Sometimes eating and weight problems stand alone and sometimes they coexist with other disorders—depressive, anxiety, dissociative, or personality disorders. Obviously there are many people who are anxious and depressed who are “normal” eaters, as well as dysfunctional eaters who lack underlying mood or character disorders. The whole subject of who has what can be very confusing to both client and therapist. The best we can do is to be alert to the fact that food and weight problems often are related to imbalanced biochemistry and/or distorted thinking and take it from there.
There are two ways to think about potential links between mood disorders and food problems. One is to be open to the idea that anyone who meets, or even partially meets, the criteria for these psychological classifications may suffer from a disregulation of neurotransmitters such as serotonin, norepinephrine, GABA, dopamine, and other assorted chemicals. That means considering that if clients are having difficulty regulating affect, they also may have difficulty regulating appetite and may be abusing food to modulate feelings. The other approach is to consider that clients who abuse food might have underlying neurotransmitter imbalances that produce mood disturbance.
In trying to connect the dots between food, weight, body issues, and clinical disorders, remember that each manifests in a unique way within an individual. No two clients will have exactly the same dysfunctional patterns and it is wise to expect the unexpected. One client may drink and overeat when depressed; another may smoke cigarettes to calm agitation or to control weight. A client may become so anxious due to problems at work or home that he rapidly puts on 10 pounds or may be so caught up in running around trying to resolve a crisis that he forgets to eat. I once treated a client who initially lost her appetite after separating and moving out from her husband, only to find that a few weeks later she was lonely and eating everything in sight.
When clients who regularly overeat become depressed or anxious and lose their appetite, they are more often than not overjoyed and may make jokes about being on the “depression diet.” They may even end up having mixed feelings about their unhappiness or agitation, disliking it, but loving the result of diminished interest in food. I have known clients who have refused to go on an antidepressant, preferring unhappiness combined with decreased appetite to an improved mood and regaining weight.
Almost any psychological condition can be associated with eating problems. The following disorder classifications may be (but are not necessarily) found in people suffering from eating problems: obsessive compulsive, depressive, post traumatic stress, bipolar and bipolar II, borderline personality, panic, generalized anxiety, attention deficit, dissociative, and multiple personality.
Depressive Disorders
As with eating problems, depression exists on a continuum, from major depressive disorder to bipolar to dysthymia. Although there is evidence that people with eating disorders tend to suffer from other mental health disorders like anxiety or depression, and that low levels of serotonin may exist in people with eating disorders and depression, this is only proof of correlation, not causation. Depression also has been associated with bulimia through a measurable change in neurotransmitter activity and mood before and after eating and purging.
One obvious connection is that eating or weight fluctuation is a criterion for depressive disorders. According to the DSM-IV-R, a symptom of major depressive disorder is “significant weight loss when not dieting or weight gain (for example, a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day” (APA, 1994, p. 327); diagnostic criteria for dysthymic disorder include “poor appetite or overeating” (p. 349); and one of the symptoms of depression with melancholic features is “significant anorexia or weight loss” (p. 384).
Although a problem with neurotransmitters may be the cause of depression, anxiety, and difficulties with food, we cannot know that from interviewing clients. We may find clients who have had eating and weight issues long before they became depressed or who have suffered from depression since childhood, with onset of food and weight problems occurring in adolescence or adulthood. There are clients whose depression is exacerbated by being overweight, but it may not be clear whether the primary reason they isolate is because they are fat, ashamed, and find it hard to get around, or because they are too lethargic and inert to get up and go. We may run into clients who have been able to restrain a tendency toward overeating for decades who suddenly fall into situational depression which overwhelms them and leads to out-of-control eating.
Clients may suffer from low self-esteem and become depressed over time because they cannot get a handle on their eating problems or lose sufficient weight to feel satisfied with their body. No matter how successful they are in other aspects of life, they may let their size define them and be unable to get past feeling defective and abnormal. Living in this anti-fat, thin-obsessed society, they are constantly treated as if they are not okay as is and need to change, do not take adequate care of themselves, and as if it is their fault that they are fat. We cannot underestimate the impact that a barrage of negative messages—for some overweight people over the span of a lifetime—can have on the ego. It is a short slide from not feeling good about yourself to experiencing yourself as worthless and unsalvageable.
Although some thin clients may have a chipper, upbeat exterior, scratch the surface and you may find that they suffer from underlying depression. In fact, very often the only thing these clients feel good about is their slimness. They use dieting to keep up their spirits and motivation to take care of themselves and often become depressed when they give up rigid food regimes. Clients may also get worn down and become depressed from years of bulimia, hoarding food, or secret binge eating. They bear tremendous shame about these behaviors and may feel they deserve to be depressed because of how bad they are.
One of the most obvious signs of depression is loss of appetite, but this does not necessarily signal an eating problem. In fact, when a relatively “normal” eater stops eating because of a low mood, that is a clear sign of depression. Usually, when a client begins taking an antidepressant, appetite returns to its premorbid level. Unless the client continues to bring up eating problems, we can assume that the temporary loss of appetite was depression related.
