What is Depressive Personality Disorder?

Introduction

Depressive personality disorder (also known as melancholic personality disorder) is a psychiatric diagnosis that denotes a personality disorder with depressive features.

Originally included in the American Psychiatric Association’s DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R. Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study. Although no longer listed as a personality disorder, the diagnosis is included under the section “personality disorder not otherwise specified”.

While depressive personality disorder shares some similarities with mood disorders such as dysthymia, it also shares many similarities with personality disorders including avoidant personality disorder. Some researchers argue that depressive personality disorder is sufficiently distinct from these other conditions so as to warrant a separate diagnosis.

Characteristics

The DSM-IV defines depressive personality disorder as “a pervasive pattern of depressive cognitions and behaviors beginning by early adulthood and occurring in a variety of contexts.” Depressive personality disorder occurs before, during, and after major depressive episodes, making it a distinct diagnosis not included in the definition of either major depressive episodes or dysthymic disorder. Specifically, five or more of the following must be present most days for at least two years in order for a diagnosis of depressive personality disorder to be made:

  • Usual mood is dominated by dejection, gloominess, cheerlessness, joylessness and unhappiness.
  • Self-concept centres on beliefs of inadequacy, worthlessness and low self-esteem.
  • Is critical, blaming and derogatory towards the self.
  • Is brooding and given to worry.
  • Is negativistic, critical and judgmental toward others.
  • Is pessimistic.
  • Is prone to feeling guilty or remorseful.

People with depressive personality disorder have a generally gloomy outlook on life, themselves, the past and the future. They are plagued by issues developing and maintaining relationships. In addition, studies have found that people with depressive personality disorder are more likely to seek psychotherapy than people with Axis I depression spectra diagnoses.

Recent studies have concluded that people with depressive personality disorder are at a greater risk of developing dysthymic disorder than a comparable group of people without depressive personality disorder. These findings lead to the fact that depressive personality disorder is a potential precursor to dysthymia or other depression spectrum diagnoses. If included in the DSM-V, depressive personality disorder would be included as a warning sign for potential development of more severe depressive episodes.

DSM-5

Similarities to Dysthymic Disorder

Much of the controversy surrounding the potential inclusion of depressive personality disorder in the DSM-5 stems from its apparent similarities to dysthymic disorder, a diagnosis already included in the DSM-IV. Dysthymic disorder is characterised by a variety of depressive symptoms, such as hypersomnia or fatigue, low self-esteem, poor appetite, or difficulty making decisions, for over two years, with symptoms never numerous or severe enough to qualify as major depressive disorder. Patients with dysthymic disorder may experience social withdrawal, pessimism, and feelings of inadequacy at higher rates than other depression spectrum patients. Early-onset dysthymia is the diagnosis most closely related to depressive personality disorder.

The key difference between dysthymic disorder and depressive personality disorder is the focus of the symptoms used to diagnose. Dysthymic disorder is diagnosed by looking at the somatic senses, the more tangible senses. Depressive personality disorder is diagnosed by looking at the cognitive and intrapsychic symptoms. The symptoms of dysthymic disorder and depressive personality disorder may look similar at first glance, but the way these symptoms are considered distinguish the two diagnoses.

Comorbidity with other Disorders

Many researchers believe that depressive personality disorder is so highly comorbid with other depressive disorders, manic-depressive episodes and dysthymic disorder, that it is redundant to include it as a distinct diagnosis. Recent studies however, have found that dysthymic disorder and depressive personality disorder are not as comorbid as previously thought. It was found that almost two thirds of the test subjects with depressive personality disorder did not have dysthymic disorder, and 83% did not have early-onset dysthymia.

The comorbidity with Axis I depressive disorders is not as high as had been assumed. An experiment conducted by American psychologists showed that depressive personality disorder shows a high comorbidity rate with major depression experienced at some point in a lifetime and with any mood disorders experienced at any point in a lifetime. A high comorbidity rate with these disorders is expected of many diagnoses. As for the extremely high comorbidity rate with mood disorders, it has been found that essentially all mood disorders are comorbid with at least one other, especially when looking at a lifetime sample size.

What is Personality Disorder Not Otherwise Specified?

Introduction

Personality disorder not otherwise specified (PDNOS) is a diagnostic classification for some DSM-IV Axis II personality disorders not otherwise listed in DSM-IV.

