THE SWING OF THE PENDULUMmFROM ANOREXIA TO OBESITY Natalie Shainess About 40 years ago, anorexia nervosa was a rare condition, and generally regarded in the psychiatric community as strange and unintelligible. Of the few cases seen, most were preadolescent or early adolescent girls, painfully thin, reluctant to eat, and at times having to be forcibly fed to maintain life. They stood out in contrast to the general community, in which people were generally well rounded, but although there were some excessively obese people, especially among the young, their number was relatively small. Today, there has been an enormous increase in the number of anorexia cases. Of course, it may reflect more accurate diagnosis. But I think this is perhaps not surprising in the light of the tremendous societal preoccupation with dieting. Food faddism has grown, but genuine concern about the nutritional value of food is also present, in part a consequence of the promotion and acceptance of junk foods, mushrooming of fast-food chains, recognition of the unhealthy doctoring of food to preserve its "shelf-life." But this is only the superficial side of the picture. The compulsive quest for youth, the narcissistic concern with appearance, the fashion dictum that we must be scarecrow clothesracks to look proper in clothes, all contribute to the social attitude about body image. It is therefore perhaps surprising that the other end of the spectrum, extreme obesity, especially in the young, and particularly young women, has also burgeoned. Let us consider another social phenomenon before turning more directly to the conditions mentioned. Women have been struggling to become liberated, that is, to have lives of their own beyond their caretaking role. Motherhood has taken its lumps, been denied as essential or important, and day care Presentedat the Symposium sponsored by the New JerseyMedical Women's Association on Psychosomatic Syndromes in Women and Girls, March 18, 1978, Mountainside Hospital, Montclair, New Jersey. Natalie Shainess, M.D., Faculty, William Alanson White Institute of Psychiatry, Psychoanalysisand Psychology; Lecturer in Psychiatry, Columbia University College of Physicians and Surgeons. The American Journal of Psychoanalysis
~) 1979Associationfor the Advancementof Psychoanalysis
Vol. 39, No. 3, 1979 0002-95481791030225-I0501.00 225
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centers, even for infants, have appeared. The emotional consequences of this have not as yet, I believe, been carefully examined. Yet it may play a part in the narcissistic preoccupations and body image concepts mentioned. Our whole population, and especially the female population, seems obsessed with food and eating, even though the concern is centered around denial of food, constant and persistent preoccupation with weight gain or loss, and continual expressions of guilt in relation to eating almost anything. But turning to the two major conditions under consideration, it is interesting that at times, and perhaps even commonly, these two extremes are merged in a single person, the anorexic, who veers from starvation thinness to extreme obesity within a period of months. One of the most telling features is body image, a delusional perception of the girl that she is "fat," no matter how thin she may be at the time. A few years ago, I worked with a young borderline schizophrenic woman who neither volunteered nor owned up to any eating or feeding problem in her history. After a few months, I noticed that she was getting very thin. Questioned about it, she had some very appropriate answers, especially since she was in the theatre and studying acting. I suggested that she had dieted very successfully, had reached an endpoint, and should resume her normal diet. But when two weeks later I noticed that she looked like a concentration camp victim, I told her this, and she replied, "But I look fat." At that point, i realized what I was dealing with, and that I had been conned by the clever rationalizations so typically provided by anorexia patients. The situation called for serious action. Another patient, a late adolescent girl, came for consultation from out of town, planning to live in New York. A huge, roly poly young woman greeted me as I appeared at the office door. After her initial consultation, she came to live in New York, and was in treatment for less than a month when she decided to give up and return home. This was after a joint consultation with her mother, whom I can best describe in two words as a "viciously phallic" woman. Two years later, I received another call from the same youngwomano She was again planni ng to come to New York, this time to embark on a career which struck me as extremely unrealistic, in view of my memories of her--to become a photographer's model. I agreed to see her, and arranged an appointment. When the day came and I opened the door this time, I wondered what had happened to my memory, as a painfully thin, sickly looking young woman floated in. She smiled as she observed my expression, which I apparently had not successfully concealed, and said "1 know it's a surprise, but don't I look good?" Unfortunately, she did not, nor was her appearance particularly appropriate to her intended work. Her hyperactive, manicky style was also a surprise. But this permits me to stress two additional factors: the inconsistency and unreliability of behavior; and the delusional nature of the
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self-concept and of goals. She felt that mere thinness qualified her to be a photographer's model, without regard to any other considerations. Her thinness seemed so life-threatening at the time that I was obliged to become preoccupied with food, eating, and the possibility of hospitalization. I had to discuss the risks with her family, and I also discussed a diet with her that she seemed to feel she could follow. But before the next session, she called to tell me that she was eating better, had decided to join a group and not continue in treatment because of the expense, and I have not heard from her since. Let me offer a third example to round out the initial picture. I had an extremely obese young borderline college girl in treatment. Her parents had been divorced for many years, and she had as fixed and intense a symbiosis with her mother as any I have seen. Her mother's saccharinity was so extreme as to be palpable. She was not a particularly attractive young woman with one exception: she had such glorious red-gold hair, which she wore hip length, that it reminded me of Rapunzel, in the fairy tale. Although seemingly not concerned about appearance, she wore jeans (and I wondered where she found any so ample in size), and she had long fingernails always impeccably polished with lacquer the exact color of her hair. She regaled me with stories of her life, which for the most part consisted of daily, lengthy struggles in the bathroom, forcing her gastrointestinal tract to release the food that she compulsively crammed into it when she was not in the bathroom. This is another major symptom of anorexia nervosa. She worked with me for a year, and she began to separate from her mother, to develop some interests, to have a few tentative dates. Her school work went well in spite of many expressed anxieties, since she was very bright, and some of her processes in relation to others were so good (humor bein 8 one of them) that she had a sizable group of friends. But at one point, as the necessity to separate from her mother even more clearly became apparent, she began to threaten suicide. In view of the times, I succumbed and had her hospitalized. I visited her a few times, and could not avoid the impression that she sported a Mona Lisa-like smile of victory. Attempts to discuss this met with avoidance, and at that point her mother dismissed me. So I do not know the outcome here. My track record with anorexics does not look very good, does it.