CLINICAL EXPERIENCE

Bulimia and the Basic Fault: A Psychoanalytic Interpretation of the

Binging- Vomiting Syndrome
WILLIAM J. SWIFT, M.D., AND RONELLE LETVEN, M.D.

A psychoanalytic formulation of bulimia based on the work of Balint and Kohut is

presented. Its central thesis is that severe bulimics demonstrate a "basic fault" in their ego,
specifically an impairment in functions which regulate tension. Because of this deficiency
they are subjected to intolerable internal tension which enfeebles their sense of self. The
typical bulimic sequence of dieting, binging, vomiting, relaxation, and repudiation is seen
as a defensive reparative device which attempts to alleviate internal tension and to bridge
the underlying fault. Illustrative case material is included.
Journal of the American Academy of Child Psychiatry, 23, 4:489-497, 1984.

Bulimia is a disorder characterized by recurrent
episodes of binge eating during which there is a rapid
consumption of a large amount of high caloric foods.
Typically the binging is surreptitious, and is followed
by self-deprecating thoughts and low mood. The bu-
limic is painfully aware that her' eating pattern is
abnormal and fears not being able to stop voluntarily.
Associated features include termination of binges by
self-induced vomiting, frequent weight fluctuations,
and repeated attempts to lose weight by severely re-
strictive diets (DSM-III).
The aim of this paper is to present a psychoanalytic
formulation of bulimia based largely upon the work of
Balint (1955, 1959, 1968) and Kohut (1971, 1977,
1979). Our thesis is that severe bulimics demonstrate
a "basic fault" in their ego structure, specifically an
impairment in certain ego functions which regulate
tension. Because of this deficiency they are chronically
subjected to intolerably high levels of internal tension
that seriously enfeebles their sense of self. The bulimic
symptomatology, a sequence of complex behavioral
manifestations reflecting grossly contradictory under-
lying attitudes, is seen as a defensive reparative ma-
Dr. Swift is Assistant Professor in the Division of Child Psychiatry
of the Department of Psychiatry, University of Wisconsin School of
Medicine, Madison. Dr. Letven is a resident in the Department of
Psychiatry, University of Wisconsin School of Medicine.
The assistance of Dr. J. P. Gustafson is gratefully acknowledged.
His unstinting willingness to discuss the key concepts of this paper
nourished its growth. Thanks are also owed to Drs. Joseph G. Kepecs
and Steven Stern for their suggestions regarding earlier versions of
this manuscript.
Reprints may be requested from Dr. Swift at the Department of
Psychiatry, Clinical Sciences Center, 600 Highland Ave., Madison,
WI 53792.
0002-7138/84/2304-0489 $02.00/0 © 1984 by the American Acad-
emy of Child Psychiatry.
1 Since the majority of bulimics are women, feminine pronouns
will be used in this paper.
489
neuver, which attempts to both alleviate the intoler-
able internal tension and to bridge the basic fault. Of
course, the bulimic solution is a maladaptive one:
while it does succeed in partially alleviating the pa-
tient's distress, it does not dispel it nor bridge that
basic fault; and furthermore it compounds her misery
by initiating a major biopsychological regression
which places her at risk for serious physical sequelae
(Russell, 1979).
We will first briefly review the pertinent literature
in this newly emerging area of study, including pre-
vious psychodynamic conceptualizations. This will be
followed by a discussion of the work of Balint and
Kohut relevant to our aim. Finally, a psychoanalytic
interpretation of bulimia will be offered, largely de-
rived from the aforementioned authors, which we be-
lieve to have explanatory power for this peculiar dis-
order. Illustrative case material is also included.
Bulimia has been defined as a distinct diagnostic
entity only in the most recent edition of the DSM-III.
Thus, our knowledge of bulimia-its predisposing fac-
tors, etiology, the complexity of interplay between
disturbed physiology and disturbed psychology, treat-
ment, and natural course-is still scant. Little has as
yet been published about bulimia. However, areas of
agreement and controversy are already evident. For
example, a number of authorities (e.g., Boskind-Lo-
dahl and White, 1978; Fairburn and Cooper, 1982;
Halmi et al., 1981; Johnson et al. 1982; Lucas, 1982;
Strangler and Printz, 1980) report that bulimia is
surprisingly common among late adolescent and
young adult females. Many clinicians believe that the
incidence and prevalence of bulimia is rapidly increas-
ing. In the most startling of these studies, Halmi et
al. (1981) surveyed 355 college students about their
weight and dietary habits by means of a questionnaire.
