Mentalization and external regulation of emotions in eating disorders.

One crucial phenomenological aspect in patients with eating disorders is a distressing feeling of emptiness. A void that cannot be filled by any object, that corresponds to the absence of a mental function, the inability to think, to symbolically represent, to attribute meanings, to recognize and communicate fantasies and emotional states. This lack of mentalization is the consequence of the failure of parental reflective capacities and of dysfunctions of attachment and family relationships. A non-psychological way to adjust the mental states is to use external regulators of the emotions, that is, objects, experiences or behaviors that stimulate the body by changing the mental states and somatic functions that accompany them. Children and adults commonly use similar behaviors to calm down, get excited, overcome boredom or distraction, without activating mentalizing psychological processes. People who have difficulty in mentalizing, however, tend to implement, compulsively, intensive and continuous increasingly extreme behavior in an attempt to regulate and control emotions. The behaviors that more frequently assume this significance are smoking, drinking alcohol, taking drugs, overeating (as in bulimic crises or severe obesity) or eating too little (as in anorexia), or intensive, extreme and potentially dangerous physical or sexual activities. These behaviors enable control of disturbing emotional tensions that cannot properly be adjusted by thinking (anxiety, fear, depression, anger, sexual arousal, feelings of helplessness, of emptiness, boredom), as they solicit bodily reactions and opposite emotional tensions (excitement, fear, euphoria, physical pain, hunger, satiety, blunting). The compulsive tendency to use external regulators of emotion, however, represents an important risk factor that affects physical and mental health and is a feature of many psychopathologies, particularly borderline personality disorders, lack of impulse control, addiction and eating disorders.