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About a Particular Type of Oral Perversion in

the Female: Hyperphagia Followed by Vomiting

Otto Doerr-Zegers
(Accepted 27 August 1993)

We present a case (from a series) of a young woman suffering from a particular abnormality in her behavior with regards to food: She ingests large quantities of food to
immediately vomit it. This behavior becomes progressively the central activity and
concern of the patients. Both the desire of eating food and of vomiting it are imperious,
but they are not experienced as foreign to the self, are considered as an irresistible
temptation. Among the secondary symptoms we find pertinacious constipation and
dysthymic states each time more intense andprolonged. (2) The clinical picture evolves
toward a narrowing of existence and a greater limitation of social and work abilities. (3)
A phenomenological analysis of the major symptom is attempted, in order to establish
essential differences with regards to hysteric, obsessive, and delusional phenomena. A
special place is granted to the differential diagnosis with regards to anorexia nervosa
and psychogenic obesity. (4) The clinical picture presented by these patients is considered as constituting an independent syndrome. This syndrome can be subordinated
to the broader group of addictions. 0 1994 by John Wiley & Sons, Inc.

The excessive ingestion of food, outside obesity, is well known as an equivalent of


anguish, even among normal people. Lopez-Ibor (1966) cites a patient of Von Bergmann
who, during certain depressive crises, ate immeasurably without satiation. Crises of
bulimia are frequently observed in anxiety neuroses. Vomiting, as a symptom of hysterical conversion, is even more frequent than crises of bulimia as a way of manifesting
a neurotic conflict. The psychoanalytic theory interprets both bulimia and vomiting
according to its well-known pan-sexualism: Excessive hunger occupies the place of a

Otto Doerr-Zegers, M.D., is Professor of Psychiatry, School of Medicine, University of Chile, and Head of the
Clinical Ward A, Psychiatric Hospital, Santiago, Chile. Address reprint requests to Dr. Otto Doerr-Zegers, Av.
Luis Thayer Ojeda 0115, Santiago, Chile.
This paper was originally published in 1972 in the Revista Chilena de Neuropsiquiatria, ISSN: 00347388, Official Journal of the Chilean Society of Neurology, Psychiatry and Neurosurgery (Rev. Chil. Neuropsiquiat. 11:27-41, 1972).
The translation from Spanish into English was made by Jorge Silva-Perez, Ph.D. (+), Santiago de Chile.

lnternationallournal of Eating Disorders, Vol. 16, No. 2, 117-132 (1994)


0 1994 by John Wiley % Sons, Inc.

ccc 0271j--3478/9410201 I 7-1 6

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sexual desire, whereas vomiting represents a resistance to the wishes of pregnancy and
to the fantasies of incorporation (Fenichel, 1966).
Both symptoms intertwined in a particular way, that is to say: crises of excessive
ingestion followed by vomiting as a permanent and prolonged pattern of behavior, seem
to defy a conceptualization as mere symptoms with their corresponding psychodynamic
meanings. Therefore, the analysis of these symptoms must be carried out by understanding them in a broader perspective and by considering the relation of the patient
with food within the wholeness of the ego-world context.
We have only found such pathological behavior described as a particular moment in
the course of anorexia nervosa (Bruch, 1965; Doerr-Zegers, Petrasic, & Morales, 1971).In
the literature reviewed, we did not find references to this behavior as a syndrome, that
is to say as a set of symptoms related to each another in a necessary way, and not
attributable to any of the known nosological entities from the ethiopathogenic point of
view.
We shall proceed, first, to describe one of our cases; then to make a psychopathological differential analysis of the syndrome which aims to demonstrate its independence
from neuroses and psychoses; finally, a phenomenological approach will be attempted
in order to allow an understanding of the structure of its form of manifestation, and of
the legalities ruling its pathogenic process.

Case Vignette
Angelica G. F., 26 years old, single, the elder of two sisters; the father, a doctor and
an industrial entrepreneur; the mother a pleasant housewife; herself after several interruptions has managed to finish a university career. The first thing that draws our
attention is the care that she has given to her personal presentation, the excessive eye
make-up, and the fact that she looks younger than 20 years when shes actually 26 and
already graduated. Her weight as well as her nutritional status appears normal. She
explains the reason for consultation in a grammatically correct language, rich in vocabulary, precise but without saving details when she thinks them necessary in order to
permit her interlocutor a better understanding: I come because I want to liberate myself
from a terrible impulse towards eating that dominates my whole life. Nothing has any
interest anymore for me except eating, the vomiting that follows eating and the innumerable diets that I try to follow so that I dont become fat, because it would cause me
horror to be fat. When Im in the mood, I begin the day having seven or eight cups of
coffee with cream, bread with butter and jam, very many pies and pastries (ten to
twenty), and then, when Im absolutely full, I go to the bathroom and vomit. To vomit
I introduce my fingers down my throat, but sometimes it suffices me to brusquely
contract the muscles of my abdomen. Ive done this so many times that a callosity has
developed in the forefinger of my right hand, as a product of the friction of the finger
with the teeth during the act of provoking the vomit. A short while after having vomited
breakfast, I continue with the things that theyre preparing for lunch in the kitchen; I eat
everything that I find: soups, spaghetti, beans, more bread, cheese, etc. If I do not find
enough food at home, I call or personally go to the neighbouring Oriente Store, and
buy a lot of prepared dishes and pastries. I have thus spent millions of my fathers pesos.
Thank God, he can afford it. The process is always the same: when Ive eaten and eaten,
and just cant eat anything else, and my abdomen feels very heavy, I go to the bathroom,
and induce a vomit. I look at myself in the mirror, I see myself disjointed, this makes me

