Clinical Social Work Journal

, Volume 25, Issue 1, pp 87–106 | Cite as

Self-Medication, Traumatic Reenactment, and Somatic Expression in Bulimic and Self-Mutilating Behavior

  • Sharon Klayman Farber


A psychoanalytic framework provided direction for research on the association between binge-purging (bulimic) and self-mutilating behaviors, comparing them for similarities and differences. The similarities in the multiple functions and psychosomatic processes served by these behaviors are presented, as well as the phenomenon of symptom substitution. Both behaviors tend to be practiced by those with severe personality and dissociative disorders and post-traumatic stress disorder. Both serve ego-compensatory needs in the absence of the adequate ability to regulate and modulate emotions, moods, and tensions. They may serve as compensatory attempts to differentiate self and object, define and differentiate body boundaries, master severe childhood trauma by means of psychophysiological addictive reenactments, and to express emotion.

bulimia self-mutilation addiction trauma symptom substitution 


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  1. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders. (4th ed). Washington, DC: Author.Google Scholar
  2. Angel. (Winter, 1992). Invitation into the dining room of a bulimic. For Crying Out Loud, 6,3, 2. Cambridge, MA: Survivors Newsletter Collective.Google Scholar
  3. Anzieu, D. (1970). Skin ego. In S. Lebovici & D. Widlöcher (Eds.), Psychoanalysis in France. New York: International Universities Press, 1980.Google Scholar
  4. Anzieu, D. (1990). Psychic envelope. New York: Brunner Mazel.Google Scholar
  5. Bass, A. (1994). Aspects of urethrality in women. Psychoanalytic Quarterly, 63, 491–517.Google Scholar
  6. Battegay, R. (1991). Hunger diseases. Lewiston, NY: Hogrefe and Huber.Google Scholar
  7. Bollas, C. (1987). The shadow of the object. New York: Columbia University Press.Google Scholar
  8. Brenner, C. (1982). The mind in conflict. Madison, CT: International Universities Press.Google Scholar
  9. Brenner, D. (1983). Self-regulatory functions in bulimia. Contemporary Psychotherapy Review, 1, 79–96.Google Scholar
  10. Brisman, J., & Siegel, M. (1984). Bulimia and alcoholism: Two sides of the same coin? Journal of Substance Abuse Treatment, 1, 113–118.Google Scholar
  11. Camper, F., Farber, S., & Gerson, S. (1988). A study of anxiety and depersonalization in delicate self-cutters. Unpublished research paper, New York University School of Social Work.Google Scholar
  12. Camper, F., Farber, S., Gerson, S., & Murphy, D. (1988). Self-mutilating behavior in female victims of sexual abuse. Unpublished research paper, New York University School of Social Work.Google Scholar
  13. Coid, J., Allolio, B., & Rees, C. (1983). Raised plasma metenkephalin in patients who habitually mutilate themselves. Lancet, September 3, 1983, 545–546.Google Scholar
  14. Cross, L. (1993). Body and self in feminine development: Implications for eating disorders and delicate self-mutilation. Bulletin of the Menninger Clinic, 57, 41–68.Google Scholar
  15. Farber, S. (1995a). A psychoanalytically informed understanding of the association between binge-purge behavior and self-mutilating behavior: A study comparing binge-purgers who self-mutilate severely with binge-purgers who self-mutilate less severely or not at all. (Doctoral dissertation, New York University, 1995). Dissertation Abstracts International, 56, 5794B.Google Scholar
  16. Farber, S. (1995b). Women and self-harm: A psychoanalytic understanding of the relationship between binge-purging behavior and self-mutilating behavior. Paper presented to the Fifth National Conference of National Membership Committee on Psychoanalysis in Clinical Social Work, October 27, 1995.Google Scholar
