1. Introduction

Bulimia nervosa (BN) is an eating disorder in which an individual alternates overeating (usually foods with high calories) with purging (through vomiting or laxative use), overexertion, or fasting [1]. People who suffer from bulimia nervosa judge themselves a lot based on body shape and weight, so after overeating and feeling out of control, they are in deep regrets and would try to make up for it. Bulimics eat far more than the majority of individuals would (during a specific time period). People with bulimia might be lean, middle weight, or overweight, as opposed to anorexics who are extremely underweight. Bulimics frequently conceal their eating and purging from others. Bulimia can cause health problems induced by vomiting, laxatives and diuretics, such as low blood pressure, irregular heartbeat, fatigue, weakness, dizziness or fainting, and dental erosion.

Binge-eating disorder is a serious eating disorder that makes individuals repeatedly eat abnormally large quantities of food and feel that they cannot stop [1]. It may be seen as an important episode of bulimia, followed by distress, disgust or guilt, but without compensating purging or fasting (i.e., marks of bulimia nervosa). Binge eating can result in weight-related health problems like fatty liver disease, diabetes, hypertension, high cholesterol, and triglycerides. Additionally, those who suffer from binge eating disorder frequently show low self-esteem, feeling out of control, furious, or helpless, and struggling to cope with intense emotions or stressful situations.

Being one of the methods of treatment of mental problems, psychoanalysis is a set of theories and therapeutic practices that deal partly with the unconsciousness [2]. Sigmund Freud, whose work was partly inspired by the therapeutic work of Josef Breuer and others, founded the estate at the beginning of the 1890s. Understanding how the unconscious mind controls conscious processes in a manner that interferes with normal psychological functioning is the main goal of the psychoanalytical approach. Repression, projection, and transference are all defense mechanisms identified by psychoanalysis. In psychoanalytical theory, repression is the removal of unpleasant memories, ideas, or emotions from the conscious mind [2]. These undesirable mental contents, which often imply cravings for sexual or violent behaviour or unpleasant childhood experiences, are pushed into the unconsciousness. When a forbidden drive threatens to reach the conscious mind, it is believed that suppression triggers anxiety and neurotic symptoms. Through free association and analysis of pent-up desires manifested in dreams, psychoanalysis aims at finding pent-up memories and feelings.

Projecting undesired emotions on someone else, an animal or an object is called projection. The term is often employed to describe defensive projection, or when someone else makes themselves feel bad. For example, if a peer is mocked for being frequently intimidated at school, the bully may project his own issues with self-worth onto the victim. Transference occurs when a patient brings strong feelings from a prior relationship in treatment and transfers these feelings to the therapist. This is frequently a subconscious action. Any sort of therapy revolves around the relationship between the patient and the therapist. Adversely, sometimes countertransference also occurs. It is when a therapist ceases to be objective toward their patients. For instance, therapists may cross ethical lines and divulge many details about their personal lives and draw focus away from the patient and toward themselves.

General statistics indicate that eating disorders account for at least 9% of the world’s population. Nine percent of the American population, or 28.8 million Americans, will suffer from an eating disorder at some point in their lives [1]. Many times, people with the disorders perceived to be somatic are actually psychological. Eating disorder is a unique type of disease, since it is usually hard to identify the problem of certain physiological structures. Instead, culture and social norms play a significant role in its formation. Nowadays people live in a fast-paced era, social attention fades as quickly as it comes. People’s insecurity of social attention can be released by food intake and eventually lead to issues in eating. Eating disorders can somehow be considered as a psychosomatic symptom. More severely, it is possible that the problem with eating is only one positive symptom that can be discovered, and the essential psychological issues are lying deeper. Under these circumstances, psychoanalysis, an approach targeting people’s unconsciousness, could be effective in treating eating disorders. Studying the underlying conflict would give people a better overview of the condition, which helps finding out the possible cause, giving proper medical care, and curing the patients radically. Furthermore, according to psychoanalysis, the family of origin is essential in one’s early childhood development and would further shape one’s personality over a lifetime. As a result, by modifying the parenting style, people can prevent more children from eating disorders or deal with one’s problem with eating before it turns into a disorder. When an eating disorder is detected early, the individual is more likely to recover.

