Eating disorders (EDs) are one of the most insidious psychopathologies to treat due to the chronical symptomatology and frequent relapses during and after the course of psychotherapy (Grenon et al., 2019). Notably, when treating patients with EDs, clinicians report distinct patterns of negative emotional responses—-including strong feelings of ineffectiveness and incompetence, frustration, anger, and lack of mutual connection—-which negatively affect the therapeutic process and outcome (e.g., Thompson-Brenner et al., 2012; Tanzilli et al., 2020). Among EDs, anorexia nervosa (AN) is the most challenging and worrying clinical condition with significantly high mortality (Papadopoulos et al., 2009; Franko et al., 2013; Gugliandolo et al., 2020). Despite indisputable research advances, the rate of patients with AN completely recovered is still very low. Among surviving patients, less than one-half recover on average, whereas one-third improve and 20% remain chronically ill (Steinhausen, 2002). It is worth noting that often patients with AN report being afraid of changes required by the treatment (psychological, medical, nutritional, and psychiatric integrative therapy) and tend to feel their pathology as protective against developmental tasks and growth (Garner and Garfinkel, 1980). Given the partial effectiveness of treatments for EDs, advances in etiology understanding and treatment tailoring are needed to improve therapeutic outcomes with patients with AN (Hay et al., 2012; Zipfel et al., 2015).

Defense mechanisms are documented to be one of the most relevant among psychological factors influencing therapeutic outcome (Di Giuseppe et al., 2020a; Giovanardi et al., 2021). Defense mechanisms are an important aspect of implicit emotion regulation that moderates psychological reactions to internal conflicts and external stressful situations, such as chronic physical and mental diseases (Conversano et al., 2020; Vicario et al., 2020; Vita et al., 2020; Martino et al., 2021), defined as mechanisms that mediate the individual's reaction to internal or external stressors (American Psychiatric Association, 2013). Research suggested that the use of immature defenses is associated with psychopathology, whereas mature defenses are related to high psychological functioning (Lucifora et al., 2021; Di Giuseppe et al., 2022). Moreover, a large body of literature demonstrated that stressful life events predict worsening in defensive functioning, together with symptom exacerbation and a higher level of psychological distress (Aafjes-Van Doorn et al., 2021; Békés et al., 2022). This is particularly disturbing for patients affected by chronic diseases, whose defense mechanisms mediate the course of the disease and survival probability (Beresford et al., 2006).

Research on defensive functioning of patients with AN still scarce, and controversial findings have been found. Gothelf et al. have found that patients with AN rely more on immature defenses compared with controls (Gothelf et al., 1995). Defenses such as intellectualization and sublimation are more frequently used by patients with AN than healthy people, while passive aggression, isolation, and devaluation are more frequently used by anorectic than bulimic patients (Stein et al., 2003; Costanzo et al., 2022). These results were not confirmed by other studies. According to Vidović et al., patients with AN display no significant difference in defense styles when compared with healthy patients, which the authors explained as the tendency to control external and internal environment and the unconscious efforts to imitate normality to avoid conflicts (Vidović et al., 2003).

Patients' use of defense mechanisms has been shown to be an important predictor of treatment outcomes. Over the course of the treatment, patients' defenses improve as they tend to use more mature defenses and less neurotic and immature defenses (Kramer et al., 2010; Babl et al., 2019). The changes in defensive functioning do not follow necessarily a linear trend, they are generally influenced by emotionally meaningful life events and the quality of significant relationships, such as the one with the therapist or important others (Tanzilli and Gualco, 2020). Improvement in defensive maturity is also associated with improvement in personality functioning and self-awareness. In this regard, it is plausible to define mature defenses as coping strategies (i.e., the defense affiliation is similar to problem-focused coping), therefore reducing the ancient dichotomy between these psychological constructs (Di Giuseppe et al., 2021a).

According to recent findings, high-adaptive defense mechanisms sustain functional personality development in healthy individuals (Costa et al., 1991; Cramer, 2015; Muzi et al., 2021). The in-deep understanding of defense mechanisms on a continuum of maturity/adaptiveness (Vaillant, 1971) requires the reference to the gold-standard interpretation of this psychological aspect of mental functioning: the Defense Mechanisms Rating Scales (DMRS), an empirically based hierarchical theory of defense mechanisms that inspired the introduction of an axis for assessing defenses in the DSM-IV (Perry, 1990). The hierarchical organization of defense mechanisms proposed in the DMRS includes 30 defense mechanisms ordered into seven defense levels and three defensive categories of maturity. Different from other theories of defense mechanisms, the DMRS hierarchy of defenses highlights both the definition and the function of each defense mechanism and describes clinical examples of how each defense operates (Di Giuseppe and Perry, 2021). Analyzing the function of defense mechanisms is possible to understand the internal conflicts experienced by the patient and, thus, address therapeutic intervention.

