Psychosomatic Disorder: Overeating associated with other psychological disturbances
Overeating is considered a behavioral disorder that is attributable to psychological disturbances. This behavior has its physiological consequences. Obesity, which is measured by a body mass index [BMI ≥ 25], is all but a consequence of this behavior. Depending on genetic factors, some people who develop overeating behavior disorder may not become obese. Other physical problems, however, eventually afflict long-term overeaters. This include metabolic syndrome, a chronic disease suffered by millions worldwide which result in morbidity and mortality. Despite much attention put into the worldwide “obesity epidemic” the problem of over-nutrition is difficult to grasp. This is attributed to the fact that the cause of the problem is multifactorial, with environmental and psychosocial influences in play (Agras, 2005).
Different Subtypes of Eating Disorders
Eating disorders are grouped together in the ICD 10 and DSM-V system. This include Anorexia Nervosa (AN) and Bulimia Nervosa (BN). Unlike AN and BN, together with other forms of Eating Disorder Not Otherwise Specified (EDNOS), overeating is a disorder associated with over-nutrition and has the opposite effect. The sufferer does not compensate for the habit by doing activities like purging in order to lose the calories consumed. As opposed to these eating disorders it is not clear if the root of over-nutrition is psychological or physical, i.e. if obesity, and other affects of over-nutrition is a cause of overeating or vice versa or both ways (ibid. p. VII).
Categorization in the ICD-10 does not specify or name the condition “Binge Eating Disorder” as in the DSM. Within the ICD-10 there are at least 3 related conditions that could relate to the condition. The closest is F50.9 which is basically Essattaken ohne Erbrechen, F50.4 which if the condition coincides with emotional disturbances. As a consequence, it could also relate to F55, addiction to non-addictive related substances.
General Description and Diagnostic Considerations
Binge Eating Disorder (BED). The behavioral problem of overeating is classified in diagnostic manuals within the category of eating disorders. Only since DSM-V has BED been recognized with its own category. Prior to this, in DSM-IV, BED was relegated to an appendix alongside EDNOS, BED is defined “as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Someone with BED may eat too quickly, even when he or she is not hungry. The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behavior. This disorder is associated with marked distress and occurs, on average, at least once a week over three months” (American Psychiatric Publishing, 2013). BED also does not result in compensatory behaviors like purging (Tuschen-Caffier & Schlüssel, 2005). It is separated but intertwined with obesity and is generally known to have emotional underpinnings (Masheb & Grilo, 2006).
It may be useful to note that BED is considered to be a separate condition from the general phenomenon of overeating according to the DSM. In the ICD, there is a condition identified as “overeating associated with other psychological disturbances” (F50.4) a situation of overeating in the presence of emotional stress or setback. Studies have shown that obese individuals with BED differ from individuals who are simply obese (Grilo, 2000).
Obesity is not the only physical consequence of BED, and many sufferers may not show significant signs of adiposity. There exists evidence of risk of metabolic disease arising from the behavior, with a higher percentage of newly diagnosed type 2 diabetics having experienced problems with binge eating compared to other groups who have not that experience. Recurrent binge eating can also make diabetes difficult to control. (Kenardy, Mensch, & Bowen, 1994)
Food Addiction. Could the cause of over-nutrition be the result of addiction to food or certain food ingredients? Is addiction to food, and/or the phenomenon of food craving related to, or contributory to BED? Food craving is known to be a cause of uncontrolled eating, which lead the scientific community to recognize food substances to be potential triggers of addiction, similar to the effect of drug addiction (Pelchat, 2009). Refined foods have been implicated to cause addiction, whereby loss control of intake of such food is a cause of health concern (Ifland, et al., 2009). There are also arguments that unlike drug addiction, what is often food “craving” has a biopsychosocial aspect that is not synonymous with addiction (Rogers & Smit, 2000). In the ICD, depending on severity of dependence to the food substance, we may, arguably, consider the classification under “Abuse of non-dependence producing substances” (F55).
