Emotional Aspects of Obesity

EMOTIONAL ASPECTS OF OBESITY WALTER

W.

HAMBURGER,

M.D.*

INTRODUCTION

The Cause of Obesity. 1"he medical literature contains many reports of careful clinical and experimental studies on obese patients. These studies have failed so far to reveal any constant etiologic cause for the usual case· of obesity. Repeated metabolic studies of obese children and adults have revealed no abnormality.l-7 Nor do obese persons usually have a demonstrable endocrine disorder. Pancreatic islet cell tumors can lead to obesity via hyperinsulinism, but such lesions are not found in the usual case of obesity. The obesity formerly associated with hypothyroidism and Cushing's syndrome has been shown to be due to water retention or to a redistribution of fat deposits rather than the development of true obesity.2, 3, 7-9 Similarly, obese patients do not usually have a demonstrable lesion in the central nervous system, although both clinical and animal observations indicate that hypothalamic lesions can in certain instances produce obesity 2, 3,7, 8,10, 14-16 The concept of juvenile obesity as a manifestation of a pituitary lesion (Frohlich's syndrome) has been largely abandoned. 3 , 7,10-12 Miscellaneous biochemical causes for obesity such as hypoglycemia, hypercholesterolemia or the presence of a lipophilic substance in the blood stream2 , 3, 5, 7 have not been consistently identified. '-fhe frequent occurrence of familial obesity would seem to implicate hereditary factors but proven data of genetic transmission in humans is meager. 2 , 3, 8 Twin studies are inconclusive. Danforth17 did demonstrate a gene connected with yellow hair calor which bred obesity in wild mice, but how this may relate to human obesity is not yet clear. Most modern authors have concluded that obesity is due to excessive inflow of energy exceeding the outflow, such disproportion being caused primarily by overeating. 1- 4 , 6-8 When the total intake of solids and water is accurately recorded, the body weights of obese persons correspond with the inflow and outflow of energy in normal fashion. 1- 3 Muscular inactivity, as well as overeating, may, of course, contribute to the disproportion between intake and outflow of energy. Bruch 6 reported that 72 per cerit of l~O obese children were physically inactive, but the degree From the Department of Psychiatry, University of Rochester School of Medicine and Dentistry, and the Strong Memorial and Rochester Municipal Hospitals, Rochester, New York. * Assistant Professor of Psychiatry, University of Rochester School of Medicine and Dentistry; Assistant Psychiatrist, Strong Memorial and H,ochester Municipal Hospitals. 483

484

WAL'IER W. HAMBURG:Mlt

of inactivity could not be correlated with the severity of the obesity. Calorically speaking, the obese person's relative inactivity seems to be of less importance than his overeating. 3 • 6 Bruch,16 by as quantitative methods as possible in both home and clinic, demonstrated that 142 obese children overate during periods of weight gain and ate a normal amount during stationary weight periods. Most clinicians dealing with obese patients have reached the same conclusion by more random observations, namely, that most of their obese patients do overeat. Conversely, if and when their patients adhere to a diet reasonable for their energy needs, they do lose weight. Thus, we arrive at the conclusion that the one consistent and demonstrable finding in obesity is overeating. Whatever the predisposition to obesity may ultimately prove to be, the symptom of hyperphagia seems to be a necessary component. Hereditary, constitutional or hypothalamic factors may all play a part and need further elucidation, but without overeating the predisposed individual will not develop obesity. In this connection it is interesting that Danforth's obese bred mice ate more than their controls. 18 Similarly the rats which Brobeck and his associates madefat by hypothalamic lesions, also first developed hyperphagia. 14 , 15 If their diet was restricted they failed to become obese. Brobeck concluded that hypothalamic lesions abolish the animals' usual controls over eating. These experiments indicate that the symptom· of hyperphagia may itself be under the influence of hypothalamic, hereditary or constitutional factors. This has been clearly summarized in Friedgood's recent discussion,19 but needs further study. Hunger versus Appetite. It may be pertinent to emphasize the difference between hunger and appetite as regulators of food intake. This difference has been stressed by Cannon,2°Harrington,21 Newburgh3 and others. Hunger is the physiological expression of the body's need for energy (food) which operates involuntarily in the healthy individual. As suggested above, this need (hunger) may well be under the control of inherited, constitutional or hypothalamic regulation. It is noteworthy that hunger is an uncomfortable sensation localized to the epigastrium. The discomfort of hunger is relieved by eating. Appetite, on the other hand, is a psychological desire to eat and gives a distinct anticipatory pleasure. Normally hunger produces appetite, but appetite also exists independently and can be stimulated by other means. For example, discussing or reading about liked food stimulates appetite. Overseas soldiers spend many a bull session discussing steak and french frieseven after a full meal of C-rations. Appetite is conditioned by the sight, smell and memory of certain foods and individual experiences while eating. Eating is well understood as an important esthetic, social and emotional experience in daily life. Food and restaurant advertisements rely on these relationships for their appeal. Thus a particular individual's

