Eating Disorders and Self-control
The current view of orthodoxy is that the eating
disordered patient is attempting to reassert control over her life by ritually
regulating her food intake and her body weight. In this respect, eating
disorders resemble obsessive-compulsive disorders.
One of the first scholars to have studied eating disorders,
Bruch, described the patient's state of mind as "a struggle for control, for a
sense of identity and effectiveness." (1962, 1974).
In Bulimia Nervosa, protracted episodes of fasting and purging
(induced vomiting and the abuse of laxatives and diuretics) are precipitated
by stress (usually fear of social situations akin to Social Phobia) and the
breakdown of self-imposed dietary rules. Thus, eating disorders seem to be
life-long attempts to relieve anxiety. Ironically, binging and purging render
the patient even more anxious and provoke in her overwhelming self-loathing
and guilt.
Eating disorders involve masochism. The patient tortures
herself and inflicts on her body great harm by ascetically abstaining from
food or by purging. Many patients cook elaborate meals for others and then
refrain from consuming the dishes they had just prepared, perhaps as a sort
of "self-punishment" or "spiritual purging."
The Diagnostic and Statistical Manual (DSM) IV-TR (2000) (p.
584) comments on the inner mental landscape of patients with eating disorders:
"Weight loss is viewed as an impressive achievement, a sign of
extraordinary self-discipline, whereas weight gain is perceived as an
unacceptable failure of self-control."
But the "eating disorder as an exercise in self-control"
hypothesis may be overstated. If it were true, we would have expected eating
disorders to be prevalent among minorities and the lower classes - people
whose lives are controlled by others. Yet, the clinical picture is reversed:
the vast majority of patients with eating disorders (90-95%) are white, young
(mostly adolescent) women from the middle and upper classes. Eating disorders
are rare among the lower and working classes, and among minorities, and
non-Western societies and cultures.
Refusing to Grow Up
Other scholars believe that the patient with eating disorder
refuses to grow up. By changing her body and stopping her menstruation (a
condition known as amenorrhea), the patient regresses to childhood and avoids
the challenges of adulthood (loneliness, interpersonal relationships, sex,
holding a job, and childrearing).
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Similarities with Personality Disorders
Patients with eating disorders maintain great secrecy about
their condition, not unlike narcissists or paranoids, for instance. When they
do attend psychotherapy it is usually owing to tangential problems: having
been caught stealing food and other forms of antisocial behavior, such as rage
attacks. Clinicians who are not trained to diagnose the subtle and deceptive
signs and symptoms of eating disorders often misdiagnose them as personality
disorders or as mood or affective or anxiety disorders.
Patients with eating disorders are emotionally labile,
frequently suffer from depression, are socially withdrawn, lack sexual
interest, and are irritable. Their self-esteem is low, their sense of
self-worth fluctuating, they are perfectionists. The patient with eating
disorder derives narcissistic
supply from the praise she garners for having gone down in weight and the
way she looks post-dieting. Small wonder eating disorders are often
misdiagnosed as personality disorders: Borderline, Schizoid, Avoidant,
Antisocial or Narcissistic.
Patients with eating disorders also resemble subjects with
personality disorders in that they have primitive
defense
mechanisms, most notably splitting.
The Review of General Psychiatry (p. 356):
"Individuals with Anorexia Nervosa tend to view themselves in terms of
absolute and polar opposites. Behavior is either all good or all bad; a
decision is either completely right or completely wrong; one is either
absolutely in control or totally out of control."
They are unable to differentiate their feelings and needs from
those of others, adds the author.
To add confusion, both types of patients - with eating
disorders and personality disorders - share an identically dysfunctional
family background. Munchin et al. described it thus (1978): "enmeshment,
over-protectiveness, rigidity, lack of conflict resolution."
Both types of patients are reluctant to seek help.
The Diagnostic and Statistical Manual (DSM) IV-TR (2000) (pp.
584-5):
"Individuals with Anorexia Nervosa frequently lack insight into or have
considerable denial of the problem ... A substantial portion of individuals
with Anorexia Nervosa have a personality disturbance that meets criteria for
at least one Personality Disorder."
In clinical practice, co-morbidity of an eating disorder and a
personality disorder is a common occurrence. About 20% of all Anorexia Nervosa
patients are diagnosed with one or more personality disorders (mainly Cluster
C - Avoidant, Dependent, Compulsive-Obsessive - but also Cluster A - Schizoid
and Paranoid).
A whopping 40% of Anorexia Nervosa/Bulimia Nervosa patients
have co-morbid personality disorders (mostly Cluster B - Narcissistic,
Histrionic, Antisocial, Borderline). Pure bulimics tend to have Borderline
Personality Disorder. Binge eating is included in the impulsive behavior
criterion for Borderline Personality Disorder.
Such rampant comorbidity raises the question whether eating
disorders are not actually behavioral manifestations of underlying personality
disorders.
Additional resources
Diagnostic and Statistical Manual of Mental Disorders, fourth
edition, Text Revision (DSM-IV-TR) - Washington DC, The American Psychiatric
Association, 2000
Goldman, Howard G. – Review of General Psychiatry, 4th ed. –
London, Prentice-Hall International, 1995
Gelder, Michael et al., eds. – Oxford Textbook of Psychiatry, 3rd
ed. – London, Oxford University Press, 2000
Vaknin, Sam –
Malignant Self
Love – Narcissism Revisited, 8th revised
impression – Skopje and Prague, Narcissus Publications, 2006
