Overeating, or eating nervously is a common condition known to all of us. Bulimia nervosa is an extreme form of this condition, when the urge to eat is immense and frequent. So the phenomenon is a spectrum from the common need to have a second coffee, a second chocolate, three chocolates, to the nervous overeating of obesity and the bingeing attacks of bulimia. Some patients then discover that they can control their weight by vomiting out the food immediately after the binge. Or they try to burn the extra calories with exercise or purge out the food by taking laxatives or diuretics.

Anorexia nervosa is at the opposite end of this eating disorder, where the patient develops an antipathy to food and eating. The two disorders frequently alternate in the same subject, clearly showing their similar origins.

In both conditions there is often an abnormal preoccupation with being the right shape and the right weight. This concern with shape and weight is part of the illness. So these patients are on a constant diet. But the additional frustration of dieting makes these eating disorders worse.

Over one half of patients with eating disorders do not fit strictly into the two categories of anorexia and bulimia nervosa. They are therefore called atypical eating disorders. Among these cases there is a large category, called binge eating disorder, that is somewhat different in presentation. These patients also have attacks of binge eating but they are older, around 40 years old at presentation, (unlike bulimia nervosa which is a condition of young women under 30). Some 25% are males. These patients are less concerned about their weight and shape. They tend not to vomit or purge themselves and so are often overweight and obese. Indeed they can be considered as part of the spectrum that leads from bulimia to obesity. Theses patients may represent some 5-10% of the obese population. Recall that nearly 30% of the general population in advanced Western countries is now technically obese (with a BMI over 30).

It is common knowledge that under certain mental conditions (stress, pressure, etc., but also in some other situations, for example sadness, anxiety or boredom), we take relief in food. Food gives us some satisfaction; it soothes an inner discomfort.

In our opinion, overeating and bulimia are the consequence of an initial inner psychological pain, which gives rise to an irresistible craving that is only assuaged by food.

Overeating and bulimia are the consequence of this initial inner psychological pain, which gives rise to an irresistible craving that is only assuaged by food.

We can say a few things about this intense hunger or craving:

• This hunger is not physiological or biological, it is purely psychological.
• But it is indistinguishable from biological hunger.
• It usually comes up slowly, but can quickly become overwhelming.
• It is variable, from day to day and situation to situation. It comes and goes.
• Even the bulimic can have days, even weeks on end, with no binging attacks.
• At other times the bulimic may have 3-4 attacks per day
• Certain psychological situations bring it on (work pressure, deadlines, sadness, boredom, sexual frustration…)
• Certain psychological situations keep it at bay (on holiday, the company of a special friend…)

Normally our weight and our eating are controlled automatically by a complicated psychological and biological system. Body weight is maintained by an equilibrium between the forces of satiety and hunger, through certain centres in the hypothalamus and other parts of the brain which control these feelings. There are several known physiological influences on hunger and satiety (blood sugar and insulin, peptide tyrosine tyrosine, glucagon-like peptide, the mass of fat cells, the leptin and ghrelin systems, the stretch receptors in the stomach,...) But in addition to these biochemical factors, we also know that the higher brain centers, the psychological mind, strongly influences the centres that control satiety and hunger, and indeed it can override them. Hence it is perfectly possible for subjects to mentally overcome physiological hunger (before exams, on a fast, in anorexia) and conversely, to mentally generate hunger when there is no biological hunger (cravings for this or that food). Hence hunger and satiety are strongly influenced by the psychological mind. And this is what is at stake in bulimia and anorexia: the psychological state of the mind overrides the physiological signals. At times we are stable, satisfied, and do not feel any urge to eat. At other times, the equilibrium tips over, the urge to eat takes over and we need something in the mouth: tea, coffee, chocolate, a pastry, a whole loaf of bread, a whole tub of ice-cream,... Now, this psychologically driven urge to eat (or not to eat) is itself the result of several psychological factor pushing and pulling in opposite directions: an underlying constant psychological problem of needing to eat (or not to eat in the anorexic) and more circumstantial precipitating factors which provoke an attack at this or that moment (work stress, emotional problems, worry or panic...). The added psychological frustration of diets and food restriction makes these patients more vulnerable to bingeing attacks, by making the patient's biological and psychological equilibrium between satiety and hunger more precarious. So when the patient’s resistance to hunger cracks, he or she immediately starts to eat voraciously.