~This either says something about me, or about the condition. Happily, there are a few 1 have been reasonably successful with, although I must caution that this is a condition that must stand the test of time, and in fact, a lifetime, because one never knows when problems may recur. There can be no confidence in change and growth as a consolidated fact. Now, let me turn a little more directly to the condition itself. Hilde Bruch 2 has pointed out that there is little direct hereditary basis for obesity as a genetic disease. Experiments with the feeding of rats in a single litter in different ways produced normal or obese animals. In considerin 8 obesity, it is necessary to
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take a thermodynamic approach: energy output is an important part of the picture. Of course, the greater the obesity, the slower the energy output. This, and the endocrine picture and biochemicals may influence, but also are influenced by the eating patterns. But the patterns of obesity distribution within the body, are, to some extent at least, governed by genetic factors. In anorexia nervosa, there is considered to be a pituitary factor, but whether this is there initially or is a result of the starvation and part of the total cybernetic interaction is not clear. However, whether on this or some other basis, if the anorexic is prepubertal, then the height is affected, and she is invariably short. As Bruch stresses, hunger is not only a reflection ofphysiological nutritional depletion, it is also a psychological experience. Hunger, in a more pleasant and less stressful form is "appetite," a zestful inclination to eat. The anorexic does not experience this. Bruch emphasizes the importance of the early mother-child interaction in the feeding process, especially where the mother may not be discriminating about the infant's cry, that is, whether it is for food or other needs, so that she may constantly offer or force food, and in addition may also reward being "good," that is, passive, with food. Here my own work on mother-child relations strongly supports this. The whole separation-individuation process or its failure is at times acted out primarily in relation to food. Of course, there are instances, in contrast to overfeeding, where starvation may be the prevailing style, usually seen in a more directly destructive mother, the sadistic or child-battering mother. As Bruch 2 puts it, "there is often a blandness in the history of anorexic patients, and the story that the child did not fuss about food." In the symptomato[ogy of anorexia, Bruch says that she considers the falsification of bodily states and lack of awareness of the patient's own thoughts and actions of fundamental importance. The problems expressed are efforts at compensating for deficiencies. All bodily functions are exposed to a variety of appropriate and inappropriate learning experiences, reinforcements, distortions, and even extinctions. Thus, Bruch feels that in understanding anorexia, while Freud's great contributions are important, more than libidinal components are involved, and "modern evidence speaks against any concept that may linger on of innate instincts.., which in a preformed way carry their own messages to the conscious or unconscious mind." Turning to the history of anorexia nervosa, before saying more about the condition itself, the disease was recognized 100 years ago, initially being differentiated from tuberculosis. It was considered an hysterical condition, in which the physical symptoms of loss of appetite, constipation, amenorrhea, loss of weight, and restless activity prevailed. It was noted that there were
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marked psychological changes. There was contradiction in the literature, also confusing it with Simmonds' disease. Binswanger 1 reported on a case of anorexia nervosa, although not labeling it as such. He described a patient, saying: "A fear of becoming fat seems the guiding force to the struggle with weight, and along with this, the desire for food increased. She could not eat in the presence of other people; only when alone." The patient recorded in her diary that her major problem was the continuous desire for food, but that her fear of getting fat acted as a brake. Her dreams were full of hunger and death, and she made many references to isolation and loneliness. Nicolle 9made this distinction: "The hysteric makes a parade of her inability to eat, and undoubtedly eats when it suits her; the anorexic tries to dissimulate that fact that she does n o t eat. The hysteric desires to elicit sympathy. This is far from the anorexic, but she may enjoy.., her ability to tease and deceive those about her." In 1969, a study by Dally 4 reviewed 140 cases and added one very important symptom: these girls induced vomiting. Some in this group avoided eating because of gastrointestinal discomfort. Among these, any vomiting was involuntary. Here I might mention my blond Rapunzel, who described at length her sessions in the bathroom, forcing herself to vomit, hating it, crying, but persisting. In this connection, Bruch feels that in the primary form of anorexia, there is a relentless pursuit of thinness: this is the driving motivation. Russell 1° and Crisp s in England characterized this symptom as "weight phobia." In his studies, Nemiah 8considered anorexia nervosa psychodynamically as the outcome of an attitude of maternal overprotection, with excessive dependency, unquestioning obedience, and a kind of wilted passivity. But of course, the refusal to eat speaks of the covert defiance that accompanies it. Meng6directed attention to the psychoticlike quality of the anorexic, not in the ordinary sense, but with a deformation of ego structure. Here, I would say that the condition can be considered a somatic delusion, and that the patient is more than potentially schizophrenic, but actually so, if properly considered. Bruch, 2 thinking about the psychodynamic basis for anorexia, said she initially felt that the psychoanalytic explanation of a fear of oral impregnation by the father was a tenable hypothesis. Now, she feels that while in some patients this concept may apply, it is insufficient for most. Turning to the symptomatology, Bruch feels that the marked psychological changes in anorexia nervosa are rationalized by the patient. The symptoms have two major components: the first is the oral factor, and the second relates to personality and life style, where the disturbance of ego function, and in interpersonal relations, is very noticeable. It includes psychogenic and self-