2. The Role of Perfectionism

People’s difference in personality can be predictive in their likelihood of developing eating disorders. As people with high self-esteem, they will not care much about others’ perceptions or criticize their figure continually. In the study of Xiang and colleagues, psychopathological processes underlying, and personality traits of eating disorders (EDs) are evaluated in psychoanalytic perspective [3]. Researchers conducted case studies of patients with ED. Participants are required to recall their experience and the specific time that they first began to restrict food intake. Qualitative evidence reveals that the lack of control of life and perfectionism personality both contribute significantly to the development of ED. Most all the participants reported that begin restricting their food intake morbidly when feeling hopeless and powerless of their lives, and controlling diet and weight is regarded as a method to regain control and improve self-efficacy. Thus, ED symptoms and accompanying behaviors could be interpreted as a desperate attempt to make up for a profound sense of inferiority and a lack of control felt in other areas of the person’s life. Secondly, noted by the study, perfectionist participants tend to hold the standard implacable and unrealistic high for themselves. This personality trait fosters feelings of guilt, distaste and denial. It is therefore clear that the persistent obsession with weight and appearance plays a role in the development and maintenance of ED.

To know a person better, studying him in a bigger social environment is important, since the trait he shows in relationships may differ from which he shows alone. It is reasonable to guess that despite the personality, the way people getting along with others and coping with problems in social environments could also be influential in the formation of EDs. Rothschild-Yakar and colleagues compare 25 male eating disorder hospitalized patients between the ages of 14 and 24 years to 25 non-ED male controls who were matched for age in their investigation of interpersonal styles and degree of difference in male patients with eating disorders [4]. The two interpersonal styles of dependency and autonomy were significantly correlated across all individuals and within each study group, according to the findings. Men with EDs displayed significantly lower levels of differentiation (as assessed by the explicit self-reported DSI measure) compared to men without EDs, substantially higher levels of dependency, significantly higher levels of obsession with autonomy, self-criticism, and control difficulties, and significantly lower levels of differentiation. In discussions, according to object relations and interpersonal theories, the ability to create a distinct identity and a capacity for reciprocity depend on a secure attachment and an effective closure of the division individuation process. Lack of development of differentiation can cause problems with establishing clear boundaries between oneself and others, with the ability to distinguish between one’s inner psychological world and the outside world, and with the control of one’s emotions. These are all fundamental deficiencies of EDs.

3. Attachment, the Psychoanalytical Approach, and Eating Disorders

3.1. Attachment and Abnormal Eating Behaviors

Attachment theory is a psychological, evolutionary and ethological theory about relationships between humans. The importance of the nature of caregiving relationships in terms of evolution and developmental outcomes is the subject of attachment theory. A continually expanding body of research has expanded on the concept of patterns of attachment and its correlates in children as well as adults. This concept holds that people have an inherent desire to develop relationships with their caregivers when they are still young. Later attachments may be influenced by these early relationships.

The AAI generates an evaluation of “state of mind with respect to attachment” based on how a person describes their relationship with their primary caregivers as children [5]. Traditionally, attachment states of mind have been classified into three primary kinds. A secure state of mind is defined by interpersonal openness, trust, and a value for close relationships. Most people acknowledge their feelings, and they can be controlled in a healthy way. In order to avoid feeling the need for attachment, an insecure dismissive mindset has a propensity to distance oneself from others and to downplay or reject sensitivity. Interpersonal enmeshment and a propensity to become engaged in unbalanced negative emotions are traits of an insecure preoccupied state of mind, which makes it difficult to reflect on relationships in a constructive way. According to a fundamental tenet of attachment theory, young children form expectations about how they should interact with others based on their early relationships with their attachment objects. They develop what Bowlby called a “internal working model” (IWM) based on these initial experiences, allowing them to approach subsequent situations armed with some preconceived notions about how to respond in the face of threat. This IWM consists of a model of the self, a model of “the other,” and a model of the relationships between each of these components.