As we said, at the beginning of the process, there is a psychological discomfort, an inner incompleteness. This builds up to the craving for food (or coffee, or tea or a cigarette) to which the individual succumbs, gives in, lets go: “What the hell! I am going to have another another pastry. I need it. To hell with the calories…”. There is then an opening of the flood gates. All previous resistance melts. An unpluggable hole opens up at the mouth. The patient cannot control himself and collapses into the satisfaction supplied by the food, a whole lot of food. And often the more you eat or drink, the more you seem to need, suggesting that it is not really the food that is being asked for but something else, unspoken. In the bulimic, often only a very full stomach, to bursting point, brings the attack to an end. The patient is at first relieved, satisfied, but quickly afterwards he or she feels ashamed at the lack of control.

This inability to stop eating once started is one of the main defects in the picture of bulimia (and obesity). It is also something commonly experienced by most people at some time or another, when we overeat. So we are all aware that there is a mental switch involved which controls our eating, signals satiety and when to stop eating. This switch to stop eating seems not to work in the bulimic when he or she is bingeing, such is the psychological need to eat. Notice that this switch works some of the time and the bulimic can stop eating on many days, except when hit by a bingeing attack, by the overwhelming psychological need to eat. It is part of the breakdown in the psychological equilibrium that was holding up up to now. In bulimia there is a psychological imperative that over-rules the normal biological and social signals of satiety.

How? The first thing to do is to break this vicious circle of bingeing, vomiting and dieting, by installing strictly timed and planned meals at regular intervals, with no calorie restriction. This is not easy to do on your own and needs the help of a therapist. Just stopping severe calorie restriction greatly reduces the bingeing in a few weeks. Up to here all therapists are agreed. But then you have to treat the underlying psychological causes of the binges, which continue. In classical Cognitive Behaviour Therapy (CBT) the therapist is not interested in the psychological origins of the problem. He does not have a theory of psychological causation. The most likely cause for this school of thought is that the condition is due to an incorrect perception (cognition) by the patient (“I am too fat.”) which leads to an incorrect behaviour (“I need to lose weight.”). His approach is to try to re-educate the patient to change her ways by rational discourse, to convince her she is misguided about being too fat, to convince her that she is being irrational in her behaviour of trying to be slim and to diet. And that is as far as the therapy goes. Against the urge to binge the CBT therapist is only able to suggest that the patient waits it out, resists, distracts herself, goes for a walk, takes a shower.

As psychoanalysts, we have a different view. We believe that all attempts at self persuasion, counselling, exhortation or advice are to little or no avail against the urge to binge. We believe the craving is itself the expression of something deeper, an unexpressed, hidden desire. To make a change we have to go to where the problem starts from: the inner psychological discomfort, the inner incompleteness that expresses itself as the craving for food. The subject is not really biologically hungry, or only a little hungry, but an inner psychological discomfort converts itself into an overwhelming craving for food, often a specific food, that the subject cannot resist.

In psychology, who says food also speaks of attention, of care, of affection. In other words, who speaks of food also speaks of childhood, of dependence, of mother’s love. Food carries with it an emotional charge; it is given and received inside a relationship, the most fundamental of relationships, between mother and child. Due to the long process of growing up with a speaking, nurturing mother, in humans, eating and (not eating) are not just biological needs but are profoundly wrapped up with words, emotions, thoughts, feelings.