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induced vomiting. Another factor is the loss or failure of development of any sexual interest. Selvini 1~and many others have observed that anorexia nervosa patients are often reserved, evasive, and not always truthful. These characteristics serve their relentless pursuit of thinness, which is the conscious and stubborn motivation of their lives. I see them as carrying on, in a compulsive way, a primal struggle of their early infancy involving their gastrointestinal tract, reenacting their experiences of starvation and of oveffullness, discomfort from infantile anxiety and rage, and a wish to reject, or eject, the "evil mother" who, both in the sense of Melanie Klein and Harry Stack Sullivan, provided the bad, poisonous nipple to nurture the young; bad and poisonous in the sense of the anxiety, anger, or hate, or a combination of all three, which accompanied the mothering activities, especially feeding. I feel convinced that the unconscious fantasies connected with food are that it is poison. The patient is trapped between the need to eat to sustain life, and the paranoid projection in relation to food. The efforts not to eat can be seen as a phobic avoidance of poison. This accounts for the dogged resistance, the seriousness of the illness, and the unreliability of the patient, as well as the poor cooperation with any treatment plan. It is a long, in fact, a lifelong illness, which produces many changes in the physical and psychological picture, and in the pattern of interaction in the family. And as might be expected, the family is usually highly critical of the doctor, or usually, a long string of doctors. Further, Bruch points out that anorexics struggle against feelings of being enslaved, exploited, unable to lead their own lives. They often engage in a desperate struggle for self-respect, and for control. Their desire is to be perfect in the eyes of others, because anything less leaves them feeling totally worthless, completely vulnerable. I have not to this point said much about body image. The distortion here is of major proportions; it is, in fact, delusional. No matter how thin they get, they see themselves as fat, and there is a total lack of concern about what is happening: it is like la belle indifference of the hysteric. I stress the fact that this all holds at a point where the emaciation is gruesome; yet it is defended as normal. Distorted body image is the single most significant finding in anorexia nervosa. With regard to treatment, Bruch feels that "a realistic body image concept is a precondition to recovery." To me, this means that regardless of how it might appear when initially seeing the patient, the image distortion is not quite delusional, or is somewhat amenable to change. As one patient put it, "1 know that l am thin, but l cannot see it when I look at myself." At least this implies a reality-oriented cognitive process. It leads one to surmise that the aim of the anorexic is really slow, socially veneered suicide, especially as this becomes painless and does not at any point demand a direct act of volition. Depressive symptoms are frequently
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observed. In addition to the inaccuracy of perception or cognitive disturbance of image is that of disturbance of perception of body stimuli, an inability to recognize hunger. As Bruch says, it does not matter whether hunger sensation is repressed or not perceived, or not there. But from other fields of observation, it is known that there is a period in the course of long starvation where hunger is not experienced. Outstanding in terms of behavior is the disorganization of the whole eating pattern: from uncontrollable eating orgies to self-induced vomiting. And as has been mentioned before, hyperactivity and denial of fatigue are also characteristic. Real starvation is rarely seen in this country, so that the anorexic in the advanced stages of starvation is a sight that makes an indelible impression. I want to mention here that I have referred to the anorexic invariably as she. Yet Bruch has included boys in her study of over 70 patients in a 30 year period. I have not seen any. I am inclined to think that the girl's identification with the mother makes the condition unique to girls, especially in view of the separation-individuation problem. But if the condition is similar in boys, I would expect it to be even more complicated and include the problem of gender identity and homosexual tendencies. I do not say "homosexuality," because the patient does not mature to a more genital level. Fat people also have misperceptions of their body appearance, often denying the reality of their size, refusi n8 to look at themselves in a mirror or to be photographed. And sometimes fat people who have gotten thin continue to see themselves as obese; here it is akin to the anorexic's perception. Along with distortion of the body image perceptions goes body function distortion: the anorexic feels full after a few bites, while the obese always has room for more, no matter how much has been eaten. There is magical thinking in relation to the body delusion; for example, "if I am thin enough, someone will love me." In both anorexia and obesity, the concept prevails that "my thin self is the real me." Before saying anything about treatment, I would like to offer a few brief comments on extreme obesity. I use the word "extreme" not to describe the size or number of pounds--it might only be 10 pounds excess----but rather, the compulsiveness of the eating need and pattern, the degree of preoccupation, the resort to.secret eating, the fixity of the symptomatology, the fact that the problem of an unresolved symbiosis exists. Possibly, the girl does not havethe projective delusion of food as poison, but instead, the need to continually retain food-as-mother oral incorporation, if you will. Years ago, it was described as an attempt to gain emotional security and a sense of being ~oved through food. But the rigidity of the problem suggests that the delusional element could be expressed as a belief that without the connecting umbilical cord, the girl will die. Food serves as the connection, the placental tie to
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mother, and with it, the sense of being a "good girl," loved and protected. The obesity also brings a lot of attention from mother, although often of a negative kind. Certainly, the battle between mother and child is acted out over food. And as with the anorexic, when long-existing and severe, it is also a passive suicidal activity. If one considered a defense which "fights" to be of a higher order than passive submission, then the obese girl would be seen as even sicker, psychologically, than the anorexic. She is less likely to be amenorrheic, although this too occurs, but often on a psychological rather than physiological basis (the result of starvation), but the obese also has a diminished sexual interest, • and shows avoidance of sexual activity, which is of course aided by unattrac~ tiveness. Stunkard 12 has observed that there is no single profile of obese eating patterns or dynamics; but Hamburger s has reported four basic eating patterns: 1. 2. 3. 4.
