Eating Disorders and Personality Disorders (Part 1)

Patients suffering from eating disorders either refrain from food intake or binge on food. Some of them are both Anorectic and Bulimic. Food binging is an impulsive behaviour. Impulsive behaviors - which cannot be controlled or restrained by the individual - also serve a DSM criterion in the case of certain personality disorders (like the Borderline PD). To a lesser extent they seem to characterize all the Cluster B personality disorders (a diagnostic cluster which includes the narcissistic, borderline, antisocial and hystrionic personality disorders).

Some patients adopt these disorders as their way of self mutilating. In these cases, we may be witnessing a convergence of two behavioral features: self-mutilation and an impulsive (rather, compulsive or ritualistic) behaviour.

Many people have two or more mental health problems. They are known as "dual diagnosis" patients. The key to improving the mental state of patients with diagnosis of both a personality disorder and an eating disorder lies in concentrating upon their eating and sleeping disorders. In my view, these disorders are a blessing in disguise.

It is very rarely, even in the lives of normal human beings, that they are faced with a veritable, identifiable enemy. An eating disorder is such a definte enemy. By controlling their eating disorders, patients can assert control over their lives. This is bound to reduce their depression (even eliminate it altogether as a constant feature of their mental life). This is bound to ameliorate other facets of their personality disorders. Here is the chain: controlling eating disorders=controlling my life=feelings of enhanced self-worth, self-confidence and self esteem=a challenge, an interest, an enemy to subjugate=a feeling of strength=improve social skills=feeling better (I am a success) etc.

When a patient has a personality disorder and an eating disorder, I see no point in concentrating at first on anything but his eating disorder. Personality Disorders are intricate and intractable. They are rarely cured (though certain aspects, like obsessive thoughts and compulsive behavior, can be dealt with using medication). It calls for the enormous, persistent and continuous investment of resources of every kind by every one involved. This is not realistic. Also this is not a realistic threat. If a personality disorder is cured but the eating disorders are aggravated, the patient 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 out-take. This way I control at least ONE aspect of my life". This is where we can and should begin to help the patient to regain control. The family or other supporting figures must think what they can do to make the patient feel that he is in control, that he manages things his own way, that he is contributing, has his own schedules, his own agenda, possesses both authority and responsibility.

REFRRENCES:

(1) Review of General Psychiatry - 4th Edition - Prentice Hall International - 1995 - pp. 309-332 and 355-368
(2) Herzog DB et al. - The prevalence of personality disorders in 210 women with eating disorders - Journal of Clinical Psychiatry - 1992a;53:147
(3) Marcus MD et al. - Psychiatric disorders among obese binge eaters - international Journal of Eating Disorders - 1990;9:69