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Eating Ones Words, Part I:

Concretised Metaphors andReflective Function in AnorexiaNervosaAn Interview Study

Finn Skarderud1,2*1Faculty of Health and Social Studies, Lillehammer University College,Norway2Centre for Child and Adolescent Mental Health, Eastern and SouthernNorway, Oslo, Norway

Anorexia nervosa still qualifies for the designation as an enigma,with an unclear aetiology and a psychopathology poorly under-stood. A striking clinical feature is the concreteness of symptoms.The concept concretised metaphor refers to instances where thereis a psychic equivalence between physical and psychic reality.Emotions are concretised.Objective: To contribute in a more precise language about thebodys symbolic roleembodiment in anorexia nervosa.Method: 10 female patients (age 1635 years) with anorexia ner-vosa describe in interviews how they conceive mindbodyrelations in their own lives.Results: Different concretised metaphors are described and cate-gorised, covering a wide range of bodily experiences and corre-

sponding emotions.Discussion: The occurrence of various concretised metaphors inthese cases suggests reduced symbolic capacity and impairedreflective function as a core psychopathological trait in anorexianervosa. This is the first of three companion papers. Part IIdevelops theory on reflective function in anorexia nervosa.Part III presents an outline for psychotherapy for anorexia nervosa.Copyright # 2007 John Wiley & Sons, Ltd and Eating DisordersAssociation.

Keywords: anorexia nervosa; embodiment; mentalisation; metaphor; psychoanalysis

INTRODUCTION

The overall aim of this study is further under-standing of the specific psychopathology ofanorexia nervosa. A more precise aim is to develop

a more precise language about the bodys symbolicrole in anorexia nervosa. Anorexia nervosa is astriking example of the complex nature of thehuman body. It is a basic premise here that thehuman body also functions as a symbolic tool, as alanguage to communicate with others and withourselves about matters beyond corporeality itself.Anorexia nervosa almost always originates from thepersons wish and attempt to change. Changingher/his actual body composition is striving to

European Eating Disorders ReviewEur. Eat. Disorders Rev. (in press)

* Correspondence to: Professor Finn Skarderud, Institute foreating disorders, Kirkeveien 64 B, N-0364 Oslo, Norway.Tel: 47 918 19 990.E-mail: [email protected]

Copyright# 2007 John Wiley & Sons, Ltd and Eating Disorders Association.

Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.777


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change oneself, in psychological, moral, religious,spiritual or social senses.

One key clinical feature in anorexia nervosa is theconcreteness of symptoms. The patient presentsher/himself with a cognitive and emotional over-

concern with bodily qualities, like body shapeand weight. Many persons with anorexia nervosadescribe this concern as obsessional, and experiencethe here and now of their bodies as a ruthlessreality difficult to escape from. This concretism inanorexia nervosa (Buhl, 2002) is often experiencedas an obstacle to recovery. Here it is discussed inrelation to reflective function. The term reflectivefunction is well known in developmental psycho-logy and refers to the psychological processesunderlying the capacity to make mental representa-tions (Fonagy, 1989).

Central concepts in this presentation are embodi-

ment, metaphor and concretised metaphor:

Embodiment

The tradition of Western thinking has been sadlynegligent in its treatment of the body. During thelast decades there has been a rediscovery of thebody in many academic disciplines. In such contextsembodiment is a more accurate expression than thebody, since the academic works are not aboutthe body per se. Instead, they are about bodilybeing-in-the-world, an existential position in whichthe body is a subjective and intersubjective groundof experience.

A major reference is the French philosopherMaurice Merleau-Ponty (1962). Merleau-Ponty raisesobjections to Descartes dualism between body andsoul, and the bodys split history by introducing theconcept of corps propre ( the lived body). In theCartesian tradition it is the physical characteristics ofthe phenomena, which are examined. By using theconcept of the lived body Merleau-Ponty attempts todiscover deeper meanings in ones experience thatonesown body is more than its physical aspects. Thebody is not a mechanical object responding to thestimuli in its environment. It is in lively interactionand in an ongoing dialogue with the world. The bodyis experiencing, acting and intentionally seeking outinto the world; it is always existential (Duesund &Skarderud, 2003). In this text the emphasis is on oneaspect of human embodiment. That is the role of thebody in symbolisation, hence the metaphor.

