Category: Weight Management

Successful Psychotherapy Comes Down to Finding the Motivation for Change

Posted on by Psychotherapy.net Team

Peter: Comfort in Food and Resistance to Change

“I have an Italian last name and I always wanted a good Italian first name like Pasquale or Aureliano, but what I got was just Peter.”

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Peter was a single man in his early 50’s when he came to the nursing facility. Until then, he had lived his whole life with his mother, and he was anguished over being apart from her. “I don’t even feel like I’m a separate person from her,” Peter said during a psychotherapy session.

Peter recalled being diagnosed in late childhood with a Rett Syndrome variant, apparently related to a speech disturbance. He had experienced early learning difficulties, yet he had developed language skills and general motor skills. He showed mild autistic features and lifelong obesity. He never fit in with his siblings or peers, didn’t play sport games, and found socializing desirable yet dreadful due to anxiety and uncertainty. His mother and brother did not have detailed recall of his childhood medical information, and his mother simply said, “He was always different, never like other people.”

After his weight reached 625 pounds, Peter refused to be weighed anymore at the nursing facility. He would sometimes request double portions of meals, ordered in fast-food meals, and often requested snacks. Peter would mimic the lectures he had so often been given by family and healthcare providers about the risks of obesity and the potential benefits of weight loss. He understood the risks inherent in his lifestyle of lying in bed, eating, and watching TV.

In psychotherapy, Peter wanted to express his outrage over his mother’s refusal to allow him to return home, yet he was willing to consider her stated viewpoint: she was aging, and his daily care needs exceeded her ability to manage them. He defended his unwillingness to consider any dieting or change of his daily routines yet was willing to review in psychotherapy the information and concerns others had communicated to him about eating and health risks. Peter was also unwilling to give up the style of eating that he felt was a lifeline. He was not motivated to change. Yet he liked psychotherapy because, “You listen to me, and you don’t look down on me, and see some good in me, and nobody else does that.”

Peter had not worn clothes for years. In bed he was covered by a sheet, and when he got out of bed, he would be clad in a checkerboard of hospital gowns draped and tied around his body. The facility purchased a custom-made wheelchair that was four feet wide. It would not fit through any doors, so it stayed against the wall outside his room. Peter would use a walker to come to the door, then edge sideways out the door, and settle into the wheelchair. Stretched out behind the chair, I would push him to a niche at the end of a hall where we could sit for sessions.

Emotional tensions in the case came from nurses and aides who felt uncomfortable with his ways of eating. Many team meetings and individual consultations were needed to clarify and resolve differences in viewpoint and approach. Individual staff persons might try to intervene by refusing his requests for foods, and by hectoring him — ‘you’re killing yourself; you know.’ Peter was cognitively capable of making informed choices about his daily behaviors and his healthcare. Nurses fretted that, ‘I might lose my license if he dies, and I didn’t do something to stop him.’

We had many conversations about the rights of a (mentally intact) person to make choices, even if we disagreed with those choices, and even if we noticed health risks attached to those choices. We spoke of how a staff person might smoke, eat fast foods regularly, text while driving, or do any number of other potentially risky behaviors, and how others do not try to take away your rights to make such choices (unless you live in California, that is).

Peter experienced developmental complications due to a type of genetic disorder — one often linked with obesity. He had a deeply conflicted relationship with his mother, and he had experienced a lack of peer relationships and appropriate socializing opportunities in his life. He exhibited social anxiety and avoidance, and profound feelings of shame and self-loathing. He felt unwilling and unable to endure prolonged discomfort and deprivation to pursue goals that he felt were not his own. But he relished therapy conversations in which he could discuss — without feeling shamed — all the above topics and many others, including his extensive knowledge of TV shows and movies over the prior few decades. He remained obese.

Mykela: Discomfort and the Motivation to Change

Mykela was also in her early 50’s. She had lived for the past few years with her father in his house. She rarely left the house due to feelings of anxiety and depression, and embarrassment over her body weight. She came to the nursing facility after an illness that required hospital care. Mykela weighed 450 pounds, and she felt strongly motivated to lose weight. She immediately wanted Bariatric surgery to assist her weight loss, yet the doctor wanted her to lose significant weight before he would agree to the procedure, due to possible risks and complications. The doctor still wanted her to lose more weight, yet he did eventually agree to surgery after she’d lost 50 pounds which took her about a year to achieve.

Mykela spoke in psychotherapy of her history of depression and its roots in childhood experiences. She verbalized the distress she felt in public when others might mock, deride, or insult her. She wept as we discussed whether she would (dare to) join a group outing from the nursing facility to an apple orchard to pick apples, but she returned more confident because she had endured unpleasant looks and comments without collapsing emotionally.

After her Bariatric surgery, she did adhere to a rigorous diet plan, and she steadily lost more weight. Mykela lost so much weight that large folds of skin would swing and clap against her body as she walked with her walker. She had further surgery to remove skin folds — and rather than feeling ashamed, she wanted to show off her surgical scars and her now slimmer body — as signs of her fortitude and motivation. Mykela returned home, walking without support. She cared for her aging father and drove her car. She became a spokeswoman at the Bariatric clinic to encourage and support others interested in making positive life changes.

***

In nursing facilities, I work with clients who, like Peter and Mykela, have quite complex problems, and who exhibit varied degrees of motivation, or even capacity to effectively make the kinds of changes others might recommend. Peter had felt rejected and despised for most of his life. He did not want for himself what others had strongly advised for decades. He felt relieved, though, to find a therapeutic relationship in which he could feel safe, and he was then willing to look at the viewpoints of others without defensiveness. But he was unwilling or unable to make comprehensive and sustained changes to his lifelong patterns of behavior. Mykela, in contrast, felt an inherent motivation to change, yet she needed the support of psychotherapy to help her connect with her strengths and to foster the fortitude and resilience needed to effectively achieve her goals. Unlike body weight, success is not always easily measured.   

Should Therapists Have Scales in their Offices?

Posted on by Psychotherapy.net Team

We were scanning electronic records of patients visiting the mental health clinic of a large local hospital to find subjects for our IRB-approved research study on antidepressant associated weight gain. Our goal was to find subjects whose weight was normal prior to starting on antidepressants and who had gained weight during the subsequent 3 or four months. But there was a problem: no one weighed the patients. Thus, there was no way to learn whether the drugs were influencing weight.

