; Ogden, 1990; Rosenfeld, 1990). For example, a normal toddler may desperately insist on having a Band-Aid put on his cut finger immediately to ensure that his insides will not drip out. (A Power Ranger or Batman Band-Aid is thought to have enhanced magical powers to do this.) In someone a good deal older, such fear may be evidence of a psychotic or liquid body image in which the body is thought of as containing only liquid, coated by a venous or arterial wall, but without skin, muscles, or skeleton (Rosenfeld,1990). In someone a good deal older, such fear may also be evidence of a psychotic core or a black hole in the ego (Taylor, 1987; Green, 1975; Grotstein, 1981,1990; Tustin, 1981; McDougall, 1974, 1989), the sense of "private madness" (Green, 1975) that underlies neurosis and perversion, or the psychopathology associated both with sexual perversion and physical disease that may be split off and encapsulated in a psychotic or primitive destructive part of the personality (Taylor, 1987).

Thus we can understand how self?mutilation functions in defining the outer surface of the body, and in making for a controlled confrontation with the primitive psychotic core, the part of the self most feared. The self-induced evacuation of a large volume of body fluids (vomitus, feces, urine, sweat) occurring in severe bulimic behavior, and the self-mutilation by cutting and branding, in which body fluids (blood and serous fluid) are shed, represent the poorest, most liquid or psychotic body image. In people who feel numb emotionally, those who self?mutilate may be unwittingly trying to stimulate their skin's ability to perceive sensation; those who binge and purge may be trying to stimulate the perception of sensations coming from within the body; and those who do both may e trying to stimulate their perception of both the outer and inner body in an unconsciously desperate attempt to define and distinguish internal and external body boundaries. So it would be expected that those bulimics who self?mutilate would have body image disturbances even more severe than the bulimics who do not self?mutilate, and that those bulimics who induce the severest purge would have body image disturbances more severe than the bulimics whose purge is milder.

Both the bulimic and the self-mutilator often suffer from alexithymia, a cognitive style and affective disturbance characterized by poorly differentiated and verbalized affects (Krystal, 1978; Taylor, 1987; Taylor, Bagby, et al, 1991). For both, these acts may also represent an attempt at mastery of severe trauma by means of a psychophysiological post?traumatic reenactment in which the body, by means of neuroendocrine pathways repeatedly reinforced in the nervous system by trauma (van der Kolk, 1989), may declare that which the mind wants to forget, making the body susceptible to a heightened somatic stimulation in general or in the part of the body that was abused or injured (Terr, 1990, 1994). Those in the sexual abuse survivor movement aptly speak of this as body memory. Perhaps it is the body of the bulimic or the self-mutilator that speaks "that which is known but not yet thought", the unthought known (Bollas, 1987, p4). In fact, the addiction to self-destructive behaviors ( self-starvation, bulimic behavior, violence against the self or others, sadomasochism, repeated involvement in abusive relationships, other risk-taking) may well represent an addiction to trauma, a compulsion to repeatedly reenact severe childhood trauma (Farber, 1995a, 1995b; van der Kolk, 1988,1989). That is, the trauma can be repeated on behavioral, emotional, physiologic, and neuroendocrinologic levels (van der Kolk, 1989) in consistent patterns of hyperarousal alternating with numbing responses.

To illustrate, the bulimic behavior in a survivor of sexual abuse may well be a presymbolic wordless physical reenactment of the trauma she suffered. It is different, however, in that in the reenactment she is in control, is active, indicating that the reenactment is in the service of an active attempt to master the trauma. In a depersonalized frenzy she shoves food into her mouth as others shoved a penis, fingers, or other objects into her body; she vomits the food out to rid her body of those things that were inserted by force. Or she penetrates her flesh with a razor blade, lit cigarette, or fingernails, as her abuser penetrated her. As she watches liquid oozing from the wound, she feels pleased that the vile stuff that had been inside her, (semen, the hateful parts of herself) is being expelled, leaving her clean and pure. She also has the pleasure of discharging rage and violence onto the abuser. She is both the abuser and the one being abused. She is the sadist and the masochist. She is a cool observer of her own self-abuse, like the parent who was present but failed to protect her. In the self-harming act she is all these, oscillating crazily from self to object and back again, traumatically attached to both the affects and her abuser.

The expressive functions served by the self-harm cluster around several themes, including conflicts between the inner and outer self, good and evil, penance and rebirth, purity and filth, fear of sexuality and expression of sexuality, and shameful secrecy and rageful disclosure. The scars or other physical evidence of the self-harm are bodily expressions of the internal emotional pain suffered. When compared with experiencing the emotional pain, experiencing the physical pain is the lesser of the evils. When compared with killing oneself or someone else, hurting oneself may well be the lesser of the evils. The self-inflicted pain may serve justice, punishing them for their badness. To binge may serve to eat the angry feelings and purging may serve to discharge them. The insatiable binge may have the erotic feel of an orgy, with purging and self-mutilation representing the mounting frenzied excitement and then the explosive orgiastic release. The blood deliberately shed may express tears that could not be cried and sorrows that could not be spoken. In individuals with Multiple Personality Disorder, one or more personality may serve punitive, superego functions, inflicting harm on a personality thought to be in need of punishment.

