Monday, March 11, 2013

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.


hopefulandfree said...

May I respectfully suggest an alternative perspective? Many of the behaviors and characteristics which you list here---and which you suggest "result in obesity that functionally impairs someone"---may represent normal human responses to chronic, severe, long-term, widespread, insidious, inhumane (and, indeed, mostly inescapable) conditions of social oppression and domination, which legitimate and enforce mandatory membership (based on body size) in a readily-identifiable and highly stigmatized group. Typically, stigmatized persons (including children) must endure, defend against, and devise strategic ways to cope with being frequent targets of: injustice, domination, irrational fear, hatred, bullying, scape-goating, harassment, discrimination, disrespect, rejection, prejudice, exclusion, assault, etc. Stigmatized persons can never be sure that others are not hiding disrespectful thoughts or feelings (disgust, disdain, dislike) behind false smiles and faked friendliness. Finally, physiological harm, biological illness, trauma, and "functional impairments" resulting from social stigma are REAL consequences of stigma (aka comorbid health issues brought on by stigma) and should never be minimized or discounted. Chronic stress can, for example, impact cardiovascular health, compromise immune system defenses and dysregulate endocrine processes.

screaming fatgirl said...

As someone who spent more years of her life (see the "Tribe-less" post) in the position of which you speak, I am fully aware of what you're saying. However, the way in which others treat you is a cause which cannot be controlled by the sufferer. Therapy cannot do anything about the treatment people receive. It can only do something about how they react to that treatment.

Reacting to prejudice, stigma, etc. by developing a disordered relationship with food that results in obesity is not a healthy coping mechanism. The role of therapy in people who have such responses is to guide them to healthier coping mechanisms and to reduce the engagement in unhealthy ones.

So, yes, you are right, but it is beside the point of what I was talking about. Social oppression and mistreatment can't be solved in a therapist's office. Helping people react to circumstances they cannot control (and we cannot control the actions of others) by not damaging themselves is what I'm talking about here, not about the causes of that damage (which I believe are the result of a large number of complex factors including upbringing, genetics, and experiences).

hopefulandfree said...


I found a few articles that may hold relevance for better understanding about the health impacts of stigma on self-regulation and coping, offered here in acknowledgement that stigma can't be diminished by therapists, but therapists may improve the efficacy of treatment (and enhance empathy within the relationship) if they take into account these potential barriers to change. I believe it would be helpful for therapists to understand the complex ways in which stigma influences an individual's abilities to choose better coping mechanisms and to self regulate personal behaviors, such as eating.
Thanks for allowing me to contribute to the discussion, even though my perspective focuses on social issues that you haven't specifically addressed as critical barriers to effective treatment.

I was suggesting (awkwardly!) that some methods of coping (although far from ideal) may actually be the healthiest ones available for a person struggling within a particular social context (while struggling to cope with forces she doesn't recognize. Facing and deconstructing the hidden power of hegemony can be empowering and liberating and validating.) Hopefully, a good therapeutic relationship can alter that context and help to open the way for healthier behaviors.

screaming fatgirl said...

I think that most therapists can and do deal with these issues in their treatment of people who have eating disorders. However, the fact that obesity related to mental suffering is not even recognized as a mental disorder only makes it harder for treatment to even be offered, let alone for a deeper understanding of the difficulties overweight people endure.

My husband is currently training to be a therapist and will eventually be a licensed provider of mental health care. Trust me when I say that empathy and being "present" for the client is foremost in what he is learning. This type of skill is something directly being taught to people.

It's also important to remember that there is a huge difference between a psychiatrist, a counselor, and a licensed therapist (and licensing is different in each state). The first two are hardly qualified to be good therapists. The last may or may not be. I would encourage anyone seeking therapy (and not medication for mental health) to deal mainly with licensed therapists. They're trained to offer healing through talk, whereas the others mainly just hold degrees of various sorts (and psychiatrists are essentially doctors).

hopefulandfree said...

Wow, SFG, thanks for sharing that about your partner's professional goals. From everything you've previously described about his personality and character, he has chosen a career that will prove mutually rewarding for both him and for his clients. I actually had a very good personal experience (as client) with a psychologist who had already been working as a therapist for about 30 years when I sought her help. I believe she helped me (enormously) to have more compassion for myself, and for others. I made a lot of progress, too, while participating in her small group sessions with other women who had very similar backgrounds (chronic childhood trauma.) Unfortunately, she, like most other professionals, understood little about disability issues relating to executive function disorders, which are (theoretically) developmental challenges that require far more external kinds of assistance/accommodations than our culture (typically/currently) is able to offer most people who struggle with these disabling conditions. It was frustrating for me, and (no doubt) for her. She could not conceptualize my disabilities with the tools and theoretical lenses in her repertoire. I appear to be extremely high functioning and socially adaptive for short periods of time, within specific contexts, e.g. able to engage actively and participate collaboratively during therapeutic sessions. But surface appearances are deceiving, and typical executive function diagnostic tests are completely inadequate to measure actual functioning ability over longer time periods and within more stressful contexts. Russell A. Barkley's working theory on "Executive Functions" (I just finished his book by that name) moves in a positive direction, although I also see many gaps (as an individual who has lived with this stuff for over 5 decades). :)
Okay. Forgive me please if I've overstepped, re: off topic comments, I certainly don't mean to be disruptive or derailing of specific ideas you are discussing. Thanks for letting me share.

Anonymous said...

Interesting that you articulate pretty much everything I articulated as a comment on another blog some time back. However, your response at that time to my thoughts was rude, to say the least. Funny how time can change your POV.

screaming fatgirl said...

Where is the comment you are referring to? I don't recall such a comment. Perhaps you didn't say what you intended to say or you are misinterpreting what I am saying. Either way, I can't say unless you provide a link to the comment.