Almost twenty years ago while directing a weight loss center at a psychiatric hospital affiliated with Harvard University, we were surprised by the number of clients claiming substantial weight gain while on their psychotropic medication. Unlike typical clients seeking weight loss advice, whose struggles with overeating may have a complex etiology, these clients were of normal weight, ate healthily, exercised routinely and had no issues with food until their treatment with antidepressants began. Their complaints were similar; uncontrollable urges for carbohydrate-rich foods and an inability to feel full after eating.

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Our clinic was able to stop and to some extent reverse their weight gain with a food plan that increased serotonin synthesis prior to lunch and dinner to potentiate satiety before eating began. The increase in serotonin also decreased their desire to snack on sweet or starchy foods

Unfortunately, now several years later, patients are still gaining weight on psychotropic drugs and although the literature is filled with articles confirming this side effect, patients may be denied this information along with interventions to halt or slow the process. One angry patient told me that her therapist accused her of justifying her urge to eat cookies as an effect of her medication and another, who was compelled to shop for plus size clothes after taking an antidepressant, said her physician never heard of weight gain as a side effect of her drug.

Many patients see their formerly normal, fit bodies transformed, and adding to their feelings of frustration and sometimes embarrassment, is the difficulty in explaining to others why they are now overweight or obese. One of our clients who went to Weight Watchers wasn’t believed when she said she had been thin before going on an antidepressant. “They assumed I was in denial about the reason I was always snacking.” Another told me that his mother keeps nagging him about his overeating and won’t believe that the combination of a mood stabilizer and antidepressant are responsible.

Ideally, patients should be alerted to the weight gaining potential of the drug(s) they are being prescribed. Since it is unlikely that the therapist has a scale in the office, information about weight changes or inability to fit comfortably into clothing worn before starting the drugs will have to come from the patient and tracked during subsequent visits.

Cravings for sweet and /or starchy carbohydrates and a decrease in satiety are the most commonly reported causes of overeating. A coach of a college women’s soccer team told me that after being put on an antidepressant, she craved French fries for the first time in her life and had trouble resisting eating them as a snack every day. A patient on a mood stabilizer often ate two dinners because an hour or so after the first was completed, he felt hungry again.

The therapist might suggest that the patient eat a small, 25-30-gram carbohydrate snack such as a ready-to-eat breakfast cereal (oat or wheat squares, or cheerios for example) 30-45 minutes prior to a meal or when craving a between-meal snack. The carbohydrate causes insulin to be secreted thereby potentiating tryptophan uptake into the brain and subsequent synthesis of serotonin. Carbohydrate craving is dampened, and satiety increased as a result. The snack should be very low in fat or fat–free to decrease calories and contain no more than 2-3 grams of protein as the latter nutrient prevents serotonin from being made. The patient may still want to overeat; after all, one is fighting drug-induced appetite with cheerios, but usually, a sense of fullness is reported.

Urging the patient to start to exercise as soon as possible by using a smartphone app or wristband to record physical activity has benefits of course beyond calorie utilization, but is very important in preventing weight gain. Asking to see records of weekly or monthly ‘steps walked’ or other activity may encourage compliance.

Weight gain on psychotropic drugs may undermine some of the beneficial effects of the drugs themselves and the psychotherapy, especially since those who gain the weight rarely announce its cause and thus are perceived as individuals who are unable to control their food intake and may be too lazy to exercise. Thus, stopping or minimizing this side effect will benefit the mental and physical health of the patient. Alert to these possibilities, psychotherapists may be in a better position to work with the prescriber, nutritional specialist or other members of the treatment community.
 

Our Hungry Selves: Women, Eating and Identity

Posted on by rezendevknowfully.com

The Tyranny of Slenderness

In the early eighties I wrote several books about eating disorders; one of them became a national best seller. In the first book: The Obsession, Reflections on the Tyranny of Slenderness, I researched the way our culture's fear of women was directed against women's bodies and, in particular, against a large woman's body. I felt that the cultural preference for very slender women revealed a wish to see women reduce themselves as women and relinquish their power.

Here’s how I reasoned back then: “The body holds meaning. A woman obsessed with the size of her body, wishing to make her breasts and thighs and hips and belly smaller and less apparent, may be expressing the fact that she feels uncomfortable being female in this culture. A woman obsessed with the size of her appetite, wishing to control her hungers and urges, may be expressing the fact that she has been taught to regard her emotional life, her passions and 'appetites,' as dangerous, requiring control and careful monitoring. “A woman obsessed with the reduction of her flesh may be revealing the fact that she is alienated from a natural source of female power and has not been allowed to develop a reverential feeling for her body.””

The second book, The Hungry Self: Women, Eating and Identity, studied the way a woman's hunger for self-development, creative expression and liberation might express itself if it was not recognized as a hunger for food. I was curious about the emotion and conflict and turbulence that might be disguised as a craving for food, and especially “forbidden” foods like carbohydrates and sweets. “In [this] book I extend [my] analysis to include the mother/daughter bond and the issue of failed female development….We cannot heal ourselves until we understand the hidden struggle for self-development that eating disorders bring to expression in a covert way. We cannot indeed even begin to think of self-healing until we stop using the words “eating disorders” to hide from ourselves the formidable struggle for a self in which every woman suffering in her relationship to food is secretly engaged.”

In the third book, Reinventing Eve: Modern Woman in Search of a Self, I issued a call to women to step up and re-invent ourselves, freeing ourselves from the pressures and constraints of a society that feared women. I saw Eve as a radical, the first woman who was forbidden to eat food and who broke the taboo. “Women speaking intimately about their lives are usually, whether they know it or name it, on the far side of outworn ideas…We [have had] to start with the assumption that we knew little, had been lied to a great deal, that secrets had been kept from us, we were setting out as pioneers together, groping to find a suitable language for our experience….”

The Tyranny of Obesity

Thirty years later these ideas are still meaningful to me but my vision of possibility has been checked. “Fat is Beautiful,” a movement I greatly admired, has now become, thirty years later, a group of aging, obese women with serious health problems. I used to refer women who wanted to lose weight to other clinicians; I explained that my work offered them a chance to make peace with their body, not to change it. I now look back and think that I was rather close-minded, as if I knew what should matter to every woman who came to me for help.