490 WILLIAM J. SWIFT AND RONELLE LETVEN
She and her colleagues found that 13% of the stu-
dents-19% of the women and 5% of the men-
reported symptomatology that would meet DSM-III.
criteria for bulimia. Such a finding raises serious ques-
tion about whether the DSM-III criteria are decep-
tively overinclusive and in need of revision. Another
interesting finding of this report was that bulimia
seemed to be a spectrum disorder: at one extreme
there appeared to be those who presented a rather
benign version of the disorder, binging only on occa-
sion and vomiting, if at all, infrequently; and at the
other extreme those who manifested a much more
malignant type with daily bouts of binging and vom-
iting.
There also seems to be a consensus about the tend-
ency of bulimia to become chronic. Such a view is
propounded by DSM-III and supported by a number
of investigators (e.g., Boskind-Lodahl and White,
1978; Guiora, 1967; Mitchell and Pyle, 1982; Russell,
1979). However, the assertions of chronicity cannot
be taken as proven fact. There are as yet no longitu-
dinal studies, either prospective or retrospective,
which could offer enlightenment about the natural
course of the disorder or its responsiveness to various
treatment interventions.
The etiological factors contributing to bulimia, as is
true of most psychiatric disorders, are undoubtedly
multiple and interactive. Nevertheless there is little
consensus about etiology. Some have postulated a
disordered neurophysiological substrate (e.g., Green
and Rau, 1974, 1977; Wermuth et a1., 1977); others
have noted the close association of bulimia with
depression (e.g., Hudson et al., 1982; Pyle et al., 1981;
Russell, 1979); some have emphasized psychological
forces (e.g., Casper, 1981; Sours, 1980; Sugarman and
Kurash, 1982); while others (Boskind-Lodahl, 1976;
Boskind-Lodahl and White, 1978) have focused on
societal and individual perplexity surrounding the role
of the modern woman as an important predisposing
factor. Naturally, when there is so much uncertainty
about etiology, treatment recommendations are likely
to be diverse and conflicting.
Progress has been undoubtedly hampered by the
nosological confusion surrounding the term "buli-
mia"-for instance, bulimia can be used to describe:
1) an exceptional pattern of eating standing free of a
syndrome context, 2) a symptom associated with other
eating disorders such as anorexia nervosa and obesity,
or 3) a discrete syndrome in its own right as delineated
in DSM-III. Even when bulimia refers to a discrete
syndrome, competing terminology abounds, such as
bulimia nervosa (Russell, 1979), bulimarexia (Bos-
kind-Lodahl and White, 1978), and the bulimic syn-
drome (Mitchell and Pyle, 1982). Needless to say,
semantic confusion must be expected when a disorder
was only offically defined within the past few years.
Given such confusion, we will take some pains to
describe what we mean by bulimia. The patients that
we are attempting to characterize meet the DSM-III
descriptive criteria. We would add these clarifying
addenda:
1. The patient is not anorectic although she may
have experienced an episode of serious weight
loss sometime in the past (Russell, 1979).Present
weight is in the normal range.
2. Like the anorectic, however, she does display an
intense preoccupation with food, figure, and body
weight. The phobic fear of weight gain, along
with the fear of losing control of the urge to
binge, leads to severely restrictive dieting.
3. There are recurrent, frequent episodes of binge
eating extending over many months and often
years.
4. These episodes are followedby self-induced vom-
iting, sometimes associated with other measures
of purging.
According to Halmi et a1. (1981), not all bulimics
necessarily vomit or purge after a binge, and those
who do may do so only infrequently. She and her
associates found that of the 10% of their sample who
reported a history of self-induced vomiting almost
85% did so on a less than monthly basis, in contrast
to a small minority (8.5%) who reported vomiting one
or more times per day. This paper focuses on the
minority of severe bulimics. who binge and vomit daily,
or almost daily, over an extended period of time, and
can be construed as manifesting a malignant form of
the disorder. Of course, this subset of the rather large
bulimic population is most likely to be referred for
psychiatric care.
Review of Psychoanalytic Conceptualizations
Discussions of the bulimic phenomenon are surpris-
ingly rare in the psychoanalytical literature. In the
first report we have been able to locate, Lindner (1961)
reported the case of "Laura," a bulimic woman who
binged but apparently did not vomit. He saw as the
core dynamic Laura's still active oedipal wish to be
impregnated by her father who abandoned the family
when she was a preadolescent. The protruding abdo-
men caused by her intense binging episodes symbol-
ized, in his view, the father's infant growing within.
In the context of discussing his assessment of a
patient's potential for psychodynamic therapy, Malan
(1979) described the case of the "Film Director's Sec-
retary," a woman of 26, whose chief complaint was
long-standing binging-vomiting. In fact, her symptom-
atology neatly fulfills the DSM-III criteria. Simply
from the symptom choice, bulimia, Malan deduced: 1)
her binge eating represented an intense need in rela-
 PSYCHOANALYTIC INTERPRETATION OF BULIMIA
tionship to others and predicted that dependence
would become a major issue in the treatment, and 2)
her overeating was a cover for depression. He felt her
underlying disturbance was of "very considerable se-
verity" as proven by the intense craving to binge, an
all-pervading preoccupation with food and weight, and
vomiting. He recommended psychoanalysis as the
treatment mode of choice. In short, Malan saw her
eating aberration as a somatic metaphor for her unmet
needs in interpersonal relationships. Unfortunately,
he did not report on the subsequent treatment and
course of the "Film Director's Secretary."
