SYMBIOTIC ILLUSION AND FEMALE IDENTITY CONSTRUCTION IN EATING DISORDERS: A PSYCHOANALYTICAL PSYCHOSOMATICS’ PERSPECTIVE¹

Ilusão simbiótica e construção da identidade feminina nos transtornos alimentares: perspectiva da psicossomática psicanalítica

Abstract:

This study aims primarily to reflect on the role of symbiotic illusion in the construction of female identity in women with eating disorders (ED), using premises from psychoanalytic psychosomatics. Considering ED as psychopathologies related to the affective economy, Oedipal relations play crucial role in the process of identity constitution. Mother-daughter relationships in ED are shaped in the molds of symbiotic illusion, with weak father figures. We presented a case study to briefly illustrate the theoretical framework. The omissive posture of a father to interdict the symbiotic relation leads daughters to find themselves unable to libidinally invest in other objects.

Keywords:
eating disorders; psychoanalytic psychosomatics; mother-child relations; symbiotic illusion; female identity

Resumo:

Este estudo teve como objetivo refletir sobre o papel da ilusão simbiótica na construção da identidade feminina em mulheres com transtornos alimentares (TAs), utilizando as premissas da psicossomática psicanalítica. Considerando-se os TAs como psicopatologias relacionadas à economia afetiva, as relações edípicas desempenham papel crucial no processo de construção de identidade. As relações mãe-filha nos TAs são moldadas pela ilusão simbiótica, com figuras paternas enfraquecidas. Nós apresentamos brevemente um estudo de caso para ilustrar os conceitos do referencial teórico. A postura omissa do pai para interditar a relação simbiótica com a mãe leva a filha à impossibilidade de investir libidinalmente em outros objetos.

Palavras-chave:
transtornos alimentares; psicossomática psicanalítica; relação mãe e filha; ilusão simbiótica; identidade feminina

1 THEORETICAL BACKGROUND

Eating disorders (ED) are psychopathologies that involve severe disturbances in eating behaviour, as well as impairment in other spheres of life, such as work, studies, social and affective relationships (AMERICAN PSYCHIATRIC ASSOCIATION, 2013). The main subtypes of ED are anorexia nervosa and bulimia nervosa, due to high rates of morbidity and mortality. Between 10 and 13% of young women in Western countries meet DSM-5 criteria for these disorders (STICE; BECKER; YOKUM, 2013). Since approximately 90% of individuals affected by ED are female (SMINK; HOEKEN; HOEK, 2013), the present study will address issues regarding identity construction among women with these disorders.

Current research (CARROTE; VELLA; LIM, 2015; SIDANI et al., 2016) has been seeking to enlighten aetiological aspects of ED, emphasizing the negative influence of the dominant esthetic standards in occidental society, making people - especially women - believe that thiness would be the solution for a more fulfilling life. Although the irrefutable importance of culture in ED aetiology, this perspective is only part of the problem. These psychopathologies tread the mind-body interface, which requires one to look deep into patients’ psychodynamic to understand the symptoms beyond their somatic aspects. Thiness as a symbol of social success does not resume the personal struggle of women with ED: symptoms also express a lonely and afflicted subjectivity, which is not easy to signify and share with others. The beggining of the disorder may seem simple and superficial - the desire to lose weight -, but such decision involves important unconscious meaning.

Scientific psychoanalytic literature (BRUNO, 2011; HALBERSTAD-FREUD, 2001; MIRANDA, 2011; RIBEIRO, 2011) has demonstrated that family dynamics in the context of ED show recurrent patters of functioning, which usually involve symbiotic relationship between mother and daughter, and emotionally distant father figure, who remains as financial and material provider (BELTRAME; BOTTOLI, 2010; ELLIOT, 2010). Thus, through psychoanalytic perspective, ED pose questioning regarding: the pre-Oedipical phase, in which mother and daughter seem to be affixed; daughter’s process of individuation and subsequent development of psychosexuality and access to genitality - which requires separation from parental figures; issues concerning the parental couple, who arise in the literature as emotionally distant (LEONIDAS; SANTOS, 2013; VALDANHA et al., 2014), making way for mothers to take their children as narcissistic extensions of themselves, aiming to overcome possible existential voids.

Considering these assumptions, we point out that complex and unsolved Oedipical issues are core in the onset of ED. The fixation to the first object of love - the mother - and the demand of father’s emotional presence - which is key to daughters to locate their place in the family and therefore constitute their identity - end up making it impossible for young women with ED to develop affective and non-incestuous relationships (GASPAR, 2010; LEONIDAS; SANTOS, 2013).

Hence, the aim of this study is to reflect on the role of symbiotic illusion in the construction of female identity in women with ED. To address this goal with this context in mind, first we briefly circumscribe the main premises from psychoanalytic psychosomatics, in which ED are outlined as psychopathologies related to the affective economy. Furthermore, we will present elements from Oedipal relations and their role in the process of identity constitution, emphasizing the concept of mother-daughter symbiotic illusion and paternal role in symbiotic illusion dissolution, specifying that these concepts offer valuable subsidies for the understanding of the psychodynamics involved in ED. Finally, excerpts of a study case will be presented, articulating the theoretical framework with clinical elements.