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angry, and I begin eating again. If I dont have anything important to do, this process
continues-interrupted only by the hours of sleep-until Im exhausted; exhaustion
comes after three days, and the way of breaking the circle is to take diuretics and lay
down to sleep. When I wake up, I feel a little lighter and less swollen-this is the effect
of the diuretic-and this makes me feel somewhat better, and I decide to follow a very
strict diet, but this decision lasts only two or three days, because theres always some
disagreeable situation that makes me fall (or that I put the blame on), and everything
begins again. I have been suffering under this condition from ten years ago, with only
three interruptions of one month each, one as a consequence of a trip, and the others
because of two physical illnesses.
The patient has not had menstrual alterations, but does have a protracted constipation
that can be traced from the beginning of her crises of voracity. The quantity of laxatives
she took was such that the doctors attributed the jaundice she had in 1971 to them. From
that day on, she takes two spoonfuls of glycerine every day, and if they are not enough,
she submits herself to intestinal enemas every other day. Other characteristics of the
patient that draw our attention with respect to her predominant symptom are the following: she always eats alone; since the beginning of her disease she doesnt remember
having sit at the table with her relatives except when she goes to some party or she is
invited to a restaurant, but in these cases she doesnt eat anything. The impulse toward
eating is exacerbated during the nights, while others sleep. During the periods of binge
eating, shes careless of her personal appearance, and she loses interest in everything.
In the periods of dieting, in turn, she devotes herself to gymnastics, she is active in
moving herself from one place to another, and her perfectionist tendencies are renewed.
She attempts to be perfect in every context: her wardrobe, the objects in her room, her
studying before and nowadays her work; but, above all, she aspires to perfection of her
body: hence, the gymnastics and the make-up. One of the causes of her frequent relapses is also found here: She is never satisfied with her body; she finds herself disproportioned, her trunk is too broad and her legs are too thin. Her major concern, perhaps,
may not be to become fat; rather, it is a search of correspondence between her thin legs
and the superior part of her body that she considers thick. This is the reason why,
besides everything she does in order to not become fat (vomiting, gymnastics, diets), she
also does every possible thing to fatten her legs, specifically the calves.

Family History
The father is currently 60 years old, a medical doctor, although for years his practice
has been only partial, because he devotes most of his time to industrial activities, because medicine did not manage to satisfy all of his capacities. He is a dynamic, vital,
intelligent, and kind man, interested in his family affairs, but very demanding especially
with Angelica. She had to be number one in everything, and it was this way until she
finished high school. When his daughters were small, he developed an intense extramarital sex life. The mother trusted her grief to Angelica, leaving her with the rage,
whereas the mother reconciled herself with the father. Nowadays the relationship of the
parents is more like that of a brother and a sister than that of a husband and a wife.
Angelica says, If I ever get married, I would not like my marriage to be that way.
The mother is also 60 years old; she is a lawyer, but, since she got married, she gave
up the possibility of working outside the home, and she had dedicated herself to be a
mother loo%. Shes a homely woman, abnegated, she washes and irons the clothes,
but her principal activity is in the kitchen. For her, there isnt anything as important as

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buying and preparing food. Her great passion are supermarkets. Shes neat, responsible, and has a good character. Her only defect is perhaps that she sacrifices too much
for the sake of others. She looks after Angelica as though she were a baby in her period
of lactation.
The sister is 25 years old, married, with three children; Shes a teacher and is also very
independent, self-assured, and laborious. She has always been very thin and has a
beautiful body. Given the personality traits of the sister, Angelica has always felt as the
smaller one. The sister was much freer than Angelica with respect to the strict norms of
behavior that the parents imposed.
Personal History

Birth, lactation, and psychomotor development, all normal. Until she entered grammar school, she didnt show any trait of abnormality in her behavior or in her way of
being. From the first day of school, she was the best pupil in her class. At that age, it
drew her parents attention that she had a great appetite, compared with that of her
sister, which always made her fatter than her sister. She was very passive and dependent on the mother. She was fearful of the father because of his demands, although,
while at school, she satisfied them fully. Until her puberty, she was friendly and played
normally in groups. She was, however, excessively obedient and submissive-the opposite of her sister. Together with the arrival of puberty and the beginning of the natural
concern of girls for boys, she began to isolate herself, to compare herself with her sister,
and to consider herself ugly and fat. Her menstruations were normal. In her last school
years, she seems to have had occasional crises of hyperphagia and vomiting, but this
behavior only became permanent when she attended the university. At the time, she
was very undecisive. Her father forced her to study one career, although she liked
another better. She interrupted her studies several times because of the impossibility to
comply with the university demands, given her strange habit that turned her almost into
an invalid. The parents have shown during this time all the range of attitudes towards
Angelica, from the greatest understanding to insults, all without success. Several psychiatric treatments have not produced results either, including a behavioral treatment
led by a psychologist. Nobody, except the parents, the sister, and the specialists, knows
what the problem is. Her sentimental life has been scarce. She has had only two boyfriends, one at the age of 17 years and the other 1 year ago. The first one turned out to
be homosexual, and the second was also a very sensitive and delicate man, probably
homosexual, whom she left as soon as he proposed marriage.
One year ago, after the jaundice, she made a great effort, and did all the delayed
exams and the degree exam, doing well on them. This year, she has been working only
part-time; she doesnt have any contact with her colleagues, and her major concern
keeps on being food.
Note

The patient was subjected to a complementary treatment of behavioral and insight


psychotherapy in a psychiatric clinic. She gave up her abnormal behavior, and since
then and until now (1972) she hasnt had any crises of hyperphagia or vomiting. Nevertheless, shes constantly suffering because of the permanent state of apathy in which
she lives and because she regrets not having lived 10 years of her life, which makes

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it difficult to face her future as a woman alone and adult. She is afraid of not finding a
fiance and of remaining single.