Over these thirty years I've counseled countless women, discussed these issues with them, found them open to these ideas, yet progressively we have realized that it was no easy task to overcome the predominant dislike for big, fat or obese women. This overcoming of cultural dictates is a task suitable for some of us, not for everyone, and why should it be? Many women would rather work towards the body our culture admires than analyze the reasons they dislike their body as it is.

When I began to speak these ideas publicly, women who had read my earlier books were shocked; they felt that I had abandoned them in their quest to accept their body and their appetites. This new orientation seemed a betrayal, a renunciation of my earlier thinking with its cultural and psychological understandings. But I myself had begun to feel that my earlier ideas were hardening into an absolute, as if what was right for some women had to be right for all women, another once-size-fits-all approach to women and food.

I’ve had to explain that these days more and more women have to lose weight for the sake of their health, and that my clients and I had found a way to transform dieting from a self-defeating, frustrating, futile exercise into a useful therapeutic tool. A diet is—or can be—a way of becoming conscious of why one eats or feels driven to eat. Paradoxically, limiting what we eat is often the most direct way to uncover the feelings that drive us into self-destructive eating. Earlier, I had been opposed to the very idea of dieting, now I was willing to offer women help if they chose to diet. I left the decision to them, offering them both possibilities of work—towards body acceptance, weight loss, or sometimes the two together.

But there is more. There are other changes during the last thirty years that I have come to take very seriously. Following Michael Pollan, I began to study the food we are given to eat, so much of which has been degraded. The additives in it actively cause weight gain, and it is offered up in mega portions we tend to accept because there they are on the plate in front of us. As Michael Pollan writes: "Researchers have found that people (and animals) presented with large portions will eat up to 30 percent more than they would otherwise." Some of the weight we unhappily carry around with us is not really ours, it isn't natural, we haven't chosen it. Much of it has come upon us in surreptitious ways, through mysteriously named presences in our food, like high fructose corn syrup and its near-relations—aspartamine, glucose, dextrose, maltodextrin, maltose—which most people do not recognize as sweeteners. Even when reading a label and consciously hoping to avoid sugar, we end up with sweetening agents we don't want.

The Tyranny of American Culture

Thirty years ago I was asked to help people suffering from anorexia, bulimia and compulsive eating; these days women are calling me because, over the years, they have gained so much weight their doctors are alarmed for them. It was short-sighted to send them to someone else when I was a person who had dieted on and off for most of my life, at times winning, at times losing, the battle against our culture’s standards. And wasn’t I now, just as then, responding to a cry for help from our culture? After all, three of every five Americans are overweight. Obesity is an epidemic.

And so too is a woman's unhappy preoccupation with the size and shape of her body, or some part of her body, or some new diet that promises to change her body. I know this, not only from my clients, but far more intimately from myself. “I am a feminist, I care about women's self-development and the cultural and psychological obstacles that inhibit it, yet I have struggled, since the age of seventeen, to be at home in a body that has never been overweight but still has not been acceptable to me.” In spite of my three books about women and food, and all the lectures I have given, and the deep conversations in which I've been engaged; even in spite of the fact that I never any longer eat compulsively, a preoccupation with food and body size is still hanging around in my life. As a result, I can no longer underestimate the power of this conflict, as I observe it listing towards a feminist understanding about a woman's right to make decisions about her body, free of cultural pressures, and then spinning off in the opposite direction towards the next miracle diet that comes along, promising a body that conforms to our culture's punishing ideals. Weight and body size present us with a problem for which we don’t have an adequate solution.

Taken together, these are good reasons to change one’s point of view. I have changed mine in an effort to supplement—not replace—my earlier work. I intend to help people find the right diet and support them while they are losing weight, an emotionally demanding task whatever the nature of the diet. But losing weight is only part of it; we have to learn to eat in a way that often contradicts everything we’ve been taught about healthy nutrition. Not three meals a day but a small meal every couple of hours; not avoiding water because it may produce weight gain but drinking quarts of it; eating at night, before bed, because the body even in sleep requires 500 calories to keep itself going. Eating fat because we feel nourished by it, learning what are desirable portions, eating local produce because the food contains more of what food should contain and will therefore nourish us in smaller amounts. There is no one diet that is suitable for everyone—creating the right diet has elements of a quest for identity, a coming to know and be able to choose what is good for one. If this isn’t meaningful therapeutic work I don’t know what is.

Catherine's Story

A client of many years returned to work with me. Her doctor had just told her she had to lose between 25 and 40 pounds because her medical condition was severe. She came full of despair, wondering how we could approach this assignment since we had always discussed body-acceptance and appreciation for big and voluptuous women, which she was. Beautiful, certainly; but perhaps not healthy?

I began to work with Catherine in 1995. She was 26 at the time, a graduate from an Ivy League school, a women’s studies major who sought me out because she had read my books. She came from a small town on the East Coast, from a family active in their Episcopal church. For her to leave home, move to the West Coast, live with a man to whom she was not married, give up all religious affiliation and develop an interest in feminism while her two sisters and one brother remained close to home, was daring. She had graduated with honors and gone out into the world eager to make the most of herself. But this promising development had stalled. She was working as a secretary at a job she hated, was preoccupied with compulsive eating and her body’s size, found life meaningless and disappointing, described herself as depressed and despairing and at times suicidal. I was then in training with Otto Will, who had trained with Harry Stack Sullivan, who had worked with Freda Fromm Reichman. I was following their interpersonal approach with a dose of object relations mixed in, supplemented by an analytic interest in childhood memories.

Catherine found it almost impossible to cook for herself, although she had no trouble cooking on the night assigned to her by her collective. She didn’t plan for her meals but grazed throughout the day, almost entirely on cookies, candies and anything sweet. She ate in secret, disliked herself for doing so, was afraid that I was judging her, and suffered from guilt and remorse. Together, we observed the nuances of our relationship as it developed over many years, curious about the fact that she always stopped for food before her session and immediately went out afterwards for a piece of cake. She suggested that she was filling herself up so as not to bring a ferocious desire to eat into the room with me, evidently afraid that she would gobble me up. The cake that came after the session was to restore the energy that she felt had been depleted in thinking about these issues. She discovered that she refused to cook for herself because she wanted her mother to cook for her and would rather not eat than have to provide food for herself. Although she had voluntarily left the family for a larger life, she missed the closeness and safety of the small town, their church and especially her mother’s devotion to feeding the family. She was brilliant and analytic and good at interpreting symptoms; her childhood memories grew richer and more plentiful over the years, as did her ability to piece together a plausible narrative of her childhood. “Catherine ate in secret, disliked herself for doing so, was afraid that I was judging her, and suffered from guilt and remorse.”