In response tovaried emotional situations, such as loneliness or frustration In response to chronic tension or frustration As a symptom of underlying emotional illness, especially depression Compulsive eating serious enough to be comparable with other addictions.
As one aspect, obesity may result from a pattern of defiance to the mother, who initially pushed food upon the child, and rewarded with food, and then tries to limit as the child becomes obese. In considering treatment, Bruch offers an amusing paraphrase of the saying: "You can lead a horse to water but you can't make him drink." It is "you can lead someone to cottage cheese, but you can't make him shrink." From a physical vantage point, manipulation of food intake and energy output are the tools of treatment (admittedly a cheerless prospect for the obese); this accounts for all the faddism in diet and treatment. Thyroid and amphetamines are useful adjuncts, but they are hardly adequate substitutes for the unsatisfactory life that leads to obesity. Physicians' attitudes have varied from the promises of a strict authoritarian "do as I say" approach, to a basically hopeless attitude: "you have the wrong genes." They need to recognize that there are many emotional currents to the overeating problem, and help the patient to acknowledge the need for help, at which point they can suggest changes in dietary and life styles; and if the patient is quite disturbed, to recognize that dieting may need to be postponed for a later time. Above all, in the treatment of obesity, there is need for a consistent, nonderogatory attitude, and a reappraisal of the patient's unrealistic expectations. Nothing in the treatment of the obese patient even approaches the problems and upheavals in the treatment of the anorexia patient, which must be
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individualized. Hospitalization may be a lifesaving measure, which comes up sooner or later; and psychiatric hospitalization may be necessary in an attempt to resolve the destructive struggle between the patient and family. It should be kept in mind that there is danger in the disturbed electrolyte balance, where vomiting, and use of laxatives and diuretics are resorted to by the patient. Recent efforts at treatment have approached the whole family as a unit, using group therapy for parents. Insulin and thyroid have been used in the past, but have a legitimate place only in treating amenorrhea. Electroshock has also been used, but the results are only temporary--for this and any other condition, in my view. Bruch has observed that psychotherapy is in such a state of flux that almost any interaction between two people is termed "therapy." She feels that change comes from paying scrupulous attention to discrepancies between misperceived past and current events, and inappropriate responses. She pays attention to the abiding sense of loneliness, and of not being respected; and feels that really being listened to is a new experience for many of these patients. The sense of not being in control is very important in the experience of these people, and they need to discover all these feelings for themselves. There is danger of acting out in the transition from self-discovew to the development of new tools for coping. Dreams, art work, and other expressive means help to enhance the patient's self-awareness. Unrealistic expectations by the patient or therapist in relation to weight gain or loss can be hurtful. It is well to remember that the obese patient may function better at a higher than normal weight level. Much in contrast to this basically psychoanalytic therapeutic approach is that of Minuchin, ~who disclaims necessity to listen to anything but the family interaction, and who makes correctional interventions, intended to change the nature of the interactions. He and his workers claim success, even as they describe the "stickiness" of the behavior of all family members, and the pseudocompliance and pseudochange, which has a constant tendency to return to its original state. Bruch feels that the hostile attack on weight as shameful and evil, from our cultural attitudes, has contributed to obesity becoming such a serious health problem. She feels further that anorexics suffer great inner hardship evoked by this attitude, because they torture themselves into starvation "to deserve respect." The pressure to be thin is on the rise. I have observed among a number of acquaintances dedicated to being thin that they eat with a speed andintensi W that proclaim that they are starving. Emaciation in itself is not beauty. Society must accept diversity rather than impose a single standard of desirable appearance for all. The therapist must be relatively free of such compulsive
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preoccupations, whichever extreme of the eating problem he or she is treating. References
1. Binswanger, L. Der Fall Ellen West. Schweiz. Arch. Neurol. Neurochir. Psychiatry, 53: 255-277, 1944. 2. Bruch, H. Eating Disorders. New York: Basic Books, 1973. 3. Crisp, A. H. Premorbid factors in adult weight disorders, with particular reference to primary anorexia nervosa (weight phobia)J. Psychosom. Res., 14:1-22,1970. 4. Dally, P. Anorexia Nervosa. New York: Grune & Stratton, 1969. 5. Hamburger, W. W. Emotional aspects of obesity. Med. Clin. North Am., 35: 483-499, 1951. 6. Meng, H. Psyche und Hormon. Berne: Hans Buber, 1944. 7. Minuchin, S., Rosman, B. L., and Baker, L. Psychosomatic Families. Cambridge, MA: Harvard University Press, 1978. 8. Nemiah, J. C. Anorexia nervosa--a clinical psychiatric study. Medicine, 29: 225-268, 1950. 9. Nicolle, G. Prepsychotic anorexia. Proc. R. Med. Soc., 3: 1-15, 1938. 10. Russell, G. F. M. Anorexia nervosa: its identity as an illness, and its treatment. In J. H. Price (Ed.), Modern Trends in Psychological Medicine Great Britain: Butterworths, 1970, Chap. 6. 11. Selvini, M. P. L'Anoressia Mentale (Milano). London: Chaucer Publ. Co., 1963. 12. Stunkard, A. J. Eating patterns and obesity. Psychiatr. Q., 33: 284-292, 1959. Reprint requests to 140 East 83rd St., New York, NY 10028.