SUMMARY OF THE PSYCHOPATHOLOGICAL, FAMILIAR, A N D


BIOGRAPHICAL FINDINGS (DESCRIPTION O F THE SYNDROME)
Lets summarize the psychopathological clinical picture that our patients present: The
major symptom is an irresistible desire to eat extreme quantities of food, without caring
for its quality, which is followed by self-induced vomiting. This abnormal behavior
toward food takes place within a particular psychological context: The desire to eat is
imperious, but is not experienced as something alien to the eg+-rather, its experienced
as a temptation. Vomiting, on the other hand, doesnt turn out to be a desire, but,
rather, a decision intended to avoid the consequences of excessive ingestion, that is
becoming fat. During hyperphagia, a feeling of insatiability persists, so that ingestion
only stops when its physically impossible to keep on introducing food into the body, or
when an external factor, such as being caught in the act, interrupts it. Both hyperphagia
and vomiting are performed secretly, procuring that nobody gets to know. It is only after
a few years that the relatives themselves come to realize this perverse habit. Because
hyperphagia doesnt achieve satisfaction of the voracious appetite, and the self-induced
vomiting exhausts the patients, although it makes them feel partial relief by getting rid
of the excess burden, they may look for marks of the effort of vomiting when they look
at themselves in the mirror, so that they end up feeling greater frustration than before
eating. This pushes them to begin the cycle all over again.
As additional symptoms we found persistent, constipation that installs itself along
with the abnormal habit and the apparition of states of dysthymia more intense and
frequent each time.
As a consequence of what has been described, a progressive lack of interest develops,
with isolation, laboral instability, and a feeling of existential emptiness, which trigger, in
turn, new crises.
When it comes to family structure, what we first observe is the strong personality of
the father, who is described in all cases as excessively manly and erotized, ambitious,
laborious, and very demanding, especially to the daughter that becomes ill, who is his
favorite, but for whom he has very high expectations. The mother is described as a
capable woman, but faced with the fathers personality, has reduced herself to an obscure and passive role. She complies acutely with her labors as a housewife and as
guardian of the children, and her only distraction seems to be food: She enjoys going out
to buy food, preparing dishes, and eating them. In all the cases examined the mother has
presented an excess of body weight, about which she doesnt care, although the daughter that becomes ill does. Among the brothers and sisters, it is outstanding to note the
role of a sister who is more independent, more beautiful, and more balanced than the
patient, for whom the patient experiences strong feelings of envy and rivalry.
With respect to the biographies and personalities of our patients, it is important to
single out our certain significant analogies: In neither of the cases are abnormalities of
character or behavior observed during the first 6 years of their lives. Beginning with
entrance into school and until their puberty, they show themselves as sociable, friendly,
intelligent, with very good academic performance, whereas at home they are somewhat
stubborn. During this period, all of them present a certain abnormality in their feeding
pattern: Angelica and Gloria are excessive eaters and they come of age with excess of

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body weight, whereas Carmen has difficulties in feeding herself and her thinness is
evident. But in all the patients the relationship with food is a central concern for the
mother. The beginning of puberty is accompanied by an important change in the patients personalities: From sociable and friendly, they turn into shy, isolated beings, who
avoid ties of friendship and social gatherings. They develop, instead, a sort of friendship
with the mother, for whom they become a comforter and a counsellor. Yet, this
relationship is not exempt of tensions. The mother, realizing the daughters greater
passivity and less stubborness, redoubles her influence based on rigid moral and religious principles, from which sexuality is totally excluded. But, at the same time, the
mother tries to impose more active socializing, to which the patients resist.
Our patients affective life is characterized by superficial, intellectualized relationships, which are full of fear of anything sexual. They showed only occasional and/or
ephemeral relationships and they ascribe this failure to the fact of feeling intellectually
superior to the boyfriend.
In none of the cases that we have examined can one properly speak of trigger situations-although we observe that in all the patients the pathological behavior begins soon
after they finish high school along with diverse failures in university studies or changes
in work activities that are not in keeping with the patients high intellectual level. It
seems that they have been unable to resist the degree of freedom and maturity that
university studies or working demand, in opposition to high school experience. If we
observe the biographical line in its totality, we shall find this impression confirmed,
because character or behavior abnormalities appear in a progressive manner at the rate
that the different stages of maturation occur.

CLINIC-PSYCHOPATHOLOGICAL ANALYSIS (DELIMITATION OF


THE SYNDROME)
As we suggested earlier, the reason for this work, which springs from the clinic and
psychotherapeutic experience with the forenamed patients, is the wish to describe and
eventually understand this behavior of eating and vomiting not as an isolated symptom,
but as a whole structured in a necessary way. In other words, we shall try to demonstrate all the way through our analysis that the crises of hyperphagia and of self-induced
vomiting are not in a relation of contiguity, but they represent essential parts of only one
phenomenon, which occurs in a characteristic constellation that includes everything,
from the additional symptoms to the previous personality and the family structure.
Both vomiting and the crises of hyperphagia, individually considered, are nonspecific
symptoms. The first one is found in vomiting children, in anorexia nervosa, in the
so-called chronic anorexias (Meyer, 1961), in hysteria, as a typical symptom of conversion, and in hemicranias, to limit ourselves to the psychiatric field. And in each of these
cases, the same symptom, vomiting, belongs to a completely different phenomenological and pathogenic context. The same occurs with crises of hyperphagia or bulimia. We
find them as a normal phenomenon among adolescents, in that period in which the
being struggles to achieve a bodily and sexual identity, and lacks tolerance to frustration;
we also find them among adults in situations of stress, as a direct compensation of
anguish; they present themselves as an almost necessary symptom in the different types
of psychogenic obesity, but curiously, they are also present in its counterpart: anorexia
nervosa; and, finally, who has not seen truly insuperable excesses of feeding in frontal
syndromes or in a manic episode of a manic-depressive illness? And what a different

