In Anorexia Nervosa, Inner Conflicts Over The 'Real' Self Have Treatment Implications

"It feels like there's two of you inside - like there's another half of you, which is my anorexia, and then there's the real K, the real me, the logic part of me, and it's a constant battle between the two." - 36 year old study participant with anorexia nervosa.

People with anorexia nervosa struggle with questions about their real, or "authentic," self - whether their illness is separate from or integral to them - and this conflict has implications for compulsory treatment, concludes a study in the Hastings Center Report. The researchers also conclude that exploring ideas of authenticity may help clinicians formulate therapeutic approaches and provides insights into whether compulsory treatment can be justified.

For the study, researchers in the U.K. interviewed 29 women who were being treated for anorexia nervosa at clinics throughout the south of England. The interviews asked questions about how the women view their condition, including their understanding of it, how they feel about compulsory treatment, and their thoughts about the impact of anorexia on decision-making. Although the researchers did not ask about authenticity or identity, almost all of the participants spoke in terms of an "authentic self," the researchers write, "and, for almost all, the relationship between anorexia nervosa and this authentic self was a significant issue."

Participants characterized this relationship in different ways. Many saw anorexia nervosa as separate from their real self. Some expressed the idea of a power struggle between their real and inauthentic self. Others said that other people could provide support to enable the authentic self to gain strength within the struggle.

The researchers interpret the patients' notion of their illness as separate from their authentic self as a sign of hope. "Conceptualizing the anorexic behavior as an inauthentic part of the self may well be a valuable strategy for many in helping to overcome it," the authors write.

The authors also say that, in their view, the distinction between an authentic and an inauthentic self is not necessarily the same as a lack of capacity for decision-making and cannot justify overriding a patient's refusal to consent to treatment, although they believe that their findings give grounds for not simply acquiescing to refusals of help. "Some authorities argue that compulsory treatment should never be used for anorexia nervosa," they write. "We believe, however, that we should take seriously the possibility that a person in the throes of anorexia nervosa may be experiencing substantial inner conflict, even though the person may not be expressing that feeling at the time."

The authors conclude that clinicians need to monitor patients' views over time and that if the inner conflict persists, it suggests a lack of capacity for decision-making and, therefore, a risk of significant harm. In this case, they say, "perhaps the evidence from these accounts is sufficient to override treatment refusal in the person's best interest." An unanswered question is whether patients who regard anorexia nervosa as an inauthentic part of the self are most likely to respond to treatment. "A question of empirical study is whether those who separate the anorexic self from a perceived authentic self are more successful at overcoming anorexia nervosa than those who do not," the researchers write.