FAMILY RELATIONSHIPS IN BULIMIA NERVOSA

ABSTRACT

Eating disorders, such as bulimia, are psychopathologies of multifactorial etiology that have one of the primary triggerings and sustaining factors for symptoms in family relationships. This study aimed to analyze the experiences of family relationships from the perspective of a young woman diagnosed with bulimia, her mother and her father, who were interviewed. This is a qualitative, descriptive and cross-sectional case study whose design encompasses the father-mother-daughter triad. Data were collected through semi-structured interview scripts and analyzed from the perspective of the psychoanalytic theoretical framework, based on the construction of thematic categories. The results showed that, as the daughter, her parents also showed weaknesses in their emotional development, culminating in difficulties in establishing the self-other differentiation in these family members. These difficulties arose instability in family experiences, with dependence bonds permeated by paradoxical feelings of invasion of intimacy and helplessness. The results expand the knowledge of the field, especially in terms of understanding family relationships in the context of bulimia, and provide support for the actions and interventions planning of professionals involved in caring for patients and their families.

Keywords:
Eating disorders; family relations; bulimia

RESUMO.

Transtornos alimentares, como a bulimia, são psicopatologias de etiologia multifatorial que têm nas relações familiares um dos principais fatores desencadeadores e mantenedores dos sintomas. Este estudo teve por objetivo analisar as vivências das relações familiares na perspectiva de uma jovem diagnosticada com bulimia, de sua mãe e seu pai. Trata-se de um estudo de caso qualitativo, descritivo e transversal, cujo delineamento abarca a tríade pai-mãe-filha. Foram entrevistados três membros de uma família (pai, mãe e filha diagnosticada com bulimia). Os dados foram coletados por meio de roteiros de entrevista semiestruturada e analisados pela perspectiva do referencial teórico psicanalítico, a partir da construção de categorias temáticas. Os resultados mostraram que, assim como a filha, os pais também apresentaram fragilidades no seu desenvolvimento emocional, culminando em dificuldades no estabelecimento da diferenciação eu-outro nos membros da família. Essas dificuldades culminaram em vivências familiares de instabilidade, com vínculos de dependência impregnados por sensações paradoxais de invasão da intimidade e sentimentos de desamparo. Os resultados encontrados trazem avanços para o conhecimento da área, em especial no nível da compreensão das relações familiares no contexto da bulimia, e oferecem subsídios para o planejamento de ações e intervenções dos profissionais envolvidos na assistência a pacientes e familiares.

Palavras-chave:
Transtornos alimentares; relações familiares; bulimia

RESUMEN.

Trastornos de la conducta alimentaria, como bulimia, son psicopatologías de etiología multifactorial que tienen las relaciones familiares como uno de los principales factores desencadenantes y mantenedores de los síntomas. Este estudio tuvo por objetivo analizar las vivencias de las relaciones familiares en la perspectiva de una joven diagnosticada con bulimia, de su madre y de su padre. Se trata de un estudio de caso cualitativo, descriptivo y transversal, con delineamiento compuesto por la tríada padre-madre-hija. Se entrevistaron a tres miembros de una familia (padre, madre e hija diagnosticada con bulimia). Los datos fueron recolectados por medio de guiones de entrevista semiestructurada y analizados por la perspectiva del referencial teórico psicoanalítico, a partir de la construcción de categorías temáticas. Los resultados mostraron que, al igual que la hija, los padres también presentaron fragilidades en su desarrollo emocional, culminando en dificultades en el establecimiento de la diferenciación yo-otro en esos miembros de la familia. Estas dificultades culminaron en vivencias familiares de inestabilidad, con vínculos de dependencia impregnados por sensaciones paradójales de invasión de la intimidad y sentimientos de desamparo. Los resultados encontrados contribuyen con avances en el conocimiento del área, en especial en el nivel de la comprensión de las relaciones familiares en el contexto de la bulimia, y ofrecen subsidios para acciones e intervenciones de los profesionales involucrados en la asistencia a pacientes y familiares.

Palabras clave:
Trastornos de la ingestión de alimentos; relaciones familiares; bulimia

Introduction

Eating Disorders (EDs) are psychopathological conditions characterized by severe disturbances in eating behavior, being the most prevalent anorexia nervosa (AN) and bulimia nervosa (BN) (Alckmin-Carvalho, Santos, Rafihi-Ferreira, & Soares, 2016). BN is characterized by periodic binge eating behaviors, in which the individual ingests an exceptional amount of calories in a short period (American Psychiatric Association [APA], 2013). Such episodes are sequenced by compensatory behaviors experienced by the patient as uncontrolled and humiliating manifestations. The national and international literature supports that EDs have a multifactorial etiopathogenesis and involve a combination of factors that act as triggers and sustainers of the psychopathological condition, highlighting family relationships, socio-cultural environment and personality characteristics (Rikani et al., 2013).

People diagnosed with ED usually have difficulties innterpersonal relationships. In bulimia, family relations, in particular, are permeated by conflicts and dysfunctional bonds, withfew problem-solving skills observed (Marcos & Cantero, 2009). The literature points out that the typical family configurations of this psychopathological condition show a firm and sometimes intrusive mother. At the same time, the father presents himself as a psychically fragile, silent, absent(or not very present) and overshadowed figure in the family routine anddaily decisions (Moura, Santos, & Ribeiro, 2015; Tuval-Mashiach, Hasson-Ohayon, & Ilan, 2014; Valdanha-Ornelas & Santos, 2017).

From the initial ideas outlined by Freud about psychic functioning to the redescriptions and expansions proposed by contemporary authors, the psychoanalytic theoretical framework offers different perspectives for thinking about human beings’ mental and emotional development. In the late nineteenth century, Freud introduced the concept of the unconscious into the medical paradigm, proposing a theoretical framework in which the body and organic diseases would also be susceptible to psychic functioning, and not just biological factors (Breuer & Freud, 1996; Peres, 2006).