Sours (1980) wrote that eating-disordered patients
who binge and vomit represent one end of the anorexic
continuum, and can be distinguished as a separate
group from self-restraining and bulimic anorexics. He
contends that bulimics function at a higher psycho-
sexual level than anorectics as evidenced by their often
active sexual lives. He postulated that binging repre-
sented a fantasied union with the idealized mother,
while vomiting enabled the patient to rid herself of
the hated food. He added that the binging-vomiting
cycles reduce internal tensions that threaten fragmen-
tation of the self.
Casper (1981) described the bulimic symptomatol-
ogy as a defensive structure regulating and alleviating
intolerable inner states. She held that the fasting, so
common among this patient group in between binges,
"spuriously consolidates" the self-experience. Contin-
uing in this vein, the binging then exerts a brief
tension-alleviating effect while vomiting undoes de-
pendence on food by expelling (rejecting) it.
A recent paper by Sugarman and Kurash (1982)
contributes a Mahlerian perspective on the bulimic
phenomenon. They posit that the core developmental
failure in bulimia occurred at the practicing subphase
of separation-individuation, and that this failure led
to a narcissistic fixation on one's own body so that it
continues to be regarded as a transitional object. In
such a capacity, the body can be used as a vehicle for
both representing (in the process of binging) and
repudiating (in the process of vomiting) the ~aternal
object (symbolized by food). The authors wrote: "Food
is not the issue; rather it is the bodily action of eating
which is essential in regaining a fleeting experience of
mother. The dread of fusion ... mobilized by the
experience of the symbiotic mother often leads to
vomiting, another bodily action " (p, 61).
Kernberg (1980) has noted that the historical de-
velopment of the psychoanalytic understanding of an-
orexia nervosa has very much paralleled the evolution
of psychoanalytic thought per se. Thus, the first for-
mulations stemmed from the drive-defense model
while later work rested on the foundations of ego
psychology and object relations theory. Much the
491
same, we believe, can be said of bulimia, although the
volume of literature is admittedly smaller. The earliest
report (Lindner, 1961) utilized a drive-defense schema
while more recent efforts have approached the same
phenomenon from the vantage point of objects rela-
tions (e.g., Malan, 1979; Sours, 1980; Sugarman and
Kurash, 1981) and ego psychology (Casper, 1981). In
this paper, we see ourselves primarily attempting to
build upon the contributions of Casper and Sours in
their emphasis on tension regulation and the consoli-
dation of the self-experience as core dynamics of bu-
limia.
Balint
The work of Michael Balint, though widely known
in analytic circles, is far removed from the mainstream
of orthodox American psychoanalytic thought. Balint
was essentially a solitary trailblazer who habitually
thought in opposition to more traditional understand-
ings. Like his contemporary Winnicott, he gave birth
to many creative ideas but he had apparently little
interest in constructing a comprehensive theoretical
system. In our attempt to formulate the psychody-
namics of bulimia, we have borrowed three concepts
from Balint: the basic fault, philobatism, and ocno-
philia. This section will briefly discuss these concepts
and takes as its source two of his books, The Basic
Fault (1968) and Thrills and Regressions (1959).
Balint described the basic fault as an ego flaw
extending far back into childhood, and like the flaw
in a crystal becoming manifest only with sufficient
stress. He attributed the development of the fault to
the "mismatch" between the infant's emerging psy-
chobiological needs and the available environmental
provision. This mismatch might be due to the extraor-
dinary demands of the infant, or more likely the
inadequacy of the care in relationship to infantile
needs, or some combination of both. The environmen-
tal (presumably maternal) care provided might fail the
infant in a myriad of ways: it could be insufficient,
haphazard, overanxious, overprotective, rigid, over-
stimulating, etc. He contended that it was unlikely
that the failure would be singular and massive, rather
more likely it would be small, multiple, and cumulative
over time. Whatever the sequence, the infant will end
up feeling disappointed, let down, "defaulted" upon in
the all-important primitive two-person relationship.