2 EATING DISORDERS AND THE SYMBOLIZATION PROCESS: INTERFACE WITH PSYCHOANALYTICAL PSYCHOSOMATICS

Previously to the 18^th century, medicine inherited an unitary concept of man, in which body and mind were indistintic and formed a global unity. The Cartesian method and the triumph of the positivist approach have increased the distance between body and mind. At the end of the 19^th century, Sigmund Freud (1856-1939) led to a change in the current medical paradigm with the discovery of the unconscious and the foundation of a new theory of psychic processes (PERES, 2006). Freud and the French psychiatrist Jean Martin Charcot (1825-1893) developed a series of studies on hysteria and proposed a theory in which the body - and consequently organic diseases - would be susceptible to the vicissitudes of the mind and not just biological agents. From this premise, it is considered that “the health of an individual is closely related to one’s own history” (PERES, 2006, p. 166). Hence, psychoanalysis was an unprecedented method of investigation and treatment, since it posed the possibility of representing the mediation of the mind in the production of the symptom (ÁVILA, 1996).

Based on these new premises, illnesses may be comprehended beyond the organic approach as somatic responses to states of emotional tension generated by mental processes that were not symbolized (PERES, 2006). The occurrence of archaic libidinal processes and the absence of connections with symbolic contents seem to result in the use of faster and more direct paths of stress flow. When the unconscious is unable to communicate through the use of mental representations, it tends to use the body as the only way of expression. The psychoanalytic assumption, therefore, is that symptoms hold meanings for each individual (ÁVILA, 1996).

Joyce McDougall (1991), a distinguished psychoanalyst in the field of psychosomatics - yet not the pioneer -, suggests that somatic individuals have little ability to elaborate potentially destructive affects and end up using archaic defensive mechanisms to avoid emotional destabilization. These individuals eject the affects from their own mental apparatus, reducing them to its pure somatic expression. In general, somatizations are processes caused by gaps in the mental apparatus that favor the body translation of a “story without words” (PERES, 2006, p. 173).

Individuals with ED present scarce and poor psychic resources to deal with reality (BRUNO, 2011). There is an impossibility of using more developed areas of the mind, hence mental organization happens from rigid principles, laws and rules, which guarantee the impermeability of the ego to developmental changes. There is no space available for fantasy and pleasure. Consequently, there is an open way for stereotyped and automated thoughts (BRUNO, 2011). Fear, pain and love can not be authentically experienced.

In the manuscript A case of cure by hipnotism (1892-1893/1969), Freud started to describe the melancholic dimension involved in anorexia. In Case 2: Mrs. Emmy von N., 40 years old, from Livonia (BREUER; FREUD, 1893-1895/1996), Freud associated anorexia to apathy, expressed by desire inhibitions and failure to act. At this point of his theory, Freud proposed that apathy in eating behavior had its onset on trauma, which led eating to be experienced as disgust. Moreover, in Draft G: melancholy (FREUD, 1895/1969), the author affirmed that anorexia was the neurosis parallel to melancholy. This statement was based on the proposition that both anorexia and melancholy involve disturbances in narcissistic identification level: there is a massive investment in the self and body, in contrast to very poor object relations. Also, such melancholy was associated to an undeveloped sexuality (FREUD, 1895/1969, p. 283).

Expanding Freud’s premises, contemporary psychoanalysis characterizes ED as symptomatic oral manifestations of psychic conflicts originated from anxieties experienced in primitive times of mental life (MIRANDA, 2011). Affects are not fully experienced and the mind is lodged in the body, which translates elements of one´s history and the gaps produced in their mental apparatus. According to McDougall (1989), disruptions in the relationship between the mother and the baby are core aetiological factors in this inability of symbolization, which the author calls disaffection - a neologism created to refer to disorders of the affective economy, in which affects, and their representations are expelled from, the psychic apparatus.

The maternal figure plays primary role in protecting the baby from environmental distress (PERES, 2006). The mother needs to interpret and name child’s communicative and affective signs, in order to favor the desomatization of the mental apparatus. The proper performance of this task enables the baby to develop the ability to access symbolization and verbalization. In contrast, when the maternal figure does not perform its para-excitation function, the baby’s pre-verbal cues are not inserted into language and his experiences can not be symbolized. Thus, conflicts become externalized in the body, generating somatizations.

3 THE ROLE OF OEDIPAL RELATIONS IN THE PROCESS OF IDENTITY CONSTITUTION AMONG WOMEN WITH ED

Until this moment, we presented one of the many available interpretations for ED: the view of the psychoanalytic psychosomatics. We showed how these psychopathologies can be interpreted as bodily expressions of unsolved internal and emotional conflicts. It is clear that the (in)ability to cope with such conflicts is related to mothers’ and fathers’ (in)ability to name and interpret the signs that the baby emits.

