go to content


Vadim S. Rotenberg   vadir@post.tau.ac.il

2000 Martin Dunitz Ltd

International Journal of Psychiatry in Clinical Practice 2000 Volume 4 Pages 89-92

Guest editorial

This paper reviews the contradictions in the literature regarding the psychological mechanisms of anorexia nervosa Neither the concept of distortion of body size perception nor the concept of artificial compensatory control over eating behaviour are appropriate explanations A new concept is proposed, whereby the essence of anorectic behaviour is an effort to maintain resistance in front of challenges, as an artificial attempt to overcome helplessness and restore search activity and self-respect

Anorexia nervosa has been investigated in detail, but there is no general agreement on either the pathogenic mechanisms of the disorder, or the most effective treatment I shall highlight contradictions in research findings, and present a new theoretical approach to the condition

According to the traditional approach, anorexia nervosa is characterized by behaviour, designed to produce or maintain marked weight loss This behaviour is related to disturbed perception (overestimation) of the subject's body weight or shape, and as a result to a negative body image (1- 3) and morbid fear of becoming fat (4).(5)Due to the misperception of body size, patients usually deny the seriousness of weight loss

However, according to some recent investigations, (5) anorectic patients' estimates of body size can be not only above, but also sometimes below and within, the normal range, and in general they do not demonstrate a significant difference from those in normal control subjects. Moreover, even if self-perception is altered, it is usually only a moderate distortion, insufficient to explain extreme anorectic behaviour. The moderate distortion of perception by itself cannot explain the tremendous denial of reality, which is comparable to a delusional state. The subject must be strongly motivated to have such peculiar perception of his/her body, especially when taking into consideration that perception of neutral objects is usually normal (6 ).This suggestion, that an anorectic person is motivated to distort perception of his/her body size, agrees with the proposal that the differences in body size distortion between subjects with eating disorder and control subjects are due exclusively to affective factors( 3).

What are these affective factors' First it is necessary to exclude the presence of depression anorectic patients are often characterized by low mood, may have sleep disturbances similar to those seen in depressed patients,(7) and obsessive ruminations, (8,9) reflective cognitive style,(10) alexithymia,(11, 12) perfectionism,(13) and inward hostility(14) are also common in patients with major depression.

Like depressed patients, anorectic patients display motivational problems for instance, reduced sexual interest(15-17). Finally, it has been shown that in 50% of all cases depression precedes the onset of anorexia nervosa by 1 year,(18) and antidepressant drugs are sometimes beneficial (19).

However, many important clinical features of anorexia nervosa do not correspond to those of depression. First, appetite in anorectic patients is not decreased, at least for a long time, and patients are continuously struggling with their strong desire for food In addition, goal-directed activity is not blocked, and patients often display sly and complicated behavioural habits in their struggle with relatives whilst attempting to avoid food In contrast to depressed adolescents, anorectics often demonstrate good academic performance (9). Finally, antidepressant drugs sometimes have a worsening effect on the disorder (20).

Thus, although anorexia nervosa has some features in common with depression, it cannot be explained only by depression. Another theoretical paradigm has to be invoked.

The concept of helplessness seems to be a good candidate for this paradigm, since helplessness is considered to be a psycho-biological basis of depression (21). Some recent investigations have shown a high rate of childhood helplessness and low rate of childhood mastery in patients with anorexia nervosa (22). There are many predispositions to the development of helplessness in the development of anorexia Patients usually experience family relationships as more complicated and less satisfactory than do normal controls (23). Their households are overprotective, but at the same time poor at problem-solving (24). Anorectic patients estimate their family as dysfunctional (25). In all areas examined, they show higher scores in negative life events than do healthy controls, and more negative life events concerning parental behaviour than do other psychiatric patients (26). They complain of inappropriate parental pressure, hostility and overprotection (27). Being characterized by greater reward dependence than normal controls,(28) they are at the same time suffering from social withdrawal (9) and social isolation (29). This reduces the possible opportunities for social support and reward, which in combination with reward dependence, builds an additional predisposition to learned helplessness.

