Not mentally ill, just big-boned

In my previous post, I talked about "normal" and "abnormal" and how such things impact how we are treated. People tend to think that the purpose of psychological treatment is to target "abnormal" and to make it "normal". That is not the of purpose psychological intervention or study. It has never been and never will be about reshaping people to some sort of acceptable average or filing off their quirks and character traits so that we are all the same.

In fact, there are critical rules for when something is considered pathological as opposed to merely "different". Unless you are demonstrably and clearly a danger to yourself or others, there is actually no way in which someone can force you to be treated. Most people who see therapists are going to them because they have problems they want help with. No one is making them change. They want to change. It's not about forcing "normal" on them, but rather their desire to find a new "normal" for themselves.

"Normal", as I said in my previous post, is a relative state within a system, but it also can be a reflection of where one falls in a statistical range. Recently, it was announced that narcissistic personality disorder was being removed from the "bible" of psychological disorder diagnoses, the DSM. In the DSM V (currently, the DSM-IV-TR is in use), narcissistic personality disorder will not appear. The reason for this is that self-absorption and self-involvement are so prevalent in society in the internet age that these are no longer considered atypical behaviors. What is more, and this is critical, they are no longer considered personality aspects which lead to functional impairment in the current social order. When everyone is self-involved, it is seen as  "normal" within the system and those who display such traits are accepted rather than rejected when it comes to jobs and relationships.

I mention this situation because it is important to remember that what is considered "disordered" and "normal" are fluid. Just as a mental state that was once considered a problem can disappear when the zeitgeist catches up with it, a mental state which wasn't a problem in the past can become one now. Changes in society can erase the idea of abnormality, and they can create new abnormal states.

The two core aspects, statistics and functionality, are important to consider when thinking about whether something should be considered a psychological disease. The former is not enough to consider a behavior or state a disease that one would do well to treat. Statistically, there may be few people who are hearing the voice of God in their heads on a regular basis, but their state is not of concern until it interferes with their functioning. If such a person can live a life as a productive member of society or at (least a non-disruptive and independent member) regardless of their atypical state, it does not matter whether they receive treatment. No one will force someone who is capable of self-care and who is not interfering with others to be treated no matter what their mental condition.

Of course, people who hear voices are often unable to function because their impairment is so great that they cannot survive in society. Indeed, there is an extremely high rate (50%) of self-injury (either suicide or self-mutilation ) among people with psychotic disorders such as schizophrenia. They are not only distracted and troubled by the voices they hear, but they are driven to harm. However, it is not unheard of that extraordinary people who suffer such disorders can develop the capacity to cope with their problems without psychiatric or pharmacological intervention.

This was the subject of the movie, "A Beautiful Mind". However, such people are extremely rare and their anecdotal cases cannot be used as reasons to fail to treat others with their condition or as an excuse to "depatholigize" a pathological condition. If you are one among thousands who has a condition and does not suffer functionally for it, that is not a reason to expect that others will manage in the same manner as you. Such exceptions are inspiring, but are nearly meaningless is the greater scheme of things.

So, while a handful of critically mentally ill people are capable of functioning despite their atypical life circumstances, the vast majority will require treatment to improve their quality of life and be functional. A necessary precursor to treatment is diagnosis, and that's why things like the DSM exist. It's also why obesity is currently being considered for insertion as a mental disorder into the DSM V.

The idea that obesity is a mental health issue is hotly debated both by laymen and experts. Personally, I think that obesity is a physical state and a symptom of a potential mental disorder or a set of disorders. The state of being obese is not, in and of itself, anything other than a reflection of body composition in regards to fat percentage. Sometimes it has an organic basis and sometimes it has a mental one. Whether you are super skinny or super fat, your functioning in life is impeded and the underlying issue, whether medical or psychological or both, could be improved if treated.

Just as an anorectic's skeletal appearance reflects deep emotional problems, the super fat person's body size also very likely reflects deep problems. The notion that one extreme is a mental disorder and the other is not seems absurd. Starving yourself to dysfunction and possible death is a mental health issue. Why isn't eating yourself to dysfunction and death one as well? This seems illogical and hypocritical.

The answer to why being super obese isn't a sign that someone has a mental disorder is, my opinion, because of both prejudice and a lot of denial. The prejudice comes from people who think that fat people are gluttons who lack self-control and if they merely exercised some restraint and moved around more, they wouldn't be fat. This is an oversimplification which is gratifying to those who need to elevate their self-worth at the expense of others. It's not seen as a mental health issue, it's a deficiency of character.

