RESEARCH AND METHODOLOGIES
Il corpo come simulacro dell'identità: il vissuto soggettivo nei disturbi del comportamento alimentare
Patrizia Brogna; Emanuele Caroppo
Università Cattolica del Sacro Cuore, Rome, Italy
This study aims at better understanding the subjective experience, the so-called Erlebnis, in individuals diagnosed with Eating Disorders (ED). We shall highlight the particular way in which people with such disorders perceive their own bodies and specifically how they perceive their bodies in the presence of other people. To this end we shall analyze the subjective experience by means of two concepts as described by French philosopher Jean-Paul Sartre: "body-self" and "body-forothers". Our hypothesis is that some people suffering from eating disorders, especially those with a diagnosis of Eating Disorders Not Otherwise Specified (EDNOS), experience their body mainly as body-for-others. Rather than a diagnostic category, EDNOS could be conceived as an anthropological configuration vulnerable to ED. Eating disorders appear as an "identity disorder" characterized by a suspension of the experiential polarity between self and other-than-self.
Key words: body, intersubjectivity, identity, eating disorders, EDNOS.
In questo studio cercheremo di evidenziare, per una migliore comprensione dei vissuti soggettivi, Erlebnis, riscontrabili in corso di disturbi del comportamento alimentare (DCA), la particolare modalità con la quale le persone affette da tale tipo di disturbi percepiscono il proprio corpo e, nello specifico, come percepiscono il proprio corpo in presenza di altre persone. Analizzeremo, a tal fine, il vissuto relativo al "sé corporeo" e al "corpo-per-altri". Nel particolare la nostra ipotesi di ricerca è che alcune delle persone che soffrono di DCA, in particolar modo persone con diagnosi di disturbi del comportamento alimentare non altrimenti specificati (EDNOS nella dicitura inglese), vivono il proprio corpo prevalentemente nella modalità del corpo-per-altri, recuperando in questa osservazione la descrizione sartriana del "corpo-per-altri". La nostra ipotesi azzarda il possibile inquadramento dei disturbi del comportamento alimentare non altrimenti specificati (EDNOS) più che come una categoria diagnostica come una configurazione antropologica vulnerabile ai DCA. Nella nostra ipotesi i DCA apparirebbero come un disturbo dell'identità contraddistinto da una sospensione nella polarità esperienziale dell'essere sé stesso tra "sé/altro-da-sé".
Parole chiave: corporeità, intersoggettività, identità, disturbi del comportamento alimentare, EDNOS.
Since eating disorders (ED) were first identified, psychopathology and nosography have been constantly struggling with the issue of the relationship between the obsession with food and that with bodyweight. This does not only appear in people suffering from eating disorders. It is equally a common trait in researchers and therapists since they mainly concentrate on body weight when they establish their clinical patterns [1-4]. The undeniable importance of this relationship for understanding ED is commonly accepted, to the extent that it is a significant psychopathological indicator whose observation allows diagnoses and consequently therapies . However, for a better understanding of subjective experience in ED, we need to investigate the particular way in which people with such disorders perceive their bodies in the presence of other people. To this end, the notions of "bodyself " and "body-for-others" are fundamentally important. The "body-self" is understood as the basis of both self-consciousness and intersubjectivity. Following the philosophical conceptualization by Husserl  and other phenomenological authors, self-consciousness does not simply designate a way of being conscious of oneself, but it is the inner experience of oneself. It is the primary prerequisite of any conscience and knowledge .
It constitutes the requirement not only of the peculiarity of what the person is experiencing, i.e. belonging to oneself , but also of the consciousness to be the subject of the experience in the here and now, in a totally implicit way which is never disconnected from the being in relationship with the world.
The self-consciousness is the primitive experience of oneself, the basic experience of self-awareness.
The self-consciuosness is the basis and primordial level of subjectivity incarnated in the individual's own body and from which other levels of consciousness, including the reflective consciousness, the intercorporeity, the personal narration, the value system, the social syntonization and common sense are structured through its syncretic and unimodal function .
It is the pre-categorial sense of self , which precedes all symbolization and conceptual thought at a level of all which has been experienced, which confers the possibility to the body-subject to be the point of origin of the intermundane meanings. This pre-categorial sense of self is the check-point in meeting the other, making it possible to be self-conscious by taking reflective action and representing oneself, given by the use of linguistic systems and by the historicalcultural context the person belongs to.