Initially, an adolescent girl was described by Freud in the context of melancholia, in which sexuality was underdeveloped, and the loss of appetite would be a manifestation of the loss of libido (Dutra, Balbi, & Seixas, 2016). The next step was to inscribe it in the context of hysteria as an expression of the aversion to sexuality (Caparrotta & Ghaffari, 2006), which implied the displacement of the genital sexual problem to the level of orality, placing in it the conflict and the consequent feelings of disgust and manifestations of inhibition.

According to Freud (2010), narcissism is a stage of libidinal development situated between autoeroticism and objectal love, that is, on the threshold of intra and interpsychic instances. The body surface, which the parents must investin since the beginning of life, produces internal and external sensations. In this sense, from the dimension of individual development, Freud outlines the importance of family relationsor the constitution of the psyche in the various unfoldings of his theoretical path.

The psychoanalysis of family relations, the framework that guides this study, suggests that the focus of the researcher/psychoanalyst on the study of these bonds should be directed towards family feelings. According to Meyer (1987), these feelings are directly related to what the individual could internalize from their family relationships, organized along with their emotional development. The family is understood as the legacy of an intricate intersubjective linking plot, consisting of internal objects and unconscious fantasies transmitted intergenerationally (Attili, Pentima, Toni, & Roazzi, 2018). The researcher’s effort is focused on finding words that could translate the unconscious meanings elaborated by these families in their interactions, so that shared experiences can take on new meanings (Mandelbaum, 2008).

The family’s psychodynamic functioning is gradually delineated with the formation of the couple, based on the baggage of conscious and unconscious needs and expectations of each spouse, added to the fantasies of each one, coined from previous generations. The baby’s arrival reorganizes this dynamic, and the parents want the child to perfectly match their aspirations and the fantasies that are projected on him (Meyer, 1987). Throughout the development process, it is the family’s role to emotionally equip and prepare their children to develop relationswith people outside the family group and, possibly, to form their family nucleus in the future, in a movement oriented towards exogamy (Mandelbaum, 2008; Meyer, 1987).

However, everyone does not always feel the necessary separation/differentiation among the family group members as an opportunity for enriching and fruitful psychic development. Such aspects can often be experienced, by some family members, in a terrifying way, with persecutory fantasies that result in a feeling of emptiness of the self (McDougall, 1991). At extreme levels of emotional distress, in families that experience primitive separation anxiety and individuation, role confusion and absence of self-other boundaries are perceived. Thus, there is no possibility of someone functioning autonomously and according to his desire or having his existence recognized as separate from other family members. In this context, emotional experiences are marked by attempts of omnipotent control and constant parental intrusion and manipulation, sometimes under the guise of being ‘responsible’ for the family (Meyer, 1987).

In the exposed theoretical scenario, EDs are considered ‘crossover’ psychopathologies, considering that they emerge mainly in adolescence - in the interval between childhood and adulthood, between the psychic and somatic levels, between the individual and the familiar/social (Benghozi, 2015; Corcos, 2015; Jeammet, 2008). This highlights the need to understand bulimic symptoms due to articulation between the intra and interpsychic dimensions, which points to the importance of psychoanalytically analyzing family interactions. Thus, this study aimed to analyze the experiences of family relations from the perspective of a young woman diagnosed with ED, her mother and her father.

Method

This study was developed according to a qualitative research approach based on the psychoanalytic theoretical framework. This is a single cross-sectional case study where the ethical precepts of research involving human beings were carried out. The Research Ethics Committee approved the institution’s study to which the researchers are linked (CAAE Process No. 39990414.1.0000.5407).

Study participants were patients and family members in regular care at a specialized service (Ramos & Pedrão, 2013) between April 2015 and June 2016. They were pre-selected after accessing the patients’ medical records in attendance, with the help of the interdisciplinary team of the hospital service. Those who met the following inclusion criteria were chosen: having a diagnosis of ED, being between 12 and 25 years old and regularly attending outpatient treatment activities. Exclusion criteria were established: the patient was not regularly followedup at the service, and one or more members of the triad, consisting of patient-mother-father, did not agree to collaborate in the research.

Among the cases that met these criteria, patients who had a living father and mother and who lived in intact family nuclei were selected. Thus, four triads composed of a father, a mother, and young people diagnosed with ED participated in the study, three with AN and one with BN. For this study, one of the cases was selected, according to the proposal of Stake (2011). The chosen case will be designated as the Borges Family and consisted of Bruna (24 years old, diagnosed with BN), Barbara (mother, 52 years old) and Bernardo (father, 50 years old). This case stood out among the four concluded because it brings more intra and interpsychic elements to consider the family context in eating disorders.

For data collection, semi-structured interview scripts were used, whose focus was to comprehensively understand the family life history and the factors that the interviewed family members associated with the development of ED symptoms by the affected member and their repercussions on the dynamics of family relationships. The interviews were applied individually in a face-to-face situation, in a reserved room of the hospital service, where the young woman regularly underwent her treatment. The researcher prepared records in a field diary immediately after the interviews to enrich the interpretations of the material obtained and enable a comprehensive analysis of the case (Chabert & Verdon, 2008).

The interviews were audio-recorded and transcribed verbatim for later analysis. The material, captured through interviews and records in the researcher’s field diary, constituted the research corpus. Data were organized and analyzed using the thematic content analysis method (Minayo, 2012), which consisted of the following steps: (1) floating and exhaustive reading of all the material, without a pre-defined focus of attention; (2) new reading, at this time with a pre-defined focus of attention, guided by the objective of the study, to identify the axes of meaning. From this reading, categories and subcategories were created that met the objectives of the study, highlighting the experiences of family relationships of each member of the triad; (3) triangulation of data obtained from different participants; (4) interpretation of the results based on psychoanalytic theory applied to the understanding of EDs.

In this last stage, the interpretive analysis of the material was carried out, which goes beyond the descriptive analysis of the data, requiring an empathic understanding guided by a reflection based on the psychoanalytic theory adopted as the study’s guiding reference. In this sense, a search was carried out for answer patterns with common meaningsas well as divergences and possible inconsistencies identified in the participants’ reports (Minayo, 2012; Stake, 2011). The strategy of comparing the interpretations of the results with those found in the scientific literature was also used.

