GROUP PSYCHOTHERAPY FOR OBESITY
A CORRELATION B E T W E E N RESULTS OF T R E A T M E N T A N D I N I T I A L PSYCHOLOGICAL TESTING
HENRICUS WlJSENBEEK BARUCH LANDAU
AVNER ELITSUR
The magnitude of the problem of obesity finds its expression in the
multitude of therapeutic approaches for treatment of this condition. The
relationship between the patient's mental make-up and obesity, and the
consequent difficulty in managing this condition, is well-known clinically,
and has been well-documented since Richardson's
7publication in 1946,
including Mendelson's
6review in 1964. In view of this, psychiatric
treatment is sometimes used in the management of obesity. Several
authors
3-
4>
5.
sstress the advantage of group psychotherapy in treating
obese individuals.
It is the purpose of this communication to report the results of group
psychotherapy for twelve obese subjects who had been resistent to previous
medical treatment. In addition, the internal conflicts characterizing this
group of patients are described and compared to those present in a random
group of obese patients who had responded to dietetic management alone.
M A T E R I A L A N D METHODS
T h e g r o u p studied comprised 12 married mothers, a g e d b e t w e e n 32 a n d 48. The a v e r a g e o v e r w e i g h t w a s 63% a b o v e t h e "ideal" w e i g h t . T h e y w e r e c h o s e n from t h e files of t h e E n d o c r i n o l o g i c a l D e p a r t m e n t on t h e basis of t h e f o l l o w i n g criteria: (1) L o n g s t a n d i n g obesity, of at l e a s t 6 year's d u r a t i o n ; (2) N o e n d o -crine p a t h o l o g y ; (3) L a c k of response to p r e v i o u s d i e t e t i c m a n a g e m e n t and l o n g t r e a t m e n t w i t h 50-75 m g . P h e n m e t h r a z i n e Hydrochloride per d a y and diuretics; (4) The impression of the i n t e r v i e w i n g p s y c h i a t r i s t s t h a t the s u b j e c t w a s suffering from psychiatric p a t h o l o g y ; (5) T h e r e a d i n e s s of the p a t i e n t to t a k e part in the t h e r a p e u t i c trial.
A l l t h e p a t i e n t s u n d e r w e n t a t h o r o u g h p s y c h i a t r i c e x a m i n a t i o n , i n c l u d i n g t h e f o l l o w i n g p s y c h o l o g i c a l t e s t s : R o r s c h a c h test, W e c h s e l e r i n t e l l i g e n c e test, Bender t e s t and t h e "Draw a m a n " test.
A t t h e b e g i n n i n g of t r e a t m e n t e a c h p a t i e n t w a s g i v e n a list of "permitted" foods, w h i c h comprised a protein-rich diet w i t h n o q u a n t i t a t i v e restrictions.
F r o m t h e D e p a r t m e n t of P s y c h i a t r y a n d t h e D e p a r t m e n t of E n d o c r i n o l o g y , B e i l i n s o n M e d i c a l C e n t e r a n d T e l A v i v U n i v e r s i t y M e d i c a l S c h o o l .
Author's acknowledgments — W e w i s h t o t h a n k t h e D i r e c t o r of B e i l i n s o n
T h r o u g h o u t t h e period of psychiatric therapy, all p a t i e n t s w e r e g i v e n 25 m g P h e n m e t h r a z i n e Hydrochloride B.I.D. T h e y w e r e periodically e x a m i n e d by the e n d o -crinologist. S e s s i o n s took place o n c e a week, t h r o u g h o u t a year's t i m e , under t h e t h e r a p e u t i c g u i d a n c e of t w o p s y c h i a t r i s t s , a n e n d o c r i n o l o g i s t and a registered nurse. T h e r e w a s a l s o in a t t e n d a n c e a d i e t i c i a n w h o g a v e g u i d a n c e in t h e pre-paration of dietetic m e n u s . F o l l o w i n g t h e group sessions, a c o m m u n a l , dietetic l u n c h took p l a c e in B e i l i n s o n H o s p i t a l .