In response, given the enormous energy and plasticity
of the infant, she will make heroic attempts to cope
with the trauma visited upon her. Since all of this
occurs in the preverbal period, the organizing and
anxiety allaying power of words are unavailable . How-
ever, she can first attempt to alert the mother to the
mismatch by noisily voicing her distress, in essence,
seeking recognition of the unhappy situation and its
492 WILLIAM J. SWIFT AND RONELLE LETVEN
rectification. If the mother can successfully read these
distress cues and take appropriate action, the basic
fault will not develop. If, however, the infant's cues
are met by nonrecognition and/or ineffective remedial
action , the infant will hit upon something of her own
creation in desperation or whatever is "thrown at" her
by the caretaker who may be a well-wisher, indifferent,
careless, or hostile, in an attempt to cope with the
distressing mismatch. Of course, the makeshift
method of coping will be inappropriate to the deeper
needs of the infant, but it will temporarily ease the
distress. It will also seriously impair further psycho-
logical growth.
We were alerted to the pertinence of this concept
of bulimia when Balint described the adult patient
suffering from a basic fault as often displaying gree-
diness, a predilection to addictive states, intolerable
internal tension, and a sense of deadness or emptiness
pervading the inner world. It occurred to us that the
severe'bulimics we have treated do indeed display just
these characteristics. Balint is very vague about the
location of basic fault in the psychic structure but
does say that is certainly extends to the ego. Our
hypothesis is that the bulimic is relatively deficient in
a certain set of ego functions which would allow herself
to insulate against overstimulation, soothe herself,
and supply herself with tension-reducing gratification.
Kohut (1971) and Gustafson (1976) have invoked the
same tension-regulating model to explain the dynam-
ics of alcoholism, a problem along with chemical de-
pendency, according to Pyle et a1. (1981), not at all
uncommon among bulimics and their first-degree rel-
atives.
We will presume that few, if any, of us as infants
experience a perfect match between our needs and
environmental provision. Thus, to some extent, in a
Balint sense, we are all faulted. The problem for the
bulimic is that the basic fault in the area of tension
regulation is rather large and she has never managed
successfully to heal it. In fact, the inherent stresses of
adolescence, especially the age-specific task of defin-
ing a personal identity, act to graphically highlight the
basic fault and to threaten disruption of the continu-
ing experience of the psychological self. In an attempt
to "heal over" or "bridge" the basic fault, Balint de-
scribed two basic human attitudes or archaic ways of
object-relating, ocnophilia and philobatism, which
each of us displays to a greater or lesser degree.
Philobatism and ocnophilia are both terms coined by
Balint and due to their obscurity deserve special ef-
forts to explain what he meant. The word philobat is
closely allied to the Greek origin of the word acrobat,
literally "one who walks on one's toes." Ocnophil
refers to quite the opposite phenomenon, i.e., "one
who loves to cling, to shrink, to hesitate, to .hang
back." Balint (1968) in The Basic Fault wrote:
The ocnophil's reaction to the emergence of objects is to
cling to them, to introject them, since he feels lost and
insecure without them ; apparently he chooses to over-ca-
thect his object relationships. The other type, the philobat,
over-cathects his own ego-functions and develops skills in
this way, in order to be able to maintain himself alone with
very little, or even no, help from his objects. Ocnophilia and
philobatism are probably instances of the basic fault, cer-
tainly not the only ones (p 68).
To elaborate, the ocnophil clings to objects (e.g.,
people, possessions, settings, ideas) for fear of losing
them. At a deeper level, she wants to be held, but since
this entails a passive, precarious situation in relation-
ship to objects, she instead actively clings when
stressed. As shown in Table 1, for the ocnophil the
expanses between objects are felt as horrid and threat-
ening while the objects themselves are safe and com-
forting. (For the present time disregard the arrows in
Table 1. Their significance will become obvious later.)
She lives in a world structured by physical proximity
and touch. As an example of a ocnophil, Balint re-
counts the case of a young woman withan active social
life full of numerous friends, living in a well-appointed
apartment cluttered with possessions that reflect her
and her personality, but who cannot bear to be alone
or to be separated from her precious objects. In a
psychotherapeutic context, he is describing patients
who cling to their therapist while at the same time
paradoxically demonstrate a deep mistrust for fear of
being"dropped" by the caretaker.
The philobat inhabits quite another world. As illus-
trated in Table 1, she sees the expanses between
objects as safe and friendly while objects are viewed
as treacherous hazards which must be negotiated with
great skill. She lives in a world structured by safe
distance and sight rather than physical proximity and
touch. A central feature of the philobatic attitude,
according to Balint, is the development of a high
degree of "skill," representative of a kind of adapta-
bility to reality since it demands excellent reality
testing and continuous control and self-criticism.
Common philobatic activities, of course, are flying,
rock-climbing, auto-racing, etc., all of which are thrill-
ing, potentially dangerous, and demand great skill.
