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Hyperorexia Nervosa (1 976)

H. U. Ziolko
(Accepted 22 March 1994)
This brief report-the English translation of a German paper originally published in 1976
(Psychotherapie und Medizinische Psychologie, 26, ?0-?2)-describes a peculiar eating
behavior as observed in neurotic patients. This remarkable syndrome, delineated as
hyperorexia nervosa, shows a close relationship with the better-known opposite syn-
drome, anorexia nervosa. 0 1994 by John Wiley & Sons, Inc.
The present article is a short and sketchy report on a circumscribed syndrome of patho-
logical peculiarities of eating behavior as seen in many neurotic patients-so far more
than 70 are known to us.
The syndrome is characterized by a greedy, urging, and compulsive desire for food;
excessive food intake, at times preferably in the evening or at night; increase of body
weight; vomiting (possibly leading to normal weight or even emaciation); constipation
and, resulting from this, use or abuse of laxatives; often menstrual irregularity; theft (of
food or money for buying food); depressive mood (with suicidal tendencies and at-
tempts, as well as diminishing social relations); the highly ambivalent attitude related to
the hyperphagia and expressing its nonacceptance.
The syndrome displays a sex and age disposition because mainly women are affected.
The onset of illness is mostly at the age of puberty or postpuberty. Its course is showing
a more continuous picture with episodic exacerbations. This unipolar (hyperorectic)
form represents the counterpart of the better known opposite-anorectic-syndrome.
The appearance and experience of this syndrome manifest itself in an intensive, often
sudden and irresistable urge to eat. Due to an uneasiness, an intolerable restlessness and
tension, the patient repeatedly pounces on food as if being on the verge of starvation.
The sensual experience of food intake or the act of devouring sometimes still adheres
to a lust to eat, with a sedative, satisfying effect. It causes, however, a state of passive
apathy, like being in a daze; the feeling of repletion only allows the patient to lazily
Horst-Ulfert Ziolko, M.D., i s Emeritus-Professor of Psychiatry, Free University of Berlin (formerly Federal
Republic of Germany). Address reprints requests to Prof. Dr. H. U. Ziolko, fichenallee 34A, 14050 Berlin,
Germany.
This article is an English translation of the German article Hyperorexia nervosa originally published in
Psychotherupie und Medizinische Psychologie (1976, 26, 10-12). For a discussion of its importance, see The
Emergence of Bulimia Nervosa as a Separate Diagnostic Entity: A Review of the Literature from 1960 to 1979
by W. Vandereycken (appearing in this issue).
fnternationat lournai of fating Disorders, Vol. 16, No. 2, 133-135 (1994)
0 1994 by J ohn Wiley & Sons, Inc. CCC 027~3478/94/020133-03
134 Ziolko
fall into bed. The dependence on food-even thoughts are centered around this as a
kind of alimentary preoccupation-is experienced as an addiction: Gluttony had de-
generated into a real addiction. J ust like an alcoholic, being a prey to drinking, I was
addicted to eating. This involves heavy expenses for the sometimes extremely large
quantities of food; amounts of 20, 50, even 100 German marks per day are not unusual.
With increasingly indifferent sensations, however, enjoyment of eating mostly fails to
come. The patients greedily, hastily and-above all, secretly-stuff themselves with any
kind of food in large amounts and preferably in the evening, usually without a sensation
of satiety. The senseless gluttony is often felt to be foreign. Even self-tormenting,
obsessive tendencies can be observed, such as the urge to eat even if the patient is not
hungry, so that her fondest wish is to be freed from the constant compulsion to eat.
Physical signs of nonacceptance are queasiness, abdominal pain, and often excessive
vomiting. Laxative abuse also belongs here. The never-absent extreme ambivalence
towards this hyperphagia expresses itself in unpleasure, in clear feelings of shame and
guilt, and already in the secrecy of overeating or the fear of being caught. One patient
felt exposed to constant fighting against a hell-hound inside her when suffering from
binge eating. After having to eat, she always felt sick and disgusted. The ultimately
missing satisfaction of the eating raids leads to further inevitable frustrations, to depres-
sive desperation with the feeling of being worn-out, empty, and dead. When I was full
up, when I felt really sick, then came the cruel depressions, everything was shattered.
Self-reproach and self-condemnation do not only refer to the greedy consumption of
food but also to the visible consequences of excessive appetite, the (mostly) increased
body weight, together with neglect of the outward appearance and the loss of esthetic
demands in looks and clothing. Contact to the surrounding is avoided by withdrawal
and isolation. The tormenting frustration, that any kind of longing with the unfulfilled
attempts of satisfaction anyway, is aptly described by a patient: The worse I looked,
and the fatter I got, the more 1 ate and the other way round. I really hated myself.
But even during the binges the self-destructive impulses are felt. The patient knows
she ruins herself by overeating in furious defiance. A patient who had gained 17 kg in
4 months as a result of her urge to eat, always imagined eating herself to death and
everything pouring out of her while eating. That way all the rage, which is actually
directed against others, is abreacted by eating. This shows the original ambivalent-
hostile object relationship. Constant stealing of food or raiding the refrigerator or the
pantry are aggressive acts of theft; they are also directed towards money, which is then
used for the increased food requirements. At night a patient took the key to the kitchen,
which had been locked by her parents, from their sleeping room. I broke into the
kitchen and devoured everything I could stuff into myself.
The oral-sadistic impulses (eating rage) are also perceived in the projection of the
devouring, swallowing, cannibalistic mother or in a direct way, because eating is
connected with the mother, who is supposed to be hurt. Thus eating becomes a vin-
dictively used weapon. At the same time the deep symbiotic longing for dependence is
resisted and replaced, because the excessive eating is an attempt to restore the unity
with the mother. In this way the patient strives for shelter and comfort, and tries to
satisfy the urge of the weak ego for closeness and security.
It is obvious that problematic and insufficient couple relations result from this regres-
sive pregenital condition. Overeating in its orgastic quality, substituting sexual-genital
satisfaction patterns, serves to avoid (hetero-) sexual relations; being fat makes it im-
possible to sleep with the partner. The object independence supposedly gained in this
way is related to this pseudoautarchic form of satisfaction. Moreover food implies the
Hyperorexia Nervosa 135
ever-available substitute one is unable to resist. In this way the patient experiences her
being special and powerful, which is also shown in her bodily sizes.
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