To assess whether the client’s eating
problems are related to depression, ask:
1. Are you eating more or less than you do when you are not depressed?
2. How much do food abuse and weight issues affect how depressed you feel?
3. Does your eating feel more under control when you’re on antidepressants?
4. (for an overweight client) Are you less depressed when you lose weight?
5. (for an underweight client) Are you less or more depressed when you gain weight?
6. How can I help you handle depression more effectively?
Generalized Anxiety Disorder
Although no eating- or weight-related criteria appear under “Anxiety Disorders” in DSM-IV-R, most of us have known clients who eat more or less when they are tense and stressed. In fact, a person need not have eating problems per se to crave carbohydrates when they are wound up. The fact is that anxiety disorders frequently co-occur with eating disorders, likely due to an imbalance of neurotransmitters causing both conditions.
It is not surprising that people who are uptight and high-strung may have difficulty self-soothing. Although many would not think of turning to food when they are a bundle of nerves or restless, others would not think of looking anywhere else for comfort. If a client is inclined to view food as special and magical and as a reward, especially if her parents used food to round off their rough edges, it is likely that food will become her primary support as well. On the other hand, anxious clients also bind emotions by obsessing about things like recipes, weight, and what to wear that will make them look thin. Whereas one anxious, overweight client might become deeply depressed thinking about how to dress for an upcoming reunion, another might detour her nervousness into going on a crash diet to slim down.
Anxiety and fear are major components of eating problems: a client’s terror of gaining 2 pounds because 2 will turn into 6, which will morph into 20; fear of being ridiculed and excluded for being fat, based on past experience or on unfounded anticipation; anxiety that the food police will come rushing in if food is left unfinished or if leftovers are thrown away; fears of being hungry and deprived, both real and imagined; and nervousness about eating enough to please others or so much that they will get upset or angry.
Clients who are anxious might not even connect their eating to their inner turmoil. They may not realize that they are ruminating or running upcoming scenarios over and over in their mind. Many anxious clients are unaware that overeating or eating when they are not hungry is due to a heightened affectual state because they are disconnected from their emotions. They may call themselves hyper, high-strung, or driven, and not recognize that they are in a constant state of arousal and vigilance. They may only know that they feel better after they eat (especially carbohydrates), but not make a connection between agita and increased appetite.
To assess the client’s anxiety
and eating problems, ask:
1. Do you eat more or less when you are anxious?
2. How do you know when you are anxious?
3. How does food help when you are anxious?
4. If you don’t eat when you are anxious, what do you think will happen?
5. How can I help you handle anxiety more effectively?
Obsessive-Compulsive Disorder (OCD)
Eating problems that are ongoing and become the center of a client’s life have much in common with OCD. For the record, obsessions are “recurrent and persistent thoughts, impulses, or images that are experienced . . . as intrusive and inappropriate and that cause marked anxiety or distress. Compulsions are “repetitive behaviors . . . or mental acts . . . that a client feels driven to perform in response to an obsession, or according to the rules that must be applied rigidly” (APA, 1994, p. 418).
Many clients will say right off that they are obsessed with food or with being or getting thin. Although it is unlikely that they have the specific criteria of OCD in mind, they know an obsession when they feel one. They will tell you that they think about food 24/7, that being thin or losing weight crowds out thoughts of family or work, that they cannot control their thinking though they have tried with all their heart and soul. If they could, they would rip open their heads and yank out their thoughts to get relief.
Some clients recognize that the problem is in their minds and some do not (those with body dysmorphic disorder, in particular). They know on some level that having intense distress and a preoccupation with food and their body is abnormal and unhealthy. If they obsess about weight, they recognize that their desire to be thin or thinner is more about chasing an elusive ideal of perfection than pursuing a realistic dream. If they obsess about food, they understand that it is not nutrients they crave but emotional gratification or oblivion. Nevertheless, knowing that their thinking is irrational does not stop it and they may struggle on and off all day long with intrusive thoughts about weighing themselves or food calling to them. These thoughts can be so intrusive that they make life, in general, exceedingly problematic, depending on the runaway nature of their thoughts and their ability to control them.
Clients describe their actions as compulsive (hence, the term compulsive eating). They talk about “going unconscious,” or being in a fugue- or foglike state—coming to as they scrape the bottom of the Häagen-Dazs container or are tossing away the empty bag of Cheez Doodles. They tell you that they went into the bathroom to grab some aspirin and could not resist hopping on the scale, though they had weighed themselves not an hour before. Often clients believe and feel that they are totally powerless in the face of inner forces that drive them to food behaviors they abhor. Clients who must eat at a certain time, weigh their food to the nth of an ounce, need to maintain a particular order of food intake, or engage in a ritual that goes along with eating certain or all foods are in the grip of compulsions. And then there are those who, once they start to eat, have to finish everything—the whole box, bag, jar, or the entire meal. There is no in between, no flexibility in regulating appetite; behavior is all or nothing.
A client might panic because a guest ate something in his refrigerator that he had planned to eat himself. Some clients will only go out to eat at a specific hour, no earlier or later. Others have to know the caloric and fat content of every morsel that goes into their mouth or will count out 9 crackers but never 10, five carrot sticks but never six, to eat every day, day after day. Although these behaviors may seem amusing, they are anything but.