EM011 IONAL ASPECTS OF OBESITY

485

appetites, taste for specific foods and his eating habits are conditioned by his entire life experiences with food and eating. Appetite and the Emotions. A particular factor in appetite is the person's emotional state. It is common kno,vledge that when a person is upset or under some emotional tension there is often a reflection in his appetite. Interestingly enough, this may be either in the direction of an increase or decrease. The ubiquitous emotional experiences of love and grief are particularly well known for their disturbing effects on appetite. Anger too may disturb appetite, as every parent knows. The child may refuse to eat as an angry or defiant gesture toward the parent. In morbid emotional states, particularly the depressions, eating disturbances are usually cardinal symptoms. Often the neurotically depressed person will overeat and gain weight, whereas the psychotically depressed person often refuses food. Thus in sickness and in health there is an intimate interrelationship of appetite and the person's emotional state. With such widespread kno,vledge concerning the relationship of emotions to appetite, it is odd that we, as physicians, have only recently turned our attention to the interaction of appetite and emotions in obese patients. The following clues have long been in evidence: (1) Despite violent protestations against their obesity, and despite the exhortations and diets of their physicians, many fat people continue to overeat. This paradox suggests the possibility that overeating subserves some strong emotional need. (2) If we take a detailed history regarding the eating habits of obese patients, we often learn that they themselves are- aware that when they are emotionally aroused, they overeat and that eating makes them feel better emotionally. Freed22 asked 500 obese patients, "When you are nervous or worried do you eat more or less?" Three hundred and seventy replied that they ate larger meals or ate more frequently. An additional ninety-five stated that they ate more when "idle, bored or tired." Only thirty-five had noted no connection between appetite and their emotional state. This reaction in obese persons does not seem to be qualitatively different from that of normal people whose appetite may increase during the experience of love, grief or other universal feelings. Closer scrutiny of obese patients' eating patterns might reveal that quantitatively, however, their appetite response to an emotional stimulus is greater than that of the healthy person. One thing that has interferred with progress in this· direction has been the traditional concept of a fat person as a jovial, happy' and well-adjusted individual. In the series of patients to be described in this paper, we found this to be usually untrue. When it was superficially true, more prolonged study revealed this attitude to be a psychological protection against underlying emotional upsets of a potentially neurotic or psychotic nature.

480

WAL'rEH W. HAMBURGER

CLINICAL MATERIAL

'I'he author therefore determined to investigate the role of emotional factors in the hyperphagia (overeating) of obese patients. The clinical data comes from the detailed psychiatric study of eighteen obese patients seen in the medical and psychiatric clinics of a gener~l hospital* (1946-50), and in the author's private psychiatric practice (1948-50). These patients do not represent consecutive cases of obesity, but were selected because they had adequate psychological study to reveal some of their motives for overeating. In the majority of instances these obese patients were referred to Psychiatric Clinic after adequate medical study, either because of known emotional illness or because of their failure to lose weight with diet and drugs. These patients were studied from one to 398 hours (Table 1), a total of approximately 900 diagnostic and therapeutic hours. Several of my colleaguest contributed detailed data on several of the clinic cases they have been treating. Also random reference will be made to published case reports of other authors. Overeating as a Response to Nonspecific Emotional Tensions. Twelve patients in the present series of eighteen had been aware of marked changes in appetite accompanying transient, nonspecific emotional upsets. Two of these were in the direction of eating less. 'l'he other ten reported eating more than usual when upset. For example, Patient 10 said, "When I feel mad or blue I eat a big piece of pie and feel better." Patient 14 noticed that when she was upset she "vent to the kitchen and took a little bite" ... whether I "vanted it or not" (whether she .was hungry or not) I)atients 11 and 15 both spoke of t.he "soothing" effect of eating when nervous. The m.edical interne wrote in his history of Patient 13: "With anxiety her hunger (appetite) increases." This data points up how likely obese patients are to experience a disturbance in appetite, usually in the direction of overeating, when emotionally disturbed. Although feelings of upset, nervousness, anger, anxiety and boredom were mentioned by various patients in this connection, the most frequently named emotional stimulus to overeating was feeling blue or depressed. This suggests that overeating in obese patients may often be a reaction to the specific mood of depression. Data to be discussed under "Treatment" and "Discussion" seem to confirm this possibility. It should be mentioned that questionnaires such as Freed's22 on the relationship of emotions to eating are of limited value because often patients are not fully conscious of ·any connection between the two.

* Strong Memorial Hospital, Rochester, New York. t The author wishes to thank I)octors Robert L. Itoesslel', Instructor

in Psychiatry; Owen Otto, Iiockefeller Foundation Fellow in Psychiatry; Philipp C. Sottong and Albert W. Sullivan, Veteran Postgraduate Fellows in Psychiatry, for their helpful data.

TABLE 1 11~IGHTEEN PATIEN'l'S WITH OBESI'rY AND VARIOUS EMO'l'IONAL DISORDERS

Patient -

--~_.

2

Sex ----

Age -------~-

Maximum Weight in Pounds

No. of lIours Studied

Diagnosis Other Than Ohesitr

------_·_·_----------·--1----------_··_-----_·······_-·----1

F

20

178

3

F

21

235

25

(1) Hysterical psychopath

(2) Attempted suicide

(1) Reactive depression, at-

tempted suicide

(2) Character disorder:

