VOLUME V.
NUMBER 5
JP SY C 111 0 S 0 MArfl I C S
OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC M:DICINE
Psychological Aspects of Overeating
And Obesity
HILDE BRUCH,
• In discussing the psychological aspects of
obesity, I shall also consider its opposite or
alternative clinical picture, anorexia nervosa.
Both conditions have certain basic features in
common. Outstanding is the fact that the bodi-
ly function of nutrition has developed in such
a way that it is available to be used, or actu-
ally misused, as a pseudo-solution for conflicts
and problems in the emotional and interper-
sonal field.
Awareness and systematic study of psycho-
logical factors in nutritional disorders, of
which obesity and anorexia nervosa are the
extreme manifestations, is of fairly recent ori-
gin. The fact that eating and emotions are
closely related is, of course, old medical and
popular knowledge. Loss of appetite during
physical and mental illness, and at the time of
grief and upsetting events is generally recog-
nized. Happy events are celebrated by feast-
ing; excessive eating is also looked upon as an
C'xpression of greed, or of lack of will power.
The fact that starvation, lack of food for
extraneous reasons, results not only in loss of
weight and energy but also in severe psychic
disturbances, has been a painful and distress-
ing part of human history.1.2
The importance of mental factors for marked
Presented at a symposium on obesity at Palo Alto,
California.
Dodor Br\l(·h is Clinical Professor of Psychiatry,
Coll!'!!e of Phvsicians and Surl(t'ons. Columbia Univer-
sity, New York, N. Y. (on leave); Proft'sscr of Psychi-
atry, Medical Collel(e, Baylor University, HOllston,
Texas.
Sl'ptemllt'r-Odohl''', J964
SEPTEMBER· OCTOBER, 1964
M.D.
variation of body weight began to be appre-
ciated during the latter part of the 19th cen-
tury, resulting in the classical description of
anorexia nervosa,:!·4 and occasional references
to emotional factors in the face of rapid gain
of weight.'··"
Preoccupation with the newly discovered
endocrines, linking nutritional disorders chiefly
to disturbances in the pituitary gland, over-
shadowed the beginning psychological inter-
est. When the importance of emotional fac-
tors was rediscovered, during the thirties, it
was necessary to delineate anorexia nervosa
from Simmond's Disease 7 • s and juvenile obesi-
ty from Froehlich's dystrophy.n.11I What we
conceive of today as disturbances in neuro-
vegetative regulation is a far cry from the ap-
plication of endocrine labels which were sim-
ply attached to fat or thin patients and were
copied from one physician to another, without
having been put to the test of objective vali-
dation. J1
Before discussing psychological factors, a
few general remarks about weight disturb-
ances are in order. Neither overweight nor
leanness can be considered manifestations of
definite or uniform clinical conditions. 12 They
may represent constitutional variations of
body build without disturbed personality de-
velopment. The weight deviation in such cases
is usually of moderate degree and fairly stable.
The abnormal conditions of over- or under-
nutrition are also of multiple origin with dif-
ferent course.':! Different types of obesity are
11111111111111111 ~ 111111 ~III~IIIIIII
269
Z927-YKJ-3WA3
 PSYCHOSOMATICS
associated with different psychiatric illness;
the same holds true for progressive loss of
weight, with the classical anorexia syndrome
being only one among several other diagnostic
possibilities. 14 The importance of emotional
factors for obesity was first recognized in cases
of sudden gain in weight precipitated by some
traumatic experience (reactive obesity) .15
After the First and Second World War, Ger-
man and French authors 1G • 17 described as "par-
adoxical" obesity its development after severe
mental shock. Obesity may occur even under
less dramatic circumstances, after death of a
beloved person, separation from home, or
other events involving fear of desertion and
loneliness. The situations that provoke over-
eating and decrease of activity are akin to
those usually accompanying grief and depres-
sion. This reactive form appears to be char-
acteristic of obesity in adults and severe
depression may become manifest when reduc-
ing is enforced. The reactive form may occur
during childhood and adolescence though the
characteristics and predominant form in the
juvenile group is what I have called develop-
mental obesity,t8 which is associated with
severe emotional and personality disturbances
and in many ways resembles pre-schizophrenic
development. 19
Obesity, and its allied symptoms, overeating
and inactivity, represents in these cases an
essential aspect of the whole development and
is endowed with important psychologic and
symbolic meaning; it holds a core of central
position in such patients' life history. For
many of these fat young people, being fat, the
very experience of their large size, the per-
sistent over-eating and the passive, inactive
way of life, represent a protection against
more severe mental illness. Obesity serves as
an alibi for the avoidance of threatening and
unacceptable social demands, and food indul-
gence permits the experience of at least a
semblance of satisfaction in an otherwise
dismal existence.