Results

The Borges family consists of Bruna, Bárbara, Bernardo and an older daughter aged 27 years. At the time of data collection, Bruna had a Body Mass Index (BMI) of 23.37 kg/m², considered within the normal range, and had been under treatment at the specialized ED service for three years. The start of therapy was troubled. Due to the severity of the symptoms, when the family sought professional help, the young woman was indicated for entire hospitalization, being admitted to a psychiatric ward.

At the time, Bruna showed considerable weight loss and intense distortion of her body image. She received a clinical/descriptive diagnosis of AN of the purgative binge-eating subtype in comorbidity with a narcissistic personality disorder. Her clinical condition was considered serious by the health team. The patient had severe malnutrition and conversive symptoms, such as muscle stiffness, involuntary spasms and fainting spells, which worried professionals and the family.

As the treatment progressed, Bruna presented gradual weight recovery. The psychiatry team reconsidered her diagnosis, changing it to BN, as the young woman no longer had malnutrition and/or other typical characteristics of AN, while her binge-eating and purging symptoms had significantly intensified.

When consulted, members of the Borges family triad readily agreed to participate in the research. Then, the categories (marked in bold) and subcategories (highlighted in italics) elaborated from the participants’ perspectives will be presented. Subsequently, a discussion of the results will be developed with the support of the literature in the area.

The family relationships dynamics

The results obtained through the interview with Bruna allowed us to sketch the typical portrait of the family that we commonly find in the ED clinic: a mother figure internalized as intrusive and a father figure experienced as fragile and unreliable. The bond with the mother was shared in a markedly symbiotic way, pointing to a codependency relationship. The young woman felt suffocated and with little space and internal freedom to outline the contours of her own identity.

I feel like she [mother] is very emotionally dependent on me. And I hers. So, as much as I don’t want to […].Oh, I don’t know, I don’t know, I feel a bit bitter, like, towards my mother, I don’t know. I can’t really explain what that feeling is, you know. Perhaps a grudge, a mixture of rancor and sadnessfor things she has already put me through (Bruna, daughter diagnosed with BN, 24 years old).

According to Bruna, the conflicts she experienced in her relationship with her mother were intensified since she ‘did not accept’ her ED. However, the primary source of turbulence was the mother’s refusal to accept that her daughter had ‘affectionate relationships with girl’s. When referring to her sexuality, Bruna used the expression ‘lack of definition’, pointing out that realizing her lack of definition caused her mother discomfort in several spheres. About her relationship with her father, Bruna said that it was a ‘quieter’ bond and that she felt more understood by him.

[…] I feel that I can help him more and he can help me more, but I think this happens, maybe, precisely because I feel more neutral, more distanced from him, do you understand? (Bruna).

Bruna described her father as an ‘insecure’, ‘pessimistic’ and ‘unhappy’ man, comparing him to a dissatisfied child. While referring to a father who seems to have been introjected as a fragile figure and not very present in the daily decisions of the house, she also reported some episodes of explosion and paternal aggression in everyday events. Regarding the fraternal relationship, Bruna mentioned that she had a good relationship with her sister. The contact between her sister and her father was perceived as permeated by conflicts. Bruna highlighted her sister’s lack of patience before her father’s simplicity and low educational and cultural level. In contrast, she reported that her father greatly admired her eldest daughter, who was organized, serious, and focused on her study and work activities.

When discussing family relationships, Barbara highlighted the mother-daughter bond, stating that she always had a very good relationship with Bruna, clearly distinguishing between this relationship ‘before’ and ‘after’ her youngest daughter’s illness. In Barbara’s perspective, conflicts between mother and daughter began after the onset of symptoms.

The participant let slip, in some moments of the interview, her preference for the youngest daughter. She mentioned that the relationship between the two, in her view, was very affectionate and that conflicts only emerged when the daughter refused to collaborate in tidying up the house or when eating symptoms became prominent. The mother revealed that the lack of definition of her daughter’s sexual orientation - in Barbara’s words, ‘to like boys and girls’ - was also a factor that increased conflicts. About her perception of her daughter, the mother added: “She would be perfect if she didn’t have this problem […]”, referring to the ED.

Still, regarding the type of established bond, Barbara reported that she considered herself a good, perfect mother before her daughter had the disorder. However, when the daughter’s symptoms broke out, and the conflicts that emerged from the dyad relationship worsened, she began to question her competence in performing the maternal role. Accepting the problem was very difficult because it highlighted her difficulty in admitting some aspects of her daughter’s personality. Maternal reports evidenced that the stormy relationship with her daughter seemed to occupy a significant space in Barbara’s psychic world and relational life.

Bernardo, in turn, endeavored to sketch a portrait of harmonious and peaceful family life. He felt that he could maintain a relationship based on dialogue and complicity with his daughter Bruna and was more open to supporting her instability in the affective-sexual, professional and nutritional spheres. Furthermore, Bernardo believed that his daughter’s problems were transitory and associated with her ‘indecision’. He did not mention his bond with his eldest daughter, but he admired her predominantly rational temperament and praised her academic qualities.

The parental couple relationship quality

In Bruna’s perception, the parents maintain a relationship of ‘quarrelsome siblings’. However, she felt a touch of companionship and a similar lifestyle in this bond, which she saw as positive. Despite this, she thought her mother harbored an unspoken desire to divorce her husband. Still, she didn’t do it because she felt she couldn’t live without the psychological security that the relationship provided.

Barbara reported that she and her husband had already faced many relationship problems in the past. She perceived Bernardo as an anxious man who was prone to aggressive outbursts, as well as being very tense and worried in everyday life. Barbara added that her husband was very dependent on her, which caused her discomfort, and that in recent years he had been in a depressed mood.

Bernardo, when discussing his marriage, highlighted the financial concerns that the Borges faced throughout their lives. He reported that he and his wife had small arguments and quarrels in their daily lives, but nothing that made them consider the possibility of a separation, as they always supported each other. His description evidenced a more superficial perception of the couple’s life and a tendency to minimize marital and family conflicts.