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world that of a manic phase than that of anorexia nervosa! Both symptoms truly associated are present only as a cultural form in decaying societies, as is told of the last days
of the Roman Empire, or as an occasional phenomenon in adolescents obsessed to keep
their bodies in shape since the fashion of thinness began. But we had not yet seen in
every-day practice cases in which hyperphagia followed by vomiting were a regular and
progressive behavior. We have found something similar (but in no way with the persistence and dramatism described by our patients) in the pre- and post-anorexic periods
of anorexia nervosa. About the relationships between both syndromes we shall refer to
later.
Nevertheless, many are the elements that would speak in favor of an interpretation of
our patients' vomiting as a symptom of conversion. When psychoanalytic authors define
the mechanism of conversion as "alterations in physiological functions that unconsciously and in a distorted way serve as expression of instinctive impulses previously
refrained" (Fenichel, 1966), the words of another case come to our minds (Carmen
V. N.), when she says, "I think I began eating and vomiting to give myself a pleasure,
pleasure that others find in going to parties, in socializing, in having friends . . . ," and
afterward, when she adds, "I wish I could love men to craziness, sow love, breathe love,
but the wishes remain very well kept, fearful of expression, as something too bold." It
is evident that in all our cases, the abnormal behavior appears as a substitute for another,
more elaborate set of behaviors that, for some reason, have been curtained and/or have
not reached the necessary development, and in that sense it follows the general dynamics of conversion symptoms. The same is true for bulimia individually considered. But
there are two elements that make their typification as conversion symptoms insufficient.
First, both of them appear together, in a different "gestalt" than that of each of them in
particular. So much that their dynamic significance is opposed because in one there is
substitutive realization of a "desire of incorporation" and in the other one rejection of
the same desires. The interpretation of both opposite acts together, would require then,
at least, of a higher symbolic level, of a second order, or a sort of "meta-interpretation."
But, on the other hand, a clinical argument can be offered against the conceptualization
of this behavior as hysterical conversion: the form of its course. Every psychogenic
symptom and/or every conversion symptom occur in a defined biographical context,
where, besides the unconscious conflict, we find a precise situation that triggers the
symptom reactivating the underlying conflict. The symptom somehow plays a strategic
role in overcoming that triggering biographical situation (gain from illness in hysteric).
This is so true that in the majority of the cases a formal psychotherapeutic approach is
not even necessary to make the symptom disappear; it seems to be enough to modify the
structure of the traumatic situation to obtain the same goal. What happens in our cases
is very different. In these, if there was any traumatic stimulus, it lost all its force before
the processal and autonomous way in which the syndrome of hyperphagia followed by
vomiting evolves through the years.
It's more difficult to clearly differentiate the phenomenon to which we refer, from
obsessive symptoms. Without going too far, one of our cases was diagnosed at the
Psychiatric Clinic of the University of Chile as an obsessive-compulsive neurosis. If we
remember the words of our patients, we shall find a series of assertions that remind us
of the obsessive world. Angelica says, "I come because I want to liberate myself from a
terrible impulse towards eating that dominates my whole life." Another one is still more
explicit with respect to this compulsive character of the symptom: "The terrible thing is
being aware that it's all absurd, and yet to relapse again and again in this . . . I try to
avoid eating in excess, and all of the sudden I find myself doing precisely what I am

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trying to avoid. It seems that its the same fear that I have towards these desires (to eat)
which makes me think of them when I least imagine. Its as though my mental state were
always expectant, as though waiting . . . and, when these horrible temptations appear,
I transform myself into a dumb idiot, it seems Im not myself, as though I was at the
entire disposition of this obsession. Carmen is also very illustrative about this: In my
mind, the supreme thought was to not become fat, yet the wish to eat was irresistible,
and the more I ate, the more I vomited, without finding an end to this vicious circle.
In addition, the impulse of our patients toward eating-with which the circle beginsappears undoubtedly with a clear egodystonic character. They feel dominated,
slaves, and at times they speak of fear and of an effort or struggle against the desire.
Nevertheless, we could not speak of a real egodystonia, such as the one seen in obsessive-compulsive phenomena. It is true that they judge the impulse toward eating as
absurd (and at times also the secondary vomiting) but it is a posteriori, to the same
extent that the feelings of fear, of which Gloria speaks, are previous to facing the
desire. But when it emerges from the feared depth, then there is neither rejection nor
feelings of absurdity, but a passionate giving oneself away to the ecstasy of eating.
Carmen says in this respect: At mealtimes, I used to eat very poorly, but between meals
there came the revenge, and what counted, then, was not the quality but the quantity
of food. It was the very act of eating that fascinated me. Another patient, Gloria Y . ,
does not reject eating for eatings sake, in such a way that she has her own hours in
which she commits herself to eating with more delight, such as the hours of the night.
And within this predominance of quantity over quality of food, she prefers eating cheese
above all things. And Angelica confesses: Nothing has any interest for me anymore
except eating . . . If I dont find enough food at home, I go to a store and I buy a lot of
take out food and pastries . . . etc.
It is clear, then, that the ego identifies itself to a great extent with this impulse,
although when the moment of passion has passed they are able to judge it as absurd.
What is proper of the obsessive phenomenon, that is, the brisk eruption into consciousness of a thought or an impulse, feared and strange, that immediately produces anguish,
is not found in our cases. In them the relation with the impulse is uncertain: It is
simultaneously accepted and rejected, although they end up yielding to it. Thus, Gloria
thinks: Its no longer a matter of will-power, because anyhow, I always end up doing
that which I try to avoid.
And if we cannot ascribe the crises of bulimia to obsession, so much the less could we
ascribe the vomiting to obsession, because it requires participation of the will in an even
greater extent than hyperphagia.
Vomiting emerges progressively into consciousness as an aspiration, each time stronger, as the patient yields to her voracious appetite: I eat till the order to stop comes and
Im already willing to vomit. I vomit to get rid of that excess of food. It produces relief
in me . . . Carmen manifests.
The other possible relationship between our cases and obsessive-compulsiveneurosis
is found in the persistence of the idea of not becoming fat. In all of our patients, this is
one of the central themes of their lives, which is closely related with both the crises of
hyperphagia and vomiting, with esthetic concerns, with difficulties in establishing erotic
relationships, etc. For Binswanger (1957) this fear of becoming fat may be the concrete
expression of a profound existential anguish, of a fear of decadence, withering, putrefaction, where the world of the self transforms itself into a tomb, a well. To this order
belongs the terror of accumulating fat and becoming mere matter. But in our patients,
the struggle against this loss of body shape is established in a direct, immediate, and