The DSM-5 does not have an equivalent to Personality Disorder NOS. However Personality disorder-trait specified (PD-TS) remains under consideration for future revisions. The DSM 5 “Unspecified Disorder” is not a personality disorder, it is used to enhance specificity of an existing disorder or it is an emergency diagnosis unto itself (i.e. Unspecified Mental Disorder, 300.9), without being attached to another disorder.

Not to be confused with PDD-NOS (Pervasive Developmental Disorder Not Otherwise Specified).

Diagnostic Criteria

DSM-IV-TR

This diagnosis may be given when no other personality disorder defined in the DSM fits the patient’s symptoms.

Four personality disorders were excluded from the main body of the DSM-IV-TR but this diagnosis may be used instead. The four excluded personality disorders are:

It is a requirement of DSM-IV that a diagnosis of any personality disorder also satisfies a set of Diagnostic criteria.

ICD-10

The World Health Organisation’s ICD-10 defines a conceptually similar disorder to “personality disorder not otherwise specified” called (F60.9) Personality disorder, unspecified.

It is a requirement of ICD-10 that a diagnosis of any personality disorder also satisfies a set of Diagnostic criteria.

Epidemiology

In one study, PDNOS was found to be the third most frequent personality disorder diagnosis.

What is Haltlose Personality Disorder?

Introduction

Haltlose personality disorder is a personality disorder in which affected individuals possess psychopathic traits built upon short-sighted selfishness and irresponsible hedonism, combined with an inability to anchor one’s identity to a future or past. The symptoms of Haltlose are characterised by a lack of inhibition.

Refer to Hysteroid Dysphoria. Other names have included Willenloser Psychopath, Unstable Psychopath, Unstable Drifter, and Disinhibited Personality.

Described by Emil Kraepelin and Gustav Aschaffenburg in the early twentieth century, and further distinguished by Karl Jaspers, Eugen and Manfred Bleuler, it has been colloquially dubbed psychopathy with an “absence of intent or lack of will”.

With other hyperthymics, Haltlose personalities were considered to make up “the main component of serious crime”, and are studied as one of the strains of psychopathy relevant to criminology as they are “very easily involved in the criminal history” and may become aggressors or homicidal. Their psychopathy is difficult to identify as a shallow sense of conformity is always present. A 2020 characterisation of mental illnesses noted of the Haltlose that “these people constantly need vigilant control, leadership, authoritarian mentor, encouragement and behavior correction” to avoid an idle lifestyle, involvement in antisocial groups, crime and substance abuse. The marked tendencies towards suggestibility are off-set by demonstrations of “abnormal rigidity and intransigence and firmness”.

After discovering a guilty conscience due to some act or omission they have committed, “they then live under constant fear of the consequences of their action or inaction, fear of something bad that might strike them” in stark opposition to their apparent carelessness or hyperthymic temperament, which is itself frequently a subconscious reaction to overwhelming fear. They frequently withdraw from society. Given their tendency to “exaggerate, to embroider their narratives, to picture themselves in ideal situations, to invent stories”, this fear then manifests as being “apt to blame others for their offences, frequently seeking to avoid responsibility for their actions”. They do not hold themselves responsible for their failed life, instead identifying as an ill-treated martyr.

They were characterised as Dégénérés supérieurs, demonstrating normal or heightened intellect but degraded moral standards. Of the ten types of psychopaths defined by Schneider, only the Gemütlose (compassionless) and the Haltlose “had high levels of criminal behavior” without external influence, and thus made up the minority of psychopaths who are “virtually doomed to commit crimes” by virtue only of their own constitution. Frequently changing their determined goals, a haltlose psychopath is “constantly looking for an external hold, it doesn’t really matter whether they join occult or fascist movements”. The ability to moderate external influence was considered one of three characteristics necessary to form an overall personality, thus leaving Haltlose patients without a functional personality of their own. A study of those with haltlose personality disorder concludes “In all of those cases, the result was a continuous social decline that ended in asocial-parasitic existence or an antisocial-criminal life”.

Haltlose has one of the most unfavourable prognoses of psychopathies. To exist safely, such a psychopath requires “a harsh lifestyle” and constant supervision.

Etymology and Criticism

“Haltlos” is a German word that contextually refers to a floundering, aimless, irresponsible lifestyle, and the diagnosis is named “Haltlose” using the feminine variation on the word. They are commonly clinically termed an “unstable psychopath”, which is differentiated from emotionally unstable personality disorder (an alternative name for borderline personality disorder). It was remarked in early studies that England, the United States and northern European countries did not use the same typology, not distinguishing between those psychopaths who were unstable and those who were “Unstable Psychopaths”.

