1. Introduction

During the Covid-19 pandemic, the morbidity of anorexia increased both in its scope and in its severity. This article argues that a psychoanalytic perspective can contribute to the understanding of the increased morbidity of anorexia.

On March 11, 2020, the World Health Organization declared COVID-19 a worldwide pandemic. COVID-19 has had (and continues to have) a drastic impact on the world’s population and provision of health services. To slow the spread of COVID-19 and to ease the burden on the health care system, governments implemented restrictions and quarantines. Regulations related to social distancing and restrictions on individuals’ social lives forced billions of people to reorganize their daily lives. Early on, these restrictions began to affect mental health [1].

Recent clinical reports and preliminary research publications have indicated that anorexia is on the rise, both regarding prevalence and illness severity [2, 3, 4, 5]. Studies from the last two years have shown that the rate of referrals for hospitalization due to anorexia has doubled [6, 7, 8] or even tripled since the COVID-19 outbreak [9].

These findings have raised questions regarding the unique influences that the pandemic imposed on individuals with anorexia and those at risk for developing it. The reasons for the increase in prevalence and severity of Anorexia nervosa during COVID-19 are not yet clear. Several contributing factors have been reported: Disruption of daily activities, social isolation, reduced access to the usual support networks and to health care services [4, 10, 5] and increased exposure to messages triggering the illness, on the internet [11]. In addition, it was found that anorexic individuals tried to reduce anxiety and depression caused by the pandemic by increased participation in sport, thus exacerbating anorexic symptoms [12].

Research conducted thus far has indicated that the COVID-19 pandemic and its social consequences have had a unique and adverse impact on the health of individuals with anorexia. According to our knowledge, no psychoanalytic explanation has been offered for the increase in anorexia during this period. Thus, this article will offer a psychoanalytic understanding of the intensification of the anorexic symptom following the outbreak of COVID-19.

In this article, we will suggest that a tendency to internal prohibitions that relies on an underdeveloped and fragile self in anorexic individuals resulted in an increased severity of the anorexic symptomology during the period of the pandemic. Specifically, we will argue that the encounter between an external reality saturated with restrictions and prohibitions and the anorexic internal reality intensified the anorexic symptomology. As a first step, we will introduce several key concepts and ideas regarding the experience of an internal prohibition from the psychoanalytic viewpoint, as well as the connection between this experience and anorexia.

1.1 Forbidden issues and prohibitions, from a psychoanalytic perspective

Psychoanalysis has, since its inception, been a discipline concerned with overcoming the ill effects of certain social taboos. Freud conjured up a vision of people struggling with impulses and wishes that had become forbidden largely because of social conventions or taboos against sexual impulses) [13]. His understanding of the underlying causes of the emotional disturbances of his hysterical patients was that they were suffering from the effects of repressing desires, due to these taboos [14].

In his early work, Freud explored social taboos through the lens of the seduction theory. This theory claims that forbidden content, which is repressed, relates to actual experiences. This view considers repressed memories as memories that cannot be accessed by the conscious mind due to their traumatizing nature. In abandoning the theory of seduction in favor of the theory of Oedipal desire, Freud transferred the responsibility for the forbidden content to females, who were then viewed as transgressing social norms. Consequently, the repressed content, which was forbidden from reaching awareness, was not perceived as reality but rather as deriving from forbidden Oedipal fantasies. Winnicott, several decades after Freud, made a connection between parental and social prohibitions and psychopathology in his presentation of the theory of the false self. The etiology of the false self develops in the early mother–infant relationship, and the mother’s contribution is crucial. A True Self begins to have life, through the strength given to the infant’s weak ego by the mother’s implementation of the infant’s omnipotent expressions [15]. Whereas a True Self feels real, the existence of a False Self results in feelings of unreality or a sense of futility (ibid., p. 148). In Winnicott's view, psychopathologies are often the result of social boundaries and intrapsychic inhibitions that restrict the expression of an individual's true self. Winnicott viewed the false self as a structure that develops to defend the true self, even—or especially—at the healthy end [16].