The goal of this behavior is not really about food, but to prevent anticipated, or lessen current, anxiety. The most helpful paradigm of obsessive-compulsive disorder (OCD) is educating clients about how obsessive thinking is reinforced by compulsive actions and vice versa, so that they can understand that they will have to tolerate some discomfort—in this case, anxiety—in order to reduce or eliminate unhealthy eating patterns.
To assess the client’s food abuse
as obsession and compulsion, ask:
1. How often do you have intrusive thoughts about eating, calorie counting, weighing yourself, or anything else related to food?
2. What do you think will happen if you don’t follow through on compulsions that drive you to obsessive food behavior?
3. Do you have other obsessions and compulsions?
4. How can I help you manage your food obsessions and compulsions more effectively?
Sexual Trauma and Dissociative Disorders
More and more studies are being done on the correlation between sexual trauma—such as molestation, rape, and incest—and eating disorders. The following summary echoes research in the field: “Young girls who are sexually abused are more likely to develop eating disorders as adolescents . . . and findings add to a growing body of research suggesting that trauma in childhood increases the risk of an eating disorder. Abused girls were more dissatisfied with their weight and more likely to diet and purge. . . . Abused girls were also more likely to restrict their eating when they were bored or emotionally upset, and [. . .] abused girls might experience higher levels of emotional distress, possibly linked to their abuse, and have trouble coping” (Wonderlich, Crosby, Mitchell, Roberts, Haseltine, Demuth, & Thompson, 2000, p. 1283).
Kearney-Cooke and Ackard (1999) evaluated the differences between females who had been sexually abused and those who had not on aspects such as body image, self-image, self-consciousness, and relationships with others. They found that females who had been sexually abused reported more body dissatisfaction, more self-consciousness, and less satisfaction with themselves in their relationships. Some of the detrimental effects of sexual abuse included dissatisfaction with and lack of control over the body, low self-esteem, increased self-consciousness, and poor sex life and relations with men. Women who had been abused also were more likely to have eating disorders.
It is not surprising that a client who has been sexually violated may have body and food regulation issues due to feelings of powerlessness, breaking of trust, unworthiness, and fear of intimacy. Although the majority of studies are being done with females, it is prudent to consider that a male client who has been sexually abused may also have eating and body image problems. Depending on other factors—difficulties with impulse control, affect regulation, substance abuse, poor self-care, and major intimacy issues—it is not unreasonable to wonder if (though certainly not to assume that) a client with eating, weight, and body-image problems may have had some kind of sexual trauma.
For most of us, the clients we counsel with dissociative disorders are few and far between. Although we may see some who misremember the past or have only a foggy notion of what it was like, most individuals on our caseload do not have fugue states or multiple personalities. However, it makes sense that clients who have been traumatized enough to dissociate may have problems staying connected to reality and to their body.
Dissociation is defined as “a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. The disturbance may be sudden or gradual, transient or chronic” (APA, 1994, p. 766). A milder form of loss of conscious functioning is described by Geneen Roth, author of many books on eating, as “going unconscious.” Clients do not fall into a true trance, but often describe the state of eating until they are sick or exhausted as dreamlike. They insist they do not remember what led them to eating, but suddenly found themselves with an empty box of cereal and a full belly; they recall little about throwing on a coat in the dead of night and driving to the 7-Eleven for a bagful of snacks, only to awaken the next morning to a floor strewn with cookie and candy wrappers.
My point is not to pathologize clients who lose touch with reality when they are in the throes of food abuse, but to make clear how debilitating and frightening loss of control is, how on the edge of deeper, more serious dysfunction. With clients who have such a profound disconnect from their minds and bodies, we need to tread lightly and carefully. They generally have good reason for going unconscious at specific moments. Perhaps they were not sexually or physically abused, but might have endured horrific fights between their parents in which their only solace was sneaking down to the kitchen and up to their room to eat in silence and safety. They may not be reacting to something terrible that was actively done to them, but to being raised in an environment in which staying conscious all the time was simply too scary and painful.
To assess if the client has suffered
sexual trauma and may dissociate
relating to food, ask:
1. Do you have reason to believe you have suffered sexual trauma or been abused?
2. Do you generally feel connected or disconnected from your body? How about when you’re eating?
3. Do you ever feel as if you’re looking at yourself eating while consuming food (that is, are you both the eater and onlooker)?
4. Do you ever find you’ve eaten but were not aware of doing so at the time or don’t remember eating?
5. What do you generally remember right before your unconscious eating experience and right after?
In many cases, we are already treating a client for depression or anxiety when we discover she has an eating problem. Other times, it becomes obvious that some underlying condition is driving her difficulties with food and we refocus on what they may be. The goal is to make no assumptions and ensure that we leave no stone unturned when trying to discover the origins of food and weight problems. There is no one avenue to help clients with dual diagnosis of food and other conditions, but Chapter 11, “Treatment Options,” will provide alternative approaches. As always, the best therapeutic route will come from keen observation and an open mind.