Anorexia Nervosa

Shortfalls of current treatment and the need for a new approach

Introduction

“Anorexia Nervosa: Characterised by a refusal to maintain a minimally normal body weight.” (DSM IV, 1994, Pp. 583-589)

In its use of the word ‘refusal’, the medical diagnostical definition of anorexia nervosa (A.N.) suggests a behavioural drive for the disorder. It makes sense then, that most approaches to treating anorexia are based in Cognitive-Behaviour Therapy (Atkinson, 2023).

However, my lived experience has become a catalyst for me to challenge this rhetoric. Although behavioural change is one aspect of successful recovery from anorexia, I believe it is a significant discount to suggest that this alone is sufficient for long term, sustained recovery (Schiff, 1971).

(NICE, 2019) reported that, of adults diagnosed with anorexia nervosa:

only 46% make a full recovery.
34% make a partial recovery.
20% develop chronic anorexia nervosa.
31% of patients relapse within the first year of discharge from treatment.

Furthermore, mortality rates amongst people suffering from anorexia are 5 times higher than that of the general population. This is the highest rate of all mental health disorders (NICE, 2019).

With these statistics as evidence, I would argue that the current approaches to treatment are less than adequate. Atkinson (2023) states that there are few problems for which psychotherapy would argue behavioural change as the only desired outcome.

Research into the relationship between diagnosis of an eating disorder and past trauma, has been growing in recent years. (Brewerton, 2007) reports that occurrences of patients having an eating disorder alone, is rare. Over 80% of adults diagnosed with an eating disorder have at least one more comorbid disorder such as anxiety, depression, mood or personality disorders (Udo, 2019). These comorbidities are associated with prior traumatic experiences (Brewerton, 2007); (Vanzhula, 2019). In a 2004 study of patients with A.N., 100% of respondents reported having experienced at least one traumatic event during childhood (Kessler RC, 2004).

This essay will briefly explain the principles of Relational Transactional Analysis (T.A.) and introduce the Model of the Undeveloped Self with links to brain development, focusing on the amygdala and hippocampus. It will examine the Mode of the Undeveloped Self in relation to my adult experience of anorexia with co-occurring depression, anxiety, self-harm and suicidal ideation. Reflecting on my treatment via the NHS, I will consider the Biphasic Rollercoaster diagram (Corrigan, 2010) and projective transference (Hargaden, 2003) as well as the importance of integrating an intersectional approach to treatment. Finally, I will introduce the Nourish Framework (Atkinson, 2023) as a possible treatment approach which could work alongside the Model of the Undeveloped Self.

Relational TA

(Hargaden, 2002) wrote that when Berne first presented his theories, the common client was a rule bound individual who needed metaphorical ‘solvent’ to loosen the confines of their script (Berne, 1967). However, as society has evolved, so have the needs of the ‘typical’ client.

In response, Hargaden and Sills (2002) developed the relational approach to T.A. in which the emphasis is on the emergence and analysis of the unconscious process in the therapy. Relational T.A. therapists are less goal oriented than more behavioural forms of TA, instead believing in the therapeutic relationship as being the main agent for change (Widdowson, 2010).

Relational T.A. is a two-person psychology, meaning that the therapist also pays close attention to their own process, and accounts for what they bring to the therapy. This approach encourages the therapist to account for their own script limitations and, through honest, mutual relating. with the client, push beyond their script beliefs to form new patterns of relating (Stark, 2000), (Widdowson, 2010).

Hargaden (2002) presents an alternative third order structure of the Child ego-state model. It shows the C0 and P0 ego states overlapping with the intersection being A0. This accounts for the work of child development theorist, Daniel Stern who argued that the ‘self’ emerges from interactions between the infant and their primary caregivers rather than appearing independently or spontaneously (Stern, 1985) (Widdowson, 2010). Relational theory of the Child ego-state argues that the infant and primary caregivers mutually influence each other with the quality of the relationship being internalised and forming early script messages (Hargaden, 2003).