It has been dubbed a part of “German-speaking psychiatry”. The term “Haltlose” is more common in the study of psychiatry, while “Willenlose” is preferred in sociology. Some like Karl Birnbaum prefer the term “Haltlose”, while others like Kurt Schneider prefer “Willenlos” shifting focus off their lack of self-control and opposed to the moralist tones of those like Birnbaum who had described the Haltlose as unable to grasp “important ideal values such as honor and morality, duty and responsibility, as well as material ones such as prosperity and health”. In 1928, Eugen Kahn argued Willenlose was a misnomer, as the patients demonstrated plenty of “will” and simply lacked the ability to translate it into action. Historically, researchers such as Schneider argued that instability is the symptom, whereas lack of volition is the underlying cause. It is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), possibly due to a modern belief that the concept of volition is outdated and overshadowed by the concepts of motivation and arousal or drive.

In 1963, Karl Jaspers defined the term as “those who have no willpower at all, the drifters, simply echoing any influence that impinges on them”. However, in 1976, the Government of Canada listed the alternate term “Unstable drifter” in a psychiatric criminology context as a problematic term for which they could not readily offer a French translation in accordance with their bilingualism laws. Similar issues have arisen trying to translate it to other languages, including Turkish. Ultimately the diagnosis was handicapped by the issues of translation, leading to criticism of “the impoverishment of psychiatric vocabulary” that led to declining research and use.

In the early 20th century, Aschaffenburg distanced himself from accusations that the diagnosis was intended to protect criminals from punishment, emphasizing instead that those with Haltlose personality disorder “generally cannot be exculpated”.

Dr. Friedrich Stumpfl cautioned against what he saw as a trend of diagnosing haltlose personality disorder without investigating comorbidities that may be even more pronounced. In condemning the idea of personality disorders generally, Joachim-Ernst Meyer suggested in 1976 that Schneider’s early description of the Haltlose personality disorder, as a lack of determination in aspects of life including parenting, could just as easily be described as an example of a neurosis rather than a psychopathy if studied only by its aetiology rather than its symptoms, and used it as an example of the nature versus nurture debate that surrounded all personality disorders. Critics ceded that the term “Haltlose” remained of value in educational and therapeutic contexts, while suggesting future collaboration between psychiatric research and sociologists would allow further definition.

Recently, it has been criticised as a “diagnosis of convenience [that] avoids all further deliberations about a psychopathic personality”. Dr. DM Svrakic and Dr. M Divac-Jovanovic suggested the ICD-10 explanations of Haltlose, Immature and Psychoneurotic personality disorders appeared “dubious”, and sociologist James Cosgrave found psychiatric use to represent a “fringe figure”. A graduate student at Bochumer Stadt & Studierendenzeitung condemned the historical diagnosis from an LGBT perspective, opining that “incredibly oppressive language” had been used by the psychiatrists studying it such as “pathological femininity”.

It may be that the evolution of test-batteries have minimised diagnoses of Haltlosen, differentiating it from some newer models in psychiatry.

Physiology

Described as bearing a “pronounced heredity burden”, the propensity for Haltlose has also been suggested to be passed only through the maternal genes. Only able to offer “primitive reactions” and “poor and immature judgement”, they are noted to display an absolute lack of purpose in their lives “except for the simple biological need to continue living”.

Gustav von Bergmann, a specialist in internal medicine rather than psychiatry, wrote in 1936 that Haltlose personality disorder was entirely biological rather than fostered through psychological experiences. Indeed, Dr. Hans Luxenburger proposed in 1939 that a toxin in the metabolism, when present with Haltlose personality disorder, might be responsible for asthenic difficulties such as shortness of breath, nausea, and cluster headaches. Dr. E.H. Hughes noted that two-thirds of Huntington’s disease patients had previously been diagnosed as Haltlose or Gemütlose psychopaths.

A study in 1949 of different psychopathies under examination by electroencephalography recordings showed that borderline personalities and haltlose personalities had increased levels of dysrhythmia, whereas other subtypes of psychopathy did not show variation. An individual in 1931 was noted as having initially improved but relapsed “because of encephalitis”. As with other personality disorders, a 1923 article suggests it can also be acquired through encephalitis. In 2006, an Essex warehouse employee who suffered head injuries was awarded £3 million compensation on the basis it had caused him to develop Haltlose personality disorder, seeking out prostitutes and pornography which destroyed his marriage.