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conscious way, contrary to what happens in authentic phobias, where what is really
feared is unknown and is substituted by the symptom.
Janet (1919) described a case of hyperphagia and permanent concern about not becoming fat, but without vomiting (the Nadia case), which he defined as the obsession
of shame of the body, because, besides the mentioned symptoms, Nadia felt ugly and
ridiculous, with her face swollen, her skin blotted, and her legs disproportionate. For the
same reason stated before, we think Nadias phenomenon does not, either, correspond
exactly to an obsession, but it seems an interesting fact to use that in the only similar case
described in the literature, something very characteristic to all our patients appears as a
central trait: not being satisfied with their bodies, feeling them disproportionate, ugly,
etc. And thus as hyperphagia presents itself in one only act with its opposite, vomiting,
in only one act, the fear of becoming fat is not a simple desire of being thin and in
fashion, but it really appears intertwined with this idea of disproportion, of ugliness,
which at times takes the form of a feeling of shame.
But the last element referred to in relation to Janets case Nadia faces us with the
problem of differential diagnosis with respect to delusion. Because, if faced with an
uncontrollable impulse toward eating, we found the dual condition of acceptance and
rejection, of judging and subjection, that made us dispute the existence of the obsessive
mechanism, with the idea of a disproportionate body we approach something experienced by the patients in a clearly egosyntonic manner, and, in that sense, close to
delusion. The lack of incorrigibility (Jaspers, 1959) and the fact of it being coherently
articulated in the wholeness of its ego-world relationship and in the biography make a
primary delusional origin of this idea improbable. Lets not forget that Angelica, ever
since she entered school, became an excessive eater, and reached puberty with the
concern for excess of body weight, and that the same happened to Carmen. Gloria,
instead, had the opposite problem, that of being excessively thin and rarely an eater, and
that of having the mother supervising all the food she ate. In other words, in the three
of them there are sufficient biographical elements to transform body and food into an
outstanding theme with puberty. In addition, in two cases of our series there is a rival
sister without problems of body weight and with a perfect shape, with whom the
patients compare themselves, and with whom they are compared by other family members.
Could we speak then of an overvalued idea in the sense of Wernicke (1906) insofar
as the idea essentially determines the way these patients feel in themselves and the way
they behave, never being judged in any case as foreign to the ego? No. Because there is
a fundamental difference between the phenomenon in discussion and the classic symptom of the overvalued idea, given that in the first case the patients dont see in this idea
the most important thing in their lives, and consequently they dont struggle for it but
rather, they suffer from it.
At last, it would be necessary to refer to the hypochondriac syndrome that is observed
in some forms of schizophrenia, especially in the pseudoneurotic. These patients frequently refer to their bodies in a very similar way as the ones we are discussing here, but
with an important difference: The hypocondriac ideas of the also called cenesthetic
schizophrenic have a much more bizarre character, they are plagued with anatomical
details, and they easily allow seeing their origin in depersonalization. In our patients,
instead, it is not the loss of the ego-character of some organ or function, but the lack
of perfection, of an ideal gestalt to which the whole being aspires with passion; in other
words, its almost the opposite of depersonalization, in which theres no place for
projects or ways because the ego is dissociated.

