In response to a recent request, I am posting my translation of Janet’s analysis of Nadia in his book, The Obsessions and The Psychasthenia. The original version, in French, can be found here. This selection begins on page 33 and carries on to the top of page 41.
One or two quick comments. I would encourage the reader to recall that this was originally written in 1903. Many terms in psychiatry have undergone significant changes since that time. So delirium, for instance, today has a quite more restriced meaning than it did 107 years ago. Also, his writing style should be taken in the context of the early 20th century. If anyone finds a difficulty in my translation, I would be indebted if you informed me of it.
Janet is here making a differential diagnosis on a very ill woman named Nadia who is initially thought to have an eating disorder. Janet is, at the same time, illuminating his conception of obsessions and psychasthenia.
I would strongly encourage the reader to review the thoughtful and knowledgeable comment about this case submitted byJames Meadows.
Without further delay, here it is:
5. – The obsessions and impulsions of the shame of the body.
This idea of contempt of oneself, this obsession with personal dissatisfaction is often on the physical person, on the body. Patients in whom we find this dissatisfaction with their bodies are very numerous, they form a unique group that we could not suspect the importance of before seeing them frequently. You could call them all “ashamed of their bodies.” The most complete have an obsession on their whole body in all its parts and thus their general obsession is divided into a number of small specific delusions. Others go less far in the same line and their obsession with shame is not primarily the body, but it is systematized on this or that part, this or that function of which they are particularly ashamed. I will first pay particular attention to a remarkable case that gives an overview of the first group, and then I shall choose a few specific examples that show the shame concerning this or that function.
A curious observation, that it is unfortunately impossible to present without going into countless details, is that of Nadia (166), a girl of 27 years, whom I managed as much as possible for more than five years. This girl came to me with the somewhat superficial diagnosis of hysterical anorexia. This diagnosis was justified simply by a more than bizarre diet that the patient imposed upon her family for years and by the appalling scenes she made when they tried to change her regime. She prescribed to herself two soups a day in a light broth, egg yolk, a tablespoon of vinegar and a cup of an extremely strong tea in which she had put the juice of a whole lemon, carefully pressed. They had been able to discover, which was not difficult, that she had imagined this regime in the fear of getting fat, and they concluded a hysterical anorexia.
Hysterical anorexia is already by itself a very strange disease, which is far from being fully elucidated. In its typical form, it is not as common as we think and confirmed hysterics frequently present this phenomenon among their countless accidents. Vomiting, regurgitation, various spasms of the esophagus, stomach, diaphragm, muscles of the abdomen also determine the eating disorders and are much more common than anorexia itself. In the presence of a case of complete refusal of food, we must, if I do not make a mistake, be wary and think that mental disorders of varying severity may be more likely than hysteria itself.
In any case, we admit for the present this hysterical anorexia; to make the diagnosis it is necessary to find at least a certain number of characteristic symptoms. Of course, it would be good to find clearly hysterical phenomena either currently or in the historical record. Unfortunately, we know that this symptom is frequently isolated, at least in its early stages. If you cannot find the signature of hysteria, it is my opinion that the refusal of food has two main characteristics.
1° You must note the complete or nearly complete suppression of hunger during almost all of the illness. This loss of hunger is often accompanied by considerable disturbances in the feelings of the mouth, either for taste, or even for touch, of anaesthesia of the pharynx, by disturbances of the movements of jaws and cheeks, anaesthesia of the esophagus and probably the stomach with or without the spread of this anaesthesia in the skin of the epigastric region. Is the loss of hunger directly related to these various anaesthesias of the mouth, the esophagus, the stomach that often but not always accompanies it? It is a problem that I discussed at length in my lectures at the Collège de France on the consciousness of the body and its functions. Without being able to go into this discussion here, I shall say only that the anaesthesia of these organs, when it exists, contributes to the elimination of hunger and, consequently, it plays a role in the diagnosis of hysterical anorexia.
2° A second symptom, more curious and much less analyzed, although it was pointed out long ago, I think is also important: that this exaggerated need for physical movement that accompanies true anorexia. Patients move constantly, make great walks, dance in the evenings, push themselves too hard in a thousand ways and there are as many scenes to retain their exaggerated walks as for refusing food. This symptom has been interpreted in various ways. Lasègue sees the result of a calculation: “these people,” he said, “are afraid to be taken as patients; they fear that we might use their weakness as an argument to force them to eat and so they simulate great activity.” Mr. Wallet regarding two curious observations, sees a technique by the patients to augment their weight loss. They do the exercise, as they drink vinegar, to lose weight. Without denying the role that such reasoning may have played in some special cases, I can accept only that this great, general symptom always depends upon reflections, in fact, quite complicated.
