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eating disorders: does attachment play a role in the onset of eating disorders?

Among the various mother-child exchanges, feeding represents an essential moment. Evolutionary clinical research in recent years offers an interpretation of early eating disorders from an interactive perspective, clearly highlighting the important role played by the attachment bond in the genesis of eating disorders in childhood.

Anna Freud (1946) was the first to identify a category of neurotic eating disorders in childhood linked to conflicting emotions towards the mother and symbolised through food.

In the child psychoanalysis scenario of recent decades, a model has been affirmed that downplays the role of drives, shifting the focus to the mother-child relationship and the latter's need for protection and security.

Within this perspective Sandler elaborates the theory of self-regulation during childhood, hypothesising that through biological rhythms, including the hunger-satiety rhythm, the child's internal states are regulated.

In line with this orientation, Stern emphasises the importance of the maternal function of affective attunement to the child's states of mind, which is the basis of self-perception as an acting being, endowed with intentionality and thus a mind and an individuality. According to Stern, feeding is a vital activity for the construction of the emerging self, as it allows repeated face-to-face contact and social stimulation.

Observations of children with feeding regulation disorders in the first months of life highlight unpredictable and inconsistent behaviour of the caregiver during feeding, along with the latter's difficulties in positioning the child to facilitate social exchanges. In some research, systematic observation of interactive behaviour and affective exchanges during feeding revealed that children with an eating disorder showed unclear communication signals and their mothers were less receptive and less cooperative, displaying arbitrary, directive and controlling behaviour, both during feeding and in play situations.

Other research, using the observational procedure of the Strange Situation to assess the quality of attachment between caregiver and child in children with an eating disorder, has shown high rates of insecure or disorganised attachment and high levels of anger, ambivalence, unpredictability, fear and emotional repression in interactions.

As far as eating disorders in adolescence or adulthood are concerned, no equally clear link can be established between the development of eating disorders and attachment disorders, although numerous clinical and empirical studies suggest that insecure attachment styles are common within the eating disorder population.

The characteristics of communication in the family of origin and the insecure attachment pattern may be the probable causes of the peculiar patterns of psychogenic eating disorder patients.

In people with an eating disorder,

an interpersonal pattern often operates in connection with a representation of the other as unreliable and somewhat threatening when it comes to revealing one's intimacy.

This generates the expectation (experienced as an almost - certainty) that the interlocutor will not understand, accept or appreciate the expression of one's inner world or that he will use knowledge of the subject's feelings against him. Faced with various disappointments, first experienced in the relationship with the care-giver and then in the first extra-familial affective bonds, the subject takes refuge in idealised images of perfect and gratifying future affective relationships.

The relationship between oneself and thesignificant other is thus represented in a dichotomised form:

on the one hand, as an ideal fusion of intentions and feelings, on the other hand, as an expected disenchantment and consequent total impossibility of the relationship.

In the current state of research it is not possible to explain linearly how attachment style can be specifically correlated with eating behaviour in adulthood.

Early experiences, responsible for the failure to develop a secure base, interacting with other factors, could favour the later onset of eating disorders in a non-linear but complex and systemic manner, acting at various levels, for example by interfering with the ability to manage unpleasant emotions, or by hindering the construction of a positive bodily identity or not allowing the development of an integrated sense of identity.

The multifactorial aetiological hypothesis of eating disorders may well be integrated within a theory that conceptualises eating disorders as disorders of affect regulation. The failure to share affects, on which children build their experiences of self-efficacy and awareness, can lead to confusion whenever they attempt to distinguish their physiological needs, being hungry or full, from emotional and interpersonal experiences.

Over the past decades, several empirical studies have explored the possible association between alexithymia and eating disorders. Taylor formulates the concept of alexithymia as a personality construct that reflects a major disturbance in the regulation of affect and is a relevant risk factor for the occurrence of psychological and somatic illnesses.

People with eating disorders are fundamentally alexithymic: they have difficulty recognising their own internal states (hunger, satiety, sense of emptiness), exploring their inner world, and have poor skills in recognising and expressing their emotions. This deficiency deprives these people of an important source of information about their state of well-being and their desires and needs, hindering the creation of stable boundaries with others and increasing dependence on the external environment for confirmation and security. In fact, dependency is a fundamental trait in people with eating disorders: while the illness can take the form of a mute claim to autonomy from the family, it also tends to recreate symbiotic relationships with reference figures.

Even if alexithymia is not directly linked to binge-eating, body image disorders or an obsessive quest for thinness, there is empirical evidence that this construct is linked to psychological traits typical in people suffering from eating disorders, in particular enteroceptic confusion, difficulty in communicating feelings, altered perception of the hunger stimulus, which becomes representative of a broader difficulty in distinguishing between internal and external stimuli, that is, in the correct recognition of one's own emotions and sensations.