Currently, family influence on the genesis and maintenance of ED is well established (CERNIGLIA, et al., 2016; LAM; McHALE, 2012; LEONIDAS; SANTOS, 2014, 2015; VALDANHA; SCORSOLINI-COMIN; PERES; SANTOS, 2013). Next, the relationship between mother and daughter with ED, as well as its central role as aetiological factors in these psychopathologies, will be further discussed.

3.1 MOTHER-DAUGHTER RELATIONSHIP: A SYMBIOTIC ILLUSION

The broad literature available on the relationship between mother and daughter affected by ED (CERNIGLIA, et al., 2016; HOOPER; DALLOS, 2012; MOURA; SANTOS; RIBEIRO, 2015; SIMONI; BASTOS, 2013; VALDANHA; SCORSOLINI-COMIN; SANTOS, 2013; VALDANHA-ORNELAS; SANTOS, 2016b a) is convergent in proposing the hypothesis of a fusion between the pair, which would involve the experience of ambivalent and antagonistic emotions (love versus hate). Mother and daughter become dependent on each other and, on the other hand, feel fear and horror about such dependence, which implies an infinite search for the completeness of a void that never seems to be fulfilled (MIRANDA, 2011; RIBEIRO, 2011).

Winnicott (1945/2000) suggests that in the early stages of life, mother and baby have an intimate, symbiotic relationship in which the baby feels the mother as an extension of him/herself. In order for the child to begin to see him/herself as an individual, i. e. to be singular and autonomous, the mother must withdraw herself from the illusory state of fusion with the baby, allowing him/her to express desires and anxieties. If the baby is never allowed to express him/herself, s/he will never learn that has a voice and that this is the voice that people will respond to. Therefore, the experience of symbiosis and subsequent separation is crucial for the child to develop self-understanding, self-sense, autonomy schemes, and the ability to act in the world.

However, the separation between mother and daughter is problematic throughout the entire development of the latter, as every step towards independence is followed by unconscious conflicts experienced by both parts, resulting in regressive tendencies to the pregenital stage (HALBERSTADT-FREUD, 2001). Daughter’s need for independence arouses feelings of guilt and fear of loss of mother’s love, especially when the mother is unable to endure such independence. For the girl, the separation - which is related to the quest for autonomy - almost always implies a sense of disloyalty and aggression against the mother, even though there are no attacks on acts or thoughts. The mother may experience the separation as betrayal, evoking feelings of guilt in her daughter, who begins to feel the separation in a paradoxical way: on the one hand, she seeks autonomy so that she can trace her own course towards the achievement of self-esteem, femininity and sexuality; on the other hand, she feels guilty for wanting autonomy, which implies suffering for the mother (HALBERSTADT-FREUD, 2001).

Literature corroborates the importance of investigating early childhood experiences to understand ED aetiology. Moura, Santos and Ribeiro (2015) designed a study that aimed to understand how mothers of adolescents with ED experienced the process of raising their daughters from pregnancy to their second year of age, trying to investigate the influence of those maternity experiences on the development of the disorder. Mothers of patients with AN who were followed up at a specialized outpatient Brazilian service were interviewed. Maternal reports showed difficulties in holding by mothers, which led to intense suffering and feeling of powerlessness facing the basic needs of their daughters. Children were described as voracious and unsatisfied, what suggests that they might have experienced difficulties in coping with the care offered by their mothers in their early development experiences.

Campos et al. (2012), when studying the characteristics of mothers of daughters with ED, identified important common traits of the mother-daughter relationship: on the one hand, there was devotion and passion from both sides; on the other, annihilation as a result of the intense fusion, which hinders the development of individuality. These relationships were marked by mutual control and intense dichotomy, i. e. at the same time that mother and daughter felt omnipotent in each other’s lives, they also felt impotent. At the same time that they loved, they annihilated themselves.

The relationship between mother and daughter with ED was well defined by the concept of “symbiotic illusion”, created by Halberstadt-Freud (2001). This concept deepens the idea of symbiosis developed by Margareth Mahler in referring to the pathological relationships between mothers and daughters that occur when the mother expects to satisfy all her needs and desires with a baby. When the baby is female, it seems easier for the mother to self-identify and to create a mutual, illusory and parasitic unconscious bond with the daughter (HALBERSTADT-FREUD, 2001). The latter, in turn, feels that her individuation and consequent separation from the mother may betray their need for unity formed in the pre-Oedipal phase. There is a precarious self, on both sides, that needs the maintenance of this unit to survive.

The symbiotic illusion seems to occur mainly in mothers who experience painful feelings of personal incompetence resulting from not elaborated conflicts with their own mothers. According to Halberstadt-Freud (2001), the mother lives ambivalent feelings: on the one hand, she wishes to share the baby’s omnipotence, who she perceives as all powerful; on the other hand, she sees the child as an impotent narcissistic extension of herself, and feels omnipotent to realize how necessary she is for that baby. These are mothers who need confirmations of their own good mothering. Feeling powerful, the mother defends herself from her own dependence of both her baby and her mother.

