Correspondence: Youl-Ri Kim, M.D., Eating Disorders Clinic, Department of Neuropsychiatry, Inje University Seoul Paik Hospital, 85 Jeo-Dong 2 Ga, Jung-Gu, Seoul 100-032, Korea
Tel: +82-2-2270-0063, Fax: +82-2-2270-0344, E-mail: yrkim@seoulpaik.ac.kr

Anorexia nervosa in S. Korea

Although rare in S. Korea a decade ago, anorexia nervosa is now becoming a common clinical problem among young women. One study with self-report questionnaires in S. Korea reported that 3.2% of Korean adolescents met the diagnosis of eating disorders.¹
Current socio-cultural explanations in eating disorders include worldwide cultural dynamics, such as cultures in transition ('Westernizing' societies).² As economic liberalization in S. Korea has led to the deregulation of media advertising, the depiction of ridiculously slender women in advertisements contributes to dissatisfaction with the body and disordered eating, especially in vulnerable individuals. Furthermore, academic performance and school life are the most distressful areas for high school students in S. Korea.³ The highly competitive educational environment in S. Korea may intensify the adolescents' vulnerability to anorexia nervosa.

Treatment of anorexia nervosa

The treatment of eating disorders is based on a multi-modal model, recognizing that these disorders do not have a single cause.⁴ In the treatment of anorexia nervosa, skilled intervention has a profound beneficial effect on the course of the illness. The treatment guide-lines of UK on eating disorders⁵ recommended that most people with anorexia nervosa should be managed with psychological treatment combined with physical monitoring provided by a competent healthcare professional. Traditional psychological approaches in anorexia nervosa include cognitive analytic therapy, cognitive behavioural therapy, interpersonal therapy, focal psychodynamic therapy and family interventions.

Art therapy and anorexia nervosa

Art therapy may provide another dimension in the psychological approach to anorexia nervosa. It is a psychotherapeutic method where the creative process is utilized and the central medium of communication is pictorial rather than verbal.^6,7 The 'therapeutic agent for change' 8 in art therapy is the patient's image-making experience itself and the patient's communication to herself through unconscious projection into the image.^9,10 The actual process of image making allows emotions to be released as a cathartic experience within a defined space.^11,12,13 By expressing herself in this way, the confusion and ambivalence which the anorexic tries to conceal can be externalized on paper. This imagery then can be used as a kind of reflector which also increases bodily awareness and thus helps to clarify problems central to the anorexic's position, particularly that of her identity.^14,15,16 The way in which the patient relates to and uses her paper and art materials is also used to explore how she deals with issues such as territory, control and boundaries, and how these issues in turn can help her to understand something about her relationship with her own body and with other people.¹⁷ In the setting where therapeutic experience is encouraged in the presence of an unobtrusive therapist who has created space for that purpose, issues of self and other-relatedness can be explored.¹⁸