  17. Farber, S. (1996). Eating Problems and Self-Mutilation in Survivors of Sexual Abuse: Self-Destructiveness or Survival Tools? Presented at N.Y. State Mental Health Association Conference, Sexual Abuse Survivors Diagnosed with Serious Mental Illnesses, Albany, April 12, 1996.Google Scholar
  18. Favazza, A. (1987). Bodies under siege: Self-mutilation in culture and psychiatry. Baltimore: Johns Hopkins University Press.Google Scholar
  19. Favazza, A. (1994). Why Patients Harm Themselves. New York Psychiatric Centers Grand Rounds Telecast.Google Scholar
  20. Favazza, A., DeRosear, L., & Conterio, K. (1989). Self-mutilation and eating disorders. Suicide and Life Threatening Behavior, 19,4, 352–361.Google Scholar
  21. Favazza, A., & Rosenthal, R. (1990). Varieties of pathological self-mutilation. Behavioral Neurology, 3, 77–88.Google Scholar
  22. Freud, S. (1923). The ego and the id. Standard Edition, 18, 7–64. London: Hogarth Press.Google Scholar
  23. Garfinkel, P., Moldofsky, H., & Garner, D. (1980). The heterogeneity of anorexia nervosa: Bulimia as a distinct subgroup. Archives of General Psychiatry, 37, 1036–1040.Google Scholar
  24. Golden, B., & Walker-O'Keefe, J. (1988). Self-injury: Hidden pain in the workplace. EAP Digest, November/December 1988.Google Scholar
  25. Goldstein, E. (1990). Borderline disorders: Clinical models and techniques. New York: Guilford.Google Scholar
  26. Goodsitt, A. (1985). Self psychology and the treatment of anorexia nervosa. In D. Garner & P. Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia. (pp. 55–82). New York: Guilford.Google Scholar
  27. Graff, H., & Mallin, R. (1967). The syndrome of the wrist cutter. American Journal of Psychiatry, 24,1, 74–80.Google Scholar
  28. Green, A. (1975). The analyst, symbolization and absence in the analytic setting (on changes in analytic practice and experience). International Journal of Psycho-Analysis, 56, 1–22.Google Scholar
  29. Grotstein, J. (1981). Splitting and Projective Identification. New York: Jason Aronson.Google Scholar
  30. Grotstein, J. (1990). Invariants in primitive emotional disorders. In L. Boyer & P. Giovacchini, (Ed.), Master clinicians on treating the regressed patient. Northvale, NJ: Jason Aronson.Google Scholar
  31. Grotstein, J. (1993). Boundary difficulties in borderline patients. In B. Boyer and P. Giovacchini, (Eds.), Master clinicians on treating the regressed patient (Volume 2). New York: Jason Aronson.Google Scholar
  32. Heller, N. (1990). Object relations and symptom choice in bulimics and self-mutilators. Doctoral dissertation, Smith College School of Social Work.Google Scholar
  33. Juno, A., & Vale, V. (1989). Modern primitives: An investigation of contemporary adornment and ritual. San Francisco: Re/Search Publications.Google Scholar
  34. Kahan, J., & Pattison, E. (1984). Proposal for a distinctive diagnosis: The deliberate self-harm syndrome. Suicide and Life Threatening Behavior. 14, 17–35.Google Scholar
  35. Kaufman, M., & Heiman, M. (Eds.). (1964). Evolution of psychosomatic concepts—anorexia nervosa: A paradigm. New York: International Universities Press.Google Scholar
  36. Kernberg, O. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson.Google Scholar
  37. Khantzian, E. (1985a). The self-medication hypothesis of addictive disorders: Focus on heroin and cocaine dependence. American Journal of Psychiatry, 142,11, 1259–1264.Google Scholar
  38. Khantzian, E. (1985b). Psychotherapeutic interventions with substance abusers—The clinical context. Journal of Substance Abuse Treatment, 2, 83–88.Google Scholar
  39. Khantzian, E. (1987). Substance dependence, repetition and the matter of addictive suffering. Presented at 76th annual meeting, American Psychoanalytic Association, Chicago, IL, May 9, 1987.Google Scholar