In sum, the symbiotic illusion implies giving up one’s own self - both mother and daughter - in view of receiving love and significance. Such withdrawal, in addition to opening possibilities for the precipitation of disorders (such as: phobias, paranoia, hypochondria and ED), also affects the sexual development of the daughter, who may feel alienated from her own body, which will still be perceived as maternal property (HALBERSTADT-FREUD, 2001). Negative feelings such as envy, hate, aggressiveness and even divergent opinions, represent threats to the maintenance of the illusion - which, in turn, maintains a certain level of integration of the self. Dependency guarantees love, and results in a feigned or simulated intimacy that suppresses feelings of guilt.

In the specific context of ED, the symbiotic illusion between mother and daughter is very clear. Miranda (2011) proposes that the girl presents failures in the internalisation of the Oedipal triangle: she begins to identify herself with the missing parts of the mother and develops a void that she tries to fulfill at all costs, seeking the unreachable completeness. On the other hand, the mother is intrusive and destructive, which impairs the use of words, thoughts and symbolization (HOOPER; DALLOS, 2012; SIMONI; BASTOS, 2013). Within this context, ED constitute a radical and unconscious way for the girl to separate herself from her mother, so as to escape the maternal intrusiveness and reach individuation, giving birth to her own desire.

According to Halberstadt-Freud’s (2001) ideas about the mother’s difficulties in separating from her daughter, Miranda (2011) suggests that she might have experienced conflicts related to the Oedipal phase, with no entry from father figure in the symbolic world. The mother takes the baby as part of herself and wishes never to forsake the fusional unit, while the daughter, perceiving her mother’s emptiness, identifies herself as an object that can supply what she lacks. However, this mother, with her unlimited hunger for completeness, penetrates the baby’s psychic space in an intrusive and devastating way. In this sense, the aforementioned author proposes that the weight loss in anorexia nervosa expresses the desire of separation from the mother, withdrawing the maternal contents placed intrusively in the girl’s psyche. Compulsive eating, on the other hand, would characterize the taking of food as a fetish that, in a fanciful way, strengthens the fragile and fragmented ego of the girl, attenuating or appeasing her anxiety. It unconsciously brings back the primitive mother-child relation: food supplies the emptiness and removes the possible threats from the environment, illusorily healing and reassuring (MIRANDA, 2007).

Despite the complexities involved in mother-daughter relationship, especially in - but not restricted to - the context of ED, it is worth mentioning that fathers play a crucial role in symbiotic illusion. Next, we will discuss the paternal role in the process of girls’ identity constitution, as well as possible entanglements emerged from fathers’ emotional detachment.

3.2 Paternal role in the symbiotic illusion dissolution: father as potential moderator of mother-daughter relationship

The human being has always needed peers to keep alive, heated and fed, and the family sets up the major group that provides the necessary care for survival. The family, as product of social construction, changes over time according to the political, economical and social organizations of the culture in which it is inserted. As humanity undergoes social transformations, the family undergoes changes as well (MANDELBAUM, 2012). Paternal role is an important expression of the changes occurring in family scenario (COSTA, 2014).

Until the 1950s, the father was considered the “head of the household”, indicating his position as the primary financial provider and therefore ultimate authority within the household. The father was emotionally distant from his wife and children, which facilitated to legitimize the mother as the main responsible figure for the care of the children and the housework (GOMES; RESENDE, 2004). However, the reorganizations of male and female social roles in the contemporary occidental society have also implied in family reconfigurations: due to current social demands, women are venturing into the labour market in ever greater frequency, meanwhile fathers are approaching the development of children and participating more effectively in education, health care, school performance, gender identity construction, among others (BELTRAME; BOTTOLI, 2010). There have been so many redefinitions in individual, conjugal and parental identities that the issues of gender, marriage, family, maternity and paternity escape the traditionally instituted standards. Currently, families are able to create and experience their own particularities and ways of functioning, not necessarily following pre-established norms (BELTRAME; BOTTOLI, 2010).

Psychoanalysis asserts that the father has the primary function of interdicting the mother-child relationship, especially during Oedipal experiences (BOUCHEREAU; CORCOS, 2008; GOMES; RESENDE, 2004). Both for Freud and Winnicott, such experiences occur around the age of three, and involve the child’s ability to libidinally invest in other objects. Father interdiction should act on the child’s desires towards the mother, and regulate the child’s ability to invest in real objects. In addition to the importance of interdicting the child’s desires, the father also plays a crucial role in adolescence, when the young person is faced with the need to define his sexual identity (COSTA, 2014).