From a biological standpoint, the idea that “non-dependence producing” could be questioned. Long-term chronic over-eating leads to metabolic disorders, which is related to the endocrine system. Insulin resistance caused by constant high levels of glucose and fructose intake results in not only physiological effects on the patient, but also psychological effects. While sugars are not considered directly “psychoactive”, glycemic levels do affect the mental state. Sufferers of metabolic disorders have problems dealing with the homeostasis of blood glucose, and face with uncontrollable craving, hunger and other emotional side effects, like stress and depression (Goebel-Fabbri, et al., 2005). Looking at the situation holistically, one can observe a vicious cycle of uncontrollable behavior resulting in physiological problems that add to more difficulty in managing the behavioral impulses (Vaidya, 2006, S. 76).
Criteria notwithstanding, for this paper, I discuss the phenomena of uncontrollable over-nutrition, since sufferers exists in varying degrees and since as psychotherapists, we may encounter many clients with difficulty controlling their tendencies to over-eat, and need help regardless of whether their symptoms fulfill the criterion stipulated in the manuals or not. As with most eating disorders, that while the symptoms may seem similar amongst patients diagnosed with the same disease, the underlying mental causation for each case is individual-specific. The challenges exist with such clients since there lies not only emotional grounds for the occurring situation, but also physiological causes.
Physical Symptoms vs. Psychological Symptoms
Table 1. lists the differences between the somatic and psychological symptoms of BED and general disorders related to over-nutrition like food addiction.
|BED and “Overeating associated with other psychological disturbances”
||Over-nutrition, consuming too many calories.
Long term result in Insulin Resistance, Metabolic Syndrome, and complications therefrom (Goebel-Fabbri, et al., 2005, S. 143).
Possible alimentary canal, teeth stomach injury.
|Uncontrollable need to consume food. Feeling lack of control over behavior.
Pre-occupation with thoughts of food.
Emotional reaction to condition: anxiety, stress, shame, frustration.
Psychosocial problems, loneliness, loss of normal social activity caused by habit.
Emotional stress caused by illness as a result of over-eating. Comorbidity with mood disorders, high rates of major depression, personality disorders
(Yanovski, Nelson, Dubbert, & Spitzer, 1993).
Vicious cycle of dealing with weight gain and medical problems.
||Over-nutrition, consuming too many calories.
Possible toxicity from abused food substance.
Long term result in Insulin Resistance, Metabolic Syndrome and complications therefrom.
|Stress caused by weight-loss efforts.
Body image shame.
Table 1 Physical and psychological symptoms
The case study cited here is a self-report by Kimberly, who posts her story online in the form of videos, otherwise known as vlogging. One can access her videos via her in a YouTube Channel @kimberlyuhles1 (Uhles, 2014). I have decided to use this material because the accounts are directly reported by sufferer. Unlike other material we may find, the case studies do not come from first person perspective and are often edited and reworded. I find it more challenging this way, partly because this “client” does not present herself as someone in the victim position, but rather, a survivor of a disease. The sufferer, in her early twenties at the time of recording, seemed to have found a way to cope with her affliction. At the time of writing this paper, Kimberly is 23, and still vlogs regularly on the same channel. With this, one can simulate a situation with a client whose journey still continues.
Kimberly has two sisters. When she was 9 years old, her father left home for another family. Kimberly reports that he took everything, including material items for their home. As a child, she says she could not understand why her father left. In the process, her mother had to spend time at work, leaving the children to their own devices at home. They ate and did what they liked. Kimberly recounts later on not having the food that she wants to eat at home. Her mother, in effort to control her children’s weight, kept only healthy foods in the house, and disallowing any junk food. Kimberly felt deprived, especially in school watching other children eat whatever they liked (mostly tastier junk food). She also said she felt left out, or the odd one out because of the food she was given for lunch, and that which was not allowed her. She started sneaking to buy junk food herself, which she would eat quickly so that her mother would not catch her eating them. At 12 years old, her mother put her on a weight-loss regime, sending her to a gym even when she was too young to be allowed in that gym. She had to lie about her age to the trainer. When she was caught eating junk food, her mother would punish her with workout. When she turned 17, her realized sense of “freedom” meant that she was free to eat whatever she wanted. Her experience of having her first car was that of having the freedom to eat. Henceforth, she recounted really being addicted to food. She would eat as much as she could while sitting in the car. Her subsequent weight gain (she was reported to weigh about 300lbs) caused depression. She tried to get gastric bypass surgery but could not afford the treatment. She tried unsuccessfully to make herself throw up, but stopped doing it shortly after realizing that it did not help with her weight problem. She reported feelings of depression and self hate.