These obese youngsters showed defects in
adaptation on many levels of development,
often apparent as an overall immaturity. They
also frequently showed defects in social rela-
tions which are usually described by such
words as "withdrawn" or "seclusive," and
usually are "explained" as being due to the
obesity. Like the schizophrenic-to-be, the
270
obese person has an exceedingly low frustra-
tion tolerance and will react with sudden
withdrawal or undermining hostility to un-
expected demands. Associated with this is a
sense of helplessness, a conviction of inade-
quacy and inner ugliness-derogatory and self-
destructive attitudes that are compensated for
by flight into fantasy and day dreams.
It was in the study of such obese children
that the importance of the family interaction
was recognized. The severe in t r a fa m il ia I
pathology was first reported in 1940 as "'The
Family Frame of Obese Children."2o Further
studies have modified and elaborated the pic-
ture in many ways, and its essential inner
meaning has become clearer. The outstanding
pathogenic factor in these families is the fact
that the child is used by one or the other
parent, sometimes by both, as a thing, an
object whose function it is to fulfill the par-
ents' needs, to compensate them for failures
and frustrations in their own lives. The child
is looked upon as a precious possession who
is offered the very best of care. Many parents
openly express their dissatisfaction with the
sex of the child, because the opposite sex
would have better fulfilled their hopes and
wishes. Severe confusion in sexual identifica-
tion, which is characteristic of the obese, can
be directly related to these misleading paren-
tal attitudes. This family constellation shows
many similarities with the family picture that
in recent years has been considered conducive
to the development of schizophrenia. 2J Frank
schizophrenic illness is a not infrequent occur-
rence, when demands beyond their precarious
adaptive capacity are made.
In the much less frequent condition of ano-
rexia nervosa, the onset is usually reported as
sudden in a seemingly well functioning indi-
vidual who may have been somewhat plump
and who continues to be active, even becomes
hyperactive, in spite of the progressive loss
of weight. Anorexia nervosa was first observed
in adolescent girls, shortly after the menarche,
or when they were confronted with commit-
ment to a more mature feminine role. In
recent years anorexia nervosa has been ob-
served with increasing frequency in girls of
pre-puberty age,22 and also in pre-pubertal
boys. Common to them is a vigorous denial
of needing to eat, or being too thin, or of
feeling fatigued. A close association to schizo-
Volume V
 OVEREATING AND OBESITY-BRUCH
phrenia may be observed, though anorexia
nervosa needs to be differentiated from schizo-
phrenic patients who refuse to eat.
The early development is usually described
as having been free of difficulties and prob-
lems to an unusual degree. They were out-
standingly good children, obedient, clean,
eager to please, helpful at home, precociously
dependable and excelling in school. They
were the pride and joy of their parents, and
great things were expected of them. The
whole story is one of robot-like obedience and
perfection.
The families seemed to be well functioning
and the mothers conscientious in their concept
of motherhood; often they were women of
achievement, or career women frustrated in
their aspirations. They were subservient to
their husbands in many details, yet without
truly respecting them. The fathers, regardless
of social and financial success which were
often considerable, felt in some way "second
best." They were enormously preoccupied
with outer appearances in the physical sense
of the word, admiring fitness and beauty, but
also expecting proper behavior and measur-
able success and achievements. Often they
had been closer to the children who thought
of them as warmer than the mothers. The
parents emphasized the normality of their
family life, with repeated statements of "noth-
ing wrong," sometimes with frantic stress on
"happiness," directly denying the desperate
illness of one of its members.