3

F F F

47 24 16

233 185 178

7

6

M M

25 20

265

1 7

8

M

32

250

56

9

M

45

243

25

10

F

22

170

44

19

166

213

4

5

11

1 25

22

12

F

20

225

13 14

F F

33 48

156 240

15 16

F F

23 22

243 205

29

17

F

38

365

2

'18

F

20

210

23

2

487

inadequacy, periodic alcoholism None Anxiety-hysteria (1) Character disorder: inadequacy, antisocial behavior (2) Attempted suicide Neurotic depression Character disorder: inadequacy, emotional instability, latent homosexuality (1) Character disorder: passive-dependent type with impotence and latent homosexuality (2) Essential hypertension Character disorder: passivedependent type with depressive trends (1) Conversion hysteria (2) Anxiety-hysteria (3) Frigidity (1) Anorexia nervosa (2) Mixed psychoneurosis, obsessive - compulsive and hysterical features (l) Conversion hysteria (2) Character disorder: immaturity reactions Sterility, cause unknown (1) Hypochondriasis (2) Neurotic depression Anxiety -hysteria (1) Character disorder (2) Possible hypothyroidism (1) Character disorder; Inadequacy with episodic alcoholism (2) Borderline intelligence (3) Chronic cholecystitis Character disorder: inadequacy with emotional instability

488

WALTER W. HAMBURGmR

For example, Patient 12, ,vho was treated for 398 hours, originally had stated there ,vas no connection between her feelings and her eating habits. Later in psychotherapy ,vhen more aware of her reactions, she reported repeatedly observing herself eating more ,vhen unhappy or upset.

Overeating as a Substitute Gratification in Intolerable Life Situations. Seven patients (Cases 2, 3, 5, 9, 12, 13, 18) gave a history of react-

ing to intolerable or frustrating life situations with chronic overeating. If a person can respond to a transient mood or an acute emotional experience with overeating, is it not logical that he might continue to overeat if the emotional stimulus itself continued over a long period? These seven patients, in some way predisposed to hyperphagia, reacted to intolerable life situations by overeating, apparently gaining some sort of substitute emotional gratification and relief of tension. Let me give some examples: Patient No. 3, Mrs. T. B., is a 47 year old 233 pound woman who developed obesity at age 25, shortly after her marriage and the birth of her first child. l~hysical examination was normal except for patient's obesity and excess hair on the upper lip. B. M. R. was +6 per cent; glucose tolerance test and other laboratory studies were nonnal. Patient's mother was described as a domineering, strict woman who told patient nothing of sex, childbirth and marital relationships. In her youth patient made poor family and social adjustments, and remained immature. She was tt.erefore poorly prepared for marriage and parenthood, had constant friction with her husband, and in-laws. Early in her marriage, patient and her husband were separated for a year and a half. Patient was unable to solve these marital problems in any mature or realistic manner, had frequent crying spells. Diagnosis other than obesity: none.

Comment. This woman began to overeat in reaction to a disturbed marital relationship which she was unable to improve. Because of her inability to make a realistic change in her situation she reacted to her continuing unhappiness and frustration with chronic overeating. In some way the eating served as a substitute emotional gratification, and a release from tension. The fact<;>rs which predisposed her to this reaction and to obesity are not known. Patient No. 9, Mr. W. H., a 45 year old married man weighing 243 pounds, consulted the psychiatric clinic because of repetitive business failures. Patient had noted. his inability to assert himself, be independent and get along with bosses. He also attributed failure to his obesity. He had been overweight since childhood, as were his parents. Father was a disciplinarian. Mother was overly protective and overly solicitous of patient ,vho was the only child. She always feared he wasn't eating enough and pushed sweets at him. Patient periodically became discouraged and depressed over his business failures and at such times

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489

ate more. In the past six years, with increasing financial worries, he has gained 55 pounds. Diagnosis other than obesity: Character disorder, passive-dependent type with depressive trends.

Comment. This man had been overweight since childhood and thus predisposed to overeating and obesity in reaction to life stresses. Hereditary and constitutional factors are suggested by the parental history of obesity. A psychological fixation on eating may have occurred in childhood due to mother's known tendencies to overprotect and overfeed her only child. In any event, when faced with repetitive business failures which he was unable to do anything about, he reverted to a childhood gratification, overate and gained an additional 55 pounds. Overeating as Symptom of an Underlying Emotional Dlness, Especially Depressions and Hysteria. Patients 1, 4, 6, 11, 12, 14, 15 and 16 developed hyperphagia as only one of many symptoms of an underlying emotional illness. This symptomatic overeating led to an increase in weight. It seems warranted in these cases to stress the underlying psychological illness because such patients may well present themselves first at an Endocrine or Medical Clinic with the complaint of obesity, the underlying emotional illness not being apparent. In Table 1 it can be seen that sixteen patients had some demonstrable psychological disorder warranting a psychiatric diagnosis. Of these sixteen cases, nine consisted of so-called character disorders, seven of definitive psychoneuroses. This, of course, does not necessarily mean that obesity is part of that disease process as they could be separate entities occurring independently in the same person. Sometimes the obesity antedated the known psychological illness. At other times the emotional illness bore a reciprocal relationship to the obesity and appeared when the patient lost weight. However, the eight patients mentioned above overate and gained weight simultaneously with the development of a demonstrable emotional illness. In these cases the symptomatic hyperphagia was found to have a specific unconscious meaning to the sick person. The underlying illnesses were neurotic depressions in Cases 6 and 14, obsessive-compulsive and hysterical neurosis in Case 11, while hysterical features were predominant in Cases 1, 4, 12, 15 and 16. It should be stressed that of the entire series of eighteen patients, twelve exhibited depressive features in their histories; three of these had mOade suicidal attempts. These histories included transient depressive feelings,' neurotic or reactive depressions, characterological depressive traits, but no instance of frank depressive psychosis. Others, as \ve will discuss under "Treatment," became depressed as they lost weight in treatment. The frequency of depressive trends in other obese patients has been pointed out several times. 23- 27 Mittleman too mentioned this