Metaphor

Metaphor is one of the main figures from classicGreek rhetoric. Aristotle (1984) defines the

metaphor in poetics as giving something aname that belongs to something else (p. 1457).The essence of the metaphor is to understandand experience one phenomenon through anotherphenomenon. The metaphor is a subgroup of

symbols. The metaphor is defined as being basedon resemblance, a similarity between the phenom-enon in the source area and the target area (Lakoff& Johnson, 1999). There is a similarity-in-difference.

Concretised Metaphor

Concretised metaphors refer to instances wherethe metaphors are not experienced as indirectexpressions showing something thus mediated,but they are experienced as direct and bodilyrevelations of a concrete reality (Enckell, 2002).There is an immediate equivalence between bodily

and emotional experience.The traditional interest has been in the linguisticmetaphor. But in the last decades authors haveexpanded the model of the metaphor to more thanlinguistic representations, like memories, feelingsand dreams. The philosophers George Lakoff andMark Johnson (1980, 1999) have been leadingfigures in terms of changing interpretations ofmetaphor from being purely a phenomenon inlanguage, a rhetoric or artistic figure of speech, tobecoming a model for the general function of mind.In their view, mind is always embodied. Theyconvincingly describe the embodied mind and

how sensorimotor experiences constitute the basisfor conceptualising. The metaphor is based on theperception of physical realities, like gravitation,sounds, vision, tactility, etc., for example, thedepressed person feels down and burdened byheavy thoughts; both examples refer to ourexperiences of gravitation organising our concep-tual system in up-down and light-heavy. Themetaphor is pervasive for mental representations,for human understanding, fantasy and reason. Themetaphor is basic, but often not conscious.

In this paper it is a basic assumption that the bodyalso functions as the source area for metaphors.

Sensorimotor experiences and bodily qualities andsensations, like hunger, size, weight and shape,are physical entities that may also representnon-physical phenomena. This is highly relevantin anorexia nervosa. In concretised metaphorssuch bodily metaphors do not function mainly asrepresentations capable of containing an experi-ence, but as presentations which are experiencedas concrete facts here-and-now and are difficultto negotiate with. The problem is to distinguish

Copyright # 2007 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev.(in press)

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between the metaphor, and the object or pheno-menon which is metaphorised. The as if of themetaphor as a figure is turned into an is.

This study aims to be original in the systematicdescription and categorisation of different body

metaphors, as presented in research interviewswith female patients with anorexia nervosa, and inrelating these to reflective function. The presenta-tion is divided into three parts. This first of threecompanion papers presents results from an inter-view study with patients with anorexia nervosa.Part II (Skarderud, 2007a) brings forth theoreticalmodels about reflective function in anorexianervosa. Part III presents an outline for psychother-apy for anorexia nervosa (Skarderud, 2007b).

METHOD

This study is based on qualitative research. Theinformants are female patients with anorexianervosa. All of them are recruited from the authorsown psychotherapeutic practice. There are twomain sources to the data analysed, due to the wishto increase research quality through methodologicaltriangulation.

Research interviews with patients in active treat-ment for anorexia nervosa. All interviews weredone by the author. The interviews followed amanual for semi-structured interviewing.

Transcripts from therapy sessions with the samepatients.

An additional source is medical data and processnotes from their medical notes. Such data were notactively used in the analysis. They contribute with awider context for interpretations, but may alsorepresent a bias. The study was approved by theMedical Ethical Committee.

Participants

Ten female patients participated in this study. Theywere between 16 and 35 years. A necessary criterionfor inclusion in the study was the fulfilment of the

diagnostic criteria for anorexia nervosa according toDSM-IV (American Psychiatric Association, 1994).Seven of ten had suffered from the restrictivesubtype of anorexia (ANR), where the mainsymptom is restriction of food. The remaining threecorresponded to the bulimic subtype (ANB), withepisodes of bingeing behaviour. Body Mass Index(BMI) at the time of interview varied in a range from10.8 to 17.2, median 16.2. BMI is calculated frombody weight divided by square of the height. BMI

less than 19 is defined as underweight. Nine of tenhad their symptom debut and had also beendiagnosed before they were 18 years old. Thetenth patient started with her anorexia at the age of19 years. The patients had been diagnosed for

anorexia nervosa from 5 months to 19 years, median5.4 years.At the point of time for data collection all the

informants, hereafter called patients, were in activetreatment with the author. The context for thetreatment was a private psychotherapeutic practicewith public funding. Some of the patients hadadditional therapy contacts, from a psychomotoricphysiotherapist or music therapist. All of them hadbeen treated by the author for more than 6 months.In this context treatment means individual psy-chotherapy, with a session every week or everysecond week. The psychotherapeutic approach

is mainly based on psychodynamic models, withconsiderable integrations with elements fromcognitive and psychoeducative traditions.

