THE
AMERICAN
JOURNAL Special
A Description
Stunkard,
This article consists of a shortened and annotated translation of a paper on “An Interesting Oral Symptorn Complex and Its Relationship to Addiction” by M. WuIff of Berlin, which was delivered before the German
Psychoanalytic
Society
on
April
12,
1932.
The article describes four cases ofan eating disorder in women that was characterized by binge eating, hypersomnolence, apathetic depression, and disparagement of the body image. After the eating binges, all four patients manifested periods of fasting, and two of the three, about whom such information is available, vomited. Translations of large excerpts of the case histories are presented together with a summary of Wulff’s discussion. (Am J Psychiatry 1990; 147:263-268)
T
following is a biographical note on Moshe Wulif. Wulif was born in Odessa in 1878 and studied medicine in Berlin. In 1908 he met Karl Abraham, who introduced him to psychoanalysis, and he soon became a dedicated proponent (E. Gumbel, personal communication, April 20, 1988). In 1909 he was dismissed from his position in Berlin because of his “Freudian views” (1, p. 76) and returned to Odessa, since “Russia was then a freer country than Germany in such matters” (1, p. 1 10). From Odessa he continued his contact with Abraham and corresponded with both Freud and Ferenczi. In 1910, according to Kurt Eissler, he accompanied the Wolf-Man from his home in Odessa to Vienna and introduced he
...
Received April 21, 1989; accepted Aug. 17, 1989. From the Dcpartment of Psychiatry, University of Pennsylvania School of Mcdicine. Address reprint requests to Dr. Stunkard, Department of Psychiatry, University of Pennsylvania School of Medicine, 133 South 36th St., Suite S07, Philadelphia, PA 19104-3246. Supported in part by NIMH Research Scientist Award MH0024S. Copyright © 1990 American Psychiatric Association.
Am
J
Psychiatry
147:3,
March
1990
PSYCHIATRY
Articles
of Eating
Albert
OF
Disorders
in 1932
M.D.
him to Freud (personal communication, Jan. 21, 1988). In 1914 Wulif moved to Moscow, where he taught psychoanalysis, and in 1917, he became docent and the first psychoanalyst in the Faculty of Medicine of the University of Moscow (E. Gumbel, personal communication). Jones mentions Wulif and Ossipow as “those most worthy of remembrance in connection with the early days-and as it was to prove, also the last days-of psychoanalysis in Russia” (1, p. 76). In 1927 Wulif returned to Berlin, where he worked in Simmel’s psychoanalytic sanitarium. In 1933 he moved to Tel Aviv, where he practiced psychoanalysis until his death in 1971. He was a founder and, for 10 years (1943-1953), the President of the Israel Psychoanalytic Society. According to a colleague, Wulif was “a good clinician, excellent teacher and productive writer. He did never undergo a personal analysis” (E. Gumbel, personal communication). It is widely believed that bulimia is a modern disease. Unlike anorexia nervosa, for which a rich history has been traced to the Middle Ages (2), bulimia seems to have burst from the blue upon modern society, and it has achieved widespread recognition in a very short period of time. A new publication, The International Journal of the Eating Disorders, is devoted to bulimia (and anorexia nervosa), and successive estimates of the prevalence of bulimia have risen to a peak of 19% of college women (3). Interest in bulimia in the popular press has risen in parallel. Personal accounts have filled the pages of women’s magazines, and Newsweek magazine pronounced 1 98 1 as “The Year of the BingePurge Syndrome” (4). Is it possible that such a distinctive disorder could have arisen de novo in the past decade? Bulimia is probably not a new disorder. The evidence is of two types-scattered historical references compatible with bulimia over the past 250 years and three detailed case histories in the past SO years. Either source alone would be insufficient to make the case. Together they barely do. It therefore seems useful to
263
EATING
DISORDERS
IN 1932
publish a translation of a paper by Wulif published in 1932 that described in considerable detail four cases of a disorder that appears similar to current descriptions of bulimia (5). The scattered historical references have been reported by Stein and Laakso (6). They noted that as long ago as 1743, James described “true boulimus,” which was characterized by intense preoccupation with food and overeating at very short intervals, followed by fainting, and a variant, caninus appetitus, in which the overeating was terminated by vomiting (7). This account was followed in 1785 by that of Motherby, who distinguished three types of bulimia-bulimia of the pure hunger type, bulimia associated with “swooning,” and that terminated by vomiting (8). The disorder was sufficiently well-recognized to warrant an entry in the 1797 edition of the Encyclopedia Britannica. The only nineteenth-century reference compatible with current concepts appears to be that of Blachez in 1869, who described two forms of “boulimie” (9). In each, food might become the major preoccupation of the person, hunger might persist even after the consumption of enormous amounts of food, and torpor might follow the binge. In the subtype called cynorexia, the eating binge was followed by vomiting. It is worthy of note that Gull’s 1874 description of anorexia nervosa included the occasional occurrence of an extremely voracious appetite (10). Bulimia attracted little attention until well into the present century, although in 1903 Janet described four patients (of a total of 236 in his book) who may have been bulimic (1 1). In their translation and comment on these cases, Pope and associates (12) noted that these four patients overate in association with other psychiatric disorders-depression (N=2), anorexia (N= 1), and agoraphobia (N= 1). Vomiting was described in the case of only one patient, the only man, and the one whose binge eating was described in the most ambiguous manner-”an often voracious appetite, given to peculiar fluctuations. The patient with anorexia nervosa, a severe obsessive, also has typical disturbances of the body image.” Modern interest in bulimia first appeared in connection with patients who suffered also from anorexia nervosa. In 1950 Nemiah reported the case histories of 14 patients with this diagnosis who had been seen on the psychiatric service of the Massachusetts General Hospital over a period of 12 years (13). Four of these patients had episodes of “abnormal eating” compatible with bulimia. One subject (patient 9) presented a classic picture of bulimia nervosa, in which eating binges were followed by vomiting, as often as once a day. Vomiting was not reported among the other three subjects (patients 1, 8, and 10), but they manifested clear eating binges. The three detailed case histories to which reference has been made were those of Binswanger’s “Case of Ellen West” in 1928 (14), Lindner’s case of Laura, first published in 1950 (15), and Stunkard’s case of T.T. in 1959 (16). The paper that forms the basis of this report
264
has
generally
creased
escaped
interest
notice
in bulimia
during
and
has
the
received
recent only
inpass-
Psychoanalytic Theory “An Interesting Oral Symptom Complex and Its Relationship to Addiction,” by M. Wulif, contained not only detailed case histories but also some speculations about the nature of the disorder that, while dated in some ways, sound surprisingly modern in others. A few notes about the translation are in order. The paper has been shortened to about one-third of its original length. I have retained much of the clinical descriptions but have summarized the lengthy theoretical discussion. As was apparently the custom, this discussion, complete with assertions of certainty such as “without doubt” and “unquestionably,” was intering
of
notice-in
Neurosis
Fenichel’s
This
(17).
The paper,
spersed among the clinical descriptions. I have omitted short descriptions of two male patients whose clinical pictures differed substantially from those of the four female patients. I have provided verbatim accounts in a literal translation that includes some redundancies, in an effort to capture the flavor of this fascinating period piece. Although Wulff included extensive verbatim statements that supposedly were made by the patients, it is difficult to imagine people talking in this way, even in Berlin in 1932. It seems unlikely that they were taken from the author’s notes, since, as he remarked at the end of the paper, most of his notes had been lost. Similarly, it is unclear if the often hyperbolic descriptions of patient behavior were based on observations by Wulff, as he often implies, or were simply his acceptance of the patients’ accounts, as seems more likely. There is, for example, no corroboration of the account of a patient who “could eat one after another three or four meals of three or four courses each and in between them sweets, chocolate and cookies by the poundful.” One final note. The German language contains two words for eating-essen (by people) and fressen (by animals). The patients in Wulff’s account frequently referred to their eating as “fressen,” and to call attention to this special meaning, it is translated as “eating like an animal.” The original text follows.
