The Maturational Crisis of Anorexia
Amy H. Olson, LCSW
Regardless of the age of the patient at onset, anorexia nervosa can be viewed entirely as a
disorder of adolescence, given the developmental deficits underpinning such primal coping
responses as starvation, bingeing and purging. This paper seeks to present the major tenants of
Arthur Crisp’s model, used at St. George’s Hospital in London since the 1960’s, understanding
anorexia nervosa (AN) as an adaptive stance, although regressive, to the crisis of maturation.
Components of the “maturational crisis” will be described, particularly the symbolic meaning of
weight and shape which maintains the phobia of normal healthy adult weight. Vulnerabilities
contributing to this “maturational crisis” will be identified. Finally, implications for treatment of the
predisposing and maintained developmental deficits will be briefly highlighted.
The maturational crisis
Puberty is a non-elective process and the associated changes may be perceived as frightening,
threatening and unwelcome by the adolescent, and sometimes by the parent(s) as well. One’s task
in growing up is to meet the challenges of puberty, and through a process of experimentation,
successes and failures, enter adulthood with an intact sense of self and one’s ability to function
interpersonally.
The individual with AN does not possess the resources, internally or within the family system, to
successfully navigate growing up. AN serves to slow, and with the cessation of menstruation,
actually reverse the biological and psychosocial changes associated with growth. Within this
avoidant stance, the underlying pathogenesis of the problem fades into the background,
overwhelmed by symptoms of AN.
How are cases of eating disorder diagnosed years post puberty accounted for within this
framework? The impact of the maturational crisis can be delayed by the employment of other
avoidant stances, such as depression, substance abuse, social avoidance via intense focus on
academia or by years of sub-threshold dieting behaviors that can go undetected as the “social
norm”. Full expression, or first expression of the eating disorder is later prompted by a life-changing
event such as leaving home, a first sexual experience or the death of a loved one. In all cases, the
business of growing up was avoided to varying degrees, leaving the individual vulnerable to
primitive methods of coping.
The symbolic meaning of food, weight and shape
Food is the substance that drives biological maturation. One fearing the challenges of growing up
can abandon maturation by cessation of caloric consumption. (Incidentally, fears about growing up
can range from simple separation from parents, to warding off incestuous sexual advances). This
phenomenon lends AN the title of an adaptive disorder. Food becomes associated with social
challenges, such as spending time with peers, exposure to the opposite sex, dinners and holidays
with extended family, and in later life, meetings with colleagues and business associates. For the
patient with AN, developmentally appropriate interpersonal experiences are frightening, and food
avoidance ensures avoidance of such experiences.
Female development can be the source of much unwanted attention and embarrassment, leading
an adolescent to feel she has little control over her own body. The perceived “fatness” of the adult
female body has sexual dimensions and perhaps signifies the inability to control bodily impulses. In
sexually phobic families, puberty threatens the status quo of the family system. A phobia of a
normal healthy weight develops. This phobia pressures one to constantly desire to lose “just few
more pounds” as an insurance policy, protection from the resultant hunger and food obsession, to
which she is constantly vulnerable.
Vulnerabilities contributing to the maturational crisis
Crisp’s model recognizes, by the time the patient seeks treatment, primary reasons for dieting
behavior, according to the patient, include wanting to be more attractive, and this is not so different
than other teens and women. However, dieting behavior has become amplified for other reasons
and she has become preoccupied with it. It indeed is an authentic account of her understanding of
her behavior, as intense focus on weight and shape has diminished, if not resolved it’s underlying
issues. It has become a source of control and confidence, feelings that are limited due to her
interpersonal/developmental deficits. “A sense of control can be seen to be an experience within
the self – related to a sense of independence an autonomy – as well as controlling the
environment. To become a more attractive shape (attractive to others) is to bring more control in
the sense of potential dominance to one’s relationship with others” (Crisp, 1980, p. 65). The
individual with AN experiences the disorder as extremely ego-syntonic despite her failing health.
Crisp identified predictable processes within the family system as vulnerabilities for the over
amplification of focus on weight and shape, but in no way is blame implied. Each parent carries his
or her own degree of emotional immaturity, and combined with the biological predisposition and
temperament of the child, the child can be deeply influenced by these deficits in the parents. Crisp
(1980) describes common familial themes in families where anorexia exists, including but not limited
to:
1. As a child develops she carries personality and/or physical traits of one parent, which are
disliked and covertly or overtly admonished by the other parent. The maintenance of such traits,
associated with development, such as a gregarious or impulsive nature or larger thighs, is sensed
by the child as a threat to her bond with one parent and in turn feels pressure to arrest
development.
2. A child recognizes within herself, traits of a parent that do not fit with social or cultural
standards, such as an alcoholic mother or a womanizing father. In an effort to repudiate what she
perceives as “her true nature” she repudiates her own development.
3. The parents have unresolved issues around their own sexuality, particularly a sexually
phobic mother, demonstrated by a passive or a negative attitude towards the daughter’s puberty.
The child feels the covert pressure to remain a child, as to not induce anxiety in the parents or
herself
4. The child senses the marriage bond is fragile, and if she were healthy and able to
individuate from her parents, the marriage may end in separation or divorce. As long as the illness
is present the family, the family has something to rally around.
In each case presented the parent(s) unintentionally send a message to the child to sacrifice her
own development in order to keep the family “comfortable”. In this process the child cannot do her
job – the business of growing up. This is the crux of the maturational crisis as identity formation is
arrested. Formation of identity, according to Crisp, “… requires the integration of the new biological
sexuality within oneself both with one’s basic social needs, sense of self-esteem and competence
and one’s set of values” (Crisp, 1980, p.57) When this phase, which takes several years, is not
worked through successfully, one is ill equipped for later adolescence and adulthood.
As development is arrested by the eating disorder, the girl remains the emotional age of the onset
of the disorder (or the onset of other avoidance behaviors as described earlier). This major
personality immaturity is evidenced by low self-esteem, deep insecurity and an inability to take care
of oneself in a functional way. She may attempt to adapt to these deficits through excellence in
academics or career if her health allows but will remain plagued by interpersonal deficits and an
unrelenting pressure to control her weight and shape.
Treatment implications
Crisp believed, as with any other type of phobia, facing the feared object – in this case, attaining a
normal healthy weight, is essential to lasting recovery. The individual must gain weight to induce
puberty, menstruation and the associated biological and psychosocial challenges. Anything less,
the “pseudo recovery” in which a woman will gain some weight, but not enough to engage in
puberty, will result in an intractable disease state. This is often most successfully achieved through
inpatient programs, or outpatient care in less medically severe cases.
As the patient gains the required weight, she is helped to pick up where her emotional
development was arrested, regardless of her current chronological age. This will require focus on
learning how to set appropriate boundaries with others, identifying and expressing needs and
wants, exploring her own values by learning about her own thoughts and feelings and experiencing
herself in “terms that transcend (the) body” (Crisp, 1997, p. 256). In the opinion of this writer, such
treatment goals can be achieved through an integration of therapeutic models including
interpersonal, psychodynamic and cognitive therapies. For younger patients, family therapy and or
marital therapy is a necessary component. For older patients, expressive and ego state therapies
can assist her in “re-parenting” herself through the growing up process.
Resources
Crisp, A.H. (1980). Anorexia Nervosa: Let me be. London: Academic Press, Inc.
Crisp, A.H. (1997) Anorexia as Flight from Growth: Assessment and treatment based on the
model. In D.M. Garner & P.E. Garfinkle (Eds.) Handbook of Treatment for Eating Disorders (2nd
ed.) (pp. 248-277). New York: The Guilford Press.