SYMPTOM SUBSTITUTION

The phenomenon of symptom substitution, the substitution of self-mutilation for bulimic behavior, has been noted by researchers (Favazza, De Rosear, and Conterio, 1989) and clinical observers (Favazza and Rosenthal, 1990; Welbourne and Purgold, 1984; Wilson, 1983, 1985, 1986, 1988, 1989). Symptom substitution is well known among clinicians who treat drug and alcohol addicted patients, especially the substitution of other orally ingested substances. It has been established that the infant's need to establish attachments with others is as compelling as his need for food (Bowlby, 1969; Spitz, 1945, 1946 ). When the infant's hunger for tactile closeness, warm care, and stimuli is not adequately met, or even when it is overgratified, the result is an interminable experience of insatiable hunger, a hunger disease (Battegay, 1991). "Hunger disease" refers to the disorders based on lack of self-esteem, in which people are driven to possess and consume people and/or things in an addictive manner, as seen in the clinical syndromes of eating disorders, substance abuse, compulsive shopping, kleptomania, compulsive sexuality, and the hunger for power. Because those suffering from hunger diseases constantly need the object or person to overcome their narcissistic deficiency and to compensate for their hunger, they cannot simply renounce that which they hunger for but rather are in need of a substitute for it.

Wilson (1983, 1985, 1986, 1988, 1989) explains the phenomenon of symptom substitution in the bulimic by suggesting that if symptoms are cleared before there has been sufficient change in the underlying neurosis and object relations, the bulimic ego functioning may be replaced by bulimic equivalents, such as self-destructive acting out, another addictive disorder, another psychosomatic symptom, neurotic symptom formation, or severe regressive symptom formation.

This author proposes that those suffering from hunger diseases will tend to satisfy their hunger by the compulsive use of substances such as food, alcohol, and drugs; activities such as shopping, gambling, sexual activity, exercise, television watching, and online computing; and people or other objects serving as their "drug of choice." When their "drug of choice" is not available or no longer maintains its self-medicating strength, they may resort to the use of other behaviors with an addictive and psychosomatic component. When binging and purging falter in their self-medicating function, the person may desperately resort to more potent forms of self-medication. Self-mutilating behavior and suicide attempts are two such extremely potent forms of self-medication, as described below:

    A binge may then become the only way of blotting out the whole hideous muddle--because at least for the actual moments when the sufferer is shoveling food into herself, she is oblivious of everything except the food in her hands and in her mouth. When the binge is over and awareness of the rest of her life returns the wretchedness of the impact of these thoughts and feelings cannot be overestimated. This is the moment above all others when suicide may be attempted. It is not only overdoses of whatever pills may be to hand which are tried. Desperate young women may bang their heads against the door, rub their hands or arms against rough brick walls until their skin is raw and bleeding, cut patterns into the skin on their arms or legs with razor blades or seriously slash their wrists so that bleeding endangers their life (Welbourne and Purgold, 1984, pp.70-71).

In this way self-mutilation may be added to the self-medicating repertoire and may come to replace binge-purging behavior as the "drug of choice." Thus, it can be readily understood that behavior modification, psychopharmacological treatment, or the wish to please the therapist may result in such precipitous relief of bulimic symptoms that may compromise the patient's sense of well being, upsetting an already fragile equilibrium, requiring that one or more additional symptoms may arise to substitute for the self-harm behavior. The following vignette from the author's clinical practice illustrates the phenomenon.

Dina, age 23, was one of numerous children from a large chaotic family. Her mother was overwhelmed and neglectful; two sisters remember being beaten by their father although Dina has no memory of this. For years Dina suffered from depression, out of control binge drinking, casual sexual liaisons that at times seemed compulsive and other times impulsive, binge-eating and purging, compulsive bargain-hunting, and shoplifting. Shortly after her first shop-lifting arrest, she recognized that her life was out of control and was hospitalized voluntarily. While in the hospital she was put on Prozac and began attending daily meetings of Alcoholics Anonymous. When she was discharged and resumed her treatment with the author, she no longer drank or engaged in bulimic behavior. At the same time, however, she began to have impulses to drive off bridges and to cut herself. When asked what the cutting would do for her, she said she felt like a balloon, so full and tight; popping it open would release the tension. Exploration of these impulses revealed that when she was around ten, her sister teased her about a large brown mole around the size of a quarter that she had on the back of her thigh. She taunted her that it looked like a piece of shit stuck there. Dina responded to the taunting by taking a paring knife and cutting the mole away. Years later, when she was around twenty, she became transfixed by the crease in her eyelid while looking in the mirror as she applied her makeup. She picked up a razor blade and in a depersonalized state drew it slowly across the eyelid crease, watching in excited fascination as drops of blood appeared and dripped down the cheek of the person reflected in the mirror. Had Dina not been in a psychotherapy which helped her explore the meaning and psychic functions served by the self-mutilating behavior, it is quite certain that self-mutilation and suicide attempts would have emerged to replace the drinking and bulimic behavior.