According to Winnicott (1945/2000), the baby experiences a state of non-integration in the early stages of life, when s/he still cannot differentiate him/herself from others. At this stage, the mother is still not perceived by the baby as separate and different entity; on the contrary: the breast - and consequently the mother - are taken as part of the same whole. Individuation and psychological development tend to occur during child’s maturation, and involve several stages. At each stage the father performs a different role: he is not only the one who interdicts the mother-child relationship, but his role changes at each stage of the child’s maturation (FULGÊNCIO, 2007). The presence or absence of the father, the existence or not of the bond between father and child, paternal sanity or insanity, his free or rigid personality, are characteristics that affect child’s development in various ways (WINNICOTT, 1945/2000).

Despite the valuable contribution of psychoanalysis to the understanding of paternal role in female identity constitution, research regarding the relationship between fathers and daughters with ED is still scarce, according to recent literature review (COSTA; SANTOS, 2016). Some authors propose the existence of an unsafe bond, marked by emotional detachment and impaired communication (BACK, 2011; COSTA, 2014; ELLIOTT, 2010; HOOPER; DALLOS, 2012; LAM; McHALE, 2012; NODIN; LEAL, 2005). According to Elliott (2010), girls with ED perceive their fathers as physically absent and emotionally unavailable, which seems to enhance the distance between them and generates fear of being abandoned and rejected. For Nodin and Leal (2005), daughters with ED have precarious unconscious awareness of their relationship with the father, originated in very primitive moments of their psychic life, due to father’s absence during the Oedipal period, when he should have been interdicting the mother-daughter relationship.

Literature defines idealization as the main defense mechanism used by both fathers and daughters to deal with the difficulties from childhood and family life (ELLIOTT, 2010; HOOPER; DALLOS, 2012; NODIN; LEAL, 2005). Hooper and Dallos (2012) suggest that fathers of daughters with ED experienced intense suffering in their own childhood, but they reported such experiences in an emotionally withdrawn way and, defensively, presented idealized vision of this time of their life. Nodin and Leal (2005) and Elliott (2010), in turn, propose that the idealized view that daughters present of their father figure also refers to a defense mechanism, used to deny affective detachment and fear of abandonment.

Finally, Winnicott (1945/2000) proposes that the mature father interdicts the fantasies disconnected from reality, while at the same time favours the child’s creativity. Thus, the father holds a dual role: on the one hand, he must accept rivalry, not disavowing or detracting from fantasy, and interdicts the execution of child’s desires. For example, the father must systematically prevent the child from sleeping with the mother in the couple’s bed in a recurring and continuous way. On the other hand, at the same time that he interdicts, and may even be angry, he continues to take care of the child, as always, taking into account the level of maturity the child presents. After the intervention, he accepts the occasional invitation to ride a bicycle or, before going to bed, he reads the storybook, resuming his ordinary life with his child (FULGÊNCIO, 2007).

The following case will demonstrate the clinical issues faced by a young woman who was being treated for ED in a public health service in Brazil’s countryside. The case of Maria demonstrates the clinical presentation of a mother-daughter relationship shaped in the molds of symbiotic illusion, with a father who was incapable of dissolving that relationship. This case is intended to demonstrate the pervasive impact of symbiosis, which impairs emotional separation and subsequent individuation, fomenting the development of mental disorders such as ED.

4 PSYCHOANALYTIC DIALOGUES WITH MOTHER, FATHER AND DAUGHTER WITH ED: CASE PRESENTATION

We are very much alike. She says, “Do you know why we fight? I know everything about you and you know everything about me.” (Mother´s interview).

At this point, we are going to briefly illustrate the presented theoretical framework with a study case, resulted from a PhD thesis (LEONIDAS, 2016). Maria was a 24 year-old undergraduate student who was being treated for AN (binge eating/purgative type) for four years in a specialized Brazilian outpatient service. Her mother was an active participant of the psychological support group offered to family members by the service. Her father had participated a few times, but he was not nearly as participative as the mother. Both parents and daughter with ED were invited to take part in the research.

Maria was the first family member to be interviewed. At the end, she was invited to assign herself a name so that confidentiality could be maintained - she chose the name Maria. The same process was carried out with Maria’s mother and father, separately. Noteworthingly, both mother and daughter chose the same name, not previously knowing each other’s choice: Maria. The daughter did not assign any special reason for choosing the name Maria, but the mother explained that it was her own mother’s name - which not only her daughter knew, but also indicated the existence of transgenerational contents permeating their processes of identity constitution. Evidently there is both singular and transgenerational bonds in the elaboration of the psychic image among mother and daughter, which seems to be alienated from the relation with the maternal figure (AZEVEDO; FÈRES-CARNEIRO; LINS, 2015).

Also, the name “Maria” refers to catholic saints, who performed intense fasts seeking “purity” for the soul (MIRANDA, 2007). Maria (daughter), during the interview, reported that her mother “was very chaste, a saint, very devoted to religion”. The fact that she chose for herself a name that refers to sanctity - characteristic that she had previously assigned to her mother -, shows the active presence of symbiotic illusion, in which daughter’s and mother’s identities are merged.

