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Obesity as a psychiatric Disease

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Premise: Obesity is, primarily, a psychiatric disorder.

As a physician who has dedicated 90% of his Internal Medicine practice for the past 15 years to the treatment of obesity, I have come to the conclusion that this disease is, primarily, a psychiatric disease. Certainly there are metabolic and endocrine conditions that can lead to obesity. However, for the vast majority of patients afflicted with this disease, it is clearly a well-defined psychological mind set that leads to the self-perpetuating set of behaviors manifests themselves in the physical state of obesity.

For the sake of argument, let us contrast obesity with the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria for the diagnosis of the polar opposite of obesity, anorexia nervosa. Anorexia Nervosa is diagnosed by the following criteria:

A. Refusal to maintain body weight at or above a minimally normal weight for age and height
B. Intense fear of gaining weight or becoming fat, even though underweight
C. Disturbance in the way in which one’s body weight or shape is experienced, under influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
D. In postmenarchal females, amenorrhea (the absences of at least three consecutive menstrual cycles.

Allow me to revise these criteria to fit the typical obese patient in order to make a point:

A. Refusal to maintain body weight at or below a maximally normal weight for age and height (easily defined by the measurement of the Body Mass Index – BMI – which statistically defines a “normal” body weight as 18-25; obesity is defined as a BMI as >30)
B. Intense fear of losing weight or becoming thin, even though overweight. [While this may initially seem paradoxical there really is a significant fear in many obese patients of actually achieving a "normal" weight. It may be due to underlying anxiety of dealing with social acceptance in circles they do not have to deal with when obese.. Specially, it may be due to fear of intimacy from which they feel protected if they remain obese. It may be fear of having to "become someone else" if they go from one physical appearance to another. Also, obese people are clearly discriminated against not just socially but also in the work place. Remaining obese protects the patient from a “fear of success.” There are other examples.] C. Disturbance in the way in which one’s body weight or shape is experienced, under influence of body weight or shape on self-evaluation, or denial of the seriousness of the current high body weight. [Obese people are often in self-denial that they actually have a weight problem. Further, they are in denial that their obesity is actually affecting their health or sense of well-being. You must remember: obese people often function and feel most comfortable within a circle of overweight friends. They develop, as a result, a distorted body image. Also, denial is a strong protective mechanism for the conscious mind. Obese patients learn to shop at clothing stores that carry "plus" sizes. Likewise, they learn to shop alone or with obese friends so that they are not exposed to the anxiety of buying in the larger sizes while friends shop in the "normal" section.] D. In postmenarchal females, dysmenorrhea (the abnormal frequency or duration of at least three consecutive menstrual cycles. [Obese women often have dysmenorrhea and do not ovulate regularly. This is due to a disturbance in the estrogen-progesterone cycle and the storage of estrogen byproducts in body fat. I cannot begin to count the number of obese patients who have started in my clinic saying that they have been told by their gynecologist that they "can't get pregnant." After even minimal weight loss (10-20% or their excess weight), obese patients begin to ovulate and, in my experience, many become pregnant.]

Clearly, obesity is also associated with higher incidence of more defined psychiatric diagnoses including depression, chronic anxiety, social panic disorder, etc. But it is the “obese mind set” that leads to self-perpetuating behaviors – sedentary lifestyle, overeating, social isolation, fatigue and feelings of being “out of control.”

So, if we are going to establish a psychiatric diagnosis category for achieving an abnormally low weight, I think it would only make sense that the DSM include the psychiatric diagnosis of obesity (an abnormally high weight). It is high time that the medical as a whole and the psychiatric profession, in particular, join in the battle against this devastating disease process.

Editorially, perhaps if obesity were given a psychiatric diagnosis, the patient afflicted by this ailment could get medical insurance coverage. It is a never ending source of bewilderment to me, as a physician, to see insurance companies refuse coverage for the treatment of obesity. I am reimbursed by insurance carriers for treatment of an obese patient’s hypertension, degenerative arthritis, high cholesterol and triglycerides, depression, fatigue, chronic back pain, and diabetes. But, if I code “obesity” on the insurance form, it universally gets returned as an “uncovered diagnosis,” even though obesity is the underlying cause of the other “covered” diseases. The hypocrisy of the insurance industry is another source of discrimination that must be overcome before the obesity epidemic can ever be effectively addressed.