Parental care dimension

Initial parental care

Bruna already had a few years of treatment and individual psychotherapy. She reported that she frequently reflected on her family bonds, but she had little knowledge of how her family life had started. Barbara mentioned that it had been a pleasant time when they lived in a small country town, which she missed. Still, regarding this initial period of family history, she revealed that she had experienced great frustration and disappointment for having breastfed her two daughters for only three months since she ‘had no milk’. On the other hand, Bernardo spoke little about this period, showing that he always remained distant from domestic matters, especially in women’s pregnancy, childbirth, and puerperium issues. Nor was he involved in the early parental care of the two daughters.

Offered and received current parental care

Concerning the care currently received, Bruna reported that her mother was always willing to annul herself so she could take care of her. She thought that her mother expected reciprocity that she, the daughter, could not respond to or put into practice. Regarding the father, the young woman observed that he kept the focus on concrete care, associated, for example, with some financial expense, paying little attention to genuine contact with her in daily life.

Barbara reported that she was very concerned about her daughter’s compulsive behaviors and purgative habits. She described the bond established with her daughter as permeated by negative feelings and persistent fear of invasion. The mother was punishing herself for not clearly identifying the boundaries she should respect when taking care of Bruna. Bernardo said he always sought to show his daughters the best path and never had serious problems because they never deviated from the right way.

The impact of eating disorders on family relationships

The family’s eating habits

Barbara reported that she felt very overwhelmed with the performance of daily activities related to the family’s food. Bernardo and Bruna showed awareness of Barbara’s burden but revealed little concern about it. Bruna complained that her mother bought and stocked many sweets and high-calorie products at home and highlighted that her parents were overweight and had several serious health problems resulting from poor eating habits, such as ‘high cholesterol’ and diabetes mellitus. In the young woman’s opinion, her parents ate compulsively when they felt anxious, just as she did in certain moments of greater tension. In the family difficulties related to food, Barbara also reported feeling uncomfortable when looking for something to eat and could not find it. She attributed the responsibility related to these events to Bruna and her uncompensated binge-eating. This type of event was also a source of conflict between the two sisters.

The onset of symptoms and the family repercussions of the diagnosis

Regarding the emergence of ED, Bruna said it was a gradual process. She did not realize she was consistently losing weight until her body shape caught her parents’ attention during a vacation trip they took to the beach when she needed to wear a bathing suit, and they, for the first time, realized how squalid her body was. Depending on the delayed perception of symptoms, the family only sought specialized help when Bruna had to undergo a brief hospitalization (seven days) due to an episode of sudden malaise. At this time, the diagnostic hypothesis of ED was raised, which for Bruna at first made no sense, and it was also received with skepticism by her parents.

Bruna said that, with the development of specialized treatment, she reflected and realized that, in her early adolescence, when she was about 12 years old, she had been affected for the first time by the symptoms of ED. At that time, she was dating a girl, her friend, with whom she learned to eat and later induce vomiting. This was the longest love relationship she had had so far, and it was clearly marked by a kind of symbiotic bond, marked by a confusion of identity boundaries.

Her mother reported that she felt ‘she was blindfolded’ at the beginning of the disorder because her daughter was losing a lot of weight. She did not accept it when people, including her husband, considered the possibility of being an ED. For her, this was a disease that only affected models, something far from her daughter’s reality. At that time, Bruna was increasingly isolating herself from friends and family. She preferred staying long periods alone in her room until one day her mother called her and realized that she had vomited on herself.

Repercussions of current eating difficulties

At the research time, Bruna showed that she was aware that her compulsive and purgative behaviors seemed to be associated with situations that elicited anxiety, such as stress triggered by studies or difficulties experienced in affective and social relationships. Regarding the family’s reactions to her symptoms, the young woman reported that her mother was very nervous when she realized she had caused vomiting, further accentuating her feelings of guilt and shame. At the same time, her father seemed to have a more positive perception of his daughter and pointed out her progress.

Meanwhile, Barbara and Bernardo also highlighted the worsening of Bruna’s symptoms during periods of more significant stress. Her mother also reinforced that she felt that her difficulty in accepting her daughter’s sexual orientation may have contributed to the triggering and maintenance of symptoms. She would also like Bruna to have a more malleable character, as she felt that her daughter had become very rebellious and inflexible after starting the ED. Bernardo associated bulimia with depression and feelings of inferiority experienced by his daughter in childhood, when she was discriminated and suffered bullying from schoolmates for being overweight. Bernardo also realized that talking directly about the symptoms with his daughter, asking her to reduce or control her excessive food intake, was a factor that generated more anxiety, which only increased conflicts,as Bruna felt that the comments were offensive, as well as uncomfortable with the invasion of her intimacy.

Speculations and fantasies about the possible origin of the eating disorder

For Bruna, the main factor that triggered her disorder was the difficulty she had experienced while dating her childhood friend. At her hospitalization, her mother discovered that she was in a loving relationship with her friend. Barbara was disappointed and took it like a bomb, a terrible discovery. Bruna listed this homosexual relationship as the first significant disappointment she inflicted on her mother, placing the development of ED as the second source of disappointment.

Regarding the possible causes of ED, in general, Bruna presented a rationalization that explains her disturbances in eating behavior as by-products of the consumer society in the contemporary era (Santos et al., 2019). When asked about the role of the family, she revealed that she was also called ‘chubby’ by her mother and sister, who put it negatively and always made derogatory comments about her weight and body shape.

At the beginning of her daughter’s clinical condition, Barbara thought that the simple act of going back to eating would solve the issue, considering that the young woman had a severe state of malnutrition. During the treatment and her psychotherapy, she became convinced that the ED only signaled a latent difficulty that already existed before and no one in the family noticed what was happening, being its ‘cause’ associated with ‘unresolved psychological problems’. She said that she always thought her daughter was a pleased child and did not realize the attacks she suffered from peers because of her overweight, nor did she know how this could affect her mental health.

