DSM-V: Make Obesity a Brain Disorder
I wanted to get this link out here first before reading it, in order to facilitate some discussion. There's an editorial in the American Journal of Psychiatry suggesting that obesity should be deemed a brain disorder in the DSM-V.
The discrepancy between the successes of the metabolic treatments of consequences of obesity and the failures of behavioral treatments to prevent or reverse obesity highlight the fact that this condition is not only a metabolic disorder but also a brain disorder. Consideration of the mental component of obesity should be a key target in the treatment of obesity to facilitate compliance and minimize relapse. Here, we propose that some forms of obesity are driven by an excessive motivational drive for food and should be included as a mental disorder in DSM-V.
Obesity is characterized by compulsive consumption of food and the inability to restrain from eating despite the desire to do so. These symptoms are remarkably parallel to those described in DSM-IV for substance abuse and drug dependence (Table 1), which has led some to suggest that obesity may be considered a "food addiction" (5).
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[Thanks, sevendayswonder.]
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Posted by paul on June 15, 2007
How are they going to determine who has a compulsive drive to overeat? Who is going to decide that? Obviously, they aren't going to believe a fat person who keeps a food log, because, as we have been told over and over and over again, we're lying (been there done that). I'm not denying there are people who compulsively overeat, but not all fat people are compulsive overeaters and I don't think it's justified to tar us all with that brush. I also don't agree that being fat is a brain disorder. There are too many unknown, as yet, factors for them to be able to blame it all on a brain disorder. No consideration at all is given to genetics, set points, etc. And I would venture to say that if they kept a fat person in the hospital for years, with no outside influences at all, and severely restricted calories and forced exercise, there would eventually come a point when that fat person would no longer be able to lose weight (they might meet an unrealistic goal, maybe...), but I'm also thinking that the fat person would have to remain on a starvation diet for the rest of their lives, and maintain the forced exercise in order to keep the weight off. I'm sorry, I'll be fat, and healthy, rather than live that kind of life. I don't want to be obsessed with every calorie that goes into my mouth, nor do I want to have to exercise 5 or 6 hours a day to meet someone's unrealistic skinny body ideal.
it's all right to be crazy, just don't let it drive ya nuts!
I was pretty miffed when I read the editorial in AJP, so I contacted the primary author (who is the Director of the National Institutes of Drug Abuse).
What I found from reading the editorial and then speaking with her is that the intention is not to paint being fat as a brain disorder, but, in her words, to encourage the "...medical community to consider the important role that the brain has in compulsive overeating that can result in obesity."
I emphasized (several times) that, while I agreed there are compulsive overeaters, I have concerns about labeling the disorder "obesity" as it seems too imprecise and liable to add to stigmatization. Compulsive Overeating might be an appropriate term, I think.
It seemed she may be under the impression that most "obese" people are compulsive overeaters (saying things like "some" obese people are just really good at storing energy from food--meaning "most" are fat for other reasons?).
I figured the best approach was to keep emphasizing the necessity for accuracy in diagnosis, even in the labels we use to diagnose brain disorders. While appearance may be a part of a diagnosis, we certainly can't use a description of someone's physical body as a diagnostic label for a psychological disorder. We'd be changing the name of anorexia to "morbidly skinny brain disorder", and what would we call other diagnoses like bi-polar, schizophrenia, or even addictions?
I'm not an addict, no way, I can stop any time I want. Anytime I want tell you! I don't need to eat. I don't need food to keep ME alive! It's lies, all lies!
Oh, I just noticed they quote Allison's 1999 figure for the healthcare costs of obesity. Hmmmm.
My thoughts are here.
Better late than never on posting this here, I guess!
Oh, hell yeah, Paul. Glad to see it get more play.
As a therapist, I have felt betrayed by my field many times. I have been told that clients will not respond to me because I am fat. I am supposedly setting a bad example. I will not deny that I have had clients look me up and down and dismiss me. However, most are there to solve issues about themselves and care little about me. I have a lot of issues with the DSM-IV and the way illness is diagnosed. It is simply a list of symptoms that have been assigned names. Most of my clients don't really fit a diagnosis but for insurance purposes I must give one. I also hate that I have to put obestiy as part of the diagnosis whether or not the client reports it as a problem or not. All I know is that I try to help people learn to love themselves and accept who they are both inside and out. I don't like identifying someone as sick or defective if that is not the case.