Aside from the choice of name, the mother’s interview brought several nuances that illustrate the mother-daughter symbiotic illusion. Although the presence of mutual loving and care feelings was undeniable, the mother’s struggle to cope with the differences between herself and her daughter was also noteworthy: daughter’s eating habits, how often she entered the bathroom, the length of her baths, among others, generated intense anxiety to Maria (mother). It is evident how difficult it was for the mother to tolerate not knowing what her daughter did in the bathroom, and away from her in a general way: “I never liked that she locked the bathroom” (Mother’s interview). Proximity and intimacy were often taken beyond the limits of individuality and generated feelings of hatred. On the other hand, on leaving the dining room table and locking herself in the bathroom, Maria (daughter) addressed something to her parents, which seemed to legitimate the times when her mother had to break open the door.

In consonance with the literature that proposes the undermined father figure as core aspect in the genesis of ED (ELLIOTT, 2010; HOOPER; DALLOS, 2012; LAM; McHALE, 2012), Maria’s father - named Lorival - used to keep his distance regarding daughter’s emotional and affective life. He assigned concrete explanations to the symptoms of ED, expressing his points of view very rationally. Despite showing himself as a pleasant person during the interview, he could not provide much details about Maria’s emotional development. Being a father of two girls, he reported feeling in disadvantage in the house: in a rather joking speech, he said that when the women of the house were fighting, he preferred to leave and return after a long time.

“When all three are together, even if I’m right, they’re on their mother’s side.” (Father’s interview).

Lorival’s report demonstrates the extremelly solid alliance between mother and daughter, sourced from the symbiotic illusion, which made it impossible for him to access. He also kept his distance of his own affective life, offering poor details about his marriage and not mentioning his extra-marital relationship, which was reported by Maria (daughter). It is evident that Lorival was not able to play his paternal role in the symbiotic dissolution.

Finally, it is worth mentioning that Maria (daughter) suffered from dyspareunia, which is a clinical condition characterized by severe pain during sexual intercourse, which supressed her attempts to establish intimate relationships with male partners. Although dyspareunia is a recognized severe illness, we highlight its symbolic content: nothing can penetrate, otherwise it will cause pain. This illness can be interpreted as somatic expression of the impossibility to cope with harmful and potentially de-structuring contents (MCDOUGALL, 1984). Dyspareunia emerges as a psychosomatic symptom that prevents Maria’s access to genitality and to libidinally invest in other objects, indicating fixation in early pre-Oedipal stages and maintaining the symbiotic illusion with her mother.

5 FINAL CONSIDERATIONS

This study aimed to present theoretical psychoanalytical frameworks regarding the constitution of girls’ identity, and to expand these concepts to the context of ED. Psychoanalytical literature, in general, proposes that the occurrence of ED primarily involves pitfalls regarding family relations, more specifically related to the pre-Oedipal period. Mothers take their daughters as narcissistic extensions of themselves, in order to fulfill existential voids. As a consequence, daughters’ individuation process is impaired, keeping them alienated to their mothers and thus compromising the construction of identity. Fathers, in turn, withdraw themselves from the relation with both daughters and wives, focusing on life outside their homes and family relations. Not having a father to interdict the symbiotic relation with the mother, daughters find themselves unable to libidinally invest in other objects and remain fixated in this relationship, both mother and daughter illusorily merged.

We used the psychoanalytical psychosomatics’ theoretical framework and illustrated the main concepts with excerpts from a study case, emphasizing the symbiotic illusion. The excerpt showed negative reverberations derived from mother-daughter symbiotic relationship, which was intensified by the withdrawal of father figure. Daughter’s somatic symptoms (ED and dyspareunia) emerged as expression of denial (both of food and sexuality) and the impossibility to access genitality, maintaining the pre-Oedipal relation between the pair.

Moreover, we conclude that the intrusive desire of a mother and the omissive posture of a father seem to collaborate decisively in the identity constitution of daughters and maintains close relation to the occurrence of the ED. The denial of food in anorexia nervosa may be considered an unconscious way of denying mother’s intrusiveness, since mothers are the main figure related to nurturing the baby. The severe emaciation, however, has appeared in the literature as means to maintain the childish body, illusorily keeping the primitive pre-Oedipal relation with the mother. This symbiotic relationship is the one that promotes some sense of self to the daughter, who was not able to constitute her own identity, independent from mother figure.

Frequently the reading of the constructs that support our argumentation by unaware persons can lead to the misunderstood interpretation that we are attributing to the parents of people with ED a preponderant role in engendering the symptomatic solution given by daughters to their psychic conflicts. It is worth mentioning that the framework presented in this study has absolutely no intention of blaming parents: we recognize that these mothers and fathers are shaped by personal stories of suffering, violence and/or emotional withdrawal from their own parents, and that this context comes from many unprocessed content, accumulated and transmitted within families for several generations. Therefore, we highlight the imperative need to include family therapy in the assistance to individuals with ED.

