The relationship between eating disorders and depression is a complex problem to understand, treat, and research. The parable of the three blind men who encounter an elephant illustrates the problem faced by patients and their providers. It is easy to misperceive that the elephant is only a long hose (trunk), a rope (tail), or the side of a building (body), depending upon which part of the elephant you encounter. People with eating disorders force us to face our collective confusion about the nature of treatment and intervention.
Which target do we treat first and what do we do about co-morbid conditions, such as depression? The problem for many patients is that often, their eating disorder is given great attention in therapy while their depression is given short shrift. Many patients receive medication for their depression, but without the benefit of being offered other therapies that can be a powerful antidote to their depression. This can be especially difficult for treatment providers who are often faced with patients who believe that if their weight were ideal, their bingeing gone or their diet perfectly correct, then all of their problems would disappear.
The patient’s concern is their body and eating. The other problem is that depressed patients can lack motivation and energy to complete any treatment because their depression symptoms of apathy fatigue, flat affect, and disturbed appetite are difficult to manage without also having the overlay of an eating disorder. For example, how do you get someone to engage in treatment when they do not care about anything and all they seem to be able to do is to sleep?
Additionally, third party payers tend to push patients out of programs when their care progresses at a slow rate, such as can happen when both an eating disorder and depression are severe. Do you send the patient to a depression-based program or try to keep them in an eating disorders-based program? What if insurance kicks them out of the eating disorders program due to suicidal ideation? Last, the average length of time in treatment to recovery suggests that no matter what therapists do, the journey will often be long and frustrating for everyone involved. That can be depressing!
For the sake of avoiding professional burnout and the accidental development of people who become professional patients (people who believe that their role is to do therapy rather than to live and thrive), we need to take a perspective that embraces the entirety of the situation and avoids the pitfall of piecemeal treatment. It means that we have to assume that all disciplines involved have something to offer and that we need to remember that living well means more than learning how to do therapeutic tasks. No amount of ability to complete a DBT worksheet or exposure food hierarchy will work unless we teach patients how to live well.
My experience as a clinician shows that many of my eating disorder patients are highly skilled at completing worksheets due to their perfectionism and desire to earn approval, but they continue to have symptoms because they have gotten in the habit of completing programs rather than learning to live well. The broader issues have been overlooked in the interest of finishing a treatment protocol.
I suggest that instead of trying to focus narrowing on just addressing the family culture, doing exposure to eating or working on body image, we need to address broad issues that place patients at risk for poor mental health, such as targeting perfectionism and implementing what we have learned from positive psychology. We know that perfectionism is a unique and critical risk factor for suicide above and beyond having depression or anxiety. This means that no matter what we attempt to do in any patient’s treatment, we need to offer treatments that have patients practicing risk taking, making mistakes, recovering from mistakes, laughing at mistakes, appreciating daily small experiences, and seeing the beauty in the challenge of stressors.
Simply learning to notice and savor daily experiences of gratitude can alleviate and prevent depression. Learning to laugh and enjoy one’s own foibles makes life fun. Instead of just treating what is wrong, we need to help patients develop the mental and behavioral skills of mental wellness. In short, we need to make developing optimism, grit, and resilience part of the 21st century eating disorders repertoire if we are to succeed in the long run. For additional information please go to the website for the National Eating Disorders Organization and the Anxiety Depression Association of America (ADAA).
Karen Cassiday, PhD is an ADAA member and former board president. Dr. Cassiday’s areas of interest are anxiety disorders in children and teens, social anxiety disorder, treatment-refractory OCD, and working with children and teens who suffer from both developmental concerns and anxiety disorders. Her research has focused on information processing in posttraumatic stress disorder and cognitive-behavioral treatment of anxiety disorders in children, teens, and adults.