To examine EDs, it’s not enough to focus on outcomes. Researchers should trace back to the patients’ childhoods. As social animals, children have learned from people around them since they are young. It is natural that they observe and mimic their parents’ behaviors. Their parents’ mode of dealing with emotions would project directly on them. O’Dwyer studied the “eating disorder states of mind” in two parent families whose children are hospitalized for eating disorders [6]. The parent work was done in an inpatient eating disorder specialty unit where the majority of patients had anorexia, and some had pervasive refusal syndrome. Parents were not independently seen as part of the treatment plan, despite the fact that they were routinely seen in household therapy and for case management by a member of the multidisciplinary team. The findings reveal that both groups of parents exhibited, to varied degrees, a propensity for separating, ambivalence toward assistance, and challenges processing emotional events. It’s likely that parenting a child with an eating disorder led to the development of parents’ “Eating Disorder States of Mind”; as a result, parents may have become accustomed to controlling their emotions in this manner, almost as a mirror. Alternately, it’s likely that these mental states already predominate in some families, which would increase the possibility that children will express their emotions in a similar way to their parents.

Most of the ED patients are distressed when they eat abnormally, but they lose control of their behaviors. It seems contradictory, but if there are actually underlying meanings behind the eating behaviors, things can be explained. Novack examines adverse psychic and somatic experiences that might explain the emergence of EDs from studying the case of Julia, an anorexia patient [7]. Julia’s mother’s mode of using food to numb her negative emotions was likely to contribute to binge-eating behaviors. Negative emotions were viewed in Julia’s perspective as signs of “low blood sugar” or hunger. It is not surprising that Julia had difficulty distinguishing between bodily and mental sensations. This instance demonstrates how people with eating disorders frequently experience their symptoms as somatic issues for which they look for somatic remedies. In therapeutic interaction, paying attention to patients’ physical symptoms can create new avenues for accessing, and eventually verbalizing and reflecting on, internal states.

Parents are the most important people for children in their early childhood. Suitable parenting styles can build secure attachments between parents and children. These children live a healthy childhood, so the probability is high that they will develop into confident adults. However, children with an insecure attachment can be anxious and avoidant. The lack of love and nourishment might turn into an unsatisfied hunger when they grow up. Wooldridge conducts a study of binge eating disorder (BED) patients [8]. In these people, the hungry self has been subdued by a different element of the self that was developed as a result of an intense connection with an abusive parental figure. The majority of them had a difficult upbringing with a narcissistic mother who used the growing child to keep her narcissistic balance. Because they have needs that do not fulfill their goal, the youngster has developed a sense of guilt. One has a great “hunger” for emotional sustenance and companionship when their emotional requirements are not met. Need is largely dissociated and usually difficult to notice or address since it has become associated with shame. Binge eating is a way for people to express their emotions. Thus, when the defense structure temporarily fails, the patients start the binge eating episode to express hunger and aggression.

3.2. The Effectiveness of Psychoanalytic Treatment

Unconsciousness is a topic that is somewhat addressed by the theories and therapeutic techniques of psychoanalysis. In the course of treating ED patients, those with securer attachment maybe easier to deal with, since due to psychoanalytic theory, they have fewer inner conflicts. Daniel organizes a psychoanalytic psychotherapy (PPT) randomized clinical study for BN to treat patients with different types of attachment [5]. The experiment employed a randomized block design, stratifying according to the presence of a personality disorder and the requirement for continued psychopharmacological treatment. Higher attachment security was a predictor of better treatment alliances for BN, according to observational data from the study’s experiment. The association between EDs and problems with mentalization, which has its roots in attachment relationships, receives a great deal of attention in research. For certain ED patients, problems with mentalization and affect control are linked to issues with food and weight, which in the end stem from a personality type defined by insecure attachment. Major associations were seen between higher degrees of attachment insecurity and attachment stabilization and more frequent binge eating.

