~< I '----w_el_·SS_-_E_n_S_IiS_h----J 1.::1 ~ymposium •
Obesity• and anoreXia nervosa HILDE BRUCH, M.D. The term "eating disorders" refers to those conditions in which food intake and body size are manipulated in an effort to solve or camouflage inner and outer adjustment problems. Clinically, these disturbances are recognized as obesity (the excessive accumulation of fat tissue, associated with helpless ineffectiveness in the face of bodily urges and social demands) and as anorexia nervosa (extreme leanness and cachexia, representing an over-rigid effort at establishing a sense of effectiveness). Obesity There is need to differentiate various forms of obesity according to the time of onset, family background, extent of the excess weight, its fluctuation over a period of time, social adaptation, and the ability, or inability, to do something about it. There are people for whom it appears normal to be heavier than the average, particularly if it accompanies a more secure station in life. It is not possible, however, to state how many overweight people
can be considered basically normal. Such a consideration would have to take into account the success with which these individuals conduct their lives, their normal activities, interests, and eating patterns, even though their weight is regulated at a higher point. There are also no statistics about how many obese people are psychologically disturbed, as their psychiatric problems are far from uniform. Obesity may be associated with every conceivable personality type of psychiatric disorder, neurosis as well as psychosis. Two subgroups can be recognized: the developmental, in which obesity is intricately interwoven with the person's whole development, with many features of disturbed behavior and adaption; and the reactive, in which obesity is a reaction to some traumatic event. Developmental obesity: This form occurs in children who are overstuffed with food and are shielded from, or not trusted with, the ordinary tasks of life. Their behavior and psychological reactions may
resemble those of people in the preschizophrenic state and some become overtly schizophrenic when they experience the demands oflife as too threatening. Enforced and untimely reducing may precipitate this form of obesity. In a group of obese children who were followed into early adulthood, about one third outgrew the condition during adolescence, usually with the encouragement of friends who supported them in their separation from their homes. Others made a good general adjustment, though they remained moderately overweight. Re-evaluation of the early records showed that those who had done well in the long run had been accepted by their parents and had not been exposed to relentless pressure to reduce. It is often assumed that severe obesity early in life denotes a poor prognosis for later weight regulation, a belief reinforced by the finding that overfeeding in early life is associated with an increase in the number of adipose cells. This leads to lasting obesity, however, only if PSYCHOSOMATICS
the environmental conditions that initially made for obesity persist. Those who remained fat and were poorly adjusted, or had grown more obese, had been literally persecuted by their families for being fat. All of them showed evidence of serious emotional problems as children. They arrived at adolescence with low self-esteem and a sense of helplessness, and they reacted with guilt and depression to the condemning cultural attitude. For the long-range outlook, the decisive difference is whether or not a fat child and his or her family receive help with the underlying problem. Those obese youngsters who had found help with their emotional problems were able to function well as marriage partners and as parents, and raised nonobese children. In contrast, those who had not received such help had children who were as obese as they themselves had been. Reactive obesity: The importance of emotional factors in the development of obesity was first recognized in those cases that followed traumatic experiences. For example, after both world wars, German and French authors described a paradoxical form of obesity that developed after severe mental shock, after bombing, or following the death of a beloved person. This form is more often observed in adults, but it occurs also during childhood and adolescence. Obesity develops not infrequently after the death of a family member, separation from home, or when a love affair breaks up. The obesity appears to be the equivalent of a depressive reaction in situations involving fear of desertion and loneliness-a defense against manifest depression. Often it is the loss of possessions and prestige that
precipitates the overeating and subsequently results in obesity. Situations that provoke overeating and a decrease in activity are akin to those usually accompanied by grief or severe depression. People with these symptoms may experience some depressive feelings and may become openly depressed when weight reduction is enforced. In the background of the patient with reactive obesity one can frequently recognize early childhood circumstances that had endowed food with an excessive degree of emotional significance. An operation or an accident may be followed by an increase in weight. This leads to persistent obesity only when there are predisposing personality traits. The obesity that develops during or after pregnancy may belong to this group. Outstanding in the psychopathology are disappointment with the marriage and unfulfilled daydreams about what the child could do for the mother. Sometimes there is frank envy about the care the child receives or resentment regarding the demands he or she is making on the mother. Occasionally a father may become fat after the birth of a child. This occurs in extremely dependent men who feel that they have never received quite enough and who resort now to overeating to combat their jealousy and to compensate for what they feel they are missing and the baby is receiving. Anorexia nervosa Until about 1960, psychoanalytic thinking influenced the many efforts to understand the factors underlying anorexia nervosa. The emphasis was on the non-eating, with the theoreticians ambitiously explaining the whole complex pic-