There is a dramatic change after the illness
starts. Refusal of food or bizarre eating habits
are part of negativistic behavior that extends
to every detail of living. The perfectionistic
drive for achievement persists and now be-
comes an obsessive preoccupation with grades
in school, cleanliness and appearance; or the
opposite, refusal to own anything and neglect
of ordinary grooming. The whole family inter-
action deteriorates from smooth control by
the mother to anxious and bewildered, and
then increasingly, angry preoccupation with
the patient's weight and caprices. In retro-
spect it becomes apparent that the earlier
climate of the so-called perfect homes had
been achieved at the price of complete sub-
jugation of the child, with impervious dis-
regard of wants and wishes. The new behavior
appears like a complete reversal of the previ-
September-October, 1964
ous pattern, like one indiscriminate and furious
"No" where there was formerly a tacit sub-
mission. The events that precipitate this
dramatic reversal appear to be often nothing
more than the ordinary re-adjustments of life,
like moving to a new neighborhood or school,
going away to summer camp, or college, or
just the demands of growing up with increased
personal responsibility.
Psychosomatic medicine has been greatly
influenced by psychoanalytic thinking. Freud's
great contribution to medicine is the recogni-
tion that the way inherent biological needs are
satisfied is closely related to emotional and
mental development. The whole gamut of
emotional experiences, character and symptom
formation, has been traced to the interaction
between instinctual demands and the more
fortunate or hapless ways in which they are
fulfilled or rejected by the environment, and
to how an individual reacts to this. Freud2~
has proposed many reformulations of this
fundamental concept of his teaching, but re-
mained critical of all his efforts to formulate
a fixed theory of instincts. Though he main-
tained that there are more than one instinct,
Freud's preoccupation was with the sexual
drive; disturbances in the nutritional field
were considered as part of the disorders in
psychosexual development.
The psychoanalytic approach has widened
our understanding of patients with severe
eating disorders. It could be recognized that
food was used to relieve the tensions of un-
solvable, often unconscious conflicts. Symbol-
ically food is equated with an insatiable desire
for unobtainable love, but also with an ex-
pression of inhibited destructive impulses. It
may stand for self-indulgence and substitute
for sexual gratification and the wish for preg-
nancy. Its refusal, as in anorexia nervosa, has
been interpreted as fear of oral impregnation.
The preoccupation with food may appear as
a helpless dependent clinging to the parents
or a hostile rejection of them.
If I do not enlarge on this aspect, it is not
because I underestimate the value of these
psychodynamic formulations, but because in
the course of my therapeutic work with such
patients, it became apparent that this inter-
pretative mode of inquiry failed to deal with
some basic problems, and that it is derived
from generalized conclusions based upon in-
271
 PSYCHOSOMATICS
dividual observations, or from findings that
have only secondary significance.
In an effort to recognize common pathog-
nomonic psychological factors, the leading clin-
ical symptoms and multiple psychodynamic
data were re-examined as manifestations of
disturbances in the perceptual and conceptual
field. Instead of asking "why and for what
purpose is food used in this inappropriate
way?", I shifted the question to "how does it
happen that the brain makes the mistake of
not recognizing bodily needs, hut confuses
them with affective and interpersonal prob-
lems?" The analysis of the clinical data re-
vealed that underlying the manifold psycho-
dynamic patterns and symholic meaning; of
food, there was a conceptual confusion. There
is a basic misconception, the conviction of
being the misshapen and wrong product of
somebody else's actions. The patients, both
the anorexic and obese, suffer from a genuine
lack of identity, from a feeling of not even
"owning" their own bodies. They lack aware-
ness of the signals of bodily urges, and also
of emotional reaction and interpersonal effec-
tiveness; specifically they are unable to cor-
rectly recognize hunger and satiation. This in-
correct awareness of their bodies is also ex-
pressed in a disturbed body image, which in
the anorexic reaches delusional proportions.