With regard to the "body-for-others", we shall reclaim the philosophical hypothesis which Morris refers to dismorphyc disorder  and extend it to the universe of ED. Morris claims that body dismorphyc disorder (BDD) is due to an excessive preoccupation with a specific aspect of one's own appearance  and that it could be more profoundly understood as a specific disturbance of the "body-for-others", one of the dimensions of the body experience described by Sartre.
Morris upholds that shame, discomfort, hiding, disgust for one's own body, wanting to get away from it and an excessive attribution of responsibility of the way one appears to others, as well as many other characteristics which we find in people suffering from BDD, could reveal a deeper comprehension in the light of Sartre's concept of the experience of one's own body as an extremization of the "body-for-others".
"Body-for-others" means how one experiences one's own body when someone else is looking at it and the subject-body being can become conscious of being a body-object for others: this is what Sartre points at when he states that the sudden appearance of the other's glance inevitably leads to the discovery of being an object. That is how, as a final result of this revelation, the experience of shame is born.
In the very instant the other sets his eyes on the subject-body, he, at once, transforms it into an object-body, by forcing it within a perceptive and distant relationship where it remains at the mercy of the person who is looking at it as an object of use, as a thing which is planned for the other's project. The I-subject becomes conscious of being a body-object for others: the other, solely through the power of his glance, deprives me of my subjectivity, dominates me, makes me an object for himself .
Our assumption of research is that some of the people suffering of ED, especially those diagnosed with eating disorders not otherwise specified (EDNOS), experience their own body mainly as "body-for-others".
MATERIALS AND METHODS
In ED, the symptomatic and pathological behavioural patterns seem to be strictly connected, if not unitary, to the sphere of the body image , and, more specifically, to the perception of the "bodyself" . In this study, conducted about the experience of the body-self in persons diagnosed with ED , we wish to conduct a detailed observation of the cinestetic and self-perceptive body perception, the objectivation of the body as it is seen by others and the functional body experience of others as a self-perceptive and self-evaluative reference. Furthermore, we intend to point out how these persons imagine themselves, by recuperating the concept of narrative identity and, specifically, of the dialectic "to be the same/ to be oneself"  which we consider, from this point of view, to be the interface between the "body-self" and the "body-for-others". In following this assumption, we shall use the phenomenological observations and works related to "self-consciousness" [8, 9, 14], "body-for-others" [2, 10] and narrative identity .
Our research aims at reading the phenomenology of ED through the analysis of comprehensive systems, the sense organizers , by following the hypothesis that subjective experiences, though they may be very discordant and abnormal if valued from outside or only on the basis of rigid, nosographical grids, can reach a unitary and coherent meaning within the subject himself.
There are numerous literary examples which evaluate scales for ED [16-21], but they are not specific for the exploration of the body perception perceived in the first person. As its consequence, this insufficiency could lead to the reduction of the importance of the category of the "body-self".
Hence, by means of the analysis of the "sense organizers" in eating disorders, the symptoms' annotations could take on a more understandable perspective tending to a greater possibility of understanding the diagnosis and nosography.
We started with a pool of 71 patients diagnosed with ED according to the criteria of the DSM-IV-TR , surveyed clinically and by giving out the Symptom check list-90 , the Eating disorders inventory-2 , the Eating disorder examination  and the Body Attitude Test .
A sample of 37 patients has accepted to participate in the study and to sign the informed consensus. On the field, a researcher has witnessed the individual and group psychotherapies of all the 37 patients as a silent observer, for a total of 30 hours distributed over a 30 months' span, in order to take note of the phrases said by these in person ; moreover, we evaluated the personal sentences of patients who were already keeping a personal diary for a long time, extracted from writings spontaneously offered by these patients. A total of 59 sentences will be shown; all the personal sentences have been accurately transcribed. The researchers and a group of 6 independent judges including psychiatrists, psychologists and philosophers evaluated the surveyed material every 15 days in order to estimate the concordance with regard to the taking of the sense organizers: "body-self" and "body-for-others". It is an exploratory, qualitative study with a clear reference to the phenomenological method established by Husserl  and, specifically, by the use of the phenomenological epoché and the eidetic resolution: Husserl refers to an explorative attitude marked by the laborious suspension of any judgement or pre-judgement of the observed reality, to which we are inevitably and naturally anchored, while the second issue refers to basic modes through which every phenomenon of the observed reality manifests itself.