The aforementioned denial comes from the very people who could be helped by a DSM V classification of obesity or an obesity-related mental state diagnosis. The claim is that 'they're not mentally ill, they're just big-boned'. There are numerous assertions about the compositions of their diets, homeostasis, exercise habits, health issues, etc. as ways of explaining being super fat.

I have no doubt that some people are naturally fat, just as some people are naturally thin. I also have little doubt that most women of average height and build (excluding the very tall, very short, and very muscular) are not naturally at a homeostatic point over 200 lbs. and most men at a point over 250 lbs. Even if you were born to be fat, chances are you weren't born to be super fat. There is either an underlying biological issue that needs some attention or a psychological one (or both).

Without a doubt, there are many organic disorders and medications that can make someone obese. No small number of drugs are known to induce metabolic syndrome and taking them requires a concurrent change in lifestyle which can be seen as "unfair." People on such drugs have to eat far fewer calories and often limit carbohydrates compared to an average person. Emotionally and physically, this can be very hard, but such restriction does not result in a loss of health due to poor nutrition. It just is very, very hard to accept that you eat 1500 calories a day and struggle not to gain weight while another person can eat 2500 a day and not worry. It's also terribly difficult to be hungry all of the time because of this type of restriction.

That being said, I personally believe the inability to comply with such restricted diets is largely (but not entirely) psychological for most people. I've been researching a lot of underweight people's lifestyles and behaviors and what I have found is that such people actually don't eat much. Many quite thin people really do just "go hungry" for so long that they learn to ignore hunger.

There's a BBC television show called "Supersize Vs. Super Skinny" that can be viewed for free on YouTube which gives a lot of anecdotal examples of the differences in eating habits between very  heavy and very thin people. It goes some way toward showing different mindsets as well as different habits. People who don't have eating disorders view food and hunger differently than those of us who do. While I don't think someone who has been fat will ever tolerate hunger as well as someone who has never been fat (because having been fat, especially for a lot of your life fundamentally changes biochemistry), I do believe one can use behavioral techniques to stretch their tolerance levels and re-frame the role of food in their lives to help improve their relationship with food. 

The fact that obesity can be brought on by drugs or organic conditions does not negate treating it or regarding it as a pathological condition. There are many organic disorders that can create psychoses, anxiety, depression, and antisocial behavior. These include brain tumors, cancers, thyroid problems, and hormonal imbalances. All of those disorders when brought on by organic or pharmacological agents are treated with concurrent medical intervention and therapy. Why should obesity, especially super obese states, be regarded differently than these other conditions? Why is it simply explained away by fat activists as being a natural state of being for some people? Well, because fat people don't want to see themselves as "sick". They just want to see themselves as fat.

Here's the thing, crazy people often don't think they're sick either. It often takes significant pressure or serious difficulty in functioning for them to come to terms with their illness. Even for those who are seriously ill, and they might be cutting themselves, drinking cleaning fluids, and beheading people on buses, they are sure they are behaving rationally.

Weighing 300+ pounds at average or near average height and saying you are in no way sick borders on the absurd. Something is wrong somewhere. Such a body will not function well in the long run and many are not performing optimally in the short haul either. Sure, there are some cases of very heavy people who are extraordinarily healthy and mobile. They are the stuff of an obesity-based version of "A Beautiful Mind", but their cases are not typical and cannot be generalized to everyone who is morbidly obese or super obese.

I'm not saying fat people are crazy, but I am saying there's a mental health issue in many cases (along with an accompanying physical one in most cases as well) and denying it doesn't change the fact that functionality is impeded, quality of life is degraded, and relationships with food are disordered. Anorectics, incidentally, similarly feel (off and on) that there is nothing wrong with their weight or relationship with food. It's not them that has a problem, it's the rest of the world. These days, fat advocates say the same thing. It's not them that has a problem, it's the rest of the world.

The question of whether obesity is a sign of a mental disorder is a tricky one because the media so often focuses on the symptoms rather than the causes. Just as being skinny (not mentally ill) isn't the same as being anorexic (mentally ill), being obese isn't the same as being super obese and engaging in the behaviors that made one so. What is more, anorexia is not a bodily state. It is a set of behaviors and thinking that result in a bodily state. Classifying obesity as a mental disorder is wrong, but classifying the set of behaviors that lead to a level of obesity that creates functional impairment would be a step toward dealing with the problem productively and without political and judgmental statements.

