To the patient suffering from both a personality disorder and an eating disorder BY FAR the most important element in his mental abnormalcy is his eating disorders. He is usually right in emphasizing their importance to him over the problems stemming from his personality disorders. They indicate the strong combined activity of an underlying sense of lack of personal autonomy and an underlying sense of lack of self control. The patient feels inordinately, paralyzingly helpless and ineffective. His eating disorders are an effort to exert and reassert mastery over his own life. At this stage, he is unable to differentiate his own feelings and needs from those of others. His cognitive and perceptual distortions (for instance, regarding his body image) only increase his feeling of personal ineffectiveness and his need to exercise even more self control (of his diet, the only thing left to him sice he belives that he lost control over everything else in his life).

The patient does not trust himself AT ALL, not in the slightest. He is his worst enemy, a mortal enemy and he knows it. Therefore, any efforts to collaborate with HIM against his disorder - will be perceived by him as collaboration with his worst enemy against his only mode of controlling his life to some extent.

The patient views the world in terms of black and white, of absolutes. So, he cannot let go even to a very small degree. He (or she) is HORRIFIED - constantly - that even the slightest loosening of his rigid eating regime will fast deteriorate into a total loss of control over his life. This is why he finds it impossible to form relationships: he mistrusts (himself and by extension others), he does not want to become an adult, he does not enjoy sex or love (which both entail a modicum of a loss of control). All these dysfunctions lead to a chronic absence of self esteem. These patients seem to be really attached only to their disorder. Their eating disorder is their only successful feat in life. Otherwise they are ashamed of themselves and disgusted by their shortcomings (expressed through shame and disgust directed at their bodies).

There is a chance to cure the patient of his eating disorders (though the duality of eating disorder plus the existence of a personality disorder is not favourable prognosticator of recovery). This - and ONLY this - must be done at the first stage. The patient's family or closest should consider therapy AND the patient's participation in support groups (the equivalent of Alcoholics Anonymous or a 12 step program for eating disorders). Recovery prognosis improves after 2 years of treatment and support. The family must be heavily involved in the therapeutic process. Family dynamics usually contribute to the development of such disorders.

Medication+ cognitive or behavioral therapy+psychodynamic therapy+family therapy ought to do it.

The change in the patient IF the treatment of his eating disorders is successful is VERY MARKED. His major depression disappears together with his sleeping disorders. He becomes socially active again and goes on with the business of living. His personality disorder might make it difficult for him - but, in isolation, without the exacerbating circumstances of his other disorders - he finds it much easier to cope with.

Patients with eating disorders may be in mortal danger. Their behaviour is ruining their bodies relentlessly and inexorably. They might attempt suicide. They might do drugs. It is only a question of time. Our goal is to buy them time. The older they get, the more experience they accumulate, the more their body chemistry changes with age - and the better their prognosis.


(1) Review of General Psychiatry - 4th Edition - Prentice Hall International - 1995 - pp. 309-332 and 355-368
(2) Herzog DB et al. - The prevalence of personality disorders in 210 women with eating disorders - Journal of Clinical Psychiatry - 1992a;53:147
(3) Marcus MD et al. - Psychiatric disorders among obese binge eaters - international Journal of Eating Disorders - 1990;9:69

Author's Bio: 

Dr. Vaknin has a doctorate in Physics and Philosophy. He has collaborated with Israeli psychologists and criminologists on matters related to personality disorders. During the years 1995-6 he studied the prevalence of personality disorders in the prison population in Israel. He is the author of "Malignant Self Love - Narcissism Revisited".

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