Obesity and Compulsive Overeating

You've read the headlines. You know the statistics. Obesity is epidemic in our culture. American children are the fattest on earth, and the Chinese are now not far behind. Explanations for this have primarily centered around the notion that our nation's longstanding economic success (and now China's emerging success) has resulted in a shift in our culture from frugality and hard work to overindulgence and sloth. In addition, this overindulgence and sloth has been coupled with the consumption of cheap, high fat foods that are addictive and have poor nutritional value. There is no doubt that these behavioral factors and food choices contribute significantly to this epidemic of obesity. However, these sociocultural and economic factors alone cannot explain this phenomenon.

The truth is that obesity often results from an eating disorder in the individual. Despite protestations to the contrary by some, it is virtually impossible to become morbidly obese without overconsumption. A person with compulsive overeating, or binge eating disorder, typically presents as preoccupied by food and frequently engages (sometimes secretly) in episodes of uncontrolled eating, or bingeing, during which she or he may feel frenzied or out of control. At these times, the person consumes food past the point of being comfortably full. These compulsive overeaters will even typically eat when they are not hungry. They often have feelings of guilt and shame after binge eating and they often binge eat alone.

In addition to binge eating, compulsive overeaters can also engage in 'grazing' behavior, during which they return to pick at food throughout the day. This results in a large overall number of calories consumed, even if the quantities eaten at any one time may be small.

Recent taxonomy has sought to distinguish between the diagnoses of compulsive overeating disorder and binge eating disorder. When a compulsive eater overeats primarily through bingeing, he or she is said to have a binge eating disorder. Where there is continuous overeating and grazing, but no bingeing, then the person is said to have a compulsive overeating disorder.

One patient who struggled with a binge eating disorder recently described her obsession with food and the excessive amounts of time and thought she devoted to food. Often, she would secretly plan or fantasize about eating alone where she would prepare what she described as a "feast." For her, eating was an opportunity to indulge in her deepest pleasure, to be a "baby queen" where every desire could be indulged without limit. She remarked, "I can go home and spend hours and hours preparing the most elaborate meal. It is grand. And then I spend several more hours eating it. I almost start to panic when I see that it is going to end. I just don't want it to end. I always want to feel that there is going to be more for me, like I'm never going to run out."

Of course, there may be genetic factors which contribute to a person's predisposition towards obesity. However, the above description reveals important psychological factors that can often contribute to these eating disorders. They include significant feelings of deprivation, significant feelings of envy and entitlement and the significant use of denial.

The significant feelings of deprivation emanate from early life. The child's enormous feelings of emptiness and longing, resulting from some emotional deprivation or trauma, become converted into an enormous appetite, needing to be filled up. There is often little consciousness of the true nature of the relationship between the person's compulsive overeating and any emotional struggle.

Significant feelings of envy and entitlement also emanate from this feeling of deprivation. The person longs for comfort and satisfaction and comes to feel that she or he deserves to indulge in order to feel good, to satisfy him or herself, to be rewarded. After all, should she not have what she wants? Why should he have to say no, or not have the desert he loves, or stop eating if it makes him feel good? Why should she have to be without? Entitlement may seem to be in contradiction to the low self-esteem often observed in the obese compulsive overeater, but it, in fact, consistent with it and results from unmet primary needs.

The significant use of denial is reflected in the failure often to acknowledge the amount of the overconsumption or the impact of it. In the moments of overindulgence, the person denies that she or he is taking more than they should. "I don't really eat that much", one 350lbs patient would frequently exclaim. Additionally, there is a denial of the limits and the boundaries of the consumption and of the body. There is also a denial of the absence of control that the person is exercising over their food.

Sometimes, of course, obesity and compulsive overeating are the sequelae of childhood abuse or neglect. In particular, emotional neglect and childhood sexual abuse have often been linked to these difficulties. Not everyone who is obese and compulsively overeats has been sexually abused, or not everyone who has been sexually abused will be obese and compulsively overeat. However, for those with the two co-exist, the obesity and overeating serve as an ineffective attempt to manage the emotional dysregulation caused by the abuse. Food is used to nurture, soothe and calm the chronic anxious feelings that ensue from childhood abuse or neglect. The obesity can sometimes serve as an unconscious attempt to create a sense of being held or a physical barrier between self and others; a soft envelope or a protective wall of fat, if you will.

