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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