Christa D. Ventling Пациенты с нарушением питания: тело без вибраций - Интеграция нейробиологии в биоэнергетическую терапию // Психология.Пермь. – 2010. - №19. с 8-18
Нарушения питания включают нервную анорексию (НА), нервную булемию (НБ), избыточный вес и тучность (Т). Они демонстрируют нарушение пищевого поведения, регуляции веса и отклонения в отношении веса и формы тела. Пациенты с НА и НБ, но не с Т имеют извращённый взгляд на образ своего тела. Все они, так сказать, находятся в состоянии войны со своим телом. В то время как НА и НБ обычно начинаются в раннем подростковом возрасте, то Т имеет началом разный период времени, хотя большинство имели уже избыточный вес в детстве. Реальные причины этих нарушений часто находят в детстве, когда они страдали голодом не из-за отсутствия пищи, а из-за чего-то другого. У этих пациентов нет нормального чувства голода и насыщения. Так как такие чувства являются фактически гормональным ответом, вызванным сигналами головного мозга, то предполагается, что эти пациенты страдают нарушениями регуляции генов контролирующих аппетит и насыщение, которые в норме ответственны за продукцию этих гормонов. Дисбаланс гормонального обмена ведёт к возникновению ненормальных пищевых стереотипов. Все эти пациенты страдают депрессией. Когнитивно-поведенческая терапия (КПТ) была терапией выбора, тем не менее рецидивы были очень часто. Данные исследований, в основном, у госпитальных пациентов показывают, что они отвечают на антидепрессанты типа ингибиторов обратного захвата серотонина (флуоксетин, прозак) в различной степени: пациенты с НБ – лучше, с НА – хорошо, когда их вес стабилен; пациенты с Т отвечают также хорошо. Иногда антидепрессанты назначали вместо психотерапии. Однако комбинированное лечение было успешнее. Данных о влиянии биоэнергетики или других видов телесной психотерапии при нарушении питания ещё недостаточно и они очень нужны.
Patients with Eating Disorders: Bodies without Vibrance
(Integration of neurobiological findings into bioenergetic therapy)
Christa D. Ventling
Abstract
Eating disorders comprise anorexia nervosa (AN), bulimia nervosa (BN) and overweight or obesity (OBE). All display aberrant patterns of eating behavior and weight regulation and disturbances in attitudes toward weight and body shape. In addition AN and BN but not OBE patients have a distorted view of their body image. All are so-to-speak at war with their bodies. While the onset of AN and BN is usually in early adolescence, OBE patients have varying times of onset, though most were already overweight as children or even as infants. The real causes for these disorders are often found in childhood, when their hunger was not for food, but for something else. In these patients a normal feeling for hunger and satiety is missing. As such feelings are actually hormonal responses elicited by brain signals, it is assumed that these patients suffer from a deregulation of the appetite-and satiety-controlling genes which normally would be responsible for the production of these hormones. The imbalance in hormonal metabolism in turn would lead to the abnormal eating patterns. All these patients are depressed. Cognitive behavioral psychotherapy (CBP) so far has been the treatment of choice, however, the incidence of relapses is reportedly very high. Research data, mostly from in-patients, show that they respond to antidepressants of the specific serotonin reuptake inhibitor (SSRIs) type like fluoxetine (Prozac) though to varying degrees. BN patients respond best, AN patients respond only well once their weight is stable, OBE patients respond also well. Light therapy as an antidepressant agent has been successful also. Sometimes the antidepressant was given in place of psychotherapy; few studies demonstrate that a combination treatment is better than either alone. Data on the effect of bioenergetics or any other type of bodypsychotherapy on treatment of eating disorders are still missing and badly needed. This article closes with proposing a 7-step bioenergetic psychotherapy program based on the neurobiological findings about hormone deregulation and the underlying depression.
Introduction
Eating disorders are increasing in socialized countries at such a rate that they are becoming a public health problem, considered the deadliest of all psychiatric disorders killing or contributing to the deaths of thousands every year. In the USA an estimated 50 000 people currently suffering from an eating disorder will eventually die as a result of it. We can expect to see people with eating disorders in therapeutic practices more often in the future: psychotherapy as the last hope to find peace with the conflicting weight, shape and image issue.
