05_Koenig_OMahoney_Chapter

■Co-occurring personality disorders of dysregulated eaters

■Co-occurring mood disorders of dysregulated eaters

■Effects of trauma on dysregulated eating

■Effects of emotional abuse on dysregulated eating

Our hearts go out to doctors and health care providers on the front lines who are dealing with patients’ eating and weight concerns (or, sometimes, their apparent lack of concern about these issues). In all honesty, you haven’t been given many effective tools to work with these difficult problems. It’s hard enough for seasoned eating disorder therapists to move clients toward healthier, more appetite-cued eating and taking better care of their bodies. Without addressing the psychological and psychosocial aspects of eating and weight complexities, we believe this challenge is doomed to fail.

We are not trying to turn primary care physicians, nurse practitioners, physicians’ assistants, or nurses into Sigmund or Anna Freud. We want only to provide you with the best of what psychology has to offer—information that actually has been available for decades—about how to motivate and work with clients to better manage their food intake and care for their bodies. Nor are we trying to pile on prescriptive lessons atop all the essential things you already do to attend to your job effectively. Based on best practices in the fields of motivation, success, and intuitive eating, our goal is to help you work smarter, not harder.

THERE’S NO SUCH THING AS YOUR AVERAGE DYSREGULATED EATER WHO STRUGGLES WITH WEIGHT CONCERNS

We all have been taught by this culture to see a heavy person and immediately think that there’s something gravely wrong with his or her eating. We also have internalized the corollary that a thin person must be healthy and have nutritional eating habits. Neither assumption is true. We should not assume that a person who wears a size 20 dress or 46 suit doesn’t care about health or fitness, or even appearance; that someone who’s a svelte six petite must be health conscious; or that average-weight people eat balanced meals and must have an okay relationship with food.

The truth is that we cannot possibly know from a person’s size how they eat, what they eat, or how healthy they are. Maybe the thin woman is so obsessed with weight or exercise that she is on a diet that she hates every minute of her life and eats so little that she’s not getting enough in the way of nutritious foods. Maybe an average-weight man is engaged in weight cycling, eating non-nutritious (or way too much) food until he gains 10 pounds, then abruptly starving himself until he loses it, over and over again.

The fact is that many people whom we think of as “overweight” would like to be of “normal” weight. For some, this thought may color every waking hour of their lives, but you would never know that to look at them. Sadly, being large in this society may keep their self-esteem low, scare them to death healthwise, restrict their current happiness and charting of future goals, make them fear social intimacy, and cause them to view their size as a deficit no matter how many positive attributes they have going for them. Our point is that providers would do better not making assumptions about weight and eating problems of patients wherever they are on the weight continuum.

DON’T MOST SERIOUS EATING DISORDERS INVOLVE CALORIC RESTRICTION AND SEVERELY DECREASED FOOD INTAKE?

In terms of mortality, the most serious and deadly of the eating disorders, or as they’re called in the DSM-5, “Feeding Disorders,” is anorexia nervosa, which is characterized by severe food and caloric restriction in order to attain or maintain a low weight.1 An equally serious, though less lethal, disorder is bulimia nervosa, which involves binge eating or overeating and subsequent compensatory behaviors, especially purging, to prevent weight gain.2 New to the DSM-5 as a disorder is binge eating, whose major criterion is frequent episodic ingestion of excessive amounts of food without purging or other compensatory behaviors. Other criteria include ingesting excessive amounts of food in a short period of time, a lack of control over eating, rapid ingestion, feeling uncomfortably full, and experiencing marked distress after eating (ashamed, remorseful, disgusted, self-hating).3

Binge eating has long been thought to be rooted in a lack of self-discipline and willpower. Fortunately, recent studies have debunked that myth, including research that “has revealed that high weight in BED is associated with metabolic processes that may exacerbate hunger, prevent satiety, and in some cases, drive food preferences,” including the malfunction of hormones such as adipokines, adponectin, gut peptides, and sex hormones.4 “The cycle of binge eating and weight gain in BED may offer mechanistic insights leading to better treatments not only for BED, but also for obesity in general.”5 What is important about this research, in addition to it pointing to more efficacious treatment directions, is that it takes the stigma off binge eaters and patients of higher weight for being morally inferior due to their excessive food intake.6

According to Bunnell and Walsh, Wilfley, and Hudson, the prevalence of binge eating disorder in the community is up to five percent, in weight loss clinics up to 30 percent, and in those with body mass indices (BMI) of 40 or greater, up to 50 percent. According to these prevalence data, in comparison with anorexia or bulimia nervosa, binge eating disorder is the most common eating disorder in existence. Unlike the traditional eating disorders, in binge eating disorder a substantial number of male individuals are affected, with the female to male ratio being 3:2.7

Additionally, there is unspecified feeding or eating disorder, which includes disordered eating that does not meet the full criteria for a disorder but causes significant distress and dysfunction in a person’s life.8

Just because patients do not qualify for a bona fide eating disorder diagnosis, however, does not mean their eating is not severely disordered or, what we would call, dysregulated—mindless, compulsive, or emotional. Another term commonly found in the medical literature is “restrained eating,” which means regulating eating by external signals, such as diet rules, rather than with attunement to internal signals of hunger and satiety. According to Linda Bacon, Ph.D., “extensive research suggests that restrained eaters are much less sensitive to hunger and satiety than unrestrained eaters . . . restrained eaters react to emotions and external cues in a nearly totally opposite manner of unrestrained eaters.”9 This point about dysregulated and restrained eaters eating in response to their thoughts and emotions is important to understanding them and why their eating patterns are often as baffling to them as they are to their health care providers. Although these behaviors do not meet a DSM diagnosis, they are as dangerous to patients’ physical and mental health as if they did.