The study is based on the analysis of the sentences in the first person in the course of the individual and group psychotherapeutical treatments, as well as in the personal writings of 37 patients diagnosed with current ED, including the EDNOS category, according to the criteria of the DSM-IV-TR .
The sample consists of 37 women aged 24.9 years on the average (15 > 42). The average age of the onset of the ailment is 19.6 years (12 > 27) and it lasts 6.13 years (1 > 22) on the average. The socioeconomic conditions of the sample are homogeneous. The sample is subdivided as follows: n. 10 are at their first admission into a structure specialized in ED; n. 27 have already been hospitalized several times in various hospitals specialized in ED; of this sample, n. 20 are hospitalized; n. 17 are admitted in structures specialized as Day Hospital; n. 11 are diagnosed with AN (of which 5 belong to the restricting subtype and 6 to the binge-/purging subtypes); n. 11 have been diagnosed with BN (thereof, 9 belong to the purging subtype); n. 1 has a diagnose of BED (uncontrolled ED); n. 14 are diagnosed with EDNOS. These diagnoses have been made according to the diagnostic criteria defined by the DSM-IV-TR  before the beginning of our study and subsequently confirmed by using the same diagnostic criteria which we shall not list here and which can be found in the DSM-IV-TR .
As far as the educational level is concerned: n. 3 have a middle school certificate (and are presently attending secondary school); n. 34 have a degree, thereof: n. 7 a college degree, n. 10 have suspended their college studies and n. 10 are currently attending University; n. 7 carry out a working activity. In the following tables, we shall indicate the subjects diagnosed with nervous anorexia of the restricting type as AN-r and those with a binge-/purging type of anorexia as AN-p. An analogous nomenclature will be applied to the subjects diagnosed with nervous bulimia: the subjects diagnosed with a purging type bulimia will be indicated as BN-p and those with a non-purging type as BN-np. EDNOS and BED will refer to the respective diagnostic, commonly recognized categories.
Reflections on literature
ED appear as a diagnostic category in the drawing up of the DSM-III  which contemplates, as diagnostic categories, nervous anorexia, nervous bulimia and the "atypical disorders" which become, in the DSM-III-R, "not otherwise specified" .
The interest in ED and the attempt to describe them in a more accurate and detailed way on the part of the clinicians and researchers is more concrete in the drawing up of the DSM-IV , where we witness a more ample description and nosography with the introduction of inter- and intra-categorial differences. The classification of the DSM-IV divides eating disorders in three main categories: anorexia nervosa, bulimia nervosa and a last category, eating disorders not otherwise specified (EDNOS).
The DSM-IV-TR  bears no particular changes in description, but there are, additionally, the updates of the section "Manifestations and associated disorders" concerning anorexia, including "co-morbidity" with personality disorders. Still, with reference to anorexia, the section on "prevailance" has been updated and it foresees the inclusion of data of male patients. Other changes concern the characteristics of the "course of the illness" in order to clarify the relationship between anorexia and bulimia; the section "course of the illness" has been updated and it includes some information on the long-term outcome.
Eating disorders are an extremely heterogeneous diagnostic category, for which the DSM-IV  lists six possible types, including the subthreshold forms of anorexia, bulimia and uncontrolled eating disorder; in particular, it identifies two subtypes as well for anorexia nervosa (AN) as for bulimia nervosa (BN), related to the method adopted by the patients to control their weight: restricting type (An-r) and binge-/purging (An-p) for anorexia and purging/non-purging type (BN-np) for bulimia. For the first time, the DSM-IV also contains a last category, binge eating disorder (BED), referring to a disorder which manifests itself by uncontrolled eating accompanied by a sense of shame and self-disgust like in bulimia, but without the compensatory methods for weight control . A different evolution has marked the categories of EDNOS which were in fact quite neglected by clinicians and researchers. Hence, there is presently an extreme difficulty in the clinical practice and a detailed description is lacking.
In literature, the profound instability of this diagnostic system and its consequent limited trustworthiness have been reported [28-30]. Presently, different epistemological studies have shown that the cases of EDNOS are rising in the western culture [23-34] compared to the cases of anorexia and bulimia with the respective subtypes [35-37].