Within the Child ego-state is P1, A1 and C1 which are aspects of the Self that develop over time from pre-birth onwards. C1 is comprised of the primary relationship between infant and caregiver; P0 and C0. This represents the earliest ways of being and interacting with the ‘other’ and this relationship is fundamental as it forms the ‘blueprint’ of future relationships (Stern, 1985) (Tronick, 1998) (Hargaden, 2003). Hargaden (2003) explains that extensive misattunement in early life leads to the under-development of the self.

As well as Stern’s (1985) work, this model is aligned with modern neuroscience. Hargaden (2003) explains that, at birth, the most developed part of the brain is the amygdala. Crucial for survival, the amygdala and its related structures are responsible for the formation of implicit memory, particularly the fear response and other primary emotions; anger, surprise, and disgust (DeMasio, 1999). This part of the brain holds generalised implicit memories and cannot distinguish between past and present (Hargaden, 2003). This means that as adults, we are unlikely to have explicit narrative memories associated to early experiences, but instead a felt sense on a somatic level (Hargaden, 2003).

The hippocampus, which is involved in the formation of explicit, coordinated sensory memories matures around the age of three. This part of the brain is essential for learning. In a ‘good enough’ caregiving environment, the hippocampus collects recent conscious memories and together with the somatic experiences collected by the amygdala, lays down long-term memories in the cortex. However, in times of extreme stress, the hippocampus becomes impaired, meaning that its role in learning and development is compromised (Stern, 1985). Hargaden (2003) explains that this underdevelopment leads to a person having a fragmented core self, as illustrated by the solid, impermeable line in A1 and P1. Within C0, the small circle represents ‘walled off’ emotions which an infant will supress as a result of cumulative misattunement.

Application of the Model of the Undeveloped Self

My suggestion would be to utilise the Model of the Undeveloped Self as a diagnostic tool. I have adapted the diagram to illustrate my own experience as I entered therapy for anorexia at the age of 33.

As I reflect on this period, I recognise that, although I was still desperately trying to be strong, perfect, and please others, my drivers (A1+) were no longer ‘keeping me afloat’ and I did not feel ‘ok’ (Kahler, 1975).

Furthermore, my internal representation of the idealised other (P1+) was ‘offline’. I felt alone and unworthy of love, meaning that it felt more manageable to shut off my previously held idealisations.

Essentially, I had fallen into a familiar internal loop of thoughts and feelings between C1 and P1-, with A1- making informed decisions about my character.

My injunctions (Goulding, 1976) (P1-) played out in a variety of ways:

‘don’t exist’ in both suicidal ideation and my starvation coupled with over exercise.
‘don’t feel’ in my attempts to numb my feelings with self-harm, over-work and starvation.
‘don’t be important’ in my reluctance to seek help and my belief that I was not ‘sick enough’ to warrant treatment.
‘don’t belong’ and ‘don’t be close’ in my withdrawal from family, friends.

(Kahler, 1975) (Hargaden, 2003).

I felt disgust and worthlessness with a belief that I was innately bad, weak, and selfish (A1-).

I can reflect that, as I entered NHS treatment, the medical focus was on physical safety and stability. Initially my belief that I was not sick enough was reinforced when I was weighed. I experienced an overwhelming feeling of shame and was convinced that I would be rejected on the basis that my weight was not low enough (C1). Furthermore, the style of talking therapy which focused solely on changing unhealthy thought and behaviour patterns, perpetuated my shame. Three years on, I have an understanding that, as my weight fell further, concern for my safety was priority. However, at the time, I heard interventions about my ‘refusal’ to eat, ‘resistance’ to treatment and recommendations for in-patient treatment as reinforcements of my script beliefs about being disgusting, selfish, bad and weak.

The EATA Code of Ethics (2007/2011) states that,

‘…the practitioner will fully consider and seek to understand the personal perspectives of every individual.’ (P7)

I would argue that a therapeutic approach which solely challenges thoughts, feelings and behaviours in the ‘here and now’, attempts to capture this on the surface but misses this ethical responsibility on a deeper level, by rushing to change the client’s destructive behaviour instead of working more carefully to establish a relationship in which the client can begin to work on processing the ‘root causes’ of their unconscious bids for survival.