~) 1979Associationfor the Advancementof Psychoanalysis
Vol. 39, No. 3, 1979 0002-95481791030225-I0501.00 225
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centers, even for infants, have appeared. The emotional consequences of this have not as yet, I believe, been carefully examined. Yet it may play a part in the narcissistic preoccupations and body image concepts mentioned. Our whole population, and especially the female population, seems obsessed with food and eating, even though the concern is centered around denial of food, constant and persistent preoccupation with weight gain or loss, and continual expressions of guilt in relation to eating almost anything. But turning to the two major conditions under consideration, it is interesting that at times, and perhaps even commonly, these two extremes are merged in a single person, the anorexic, who veers from starvation thinness to extreme obesity within a period of months. One of the most telling features is body image, a delusional perception of the girl that she is "fat," no matter how thin she may be at the time. A few years ago, I worked with a young borderline schizophrenic woman who neither volunteered nor owned up to any eating or feeding problem in her history. After a few months, I noticed that she was getting very thin. Questioned about it, she had some very appropriate answers, especially since she was in the theatre and studying acting. I suggested that she had dieted very successfully, had reached an endpoint, and should resume her normal diet. But when two weeks later I noticed that she looked like a concentration camp victim, I told her this, and she replied, "But I look fat." At that point, i realized what I was dealing with, and that I had been conned by the clever rationalizations so typically provided by anorexia patients. The situation called for serious action. Another patient, a late adolescent girl, came for consultation from out of town, planning to live in New York. A huge, roly poly young woman greeted me as I appeared at the office door. After her initial consultation, she came to live in New York, and was in treatment for less than a month when she decided to give up and return home. This was after a joint consultation with her mother, whom I can best describe in two words as a "viciously phallic" woman. Two years later, I received another call from the same youngwomano She was again planni ng to come to New York, this time to embark on a career which struck me as extremely unrealistic, in view of my memories of her--to become a photographer's model. I agreed to see her, and arranged an appointment. When the day came and I opened the door this time, I wondered what had happened to my memory, as a painfully thin, sickly looking young woman floated in. She smiled as she observed my expression, which I apparently had not successfully concealed, and said "1 know it's a surprise, but don't I look good?" Unfortunately, she did not, nor was her appearance particularly appropriate to her intended work. Her hyperactive, manicky style was also a surprise. But this permits me to stress two additional factors: the inconsistency and unreliability of behavior; and the delusional nature of the
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self-concept and of goals. She felt that mere thinness qualified her to be a photographer's model, without regard to any other considerations. Her thinness seemed so life-threatening at the time that I was obliged to become preoccupied with food, eating, and the possibility of hospitalization. I had to discuss the risks with her family, and I also discussed a diet with her that she seemed to feel she could follow. But before the next session, she called to tell me that she was eating better, had decided to join a group and not continue in treatment because of the expense, and I have not heard from her since. Let me offer a third example to round out the initial picture. I had an extremely obese young borderline college girl in treatment. Her parents had been divorced for many years, and she had as fixed and intense a symbiosis with her mother as any I have seen. Her mother's saccharinity was so extreme as to be palpable. She was not a particularly attractive young woman with one exception: she had such glorious red-gold hair, which she wore hip length, that it reminded me of Rapunzel, in the fairy tale. Although seemingly not concerned about appearance, she wore jeans (and I wondered where she found any so ample in size), and she had long fingernails always impeccably polished with lacquer the exact color of her hair. She regaled me with stories of her life, which for the most part consisted of daily, lengthy struggles in the bathroom, forcing her gastrointestinal tract to release the food that she compulsively crammed into it when she was not in the bathroom. This is another major symptom of anorexia nervosa. She worked with me for a year, and she began to separate from her mother, to develop some interests, to have a few tentative dates. Her school work went well in spite of many expressed anxieties, since she was very bright, and some of her processes in relation to others were so good (humor bein 8 one of them) that she had a sizable group of friends. But at one point, as the necessity to separate from her mother even more clearly became apparent, she began to threaten suicide. In view of the times, I succumbed and had her hospitalized. I visited her a few times, and could not avoid the impression that she sported a Mona Lisa-like smile of victory. Attempts to discuss this met with avoidance, and at that point her mother dismissed me. So I do not know the outcome here. My track record with anorexics does not look very good, does it.~This either says something about me, or about the condition. Happily, there are a few 1 have been reasonably successful with, although I must caution that this is a condition that must stand the test of time, and in fact, a lifetime, because one never knows when problems may recur. There can be no confidence in change and growth as a consolidated fact. Now, let me turn a little more directly to the condition itself. Hilde Bruch 2 has pointed out that there is little direct hereditary basis for obesity as a genetic disease. Experiments with the feeding of rats in a single litter in different ways produced normal or obese animals. In considerin 8 obesity, it is necessary to
228
SHAINESS