  40. Khantzian, E. (1989). Addiction: Self-destruction or self-repair? (Editorial). Journal of Substance Abuse Treatment, 6, 75.Google Scholar
  41. Khantzian, E., & Mack, J. (1983). Self-preservation and the care of the self: Ego instincts reconsidered. Psychoanalytic Study of the Child, 38, 209–232.Google Scholar
  42. Krueger, D. (1989). Body self and psychological self. New York: Brunner Mazel.Google Scholar
  43. Krystal, H. (1978). Trauma and affects. Psychoanalytic Study of the Child, 33, 81–116.Google Scholar
  44. Lacey, J.H. (1993). Self-damaging and addictive behaviour in bulimia nervosa: A catchment area study. British Journal of Psychiatry, 163, 190–194.Google Scholar
  45. Le Blanc, A. (1994, August 14). Gang girl: While Manny's locked up. The New York Times, 6, p.26.Google Scholar
  46. Lesser, W. (1995). Everybody is peculiar. Review of Oliver Sacks' An Anthropologist on Mars (1994). New York Times Book Review, February 19, 1995.Google Scholar
  47. Mahler, M., Pine, F., & Bergmann, A. (1975). The psychological birth of the human infant. New York: Basic Books.Google Scholar
  48. McCann, L., & Pearlman, L. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131–149.Google Scholar
  49. McDougall, J. (1974). The psychosoma and the psychoanalytic process. International Review of Psycho-analysis. 1, 437–459.Google Scholar
  50. McDougall, J. (1989). Theatres of the body: A psychoanalytic approach to psychosomatic illness. New York: Norton.Google Scholar
  51. Miller, D. (1994). Women who hurt themselves: A book of hope and understanding. New York: Basic Books.Google Scholar
  52. Ogden, T. (1990). On the structure of experience. In B. Boyer, & P. Giovacchini (Eds.), Master clinicians on treating the regressed patient. (pp. 69–95). New York: Jason Aronson.Google Scholar
  53. Pattison, E., & Kahan, J. (1983). The deliberate self-harm syndrome. American Journal of Psychiatry. 140, 867–872.Google Scholar
  54. Richards, A.K. (1992). The influence of sphincter control and genital sensation on body image and gender identity in women. Psychoanalytic Quarterly, 61.3, 331–351.Google Scholar
  55. Ritvo, S. (1988.) Mothers, daughters, and eating disorders. In H. Blum, Y. Kramer, A.K. Richards, & A.D. Richards, (Eds.), Fantasy, myth, and reality. Madison, CT: International Universities Press.Google Scholar
  56. Rosenfeld, D. (1990). Psychotic body image. In L. Boyer, & P. Giovacchini (Eds.), Master clinicians on treating the regressed patient. Northvale, NJ: Jason Aronson.Google Scholar
  57. Rosenthal, R., Rinzler, C., Walsh, R., & Klausner, E. (1972). Wrist-cutting syndrome: The meaning of a gesture. American Journal of Psychiatry, 128,11, 47–52.Google Scholar
  58. Sacks, O. (1995). An anthropologist on Mars: Seven paradoxical tales. New York: Alfred A. Knopf.Google Scholar
  59. Schemo, D. (1996, May 22). Recife journal: The decorated veterans of Brazil's stark streets. The New York Times, p.4.Google Scholar
  60. Simeon, D., Stanley, B., Frances, A., Mann, J., Winchel, R., & Stanley, M. (1992). Self-mutilation in personality disorders: Psychological and biological correlates. American Journal of Psychiatry, 149, 221–226.Google Scholar
  61. Simpson, C., & Porter, G. (1981). Self-mutilation in children and adults. Bulletin of the Menninger Clinic. 45,5, 428–438.Google Scholar
  62. Stoller, R. (1991). Pain & passion: A psychoanalyst explores the world of S & M. New York: Plenum Press.Google Scholar
  63. Taylor, G. (1987). Psychosomatic medicine and contemporary psychoanalysis. Madison, CT: International Universities Press.Google Scholar
  64. Taylor, G., Bagby, R., & Parker, J. (1991). The alexithymia construct: A potential paradigm for psychosomatic medicine. Psychosomatics. 32,2, 153–164.Google Scholar
  65. Terr, L. (1990). Too scared to cry: Psychic trauma in childhood. New York: Harper and Row.Google Scholar