The major problem of many patients is that their eating is substantially dysregulated and that they don’t feel an internal locus of control over it (which is why they turn to diets for instruction). Some clients might suffer from night eating syndrome, which is awakening and eating in the middle of the night or taking in excessive amounts of food after the dinner hour and before bedtime.10 The fact is that a great deal of mindless and emotional eating occurs in the hours between dinner time and bed time because this is when patients are bored, lonely, unhappy, looking to de-stress, or simply have gotten into the habit of munching on typical snack foods while watching TV or using the computer. For more information on emotions and eating, we refer you to The Food & Feelings Workbook by Karen R. Koenig.

HOW DO PATIENTS’ PERSONALITIES MAKE IT HARDER FOR HEALTH CARE PROVIDERS TO MOVE THEM TOWARD ATTAINING AND MAINTAINING HEALTHY, FUNCTIONAL FOOD AND FITNESS GOALS?

Personality Traits

When people fail to meet DSM criteria for personality disorders, which you’ll learn about later in this chapter, they’re said to possess personality traits that cause self- or interpersonal dysfunction. “A personality trait is a tendency to feel, perceive, behave, and think in relatively consistent ways across time and across situations in which the trait may manifest.”11 Obviously, we all have personality traits, not all of which (hopefully) are dysfunctional. The point is that some traits work well for us, such as being reliable or assertive, and some prevent us from having the quality of life we wish to have, such as being unreliable or a pushover.

Traits that make it difficult to eat intuitively, mindfully, and healthfully and engage in physical activity on a consistent basis include (1) categorical (all-or-nothing, black/white and good/bad) thinking, (2) perfectionism, (3) a deficit mindset (focusing on what hasn’t been accomplished and has yet to be done rather than on what has been achieved), (4) help avoidance or hyper-responsibility, (5) external rather than internal motivation, (6) people pleasing and approval seeking, (7) a victim mindset, (8) evasion of emotional discomfort, (9) a pattern of acting impulsively, and (10) self-talk about eating, food, fitness, weight, and appearance that is constantly critical, discouraging, punishing, negative, and judgmental.

One overarching characteristic of dysregulated eaters is poor self-care, which occurs on a continuum, from patients who are well put together and look great from the outside to patients whom we recognize are not taking care of themselves the moment they step into our offices. Sure, self-care is about grooming, but it also includes activities such as saying yes and no in the right proportion, carving out alone time, balancing work and play, engaging in effective emotional and stress management, and tending to your needs at least as well and often as you tend to those of others. This kind of self-care is often sorely missing in patients with eating concerns and what gets them into trouble with food. Coincidentally, this is also the kind of care that doctors and medical professionals often lack: while they’re taking care of others, who’s taking care of them?

If patients don’t value themselves or have enough self-esteem to believe they’re worth top-notch care and attention, it’s going to be an uphill battle to get them to eat well. To mix metaphors, a classic case of putting the cart before the horse. Aside from the aforementioned lack of self-care, here are some dysfunctional personality traits your patients may have.

Patients who engage in categorical all-or-nothing, black/white, or good/bad thinking

Many people with dysregulated eating engage in mostly all-or-nothing, rigid thinking, not only about food but also in other areas of their lives. They either eat totally nutritiously or go overboard with sugar, fats, and highly processed food. In their minds, foods are labeled as “good” or “bad,” with nothing in between, and being good around food feels like a moral imperative to them. They see themselves as successes or failures in eating or exercise (and most of life). This is why when they eat something “good,” they think of themselves as virtuous and proud, and when they eat something “bad,” they think of themselves as greedy, disappointing failures.

The terms “good” and “bad” inundate their thoughts, self-talk, and conversations, and, like most people in this culture (maybe even you), they think of eating and exercise in highly moralistic terms. The truth is that a person doesn’t don a halo because he or she eats nutritious foods, nor become a bad person because he or she enjoys a steady diet of pizza and Twinkies. This kind of self-judgment is far too simplistic to be mentally healthy or helpful. The words “good” and “bad” are part of diet-speak and the antithesis of the approach that will help our patients. In fact, these words are best avoided completely when referring to health-related behaviors. Stealing, lying, cheating, and harming others are moral issues. Eating a Mars bar is not.

A doctor or health care professional’s best strategy in talking with patients with black-and-white thinking is to discuss and emphasize the merits of incremental thinking and learning to enhance long-term behavioral change gradually. It is helpful to speak in terms of progress, baby steps, making consistent efforts, plateaus being necessary resting places, how to get back on track after relapse, being self-compassionate, and the fallibility of humanity. The most useful approach you can take is to praise rigid-thinking patients for their efforts (minimal as they might be) over and over and over again.

Patients who are perfectionists

Being habituated to perfection is bound to stress out patients (a common trigger for mindless eating) and lead them down the disappointing road to failure one way or another. Either they’ll be overwhelmed with unbearable anxiety from struggling to keep up impossibly high standards of eating or exercising or they’ll crack under pressure and give up, feeling doomed. This is what the diet mentality has done to us and what we have done to ourselves in our irrational quest for thinness and “good health.” Of course, not everyone is perfectionistic, but eating and exercise can be self-destructive paths paved with good intentions in the hands of someone who needs to perform these activities flawlessly in order to have or maintain self-esteem. In fact, one recent study concluded that, compared to women of other weights, “women who are overweight had higher total scores of perfectionism.”12 Moreover, many patients are not only perfectionists around food or fitness. They must do everything (washing dishes, studying for a test, playing tennis, raising their children) so flawlessly that they are stressed when they fail to live up to their excessively high standards and console themselves with food.

