Dear colleagues, welcome to the third international conference on neurology and brain disorders, in Dublin, June 2019.
My name is Sam Vaknin. I am the author of Malignant Self-Love, Narcissism Revisited, and other books on personality disorders. I am a professor of psychology in Southern Federal University, Rostov-on-Don, Russian Federation, and a professor of finance and a professor of psychology in CIAS-CIAPS, the Centre for International Advanced and Professional Studies.
Today I would like to discuss the issue of eating disorders. 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 that they are addicted, either to food or to the euphoric feeling they derive from starving. They report enjoying exerting control over food and watching the effect that their condition has on people around them.
This is from the book Zovbekuti by Barbara Neumann Horowitz, Vintage Books, 2012.
Patients suffering from eating disorders either binge on food or refrain from eating. Sometimes they are both anorexic and polemic.
This is an impulsive behavior, as defined by the Diagnostic and Statistical Manual. It is sometimes comorbid with cluster B personality disorders, particularly with borderline personality disorders.
Some patients develop eating disorders as the convergence and confluence of two pathological behaviors, self-mutilation or self-harm, and an impulsive, rather obsessive-compulsive or ritualistic behavior.
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.
Why is that? Why shouldn't we treat the fundamental core problem of personality disorders first?
By controlling his eating disorder, the patient reasserts control over a life. This newfound power is bound to reduce depression or even eliminate it altogether as a constant feature of her mental life. It is also likely to ameliorate other facets of her personality disorder.
It's a kind of chain reaction, virtuous cycle.
Controlling one's eating disorder leads to a better regulation of one's sense of self-worth, enhanced self-confidence and self-esteem.
Successfully coping with one challenge, the eating disorder, generates a feeling of inner strength that results in better social functioning and an enhanced sense of well-being.
When a patient has a personality disorder and an eating disorder, a dual diagnosis, the therapist would do well to first tackle the eating disorder.
Personality disorders are intricate and intractable. They are rarely curable to certain aspects like obsessive-compulsive behaviors or depression. This can be ameliorated with medication and certain abrasive and antisocial behaviors can be modified.
Still, the core, the nucleus, the kernel of personality disorder is usually untouchable. The treatment of personality disorders requires enormous, persistent and continuous investments of resources of every kind, but everyone involved, not least the patient, Depleted by the eating disorder, such a patient is unlikely to invest these resources or to have their way with them.
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 at home mentally healthy.
An eating disorder is both a signal of distress – I wish to die, I feel so bad, somebody help me – and also a message – I think I lost control. I'm 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, my nutrition.
This is where we can and should begin to help the patient by letting her regain control of her body.
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 agendas, and that she, her needs, preferences, wishes, will 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. Her eating disorders are an effort to exert and reassert mastery over her own life.
At this early stage, the patient is unable to differentiate her own feelings and needs from those of others.
Her cognitive and perceptual distortions and deficits, for example, regarding her body image, this only increases her feeling of personal ineffectualness and her need to exercise even more self-control via her diet.
So much of form disorders, body image disorders, usually accompany eating disorders.
There's a misreading, wrong assessment and wrong evaluation of everything about the body, starting with its dimensions and ending with its aesthetics.
The patient does not trust herself in the slightest. She rightly considers herself to be her worst enemy, a mortal adversary.
Therefore, any effort to collaborate with a patient against her own disorder is perceived by the patient as self-destructive.
The patient is emotionally invested in her disorder. This is her vestigial mode of self-control, the only thing she controls.
The patient views the world in terms of black and white. She has dichotomous thinking, a kind of splitting of absolutes.
Thus, she cannot let go, even to a very small degree.
She is constantly anxious. And this is why she finds it impossible to form relationships. She mistrusts herself and, by extension, others.
She does not want to become an adult. She does not enjoy sex or love, which both entail a modicum of loss of control and some kind of positive attitude to one's body, positive relationship with one's body.
All this leads to a chronic absence of self-esteem.
These patients like their disorder. Their eating disorder is their only accomplishment. Otherwise, they are ashamed of themselves and they are disgusted by their shortcomings, as expressed via the distaste with which they hold their bodies.
Eating disorders are amenable to treatment, though comorbidity with a personality disorder presages a poorer prognosis.
The patient should be referred to talk therapy, possibly be put on medication, and enroll in online and offline support groups, such as over eaters anonymous.
Recovery prognosis is good after two 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, so the family must be involved.
In short, medication, cognitive or behavioral therapy, psychodynamic therapy, and family therapy, family systems therapy, for example, ought to do it, ought to demonstrate some progress.
The change in the patient following the successful course of treatment is very mild. Her major depression disappears together with her sleeping disorders. She becomes socially active again. She gets a life. Her personality disorder might make it difficult for her, but in isolation, without the exacerbating circumstances of her other disorders, she finds it much easier to cope with.
