The Meaning of Self-Starvation: Qualitative Study of Patients’ Perception of Anorexia Nervosa Ragnfrid H. S. Nordbø, Cand Psychol 1 * Ester M. S. Espeset, Cand Psychol 1 Kjersti S. Gulliksen, Cand Psychol 1 Finn Ska ˚rderud, MD 2 Arne Holte, PhD 1,3 ABSTRACT Objective: Anorexia nervosa (AN) patients tend to place a positive value on their symptoms. Many clinicians believe that this plays a central role in maintaining the disorder. However, empirical research on how patients attribute meaning to their symptoms is lacking. This study aims at sys- tematically exploring the meaning that the patients with AN attribute to their anorec- tic behavior. Method: A qualitative, descriptive, phe- nomenological design was used. Eighteen women aged 20–34 with AN (DSM-IV) were interviewed with an informant-centered interview. The interviews were tape- recorded, verbatim transcribed, coded, and analyzed phenomenologically, using a QSR-N*Vivo software program. Results: The psychological meanings that the informants attributed to their anorectic behavior could be summarized in eight constructs: ‘‘Security’’ (feeling of stability and security), ‘‘Avoidance’’ (avoiding negative emotions), ‘‘Mental strength’’ (inner sense of mastery), ‘‘Self-con- fidence’’ (feeling acknowledged and wor- thy of compliments); ‘‘Identity’’ (achieving new identity), ‘‘Care’’ (eliciting care from others), ‘‘Communication’’ (com- municating difficulties), and ‘‘Death’’ (wishing to starve oneself to death). Conclusion: The eight constructs may have central functions in the mainte- nance of AN and should be regarded when patients’ motivation and goals for treatment are assessed. Further study of the possible functions of the constructs in maintaining AN is warranted. V V C 2006 by Wiley Periodicals, Inc. Keywords: eating disorder; psycho- therapy; treatment; function; illness per- ception (Int J Eat Disord 2006; 39:556–564) Introduction Ambivalence about recovery is a central feature of anorexia nervosa (AN). Patients with AN rarely seek treatment on their own initiative, 1 the motivation to change is often low, 2 approximately one half of the patients drop out of treatment, 3,4 and treatment outcome is generally poor. 5 The strong hesitance to change has been attributed to the function of the anorectic symptoms. 2,6–8 Different from many other patient groups, AN patients tend to appreci- ate their symptoms. 7–10 This may explain their low motivation for change 11,12 and play an important role in maintenance of the disorder through self- reinforcement rather than social reinforcement. 9,10,12 In this way, anorectic behavior may be regarded not only as a set of physical and psychological symptoms, but also as a set of behaviors that have become meaningful to the individual. For many years, clinicians and researchers have discussed how to understand the meaning of ano- rectic behavior. 8,9,12–17 AN is suggested to function as a way of regaining control of psychobiological maturing 18 or as a self-punishing defense when fearing lack of control. 19 Many of these meanings postulate motivational constructs (e.g., need for control, resistance to sexual maturation). These are based on theoretical inferences from clinical expe- rience rather than systematic empirical studies. Systematic empirical studies on how AN patients themselves perceive their anorectic behavior as meaningful are scarce. Such insights may, however, be important in the study of the development, maintenance, and treatment of anorectic behavior. Furthermore, to help ambivalent patients achieve durable change in their condition, it is crucial to establish a sustainable therapeutic alliance. To 1 Division of Mental Health, Norwegian Institute of Public Health, Oslo, Norway 2 Lillehammer University College, Lillehammer, Norway 3 University of Oslo, Oslo, Norway Accepted 13 December 2005 RHSN was supported by a grant awarded from the Health and Rehabilitation Foundation via the Norwegian Council for Mental Health; EMSE and KSG were supported by grants from the Norwegian Research Council. *Correspondence to: Ragnfrid H. S. Nordbø, Division of Mental Health, Norwegian Institute of Public Health, Oslo, Norway. E-mail: ragnfrid.nordbo@fhi.no Published online 14 July 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/eat.20276 V V C 2006 Wiley Periodicals, Inc. 556 International Journal of Eating Disorders 39:7 556–564 2006—DOI 10.1002/eat REGULAR ARTICLE