Here again, clinicians can play a crucial role in helping patients identify with progress, not perfection. For better or worse, patients may take their cues from their providers. If you’re a perfectionist (both authors admittedly have been known to struggle against this tendency), you will want to rein it in when conversing with patients about their eating and fitness goals and avoid placing heavy expectations on them. This is one of those times you will want them to do as you say, not as you might do yourself.

Patients with a deficit mindset

Patients with dysregulated eating often put far more attention and value on what they haven’t accomplished or have yet to achieve than on what they have done well. For a number of reasons, they have difficulty recognizing and acknowledging their strengths and successes and feel unrelenting pressure about all the changes they need to make to “become healthy.” In psychotherapy sessions, for example, they will often go on and on about their binges and the times they’ve engaged in secret or sneak eating and need to be asked if they did anything with food or exercise that they considered positive or hopeful recently. Only then will they reveal achievements such as having survived a buffet without overeating, passed up the cookies in the lunch room, hired a trainer, or bought a treadmill. Sadly, their myopia about their achievements needs a cure as much as any other ailments they present with. So, be sure to always ask, “So, tell me, what went well in the self-care department since I saw you last?” You might even start appointments by inquiring about what patients have been doing to take care of themselves, and you will hopefully be surprised by their encouraging baby-step answers.

One caveat: Some patients function in the opposite mode and will tell you only what they did well in the eating or fitness arenas. Too ashamed to reveal their binges or secret overeating or to tell you that they dropped out of the gym a month ago, you may want to praise them to the hills for whatever they’ve achieved and (this is key) ask, seemingly offhandedly, if there was anything which hasn’t been going well or that they regret doing regarding food or fitness. Paradoxically, with these kinds of shame-based patients, you’re more likely to hear about backsliding if you act as if it’s no big deal and you’re only asking to be polite. The more nonjudgmental and compassionate you are, the more they’ll cough up where they’re having difficulties.

Patients who are help avoidant

While overly dependent patients might test your forbearance with a panoply of seemingly petty questions that feel urgent to them, there are other patients who will avoid asking for your help about their eating problems at any cost. Most have been brought up to believe they must “be strong” or mustn’t burden other people with their problems, and learned early on not to bother soliciting help because it wasn’t going to be forthcoming in a caring way. When you sense that they’re struggling with food or with staying active and reach out to help these patients, they may act as if everything is fine, there’s nothing you can do for them, and they’ll handle their problems on their own, thank you very much.

Troubled eaters are highly skilled at covering up their feelings of frustration and despair about ever eating more sanely and healthfully or having the positive body image they desperately wish for. Most live in abject terror of being judged harshly by the world at large and by medical professionals, in particular, so they’ve learned it’s just easier to say they’re doing fine—even when their weight gain, blood pressure, or serum cholesterol tell a radically different story. With these clients, the more nonjudgmental and sincere you appear to be in wanting to hear how they’re really doing, the better the chance that they’ll be honest and reach out to you for help. Maybe they’ll accept a referral to a dietician, wellness coach, or a therapist. Who knows? You won’t have a clue until you ask with kindness, curiosity, empathy, and—above all—compassion. We’ll discuss specific how-to strategies in Chapter 7.

Patients who are externally, rather than internally, motivated

Many troubled eaters are externally motivated to become healthier and that motivation is focused almost entirely on losing weight. We can’t blame them. They want to please you as their doctor, to shed pounds for an upcoming wedding or cruise, to have their partner, parent, or children be proud of how they look, and they want their friends to shower them with compliments—and maybe throw a little bit of envy their way as well. Rightly or wrongly, many want to wear current fashions or fit the cultural thin ideal. Their goal might be to reach a specific number on the scale, wear a certain size, or to fit into the tuxedo or dress they wore on their wedding day.

These goals sound commendable until we look at the scientific evidence that says in no uncertain terms that weight loss is not the most effective goal for motivating most people to sustain healthy eating behaviors for the long term. Fifty years of psychological research has confirmed repeatedly that in humans, rewards have a complex relationship to motivation. Human nature is such that we do not necessarily internalize motivation based on outcomes or external rewards. In fact, rewards can backfire, so that we are less likely to choose to repeat behaviors that were supported by incentives.13

In fact, coaching psychology tells us that the best motivators have been found to be much more personal and tied to values and life vision. For example, a father who travels for work, and thus is faced with heavy restaurant meals every night while on the road, might be more likely to commit to a daily walk or to a salad instead of fries with his meal, because he believes that these behaviors will help him be able to keep up with his children and feel more energetic during family time on weekends. These activities are likely to be much more important to him than seeing a particular number on the scale or BMI chart, although even he may not realize it. That is how motivation works. We and our patients are interested in pretty much the same outcomes: a healthy body, plenty of energy, and zest for life. It’s just that patients tend to do better at sustaining the behaviors that promote these outcomes when the behaviors are tied to their values and vision for their best life.

Moreover, nothing tastes or feels better than pride. Interestingly, many troubled eaters are oddly reluctant to use the word pride (one client of Karen’s uneasily called it “the P-word” for years), which they associate with boastfulness and excessive self-importance, qualities they were raised to disdain. However, when they understand that pride is nothing more than feeling good about making specific choices that enhance well-being, they begin to comprehend how to grow self-esteem and feel better about valuing taking care of themselves. Even more interestingly, many dysregulated eaters live for others to be proud of them but shrug off being proud of themselves. This externally oriented dynamic, in a nutshell (and explained in more detail below), helps us understand why so many of them fail at sustaining healthy behaviors.

Patients who are people pleasers and approval seekers

One kind of external motivation in particular stands out and is highly relevant to this book: the desire to please others, especially authority figures, in this case you, a doctor, or other health care professional. At first glance, this may seem like a win-win situation: your patient brings in the great news that he or she is starting to eat more normally and nutritiously and gives you the credit for making it happen, perhaps starting the conversation by saying, “You’re going to be so proud of me.” You smile and can’t help but feel encouraged. Your patient feels great and so do you.