It seems that Kimberly managed to cope with her situation through her vlogs, which she has done so regularly for almost three years. Much of what she has talked about were her eating disorder, the emotional triggers, and her efforts to self help through diet and exercise. She also likes to give advise to others. Kimberly is also in a long-term relationship, and has recently found out that she is pregnant. She reports her pregnancy to be a happy situation.
From the case presented above, one can appreciate the process that triggered such an eating disorder in a young person. The problems started in childhood and progressed over more than a decade, and is a culmination of situations from which one can hypothesize:
At 7 years old having feelings of loss and betrayal because of father’s leaving.
Feelings of further loss because of mother’s reduced presence at home because of work, and possibly mother’s emotional state.
- Probably lack of food in home (because mother was not home) and associating this with loss of parental presence and loss of emotional support.
- Stress from mother’s negative reaction, and harsh remedial actions in response to children’s weight gain (probably caused by mother’s own guilt feelings).
- Feeling alienated at school. It could have been caused by shame because of parent’s situation, but client associates it with the food she got for lunch.
- At 17, she associated freedom with having food. At the same time, realizing she was addicted, then judging her own state of mind.
- Stress and depression from dealing with being overweight.
- Compensatory measures attempted by client does not fit that of sufferers of Bulimia Nervosa (BN), since the client claimed that she tried it, but found that it did not suit her.
These are intervention questions for client at the present time. The client seems to have coped with her initial situation of over-eating and she has found an outlet for her problems through what Freud considers “sublimation” in the form of vlogs. Exercising is also a compensatory measure (and the voice of her internal mother). I believe that dealing with the client at this point is a more challenging task. The personality of the client is one of an independent person who meets up to personal challenges. She also intellectualizes her inner existence through self-analysis. She has not got counselling, and may may not have had time to deal with experiences that underlie feelings of loss, betrayal and need to be shown love. In a video in the channel where she talked about a breakup with her boyfriend, she repeated that she wasn’t given the love that she wanted even when she knew he loved her (they got back together and are having the baby). My impression from watching the video is that this need for “assured signs of affection” reflects the mistrust felt from earlier abandonment, and could be good direction to take in treatment. I would ask these questions (in italics), and try to get the phenomenological experience of the client. What I would try not to do is to talk about physical symptoms or the over-eating habits that the client is already aware of and is ashamed of, unless the client brings it up.
Questions directly addressing binge eating disorders and the somatic aspects:
- Help me understand your relationship to food. How often do you eat? What do you like to eat? Etc.
- When you were a child, in what way does food play a role?
- Did your family eat together?
- When did you realize that you have a “problem” with binge eating? When did it happen, where were you, how did you feel?
- You mentioned you got hungry when you were alone, can you help me understand how you felt as you reached for the refrigerator?
- When you had your first car, help me understand how it felt to gather the food and eat it.
- Imagine yourself in the car, please say what your experience is like.
- After the session of eating, please tell me what it was like for you.
- What are the physical effects? Do you feel discomfort? Where in your body?
- How long did the discomfort last?
- What are you feeling about this now as you are telling me this?
- Are there long term effects of this habit?
- What have you done in efforts to overcome the effects (weight gain)?
- How has this affected your relationships/life/work?
- What can you imagine you would have done have you did not binge eaten?
