Molecular Psychiatry (2006) 11, 1070–1072

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PERSPECTIVE

150 years of Sigmund Freud: what would Freud have said

about the obesity epidemic?
SR Bornstein1, M-L Wong2 and J Licinio2
1
Department of Medicine, University of Dresden, Dresden, Germany and 2Department of Psychiatry & Behavioral Sciences,
University of Miami Miller School of Medicine, Miami, FL, USA

The 150th birthday of Sigmund Freud has triggered widespread interest and media coverage
on his unique contribution and impact on society. Recent evidence from neuroscience and
advanced imaging technology has provided support for some of his major concepts including
the unconscious and the key role of early life events. In this perspective, we attempt to write on
his behalf an updated version of a Freudian way of thinking focused on the current high rates
of obesity and depression.
Molecular Psychiatry (2006) 11, 1070–1072. doi:10.1038/sj.mp.4001912
Keywords: Sigmund Freud; unconscious; obesity

I, Sigmund Freud, am 150 years old now, and even if
you do not support my way of thinking, you should
give me the consideration that is commensurate with
my age and the relevance of a vast life experience. If
you had listened earlier, I could have told you that
what we are seeing today is a logical consequence of
what could have been predicted for the Western
world many decades ago. There is now an unprece-
dented and uncontrollable rise in overweight, obesity
and eating disorders associated with metabolic,
cardiovascular and mental morbidity.
This major health problem of our modern world is
not only starting to cause the financial collapse of our
health care systems, but is also affecting transporta-
tion, fashion, food manufacturing, and most impor-
tantly our self-esteem. I believe it would be fair to say
that the enormous rise in the rates of obesity is calling
the way we live and the foundations of our modern
society into question. Current strategies hastily
implemented to address this issue by appealing to
reason, proposing behavioral strategies, promoting
changes in the way we lead our lives – including
sport and eating habits, and developing new diets and
pharmacological interventions have all failed to
reverse this process.
It comes to me as no surprise that you should at last
seek my advice and counsel on this most precarious
of matters, asking me why you have erred, and how
you should act now. I must admit to a modicum of
pride at the publicity on my 150th birthday. After
years of condemnation, great and renowned news
Correspondence: Professor SR Bornstein, Department of Medi-
cine, University of Dresden, Carl Gustav Carus, Fetscherstrasse
74, 01307 Dresden, Germany.
E-mail: Stefan.Bornstein@uniklinikum-dresden.de
Received 13 July 2006; accepted 25 August 2006
agencies and even Nobel laureates are raising my
name to high repute.
The integration of psychoanalysis in neuroscience,
modern imaging and molecular medicine is an
exciting development that I have long since been
awaiting and anticipating. I am pleased to learn that
neuroscientists are finally confirming the existence of
unconscious mental processing. Cognitive scientists
are now providing biological proof for ‘implicit’ or
‘unconscious’ memory processing following brain
injury or mediation of emotional learning. Irrational
fear responses and other abnormal behavioral patterns
are based on the bypassing of the hippocampus,
which mediates conscious memory, thus connecting
the conscious cortex with primitive brain structures,
triggering unconscious remembrances of early stress-
ful events. Fear conditioning induces associative
long-term potentiation in the amygdala, and early life
stress impairs fear conditioning.1–8 You may, however,
ask how this might relate to the problem of obesity in
our society? I would say the answer to this question
should be self-evident.
I have always claimed that the most critical events
take place early in life. What I first called infantile
amnesia is our inability to realize and recall to
consciousness our earliest memories, which affects
our adult life and health. I am glad to learn that
neuroscientists have now confirmed this concept by
showing that the essential brain structures relevant
for the formation of explicit or conscious memories
are only fully functional after the first 2 years of life.
Concerning the rise in eating disorders and obesity,
recent studies have clearly demonstrated that the
most critical events occur in early maladaptive
programming of the brain.9 The pleasure principle
was based on my proposal that the unconscious ego is
not ruled by the reality principle. It is therefore