TRANSLATION
OF WULFF’S
PAPER
The clinical picture to be described consists of a symptorn complex that always appears at the same time or in a certain order, and that, as far as I know, has never before been described. My first observation of this symptom cornplex occurred nearly 1 6 years ago. Since then I have been able to observe three further cases . . . . I will now describe in words
a picture
complex
is particularly
of this condition
by one
of my patients,
clearly
in which
depicted,
a 20-year-old
the symptom
as was told to me woman
student.
Case A: “I don’t always eat in the same way. Sometimes there occurs to me a particular mental state and then I eat a great deal. I call this condition the ‘spiritually degenerate
Am
J
Psychiatry
147:3,
March
1990
ALBERT
condition of a person who has fallen to a low moral level.’ As soon as I begin to eat very much I am possessed by a bad mood, deep despair and hopelessness, apathetic indifference, complete loss of will, no desires, no joy. I don’t
work, become completely apathetic and very sleepy. I eat a great deal and sleep a great deal, almost all day long. And then I become very fat, as if swollen, as if edematous. My appearance changes, I look completely different. I don’t want to get dressed and wear only old dirty clothes, preferably only an old bathrobe, don’t comb my hair, wash very little and insufficiently. At such times my room is a terrible mess; everything is in confusion; nothing is put away; washing, clothes, books, and various articles lie cv-
erywhere
in chaotic
disorder.
In this condition
eating
is an
unconquerable passion to which I succumb and that I cannot fight against. I have compared myself to an alcoholic, an addict. Sweets and baked goods have a particularly
degree
when
thereafter
the
patient
.
.
was
fairly chronically.
.
IS years
to a pronounced old
The patient
and
a strong
disgust
with
as dirty,
myself,
was very fat then,
dition the patient is irritable and surroundings, toward everyone.
The condition
of my
loathsome,
can suddenly
own
body;
repulsive.” full of hatred
disappear
I ap-
In this contoward
her
and give way to a
heightened feeling of self: “One evening it is completely unbearable-and the next morning I get up as if transformed, don’t know why, and feel that I am fresh, lively, energetic; I feel well. Then I eat very little. In a very good spiritual condition I eat absolutely nothing; then I feel particularly good, lively, in an elevated mood and eat nothing, even though I am hungry. However, if I once eat my fill, there follows remorse, anxiety, and despondency;
I feel that believe
once
that
again
I have
fallen
to a low
moral
level,
I have spoiled everything, promise myself that do it again. I make a powerful effort of will to
I will never come out of this condition, and I am in complete despair if I am not successful! And I remain in this condition as long as I am not able myself from these
to abstain tormenting
the good
condition
Case
elevated B: The
from food, thereby freeing feelings and bringing back
of abstinence
second case large number
concerns of other
.
.
.
she
a severe symptoms,
hysteric which I
become very upset, her face red and puffy, her eyes her appearance agitated; the upset increased so that
could
neither
her became
a severe headache her skull, precisely
strong
sit nor
impossible
feelings
remain
because
followed,
J
Psychiatry
conversation
with
not listen. in one
place
Then on
in the middle (an hysterogenous zone), of sickness and vomiting. After vomiting, a
certain calm began, but the til it led to unconsciousness;
Am
calm;
she could particularly
147:3,
headache became stronger unthe patient fell into an un-
March
1990
raw
she was tween
fruit,
alone
meals,
eventually
she
would
piece
of meat.
in particular,
secretly
to
in kinds of foods, parfoods; she ate pri-
many pulpy
a small
in her room,
take
When
frequently
some
fruit
be-
as if she
were stealing-and she was best able to retain this. There also occurred periods of differing duration-from a few days up to three weeks-in which the picture suddenly changed. The patient called these “circumstances of animal eating,” in which she had impossible to withstand. At these erything edible that she could reach
at all full. She did not vomit circumstances,
in contrast
of this
a drive to eat that was times she devoured cvand would not become
but retained to her
enormous
the food.
usual
food
amounts
In these
intake,
she
of food and at the
condition
would consume even inedible obfruit cores, even scraps of paper and similar things if she could not find anything else. Her eating appeared to be that of greedy eating like an ani-
mal
. . . .
tiful,
thin
peels,
It was no longer possible to recognize the beau20-year-old girl during these days; mostly she lay in bed behind closed windows and quickly covered her face with her hand when someone came into the room. She remained all day long unwashed and unkempt in a dirty, loose dressing gown. From time to time she got out of bed and walked around the room bent over, as if bowing, with a puffy, swollen, somewhat edematous face, a gloomy, despairing look on her face, with her bowels knotted together and her glance directed toward the floor. Often she did not speak if she wanted
all day long and quickly averted her face, as to hide, when anyone came into the room.
At such times she had a particularly strong feeling of disgust toward her own body. If she let her hand fall even very
lightly
on
her
body
she
twitched
full
of disgust
and
pulled it back quickly with a look on her face as if she had disturbed something terrible, dirty, and disgusting; at such times she would often say “disgusting.” Looking at her own body and its outlines through her clothes was so painful to her that she could tolerate only a very loose nightgown so that the outline of her body was not visible. She liked best to wear a wide coat or a large shawl; at night she did
not
get
undressed
but
remained
in her
bathrobe
and
coat. This feeling of disgust toward her own body also began in this patient in puberty, when she was 13 to 14 years old, and the first signs of a female body form and her breasts,
in particular,
self with a towel
.
with . . . a very will not recount here. Among these other symptoms eating disorders are clearly in the first rank . . . The following situation was repeated daily for several months: Within a few minutes after eating the patient
would shone,
manly
height
affront, loss of self-confidence can lead to this condition. Then there appears also a tormenting feeling of inferiority pear to myself
good periods and did not touch ticularly bread, puddings, and
jects such as orange
continued
obese; menstruation was scanty and irregular, and physicians assumed that it was an endocrine disorder. The condition improved with time; it recurred periodically from time to time, remained at first for some months, then for shorter periods of time, sometimes for only a few days, even for only one day. “Any kind of failure, an illness, an
and
and underwent an attack. In order was only occasionally successful-the to keep food intake to a minimum
was able to consume
powerful attraction for me The condition began for the first time .
conscious condition avoid this-which patient attempted
STUNKARD
under
became
hardly nected
breathe. This feeling with strong feelings
shame
and of disgust
particularly
strongly
noticeable.
her clothes
She
so tightly
of disgust of shame.
were
concentrated
on her
abdomen,
bound
her-
that she could
was These
closely confeelings of
on her face and in addition
to her
breasts. During an eating episode her abdomen was very blown up, and when she walked it stuck out so far that she looked exactly like a woman in her fourth or fifth month of pregnancy. Her vertebrae became bent forward in the form of a pronounced kyphoscoliosis. It was remarkable, however, that this condition could disappear without a trace fairly quickly, sometimes even overnight; but sometimes it would also fade away in the course of four or five days. The onset of menstruation often appeared to favor the disappearance of the condition. This
good
condition
condition
of “eating
that
could
like
an animal”
gave
way
to a
last for a few
days;
then
the
26S
EATING
DISORDERS
patient
would
good
IN 1932
get up early
spirits,
would
in the morning
wash
and dress
refreshed
herself,
and in
was
lovable
and such little
sometimes even in a remarkably cheerful mood. At times she ate very little, sometimes only coffee and a bit of fruit all day until evening, and at night slept hardly more than two or three hours. But then one day she could no longer control herself, ate a great deal at one time, retained her food, and at this point the other condition began again.