Furthermore, the therapist has a commitment to consider the interpersonal world of the individual as well as their impact on it (EATA, 2007/2011).

As a diagnostic tool, the Model of the Undeveloped Self would be useful in helping to build a picture of a client, going much deeper than behaviour and thought patterns to establish the underlying pain behind an eating disorder (Hargaden, 2002).

Atkinson (2023) explains:

“Addressing safety and protection issues must take priority. However, this should not happen at the cost of simultaneously developing curiosity about the origins of the eating behaviour and how this communicates the underlying level of distress and trauma.” (p2).

Leach(1998) explains that when we can see the behaviours exhibited in eating disorders through a psychological lens, we can conceptualise it as an unconscious defence against early trauma.

Alongside the Model of the Undeveloped Self, the Window of Tolerance (state of optimal arousal) could be useful for identifying hyper-arousal and hypo-arousal states in clients presenting with A.N. (Siegel, 1999) (Ogden, 2006) (Corrigan, 2010).

Dysfunctional behaviours such as deliberate self-harm and restriction of food are efforts to regulate an autonomic nervous system which is readily triggered into extreme states by reminders of the original traumatic events (Corrigan, 2010).

Corrigan (2010) presents the Biphasic Rollercoaster which represents dysfunctional defences adopted in attempt to re-enter the Window of Tolerance when feelings of distress bring a client out of their state of optimal arousal.

I have adapted the model to reflect my own experience. This diagram illustrates how my states of hyper-arousal and hypo-arousal correspond with the Model of the Undeveloped Self:

Restriction of food is in response to feelings of anxiety and fear. It is an attempt to numb the feelings – ‘don’t feel’ (P1-). There is a small drop before another spike to illustrate how I often felt initial relief at the decision to restrict. However, I would become more heightened again before longer lasting relief.
Spending only a short time feeling regulated within my Window of Tolerance, my pattern would be to fall into a hypo-arousal state where I would feel ashamed (C1) and depressed. To counteract this, I would exercise excessively.
As my illness progressed, I would often find that food restriction alone was not enough to regulate my system. Although anger was a ‘walled off’ emotion regarding the outside world, I would internalise self-hatred and rage. I returned to old habits of self-harm as a way of numbing and self-punishment – ‘don’t be important’, ‘don’t feel’ (P1-), ‘I’m bad’ (A1-).
In hypo-arousal I would feel worthless, weak, and selfish (A1-) with shame (C1) running alongside and I would play out my fears of abandonment and rejection (C1) by isolating myself from friends and family.
With frequent nighttime panic and nightmares (C1), I became fixated on walking to release nervous energy as well as cleaning and controlling my environments in search of a level of safety.
Suicidal ideation became a regular occurrence and my escape hatch when my illness became severe – ‘don’t exist’ (P1-) (Cowles-Boyd, 1980).

My Window of Tolerance was very narrow and my self-regulation skills very under-developed meaning that I was more often in hyper-arousal or hypo-arousal than in a regulated state (Corrigan, 2010) (Hargaden, 2003).

It is important to note that shame is present consistently throughout. This is common for clients with eating disorders. Cornell (1994) describes shame as the unifying strand as well as the underlying issue. It is both hidden and holding the pain beneath. Atkinson (2023) explains that shame leads to separation, detachment and isolation. Furthermore, it is essential to work with shame gently and sensitively in order for the client to open up to the rest of the work.

Figure 4 illustrates how, without this care and attention to the underlying shame, I projected my feelings that the medical staff were judgemental, persecutory, abandoning and rejecting. Although I desperately wanted someone to care for me, I did not trust that they could or would.

I believe this oversight in the current treatment models for anorexia is a significant contributing factor to so called ‘resistance to treatment’ and relapse after treatment ends; when patients have cooperated with the medical staff but have not healed the underlying trauma for which anorexia is a defence.

