خشم درونی، خودکنترلی و تجربه تسلط در نوجوانان بی اشتها بستری شده

Objectives: To evaluate the implications of internalized anger, self-control and experience of mastery for adolescent girls with severe anorexia nervosa (AN). Methods: Internalized and externalized anger, internal and external control, mastery, use of methods for self-control, and severity of anorexic symptoms were measured by self-report questionnaires in inpatient anorexic teenagers (N=26), inpatient female adolescent psychiatric patients (N=24), and a normal female comparison group (N=29). Results: Internalized anger was significantly higher in both the anorexic and general psychiatric patients as compared to normal controls, but this difference was significant only for the anorexic patients. Anorexic and general psychiatric patients experienced significantly less mastery than normal controls, but again this difference was significant only in the anorexic group. Within the anorexic group, severity of symptoms correlated significantly with internalized anger, low mastery, and external locus of control, and negative significant correlations among control measures and anger were found. Total length of hospitalization correlated positively with internalized anger only for the anorexics. Conclusion: The findings support the notion that internalized anger and defective experience of self-control are important factors in the psychopathology of adolescent anorexic inpatient females The results may have implications for the clinical management of patients with severe AN.

Anorexia nervosa (AN) has been a focus of both clinical and theoretical interest for at least two centuries. Two issues that have attracted particular attention are the roles of anger and control in the etiology of anorexia. More specifically — the parts played by internalized anger and self-control (including locus of control and mastery) have been the subject of many theoretical writings on this topic. Anger and anorexia Internalized anger is anger directed towards oneself and according to Bruch [1] and Crisp [2] is rooted in aggression to family members. These authors see the anorectic's anger as being due to family pressures that drive the girl to perfectionism and that force her to deny her autonomy. The family needs are seen as being placed above those of the girl making her feel bitter and resentful [3]. Moreover, social influences that encourage women to be passive and restrain their expression of anger contribute to the anorectic girl's need to turn anger inwards and to express this feeling indirectly. Thus, anorexia can be conceptualized as both an aggressive act towards family and society and as a self-punishment for these unacceptable hostile wishes [4] and [5]. In similar vein, Friedman [6] has described a family constellation, which makes the girl feel responsible for other people's hurt. As a result, she sees anger as being destructive and painful and feels guilty whenever angry feelings arise. Engel and Meier [7] found that AN patients reported more internalized anger and anxiety than patients with other psychosomatic illnesses. Williams et al. [8] and Tiller et al. [9] also found that women suffering from eating disorders had higher levels of hostility than controls and that anorexic females had a greater tendency to turn their aggression inwards. In contrast, Ondercin [10] examined angry and dependency feelings in college students with AN using the Revised Picture Identification Test and found that the AN subjects felt less angry and more dependent than healthy and obese controls. However, the AN subjects were only mildly impaired and were receiving therapy in a student counseling service. Control and anorexia The feeling of being controlled by outside forces is another central theme in the classical formulations of Bruch [1] and [11] and Pallazzoli [12]. People feel control when they are mastering their internal or external environment, or when they are turning the unfamiliar to the familiar. Self-control is the process by which the individual directs his behavior or controls his drives [13] and [14]. Traditionally, the pre-morbid personality of girls with AN is described as being obedient and conformist with inner feelings of “pervasive ineffectiveness”. Bruch [1], Masterson [15], and Mushatt [16] ascribe the feelings of lack of control and mastery to a failure of separation — individuation and fear that too much autonomy will result in a loss of the loved object. Some system theorists such as Minuchin et al. [3] also stress this theme. These feelings are exacerbated with puberty as the adolescent girl loses control over her physical development [17]. Similarly, Waller et al. [18] and Wilson [19] postulated that the anxieties around loss of control form the basis of the fear of becoming fat, since the fantasy is that staying in a childish body will allow the girl to control her sexual desires. Thus, the pubescent sexual body comes to symbolize the danger of loss of control [2], [20] and [21]. These postulates have been the subject of a number of empirical studies. Some of these have found a relative lack of self-control in AN individuals. For instance: Roth and Armstrong [22], showed that lack of control of eating habits correlated with dysfunctional attitudes to food and suggested that these persons lacked control over their lives. Similarly, Rezek [23] and Shapiro et al. [24] reported the same. Contrary to these findings, Strober [25] found that AN individuals had significantly more self-control, “responsibility,” and “social presence” than depressed subjects. “Self-control” however, was scored using only one item from the California Personality Inventory. Locus of control has also been looked at in eating disordered subjects. Some individuals feel that there is a connection between their behavior and its consequences while others feel that consequences depend on factors external to oneself. This is not an either/or concept but rather a continuous psychological variable [26] and [27]. External locus of control appears to be a non-specific variable differentiating AN and other psychiatric conditions from normal controls in some samples [8] but not in others [28]. Interestingly, Hood et al. [29] looked at “ineffectiveness” in AN using a revised version of the Locus of Control Scale and reported that high internal locus of control in the areas of “fatalism” and “social systems” characterized younger, but not older anorexic patients. Mastery and anorexia The concept of mastery [30] is related to that of locus of control [26] and [27] and is defined as the person's belief in his ability to control significant events in his life and the feeling that one can control one's own life. Mastery enables the individual to cope with life stresses over which he has no control [30]. Although this concept has hitherto not been examined in AN, there appears to be a sound basis for hypothesizing that AN sufferers would have severe difficulties in this area. In summary, many theories of the development of anorexia in adolescent girls emphasize both the turning inwards of illegitimate aggression and anger as well as conflicts around issues of control and mastery. These ideas have been widely accepted by clinicians and have received some support from empirical testing. Although these studies have aided our understanding of the anorexic process, some of the findings are contradictory and require further elucidation. Moreover, most have focused on adults and not on adolescents though the disease is beginning to crystallize in adolescence. Thus, the interrelationships need more systematic study, especially in teenagers, and it was to this end that the present inquiry was undertaken. In addition, we were interested in assessing if these constellations were specific to AN or generic to other psychiatrically ill adolescents as suggested by Williams et al. [8], and therefore we also recruited a general psychiatric comparison group. This was done in order to control for non-specific effects of psychopathology such as those found in the study of sex abuse and eating disorder. Thus, when AN patients were compared to normal controls they showed a marked increase of a past history of sex abuse. However, when psychiatric controls are used as a comparison group this difference disappears [31], [32] and [33]. More specifically, we attempted to evaluate the hypothesis that anorexic girls experience more internalized anger and less self-control and mastery than other girls with psychiatric illness and healthy controls, in addition to having a more external locus of control. We also hypothesized that lack of feelings of mastery and control would correlate with feelings of anger and symptoms of eating disorder. Since this was basically a pilot study we decided to limit our study to restricting anorectics and to compare them with a heterogeneous sample of adolescent psychiatric patients from the same unit and with healthy controls.