In Winnicott’s language, compliance is always associated with dimensions of life dominated by the false-self and is connected with despair rather than hope. Compliance brings immediate rewards and adults only too easily mistake compliance for growth [17]. However, Winnicott argues that there is a true and a false self within each person and that the balance between them is what contributes to the development of a healthy self: “…each person has a polite or socialized self, and also a personal private self that is not available except in intimacy. This is what is commonly found, and we could call it normal. If you look around, you can see that in health this splitting of the self is an achievement of personal growth; in illness the split is a matter of a schism in the mind…” [18]. Thus, Winnicott argues that internal prohibitions arise when a person cannot express his spontaneous, authentic gestures, needs, and desires in his interpersonal relationships, beginning with the initial relationship with his mother. It is in this situation that a false self emerges, responding to the desires and needs of others while preventing the expression of one's individual and authentic needs.

1.2 Anorexic prohibitions from a Psychoanalytic Perspective

In their formulations of the psychodynamics of anorexia, psychoanalytic theories concentrated on the mechanisms of prohibition. From the 1930s and into the 1950s, anorexia was viewed according to Freud's impulse-defense model. In this model, there is a conflict between sexual and aggressive impulses and the prohibitions of a rigid 'super ego,' wherein the ego activates defense mechanisms in order to mediate the conflict. Thus, it was hypothesized that self-starvation was a defense against fantasies of becoming pregnant through the oral aperture: anorexia was viewed as a regressive defense against Oedipal desires [19]. Psychoanalysts have viewed anorexia as an illness that mainly manifests as a somatic expression of the fantasy of oral fertilization. Therefore, the stubborn refusal to eat was hypothesized to be a defense against cannibalistic sadistic oral fantasies (ibid). Unlike Freud's seduction theory, psychoanalytic and psychological thinking about eating disorders today recognizes and emphasizes the real connection between past sexual traumas and the development of eating disorders [20, 21].

After the transition from viewing anorexia as a product of oedipal conflicts to the view of anorexia as a manifestation of pre-oedipal conflicts, anorexia began to be studied within the framework of object relations theory. According to this theory, anorexic’s patterns of relationships are based on mechanisms of survival and control, wherein the anorexic fantasizes controlling significant objects in her life [22]. According to researchers from the object relations stream, anorexics find it difficult to separate from their mothers and to develop an independent self.

Unlike Freud and Winnicott who specifically discussed the role of cultural and social prohibitions in the development of mental disorders, the object relations stream examines prohibitions, almost exclusively through the lens of interpersonal relations, as well as the anorexic prohibition. The Kleinian view, for example, interprets anorexia as a reflection of pathological narcissism, wherein the mother is not only perceived as unseparated from the child, but as having nothing to offer the child. The object relationship is characterized by a strong sense of envy that destroys any knowledge of the 'good breast', since any awareness of it implies acknowledging the existence of something good outside of the individual, which the anorexic cannot tolerate [23]. As part of her survival strategy, the anorexic perceives herself as omnipotent. The absence of need, in her fantasy, implies the absence of separateness, since being self-sufficient enables her not to recognize her dependency on an other. According to this view, if the desire does not exist, then the need for the mother does not exist as well. Many anorexics, on an unconscious level, still associate food with the mother. Food serves as a substitute for the desire to merge with the mother (ibid.)