490

\VAL'rER W. HAMBUItGER

in his psychological study of sixteen boys with the so-called adiposogenital dystrophy (Frohlich's) syndrome. 28 In patients 1, 4, 11, 12, 15 and 16, all hysterical women, overeating was associated with a sexual conflict, either phantasied or realistic. More often than not, an external sexual temptation or upsetting sexual experience could be demonstrated. Patient 15, for example, obese all her life, had an exacerbation of hyperphagia and gained an additional 50 pounds when she began to date steadily for the first time in her life. '-The constant feature of all women in this group was marked difficulty in adjustment to men, leading either to shyness and retirement, or to promiscuity. In marriage they were usually frigid. They often demonstrated other hysterical features in their histories. Several gave a story of preexisting hysterical conversion symptoms or anxiety-hysteria (phobias). Patient 12, for example, had a fourteen year history of conversion symptoms in almost every system of the body: hysterical aphonia, globus hystericus, fainting, abdominal pain, headaches. For various reasons these women failed to mature emotionally and were incapable of enjoying an adult sexual life. This has happened to some because they have remained emotionally, and in a childlike way, attached to their fathers. Patients 12 and 16 gave a history of childhood sexual assaults which also served as traumatic sexual fixations. In any event, sexual impulses are inacceptable to these people and a sexual phantasy, temptation or experience provokes displeasure and symptom formation. These hysterical patients all reacted to their sexual conflicts by overeating. Inasmuch as they could not accept genital gratification they displaced their sexual impulses (from below, above) to overeating. To them eating had an unconscious (repressed) sexual significance. 1'he proof of this formulation is given explicitly by Patients 11 and 12, both of whom disclosed childhood oral impregnation phantasies. They both had thought that a woman became pregnant by taking something by mouth and that the baby grew in the stomach. Patient 12 had thought that women became pregnant by eating an egg. Since childhood she had had an irrational disgust and felt nauseated at the sight of a poached egg! These oral impregnation phantasies are well-known in young children and in hysterical patients who do not have obesity. Overeating is thus a classical hysterical symptom: whereas sexual impulses were rejected (repressed), the symptom itself symbolically contained the repressed sexual impulse, Le., the desire to become pregnant. In this particular subgroup, where the hyperphagia is an hysterical symptom, the obesity itself has taken on an unconscious secondary symbolic significance. On the one hand it stands for physical unattractiveness and hence a protection against men, consistent \vith these women's rejection of their own sexuality. Patient 16, for example, at age 22 had never dated, could not dance, was shy and ill at ease with men.

EMo'rIONAL ASPECTS OF OBESITY

491

In psychotherapy she associated her fears with a sexual assault at age 7. In treatment she discovered how her obesity was a protection against men, and as she herself put it, "an escape from the problems of sex." At the same time as she discussed her sexual conflicts in treatment she began to go steady with a young man, became more confident of herself, lost 22 pounds. On the other hand, obesity itself may unconsciously symbolize pregnancy due to the childhood association that a pregnant woman is a fat woman. Patient 11 demonstrated hysterical features. When she was fat this 18 year old girl said "I feel as big now as if I'm carrying someone around with me." Again she said her abdomen puffed out after eating, "like a pregnant woman's." It was this patient who had previously had anorexia nervosa starting after a friend had jokingly said she looked pregnant in a certain photograph. Both her overeating and her obesity thus had an unconscious symbolic meaning of oral impregnation and pregnancy itself. This secondary symbolic meaning of the obesity itself as either a protection against physical attractiveness and men or as an unconscious equivalent of pregnancy has been pointed out by a number of authors. 23 , 24, 25, 29 Reeve 29 cites the case of a female college student who gained weight when a suitor became attentive, lost weight when he became disinterested. This may help to explain the original paradox of why many fat female patients consciously complain of their weight and wish to be thin and attractive, while actually they do not adhere to their diets and do not make healthy heterosexual adjustments. Overeating As an Addiction to Food. Still another motive for overeating was disclosed in Patients 1, 6, 7, 8, 10, 14, 17 and 18. This type of hyperphagia seems to be the most malignant type, characterized by a compulsive craving for food, often starting in earliest childhood and apparently independent of external precipitating events. However, external stresses may aggravate the preexisting obesity. This overeating might well be regarded as an addiction to food. These patients have a constant craving for food, especially candy, ice cream and other sweets. l~his craving is frequently uncontrollable and must be satisfied. Three patients in this series (Cases 5, 7, 11) stole food or money with which to go on candy and ice cream sprees. Patient 18 lied to her parents to escape their discovery of candy and other goodies hidden in her room. Similarly Lurie31 in describing children with Frohlich's syndrome cites a 15 year old boy referred from the Juvenile Court for stealing money from relatives and friends. It was learned that his sole purpose in stealing was to have money with which to buy huge quantities of ice cream. The compulsive, uncontrollable quality of appetite in these food addicts can thus be seen. These patients crave food like an alcoholic addict craves drink. Over