If ED patients’ somatic symptom is related to a specific meaning, targeting that meaning would be an important step in the treatment. Hamlin discusses fluid restriction, a type of EDs that has received less attention [9]. In a cohort of 20 adult inpatients of fluid restriction, all of them reported significant anxiety, depressive symptoms, or bipolar illness. By focusing on the symptoms’ underlying meanings, a psychodynamic approach of fluid restriction was used, and resulted in behavioral and emotional transformation. Although fluid restriction is still a diverse occurrence, viewing it through a psychodynamic lens reveals two similar themes: a strong desire for human connection and the expression of excruciating suffering, as well as a strong loathing for and separation from the body. In contrast to the patterns previously discussed in the psychoanalytic literature on eating disorders, Hamlin’s research focuses on how patients who actively restrict fluid intake display a “thirst” for connection. Patients can gradually release their emotional hunger and rejuvenate their bodies during treatments by being aware of their “thirst” and underlying discomfort.

Psychoanalytic therapy focuses on the unconscious part of mind that people normally can’t discover. Therefore, it can be helpful in solving eating disorders related to the meaning. On a cohort of patients with DSM-V diagnosed ED, Nowoweiski and associates examined the therapeutic efficacy of intensive short-term dynamic psychotherapy (ISTDP) [10]. Even after completing a full course of therapy, ED patients frequently suffer with unresolved or only partially erased psychiatric symptoms, making them susceptible to relapse and continuous excessive use of the healthcare system, so it is necessary to target unconsciously occurring mental and behavioral processes that could cause or maintain EDs. On the inventory, these cases demonstrated a significant pre-to-post-treatment improvement. The findings imply that ISTDP treatment can assist in lowering psychological discomfort in those with ED diagnoses. Having emotional needs unsatisfied, one develops a profound “hunger”, and can turn into EDs if cannot be properly addressed. Short-term dynamic psychotherapy helps lessen psychological distress.

4. Conclusion

EDs are more likely to develop in perfectionists, since their high standard of themselves often lead to a tight control on figure and weight in as a mean of controlling their lives. ED patients frequently exhibit higher degrees of reliance, noticeably higher levels of obsession with autonomy, self-criticism, and control issues, and noticeably lower levels of differentiation in interpersonal relationships. The “Eating Disorder States of Mind” that exists in parents can increase the likelihood that the young children will control their emotions similarly to their parents and result in raising a child with EDs. Patients’ bodily experience, especially their childhood experiences can reflect on their internal mind and behavior. Many of the ED patients lack emotional nourishment and accompanying, and develop an unsatisfied need, so binge eating is their way of expressing their emotions. Better therapeutic alliances in the treatment of bulimia nervosa were predicted by higher attachment security. Finding the cause of a patient’s underlying discomfort throughout treatment can gradually assist patients in quenching their emotional hunger and reviving their bodies. Patients with unmet emotional needs in the ED may benefit from brief dynamic psychotherapy.

Most studies included in this review applied the method of asking participants to recall past events or their childhood experiences. However, considering flashbulb memories and primacy effect, their memory might not be accurate. People tend to amplify events that have great emotional impact on them and events that happened when they first began to memorize things, so the memories have actually been re-processed many times. There is a high probability that what the participants stated differs from the reality. To solve this problem, longitudinal studies can be applied. Tracing a group of participants from child to adults is much more accurate. Researchers can first choose the children with distinct family of origin to be participants in their studies. As the participants grow up, their predispositions to EDs can be related back to their childhood attachment types. In this way, the results can not only avoid the effects of false memories, but also cohort effect. This review can also provide some insights for developing effective prevention and parent education programs.