I would argue that the root of anorexia is almost always based in psychological distress caused by relational trauma. Therefore, the Adult ego-state has a limited capacity to form a positive self-narrative which results in dissociated ego-states and makes treatment very challenging (Stuthridge, 2006).

Finding a way to connect with clients suffering from anorexia, although difficult, is most important. Atkinson (2023) explains that evidence from people recovered from anorexia indicates that the therapeutic relationship was the ‘first to provide the person with unqualified and unconditional acceptance’ (p.5).

Meeting the client’s physiological and psychological hungers (Berne, 1970/1973) for food involves more than re-feeding, medical stabilisation and challenging thoughts, feelings, and behaviours. It requires relationship, built on a bridge through the shame and misery faced by clients (Atkinson, 2023).

Considering Intersectionality

As I work with clients, I have a strong sense that the words, challenges and interventions I choose will have a significant impact. Furthermore, although shame is a thread that appears to be interwoven in those suffering from anorexia, to assume the experience, history or ‘window to the world’ that each individual has, could be damaging and is ethically unsound. It is important that I both consider the client’s world as well as my own prejudices, privilege and assumptions.

EATA (2007/2011) states that the practitioner must consider the consequences for the client, and account for their own views, sensitivities, histories, cultures and values whenever they are choosing an intervention.

Baskerville (2022) describes intersectionality as the multidimensional nature of the self in relationship to the wider world.

“It is a way of accounting for the cultural narrative in each of us and enables us to own and identify oppression and privilege, and the power dynamics between us.” (p.2)

I believe this is important in all ethically sound counselling and psychotherapy practice. When working with a client suffering from anorexia nervosa and the thread of shame they carry with them, it is imperative. Therefore, alongside the Model of the Undeveloped Self, I would also remain curious and open minded about how gender, race, ethnicity, class, culture, sexual orientation and disability influence and impact their ‘window to the world’ as well as their experience of shame (Baskerville, 2022) (Hargaden, 2002) (Atkinson, 2023).

Neurodivergence will also have a significant impact on the client’s experience. Recent research by Edinburgh University and the University of the West of Scotland has suggested that neurodivergence, and in particular autistic adults with lived experience of anorexia, have a different perception of their relationship to the illness compared with neuro-typical adults with anorexia (Nimbley, 2023).

Furthermore, research into the intersections of society affected by anorexia, has recently begun to challenge the shaming and damaging stereotype that only skinny, white, affluent girls (SWAG) are diagnosed with the illness (Halbeisen, 2022).

Working Relationally

Whilst my experience of treatment on the NHS was intensely challenging, I was privileged to find a therapist who recognised the underlying thread in my presentation. In order to remain ethically sound and ensure I was as safe as possible, she insisted I remain under the care of medical teams. However, I believe the real healing began as the therapeutic relationship was forged. On reflection, I appreciate how challenging this would have been as I was so driven by shame. However, I recognise that, contrary to my projections onto medical staff, I projected my internal representation of the idealised other (A1+) and she recognised my need to be seen and cared for without judgement or risk of abandonment or rejection.

Atkinson (2023) presents the Nourish Framework which prioritises therapeutic relationship in treatment of eating disorders.

“If eating disorders have relational trauma at their root… then therapeutic work must begin in the relational realm.” (p. 6-7)

I suggest this would be an effective model of treatment to utilise alongside the diagnostic tools presented in this essay.

Atkinson (2023) explains that that this framework incorporates the elements required for a holistic approach to the treatment, attending to both the

psychological and physiological needs of the client in an integrative framework.

This framework requires the therapist to pay attention to their impact on the client and to work in a one-and-a-half-person psychology (Stark, 2000), attuning and reflecting using care and sensitivity. It considers the essential empathic bond between the client and therapist as the implicit foundation needed to bridge the gap, working with and through expressions of anger, shame and fear (Atkinson, 2023).