Mistakes cannot be fully avoided when placing children under care. even an experienced specialist often cannot distinguish between a blossoming hebephrenia and a Gemutlose or Haltlose personality disorder. Even with weeks of institutional observation, the certainty of our diagnostic aids can remain doubtful…under certain circumstances a doctor will advise medical care even at the risk of learning the patient cannot improve as a result of mental illness and will end up in a madhouse. Kurt Schneider.

Dr. W. Blankenburg posited in 1968 that those with haltlose personality disorder exhibited less categorical orientation than those patients who were simply unstable. By 1962, lobotomy was being tested as a possible means to limit the chaotic thinking of the Haltlose personality.

Kraepelin, in noting “an increased risk of criminal behavior”, estimated that 64% of men and 20% of women with Haltlose descended into alcoholism in the early twentieth century. The frequent intersection between HLPD and alcoholism means modern clinical researchers may use “haltlose” as a grouping when separating subjects by disposition. Research in 1915 noted an increased propensity for lavish spending, and overconsumption of coffee, tea and medication.

One 1954 study suggested female Haltlose patients may experience “manic excitement” during their menses. According to 1949 research, they have a higher rate of homosexuality, and 1939 evidence suggested that masturbation is more prevalent in Haltlose and Gemütlose (compassionless) psychopaths than in other disorders, and Haltlose erethics leave them “usually very sexually excited” and seeking out “atypical, irregular and unusual” debauchery whether in brothels, adultery or destroying marriages.

They demonstrate similarities to hysteroid dysphoria. In 1928, it was proposed that Fantasy prone personality was likely a subset of Haltlose personalities, suffering from maladaptive daydreaming and Absorption.

The eugenicist Verners Kraulis of the University of Latvia noted it was frequently comorbid with Histrionic personality disorder.

Symptoms

According to 1968 research, haltlose personality disorder is frequently comorbid with other mental health diagnoses, and rarely appears isolated on its own. Hans Heinze focused on his belief that Haltlose ultimately stemmed from a sense of inferiority, while Kramer held there was a battling inferiority complex and superiority complex.

The Haltlose were said to have a dynamic instinctual drive to “cling” to others, to avoid a horrible loneliness they fear – but they will always represent a “lurking danger” because they were unable to actually maintain the necessary relationship and were in a class with the “forever abandoned”. According to 1926 research, they view all interaction as a means of winning “indulgence from some people, help from other people”.

One early study indicated that 7.5% of psychopaths were Haltlose, and Kraepelin estimated that his own practice determined fewer than 20% of psychopaths he saw were Haltlose. However more recent studies, after differentiating out newer diagnoses, have suggested that it may be fewer than 1% of psychopaths who are truly Haltlose.

Described in 1922 as both “moody” and “passive”, they quickly switch from over-confidence in victory to sullen defiance.

Their emotional lability means they alternate between projecting an optimistic and competent image claiming they are “destined to do great things”, and a more honest cynicism and depression. Research in 1925 indicates they display “great emotional irritability, which may result in violent loss of temper…and interpret every limitation as an undeserved insult” and have a “pronounced lust for argument”. The symptoms are considered to worsen if patients are granted greater independence “in the home and in their work”.

Their self schema only encompasses the immediate present. They are described as “living in a random location and moment”. A common pitfall in therapy is that they proved in 1917 to be “very superficial, they easily acquire knowledge but do not apply it in any way and soon forget it”.

The essence of these people…playthings of external influences, allowing themselves to be carried away by events like a leaf in the wind! …Impermanence is everything. In one hour, they are happy and excited with the whole world lying open for them in the splendor of the joy of life, but the next hour casts aside this optimism and the future now seems bleak, gray on gray…sympathies and antipathies quickly replace each other, what was worshipped yesterday is burned today, and despite all oaths of eternal loyalty, the best friend is transformed into the deeply-loathed enemy overnight.” Dr. L. Scholz, Anomale Kinder, Berlin, 1919.

Those with HLPD display “a number of endearing qualities, charming with an apparent emotional warmth, but also an enhanced suggestibility and a superficiality of affect”, which can lead to unrealistic optimism. and “wandering through life without ever taking firm root”. They are also noted as “absolutely indifferent to others…likes to live for [their] pleasure today, does not make plans not only for the future but even for tomorrow, studying and working are not for them”. Persons with HLPD typically lack any deep knowledge, and “look for easy life and pleasures”. They have been described as “conquerers with an appearance of emotional warmth”.

