Themes of Death: Helmut Thoma’s “Anorexia Nervosa” (1 967)-A Research

Note

Craig Jackson Johanna K. Tabin

Janice Russell Stephen Touyz

(Accepted 3 December 1992)

In the recent literature on eating disorders, little attention is usually given to the possible role played by heightened death fears and anxieties and failed death transcendence in the dynamics of patients who suffer from anorexia and bulimia nervosa. For reasons that remain unclear, early texts and articles in the literature do address death themes, particularly as they are discernible from patients’ dreams and nightmares.

Thoma’s 1967 text Anorexia Nervosa may be interpreted as giving further illustration to this thesis. 0 1993 by lohn Wiley & Sons, lnc.

Our research has shown the significance of recognizing themes of death-related anxi- ety in anorexic patients (Jackson & Davidson, 1986, 1989; Jackson, Beumont, Thornton, & Lennerts, 1992). Evidence for this assertion abounds in previously reported cases in the literature, especially as found in unconscious material such as dreams. Nonethe- less, it has not as yet become routine in clinical practice to take death themes into ac- count in theorizing about eating disorders or in trying to assist these patients in treatment. This is why Jackson and Davidson (1989) have described the existing litera- ture bearing on death themes as the ”hidden” literature on eating disorders. The cen- tral postulated dynamic, that of failed death transcendence, is mostly regarded as an unusual if not unacceptable approach to understanding the etiology and maintenance of an eating disorder (Lifton, 1976; Yalom, 1980).

References to death as a theme in the literature on eating disorders are more likely found in articles in German and French (Bensoussan, 1986; Fouraste, 1979; Nicholle,

Craig Jackson, M.A. Dipl. Ed. Psych., is Senior Educational and Child Psychologist with the Special Education Ser- vice in Wellington, New Zealand. Johanna K. Tabin, Ph.D., i s Psychoanalyst practicing in Glencoe, Illinois. She is a member of the Faculty and of the Registration Board, Chicago Center for Psychoanalysis. Janice Russell, M.B., F.R.A.N.Z.C.P., is Senior Lecturer in the Department of Psychiatry, University of Sydney, and Director of the Eating Disorders Unit, Northside Clinic, Greenwich, New South Wales, Australia. Stephen Touyz, Ph.D., is Associate Professor in Psychiatry, University of Sydney and Head, Department of Clinical Psychology, Westmead Hospital, New South Wales, Australia.

International journal of Eating Disorders, Vol. 14, No. 4, 433-437 (1 993) 0 1993 by John Wiley & Sons, Inc. CCC 0276-3478/93/040433-05

Jackson et al. 434

1938; Raimbault, 1971; Thouzery-Loras, 1984) rather than in English, although an ex- ception is provided by Spignesi (1983), and Tabin (1985). Two further contributions from the German literature illustrate the veracity of this observation. In an earlier research note "Dreams of Death," a paper by Viktor von Weizsacker, published in 1937 and en- titled Dreams in So-called Endogenic Magersucht (Anorexia) was reinterpreted to more clearly identify the themes of death that permeated his patients' nightmares.

Another seminal work that analyzes the dream content of anorexic patients is Hel- mut Thoma's Anorexia Nervosa (1967). Themes of death are evident in the many examples of his patient's dreams, which are included in this text. Thoma does not cite von Weizsacker's paper and may not have been aware of his work on the nightmares of his anorexic patients.

Thoma, a psychiatrist who was trained in Germany, carried out the preparation for his book in the 1950s, the German edition first appearing in the autumn of 1961. His theoretical orientation was primarily psychoanalytic. This text consists of a summary of research on anorexia including a comprehensive review of the field to that date; five case histories in detail, and finally in chapter 7, a rather complex and rambling presen- tation of the psychogenesis and psychosomatics of anorexia nervosa. This theoretical chapter avoids the integration of death-related clinical material into theory. It is strik- ing how evident this failure to integrate death-related material into his theoretical sche- mata is, in view of the actual death-laden content of the case histories, which supports the importance of the death themes in the dreams. This is well illustrated by one of "Sabine B's" dreams, here quoted in full (Thoma, 1967):

I arrived for the interview. But Dr. T. was not in his room. The doorman told me that Dr. T. had been run over by a car and was dead. I went to the scene of the accident. There I heard that Dr. T. was squashed flat and that there was nothing left of him. I searched for myself and eventually found a small piece of flesh, which revolted me at first. Then I took it with me after all, thinking, "Perhaps a new human being will grow out of it." It occurred to me at home that Dr. T. had once told me that babies in their mothers' stomachs are nourished by blood. I thought to myself, "I can also nourish the piece of meat with blood; 1 only need to have a good nosebleed-which then actually happened. [The patient had occasional nosebleeds.] I caught the blood in a bowel and put the piece of meat in it. Now I could see exactly how the arms and legs grew, and I thought, "Later on there'll be a head as well."