Case C: The third case concerned a bright, intelligent, well-educated woman of more than 30 years of age, a mother with two children. After a separation from her husband, it was necessary for her to support herself and her children, and her profound social incompetence was exposed . . . . In this woman there also appeared the typical picture of the symptom complex that scribed, although in an attenuated and more
She also had periods of a greedy accompanied by all of the psychic dysphoria,
dull
expression. uncombed,
She could unwashed,
in reverie,
apathy,
passion picture
irritability,
has
been
de-
chronic form. to eat and sleep, described above:
carelessness
in
sit for hours in her bathrobe, almost completely motionless,
brooding,
not
knowing
herself
which
her
hair lost
thoughts
were
preoccupying her, in a dirty, disorderly room in which her clothing, books, pieces of paper, food remnants, etc. lay around; or she lay for many hours in a peculiar, deep, tormented kind of sleep. Only food was able to arouse her from this apathetic, depressed psychic state. At such times she would eat greedily and quickly wolf down whatever there was that was edible upon the table, right out of the paper in which it had been wrapped, particularly things that she liked but was not supposed to eat because of her obesity, such as sweets, pastries, bread, and so forth; and she had to think as she was doing it, “This is good; the worse, the better!” This lasted until every available edible thing had been devoured. Then there appeared again the depression, the apathetic indifference, ing, reverie, and finally the tormented sleep
kind
of pleasant
the patient
event,
a success,
could
out of this condition.
very
Then
reAny bring
quickly
she was energetic,
lively, her mood cheerful and elevated; she happily felt a return of her ability to work; her room, clothes, the things in her wardrobe, the books would all be tidied up; then she
opened vain
up a great
and
deal to her environment
flirtatious.
“to
However,
a great
deal
take
did not sufficient ing like
last very long, and to lead once again an animal.”
Case D: The fourth middle
twenties she was 7 years
[After and
she
love
her
Usually,
the
to another
food
intake
however,
slightest
case concerns
a long description of “countless
limited
off weight.”
who, since old-suffered
and was even that
misfortune
condition
a young
was
of “eat-
woman
affairs,”
childhood
Wuiff
went
of abstinence
that
could
for the entire
day. The amount
in the
of the
266
course
day,
particularly
extend
of food
She
could
of three
eat
one
or four courses
each and in between them sweets, chocolate, and cookies by the poundful. Sometimes there was an almost unbroken greedy eating of every available food, with a particular preference for sweets and carbohydrates; she particularly liked to buy anything edible that was being sold on the street and to swallow them rapidly and greedily on the spot. She ate, moreover, in such a manner that she could hardly breathe; her abdomen protruded then, and she liked to show it with the observation, “Look how much I am like a pregnant woman!” Often her eating ended with severe abdominal pain and vomiting, but immediately
thereafter she ate again Her mental condition
and even more. during the periods
dreadful; despair overcame lost, my whole life has now
of eating
was
her: “As if now everything is lost its value, impossible, com-
pletely impossible, to live any longer now; loathsome like this, dirty, spoiled, turned
I will always
be
into an animal, and I can never again be a human being. I feel disgust for myself, feel soiled, and in order to be clean I would have to
take
a lot of castor
oil . . . . I feel fat, so fat, and that is In this condition the flirtatious woman was extremely negligent about her appearance; she took no baths, hardly washed her face and hands, rarely frightening
combed
.
.
.
.
“
her hair,
wore
only
old
dirty
clothes,
slept
in her
clothes without taking them off so as not to see her body, not to touch herself, and not to feel anything; even when it was very hot she had to go out on the street in a large dark coat “so that people cannot see my disgusting fat body” [exactly like patient B]. During this time she also slept a great deal, but her sleep was not refreshing, and instead very restless and tormented. In these circumstances, which she called “swine conditions,” she was indifferent to everyone, uninterested, psychologically alien-
ated and empty,
and accessible
in these times “All of my love
only to sexual
she experienced affairs come out
arousal;
yes,
all of her love of this condition
of mine. In those times when I do not eat I can give up rendez-vous; that doesn’t interest me then and I also can’t be attractive, a three-day
interesting, fast, I have
The circumstances primarily through affairs,
when,
charming. Because of that, a feeling of inner cleanliness
of her addictive eating some insult, particularly
for example,
admirers let her notice she was ugly, repulsive,
a young
man
after .
.
.
.
were released in her erotic
from
her host
of
his indifference. Then she felt that disgusting because she was fat and
big and then began to eat out of spite, as she said, “out of feelings of revenge”: “If I am not loved because I am like this, good; now more than ever, I will be completely bestial, cornpletely disgusting, completely dirty, and I will do what is harmful, what is forbidden, that is, eat a great deal.”
WULFF’S
on to state
the
to complete
fasts
that was devoured
in the
unbelievable.
three or four meals
DISCUSSION
upbringing
following.] The symptom complex that interests us here was developed to its fullest after her separation from her husband, which means after her failed attempt at a normal sexual life; periods of strong drives to eat that lasted for up to three weeks alternated with short, three- to six-day-long periods
sometimes
in her
her earliest childhood-since from a compulsive neurosis.
of a bizarre
was
after the other
precisely affairs:
self-loaththat brought
no rest or refreshment. And finally-self-reproaches, morse, despair, and the promise never to do it again.
evenings,
afternoons
and
Wulif’s discussion ranged widely throughout the paper, interspersed with the clinical descriptions as noted earlier. Much of it is of primarily historical interest, for example, the discussion of the role of the female castration complex. I have omitted such sections and have summarized the remaining theoretical considerations but will begin with a brief summary of the clinical picture in Wuiff’s words.
Am
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1990
ALBERT
If in my description up until now I have perhaps drawn out the clinical material in somewhat more detailed fashion than it may seem necessary and have not avoided some repetition, I did this in order to impress more sharply the special picture of this symptom complex; thereby we saw that this symptom complex is not tied to any particular known clinical picture of illness, but occurs in different neuroses, certainly having modified the character of the basic neuroses . . . . Despite the . . . different clinical pictures of this peculiar symptom complex-compulsive, greedy eating, the drive to sleep, apathetic depression, loathing of one’s own corporeality-the clinical picture and the course of the illness were uniformly governed by a certain periodicity, even though the basic character of the clinical picture varied greatly. One gets the impression that
we
are dealing
here
with
a complex
of morbid
clinical
pictures that do not belong at all in the framework of a typical neurotic structure, but rather display a peculiar pathological alteration of important biological functions that can appear in different forms of neurotic types.
defined
Wulff
the clinical
syndrome
eating,
hypersomnolence,
behaviors-binge depression, onset
C,
and
disparagement
occurred
during
of
in terms the
adolescence,
of four apathetic
body
Much
it occurred
image.
except
for
of Wulif’s
Its
patient
after
theoretical
discussion
focused
upon
the relationship of the syndrome to addiction, melancholia, and compulsive neurosis. He was convinced that the syndrome did not represent a compulsive neurosis,
and
he
compulsion
cited
two
represents
ceptable
inhibited
he
the
saw
drive
disturbed
reasons. the
First,
he
breakthrough
toward eating
stated of
a substitute not
as
an
that an
a
unac-
object,
and
unacceptable
but
as a form of oral satisfaction in a severely regressed person. Second, he stated that the repression of a compulsion should lead to anxiety, whereas in these patients control of their eating led not to anxiety but to an increase in the pressure to eat, a pressure that he termed “addictive desires.” WuIff then turned to his primary concern, the differential diagnosis between addiction and melancholia, noting that he believed that the syndrome “is something between melancholia and addiction.” He described its relationship to each condrive
dition,
at
first
appearing
to
favor
melancholia:
“The
condition is to be viewed as a neurotic modification of the unconscious processes of melancholia.” The two conditions had in common, he believed, their precipitation by “a loss of love . . an insult to the patient’s .
narcissism,” which the
which led eating binges
to a depressed emerged. The
mood eating
out of binges,
however, in his view, did not represent the oral incorporation characteristic of the melancholic patient, with “oral sadism leading to eating as annihilation.” Instead, “because the object is not ambivalently regarded” (as would presumably be the case in melancholia),
Am
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Psychiatry
147:3,
March
1990
constituted
“regression
. . . almost
satisfaction
to a pure
a sexual
oral
erotic
perversion.”