There is absence of concern over even ad-
vanced stages of emaciation, and the often
gruesome appearance is vigorously defended
as right for them, not too thin, and as the
only possible security against the dreaded
fate of becoming fat. The obese ones. too,
do not "see" themselves objectively and are
more concerned with the iudgment hy the
sC:lle than with what they feel and observe.
Looking upon the problem from this angle,
the question may be asked: Under what cir-
cumstances does such a disordered sense of
self-awareness develop? What happens in a
family that fails to teach a child to correctly
recognize his needs and transmits such con-
fusion about his bodily and psychological
existence?
Psychoanalysis speaks of drives and instincts
as innate properties, and clinicians in general
assume that human beings have an inborn
knowledge of their bodily needs. My deduc-
tion, from clinical ohservations, was that hody
awareness needs to be learned, and these
patients have been exposed to incorrect learn-
272
ing experiences. This concept finds support
in neurophysiological evidence. Hehh," sum-
marizing his own observations and those of
others, demonstrated that lack of food, the
state of nutritional deprivation, is apt to be
disruptive of behavior. The first effect of lack
of food is not an increased directedness and
even in an animal as low as the rat, certain
learning knowledge must be acquired for
appropriate behavior. There are cognitive fac-
tors to be considered when "hunger" and also
the sensation of "satiation" is studied in the
mature animal. In man, with his much more
complex brain structure, the ways of learning
are also more complex. The usual psychiatric
histories, with emphasis on the motivational
significance of early experiences, are apt to
neglect obtaining detailed data ahout these
early learning experiences.
elise l.-As illustration, I should Iikl" to rl"port
hriefly thl' l>arly fl"eding l'xpl'ril'nces in a 14-yl"ar-olcl
boy who was 5 fed 2 inches tall and weighed nearly
300 pounds. His life had been so dominated hy bdng
fat that he lacked ordinary social experiences and
indulged in a private life of magnificent daydreams.
Initially, the mothPr had statl'd that hl' had "al-
ways" heen an insatiable cater. On detailed inquiry,
it was learned that he had weighed only 5 pounds at
hirth and was difficult to feed. The desire for food
became limitless only after he was 10 months old.
During the first six months of his life the family Iivl'd
in the grandfather's household and the infant slept
in the parents' hedroom. Hl' cried a good deal and.
during these early months, his father or grandfather
would pick him up and carry him around. \Vhen thl'
family moved to their own apartment, the infant slept
in a separate room.
The mother had been reluctant to have another
child and developed a severe backache shortly after
his birth. Thus she was unahIt' to lean over the crih
or pick him up. By the time they moved to the new
apartment, the child was able to sit in a high chair.
The mother still could not lift him easily and he sat
for long stretches. He would become restless and cry,
and the mother discovered that she could keep him
quiet hy putting a cookie or cracker into his mouth.
This would not keep him quiet for long and the
mother complained that no amount of food would
keep him quiet and her rate of feeding increased;
so did his weight. At eight months, he was normal,
hut by 10 months he began to look chuhby. At the
age of two years he weighed 65 pounds, and from
then on therl" was great concern about his progressive
obesity.
In a previous psychiatric consultation, the excl"s-
sive desire for food had hl"en intl'rpreted as the
infant's responSl' to thl" loss of love and emotional
neglect after they moved to the new housl". There is
evidence for this, but the grotesquely inappropriate
Volume V
 OVEREATINC AND OBESITY-BRUCH
learning experience appears to me to represent the
more important aspect. Food was olh'red as the
great pacifier for any discomfort that made him ery.
This early "programming" of his regulatory centers
as well as that of the higher brain function became his
permanent pattern. This incorrect learning took place
during the time of beginning of differentiating per-
ception, cognition and outward directed exploring be-
havior. The mother in this case had failed to respond
to the various needs of her child in a discriminating
way.