Persons with HLPD were noted as struggling with hypochondria in 1907. They also struggle with alcoholism, and identify with antisocial personality disorder.

Kraepelin said they were “apt to take senseless journeys, perhaps even becoming vagabonds”. Kraepelin argued only lifelong wanderlust was tied to Haltlose, whereas Kahn argued that the Haltlose often lost their wanderlust as they aged and preferred to settle into mediocrity. Some make their fortune, but the disappearance of less fortunate travelers is not mentioned by their families who considered them to have been burdensome.

To early twentieth-century researchers, they appeared amiable, well-spoken, self-confident and to be making strong efforts to improve their weaknesses, thus making a misleading first impression and endearing themselves to superiors. The lack of a sense of identity, or internal support, was thought to a lack of resistance to both external and internal impulses in 1927. Their “gradual deterioration in the swamp of neediness and immorality” still does not make a lasting impression on the patients. Thus Haltlose patients who recognize their shortcomings were thought to possibly be overwhelmed by a subconscious fear about participating in the world without restraints in a 1924 account. Similarly, researchers in the early twentieth-century believed that the inauthenticity of their projected self and superficiality of knowledge means that when “someone who is really superior to [them]”, after a period of stiffly asserting themselves hoping to avoid submission, will ultimately and without explanation fully embrace the position of the other.

Pathological lying is closely linked to Haltlose personality disorder, with Arthur Kielholz noting “They lie like children…this activity always remains just a game which never satisfies them and leaves them with a guilty conscious because neither the super ego nor the Id get their due…Since they are offering such a daydream as a gift, they consider themselves entitled to extract some symbolic gift in return through fraud or theft”. Adler maintained “Memory is usually poor and untrustworthy…often they seem to have no realization of the truth”, while Homburger felt they held “no sense of objectivity, no need for truth or consistency”.

According to early accounts, choices are made, often in mirroring others around them, but “do not leave even a passing imprint on the person’s identity”. Thus, they can “behave properly for a while under good leadership”, and are not to be trusted in leadership positions themselves. Gannushkin noted they must be urged, scolded or encouraged “with a stick, as they say”. They demonstrate poor mood control and “react quickly to immediate circumstances” since “mood variation can be extreme and fluctuate wildly”, which led to the denotation “unstable psychopath”.

They have been described as “cold-blooded”, but must be differentiated from dependent personality disorder, as the two can appear similar, due to the artifice of the Haltlose patient, despite having starkly opposing foundations. Persons with Dependent Personality Disorder are defined by a tendency to embarrassment, and submissiveness which are not genuine facets of those with Haltlose even if they mimic such. Haltlose was thus deemed the “more troublesome” personality in 1955.

Childhood Origins, and Later Role of Family

“Whomever is abandoned in youth to the inexorable misery of existence, and at the same time is exposed to all manner of seductions, will find it very difficult to curb their constantly incited desires, and to instead force themselves through to the lofty vantage of moral self-assertion. Kraepelin speaking about the Haltlose, 1915.

It has been proposed that haltlose personality disorder may arise from “traumatization through maternal indolence” or institutionalisation in early life, although without definite conclusion. It may present in childhood simply as a hypomanic reaction to the loss of a parent or incest object. They often display a fear of abandonment that appeared in childhood, a common borderline personality disorder symptom. Male Haltlose personalities may come out of families with a pampering, over-protective and domineering mother with a weak father. Homburger noted the “childhood and youth of the Haltlose are extraordinarily sad”. It is possible, but rare, for Haltlose personalities to develop within healthy family structures.

Gerhardt Nissen referenced the possibility of intrauterine factors in the shaping of anti-social behaviours in Haltlose psychopaths, while noting the concept of psychopathy had been so weakened in modern psychopathology as to be indistinguishable from other conditions. Others have suggested there is a strong heredity correlation, as the parents often also display Haltlose personality disorder, especially the mother. Raising a haltlose child can, in some cases, destroy the family structure by forcing relatives to take opposing positions, provoking disagreement and creating an atmosphere of bitterness and dejection. They have been clinically described as disappointments to their families, and are unable to feel actual love for their parents and are indifferent to the hardships of relatives – since all relationships are seen only as potential means towards acquiring pleasure.