‘Working with care, compassion, and respect, the therapist communicates an abiding interest in the client and reinforces the experience of their inner world being important. Without the cocreation of this relational realm, progress is not possible.’ (Atkinson, 2023, p. 7)

I believe this model accounts for the journey to recovery being non-linear and instead, being more of an emergent process in which the relational realm, built at the beginning, is continuously present. It also provides therapists with the structure to fully consider all aspects impacting the client’s world, including intersectionality and the therapist themselves. It would be important to work closely with medical staff to ensure physiological safety. However, I would argue that medical staff should also receive training about the psychological impact they are certain to have on patients when interacting with them, for a truly holistic approach to be possible. Otherwise, shame is likely to be exacerbated and progress negatively affected.

Conclusion

Evidence of low recovery rates and relatively high occurrence of relapse shows that current standard treatment for adults with anorexia nervosa falls very short of adequate. It fails to consider the client’s experience beyond their current thought, feeling and behaviour patterns and misses essential opportunities to consider relational trauma as a contributing factor.

Utilised as a diagnostic tool, my application of the Model of the Undeveloped Self (Hargaden, 2002), cross referenced with the Window of Tolerance Biphasic Rollercoaster diagram (Corrigan, 2010) identified shame as the thread that ran through my presentation and my reflections concluded that this script emotion was reinforced in interventions.

Considering my impact on future clients, I identified the need to include intersectionality in the diagnostic analysis and throughout therapeutic interventions. Importantly, the stereotype about the cross section of society affected by anorexia nervosa is vastly inaccurate and it is ethically critical to consider all aspects of the client’s inner and outer experiences. The Nourish Framework (Atkinson, 2023) provides an opportunity for therapists to approach treatment of eating disorders in a holistic way with the therapeutic relationship taking priority throughout. I acknowledged that medical staff would still have to be involved in treatment to ensure physiological safety. However, I believe they should also have training to ensure they fully understand the impact they have on patients which, when ill considered, exacerbates shame and stalls progress.

References

Association., A. P., 1994. DSM-IV: Diagnostic and statistical manual of mental disorders:. Fourth ed. Washington D.C.: American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596.

Atkinson, M., 2023. Nourish: A Framework for Nourishing Eating-Disordered Clients Using a Structural and Relational Methodology. Transactional Analysis Journal, 6 April, 53(2), pp. 147-161. https://doi.org/10.1080/03621537.2023.2184147

Baskerville, V., 2022. A Transcultural and Intersectional Ego State Model. Transactional Analysis Journal, 52-3(228-243), p. 2. https://doi.org/ 10.1080/03621537.2022.2076398

Berne, E., 1967. Games People Play. The Psychology of Human Relationships. New York: Grove Press.

Berne, E., 1970/1973. Sex in human loving.. New York: Penguin.

Brewerton, T., 2007. Eating Disorders, Trauma, and Comorbidity: Focus on PTSD. Eating Disorders, 15(4), pp. 285-304. https://doi.org/ 10.1080/10640260701454311

Cornell, W. F., 1994. Shame: Binding affect, ego state contamination, and relational repair.. Transactional Analysis Journal, 24(2), pp. 139-146. https://doi.org/10.1177/036215379402400209

Corrigan, F. F. J. N. D., 2010. Autonomic dysregulation and the Window of Tolerance model of the effects of complex emotional trauma. Journal of Psychopharmacology, 0(0), pp. 1-9. https://doi.org/ 10.1177/0269881109354930

Cowles-Boyd, 1980. Psychosomatic Disturbances and Tragic Script Payoffs. Transactional Analysis Journal, 10(3), pp. 230-231. https://doi.org/ 10.1177/036215378001000311

DeMasio, A. R., 1999. The Feeling of What Happens. New York: Harcourt Brace.

EATA, E. A. o. T. A., 2007/2011. EATA Ethical Code, Konstanz: EATA.

Goulding, R. and Goulding, M. (1976) ‘Injunctions, Decisions, and Redecisions’, Transactional Analysis Journal, 6(1), pp. 41–48. doi: 10.1177/036215377600600110.