An important feature of helplessness is the inability to control life events According to Slade,(30) the central factor in the development of eating disorders is a perceived lack of control over any aspects of life. The less this control, the higher the frustration, which results in a great desire for control at least in one domain. The control over the body (31) is an attempt to compensate for lack of primary natural control over life events and social relationships by an

artificial secondary control over eating behaviour. According to this model, anorexia is the first successful attempt by the patient to control at least something in life, which compensates for the frustrating feeling of loss of control elsewhere In this context, a breakdown of anorectic behaviour produces a terror of losing control, this being a reason why it is so difficult to treat anorexia. According to this model, reducing control should result in greater body image distortion, stimulating patients to increase their anorectic behaviour.

Although this concept of helplessness and of the lack of control is psychologically oriented and able to integrate many clinical data, it is not free from contradictions and limitations. First of all, the inability to keep control is an important, but not the sole, or even the main, predisposition to learned helplessness The complete control achieved without efforts does not 'immunize' subjects to learned helplessness (32). On the contrary, even unsuccessful but continuous efforts in a situation which makes real control impossible preserve the subject from learned helplessness (33). This suggests that efforts to achieve control may be more important than the control itself The 'search activity' concept (34-37) presents an explanation of these data.

'Search activity' is defined as activity oriented to change a situation (or at least to change the participant's attitude towards it) in the absence of the precise prediction of the final outcome of this activity, by taking into consideration immediate outcomes. Search activity can be regarded as a psycho-biological state that is common for active self-stimulation in non-human animals, and creative behaviour in humans, as well as exploratory and active defense (avoidance of fight/flight) behaviour in both species. Renunciation of search is the opposite psycho-biological state, and encompasses neurotic anxiety and depression in humans and 'freezing' in animals. Helplessness is a typical renunciation of search In panic and stereotypical behaviour search activity is also absent.

Search activity and renunciation of search display opposite influences on body resistance in normal and especially in stressful conditions. Search activity increases body resistance, whereas renunciation of search decreases it (34, 37, 38). According to this concept, the process of search is more important than its pragmatic outcome search activity, whether it leads to goal achievement or not, is adaptive, protects the body from disease and subjects from helplessness. Thus, it is not control by itself, but rather search activity, which displays itself in efforts to achieve control, which determines the resistance to helplessness, and in this context it is not crucial whether real control is achieved.

On the other hand, it is difficult to argue about keeping control over eating behaviour in patients with anorexia nervosa. For instance, drugs which reduce appetite should be helpful in keeping such control, but they are rarely used by patients - perhaps because they decrease efforts to keep control (search activity). Real control is based on the feedback between behaviour and goal achievement, and makes behaviour flexible. The behaviour of anorectic

patients is not flexible. It is more reasonable to suggest that the behaviour of these patients is controlled by the anorexia than to suggest that the patients are keeping control over their eating behaviour. The patient is for some reason motivated not to eat, and this motivation is out of control. But what is beyond this motivation? Helplessness, as mentioned above, displays a particular form of renunciation of search-a state of giving up in the face of challenges. Renunciation of search is a regressive type of behaviour which predisposes the subject to failure and decreases his/ her self-esteem (39). That is why renunciation of search is inappropriate for the subject. Anorectic patients display helplessness in different domains of life, before developing anorectic behaviour. In this context, the ability to refuse food in the face of strong and stable challenges (challenge of appetite, challenge of the requirements of relatives and doctors) displays a continuous effort, and a particular search activity, which compensate for the lack of search activity in other domains. Anorectic behaviour is a process of struggling with challenges, and this process restores self-esteem, at least partly. It is not a phobia of eating, of weight increase or even a phobia of losing control - but a phobia of giving up in the face of challenges. Distortion of body image is secondary to this challenge and is a rationalization of active anorectic behaviour. Until the subject continues this behaviour, he/she is at least partly overcoming helplessness, and renunciation of search activity.

This suggestion is supported by some recent investigations. One experimental study examined the effects of actual and perceived control on body image distortion in anorexia (40). The authors used anagrams as intellectual tasks. The task performance of healthy and anorectic women was affected by the actual difficulty of the tasks, and there was no effect of perceived controllability on the number of anagrams solved. At the same time, women with eating disorders overestimated their body size when carrying out an objectively easy task that they perceived as a difficult one, while healthy controls overestimated their body size when they were performing a difficult task that they perceived as such. When the task is easy but it is suggested that it is difficult, a person must have a feeling of a high controllability because, as mentioned above, the ability to solve the task depends on the real difficulty of the task. However, this feeling of high controllability does no improve body image. Moreover, patients even overestimate body size, since the level of challenge in this situation was less than was expected, and efforts (search activity) were under-used. On the other hand, the suggestion of low controllability because of the difficult task had no effect n body size estimation-because the expectation of challenge corresponds to the real challenge. Thus, challenge is more important than the level of control.