LumpyLuv, where in the DC area are you? I work near Tyson's I.
Sorry I didn't respond earlier, I only just read your comment. I actually live in Loudoun County, that is only about 15 minutes from Tysons up Route 7. I grew up in Alexandria, so I consider myself a native to the DC area.
I've started listening to Amy Winehouse (btw, anorexic, bulimic and probably an alcoholic, but whatever), and she has a great song - Rehab. Whenever I read articles like this one, I sing that song in my head. We are the pitiable obese, and certainly we just need to be in treatment for our disordered brains (eyeroll), and those of us who actively love ourselves should certainly be committed for abject insanity. I've been to a very expensive rehab facility for family week (visiting my mother), and it always struck me as funny that the counselor for the fatties was visibly bony and never let anything pass her lips except Diet Coke.
"They tried to make me go to rehab, and I said no, no, NO..."
kg
Too creepy for words.
The discrepancy between the successes of the metabolic treatments of consequences of obesity and the failures of behavioral treatments to prevent or reverse obesity...
Say what? What are these "consequences" (correlation is not causation)?
And what does the treatment of the "consequences" have to do with the "obesity" itself?
This sounds like "We can successfully treat the severe symptoms of flu, and yet we haven't managed to find any behavioral change that will eradicate the flu -- therefore, there must be a brain disorder causing flu."
That just disgusts me to no end. I am obese, and I am nothing near a compulsive eater. My average caloric intake is under 2000 calories a day. (Believe me I've counted) Yet doctors tell me, everyone tells me, this can't be so and that I'm "lying" or "sneaking snacks". I also walk for thirty minutes at least three times a week (not counting walking my three dogs twice a day in the yard so I'm sure it adds up to more than that). I'm not crazy, I"m just fat!
What is meant by "brain disorder"? Do they mean there could be a biochemical component to obesity, in terms of appetite and hunger drive --which would of course reasonably suggest tht "behavioral modification" is not the answer because behavior is not the issue in the first place? (Heaven forbid people acknowledge that diets don't work).
From the excerpt, though, it does not appear so. It's interesting (read: outrageous and absurd) that they're claiming "obesity" itself is compulsive eating despite a desire to stop. Even if we were to accept this notion, it would seem "obesity" is a SIDE EFFECT of compulsive eating despite a desire to stop.
It's somewhat complicated, because some people DO eat compulsively despite a desire to stop. I know because I'm one of them. However, it is ABSURD for the DSMV to speak as though everyone who is fat is fat for this reason and can all be treated in the same manner--or even need to be treated in the first place.
According to Gina Kolata's book, one doctor wanted "binge eating disorder" listed in the DSMV for clinical reasons, but they wouldn't do it. this doctor did not seem to be claiming that ALL fat people suffer from "BED," only that some did. In fact, he, or possibly other doctors Kolata spoke to, showed through careful studies that fat people do NOT have a screwed up relationship with food and no particular neurosis drives them or makes them fat. "There is," she writes, "no response to food that is not shared by thin people."
Wonder if the DSMV folks took note of that. From the looks of things, it does not appear so. And so, the media are left with yet one more example of oversimplfying something incredibly complicated and something that is unique to each and every individual on earth.
Also, this does not take into consideration the fact that the more people diet, the fatter - on average - they become.
This is a bizarre example of pyschological mumbo jumbo at its finest. Having large amounts of body fat is more properly classified as a symptom than a disease of it's own. Telling a fat person to just lose weight is a lot like telling a schizophrenic to get rid of the voices and then they'll be cured. Some fat people do eat a lot....some don't. Some fat people have a disordered relationship with food....some don't. And not all schizophrenics hear voices....some have other symptoms.