Hence, there are words stamped inside each of us, around this question of food and the delicious things we received from our mother (or similar person). And here lies the origin of the mysterious craving in bulimia, or its opposite in anorexia. To make a change, you have to go to this part of the personality, to the hidden marks that were left inside us around the question of food, during our relationship with our mother. (We psychoanalysts have a hypothesis that a deep psychological relationship between the mother and baby occurs around each of the orifices of the baby and the functions involved: the mouth and eating, the eyes and seeing, the ears and hearing, the excretory orifices and the acts of urination, defecation and sex. And the whole makes for the final personality of the boy or girl. What is important to understand is that this process of nurturing a baby into a sexed little boy or girl is not automatic or biological. Each mother (and a few others) have to put all the pieces into place, step by step, with words. So that a blueprint, a software, is laid down in the child's mind allowing him or her to function autonomously as a speaking, thinking, sexed boy or girl. This is a real, concrete, step by step process and things can sometimes go wrong.

Sometimes the mother child relationship can go wrong

Sometimes the mother child relationship can go wrong. For example if the mother herself has certain needs around food and being fed, around seeing and being seen, around talking and being heard, or of a sexual nature. In this way a mother can pass on her blind side to her children. There are mothers who talk too much or too loudly. There are mothers who need to be seen so much they cannot notice others... This is one sort of mechanism involved in traits we inherit from the mother. Such a phenomenon is fairly often seen in bulimia and anorexia, when the mother’s own problems with food, weight control and shape are passed on to the adolescent girl child. Some mothers are too generous with food, force feeding the child. There are other mothers who can be stingy with food. These traits of the relationship leave a mark. But usually the basic setup is fine, the psychological machinery is more or less correctly put into place between mother and child. And the satisfaction of all eating, and especially binge eating, recalls the comfort of this early relationship with the good mother.

We can now describe what we think to be at the origin of the strange symptoms of bulimia. In bulimia, and in the nervous eating of obesity, under certain circumstances of stress, a hole opens up in the psychological structure. There is a babyish regression in the patient and she has to have her fix of food. She craves food which brings her relief. This is because the food stands for something else, represents something else: maternal attention. When the internal or external mental demands on the subject are too much, build up to a point that the patient’s inner reserves are exhausted, then the baby inside starts to cry, scream, needs help, needs attention, needs to be comforted, needs food. Needs the satisfaction provided by a large quantity of food. Sometimes even a specific food that was once offered and enjoyed with pleasure between child and mother.

One can simplify and say that an attack of bulimia is a state of lack of internal maternal love. There is a paucity of internal words, a paucity of self worth, a paucity of internal self regard. All these things are originally supplied to us by our mother as a child and there is inside us a part of our psychological machinery which generates these things for ourselves in later life, when we no longer have mother near us. It is our inner “love generating” machine. In bulimia it seems this part of the machinery does not function properly at certain times and the patient needs a fix of real food to taste mother’s love. The friendly internal conversation has stopped somewhere. The mother's words, her internal presence, are not available to the bulimic. And instead there is a craving for food. Strange as it may seem, the psychological origins of the craving for food (and cigarettes) are of this order: a break-down in the flow of friendly internal words. Of course each case is different, but we advance this as the general mechanism at work in bulimia and nervous eating.

So my thesis is: there are certain thoughts, incidents, old memories, related to delicious food and the comfort of being fed by mother, which are at the origin of the hunger of each bulimic patient. Behind the hunger, there are some hidden demands, needs, desires that are still present. Some old conversations have not yet been completed, including about femininity, beauty and motherhood. This in our view is the origin of the mysterious craving of bulimia (or its opposite in anorexia).

From our mother we get words, food, nourishment, music, clothes, and encouragement – she is our life force. But for a girl at puberty she is also an important role model of femininity and motherhood, and a sexual rival. So this is a very delicate passage to negotiate for mother and daughter, fraught with the possibilities of hurts, misunderstandings and rivalry. In this dangerous territory accidents can happen. And it is not hard to see that this mental drama in a girl's mind can find expression in and on her body. A young girl may both need mother's love (food) and want to refuse it (to be slim, slimmer than mother). So some mixture of these tensions can lead to the syndromes that we see, where there is intense hunger and intense desire to be slim.

So to make a change, and not just comfort the patient, the therapist must go to this hidden part of the personality, the invisible marks that were left inside us around the issues of food and femininity, in our relationship with our mother (or equivalent person) and complete the process of separation from her.