Case 2.-Equally inappropriatt', though entirely
diRerent, was the early feeding experience of a young
man who had becoml.' anorexic at age 12, his wdght
dropping from 95 to 50 pounds. In spite of l.'xtensive
ml.'dical and psychiatric treatment, he had remained
anorexic and weighed only 45 pounds when I met
him at age 18~. He was the first son of a seemingly
wt'll-functioning family, and of a mother who took
pride in doing things wt'11. Spt'aking about her son's
infancy, sht' emphasized how exactly she had followl'd
every one of her pediatrician's prl'scriptions, with
strict adlll.'renct' to time and amounts. \Vht'n the in-
fant was two months old, some solid food was intro-
ducl.'d which he refused. The mother felt it was hN
duty to make him eat it, and would not give him his
accustomed formula until he had l.'aten the solid food.
Overpowered in this way, it bl.'came thl.' pattern of all
his eating experiences, with the mother introducing,
like a perfectly functioning machine, whatever sill'
felt he needed. Tht' child st'emed to bt' doing well
under this regimen and was described as a gifted and
athletic boy. When he was 9 years old, the mother
hecaml.' concerned about his negativistic hehavior
which t'xtended now to many arl.'as, and not only to
food where she had felt he was always stubborn. The
hoy became prt'occupied with his physical fitness and
began to diet because he felt he was too plump. This
I(,d to a drastic change in his food habits, alternating
Iwtween refusal to eat and indiscriminate gorging
followl.'d by vomiting. In speaking about his life,
this young man would say, with great bitternl.'ss: "It
never matterl.'d what I wanted, my mother always
knew what was best for me."
DISCUSSIO:\"
In order to come to an understanding of
how this disturbance in the food area is re-
lated to the severe breakdown in total func-
tioning, it is necessary to construct a model of
personality development that is simpler, but
also more general than the traditional psycho-
analytic theories. On the basis of clinical
observations it is possible to differentiate two
forms of behavior, namely, behavior that is
initiated by the individual, and behavior in
response to stimuli from the outside. This
distinction applies both to the biologic and
social emotional field, and also to pleasure and
pain-producing states. These two modes of
September-October, 1964
hehavior are present beginning from birth. It
is incorrect to speak of early infancy as a time
of complete dependence on the environment.
Though an infant needs cooperation for the
physical aspects of his care, he is not solely
dependent upon stimuli from the outside, but
is active in letting his wants and needs be
known.
Behavior in relation to the child can be
classified as stimulating and responsive. The
interaction between child and environment
can be rated as appropriate or inappropriate,
depending upon whether it serves survival
and development, or is retarding and destruc-
tive. These elementary distinctions permit the
dynamic analysis of interaction, irrespective of
the specific area or content of the behavior,
of an a m a z in g Iy large variety of clinical
problems.
Similar subdivisions are used in experi-
mental psychology under the term emitted
and elicited behavior, in learning theory as
operative and respondent, and by Piaget as
assimilation and accommodation.
It appears to be essential for normal devel-
opment that stimulation coming from the out-
side, and confirmation of impulses originating
in the child are well balanced. Deprivation of
the regular sequence of experience of felt
need, signal, appropriate response and felt
satisfaction may exert a profound disruption
in essential early learning, one result of which
is disordered awareness of bodily function.
Such an individual will be poorly equipped
for orienting himself about his body and his
social-emotional environment, and for facing
the problems inherent in each developmental
step. As a result he will grow up bewildered
and anxious, incapable of effective self-asser-
tion in an incomprehensible world. It seems
to me that this lacking sense of self-effective-
ness represents the link between the severe
eating disorders and schizophrenic develop-
ment.
SUMMARY A:\"D CONCLUSIONS
The importance of emotional factors for
eating disorders, both for obesity and anorexia
nervosa, has been recognized in the past.
Psychoanalytic concepts helped to clarify the
psychodynamics of the disturbed eating be-
havior, and the symbolic significance of food
273
 PSYCHOSOMATICS
and body size, but proved to be disappointing
for effective therapy.
Analysis of the mental processes underlying
the motivational factors brought evidence of
conceptual and perceptual deficits. The in-
ability to correctly identify hunger, and also
other bodily sensations and emotional states,
could be recognized in patients with eating
disturbances.