Regarding the family, Barbara mentioned that Bruna once accused all family members of having their share of responsibility in producing the problematic situation in which she found herself. The mother also reported that she agreed with her daughter’s reflection:

Sometimes, when this subject becomes an argument, she says, ‘Everyone is to blame here. You, mother, say that I was your disappointment when I told you I liked a girl’. And it’s true, I did say. To her father, she thinksher older sister was always his favorite, so […] I guess everyone is to blame, right? (Barbara, mother, 52 years old, emphasis added).

For Bernardo, the symptoms of bulimia started with the disillusionment he believes his daughter suffered: the end of the first love relationship. Despite not participating in Bruna’s treatment, Bernardo reported that he has continuously researched the topic on the internet to try to help her, having even contacted testimonials from patients to get closer to the young woman’s reality. In his perspective, the family had no relationship with the precipitation of the disorder since, according to his perception of family life, no member had ever discriminated against Bruna because of her weight. However, he said her daughter often complained that her parents preferred her older sister. He also believed that his daughter’s diffuse anxiety, and what he called her ‘indecision’ in the affective-sexual and professional sphere, made it difficult to achieve improvement

Discussion

In the intersection of the perspectives of the mother, father and their young daughter with BN, it was possible to verify that manifest and latent conflicts permeated the experiences of family relationships. This brought additional difficulties to the arduous process of family adaptation to the ruptures established by the mental disorder in the domestic routine. Bruna’s symptoms were noticed late, which delayed the search for help (Valdanha-Ornelas & Santos, 2016). The family had to adjust to the destabilization caused by the installation of chronic psychopathology and continued to be demanded in its capacity to assimilate the changes that had occurred in the life of its members. The perception stands outfrom Barbara that the family was ‘perfect’ before Bruna’s illness. The mother narrated an idealized atmosphere of peace and tranquility in the family, interrupted only by the onset of her daughter’s bulimic symptoms. Thus, the parents’ perfectionism was present as one of the constitutive elements of the dynamics of family relationships, feeding an idealized view of the past.

Concerning the bonds established in the intra-family space, it is clear that they were intensely ambivalent. The eldest daughter occupied less space in the speech of the parents and Bruna, which may result from the perception that she would be, according to the reports of the triad, the healthy, competent daughter who kept her functionality fully preserved. However, it is also important to emphasize that the eldest daughter showed a dynamic of self-closure and isolation. In a rational, solitary and self-sufficient way, she seemed to seek to deal with her emotional difficulties and daily challenges. Meanwhile, in a two-way street, it is necessary to consider that this functioning of the young woman may have developed unconsciously, as she realized that her parents had few emotional resources to invest in caring for her, which may have generated a withdrawal in establishing her family bonds. Thus, the symptoms may be translating the daughter’s unconscious response to the parental couple’s immaturity. As Anzieu (2006) and Corcos (2016) described, this dynamic evidences flaws in the double request in whichthe baby/child calls the family’s attention while being summoned by it in a constant movement of identity construction. In this sense, the eldest daughter seems not to have found the echo she expected to meet her affective demands in her parents.

On the other hand, the relationship between the two sisters proved to be less conflictual, as Bruna realized that her sister’s more rational functioning efficiently controlled her emotions. Fraternal conflicts started when the older sister got angry with something that Bruna had done. In the speeches of mother and daughter, this often happened when Bruna ate products that were available at home and that her sister would also like to consume. It should be noted that the psychic economy of unconscious desire related to food is also involved in the drama of fraternal rivalry. The premise of imbalance permeates the relational dynamic. Food and affective resources available in the family are scarce, and there will always be someone who goes hungry and, at the same time, another member gorges himself until he vomits.

The relationship of fusional complementarity between Barbara and Bruna proved to be intensely ambivalent. Thus, it was experienced, especially by Bruna, who rationally manifested awareness of this bond characteristic. Mother and daughter narrated experiences of a symbiotic relationship permeated by ambivalent feelings of love and hate (Ribeiro, 2016). Considering, more specifically, the girl’s emotional development, according to Ribeiro (2011), the female pair - mother and daughter - is more vulnerable to being ‘con-fuse’ in the identification process. This happens because, in the resolution of the Oedipus Complex, the girl needs, first, to identify with the maternal object, then to partially separate from the mother and then re-identify with her, which can arouse feelings of love or competitiveness. Mother and daughter remain linked by intense and ambivalent bonds of love and hate, which are difficult to accept and elaborate on considering the fragile defense mechanisms.

In Barbara’s reports, the beginning of the rupture of the relationship of marked psychic indifferentiation, which was previously experienced in a deceptively positive way, was precipitated by the onset of her daughter’s symptoms concomitantly with the discovery of the young woman’s homo-affective relationship. The mother experienced these two important moments in the construction of Bruna’s subjectivity with ‘profound disappointment’. Still, they can also be understood as the daughter’s movements in the sense of trying to break the umbilical psychic relationship and differentiate herself from the maternal figure in search of the contours of her own identity. A recent literature review found that understanding the fusional nature of the mother-daughter bond is an essential step for effective symptom treatment since the idiosyncrasies of this relationship may be at the core of eating and family difficulties (Siqueira, Santos, & Leonidas, 2020).

Until the moment when Bruna’s attempt to break the psychic indifferentiation emerged, mother and daughter lived immersed in an idealized bond, without apparent contradictions and conflicts, which enabled Barbara to perceive herself as ‘a perfect mother’. Hateful feelings emerged with subsequent disappointments. The pair still seemed to live under a ‘common skin’ (Anzieu, 2006). According to the aforementioned author, mother and baby maintain a mutually symbiotic relationship at the beginning of life, a ‘common skin’. This common skin is undoing throughout the development, and everyone gradually recognizes his own skin and his own body. Despite being part of human development, this individuation process always involves suffering and resistance from both parties. When the investment, both narcissistic and libidinal, from mother to baby is not experienced as good enough, the baby becomes fragile and may have health problems. This process and the imminence of separation-individuation seem to have been shared with terror and suffering on both the mother and the daughter, with strong resistance that contributed to maintaining the symbiotic illusion indefinitely. This illusion is necessary and even fundamental, but only in the early stages of emotional development.