The bottom line is that I believe that there is a set of behaviors that lead to super obesity. A new term, I might suggest "redundorexia" (excess appetite, which is the opposite of anorexia or no appetite), might be in order. The term would not refer to body size, though body size would be one of the symptoms. It would refer to a set of behaviors that result in obesity that functionally impairs someone. Now I will say that, if such a disorder existed, I would be diagnosed with it (possibly with it being seen as being in a state of remission at present, possibly not). The characteristics would be as follows:

• high body weight (at least obese, if not class 1 or 2 obesity)
• strong identification with body size
• restriction of social or work activities due to feelings related to body size
• feelings of dissociation of mind from body (e.g., the sense that the body has betrayed one or that one exists separately from ones body)
• inability to operate in the world due to body size (e.g., inability to use public facilities like stall-size toilets, ride on airplanes due to seat size, etc.)
• physical impairment due to comorbid health issues brought on by body size (e.g., back pain, type 2 diabetes, joint pain, edema, etc.)
• impairment of relationships due to body size (including conflict over weight with significant others, inability to be physically intimate for physical or psychological reasons, misdirected anger or paranoia about being judged because of ones weight, etc.)
• preoccupation with food or dietary habits
• anxiety about eating in front of others
• inability to moderate eating habits despite repeated attempts (e.g., repeated attempts at "dieting")
• hidden eating/hiding food
• moralizing of food and changes in self-esteem in line with what sort of food one eats ("good food"/"bad food")

This is not a complete list of potential issues, and certain other disorders (comorbidities) would be common. In particular, anxiety and depression would often accompany a diagnosis with an obesity-related mental disorder.As is the case with all DSM disorders, one would have to meet all or a certain high number of these criteria in order to be considered to have such a disorder and those behaviors would have to persist over a long period of time (at least a year, if not longer). Merely having several would not be enough and engaging in them only occasionally would also not be enough. Most people have experienced some of these attributes, if not all of them, on occasion in their lives. Persistent suffering is always a part of whether or not someone has an actual disorder.

Why am I talking about diagnosing obesity-related behaviors as a mental health disorder? Well, I'm talking about it because it would be a significant step forward in dealing with the problem in a manner which does not blame the sufferer as well as create a system which would facilitate treatment. Before there was a term for H.I.V., there wasn't a treatment system. There was just labeling and blame, especially in the gay community.

Beyond the fact that a diagnosis will create a system for research and treatment, it also creates an economic avenue for receiving help. Insurance companies won't pay for things which are not officially called diseases. If you are obese and want therapy for your condition, it's harder to get your insurance company to pay for it than something like bariatric surgery. They recognize that being fat is a health issue, but not a mental health issue. If you want CBT (cognitive behavioral therapy) to deal with your food relationship, you may or may not get insurance coverage for it.

Mental disorders come and go with the times as we can see by the removal of narcissistic personality disorder from the DSM. Given modern lifestyles, I think it's more than past the time that "redundorexia" or something to that effect was added to the list of possible mental health disorders. In my next post, there is another related disorder which I have noticed has evolved as a result of the obesity epidemic and the manner in which fat people are treated.

It's Not a Psychological Failure

Occasionally, well, perhaps more often than that, I will run across a woman who is so frustrated with herself because she was hungry and ate and ate and ate. These are always women who have been "dieting" and are perplexed about incessant and increasingly irresistible hunger. They view eating a lot as a failure of will and are disappointed in themselves.

I've written before that I sometimes simply have to just eat, and at those times, I will eat a lot. I recognized this a long time ago as the predictable physiological outcome of consistent deprivation and that it's not about mental desire to eat more, but biological pressure. For those women who are confused, I would recommend that they view what they are doing from the body's point of view rather than their own more highly developed mental viewpoint.

From the body's point of view, it is being consistently deprived of necessary energy. It has been successfully "saving" energy as fat on your body for a long time and is pleased to have reserves on hand for need. Suddenly, it is having to use those reserves day-in and day-out. It's like a miser who suddenly finds the cash flow has utterly dried up and now he has to constantly take from savings. There is utter biological panic at the idea of being under-fueled constantly over a long period of time. The more extreme the deprivation, the more extreme the response from the body.

As far as your body is concerned, you are not getting fit and healthy. In fact, as far as your body is concerned, you are slowly dying of starvation. Its priority is to send as many biochemical cues to you as possible to get you to eat more and stop the starvation which it is reading as the current state of affairs. Unlike the miser, who may have an account book somewhere telling him exactly how much is in the savings account, the body does not know you've got energy to spare hanging off your hips and belly. It only knows that it's constantly diving into savings and is uncertain when it will run out.