She was the youngest in her family, and by the time she arrived her mother was exhausted and depleted. She hadn’t wanted another child, her milk dried up when Catherine was a few weeks old, and the care of the infant was largely handed over to her elder sister. Nevertheless, on the surface they were a happy, close-knit family, admired in their church and appreciated for their good works. Mother spent the day cooking for them, trying out new menus and culinary ideas, seemingly satisfied with her life but with an undercurrent of bitterness only Catherine seemed to recognize. Although well fed by her mother as she was growing up, Catherine began to wonder if she’d ever been nourished. Even her desire to have mother cook for her now that she was an adult began to seem a poignant wish that mother’s care and even her cooking had contained more authentic nourishment. The family dinners, which she’d always remembered as happy occasions, began to reveal their seams of stress—her older sister resenting her for the care she’d given her, her brother, two years older, in fierce competition for attention, her father absent, the second sister gentle and meek, as if she’d early decided that life was not going to offer her much, mother tyrannical when it came to the family’s enjoyment of her cooking. Dinner table conversation was lively but largely restricted to comments and conversation about food.

Catherine’s life changed dramatically through our work. She left her job, started a not-for-profit organization that became very successful, developed a strong interest in psychology, got an M.A. in counseling, worked out an honest and passionate relationship with her boyfriend, bought a house with several friends and lived collectively. When she got pregnant she decided to stop her work with me, owing both to financial concerns and to a general feeling that we had accomplished much and that she wasn’t capable at that time of going further. She still ate compulsively, giving us both the impression there was a lot more to understand.

I present this story in order to muse about the fact that excellent psychological work can be done that nevertheless does not reach a troubling emotional core. This did not surprise me. In my decades of work with eating disorders I have found that the underlying reasons a person eats compulsively, or eats more than they want, or far less than they ought, are hard to experience as direct, unmediated emotional events. The symptoms of a troubled relationship to food are so powerful and so deeply ingrained in the way one soothes and rewards oneself, hides from loneliness, expresses outrage and sorrow and in general shuts off consciousness, that it is hard to get beneath symptom into the raw emotion that is giving rise to it. She sensed that there was more to her emotional life than we'd yet explored; nevertheless, that is where we left it until, six years later, she came to speak with me about her doctor’s insistence that she lose weight.

Catherine's Diary

I have permission to quote from the diary she kept during the first three weeks of the diet. My comments follow her diary entries. This is not a description of the way Catherine and I worked together but an account of her process of uncovering meaning in what earlier had been unconscious, compulsive acts.

Catherine: I have a strange sensation—I am not really that hungry, though I can feel an underlying pull in my stomach now that's it's been a few hours since my breakfast. I am sad and irritable. My mind brightly goes to "treat" several times an hour, for myself, and socially ("like, oh I should take the girls out for burritos for lunch!" "I want a latte and a scone!"). Then I am disappointed in some deep way when I remember, but it's not exactly about being hungry. Fascinating. What is it about?

I am interested in the fact that from the first day of dieting hunger is put under suspicion. It can’t be taken at face value. This is an insight Catherine has not had before.

Catherine: Today, the glutton, the sensualist in me rebels. I can feel a sense of victimization mounting. "I hate restriction, I don't want to do this."

Here, as we can see, the issue has now become one of dislike for restriction. Insight is developing: this is a character trait, not an eating behavior. Catherine has not previously named in herself this rebellion against limitation. Indeed, it would be hard to recognize when there is a lifetime pattern of instant self-gratification.

Catherine: “OK, this is bearable, I am OK. But the sense of comfort I am missing—I am working so hard, I am so tired and worn out from childcare. How will I replace food as comfort? How? How? So far there is no replacement and I’m not sure there ever could be one. I am working so hard.

An additional meaning has been attributed to food. It is now recognized not only as a comfort but also as a reward for having had a hard time. This is a steady growth in the capacity to think symbolically. Hunger is no longer simply hunger and food is no longer simply food.

Catherine: It’s not hunger that’s hard. What I have to know about myself is what’s hard. I’d rather not know.

The progression of self-awareness has moved on into the striking discovery that the struggle with food has been a drama about self-knowledge. Or rather, about refusing self-knowledge. This is a lot of insight to achieve in a week.

Catherine: Last night at the party someone said I seemed like a happy person and I felt so embarrassed I almost cried. "I am having a terrible time, I'm filled with jealousy and poison," I thought. "Why does she think I'm happy?

Catherine has always had the capacity to seem happy, well-adjusted and cheerful, traits that were required by her family. They’ve been a second skin and only now are being viewed as alien. Although these traits have served as a protective covering, they have also been misleading as to who she really is. As she comes to know herself authentically, a wish to be authentically known begins to emerge.

Catherine: The depressive, dark, roiling, murky, angry, resentful, revengeful part of me is so present now when I am alone and I never show it in public—Who is this? I can see why she’s been out of sight. I don’t want her. I feel suffocated by these feelings and their bare truth. I can't push this part of me away and "think positive." I must integrate, integrate, integrate. I wish I could cry, but I feel so bottled up. Maybe I will cry today. Would crying be more satisfying than a burrito?

I thought of this as an important breakthrough. A subterranean world of feeling, now present in her awareness, has brought in the crucial thought that an ability to feel, to cry, or even to want to feel might be more satisfying than eating.

Catherine: It's very hard for me. These feelings are hard for me. I didn’t know I was filled with so much poison. Feeling these feelings is what’s hard for me. I don’t like who I am. But I do like myself for knowing all this.

The capacity to know and name herself is making the emergence of difficult self-knowledge bearable. We know how crucial this particular exchange is in psychological work. Not liking who one is but liking oneself for the ability to know it. The supposed safety of not-knowing is falling away before the power of insight.

Catherine: Last night I dreamed I was trying to warn a school full of small children (preschool) and teachers that a huge tidal wave was coming. Everyone was very busy and distracted and could not focus. Then I was in a meeting where someone was presenting us with his new beautiful chocolate bar. I raised my hand and asked, "What was your aesthetic inspiration for making this chocolate?"