Data Collection

The patients were thoroughly informed, verballyand in text, about the aims of the study, and theirtherapists dual role as clinician and researcher. Theresearch interview was presented as separatedfrom the therapeutic context. The patients signeda written declaration of consent. Both verbally andin text there was great emphasis on that all

participation in the study was voluntary, and thatabsence from participation would have no negativeconsequences. But it is of course difficult to assesshow much liberty the patients actually experienced.One patient of the eleven said no to the invitation toparticipate. She feared that recorded sessions,interviews or transcripts could get in wrong hands.Due to a limited number of patients fulfillingthe criteria for anorexia nervosa in the psychother-apeutic practice, the data collection lasted for 2years.

Research interviewsThe interviews were semi-structured. In the

information given to the patients in advance, thefollowing themes were presented:

The history of your eating disorder with yourown words. Attributions: Your ideas why youhave got such a problem.

Important turning points, for the better or worse. How the eating disorder impinges on your life,

negative or positive aspects.


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The interaction between emotions and cognitionsand body shape, weight and food.

In a semi-structured interview the written guide isnot used slavishly. The interview may followdifferent themes that appear in the dialogue. In

the practical accomplishment, emphasis, in theinterview sessions, was put on clarifying, repeating,confirming and diving deeper into the answers.Such a practice corresponds to what Kvale (1996)describes as communicative validity or memberchecks (Denzin & Lincoln, 2000). These aremethods to improve the validity. The interviewinglasted for approximately 1 hour.

Therapy sessionsFour consecutive therapy sessions were recorded.

This was done before the interviews, in a time spanof up to 3 months before the research interviews.Four consecutive sessions were chosen partlybecause this gives more data, but also to reducethe possible impact of experiencing the recording asa stressor. The patients may behave differently/bemore shy or timid when recording is introduced. Arecorder is not usually used in sessions. Interviewsand therapy sessions were transcribed by oneassistant in Word text format.

Reflections on Method

In a discussion on the method used in the present

study it is inevitable to look into the dual role astherapist and researcher.There are certain basic differences between the

roles of clinician and researcher. For the researcher,the goal is the generation of knowledge. For thepsychotherapist, the patients therapeutic improve-ment is the goal (Fog, 1994). In combining both, onemust serve two masters. This can lead to ethicalproblems that must be addressed in every materialinstance. In the opinion of the author, no seriousethical objections were experienced in this caseconcerning the dual role of researcher/therapist.The nature of the task is such that it is compatible

with therapeutic aims: the patients improvedself-understanding and articulation of her ownsituation. In fact, a change of the context for thedialogue may itself be advantageous for thetherapeutic process. The research practice takesits place in a context an ongoing therapeuticrelationshipwhich is basically oriented towardsincreased self-understanding and insight. In thatmanner, the twofold contexts may be seen as partialaspects of a common context of inquiry and

introspection. It is also essential to repeat the factthat the researcher/therapist has more comprehen-sive background information about the patients,and that this may influence the interpretations.

The fact that the therapist accomplishes

research interviews with his own psychotherapypatients must be viewed as an intersubjectiveco-construction of meaning. This particular taskshould be seen as a part of the dialogical process, inwhich research and therapy cannot distinctly beseparated. One must be willing to accept that thepatients have, in varying degrees, assimilatedterms, expressions, fragments or entire modes ofreasoning that form part of the therapists/researchers preconceptions. And that the patientsanswers in the research context are also a communi-cation to the therapist. This may contribute tocircular proofs. And one may critically state that

anorectic patients are a risk group, being com-pliant with the interviewer. The group as such isdescribed as other-directed, sensitive to and depen-dent on others needs and views (Buhl, 1990).

Analysis

A computer programme, NVivo, was used for thequalitative text analyses (Gibbs, 2002). With refer-ence to the main research questions in this paper,the text analysis was carried out in five consecutivesteps:

1. First, all statements involving food and/or bodywere marked. The computer program is basedon making so-called nodes. This part of theanalysis selected excerpts from the text withreference to two basic nodes, food and body.That includes all kinds of mentioning of thesetopics.

2. Second, the next step was a further selection of allof these statements that made a connectionbetween food and/or body and descriptions ofemotions or cognitions, that is an empty stomachgives me a sense of being strong. Hence, state-ments about food and/or body without such

emotional-cognitive valuation were eliminated.In practical analytical work the context ofinvestigation of such linkages were two to threeconsecutive paragraphs in the transcripts. Theselected parts could vary from very brief state-ments to coherent narratives.