This theoretical approach determines a possible therapeutic strategy in anorexia nervosa. It is necessary to collaborate with the patient to discover those domains their life where they are still able to start search activity and to increase their self-esteem in order to produce this search activity. Even small initial achievements in any area may increase the subject's feeling that it is possible to confront challenges, not only in the domain of eating behaviour. According to our own initial clinical experience, even explaining this mechanism, together with the psychotherapeutlc restoration of self-confidence (by using episodes of previous achievements, etc) and the stimulation toward moderate challenges, have a positive outcome on the disorder.

The main conclusions are:

1 Anorectic behaviour displays a pathological search activity - confrontation with challenges - which partly compensates for a feeling of helplessness and thereby restores self-esteem, and this is the reason why this behaviour is so resistant to treatment.

2 It is reasonable to stimulate the patient to start search activity in any other domain, as a therapeutic strategy.


1. Bruch H (1962) Perceptual and conceptual disturbances m anorexia nervosa. Psychosom Med 24 : 187-94

2. Gupta MA, Gupta AK, Schork NJ, Watteel GN (1995) Perceived touch deprivation and body image some observations among eating disordered and non-clinical subjects. J Psychosom Res 39: 459-64

3. Gardner RM, Bokenkamp ED (1996) The role of sensory and nonsensory factors in body size estimation of eating disorder subjects. J Clm Psychol 52- 3-15

4. Mohnan E (1995) Body-size estimation m anorexia nervosa Percept Motor Skills 81: 23-31

5. Probst M, Vandereycken W, Van Coppenolle H, Piters G (1995) Body size estimation in eating disorder patients testing the video distortion method on a life-size screen. Behav Res Ther 33: 985-90

6. Majewski ML (1997) Children and adolescents with eating disorders: How do they estimate their body size? In Abstracts of the 14th World Congress on Psychosomatic Medicine, Cairns, Australia

7. Benca R, Obermeyer WH, Thisted RA, Gillm J. .(1992) Sleep and psychiatric disorders A meta-analysis Arch Gen Psychiatry 49: 651-68

8. Zubietta JK Demitrack MA, Femck A, Krahn DD (1995) Obsessionality in eating-disordered patients :relationship to clinical presentation and two-year outcome. J Psychiatr Res 29: 333-42

9. J, Nicolau R, Cervera M et al (1995) A clinical and phenomenological study of 185 Spanish adolescents with anorexia nervosa. Eur Child Adolesc Psychiatry 4: 165 - 74

10. Kaye WH, Bastiam AM, Moss H (1995) Cognitive style of

patients with anorexia nervosa and bulimia nervosa. Int] Eating Disord 8: 287-90

11. de Zwaan M, Biener D, Bach M et al (1996) Pain sensitivity, alexithymia and depression in patients with eating disorders- are they related? J Psychosom Res 41: 65-70

12 Troop NA, Schrmdt UH, Treasure J-L (1995) Feelings and fantasy in eating disorders a factor analysis of the Toronto Alexithymia Scale. Int J Eating Disord 18: 151-7

13. Bastiam AM, Rao R, Weltzm T, Kaye WH (1995) Perfectionism in anorexia nervosa. Int ] Eating Disord 17: 147-52

14 . Tiller J, Schrmdt U, Ah S, Treasure J (1995) Patterns of punitiveness in women with eating disorders. Int J Eating Disord 17 : 365-71

15. Schmidt U, Evans K, Tiller J, Treasure J (1996) Puberty, sexual milestones and abuse- how are they related in eating disorder patients? Psychol Med 25: 413-7

16. Morgan CD, Wiederman MW, Pryor TL (1995) Sexual functioning and attitudes of eating disordered women a follow-up study. J Sex Marital Ther 21: 67-77

