Food disturbance

Treatment of eating disorders: vomiting syndrome

food disorders

Today we observe the increasing frequency of eating disorders, in their various expressions and among these, one in particular appears very bizarre and upsetting.
This is the case of a young woman of 25, very beautiful and seductive, who comes to the first session saying that she eats and vomits, as if she were kidnapped by a demon, by a dark force that overwhelms her. She states that when she eats she feels the irrepressible desire to fill up, until she burst, then runs to the bathroom to throw up. She has tried to restrain herself but her efforts have so far been unsuccessful. The urge to eat and vomit is too strong. She would like to get rid of this problem, but she can't. She defines herself as "bulimic".
More and more often patients are attributed diagnoses, applying psychiatric terminology, perhaps after consulting the internet, without knowing exactly what it is. Can we talk about bulimia in these cases? The DSM, statistical and diagnostic manual, agrees with this definition. The binges followed by self-induced vomiting are part of the so-called "bulimia nervosa" and "anorexia nervosa" in the type with binges and elimination conducts.

However, for Brief Strategic Therapy, things are different. Given the ineffectiveness of the treatments commonly used for anorexia and bulimia applied in the cases of patients who eat and vomit, the "research - intervention", conducted by Giorgio Nardone and his collaborators, led to the discovery of the so-called "Vomiting syndrome" (Nardone, Verbitz, Milanese, 1999). The research method used is what Kurt Lewin has called "research - action", whose basic premise is "knowing by changing". And it is on this line that it was discovered that eating and vomiting is a specific disorder, a real compulsion, a ritual that is based on the search for extreme pleasure.

This is one of the pathologies that most confirm the validity of a fundamental construct of Brief Strategic Therapy, the concept of attempted solution that turns into the problem. In the beginning, vomiting is the solution, which is a way to eat without gaining weight. However, through its repetition, the sequence of eating and vomiting becomes an increasingly pleasant ritual. Laborit, Nobel Prize in Biology, shows us how any type of behavior, if repeated a certain number of times, can take on a connotation of intense pleasure. The problem transforms with respect to the initial form, from the attempt to control weight (which can have an anorexic or bulimic matrix), it passes to a real irrepressible compulsion. Eating and throwing up is a perverse pleasure that cannot be renounced, as the patient says: "It's too good!"
Moreover, if we stop to analyze the structure of the disorder, we note that this is characterized by an excitatory phase, in which the binge is mentally anticipated, a consuming phase, in which a large amount of food is swallowed up to fill, and finally, a discharge phase, in which we are free. And what does it remind us of? I imagine it is evident that this sequence is isomorphic to the sexual one, the act of eating and vomiting is a real erotic ritual. In therapy we tune into the pleasant perception that characterizes the compulsion and use the analogy that associates eating and vomiting with the "secret lover", always available and accessible. It is through evocative language that we capture the patient who feels she is facing a therapist different from all the others, an expert in the functioning of the problem.

Get out of the trap
At this point we just have to move on to the intervention, we do it using the interval technique (Nardone, 2003) and we prescribe to the young woman: "From now until we meet again, you are free to eat and throw up as often as you you want without any restrictions, eat what you want as much as you want. When you get so full that you are about to burst and want to run to vomit, you stop, look at your watch and wait for an hour, the exact time, neither a minute before nor a minute later, then run and go throw up , avoiding eating or drinking anything in this range. So I'm not asking you not to do it, but I'm asking you to do it very precisely so that when the demon comes to take over you, you eat as much as you can, eat, eat and eat again, until you almost feel yourself bursting, at that point you stop and wait an hour ”.

What is the effect of this prescription? It is usually disruptive, if we can get them to do it, most of the time the disturbance breaks down. The patient comes back and states that eating and vomiting an hour later are no longer the same. The sensation changes from pleasant to unpleasant. We have turned pleasure into torture. Through a work of persuasion, of which the therapist's communicative and relational ability is fundamental, the patient is guided to implement a variation of her eating and vomiting ritual: postpone the act of vomiting one hour after the binge. . In particular, the strategy affects the pleasant sequence by interposing a time interval between the consumption phase and the discharge phase. The temporal sequence of the ritual is interrupted and in this way its irrepressible pleasure is altered. Imagine being with your partner and when you are at your maximum pleasure you stop and say: “In an hour we will start again”… it's not the same thing anymore, right?

Once this change has been achieved, the patient will be guided to dilate the interval more and more: the strategy first involves prescribing the one-hour interval, then two hours, and then moving on to three hours up to four hours. Thus the compulsion is extinguished. Furthermore, for fear of gaining weight, the patient comes to spontaneously reduce the amount of food ingested. Two results are obtained with a single technique. We used the stratagem of “making the enemy go up to the attic and remove the ladder” (Nardone, 2003).
Through this strategy the young woman, as happens in the majority of cases, is unlocked: the percentage of success, obtained at the Strategic Therapy Center of Arezzo and from Affiliated Centers present in Italy and all over the world, exceeds 80%, the therapeutic change occurs in a short time, from 3 to 6 months (Nardone.

In the words of Arthur Clarke "A very advanced technology in its effects is not unlike magic".

Dr. Elena Boggiani (Official Psychologist-Psychotherapist of the Strategic Therapy Center)

BIBLIOGRAPHY

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