3. The third step in the analysis was a furtherselection of those of the statements which con-tained direct descriptions or indications of asimilarity between the emotional-cognitive state


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and a sensorimotor experience, that is controll-ing my appetite gives me a feeling of control inother areas of my life.

4. A fourth step was to categorise such body meta-phorsto arrange the different units of meaning

into categories. New nodes were created con-secutively in the analytical work, defining dif-ferent forms of body metaphors.

5. Finally these categories were organised in a hier-archy, in relation to superior common categories.

In the analyses, the interviews and transcribedtherapy sessions were originally treated as separatedata sources. The same process of analysing, asdescribed above, was carried out for both sets. Butin the finishing phase the main categories wereintegrated. It is the authors view that the two textmaterials did not differ markedly in content, but

more in form. This can easily be controlled bythe extracted texts and nodes created in thedifferent text sources in the data program. In thetranscribed texts from the therapy sessions,categories were developed from more fragmentedand abrupt statements, while the texts from theinterviews gave more coherent narratives andarguments.

RESULTS

In analysing the texts there are numerous state-

ments that illustrate symbolisation via the body.Here they are conceptualised as body metaphors,where bodily qualities and behaviour representsemotional, social or moral phenomena. Many of thepatients statements illustrate the very concrete anddirect character of many of the body metaphors. It isstriking how such statements point to a basic andclose relationship between emotion and physicalbody, a more or less immediate translation. Inthese body metaphors there is a striking closeness, adirect analogy and primary relation betweenemotions and different sensorimotor experiences.Emotional experiences are organised and felt, based

on different domains of physical life. Emotions areconcretised.

Categories from the analyses will be presented.The final categorisation ended up with two maincategories. A distinction was made between specificand compound body metaphors. Specific bodymetaphors refer mainly to one domain of thesensorimotor experience. They are more local.They are presented here, referring to their differentdomains of physical experience. Compound body

metaphors may be based on some or more of thespecific metaphors. They are more global, beingless distinct concerning the sensorimotor domain orphysical experience. It can be difficult to distinguishbetween some of the categories. Hence, they are not

reciprocally expelling, but rather different punctua-tions of the anorectic experience. The differentcategories are presented by text examples from thetranscripts. In the presentation of results there isno reference to the frequency of the differentcategories, considered not to be the topic of thisstudy. The topic of the study is to elucidate thephenomena.

Specific Metaphors

In the superior category specific body metaphorslisted in Table 1 will be described. These sub-

categories are not meant to be complete. Interviewswith more patients with anorexia nervosa wouldincrease the number of examples.

Emptiness/fullnessFear of eating and of gaining weight is a key

feature in anorexia nervosa. But statements alsounderscore the metaphorical connections betweeneating as an act of filling oneself and emotions ofbeing overwhelmed. Too much is not only aboutthe physical amount of food, but also about theproblem of handling difficult emotions and cogni-

tions. The feeling of too much induces the urge foremptying.

Sol:I am so confused. It is simply too much for me.I have to reduce. I am completely filled up. In someway or another I do have to empty myself. (Sherefers to her frequent vomiting and misuse of

large doses of laxatives.)

Hanna:Some days ago I should have had a meetingwith my boss. I was anxious about this. Then Idecided to vomit. I couldnt stand having the lunchin my stomach. I cannot have anything in my

Table 1. Specific body metaphors

Emptiness/fullnessPuritySpatialityHeaviness/lightnessSolidityRemoval


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stomach, because then I cannot concentrate. I needto be empty to feel alert.

Both cases illustrate the immediate metaphoricalconnections between the physical act of emptyingthe stomach and bowels, and clarifying ones mind.

PurityThis category is close to the former. But there are

significant differences. Purity has connotations toascetism and spirituality, often relevant in anorexianervosa. Pure food refers to low fat and low calories.But some of the patients also describe purity as fewitems of food, served separately and not blended.This serves to keep an overview and certainty ofwhat one takes in. The purity and certainty on theplate refers to the longing to simplify ones life.

Emily: My anorexia was there when everythingelse seemed unpredictable, excessive, in a franticstate. Its austerity, its plain, straightforward andconcrete nature infused the unsure with somethingsafeit served as a channel to something morebasic, minimalist, uncluttered, pure.

This statement compounds purity withreductionminimalistmaking the anxiousand emotionally overwhelmed Emily getting incontact with some basic experiences.