The f a c t t h a t n o n e of our p a t i e n t s h a d responded to p r e v i o u s d i e t e t i c and drug t h e r a p y served a s a control for t h e e f f e c t i v e n e s s of t h e group p s y c h o t h e r a p y , w h i c h w a s n o w g i v e n in a d d i t i o n to t h e v e r y s a m e m a n a g e m e n t . A n o t h e r e l e v e n , obese w o m e n , c h o s e n from t h e files of the E n d o c r i n o l o g i c a l D e p a r t m e n t , served a s a n a d d i t i o n a l control. T h e s e w o m e n had t h e s a m e s o c i o - e c o n o m i c a l b a c k g r o u n d , w e r e a l s o married m o t h e r s . All of t h e m had p r e v i o u s l y b e e n t r e a t e d by t h e s a m e e n d o c r i n o l o g i s t , u s i n g t h e s a m e dietetic and d r u g therapy, and h a d been a b l e to l o s e 15-30% of their initial w e i g h t d u r i n g t h e y e a r of therapy. This control g r o u p w a s subjected to the s a m e psychiatric e v a l u a t i o n , the r e s u l t s of w h i c h were compared to t h o s e o b t a i n e d from t h e t r e a t m e n t group.
Course of the Therapy — The a t m o s p h e r e in t h e t r e a t m e n t group w a s r e l a x e d and friendly. The w o m e n were in good spirits and free in speech and m o v e m e n t . F r o m the start, t h e p a r t i c i p a n t s had a p o s i t i v e a t t i t u d e t o w a r d s t h e therapy. In the w o r d s of o n e m e m b e r of the group, t h e y regarded t h e m e e t i n g s a s "the day on w h i c h o t h e r s concern t h e m s e l v e s w i t h us, and not w e w i t h others". This a t t i t u d e soon b e c a m e v e r y consolidated d u r i n g t h e course of the sessions, w i t n t h e d e v e l o p m e n t of a c h a r a c t e r i s t i c f e e l i n g of d e p e n d e n c e on the group.
F r o m t h e s t a r t t h e y w e r e strict a b o u t p u n c t u a l i t y and f a s t i d i o u s a b o u t their a p p e a r a n c e . A t a l a t e r s t a g e , w i t h t h e i m m i n e n c e of the s u m m e r v a c a t i o n break, s o m e t e n s i o n w a s discernible. As t h e y e a r of t r e a t m e n t drew to a close, d e p e n d e n c e w a s so g r e a t t h a t t h e m e r e s u g g e s t i o n of c e s s a t i o n of t h e r a p y caused r e a c t i o n s of a n x i e t y and d i s m a y a m o n g s o m e of the p a r t i c i p a n t s . T h e y expressed t h e i r fear of loss of c o n t a c t w i t h the t h e r a p i s t and their trepidation t h a t w e i g h t g a i n would recur. This a t t i t u d e required a special a p p r o a c h on t h e part of the therapists. M e e t i n g s w e r e reduced to t w o a m o n t h , and t i m e w a s d e v o t e d to s e s s i o n s on a p e r s o n a l basis. Impressed upon t h e p a t i e n t s w a s t h e f a c t t h a t the f u n c t i o n of t h e t h e r a p y w a s not so m u c h t o c a u s e w e i g h t reduction, as to t e a c h t h e m t o h a n d l e their i n t e r n a l problems w i t h g r e a t e r e a s e and w i t h o u t h a v i n g to resort to the s p u r i o u s s a t i s f a c t i o n g a i n e d from o v e r e a t i n g .
of c o n t a c t and cooperation, c o n s t i t u t e d a p r a c t i c a l g u i d e to t h e p r e p a r a t i o n of t a s t y , d i e t e t i c m e a l s and, finally, i t t o o k on s y m b o l i c m e a n i n g , b e i n g regarded as a reward or p u n i s h m e n t , in a c c o r d a n c e w i t h t h e p a t i e n t ' s r e l a t i v e s u c c e s s or f a i l u r e in l o s i n g w e i g h t .