But with further scrutiny, do you really want your patients to be doing things for you to be proud of them or do you want your patients to enhance their health so that they will be proud of themselves? Be careful of this trap. When patients openly seek your approval, they are taking the exact wrong route to success.14 Sure, you can feel happy for them and their achievements, but they must be the ones to feel proud of their achievements because that’s the only thing that matters and is going to keep them consistently chugging along to do more of the same in the future—unless you’re willing to be intimately involved in their daily lives, cheering them along, for the rest of your time on earth.

The idea is to encourage patients to approve of and be proud of themselves. Wanting to please you or anyone else may get them started on the right track, but it’s not going to keep them going. For that, they will need a locus of motivation within them: to own their achievements, be their best cheerleader, and take time and mindful space to celebrate small successes (even for a brief moment, giving themselves an internal “good for me!”). When they speak of you being proud of them, you can sidestep the tribute and help them enormously by saying, “What matters is that you learn to be proud of yourself.”

Patients who view themselves as victims

Many health care professionals find it difficult if not impossible to help people who have a victim mentality: these poor souls live under a dark cloud, don’t have any luck except bad luck, never catch a break, have a million and one excuses about why they can’t eat better or become more active, and don’t want to even bother trying to get healthy because they’ve tried before and it hasn’t worked, don’t ya know? Sometimes they act as if not one good thing ever has happened in their whole lives and they aren’t expecting their fortune to turn around just because of a few appointments with you.

Patients with a victim mindset can be a big challenge. You try to motivate them until they “yes-but” you to death so that you throw up your metaphoric hands in frustration. The truth is that in your brief time with them, you’re not going to suddenly reverse years or, more likely decades, of their feeling like the underdog or last week’s garbage. Perhaps the most you can do is to find a therapist who will support them in exploring their beliefs about their powerlessness. Your best bet in this situation is to keep your compassion high and your referral list of skilled therapists close at hand.

Patients who evade emotional discomfort

Few people joyously seek out emotional discomfort or psychic dissonance, but there are some folks who are champions at avoiding it at all costs. At the slightest flicker of emotional distress, they distract themselves. Psychotherapists call this duck-and-cover reaction Experiential Avoidance (EA), which “is a coping style characterized by the tendency to try to change or get rid of unwanted thoughts, feelings or bodily sensations. EA can be harmful because a rigid focus on short-term relief or comfort can sometimes come at the expense of long-term functioning.”15 Patients engaging in EA will seek out food or any kind of momentary distraction. They don’t actually get to avoid distress, however; they only exchange whatever uncomfortable feeling they’re experiencing before eating with a battery of painful emotions after mindless eating such as guilt, shame, remorse, self-hate, despair, and so forth.

What you experience with them as patients in your office is this same kind of EA reaction. You raise an uncomfortable subject (their bad knees, hypertension, high cholesterol, diabetes, etc.) and they become so distressed that they change topics or execute some other communication maneuver to feel better. It’s fine to bring them back to the topic at hand, as long as you understand that their modus operandi is nothing personal.

These individuals either don’t understand how short-term emotional discomfort leads to long-term life enhancement or lack the skills to tolerate unpleasant feelings even if they wanted to bear them. While your impulse, in this case, may be to ramp up their discomfort (in case they missed your point the first two times you brought it up), this tactic is doomed to failure and will only make them more well defended. Instead, drop the subject and try again another time. It’s fine to say something such as “The subject of eating and health is often hard for my patients to talk about. In my experience, it can stir up a lot of uncomfortable feelings.”

Patients who often act impulsively

Taking care of our health effectively involves a great deal of foresight, planning, and monitoring, including planning meals, reading nutritional labels, keeping a stocked pantry, and, of course, cooking. Even restaurant meals take some planning: where to go and what to eat. It also takes deliberate intent to get exercise on a regular basis. We need to make time for it, ensure that it’s a priority, and fit it into our busy schedules. When patients are generally impulsive, especially if self-care is not a priority for them, they often have a difficult time doing relatively simple tasks consistently. Moreover, if they cannot easily tolerate frustration or defer gratification, it will be a source of misery for them to keep to a routine with food or regular exercise. These are your patients who “forget” to take their medications daily or even brush their teeth.

Those of us who have a fairly high frustration tolerance and are relatively easily able to delay gratification (like those in the medical field who spent a fortune and many years of arduous work getting to where they are now) might find it mind-boggling that patients can make the erratic decisions they do and fail so utterly to plan ahead when it’s obvious that they need to. It’s not unusual for impulsive people to clear all the “junk” food out of their house in the morning in one fell swoop, then pass by the supermarket in the afternoon and restock their pantry with these same exact items. Such seemingly “self-sabotaging” moves are often indicators of mixed feelings or internal conflict, or even of an ongoing reaction to a deprivation mindset caused or exacerbated by years of chronic dieting. We will discuss this situation in more detail in Chapter 5. These actions are more about gratification (short-term pleasure) than about happiness (long-term pleasure), and many patients don’t realize that sometimes they can’t have both.

With patients who are impulsive, you, as a health care provider, cannot expect miracles and will need to markedly lower your expectations of what they can achieve and how fast they can achieve it. It is not your job to teach your patients how to think and act rationally. Nor is it within the scope of your duties to provide patients with a crash course on effective decision-making and goal setting. If you suspect that they have attention and impulsivity problems that strongly affect their functioning and self-care, you may want to enlist the aid of a psychotherapist to help them learn new skills so that you can work with them more effectively.