take a thermodynamic approach: energy output is an important part of the picture. Of course, the greater the obesity, the slower the energy output. This, and the endocrine picture and biochemicals may influence, but also are influenced by the eating patterns. But the patterns of obesity distribution within the body, are, to some extent at least, governed by genetic factors. In anorexia nervosa, there is considered to be a pituitary factor, but whether this is there initially or is a result of the starvation and part of the total cybernetic interaction is not clear. However, whether on this or some other basis, if the anorexic is prepubertal, then the height is affected, and she is invariably short. As Bruch stresses, hunger is not only a reflection ofphysiological nutritional depletion, it is also a psychological experience. Hunger, in a more pleasant and less stressful form is "appetite," a zestful inclination to eat. The anorexic does not experience this. Bruch emphasizes the importance of the early mother-child interaction in the feeding process, especially where the mother may not be discriminating about the infant's cry, that is, whether it is for food or other needs, so that she may constantly offer or force food, and in addition may also reward being "good," that is, passive, with food. Here my own work on mother-child relations strongly supports this. The whole separation-individuation process or its failure is at times acted out primarily in relation to food. Of course, there are instances, in contrast to overfeeding, where starvation may be the prevailing style, usually seen in a more directly destructive mother, the sadistic or child-battering mother. As Bruch 2 puts it, "there is often a blandness in the history of anorexic patients, and the story that the child did not fuss about food." In the symptomato[ogy of anorexia, Bruch says that she considers the falsification of bodily states and lack of awareness of the patient's own thoughts and actions of fundamental importance. The problems expressed are efforts at compensating for deficiencies. All bodily functions are exposed to a variety of appropriate and inappropriate learning experiences, reinforcements, distortions, and even extinctions. Thus, Bruch feels that in understanding anorexia, while Freud's great contributions are important, more than libidinal components are involved, and "modern evidence speaks against any concept that may linger on of innate instincts.., which in a preformed way carry their own messages to the conscious or unconscious mind." Turning to the history of anorexia nervosa, before saying more about the condition itself, the disease was recognized 100 years ago, initially being differentiated from tuberculosis. It was considered an hysterical condition, in which the physical symptoms of loss of appetite, constipation, amenorrhea, loss of weight, and restless activity prevailed. It was noted that there were
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marked psychological changes. There was contradiction in the literature, also confusing it with Simmonds' disease. Binswanger 1 reported on a case of anorexia nervosa, although not labeling it as such. He described a patient, saying: "A fear of becoming fat seems the guiding force to the struggle with weight, and along with this, the desire for food increased. She could not eat in the presence of other people; only when alone." The patient recorded in her diary that her major problem was the continuous desire for food, but that her fear of getting fat acted as a brake. Her dreams were full of hunger and death, and she made many references to isolation and loneliness. Nicolle 9made this distinction: "The hysteric makes a parade of her inability to eat, and undoubtedly eats when it suits her; the anorexic tries to dissimulate that fact that she does n o t eat. The hysteric desires to elicit sympathy. This is far from the anorexic, but she may enjoy.., her ability to tease and deceive those about her." In 1969, a study by Dally 4 reviewed 140 cases and added one very important symptom: these girls induced vomiting. Some in this group avoided eating because of gastrointestinal discomfort. Among these, any vomiting was involuntary. Here I might mention my blond Rapunzel, who described at length her sessions in the bathroom, forcing herself to vomit, hating it, crying, but persisting. In this connection, Bruch feels that in the primary form of anorexia, there is a relentless pursuit of thinness: this is the driving motivation. Russell 1° and Crisp s in England characterized this symptom as "weight phobia." In his studies, Nemiah 8considered anorexia nervosa psychodynamically as the outcome of an attitude of maternal overprotection, with excessive dependency, unquestioning obedience, and a kind of wilted passivity. But of course, the refusal to eat speaks of the covert defiance that accompanies it. Meng6directed attention to the psychoticlike quality of the anorexic, not in the ordinary sense, but with a deformation of ego structure. Here, I would say that the condition can be considered a somatic delusion, and that the patient is more than potentially schizophrenic, but actually so, if properly considered. Bruch, 2 thinking about the psychodynamic basis for anorexia, said she initially felt that the psychoanalytic explanation of a fear of oral impregnation by the father was a tenable hypothesis. Now, she feels that while in some patients this concept may apply, it is insufficient for most. Turning to the symptomatology, Bruch feels that the marked psychological changes in anorexia nervosa are rationalized by the patient. The symptoms have two major components: the first is the oral factor, and the second relates to personality and life style, where the disturbance of ego function, and in interpersonal relations, is very noticeable. It includes psychogenic and self-