Thoma regards this dream as a further example of how Sabine B was still pursuing her fantasies of oral pregnancy. While the sexual elements here are clear enough, and also the theme of redemption, the most pronounced and unmistakable mode of expression is through the violent and destructive elements of death itself that permeate this dream. It serves to express Sabine's ambivalence over recovery and growing up to mature wom- anhood and fecundity on the one hand, versus death and destruction on the other.

Sabine B s ideal of ascetic perfection caused her to try to become a doll that did not eat or defecate. Thoma quotes Sabine as linking food with being poisoned, with feces, and with cannibalism. No wonder Sabine regarded her natural bodily functions with revulsion and disgust. Only a nonliving, inert doll could achieve purity, not a living person who needs to process death as food in order to remain alive.

Sabine was readmitted to the hospital to continue her therapy after her mother suf- fered a stroke. Sabine planned to die before her mother did in a white robe like a wed- ding dress so as to be beautiful even in death. In another dream, she dreamt she was dead but yet alive; in yet another she was in slaughter-house so interested in the sight of dismembered animals that she could not tear herself away from the building. In fur-

Themes of Death 435

ther dreams her dead grandmother reappeared as a beloved figure even though in life grandmother had sought to discipline her by inventing infernal punishments that fur- ther increased the child’s insecurity and terror. In another of her bad dreams Sabine’s mother brings a wash basket in. Inside lay pieces of flesh, head, feet, arms, and other dismembered pieces. They were the bodily parts of her obviously dead sister Maria. Sabine struggled with death wishes towards Maria. While her baby sister subject of in- tense sibling rivalry was being bathed she imagined that the bath water would turn to ice and that Marie would freeze to death-she could watch this dreadful process through the ice.

Other fantasies involved burning or starving animals to death in place of her sisters and in enjoying watching a cat tease a mouse to death. Her picture of an “ideal” woman is what she used to look like. “The woman is like a corpse, like a ghost.” Sabine devel- ops pruritus, activating scratching of herself, interpreted by Thoma as “a self-destructive transposition of her repressed aggressive impulses.” In the recovery phases of her ill- ness Sabine begins to masturbate. “It used to feel dead before, like withered flesh” (Thoma, 1967). Ellen West and Sheila MacLeod also occupied dead bodies while their self remained alive (Binswanger, 1944- 1945-1958; MacLeod, 1981).

In the third case history described by Thoma, Agnes C., themes of death are also manifestly evident. Her illness was preceded by her dream of being in the underworld with a lot of skeletons. Although she too was a skeleton, unlike the others she was wearing a hooded cape which she tossed aside. She then had a distinct feeling that a new life was about to start. This dream transformed her, leaving her with a feeling of relief that it was now up to her to choose whether to live or to die.

Gertrude D., case four, formed direct associations between eating, food, killing, and death. She once dreamt that after three hours of cooking, a chicken was still not ready to eat; in fact it was still alive and had to be killed once more. Other dreams revealed to her the danger of eating-”Killing and being killed, devouring and being devoured.” Here eating is perceived as an encounter with death.

Martha E.’s father died when she was aged three years. Thoma suggests that her mother had projected the image of her dead husband onto her daughter. Her father- less childhood had given ”a particularly firm anchorage to the patient’s identification with an unreal father image.”

Thoma observes that very few anorectic patients have an affectionate relationship with their mothers. Instead they place themselves at a distance behaving like strangers to- ward their families by the time their illness starts. They experience their demands for love as destructive and as something that removes the separate existence of others. Love, in a word, is dangerous. “Masochism and narcissism, self-hate and self-love ex- ist simultaneously because of an ambivalent identification” with the mother (Thoma, 1967).

Reciprocated matricidal and filicidal impulses are evidenced from Henrietta A s dream of murder. After that dream, Henrietta’s anger against her mother and anxiety in re- gard to her, could at last be verbalized. For some reason Thoma considered that ”. . . the time was not yet ripe for any clarification of the connection between dream, con- scious experience, and symptom formation.” Clarification of that connection may have been vital to a proper understanding of Henrietta’s illness, but Thoma turns aside from the obvious and avoids making that connection. Henrietta has death wishes towards the mother, towards her analyst, and towards her four-year-old nephew. The theme of reunification with her dead father through her own death, and daytime fantasies of strangling her mother to death are also discernible. Her father died one year after Henrietta’s birth, an event casting a shadow over her childhood. This forced her to to-

436 Jackson et al.

tally repudiate the hostile aspects of her ambivalent feelings towards her mother, be- cause losing her mother meant total loss of love. Mother was also ambivalent towards her daughter- mother’s fears reflected and heightened Henrietta’s fears.