Patients whose self-talk about eating, food, fitness, weight, and appearance is constantly critical, discouraging, negative, punishing, and judgmental

If we are, in large part, what we think we are, then, to succeed, we need to have positive thoughts about who we are and what we are doing. However, this is exactly the opposite of the self-talk of many people who have eating and weight concerns. They regularly compare themselves to others and fail to measure up. They are immensely hard on themselves for their weight and their “out of control” eating (and many other activities). Their constant mind chatter is full of self-shaming, self-loathing, and condemnation. No matter what their accomplishments, they end up focusing on their failures. All that matters, they tell themselves, is that they are fat, feel fat, hate fat, and will probably always be fat.

They are generally people who have enormous compassion for others (including you, their provider, who they believe is stuck treating them) and next to nothing for themselves. The negative chatter running through their head must be turned off and tuned out if they are to make progress on the health front. Only when self-talk reverses itself from negative and critical to positive and compassionate will patients change their behavior on a consistent basis.

One of the best ways to help patients stop the negative blah, blah, blah is to show deep empathy and compassion for them. Shaming them only makes them feel more worthless and shame, rather than motivating them, actually does the opposite and causes them to feel as if they are right to not value themselves. What a negative spiral this produces. And what a positive spiral you can generate from the simple, human act of showing compassion to patients, whatever size they are.

Brain food for providers: Thinking about the patients you see regularly, can you identify any of the above personality traits in them? What could you do to have more compassion for and work better with them?

Brain food for patients: Do you have any of the above traits? What would you like your health care providers to know about you that would make your relationship work better, especially when talking about your health? How would you like to modify your traits to work better with your providers or enhance your chances of success?

WHAT ABOUT DYSREGULATED EATERS WHO HAVE MORE MARKED PERSONALITY DYSFUNCTION?

Psychology differentiates between personality disorders and personality traits and some of your patients may have underlying disorders. According to the DSM-5TM, “A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” in functioning.16

You don’t need to be a psychotherapist to recognize if a patient has a personality disorder. You just need to consider the possibility and have a general idea of the criteria for the most likely ones you’ll encounter.We know them when we see them or, more accurately, when we interact with an individual who has one. You might think of personality-disordered folks as difficult people who have a pattern of being rude or rebellious, calling you excessively about minor issues, expecting special treatment, lying about or refusing to discuss their health problems, needing to be dragged into your office by loved ones or dragged out once you get them talking, constantly running off on tangents, rebelliously viewing you as the enemy, or acting as if they were powerless victims incapable of improving the quality of their lives.

Co-occurring Personality Disorders

Personality can play several major roles for those with eating disorders: as a risk factor, as a moderator of symptomatic expression, in choice of treatment, and also as a predictive factor in outcome. Some personality traits are common to all eating disorders, while others are strongly related only to certain types of eating disorders, such as high perfectionism in anorexia nervosa (AN) and increased sensation-seeking in binge eating disorder.17

Several types of personality disorders may make it difficult for patients to take care of their health effectively by engaging in activities such as in nutrition-minded grocery shopping, planning ahead (an oddly difficult task for many dysfunctional eaters who are otherwise quite functional) and preparing healthy meals, eating mindfully, and getting or staying in shape. In truth, some patients are able to do all of the above activities, but generally not consistently or for long. We’re not expecting you to learn to assign a mental health diagnosis to all of your patients. Rather, we’re hoping that when you spot a particular trait or disorder, it will click in your mind why your patient might be having a hard time listening to you or taking your advice about health and wellness, and that you will respond with compassion and caring.

Below are brief descriptions of the personality disorders you may encounter with your patients who have eating and weight concerns, with the important caveat that, of course, not all patients with dysregulated eating or weight concerns have any of them.

Borderline Personality Disorder (BPD) “is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.”18 Patients with this disorder may:

■Have unstable relationships, putting you up on a pedestal for several appointments, treating you as a god and insisting that you’re the best doctor in the world, and then showing up at another appointment furious that you suggested they might benefit from an antidepressant to help reduce their anxiety, which causes them to binge, or see a psychotherapist to help with their impulsivity or low self-esteem.

■Give you double messages that make you feel both sorry for them as victims (as they often see themselves) and also makes you angry at them if they lash out at you.

■Have great difficulty with emotional regulation, especially self-soothing (there is a high correlation between BPD and bulimia and binge eating disorder).

■Seem to push a great many of your buttons (or those of your staff), though you’re not sure why.

■Seem oversensitive and cause you to feel you need to walk on eggshells around them.

■Be manipulative and lie about their weight or what they’re eating, although inside they are frightened, fragile people living in a high-stress world with few comfort or coping skills.

■Have an unstable sense of self, which is characterized by experiencing a sudden drop or escalation in perception of self-worth based on external factors—a compliment or insult, praise or criticism, rejection/abandonment/betrayal, or success or failure in achieving a goal.

■Easily become emotionally triggered by internal cues—a favorable or unfavorable comparison of self to another, the trigger of memories of feeling undervalued or unloved, self-judgment of poor decision-making, or a reaction to the number on the scale traveling up or down.

“Up to 53.8% of patients with borderline personality disorder also meet criteria for an eating disorder, and up to 21.7% of patients with borderline personality disorder meet criteria specifically for anorexia nervosa and 24.1%, specifically for bulimia nervosa.”19 BPD can be characterized by “impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating”(italics ours).20Research on personality and eating styles even suggests that “neurotic and emotionally unstable individuals seem to adopt counter-regulatory external or emotional eating and eat high-energy dense sweet and savory foods.”21

Helping patients with BPD get into therapy if they aren’t already engaged in it may be the best approach health care providers can take, while putting aside discussions on eating and weight concerns until the patient is more stable, less impulsive, and more trusting of a provider. Consistently letting these patients know you care about them and walking the fine line between not being put off by their sometimes difficult personalities and setting limits for them in your office may be the wisest effort you can make on their (and your) behalf.