Barbara reported, superficially, that she had difficulties in providing for her daughter’s care needs since she was a baby. Breastfeeding took place for a short time. This may be associated with maternal challenges in getting involved in this bonding more deeply. Currently, the situation of psychological vulnerability and the distortion of Bruna’s body image reinforce this idea that there were sudden failures in the provision of initial care. These failures, considered remarkable for psychic functioning, may have led to weaknesses in identity development, health problems and difficulties in interpersonal relationships (Anzieu, 2006; Durski & Safra, 2016).

Considering the suggestive aspects of emotional fusion that characterize the mother-daughter relationship, it is possible to observe that, at least to some extent, this condition favors feelings of comfort and protection (Mendonça, 2015). However, the so-called normal development favors separation, which may have been premature in this case and seems to have been experienced with great hatred for Barbara. The mother reported experiences of intense suffering whenever her daughter showed some behavior that she considered inappropriate. Bruna does not seem to have had the resources to promote a less conflictual separation, both intrapsychic and relational. In this sense, her attempts at individuation were inadequately expressed in self-destructive behaviors, which mostly evoked the body contours (weight instability) and her internal/external boundaries (binge-eating/purging behaviors), evidencing elements that refer to a fragile narcissistic basis (Fernandes, 2016; Vibert, 2015).

The relationship between Bruna and Bernardo proved to be less conflictual. The father showed superficiality in the perception of the difficulties that permeated family life, which seems to be frequent in the context of EDs (Scaglia, Mishima-Gomes, & Barbieri, 2018). Bruna presented an internalized father figure, sometimes as a hopeful man who would have resources to support her, sometimes as a psychically immature and impulsive being.

In this context of Bruna’s experiences, in which there is an emotionally absent father, an intrusive mother and a resentful and withdrawn sister, bulimic symptoms seem to manifest as an unconscious attempt to awaken her father to family life to fulfill his role of ensuring a safe and reliable base for the daughter to deal with the re-edition, in adolescence, of the passage through the Oedipus complex. Contemporary psychoanalytic literature points out that the girl’s Oedipal resolution can occur if, in her process of further development, she finds in the father the necessary security she needs to free herself from the maternal bond (Costa & Santos, 2016; Diaz, 2015; Leonidas & Santos, 2020).

In this sense, it is possible to make the conjecture that Bernardo could not act as a containing agent and, eventually, an interdictor of the mother-daughter relationship, so that both continued imprisoned to each other and intertwined by a toxic and mortifying symbiotic bond (Leonidas & Santos, 2020). In this deadly pact, mother and daughter are condemned to resist any investiture that points the path to differentiation/individuation. Bruna showed that she could not experience her body as an instance of her own through symbolization and thus affirm her femininity as an experience of pleasurable enjoyment (Goulart & Santos, 2015). Her first attempt at establishing an exogamous relationship was with her childhood best friend, also re-editing a binding model that seems to be based on the blurring of borders and the lack of differentiation between self and other. This relationship lasted several years without her parents being aware of what was going on.

Considering the dimension of conjugality, an atmosphere of ‘emotional emptiness’ hovering over the couple was perceived as they showed very different perceptions about the marital relationship. While Bernardo highlighted the supposed absence of conflicts as an intrinsic quality to his family, optimistically projecting a promising future with his wife (manic defenses), Barbara reported several intrafamily conflicts and outlined a future in which she would like to take more care of herself, suggesting the possibility of deciding for marital separation, something that never seems to have crossed the mind of the husband. Bernardo also showed himself to be nonparticipatory in caring for his daughters and not empathetic to the difficulties experienced by his wife in handling the household chores and daily care of their offspring, which is in line with the literature on paternal care in the ED scenario (Costa & Santos, 2016). It is possible to infer that the couple remained together and reasonably tuned when it came to providing care concerning their daughters (Favez, 2017), which seems to have been destabilized as the young women advanced in their development trajectories towards entry into adulthood.

The symptoms, then, seem to be an invitation to the mother and daughter to recognize the psychic/body space/gap that differentiated them, announcing a possibility of individuation of both, previously denied and rejected. However, this separation is intensely feared, as it is experienced as a threat of dismantling the ‘common skin’, which could trigger the collapse of the ego. This imminence of radical rupture, according to psychoanalytic literature, can be felt as a danger that hovers over the family group, as the family can experience separation as an act of betrayal and disloyalty to the family pact (Anzieu, 2006; Benghozi, 2010; Chabert, 2015; Meyer, 1987). In this context, Bruna’s individuation process would be at risk, as it seems to have been permeated by intense suffering, both at the individual and group (family) levels.

Considering the fragile narcissistic bases of the triad members, the separation is unbearable, hindering the daughter’s development towards a sexual female identification (Leonidas & Santos, 2020; Vibert, 2015). This issue, which refers to boundaries (self-other, inside-outside), highlights issues related to sexual differentiation, with the possibility of maintaining psychic bisexuality or building a more precise sexual identity (Chabert, 2015). For Bruna, the body itself was experienced with failures and instability. An opaque body to the unconscious meanings that cross it and mortified by atrocious sufferings, evidence of the internal fragility manifested in contact with the world, especially in stages of psychosocial transition).

Final considerations

This study aimed to analyze the experiences of family relationships from the perspective of a young woman diagnosed with bulimia, her mother and her father. The results show that the young woman diagnosed with ED perceives their parents as saddened and fragile, with few resources available for self-care, inhibiting her efforts to seek autonomy and what she considers could improve their lives. In this climate of little affective investment, the young woman with bulimia seems to feel that she did not find the welcome she needed to calm down and process her most distressing experiences, which may have contributed her to develop evolutionary failures at the egoic, corporal and relational levels.