Care must be taken in making Haltlose diagnoses of children, since “the traits of instability of purpose, lack of forethought, suggestibility, egoism and superficiality of affect…are to some extent normal in childhood”. Children with haltlose personality disorder demonstrate a marked milieu dependency, which may be a cause rather than effect of the Haltlose. It is of great importance that only children with Haltlose have peers and friends to surround themselves to try and learn associations and behaviours. They often become sexually active at a young age but delayed sexual maturity, and as adults retain a psychophysical infantilism. Regressive addictions amongst Haltlose psychopaths typically are infantile, and seek to replace the lost “dual union” arising from their parents’ rejection, and later morph into a focus on subjects including vengeance or sado-masochism.

The Russian storybook character Dunno has been noted as an example of a child with Haltlose personality disorder.

The age at which parents or professionals exhibited concern about psychopathy ranged; rarely even at a preschool age. Haltlose children confusingly tend to appear very strong-willed and ambitious, it is only as they age and the lack of perseverance becomes manifest that caretakers become puzzled by their “naughtiness” as it contradicts what had earlier appeared. This arises principally due to their rigid demands for short-term wishes being mistakenly interpreted as having a fixed purpose and persistence. Some patients later shown to be Haltlose, had shown neuropathic traits in childhood such as bedwetting and stuttering. They were also more likely to run away from their home, begin drinking before the socially acceptable age, and were afraid of punishment. Although struggling to make friends in young childhood, they find it easier as they age.

Kraepelin contended the disorder was “based on a biological predisposition” but also affected by factors such as childrearing practises, social position and state of the parental home. His analysis showed that 49% of diagnosed Haltlose had obvious parental issues such as alcoholism or personality disorders. A 1944 study of children produced by incest by Dr. Alfred Aschenbrenner found a high rate of Haltlose personality disorder, which he suggested might be explained as inherited from overly suggestive mothers. It is possible, although difficult, to diagnose from the age of five and presents one of the stronger psychiatric difficulties if present at such young age. It may be possible to prevent social failure “through welfare measures” akin to early intervention. Italian courts stressed mimicry of positive role models as a means to combat Haltlose youth who had fallen afoul of the law.

Schooling

Haltlose can cause educational difficulties, and if parents do not understand the peculiarities of their haltlose child, they may try to through good intentions to force the child into an educational regimen inappropriate for them, which then creates a feeling of isolation in the child which grows into a rebellious tendencies, “which turns out to be disastrous for further development”. Students with Haltlose personalities may prefer the arts over the sciences, since the former does not require a consistent sense of truth and entails less disciplined study. Given their inability to anchor a self-schema and tendency to play-act roles, the theatre and film have great attraction and influence over them.

With proper leadership and controls from teachers, they are able to become “model pupils” in terms of behaviour, although Schneider opined that it was worthless to educate an inability to learn from mistakes prevented actual education, and bemoaned that the late onset of anti-social behaviours kept the Haltlose in school when they might otherwise be removed. Walter Moos believed that Haltlose personality disorder and hyperthymia had shown itself to be contagious in rare cases, wherein classmates developed the same disorder from interaction with patients. Homburger argued for removing a Haltlose child from their family of origin as soon as the disorder was confirmed, to resettle in a rural educational centre.

Adolescence, Young Adulthood and Efforts to Intervene

When required to live independently, they “soon lose interest, become distracted and absent-minded, and commit gross errors and negligence”. Ruth von der Leyen noted that “every care provider, teacher and doctor knows the Haltlose Psychopath from their practice”, and remarked that caring for such a patient was made more difficult because of the need to lecture and intervene to enlist the psychopath’s cooperation in short-term improvements, despite being aware the psychiatric reports have determined such efforts are ultimately useless but should be practised regardless.

The tendency to accumulate debts while seeking pleasure or escaping responsibility is often the attributed cause for their descent into crime, although Kramer noted those who displayed “extreme dexterity, sufficient talent for imagination, and a tendency towards dishonesty” were able to find alternative sources of income without necessarily becoming criminal, although warned that “again and again, their debts have to be paid until the parents no longer can, or want to, do this and leave them to their selves”.

Gannushkin noted “Such people involuntarily evoke sympathy and a desire to help them, but the assistance rendered to them rarely lasts, so it is worth abandoning such people for a short while”. The wasted good intentions resulted in the summary:

“probably the most important function of the psychiatrist when dealing with these patients is to protect their relatives and friends from ruining themselves in hopeless attempts at reclamation. With most of these patients a time comes when the relatives will be best advised…to allow the patient to go to prison, or otherwise suffer unsheltered the consequences of his deeds.”