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The analysis of the more important psychopathological elements of this syndrome and
their delimitation with respect to hysteric, obsessive, phobic, and schizophrenic symptoms is valid, too, as a differential diagnosis of the syndrome with respect to the nosological entities that show these symptoms. Because of limited space, we shall not extend
the clinical-differentia1 analysis to other aspects such as the previous personality, the
family structure, and the course. It is necessary to say that in the same way we found
essential differences in the described symptoms, we have also found them in other
elements of the syndrome, which reinforces our idea that this clinical picture represents
an independent syndrome.
If we are not dealing with an organic symptom nor with one of the four major
symptomatological structures (hysteric, phobic-obsessive, schizophrenic, or depressive), how could we typify this behavior and this experience? If we recall the summary
of the clinical picture detailed above, we shall see that, fundamentally, it deals here with
a two-faced act (hyperphagia and vomiting) repeating itself indefinitely. It emerges as an
imperious desire in an unpleasant situation. The patient yields to it as though yielding
to a temptation, in the pursuit of ecstasy, of drunkenness, but as the eating progresses,
far from achieving the longed-for happiness or plenitude, she finds herself with the
terror of what she has incorporated (thaf she rationalizes as fear of becoming fat) to give
way to vomiting as a discharge, as a "step backwards." Once the act is finished, the
feeling is doubly unpleasant, because to the feeling that existed in the previous moment
of the act is added the exhaustion left by vomiting, plus the emptiness of having had to
immediately give up what was pursued with so much passion. This double frustration
is what is transformed into the motor of the new act in the same direction.
From a formal point of view, this corresponds exactly to what von Gebsattel (1954)
described as the "legality of vice" or addition (Sucht), which is valid both for alcoholics
and for drug abusers. We believe that von Gebsattel (1954) took a transcendental step
when he delimited this phenomenon with respect to the rest of the psychopathological
syndromes. In spite of all the attempts to ascribe these cases to neurosis, to psychopathies, and even to psychosis-as has happened with anorexia nervosa-still in classic
systematizations they maintained an isolated and not well-defined place. The nosological problem emerged not only from the particular combination of diverse symptoms,
which were never clearly identifiable with some of the neuroses or psychoses, but also
from the fact that their evolution was generally unfortunate, which made it easy to
confuse them with psychotic processes (according to Jaspers, 1959). It thus happened
that Binswanger (1957) diagnosed his Ellen West case as schizophrenia, which afterwards has been recognized by several authors as a typical example of anorexia nervosa.
Kraepelin himself was called to a medical meeting to examine Ellen West, and he diagnosed a manic-depressive psychosis (mentioned by Binswanger, 1957). The fact that
relevant figures of psychiatry were mistaken in such a way draws our attention to the
extreme complexity in certain cases of addiction, and to the imperious need-which was
lacking-of a phenomenological description in depth, a task that was achieved later by
von Gebsattel (1954). His analysis allows us to understand not only the polymorphism
of the symptomatology but also their preferent evolution toward a chronic state, given
the ever-growing existential emptiness that takes place. Haefner (1963) later defined the
differences between these processes, which he called "restrictive," and the schizophrenic ones, which he called "modificatory processes ."
Considering our cases as affected by a particular form of addiction, in which the
pursuit of compensation for what has not been "lived' is manifested through a perver-

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sion in the act of eating, we must now delimit this precise form of addiction from others
that are close to it such as obesity (Fettsucht) and anorexia nervosa (Magersucht).
With respect to the first, we could say that in it, hyperphagia has a less violent and
dramatic character, but at the same time it is more permanent. Vomiting is not a part of
the addictive behavior in obesity. The psychology and the interactional patterns of obese
children have been studied by Bruch and Touraine (1940) and show some analogies, but
also differences, with respect to what has been observed in our cases. But there are two
points we do not want to omit in this context. The first one is the following: The degree
of egosyntonia with respect to the desire is much greater among the obese than among
our hyperphagic patients, and in that sense the obese is closer to the alcoholic. Therefore, the obeses life is much less dramatic and less limited than in our cases. This has
to do necessarily with the structure of the addictive act itself, which in the obese one is
one-sided, whereas in the hyperphagia and vomiting syndrome is two-sided, that is to
say, it contains a contradiction in itself. The second point refers to body image. It is well
known that the obese perceive themselves thinner than what they really are, and they
always believe they have eaten less than what they have really eaten (exactly the opposite in both respects occurs in anorexia nervosa). In the syndrome we are describing,
instead, the alteration of the body image is not given in the sense of more or less
but of how. Our patients, just like the Nadia case of Janet (1919), perceive themselves
disproportionate, disharmonic, and this is the reason why they feel ashamed of their
bodies. In a session of group psychotherapy with three patients of our series (one of
them, Angelica) once they reached the subject of the root of their illness, all of them
agreed that it was not so much the search of a more or less thin figure, but rather of the
respective adjustment of some (disproportionate) parts of their bodies. And so, together with following diets to lose body weight, they exercised to become stronger in
some bodily parts. Perhaps we are facing here something like a structural law that will
allow us to understand this double and profoundly contradictory character of this perverse behavior, because harmony can be achieved both by fattening the more rickety
parts, as much as thinning the grosser and less delicate ones. It turns out that in each
perverse act they follow both courses, both possible acts that may lead them to a perfect
and proportionate shape. For example, they eat to make their legs thick and they vomit
to make their torsos thinner. In other words, the essential ambivalence that marks these
lives finds its expression even in the perception of their own bodies. And just as they
want to be wise and remain childish, they want to conquer all men but not anyone in
particular, they love and hate their mothers, they desire and reject their fathers, they
ingest and throw out food, thus also they experience themselves both as thin and fat
simultaneously.
The delimitation regarding anorexia nervosa is, however, not so clear. There are a
series of common elements both in the forms of presentation and in the intrafamiliar
dynamics: In both cases there is a narrowing of existence to the oral dimension, appearing in adolescence and having to do with the incapacity to assume an adult role; both
disorders appear almost only in women, and show somehow an evolution with processal character (in the sense of Jaspers, 1959). Besides this, periods of hyperphagia and
even of vomiting are observed in anorexia nervosa, especially at the early stages of the
beginning of the progressive thinning. Nevertheless, we have not observed the symptom of bulimia followed immediately by vomiting in anorexic cases. In these girls,
bulimia appears as an occasional runaway from their persistent fasting, and vomiting
as an aggressive answer to coercive measures directed to make them eat: family pres-