Case study

A 15-year-old Korean high-school girl, whom we shall call Mia, started dieting in response to teasing by her friends for being overweight. At that time, she only weighed 56 kg, and being 1.64 m tall [body mass index (BMI, kg/m²) 20.8], she felt 'very fat'. She began to miss meals, and within 3 months her weight had dropped to 47 kg (BMI 17.5), by which time she had stopped menstruating. Despite this evidence of weight loss, she remained energetic and used strenuous exercise as a way of further controlling her weight. When medical help was finally sought by her mother, Mia had met the criteria for anorexia nervosa defined in the 4^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)¹⁹ for 8 months.
The symptom was developed when Mia left her family home in Deajeon to study music at a renowned high-school of art in Seoul, where she lived alone with her elder sister. She became overwhelmed by other good looking girls in her school and her low self-esteem was further aggravated by the absence of her mother. She progressively reduced her food intake to lose weight. Her mother was very discouraged and was not able to understand her daughter's change. Mia became introverted, and gradually avoided developing any meaningful relationships.
After comprehensive risk assessment, the outpatient psychological treatments with physical monitoring was offered with consideration for her symptom as a first episode of short duration, a relatively low-risk BMI, the absence of medical complications and her educational need.
Art therapy was provided by an art therapist, one of the authors (Jeong HY) combined with other multi-modal approach. Our particular interest in the use of art therapy with Mia lay in the creation of a channel for communication and the development of a relationship with her. Her first image drawn in pencil reflected her fear and anger (Figure 1). She said that she was unwilling and unable to go behind the boundary by which she was separated. The sensitivity and authenticity of this image reflected her unconscious wish to cooperate with the therapist in overcoming internal difficulties. It was important at this point for the therapist to acknowledge and address Mia's fears and anger and to show concern but not anxiety in order to be able to offer containment for her.
At the next session, she painted herself in pale color, effectively making herself invisible (Figure 2). It was suggested that this might be connected with her distorted body image.²⁰ Mia described a sense of having no self. However, this process presented her with the experience of two incongruities-visual evidence of her.109 bodily existence drawn on paper and her own perception of not existing.
Over the next few sessions, held weekly, she did a series of drawings which embodied her negative emotions; anger, in particular. One aspect of her anorexia seemed a distorted expression of her anger, anger turned inward. The image-making served her as a channel for this acting out and enabled her to externalize her fury in a safe way. It was important for the therapist to facilitate the expression of these negative feelings in a contained way. Mia, who had been depressed, began to acknowledge some improvement in her mood and reduction in her preoccupation with food. Gradually she regained her optimistic attitude and openness towards people around her. Mia said she became to overcome her fear of gaining weight and endure the urge to exercise after eating.
Later, Mia drew a picture she called 'the Mum Mountain' (Figure 3). Each colour represented herself in relation to her mother. She described dark green was her current self, pink herself in the past, and blue a desired self in the future. It revealed some aspect of her concept of self still held within the mother. It became clear that her anorexia was expressing an inability to separate from her mother and that this separation issue was the crucial one most needing to be worked out. The therapist encouraged her to explore more of the three differentiated images related to her mother. This process helped Mia to feel confident in the physical absence of her mother. Mia's mother also shared information with therapist and facilitated communication with Mia throughout the treatment.
In the final session, after 2 months of art therapy, Mia drew two pictures. The first was of a smiling girl, herself, in a landscape (Figure 4), which clearly represented a return to the outer world and the beginning of her self-perception as a whole, independent being. Then, she drew a festive scene evoking a sense of together-ness (Figure 5). In the end of the session, she stated her true desire was not to be a thinner but to be a good musician. At treatment termination, she regained her weight to 54 kg with 2 cm growth over the treatment period (BMI 19.8).
At follow up after 4 months, her weight was maintained in healthy range and menstruation was regained. Her ability to deal with relationships between other people and herself was improved. She also reported giving a successful performance in her final school concert.

Discussion

Mia's case, the therapeutic outcome of brief intervention with art therapy, suggests the potential benefits of applying art therapy as another tool of psychological approach in anorexia nervosa. Through the art-making process, Mia could creatively deal with her negative emotions and give herself shape by drawing herself. In forming these images and discussing them with the therapist, she became aware of her need to establish a separate identity distinct from her mother, and could work towards a more clarified sense of self. When the creative expression encouraged her to disclose unconscious materials, some of her underlying problems could be resolved with the therapist's help, enabling her to change her anorexic behaviours. Throughout the work with her, the therapist's fundamental task was maintaining the boundaries of a safe environment and a trusting relationship and facilitating the development of self-awareness and a secure, separate sense of self.
The involvement of the patient with anorexia nervosa in the creation of artwork, using concrete, durable imagery, in the presence of a facilitating therapist is an important step towards the development of a whole-person relationship. Despite the success of this case report in supporting the value of art therapy as another effective psychological approach for the treatment of anorexia nervosa, few randomised controlled studies into the art therapy have been performed. Therefore, our case report warrants more controlled research into the evidence-based treatment of art therapy in anorexia nervosa.

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