Patients with eating disorders may be in mortal danger. Their behavior 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 their time. The older they get, the more experienced they become, the more their body chemistry changes with age, homonally and otherwise, the better their chances are to survive and to thrive.
Eating disorders, notably anorexia nervosa and bulimia nervosa, are complex phenomena.
The patient with eating disorder maintains a distorted view of her body as too fed or as somehow defective. She may have, as I said, a body dysmorphic disorder.
Many patients with eating disorders are found in professions where body form and body image are emphasized, such as ballet dancers, fashion models, actors.
The Diagnostic and Statistical Manual, Edition 4, text revision, says on pages 584, 585, the following.
Patients with eating disorders exhibit feelings of ineffectiveness, a strong need to control one's environment, inflexible thinking, limited social spontaneity, affectionism, and overly restrained initiative and emotional expression.
Bulimics show a greater tendency to have impulse control problems, abuse alcohol or other drugs, exhibit mood lability, have a greater frequency of suicide attempts.
The current view of orthodoxy is that the eating disordered patient is attempting to reassert control over her life by ritualizing her food intake and her body weight, and in this respect, eating disorders resemble obsessive compulsive disorders.
One of the first scholars to have studied eating disorders, Brache, described the patient's state of mind as a struggle for control, for a sense of identity and effectiveness.
In works written in 1962 and 1974, he kept emphasizing this theme.
In Bulimia Navosa, protracted episodes of fasting and purging, induced vomiting and the abuse of laxatives and duoretics, they are precipitated by stress, usually fear of social situations akin to social phobia.
There's a breakdown of self-imposed dietary rules which leads to heightened anxiety and self-medicating fire-baking disorder.
In this sense, eating disorders seem to be life-long attempts to relieve anxiety, to ameliorate it.
Ironically, binging and purging render the patient even more anxious and provoking, of overwhelming self-loathing and guilt.
Eating disorders involve masochism. The patient tortures herself and inflicts on her body great harm by aesthetically 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 kind of self-denial, self-punishment, or spiritual purging and cleansing.
The Diagnostic and Statistical Manual 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 is an exercise in self-control hypotheses, maybe a bit overstated.
If it were true, we would have expected eating disorders to be prevalent among minorities, among the lower classes, people whose lives are controlled by others, people with an external focus of control.
Yet the clinical picture is totally reversed. The vast majority of patients with eating disorders, 90 to 95 percent, are actually 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.
So perhaps we should look at eating disorders as a kind of refusal to grow up.
Some scholars believe that the patient with eating disorder refuses to become an adult. By changing her body and stopping her menstruation, a condition known as amenorrhea, the patient regresses to childhood and she avoids the challenges of adulthood, loneliness, interpersonal relationships, sex, holding a job, and child regret.
There are similarities between eating disorders and personality disorders.
Patients with eating disorders maintain great secrecy about their condition, not unlike narcissists or paranoid, 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 their subtle and deceptive signs and symptoms of eating disorders often misdiagnose eating disorders as personality disorders or as mood or affective or anxiety disorders.
Patients with eating disorders are emotionally led by, frequently suffer from depression, are socially withdrawn, lack sexual interest, and are irritable. Their self-esteem is low. Their sense of self-worth fluctuates. They are perfectionists.
The patients with eating disorders derive narcissistic supply from the praise that they garner for having gum down in weight. The eating disorder patient kind of demonstrates the way she looks post-diating.
Small wonder that eating disorders are often misdiagnosed 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 the aforementioned spleaking.
The review of general psychiatry, page 356, says individuals with anorexia nervosa tend to view themselves in terms of absolute and polar opposites.
Behavior is either all good or all bad. The decision is either completely right or completely wrong. One is either absolutely in control or totally out of control.
Patients with eating disorders are unable to differentiate their feelings and needs from those of others, as the author.
To add confusion both types of patients with eating disorders and with personality disorders share an identically dysfunctional family background.
Munching and allies described it in this way in 1978 and Measurement Over-Protection, rigidity, and lack of conflict resolution.
Both types of patients are reluctant to seek help.
The Diagnostic and Statistical Manual says individuals with anorexia nervosa frequently lack insight into or have considerable denial of their 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, comorbidity or neural diagnosis of an eating disorder or a personality disorder is very common. About 20% of all anorexia nervosa patients are diagnosed with one or more personality disorders, though mainly cluster C, avoidant, dependent, compulsive, obsessive, but also cluster A, schizoid, and paranoid. A whopping 40% of anorexia nervosa and bulimics patients have comorbid personality disorders of cluster B type, narcissistic, histrionic, antisocial, or borderline.
Pure bulimics tend to have borderline personality disorder. Binge eating is included in the impulsive behavior criterion for borderline personality disorder.
And such rampant comorbidity raises the question whether eating disorders are not actually behavioral manifestations of underlying personality disorders.
Thank you for listening.