In some interesting observations that I discussed in my classes, I could show that the exaggeration of movement sometimes comes earlier than refusal of food and therefore precedes all these arguments. In a very curious case, a reasonable woman of thirty-five years, comes to me seeking treatment, and therefore does not seek to deceive. In her anorexia, which is very rare, is a repetition and it proceeds by fits and starts. Following an emotion, she feels excited and shaken up as if she was carried off like a feather. She has the need to gesticulate, to speak, to walk. She no longer returns to her home, but she still continues to eat, while saying she does not feel the need for more “because she is strong enough without it.” Then two days later, she was disgusted with “useless” food and she began to refuse to eat.
One approaches the truth by saying that muscular anesthesia and especially the anesthesia to fatigue plays a role in this perpetual motion. I think we must go further and say that in this feeling of euphoria there is a genuine excitement in connection with the emotions of a particular mechanism, if one prefers anatomical language, a true excitement of the cortical motor system. This stimulation seems to play a significant role in the loss of the feeling of hunger, perhaps more important than that of anesthesia in the stomach, because hunger, before the feeling of the involvement of various reflexes of nutrition, is a general feeling related to the impression of weakness and exhaustion. In any event, it does not suffice that a young girl refuses to eat or even that she obviously has the fear of getting fat for us to call her condition a hysterical anorexia. It is also necessary, in addition to the various symptoms of hysteria that we can see, that there is a considerable decrease in the feeling of hunger and an exaggeration of movements. Was it so in this patient, Nadia, to whom I return?
This patient, who was examined many times with great care, never presented the slightest signs of hysteria. She has no decrease of sensitivity, not in the epigastric region or in the rest of the body. In her history there is noted an appalling anger, but she is described as free of attacks of hysteria. What is more important, she has no true anorexia at all. She has perfectly preserved the feeling of hunger. Often, it is true, in the last period of illness, hunger is masked, because there are inevitable stomach problems after years of this regime, but usually Nadia is hungry, she even gets very hungry. This is reflected first by her actions: from time to time, she forgets herself until she greedily devours everything she encounters. In other cases, she cannot resist the urge to eat something, and she takes the cookies secretly. She feels horrible remorse for this act, but she resumes it all the same. This can be seen even better by her very curious secrets. She acknowledges that she needs to make a great effort to go without eating. “She is a heroine to have been able to resist for so long a time… Sometimes I spent hours thinking only about food, I was so hungry: I swallowed my saliva, I bit my handkerchief, I rolled on the floor, so much I craved to eat. I was looking in books for descriptions of meals and great feasts, and I tried to cheat my hunger by imagining that I tasted all these good things. Really, I was absolutely starving, and despite some failures with cookies, I know I had a lot of courage.” Is it hysterical anorexia that she speaks of? In addition, in no way does Nadia present the unrest of hysterical movement. It is interesting to note that she makes the precise reasonings of which Lasègue speaks. She sought to work well, to walk to her courses so that her mother was not worried about her refusal of food, and the exercise made her lose weight, but that cost her a painful effort that she did only by necessity; most often, and especially now, she wants to stay quietly in her room and feels no need to walk and spend her strength. The disease is therefore different: the refusal of food is only the result of an idea or a delusion.
This idea, if one considers it in a superficial way, is evidently the fear being fat. Nadia is afraid of becoming strong like her mother; she is anxious to remain lean, pale, only that pleases her, is in harmony with her character: of her continual anxiety, she is afraid of to have the swollen face, to puff, to have big muscles, to get a better complexion. One must take great care to avoid making compliments on her health, a blunder by her father who, seeing again her at the end of some months, said that she looked well which began a serious relapse. We must be prepared to answer the questions that she constantly poses: “Please, tell me what you really think? Do you find that I have big, round and pink cheeks since I am eating more? Out of the kindness of the heart, tell me and console me, I beg you. Did you find me as thin as other times? Do me the pleasure of telling me that I shall always be thin… Look, today I was in a hansom cab that did not walk, the horse could not drag me, it’s because of these chops you make me eat. I beg you, reassure me.”
But this obsession is not at all an isolated and unexplained obsession, as sometimes happens in hysterics. It relates to a system of extremely complex thoughts. First, stoutness is not only considered from the point of view of an interest in one’s looks: it presents to the patient something immoral. She always repeats: “I do not want to be pretty, but I would be too ashamed if I became bloated, it horrifies me and if by misfortune I got fat, I would not dare to let anyone see me, neither in the house nor in the street, I’d be too ashamed …” And notice that it is not the obesity itself that appears to her to be shameful. She loves people who are very stout and finds that it suits them, but for her it would be immoral and shameful. This is not just stoutness, but also it is all that is linked with the act of eating that deserves this character.