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induced vomiting. Another factor is the loss or failure of development of any sexual interest. Selvini 1~and many others have observed that anorexia nervosa patients are often reserved, evasive, and not always truthful. These characteristics serve their relentless pursuit of thinness, which is the conscious and stubborn motivation of their lives. I see them as carrying on, in a compulsive way, a primal struggle of their early infancy involving their gastrointestinal tract, reenacting their experiences of starvation and of oveffullness, discomfort from infantile anxiety and rage, and a wish to reject, or eject, the "evil mother" who, both in the sense of Melanie Klein and Harry Stack Sullivan, provided the bad, poisonous nipple to nurture the young; bad and poisonous in the sense of the anxiety, anger, or hate, or a combination of all three, which accompanied the mothering activities, especially feeding. I feel convinced that the unconscious fantasies connected with food are that it is poison. The patient is trapped between the need to eat to sustain life, and the paranoid projection in relation to food. The efforts not to eat can be seen as a phobic avoidance of poison. This accounts for the dogged resistance, the seriousness of the illness, and the unreliability of the patient, as well as the poor cooperation with any treatment plan. It is a long, in fact, a lifelong illness, which produces many changes in the physical and psychological picture, and in the pattern of interaction in the family. And as might be expected, the family is usually highly critical of the doctor, or usually, a long string of doctors. Further, Bruch points out that anorexics struggle against feelings of being enslaved, exploited, unable to lead their own lives. They often engage in a desperate struggle for self-respect, and for control. Their desire is to be perfect in the eyes of others, because anything less leaves them feeling totally worthless, completely vulnerable. I have not to this point said much about body image. The distortion here is of major proportions; it is, in fact, delusional. No matter how thin they get, they see themselves as fat, and there is a total lack of concern about what is happening: it is like la belle indifference of the hysteric. I stress the fact that this all holds at a point where the emaciation is gruesome; yet it is defended as normal. Distorted body image is the single most significant finding in anorexia nervosa. With regard to treatment, Bruch feels that "a realistic body image concept is a precondition to recovery." To me, this means that regardless of how it might appear when initially seeing the patient, the image distortion is not quite delusional, or is somewhat amenable to change. As one patient put it, "1 know that l am thin, but l cannot see it when I look at myself." At least this implies a reality-oriented cognitive process. It leads one to surmise that the aim of the anorexic is really slow, socially veneered suicide, especially as this becomes painless and does not at any point demand a direct act of volition. Depressive symptoms are frequently
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observed. In addition to the inaccuracy of perception or cognitive disturbance of image is that of disturbance of perception of body stimuli, an inability to recognize hunger. As Bruch says, it does not matter whether hunger sensation is repressed or not perceived, or not there. But from other fields of observation, it is known that there is a period in the course of long starvation where hunger is not experienced. Outstanding in terms of behavior is the disorganization of the whole eating pattern: from uncontrollable eating orgies to self-induced vomiting. And as has been mentioned before, hyperactivity and denial of fatigue are also characteristic. Real starvation is rarely seen in this country, so that the anorexic in the advanced stages of starvation is a sight that makes an indelible impression. I want to mention here that I have referred to the anorexic invariably as she. Yet Bruch has included boys in her study of over 70 patients in a 30 year period. I have not seen any. I am inclined to think that the girl's identification with the mother makes the condition unique to girls, especially in view of the separation-individuation problem. But if the condition is similar in boys, I would expect it to be even more complicated and include the problem of gender identity and homosexual tendencies. I do not say "homosexuality," because the patient does not mature to a more genital level. Fat people also have misperceptions of their body appearance, often denying the reality of their size, refusi n8 to look at themselves in a mirror or to be photographed. And sometimes fat people who have gotten thin continue to see themselves as obese; here it is akin to the anorexic's perception. Along with distortion of the body image perceptions goes body function distortion: the anorexic feels full after a few bites, while the obese always has room for more, no matter how much has been eaten. There is magical thinking in relation to the body delusion; for example, "if I am thin enough, someone will love me." In both anorexia and obesity, the concept prevails that "my thin self is the real me." Before saying anything about treatment, I would like to offer a few brief comments on extreme obesity. I use the word "extreme" not to describe the size or number of pounds--it might only be 10 pounds excess----but rather, the compulsiveness of the eating need and pattern, the degree of preoccupation, the resort to.secret eating, the fixity of the symptomatology, the fact that the problem of an unresolved symbiosis exists. Possibly, the girl does not havethe projective delusion of food as poison, but instead, the need to continually retain food-as-mother oral incorporation, if you will. Years ago, it was described as an attempt to gain emotional security and a sense of being ~oved through food. But the rigidity of the problem suggests that the delusional element could be expressed as a belief that without the connecting umbilical cord, the girl will die. Food serves as the connection, the placental tie to
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mother, and with it, the sense of being a "good girl," loved and protected. The obesity also brings a lot of attention from mother, although often of a negative kind. Certainly, the battle between mother and child is acted out over food. And as with the anorexic, when long-existing and severe, it is also a passive suicidal activity. If one considered a defense which "fights" to be of a higher order than passive submission, then the obese girl would be seen as even sicker, psychologically, than the anorexic. She is less likely to be amenorrheic, although this too occurs, but often on a psychological rather than physiological basis (the result of starvation), but the obese also has a diminished sexual interest, • and shows avoidance of sexual activity, which is of course aided by unattrac~ tiveness. Stunkard 12 has observed that there is no single profile of obese eating patterns or dynamics; but Hamburger s has reported four basic eating patterns: 1. 2. 3. 4.