In this context of difficulties in the maturation process, the development of ED in the daughter appears as the unconscious mobilization of resources to meet the unrewarded needs for attention and care. Alongside this, the symptoms may also have an unconscious sense of getting rid of the omnipresent and overwhelming presence of the mother figure introjected as voracious and intrusive, eternally dissatisfied because she cultivates perfectionism and thereby inhibits the daughter’s emotional development. The mobilization of symptoms also seems to have the unconscious function of waking up the father to reposition himself in the Oedipal scene, implying him, since he presents himself as an almost inert and passive figure before the events. Thus, the results suggest the importance of including the listening of fathers and mothers in the treatment of the daughter with ED to capture the unconscious meanings of the symptoms that configure the psychopathological picture and its repercussions on the family environment and on the web of unconscious fantasies and bonds that support the family psychic functioning.

The results showed that, like the daughter, the parents also showed weaknesses in their social-emotional development, culminating in difficulties in establishing the self-other differentiation. These difficulties arose instability in family experiences, with bonds of dependence permeated by paradoxical feelings of invasion of intimacy and feelings of abandonment and helplessness. Thus, the results of this psychoanalytic study of dyadic and triadic relationships between fathers, mothers and daughters contribute to the advancement of knowledge in the field, especially in the level of understanding of family relationships in the context of EDs, offering subsidies to structure the interventional actions of the professionals involved in caring for patients and their families.

According to the analyzed reports, it was also possible to identify changes that occurred in Bruna’s behavior and attitudes during the treatment, especially in terms of interpersonal relationships, ruptures that could not be adequately elaborated. In the beginning, the young woman showed an arrogant posture and an extremely rational and intellectualized speech, sometimes showing herself inadequate in different treatment contexts, especially in the patient support group. Over time, she became more malleable, sensitive and empathetic to the suffering of the other, and there was also a noticeable improvement in her relationships and social life.

Like any case study, this report presents some limitations, such as the impossibility of generalizing the results obtained and the fact that other perspectives that could enrich the data triangulation were not confronted, such as the healthy sister and the health professionals who follow the case.

