Karme, L. (1985). Obesity. J. Amer. Psychoanal. Assn., 33S:162-165.

(1985). Journal of the American Psychoanalytic Association, 33S:162-165 Obesity Review by: Laila Karme, M.D. Edited by Albert J. Stunkard. Philadelphia: Saunders, 1980, 470 pp., $28.00. Obesity is a complex medical and psychosocial phenomenon. There is an abundance of empirical observations, new findings, and a growing number of theories on the subject. Many specialists in research or clinical practices may not be fully aware of important work in related fields. Dr. Stunkard, a recognized authority on the subject of obesity, has attempted to integrate these different areas, bringing together descriptions of the skills and attitudes of those working in the field. The first section, "Basic Mechanisms," explores the genetic, physiological, biochemical, pharmacological, and experimental psychological theories about obesity. This is an admirable attempt to present many current theories and controversies concerning them. This section is no light reading. It is technical and demands considerable effort from the reader. The second section is devoted to "Treatment" and examines the different treatment modalities available. This covers a wide range from a flow chart "algorithm," which is ahelpful practical tool to both physician and patient, to chapters on diet, physical activity, drugs, surgical procedures, self-help groups, social environment, behavior modification, and psychoanalysis and psychotherapy. There are also chapters on obstetrical problems in obese patients and on obesity in childhood. Of special interest is a chapter on behavior modification, which provides a summary of the current status of this modality of treatment. Unfortunately, the results are short-term, variable, and rather disappointingespecially in the area of maintenance of weight loss. Some of this chapter could be looked at with an added dynamic perspective, - 162 but the author makes no attempt to integrate behavioral concepts and dynamic ones. There is a passing reference to the evidence that characteristics of the therapist have important effects on treatment outcome and that the therapeutic relationship is important. In discussing the violation of post-treatment adherence to a program for control of weight gain, the author states, It may not be the violations per se that will determine subsequent behavior but the meaning [italics added] that the person attaches to them (p. 338). The author underscores the importance of

a heightened sense of self-efficacy based on one's attributing behavior change and weight loss to one's own effort (p. 239) but does not address how this can best be accomplished. On the issue of noncompliance, the author states categorically, Noncompliance is far from inevitably purposive as the psychodynamicists would have us believe. Direct training and rehearsal of assignment during treatment is indicated (p. 340). Here is an outright negation of unconscious motivation, meanings, and defenses. Paradoxically, at the end of the chapter, the author, apparently unaware of the implications, states, Continued noncompliance should lead the therapist to evaluate the nature of his or her therapeutic relationship with the client it is recommended that the therapist encourage subjective feedback about the client's feelings and expectations elements of the therapeutic relationship such as the person's trust in the physician (therapist) can significantly influence compliance (p. 341). The next chapter, on self-help groups, reflects the recent development of this movement. These groups can be of some benefit, especially the ones utilizing additional behavioral techniques. The most highly valued elements of such programs are social monitoring and peer help. I approached the chapter on "Psychoanalysis and Psychotherapy" with hopeful expectation and heightened interest. The main body of the chapter is devoted to describing a study (first published in 1977) by 72 psychoanalysts who collected data on 84 obese and 64 matched nonobese patients over a period of four years. Weight losses at the time of the first survey (after a mean 42 months of psychoanalytic treatment) compared favorably with those after traditional medical efforts. At the time of the second survey18 months after the firstthe psychoanalytic patients lost much additional weight. The figures compared favorably with the best weight losses reported in behavior therapy programs and even more favorably with reports of the maintenance of weight loss in behavior therapy. The third surveyfour years after the first questionnaireadded support for the - 163 efficacy of long-term maintenance (a weakness in behavior therapy programs). A related phenomenon: bdy image disparagement, a chronic intractable disorder, strongly resistant to change and little affected by weight reduction, was largely improved by psychoanalysis. The reduction in the number of patients with severe body disparagement from 40 percent to 14 percent was impressive. The accuracy and validity of the survey were substantiated. Unfortunately no new perspective was added to the analysis of the data since the first publication of this important and interesting work. There is no attempt to utilize

psychoanalytic knowledge or dynamic understanding to explain such impressive results, just the understatement, It is tempting to speculate that improving their personal functioning helped patients to better control their eating, or that those who had eaten in response to feelings of anxiety or depression learned to tolerate or avoid these feelings without overeating. We do not know (p. 358). The favorable results of this survey prompted Dr. Stunkard to present clinical considerations about psychotherapy, indications for it, and recommendations on its conduct. It is here that I was mostly disappointed and in disagreement with some of his statements. Disparagement of body image is his first indication for psychotherapy, which provides the greatest evidence of efficacy. I agree with this. For bulimia (bingeeating) which is found in fewer than 5 percent of obese persons, Dr. Stunkard recommends that all patients should first receive a therapeutic trial with phenytoin (dilantin); only if this trial proves ineffective, would psychotherapy be indicated. Dr. Stunkard's third indication is: "if all else fails and other signs are favorable, a therapeutic trial for the purpose of weight reduction" might be considered. Some of Dr. Stunkard's assertions about the conduct of psychotherapy are surprising and paradoxical to the results of the quoted study. For example, he cautions against explorations of the psychodynamics of obese persons, There is little value in searching for unconscious causes of overeating except possibly in the rare instances of bulimia. Preoccupation with unconscious causes or meanings of overeating is more likely, in fact, to lead to the inordinate regression which is a major danger of treatment (pp. 364-365). He recommends that efforts be made to isolate the most important of the patient's problems. Considerable help in this endeavor is provided by careful attention to fluctuations in the patient's body weight, and it seems advisable to have the patient keep careful weight records [and] careful records of episodes of eating and the associated events and - 164 feelings, as introduced by behavior therapists (p. 365). He also considers a program of assertive training and newer cognitive approaches as useful adjuncts. Of course this is not the way psychoanalysts conduct analysis or dynamic psychotherapy. Dr. Stunkard's caution against dynamic exploration is antithetical to such treatment modalities and is contrary to my own experience with obese patients. Exploration of the obese patient's dynamics are crucial in eliciting the defensive aspects of maintaining obesity, for example fear of close relationships or sex. Such exploration alleviates or prevents what has been described by Stunkard and Rust as "dieting depression." It also lessens the emotional disturbance reflected in body image disparagementa phenomenon which does not improve by weight loss alone.

Exploration is helpful in understanding the stress-related syndromes, for example bingeeating and night-eating, in improving ways of coping with stress, and in improving functioning in general. This is of course in addition to understanding the ersonality, its adaptive and defensive functioning in an integrated way. Despite this, the book is an excellent work for stimulating interest in a topic that is of central concern to all of us and remains not well understood. It provides a great deal of information and is a comprehensive reference text. It is best read by the general practitioner, the internist, the psychiatrist whose practice is hospital or liaison in nature, or anyone interested in obesity. It is useful for psychoanalysis as a stimulus to psychoanalytic contributions to the important subject of obesity.

Article Citation [Who Cited This?]

Karme, L. (1985). Obesity. J. Amer. Psychoanal. Assn., 33S:162-165