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Much has been written about the psychological aspects of obesity. Among its many functions the diencephalon is also the seat of our primitive animal instincts, and just as in an emergency it can switch energy from one center to another, so it seems to be able to transfer pressure from one instinct to another. Thus, a lonely and unhappy person deprived of all emotional comfort and of all instinct gratification except the stilling of hunger and thirst can use these as outlets for pent up instinct pressure and so develop obesity. Yet once that has happened, no amount of psychotherapy or analysis, happiness, company or the gratification of other instincts will correct the condition.
No end of injustice is done to obese patients by accusing them of compulsive eating, which is a form of diverted sex gratification. Most obese patients do not suffer from compulsive eating; they suffer genuine hunger - real, gnawing, torturing hunger - which has nothing whatever to do with compulsive eating. Even their sudden desire for sweets is merely the result of the experience that sweets, pastries and alcohol will most rapidly of all foods allay the pangs of hunger. This has nothing to do with diverted instincts.
On the other hand, compulsive eating does occur in some obese patients, particularly in girls in their late teens or early twenties. Fortunately from the obese patients' greater need for food, it comes on in attacks and is never associated with real hunger, a fact which is readily admitted by the patients. They only feel a feral desire to stuff. Two pounds of chocolates may be devoured in a few minutes; cold, greasy food from the refrigerator, stale bread, leftovers on stacked plates, almost anything edible is crammed down with terrifying speed and ferocity.
I have occasionally been able to watch such an attack without the patient's knowledge, and it is a frightening, ugly spectacle to behold, even if one does realize that mechanisms entirely beyond the patient's control are at work. A careful enquiry into what may have brought on such an attack almost invariably reveals that it is preceded by a strong unresolved sex-stimulation, the higher centers of the brain having blocked primitive diencephalic instinct gratification. The pressure is then let off through another primitive channel, which is oral gratification. In my experience the only thing that will cure this condition is uninhibited sex, a therapeutic procedure which is hardly ever feasible, for if it were, the patient would have adopted it without professional prompting, nor would this in any way correct the associated obesity. It would only raise new and often greater problems if used as a therapeutic measure.
Patients suffering from real compulsive eating are comparatively rare. In my practice they constitute about 1-2%. Treating them for obesity is a heartrending job. They do perfectly well between attacks, but a single bout occurring while under treatment may annul several weeks of therapy. Little wonder that such patients become discouraged. In these cases I have found that psychotherapy may make the patient fully understand the mechanism, but it does nothing to stop it. Perhaps society's growing sexual permissiveness will make compulsive eating even rarer.
Whether a patient is really suffering from compulsive eating or not is hard to decide before treatment because many obese patients think that their desire for food (to them unmotivated) is due to compulsive eating, while all the time it is merely a greater need for food. The only way to find out is to treat such patients. Those that suffer from real compulsive eating continue to have such attacks, while those who are not compulsive eaters never get an attack during treatment.
Reluctance to Lose Weight
Some patients are deeply attached to their fat and cannot bear the thought of losing it. If they are intelligent, popular and successful in spite of their handicap, this is a source of pride. Some fat girls look upon their condition as a safeguard against erotic involvements, of which they are afraid. They work out a pattern of life in which their obesity plays a determining role and then become reluctant to upset this pattern and face a new kind of life which will be entirely different after their figure has become normal and often very attractive. They fear that people will like them - or be jealous - on account of their figure rather than be attracted by their intelligence or character only. Some have a feeling that reducing means giving up an almost cherished and intimate part of them. In many of these cases psychotherapy can be helpful, as it enables these patients to sec the whole situation in the full light of consciousness. An affectionate attachment to abnormal fat is usually seen in patients who became obese in childhood, but this is not necessarily so.
In all other cases the best psychotherapy can do in the usual treatment of obesity is to render the burden of hunger and never-ending dietary restrictions slightly more tolerable. Patients who have successfully established an erotic transfer to their psychiatrist are often better able to bear their suffering as a secret labor of love.
There are thus a large number of ways in which obesity can be initiated, though the disorder itself is always due to the same mechanism, an inadequacy of the diencephalic fat-center and the laying down of abnormally fixed fat deposits in abnormal places. This means that once obesity has become established, it can no more be cured by eliminating those factors which brought it on than a fire can be extinguished by removing the cause of the conflagration. Thus a discussion of the various ways in which obesity can become established is useful from a preventative point of view, but it has no bearing on the treatment of the established condition. The elimination of factors which are clearly hastening the course of the disorder may slow down its progress or even halt it, but they can never correct it.
Not by Weight Alone
Weight alone is not a satisfactory criterion by which to judge whether a person is suffering from the disorder we call obesity or not. Every physician is familiar with the sylphlike lady who enters the consulting room and declares emphatically that she is getting horribly fat and wishes to reduce. Many an honest and sympathetic physician at once concludes that he is dealing with a “nut.” If he is busy he will give her short shrift, but if he has time he will weigh her and show her tables to prove that she is actually underweight.
I have never yet seen or heard of such a lady being convinced by either procedure. The reason is that in my experience the lady is nearly always right and the doctor wrong. When such a patient is carefully examined one finds many signs of potential obesity, which is just about to become manifest as overweight. The patient distinctly feels that something is wrong with her, that a subtle change is taking place in her body, and this alarms her.
There are a number of signs and symptoms which are characteristic of obesity. In manifest obesity many and often all these signs and symptoms are present. In latent or just beginning cases some are always found, and it should be a rule that if two or more of the bodily signs are present, the case must be regarded as one that needs immediate help.
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