Wulff believed binges as addictive lence that followed
that an interpretation of eating was strengthened by the somnothem, “a kind of sleep drunken-
ness,”
in stark
which
stood
contrast
to the
insomnia
of
the melancholic patient. In fact, he ascribed particular importance to this somnolence, contending that such sleep during the digestion that followed the eating binges “is as responsible as is oral erotic stimulation for the instinctual initiation of the drive to eat.” He saw a kind of positive reinforcement of eating binges by an “alimentary orgasm” (18), “the libidinal investment of the entire digestive process which extends then to the entire body just as do the reactive feelings of disgust
Wulif
that
follow.”
argued
binges
appeared
distic,
the
suaded
from
that, to
superego what
be
despite
the
more
oral
was appeared
evidently
fact
that
erotic not
the
than
eating oral
entirely
to it as a forbidden
sadis-
activ-
incorporation of the penis. Accordingly, kind of compromise, the superego took its revenge, in the form of a full-blown attack of melancholia,
in a not but instead in an attack on the body image, eliciting the profound disgust with their bodies that was seen in these patients. By drastic restriction of their eating the patients were able to placate the superego and escape from the depression and the associated body image disparagement. But in these “good periods,” the patients “bring the same feeling of disgust to food or even to the act of eating itself,” which, Wulif noted, “is understandable if we consider that what is eaten is a symbolic substitute for the disgusting, dirty but, at the same time, highly desired penis.” He closed his discussion with a description that, despite its special language, has a certain modern quality.
ity-oral
the age of 30. Although not listed by Wulff in his summary, the question of purging can be answered by the case histories. After eating binges, all of the patients fasted and two (patients B and D) vomited. Patient A did not vomit, and there is no information about vomiting by patient C. in whom
the eating
STUNKARD
As soon as the superego is able to overcome the instinctual eating addiction there occurs an inner satisfaction, a peacefulness and feeling of well-being . . . . In this phase the patients are able, although only transiently, and at the cost of almost completely giving up an important life function, to raise themselves to the normal genital stage. The price-if at all possible, not to eat anything more-is, however, too high; it would cost one’s life, if normal hunger did not reassert itself, as a result of which this effort at self-treatment can succeed only to a limited extent and must in the end miscarry. For the first reexperiencing of strong feelings of satiation brings with it the satisfaction of the alimentary orgasm and its unfailing consequencesand the whole situation begins again.
TRANSLATOR’S
DISCUSSION
Rereading Wulif’s paper in preparing this translation aroused in me much of the excitement that I had felt when I first read it 40 years ago, but with a difference. At that time his case histories seemed to describe people of another era, the flamboyant hysteric patients of Charcot’s Paris and Freud’s Vienna. Since then
267
I
EATING
DISORDERS
IN 1932
have known the kind of patients whom Wuiff was describing, and his account, which had once seemed so exotic, now appeared to be, instead, careful clinical description. In fact, I was struck with the quality of the description. How many of us today, encountering such a strange and heretofore unknown disorder, could have described in such detail so many of what we have come to see as its major elements. The contrast between Wulff’s case histories and our current ratingscaled descriptions of patients provides in microcosm an example of the atrophy of a set of once-valued dinical skills. We no longer make these kinds of observations, and, if we did, it is not clear where they could be published. Wulif’s report makes it clear that bulimia is not the peculiarly modern disorder that it has sometimes seemed. Eating disorders of a type similar to modern bulimia existed in revolutionary Moscow and in Berlin just before Hitler’s seizure of power in 1933. The fact that bulimia could be recognized half a century ago gives added credence to the occasional earlier reports extending back over the past two centuries. There are clearly differences between these reports and modern descriptions, but these differences may be no greater than those between recent versions of APA’s Diagnostic and Statistical Manual. These latter differences are so great that a recent study found little overlap between DSM-III and DSM-III-R criteria for bulimia: Only a minority of persons who met the criteria in either edition met the criteria in both editions (19). If bulimia could be recognized in the past, why was it recognized so rarely? It may have been less common, it may have been underreported, or both. It seems quite possible that bulimia was less common in earlier periods. The prevalence of some behavioral disorders has fluctuated widely over time, a notable example being hysteria, which appears to be far less common now than in earlier days. Bulimia may also have been underreported. Although one might expect such a distinctive disorder to have been recognized, particular social circumstances may have led to lesser attention to it. If underreported in the past, it is probably overreported
today,
with,
as noted
earlier,
reports
of a prey-
alence as high as 19% (3). Recent careful studies, by contrast, have found clinically significant bulimia in less than 2% of college women (19, 20). A virtue of careful clinical descriptions from the past is the perspective they provide on clinical problems in the present. An example is the light thrown on one popular modern explanation for bulimia-the feminist critique-as exemplified particularly in Orbach’s Fat Is a Feminist Issue (21). Placing strong emphasis on the predominance of bulimia among women, this critique located its cause in the oppression of women by men, particularly as expressed in the premium placed by men on thinness for women. According to Orbach, women’s resulting conscious quest for thinness is subverted and betrayed by their unconscious desire for fatness and fear of thinness. On the face of it, there are problems with this explanation: By most criteria, Or-
268
bach’s
been
American
women
in
1978
would
seem
to
have
less
oppressed than their counterparts of half a century before in Moscow and Berlin. If oppression of women is a cause of bulimia, bulimia should have decreased in prevalence, not increased. Of course, such historical parallels have their limitations. Was the oppression of women that has been considered by femifist writers as a critical element in bulimia today focused to the same extent on pressures for thinness at that time? It may have been; this was, after all, the age of the flapper. But it will take good social history, which is now lacking, to trace the shifts in the ideal of female beauty during this period. The argument from psychodynamics
is even
less
convincing.
Wulff’s
care-
ful analyses found neither of the unconscious motivations that Orbach postulated as etiological in bulimia-the drive for fatness or the fear of thinness. Wulif’s descriptions of bulimic behaviors are likely to prove more enduring than his psychodynamics. They have already made it clear that bulimia is not an exclusively modern disorder. This translation will have served its purpose if it provides investigators with tools for further understanding of this disorder.
REFERENCES 1. Jones E: Life of Freud, vol 2. New York, Basic Books, 19SS 2. Bell RM: Holy Anorexia. Chicago, University of Chicago Press, 1986 3. Halmi KA, Falk JR. Schwartz E: Binge eating and vomiting: a survey ofa college population. PsycholMed 1981; 11:697-706 4. Newsweek, Jan 4, 1981, p 26 S. Wulif M: Eine interessante orale Symptomkomplex und seine Beziehung zur Sucht. Int Z Psychoanal 1932; 18:28 1-302 6. Stein DM, Laakso W: Bulimia: a historical perspective. Int J Eating
Disorders
1988;
7:201-210
7. James R: A Medical Dictionary. London, T Osborne, 1743 8. Motherby G: A New Medical Dictionary: Or a General Respiratory of Physic. London, J Johnson and J Robinson, 1785 9. Blachez PF: Boulimie, in Dictionarie Encyclopedic des Sciences Medicales, vol 10. Edited by Dechandre A. Paris, Victor, 1869 10. Gull WW: Apepsia hysterica: anorexia nervosa. Transcripts of the Clinical Society of London 1874; 7:22-28 I 1 . Janet P: Les obsessions et Ia psychasthenie. Paris, Felix Alcan, 1903 12. Pope HG, Hudson JI, Mialet JP: Bulimia in the late nineteenth century: the observations of Pierre Janet. Psychol Med 1985; 15:739-743 13. Nemiah JC: Anorexia nervosa: a clinical psychiatric study. Medicine 1950; 29:225-268 14. Binswanger R: The case of Ellen West, in Existence. Edited by May R, Angel E, Ellenberger HF. New York, Basic Books, 1957 15. Lindner R: Solitaire, in The Fifty-Minute Hour. New York, Bantam
16. 17.
