Self-starvation, bulimic behavior, and self-mutilation comprise a triad of associated self-harm syndromes that are potentially life threatening, with anorexia nervosa having the highest mortality rate of any psychiatric disorder. They are associated with trauma and are extremely resistant to treatment. These patients present a disturbing lack of anxiety about their own life-threatening behavior, yet are preoccupied with death and anxiety about annihilation. Because dissociation compartmentalizes and separates psychological and somatic aspects of traumatic experience (psychological and somatoform dissociation), it enables these patients to disavow the life-threatening nature of their behavior, which makes the dissociative processes the most destructive factor in this psychopathology. The self-harm symptoms are a presymbolic form of communication that must be decoded and confronted in treatment to make recovery possible. For many patients who starve, purge, or mutilate themselves, the body is speaking of death. They require a treatment that protects their safety, determines their personal construct of death, treats the dissociative pathology and sadomasochism, and builds signal anxiety and other ego functions, especially affect regulation.

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The family romance is typical of latency-aged children. A quality of this conscious fantasy is that the imagined parents are usually of exalted rank, such as royalty or other celebrities. This aspect is a clue to the unconscious meaning of the family romance. Exploring its significance deepens understanding of the latency child and derivative behavior in the transference reactions of adult patients in treatment.The family romance is a fantasy that one's parents are not one's real progenitors, that one really came from exalted people (e.g., royalty). Its wide appeal is apparent in the many folktales that express this idea of the true prince or princess who is brought up by a woodsman and his wife. Such fantasies, however, are also characteristic of children between the resolution of the Oedipus complex and the beginning of adolescence.

In the recent literature on eating disorders, little attention is usually given to the possible role played by heightened death fears and anxieties and failed death transcendence in the dynamics of patients who suffer from anorexia and bulimia nervosa. For reasons that remain unclear, early texts and articles in the literature do address death themes, particularly as they are discernible from patients' dreams and nightmares. Thomä's 1967 text Anorexia Nervosa may be interpreted as giving further illustration to this thesis. © 1993 by John Wiley & Sons, Inc.

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