ture through one specific psychodynamic formulation. Recently, however, a definite change has occurred in the entire approach, with agreement that true or primary anorexia nervosa needs to be differentiated from unspecific types (atypical) of psychologically induced weight loss. Primary anorexia nervosa: In true anorexia nervosa, the leading symptom is the desire to be thin, a phobic avoidance of being fat. Paradoxically, this is associated with an intense interest in food, without real loss of appetite. Food is actively refused in the service of the relentless pursuit of thinness. This preoccupation with the body and its size is a late step in the development of youngsters who have been engaged for years in a desperate but futile struggle to establish a sense of control and identity, and who have tried to make themselves appear "perfect" in the eyes of others. This search for control is the basic psychological issue in primary anorexia nervosa, which shows definite areas of disordered psychological functioning. Body-image disturbance: True anorexics will vigorously defend their often gruesome emaciation as not being too thin, as the only possible protection against the dreaded fear of being fat; they identify with the skeleton-like appearance, actively maintain it, and deny its abnormality. Though anorexic patients uniformly explain that they began dieting because they felt they were "too fat," excess weight precedes the illness in riot more than 15% to 20% of the cases; most had been of normal weight and a few had been on the thin side. Anorexic patients will gain weight for a variety of reasons, but they are apt to relapse unless the body109
APRIL 1978 • VOL 19· NO 4
- .........
~ Weiss-English
1::1 Symposium
image disturbance corrects itself. Many will confess that they felt they were hurting their parents by not eating and gained satisfaction from seeing them worry, but were completely unaware that they themselves were undergoing the ordeal of starvation. True progress involves their developing an active and positive interest in their own body and its well-being. The illness represents a split between the "self' and the body, which they often experience as not truly their own. Misperception of bodily functions: The symptom that arouses most concern, anxiety, frustration, and rage is the anorexic's refusal to eat. Though there is no true loss of appetite, awareness of hunger in the ordinary sense seems to be absent, and this deficit appears to be closely related to other aspects of the underlying personality disturbance. Anorexics are frantically preoccupied with food, and develop unusual, even bizarre, eating habits, similar to those observed in victims of famine. They will complain of feeling "full" after a few mouthfuls, and some even feel "full" through watching others eat. In some, food refusal alternates with uncontrollable eating binges that are experienced as submission to a force compelling them to do something they do not want to do, or as an expression of complete loss of control. Many try to remove the unwanted food through self-induced vomiting, laxatives, enemas, and increasingly frequent diuretics that may lead to serious disturbances in the electrolyte balance. Another sign of falsified body awareness is hyperactivity, walking by the hour, or doing calisthenics to the point of exhaustion, without experiencing fatigue. The failure of sexual functioning and the absence 210
of sexual feelings may also be considered in this context. Other bodily sensations, too, such as awareness of temperature or sensitivity to pain, are not correctly perceived or responded to. Anorexics are also deficient in identifying emotional states, and even severe depressive feelings may remain masked or are recognized only when there is fear of losing control over the weight. Ineffectiveness: Underlying their spirited fa~ade, anorexics suffer from a deep sense of ineffectiveness, a conviction of acting only in response to demands coming from others and not on their own initiative. Their early development is described as free of difficulties and problems; parents consider the patient their pride and joy, their most gifted and pleasing child, of whom great things are expected. This admired behavior is an expression of robot-like obedience that camouflages serious underlying selfdoubt. Ordinary experiences of adolescence are often mentioned as precipitating this very serious illness. The drastic reducing is started when they fear not being recognized as "special"; but whatever low weight is reached, it is "not enough." By becoming thinner and thinner, they try to erect a bulwark against the fear of feeling not truly respected. Unable to solve their real problems, anorexics get a sense of accomplishment and superiority from manipulating their own figures. They react with self-devaluation, depression, and self-hatred when there is any gain in weight. Family transactions: Not only is the patient's childhood described as trouble-free, but the families present themselves as "happy." There are few divorces or broken homes. Most are well-to-do and success-, achievement-, and appearance-