Many studies have compared the clinical characteristics of EDNOS patients with those of AN and BN patients, including body weight and the presence of binges with or without purging. Substantially, they have similar symptomatological patterns and overlapping psychiatric pictures [34-37].
The diagnostic criteria of EDNOS include the presence of a clinical eating disorder and the nonappliance of the criteria of inclusion for anorexia nervosa, bulimia nervosa and uncontrolled eating disorder. They group the conditions which cannot be fully included into the described situations, such as anorexia with a menstrual cycle and a regular weight.
From a purely descriptive point of view, EDNOS show symptoms which can correspond to the clinical patterns which are characteristic of AN tout court as well as of the restricting and binge-/purging subtypes, of the purging/non-purging subtypes of bulimia and of the specific symptomatology of BED. The symptomatologic picture can show anorexia with normal weight and anorexia without amenorrhea, subthreshold bulimia without binges or vomiting and eating behavior like slow rumination of the food without swallowing, chewing and spitting and obsessive touching of body parts, body checking .
EDNOS present themselves attached with a string of symptoms which include elements of clinical patterns which can even differ greatly and which determine an extremely varied psychopathological picture which is absolutely difficult to define, to the point that we refer to them with the expression "not otherwise specified" in order to find a nosographical classification for them, at least apparently.
At this point, indicative and necessary reflections arise: are we facing the impossibility of determining a well defined nosographical placement on the basis of behavioural patterns?
What is hiding in the part of EDNOS which "still has to be specified" from the point of view of a psychopathological speculation?
Could the lack of an answer to this question lead to such a relapse that it would impede a deeper understanding of the whole ED category?
In other words, we are supposing that, sometimes, the symptoms' placement could not be sufficient to make a diagnose. We deem that the process of individuation of the clinical phenomenology must absolutely take the subjective experience into consideration besides the behavioural patterns. Indeed, this subjective experience, as has been shown by the phenomenological studies on schizophrenia , seems to represent a specified/non- specified razor blade line of demarcation.
In our observations, we have mainly determined two sense organizers, the "body-self" and the "body-forothers" and the way in which these two factors outline an identity disorder, as a suspension from within of the dialectic of the personal identity between "self/other-than-self".
Here, we refer to the meaning of narrative identity devised by P. Ricoeur  according to whom to-bethe-same (être le même) and to-be-oneself (être soimême) are the two polarities of experience which, in their unity, form personal identity, whose relationship is regulated by narrative identity, the primary basis for self-representation. The first guarantees a sense of permanence in time and does not depend on the current situations: it confers the possibility to always recognize oneself as the same. The second, instead, provides a sense of self bound to the mutability of situations and the fickleness of emotions which are experienced in the here and now: the multiple sense of self given by the continuous contrast between self and other-than-self with, in the background, the cultural meaning codes which are socially and implicitly shared and which, at the same time, form the scenario upon which the value system of each of us is organized and moves .
In the following paragraphs, we shall first report some reflections on the results of the analysis by numbering the sentences expressed in the first person of the whole examined sample in a progressive order. This will be done independently from the specific diagnose; subsequently, we shall analyze some narrative elements found in the subdivided sample in the tables reported for the specific diagnoses; each numbering will refer to one person and, where we repeat sentences of the same subject, this will be signalled with the caption "subject and reference to the specific numbering".
Body-self sense organizer
By analyzing this sense organizer we have observed a particular way of experiencing one's own body and we have determined three experiences on the basis of which it can be seen that the examined patients lack a syntonization of the self-consciousness and that they perceive their body in a fragmented way and as something which does not belong to themselves, but is extraneous.
The important phenomena in the experience of the "body-self" seem to be characterized by:
1) a lack of perception of the body-self: "I don't feel. I don't feel myself and I don't belong to myself" (Table 1.1 Sentence n. 1);
2) a fragmented cinestetic and self-perceptive experience: as an example, we report: "I see myself as fragmented: my leg, my belly, my buttocks, my back. I don't have the possibility to look at my total image which always appears to me in the mirror, instead, I see only parts of me which don't fit when put together"(Table 1.2 Sentence no. 9). When we talk about cinestetic experience, we refer to the unitary experience of the sensitive sensations experienced implicitly, without a reflective action; when we talk about selfperceptive experience, we refer to the perception of the bodily experiences implicitly which are implicitly felt as belonging to oneself;
3) an experience outside of the body-self: "I have always experienced my body as something which does not belong to me" (Table 1.3 Sentence n. 19);
4) an objective body experience in the third person and an instrumental experience of the body: "What I see in the mirror is not really a machine but something that accompanies what is inside" (Table 1.4 Sentence no. 30).
