Psychodynamic Therapies and Eating Disorders

Psychodynamic psychotherapies are derived from and integrate basic concepts of psychoanalysis. Psychodynamic psychotherapies focus on interventions and techniques to identify and target dysfunctional intrapsychic and interpersonal patterns that underlie disorder specific symptoms. In a detailed psychodynamic interview dysfunctional relationship patterns, central neurotic conflicts as well as structural limitations (i.e., impaired personality development and organization) are assessed in addition to eating disorder symptomatology. Based on this interview, the treatment focus of the therapy is formulated for the individual patient. Currently, from the viewpoint of psychodynamic theory, eating disorder (ED) symptomatology encompasses profound feelings of ineffectiveness and loss of control, difficulties in affect differentiation and regulation, a disturbed sense of self or negative self-evaluation, and interpersonal difficulties. Individuals with an ED are incapable of dealing with these difficulties on an intrapsychic and interpersonal level, using the body and disordered eating behavior as a dysfunctional strategy for defense and coping. In terms of interventions, early psychoanalytic concepts assumed that insight has to forego symptom change. In contrast, modern psychodynamic approaches acknowledge that restrictive eating accompanied by weight loss or bulimic eating patterns, can maintain psychopathology, and must be directly addressed to connect patients with underlying conflicts and emotions. The evidence that psychodynamic therapy is efficacious in EDs is growing. However, there is a need for further RCTs, not only in patients with a binge-eating disorder (BED) for which only two RCTs exist but also in bulimia nervosa (BN) patients where available trials are small and have somewhat conflicting findings. Future studies must not exclusively focus on symptoms related to the DSM criteria; they should also focus on measures that are more specific to a psychodynamic understanding of eating disorders (e.g., affect regulation, relationship patterns, and personality organization).