oriented. In some way this seems to influence these youngsters to try to change their bodies in the search for something that earns them "respect" from their parents. The families of anorexics are of small size, with a conspicuously greater number of daughters than sons, but with few instances of only children. The position of being the older of two girls was most frequent in my patient group; next, that of being the youngest in a three- or four-girl family. Underlying the apparent marital harmony, there are serious problems and in their dissatisfaction with each other, each parent seeks affection and confirmation from the "perfect" child. The illness appears as an escape into selfhood when this role becomes too difficult. Atypical anorexia nervosa: The underlying dynamic issues of the primary syndrome are very similar. In contrast, no general picture can be drawn for the atypical group, where weight loss is incidental to a variety of problems and is frequently complained of, or valued, only secondarily for its coercive effect. Often there is a desire to stay sick in order to remain in the dependent role, in contrast to the struggle for an independent identity among the primary group. Certain subgroups can be recognized, such as neurotic and hysterical symptomatology, schizoid reaction, and adolescent depression. In hysterics, the morbid rejection of food and what it symbolically stands for often coincides with a frightening or disgusting sexual experience; in an occasional case, unconscious fear of impregnation (formerly considered the basic dynamic issue) may be found as a relevant issue. Patients with schizoid reactions are more disturbed in their sense of PSYCHOSOMATICS
reality and misinterpret the whole eating function, often refusing food beca use they feel un worthy. Characteristically, they are often apathetic and indolent and show no signs of hyperactivity or perfectionistic striving. They usually are indifferent toward the emaciation, and they certainly do not express any pride in it. A depressive tone is frequently encountered in anorexic patients; occasionally severe depressive reactions can be traced to repeated early experiences of separation and desertion. In such cases the depression and social withdrawal precede the onset of anorexic behavior which may represent an effort to fight the depression. Notably absent are the defiant pride in being thin, the hyperactivity, and the perfectionism.
Anorexia nervosa in the male: Anorexia nervosa occurs conspicuously less often in males than in females, the ratio being about I to 10, although both the atypical and primary forms occur. The atypical picture shows a great variety of problems. It may be found in adults who become anorexic, with true loss of appetite, in response to life situations that they experience as overdemanding. They complain about the weight loss, or are indifferent to it, but they do not actively pursue it. In contrast, those with the primary condition have many features in common with relentless pursuit of thinness as the leading motive. As in anorexic girls, their accomplishments as children are fa
Obesity• and anoreXia nervosa HILDE BRUCH, M.D. The term "eating disorders" refers to those conditions in which food intake and body size are manipulated in an effort to solve or camouflage inner and outer adjustment problems. Clinically, these disturbances are recognized as obesity (the excessive accumulation of fat tissue, associated with helpless ineffectiveness in the face of bodily urges and social demands) and as anorexia nervosa (extreme leanness and cachexia, representing an over-rigid effort at establishing a sense of effectiveness). Obesity There is need to differentiate various forms of obesity according to the time of onset, family background, extent of the excess weight, its fluctuation over a period of time, social adaptation, and the ability, or inability, to do something about it. There are people for whom it appears normal to be heavier than the average, particularly if it accompanies a more secure station in life. It is not possible, however, to state how many overweight people
can be considered basically normal. Such a consideration would have to take into account the success with which these individuals conduct their lives, their normal activities, interests, and eating patterns, even though their weight is regulated at a higher point. There are also no statistics about how many obese people are psychologically disturbed, as their psychiatric problems are far from uniform. Obesity may be associated with every conceivable personality type of psychiatric disorder, neurosis as well as psychosis. Two subgroups can be recognized: the developmental, in which obesity is intricately interwoven with the person's whole development, with many features of disturbed behavior and adaption; and the reactive, in which obesity is a reaction to some traumatic event. Developmental obesity: This form occurs in children who are overstuffed with food and are shielded from, or not trusted with, the ordinary tasks of life. Their behavior and psychological reactions may