492

WALTER W. HAMBURGER

and over Patient 11, during psychotherapy, spontaneously compared her compulsive eating jags to the behavior of an alcoholic. She said she could no more eat one piece of food than an alcoholic can take one drink. On an eating spree she would go from drugstore to restaurant "like an alcoholic making his rounds." She was afraid to take a cocktail for fear her compulsion would switch from food to alcohol. This patient was the one who stole candy from other patients' rooms while institutionalized. The similarity of this craving for food to the alcoholic's craving for alcohol has been noted by a number of clinicians. 23 , 24,27,32,33 Fenichel in his Psychoanalytic Theory of N eurosis32 actually discusses the psychological aspects of obesity under addiction (pp. 241, 381-382). In this connection, it may be more than chance that two patients in this series were known alcoholics at one time or other. Patient 17 had a period of alcoholism when her weight was 270. When she stopped drinking in 1947, she promptly gained to 365, suggesting that food was a substitute for the alcohol. Benedek34 reported a case of obesity (later inability to eat) in a female alcoholic. The most revealing example of a food addict is Patient 18, a 20 year old woman who became obese at age 5 to a high in young adulthood of 210 pounds. The endocrinologist recorded in his history that in addition to a constant craving for sweets, she hoarded candy and other food which she hid in her room, enjoying their presence without necessarily eating them. When I asked why she hoarded the food and candy, tears came to her eyes and in a desperate and defiant tone of voice said simply, "They're mine." It was learned that she also hoa\'ded all the letters she had ever received, playing cards from a grade school collection, and as an adult collected different kinds of stationery. Food seemed to be invested with the attributes of personal property, and as such enhanced this patient's self-esteem. This unhappy young woman had felt unwanted and unloved her entire life. She was the only child raised in a troubled home of constant discord between neurotic parents and a paternal aunt and grandmother who also lived there. Patient had become the emotional whipping post for all members of this unhappy family. There had always been an overemphasis on food. A Kosher table was kept; grandmother was diabetic and dieted and there was constant wrangling among the three adult women as to who should do the cooking. Patient was thin until age 5. Mother was alleged to have had a "nervous breakdown" when patient hadn't eaten well as an infant. Father used to stand on his head to get patient to eat. Since patient got fat, mother threatens to have another "nervous breakdown" because of patient's overeating. Patient's food habits are a constant source of family discussion and not eating is used as a bribe for parental demonstrations of affection.

Comment. In this case it would seem that the possession and eating of food served as a substitute emotional satisfaction for the love and affection which she basically craved. Hence, we postulate that the food addict

EMOTIONAL ASPECTS OF OBESITY

493

may unconsciously be substituting a craving for food for a primary craving for love, affection and security. Not only did Patient 18 give a lifelong history of feelings of rejection, loneliness and lack of love, but eight others in this series of eighteen patients similarly had severe emotional deprivations in earliest childhood (Cases 1, 5, 6, 7, 9, 12, 15, 17). The parents in these cases were usually either dead, divorced, rejecting, alcoholic or badly neurotic. This explains why Patient 18 who so desperately wanted a mother's love, gave her doctor a diet history of liking orange juice "when mother fixed it," but not when grandmother did. Bruch,t3,38 and others have stressed the point that the very physical fact of obesity, the "bigness," is itself a symbol of strength and security, and may represent a symbolic defense against feelings of rejection, loneliness and insecurity. Actually there was no patient among the eighteen who did not give a history of some type of disturbed intrafamilial relationships in his or her home during the formative years. Interestingly enough, this did not always take the form of a broken home or openly rejecting parents, but as in Cases 7 and 8 (both men), there was a history of a doting, overprotective, "smothering" type of mother. This particular type of overprotecting mother has been noted before in the family history of obese patients. Bruch has particularly stressed this in her studies of the family backgrounds of obese patients. 13 , 16, 37-40 Olga Lurie41 and Selling42 pointed out the same thing in the background of children with a variety of eating problems. David Levy43 and Mittleman28 commented on the frequent overprotective mothers found in their studies of boys with the so-called Frohlich syndrome. Usually, such overprotective mothers are overcompensating for underlying tendencies toward hostility, competitiveness or rejection of their children and the child may sense this as inadequate love. PSYCHOLOGICAL ASPECTS OF TREATMENT

Although treatment was not the primary aim of this study, and those patients who were in psychotherapy were not necessarily seeking help for their obesity, it is noteworthy that only three patients lost any weight while under observation. Some were receiving diet and drugs in addition to psychotherapy, others not. Therefore, the role of the psychotherapeutic intervention is not clear. It is clear that in this particular series, psychotherapy was not generally effective in achieving weight reduction. Our clinical material furnishes one suggestion as to why the traditional treatment of obese persons with diet, exercise and drugs has often been difficult and sometimes of no avaiL The data indicated that the obese patients in this series overate in relation to underlying emotional problems. Sometimes the hyperphagia was a symptom of an underlying psychological illness, sometimes in reaction to an acute or chronic emo-

494

WALTER

w.