This conceptual confusion may be conceived
of as the outcome of incorrect learning experi-
ences early in life, in the absence of appropri-
ate respome to signs and signals originating
in the child. While this may apply to any
aspect of a child's development, it will result
in disturbed weight regulation when the fail-
ure of appropriate response is pronounced
in relation to the feeding situation. Detailed
family studies revealed the historical develop-
mental background of such learning deficits.
If failure of confirmation of child initiated
behavior is severe, the outcome will be an
individual who lives chiefly by responding to
stimuli coming from others, be it with passive
compliance or rigid negativism, without ex-
periencing sensations, thoughts or feelings as
originating within himself. Such a defective
sense of self-effectiveness, a feeling of being
influenced from the outside, also occurs in
schizophrenic development.
BIBLIOGRAPHY
1. Keys, A., Brozek, B., Henschel, A., Mickelsen, O.
and Taylor, H. L.: The Biology of Human Star-
vation. Minneapolis: University of Minnesota
Press, 1950.
2. Bruch, H.: Psychopathology of hunger and ap-
petite. In Changing Concepts of Psychoanalytic
Medicine. New York: Grune & Stratton, 1956.
3. Gull, W. W.: Anorexia nervosa. Tr. Clin. Soc.,
7:22, 1874.
Everything that happens, happens as it should, and if you ohserve carefully, you,
will find this to be so.
274
4. Lasigne, C.: Hysteria anorexie. Arch Gen. de
Med., 1:385, 1873.
5. Worthington, L. S.: De l'Obesite: Etiologie, Ther-
apeutique et Hygien. Paris: Martinet, 1877.
6. Meyer, J.: Ueber den Werth und die Resultate
der t;erschiedenen EntfeUungsmethoden. Berlin:
Reimer, 1886.
7. Simmons, M.: Ueber Kachexie hypophysaeren
Ursprungs. Deutsch. med. Wchnschr., 42:190,
1916.
8. Richardson, H. B.: Simmonds' disease and ano-
rexia nervosa. Arch. Int. Med., 63: 1, 1939.
9. Froehlich, A.: Ein Fall von Tumor der Hypo-
physis cerebri ohne Akromeglie. Wien. Klin.
RdYch., 15:883 u. 906, 1901. Reprinted in Res.
Public. Ass. Nero. Ment. Dis., 20:XVI, 1940.
10. Bruch, H.: The Froehlich syndrome. Amer. ].
Dis. Child., 58: 1282, 1939.
11. Bruch, H.: Obesity in childhood and endocrine
treatment. ]. Ped., 18:36, 1941.
P Bruch, H.: The Importance of Overweight. New
York: \Y. W. Norton, 1957.
13. ~Ieyer, J.: Genetic, traumatic and environmental
factors in the etiology of obesity. Physiolog. Rev.,
33:472, 1953.
14. Bruch, H.: Perceptual and conceptual disturb-
ances in anorexia nervosa. Psychosom. Med.,
24:L87, 1962.
15. Bruch, H.: Reference 12, Chapter XII.
16. Dreyfus, G.: L'obesite paradoxale: syndrome
psycho-somatique. Presse Med., 56: 107, 1948.
17. Lichtwitz, L.: Ueber die Beziehung der Fettsucht
'. zur Psyche und Nervensystem. Klin. Wchnschr.,
2:1255, 1923.
18. Bruch, H.: Reference 12, Chapter XI.
19. Bruch, H.: Developmental obesity and schizo-
phrenia. Psychiatry, 21:65, 1958.
20. Bruch, H. and Touraine, G.: ObeSity in child-
hood: 5. The family frame of obese children.
psyc~Qsom. Meel., 2:141, 1940.
21. Fleck, S.: Family dynamics and origin of schizo-
phrenia. Psychosom. Med., 22:333, 1960.
22. Langford, \V. and Dunton, H. D.: Anorexia ner-
vosa b~fore puberty. (to be published)
23. Freud, S.: Instincts and their Vicissitudes (1915).
In Collected Papers, Vol. IV, p. 60. London:
Hogarth Press, 1934.
24. Hebb, D.O.: Organization of Behavior. New
York: John Wiley and Sons, 1949.
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