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Section 9
Dissociative States in Eating Disorders

CEU Question 9 | CEU Test | Table of Contents | Eating Disorders CEU Courses
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On the last track, we discussed three different exceptional situations regarding anorexic clients.  These exceptions to the norm included:  the chronic adult client; stressors and enablers; and very young clients.

On this track, we will examine three concepts of dissociative behavior in an anorexic client.  These three concepts of dissociative behavior in an anorexic client include:  bizarre behavior; trances; and manipulative strategies.

3 Concept of Dissociative Behavior

Concept #1 - Bizarre Behavior
The first concept of dissociative behavior in an anorexic client is bizarre behavior. As you already well know, this does not just include the client’s eating habits, but also his or her daily practices. This behavior seems strange and outrageous to those outside of the reality of the disorder. The clients will try to embarrass those around them by screaming, crying, or even sitting down in puddles. Many of these acute clients do not receive enough regenerative sleep at night. 

Because their bodies have switched into perpetual foraging mode, they must battle nightly between waking up, going to the refrigerator or cabinet, and fight off their hunger. Some clients do not get more than an hour to an hour and a half of sleep a night. Other strange and bizarre behavior is designed to alienate the client from the rest of society.  The client obviously has an acute sense of worthlessness and to confirm this will act out in indescribable ways.  When others begin to back away because of these disturbing acts, the client’s self-loathing is proved and validated. 

Joe, age 19, was diagnosed with anorexia when he weighed in at 100 pounds.  Not only did Joe experience the physical trauma of the disorder, but he also suffered from a sexuality crisis at the same time.  Desperate to define his identity, Joe began to wear women’s dresses out in public firstly to embarrass his father and secondly because he knew that this would disgust and horrify everyone else around him.

Joe stated, "I don’t want to be thought of as a normal person, it terrifies me!  I have this disease that is eating away at me and I don’t deserve to be thought of as normal.  I scare people this way because then I feel as though I have control over what repels them.  I don’t want to be thought of as a woman or a man, just a thing!" Joe’s sense of self-loathing culminated in this antisocial display of a rejection of sexuality.  Instead of his cross-dressing being a sign of a new identity, Joe had twisted it into a garish demonstration of self-alienation. 

Think of your Joe.  How is he or she alienating him or herself from society?

Concept #2 - Trances
The second concept of dissociative behavior in an anorexic client is trances.  Many clients in the acute stage of anorexia will completely retreat from reality itself.  During this time, the voice of the client will become quiet and almost inaudible.  He or she will stop moving and may curl up into a fetal position or freeze into position.  The client will not make eye contact with anyone around him or her and looks as though he or she is preoccupied by something in his or her mind.  At this point in time, the client has turned inward and is hearing a sort of broken record of the internalized anorexic voices. 

As mentioned on a previous track the voice becomes loud and commanding, trying to maintain control of its victim.  It tells the client that his or her caregivers are trying to make him or her fat.  It also gives disastrous prophecies such as, "If you eat that sandwich, your mom is going to have a heart attack!"  Usually, frequency of trances increases during the first few months of therapy.  The client is being monitored and the anorexic part of the client's mind is not being allowed to manifest itself.  It’s trapped, and forces the client to shut off the outside world completely. 

Technique:  Trance Emergency Training
Rebecca, age 16, weighed 85 pounds and was diagnosed with anorexia by her school counselor.  Her parents, Sam and Barbara, were willing and committed to helping their daughter.  They monitored her closely and refused to allow her any room for her delinquent eating habits.  In response, Rebecca had begun to go into trances where she would respond only very slowly to outside stimuli.  To help Barbara treat Rebecca during a trance, I suggested the Trance Emergency Training exercise.  This technique includes several methods that I have compiled that have proven useful in retrieving a client from a trance. 

I told Barbara and Sam that the next time Rebecca fell into a trance that one of them holds her and rock her back and forth, as though she were a baby while the other wipes her forehead with a cool cloth.  I asked them both to repeat phrases such as, "It’s safe, you can come out now."  To determine how far Rebecca has fallen into a trance, I suggested Sam or Barbara ask her such questions as, "How much of you is with us?"  The slower and quieter the response, the more internalized Rebecca has become.  I also made the suggestion to ask distracting, neutral questions such as, "What is the weather like today?" or "How is the dog?" 