Halbeisen, G. B. G. P. G., 2022. A Plea for Diversity in Eating Disorders Research.. Front Psychiatry, Volume 820043, pp. 2-8. https://doi.org/ 10.3389/fpsyt.2022.820043

Hargaden, H. a. S. C., 2002. Transactional Analysis: A Relatonal Perspective.. s.l.:Hove: Brunner Routledge. https://doi.org/10.1177/036215370103100107

Hargaden, H. a. S. C., 2003. Key Concepts in Transactional Analysis; Comtemporary Views: Ego States. London: Worth Ltd.

Kahler, T., 1975. Drivers: The key to the process of scripts. Transactional Analysis Journal, Volume 5, pp. 280-284. https://doi.org/10.1177/036215377500500318

Kessler RC, M. K., 2004. The National Comorbidity Survey Replication (NCS-R): background and aims.. International Journal Methods Psychiatry Res., 13(2), pp. 60-80. https://doi.org/10.1002/mpr.166

Leach, K., 1998. Treatment considerations for female overeating and obesity using a transactional. Transactional Analysis Journal, 28(3), pp. 216-223. https://doi.org/10.1177/036215379802800305

NICE, N. I. f. C. E., 2019. Eating Disorders: What is the Prognosis?. [Online]
Available at: https://cks.nice.org.uk/topics/eating-disorders/background-information/prognosis/#:~:text=A%20systematic%20review%20%28n%3D16%20studies%29%20found%20that%2031%25,relapse%20was%20during%20the%20first%20year%20after%20discharge.
[Accessed February 2024].

Nimbley, E. e. a., 2023. It’s not about wanting to be thin or look small, it’s about the way it feels”: an IPA analysis of social and sensory diferences in autistic and non-autistic individuals with anorexia and their parents.. Journal of Eating Disorders, 11(89), pp. 1-15. https://doi.org/10.1186/s40337-023-00813-z

Ogden, P. M. K. P. C., 2006. Trauma and the body: a sensorimotor approach to psychotherapy. New York: Norton.

Schiff, A. S. J., 1971. Passivity. Transactional Analysis Journal, 1(1), pp. 71-78. https://doi.org/10.1177/036215377100100114

Siegel, D., 1999. The Developing Mind. New York: Guildford.

Stark, M., 2000. Modes of Therapeutic Action. Northvale: Jason Aronson.

Stern, D. N., 1985. The Interpersonal World of the Infant.. New York: Basic Books.

Stuthridge, J., 2006. Inside out: A transactional analysis model of trauma.. Transactional Analysis Journal, 36(4), pp. 270-282. https://doi.org/10.1177/036215370603600403

Stern, D.N. et al 1998. Non-interpretative mechanisms in psychoanalytic therapy: the “something more” than interpretation. International Journal of Tronick, E. Z. and the Process of Change Study Group. Psychoanalysis Journal, 75(5), pp. 903-921. https://pubmed.ncbi.nlm.nih.gov/9871830/

Udo, T. et al. 2019. Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States.. International Journal of Eating Disorders, 52(1), pp. 42-50. https://doi.org/ 10.1002/eat.23004

Vanzhula, I. et al., 2019. Illness pathways between eating disorder and post-traumatic stress disorder symptoms: Understanding comorbidity with network analysis.. European Eating Disorders Review, 27(2), pp. 147-160. https://doi.org/10.1002/erv.2634

Widdowson, M., 2010. Transactional Analysis; 100 Key Points and Techniques. 1st ed. East Sussex: Routledge.

Bibliography

Association., A. P., 1994. DSM-IV: Diagnostic and statistical manual of mental disorders:. Fourth ed. Washington D.C.: American Psychiatric Association.

Atkinson, M., 2023. Nourish: A Framework for Nourishing Eating-Disordered Clients Using a Structural and Relational Methodology. Transactional Analysis Journal, 6 April, 53(2), pp. 147-161.