ASSESSMENT, ENGAGEMENT, AND COUNTERTRANSFERENCE

Self-harm behaviors should be assessed in all patients in terms of directness, lethality, repetitiveness, and the degree of consciousness maintained during the act. The psychosomatic focus of the symptoms must be understood in relation to the patient's ego structure and ego functioning, especially the defensive and adaptive functions and the punitive aspects of the superego. It is important to consider how the self-harm serves to bolster or glue together a fragmented sense of self. When a brilliant and beautiful college student says proudly, "I am the Miss America of purging" or when a chronic hospital patient brags "The staff can't stop me. I am a master, a cutter with no equal,", personal identity has become organized around the self-harm, making the patient especially loathe to give it up. The self-harm behavior attaches the person to a group, defines him as being part of that group, and thus serves to foster social affiliation and group identity. For example, some traumatized people may express and reenact their trauma by means of blood letting, burning and other painful behaviors conducted within a sadomasochistic context (Stoller, 1991; Juno and Vale,1989). Other traumatized people with numerous self-inflicted scars or body piercings and tattooes may well be affirming their identification as members of a large modern tribe of traumatized people. Therefore, the assessment of self-harm is quite complex and should be thought of in the context of how it relates to the self-care functions of the ego, body image, self cohesion, transitional object development and object relations, somatization, dissociative processes, body memory, alexithymia, and personal and group identity.

Engaging these patients is the most difficult task of all. They are angry, distrustful, and likely to regard themselves as crazy to do these things that they must do in order to live. They may believe that they are beyond hope and understanding. So if their therapist joins them in focusing on the pathological aspects of their behavior, they are likely to experience him as punitive and unempathic, joining with them in their own assessment of themselves as worthless, contemptible, and out of control, a re-creation of an abusive or sadomasochistic relationship with the patient, replicating past traumatic experience.

If the therapist can let the patient know from the outset that she must have good reasons for her behavior even if she cannot articulate what they are, that the therapist will work together with her to help her to understand and articulate this, the conviction about this gives the patient a new and welcome idea about herself, one that emphasizes something good and healthy in her. An attitude of curiosity and willingness to serve as a navigational guide to uncharted psychological territory provides hope, helps engage the patient's curiosity about herself, and fosters an ability to observe herself. Then the patient starts to feel that she has more control over herself than she had thought. Because control is a major issue with these patients, this is a crucial turning point. Such an approach enhances the patient's self esteem while engaging her in wanting to understand more and talk more with this intriguing therapist who somehow can see some value in her illness, and therefore in her. Thus a relationship is provided that holds and contains her while fostering her healthy narcissism, what Winnicott described as the experience of "going on being". If the patient can find a safe harbor with her therapist, this is an enormous achievement, the foundation for all else that follows. The victim in the patient will fight and resist it, will try to cast the therapist in the role of her abuser while clinging to her role as victim, will try to cast the therapist in the role of the parent who failed to protect her while demonstrating her need for protection, will cast the therapist in the role of the helpless victim while she traumatizes the therapist as she had been traumatized. If the therapist can wrestle with his or her own hateful wishes to control, destroy and abuse the patient, wishes that have their root in the counter-transference as well as in the patient's projective identification, if therapists can tolerate these wishes in themselves while continuing to "go on being", treatment is likely to be successful. The help of a consultant, supervisor, or trusted colleagues will be necessary to monitor the countertransference, maintain the therapist's own self-care functioning, and prevent himself from becoming vicariously traumatized by the treatment (McCann and Pearlman, 1990).

Despite their bizarre quality, both bulimic and self-mutilating behavior may be far more common than has been thought. "How common are the little sadomasochisms of everyday life, covert but observable: the skin pinching, cuticle tearing, gum picking, colonic treatments, deep massage, hairpulling-dreamy-self-and-other-stimulations? (Stoller, 1991, p.23)" Both bulimic and self-mutilating behavior have been found in numerous animal studies (Favazza, 1987; Winchel, 1991), suggesting that these behaviors may well be biologically based primal and universal urges that remain relatively unarticulated or only covertly articulated in the human animal. Studying self-harm gave the author excellent opportunity to observe the fluctuations of her eating and nail-biting behavior, and some friends and colleagues confided with some degree of anxiety that they had begun to notice their own similar behaviors. Who among us has not at times felt so impotently enraged as to want to tear out our hair or to vomit? In his recent book, An Anthropologist on Mars (1995), Oliver Sacks sees aspects of himself in people afflicted with grotesque neurological conditions. And so, reviewing the book, Wendy Lesser (1995) summarizes: "Everybody is peculiar. . . Oliver Sacks wants us to know that we are all links in the great chain of weirdness". Perhaps when we can know that as clinicians, we can better identify with and provide more empathic treatment for our patients who harm themselves.

Sharon Klayman Farber, Ph.D., B.C.D., 142 Edgars Lane, Hastings-on-Hudson, N.Y. 10706-1108. Phone: (914) 478-1924

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©2002 Sharon Klayman Farber, Ph.D., B.C.D. Reprinted with permission.

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