ltAMBURGmn

tional stress, sometimes as a substitute gratification for other unsatisfied longings. Usually there were multiple emotional factors in the hyperphagia of anyone patient. In any event, we would say psychologically that these obese patients seemed to have an "emotional need" to overeat. It is thus logical to assume that these patients might cling to their overeating as long as their underlying emotional conflicts continued or unless some other substitute gratification could be utilized. In this connection, let us listen to how some of the patients in this series had responded to treatment in the past. Patient 17 said to her endocrinologist-and I quote from her chart-"When I go on the diet I feel weak. When I eat what I want, I feel fine. So why should I stick to the diet?" When Patient 7 dieted in 1947 and lost 67 pounds in six months, he became progressively depressed and agitated. This reached such a degree of upset that his physician finally suggested he regain some weight. He regained it all and lost his nervous symptoms. Patient 4 had gone on a voluntary diet and lost 55 pounds. She developed globus hystericus, fears of being alone and dying, wished she were fat again as she felt happier. Patient 10 gave a history of "nervous symptoms" appearing every time she lost weight by dieting: ringing in the ears, weakness, dizziness, irritability and headaches. rfhis was documented on four separate dietary occasions. Six patients in this series had developed emotional upsets when they lost weight (Patients 3, 4, 7, 10, 12, 15). 1"his response to weight reduction might well be termed a negative therapeutic reaction. It is logical in terms of the preceding formulations. In addition, Patients 12 and 18 became frankly depressed in psychotherapy, not related to weight loss, but apparently because psychotherapy threatened to undermine the defensive meaning of their overeating and disclose the patient's underlying emotional conflicts. At one point it was necessary to inform the colleagues of Patient 12 that she was suicidal, and hospitalization was considered. Case 18 had to be terminated when patient became so depressed that she cried through each interview (and had gained an additional13 pounds). The outlook for reducing or eliminating the obese patients' hyperphagia should theoretically depend upon the underlying emotional conflicts of which the hyperphagia is thought to be a symptom. If the overeating is in reaction to an acute or chronic external stress or frustration, the need to overeat should disappear if the stress can be eliminated. If the hyperphagia is but one symptom of an underlying psychological disease, the prognosis for symptom relief should depend on the prognosis of the underlying illness. If the overeating, for example, is an hysterical symptom, the prognosis should be that of hysteria in general. We would anticipate that the patient addicted to food as a substitute gratification for cravings of love, affection and security, would be the

EMOTIONAL ASPECTS OF OBESITY

495

least reversible, for these underlying emotional needs are the most difficult to satisfy. This entire theoretical prognosis can refer only to the emotional aspects of hyperphagia. The reversibility of hereditary, constitutional, hypothalamic or biochemical" factors in obesity is still less clear, and beyond the scope of this paper. DISCUSSION

Application of the Psychoanalytic Concept of Orality to Obesity. Fortunately, psychoanalytic psychology provides us with a theoretical frame of concepts which make the preceding clinical observations more meaningful. In Freud's libido theory, the concept of orality has been validated by a generation of psychoanalysts working in many different countries. 32 , 44,45 I would like to enumerate in simple terms some of the various meanings of this concept and try to relate them to the preceding clinical data. 1. Mouth activities play a large role in the earliest part of human life. These activities have great emotional significance for the infant. Through suckling at the mother's breast, the infant associates the receiving of food with the warmth of mother's love. As Alexander puts it, "The first relief from physical discomfort the child experiences during nursing, and thus the satisfaction of hunger becomes deeply associated with the feeling of well being and security.... "37 Babcock30 has stressed the early nursing process as the infant's first interpersonal experience with the' mother, and as such a nonverbal means of communication between mother and child. Certain children become fixated at this oral stage of emotional development due to either inadequacy or, at times, an excess of maternal love. In later life these individuals may have excessive oralreceptive needs. Sometimes we actually speak of these individuals as "oral characters" or "unweaned sucklings." They are very dependent, childlike, demanding people. Their craving for love and security, if not satisfied, may be translated into a craving for food because of this unconscious infantile association of being fed with being loved. This intimate association of eating with love and security continues throughout our lives. Later in childhood it is still the loving parents who supply the food. Patient 11 dwelled at length in psychotherapy on her jealousy of her father and brother because mother had always served them their food first at meal time and patient felt this meant mother "loved them more.'; Another patient not included in this series spoke of competing with his siblings at table for the largest food servings as a symbol of parental affection. Even the advertiser whose slogans "Pies like mother makes," and "Home Cooking," is relying on the consumer's appetite being stimulated by associating the food appeal with the love appeal. Alexander's discussion of this relationship between eating and being loved is particularly clear and convincing. 35- 37,

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WALTER W. HAMBURGER

2. In infancy, stimulation of the oral cavity, ,vhether by suckling on the breast, pacifier or thumb, is a pleasurable (erotic) activity divorced from the nutritional aspects of eating. As the normal child develops, the nutritional aspects of eating become separated from the erotic ones and the erotic component gradually shifts to the genitals. However, traces of oral eroticism normally persist into adult life. These are evident in the oral gratification of kissing, smoking and chewing. The individuals who ,vere in some way fixated at the oral stage of emotional development may in the face of adult emotional conflict, return to that stage. This seems to be the case in hysterical hyperphagia where the patients react to a sexual threat or experience not with genital excitation but by displacement to hyperphagia where eating again becomes highly erotized. An important paper in this connection is Coriat's46 which discusses the relationship of sexual and nutritional cravings. 3. The particular psychological illness characterized by a return to this oral stage of emotional development is the depression. 32 , 45, 47,48 This furnishes a theoretical common denominator to the somewhat rfl.ndom clinical observations that overeating often seems to be a specifip, defense against depression and that when some fat people lose weight they become depressed. The common denominator is this concept of orality. It is also generally agreed among psychoanalytic investigators that oral fixations are prominent psychological features in alcoholism and other drug addictions. More recently it has been correlated with certain cases of peptic ulcer. Other Evidences of Oral Fixations Besides Overeating. In view of this application of the psychoanalytic concept of orality to obese persons, might we not expect to find other evidences of oral fixation in addition to that of overeating? The case material reveals that seven patients (Cases 2,5, 8, 11, 12, 17, 18) had other excessive or inappropriate oral traits in childhood or adult life. These included alcoholism, excessive finger sucking or nail biting, gnashing of the teeth, and one patient who repetitively bit her arm during sleep. Patient 17 was interesting as she repeatedly smacked her lips and drooled during her interview. Four of Mittleman's "Frohlich" cases28 were described as excessive nail biters and chewers of sand, pencils, wood, and in one case, plaster. Predisposing Factors. If the concept. of oral fixations applies to depressions, alcoholism, drug addictions and possibly peptic ulcer, then we are faced with the question "Why do fat people overeat and become obese rather than developing any of these other syndromes?" In other words, what predisposes these people to hyperphagia and obesity rather than another of these illnesses? Here we are on increasingly unsteady ground. The possible hereditary, constitutional, biochemical, hypothalamic or metabolic factors are not known at the present time. Psychosocial Predisposition to Eating Disturbances. If we continue