So, the body says, "I'm going to die and I must act to pressure you into stopping this." That insatiable hunger is the culmination of a week, a month, or however long it has been of deprivation. The nice thing is that you can deal with this effectively by stopping with the head games and just eating once in awhile. Cue the body occasionally such that it thinks you're not starving every single day. This isn't "cheating". It isn't about "giving in." It's about occasionally succumbing to a biological need such that the body stops going into panic mode and driving you insane with hunger.

I haven't plateaued in my weight loss, and I do wonder (though can never know) if this is because I've never practiced extreme deprivation (usually eating between 1500-1800 calories) and do occasionally just respond to these super hungry times by eating until I'm full. That's right, not "just sated", not "no longer hungry", but damn good and full. Is it possible that I'm cuing my body occasionally such that it feels all is well and I'm not starving to death and there's no need to cling to fat reserves? I don't know, but it is possible.

I also wonder at times if a lot of women who have turned to fat acceptance after dieting, many of whom pushed themselves hard and cut calories far back and eventually stopped losing, wouldn't have suffered metabolic damage had they practiced more moderate behavior. As far as I can tell based on weight loss and calorie consumption values (and I've been eating consistently more since the beginning of this year and exercising no more), I have not suffered any sort of metabolic slowdown from modest deprivation.

I also know that I am careful about exercise in terms of never doing it too hard and allowing for resting periods for my modest weight lifting and stretching when the muscles are aching or the glycogen reserves seem unusually low (signaled by unusually difficult muscle movement). In other words, I'm not doing anything which would cue my body to believe more exertion and damage is going on than necessary. I'm also not pushing so hard that it would need to be consuming the muscle mass instead of the fat.

I'm not saying that my way is the right way, but I am saying that it's not a psychological issue when you deprive yourself everyday of food and then find yourself starving and wanting to eat and eat and eat. It's your body seeing what is happening to it from another perspective. Yes, you can fight it, but perhaps only to your own detriment. Starvation reactions are real and proven, no matter how many people want to deny them in order to validate the irrational  notion that the body is simply a calculator into which calories in and calories out can be input and predictable results will occur. Give your body a break. Give your self-esteem a break, too, and just eat once in awhile and stop beating yourself up for it. It's not going to sabotage your weight control efforts as long as you're reading it as a real cue and not acting on emotional needs to binge.

Bulimia

When you can't control your eating and you're desperate to lose weight, there are a lot of imprudent things that you can do to try and deal with your situation. One is starting to smoke. Smoking increases metabolism and suppresses appetite. A lot of the ever so slightly voluptuous women in Hollywood who become thinner after they become more famous are helped along by picking up this nasty habit. They trade in one problem for another.

It's also possible to start throwing up after you eat (bulimia nervosa). I will admit that there have been times when the thought that the answer to my problems could be as simple as putting my finger down my throat or taking some ipecac after binging or eating too much. This "solution" is very dangerous, of course. It carries a lot of health issues, one of which is heart problems.

In the end, I just couldn't manage to do it, appealing as it was to have my cake and not get fat from it, too. The bottom line is that I'm just not the type of person who can force myself to vomit up the food I've just ingested. Perhaps it has to do with growing up poor and not feeling that it's okay to spend money on food then flush it down the toilet. I could also simply have been frightened of the consequences, but I don't recall that being a part of my thinking process at the time that I rolled the idea around in my head.

Just today, I had a revelation. I was watching an old re-run of the medical drama "House" and he was sitting in the clinic with a patient and said that her bad breath and gnarly-looking fingers indicated she's been regurgitating her food. I had known for quite some time that both of these were signs of bulimic behavior, but hearing it said aloud made something click in my mind about a client of mine.

I sometimes meet with a client in a small space and she often has very bad breath. In fact, the breath issue is so bad at times that it lingers in the air after she has left unless I specifically air out the meeting room. I'm sure that anyone who uses the room immediately afterward can smell it as some odd funk. I didn't think much of this because she's not the only client I encounter who has halitosis. However, she is the only one with deformed fingernails and chewed up fingertips.

I had noticed both the breath and fingers for quite some time, but I never put two and two together. This particular client is quite slender, though certainly not emaciated. I'm pretty sure that she is selectively purging her meals. I mainly think this because she is not engaged in any work or hobby that would explain the condition of her nails and fingers. The worst finger of all is the index finger on her right hand, a prime candidate for sticking down her throat.

I like this client and now I feel sorry for her as well. She's always been friendly to me and we've gotten along well. She doesn't appear to judge me by my weight despite being thin herself. I now wonder if she might have some hidden understanding and compassion for what I face.