Baskerville, V., 2022. A Transcultural and Intersectional Ego State Model. Transactional Analysis Journal, 52-3(228-243), p. 2.

Berne, E., 1966. Principles of group treatment. New York: Oxford University Press; Grove Press.

Berne, E., 1967. Games People Play. The Psychology of Human Relationships. New York: Grove Press.

Berne, E., 1970/1973. Sex in human loving.. New York: Penguin.

Brewerton, T., 2007. Eating Disorders, Trauma, and Comorbidity: Focus on PTSD. Eating Disorders, 15(4), pp. 285-304.

Clarkson, P., 1992. Transactional Analysis Psychotherapy, an integrated approach. Hove, East Sussex: Routkedge.

Cornell, W. F., 1994. Shame: Binding affect, ego state contamination, and relational repair.. Transactional Analysis Journal, 24(2), pp. 139-146.

Corrigan, F. F. J. N. D., 2010. Autonomic dysregulation and the Window of Tolerance model of the effects of complex emotional trauma. Journal of Psychopharmacology, 0(0), pp. 1-9.

Cowles-Boyd, 1980. Psychosomatic Disturbances and Tragic Script Payoffs. Transactional Analysis Journal, 10(3), pp. 230-231.

DeMasio, A. R., 1999. The Feeling of What Happens. New York: Harcourt Brace.

EATA, E. A. o. T. A., 2007/2011. EATA Ethical Code, Konstanz: EATA.

Fisher, J., 2017. Healing the Fragmented Selves of Trauma Survivors: Overcoming Internal Self Alienation.. New York: Routledge.

Goulding, R. a. G. M., 1976. Injunctions, Decisions and Redecisions. Transactional Analysis Journal, 6(1), pp. 41-48.

Halbeisen, G. B. G. P. G., 2022. A Plea for Diversity in Eating Disorders Research.. Front Psychiatry, Volume 820043, pp. 2-8.

Hargaden, H. a. S. C., 2002. Transactional Analysis: A Relatonal Perspective.. s.l.:Hove: Brunner Routledge.

Hargaden, H. a. S. C., 2003. Key Concepts in Transactional Analysis; Comtemporary Views: Ego States. London: Worth Ltd.

Kahler, T., 1975. Drivers: The key to the process of scripts. Transactional Analysis Journal, Volume 5, pp. 280-284.

Kessler RC, M. K., 2004. The National Comorbidity Survey Replication (NCS-R): background and aims.. International Journal Methods Psychiatry Res., 13(2), pp. 60-80.

Leach, K., 1998. Treatment considerations for female overeating and obesity using a transactional. Transactional Analysis Journal, 28(3), pp. 216-223.

Ogden, P. M. K. P. C., 2006. Trauma and the body: a sensorimotor approach to psychotherapy. New York: Norton.

Schiff, A. S. J., 1971. Passivity. Transactional Analysis Journal, 1(1), pp. 71-78.

Siegel, D., 1999. The Developing Mind. New York: Guildford.

Stark, M., 2000. Modes of Therapeutic Action. Northvale: Jason Aronson.

Stern, D. N., 1985. The Interpersonal World of the Infant.. New York: Basic Books.

Stuthridge, J., 2006. Inside out: A transactional analysis model of trauma.. Transactional Analysis Journal, 36(4), pp. 270-282.

Tronick, E. Z. a. t. P. o. C. S. G., 1998. Non-interpretative mechanisms in psychoanalytic therapy: the “something more” than interpretation. International Journal of Psychoanalysis, 75(5), pp. 903-921.

Udo, T. &. G. C. M., 2019. Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States.. International Journal of Eating Disorders, 52(1), pp. 42-50.

Vanzhula, I. A. C. B. F. L. &. L. C. A., 2019. Illness pathways between eating disorder and post-traumatic stress disorder symptoms: Understanding comorbidity with network analysis.. European Eating Disorders Review, 27(2), pp. 147-160.

Widdowson, M., 2010. Transactional Analysis; 100 Key Points and Techniques. 1st ed. East Sussex: Routledge.