"Body-for-others" sense organizers
This "body-for-others" sense organizer is highlighted in the dialectic of "body-for-other" and "look-of-other", realized by the single experience which consists in perceiving that one's own body is taken away by the other's glance, in the sensation of feeling reduced to the level of an object under the other's glance and, hence, not to count as a subject, as a person, but only as a mere thing among other things.
We can mainly observe two modes of experience:
1) an instrumental experience of intercorporeity: through a perceptive and tactile comparison with the other's body aiming at perceiving one's own bodily dimensions: "I can't find my position in space; in a double sense: I always put myself in relation with others, without ever feeling any autonomy when I choose the position; I am not aware of the space I occupy: a lot or little? I am, in any case and always, fat" (Table 2.1 Sentence n. 34).
2) an aimed experience of the intersubjective dimension (the look-of-the-other which glances at the subject-body as an object-body): "It is the others who see it as I would like to see it, that's why I need them... they make me understand whether I am doing fine or not... alone, I am in a chaos" (Table 2.2 Sentence no. 44).
What these people are experiencing could be described as a constant suspension of a doubt belonging to themselves which we indicate as a disarticulation of the character of "selfness" , i.e. the inability to feel the sense of the experience of perceiving themselves as a subject of what it is they are going through. What they report is that they touch themselves without feeling that they are themselves.
We have been able to determine an anomaly of the unitary experience of the self which leads to the first fracture inthedialectic"self/other-than-self" referred to the personal identity. They express a fragmented cinestetic and self-perceptive experience, the sensation that they can't perceive themselves as a totality: they see and perceive themselves from part to part. This fracture of identity starts to encourage the shaping of an individual representation which is based on self-reflection, on thinking about themselves through the abstract expectations of the "other", concretized in the tendency to nourish values, belief systems and wishes of the cultural context they find themselves immersed in and tending towards the realization of a bodily reality, since it is the body which identifies them, which the other proposes.
The relocationof the "body-self" towards the "body object" and, consequently, the "body-for-others" takes place, intended in purely physical terms - the concrete body of the other - as well reflectively as representatively (what the other thinks I am and I must, hence, become).
The value system of these people bears an extreme tendency to incorporate the beliefs, meanings and expectations of the other, of the external context (heteronomy), without even faintly discussing these values which become their own life indicators. Everything they experience is filtered by a cognitive and rational reflection whose point of comparison lies in accepting the other and the other's concrete body.
The body, as an object, is something they place outside themselves and which can be used as a delegated tool mediating with the external world, as a passive container. They are conscious of themselves through a reflective action, by reflecting on their reflection.
Through the bodily being of the other, they represent themselves, they shape their own idea about themselves, but a different and peculiar situation seems to appear in the intersubjective space of the social dimension which happens when they meet the objectivation of the other's body in order to reflectively define their self-experience by delimiting their own body.
Within this way to relate, they experience the possibility to get an orientation and to perceive themselves, by perceiving, with an extreme intensity, the responsibility of how they appear in the eyes of those who surround them and by experiencing the suspension of a person who is waiting for a verdict to be pronounced, something which we could sum up with the constant question they ask themselves: who/what am I?
The body becomes the simulacrum of their own identity, it becomes the mirror of their self, like one of the attributes of the external image, a shape they identify with and which they use in order to represent themselves. Their self-representation, i.e. the concept they have about themselves, on the basis of what has been said before, appears with a disarticulation of the narrative identity of the dialectic "to be the same" and "to be oneself" (Table 3).
Even before we talk about an eating disorder, these people seem to exhibit a disorder of the self-syntonization, related to self-consciousness, to the realm of social syntonization and to the personal identity of "being-oneself".
