Abstract

Dissociation is often present in Eating Disorders (ED) at different levels and, if not properly diagnosed, may complicate treatment. This article presents a general review of eating disorders, explaining their origins and most significant peculiarities.

Many of the difficulties faced by professionals when working with these disorders are pointed out, in order to develop an appropriate treatment plan. Understanding the relationship between ED and dissociation is crucial, given that treatment may often become complicated by the underlying dissociation of the personality.

Introduction

Dissociation in eating disorders (ED) was initially recognized by Pierre Janet (1907/1965), who was the first author to specifically study the relationship between traumatic experiences and dissociation in different mental disorders, including ED.

Janet (1965) stated that dissociation is a major psychosomatic response to overwhelming trauma. Memories and ideas associated with trauma may become separate from conscious awareness, resulting in a dissociative organization of mind and a variety of dissociative symptoms (Janet, 1907; Van der Kolk & Van der Hart, 1989).

In ED, dissociative eating activity can be seen at a somatic level, such as when clients with Anorexia Nervosa (AN) embody their eating disorder through body changes such as weight and shape variations, and, due to this, in changes in bodily functions and the cessation of the menstruation cycle.

Also, in Binge Eating Disorder (BED) and Bulimia Nervosa (BN), the body changes as a result of binging and purging.

Dissociation can be perceived through these patients’ poor insight regarding their body as being a part of themselves. In EDs, some parts are dissociated from the body, but in severe cases such as AN or BED, it is difficult to find parts that do not reject the body and want to be part of it. The body is the enemy, and this is the reason why they dissociate from it.

“I don’t feel like the body is me, it’s like a carcass in which I live.”
“I’m trapped inside this body; I want to get out of it and I can’t.”
“The real me is the person who is inside this body in which I am locked up.”

Another way of identifying dissociation is through the rejection clients develop toward their body, thus responding to the self-harming behaviours that lead them to the double meaning of “being”: on the one hand, being able to feel their own body and, on the other, channelling the emotion of rage they feel against it.

After Janet, interest in the concept of dissociation in ED disappeared for over half a century. In 1979, the British psychiatrist Russell identified the presence of dissociative parts in clients with BN. Torem (1986) stresses the importance of a systematic exploration of dissociative symptoms and ego states in clients with ED.

The importance of recognizing dissociation becomes clear, given the frequency with which it presents. In binge eating and during the binge-purge cycle, clients describe dissociative parts, often talking about how they feel completely disconnected when they binge and purge.

Authors such as Everill, Waller, and Macdonald (1995) find the presence of dissociative symptomatology in bulimia indicative of a history of early experiences of abuse or significant loss, linking the presence of dissociation to trauma, as Janet had done before.

Many studies on the presence of dissociation in eating disorders focus on childhood abuse as the basis for these disorders. However, neglect, excessive parental control, role reversal, emotional abuse, or abuse of power may precipitate ED and dissociation.

Within these causes are also included a type of traumatization that is often overlooked and is closely associated with ED: the so-called “hidden traumas.”
These refer to the silent, everyday traumas which are invisible — children can be traumatized by medical treatments, child-rearing practices, and circumstances considered to be normal, including the failure to develop a secure attachment to the primary caregiver.

It is possible to be born into and grow up in a loving, caring family and have a seemingly normal childhood, and still be traumatized.
(Robin Carr-Morse, Meredith Wiley, 2012)

Recognizing this type of traumatization is crucial for professionals working with these disorders, since it facilitates understanding of clients’ internal worlds and helps increase treatment effectiveness.

Treatment with an ED structure has to be done from the outside in, that is, working through the outermost layers to reach the innermost ones. These layers contain parts and defences that emerge when the therapist tries to delve inside.

Types of Dissociation

Dissociation of the personality in EDs is usually present in different degrees and can manifest in various ways. Depending on the degree of dissociation, its severity varies from the less pathological to the more pathological.

Somatic dissociation

This is the most common type of dissociation in eating disorders. The body is perceived as strange and not felt as one’s own — instead, it is felt as an enemy against whom they must fight, or as anesthetized parts felt as foreign at a biological level.

“I feel my legs melting sideways into the chair.”
“After eating, I feel my body starting to swell up from the neck down to my toes.”

These perceptions and sensations, experienced as real, reflect depersonalisation or derealisation symptoms due to the anguish they generate.

Dissociative fantasy

A very common type of dissociation in eating disorders, often unnoticed due to clients’ lack of awareness. This defence serves as a safe place since childhood, when the real world is no longer safe.

“The other day, I returned to my world in which I was the heroine: everyone cheered me, I felt important, and all the characters recognized my victory.”

One therapeutic goal is to help patients differentiate reality from fantasy, since they tend to confuse both. This fantasy often covers unmet needs in real life (Seijo, 2012).

Body image distortion

This is psychoform dissociation, of a mental nature. The client perceives her body in dimensions that are not real and idealises or fantasises about a body that does not match the real one.
This dissociation is associated with the rejected self and the fear of a past body image (Seijo, 2012).