Referências

• Alckmin-Carvalho, F; Santos, D. R; Rafihi-Ferreira, R; & Soares, M. R. Z. (2016). Análise da evolução dos critérios diagnósticos da anorexia nervosa. Avaliação Psicológica, 15(2), 265-274.
• American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual of eating disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• Anzieu, D. (2006). Le Moi-peau (2ª ed.). Paris, FR: Dunod. Original publicado em 1985.
• Attili, G; Di Pentima, L; Toni, A; & Roazzi, A. (2018). High anxiety attachment in eating disorders: intergenerational transmission by mothers and fathers. Paidéia(Ribeirão Preto ), 28, e2813. doi: http://dx.doi.org/10.1590/1982-4327e2813
• Benghozi, P. (2010). O engodo como sintoma dos continentes genealógicos esburacados. In Malhagem, filiação e afiliação - psicanálise dos vínculos: casal, família, grupo, instituição e campo social(E. D. Galery, trad.) (p. 103-120). São Paulo, SP: Vetor.
• Breuer, J; & Freud, S. (1996). Estudos sobre a histeria. In S. Freud. Edição standard brasileira das obras de psicológicas completas de Sigmund Freud (Vol. 2, p. 15-297). Rio de Janeiro, RJ: Imago. Trabalho original publicado em 1893-1895.
• Caparrotta, L; & Ghaffari, K. (2006). A historical overview of the psychodynamic contributions to the understanding of eating disorders. Psychoanalytic Psychoterapy, 20(1), 175-196.
• Chabert, C. (2015). La jeune fille et le psychanalyste Paris, FR: Dunod.
• Chabert, C; & Verdon, B. (2008). Psychologie clinique et psychopathologie Paris, FR: Presses Universitaires de France.
• Corcos, M. (2011). Le corps insoumis: psychopathologie des troubles des conduites alimentaires (2eme ed.).Paris, FR: Dunod. Obra original publicada em 2005.
• Corcos, M. (2016). La maternité-perpétuité dês mères vierges. Le Carnet PSY, 2(196), 35-40.
• Costa, L. R. S; & Santos, M. A. (2016). Cuidado paterno e relações familiares no enfrentamento da anorexia e bulimia. In D. Bartholomeu, J. M. Montiel, A. A. Machado, A. R. Gomes, G. Couto & V. Cassep-Borges (Orgs.), Relações interpessoais: concepções e contextos de intervenção e avaliação(p. 253-279). São Paulo, SP: Vetor .
• Diaz, S. M. F. (2015). Porque o apego a pessoas e lugares que a diminuem?In M. Ramos,& M. P. Fuks (Orgs.), Atendimento psicanalítico da anorexia e bulimia (p. 14-27). São Paulo, SP: Zagodoni
• Durski, L. M; & Safra, G. (2016). O Eu-pele: contribuições de Didier Anzieu para a clínica da psicanálise. Reverso, 38(71), 107-114.
• Dutra, C. C; Balbi, L. M; & Seixas, C. M. (2016). A escolha pelo “nada”: reflexões psicanalíticas sobre a anorexia. Demetra 11(3), 687-695. doi: 10.12957/ demetra.2016.22502
  » https://doi.org/10.12957/ demetra.2016.22502
• Favez, N. (2017). Psychologie de la coparentalité: concepts, modèles et outils d’évaluation Paris, FR: Dunod.
• Fernandes, M. H. (2016). A anorexia e a bulimia em Freud. In C. Weinberg (Org.), Psicanálise de transtornos alimentares (Vol. II, p. 170-190). São Paulo, SP: Primavera Editorial.
• Freud, S. (2010). Formulações sobre os dois princípios do funcionamento mental (P. C. de Souza, trad; Vol. 10, p. 81-91). São Paulo, SP: Companhia das Letras. Original publicado em 1911.
• Goulart, D. M; & Santos, M. A. (2015). Psicoterapia individual em um caso grave de anorexia nervosa: a construção da narrativa clínica. Psicologia Clínica, 27(2), 201-227.
• Jeammet, P. (2008). Abordagem psicanalítica dos transtornos das condutas alimentares. In R. Urribari(Org.), Anorexia e bulimia (M. Seincman, trad; p. 24-49). São Paulo, SP: Escuta.
• Leonidas, C; & Santos, M. A. (2020). Symbiotic illusion and female identity construction in eating disorders: a psychoanalytical psychosomatics’ perspective.Ágora: Estudos em Teoria Psicanalítica,23(1), 84-93. https://doi.org/10.1590/1809-44142020001010
  » https://doi.org/10.1590/1809-44142020001010
• Mandelbaum, B. (2008). Psicanálise da família São Paulo, SP: Casa do Psicólogo.
• Marcos, Y. Q; & Cantero, M. C. T. (2009). Assesment of social support dimensions in patients with eating disorders. The Spanish Journal of Psychology, 12(1), 226-235. doi:10.1017/S1138741600001633.
  » https://doi.org/10.1017/S1138741600001633
• McDougall, J. (1991). Teatros do corpo (P. H. B. Rondon, trad.). São Paulo, SP: Martins Fontes.
• Mendonça, L. B. V. G. (2015). Adolescência e anorexia: o que entra na pele. InM. Ramos ,& M. P. Fuks (Orgs.), Atendimento psicanalítico da anorexia e bulimia (p. 14-27). São Paulo: Zagodoni.
• Meyer, L. (1987). Família: dinâmica e terapia (uma abordagem psicanalítica (2a ed.) (G. Schlesinger, trad.). São Paulo, SP: Brasiliense.
• Minayo, M. C. S. (2012). Análise qualitativa: teoria, passos e fidedignidade. Ciência & Saúde Coletiva, 17(3), 621-626.doi: 10.1590/S1413-81232012000300007
  » https://doi.org/doi: 10.1590/S1413-81232012000300007
• Moura, F. E. G. A; Santos, M. A; & Ribeiro, R. P. (2015). A constituição do vínculo mãe-filha e sua relação com os transtornos alimentares. Estudos de Psicologia (Campinas), 32(2), 233-247. doi:10.1590/0103-166X2015000200008
  » https://doi.org/10.1590/0103-166X2015000200008
• Peres, R. S. (2006). O corpo na psicanálise contemporânea: sobre as concepções psicossomáticas de Pierre Marty e Joyce McDougall. Psicologia Clínica, 18(1), 165-177.
• Ramos, T. M. B; & Pedrão, L. J. (2013). Acolhimento e vínculo em um serviço de assistência a portadores de transtornos alimentares.Paidéia (Ribeirão Preto),23(54), 113-120. doi: 10.1590/1982-43272354201313
  » https://doi.org/doi: 10.1590/1982-43272354201313
• Ribeiro, M. F. R. (2011). De mãe em filha: a transmissão da feminilidade São Paulo, SP: Escuta .
• Ribeiro, M. (2016). Entrelaces psíquicos entre mães e filhas. In C. Weinberg (Org.), Psicanálise de transtornos alimentares (Vol. II, p. 209-222). São Paulo, SP: Primavera Editorial .
• Rikani, A. A; Choudhry, Z; Choudhry, A. M; Ikram, H; Asghar, M. W; Kajal, D; & Mobassarah, N. J. (2013). A critique of the literature on etiology of eating disorders. Annals of Neurosciences, 20(4), 157-161. doi: 10.5214/ans.0972.7531.200409
  » https://doi.org/10.5214/ans.0972.7531.200409
• Santos, M. A., Oliveira, V. H., Peres, R. S., Risk, E. N., Leonidas, C., Oliveira-Cardoso, E. A. (2019). Corpo, saúde e sociedade de consumo: a construção social do corpo saudável.Saúde & Sociedade, 28(3), 239-252. doi: 10.1590/s0104-12902019170035
  » https://doi.org/10.1590/s0104-12902019170035
• Scaglia, A. P; Mishima-Gomes, F. K. T; & Barbieri, V. (2018). Paternidade em diferentes configurações familiares e o desenvolvimento emocional da filha.Psico-USF,23(2), 267-278. doi: 10.1590/1413-82712018230207
  » https://doi.org/10.1590/1413-82712018230207
• Siqueira, A. B. R.; Santos, M. A; & Leonidas, C. (2020). Confluências das relações familiares e transtornos alimentares: revisão integrativa da literatura.Psicologia Clínica,32(1), 123-149. doi: 10.33208/PC1980-5438v0032n01A0
  » https://doi.org/10.33208/PC1980-5438v0032n01A0
• Stake, R. E. (2011). Pesquisa qualitativa: como as coisas funcionam (K. Reis, trad.). Porto Alegre: Penso.
• Tuval-Mashiach, R., Hasson-Ohayon, I., & Ilan, A. (2014). Attacks on linking: stressors and identity challenges for mothers of daughters with long lasting anorexia nervosa. Psychology and Health, 29(6), 613-631. doi: 10.1080/08870446.2013.879135
  » https://doi.org/10.1080/08870446.2013.879135
• Valdanha-Ornelas, E. D; & Santos, M. A. (2016).O percurso e seus percalços: itinerário terapêutico nos transtornos alimentares. Psicologia: Teoria e Pesquisa, 32(1), 169-179.doi: 10.1590/0102-37722016012445169179
  » https://doi.org/10.1590/0102-37722016012445169179
• Valdanha-Ornelas, E. D., & Santos, M. A. (2017). Transtorno alimentar e transmissão psíquica transgeracional em um adolescente do sexo masculino. Psicologia: Ciência e Profissão, 37(1), 176-191.doi: 10.1590/1982-370300287-15
  » https://doi.org/10.1590/1982-370300287-15
• Vibert, S. (2015). Psychopathologie et psychanalyse de l’anorexie mentale: modèles dynamiques Paris, FR: PressesUniversitaires de France.

Publication Dates

• Publication in this collection
  06 Dec 2021
• Date of issue
  2021

History

• Received
  05 Apr 2019
• Accepted
  14 Oct 2020