Sol:I became so pure, I hadnt sullied myself with

food, conversation with others, or dirt on my body.Sol speaks about the period in adolescence when

her anorectic symptoms started, how she isolatedand devoted herself to this condition. In thisstatement, in one single sentence, purity is con-nected to three different realms; physical dirt, foodand relations to others. This category demonstratesa metaphorical link between a physical experienceof purity and simplicity and an emotional andrelational reality.

Spatiality

This category is about the concrete sensations ofoneself filling space, meaning size, and the meta-phorical links to the feelings of being allowed totake space emotionally and in relations.

Else: I am a hopeless person, not worth loving.Everything I do is stupid. I should not have beenborn, and very often I do think that I do not deserveto live. I cannot stand myself, I cannot stand moreof myself than this(referring to her actual body size

with her hands). If I grow bigger, it will beunbearable.

Ingrid:It is difficult enough as it is. How big can Ibe? It is not about fat, it is about how much of me?

How can I stand it if it becomes even more of me?

Again, through the two cases, it is demonstratedhow there is close and immediate relationshipbetween a physical experience, and an emotionaland relational analogue; with low self-esteem andnegative self-evaluation linked to the sense of notbeing worthy taking up space.

Heaviness/lightnessThe patients statements confirm how weight

phobia is a key feature in anorexia. But they also

show how the experience of weight goes beyond thepure physical experience. Some of the patients referto a correspondence between the physical experi-ence of weight and heaviness, and negative feelingsof being burdened. Lightness is a relief, both aphysical experience and an emotional state of relief.

Christina:I dream of being so light that I can floatin the air. Then I can move down the main streetamong the people, one meter above the ground, andI will feel that all my worries are gone, lifted off myshoulders.

Karen: I feel sad. And when I am sad, I feelburdened and heavy. . . and then comes the urge tolose weight.

The last statement shows how a physical sen-sation follows an emotional reaction; emotions areconcretised within a realm where she is obsessivelyworried.

SolidityThe physical contact with ones body, experien-

cing the hardness of the skeleton and/or trained

muscles, is underscored as important, bringingexperiences of predictability and reducing anxiety.

Hanna: Nobody can be trusted. Not my parents, nottherapists, neither my friends. I am disappointed allthe time. And then I get scared. I know it soundscrazy, but when I get scared, I really need somefixed points in my life. I need to feel my skeleton. Iwant physical contact with my bones. My bones areto be trusted. There have been times when I have


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gained weight. That has been extremely difficult; Ihave not been able to sense my firmness.

Maria: When I dont have access (to bones andskeleton),when there is something between what I

feel when I touch myself and my inside, then I getscared. I dont like it. Things are blurred.

. . .

I want to be hard. I will be hard as rock. Then Ibecome more distinct to myself. If there are dayswithout exercise, I sense that I am inert andterrible, and I lose control.

Emily: When my anorexia came, it concealed mysoft, open vulnerability. It defined the blurry edgesof my being with clear, hard straight lines; nodiffuse, wandering self, no doubts about what I was,where I started and ended, I became fixed andunfluctuating.

In all three cases the physical contact with thebodys solidity corresponds with the experience ofoverview and certainty.

RemovalThis category is constituted of examples of how

reducing body weight and body tissue metaphori-cally signifies to take something negative away.Getting slender relates to changing identity, takingsomething away and to open the possibility ofreconstructing a new self, for a new start.

Hanna:When I was in hospital, admitted because ofmy extremely low weight, I remembered thinkingthat this is good. The old, chaotic, unhappy me isgone, and this is a new opportunity. Now I amdown to bedrock. And this time I will be anotherperson.

Else:I felt guilty all the time. . .

People behaved farbetter towards me than towards my . . .friends. Ihad got too much of too many good things. I wasrich, and they were poor. And I had not deserved it.By not eating, I think I tried to be another person,by peeling off my outer parts.

Removing body tissue is equated with removingnegative emotions and cognitions. These two casesdemonstrate how issues of identity and psycho-

logical self are bodily concretised in anorexianervosa.

To sum up, specific body metaphors are named sobecause they so directly refer to one domain ofphysical experience relating to an emotional and

cognitive experience. This specificity makes clearthe equivalent relation between emotion/cognitionand sensorimotor experience/behaviour. It is worthemphasising that these quotations demonstratethat the drive for thinness in anorexia nervosarepresents far more than reducing weight as such.They refer to a rich diversity of meanings ofself-starvation, again based in a variety of bodilyexperiences, for example purity, spatiality andsolidity. And it is to be repeated, as shown, thatone patient can contribute to more of thesecategories.