As Kohut's theory of the self-evolved in the 1970s, the concept that anorexia is the result of difficulty separating and forming an independent self was further developed [19]. The self-theory asserts that a failure occurred during the development stages of the anorexic’s 'self-object’. Thus, a girl who develops an eating disorder does not believe that she can rely on humans to fulfill her needs. During the child's development, there is a role reversal between the parent and the child, when the parent leans narcissistically on the child, expecting them not to act according to their own interests, but to listen to and fulfill the parent's wishes. Therefore, these children are inhibited from expressing their individual needs and desires: they are forbidden to develop as individuals. Eating involves both self-giving and responding to internal needs. The anorexic views eating itself as an unwarranted act of self-indulgence which betrays the role of being a self-object to others. Therefore, the image of the anorexic patient is of a selfless person. Anorexics have a dualistic view of the world. They attempt to cleanse themselves of the body's troubles so as to reach a higher 'spiritual' or human level - one that does not succumb to the body's desires.

Accordingly, anorexia can be viewed as imposing a prohibition on connecting the body and the soul. Bordo describes anorexic subjectivity as constructed by a soul that is detached from the body. The split body is viewed as out of control, a foreign factor, and an enemy that threatens the mind. Bordo says that “the body is the locus of all that threatens our attempts at control. It overtakes, it overwhelms, it erupts and disrupts”)  [24]. In anorexia the fundamental identification is with mind (or will), ideals of spiritual perfection, and fantasies of absolute control (ibid., p. 97-98). Cartesian dualist view perceives the body as alien to the mind or self. As eruptive other, the body threatens to overwhelm the self and to disrupt self-integrity [25].

In conclusion, the anorexic's need to control their body, whether as a result of forbidden fantasies, physical-sexual injuries, or restrictions on separation from the mother and developing an individual self, leads to a conscious avoidance and recognition of physical vulnerability. In order to avoid this recognition, the anorexic maintains a fantasy of omnipotence and invulnerability [26]. Taking an extreme Cartesian view, they believe that their soul transcends their physical body and gives them an infinite amount of power and control over their own behavior and that of others [27].  In severe anorexics, the strong desire to disconnect from the physical world contributes to a common delusion, which is that extreme weight loss does not cause death: The body will die, but not the nuclear self [28].

1.3 Anorexia and issues of control

Issues of control are at the source of the anorexic experience [29, 30]. According to some theories, anorexia is a disorder that develops as a result of an attempt to control one's body, emotions, thoughts, objects, and life events.

 As a result of the rapid physical changes brought about by puberty, girls may have an experience of loss of control over their bodies. Bruch argued that anorexic girls grow up confused about the body and its functions and feel that neither their body nor their actions are self-directed or even their own [31]. She argues that in anorexic’s development there has been early failure in the establishment of a cohesive sense of self. In view of the usual developmental tasks precipitated by puberty, the anorexic withdraws to her own body as the only realm where she can exercise control and dominance [32]. The anorexic does not experience her body as something she is, but as something she has. Her body becomes an object of rigid control [14].

According to self-theory, the anorexic's experience of needing others evokes unbearable feelings, which she attempts to suppress. Orbach argued that the girl's avoidance of food is due to her need to control her body, symbolizing her emotional needs. Thus, if she can gain control over her body, she may also be able to control her emotional neediness [33].According to object-relations theory, anorexics' relationships are based on mechanisms of survival and control, while anorexics maintain a fantasy of controlling significant objects in their lives [22]. It has been suggested that anorexic girls have strong dependency needs in relation to their families, and, at the same time, strive for autonomy, self-containment and separation from their parents. The latter are expressed through self-starvation mechanisms [34]. In controlling their body, eating and weight, the anorexic appears to have exclusive control over satisfying their needs and maintaining an autonomous mechanism of nourishment and satisfaction.

Although anorexics believe that they are in full control of their bodies and their surroundings, this belief may collapse when confronted with real changes. Anorexia can be described as a ‘disease of control’ that develops against the background of uncontrollable life events [35]. Accordingly, there may be an increase in concern regarding weight, body shape, and eating when the sense of self-control is impaired by external circumstances [36], as in the current pandemic. It is in such situations that anorexic individuals feel that they cannot control their life and use control of their appetite as a tool to enhance their sense of self-control.