This is all very mixed up. Compulsive eating should be classified as a disorder, with the number one cause listed to be restricted eating, also known as dieting. And being fat is no more a disorder than being thin. Just because we can't make fat people thin doesn't mean being fat is a disorder. What it might mean is that fatness is an essential part of one's biological make-up in the same way that thinness is. And the best thing we as a society can do about fatness is to leave it alone.
Labrador dogs often have genetic hunger, probably as a result of the harsh conditions the breed developed in. They also tend to be fat, even when fed small amounts of food. Do people say they have a brain disorder? No! They understand it as a trait of the breed.
Why can't they allow humans the same understanding? Some of us come from lines that developed in very harsh conditions. Being hungry all the time and not finicky allowed Labs to survive. It probably did the same for humans from some parts of the world. Genetic hunger is probably a very valuable trait in the gene pool, as is the ability to do well from small amounts of food.
Whether we are fat from overeating, or we don't eat much, fat people are still very valuable members of the gene pool. If we weren't useful, then our sorts would probably have disappeared long ago.
That is the biggest bunch of crap!!!
Going by that definition, I'm not obese but many of my friends (especially male ones), who happen to be pretty skinny, ARE.
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"The first thing you lose on a diet is brain mass."
~Margaret Cho
Just to clarify, they are recommending it as inclusion as a mental disorder. However, this would be a hard case to make. Binge eating is already identified as a disorder in the DSM-IV-TR, so to add obesity when it is impossible to identify behaviors that characterize everyone who is considered obese would be crazy-making. It is also incredibly slow to get inclusions into the DSM, so I don't have a sense that this is really going to be an issue for the DSM-V.
Ah, well, by the time I read all the comments, most of what I was going to say was already said. Obesity is a result of many possible things, but it's not a disease. Like saying that passing out while drunk is a disease, or having a bout of insuline shock is a disease. It's ignorant, but it's also quite dangerous to confuse a state of being with a disease. As commented above, it puts ALL people who are higher than a certain BMI rating into one lump "disease" category, regardless of how they got there. And it reinforces the dangerous notion that if you look a certain way, or the scale looks a certain way when you get on it, you must be treated by the medical profession. Or by the state, in the case of children.
"to facilitate compliance and minimize relapse"--what does this phrase make YOU think of? Prison? 1984? There is, at the very least, a strong suggestion that those who don't succeed in losing weight via some medically approved means are refusing to comply.
All of this sounds to me like some people are trying fit some other people into the wrong shaped hole. They can't jam them in, so they call them brain disordered and wipe their hands clean.
Don't we need to get out there and make a lot of noise about this kind of thing, in addition to commenting on this blog? And, how do we do it? Who will do it? If not NAAFA, then who?
Deb Burgard, who is a licensed therapist, wrote a very articulate letter to the people in charge of putting together the DSM, which you can see on the Yahoo Fat Studies list. She has treated many people with EDs and thus was able to make a very strong case that calling "obesity" a "mental disorder" was not going to be useful to her or her patients. Anyone here who is a mental health clinician, or is studying to be one, probably has more "pull" with these people than anyone off the street.
Frankly, a bunch of us writing in and going, "I am NOT crazy! Fuck you!" is probably going to do us more harm than good in this case. I myself plan on writing in and reminding them that many of us gain serious weight on psychiatric medications, as I did, and that it would be a double dosage of cruelty to stick us with an "obesity" diagnosis after that. But it's going to take me multiple drafts, because these people make me sick to my very bones and the first couple of drafts are going to have a whole lot of "fuck you" in them.
Meowzer, while I totally agree with what you've had to say in your post, I can't help but let you know that the "I am NOT crazy! Fuck you!" comment made me crack up. Of course I think I've used those exact words before, but never dealing with my "obesity." Good luck with those drafts. If you need someone to edit the "fuck you's" out let me know.
arrgh. I just finished my Psych degree and have written a bunch of ranty essays about the DSM-IV-TR and how they classify Childhood Gender Identity Disorder as a mental illness. Which justifies putting kids through therapy to help them accept their "natural" gender roles (not always, but in a lot of cases). Obviously this is just as fucked up - labelling people as sick and crazy because they don't fit into what they consider "normal"
Also the phrase "facilitate compliance" in there is totally horrifying.