The following are questions I would ask considering methods in Gestalt therapy. If the client does not acknowledge binge eating as a problem, or if he/she is convinced that he/she has it under control but still shows signs of dependency issues in relationships, these questions may be a way to help work the client towards the issue:
- Congratulations on the baby. Tell me what having this baby means to you? What is it like for you to be a mother? What is it like to hold the baby?
- What do you want for your baby? What is your wish? The client may express aspirations for her child, or for her family.
- Very nice. Lucky baby. Look for phenomenological expression. On this remark. Is she touched? Eyes moist? Smiling? I wouldn’t ask question but state what I observe. E.g. I notice you were touched/ your eyes are moist/you were smiling when I said this. Then wait for response.
- If client makes reference to her past experience as a child, e.g. “I do not want my child to bear the same problems,” then ask about it. Otherwise, stick with the moment of happiness with having the baby. Dwelling with the positive makes for good rapport.
- If client talks about disappointing childhood, say, tell me, what happened when your father left? What did that mean to you then?
- Imagine you were back there, what would you like to say to him? What would you like to ask him? Use empty-chair if client is okay with it, and guide client through experience. One may also continue with discussion on the client’s father, but with focus on what the client feels about him, look for emotional queues on the face and body language.
- Tell me, what is your father’s response now? This question one can ask after empty chair or some kind of constellation technique. This is to help client gain insight into the father’s motives/weakness.
- So he said this. What do you take from it? Usually client will experience that father’s leaving was not her fault and/or that it is his weakness and/or this is how grown ups behave…etc.
- I can see that this is happening right now. I feel… Acknowledge client, allow her to experience this with someone empathizing along with her.
- Imagine yourself as the child, and your father just left suddenly. What do you want to say to your mother? Again, empty chair or phenomenological discussion. This is to establish client’s idea of what was going on with mother.
- How did you feel being alone at home without her? It is to help client find out Was it fear? Anger? Hunger? What? Then allow the client to take it in.
- I can see that this is happening right now. I feel… Acknowledge client, allow her to experience this with someone empathizing along with her.
- As an adult, here and now, tell me what you think of this little girl?
- I think she’s ……too! Repeat the positive things client says about herself as a child.
- Give us one word to describe this session. This is to crystalize the insight, at the same time to put distance again from the past and return to the present.
While many people may face the same kind of childhood trauma, only some children develop, for example, Anorexia Nervosa. Others may do the opposite and become binge eaters and /or become obese. For others, eating disorders do not become a problem, but they develop an array of physiological symptoms as a result of anxieties, phobias and internally directed aggression. Question that arise are: is there ever a psychological problem that does not have somatic implications? Are there ever somatic symptoms that do not affect the psyche? What has personality—what many would agree to be caused by the ego— got to do with the physical attributes of a person? Does personality, then, correlate in some way to the manner of physiological disorders an individual might contract? For that matter, is every individual really unique, and what can personality traits tell us about the motivation behind these disorders?
We may find some good advice from pioneer Gestalt therapist, Erving Polster (1987); he has trained therapists of the modality to see, and value every persons’ life as a novel. This idea may be very helpful, because it puts the therapist on a mindset of valuing the clients’ life as something interesting and worthwhile to investigate. When the therapist is interested in the life of someone, he/she would naturally ask appropriate questions and go beyond the stories he/she tells, or that of his/her doctors. The therapist would be able to work authentically without fear of seeming unprofessional, losing the client to other therapists, making the client angry or other problems we have discussed at class. In dealing with dialogue, I’d often refer to the works of Lynn Jacobs, one of which tackles shame (of both client and therapist) in the therapeutic dialogue (Jacobs, 1995). What one can infer from Jacob’s argument is the possibility that shame (or unrecognized shame) in therapy prevents the therapist and client from getting to the heart of the matter, thus leaving problems to persist and the therapy ineffective. One can only imagine that ineffective therapies, especially encountered by clients dealing with somatic symptoms, can be intolerable and frustrating. This leaves for interesting work and more detailed efforts into psychotherapy process research.
Read also: What is Psychosomatics?
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