Anorexic prohibitions are central to the anorexic’s sense of control. These prohibitions are usually activated by an internal ‘anorexic voice’ which comments on the individual’s eating, weight and shape and instructs the individual to restrict or compensate [37]. According to this voice food is forbidden, desires are forbidden etc. When these prohibitions are not followed, the anorexic voice punishes and devalues the individual, leading to behaviors such as starvation and obsessive physical activity. The anorexic believes that compliance with these prohibitions enables her to maintain control over her body. It helps her to feel in control over her internal and external worlds.

1.4 How did COVID-19 undermine the anorexic defenses and contributed to the increase and exaggeration of anorexia in the population?

In response to the loss of control caused by the Corona pandemic, many people reacted similarly to the anorexic mechanisms of an extreme need to control the uncontrollable. People imposed several restrictions and prohibitions on themselves, sometimes punishing themselves for violating their restrictions. Thus, it can be argued that the reality created by COVID-19 corresponded with the psychological and behavioral mechanisms of anorexia.

When anorexics are faced with a reality that becomes overwhelming, their control can extend into omnipotence, facilitating a psychic retreat [38]. According to Selvini Palazzoli, (1978), anorexics have an extreme Cartesian internal dichotomy: they believe that their soul transcends their bodies, giving them complete control and power over their own behavior as well as the behavior of others [27]. Having the perception of being able to withstand limitations and prohibitions may serve as a platform for feelings of superiority and as a defense against desires and needs, which they may perceive as humiliating. Thus, the body serves as a means of enhancing self-esteem; “...in anorexia, the body serves as an instrument to achieve control, purity and psychological, social, and spiritual perfection” [39]. In its intensity and speed of spread, COVID-19 exposed the fragility of the human body. In spite of the technological and digital advancements that mankind has achieved in recent decades, the Corona virus has exposed humans as vulnerable and as lacking the knowledge and tools to combat it. The belief of humans that they were superior to other living creatures collapsed almost instantly. In this regard, it can be assumed that the Corona pandemic, in its immediate and extreme consequences, led to the collapse of the omnipotent anorexic defense. In the face of the extraordinary reality created by COVID-19, it has become difficult to maintain a Cartesian dichotomy, which gives the body the status of a controllable object. In sum, it can be argued that COVID-19 has led to the exacerbation and escalation of the incidence of anorexia through employment of two key defense mechanisms of anorexia, which are:

1. Implementation of prohibitions, reductions, and restrictions.
2. Having an omnipotent sense of self, in which the body is regarded as controllable.

The Corona pandemic forced us to undergo experiences never imagined. It especially forced us to cope with experiences of a total lack of control over our bodies, which comprises the source and the nuclear experience of the anorexic motivation. It is our view that further investigation and research is necessary, regarding the increased morbidity of anorexic illness in the context of the Corona pandemic. 

Data Availability statement:

We declare that this paper has all data & analysis freely available upon request.

Our data doesn’t violate the protection of human subject, or other valid ethical, privacy, or security concern.

Statements & Declarations

Conflict of interest statement: The authors declares that she has no conflict of interest.

Competing interest: The authors has no financial or non-financial interests that are directly or indirectly related to the work submitted for publication.