Compound Metaphors

In compound body metaphors, different andmore domains of sensorimotor experience mayinteract with the experienced feelings. It is still thedirect translation from emotion and situation tobodily experience, but different functions of thebody may take part in these symbolic processes.The categories that will be presented here areVulnerability/protection, Control and Self-worth Table 2.

ControlControl and self-control are often referred to as

central psychological topics in anorexia nervosa(Surgenor, Horn, Plumridge, & Hudson, 2002). Theanorectic person, who has a feeling of not controll-ing her life, uses the control of appetite as a tool foran increased sense of control. There is a clearconnection between the concrete eating as a sourcearea and psychological control as a target area in themetaphorical process.

Emily:My anorexia is the mask I wear to hide mygooey, amorphous, swirling insides from seeping

out.. . .

In its absence, I feel I am being propelledalong forces outside myself, out of control, merging

Table 2. Compound body metaphors

ControlVulnerability/protectionSelf-worth


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into other roads without the time to react in anappropriate way. It helps me slow down and take alook around before I proceed. Through my eatingdisorder I have learned how I can avoid steep,crumbling roads, dark passages, and unknown

territory that bring with it an array of surprises. . .

The questions that haunted me, the fluxes of life,and the inexplicable desires were harnessed whenmy anorexia and I were working together in ourlofty pursuit of some unabashed true me. It wasguidance, or faint whispers of it, as an alternative tothe unfamiliar course I was travelling alongwithout brakes, road signs, and power steering.

. . .

I think my anorexia helped to restore some orderand direction to my life, and return to somethingmore wholesome when my environment seemedoverwhelming with endless choices. It assisted mein having not to choose. It was like a static,uncluttered refuge within me.

Elisabeth:I cant take any more changes. I need tocontrol my life. I want the state of things to remainconstant over time, so that existence is aspredictable as possible . . .When, in my anorexiccondition, I keep to a rigid food regime thatmaintains my weight at a very low level; itcontributes to creating the security and stability,the sense of control, in my existence that Ive neverhad.

Sol: My anorexia and I, together we had fullcontrol. It made me almost invulnerable. Otherpeople? Who were they? Ignorant, superficial,boring people who did understand absolutelynothing. For us their way of living was worthless,

we had something much bigger, better and moretrue. . .This not eating . . . was simply enormous. Atlast Id found a way of bringing order to a worldthat had been nothing but chaos.

Helena: When I got the message that T, whom Iloved so much, had committed suicide, the firstthing I did was to go on the scale. I was loosing thegrip, and I felt my body expanding. I needed to do

something about that. . .that was the time when Igot worse.

The transcripts from the interviews also demon-strate the possibility of a two-way direction in themetaphoric process. Bodily experiences induceemotional and cognitive experiences, like control-ling appetite may induce satisfaction. But emotionsmay also induce bodily sensations, as illustrated byHelena in the last statement.

Vulnerability/protectionMany of the patients descriptions of their eating

disorder refer to its role as a kind of protection. Theanorexia is described as a reaction to a sense ofvulnerability and of being unprotected, an open-ness in body and relations. An emotional andrelational openness induces a physical closing of

the mouth and the body.

Helena:Now I must get well! I cannot stand thisany longer. My anorexia has destroyed almost tenyears of my life. But I am so afraid of the last kilos. Iknow I must, and that I shall. But I lose my nerve .

Why? Well, I think it is because I then will giveaway a kind of protection. When people see metoday, they see that I am weak and vulnerable.When I have normal weight, they wont thinkanymore that I am weak. They will think I am

strong, and they will attack me and put heavydemands on me. I am not sure that I am readyenough.

Sol:I well remember when I became sick, the worldwas difficult, it was full of perhapses; perhaps Mumand Dad were going to divorce, perhaps we weremoving . . . and I was just supposed to stand thereand be too little to understand anything. Every-thing was just DOUBLE. At the same timeeverything gradually became chaos; nothing fitted;things werent the way I saw them, they said. I

found the world difficult, but that wasnt right,they said. When I got anorectic, I felt safer. I had amission. I could do things again. It protected me,understood me from top to toe from the verybeginning. That was incredibly lovely.

The protective nature of the anorectic syndromebecomes explicit through these statements. Majorityof the patients also comment on the feeling ofprotection related to boundaries. The eating


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disorder is described as a strategy for institutingboundaries, and boundaries are experienced aspositive and protective.