Avoidant Personality Disorder (APD) “is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.”22 Patients with this disorder may:

■See negative judgment in practically every suggestion you make, no matter how benign your words are, how kind your tone is, or how helpful your intent is.

■Be especially sensitive to fat stigma and may feel a great deal of shame (perhaps even more than you can imagine) about their bodies.

■Talk about absolutely anything but what you wish to discuss about their eating or weight.

■Keep changing the subject, go off on wild tangents, bombard you with questions to avoid delving into a distressing topic, or fail to keep appointments when they haven’t done what you’ve asked or what they promised they’d do.

Really, they’re not avoiding you; they’re avoiding their internal distress and problems. If you two were discussing your favorite movies, they’d probably love to stay and chat. Feel free to patiently and tactfully bring them back to the health topic at hand or give it another try at another appointment.

Dependent Personality Disorder (DPD) “is a pervasive and excessive need to be taken care of that leads to submissive and clingy behavior and fears of separation.”23Patients with this disorder may:

■Require frequent reminders about what actions to take and wish to put you in the position of being responsible for their success in taking care of their health.

■Have tremendous anxiety about making decisions and being or doing wrong.

■Need a great deal of advice and reassurance from health care providers that they’re doing the best thing or doing it well enough.

■Need far more support and reassurance than you can possibly give them.

■Have great difficulty being accountable for what they promise to do between appointments and for being responsible for themselves.

■Feel shame and self-contempt for their perceived ineptitude and ineffectiveness, and especially for their dependence on others.

If patients with APD can’t wait to leave your office, those with DPD would be happy to have you on call 24/7 to help them and tell them what to do. Many of them act helpless (consciously or unconsciously) in order to have caring people in their lives, believing that if they succeed, they will be abandoned and, therefore, alone. Be patient and compassionate, and you will earn their trust, especially if you approach them in a collaborative style.

HOW DO MOOD DISORDERS AFFECT TREATMENT OF PATIENTS WITH DYSREGULATED EATING OR WEIGHT DISSATISFACTION?

The answer, in a word, is that mood disorders have a huge impact on the origins and treatment of eating and weight concerns, far more than most health care providers might expect. Patients who have Generalized Anxiety Disorder (GAD) or who are easily stressed might be inclined to de-stress by heading for a carbohydrate fix more than patients who are not particularly anxiety prone in the first place. It is the constancy and the intensity of GAD coupled with the accessibility of food that makes refraining from mindless eating so arduous. Just as saying “eat less” doesn’t do the trick because many patients don’t have the skills to do so, saying “be less anxious” works just as poorly.

Patients who have depressive disorders may feel equally powerless to improve their eating or fitness, and their low energy level and lethargy will make it difficult for them to get out and exercise or, perhaps, even go grocery shopping. Moreover, their despair may cause them to feel that it doesn’t matter if they eat “junk food” because they may believe they’ll never reach their goals or that they don’t deserve to live a healthy life. We’ve all been around long enough to know that depression can undermine self-care, even if patients have the best intentions when they are in your office.

Moreover, “A new study in the Journal of the Academy of Nutrition and Dietetics (JAND) points to obesity and depression as co-conspirators undermining the health of people in low-income neighborhoods characterized as food deserts.” Researchers found that “higher scores on depression predicted both higher BMI and lower dietary quality. And then there is the understanding that adverse childhood experiences are an important risk factor for depression, as well as it is for obesity. These experiences paint an increasingly clear picture about why simplistic efforts to urge people to move more and eat better are not moving the needle on obesity in these communities.”24

Patients who carry a diagnosis of Bipolar Disorder may be gung ho to follow healthful routines when they are in the manic or hypomanic phase of their disorder. However, as their mood plummets and they begin the gradual (or, for rapid-cyclers, swift) descent into depression, they may grab fast food every day because they’re too fatigued to food shop, and keep their running shoes and water bottle by the front door, but never use them.

HOW DOES HAVING POSTTRAUMATIC STRESS DISORDER (PTSD) AFFECT EATING PROBLEMS?

There is no one way that PTSD will affect patients with eating and weight concerns. Depending on the stresses in their lives, especially triggering situations, they may have different reactions. They may suffer from depression and may have limited energy for or interest in taking care of themselves. They might be passive and overly compliant because they fear you’ll be angry with them if they don’t do exactly as you say, or they may be aggressive and belligerent due to anger management issues. Some truly may have difficulty with concentration and may not be able to follow an eating plan or activity schedule because their thoughts are preoccupied with ensuring that they feel safe. Moreover, it’s important to remember that witnessing violence or a horrific event can be as traumatic for patients as having experienced the event themselves.

About one-quarter of people who binge eat have PTSD. “People with PTSD have such a hard time focusing on the present and future because they are preoccupied with traumatic memories or trying to avoid traumatic reminders,” says Rachel Yehuda, Ph.D., director of the traumatic stress studies division at the Icahn School of Medicine at Mount Sinai in New York. “Sometimes that means they don’t plan well for future meals, and [as a result], they may get very hungry and overeat or overeat compulsively.”25

Of course, there is no reason you would know any of this unless you are aware of their diagnosis. If you suspect a patient has PTSD, you might try gently bringing up the subject and see where that gets you. If patients have been treated for trauma in psychotherapy, they will likely be more willing to talk about it than if they’ve been keeping it a secret for months, years, or decades.

ARE THERE OTHER MENTAL HEALTH ISSUES THAT COULD POTENTIALLY PREVENT PATIENTS FROM RESOLVING EATING PROBLEMS AND TAKING BETTER CARE OF THEIR HEALTH?