  66. Terr, L. (1994). Unchained memories: True stories of traumatic memories lost and found. New York: Basic Books.Google Scholar
  67. Turnbull, J., Freeman, C., Barry, F., & Henderson, A. (1989) The clinical characteristics of bulimic women. International Journal of Eating Disorders, 8,4, 399–409.Google Scholar
  68. Tustin, F. (1981). Autistic states in children. London: Routledge and Kegan Paul.Google Scholar
  69. van der Kolk, B. (1989). The compulsion to repeat the trauma: Re-enactment, revictimization, and masochism. Psychiatric Clinics of North America, 12,2, 389–411.Google Scholar
  70. Waelder, R. (1930). The principle of multiple function: Observations on overdetermination. Psychoanalytic Quarterly, 5, 1936.Google Scholar
  71. Walsh, B. (1987). Adolescent self-mutilation: An empirical study. Unpublished doctoral dissertation, Boston College Graduate School of Social Work.Google Scholar
  72. Walsh, B., & Rosen, P. (1988). Self-mutilation: Theory, research and treatment. New York: Guilford.Google Scholar
  73. Weiner, H., & Fawzy, F. (1989). An integrative model of health, disease, and illness. In S. Cheren (Ed.), Psychosomatic medicine (Vol. 1). Madison, CT: International Universities Press.Google Scholar
  74. Welbourne, J., & Purgold, J. (1984). The eating sickness. Bristol, England: Harvester Press.Google Scholar
  75. Wilson, C. (1983). The family psychological profile and its therapeutic implications. In C.P. Wilson, C. Hogan, & I. Mintz (Ed.). Fear of being fat: The treatment of anorexia and bulimia. Northvale, NJ and London: Jason Aronson.Google Scholar
  76. Wilson, C. (1986). The psychoanalytic psychotherapy of bulimic anorexia nervosa. Adolescent Psychiatry, 13, 274–314.Google Scholar
  77. Wilson, C.P. (1988). Bulimic equivalents. In H. Schwartz (Ed.), Bulimia: Psychoanalytic theory and treatment. Madison, CT: International Universities Press.Google Scholar
  78. Wilson, C.P. (1989). Ego functioning in psychosomatic disorders. In C.P. Wilson, & I.L. Mintz (Eds.), Psychosomatic symptoms: Psychodynamic treatment of the underlying personality disorder. New York: Jason Aronson.Google Scholar
  79. Winchel, R. (1991). Self-mutilation and aloneness. Academy Forum of American Academy of Psychoanalysis, 35, 10–12.Google Scholar
  80. Winchel, R., & Stanley, M. (1991). Self-injurious behavior: A review of the behavior and biology of self-mutilation. American Journal of Psychiatry, 148,3, 307–317.Google Scholar
  81. Winnicott, D. (1949). Mind and its relation to the psyche-soma. In Collected papers: Through paediatrics to psychoanalysis. New York: Basic Books.Google Scholar
  82. Winnicott, D. (1953). Transitional objects and transitional phenomena: A study of the first not-me possession. International Journal of Psycho-Analysis, 34, 89–97.Google Scholar
  83. Witherspoon, T. (1990). Self-destruction. Employee Assistance, 2, 11–14.Google Scholar
  84. Yaryura-Tobias, J., & Neziroglu, F. (1978). Compulsions, aggression and self-mutilation: A hypothalamic disorder. Orthomolecular Psychiatry, 7, 114–117.Google Scholar
  85. Yaryura-Tobias, J., Neziroglu, F., & Kaplan, S. (1995). Self-mutilation, anorexia, and dysmenorrhea in obsessive-compulsive disorder. International Journal of Eating Disorders, 17, 33–38.Google Scholar
  86. Yellowlees, A. (1985). Anorexia and bulimia in anorexia nervosa. British Journal of Psychiatry, 146, 648–652.Google Scholar
  87. Zakin, D. (1989). Eating disturbance, emotional separation, and body image. International Journal of Eating Disorders, 8,4, 411–416.Google Scholar

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© Human Sciences Press, Inc. 1997

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  • Sharon Klayman Farber

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