I often dream about tidal waves: massive, blind destruction. But I never thought they were about what I was feeling. Or not feeling.

I think they represent my dread and fear and the sense of overwhelm I have about things. And the chocolate is so funny! That’s what I’ve found in my life, a chocolate bar to keep me safe against a tidal wave.

This is a curious insight because in fact the chocolate bar and its sister-sweets have served to protect her from the tidal wave of feelings that she fears. They’ve worked; they’ve captured her consciousness and shut it off. That’s why chocolate and muffins and brownies have been so hard to give up. Nevertheless, they are now seen for what they are and have become ludicrous.

Catherine: Any choice about my size, about losing weight, is astonishing to me. It lifts a lifetime of discouragement. How do I comfort and reward myself if not with food? (I want to replace compulsive eating with compulsive writing!) My shoulders ache, my eyes are heavy with un-slept sleep. I want to lie down right now in this library and cry.

Wonderful, this wish to replace compulsive eating with compulsive writing. She is in fact a very good writer and will, in a few months, discover that when she sits down to write, the inner turbulence she feels will subside. Not every time, not completely, but often enough to make her aware she has a choice between chocolate and self-expression.

Catherine: It's getting somewhat easier for me. Still many fantasies of treats, but it is balanced out by feelings of excitement and accomplishment. After all, it wasn’t hunger that was the problem. But all this poison inside me. So, now that I know it’s here? Now what? Can I just live with it? I don’t think so. But that’s what I’ve been doing, isn’t it?

The sense that these feelings are unbearable has not gone away, but there is the simultaneous discovery that after all they have been borne. The unbearable has become bearable. If this happens once, it can happen again: “I can’t live with it, but paradoxically I’ve just discovered that I have been living with it.”

Catherine: Clothes that were a bit too tight feel good and are fitting. Joy. Joy. JOY. Having these intense, florid cravings a few times a day. They stop me in my tracks. Today it was my childhood birthday cakes—"bakery cakes" we called them—white cake and frosting with clusters of pink frosting roses, they were even better slightly stale. Everyone wanted a rose on their slice—a mouthful of pure frosting. I practically moaned aloud as I pictured this. Bizarre. I could eat a truckload of that soft, fragrant, sweet white cake and frosting. Yesterday had a craving about thick ice cream shakes full of candy. Amazing that this is there, so deeply. Much much more than a memory. I can right now taste that pink frosting. Like those frosting roses were going to make up for everything that wasn’t so great in our childhood?

I still find it extraordinary that this transformational journey is taking place simply because Catherine isn’t eating in the way she ordinarily would. Through this precise memory, this sensually present image of the pink frosting roses, she has understood the full power of the emotions that she is engaging.

Catherine: I am starkly alone with all these bad feelings. I am hungry and I want to eat. I am sad and I want a treat and a reward. The only thing I can think of is going to bed, not so much as a reward but as a way to live through this. I am going to live through this. I have to live through this.

I admire this knowledge, this clear seeing of these very difficult feelings and the search for something other than food to see her through. Above all I am taken with this resolution: “I am going to live through this. I have to live through this.” It has some of the quality of a hero’s, or more precisely, a heroine’s journey.

Catherine: It gets easier. I am living with medium to mild cravings and longings; not much hunger; and a mounting pleasure in what I have done. It has been so hard and it’s not about hunger. I have been wrestling with an angel and trying to find my meaning in it all. The feelings are so intense: jealousy, grief, rage, cruelty, indifference, helplessness, mad cravings and feeling crushed. It's like living through a hurricane at times. I’m thinking again this is the hardest thing I’ve ever done in my life. But somehow I’m doing it.

I take this testimony seriously; this probably is the hardest thing she’s ever done in her life, harder than giving birth or separating from her family. The newly discovered feelings write the emotional narrative that had been driven out of awareness but was always lurking, lurking, driving the compulsion to eat.

Catherine: I am at my desired weight. I am really pleased. It's amazing. On the feelings front, I am in lots of turmoil. My temper is short, I am touchy and sad. This is the perfect moment to "assault eat." And I will not. I want to be able to handle my feelings and not use food to soothe them, but will I be able to do that for the rest of my life? Maybe if I ever am told I have 3 months to live I promise myself I will eat only ice cream.

I love the way she can simply say, after a lifetime of struggle with eating: I will not. She has acquired choice where she previously experienced compulsion. This transformation of compulsion into choice may be the single most crucial accomplishment in anyone’s therapeutic work.

Catherine: I want support from you and from my man but I feel vulnerable and raw when I think about sharing all this. But maybe it will be better if I talk to him? Maybe I will feel more recognized for how hard this is for me? I am not sure.

Food has so many purposes, meanings and uses; no wonder it’s so hard to work them all out. You give up food as comfort then it shows up as reward; you recognize it as a consolation, then it appears as an interpersonal shield.

Catherine: I spoke to you on the phone about how I'm feeling today. I'm noticing this kind or foundational feeling (that's the word I keep finding)—as if I have more of a right to be here. I think it has to do with feeling proud of myself for doing the hardest thing I can do. Working on my relationship to food is the oldest, toughest, most entrenched part of me. As we said today—it's not likely for me to find something harder. With my clients, I feel a new sense of balance, of rootedness. If I can deal with this for myself, I can ask them to do the hard things they need to do for themselves too. I can support them to do those things. This makes me feel transparent, more authentic. Like I am not a fraud.

This is a beautiful piece of psychological work. Catherine has discovered that experiences and moods she took at face value are actually the expression of emotions and conflicts. I love to recall that resounding phase: “I will not.” She has been able to substitute choice for compulsion. She has gained a great deal of self-respect by succeeding at something she found really difficult. She feels more confident in the work she does with her clients. She understands the meaning of her dreams, she sees life-patterns emerging, she has achieved much more self-knowledge than she’s had before. I like to think of this as the deconstruction of eating in favor of meaning. To this day, after some thirty years of work with these issues, I’m still astonished that something as seemingly mundane, concrete and literal as eating and food can have this crucial importance. Maybe it’s not surprising if we remind ourselves that our first act after birth and taking our first breath is a reaching out for food.

The Journey Continues

Successfully losing weight is not the end of the story, far from it.