References

1. Holmes, E. A., O'Connor, R. C., Perry, V. H., Tracey, I., Wessely, S., Arseneault, L., Ballard C., Christensen, H., Silver, R. C., Everall, I., Ford, T., John, A., Kabir, T., King, K., Madan, I., Michie, S., Przybylski, A. K., Shafran, R., Sweeney, A., Bullmore, E. (2020). Multidisciplinary research priorities for the COVID-19 pandemic: A call for action for mental health science. The Lancet Psychiatry, 7(6), 547-560.
2. Agostino, H., Burstein, B., Moubayed, D., Taddeo, D., Grady, R., Vyver, E., ... & Coelho, J. S. (2021). Trends in the incidence of new-onset anorexia nervosa and atypical anorexia nervosa among youth during the COVID-19 pandemic in Canada. JAMA network open, 4(12), e2137395-e2137395.
3. Fernández-Aranda, F., Casas, M., Claes, L., Bryan, D. C., Favaro, A., Granero, R., Gudiol, C., Jiménez-Murcia S., Karwautz, A., Le Grange, D., Menchón, J. M., Tchanturia, K., & Treasure, J. (2020). COVID-19 and implications for eating disorders. European Eating Disorders Review, 28(3), 239-245.
4. Haripersad, Y. V., Kannegiesser-Bailey, M., Morton, K., Skeldon, S., Shipton, N., Edwards, K., Newton, R., Newell, A., Stevenson, P. G., & Martin, A. C. (2021). Outbreak of anorexia nervosa admissions during the COVID-19 pandemic. Archives of Disease in Childhood, 106(3), e15-e15.
5. Schlegl, S., Maier, J., Meule, A., & Voderholzer, U. (2020). Eating disorders in times of the COVID-19 pandemic—Results from an online survey of patients with anorexia nervosa. International Journal of Eating Disorders, 53(11), 1791-1800.
6. Asch, D. A., Buresh, J., Allison, K. C., Islam, N., Sheils, N. E., Doshi, J. A., & Werner, R. M. (2021). Trends in US patients receiving care for eating disorders and other common behavioral health conditions before and during the COVID-19 pandemic. JAMA Network Open, 4(11), e2134913-e2134913.
7. Goldberg, L., Ziv, A., Vardi, Y., Hadas, S., Zuabi, T., Yeshareem, L., & Levinsky, Y. (2022). The effect of COVID-19 pandemic on hospitalizations and disease characteristics of adolescents with anorexia nervosa. European Journal of Pediatrics, 181(4), 1767-1771.
8. Springall, G., Cheung, M., Sawyer, S. M., & Yeo, M. (2022). Impact of the coronavirus pandemic on anorexia nervosa and atypical anorexia nervosa presentations to an Australian tertiary paediatric hospital. Journal of paediatrics and child health, 58(3), 491-496.
9. Matthews, A., Kramer, R. A., Peterson, C. M., & Mitan, L. (2021). Higher admission and rapid readmission rates among medically hospitalized youth with anorexia nervosa/atypical anorexia nervosa during COVID-19. Eating Behaviors, 43, 101573.
10. Brown, S. M., Opitz, M. C., Peebles, A. I., Sharpe, H., Duffy, F., & Newman, E. (2021). A qualitative exploration of the impact of COVID-19 on individuals with eating disorders in the UK. Appetite, 156, 104977.
11. Branley-Bell, D., & Talbot, C. V. (2020). Exploring the impact of the COVID-19 pandemic and UK lockdown on individuals with experience of eating disorders. Journal of Eating Disorders, 8(1), 1-12.
12. McCombie, C., Austin, A., Dalton, B., Lawrence, V. & Schmidt, U. (2020). “Now it's just old habits and misery” – Understanding the impact of the Covid-19 pandemic on people with current or life-time eating disorders: A qualitative study. Frontiers in Psychiatry, 11, 1140.
13. Mitchell, S. A., & Black, M. J. (1996). Freud and beyond: A history of modern psychoanalytic thought. Basic Books.
14. Baerveldt, C., & Voestermans, P. (1996). The body as a selfing device: The case of anorexia nervosa. Theory & Psychology, 6(4), 693-713.Bohm, L. C. (2018). Taboo Or Not Taboo?: Forbidden Thoughts, Forbidden Acts in Psychoanalysis and Psychotherapy. Routledge.
15. Winnicott, D. W. (1965) Ego Distortion in terms of True and False Self (1960). The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development 64:140-152.