WW
18. Rado 1933; 19.
Schotte 1987;
20.
21.
Books,
1971
Stunkard AJ: Eating patterns 33:284-294 Fenichel 0: The Psychoanalytic Norton,
1945,
and obesity. Theory
Q
Psychiatr
of Neurosis.
New
1959;
York,
p 241
S: The psychoanalysis
of pharmacothymia.
Psychoanal
Q
2:1-23
D, Stunkard
AJ: Bulimia
and bulimic
behaviors.
JAMA
258:1213-1215
Drewnowski A, Hopkins SA, Kessler RC: The prevalence of bulimia nervosa in the US college student population. Am J Public Health 1988; 78:1322-1325 Orbach S: Fat Is a Feminist Issue. New York, Paddington Press, 1978
Am
J
Psychiatry
147:3,
March
1990
AMERICAN
JOURNAL Special
A Description
Stunkard,
This article consists of a shortened and annotated translation of a paper on “An Interesting Oral Symptorn Complex and Its Relationship to Addiction” by M. WuIff of Berlin, which was delivered before the German
Psychoanalytic
Society
on
April
12,
1932.
The article describes four cases ofan eating disorder in women that was characterized by binge eating, hypersomnolence, apathetic depression, and disparagement of the body image. After the eating binges, all four patients manifested periods of fasting, and two of the three, about whom such information is available, vomited. Translations of large excerpts of the case histories are presented together with a summary of Wulff’s discussion. (Am J Psychiatry 1990; 147:263-268)
T
following is a biographical note on Moshe Wulif. Wulif was born in Odessa in 1878 and studied medicine in Berlin. In 1908 he met Karl Abraham, who introduced him to psychoanalysis, and he soon became a dedicated proponent (E. Gumbel, personal communication, April 20, 1988). In 1909 he was dismissed from his position in Berlin because of his “Freudian views” (1, p. 76) and returned to Odessa, since “Russia was then a freer country than Germany in such matters” (1, p. 1 10). From Odessa he continued his contact with Abraham and corresponded with both Freud and Ferenczi. In 1910, according to Kurt Eissler, he accompanied the Wolf-Man from his home in Odessa to Vienna and introduced he
...
Received April 21, 1989; accepted Aug. 17, 1989. From the Dcpartment of Psychiatry, University of Pennsylvania School of Mcdicine. Address reprint requests to Dr. Stunkard, Department of Psychiatry, University of Pennsylvania School of Medicine, 133 South 36th St., Suite S07, Philadelphia, PA 19104-3246. Supported in part by NIMH Research Scientist Award MH0024S. Copyright © 1990 American Psychiatric Association.
Am
J
Psychiatry
147:3,
March
1990
PSYCHIATRY
Articles
of Eating
Albert
OF
Disorders
in 1932
M.D.
him to Freud (personal communication, Jan. 21, 1988). In 1914 Wulif moved to Moscow, where he taught psychoanalysis, and in 1917, he became docent and the first psychoanalyst in the Faculty of Medicine of the University of Moscow (E. Gumbel, personal communication). Jones mentions Wulif and Ossipow as “those most worthy of remembrance in connection with the early days-and as it was to prove, also the last days-of psychoanalysis in Russia” (1, p. 76). In 1927 Wulif returned to Berlin, where he worked in Simmel’s psychoanalytic sanitarium. In 1933 he moved to Tel Aviv, where he practiced psychoanalysis until his death in 1971. He was a founder and, for 10 years (1943-1953), the President of the Israel Psychoanalytic Society. According to a colleague, Wulif was “a good clinician, excellent teacher and productive writer. He did never undergo a personal analysis” (E. Gumbel, personal communication). It is widely believed that bulimia is a modern disease. Unlike anorexia nervosa, for which a rich history has been traced to the Middle Ages (2), bulimia seems to have burst from the blue upon modern society, and it has achieved widespread recognition in a very short period of time. A new publication, The International Journal of the Eating Disorders, is devoted to bulimia (and anorexia nervosa), and successive estimates of the prevalence of bulimia have risen to a peak of 19% of college women (3). Interest in bulimia in the popular press has risen in parallel. Personal accounts have filled the pages of women’s magazines, and Newsweek magazine pronounced 1 98 1 as “The Year of the BingePurge Syndrome” (4). Is it possible that such a distinctive disorder could have arisen de novo in the past decade? Bulimia is probably not a new disorder. The evidence is of two types-scattered historical references compatible with bulimia over the past 250 years and three detailed case histories in the past SO years. Either source alone would be insufficient to make the case. Together they barely do. It therefore seems useful to
263
EATING
DISORDERS
IN 1932
publish a translation of a paper by Wulif published in 1932 that described in considerable detail four cases of a disorder that appears similar to current descriptions of bulimia (5). The scattered historical references have been reported by Stein and Laakso (6). They noted that as long ago as 1743, James described “true boulimus,” which was characterized by intense preoccupation with food and overeating at very short intervals, followed by fainting, and a variant, caninus appetitus, in which the overeating was terminated by vomiting (7). This account was followed in 1785 by that of Motherby, who distinguished three types of bulimia-bulimia of the pure hunger type, bulimia associated with “swooning,” and that terminated by vomiting (8). The disorder was sufficiently well-recognized to warrant an entry in the 1797 edition of the Encyclopedia Britannica. The only nineteenth-century reference compatible with current concepts appears to be that of Blachez in 1869, who described two forms of “boulimie” (9). In each, food might become the major preoccupation of the person, hunger might persist even after the consumption of enormous amounts of food, and torpor might follow the binge. In the subtype called cynorexia, the eating binge was followed by vomiting. It is worthy of note that Gull’s 1874 description of anorexia nervosa included the occasional occurrence of an extremely voracious appetite (10). Bulimia attracted little attention until well into the present century, although in 1903 Janet described four patients (of a total of 236 in his book) who may have been bulimic (1 1). In their translation and comment on these cases, Pope and associates (12) noted that these four patients overate in association with other psychiatric disorders-depression (N=2), anorexia (N= 1), and agoraphobia (N= 1). Vomiting was described in the case of only one patient, the only man, and the one whose binge eating was described in the most ambiguous manner-”an often voracious appetite, given to peculiar fluctuations. The patient with anorexia nervosa, a severe obsessive, also has typical disturbances of the body image.” Modern interest in bulimia first appeared in connection with patients who suffered also from anorexia nervosa. In 1950 Nemiah reported the case histories of 14 patients with this diagnosis who had been seen on the psychiatric service of the Massachusetts General Hospital over a period of 12 years (13). Four of these patients had episodes of “abnormal eating” compatible with bulimia. One subject (patient 9) presented a classic picture of bulimia nervosa, in which eating binges were followed by vomiting, as often as once a day. Vomiting was not reported among the other three subjects (patients 1, 8, and 10), but they manifested clear eating binges. The three detailed case histories to which reference has been made were those of Binswanger’s “Case of Ellen West” in 1928 (14), Lindner’s case of Laura, first published in 1950 (15), and Stunkard’s case of T.T. in 1959 (16). The paper that forms the basis of this report
264
has
generally
creased
escaped
interest
notice
in bulimia
during
and
has
the
received
recent only
inpass-
Psychoanalytic Theory “An Interesting Oral Symptom Complex and Its Relationship to Addiction,” by M. Wulif, contained not only detailed case histories but also some speculations about the nature of the disorder that, while dated in some ways, sound surprisingly modern in others. A few notes about the translation are in order. The paper has been shortened to about one-third of its original length. I have retained much of the clinical descriptions but have summarized the lengthy theoretical discussion. As was apparently the custom, this discussion, complete with assertions of certainty such as “without doubt” and “unquestionably,” was intering
of
notice-in
Neurosis
Fenichel’s
This
(17).