In this way the body takes on a symbolic value in relation to the social, in that it condenses in the anorexic-bulimic act psychic contents that are difficult to communicate and poorly mentalised. It becomes a point of encounter-clash between what is inside and what is outside, a space-surface that delimits a Self that is still uncertain. The dynamics of filling and emptying, typical of the anorexic-bulimic oscillatory movement, could be attempts to contain emotions on a concrete level: the empty stomach evokes the loneliness to which one escapes through devoured food, which fills without nourishing.

Some studies seem to link anorexia to an avoidant attachment style.

People with an avoidant attachment style are characterised by good cognitive development at the expense of the affective sphere. They implicitly assert their independence, are perfectionists, have resistance to tolerating affective closeness and intimacy and tend to distance themselves from feelings such as tenderness, anger, sadness.

This style is structured by the relationship with an attachment figure (often the mother) with an anxious, rigid, overprotective, hyper-focused on 'doing well' but incapable of making the relationship intimate. The mother discourages emotional contact by highly stimulating autonomy and self-control. This figure is unable to provide emotional training for the child and focuses mainly on the physical aspects of caring. Faced with the child's emotional distress, he frantically returns inadequate responses, making it difficult for him to recognise his own internal states. In this way the body becomes a mediator of the relationship with the mother, a symbolic ground on which to represent one's own internal experiences.

The parent's difficulty in containing the child's affective states is experienced by the latter as a rejection of his own needs for comfort. This child perceives the parent's discomfort in the face of intimacy and emotional contact and paradoxically perceives distance as the only way he or she feels effective in obtaining the closeness of the caregiver.

he father usually represents a marginal, distant figure, initially idealised but then inevitably a source of disappointment in adolescence.

Bulimia, on the other hand, seems more compatible with a disorganised attachment style. In fact, whereas people with anorexia are usually characterised by high self-control, bulimia is frequently associated with poor impulse management. Binge eating may be an attempt to manage unpleasant affective states by discharging emotional tensions through acting out. Here there is no repression of emotions, but rather there is a difficulty in containing them, which may be due to a disorganised attachment style.

People with a disorganised style as children have experienced an unresolvable conflict between the tendency to turn to the parent as a source of reassurance in the face of a frightening stimulus and the fact that it is the parent himself who arouses fear. The tendency to approach and the tendency to move away inhibit each other and the child experiences emotions that overwhelm their ability to organise coherent behaviour. They have often learnt to regard situations that are not dangerous as dangerous and situations that are positive.

Disorganised children occur more frequently in high psychosocial risk samples, with depressed, drug-addicted, abused mothers. These mothers have a prevalence of intrusive, role-reversal, frightening or frightening behaviour (e.g. frightened tone of voice, intimidating attitude towards the child, scolding the child during crying, not calming the child if he is distressed, laughing if he cries or is in distress, giving contradictory verbal and non-verbal messages).

This attachment style is also frequent in low psychosocial risk samples, but with mothers who have suffered trauma or unresolved bereavement. These parental figures exhibit behaviours of withdrawal and fear (they hold their children, keeping them far away from their chests, show fear) that frighten the child.

In explaining the link between problems in the attachment process and eating disorders, the concept of body identity may play an important role.

Personal body image is a self-representation that is only partially linked to objective physical appearance. It is the root of identity, the fruit of the sedimentation of relational experiences with significant figures, and is the result of the interaction of three dimensions: perceptual (degree of accuracy in the estimation of one's own body, in its entirety and in its individual parts), cognitive-affective (feelings and thoughts about one's own body), and behavioural (activities that the person undertakes or avoids based on how he or she feels about his or her body).

Body identity is formed within precocious relationships with early attachment figures. Negative experiences related to one's body dimension in the relationship with one's significant other can lead to distortions in one's way of perceiving oneself and perceiving reality. The unpleasant emotions aroused by a distorted mental representation of one's physical appearance (altered body image) can lead to the implementation of incorrect eating behaviours and habits both in the restrictive sense and in the sense of loss of control. It is therefore plausible to hypothesise a link between insecure attachment styles to significant figures in childhood and possible alterations in body image, which later, interacting with other factors, may favour the appearance of eating disorders.

In conclusion, in the current state of research, it is not yet possible to draw definitive conclusions on the role of attachment styles in the development of an eating disorder in adulthood.

From the often incomplete and contradictory clinical and empirical data, however, a correlation between avoidant attachment style and anorexia, disorganised attachment style and bulimia seems to emerge. The avoidant attachment style is compatible with the characteristics of alexithymia and perfectionism common in anorexics, while the disorganised attachment style is compatible with the difficulty in managing emotions and the tendency to act out in people with bulimia.

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