Strange as it may seem, the deep psychological origins of the craving for food (or its opposite in anorexia) are of this order.

And as you find the missing words, as you resolve these issues with mother (and perhaps some others) in your mind, there is a delicious change. Instead of a craving at the mouth (for food, cigarettes, tea, coffee, chocolate, cannabis) there is the opposite: fullness, deep satisfaction. You feel at last a calm in the chest, a mental release from the demons you were struggling with inside your head all these years.

In simple obesity (the most frequent kind, because metabolic obesity – hypothyroidism, Cushing's syndrome, leptin insufficiency and a few others – is very rare), there is often a similar mechanism of nervous over eating as in bulimia. Of course, several other factors play a role: depression, lack of exercise, calorie rich food, large portions…or sheer debauchery! Obesity is the result of eating too much and not moving enough. And psychological factors affect both sides of this equation. As in bulimia, obese people overeat nervously, to soothe their inner psychological pain (depression, anxiety, boredom). Obese people are often depressed and when we are depressed we become slow and lethargic physically. These psychological traits can be corrected by the same psychological treatment as for bulimia nervosa. In about three or four months of this psychological work, you will find that your nervous eating has calmed down a lot.

You will find you now have the strength to follow the common sense advice of a dietician. Everybody knows what we should and should not eat! But when you are suffering from an intense psychological craving for food, you cannot follow this advice. Once the craving has nearly stopped, you have the freedom, the possibility to control your diet.

Similarly, another change that the psychological treatment produces is in movement. You are less depressed, less discouraged and therefore able to move physically more easily. This allows you to walk more and take more exercise. The three things together: reduced nervous appetite, eating more sensibly and more exercise, soon produce significant weight loss. With no severe dieting, no will power and no frustration.

We psychoanalysts work to make a change in the deeper personality. How? By the talking cure. By examining the parts of the system that need to be repaired, that need to be changed. Every childhood is different. But in every childhood there are things that should not have happened. There are things that should not have been said. Equally, there are things that should have been said and were not said…).

So there can be mistakes, errors in the construction of the personality. Equally, there can be accidents and damage to the psychological apparatus in later life, sometimes resulting in bulimia or anorexia (break ups, infidelity, loss, change of place or country…).

These wounds, old or new, make themselves felt today, in our personality, in our behaviour, in our voice. In bulimia and anorexia we see this over concern about weight and shape, we see lack of self esteem, we see a perfectionist personality, trying to be in control of everything, we see obsessions about good and bad food....Behind these traits, there is an explanation. Psychoanalytical treatment looks at and changes the building blocks of the personality, foremost our relationships with our mother, father, brothers and sisters, but also some other things, such as our name, our body, food, toilet, sex, the important people, places, ideas, beliefs, that have influenced us, make us who we are.

By this psychological work it is possible to make a change in the personality, to repair certain defects, to be a calmer person. Often it is only a few important sentences that have to be changed or spoken. At other times whole chapters of the life story have to be rewritten. This is the theory and practice of psychoanalytical therapy.

Through my work with my patients and with children (drawing, story telling, playing with puppets), I have taken “the talking cure” one step further and developed the writing cure. The therapist writes down in short hand, word for word, quickly and in pencil, the patient’s discourse as he or she speaks. And at the next session we read out what was said the last time. The patient hears what he said a second time. By this method the beneficial effects of the talking cure are multiplied. He gets distance and perspective on his own words. This allows us to wipe out more completely certain passages and write new ones in their place. Please see the section Process and Method for a fuller description.

Please see the section “Process and Method” for a fuller description.

My experience of the last few years allows me to say that it is possible to cure simple nervous eating and snacking fairly quickly. Full fledged bulimia nervosa, with vomiting, takes more time, but it is curable by my method.

Motivated obese patients who are ready to look at themselves in therapy, and then increase their walking every day, can be greatly helped. There is no need for will power and severe diets, just psychotherapy, healthy food and a little exercise.