She began to refuse to eat with other people: she must eat alone, as in secret. Truly, if one can permit such a comparison, she hides to eat, she is embarrassed to do the act in front of someone, as if asking her to urinate in public, and, moreover, she recognizes that the comparison is fair. When she happens to eat a little more, she is still in hiding; there are protests to pardon her as if she had committed an indecency. At the time of the Christmas holidays, she took the liberty of tasting some boxes of chocolate sent by her friends. She wrote me more than ten letters on this subject, confessing as a crime each of her bonbons, trying to explain, by a feeling of greed or curiosity, an act that she regrets so much. She would have been very ashamed if they had surprised her in the act. Not only must they not see her while she eats, but they must not hear her as well. Mastication is something so vile that, if you could hear her, it would make her go underground. Here again, it is not the behavior of eating in general that she despises: you can eat in front of her; she found nothing reprehensible in that, on the contrary, she is happy to offer something to people who come to see her. But it is the chewing to her “that makes a special noise, ridiculous and disgraceful. I am willing to swallow, but do not force me to chew.”
We should not believe that this shame limits itself to being overweight and to the act of eating. Nadia has other torments.
Although she is thin and has rather pretty traits, she is convinced that her face is not only bloated but also red and covered by spots. As I did not succeed in seeing these so-called spots, she declared of me that “I know nothing and I do not recognize spots that are between the skin and flesh.” Anyway, they give her an abominably ugly face and although she has no vanity, a self-respecting person cannot allow such a face to be seen. Alongside the refusal of food has developed another delusion that has been too little noticed, it is the fear of going out into the street. There are horrible scenes in order to go out for a little while, by closed carriage. It is necessary that the coachman and the housemaid look away when she rushes into the carriage. She goes out more easily in the evening, in deserted places, where there are few risks of her being seen. Even in her room, if I let her do so, she would maintain a semi-darkness and she is always situated in the darkest corner, her back turned to the light. If they did not stop it, she would not delay in, as a patient whom I knew, living in complete darkness.
If her face embarrasses her so, the other parts of her body are left far from indifferent. Since the age of four years, she claims, she has been ashamed of her size, because they said to her that she was big for her age. Since the age of eight years, she began being ashamed of her hands which she finds long, ridiculous. Towards the age of 11 years, as she wore short skirts, it seemed to her that everybody looked at her legs and she could no longer endure them. She needed put on long skirts and then she was ashamed of her feet, then of her too broad hips, of her arms with big muscles, etc. Of course, the arrival of puberty singularly aggravated all these strange feelings. Menarche made her half-mad. When she started growing pubic hair, she was convinced she was alone in the world with this monstrosity and up to the age of 20 years, she plucked “to remove the savage ornament.” The development of breasts especially aggravated the obsessions, because fears about modesty were added to the old ideas about obesity. At this moment, especially, she began completely refusing to eat and no longer want to show herself. By all means possible, she tried to conceal her sex, of which she is particularly ashamed: her blouses, her hats, her hairstyles should be closer to the male costume. She cuts her hair half-long and curls it and she would like to have the appearance of a young student. It should not be thought that here is a sexual inversion, as is assumed too quickly in such cases. She would be as ashamed to be a boy as to be a girl. She would like to be without any sex, and she would even like to be without any body, for we see that all parts of the body determine the same feeling of which the refusal of food was just a very partial manifestation.
What is deep down the dominate idea that determines these singular assessments? Modesty certainly plays a considerable role and this feeling is pushed to quite an extreme. Not since the beginning of childhood could she undress in front of her parents and until the age of twenty-seven, she had never consented to be auscultated by a doctor. But she combines with it a crowd of things: vague guilt feelings, reproach relating to greed and all kinds of possible vices. She herself blends in an especially more interesting feeling, that we already noticed about the preceding obsessions and that will become more and more important with our Scrupulous. “I did not want,” she says, “to put on weight, nor to grow, nor to resemble a woman because I would have liked to remain always a small girl.” It is obvious that this desire to remain a child played a considerable role, for what she always dreaded is to develop, more than to actually get fat. But why this desire? The reason for this strange desire is summed up in one word that many patients repeat to us: “Because I was afraid of being less loved.” Deep down, this is the idea she has, when she is afraid of being ugly, of being ridiculous. “They will laugh at me and love me no more. They will discover that I am not like everybody else and they will love me no longer. If they could see me well in full light, they would be disgusted and not love me anymore.”
This desire to be loved, this worried fear that one does not deserve the affection that one so desires mingles certainly in this case with the ideas of possible faults and fears of modesty to produce this obsession with body shame and all the impulses to refuse food, to lose weight, to hide oneself that we have just seen. It will be used again in the following observation.
© Translated by Michael W. Adamowicz, LICSW, LLC. All rights reserved 2010.