Naturally a philobatic attitude can be taken to a
TABLE 1
Balint Attitudes
Philobatic Ocnophilic
Expanses Safe, Friendly ~ Horrid, Threatening
Objects Treacherous Hazards ~ Safe, Comforting
 PSYCHOANALYTIC INTERPRETATION OF BULIMIA
pathological extreme; for example, a young man or
woman who feels alive only when rock-climbing and
is dangerously overly optimistic regarding his/her
skills. For the philobat, one false move can have dire
consequences.
Bulimia
What sorts of maternal-infant mismatch could ac-
count for such a basic fault in the domain of tension
regulation? Balint has indicated that such a state
could be reached by many pathways. A convincing
answer to such a vexing question is hard to determine
but we will make a speculative attempt. Here we will
refer to the work of Kohut and his associates (Kohut,
1971, 1977; Kohut and Wolf, 1978). Kohut and Wolf
(1978) described various pathologies of the self, one
of which, the "overburdened self" may have particular
relevance to the severe bulimic. They wrote, ". . . the
overburdened self is a self that had not been provided
with the opportunity to merge with the calmness of
an omnipotent self-object. The overburdened self, in
other words, is a self that has suffered the trauma of
unsharded emotionality" (pp. 419-420). We are pos-
tulating then that the archaic idealizing needs of some
future bulimics were not met during development: they
were not allowed, for one reason or another, to merge
their anxious selves with parental tranquility and
strength. The results of such a repeated failure is the
emergence of an overburdened self-deficit in tension-
regulating capacities. However, quite the opposite sit-
uation could just as well obtain: that is, because of the
threat of fragmentation the parental self-object main-
tained a merger with the child long beyond the time
appropriate, and failed to attend to and to confirm the
child's own attempts to regulate tension. In such a
case, the archaic mirroring needs of the child would
not have been met. It is likely such mismatches, in
concert with others factors (e.g., biological vulnerabil-
ities and social context), predisposes an individual to
bulimia. Continuing in a Kohutian context, the buli-
mia itself could be understood as an example of a
narcissistic behavior disorder (Kohut and Wolf,
1978)-Le., an underlying distortion of the selfleading
to symptomatic behavior (bulimia) which exposes the
individual to serious physical and social dangers. (Fur-
ther discussion of Kohut and his self-psychology
would be digressive. Gustafson (1976) has made some
interesting links between the work of Balint and Ko-
hut. Curious readers are referred to his paper.)
It is clear that the syndrome bulimia is clinically
manifested as a sequence of discrete behaviors and/or
mental states which unfold over time. A typical se-
quence, which we have come to call the "bulimic
sequence," is as follows: restrictive dieting, binging,
493
vomiting, relaxation, and repudiation. (Although all
bulimics per definition binge, combinations with the
other four features are invariably found. Of course,
the sequence of each bulimic is unique: e.g., some
binge, vomit, and repudiate, but do not diet excessively
or experience relaxation; others diet, binge, vomit, and
relax, but do not repudiate, etc. Nevertheless, for the
purposes of this paper five phases of the sequence are
delineated.) This driven sequence can occur over min-
utes or hours depending on the individual patient.
What we will have to say about this sequence rests on
three cardinal assumptions:
1. The bulimic sequence is a behavioral reflection
of deeply held, grossly contradictory attitudes
toward food;
2. The sequence acts as a defensive reparative ma-
neuver which attempts to bridge the basic fault
and to fulfill vital human needs which cannot
otherwise be met by the patient;
3. Her shifting relationship to food during the se-
quence is a concretization of her shifting rela-
tionship to human objects, whether it be the
archaic parents, contemporary interpersonal re-
lationship, or within a transference context.
(This assumption, of course, has very direct clin-
ical significance.)
During the dieting phase of the sequence, the bu-
limic assumes the attitude of a nutritional philobat-
i.e., she overcathects her ego functions in an attempt
to gain mastery over her appetitive urges and food.
She sees food as a treacherous hazard which must be
negotiated, and finds comfort in safe, friendly expan -
ses (see Table 1). These expanses are represented
internally by persistent hunger which reassures that
there is a comfortable emptiness within and externally
by the long time intervals between feedings. While in
the midst of philobatic dieting, she must display an
extraordinary degree of skill. She demonstrates exper-
tise around nutritional issues: for instance, she knows
the caloric and nutritional value of the food she keeps
at a safe distance; she constantly surveys the sur-
rounding food environment; and she is exacting self-
critical in her relationship to food. Moreover, she
temporally bridges one of her deficient tension-regu-
lating functions: she established a stimulus barrier to
food, a threatening object, albeit a rigid one vulnerable
to collapse. Thrill would be too strong a word to
describe the satisfaction stemming from her philoba-
tism, but she does experience a satisfying sense of
self-mastery and psychological cohesion, vital needs
difficult to meet in other contexts. Table 2 summarizes
the underlying attitude, as well as reparative gains in
tension regulation and vitals needs, found during di-
eting and the other phases of the bulimic sequence.