Patients with eating disorders according to the DSM-IV or ICD-10, the two international classification manuals of psychological disorders, are among others defined by their deviation from the normal BMI of 20 in both directions. Underweight persons have a BMI below 20, whereby 17.5 is considered a cut-off point as a weight drop below this limit is considered dangerous to the health; circulatory breakdowns are common. Overweight and obese people have a BMI of 25 – 29.9, adipose persons have a BMI of 30 to 40. Their life is also in danger but for different reasons; diabetes, heart attacks, strokes and some types of cancer, including breast and colon cancers are threatening secondary diseases (Marx 2003).
The following table lists the eating disorders of the patients we see in therapy, with the specific symptoms around food and eating, their means of controlling body weight and their body image.
Eating disorders comprise three main categories: Anorexia nervosa (AN), Bulimia nervosa (BN), and Obesity (OBE). All are characterized by aberrant patterns of eating behavior. AN and BN patients demonstrate a disturbed attitude toward weight and shape and a distorted perception of their body image. Both begin with dieting and are propelled into a full-blown disorder requiring medical attention. Sometimes anorexic persons turn into bulimics. Women are overrepresented in the categories AN and BN, while men and women are about equally distributed among the overweight or obese. The anorexic woman, extremely slim in appearance from never eating enough, or the bulimic woman maintaining a relatively normal weight and therefore undistinguishable from the rest of the population by appearance, both rarely come into therapy on their own in the beginning of their disorder. For at this stage – onset of AN and BN is in early adolescence - they are convinced that they are in control of their body and their life, while they are struggling for autonomy. Even their parents often regard the strange eating habits of their teenagers as just a passing, rebellious thing and remain unaware of the danger ahead. Amazing that even scientists, at least in the 1980ies, considered the figure-conscious eating behavior of teenagers normal for this period of development (Abraham et al. 1983a). The young anorexic woman feels on top of the world because she has almost achieved the impossible, to be independent of food. The bulimic woman thinks she has found the secret for perfect weight control by eating either little for days or binge eating followed by induced vomiting. When they suffer a circulatory breakdown due to nutritional deficiencies, there is a rude awakening. The emergency hospitalization usually ends with psychotherapeutic counseling. However, such an event can happen months or even years after onset. The multi-impulsive type of BN is characterized by the typical BN features, but in addition exhibits impulse control problems. These can take on the form of compulsive buying of unnecessary objects or of shoplifting or of injurious behavior, like cutting the wrists with razor blades or scissors, this as a means to break the intolerable tension, anger and fragmentation. Injurious behavior is seen in 25-40% of all BN cases (Leithner et al. 1998) Sometimes it is these very frightening moments of unbearable tension which will motivate a BN woman to seek psychotherapy. However altogether it is estimated that only 30% of all bulimic women do so (Tarr-Kr?ger 1989).
Anorexia and bulimia are by no means modern disorders, in fact they have existed already in Antiquity. In those days food was not produced in excess like now, therefore one cannot blame society as the originator of eating disorders, as it is often done these days. Anorexia is Greek, the name “an” plus “orexia” means longing for, reaching for something. Homer (around 800 b.c.) described a person with a form of binge eating as “eating an entire oxen”; Hippokrates (460-370 b.c.) described a form of unbearable hunger leading to excessive eating as “limos” and came up with the oldest therapeutic advice in treating bulimia, which was to drink a glass of wine – an advice which was followed until 1920. And Xenophon (430-354 b.c.) thought “bulimos” was a form of helplessness and weakness (Ziolko 1996). Their descriptions and psychological interpretations were absolutely correct!