The paper,
spersed among the clinical descriptions. I have omitted short descriptions of two male patients whose clinical pictures differed substantially from those of the four female patients. I have provided verbatim accounts in a literal translation that includes some redundancies, in an effort to capture the flavor of this fascinating period piece. Although Wulff included extensive verbatim statements that supposedly were made by the patients, it is difficult to imagine people talking in this way, even in Berlin in 1932. It seems unlikely that they were taken from the author’s notes, since, as he remarked at the end of the paper, most of his notes had been lost. Similarly, it is unclear if the often hyperbolic descriptions of patient behavior were based on observations by Wulff, as he often implies, or were simply his acceptance of the patients’ accounts, as seems more likely. There is, for example, no corroboration of the account of a patient who “could eat one after another three or four meals of three or four courses each and in between them sweets, chocolate and cookies by the poundful.” One final note. The German language contains two words for eating-essen (by people) and fressen (by animals). The patients in Wulff’s account frequently referred to their eating as “fressen,” and to call attention to this special meaning, it is translated as “eating like an animal.” The original text follows.
TRANSLATION
OF WULFF’S
PAPER
The clinical picture to be described consists of a symptorn complex that always appears at the same time or in a certain order, and that, as far as I know, has never before been described. My first observation of this symptom cornplex occurred nearly 1 6 years ago. Since then I have been able to observe three further cases . . . . I will now describe in words
a picture
complex
is particularly
of this condition
by one
of my patients,
clearly
in which
depicted,
a 20-year-old
the symptom
as was told to me woman
student.
Case A: “I don’t always eat in the same way. Sometimes there occurs to me a particular mental state and then I eat a great deal. I call this condition the ‘spiritually degenerate
Am
J
Psychiatry
147:3,
March
1990
ALBERT
condition of a person who has fallen to a low moral level.’ As soon as I begin to eat very much I am possessed by a bad mood, deep despair and hopelessness, apathetic indifference, complete loss of will, no desires, no joy. I don’t
work, become completely apathetic and very sleepy. I eat a great deal and sleep a great deal, almost all day long. And then I become very fat, as if swollen, as if edematous. My appearance changes, I look completely different. I don’t want to get dressed and wear only old dirty clothes, preferably only an old bathrobe, don’t comb my hair, wash very little and insufficiently. At such times my room is a terrible mess; everything is in confusion; nothing is put away; washing, clothes, books, and various articles lie cv-
erywhere
in chaotic
disorder.
In this condition
eating
is an
unconquerable passion to which I succumb and that I cannot fight against. I have compared myself to an alcoholic, an addict. Sweets and baked goods have a particularly
degree
when
thereafter
the
patient
.
.
was
fairly chronically.
.
IS years
to a pronounced old
The patient
and
a strong
disgust
with
as dirty,
myself,
was very fat then,
dition the patient is irritable and surroundings, toward everyone.
The condition
of my
loathsome,
can suddenly
own
body;
repulsive.” full of hatred
disappear
I ap-
In this contoward
her
and give way to a
heightened feeling of self: “One evening it is completely unbearable-and the next morning I get up as if transformed, don’t know why, and feel that I am fresh, lively, energetic; I feel well. Then I eat very little. In a very good spiritual condition I eat absolutely nothing; then I feel particularly good, lively, in an elevated mood and eat nothing, even though I am hungry. However, if I once eat my fill, there follows remorse, anxiety, and despondency;
I feel that believe
once
that
again
I have
fallen
to a low
moral
level,
I have spoiled everything, promise myself that do it again. I make a powerful effort of will to
I will never come out of this condition, and I am in complete despair if I am not successful! And I remain in this condition as long as I am not able myself from these
to abstain tormenting
the good
condition
Case
elevated B: The
from food, thereby freeing feelings and bringing back
of abstinence
second case large number
concerns of other
.
.
.
she
a severe symptoms,
hysteric which I
become very upset, her face red and puffy, her eyes her appearance agitated; the upset increased so that
could
neither
her became
a severe headache her skull, precisely
strong
sit nor
impossible
feelings
remain
because
followed,
J
Psychiatry
conversation
with
not listen. in one
place
Then on
in the middle (an hysterogenous zone), of sickness and vomiting. After vomiting, a
certain calm began, but the til it led to unconsciousness;
Am
calm;
she could particularly
147:3,
headache became stronger unthe patient fell into an un-
March
1990
raw
she was tween
fruit,
alone
meals,
eventually
she
would
piece
of meat.
in particular,
secretly
to
in kinds of foods, parfoods; she ate pri-
many pulpy
a small
in her room,
take
When
frequently
some
fruit
be-
as if she
were stealing-and she was best able to retain this. There also occurred periods of differing duration-from a few days up to three weeks-in which the picture suddenly changed. The patient called these “circumstances of animal eating,” in which she had impossible to withstand. At these erything edible that she could reach
at all full. She did not vomit circumstances,
in contrast
of this
a drive to eat that was times she devoured cvand would not become
but retained to her
enormous
the food.
usual
food
amounts
In these
intake,
she
of food and at the
condition
would consume even inedible obfruit cores, even scraps of paper and similar things if she could not find anything else. Her eating appeared to be that of greedy eating like an ani-
mal
. . . .
tiful,
thin
peels,
It was no longer possible to recognize the beau20-year-old girl during these days; mostly she lay in bed behind closed windows and quickly covered her face with her hand when someone came into the room. She remained all day long unwashed and unkempt in a dirty, loose dressing gown. From time to time she got out of bed and walked around the room bent over, as if bowing, with a puffy, swollen, somewhat edematous face, a gloomy, despairing look on her face, with her bowels knotted together and her glance directed toward the floor. Often she did not speak if she wanted
all day long and quickly averted her face, as to hide, when anyone came into the room.
At such times she had a particularly strong feeling of disgust toward her own body. If she let her hand fall even very
lightly
on
her
body
she
twitched
full
of disgust
and
pulled it back quickly with a look on her face as if she had disturbed something terrible, dirty, and disgusting; at such times she would often say “disgusting.” Looking at her own body and its outlines through her clothes was so painful to her that she could tolerate only a very loose nightgown so that the outline of her body was not visible. She liked best to wear a wide coat or a large shawl; at night she did
not
get
undressed
but
remained
in her
bathrobe
and
coat. This feeling of disgust toward her own body also began in this patient in puberty, when she was 13 to 14 years old, and the first signs of a female body form and her breasts,
in particular,
self with a towel
.
with . . . a very will not recount here. Among these other symptoms eating disorders are clearly in the first rank . . . The following situation was repeated daily for several months: Within a few minutes after eating the patient
would shone,
manly
height
affront, loss of self-confidence can lead to this condition. Then there appears also a tormenting feeling of inferiority pear to myself
good periods and did not touch ticularly bread, puddings, and
jects such as orange
continued
obese; menstruation was scanty and irregular, and physicians assumed that it was an endocrine disorder. The condition improved with time; it recurred periodically from time to time, remained at first for some months, then for shorter periods of time, sometimes for only a few days, even for only one day. “Any kind of failure, an illness, an
and
and underwent an attack. In order was only occasionally successful-the to keep food intake to a minimum
was able to consume
powerful attraction for me The condition began for the first time .
conscious condition avoid this-which patient attempted
STUNKARD
under
became
hardly nected
breathe. This feeling with strong feelings
shame
and of disgust
particularly
strongly
noticeable.