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to restrict our attention to the data at hand, we learn that in at least five of our patients, a psychological predisposition to eating disturbances was apparent in the undue emphasis placed on food and eating in the patient's childhood. Patient 18's history is a good example: (1) Her family kept an Orthodox Jewish table with great emphasis on the traditional religious rituals and prohibitions. (2) The paternal aunt and grandmother lived in tlie home and they and the mother were in constant battle as to who should do the cooking, and what and how they cooked. (3) The paternal grandmother was diabetic and on a diet. (4) Patient was told that as a young child she often refused her food, that father "stood on his head to make her eat," and mother had to go to a sanitarium, she worried so about patient's not eating. The possibility that family attitudes, habits and customs about food and eating predispose children to hyperphagia in later life is given support by Bruch's study of a larger number of obese patients. She reports 39 that many mothers of obese children overvalued food, especially immigrant mothers who had themselves been deprived of food abroad. Forty per cent were Jewish families where food had a deep emotional and religious significance. In many instances a disproportionate amount of income was spent for food. Many of these mothers were overprotective and oversolicitous and they too may have substituted the giving of food for real affection. Such psychological factors may well contribute to the predisposition to overeating. Nonpsychological Factors in Overeating. This investigation has been devoted exclusively to the study of the emotional aspects of obesity. It seems probable that genetic, constitutional, metabolic or other factors are necessary to convert simple overeating into the syndrome we know as obesity. Similar nonpsychological factors, especially hypothalamic regulation, may abnormally influence the appetite of obese persons. The ultimate demonstration of such factors will not necessarily invalidate the emotional elements discussed. Alexander's concept of "multicausality",36 may well apply to obesity as to other psychosomatic syndromes. The purpose of this paper is to report only on some of the emotional meanings of overeating which were discovered in the psychiatric study of eighteen obese patients. This series of cases is not necessarily a true cross section of obese patients, inasmuch as many of them had selectively oeen referred to Psychiatry. As a group they are unquestionably very sick emotionally. Nevertheless, it is hoped that by studying even a few obese patients intensively, we can learn more directly why some obese patients overeat and seem to cling to their symptom of hyperphagia. It will be necessary to apply some of the findings to consecutive obese patients, preferably in a Medical or Endocrine Clinic setting.

498

WALTEH W. HAMBURGER

SUMMARY

1. A review of the pertinent literature on obesity fails to reveal any intrinsic metabolic, endocrinologic or central nervous system abnormality in the usual case. The symptom of hyperphagia has been the only consistent finding in obese patients. 2. The hyperphagia of eighteen selected obese patients was studied by psychiatric interviewing and multiple emotional meanings to overeating were discovered: in response to nonspecific emotional tensions; as a substitute gratification in reaction to intolerable life situations; as a symptom of an underlying emotional illness, especially -depressions and hysteria; as a malignant addiction to food. 3. Obesity is a psychosomatic syndrome, the cardinal symptom of which is hyperphagia. Whatever metabolic, genetic or biochemical factors may play a role in either the symptom or the syndrome, emotional elements, of which the patient is often unaware, contribute a large part. REFERENCES 1. Newburgh, L. H.: The Cause of Obesity. J.A.M.A. 97:1659,1931. 2. Newburgh, L. R.: Obesity. Arch. Int. Med. 70:1033, 1942. 3. Newburgh, L. H.: Obesity (Chapter 11) in Williams, Textbook of Endocrinology, W. B. Saunders Co., Philadelphia, 1950. 4. Newburgh, L. H.: Obesity. L Energy Metabolism. Physiol. Rev. 4.1:18,1944. 5. Bruch, Hilde: Obesity in Childhood: 11. Basal Metabolism and Serum Cholesterol of Obese Children. Am. J. Dis. Child. 58(2) :1001, 1939. 6. Bruch, Hilde, "Obesity in Childhood: IV. Energy Expenditure of Obese Children," Am. J. Dis. Child., 60 (2): 1082, 1940. 7. Rynearson, E. H. and Gastineau, C. F.: Obesity. Springfield, Ill., C. C. Thomas 1949. 8. Conn, J. E.: Obesity: II. Etiological Aspects. Physiol. Rev. 4.1:31,1944. 9. Evans, Frank A.: Obesity (Chapter X) in Duncan, Diseases of Metabolism, W. B. Saunders Co., Philadelphia, 1947. 10. Bruch, Hilde: The Frohlich Syndrome. Am. J. Dis. Child., 58(2) :1282,1939. 11. Bruch, Hilde: Obesity in Childhood: I. Physical Growth and Development of Obese Children. Am. J. Dis. Child. 58(1) :457, 1939. 12. Bruch, Hilde: Obesity in Relation to Puberty. J. Pediat., 19:365, 1941. 13. Bruch, Hilde: Obesity in Childhood and Personality Development. Am. J. Orthopsychiat. 11:467, 1941. 14. Brobeck, John R., Tepperman, Jay, and Long, C. N. H.: The Effect of Experimental Obesity Upon Carbohydrate Metabolism. Yale J. BioI. & Med. 15:893, 1942-43. 16. Bruch, Rilde: Obesity in Childhood: Ill. Physiologic and Psychologic Aspects of the Food Intake of Obese Children. Am. J. Dis. Child., 59(2) :739, 1940. 17. Danforth, C. H.: Hereditary Adiposity in Mice. J. Hered. 18:153, 1927. 18. Rytand, D. A.: Hereditary Obesity of Yellow Mice. Proc. Soc. Exper. BioI. & Med. 54.:340, 1943. 19. Friedgood, Harry B.: Neuroendocrine and Psychodynamic Aspects of the Endocrinopathies (Chapter X) in Williams, Textbook of Endocrinology, W. B. Saunders Co., Philadelphia, 1950. 20. Cannon, WaIter B.: The Wisdom of the Body. New York, W. W. Norton & Co., 1932.