Weight-loss faces anyone who has accomplished it with a number of immediate dilemmas. The body has changed but intimacy is still frightening; being dressed in size 8 clothes doesn’t necessarily secure a job; if one was shy before very likely one is still shy. A lot more social attention may be directed towards a woman who has changed her body’s size but cat calls, whistles, crude remarks, are not necessarily the attention she desires. The magic that weight-loss was supposed to produce as it solved all of life’s problems gets tarnished very fast. And there we still are, the same self in a different body, unless the dieting has helped us to change that self.

There’s still a long, hard road ahead. Learning to eat properly, sticking to the new habits one has acquired, shifting from the food of immediate gratification to food that supports health, these are going to present an ongoing struggle.

Catherine’s is not a typical story. Most people who lose weight on any kind of diet do not make a transformational journey. Nevertheless, many do. My intention in writing this article is to suggest that, as clinicians, we are going to be faced increasingly with the problem of obesity and its effect on health. If we learn to use dieting as a therapeutic tool, as a way of uncovering unconscious impulses and compulsions, weight-loss may be easier to accomplish, and certainly will be more rewarding, as knowledge of the self is acquired at the same time.

In closing, I would like to point out that I am not just speaking about dieting here. Any close examination of one’s eating habits and behaviors can yield the same consciousness of deep feelings, memories and life-patterns. As clinicians, I have the impression that we tend to be overly interested in people’s sexual experience and fantasy, and far less concerned than we ought to be in what food and eating have meant to them. In that sense, there is no contradiction between my work of thirty years ago and my work now: whether an individual chooses to diet or to become conscious of the ways she eats, the shared goal can be self-knowledge. Eating behaviors, as I wrote many years ago, can be the royal road to the unconscious as much as, or maybe even more than dreams, Freud’s favorite candidates for that distinction.

Eda Gorbis on Body Dysmorphic Disorder

Posted on by Psychotherapy.net Team

Characteristics of Body Dysmorphic Disorder (BDD)

David Bullard: To begin, could you give us a little background on BDD for our readers who may not be familiar with it?
Eda Gorbis: I began learning about treatment for obsessive-compulsive disorder (OCD) when I was helping to create day treatment protocols at UCLA Neuropsychiatric Institute in 1992, and then I furthered my knowledge by studying with Dr. Edna Foa in 1994. In 1996, I began work with a patient who had both OCD and BDD and was addicted to plastic surgery procedures. After successful treatment that was specifically designed to ameliorate the stress associated with her BDD, we were able to work with her on her remaining OCD, and my interest grew in this patient population.

Body dysmorphic disorder is self-perceived ugliness. It is when a person feels ugly inside about a minute anomaly—usually invisible to the naked eye of another—or has a markedly excessive preoccupation with even a slight defect, together with the feeling of being unable to make it right.

DB: So it’s a feeling and self-perception. I’ve noticed that, for some people with BDD, there is a vivid visual picture in their minds. One study highlighted the intrusive visual imagery these people have in addition to negative self-cognitions and feelings.
EG: When they look into the mirror, they see themselves as ugly.
They do not perceive themselves in the mirror as we perceive ourselves. They see a distortion that is invisible to others.
They do not perceive themselves in the mirror as we perceive ourselves. There is something wrong in their visual fields, from the eyes into the brain, that gives them inaccurate feedback. They see a distortion that is invisible to others.

What people with BDD perceive is actually similar to the reflection we have all seen in carnival funhouse mirrors. This differs from the common feelings of insecurity or self-consciousness about one's appearance that most people experience from time to time. Many people who have had cosmetic surgery are happy with the results and can move on with their lives without continuing to obsess about the original defect. With BDD, however, any surgical "correction" will itself be seen as imperfect, or an obsessive fixation with another body part will take over.

There are some theories, but the specific causes of BDD are not known. Many experts agree that sociological and biological factors play a role in the development of BDD.

DB: And it can be extremely debilitating.
EG: Yes, one of the most disabling conditions I know of. People experience extreme self-consciousness, and often avoid social situations, feeling others are judging and criticizing their self-perceived imperfections. The more the fixations intensify, the more it seems rational that others are also focusing on the “defect.” It can be a kind of paranoid ideation.

Then a person’s relationships suffer, along with many aspects of daily life. They can repeatedly request reassurances from others, but with no relief from their certainty about the ugliness. These compulsive requests for reassurance actually reinforce the false belief system and fixations; this leads to further compulsive questioning in a continuing cycle. They get so focused on their appearance that much time is spent hiding or trying to perfect the “flaw” cosmetically. These people are often unable to leave the house to make appointments, or to hold a job.

DB: Can you tell us about co-morbidity?
EG: BDD has a high co-morbidity with other anxiety disorders. The research is not perfect, but it seems that more men are treated for BDD than women. Perhaps female BDD symptoms are more likely to be interpreted as "normal" female behavior in our culture and are likely to be overlooked and remain untreated. The onset of BDD is not exclusive to a particular age, though symptoms often emerge during the teen-age years.

Treatment Considerations

DB: Could you give our readers an idea of how you work with someone with this particular disorder?
EG: More often than not, BDD is intertwined and co-morbid with OCD. Both disorders must be targeted at the same time—the perfectionistic concerns or fear of being criticized on a performance level that are characteristic of OCD, and also elements of social phobia that are associated with BDD.

BDD has certain expected features: for example, an exaggerated physical anomaly would be chin, eyelids, cheekbones—oftentimes in males, it would be penile size—with symmetry and exactness issues. I have found that women compare and contrast their breasts or their arms—any body part can be compared with the corresponding part on the other side of the body. The self-perceived anomaly also has a tendency to move from one body part into another: it can shift from the nose into the ear, for example.

DB: You mentioned that the first patient you worked with had had multiple surgeries. That’s a good example of how it shifts from one body part to another, and they get the surgery based on that.
EG: Right. That patient had more than a hundred cosmetic surgery interventions.
There is an element of addictive behavior and impulsivity associated with BDD, which can be a great warning sign for the clinician.
There is an element of addictive behavior and impulsivity associated with BDD, which can be a great warning sign for the clinician, because you do not find this so much in strictly obsessive-compulsive disorder. Some of the patients with BDD have also met diagnostic criteria for sexual addiction and gambling. It is the exact opposite for people with OCD. Patients with OCD are not impulsive. They would be like Rodin's "Thinker."