494 WILLIAM J. SWIFT AND RONELLE LETVEN
TABLE 2
Functions of Bulimic Symptomatology in the Psychic Equilibrum
Symptom Tension Vital
Attitude
Sequence Regulation Needs
Dieting Philobatic Adequate stim- Mastery, self-cohe-
ulus barrier sion
Hinging Ocnophilic Self-soothing Meeting disavowed
nutritional, de-
pendency and af-
fectional needs
Vomiting Orgiastic Tension-reliev- Libidinal release
ing gratifica-
tion
Relaxation Primary love, Harmony with self
merger and environment
Repudiation Denial and Alleviation of
undoing shame/guilt re-
garding the bu-
limic sequence
Keeping food at a safe distance and in sight, but
never too near, has another defensive benefit: it allows
the bulimic to selectively focus her powers of concen-
tration on the external world and thus avoid anxiety-
provoking internal issues. Her situation, however, is
very much more complicated than that of an alcoholic
who maintains sobriety by total abstinence. One can
live without alcohol but life is impossible without food.
Her philobatism places her in a precarious situation.
She must eat but one false step can have dire conse-
quences-loss of control and a greedy binge.
The transformation from philobatic dieting to oc-
nophilic binging is an example of "vertical splitting"
(Kohut, 1971). These two primitive attitudes, sitting
side-by-side in the psyche, as it were, are acted out
one at a time in different situations, at different times,
and with different internal stimuli. The arrows in
Table 1 represent the rapid, complete, unexpected
shift from one attitude to another. Several factors
must contribute to this dramatic dislocation. The skill
and attention needed to maintain the philobatic atti-
tude is perhaps simply too exhausting, too exacting,
to carryon for prolonged periods of time. Another
contribution could be the buildup of warded off nutri-
tional and passive-dependent needs, a direct conse-
quence of the restrictive dieting.
During the binge, the bulimic assumes the attitude
of a nutritional ocnophil-Le., she overcathects food,
disregarding any ego control, in an attempt to self-
soothe and fulfill disavowed nutritional and depend-
ency needs (see Table 2). Expanses which had been
seen as safe and friendly while dieting are now felt as
horrid and threatening; food is transformed from a
treacherous hazard to a safe and comforting object. In
fact, she desperately clings to food. Eating takes on a
ferociouscast as large volumesof foodare bolted down.
She can not enjoy the leisurely pace, the spatial!
temporal intervals, associated with a good feed since
they are now felt as threatening external expanses.
Thus such activities as seeing, smelling, tasting, and
even at times, chewing food are utterly neglected.
Since food now symbolizes objects which have de-
faulted on her, or "dropped" her, the eating pattern
appears to be an attempt to control an untrustworthy
object by magical introjection; although really wanting
to be held and cared for, the bulimic instead fills her
belly to the bursting point lest she should once again
lose the object or be let down by it. This effort to self-
soothe proves to be illusionary. True, the threatening
internal empty spaces have now vanished, but they
are quickly replaced by an explosive, persecutory full-
ness near the conclusion of the binge. She then de-
spises herself for losing control of her urges and her
dependence on untrustworthy objects. Self-induced
vomiting quickly follows.
The place of vomiting in the sequence can be inter-
preted in several different ways. As·previously men-
tioned' Casper (1981) believes the bulimic undoes her
dependence on the hated food by expelling it. Sours
(1980) and Sugarman and Kurash (1982) hold that
vomiting counters the wished for but dreaded fusion
with the archaic mother which is implicit in binging.
In contrast, we would submit that the vomiting pri-
marily provides an avenue of tension-relieving grati-
fication (see Table 2). The bulimic is typically so
uncomfortable with her aggressive and sexual urges
that more usual modes of release are unavailable to
her. By raising her abdominal and psychological ten-
sion to the bursting point and then dramatically re-
leasing it, as occurs with vomiting, she does achieve
some measure of gratification. Moreover, it is a safe,
solitary release not involving another. In some pa-
tients the vomiting is frankly eroticized.
In the fourth phase-relaxation-she briefly attains
a state of harmony within the psychological self and
with the environment. Balint (1968) has called this
underlying attitude "primary love," a sort of harmo-
nious merger between the self and the environment in
which one feels free of threat from either sphere.
Following the vomiting, she feels drained of the ten-
sion that chronically besets her and overspread with
a deep relaxation; the bulimic sequence may be her
only way of reaching this tension-free position. A
rough analogy would be the relaxation felt after a
satisfying sexual experience. This phase may last for
minutes or hours depending again on the individual.