These questions leave no opportunity for subjectivity so the client can respond neutrally and honestly.  When the client begins to flutter his or her eyelashes, this is an indication that he or she is coming out of the trance.  When this happens, I asked Sam and Barbara to continue encouraging Rebecca to "come back" and also to remind her that she is safe.  Think of your Rebecca.  Would his or her parents benefit from Trance Emergency Training?

Concept #3 - Manipulative Strategies
In addition to bizarre behavior and trances, the third concept of dissociative behavior in an anorexic client is manipulative strategies. To maintain his or her weight loss, the anorexic client will develop certain strategies that may be able to trick a caregiver into allowing certain weight loss behavior. While some clients, as discussed earlier, will perpetrate actions that encourage alienation, these clients will try to justify their delinquent eating habits through untrue rationalization. 

For instance, some will state that they are vegetarian so can’t eat meat, or that they are diabetic so they cannot consume sugar. Others will try to find any excuse to do exercise such as fidgeting or offering to do housework. Although on the surface, this may not appear as dissociative behavior, those caregivers who are "duped" into allowing this behavior feel manipulated and thus may become more frustrated or discouraged from helping the client further.

Laney, age 15, had been diagnosed with anorexia a year before.  When the eating habits began to change, Laney’s mother Rita noticed an increase in house chore activity.  Laney would offer to take out the garbage, believing she would burn extra calories if she were walking with something heavy.  She would also offer to wash windows, vacuum the stairs and any other small activities that she believed would constitute exercise.  At first, Rita was thrilled that her daughter had begun to help around the house. 

Rita stated, "Eventually she cleaned our entire home, top to bottom.  I couldn’t believe it!  She never offered to wash a dish before.  When I found out she was just trying to exercise, I felt used and kind of like an idiot at the same time.  Now, I won’t trust her to do any chores because I’m afraid to she’s using them to exercise needlessly."  Laney’s manipulation of her mother’s trust has led to a rift in the relationship and has caused Laney to lose a valuable character building responsibility.  Think of your Laney.  What has his or her manipulative behavior cost them?

On this track, we discussed three concepts of dissociative behavior in an anorexic client.  These three concepts of dissociative behavior in an anorexic client included:  bizarre behavior; trances; and manipulative strategies.

On the next track, we will examine three concepts related to anorexic clients who are survivors of incest.  These concepts of anorexic clients who were victims of incest include:  inability to trust; skewed sexuality; and learned defenses.

Peer-Reviewed Journal Article References:
Engel, S. G., Wonderlich, S. A., Crosby, R. D., Mitchell, J. E., Crow, S., Peterson, C. B., Le Grange, D., Simonich, H. K., Cao, L., Lavender, J. M., & Gordon, K. H. (2013). The role of affect in the maintenance of anorexia nervosa: Evidence from a naturalistic assessment of momentary behaviors and emotion. Journal of Abnormal Psychology, 122(3), 709–719.

Obeid, N., Carlucci, S., Brugnera, A., Compare, A., Proulx, G., Bissada, H., & Tasca, G. A. (2018). Reciprocal influence of distress and group therapeutic factors in day treatment for eating disorders: A progress and process monitoring study. Psychotherapy, 55(2), 170–178.   

Raykos, B. C., Erceg-Hurn, D. M., McEvoy, P. M., Fursland, A., & Waller, G. (2018). Severe and enduring anorexia nervosa? Illness severity and duration are unrelated to outcomes from cognitive behaviour therapy. Journal of Consulting and Clinical Psychology, 86(8), 702–709.

Solomon-Krakus, S., Uliaszek, A. A., & Bagby, R. M. (2020). Evaluating the associations between personality psychopathology and heterogeneous eating disorder behaviors: A dimensional approach. Personality Disorders: Theory, Research, and Treatment, 11(4), 249–259.

Tibon, S., & Rothschild, L. (2009). Dissociative states in eating disorders: An empirical Rorschach study. Psychoanalytic Psychology, 26(1), 69–82.

Online Continuing Education QUESTION 9
What are three concepts of dissociative behavior in an anorexic client? To select and enter your answer go to CEU Test.

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