Elisabeth:A buffer against the cruelty in the world;that is what my anorexia represents. It makes meunique; I cannot be confused with other people. Ihave a distinct outline towards the rest of the world.

Maria:I was not able to limit myself; I did no knowwhere I started and where I ended. That is why I didlike this: (She describes with her whole body howshe diminished herself). Like from a grape to araisin.

Sol:. . . in an otherwise limitless world, I was sureof my limit. In a world of empty stomachs and

laxatives after the bouts of vomiting, I was certain,that boundary was quite certain, and the others hadno choice, they had to respect the limit I laid down.

These statements do, in various ways, illustrateproblems of identity in anorexia, striving to achievea more distinct experience of oneself and makingpsychological distinctions between inside and out-side, self and others. Majority of the statementscomment relations as potentially invading anddamaging. The anorectic no represents an exis-tential and psychological closing towards suchthreats.

Self-worthMany of the patients describe food not as a natural

good, but as a reward. This may be surprising forsome; they describe that they like food. The problemis that it is a luxury they cannot indulge in. Food isa benefit related to performance and efficacy,something one has to work hard for really todeserve.

Else:This has been a bad day. I am a lazy person, Ihave done nothing extra. I dont feel I deserve to eatanything today.

Again, there is a demonstration of the immediateconnection, in the sense of the close analogybetween the physical realm of eating and psycho-logical realities. This category also, again, clearlydemonstrates the central role of self-esteem andnegative self-evaluation in anorexia nervosa. Thiscategory covers the feeling of not deserving some-thing good, concretely expressed in food.

To sum up, these compound body metaphors aremore global than the specific local ones, and

referring to emotional and cognitive experiencesoften referred to as central in anorexia nervosa, tomention a few, the sense of vulnerability and athreatened and overburdened self, experiences oflack of control in different realms of life, and low

self-esteem inducing the feeling of not deserving.The compound body metaphors can be based on acombination of more specific body metaphors, thatis the sense of control can refer to an empty stomach,a firm and solid body, being thin and a feeling ofpurity. But what is considered as the main finding inthis main category of body metaphors, and similarto specific metaphors, is the immediate relationbetween emotion/cognition and sensorimotorexperience/behaviour.

DISCUSSION

In this discussion section the emphasis will be onthe interactions between body and mind aspresented above in the categorised statements frompatients with severe anorexia nervosa. A limitationto the study is the limited number of interviewees.One should particularly be aware of the risk ofextrapolating observed phenomena in a verylimited clinical group to the whole clinical popu-lation fulfilling the criteria for the same diagnosis.The selected group in this study may be skewed orin some senses atypical.

To conclude the results:

The categorised statements refer to a particularform of psychological functioning. The manyquotations from patients in this text demonstratethe immediate connections between physical andpsychological realities; the concretised feelingshere-and-now.

The transcripts from the interviews demonstratethe possibility of a two-way direction in themetaphoric process. Bodily experiences induceemotional and cognitive experiences, like thefeeling of hunger may induce satisfaction. But

emotions may also induce bodily sensations, likethe urge to bodily purification in complex socialsituations, or the feeling of bodily expansion instressful situations.

The many different categories of body metaphorsrefer to the polysemic character of embodimentin anorexia nervosa. Polysemi means that the signrefers to more meanings (Ricoeur, 1976; Johnson,1987). Some of the patients contribute to moreof the categories. They may contribute to different


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specific metaphors and also to more of thecompounds metaphors. This demonstrates anambiguous nature in body symbolic in thesecases of anorexia nervosa. There is no closedand unequivocal relationship between symptom

and meaning. This is more open. The patientsstatements demonstrate that denial of foodmay have many different, and also opposing,meanings at the same time. For the personwith anorexia, a slender or emaciated bodymay simultaneously signify both strength (con-trol) and weakness/vulnerability (hence, search-ing for experiences of protection). The anorecticbehaviour represents a psychological crisis, akind of poverty in mastering, but still the anor-ectic body is rich in a semiotic sense.

Reflective Function

The human body is unavoidably metaphorical. Weall ascribe a metaphorical meaning to the body thatgoes beyond the purely physical. This is neithermystical nor incomprehensible. But it is regularlyhidden, being an everyday experience. It is so closethat it is difficult to see.

The statements presented in this study illustrateinstances where the metaphors are not experiencedas indirect expressions showing something thusmediated, but they are experienced as direct andbodily revelations of a concrete, often ruthless,

reality. These bodily metaphors do not functionmainly as representations capable of containing anexperience, but as presentations which are experi-enced as concrete facts here-and-now and aredifficult to negotiate with. The as-if quality ofthe more abstract meaning of the metaphor is lostand it becomes an immediate concrete experience.This suggests impairment of the reflective functionof the mind.