There are many who treat obesity and compulsive overeating like an addiction, utilizing a medical model of disease. They see the compulsive overeater as being driven merely by her or his disturbed brain chemistry. This disturbed brain chemistry results in a dysregulation of the person's consumption. While there may be real clinical evidence of a biochemical component to the compulsivity seen in eating disorders, to ignore the psychological underpinnings of this illness is to suggest that the person is merely the victim of their bad chemistry, with little or no responsibility for or capacity to make choices about their behavior. "I'm an addict, I can't stop myself" one patient would often repeat, in explaining why she could not be responsible for having eaten nearly two dozen Krispy Kreme doughnuts.

Dieting is often unsuccessful for the compulsive overeater as feelings of deprivation are often activated by the restriction inherent in dieting. This then eventually fuels greater need for gratification, often leading to a binge episode. Appropriate treatment for obesity and compulsive overeating should include both attention to the biochemical components driving the compulsive behaviors, as well as attention to the psychological factors which contribute to the person's denial and feelings of deprivation, envy and entitlement.

Women and Bad Relationship Choices

You all know who she is. Or maybe she is you. She drives 200 miles across state lines to meet the 'really great guy' she met on the internet. She always seems to find the man who is chronically unemployed or underemployed, who requires her support. Her boyfriends or partners often cheat on her. Or sometimes they are married or otherwise unavailable. Or they are so self-focused that they never plan anything or do anything with her that is not related to meeting their own needs. Sometimes they are emotionally absent or emotionally or physically abusive. Sometimes they are addicts. Sometimes it turns out that all they wanted was the sex that she too quickly offered.

Why do some women make these bad relationship choices, over and over again?

First, let's talk about self-concept. Her ideas about herself, her sense of her value and her conclusions about things to which she is entitled are formed early on in life. These earlier life experiences inform her about what she can expect from the world, and communicate to her about how others will value her. This woman, like all of us, is guided by her internalized model of relationships and the quality of attachment in her early life experiences (see previous postings for a discussion of attachment). Her self-concept is also impacted by her experiences in society at large. The woman who has had an earlier life in which she experienced excessive criticism, deprivation, devaluation and denigration, whether subtle or overt, whether in her family and/or in society at large, will come to view herself in a less than positive light. She may feel that there limits to what she can expect from the others, from the world and in relationships. Being treated as 'less than' in her relationship may, unfortunately, not be foreign for her. Therefore, to engage in a relationship in which she may not be sufficiently valued may be ego-syntonic and thus hardly noticed at all.

Denial is also a powerful psychological tool, aimed at helping her tolerate what would otherwise be felt to be intolerable. Is it not easier for her to believe that she is deeply cared for, rather than acknowledge that she is being exploited? Is it not less painful to believe that he is pining and longing and for her and will soon leave his non-understanding wife, than to believe that he is no more able to offer her a whole relationship than he is his wife? And besides, his drinking really isn't that bad. Powerful denial is required to protect the woman from the pain of these realities. She may have such a history of denying reality, or needing to deny a painful reality (or her reality being denied) that she can too easily convince herself of the most foolish things. When she is offered a crumb, she mistakes it for (or converts it into) a whole cake. She convinces herself that her belly is full and that she is truly being satisfied. Or she convinces herself that she really doesn't need very much. Yet, a crumb is still a crumb.

Are you a woman who keeps making bad relationship choices? Think about the messages you got about yourself and your value during your childhood. For example, were you seen as special, a burden, demanding, needy, greedy, bad, beautiful, invisible, stupid, intelligent? What role did you occupy in the relationships with your family? Do you feel any of those feelings in your life today? What do you think you should expect in a relationship? What do you think any woman should expect in a relationship? What boundaries do you feel are appropriate for you to set in a relationship? What are you really getting in the relationship that you have now?

Are you getting the whole cake, or are you settling for crumbs?

Pornography and Sexual Addiction

I recently supervised a psychologist on a case in which I was introduced to a verb that was new to me - porning. This was a word that was used by the patient to describe his compulsive engagement in online pornography and masturbation. He revealed that he would spend hours and hours 'porning' at the expense of other activities and at the expense of engaging in real relationships.

Pornography has grown exponentially over the last decade, encouraged by cultural shifts around issues of sex and sexuality and by the expansion of technology and the internet. As a result, more and more patients are presenting with primary or secondary concerns around compulsive sexual behaviors, which sometimes includes the use of pornography.