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sures, hospitalizations, feeding through a catheter, etc. In other words, each of these
acts happens in different and precise contexts. In this sense, we would need to acknowledge that the main symptom in both syndromes is not identical: The anorexic patient
enjoys fasting, now and then she falls into bulimia, and if shes forced to eat, she vomits.
The hyperphagic-vomiting patient enjoys and suffers in both moments, which always
happens closely together.
But also from the etiopathogenic perspective there are significative analogies: In both
types of cases, food plays a central role in the families. The parents in both groups show
a striking similarity. In our preceding work about the role of family and biography in the
pathogenesis of anorexia nervosa (Doerr-Zegers, Petrasic, & Morales, 1971), we described an enterprising, laborious, demanding, strongly erotized father, but whose relation to his wife is that of a brother. He thus coincides with the fathers of our hyperphagic patients. The mother, however, shows certain differences in her typology and
preferential forms of interaction. In the cases of anorexia nervosa, she is mostly an
omnipotent, rigid, moralist figure who, in her overprotection devours and makes somehow disappear the daughter who falls ill. This role is not necessarily fulfilled by the
mother; it may be the grandmother, as long as she lives in the home of the patient. In
this case the mother is a weak women, not mature enough, who engages her whole life
in a deaf struggle, bound for failure, with her respective mother. She also rivals with the
patient as though she were her sister. In hyperphagics, instead, mothers are submissive
to the father and they abandon their own interest and abilities in his honour, to dedicate
themselves to their children and the kitchen. Just like the first, though, they are also
moralists and are overprotective. The theme of rivalry with the polarly structured sister
is also found in both groups. Finally, it is a well-known fact, statistically demonstrated,
that women affected with anorexia nervosa have a quite above-average intelligence, and
we have found the same among our patients.
One could assert that the analogies outnumber the differences. But we cant speak of
identity, because the defining character of anorexia nervosa is stubborn fasting and
thinning under 75% of normal body weight, all of which dont happen among hyperphagics, who maintain a more or less normal body weight.
The problem of the relationship between both syndromes is complex, and its resolution will require in-depth comparative studies of a larger number of patients. We would
like to raise here certain questions or eventual leads to follow in future investigations.
If the crises of hyperphagia are observed in anorexic patients in the period previous to
the beginning of the illness properly speaking, that is to say, before the fasting and the
thinning, we could think that the syndrome described by us corresponds to an abortive
anorexia, given the similarities found in the biography and in the families of both
groups of patients. The question would be then: What is it that makes some of these
adolescents, who have reduced their lives to orality, able to take the step towards
fasting, taming, or dominating that strong impulse toward food, which is common to all
of them? We do not have a definite answer, but in our study on anorexic girls families
and their biographical legalities, our attention was drawn by the regularity in which
fasting and the loss of body weight followed a tragic circumstance that generally affected
the fathers (accident, serious ilIness, economic ruin), and that involves the patient decisively in their care; such a situation has not appeared in the group affected with the
hyperphagia and vomiting syndrome. It could be then that a circumstance of this kind,
given the already mentioned biographical and particular psychodynamic characteristics,
encourages anorectics to an act of sacrifice, of holocaust, that allows them both to
redeem the father from his wild sexual behavior and to keep themselves united to him,

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now without a body, deprived by means of cachexia of their feminine shapes. But this
is a mere hypothesis that requires further demonstration.
The other idea that we would like to state refers to the problem of body image
alteration, which seems to be in the root of these cases of oral perversion: the ideal of the
spiritualized body, as Binswanger (1957) described regarding the Ellen West case. This
is frequently the fundamental aspiration of anorexic girls and is given together with an
already demonstrated perturbation of body image, which leads them to perceive themselves always as fatter than what they are-in other words, they are not able to see their
cachexia. In the hyperphagia and vomiting syndrome, instead, the ideal is the perfect
proportion, and the alteration of body image consists of perceiving themselves as
disproportionate, certain segments as too thick and others as too thin.

PHENOMENOLOGICAL-ANTHROPOLOGICALASPECTS
If we abandon the clinical-psychopathological and etiopathogenic fields, and we analyze perversion starting from a broader conception of what is human, as a point of
departure well have to accept that what is here altered is the relationship of the subject
with food, or rather of the human body with what it requires for its individual maintenance. We can find something similar in sexual perversions, where the deviation occurs
in the relationship between the sexed body and the object of its appetence in the framework of survival of the species.
Just as there is a sexual or loving act or encounter, there also exists something that we
could call a nutritive or feeding act, which has its own features. Which are these?
The human being not only has a body, but he is his body (cf. Zutt, 1963). I have legs
of such and such characteristics, but it is not they but me who walks. I have eyes, but
I am the glance, and if somebody wants to see my eyes, he will not perceive my glance,
and vice versa. In every human act this body that I am becomes formed in a particular
way, it acquires a gestalt in which both the body I have, as an indispensable material
condition (e.g., the legs muscles are conformed in a very different way for dancing than
for sleeping), and the world to which I am referred, come to participate. Because the
body I am, unlike the body I have, is referred to the world, it is world; one cannot
separate the glance from the fraction of world that is opened to me through it. And thus,
to the dancing of the ballerina belong the trained muscles as much as a determined
pavement, a lighting, a stage, an audience-in other words, a fraction of the world,
which wholly constitutes the gestalt of dancing. And that body I am while dancing is
different from the body I am while engaged in intellectual activity. While during intellectual activity the central point from which my reference to the world is given, that is,
the place where I feel my Self, is between both eyes and in the base of the nose, the
ballerina feels it in her waist, and the oarsman in the part of the back from which both
arms separate their movement toward the oar.
To the sexed or loving body belongs essentially the presence of the other, of the mate,
as well as an atmosphere and a place. And different to the body of the oarsman, dressed
sportively, or the body of the ballerina, dressed in her tights, to the loving body belongs
nakedness, the disappearance of every typifying and supraindividual element. Gebsattel
(1954) has described sexual perversions as a breaking of this gestalt of love, of this body
made u p and transfigured in the act of love. And thus he sees in vicious masturbation
the breaking up of the gestalt due to the absence of the other, whereas in fetishism the
rupture of the gestalt is due to incapacity of the perverse to face the other as a whole. In