REFERENCES

• AMERICAN PSYCHIATRIC ASSOCIATION. Diagnostic and statistical manual of mental disorders - DSM-5, 5^th ed. Arlington: American Psychiatric Publishing, 2013.
• ÁVILA, L. A. Doenças do corpo e doenças da alma São Paulo: Escuta, 1996.
• AZEVEDO, L. J. C.; FÈRES-CARNEIRO, T.; LINS, S. L. B. A família e a transmissão psíquica. Psicanálise & Barroco, v. 13, n. 1, p. 57-71, 2015.
• BACK, E. A. Effects of parental relations and upbringing in troubled adolescent eating behaviors. Eating disorders: The Journal of Treatment & Prevention, v. 19, n. 5, p. 403-424, 2011.
• BELTRAME, G. R.; BOTTOLI, C. Retratos do envolvimento paterno na atualidade. Barbarói, v. 32, p. 205-225, 2010.
• BOUCHEREAU, D.; CORCOS, M. The role of fathers in eating disorders. Revue du Praticien, v. 58, n. 2, p. 150, 2008.
• BREUER, J.; FREUD, S. Studies in Hysteria. In: Brazilian Standard Edition of Sigmund Freud Collected Works. Rio de Janeiro: Imago, 1996. (Original paper published in 1893-1895).
• BRUNO, C. A. N. B. Anorexia: um ponto de vista freudiano. In: BRUNO, C. A. N. B. (org.), Distúrbios alimentares: uma contribuição da psicanálise. Rio de Janeiro: Imago , 2011, p. 49-60.
• CAMPOS, L. K. S. et al Psychological characteristics of mothers of patients with anorexia nervosa: implications for treatment ad prognosis. Trends in Psychiatry and Psychotherapy, v. 34, n. 1, p. 13-18, 2012.
• CARROTTE, E. R.; VELLA, A. M.; LIM, M. S. Predictors of “liking” three types of health and fitness-related content on social media: a cross-sectional study. Journal of Medical Internet Research, v. 17, n. 8, e205, 2015.
• CERNIGLIA, L. et al Do parental traumatic experiences have a role in the psychological functioning of early adolescents with binge eating disorder? Eating and Weight Disorders, v. 21, n. 4, p. 635-644, 2016.
• COSTA, L. R. S. Relação pai-filha no contexto dos transtornos alimentares: uma perspectiva winnicottiana. Dissertação de Mestrado, Universidade de São Paulo, Ribeirão Preto/SP, 2014.
• COSTA, L. R. S.; SANTOS, M. A. Cuidado paterno e relações familiares no enfrentamento da anorexia e bulimia. In: BARTHOLOMEU, D. et al (orgs.), Relações interpessoais: concepções e contextos de intervenção e avaliação. São Paulo: Vetor, 2016, p. 253-279.
• ELLIOTT, J. C. Fathers, daughters, and anorexia nervosa. Perspectives in Psychiatric Care, v. 46, n. 1, p. 37-47, 2010.
• FREUD, S. A case of cure by hipnotism (1892-1893). Rio de Janeiro: Imago, 1969. (Brazilian standard edition of Sigmund Freud collected works).
• FREUD, S. Draft G: melancholy (1895). Rio de Janeiro: Imago, 1969. (Brazilian standard edition of Sigmund Freud collected works).
• FULGÊNCIO, C. D. R. A presença do pai no processo de amadurecimento: um estudo sobre D. W. Winnicott Tese de Mestrado, Pontifícia Universidade Católica de São Paulo, São Paulo, 2007.
• GASPAR, F. L. Anorexia e violência psíquica Curitiba: Juruá, 2010.
• GOMES, A. J. S.; RESENDE, V. R. O pai presente: o desvelar da paternidade em uma família contemporânea. Psicologia: Teoria e Pesquisa, v. 20, n. 2, p. 1-14, 2004.
• HALBERSTADT-FREUD, H. C. Electra cativa: sobre a simbiose e a ilusão simbiótica entre mãe e filha e as consequências para o complexo de Édipo. Revista Brasileira de Psicanálise, v. 35, n. 1, p. 143-168, 2001.
• HOOPER, A.; DALLOS, R. Fathers and daughters: their relationship and attachment themes in the shadow of an eating disorder. Contemporary Family TherapY v. 34, n. 4, p. 452-467, 2012.
• LAM, C. B.; MCHALE, S. M. Developmental patterns and family predictors of adolescent weight concerns: a replication and extension. International Journal of Eating Disorders, v. 45, n. 4, p. 524-530, 2012.
• LEONIDAS, C. Das (im)possibilidades do feminino: a sexualidade de mulheres com transtornos alimentares na perspectiva das adolescentes, suas mães e seus pais. Tese de Doutorado, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, 2016.
• LEONIDAS, C.; SANTOS, M. A. Significant social networks of women with eating disorders. Psicologia: Reflexão e Crítica, v. 26, n. 3, p. 561-571, 2013. DOI: http://dx.doi.org/10.1590/S0102-79722013000300016