her clothes
She
so tightly
of disgust of shame.
were
concentrated
on her
abdomen,
bound
her-
that she could
was These
closely confeelings of
on her face and in addition
to her
breasts. During an eating episode her abdomen was very blown up, and when she walked it stuck out so far that she looked exactly like a woman in her fourth or fifth month of pregnancy. Her vertebrae became bent forward in the form of a pronounced kyphoscoliosis. It was remarkable, however, that this condition could disappear without a trace fairly quickly, sometimes even overnight; but sometimes it would also fade away in the course of four or five days. The onset of menstruation often appeared to favor the disappearance of the condition. This
good
condition
condition
of “eating
that
could
like
an animal”
gave
way
to a
last for a few
days;
then
the
26S
EATING
DISORDERS
patient
would
good
IN 1932
get up early
spirits,
would
in the morning
wash
and dress
refreshed
herself,
and in
was
lovable
and such little
sometimes even in a remarkably cheerful mood. At times she ate very little, sometimes only coffee and a bit of fruit all day until evening, and at night slept hardly more than two or three hours. But then one day she could no longer control herself, ate a great deal at one time, retained her food, and at this point the other condition began again.
Case C: The third case concerned a bright, intelligent, well-educated woman of more than 30 years of age, a mother with two children. After a separation from her husband, it was necessary for her to support herself and her children, and her profound social incompetence was exposed . . . . In this woman there also appeared the typical picture of the symptom complex that scribed, although in an attenuated and more
She also had periods of a greedy accompanied by all of the psychic dysphoria,
dull
expression. uncombed,
She could unwashed,
in reverie,
apathy,
passion picture
irritability,
has
been
de-
chronic form. to eat and sleep, described above:
carelessness
in
sit for hours in her bathrobe, almost completely motionless,
brooding,
not
knowing
herself
which
her
hair lost
thoughts
were
preoccupying her, in a dirty, disorderly room in which her clothing, books, pieces of paper, food remnants, etc. lay around; or she lay for many hours in a peculiar, deep, tormented kind of sleep. Only food was able to arouse her from this apathetic, depressed psychic state. At such times she would eat greedily and quickly wolf down whatever there was that was edible upon the table, right out of the paper in which it had been wrapped, particularly things that she liked but was not supposed to eat because of her obesity, such as sweets, pastries, bread, and so forth; and she had to think as she was doing it, “This is good; the worse, the better!” This lasted until every available edible thing had been devoured. Then there appeared again the depression, the apathetic indifference, ing, reverie, and finally the tormented sleep
kind
of pleasant
the patient
event,
a success,
could
out of this condition.
very
Then
reAny bring
quickly
she was energetic,
lively, her mood cheerful and elevated; she happily felt a return of her ability to work; her room, clothes, the things in her wardrobe, the books would all be tidied up; then she
opened vain
up a great
and
deal to her environment
flirtatious.
“to
However,
a great
deal
take
did not sufficient ing like
last very long, and to lead once again an animal.”
Case D: The fourth middle
twenties she was 7 years
[After and
she
love
her
Usually,
the
to another
food
intake
however,
slightest
case concerns
a long description of “countless
limited
off weight.”
who, since old-suffered
and was even that
misfortune
condition
a young
was
of “eat-
woman
affairs,”
childhood
Wuiff
went
of abstinence
that
could
for the entire
day. The amount
in the
of the
266
course
day,
particularly
extend
of food
She
could
of three
eat
one
or four courses
each and in between them sweets, chocolate, and cookies by the poundful. Sometimes there was an almost unbroken greedy eating of every available food, with a particular preference for sweets and carbohydrates; she particularly liked to buy anything edible that was being sold on the street and to swallow them rapidly and greedily on the spot. She ate, moreover, in such a manner that she could hardly breathe; her abdomen protruded then, and she liked to show it with the observation, “Look how much I am like a pregnant woman!” Often her eating ended with severe abdominal pain and vomiting, but immediately
thereafter she ate again Her mental condition
and even more. during the periods
dreadful; despair overcame lost, my whole life has now
of eating
was
her: “As if now everything is lost its value, impossible, com-
pletely impossible, to live any longer now; loathsome like this, dirty, spoiled, turned
I will always
be
into an animal, and I can never again be a human being. I feel disgust for myself, feel soiled, and in order to be clean I would have to
take
a lot of castor
oil . . . . I feel fat, so fat, and that is In this condition the flirtatious woman was extremely negligent about her appearance; she took no baths, hardly washed her face and hands, rarely frightening
combed
.
.
.
.
“
her hair,
wore
only
old
dirty
clothes,
slept
in her
clothes without taking them off so as not to see her body, not to touch herself, and not to feel anything; even when it was very hot she had to go out on the street in a large dark coat “so that people cannot see my disgusting fat body” [exactly like patient B]. During this time she also slept a great deal, but her sleep was not refreshing, and instead very restless and tormented. In these circumstances, which she called “swine conditions,” she was indifferent to everyone, uninterested, psychologically alien-
ated and empty,
and accessible
in these times “All of my love
only to sexual
she experienced affairs come out
arousal;
yes,
all of her love of this condition
of mine. In those times when I do not eat I can give up rendez-vous; that doesn’t interest me then and I also can’t be attractive, a three-day
interesting, fast, I have
The circumstances primarily through affairs,
when,
charming. Because of that, a feeling of inner cleanliness
of her addictive eating some insult, particularly
for example,
admirers let her notice she was ugly, repulsive,
a young
man
after .
.
.
.
were released in her erotic
from
her host
of
his indifference. Then she felt that disgusting because she was fat and
big and then began to eat out of spite, as she said, “out of feelings of revenge”: “If I am not loved because I am like this, good; now more than ever, I will be completely bestial, cornpletely disgusting, completely dirty, and I will do what is harmful, what is forbidden, that is, eat a great deal.”
WULFF’S
on to state
the
to complete
fasts
that was devoured
in the
unbelievable.
three or four meals
DISCUSSION
upbringing
following.] The symptom complex that interests us here was developed to its fullest after her separation from her husband, which means after her failed attempt at a normal sexual life; periods of strong drives to eat that lasted for up to three weeks alternated with short, three- to six-day-long periods
sometimes
in her
her earliest childhood-since from a compulsive neurosis.
of a bizarre
was
after the other
precisely affairs:
self-loaththat brought
no rest or refreshment. And finally-self-reproaches, morse, despair, and the promise never to do it again.
evenings,
afternoons
and
Wulif’s discussion ranged widely throughout the paper, interspersed with the clinical descriptions as noted earlier. Much of it is of primarily historical interest, for example, the discussion of the role of the female castration complex. I have omitted such sections and have summarized the remaining theoretical considerations but will begin with a brief summary of the clinical picture in Wuiff’s words.