With patients with body dysmorphic disorder, you have an overlap between impulsivity and compulsivity. Whereas people with OCD are extremely moral and truthful, people with this overlap of impulsivity and compulsivity would show no guilt or remorse. This overlap makes treatment extremely challenging. Some patients with BDD have also met diagnostic criteria for sexual addiction and gambling, which was a little bit surprising to me. Well, not really surprising, but interesting how impulsivity and the pleasure is associated with the alleviation of tension or excitation. For example, in gambling, it's not the reduction of anxiety that is the aim of the behavior. The aim is the attainment of tension release, like hair pulling or when they squeeze pimples, and excitation—the adrenaline rush in gambling or sexual addition. So you have very different aims of the behaviors that are intertwined in very complex ways.

DB: Some of the people who have written in the field make a distinction between delusional versus nondelusional BDD—for instance, someone who looks in the mirror and sees that his ears are too big, and he really thinks that they are too big, versus someone who looks in the mirror and knows he feels bad about it but accepts reassurance. He knows that his ears are really okay, and he recognizes that he has a problem in his perception. Do you see that distinction? Is it helpful to you in your work?
EG: Let's call it poor insight. That is a better term than "delusional." And it is classified along with other OC-spectrum disorders, such as Tourette's syndrome, eating disorders, trichotillimania, and compulsive skin picking. BDD is also often seen as part of the impulse control disorders—where impulsivity can be thought of as seeking a small, short-term gain at the expense of a large, long-term loss. People with BDD get completely dysfunctional, as I described earlier-becoming addicted to surgical procedures, getting stuck in front of mirrors, needing to ask constantly for reassurance, etc.

Cognitive-behavioral therapy

DB: Although each case is individualized, can you give us an overview of how a cognitive-behavioral approach can be utilized in treating OCD?
EG: With cognitive-behavior therapy (CBT) a person learns to change the way he or she thinks and acts. We know different people can have different attitudes about the same specific conditions: A large facial birthmark can certainly be noticeable to others, but may have no negative impact on someone who has accepted it, while being debilitating to someone with BDD. And, of course, even a nonexistent or minor flaw can be devastating to a person with BDD. It is important to help people change their thinking habits. Exposure and response prevention are taught to people with BDD to help them face their anxiety and any co-morbid BDD concerns. This means repeatedly learning to tolerate discomfort. Anxiety gradually subsides as they continue to confront situations without the avoidance response.

We also use the 4-step model of our colleague Jeffrey M. Schwartz, MD, as
outlined in his books Brain Lock and You Are Not Your Brain: The 4-step solution for changing bad habits, ending unhealthy thinking, and taking control of your life.

The steps we teach our patients to help them get freed from obsessional thinking are:
Step 1: Relabel (recognize that the intrusive obsessive thoughts and urges are the result of OCD).
Step 2: Reattribute (Realize that the intensity and intrusiveness of the thought or urge is caused by OCD).
Step 3: Refocus (Work around the OCD thoughts by focusing your attention on something else, at least for a few minutes: do another behavior).
Step 4: Revalue (Do not take the OCD thought at face value. It is not significant in itself).

The Role of Psychoeducation

DB: Yes, I've found that simple process very useful for some OCD clients, and it goes along with my favorite bumper sticker: "Don't Believe Everything You Think!"
How helpful do you find psychoeducational materials?
EG: I think psychoeducational materials are always very helpful and important, because then patients know they are not alone. In fact, we now believe 5 million Americans are afflicted with this very debilitating illness. It removes a lot of people from the workforce.
We now believe 5 million Americans are afflicted with this very debilitating illness. It removes a lot of people from the workforce.
DB: Isn’t it a characteristic of BDD that it feels so shameful that the majority have hidden it from the people who are closest to them?
EG: Well, the dysfunction is most often extreme, and usually afflicts young people by the time they are 18 and ready to get out of the house and into college. Then, because of the self-perceived ugliness, they are unable to get into social situations or attend lectures. They can't date. They camouflage themselves with glasses and excessive makeup. It is similar to an anorexic who is quite underweight and having cardiac problems and broken bones, and losing consciousness and so forth, but still worries that she's too fat. These people, in a very similar way, feel ugly, and there is a delusional component to this feeling ugly, as in anorexia. A distinction from anorexia, however, is that an individual with BDD would be preoccupied with the appearance of his or her face, while the anorexic will be more preoccupied with self-control strategies regarding weight and shape.
DB: Can you recommend some books for therapists who want to learn more about this disorder?
EG: The classic in the field of BDD is Dr. Katharine Phillips' The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (2005). She also has a newer one: Understanding Body Dysmorphic Disorder (2009). I have already mentioned the books of Dr. Schwartz. Other good ones are Feeling Good About the Way You Look (2006), The BDD Workbook (2002), and The Adonis Complex (2000).

We also have information on our website: hope4ocd.com. There are some other good ones such as Dr. Phillips' at www.butler.org; and the Massachusetts General Hospital BDD clinic; and www.bddcentral.com.

Mirror Externalization

DB: On the treatment end of it, would you say something about the mirror approach to your work?
EG: Because the physical anomaly is so exaggerated in the minds of these patients, I was thinking one day, "How do we externalize this self-perceived ugliness?" And I thought of the carnival funhouse mirrors, because they really exaggerate everything. It's a form of exposure. So we have a laboratory at the Westwood Institute in which a certain part is exaggerated when they're looking into a mirror. The room also has lighting controls, because different lighting and angles change our perception of the reflection. At this time the patients are just writing their anxiety levels.

We then cover all the mirrors for three days in a row, and all violations are recorded to track the compulsion. Compare-and-contrast behaviors—with those around them or with photos in magazines—are also counted as compulsive because they're done out of the anxiety. Or asking for reassurance: "Do I look good?"

The process of "externalization" works by causing the breakdown of maladaptive associations and repetitive manipulation of their external, material icons. In exposure therapy, BDD patients are provided with a symptoms list and must then induce the debilitating condition and self-monitor/rate objective signs, such as pulse rate, extent of nausea, dizziness, and cognitive distortions—for example, "My nose and forehead are too big." Cognitive restructuring through writing exercises and observational records are emphasized.

