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In spite of extensive experience with patients with eating disorders, I have been reluctant to write about psychotherapy with them. One reason is the complexity of the problem, with food always available to arouse or appease anxiety, and weight as a visible symptom, a measurable sign of success or failure. Another factor is related to my gradually coming to the conclusion that certain tacitly assumed psychotherapeutic or psychoanalytic principles were in need of reevaluation.
I shall limit my comments to those disturbances in food intake that result in a changed appearance, be it the grotesque bulk of obesity, or the pitiful emaciation of anorexia nervosa, or the inability to stabilize at any level, with a weight curve resembling the temperature chart of septic fever.
Obesity is a far from uniform condition. Many people rated as “too fat”—be it statistically, or by appearance, or by their sense of well being—probably follow medical advice and combat their excess weight more or less successfully. The psychiatrist sees those who fail in repeated efforts at dieting, or who encounter severe difficulties in living. Psychiatric symptoms cover a wide range; they may be intrinsically related to the weight disturbance, or coincide only accidentally.4 There is no personality structure that would apply to all