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About Diet Doc

  • http://www.angel-and-soulmate-selfhelp.com/blog.html Angela Chen Shui

    sorry.. just thought of this…

    would be interesting to do a poll of heterosexual women who feel they are fat to see how many of them do not climax during sex…

    many women feel climaxing with a man in bed who they have power issues with in other areas of their relationship is just giving away more of their power to the man… so they don’t climax, although to ‘get it over with’ they may pretend to…

    sounds like a poll to add to my site…!!! ;-)

  • http://www.angel-and-soulmate-selfhelp.com/blog.html Angela Chen Shui

    this doesn’t negate the reality that enough may not be going on in bed to entice her over the edge… :-)

    i know, i know… we’re all responsible for our own pleasure… but why the hell be in bed w/ someone if u have to deal w/ business b4, during or after, yourself, w/out much input from whomever?

    anyway, i don’t think any other comments on all of this will come again after i press ‘post’!

  • ZENA

    THIS IS ALL VERY INTERESTING

  • something

    i really think this is all very interesting

  • dietdoc

    Zena and “something” write:

    “THIS IS ALL VERY INTERESTING”

    Reply: Then, by all means, let us know what you find interesting! Specific would help continue the discussion and bring up points that others might not have thought of. BLOGs are very multi-authored….every throws a little something in the fire and it can burn very brightly at time.

    Thanks for dropping by!

  • http://dementeddelusions.blogspot.com/ Michelle

    I get so frustrated reading things like ‘change your attitude’ and ‘change your behavior’ etc… Plus I find the terminology “refusal to lose weight” and all this poppycock that I surround myself with fat people and only shop with fat people incredibly offensive, not to mention, untrue. (Just this past Xmas I went shopping with my size 6, model pretty friend at Lane Bryant–I bought fat clothes in public! Gasp!)

    The fact is science still does not have a good handle on how to treat obesity. If they did, this discussion wouldn’t even be occuring. It’s easy to point the finger at fat people, implying it’s their own damn fault. But that is not always the case.

    Case in point: Me.

    History of adrenal insufficiency, leading to development of PCOS (with NO family history of either PCOS or diabetes)and subsequent diagnosis of Metabolic syndrome (again NO family history). Two endocrinologists independently agree that the root cause of my weight and hormonal issues are due to the adrenal insufficiency (caused by medication).

    I know I am fat. There is no denial, none.

    I take steps, sometimes extreme steps, to try and lost weight.

    I have yet to be successful.

    I did more than 16miles of exercise last week. I have gotten to where I can lift 20lb free weights in my weight routine.

    I do all this yet I do not lose weight.

    I’m allergic to the medical regimen normally prescribed for people like me (as in an allergic reaction that could be fatal).

    Stomach stapling would be a short term fix. I already have good habits so once the stomach stretched out again, my body would pack on the pounds with even a restricted caloric intake.

    I am likely going to die 20 years before I should.

    It’s nice to know that, while I struggle with a very real physiological problem that society will whisper about my lack of self control behind my back (or say it to my face) and assume the worst about who I am.

    Thanks for perpetuating all that crap, because it’s not like I have enough to deal with already.

    Michelle

  • Eric Olsen

    Michelle, very sorry to hear about your situation and congrats on doing so much and trying so hard. This story speaks in generalities about most people, not the relatively few with actual physical conditions such as yours. No offense meant and only the best wishes for your health and happiness

  • http://www.docofdiets.com dietdoc

    Michelle writes:

    “The fact is science still does not have a good handle on how to treat obesity.”

    Reply: You are absolutely right. But to say that, for the majority of obese people, psychological issues are important is an understatement.

    For a more detailed reply, I would certainly need more information because wnat you describe sounds very odd. As an internist and not a gynecologist, I know of PCOS but am also aware there are a multidue of treatments for it. AS for the adrenal insufficiency you describe, what medications caused that? And it is my understanding that adrenal insufficiency causes weight loss and asthenia more commonly than obesity. The whole medical picture your describe is a bit nebulous.