The unitary self-experience seems to disintegrate, to fade away into external space, in a continuous oscillation of the experience of personal identity between I/not mine, resulting from the suspension of the contraposition "self vs. other-than-self", which is not a dialogue anymore, but a suspension of the identity.
By accepting the hypothesis of a destructuring self-consciousness, that particular way of experiencing their own body as an object, which we recognized through the analysis of the phrases, could be founded on this primordial basis of the experience of the body-self. Thus, we could determine two meaningful experiences:
1) an experience of pure objectivation, almost the bodily concretization of a linguistic metaphor, whereby language is an experience of the thought  and the body is not like a visiting card anymore, but the visiting card itself. The body becomes the only tool for the symbolization in a peculiar coincidence between expression and means of expression which has been defined as a "concretized metaphor" .
2) perceiving oneself through the eye of the mind, the incarnation of Descartes' cogitation, clear reflective consciousness which, by looking at one's "own-body-thing", topicalizes their own appearance by doubting their own being, with the constant sensation "to be a bluff".
On the basis of these experiences of the "bodyself"organizer, we acknowledged a failure of the social syntonization, a particular way of experiencing intercorporeity and intersubjectivity.
Merleau-Ponty firstly places the recognition of subjectivity (body-subject) as being contingent to theencounter with the other's body and he distinguishes the capacity to simultaneously experience one's own body as subject and object as a persistent ambiguity of "being a body" and "having a body" .
By following up our hypothesis, it would appear, moreover, that the analyzed sample concretizes Sartre's conflict of being-for-others  as an original and primordial sense of self-consciousness and intersubjectivity which jeopardizes the identity of the subject himself.
Substantially, the disarticulation of the polarity of "being-oneself" within the dialectic of personal identity and the suspension of the contraposition between "self/other-than-self" becomes an identity disorder which is caused by the lack of possibility of the parties to dialogue with each other.
The self-representation, mediated by language, through the use of symbolic systems which allow a re-ordering of one's own existence and the attribution of a meaning to it, shows in purely bodily terms and food and the so-called "dysfunctional behavior" would result in a semantic and metaphorical continuity of this lack of dialogue.
The summary quantitative analysis and comparison shows that all the diagnostic categories exhibit a significant presence of the sense organizer "body-self", particularly as a fragmentation and extraneousness of the body-self, while all 14 cases of EDNOS were significantly present in the second sense organizer which has been determined by us, as shown in Diagramme 1. By reading the data as a comparison between diagnoses, we realized that in the case of anorexia and bulimia there is no prevalence of the sense organizers, while, in the specific case of EDNOS, there is a prevalence of both sense organizers.
As far as the sense organizer "body-self" is concerned, there is a predominance of EDNOS compared to the other diagnostic categories which, instead, appear to be homogenous; we notice an even more evident predominance of EDNOS in the sense organizer "body-for-others" in the double modality of "body-of-other" and "look-of-other".
We believe that ED are mainly characterized by a failure to realize corporeity which occurs through the dialectic body/body-of-other and by a refusal of the bodily reality. Even though the results of this pilot study must still be defined, we believe that subsequent studies could provide more clarity. As a matter of fact we think that the phenomena of bigorexia and some addictive phenomena could be more properly understood through this preliminary hypothesis. The emergent pathologies of the recent generations of our cultural context seem to concern more and more the specific identity disorder which we have herein described . Indeed, we observed to which extent the otherness is not useful anymore for a (bodily) recognition and food becomes its substitute because it is semantically adjacent to what corporeity "realizes". In order to comment the information gathered and by comparing the specific diagnoses, we could hypothesize that, when the possibility to articulate and to convey meaning about the self-experience through language is lost, ED show as a possible psychic residue of an identity disorder and EDNOS as an anthropological configuration, meant as a personal structure which is characterized by a vulnerability of the identity dialectic between "self/other-than-self". Hereby, we include essential phenomena which have been hereto observed and which signal a disorder of the syntonization of selfconsciousness and the intersubjective sphere.
Proceeding from this vulnerability, ED could be the result of the interruption of the identity dialectic "self-other-than-self" and they should thus exhibit an identity disorder which finds its own simulacrum in the body.
Conflict of interest statement
There are no potential conflicts of interest or any financial or personal relationships with other people or organizations that could inappropriately bias conduct and findings of this study.
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Received on 5 October 2010.
Accepted on 5 November 2010.