An Equivalent of Depression, Anorexia. Gero, G. M.D. (1951). In: Affective Disorders, ed. P. Greenacre, New York, N.Y.; Int. Univ. Press, (1953), pp. 117-140. Abstracted by Kenneth D. Cohen, M.D.
Dr. Gero seeks to clarify and elucidate symptom formation and depression in anorexia. Using a detailed analytic formulation which unfolded as he analyzed the case of "severe anorexia," he explores the vicissitudes of the oral drive as it relates to anorexia and depression.
From the beginning of the paper, he observes that similar conflicts exist in both depression and anorexia. Yet, conflict over food present in depression does not invariably lead to anorexia. Therefore, by clarifying the similarities and the differences, he wants to understand why the symptom picture is not similar. This is, of course, a longstanding epistemologic dilemma with whicants to understand why the symptom picture is not similar. This is, of course, a longstanding epistemologic dilemma with which psychoanalysis has been concerned and continues to be concerned.
The patient, with a long history of eating disturbance and phobic symptoms had experienced a progressive interference with her social life. Although analysis improved the symptom picture, it did not disappear, giving the analyst a rather prolonged period of observation. The patient presented with a rather classic picture of severe revulsion against food together with a variety of body concerns reflecting the underlying body image disturbance. Paradoxically, her dreams were of greedy ingestion of feasts with cannibalistic impulses having "phallic and "coprophagic" overtones.
Successful as a business woman, but unmarried, she felt unfulfilled as a woman and was unable to establish meaningful relationships with men. Analytic sessions were filled with endless "self-flagellating" accounts of her misery with conviction that she was destined to remain mired in her suffering.
Significant in her history was mother, who only felt fulfilled when she gave birth to a son after two daughters. The patient, the second daughter, was five years old at the time of that birth. She entered into a period of intense masturbation and eating disturbance, brought on by the trauma of seeing "the doctor's bloody instruments in the bathroom" after hearing mother's suffering moans during the delivery. The masturbation fantasy had two distinctive themes. The first centered eating disturbance, brought on by the trauma of seeing "the doctor's bloody instruments in the bathroom" after hearing mother's suffering moans during the delivery. The masturbation fantasy had two distinctive themes. The first centered about mother being alone and masturbating which made the patient feel rage against the mother. The patient's masturbation represented an attack on mother as she attacked her own body with vigorous clitoral manipulation. In adolescence the fantasies change with the patient as a "bad girl" lasciviously provoking one or two men into attacking her. Ashamed of this fantasy, she developed the image that her clitoris was "disfigured and enlarged." The genital region became painful, serving as a somatic conduit for all the consequent memories that came into focus when she revealed and worked with these fantasies. Thus, as she rejected food by upper GI spasm she rejected penetration vaginally.
The author states that the eating represented a condensation of sexual fantasies. Eating lead to a form of femininity in which the mother was seen as big, with the power to grow things. This provided a means by which one regained the lost penis which eventually was regarded as the wished for baby. This was a repeated masochistic struggle with the decisive moment for symptom formation being the disposition of the organism to express psychological conflicts in a somatic way. (p 124).
Dr. Gero following his goal proceeds to detail aspects of the patient's depression that were based on her feeling that she could not be loved by a man - a defense against the "danger of sexual relations with men." This showed itself in the transference where it was seen that the depression was not about the lost external object, but rather about her narcissistic investment in herself with the concomitant disappearance of sexuality. This represented a "breakdown of the oedipal longing, and a shifting of the affect to the loss of the penis."
The oral drive, quite cannibalistic, represented itself in the transference which to the patient meant love with a tearing quality; an action against herself which she did to herself in her own masturbatory fantasy. Refuting Abraham's formulation, Dr. Gero states that the hostile oral incorporation is not necessarily destructive, but also a means of expressing the wish to merge with the object. Moreover, the strict did to herself in her own masturbatory fantasy. Refuting Abraham's formulation, Dr. Gero states that the hostile oral incorporation is not necessarily destructive, but also a means of expressing the wish to merge with the object. Moreover, the strict superego pressure is seen as a withdraw of libido from the genitals and secondarily from the whole body. The evidence for this was seen in the analysis with "re-repression and grieving over the deadness of the body." The complaints represented "desexualized masochism" and were seen really as an appeal for maternal succor.
In a final discussion, Dr. Gero emphasizes a strong connection between separation anxiety and castration anxiety. It is his understanding that hostility is not solely responsible for super ego harshness for the intensity of the oral libidinal urges creates a greater need for the approval of the love object. Masochism is explained by citing Lewin's (1950) observation of the frequent coexistence of oral and masochistic conflicts about the libidinal ties to mother during the nursing experience. Aspects of depression are the outcome of these strong maternal longings. The depressive patient is blocked from the love object by curbing genital sexuality. Dr. Gero concludes that the nature of the oral drive pattern does not determine the symptoms. "A complicated set of factors ...will decide whether or not an eating disturbance occurs."
In effect this paper seeks to clarify and extend the formulation of the eating disorders in an effort to discern how similar conflict can produce different symptomatology. The paper certainly goes a long way toward enunciating the nature of the underlying dynamics. A more definitive answer rests with future researchers.
Kenneth D. Cohen M.D.
Philadelphia
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