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21. Harrington, M. M.:' Appetite in Ilelation to Weight. J. Am. Diet. A. 6:101, 1930. 22. Freed, S. C.: Psychic Factors in the Development and Treatment of Obesity. J.A.M.A. 133:369, 1947. 23. Schick, Alfred: Psychosomatic Aspects of Obesity. Psychoanalyt. Rev. 34:173, 1947. 24. Richardson, H. B.: Obesity as a Manifestation of Neurosis. M. CLIN. NORTH AMERICA 30(2) :1187,1946. 25. Richardson, H. B.: Obesity and Neurosis. Psychiat. Quart. 20:400, 1946. 26. Richardson, H. B.: Psychotherapy of the Obese Patient. New York State J. Med. 47:2574, 1947. 27. Rennie, T. A. C.: Obesity as a Manifestation of a Personality Disturbance. Dis. Nerv. System 1:238, 1940. 28. Mittlemann, Bela: Juvenile Adiposogenital Dystrophy. Endocrinology 23:637, 1938. 29. Reeve, George H.: Psychological Factors in Obesity. Am. J. Orthopsych. 12: 674,1942. 30. Babcock, Charlotte G.: Food and Its Emotional Significance. J. Am. Dietet. A. 24:390, 1948. 31. Lurie, L. A.: Endocrinology and the Understanding and Treatment of the Exceptional Child. J.A.M.A. 110:1531, 1938. 32. Fenichel, Otto: The Psychoanalytic Theory of Neurosis. New York, W. W. Norton & CO.,1945. 33. Weiss, Edward, and English, O. Spurgeon: Psychosomatic Medicine. 2nded. Philadelphia, W.B. Saunders Co., 1949. 34. Benedek, Therese: Dominant Ideas and Their Relation to Morbid Cravings. Internat. J. Psychoanaly. 17:1936. 35. Alexander, Franz :The Influence of Psychologic Factors Upon Gastrointestinal Disturbances. Psychoanalyt. Quart. 3:501, 1934. 36. Alexander, Franz: Psychosomatic Med. New York, W. W. Norton & Co., 1950. 37. Alexander, Franz : Gastrointestinal Neurosis (Chapter VI) , in Portis, Diseases of the Digestive System, Lea & Febiger, Philadelphia, 1941. 38. Bruch, Hilde: Psychiatric Aspects of Obesity in Children. Am. J. Psychiat. 99 :752, 1943. 39. Bruch, Hilde, and Touraine, Grace: Obesity in Childhood. V. The Family Frame of Obese Children. Psychosom. Med. 2:141, 1940. 40. Bruch, Hilde: Psychological Aspects of Obesity. Bull. New York Ac~d. Med. 24:71, 1948. 41. Lurie, Olga R.: Psychological Factors Associated with Eating Difficulties in Children. Am. J. Orthopsych. 11:452, 1941. 42. Selling, L. S.: Behavior Problems of Eating. Am. J. Orthopsychiat. 16:163, 1946. 43. Levy, D. M.: Aggressive-Submissive Behavior and the Frohlich Syndrome. Arch. Neurol. & Psychiat. 36:991, 1936. 44. Freud, Sigmund: Three Contributions to the Theory of Sex. New York, N. M. D. Pub. Co., 1910. 45. Abraham, Karl: A Short Study of the Development of the Libido (1924), (Chapter 26) in Selected Papers of Karl Abraham, Hogarth, London, 1927. 46. Coriat, I. H.: Sex and Hunger. Psychoanalyt. Rev. 8:375,1921. 47. Freud, Sigmund: Mourning and Melancholia (1917), ColI. Papers, Vo!. IV, · Hogarth, London, 1925. 48. AbrahaIn, Karl: The First Pre-Genital Stage of the Libido (1916), (Chapter 12) in Selected Papers of Karl Abraham, Hogarth, London, 1927. 49. Gill, Dorothy J.: The Role of Personality and Environmental Factors in Obesity. J. Am. Dietet. A. 22:398, 1946. 50. Rascovsky, A., de Rascovsky, M. W. and Schlossberg, T.: Basic Psychic Structure of the Obese. Int. J. Psychoanal., 31 :144, 1950.