R E S U L T S
The initial p s 7 c h i a t r i c e v a l u a t i o n of t h e t r e a t e d group b r o u g h t f o r w a r d some c h a r a c t e r i s t i c t r a i t s c o m m o n to t h e m a j o r i t y of t h e p a r t i c i p a n t s . Their perso-n a l i t y m a y be described a s beiperso-ng d o m i perso-n e e r i perso-n g , a g g r e s s i v e aperso-nd i m p u l s i v e . A t the s a m e time, there w e r e w e l l - r e c o g n i z a b l e s i g n s of a l a c k of m a t u r i t y , i n f a n t i l i t y and d e p e n d e n c y . T h e i r s e a r c h for oral g r a t i f i c a t i o n w a s prominent, e a t i n g b e i n g an e x p r e s s i o n of t h e i r a g g r e s i v e trends. E x c e s s w e i g h t w a s regarded as a n e x -pression of f e m i n i n i t y and m o t h e r h o o d , but a t t h e s a m e t i m e t h e r e w a s no a c c e p t a n c e of t h i s role. A n o t h e r c o m m o n e x p e r i e n c e w a s t h e f e e l i n g of rejection w h i c h t h e y h a d had in childhood and w h i c h c o n t i n u e d i n t o t h e i r a d u l t life. In addition, a l l of tern suffered f r o m s e v e r e d i s t u r b a n c e s in t e i r s e x u a l a d j u s t m e n t . W h e n under e m o t i o n a l stress in t h e past, t h e y used to g o r g e t h e m s e l v e s indiscri-m i n a t e l y and u n c o n t r o l l a b l y .
Six of t h e w o m e n w e r e d i a g n o s e d to be suffering from d e e p - s e a t e d m e n t a l d i s t u r b a n c e s w i t h suppressed p s y c h o t i c t r a i t s and suicidal t e n d e n c i e s . T h e rest of t h e p a r t i c i p a n t s w e r e d i a g n o s e d a s b e i n g n e u r o t i c s w i t h h y s t e r i c a l t e n d e n c i e s .
T h e s e findings were compared t o a s i m i l a r p s y c h i a t r i c e v a l u a t i o n m a d e of the control group. T h e o n l y differences to be found b e t w e e n t h e t w o groups c a n be e x p r e s s e d in t w o a s p e c t s : in the control group, t h e a d j u s t m e n t to stress s i t u a t i o n s in the p a s t had been good, and their s e x u a l a d j u s t m e n t had been s a t i s f a c t o r y . D i f f i c u l t i e s had arisen o n l y a f t e r o b e s i t y had d e v e l o p e d . This is in c o n t r a s t to the finding in t h e s t u d y group, w h i c h had suffered from s u c h p r o b l e m s prior to d e v e l o p m e n t of obesity.
T h e r e s u l t s o b t a i n e d from t r e a t m e n t can be m e a s u r e d by e v a l u a t i n g t w o f a c t o r s : ( ( A ) Loss of w e i g h t ; ( B ) I m p r o v e m e n t of the e m o t i o n a l s t a t e .
A . Under combined dietetic and p s y c h i a t r i c t r e a t m e n t , s o m e p a t i e n t s were s u c c e s s f u l in l o s i n g w e i g h t . In h a l f of the group, t h e final r e s u l t s s h o w e d a loss of 7-25% of their initial w e i g h t . In the second h a l f t h e r e w a s no w e i g h t loss a t all. The w e i g h t reduction c u r v e w a s n o t uniform d u r i n g the y e a r of t r e a t m e n t ; part of the w o m e n reduced g r a d u a l l y and s t e a d i l y , w h e r e a s others s h o w e d a sharp drop a t t h e b e g i n n i n g and o n l y a s h a l l o w one a f t e r w a r d s .
B . There w a s a considerable i m p r o v e m e n t in t h e e m o t i o n a l condition of 4 of t h e 12 w o m e n and a partial one in a n o t h e r 4 w o m e n . F o u r w o m e n did not respond.
The e m o t i o n a l c h a n g e s expressed t h e m s e l v e s in a relief of tension, increased self-control, t h e a c q u i r e m e n t of s o m e m a t u r i t y , a certain a m o u n t of indepen-dence and t h e gain of i n s i g h t into t h e problem of obesity. The c o r r e l a t i o n b e t w e e n e m o t i o n a l s t a t e and reduction of w e i g h t w a s pronouced. A loss of w e i g h t b r o u g h t m u c h approval and s a t i s f a c t i o n , w h e r e a s a lack of r e d u c t i o n resulted in tension, often a c c o m p a n i e d by despair. W e further observed t h a t in t h e m a j o r i t y of t h e cases, a sudden and rapid r e d u c t i o n in w e i g h t a g g r a v a t e d t h e patient's irritability, restlessness, depression and hypochondric c o m p l a i n t s .