As her internal tension, stemming from the basic
fault in the area of tension-regulation, rises again the
bulimic enters into the fifth and final phase, repudia-
tion. At this point she feels intense shame and guilt
about the entire sequence and promises to her self
that she will now finally be reasonable about food. She
 PSYCHOANALYTIC INTERPRETATION OF BULIMIA 495
forswears any future episodes of binging-vomiting. done it, you might just as well show what a pig you
She determines to set her life right. Her underlying really are." These words invariably heralded the start
attitude is one of denial and undoing (see Table 2). of a gigantic binge. Her binging occurred in the context
Her excessive "snap-out-of-it" 'optimism is well-in- of a disassociated, "not me" mental state. She de-
tended but short-lived as she slides once again into scribed that her usual reticent personality receded and
philobatic dieting, thus renewing the entire sequence was replaced by that of a "greedy, powerful male." She
which over time becomes a vicious cycle. gorged to the bursting point.
As her abdominal distention became unbearable,
The Case of Avis she related "returning to my senses," i.e., the greedy
Avis, a 21-year-old female patient, entered treat- male receded and her enduring personality returned
ment with a 2-year history of daily binging and vom- to the fore. Vomiting was a great relief as the oppres-
iting. Over a 1-year period she was seen twice weekly sive food was expelled over a matter of minutes. She
in psychoanalytic psychotherapy with marked symp- now felt purged of all tension. She spontaneously
tom reduction. Her case is presented in order to bring characterized her binging and vomiting as "my stom-
to life our dynamic formulation of bulimia. In this . ach orgasm." (Not only was she without sexual expe-
brief vignette, emphasis is placed on her impairment rience, she could not recall ever engaging in sexual
in tension-regulation, the bulimic sequence, internal fantasy.) As her relaxation subsided,.she scolded her-
object relations, and a transference distortion which self and promised that she would never again yield to
developed when the therapist approach her symptom- such urges. Soon, however, she was fasting, thus re-
atology too directly. We think her case to be rather initiating the entire sequence.
typical of the severe bulimic. Avis had great difficulty in reconciling contradictory
Besides her eating problem, Avis complained of parental introjects. She was merged in an archaic,
feeling continually tense, demoralized, and drained. intrapsychic sense with her mother whom she ideal-
Her stimulus barrier to internal and external impinge- ized as the perfection of womanhood. In Avis' eyes,
ment was inadequate, e.g. she was easily overwhelmed mother was good, nurturant, self-disciplined and self-
by the perceived needs and demands of others as well sacrificing, and utterly beyond reproach. Kohut (1971)
as by her own needs and self-exacting standards. She has described such a constellation as an archaic ideal-
had no abiding cultural, religious, or aesthetic inter- ized parental image. In comparison, Avis judged her-
ests that she could turn to when solace was necessary; self to be a miserable failure, her symptomatology
moreover, she had little capacity to be alone (Winni- graphically confirming her shortcomings. As the mid-
cott, 1965) finding that it only increased her unease. dle of five children she had been closely tied to her
Her global inhibition left her with few channels for mother during her early years and had served as an
instinctual or subliminal release. She demonstrated auxillary parent to her younger siblings as mother was
what Malan (1979) has called a "negative emotional often preoccupied with other family and work com-
balance," i.e., feeling that she paid out much more to mitments. She both relished and detested this role.
life and others than she ever received back. She was Mother did indeed have some exemplary properties:
aware she sought emotional relief in her aberrant she was a woman of resolve who had overcome some
eating. Early in the course of treatment she said, "I desperate circumstances in her own childhood and she
feel like a 2-year-old with a Linus blanket (food)whose obviously cared for her children. However, genetic
parents have left on a trip and is scared." reconstruction and a series of family meetings also
Avis exhibited a feast or famine eating pattern. She disclosed a number of patent personality limitations.
dieted constantly between her massive binges, often She was emotionally inhibited, tending to be overcon-
skipping meals completely. She assiduously counted trolled and overcontrolling, but most prominently, her
calories and especially avoided all sweets since they empathic capacity was limited-she had difficulty dis-
were likely to precipitate a binge. She was slim, though cerning the needs of others and responding appropri-
not emaciated, and took great pride in her figure and ately to them. In contrast, Avis perceived her father
the willpowerto which it so dramatically attested. Her in a vastly different light. She saw him as a warm,
self-esteem was painfully low and her philobatic diet- albeit more distant figure than mother, whose unpre-
ing served as a means of bolstering it. dictability and emotional outbursts frightened her. It
Avis did not impulsively binge food regularly found appeared that her philobatic dieting, in part, repre-
in her home. Rather she meticulously planned each sented an identification with her always-in-control
binge and made separate trips to the store for the mother while her ocnophilic binging was an identifi-
required "forbidden" items. Upon return she would cation with her passionate father.
