Misdiagnosing Personality Disorders as Eating Disorders

The Eating Disordered Patient

Eating disorders - notably Anorexia Nervosa and Bulimia Nervosa - are complex phenomena. The patient with eating disorder maintains a distorted view of her body as too fat or as somehow defective (she may have a body dysmorphic disorder). Many patients with eating disorders are found in professions where body form and image are emphasized (e.g., ballet students, fashion models, actors).

The Diagnostic and Statistical Manual (DSM) IV-TR (2000) (pp. 584-5):

"(Patients with personality disorders exhibit) feelings of ineffectiveness, a strong need to control one's environment, inflexible thinking, limited social spontaneity, perfectionism, and overly restrained initiative and emotional expression ... (Bulimics show a greater tendency to have) impulse-control problems, abuse alcohol or other drugs, exhibit mood lability, (have) a greater frequency of suicide attempts."

Eating Disorders and Self-control

The current view of orthodoxy is that the eating disordered patient is attempting to reassert control over her life by ritually regulating her food intake and her body weight. In this respect, eating disorders resemble obsessive-compulsive disorders.

One of the first scholars to have studied eating disorders, Bruch, described the patient's state of mind as "a struggle for control, for a sense of identity and effectiveness." (1962, 1974).

In Bulimia Nervosa, protracted episodes of fasting and purging (induced vomiting and the abuse of laxatives and diuretics) are precipitated by stress (usually fear of social situations akin to Social Phobia) and the breakdown of self-imposed dietary rules. Thus, eating disorders seem to be life-long attempts to relieve anxiety. Ironically, binging and purging render the patient even more anxious and provoke in her overwhelming self-loathing and guilt.

Eating disorders involve masochism. The patient tortures herself and inflicts on her body great harm by ascetically abstaining from food or by purging. Many patients cook elaborate meals for others and then refrain from consuming the dishes they had just prepared, perhaps as a sort of "self-punishment" or "spiritual purging."

The Diagnostic and Statistical Manual (DSM) IV-TR (2000) (p. 584) comments on the inner mental landscape of patients with eating disorders:

"Weight loss is viewed as an impressive achievement, a sign of extraordinary self-discipline, whereas weight gain is perceived as an unacceptable failure of self-control."

But the "eating disorder as an exercise in self-control" hypothesis may be overstated. If it were true, we would have expected eating disorders to be prevalent among minorities and the lower classes - people whose lives are controlled by others. Yet, the clinical picture is reversed: the vast majority of patients with eating disorders (90-95%) are white, young (mostly adolescent) women from the middle and upper classes. Eating disorders are rare among the lower and working classes, and among minorities, and non-Western societies and cultures.

Refusing to Grow Up

Other scholars believe that the patient with eating disorder refuses to grow up. By changing her body and stopping her menstruation (a condition known as amenorrhea), the patient regresses to childhood and avoids the challenges of adulthood (loneliness, interpersonal relationships, sex, holding a job, and childrearing).

Similarities with Personality Disorders

Patients with eating disorders maintain great secrecy about their condition, not unlike narcissists or paranoids, for instance. When they do attend psychotherapy it is usually owing to tangential problems: having been caught stealing food and other forms of antisocial behavior, such as rage attacks. Clinicians who are not trained to diagnose the subtle and deceptive signs and symptoms of eating disorders often misdiagnose them as personality disorders or as mood or affective or anxiety disorders.

Patients with eating disorders are emotionally labile, frequently suffer from depression, are socially withdrawn, lack sexual interest, and are irritable. Their self-esteem is low, their sense of self-worth fluctuating, they are perfectionists. The patient with eating disorder derives narcissistic supply from the praise she garners for having gone down in weight and the way she looks post-dieting. Small wonder eating disorders are often misdiagnosed as personality disorders: Borderline, Schizoid, Avoidant, Antisocial or Narcissistic.

Patients with eating disorders also resemble subjects with personality disorders in that they have primitive defense mechanisms, most notably splitting.

The Review of General Psychiatry (p. 356):

"Individuals with Anorexia Nervosa tend to view themselves in terms of absolute and polar opposites. Behavior is either all good or all bad; a decision is either completely right or completely wrong; one is either absolutely in control or totally out of control."

They are unable to differentiate their feelings and needs from those of others, adds the author.

To add confusion, both types of patients - with eating disorders and personality disorders - share an identically dysfunctional family background. Munchin et al. described it thus (1978): "enmeshment, over-protectiveness, rigidity, lack of conflict resolution."

Both types of patients are reluctant to seek help.

The Diagnostic and Statistical Manual (DSM) IV-TR (2000) (pp. 584-5):

"Individuals with Anorexia Nervosa frequently lack insight into or have considerable denial of the problem ... A substantial portion of individuals with Anorexia Nervosa have a personality disturbance that meets criteria for at least one Personality Disorder."

In clinical practice, co-morbidity of an eating disorder and a personality disorder is a common occurrence. About 20% of all Anorexia Nervosa patients are diagnosed with one or more personality disorders (mainly Cluster C - Avoidant, Dependent, Compulsive-Obsessive - but also Cluster A - Schizoid and Paranoid).

A whopping 40% of Anorexia Nervosa/Bulimia Nervosa patients have co-morbid personality disorders (mostly Cluster B - Narcissistic, Histrionic, Antisocial, Borderline). Pure bulimics tend to have Borderline Personality Disorder. Binge eating is included in the impulsive behavior criterion for Borderline Personality Disorder.

Such rampant comorbidity raises the question whether eating disorders are not actually behavioral manifestations of underlying personality disorders.

Additional resources

Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision (DSM-IV-TR) - Washington DC, The American Psychiatric Association, 2000

Goldman, Howard G. – Review of General Psychiatry, 4th ed. – London, Prentice-Hall International, 1995

Gelder, Michael et al., eds. – Oxford Textbook of Psychiatry, 3rd ed. – London, Oxford University Press, 2000

Vaknin, Sam – Malignant Self Love – Narcissism Revisited, 8th revised impression – Skopje and Prague, Narcissus Publications, 2006