resemble those of people in the preschizophrenic state and some become overtly schizophrenic when they experience the demands oflife as too threatening. Enforced and untimely reducing may precipitate this form of obesity. In a group of obese children who were followed into early adulthood, about one third outgrew the condition during adolescence, usually with the encouragement of friends who supported them in their separation from their homes. Others made a good general adjustment, though they remained moderately overweight. Re-evaluation of the early records showed that those who had done well in the long run had been accepted by their parents and had not been exposed to relentless pressure to reduce. It is often assumed that severe obesity early in life denotes a poor prognosis for later weight regulation, a belief reinforced by the finding that overfeeding in early life is associated with an increase in the number of adipose cells. This leads to lasting obesity, however, only if PSYCHOSOMATICS
the environmental conditions that initially made for obesity persist. Those who remained fat and were poorly adjusted, or had grown more obese, had been literally persecuted by their families for being fat. All of them showed evidence of serious emotional problems as children. They arrived at adolescence with low self-esteem and a sense of helplessness, and they reacted with guilt and depression to the condemning cultural attitude. For the long-range outlook, the decisive difference is whether or not a fat child and his or her family receive help with the underlying problem. Those obese youngsters who had found help with their emotional problems were able to function well as marriage partners and as parents, and raised nonobese children. In contrast, those who had not received such help had children who were as obese as they themselves had been. Reactive obesity: The importance of emotional factors in the development of obesity was first recognized in those cases that followed traumatic experiences. For example, after both world wars, German and French authors described a paradoxical form of obesity that developed after severe mental shock, after bombing, or following the death of a beloved person. This form is more often observed in adults, but it occurs also during childhood and adolescence. Obesity develops not infrequently after the death of a family member, separation from home, or when a love affair breaks up. The obesity appears to be the equivalent of a depressive reaction in situations involving fear of desertion and loneliness-a defense against manifest depression. Often it is the loss of possessions and prestige that
precipitates the overeating and subsequently results in obesity. Situations that provoke overeating and a decrease in activity are akin to those usually accompanied by grief or severe depression. People with these symptoms may experience some depressive feelings and may become openly depressed when weight reduction is enforced. In the background of the patient with reactive obesity one can frequently recognize early childhood circumstances that had endowed food with an excessive degree of emotional significance. An operation or an accident may be followed by an increase in weight. This leads to persistent obesity only when there are predisposing personality traits. The obesity that develops during or after pregnancy may belong to this group. Outstanding in the psychopathology are disappointment with the marriage and unfulfilled daydreams about what the child could do for the mother. Sometimes there is frank envy about the care the child receives or resentment regarding the demands he or she is making on the mother. Occasionally a father may become fat after the birth of a child. This occurs in extremely dependent men who feel that they have never received quite enough and who resort now to overeating to combat their jealousy and to compensate for what they feel they are missing and the baby is receiving. Anorexia nervosa Until about 1960, psychoanalytic thinking influenced the many efforts to understand the factors underlying anorexia nervosa. The emphasis was on the non-eating, with the theoreticians ambitiously explaining the whole complex pic-
ture through one specific psychodynamic formulation. Recently, however, a definite change has occurred in the entire approach, with agreement that true or primary anorexia nervosa needs to be differentiated from unspecific types (atypical) of psychologically induced weight loss. Primary anorexia nervosa: In true anorexia nervosa, the leading symptom is the desire to be thin, a phobic avoidance of being fat. Paradoxically, this is associated with an intense interest in food, without real loss of appetite. Food is actively refused in the service of the relentless pursuit of thinness. This preoccupation with the body and its size is a late step in the development of youngsters who have been engaged for years in a desperate but futile struggle to establish a sense of control and identity, and who have tried to make themselves appear "perfect" in the eyes of others. This search for control is the basic psychological issue in primary anorexia nervosa, which shows definite areas of disordered psychological functioning. Body-image disturbance: True anorexics will vigorously defend their often gruesome emaciation as not being too thin, as the only possible protection against the dreaded fear of being fat; they identify with the skeleton-like appearance, actively maintain it, and deny its abnormality. Though anorexic patients uniformly explain that they began dieting because they felt they were "too fat," excess weight precedes the illness in riot more than 15% to 20% of the cases; most had been of normal weight and a few had been on the thin side. Anorexic patients will gain weight for a variety of reasons, but they are apt to relapse unless the body109
APRIL 1978 • VOL 19· NO 4
- .........