  » https://doi.org/10.1590/S0102-79722013000300016
• LEONIDAS, C.; SANTOS, M. A. Social support networks and eating disorders: an integrative review of the literature. Neuropsychiatric Disease and Treatment, v. 10, p. 915-927, 2014. doi:10.2147/NDT.S60735.
  » https://doi.org/10.2147/NDT.S60735
• LEONIDAS, C.; SANTOS, M. A. Family relations in eating disorders: the Genogram as instrument of assessment. Ciência & Saúde Coletiva, v. 20, n. 5, p. 1435-1447, 2015.
• MANDELBAUM, B. Família incestuais. Psicologia Clínica, Rio de Janeiro, v. 24, n. 11, p. 55-66, 2012.
• MCDOUGALL, J. Teatros do corpo São Paulo: Martins Fontes, 1991.
• MCDOUGALL, J. Teatros do eu Rio de Janeiro: Francisco Alves, 1989.
• MCDOUGALL, J. The “dis-affected” patient: reflections on affect pathology. Psychoanalytic Quarterly, v. 53, n. 3, p. 386-409, 1984.
• MIRANDA, M. R. A complexidade da relação mãe-filha nas patologias dos contrários. In: BRUNO, C. A. N. B. (org.), Distúrbios alimentares: uma contribuição da psicanálise. Rio de Janeiro: Imago , 2011, p. 123-154.
• MIRANDA, M. R. Em busca das palavras perdidas: corpo-carcereiro da mente nos distúrbios alimentares. Ide, v. 30, n. 45, p. 28-34, 2005.
• MOURA, F. G.; SANTOS, M. A.; RIBEIRO, R. P. P. A constituição da relação mãe-filha e o desenvolvimento dos transtornos alimentares. Estudos de Psicologia (Campinas), v. 32, n. 2, p. 233-247, 2015. doi:10.1590/0103-166X2015000200008.
  » https://doi.org/10.1590/0103-166X2015000200008
• NODIN, N.; LEAL, I. P. Representações paternas na anorexia nervosa. Análise Psicológica, v. 23, n. 2, p. 201-208, 2005.
• PERES, R. S. O corpo na psicanálise contemporânea: sobre as concepções psicossomáticas de Pierre Marty e Joyce McDougall. Psicologia Clínica, v. 18, n. 1p. 165-177, 2006.
• RIBEIRO, M. De mãe em filha: a transmissão da feminilidade. São Paulo: Escuta , 2011.
• SIDANI, J. E. et al The association between social media use and eating concerns among US young adults. Journal of the Academy of Nutrition and Dietetics, v. 116, n. 9, p. 1465-1472, 2016.
• SIMONI, J. M.; BASTOS, A. Quando a anorexia é uma questão de sexuação. Arquivos Brasileiros de Psicologia, v. 65, n. 3, p. 409-420, 2013.
• SMINK, F. R. E.; HOEKEN, D. V.; HOEK, H. W. Epidemiology, course and outcome of eating disorders. Current Opinion, v. 26, n. 6, p. 543-548, 2013.
• STICE, E.; BECKER, C.; YOKUM, S. Eating disorder prevention: current evidence-base and future directions. The International Journal of Eating Disorders, v. 46, n. 5, p. 478-485, 2013.
• VALDANHA-ORNELAS, E. D.; SANTOS, M. A. Family psychic transmission and anorexia nervosa. Psico-USF, v. 21, n. 3, p. 635-649, 2016b.
• VALDANHA-ORNELAS, E. D.; SANTOS, M. A. O percurso e seus percalços: itinerário terapêutico nos transtornos alimentares. Psicologia: Teoria e Pesquisa, v. 32, n. 1, p. 169-179, 2016a.
• VALDANHA, E. D.; SCORSOLINI-COMIN, F.; SANTOS, M. A. Anorexia nervosa e transmissão psíquica transgeracional. Revista Latinoamericana de Psicopatologia Fundamental, v. 16, n. 1, p. 71-88, 2013.
• VALDANHA, E. D.; SCORSOLINI-COMIN, F.; PERES, R. S.; SANTOS, M. A. Influência familiar na anorexia nervosa: em busca das melhores evidências científicas. Jornal Brasileiro de Psiquiatria, v. 62, n. 3, p. 225-233, 2013.
• VALDANHA, E. D. et al A arte de nutrir vínculos: psicoterapia de grupo nos transtornos alimentares. Revista da SPAGESP, v. 15, n. 2, p. 94-108, 2014.
• WINNICOTT, D. W. Desenvolvimento emocional primitivo (1945). In: WINNICOTT, D. W. Textos selecionados: da pediatria à psicanálise. Rio Janeiro: Imago, 2000.

• 1
  Agradecimentos: Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), processo número 2012/23854-2, e Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), bolsa de Produtividade em Pesquisa PQ-1A.
• Este artigo foi escrito originalmente em inglês pelos próprios autores.

Publication Dates

• Publication in this collection
  24 Jan 2020
• Date of issue
  Jan-Apr 2020

History

• Received
  05 Feb 2018
• Accepted
  26 Dec 2019