17. Wiederman MW, Pryor T, Morgan CD (1996) The sexual experience of women diagnosed with anorexia nervosa or bulimia nervosa. Int J Eating Disord 19: 109-18

18. Deep AL, Nagy LM, Weltzm et al (1995) Premorbid onset of psychopathology in long term recovered anorexia nervosa. Int J Eating Disord 17: 291-7

19. Halmi KA, Agras S, Crow S, Mitchell J (1997) Fluoxetine and anorexia nervosa. In Abstracts of the 14th World Congress on Psychosomatic Medicine, Cairns, Australia

20 . Brambilla F (1997) Neuro- transmitter and neuroendocrine dysfunctions in anorexia nervosa- do they have clinical significance? In Abstracts of the 14"1 World Congress on Psychosomatic Medicine, Cairns, Australia

21. Sehgman MP (1975) Helplessness on depression development and death Freeman, San Francisco

22. Troop NA, Treasure JL (1997) Setting the scene for eating disorders II. Children helplessness and mastery. Psychol Med 27 : 531-8

23. Wewetzer C, Deimel W, Herpertz-Dahlman et al (1996) Follow-up investigation of family relations m patients with anorexia nervosa. Eur Child Adolesc Psychiatry 5 : 18-24

24 . Blair C, Freeman C, Cull A (1995) The families of anorexia nervosa and cystic fibrosis patients. Psychol Med 25: 985-93

25. North C, Gowers S, Byram V (1995) Family functioning m adolescent anorexia nervosa. Br J Psychiatry 167 : 673-8

26. Horesh N, Apter A, Lepkifker E et al (1995) Life events and severe anorexia nervosa in adolescence. Acta Psychiatr Scand 91 o 5-9

27. Horesh N, Apter A, Ishai J et al (1996) Abnormal psychosocial situations and eating disorders in adolescence. J Am Acad Child Adolesc Psychiatry 35: 921 - 7

28. Buhk CM, Sullivan PF, Weltzm , Kaye WH (1995) Temperament in eating disorders. Int J Eating Dtsord 17: 251-61

29. Tiller JM, Sloane G, Schmidt U et al (1997) Social support in patients with anorexia nervosa and bulimia nervosa. Int J Eating Disord 21: 31-8

30. Slade PD (1982) Towards a functional analysis of anorexia nervosa and bulimia nervosa. Br J Clin Psychol 21: 167-79

31. Rothbaum F, Weisz JR, Snyder SS (1982) Changing the world and changing the self :A two-process model of perceived control. J Pers Soc Psychol 42: 5-37

32. Rotenberg VS, Arshavsky W (1984) Search activity and adaptation. Nauka Moscow (in Russian)

33. Brosschot J, Benschop RJ, Godaert LR et al (1992) Effects of experimental psychological stress on distribution and function of peripheral blood cells. Psychosom Med 54: 394 - 406

34. Rotenberg VS (1984) Search activity m the context of psychosomatic disturbances, of brain monoamines and REM sleep function. Pavlov J Biol Sci 19: 1-15

35. Rotenberg VS (1993) REM sleep and dreams as mechanisms of search activity recovery. In Functions of dreaming (eds A Moffitt, M Kramer, R Hoffmann) pp 261-92 State University Press of New York, New York

36. Rotenberg VS, Boucsein W (1993) Adaptive vs maladaptive emotional tension. Genetic, Social and General Psychology Monographs, 119: 207-32

37. Rotenberg VS, Sirota P, Elizur A (1996) Psychoneuroimmunology: Searching for the main deteriorating psychobehavioural factor. Genetic, Social and General Psychology Monographs, 122: 329-46

38. Rotenberg VS, Arshavsky W (1979) Search activity and its impact on experimental and clinical pathology .Activitas Nervosa Superior (Prague) 21: 105-15

39. Rotenberg VS, Tobm M, Krause D, Lubovikov I (1996) Psychosocial problems faced during absorption of Russian-speaking new immigrants into Israel: A systemic approach. Isr J Psychiatry Relat Sa 33: 40-9

40. Waller G, Hodgson Sh (1996) Body image distortion in anorexia and bulimia nervosa. The role of perceived and actual control. J Nerv Ment Dis 184: 213-9.