In this study, we examined changes in defensive functioning during long-term psychotherapy with two patients diagnosed with severe AN. The changes in defensive functioning have been qualitatively described together with the body mass index (BMI) and personality functioning (PF). We aimed to verify whether changes in overall defensive functioning (ODF) and specific defense mechanisms together with BMI and PF can be detected during intense dynamic psychotherapy with patients having AN. We expected that high-adaptive defense mechanisms such as self-assertion and self-observation would be associated with improvement in BMI and PF, while image-distorting defenses such as splitting and devaluation of self-image would be associated with a decrease in both outcome indexes.

Known as a key factor of personality structure, defensive functioning influences cognitive, affective, relational, and behavioral strategies activated by an individual in response to internal conflicts and external stressors (Lingiardi et al., 2010; Hersoug et al., 2021). Like other emotion regulation strategies, defense mechanisms tend to change throughout psychotherapy, and their improvement impact symptoms severity and overall mental health (Perry and Bond, 2012; Di Giuseppe et al., 2020b; de Roten et al., 2021; Perry et al., 2022). The present study described the variation of defensive functioning, body weight, and overall personality functioning in two cases of severe AN-treated integrated therapy for ED, including long-term dynamic psychotherapy. Qualitative and quantitative assessments of defense mechanisms have been done with a measure inspired by the gold-standard and empirically based theory of defense mechanisms (Perry, 1990), the Q-sort version of the DMRS (DMRS-Q) developed for assessing defenses in clinical work (Di Giuseppe et al., 2014, 2021b). Despite the evident limitations of the case study design, the present research represents a pioneer attempt at a systematic longitudinal assessment of defense mechanisms and BMI variations in severe AN. Moreover, it provides an example of how observer-rated measures such as the DMRS-Q might be easily applied in process-outcome research with limited costs (Békés et al., 2021).

Improvement in ODF, PF, and BMI was observed in both cases after 1 year of dynamic psychotherapy. Conversely, we observed decreased defensive maturity and symptom relapses right before scheduled therapy interruptions. These findings confirmed our hypothesis that improvement in defensive maturity was associated with an increase in BMI and PF. Interestingly, we found that only the patient who returned to psychotherapy after 6 months of interruption (Daphne) showed complete remission. In this case, the increase in outcome measures followed different trends depending on the treatment provided and the specific therapeutic setting. In the cases analyzed, the outpatient nutritional therapy setting was only slightly helpful for improving BMI, although it allowed the patient to continue her intense dynamic psychotherapy, which therefore fostered defensive and personality improvements. Residential treatment for ED dramatically impacted BMI but did not allow psychotherapy continuation, which resulted in a sort of “freezing” of psychological functions and outcomes. Regarding the defense mechanisms on the basis of our observation, it can be speculated that the ability to recur to high-adaptive defenses such as self-observation and self-assertion allowed patients with AN to understand, reflect, and actively take care of their illness with the effect of reducing maladaptive eating behaviors, obsessive thoughts, social isolation, and body misperception. Accordingly, using less repression and denial facilitated patients' awareness of their severe chronic disease instead of keeping them blind and disengaged from solving the problem. Moreover, less use of devaluation, splitting, and passive aggression decreased self-harming behaviors and pervasive self-image distortion with the effect of symptoms decrease and BMI increase. Looking at the specific function of defense mechanisms in these severe AN cases, there might be an inhibited awareness of conflictual ideas, thoughts, and desires (repression), possibly related to body perception and identity (devaluation of self-image), which led to an extreme negative image distortion that could not be mitigated by considering positive aspects of the self and the others (splitting). Dramatic chronic food restriction might be seen as a strategy for turning anger toward the self (passive aggression). However, this symptom is denied and instead justified as a fear of fat body shape (denial).

Moreover, we noted that residential treatment impacted BMI, while it “freezed” improvements in defensive and personality functioning. Different therapeutic interventions (i.e., residential therapy for ED, intense dynamic psychotherapy, and drug therapy) might work for specific purposes at specific times (Roth and Fonagy, 2005), but they should not be exchanged one for the other. They instead should be integrated when treating complex psychopathological conditions such as severe AN. The absence of an integrated approach or the poor intensity of the intervention might compromise the effectiveness of the whole therapeutic process and thus foster relapses, symptoms exacerbations, and chronicity.

Treating ED is a long-term journey studded with pitfalls. Understanding psychological mechanisms behind symptom maintenance and relapses is essential to contrast dysfunctional patterns activated during the treatment with patients affected by severe AN. Effective therapeutic interventions should adopt the biopsychosocial approach to care and consider the daily monitoring of such mechanisms to lead the patient toward the genuine acceptance of changes in weight and body shape promoted by nutritional therapy.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the individual(s) and/or minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.

CC conceived the research design and analyzed the data. MD wrote the first draft of the manuscript and collected data by coding the therapy sessions. CC, MD, and VL contributed to the interpretation of the results and critically reviewed the final draft of the manuscript. All authors contributed to the article and approved the submitted version.