Eating Disorders and Personality Disorders
Anorexia and Bulimia Nervosa and Comorbid Personality Disorders
Frequently Asked Question # 65
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“Sufferers (of eating disorders) tend to be fearful and anxious, specifically about gaining weight and being fat ... Some anorexics admit to being perfectionists or wanting to punish themselves. Many say they’re addicted – either to food or to the euphoric feeling they derive from starving. They report enjoying exerting control over food and figure, and watching the effect their condition has on people around them.”
(Zoobiquity by Barbara Natterson-Horowitz, M.D. and Kathryn Bowers, Vintage Books, 2012)
Do narcissists also suffer from eating disorders such as bulimia nervosa or anorexia nervosa?
Patients suffering from eating disorders either binge on food or refrain from eating and sometimes are both anorectic and bulimic. This is an impulsive behaviour as defined by the DSM and is sometimes comorbid with Cluster B personality disorder, particularly with the Borderline Personality Disorder.
Some patients develop eating disorders as the convergence and confluence of two pathological behaviours: self-mutilation and an impulsive (rather, obsessive-compulsive or ritualistic) behaviour.
The key to improving the mental state of patients who have been diagnosed with both a personality disorder and an eating disorder lies in focusing at first upon their eating and sleeping disorders.
By controlling his eating disorder, the patient reasserts control over his life. This newfound power is bound to reduce depression, or even eliminate it altogether as a constant feature of his mental life. It is also likely to ameliorate other facets of his personality disorder.
It is a chain reaction: controlling one's eating disorders leads to a better regulation of one's sense of self-worth, self-confidence, and self-esteem. Successfully coping with one challenge - the eating disorder - generates a feeling of inner strength and results in better social functioning and an enhanced sense of well-being.
When a patient has a personality disorder and an eating disorder, the therapist would do well to first tackle the eating disorder. Personality disorders are intricate and intractable. They are rarely curable (though certain aspects, like obsessive-compulsive behaviours, or depression can be ameliorated with medication or modified). The treatment of personality disorders requires enormous, persistent and continuous investment of resources of every kind by everyone involved.
From the patient's point of view, the treatment of her personality disorder is not an efficient allocation of scarce mental resources. Neither are personality disorders the real threat. If one's personality disorder is cured but one's eating disorders are left untouched, one might die (though mentally healthy)…
An eating disorder is both a signal of distress ("I wish to die, I feel so bad, somebody help me") and a message: "I think I lost control. I am very afraid of losing control. I will control my food intake and discharge. This way I can control at least ONE aspect of my life."
This is where we can and should begin to help the patient - by letting her regain control of her life. The family or other supporting figures must think what they can do to make the patient feel that she is in control, that she is managing things her own way, that she is contributing, has her own schedules, her own agenda, and that she, her needs, preferences, and choices matter.
Eating disorders indicate the strong combined activity of an underlying sense of lack of personal autonomy and an underlying sense of lack of self-control. The patient feels inordinately, paralyzingly helpless and ineffective. His eating disorders are an effort to exert and reassert mastery over his own life.
At this early stage, the patient is unable to differentiate his own feelings and needs from those of others. His cognitive and perceptual distortions and deficits (for instance, regarding his body image – known as a somatoform disorder) only increase his feeling of personal ineffectualness and his need to exercise even more self-control (by way of his diet).
The patient does not trust himself in the slightest. He rightly considers himself to be his worst enemy, a mortal adversary. Therefore, any effort to collaborate with the patient against his own disorder is perceived by the patient as self-destructive. The patient is emotionally invested in his disorder - his vestigial mode of self-control.
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The patient views the world in terms of black and white, of absolutes ("splitting"). Thus, he cannot let go even to a very small degree. He is constantly anxious. This is why he finds it impossible to form relationships: he mistrusts (himself and by extension others), he does not want to become an adult, he does not enjoy sex or love (which both entail a modicum of loss of control).
All this leads to a chronic absence of self-esteem. These patients like their disorder. Their eating disorder is their only achievement. Otherwise they are ashamed of themselves and disgusted by their shortcomings (expressed through the distaste with which they hold their body).
Eating disorders are amenable to treatment, though comorbidity with a personality disorder presages a poorer prognosis. The patient should be referred to talk therapy, medication, and enrol in online and offline support groups (such as Overeaters Anonymous).
Recovery prognosis is good after 2 years of treatment and support. The family must be heavily involved in the therapeutic process. Family dynamics usually contribute to the development of such disorders.
In short: medication, cognitive or behavioural therapy, psychodynamic therapy and family therapy ought to do it.
The change in the patient following a successful course of treatment is VERY MARKED. His major depression disappears together with his sleeping disorders. He becomes socially active again and gets a life. His personality disorder might make it difficult for him – but, in isolation, without the exacerbating circumstances of his other disorders, he finds it much easier to cope with.
Patients with eating disorders may be in mortal danger. Their behaviour is ruining their bodies relentlessly and inexorably. They might attempt suicide. They might do drugs. It is only a question of time. The therapist's goal is to buy them that time. The older they get, the more experienced they become, the more their body chemistry changes with age – the better their chances to survive and thrive.
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