Psychoanalytic treatment of the obese person. Part III.
This paper is an attempt to clarify some of the issues which face the psychiatrist in his efforts at treating the obese patient through analytic means. A thoroughgoing bias in Western culture impairs the psychiatric and non-psychiatric medical care of the obese person. Inconclusive evidence concerning the causal relation between obesity and chronic disease does not deter this cultural bias from exaggerating the role that obesity is thought to play in disease process. Whatever contribution it makes to physical illness, obesity remains a substantial social disability that is frequently associated with self-hate and feelings of ineffectiveness. Scientific investigations indicate that adiposity is determined by interactions of genetic and environmental influences acting at different levels of complexity within the organism. Hence, the adipocyte itself may influence existing fatness and retard weight reduction. Constitutional factors affecting the hypothalamus may contribute to obesity in certain individuals. Also, cortical effects determine maladaptive eating behavior and excessive adiposity. Poor eating habits which are associated with emotional conflict seem to strongly affect the development and continuance of obesity in most fat persons. The interaction among adipocyte, hypothalamus, and cerebral cortex remains unclear. The various treatments of obesity have been shown to be of little impact in helping overweight persons to sustain weight loss. Diet control, exercise, group psychotherapy, and behavior modification show slight benefit. Recent controlled studies dispute earlier claims that behavior modification is effective in achieving meaningful and lasting weight loss. Claims that intestinal bypass procedures are a useful treatment also require further supporting evidence. Psychoanalytic or intensive sustained psychotherapeutic treatment of the obese person emphasizes exploration of the entire personality. As long-neglected constructive forces are stregthened, weight loss may proceed. Psychoanalytic treatment is not indicated for obesity uncomplicated by neurotic distortions. In the presence of interpersonal problems and personal ineffectiveness, psychoanalysis has real utility. It is not clear that obesity is a major determinant of impaired physical or emotional health. Rather, the medical indictment of obesity seems to stem from the need to justify an intensely negative cultural bias. Casual disregard of this fact and of the complexity involving issues of etiology and treatment may signify inadequate appreciation in the psychoanalyst of the extent to which he participates in this cultural bias. The continuing failure of medical science to devise a means to help fat persons sustain weight loss to any meaningful degree has prevented the development of studies which would show if weight reduction truly does provide uniformly enhanced physical and emotional well-being...