In response tovaried emotional situations, such as loneliness or frustration In response to chronic tension or frustration As a symptom of underlying emotional illness, especially depression Compulsive eating serious enough to be comparable with other addictions.
As one aspect, obesity may result from a pattern of defiance to the mother, who initially pushed food upon the child, and rewarded with food, and then tries to limit as the child becomes obese. In considering treatment, Bruch offers an amusing paraphrase of the saying: "You can lead a horse to water but you can't make him drink." It is "you can lead someone to cottage cheese, but you can't make him shrink." From a physical vantage point, manipulation of food intake and energy output are the tools of treatment (admittedly a cheerless prospect for the obese); this accounts for all the faddism in diet and treatment. Thyroid and amphetamines are useful adjuncts, but they are hardly adequate substitutes for the unsatisfactory life that leads to obesity. Physicians' attitudes have varied from the promises of a strict authoritarian "do as I say" approach, to a basically hopeless attitude: "you have the wrong genes." They need to recognize that there are many emotional currents to the overeating problem, and help the patient to acknowledge the need for help, at which point they can suggest changes in dietary and life styles; and if the patient is quite disturbed, to recognize that dieting may need to be postponed for a later time. Above all, in the treatment of obesity, there is need for a consistent, nonderogatory attitude, and a reappraisal of the patient's unrealistic expectations. Nothing in the treatment of the obese patient even approaches the problems and upheavals in the treatment of the anorexia patient, which must be
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individualized. Hospitalization may be a lifesaving measure, which comes up sooner or later; and psychiatric hospitalization may be necessary in an attempt to resolve the destructive struggle between the patient and family. It should be kept in mind that there is danger in the disturbed electrolyte balance, where vomiting, and use of laxatives and diuretics are resorted to by the patient. Recent efforts at treatment have approached the whole family as a unit, using group therapy for parents. Insulin and thyroid have been used in the past, but have a legitimate place only in treating amenorrhea. Electroshock has also been used, but the results are only temporary--for this and any other condition, in my view. Bruch has observed that psychotherapy is in such a state of flux that almost any interaction between two people is termed "therapy." She feels that change comes from paying scrupulous attention to discrepancies between misperceived past and current events, and inappropriate responses. She pays attention to the abiding sense of loneliness, and of not being respected; and feels that really being listened to is a new experience for many of these patients. The sense of not being in control is very important in the experience of these people, and they need to discover all these feelings for themselves. There is danger of acting out in the transition from self-discovew to the development of new tools for coping. Dreams, art work, and other expressive means help to enhance the patient's self-awareness. Unrealistic expectations by the patient or therapist in relation to weight gain or loss can be hurtful. It is well to remember that the obese patient may function better at a higher than normal weight level. Much in contrast to this basically psychoanalytic therapeutic approach is that of Minuchin, ~who disclaims necessity to listen to anything but the family interaction, and who makes correctional interventions, intended to change the nature of the interactions. He and his workers claim success, even as they describe the "stickiness" of the behavior of all family members, and the pseudocompliance and pseudochange, which has a constant tendency to return to its original state. Bruch feels that the hostile attack on weight as shameful and evil, from our cultural attitudes, has contributed to obesity becoming such a serious health problem. She feels further that anorexics suffer great inner hardship evoked by this attitude, because they torture themselves into starvation "to deserve respect." The pressure to be thin is on the rise. I have observed among a number of acquaintances dedicated to being thin that they eat with a speed andintensi W that proclaim that they are starving. Emaciation in itself is not beauty. Society must accept diversity rather than impose a single standard of desirable appearance for all. The therapist must be relatively free of such compulsive
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preoccupations, whichever extreme of the eating problem he or she is treating. References
1. Binswanger, L. Der Fall Ellen West. Schweiz. Arch. Neurol. Neurochir. Psychiatry, 53: 255-277, 1944. 2. Bruch, H. Eating Disorders. New York: Basic Books, 1973. 3. Crisp, A. H. Premorbid factors in adult weight disorders, with particular reference to primary anorexia nervosa (weight phobia)J. Psychosom. Res., 14:1-22,1970. 4. Dally, P. Anorexia Nervosa. New York: Grune & Stratton, 1969. 5. Hamburger, W. W. Emotional aspects of obesity. Med. Clin. North Am., 35: 483-499, 1951. 6. Meng, H. Psyche und Hormon. Berne: Hans Buber, 1944. 7. Minuchin, S., Rosman, B. L., and Baker, L. Psychosomatic Families. Cambridge, MA: Harvard University Press, 1978. 8. Nemiah, J. C. Anorexia nervosa--a clinical psychiatric study. Medicine, 29: 225-268, 1950. 9. Nicolle, G. Prepsychotic anorexia. Proc. R. Med. Soc., 3: 1-15, 1938. 10. Russell, G. F. M. Anorexia nervosa: its identity as an illness, and its treatment. In J. H. Price (Ed.), Modern Trends in Psychological Medicine Great Britain: Butterworths, 1970, Chap. 6. 11. Selvini, M. P. L'Anoressia Mentale (Milano). London: Chaucer Publ. Co., 1963. 12. Stunkard, A. J. Eating patterns and obesity. Psychiatr. Q., 33: 284-292, 1959. Reprint requests to 140 East 83rd St., New York, NY 10028.