In obesity (OBE) we also find an aberrant though different pattern of eating behavior yet a realistic perception of body weight and shape. Obese people are very well aware of their excess fat and weight and the everyday problems this creates. In company of others they adjust to the group’s eating habits, which is less than their body requires. They make up for the missing difference by eating secretly in between or at night. Night eating is considered an addiction. They hate their body. Secretly they are depressed. They have usually tried dieting more than once with little success and not much more than a short temporary weight loss. Exercising is too strenuous, long walks bear heavily on their joints and feet causing pain. The sexuality, or better the sex life of obese people is an ambivalent story. Although they are hungry for contact, their shape serves as a protecting wall and prevents close contact. Overweight persons will occasionally seek a psychotherapy as a last resort for losing weight after they tried Weight Watchers or Overeaters Anonymous or any number of diets without success, but they will rarely admit their emotional suffering and only reluctantly look at their own story.
Data from the USA 1999-2000 National Health and Nutrition Examination Survey (NHANES) showed that almost 35 % of the adult population are overweight and another 30% are obese; while 15% of the US children are overweight (Hill et al. 2003; Marx 2003). In Europe and Australia we are nearing these figures.
Onset and Possible Causes of Eating Disorders
AN and BN start in early adolescence
Our “eat yet remain slim”- oriented society is often made into the chief culprit for eating disorders. For we produce food in excess and are advised in tempting ways to consume it, but we are also told that adding weight is bad, ugly and unhealthy, while remaining slim is equal to beautiful and successful. The sad result is that for women especially, life has become a daily battle around eating, an obsession, a life under pressure and fear often lived in secrecy and shame. The body has become an enemy which needs to be stretched, worked at and pounded into shape. Fitness centers around the globe serve this purpose aided by the health food and diet industry.
But is society alone to be blamed ? Not entirely. AN and BN emerge in early adolescence when girls become women and when the changing body shape is noticeable and menarche sets in (Halmi et al. 1979; Fairburn et al. 1997). The world of a woman may seem frightening, even dangerous; to remain a child may seemingly be the solution for the AN adolescent. Refusing dinners at home, not eating, even starving herself helps to remain skinny and lean. AN adolescents prefer to remain in their little-girl bodies. BN adolescents struggle with their feminine body shape due to an idealistic fixed picture in their mind what their body should look like. Some will go to extremes in order to obtain it (eating, purging, use of laxatives, exercising, everything in excess), but are never satisfied and others wish they had a different body altogether (Halmi 2002). Both AN and BN personality types have a distorted body image and an identity problem as a developing woman. Neither likes what she sees in the mirror.
When we start probing into their history we almost always find serious childhood deficits (Battegay 1987, K?mmerer & Klingenspor 1989). They have to do with not being loved enough, not being seen, not being supported, not being valued, not being praised enough, etc. etc. and this by either the father or the mother (Abraham et al. 1983a; Battegay 1987) or by getting ambivalent messages from a parent (Downing 2002). Clearly by the time they are teenagers, since they have never felt secure in mind and body, they now feel even worse and the problems are aggravated. If the marriage of the parents after all these years is on the rocks, but they stay together, then the prevailing silent tension does not go unnoticed by the teenagers and secretly they worry a great deal about the marital problems of their parents. They also rebel against their authority yet feel ambivalent towards them. Identification of the boy with the father seems less problematic than identification of the girl with the mother, as we see only rarely AN and BN in male adolescents. Not wanting to be like the parent (an unconscious process at first) can take the form of not wanting to grow up. And for girls there is the additional problem of rivalry with other girls about looks and shapes. Thus while some young adolescent girls rebel by not eating and become anorexic, others having discovered how to get rid of ingested calories, outwardly conform to the family’s eating pattern and become bulimic. Purging, e.g. induced vomiting, excessive use of laxatives and excessive exercising, all done daily or even after every meal is their secret for staying slim. While the AN woman although constantly at the edge of a physical breakdown feels at peace with herself and is sociable, the BN woman feels dirty, ashamed, miserable, worthless and wants to hide. She will socialize in order not to be different, but secretly she is very lonely.
In Europe and the USA about 1% of all women between the age of 15 and 35 years are estimated to suffer from AN (Kaye et al. 1998). About 3% of European women are bulimics; in Switzerland this number is 5% (Hettinger 2002) and in the USA 10% or more (Kuhn 1990, Hettinger 2002). AN figures are more precise than those for BN, for more AN women require hospitalization than BN women do and figures are based on registered hospital stays...
Психотерапевт Криста Д. Вентлинг
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