COMMENTS
The therapeutic results obtained in our study, when evaluated solely
in terms of loss of weight, were in agreement with those obtained by
Suczek
9trial. All the patients were refractory to dietetic and drug treatment and,
in addition, most of them suffered from a deep-seated mental pathology.
The achievement of weight reduction is not the only advantage of
mental treatment of obesity. We agree with Hilde Bruch
2who states that
in certain cases of overweight, the obesity is only a symptom of deep-seated
emotional disturbances and that behind the veneer of fat lie hidden sick
and, sometimes, even psychotic minds. In such patients the removal of the
symptom (overweight), which has served as a defense mechanism, may
precipitate a severe state of anxiety, depression or even psychoses. The
protective influence of psychotherapy may prevent the arisal of such
emo-tional complications. It seems to us that this is what happened in some
of our patients.
The combined results of our therapeutic measures, i.e. loss of weight
and improvement of the mental state, raise an interesting problem: is there
any correlation between the response to therapy and the findings of the
initial psychological testing. Six patients had been diagnosed as harbouring
psychotic tendencies. Only one of these benefited slightly from the year's
therapy. In contrast, four of the six patients who had been diagnosed as
neurotics, lost weight and experienced an improvement in their mental
condition. The other two members of this group also showed a
signifi-cantly better social adjustment (See Table 1).
This difference in response in this small group of patients gives rise
to another question: can it be predicted which patient will respond to
psy-chotherapeutic management of obesity. According to Brosin
1SUMMARY
Twelve obese women, who had been refractory to Phenmethrazine
hydrochloride and dietary treatment, were theated throughout one year
with a combination of group psychotherapy and diet instructions. A
signi-ficant correlation was found between the findings of the psychological
testing and the results of group treatment. Patients who had been diagnosed
by various tests as being neurotic responded much better to the combined
treatment (as evaluated by weight-reduction and emotional improvement)
than those patients which had been diagnosed as psychotics.
RESUMO
Psicoterapia de grupo na obesidade. Correlação entre os resultados
do tratamento e a testagem psicológica inicial.
Doze mulheres obesas, que não tinham tido proveito com o tratamento
dietético associado à administração de cloridrato de fenmetrazina, foram
tratadas durante um ano com uma combinação de psicoterapia de grupo
e instruções dietéticas. Correlação significativa foi encontrada entre os
elementos colhidos pela testagem psicológica e os resultados do tratamento
em grupo. As pacientes que, após a testagem inicial, foram consideradas
como neuróticas responderam melhor ao tratamento combinado (avaliada a
melhora pela diminuição do peso corporal e pela regularização do estado
emocional) do que as pacientes que previamente tinham sido consideradas
como tendentes a psicoses.
R E F E R E N C E S
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4 . H O L T , H . & W I N N I C H , Ch. — G r o u p t h e r a p y w i t h o b e s e w o m e n . A r c h . G e n . P s y c h i a t . 5:2, 1961.
5 . K O T K O V , B . — E x p e r i e n c e s i n g r o u p t h e r a p y w i t h o b e s e w o m e n . P s y c h o s o m . Med. 1 5 : 2 4 3 , 1953.
6 . M E N D E L S O N , M. — P s y c h o l o g i c a l a s p e c t s of o b e s i t y . M. Clin. N o r t h A m e -r i c a 4 8 : 5 , 1964.
7 . R I C H A R D S O N , H . B . — O b e s i t y a s a m a n i f e s t a t i o n of n e u r o s i s . M. Clin. N o r t h A m e r i c a 3 0 : 1 1 8 4 , 1946.
8 . S I M M O N D S , W. D . — G r o u p a p p r o a c h t o w e i g h t r e d u c t i o n . J . A m e r . D i e t . A. 30:442, 1947.
9 . SUCZEK, R. — P s y c h o l o g i c a l a s p e c t s of w e i g h t r e d u c t i o n . W e i g h t . C o n t r o l C o l l o q u i u m . I o w a S t a t e C o l l e g e P r e s s , 1955.