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sadomasochism, in turn, the breaking is due to something like an inversion of the


natural sense of the loving act: Instead of elevating the other, of getting to be more,
respectively, by way of union, sadomasochist love looks for self-assurance of the subject
through humiliation and destruction of the other, or inversely-in the masochist moment-acknowledging the power of the other by means of self-destruction.
And what happens to our patients with oral perversion when we look at them from
the point of view of this body I am acting in a determined gestalt? To the act of eating
belongs a certain bodily preparation (of the body that I have): secretion of clorhydric
acid, of saliva, in some extent, of appetence. But what is appetized also belongs to this
act: A certain food that I prefer over another food, or that in a certain moment I have
chosen and has become a habit at a given time of the day. But a given dress for every
occasion also belongs to the same gestalt. Theres no place for nakedness in the act of
eating, and so I get dressed in a given way when I am invited to dinner and in another
when I eat at home only with my family, and again in another way in winter or in
summer. Neither do I eat at random times, but at relatively fixed times, as breakfast,
lunch and dinner, times that various countries and cultures have determined, transforming given hours in decisive elements that condition interpersonal life, and to which
one must adapt oneself when travelling abroad. But not only appetence and the appetized, a given dress, a determined place, and hour belong to this gestalt of eating, to this
body that nurtures itself, but also, and essentially, the other. Rarely do we eat alone, and
it is unpleasant to do so. The table is the place of family gathering, where impressions
and projects are exchanged, where children are educated, where friendly chats take
place, where starting friendships are sealed or the ones that must end are interrupted.
The most important entertainment in modern society is maybe going out to dinner to
some special place, in the company of the people with whom we want to share.
Seen in this way, we have to acknowledge that in our patients this gestalt is thoroughly distorted: There is no relationship with food to the extent that what is eaten
doesnt matter; what does matter is eating without stopping. There is no dress for
eating, because the patients yield to the impulse immediately, and frequently it occurs
at night or at dawn, in a sleeping gown. Neither does the place matter, because they
hide anywhere to do it, as long as they are not seen (with regards to this point, one
cannot but think of an analogy with perverse sexual acts as masturbation or with anal
and urinary functions). And they submit to no schedule, because for them mealtimes
do not exist at all. We already said that they generally eat during mid-morning, when the
house is messed up with cleaning or without people in it, or else at dawn when their
relatives are asleep. But the most eloquent fact is perhaps the incapacity that hyperphagic patients show to eat in the company of others: their absence at mealtimes at
home, their rejection of going out to dinner or their inability to ingest anything when
they have to go out, their clandestine ingestions, away from the sight of others, in the
pantry, in the yard, in the bathroom. This indicates a profound alteration in the realm
of interpersonal encounter, which coincides with the general tendency to isolation that
is observed in them beginning with their coming of age, and which is common both to
our hyperphagics and to anorexic girls.
But what relation is there between these anthropological features of a general order
and the perverse act of eating and vomiting in itself?
In the act of vomiting one finds a reciprocal relationship between subject and food,
analogal to some degree with the reciprocal relationship of the loving act with its circular
dynamics of giving and possession. When I eat, I possess, I incorporate the food, but at
the same time I surrender to it, to its effects, to its risks: poisoning, indigestion, pain,

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131

growing fat, etc. Among our patients, instead, there is an absolute lack of respect for the
object of their appetence: We saw that they did not care for the food in itself, as long as
they could experience the act of chewing and swallowing. Their relatives, amazed, tell
us that catching them in their eating, they show an expression as though of an animal.
Another patient told us that what really fascinated her was to hold the food in the mouth
and to chew it. It is evident, then, that the act of eating lacks for them all connotations
proper of a love-like act, postponing the degustation, the taste of something special in
a given circumstance and in the company of the loved ones, for the sake of the destructive moment of trituration.
Undoubtedly in oral activity there is an aggressive moment that has been studied by
psychoanalysis, which even speaks of an oral-sadistic evolutive stage. Vomiting becomes then the necessary consequence of this food-related perversion, because it is not
food that matters-even in relation with the pleasure it will bring me-but the fact of
destroying it. And this is the reason why food cannot be tolerated in the stomach,
because it would clearly mean to incorporate what is hated, what one wants only to
destroy. That is also the reason why this act id not satisfying, and thus our hyperphagics
never achieve complete satiation. This new frustration is the starting point of new cycles
of perverse acts, and so ad infinitum. Because, to get pleasure, to achieve the ecstasy in
the satisfaction of any appetence, it is necessary to offer oneself to the desired object.
And this offering is here inexistent. We only see in this act an arbitrary manipulation
of food, which is isolated and taken apart from every worldly and bodily context that
permits its being what it is: not only a necessary element for metabolism, but also a
vehicle of communication and love by way of the shared pleasure.
Finally, we would like to state the idea of a parallelism between sexual perversions
and oral perversions, which we will develop in the future: There is a correspondence
between voyeurism and anorexia nervosa. The achievement of pleasure is reduced to
watching. The obsession of anorexic girls of forcing others to eat and watching them
without eating themselves, is well known. A second correspondence is found between
fetishism and those curious oral perversions in which there is a preferred ingestion of
isolated and noneatable elements: We have some cases of ingestion of earth, of wool,
and of hair. In both forms, it is the fractioning of the appetized object what essentially
constitutes the perverse act. And, finally, there is a certain analogy between sadomasochism and the hyperphagia and vomiting syndrome. In the latter, as we said before,
the nutritive act is altered in all of its gestalt, but also in the relationship with food itself
in the sense of the existence of one sadistic moment (the destructive and massive incorporation), and one masochist moment (the self-destructive vomiting). This points to
a distorted pleasure obtained by way of not allowing oneself the normally pleasurable
incorporation of food, but also to something like giving up, and annihilating oneself,
precisely in the face of that element that is pursued with incontrollable passion.

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