    Like Eric, I wish you every bit of success. I do know that a rare subset of obesity is caused by medical disease, but it is a small segment of the overall group. I also feel there are some things, medically and surgically, that can be done for your condition. I would strongly recommend you continue your search for subspecialty assistance of your medical problems. Perhaps at a major medical center in your state?

    At least you, unlike many of the folks at bigfatblog.com (an unfortunate name, I agree), you realize that your obesity is life-threatening and deserving of treatment. I wish you every success in finding some assistance in this complex matter.

    Good luck and best wishes,

    Ron

  • http://dementeddelusions.blogspot.com Michelle

    “This story speaks in generalities about most people, ”

    Eric, for me that is the problem. You may know there are exceptions, but the public at large does not.

    These ‘generalities’ are what fuel discrimination (sometimes even from doctors) of people in my situation. The lack of disclaimers and exceptions effectively translates into a fat stereotype believed by society to be true. They also are primary drivers of any psycho-dysmorphic (can I make that word up?) that the overweight struggle with. This is why I find these general statements so offensive and even irresponsible.

    Secondly, I suspect there are more than a few people in my shoes, whether science can recognize them or not. We won’t be able to differentiate those who are overweight solely due to behavior vs. those who are due to underlying physiology problems until we see more people exercising and modifying their habits–we still have not reached critical mass on changing behavior on a large demographic specific scale. Once we do, the people who have problems beyond eating too much and exercising too little will be identifiable. At the moment, we are just assuming based on what looks like logic that all fat people can lose weight if they just exercise and change their diet. That hypothesis, in my opinion, has not been throughly proven or else we wouldn’t be having problems with obesity.

    We are still at the point where, if I were to come to you as a patient telling you I try to lose weight, but can’t, that you are more likely to not believe me or think I don’t have the right information to be successful than to suspect any underlying physiological cause. I don’t think it’s just the fat people who need to adjust their attitudes.

    In fact, I was so frustrated with my inability to lose weight, I did an experiment on myself. For three months I followed a strict diet and exercised like I had found my long lost religion. I did not screw up once, not once. I followed my program without deviation. I did not lose a pound. Yet when I went to the doctor and relayed what I had learned, I was ignored. I was treated as if I didn’t know what I was talking about, or worse, as if I was a liar. It was impossible for my doctor to intellectually accept that I could not lose weight. She had to believe, because of her own bias, that I must have done something wrong.

    I have even told doctors I exercise only to have them ‘forget’ that fact and lecture me on how I need to exercise a mere five minutes later. Once one of them said, “Why are so chubby then?” (yes I do remember the words exactly) The denial is absolute.

    Ron: My body, I think, is specializing in the unexpected. My adrenal glands weren’t supposed to shut down, but they did. The med that caused it was prednisone and it did it to me 2x in my 20s (which made for a terrible decade).

    The weight gain was primarily from an inability to maintain good habits between the huge appetitie prednisone sparks and the muscle cramping it caused (it took me 2 years to be able to walk w/o pain the last time.) I am a gainer, the only reason I do not weigh 500 pounds is through extreme effort on my part to not gain weight. So take away my exercise, give me an almost insatiable appetite and that is a recipe for disaster. And when it was all over, it seemed my ability to lose weight and ovulate had disappeared.

    It is so clear, in hindsight, that this is when the PCOS kicked in.

    At least with the PCOS diagnosis I understand why now, because I did (and still do) blame myself quite a lot for being overweight. It doesn’t help that society is more than willing to assist me with my internal guilt trips. Books like the one discussed here are just another flog with which I can be whipped.

    I have been looked at by 4 separate endocrinologists and have access to on- going specialist care. I have also tried accupuncture (which was sooo not fun and was the one time I was glad something didn’t work so I could stop).

    The problem is, thus far, the standard paradigms of care have not been terribly effective and the doctors haven’t been willing to accept that. They keep trying to cram me into a cookie cutter template of care (with the best of intentions) despite any feedback to the contrary. The endocrinologist I’m working with now is hearing me and I think once I prove to him that I can’t tolerate certain things, we’ll be able to move on to the next step.

    In my experience, it is never good to be the odd one out when it comes to illness because they don’t know what to do with you and you don’t always get the attention to detail you need. Generalities, social or medical, can be dangerous for people like me.

