I am Sam Vaknin, and I am the author of Malignant Self-Love, Narcissism Revisited.
Patients with eating disorders either binge on food or refrain from eating altogether. They are sometimes both anorectic and bullying.
Eating disorders are impulsive behaviors, as defined by the Diagnostic and Statistical Manual, and they are sometimes homomorphic, exist 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 and impulsive behaviors.
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 it first upon their eating and sleeping disorders and only then on their personality disorders.
By controlling her eating disorder, the patient reasserts control over her life, and 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.
You see, it is a chain reaction. Controlling one’s eating disorders leads to a better regulation of one’s self-worth, self-confidence, self-esteem.
Successfully coping with one’s challenge, the eating disorder, generates a feeling of inner strength and results in better social functioning and an enhanced sense of well-being.
When a patient has a personality disorder and an eating disorder, the therapist would do well to first tackle the eating disorder.
Personality disorders are intricate and intractable. They are rarely curable. Certain aspects like obsessive-compulsive behaviors or depression can be ameliorated with medication or modified, but the underlying disease is very hard to uproot.
The treatment of personality disorders requires enormous, persistent and continuous investment of resources of every kind by everyone involved, especially the patient.
From the patient’s point of view, therefore, the treatment of a personality disorder is not an efficient allocation of very scarce mental resources. Neither are personality disorders the real threat.
If one’s personality disorder is cured but one’s eating disorder is left untouched, one may die albeit mentally healthy.
An eating disorder is a signal of distress. It says, I wish to die. I feel so bad. Somebody help me.
It is 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 eating.
And this is where we can and should begin to help the patient by letting her regain control of her life.
The family or other supporting figures in the patient’s life 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 agenda, and that she, her needs, preferences and choices, do 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, reassert mastery over her wayward and chaotic life.
At this early stage the patient is unable to differentiate her own feelings and needs from those of others.
Cognitive and perceptual distortions and deficits only increase her feelings of personal ineffectualness and her need to exercise even more self-control by way of her diet.
She develops somatoform disorder. 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. That’s her vestigial mode of self-control.
The patient views the world in terms of black and white, of absolutes. This is a primitive defense mechanism called splitting.
Thus she cannot let go, even to a very small degree. She is constantly anxious. 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.
All this leads to a chronic absence of self-esteem.
These patients like their disorder. Their eating disorder is the only achievement in life. Without their disorder, they are ashamed of themselves and disgusted by their shortcomings, expressed through the distaste with which they hold their own body.
Eating disorders are amenable to treatment, though comorbidity with a personality disorder presages a poorer prognosis. The patient should be referred to talk therapy, medication, and enroll in online and offline support groups, such as over eaters and others.
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.
In short, medication, cognitive and behavioral therapy, psychodynamic therapy, and family therapy ought to do it.
The change in the patient following a successful course of treatment is very marked. 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 eating disorders, she finds herself 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 before they succumb.
The therapist’s goal is to buy them that time. The older they get, the more experience they become. The more their body chemistry changes with age, the better the chances to survive and thrive.