Some of these compulsive sexual behaviors include compulsive masturbation, anonymous or near-anonymous sexual encounters, frequent and indiscriminate 'hooking up', frequent visitation to strip clubs and 'massage' parlors, voyeurism, exhibitionism, sadomasochism and the compulsive use of internet pornography.

According to recent statistics, 40 million people regularly visit pornography sites; 72% male and 28% female. Every second, approximately $3100 is spent on pornography. Asian countries, like China, South Korea and Japan, make a total revenue of $75 billion per year on internet pornography alone. The United States makes a total revenue of about $15 billion per year on internet pornography. According to some statistics, an astonishing 12% of all website are considered to be pornographic, and 20% of these are considered to be child pornography.

With such increasing access to sexual images, sexual addictions appear to have become more commonplace than ever before. In fact, in many ways, our culture has moved towards glorifying such compulsive behaviors, evidenced by the success of such television shows as 'Californication' and 'Sex and the City'. These shows have served to normalize compulsive sexual behavior in both men and women, allowing for a more open discussion of the issue.

Sexual addictions, like all addictions, arise from the combination of satisfying a physiological desire and a psychological need. Like other addictions, the pleasure centers of the brain (specifically, the nucleus accumbens), play a significant role. In addition to cocaine and amphetamine, almost every recreational drug has been shown to increase dopamine levels in the nucleus accumbens. Thus activating this part of the brain by engaging in these compulsive behaviors, results in dopamine release deep within the limbic system of the brain. This is the true physiologic addiction.

Of course, there are significant psychological factors that contribute to sexual addiction. Many psychologists understand that sexual addiction often emanates from an attempt on the part of the patient to self regulate and self soothe. While some patients become orally fixated and utilize alcohol or food to compulsively provide this soothing, a person's genital can sometimes become a substitute to compulsively gratify these early needs. Sometimes this genital/sexual preoccupation results from neglect, where the child has been left with only his or her sexual pleasure for comfort. At other times, this genital/sexual preoccupation occurs as a result of trauma. While experiences such as childhood sexual abuse or traumatic sexualization serve to compound the possibility of sexual addiction, sexual addiction is not a necessary sequelae of sexual abuse. However, for those with such a history of trauma and resulting sexual compulsivity, their compulsive sexual behavior can be described as 'abuse reactive'. That is, their compulsive sexual behavior remains some way of perpetually re-enacting and/or attempting to re-work their earlier traumatic experiences.

One patient described her compulsive masturbation which resulted in her spending entire weekends locked in her apartment, masturbating and binge eating. For this patient, her feelings of extreme deprivation and need for gratification were enormous and were reflected in her insatiable appetites. This, behavior of course, was followed by tremendous feelings of guilt, shame and self-loathing, which ultimately resulted in a greater need for self-soothing. Psychotropic medication to address the patient's impulsivity and powerful need for dopamine in her brain's pleasure centers, coupled with three times a week psychotherapy, led to a significant decrease in this patient's compulsive masturbation and binge eating.

Another patient presented in couples therapy to address the impact of his chronic cheating behaviors. The patient, who had justified his frequent cheating as part of his culture and his 'natural' large sexual appetite, was having to face the destructive relationship consequences of his sexual escapades. Further work revealed a history of premature (and ultimately traumatic) sexualization, which resulted in cementing the patient's identity around his sexual prowess.

Treatment for sexual addictions has become more commonplace, with the increase in the number of treatment facilities aimed specifically at sexual addictions. 12-Step self-help groups like SAA (Sex Addicts Anonymous) and SLA (Sex and Love Addicts Anonymous) have also grown in membership as people are less ashamed to acknowledge their addictions. A string of high profile people forced to acknowledge sexual addiction (e.g. former NY Governor Eliot Spitzer, TV actor David Duchovny) and former President Bill Clinton's documented struggle around sexual behavior have served to highlight the pervasiveness of this problem.

Untreated sexual addiction, like any other addiction, ultimately results in numerous personal consequences for the addict, but also results in significant social problems for any society. As sexual boundaries become more diffuse, and as sexual addiction more pervasive, all of us (and our children) become increasingly at risk for being exploited to meet the addict's needs. Parents should, therefore, pay special attention to their children's online use and openly address internet pornography use as well as their children's developing sexuality. Parents should not assume that this issue does not affect their child. Statistics indicate that the average age at which a child is likely to first encounter online pornography is 11 years. Children are able to become addicted to pornography in the same ways that they are able to become addicted to drugs, and parents should, therefore, give importance to this growing problem. They, too, might be out there, porning.