16. Abram, J. (1997). The language of Winnicott: A dictionary and guide to understanding his work. Jason Aronson.
17. Winnicott, D. W. (1965) Morals and Education (1963). The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development 64:93-105
18. Winnicott, D. W. (1986). Home is where we start from: Essays by a psychoanalyst, ed. Clare Winnicott, Ray Shepherd & Madeleine Davis. Harmondsworth: Penguin.
19. Bachar, E. (2001). Ha-pachad Litfos Makom [The Fear of Occupying Up Space: The Self-Psychology and the Treatment of Anorexia and Bulimia.] Jerusalem: Magnes Press.
20. Root, M. P. (1991). Persistent, disordered eating as a gender-specific, post-traumatic stress response to sexual assault. Psychotherapy: Theory, Research, Practice, Training, 28(1), 96.
21. Wonderlich, S. A., Brewerton, T. D., Jocic, Z., Dansky, B. S., & Abbott, D. W. (1997). Relationship of childhood sexual abuse and eating disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 36(8), 1107-1115.
22. Farrell, E. M. (1995). Lost for Words. London, Process Press.
23. Boris, H. N. (1984) On the Treatment of Anorexia Nervosa. International Journal of Psychoanalysis 65:435-442
24. Bordo, S. (2004). Unbearable weight: Feminism, Western culture, and the body. Univ of California Press.Boris, H. N. (1984). The problem of anorexia nervosa. International Journal of Psycho-Analysis, 65, 315-322.
25. Malson, H. (1998). The thin woman: Feminism, post-structuralism and the social psychology of anorexia nervosa. Routledge.
26. Mushatt, C. (1992). Anorexia nervosa as an expression of ego-defective development. Psvchodvnamic technique in the treatment of the eating disorders, 301-309.
27. Selvini Palazzoli, M. (1974). Self-starvation, from individual to family therapy in the treatment of anorexia nervosa (A. Pomerans, Trans.). Northvale, NJ: Jason Aronson.(Original work published 1963).
28. Cross, L. W. (1993). Body and self in feminine development: Implications for eating disorders and delicate self-mutilation. Bulletin of the Menninger Clinic, 57(1), 41.
29. Farrell, E., & Magagna, J. (2003). Em Farrell talks with Jeanne Magagna about anorexia nervosa. Free Associations, 10(2), 264-274.
30. Surgenor, L. J., Horn, J., Plumridge, E. W., & Hudson, S. M. (2002). Anorexia nervosa and psychological control: a reexamination of selected theoretical accounts. European Eating Disorders Review, 10(2), 85-101.
31. Bruch, H. (1978). The golden cage: The enigma of anorexia nervosa. Harvard University Press.
32. Bruch, H. (1980). Preconditions for the development of anorexia nervosa. American Journal of Psychoanalysis, 40(2), 169.
33. Orbach, S. (1993). Hunger Strike: The Classic Account of the Social and Cultural Phenomenon Underlying Anorexia Nervosa, Bulimia and Other Eating.. Problems; Ne of'Hunger Strike'. Penguin Books.
34. Fischer, N. (1989). Anorexia nervosa and unresolved rapprochement conflicts. The International Journal of Psycho-Analysis, 70, 41.
35. Kaplan-Zarchi, R. (2021). The language of anorexia: Semiotic, symbolic ans metaphorical features in the language of anorectics. (Doctoral dissertation). Bar-Ilan University, Ramat Gan
36. Fairburn, C. G., Shafran, R., & Cooper, Z. (1999). A cognitive behavioral theory of anorexia nervosa. Behaviour research and therapy, 37(1), 1-13.
37. Pugh, M., & Waller, G. (2017). Understanding the ‘anorexic voice’ in anorexia nervosa. Clinical psychology & psychotherapy, 24(3), 670-676.
38. Steiner, J. (1993). A theory of psychic retreats. In The Claustro-Agoraphobic Dilemma in Psychoanalysis (pp. 113-125). Routledge.
39. Duesund, L., & Skårderud, F. (2003). Use the body and forget the body: Treating anorexia nervosa with adapted physical activity. Clinical child psychology and psychiatry, 8(1), 53-72.