Alexithymia

This dissociation involves difficulty identifying and expressing feelings. Clients have trouble describing their emotions and differentiating them from bodily sensations.
Different studies have found that 69% of clients with anorexia and 50% with bulimia suffer from alexithymia (Spina, Ortego, Ochoa de Alda, & Aleman, 2002).

Somatoform dissociation

This differs from somatic dissociation in that somatoform dissociation does not involve body distortion. The client projects discomfort through multiple physical symptoms, reducing quality of life (abdominal pain, nausea, dysmenorrhea, menstrual irregularities…).

Dissociative Parts

Depending on the degree of dissociation, different parts can be distinguished within the clients’ internal world. Understanding these parts is essential for treatment.

“People with EDs are often little girls who never were.” (Seijo, 2000)

These individuals were treated as small adults, taking on premature responsibilities that overwhelmed their internal world. This creates frozen, childlike parts — behaviours inappropriate for their age but necessary to survive.

Common dissociative parts include:

The Little Girl Who Never Was Holds the belief: “I do not accept boundaries other than my own.”
Self-sufficient, forced to grow up too soon, learned self-regulation and control through food. (Seijo, 2012)

The Little Girl Who Could Not Grow Up Holds the belief: “In this home, one needs to get sick in order to get attention.”
Did not receive adequate affection; through food, found a way to be seen. (Seijo, 2012)

The Pathological Critic inner critic that blocks self-esteem, filters reality through self-rejection.
Belief: “Nothing is okay in me.” (Seijo, 2012)

The Rejected Self Contains body image distortion and shame toward a past self.
This part sees in the mirror the body from the past, not the present. (Seijo, 2010)

The Hidden Self Holds the belief: “I cannot show myself or stand out, or I will get hurt.”
Protects the inner world through invisibility; developed early as a safety mechanism. (Seijo, 2012)

Understanding and validating these parts allows therapists to focus on the inner structure, rather than only on food, which is merely the symptom.

Treatment

Rosen and Petty (1994) indicated that treatment for ED should include psychoeducation to help clients recognise their dissociative capacity. Awareness of dissociative parts reassures clients, bringing order to their inner chaos.

Therapists must provide time, safety, and consistency, since trust and pacing are key to effective treatment.

Treatment of EDs requires patience. There will be stagnation and resistance — understanding this as part of the process prevents burnout and dropout.

Psychoeducation

Teaching clients about their parts (e.g., the little girl who never was, the pathological critic) validates their experience and helps them feel seen.

Feeling seen is one of their basic needs.

Therapists act as surrogate attachment figures, helping repair attachment wounds. Treatment progresses from the outside in, uncovering inner vulnerability with care.

Phases of therapy

Following the three-phase model: stabilization → trauma processing → integration and transformation.

Defences protect the vulnerable child parts. Therapists must respect these layers, working gradually (“the artichoke metaphor”).

Changing beliefs

Each part holds a core belief that sustains the disorder.
Identifying and replacing these beliefs facilitates regulation and healing.

Beliefs like “I must be perfect” or “I deserve punishment” must evolve toward “It’s safe to exist as I am.”

Collaboration and compassion between parts are key milestones in therapy. Clients must come to see that every part was necessary for survival, even if now it no longer serves them.

Steps in Treatment

Step 1

Name and describe all parts of the internal world. Understand how dissociation functions as defence and compliance.

Step 2

Identify life events — both “T” trauma and “t” trauma — including attachment wounds and hidden traumas.
Use EMDR to process and integrate these memories adaptively.

Step 3

Work with beliefs tied to each part:

“To be rejected,” “To feel inferior,” “To eat in order not to think,” “To vomit in order not to scream.”

These beliefs often belong to “the little girl who never was,” “the little girl who could not grow up,” and “the pathological critic.”

Step 4

Address defences protecting parts. Allow suppressed parts (e.g., the Hidden Self) to emerge safely.

One client described her hidden self as “a bubble” — inside it, she discovered her childhood abuse once it burst.

Step 5

Work with anger, shame, and sadness — the most common emotions in ED. Encourage expression through words rather than somatic symptoms. Child parts often express trauma through the body (collapse, posture, tension).

Step 6

Facilitate grieving once integration begins. Clients must mourn the childhood, safety, or life they didn’t have.
Normalize this process so they don’t confuse grief with relapse.

Conclusion

Recognizing and addressing dissociation in ED is essential to prevent chronicity and facilitate healing.

Therapists must remember: all parts have a function.
Avoid interventions that suggest “removing” or “eliminating” parts — this can worsen fragmentation.

Healing lies in integration, compassion, and understanding that every part once served survival.

References

Everill, J., Waller, G., Macdonald, W. (1995). Dissociation in bulimic and non-eating disordered women. International Journal of Eating Disorders, 17(29), 127–134.
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Janet, P. (1965). The major symptoms of hysteria. New York and London: Hafner. (Original work published in 1907.)
Knipe, J. (1995). Targeting defensive avoidance and dissociated numbing. EMDR Network Newsletter, 5(2), 6–7.
Lyons-Ruth, K., Dutra, D., Schuder, M., & Bianchi, L.L. (2006). From Infant Attachment Disorganization to Adult Dissociation: Relational Adaptations or Traumatic Experiences. Psychiatric Clinics of North America, 29(1), 63.
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