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Birksted-Breen, D. (1989). Working with an Anorexic Patient. Int. J. Psycho-Anal., 70:29-40.

(1989). International Journal of Psycho-Analysis, 70:29-40

Working with an Anorexic Patient

Dana Birksted-Breen

There exists an extensive literature, though perhaps more psychiatric than psychoanalytic, on anorexia nervosa, the syndrome which includes the relentless pursuit of thinness and the preoccupation with food as a way of life (Bruch, 1974).

Some authors have focused on the oral symptom—not eating—which they view as a defence against greed and the wish for oral impregnation (Berlin et al., 1951, for instance); others emphasize the disturbance in body image as does Crisp (1973) who states that 'the disorder is primarily one of the psychological meaning of body weight with reference to puberty and not to food and its direct relevance in terms of mother'. Freud, in a very early paper (1895) makes a link between anorexia nervosa and melancholia, focusing on the loss of appetite. The Kleinian perspective points to the paranoid fears of being poisoned, sometimes connected with the mother's projection into the child of her own wishes (Menzies-Lyth), or the depressive fear of endangering the good internal objects. Tustin (1984) points out the connexions with autism and suggests that the anorexic turns away from the extreme sensations of the ecstasy of food and rage when the food is not there. The French authors Kestemberg et al. (1972p. 11) were particularly impressed by the perverse and masochistic components and felt that their patients were 'dying of pleasure' (my translation).

In recent years anorexia has also been considered from the angle of the family as a system (Minuchin et al.

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