    Since, to date, we have found no pill that my body will tolerate, I’ve been focusing on exercise and diet. I will spare you the details, just suffice it to say I’m doing the best I can with the circumstances dealt to me.

    Reading things like the summary of this book, remind me of when women were thought to be ‘hysterical’ just because they didn’t behave the way a male dominated society thought they should. There seems to be a kneejerk reaction in science and society that if something can’t be explained then it must be ‘all in our heads’ and, ergo, our fault due to a personal failing. That kind of belief system is just as damaging as being overweight and it would be nice if we could move past that kind of derogatory thought pattern.

    Secondly, I wish the medical community, when dealing with patients, would focus more on encouraging exercise and providing nutritional information than telling patients to lose weight. All patients, regardless of weight, should be exercising and avoiding trans fats, but for some reason the size 4 woman with so little stomach tone she’s got cellulite on her gut isn’t told she needs to exercise. Somehow she gets a free pass while the fat people get a lecture. Yet her lack of fitness is detrimental to her long term health as well. In my opinion this is a prime example of the hypocrisy fat people seeking medical care experience.

    This is too long already, so I shall stop here. I hope I have given you some food for thought.

    Michelle

  • Eric Olsen

    all makes sense to me Michelle, I would think that your intelligence and articulateness will help you find the medical assistance you need – don’t give up

  • http://www.docofdiets.com dietdoc

    Michelle writes:

    “It doesn’t help that society is more than willing to assist me with my internal guilt trips. Books like the one discussed here are just another flog with which I can be whipped.”

    Reply: Once again, I reitterate, my BLOG is totally unrelated to this book. The book was tacked on without my knowledge. It has nothing to do with my comments.

    Michelle writes:

    “just suffice it to say I’m doing the best I can with the circumstances dealt to me.”

    Reply: All that anyone and, in particular, physicians, could ask of anyone.

    Michelle writes:

    “Secondly, I wish the medical community, when dealing with patients, would focus more on encouraging exercise and providing nutritional information than telling patients to lose weight. ”

    Reply: I certainly agree with you. And I know that, while things are changing, some of the “old school” physicians (especially those who don’t actually deal with obesity daily) continue to harbor the belief that obesity equates with gluttony, sloth, etc. etc. It doesn’t.

    In my clinic, weight loss and a size 6 body are not goals I discuss with patients. It’s not realistic. In point of fact, among the things we do – together – at our initial encounter, is decide what a realistic health goal should be. Healthy habits are the focus – not weight loss. If you establish a healthy lifestyle, everything else, except for rare exceptional cases, usually takes care of itself.

    When I see people in follow-up, my first question is not: “Have you been following a diet?” It is, invariably and unrelentingly, “What have you done for exercise?” What people are eating is not, IMHO, the problem I need to work on. It’s what they are not doing – specifically, not being active.

    I do sympathize, truly, with your plight. You seem to be, unfortunately, an extremely complex physiological conundrum. You are doing what you can, it appears, and I commend you for it. Perhaps there are medical solutions in the near future. I do hope so. And, in the interim, I wish you continued resolve to do what you can with the cards dealt to you. No greater effort could anyone ask for.

    Warmest regards, Ron

  • http://www.angel-and-soulmate-selfhelp.com/blog.html Angela Chen Shui

    ((((((((Michelle))))))))))

    Thanks so much for joining the discussion.

  • Dr. C

    Sorry but pure rubbish.

    The hormonal influences on obesity are well established. Combine these with dietary advice for the past 40 years that stands in the face of the methods in which our body has become accustomed to dealing with nutrients (and by nutrients I mean proteins, fats, and very little carbohydrates only in the form of frueits and vegetables – i.e. the diet we have been eating for millions of years). Feed people a diet heavy in substances that their bodies are poor at metabolizing (simple carbohydrates) and they get fat and feel terrible.

    People are not fat because they are lazy, eat too much, or have a psychiatric illness, but rather because they are eating the wrong nutrients and unnaturally stressing their body with large amounts of sugars and other “new” food items that are a burden on the body (thus causing release of abnormal amounts of insulin and irregular storage of fat).

    This has been beyond proven, yet we choose to ignore the elephant in the room and it is both harmful and a shame.