You might already know that there is a high correlation between trauma (even in the absence of PTSD) and eating disorders. Because binge eating disorder has only recently been added to the DSM-5 as a stand-alone, bona fide diagnosis, it is less likely to be associated with trauma than anorexia or bulimia nervosa. Even chronic overeating or unhealthy eating may have subclinical correlations to trauma and we simply do not have the research to prove it yet.

Timberline Knolls, a residential eating disorder treatment center, says this about trauma, its nuances, and its repercussions:

Trauma is defined as any injury, whether physically or emotionally inflicted. In psychiatry, trauma refers to an overwhelming experience that is physically and emotionally painful, distressful, or shocking, which often results in lasting effects. In the behavioral health field, trauma is separated into two categories: discrete traumas (sometimes called big “T” trauma) and chronic, insidious traumas (sometimes called little “t” trauma). Basically, these categories are predicated on frequency and severity.

Discrete trauma is a highly identifiable and catastrophic event, including severe physical abuse, rape, extreme injury, witnessing violence, or an unexpected death of a relative or friend. Vivid and explicit memories usually, but not always, surround this type of trauma. Chronic trauma is less about one identifiable event and more about reoccurring painful situations or experiences, such as ongoing parental criticism, childhood neglect, being bullied or teased, or experiencing alcoholism, another addiction or mental/medical illness in the family. The ongoing nature and the more “acceptable” aspect of this type of emotional trauma often makes it more difficult to identify and treat.26

Note that being bullied or teased is exactly what many high-weight patients have experienced, sometimes since childhood.

“There is a strong correlation between trauma and eating disorders. A number of studies have shown that people who struggle with eating disorders have a higher incidence of neglect and physical, emotional and sexual abuse. In particular, binge eating disorder is associated with emotional abuse while sexual abuse has been linked to eating disorders in males. An eating disorder may develop in an attempt to cope with the trauma, suppress painful emotions or to regain a sense of control. Individuals with a history of trauma may not fully recover from an eating disorder, or may experience chronic relapse from their eating disorder until they address the underlying trauma.” Moreover, and vital for health care providers to remember, “A traumatic experience in childhood can manifest as an eating disorder years later.”27

Numerous studies have looked at how trauma may be a causative factor in obesity. For example, “In a study of 286 obese people in the program,” Vincent J. Felitti, M.D., coprincipal investigator of the Adverse Childhood Experiences (ACE) Study, doing ongoing collaborative research between the Kaiser Permanente Medical Care Program and the Centers for Disease Control, “discovered that half had been sexually abused as children. For these people, overeating and obesity weren’t the central problems, but attempted solutions. Food was an old, reliable friend that soothed and calmed them, while being fat protected them from a hostile world.”28

The article goes on to say, “Notwithstanding all the bean counters obsessing about cost containment, the vast implications of this study—medical, social, political—seem to trigger a kind of cognitive dissonance in the world of health care. The medical profession isn’t designed, organized, or financed, much less philosophically ready, to grapple with these facts. Rather than exploring amorphous, hard-to-measure psychosocial and emotional factors lost in the mists of time and patients’ unverifiable memories, both medical researchers and clinicians focus on what’s directly in front of them—current physical symptoms and directly preceding causes. So the traumatic ‘insults’ in childhood to complex neurobiological systems remain ‘silent’ until the middle-aged or elderly patient brings her obesity and diabetes, his high blood pressure and clogged arteries, to a physician half a century or more later.”29

This is particularly true of childhood or adolescent sexual abuse. According to the National Eating Disorders Association, “Particularly with child sexual abuse (CSA), there has been a large amount of research related to the effect of CSA on body image. It is believed that 30% of individuals with an eating disorder have been sexually abused. Some researchers connect the large association of self-harm with victims of CSA and other traumas to those with eating disorders. Those at high risk for eating disorders because of trauma include: victims of sexual abuse, particularly those who suffered at a younger age, and victims or observers of domestic violence.”30

“Scientists don’t yet know exactly how PTSD and binge eating are linked in the body. Both conditions are related to problems with stress hormones and mood-boosting brain chemicals, though, research shows. Your genes might also determine whether or not you get these two disorders.31 More often than not, the trauma (which leads to PTSD) comes first and the binge eating comes later. Scientists think people binge eat to ‘escape’ the painful memories related to the traumatic event. ‘People with Binge Eating Disorder often don’t understand what they’re feeling or why,’ says Timothy Brewerton, MD, executive medical director of The Hearth Center for Eating Disorders in Columbia, S.C. ‘They’re too busy compulsively trying to numb the pain with food.’”32

Most of the time, patients who are trauma survivors and have eating and weight concerns won’t necessarily put two and two together when talking with health care providers. They won’t say, “I was sexually abused by my step-father for three years and now I am more comfortable being fat than being thin because I feel that somehow my size protects me from being sexually assaulted” or “When my gym teacher sexually abused me after soccer practice, I would always go home and raid the refrigerator to numb out my feelings.”

DOES A PATIENT HAVING BEEN ABUSED RISE TO THE LEVEL OF TRAUMA?

Emotional abuse may have a strong, serious and long-standing effect on a person, yet not reach the level of big T trauma. Verbal and emotional abuse, especially shaming, can have a lasting impact on one’s eating and self-image. One study exploring the role of childhood emotional abuse (CEA) as a predictor of disordered eating found that “CEA had a direct, unmediated effect on eating pathology.”33

Here are several kinds of behaviors that occur in childhood which, if they happen on a regular basis, have a lasting negative effect on self-image, identity, and general functionality—and often, eating. Although you and they may not recognize the impact of such behaviors on your patients’ ability to engage in positive self-care, invalidation, shaming, humiliation, and bullying have a strong negative effect on developing self-esteem.