obvious that rational and logical recommendations for
changing our lifestyles and our eating behavior are
destined towards failure in the long term. One’s
motivation to address a problem that one is not aware
of at the unconscious level is naturally quite low. All
of us dealing on a routine basis with overweight
patients are amazed by their ability to rationalize and
nurture false beliefs. Their caloric intake objectively
surpasses by far the amount of calories that they burn,
which is why they gain weight. Nevertheless, they are
profoundly convinced that they eat almost nothing
and are completely innocent in this process of
becoming obese. It is almost as if all others besides
themselves are responsible for their obesity. What
strikes every dietician or practitioner dealing with
obese individuals is the strength of the ‘repressing
ego’ governing illusions, wishful thinking and denial
in these individuals.
That pleasure-seeking behavior and instinctual
elements are dictating fundamental aspects of our
daily life has always been most difficult to accept for
those who dictate the moral standards of our society.
For me, it comes as no surprise that neuroscientists
have identified endogenous pathways for addiction
such as the endocannabinoid system, and that it is
this system that holds the latest promise for control-
ling obesity.10–12 However, this will merely scratch the
surface, as it does not address the causes of weight
gain. Psychoactive medication to treat craving for
food based on early programming of libidinal and
other neurochemical pleasure-seeking systems must
be combined with psychotherapy. Indeed, your
modern techniques of brain imaging are documenting
the synergism of such a combined approach.
Having said this, I easily picture the disdain and
fierce criticism of my most faithful opponents who
had hoped that my ideas and the therapeutic
strategies of psychoanalysis were finally buried on
the graveyard of scientific aberrations. And now this,
a home for my ideas in the context of a problem as
serious as worldwide obesity. Could there be anything
more absurd? Is this another case of complete
speculation in the era of evidence-based medicine?
How dare an old Viennese gentleman propose lengthy
and certainly ineffective therapies in a time when
health care systems are collapsing due to unprece-
dented financial burdens? Yet, biomedical science
needs new directions to break the negative vicious
cycle that is leading to a downward spiral. And as
requested by Eric Kandel, modern psychoanalysts
must open their mind towards current principles of
biomedicine and integration into clinical trials with
defined, end point pharmacogenomics and modern
imaging techniques.
There is a logical explanation to the current and
uncontrollable obesity epidemic, which is the evolu-
tionary component of human obesity. We know that
fat deposition in humans peaks during late gestation
and early infancy. We also know that human fat stores
not only buffer malnutrition but also influence
reproduction, immune function and even sexual
150 years of Sigmund Freud
SR Bornstein et al
1071
selection. Therefore, the increased value of energy
stores in our species may be the consequence of
factors increasing uncertainty to nutrient availability
and vulnerability to that uncertainty.13 In our own
evolution, the capacity to accumulate fat has been a
major adaptive feature of our species, but modern
environment has made energy expenditure an op-
tional event in the context of abundant and cheap
food. In rich, Western societies, and gradually all over
the world, there is almost no fluctuation in food
supply, lifestyle is sedentary and stress is psycholo-
gical and not physical. Activities that require physical
labor such as farming and factory work are rapidly
replaced by the service and technology industries
where work is conducted sitting down, with minimal
physical energy requirements. This obviously leads to
a disequilibrium, overtaxing our metabolic system.14
It is evident now that the increasing incidence of
childhood diabetes and the shift to younger age at
onset are not primarily a consequence of early
triggering of autoimmunity, but due to overload of
effects including insulin resistance due to excess fat
cell accumulation and increased insulin requirement
due to accelerated growth rate, inflammatory milieu
and psychological stress.
The conundrum faced by experts today is that
public health programs raising this awareness in
pregnant mothers and young families aimed at
changing overfeeding and the sedentary lifestyle of
children are hard to be successful if there are strong
mechanisms of repression and denial at play. We
know that exposure to early life trauma is associated
with adult obesity. Recent studies have confirmed
that there is a highly significant correlation of early
life stressors with body mass index independent of
any other relevant medical or psychiatric history.9 A
history of being bullied, rejected and emotionally
abused predicts adult obesity. There is clearly a
shared biology of obesity and metabolic disease on
the one hand, and anxiety and depression on the
other.15
Based on these recent revelations and insights,
would it not seem reasonable to give my approach at
least a second thought? First of all, accepting the
notion of unconscious mechanisms that repress
rational approaches for changing our lifestyle will
help us approach the roots of the obesity problem. We
seem to have not only an obesogenic modern
environment, but also obesogenic early programming
of our brain. Theseus used a ball of thread as he
entered the labyrinth of the Minotaur. He fastened
this thread to the door and let it trail behind him as he
went in. After killing the Minotaur in the remotest
section of the labyrinth, he managed to make his way
out again by pulling himself along the thread. I used
this legend to develop this technique of psycho-
analysis, disclosing key events of early life as the
origin or cause of the actual problems of a patient.
It seems worthwhile to use the thread of Theseus
to unmask the biological and genetic mechanism
leading to an enhanced susceptibility to both
Molecular Psychiatry
 150 years of Sigmund Freud
SR Bornstein et al
1072
environmental and mental maladaptation to our
modern environment. Additionally, the principles of
psychoanalysis may help unearth early traumas, fear
and anxieties that lead to stress and comfort eating.
The combination of repressed angst caused by early
life trauma, chronic psychological stress, depressive
features, paralyzing lack of physical activity and
eating that is dissociated from actual caloric needs
keeps large segments of our society from controlling
their weight. Lasting solutions to obesity must
address the interface of reality, repressed fears and
unconscious conflicts that determine the specific
pathways of the search for pleasure. Testing of these
hypotheses would be a most appropriate 150th
birthday present for me.
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