neatly spread out the foods before her, take the slight- In therapy, Avis formed a stable narcissistic trans-
est bite and self-accusingly say, "Well, now you have ference with rather minimal resistance. It was largely
496 WILLIAM J. SWIFT AND RONELLE LETVEN
of the idealizing type in which her infantile need for
a merger with a source of idealized strength and calm-
ness was revived (Kohut and Wolf, 1978). However,
she also seemed to draw strength from the therapist's
empathic mirroring ofher nascent attempts to develop
gratifying outlets, to self-soothe, and to be judiciously
self-protective in relationship to others. Distorted,
shifting attitudes toward objects, as manifested in her
eating, remained latent in the transference until the
therapist took a suggestive approach to her eating
problem when he recommended that she not binge
and vomit before the next appointment, as was her
custom, and instead bring her full-blown psychoso-
matic tension to the hour. At the time, the therapist
hoped that this would bring her anxiety more directly
into the treatment. In retrospect, it was clearly a
countertransference reaction as the therapist had
grown frustrated with her slow progress. He had un-
wittingly intruded by becoming defensively preoccu-
pied and controlling of her noisy symptoms. His sug-
gestion threatened the breakup of her precarious sense
of self with the result that shifting attitudes were
activated in the transference-at times she would
emotionally disengage as if to keep the therapist at a
safe distance, at others she would desperately cling
and attempt to assert omnipotent control, while at
still others she would repudiate the therapy and the
therapist as inconsequential and declare herself cured,
a classic "flight into health." Order was restored when
the .therapist was able to empathically clarify the
threat his suggestion had posed, her disappointment
and rage with him, and her subsequent defensive
maneuvers. With such efforts the stable narcissistic
transference was revived and the ultimately successful
work of therapy was able to proceed.
Conclusion
If bulimia is similar to other psychiatric disorders,
and there is no reason to assume it is not, there are
undoubtedly a great number of psychopathologies and
character structures for which it can serve as a com-
mon symptomatic solution. In this paper we have
chosen to focus upon the more malignant form of
bulimia. Our psychodynamic formulation may be ad-
mittedly misleading or inadequate when applied to
milder forms. Another caveat concerns the exclusively
intrapsychic framework upon which our construction
is founded. We are convinced that bulimia will be
most fully understood by means of a biopsychosocial
model. As Lewis (1982) has written, until a genius
arrives to adumbrate a superordinate general theory
of human behavior, the biopsychosocial model, even
though far from elegant, is the most comprehensive
now available. In this paper we gave short shrift to
this conviction. We emphasized psychodynamics but
largely disregarded biological vulnerabilities (e.g., de-
pressive diathesis', mood instability), family context,
and sociocultural forces which all contribute to the
emergence of the illness (Schwartz et al., 1982). We
did this not because we doubt their importance but in
order to maintain a steady, "in-depth" focus on the
salient dynamic issues.
Previously we alluded to the apparent chronicity of
this disorder. We think that our conceptualization
which sees the basic fault residing at a fairly deep
level and the symptomatology acting as a partially
successful defensive reparative device is in concert
with this generally held clinical impression. The bu-
limic sequence is the best the patient can do given her
past and present circumstances, and, in that sense, it
has undoubted staying power. However, bulimia is an
ersatz solution and no substitute for more mature,
adaptive forms of tension-regulation such as subli-
mation, genital sexuality, a personal identity, stable
self-esteem, and freedom from an archaic superego.
Lastly, a few remarks about bulimia and psycho-
therapy. We, of course, agree with Malan (1979) that
the underlying disturbance, in the more malignant
form of the disorder, at least, is of "very considerable
severity," as demonstrated by the intensity of preoc-
cupation and the driven quality of the sequence. In
such situations, the conveying of insight may be ther-
apeutically less important than the intuiting of unmet
developmental needs and empathic ally responding to
them (Marohn, 1982). This is not to say that insight
by means of clarification and interpretation is unim-
portant. For instance, many of these patients are
undoubtedly strengthened by the clarification of feel-
ing states Which they perceive in only the most vague
and fleeting terms, and by eludicating the stimuli,
both internal and external, which heighten the urge
to binge. Insight also has its place as the bulimic
comes to understand the genetic roots and dynamic
purposes of her symptomatic behavior, and thus be-
gins to establish some mastery over her urges and
conflicts.
On balance, though, we think it is most important
for the therapist to be attuned to the impairment in
tension-regulation and to empathically respond to
emerging mirroring and idealizing needs (Kohut,
1971); for example, by confirming the patient's nas-
cent, often halting attempts to develop self-soothing
capacities, to erect a protective stimulus barrier, and
to discover new outlets. When such attempts fail, it is
incumbent upon the therapist to provide an appropri-
ately calming and self-enhancing environment from
which the patient can temporarily draw strength until
she can once again resume her quest for physiological
health and psychological maturity.
 PSYCHOANALYTIC INTERPRETATION OF BULIMIA
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