~ Weiss-English
1::1 Symposium
image disturbance corrects itself. Many will confess that they felt they were hurting their parents by not eating and gained satisfaction from seeing them worry, but were completely unaware that they themselves were undergoing the ordeal of starvation. True progress involves their developing an active and positive interest in their own body and its well-being. The illness represents a split between the "self' and the body, which they often experience as not truly their own. Misperception of bodily functions: The symptom that arouses most concern, anxiety, frustration, and rage is the anorexic's refusal to eat. Though there is no true loss of appetite, awareness of hunger in the ordinary sense seems to be absent, and this deficit appears to be closely related to other aspects of the underlying personality disturbance. Anorexics are frantically preoccupied with food, and develop unusual, even bizarre, eating habits, similar to those observed in victims of famine. They will complain of feeling "full" after a few mouthfuls, and some even feel "full" through watching others eat. In some, food refusal alternates with uncontrollable eating binges that are experienced as submission to a force compelling them to do something they do not want to do, or as an expression of complete loss of control. Many try to remove the unwanted food through self-induced vomiting, laxatives, enemas, and increasingly frequent diuretics that may lead to serious disturbances in the electrolyte balance. Another sign of falsified body awareness is hyperactivity, walking by the hour, or doing calisthenics to the point of exhaustion, without experiencing fatigue. The failure of sexual functioning and the absence 210
of sexual feelings may also be considered in this context. Other bodily sensations, too, such as awareness of temperature or sensitivity to pain, are not correctly perceived or responded to. Anorexics are also deficient in identifying emotional states, and even severe depressive feelings may remain masked or are recognized only when there is fear of losing control over the weight. Ineffectiveness: Underlying their spirited fa~ade, anorexics suffer from a deep sense of ineffectiveness, a conviction of acting only in response to demands coming from others and not on their own initiative. Their early development is described as free of difficulties and problems; parents consider the patient their pride and joy, their most gifted and pleasing child, of whom great things are expected. This admired behavior is an expression of robot-like obedience that camouflages serious underlying selfdoubt. Ordinary experiences of adolescence are often mentioned as precipitating this very serious illness. The drastic reducing is started when they fear not being recognized as "special"; but whatever low weight is reached, it is "not enough." By becoming thinner and thinner, they try to erect a bulwark against the fear of feeling not truly respected. Unable to solve their real problems, anorexics get a sense of accomplishment and superiority from manipulating their own figures. They react with self-devaluation, depression, and self-hatred when there is any gain in weight. Family transactions: Not only is the patient's childhood described as trouble-free, but the families present themselves as "happy." There are few divorces or broken homes. Most are well-to-do and success-, achievement-, and appearance-
oriented. In some way this seems to influence these youngsters to try to change their bodies in the search for something that earns them "respect" from their parents. The families of anorexics are of small size, with a conspicuously greater number of daughters than sons, but with few instances of only children. The position of being the older of two girls was most frequent in my patient group; next, that of being the youngest in a three- or four-girl family. Underlying the apparent marital harmony, there are serious problems and in their dissatisfaction with each other, each parent seeks affection and confirmation from the "perfect" child. The illness appears as an escape into selfhood when this role becomes too difficult. Atypical anorexia nervosa: The underlying dynamic issues of the primary syndrome are very similar. In contrast, no general picture can be drawn for the atypical group, where weight loss is incidental to a variety of problems and is frequently complained of, or valued, only secondarily for its coercive effect. Often there is a desire to stay sick in order to remain in the dependent role, in contrast to the struggle for an independent identity among the primary group. Certain subgroups can be recognized, such as neurotic and hysterical symptomatology, schizoid reaction, and adolescent depression. In hysterics, the morbid rejection of food and what it symbolically stands for often coincides with a frightening or disgusting sexual experience; in an occasional case, unconscious fear of impregnation (formerly considered the basic dynamic issue) may be found as a relevant issue. Patients with schizoid reactions are more disturbed in their sense of PSYCHOSOMATICS
reality and misinterpret the whole eating function, often refusing food beca use they feel un worthy. Characteristically, they are often apathetic and indolent and show no signs of hyperactivity or perfectionistic striving. They usually are indifferent toward the emaciation, and they certainly do not express any pride in it. A depressive tone is frequently encountered in anorexic patients; occasionally severe depressive reactions can be traced to repeated early experiences of separation and desertion. In such cases the depression and social withdrawal precede the onset of anorexic behavior which may represent an effort to fight the depression. Notably absent are the defiant pride in being thin, the hyperactivity, and the perfectionism.
Anorexia nervosa in the male: Anorexia nervosa occurs conspicuously less often in males than in females, the ratio being about I to 10, although both the atypical and primary forms occur. The atypical picture shows a great variety of problems. It may be found in adults who become anorexic, with true loss of appetite, in response to life situations that they experience as overdemanding. They complain about the weight loss, or are indifferent to it, but they do not actively pursue it. In contrast, those with the primary condition have many features in common with relentless pursuit of thinness as the leading motive. As in anorexic girls, their accomplishments as children are fa