Such impairments in reflective function in anor-exia nervosa have been described in terms ofconcretism (Buhl, 2002), concrete attitude (Miller,1991), psychic equivalence (Bateman & Fonagy,

2004; Fonagy, Gergely, Jurist, & Target, 2002) andconcretised metaphor (Enckell, 2002). These aredifferent namings of basically similar phenomena.Within the context of this study, with emphasis onmetaphorical processes, the concept of concretisedmetaphor is used. This is due to the fact thatthis concept has been thoroughly developed in apsychoanalytic context, linked to theory as well asclinical cases; hence being more than a puredescription. In a review of literature, mainly

psychoanalytic, Enckell (2002) refers to such andsimilar concretised body metaphors as a reductionof the capacity to use functioning metaphors; acollapse of the symbolic room between the bodyand emotion/cognition. Through bodily sensations,

the internal as well as the external world is givenform.A proposal for a distinction between pathological

and non-pathological ways of functioning is thelevel of freedom in the metaphorical processes.Persons with anorexia nervosa themselves oftenexperience their preoccupation with food, calories,weight and size as a pervasive obsession. Typically,the anorectic patient has unfortunately little con-scious awareness of the metaphoric connectionsbetween her/his concrete symptoms and theunderlying emotions and sense of self.The anorecticproblem is not that thinking is metaphorical but rather

that she/he is possessed by these interactions of body andmind. The patient is used by rather than using themcritically in his/her thinking and acting.

There is an agreement among many authors thatsuch phenomena represent a regression or aninsufficient development of symbolic capacity(Enckell, 2002). Campbell and Enckell (2002),among others, propose that concretised metaphorscan be viewed as restitutional efforts. The concretepresentation can be seen as a reaction to a threat ofinner fragmentation, and an attempt to maintain acohesive mental configuration, albeit a concreteone. Different forms of stress may threaten the

integrity of the self, and through concretisationthese persons attempt to bolster their sense of selfby trying to strengthen the experience of beinggrounded in their own bodies. Hence, the con-cretisation of metaphorical processing describedhere points to a vulnerable or distorted self-organisation in anorexia nervosa. This will befurther developed in Part II of this study.

The Polysemic Body

The results demonstrate that there is no unambigu-ous or closed relationship between food denial in

anorexia nervosa and metaphorical content. In thehistory of anorexia nervosa, there are numerousexamples of descriptions of possible meanings ofsymbolisation via the slender body. From the verybeginning, since the diagnosis anorexia nervosa wasmade by Gull in England in 1872 and hystericalanorexia by Lasegue in France in 1873, there havebeen interpretations of the sexual, or rather anti-sexual, nature of the symptoms (Lasegue, 1873/1965). Psychoanalysis has without doubt been


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influential in such an emphasis. Freud describedanorexia nervosa as a melancholy where there isundeveloped sexuality (1885, p. 200).

Reviewing literature from the last decades, theanorexic denial and isolation have been read in

many different ways, both with reference tospirituality, religion, psychology; and in the con-texts context of interpersonal relations, family andculture. It is the statement of the author that suchinterpretations are random, based on a limitednumber of clinical cases, and primarily theory- andideology-driven from therapists and authors. Thedifferent symbolic readings of the anorectic body astext demonstrate the importance of cultural, theor-etical and ideological contexts.

CONCLUSION

The main topic of this interview study is the bodilyconcreteness of symptoms in anorexia nervosa.To understand the specific pathology of thisdisorder one should not look only for the possiblemetaphorical meaning of the anorectic behaviour,but for reflective function itselfthe compromisedcapacity of making mental representations; ofmetaphorisation. It is necessary to search not onlyforwhatis symbolised, but also forhowsymbolised.Concretised metaphors is a fruitful concept fordescribing such phenomena. It emphasises thedeficit in reflective function and the acting-outnature of symptoms, and brings us closer to the

specific pathology of this disorder. It may help us torealise why anorexia may be difficult to understand,and that the patient may be difficult to engage,because she or he is trapped in the concreteness ofbody symbolism.

ACKNOWLEDGEMENTS

The author wants to thank Sonja Heyerdahl andSteinar Kvale whose contributions have been ofvital importance for the realisation of this paper.And a great thank to the patients who have been

brave to share difficult aspects of their lives. Theresearch work has been financially supported byResearch Council of Norway.

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