Invalidation

Invalidation causes children to disconnect from feelings and sensations, assuming they are wrong or bad. For example, when Mom asks (which sounds more like telling) the child, “You’re not really angry, are you?” the child may think, “I guess I shouldn’t be angry, that I’m a bad person for being angry that Mom forgot to pick me up after debate club today.” Or the child may feel invalidated if he’s still hungry after his plate is taken away before he’s finished eating, and think to himself, “Dad said he doesn’t want me to get fat and took away my plate, so I must be full.”

Lack of self-trust in one’s feelings due to emotional invalidation is a major issue for dysregulated eaters. They often lack the ability to identify what they think or feel, are filled with self-doubt and self-mistrust, and are constantly second-guessing themselves. They actually can be unsure if they are hungry, full, satisfied, or have eaten enough, because they’ve disconnected from their internal cues for eating, and in other ways as well. They regularly confuse affect sensation for hunger and may routinely eat in a misguided attempt to comfort themselves when they are bored, lonely, sad, anxious, or even tired. It’s easy to appreciate how such behaviors and habits could ultimately manifest as an uncomfortably high or steadily increasing weight for such patients, despite their “trying to eat better.” Importantly, these patients are often completely unaware of the emotional and self-regulatory skill sets that they lack. Maintaining a high index of suspicion regarding the possibility of an inadequate emotional regulation skill set can increase your effectiveness in serving and supporting these patients immeasurably. A sensitive question or timely referral to a therapist or qualified coach can be the first step toward healing and improvement in self-efficacy.

Shaming

A major kind of abuse, which may be traumatizing, is when children are shamed for their bodies or eating behaviors, whether by parents, relatives, adults they know, strangers, or other children. When shame and eating pathology is studied, “findings revealed the impact of shame memories on eating psychopathology is completely moderated by social comparisons based on physical appearance. These results showcase the significance of early shame experiences including peers and other social agents that become traumatic memories, central to self-identity, to eating disorder patients’ perceptions of inferiority and their core psychopathology features.”34

There is no way for you to know about these experiences unless you ask about previous trauma or shaming, but, even then, patients may not tell you because they may feel responsible for what occurred (e.g., for being abused or assaulted) and, therefore, deeply ashamed. Alternately, they may not want to trigger their own distress by talking about it. Dysregulated eating is a shame-based behavior and may often come from growing up in a shame-based household. Once again, your empathy, compassion, and sensitive inquiry can be a corrective, healing experience.

Humiliation and Bullying

One more type of trauma is relevant to this discussion—the shame of being humiliated or bullied because of one’s weight. Some patients have suffered terribly in childhood, adolescence, and adulthood for being a higher than average weight. They have been physically hurt, excluded from activities, laughed at and made fun of, and can barely think or talk about their eating or weight without tail-spinning back into memories of these horrors. We, as health care providers, would do well to remember that this experience with weight stigma has the potential to cause much more long-term damage than the presence of extra fat.

It is your recognition that these patients have suffered from bullying which will help you be compassionate with them. And it is your caring and compassion which can help them look at how their suffering affects their eating and seek treatment so that they can truly put it behind them.

In summary, in the brief time allotted to you—perhaps over the long haul—it pays for you to get to know your patients with eating and weight concerns inside out. Maybe it’s by asking a routine question about their relationship with food and if they’re happy or unhappy with their health. Maybe it’s by adding a few questions about eating or perceived weight stigma on your medical intake form in the social history section. Each one of your patients with eating and weight concerns is uniquely more than meets the eye and has an individual story behind how he or she arrived at having a poor or unsatisfying relationship with food and body image. The more you know and understand about this relationship, the more effective a clinician you’ll be and the more these patients will value and heal from your help.

Brain food for providers: How have mood or personality disorders or having suffered trauma affected your discussions with patients about treatment of their eating and weight concerns? What would you like to do differently in the future to improve their treatment?

Brain food for patients: How have mood disorders or having experienced trauma, weight stigma, or abuse affected your relationship with food and your body? What would you like your providers to know about these issues and how to treat you?

Providers, try . . .

1.Recognizing that each patient has a unique combination of physical traits, medical conditions, diet history, genetic temperament, personality traits, and mental health issues that will make it easier or harder for him or her to eat “normally” and healthfully consistently and become and remain fit.

2.Getting to know the eating disorders therapists in your community, or contacting your nearest eating disorders treatment center for names of outpatient clinicians or coaches who work with emotional and binge eating.

3.Asking open-ended questions about whether patients have depression and anxiety problems or have suffered trauma or abuse, explaining how all of these can affect weight and dysregulate affect and eating.

4.Leading with caring, compassion, and empathy when talking to trauma survivors with eating and weight concerns.

5.Reacting without judgment, no matter what patients tell you in the area of eating and weight.

6.When necessary, making the case for psychotherapy for patients who have been struggling for a long time or are frustrated with their lack of progress in managing their eating problems.

7.Treating patients the way you wish your family members or friends with mental health issues would be treated in medical settings.

Patients, try . . .

1.Having positive expectations of medical visits and giving yourself time to get to know a practitioner and for him or her to get to know you.

2.Not being defensive when asked a question about food or weight and answering honestly.

3.Reflecting upon your feelings as a patient struggling with eating and weight concerns, and whether you might benefit from support from a psychotherapist, lifestyle medicine practitioner, dietician, coach, trainer, or a group focused on enhancing life skills for a better relationship with food and your body.

4.Telling providers what they do well and could do better regarding your eating and weight concerns.

5.Being curious and not defensive if your provider suggests that you might be suffering from depression, anxiety, or some other mental health problem.

6.Reading up on how trauma, neglect, abuse, depression, and anxiety can trigger and adversely impact dysregulated eating.

7.Being honest and open with your providers about your eating habits, even secret eating, hoarding food, binge eating, purging, extreme food restriction, or taking laxatives.