Thoma does interpret the closed circuit of Henrietta’s dreams as pointing to a fear of loss and of death, while at the same transcending it-”hovering between life and death.” The anorexic clings irrationally to her belief in immortality and believes that she is no longer subject to the dangers of an exchange that ends in death.” “This sweep- ing disavowal frees the patient from any fear of death.” Here Thoma does acknowl- edge the importance of this observation but still fails to integrate it into his main theory.

Thoma’s denial of his patients preoccupation with death may also be found in his discussion and interpretation of L. Binswanger’s Ellen West (1944- 1945-1958). As a re- cent further reinterpretation has shown, her death anxiety and ”immersion” in death constitutes the ”leit motif” of this famous case history (Jackson, Davidson, Russell, & Vandereycken, 1990). He studiously avoids this perception but does, however, touch lightly on Ellen’s ethereal or ”tomb-world,” and seems in agreement with his fellow author, Schultz-Hencke, that anorexia may represent, ”. . . an existential reaction, a negation of progress, maturation, the future, and of life itself” (Thoma, 1967).

Thoma does acknowledge that the symptoms of anorexia may develop as a defence against anxiety, so as to avoid a situation perceived as dangerous by the patient. He also acknowledges that various anxieties and fears beset his patients but does not go a step further to the more basic insight that death fears and anxieties and fears of cata- strophic disintegration might also be a significant dynamic in symptom formation.

Thoma’s comment of his fellow therapists that ”they either underestimate the true seriousness of the situation, or hide their heads in the sand and refuse to draw the obvious conclusions” are comments that may well apply to Thoma himself in view of his failure to integrate his case history data into an appropriate theoretical schemata. A more recent example of this process of denial and disavowal is to be found in the work of Stierlin and Weber (1989).

Interestingly Thoma draws a parallel among anorectics, refugees, and the inmates of concentration camps in so far as all groups suffer from amenorrhea, and notes that women often cease to menstruate in circumstances in which they fear for their safety or their lives. The anorexic patient’s amenorrhea could be in response to the perception that a real danger was at hand. However, although for refugees and concentration camp survivors the danger is real and coming from the outside, the danger for the anorectic female is from within and connected with the patient’s frame of mind. Thus, the psy- chological defenses are not in most anorexia nervosa cases directed against an external danger, “It is the developmental processes themselves that are experienced as danger- ous, independently from any massive external cause” (Thoma, 1967).

DISCUSSION

Thoma’s Anorexia Nervosa provides yet another example from the “hidden” literature (Jackson & Davidson, 1986, 1989) on eating disorders of the possible role played by the life-death conflict, death anxiety, a preoccupation with death, and failed death tran- scendence in the etiology of this illness. The text also provides an illustration of the process of denial of death in the literature, as the morbid themata so clearly evident in the many dreams quoted and analyzed by Thoma do not integrate into the logic of his theory.

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To summarize, morbid themata are frequently discernible in Thomi’s five detailed case histories, the image of the deadly destructive mother is powerfully portrayed and there are links with the psychology of the concentration camp survivor, yet all these important threads are not logically integrated into a coherent theoretical framework in the final sections of this text. Instead death-related material is sidelined and avoided because of its lack of fit with the classic psychoanalytical interpretation of anorexia and bulimia, that of fear of oral impregnation.

Is it valid to argue that the same processes of denial of death preoccupations and concerns continues to affect contemporaneous thinking about theory and therapy in the field of eating disorders? The comprehensive literature reviews by Jackson and Dav- idson (1989) attest to the fact that death as a theme is not entirely neglected in the lit- erature yet arguably, these “hidden” threads are not given the prominence they deserve.

Failed death transcendence and an underlying preoccupation with death may well be an important factor highly germain to the development and maintenance of an eat- ing disorder. If this assumption is correct the implication for successful treatment for some individuals in therapy is obvious. Greater empathetic awareness by therapists of the basic life-death conflicts troubling their clients, and of the significance of violent, destructive, and death-related themes in the patients’ cognitions and dreams should lead to more effective therapeutic outcomes if these issues are not phobically avoided and are instead confronted openly in the counselling transaction.

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