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1990
ALBERT
If in my description up until now I have perhaps drawn out the clinical material in somewhat more detailed fashion than it may seem necessary and have not avoided some repetition, I did this in order to impress more sharply the special picture of this symptom complex; thereby we saw that this symptom complex is not tied to any particular known clinical picture of illness, but occurs in different neuroses, certainly having modified the character of the basic neuroses . . . . Despite the . . . different clinical pictures of this peculiar symptom complex-compulsive, greedy eating, the drive to sleep, apathetic depression, loathing of one’s own corporeality-the clinical picture and the course of the illness were uniformly governed by a certain periodicity, even though the basic character of the clinical picture varied greatly. One gets the impression that
we
are dealing
here
with
a complex
of morbid
clinical
pictures that do not belong at all in the framework of a typical neurotic structure, but rather display a peculiar pathological alteration of important biological functions that can appear in different forms of neurotic types.
defined
Wulff
the clinical
syndrome
eating,
hypersomnolence,
behaviors-binge depression, onset
C,
and
disparagement
occurred
during
of
in terms the
adolescence,
of four apathetic
body
Much
it occurred
image.
except
for
of Wulif’s
Its
patient
after
theoretical
discussion
focused
upon
the relationship of the syndrome to addiction, melancholia, and compulsive neurosis. He was convinced that the syndrome did not represent a compulsive neurosis,
and
he
compulsion
cited
two
represents
ceptable
inhibited
he
the
saw
drive
disturbed
reasons. the
First,
he
breakthrough
toward eating
stated of
a substitute not
as
an
that an
a
unac-
object,
and
unacceptable
but
as a form of oral satisfaction in a severely regressed person. Second, he stated that the repression of a compulsion should lead to anxiety, whereas in these patients control of their eating led not to anxiety but to an increase in the pressure to eat, a pressure that he termed “addictive desires.” WuIff then turned to his primary concern, the differential diagnosis between addiction and melancholia, noting that he believed that the syndrome “is something between melancholia and addiction.” He described its relationship to each condrive
dition,
at
first
appearing
to
favor
melancholia:
“The
condition is to be viewed as a neurotic modification of the unconscious processes of melancholia.” The two conditions had in common, he believed, their precipitation by “a loss of love . . an insult to the patient’s .
narcissism,” which the
which led eating binges
to a depressed emerged. The
mood eating
out of binges,
however, in his view, did not represent the oral incorporation characteristic of the melancholic patient, with “oral sadism leading to eating as annihilation.” Instead, “because the object is not ambivalently regarded” (as would presumably be the case in melancholia),
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1990
constituted
“regression
. . . almost
satisfaction
to a pure
a sexual
oral
erotic
perversion.”
Wulff believed binges as addictive lence that followed
that an interpretation of eating was strengthened by the somnothem, “a kind of sleep drunken-
ness,”
in stark
which
stood
contrast
to the
insomnia
of
the melancholic patient. In fact, he ascribed particular importance to this somnolence, contending that such sleep during the digestion that followed the eating binges “is as responsible as is oral erotic stimulation for the instinctual initiation of the drive to eat.” He saw a kind of positive reinforcement of eating binges by an “alimentary orgasm” (18), “the libidinal investment of the entire digestive process which extends then to the entire body just as do the reactive feelings of disgust
Wulif
that
follow.”
argued
binges
appeared
distic,
the
suaded
from
that, to
superego what
be
despite
the
more
oral
was appeared
evidently
fact
that
erotic not
the
than
eating oral
entirely
to it as a forbidden
sadis-
activ-
incorporation of the penis. Accordingly, kind of compromise, the superego took its revenge, in the form of a full-blown attack of melancholia,
in a not but instead in an attack on the body image, eliciting the profound disgust with their bodies that was seen in these patients. By drastic restriction of their eating the patients were able to placate the superego and escape from the depression and the associated body image disparagement. But in these “good periods,” the patients “bring the same feeling of disgust to food or even to the act of eating itself,” which, Wulif noted, “is understandable if we consider that what is eaten is a symbolic substitute for the disgusting, dirty but, at the same time, highly desired penis.” He closed his discussion with a description that, despite its special language, has a certain modern quality.
ity-oral
the age of 30. Although not listed by Wulff in his summary, the question of purging can be answered by the case histories. After eating binges, all of the patients fasted and two (patients B and D) vomited. Patient A did not vomit, and there is no information about vomiting by patient C. in whom
the eating
STUNKARD
As soon as the superego is able to overcome the instinctual eating addiction there occurs an inner satisfaction, a peacefulness and feeling of well-being . . . . In this phase the patients are able, although only transiently, and at the cost of almost completely giving up an important life function, to raise themselves to the normal genital stage. The price-if at all possible, not to eat anything more-is, however, too high; it would cost one’s life, if normal hunger did not reassert itself, as a result of which this effort at self-treatment can succeed only to a limited extent and must in the end miscarry. For the first reexperiencing of strong feelings of satiation brings with it the satisfaction of the alimentary orgasm and its unfailing consequencesand the whole situation begins again.
TRANSLATOR’S
DISCUSSION
Rereading Wulif’s paper in preparing this translation aroused in me much of the excitement that I had felt when I first read it 40 years ago, but with a difference. At that time his case histories seemed to describe people of another era, the flamboyant hysteric patients of Charcot’s Paris and Freud’s Vienna. Since then
267
I
EATING
DISORDERS
IN 1932
have known the kind of patients whom Wuiff was describing, and his account, which had once seemed so exotic, now appeared to be, instead, careful clinical description. In fact, I was struck with the quality of the description. How many of us today, encountering such a strange and heretofore unknown disorder, could have described in such detail so many of what we have come to see as its major elements. The contrast between Wulff’s case histories and our current ratingscaled descriptions of patients provides in microcosm an example of the atrophy of a set of once-valued dinical skills. We no longer make these kinds of observations, and, if we did, it is not clear where they could be published. Wulif’s report makes it clear that bulimia is not the peculiarly modern disorder that it has sometimes seemed. Eating disorders of a type similar to modern bulimia existed in revolutionary Moscow and in Berlin just before Hitler’s seizure of power in 1933. The fact that bulimia could be recognized half a century ago gives added credence to the occasional earlier reports extending back over the past two centuries. There are clearly differences between these reports and modern descriptions, but these differences may be no greater than those between recent versions of APA’s Diagnostic and Statistical Manual. These latter differences are so great that a recent study found little overlap between DSM-III and DSM-III-R criteria for bulimia: Only a minority of persons who met the criteria in either edition met the criteria in both editions (19). If bulimia could be recognized in the past, why was it recognized so rarely? It may have been less common, it may have been underreported, or both. It seems quite possible that bulimia was less common in earlier periods. The prevalence of some behavioral disorders has fluctuated widely over time, a notable example being hysteria, which appears to be far less common now than in earlier days. Bulimia may also have been underreported. Although one might expect such a distinctive disorder to have been recognized, particular social circumstances may have led to lesser attention to it. If underreported in the past, it is probably overreported
today,
with,
as noted
earlier,
reports
of a prey-
alence as high as 19% (3). Recent careful studies, by contrast, have found clinically significant bulimia in less than 2% of college women (19, 20). A virtue of careful clinical descriptions from the past is the perspective they provide on clinical problems in the present. An example is the light thrown on one popular modern explanation for bulimia-the feminist critique-as exemplified particularly in Orbach’s Fat Is a Feminist Issue (21). Placing strong emphasis on the predominance of bulimia among women, this critique located its cause in the oppression of women by men, particularly as expressed in the premium placed by men on thinness for women. According to Orbach, women’s resulting conscious quest for thinness is subverted and betrayed by their unconscious desire for fatness and fear of thinness. On the face of it, there are problems with this explanation: By most criteria, Or-
268
bach’s
been
American
women
in
1978
would
seem
to
have
less
oppressed than their counterparts of half a century before in Moscow and Berlin. If oppression of women is a cause of bulimia, bulimia should have decreased in prevalence, not increased. Of course, such historical parallels have their limitations. Was the oppression of women that has been considered by femifist writers as a critical element in bulimia today focused to the same extent on pressures for thinness at that time? It may have been; this was, after all, the age of the flapper. But it will take good social history, which is now lacking, to trace the shifts in the ideal of female beauty during this period. The argument from psychodynamics
is even
less
convincing.
Wulff’s
care-
ful analyses found neither of the unconscious motivations that Orbach postulated as etiological in bulimia-the drive for fatness or the fear of thinness. Wulif’s descriptions of bulimic behaviors are likely to prove more enduring than his psychodynamics. They have already made it clear that bulimia is not an exclusively modern disorder. This translation will have served its purpose if it provides investigators with tools for further understanding of this disorder.
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