Our patients stay in the program from six to eight hours a day, and there are three clinicians working with them in shifts on a daily basis. After they work with the clinicians, I expose them in a controlled way to a regular mirror where they have to write a self-description, like someone in the police department is looking for them—a profile with no emotion associated with it.

We use cognitive-behavior therapy (CBT) with exposure and response prevention, and add mindful awareness training, cognitive restructuring, and Socratic questioning. We also use videotaping. Very often, I will use makeup artists to do an exaggerated prosthetic part. We have an interdisciplinary team. Treatment is tailored to each case. We also have six psychiatrists associated with us, who are OCD and anxiety disorder specialists.

DB: You have mentioned in the past that the model most clinicians have in private practice of the 50-minute session once or twice a week is inadequate for extreme cases of powerful dysfunctions such as BDD. It is wonderful that you are able to do such intensive work with those who are suffering with the most severe cases.
EG: We are able to do this work because we specialize only in OCD and BDD and other anxiety disorders. We don't treat anything else. And because of this narrow specialization, it is possible for one patient to work with three or four clinicians in a day. However, insurance companies just rejected one BDD case because they still don't accept the necessity for this intense treatment—they think it can be treated once a week, although this particular patient had been treated unsuccessfully once a week for years. It is a very debilitating illness—far more severe, I think, than OCD.

Medication

DB: That brings us to the issue of medications. SSRIs have been often prescribed to people with BDD. Would you say the majority of these people you work with are already on SSRIs, or do they end up on SSRIs?
EG: Based on my work with the six psychiatrists at the Institute, SSRIs alone do not seem to be helpful. There is no scientific evidence at this point for what really works with body dysmorphic disorder because of the delusional component and extremely poor insight. For people with high baseline anxiety, medication may be targeted to reduce anxiety. Depression and panic attacks can also be addressed with some medications, and atypical psychotic medications have also been used. But I have to emphasize that some kind of effective therapy is required, such as cognitive-behavioral therapy tailored to the individual case.

Families can also be a crucial part of the treatment.

It is important that family members see that this is a true debilitating disorder, rather than merely shallowness and self-absorption.
It is important that family members see that this is a true debilitating disorder, rather than merely shallowness and self-absorption. The love, support, and understanding of the family are very important, and they also have to be educated in how not to reinforce the obsessing and compulsions. Then, it is also important where they go after the treatment program.

Post-Treatment Care

DB: What are your experiences with post-treatment care?
EG: There are few referral possibilities for BDD patients to follow through. I think that these people are extremely high risk for relapse—maybe even more so than obsessive-compulsives, who have much greater compliance levels. Because of the impulsivity characteristic of BDD, you have less compliance, so even if patients do extremely well during the program, it is necessary to continue the self-therapy and self-treatment, because this illness is not really cured. I oftentimes give my patients examples: you can go through the best weight-loss program in the world, but if you then resort to your old eating habits, everything is going to come back right away. So really, I think it depends on finding out their interests or what they're best at while they're in the program, so that these dysfunctional compulsions can be immediately replaced with other activities. I tell them, "I don't care if you study Chinese, take a cooking class, or paint your house, as long as you get up in the morning and get going." Otherwise, all of the compulsions have a tendency to come back if the patients don't do anything that is productive.

Specialty Training in BDD

DB: I can see how important it is that they really understand what you're telling them about exposure and response prevention, and not reinforcing those dysfunctional behaviors. For any of the clinicians reading this who want to get the specific training needed to work in this arena, are you doing any training at the Westwood Institute or at UCLA?
EG: I would think that it's very important for them to go through training, but it would have to be hands on. It takes me approximately six months to train a good clinician for complicated cases, but I do specialize in extreme cases—patients who have failed a few other programs. Perhaps even a month of training would be sufficient if the clinicians saw a couple of cases that they would have to really work with intensively, because of the tailoring to the individual needs. It is not a cookie-cutter training; I couldn't tell you, "Here is a cookbook for any BDD case." Each case is like a snowflake. I've never seen two that were exactly alike, so we duly tailor the treatment to the individual needs of the patient.
DB: Absolutely. Finally, could you say something about the satisfaction you’ve gotten as a clinician in being able to help people who have experienced such terrible suffering and misery?
EG: My satisfactions are now taken with a grain of salt. Ten years ago, I was far more optimistic about the outcomes. I know now how debilitating and co-morbid this is with other illnesses, and how "feeling good" is dangerous for them. People with BDD have to be alert and vigilant to not fall into their old habits of dealing with their anxieties.

It's a medical illness that is extremely serious—like tremors of the mind. You could compare it a stroke or cancer that must be attended to. It is chronic; it waxes and wanes. People can definitely get to completely functional levels provided they attend to it on a daily basis. But, like a person with extremely high blood pressure or diabetes or even cancer, that person must be mindful and aware that there's a problem. Lately I've seen a few cases that had been in remission for 10 or 12 years and then they relapsed. I cannot tell you why. I don't even know if I have a hypothesis about the relapse after years in remission. And it sometimes takes longer to get them out of the condition the second time.

DB: That’s a very sobering indication of the great suffering and difficulty of having this disorder. I really appreciate your helping these people even without necessarily always having easy answers. On the other hand, I know of some people over the past several years that have made tremendous improvement in their functioning, even if they’ve had to come back and see you periodically. It’s made a big difference in the quality of their lives.
EG: I appreciate that, but the truth is I want to warn people against being extremely optimistic. There is no cure, and even if we ourselves have some of the highest levels of successful outcomes, let’s not forget that I’m extremely careful, having been trained by Dr. Foa to assess cases for hours and hours and to administer up to 15 tests to make our understanding of the individual even more precise. We also need to reject and refer elsewhere about 50% of the cases that come to us that I think we cannot help. People who come here are self-selected. We never have more than three cases at a time in the entire Institute, and we are able to pay a lot of personal attention to each individual and tailor the treatment. If something is not working from yesterday to today, we change it. We have that luxury. If I need to, I can dedicate the entire Saturday to this patient. That said, I don’t think other therapists have that luxury, and I think it’s very important to put this element into the level of success. It was never the quantity but the quality of the work that we have been focused on.
DB: I think that's one clear understanding that your patients have about your work—the intense dedication. Without being able to promise success, you are certainly one of the most dedicated people I know working in this challenging field
EG: You are most welcome.