By contrast, others have advanced the “rather optimistic” belief that “a suitable [spouse]” or similar “strong-willed” relative could drastically improve the outcome of Haltlosen patients. This was echoed by Andrey Yevgenyevich Lichko who, while preferring the term “accentuation of character” to describe the psychopathy rather than “personality disorder”, noted “if they fall into the hands of a person with a strong will, for example a wife or husband, they can they live quite happily…but the guardianship must be permanent.”

Criminology

While some Haltlose have risen to the level of dangerous offenders multiple times over, it is more frequent that they attract attention early from their “vagabond” nature.

Heinrich Schulte, a wartime medical judge and consulting psychiatrist for the military, continued advocating for the sterilization of Haltlose and other “Schwachsinnigen” after the war’s end. In 1979, the Neue Anthropologie publication referred to a need to sterilize those like alcoholics, “who are often Haltlose psychopaths”, from bearing children, to reduce crime.

Although Kraepelin believed those with Haltlose personality disorder represented the antithesis of morality, there is not necessarily a tendency towards deliberate amorality among the demographic despite its frequent criminal violations since they may lack the ability to premeditate. But their demonstrated lack of self-control is “especially manifested in the sphere of morality”.

In 1935, it was estimated that 58% of recidivist criminals were diagnosed with Haltlose personality disorder, higher than any other personality disorder. More recently, Haltlose and Histrionic were the most common personality disorders found in female juvenile delinquents by forensic psychologists in Russia in the year 2000.

Domestic Violence, Incest and Molestation of Children

[Patients resembling Haltlose] as a rule show little insight into the peculiarities of their conduct. They do not understand how they could have done these things, or they blame their relatives, neighbors and so forth”. Dr. Herman Morris Adler, 1917.

Although they enter relationships easily, Andrey Yevgenyevich Lichko contends they are not capable of actual loyalty or selfless love, and sex is treated as a form of entertainment rather than intimacy. They are therefore described as acting as “family tyrants”.

Although they may not qualify as “true” pedophiles, Haltlose personalities demonstrate an increased risk of sexually molesting children, since other potential victims would require the realisation of greater planning, but children are suggestible and easily overwhelmed.

A 1967 German study had suggested over 90% of adult-child incest offenders were diagnosed with Haltlose Personality Disorder. Female patients may also live vicariously through encouraging and directing the sexual lives of their daughters.

Drunk Driving, Hit-and-Run

Some Haltlose personalities are drawn towards dangerous driving habits “as a source of almost hedonist pleasure”. In 1949 the Automobil Revue proposed that additional tests should be necessary for Haltlose personalities to obtain a driver’s license. They have been known to steal cars to joyride at high speeds if they are not otherwise able to find satisfy their urge.

The American Journal of Psychiatry published a study of hit and run drivers in 1941, which showed 40% of drivers who fled the scene of a traffic accident tested positive for haltlose personality disorder. This was consistent with the earlier finding that Haltlose Personalities were among the most likely to attempt to flee if caught in commission of any crime.

Suicidality and Murder-Suicide

Research in the early twentieth century on suicidality among the Haltlose indicated several things: they chafe at the notion of any religion as it introduces unwanted inhibitions, especially against parasuicidal demonstrations; women Haltlose most frequently indicated suicidality was based upon fear of punishment or reproach, as well as the “excitement” of being institutionalised; and although frequently planning or attempting suicide, including through suicide pacts or murder suicide, Haltlose typically do not succeed since they lacked courage and were easily distracted.

Institutionalisation

Haltlose patients respond very well to institutionalization where their influences can be controlled, becoming “model inmates” of sanitariums even within hours of first arriving despite a chaotic life outside of the regimen, “but if you leave them, through good intentions, to their own devices – they don’t last long before collapsing their current state and being seduced back onto the wrong track”. Schneider recommended warning them “through punishing them” as it was the only control on their action. Bleuler said the court system needed to understand such persons were in “urgent need of inhibitions”.

Pyotr Gannushkin noted they joined military service due to peer pressure but given the lack of alcohol and stern, hard work required of them were able to function without their normal impairment. A 1942 study of the Wehrmacht found that only Haltlose and Schizoid were not measurable among soldiers despite their presence in the civilian population. A 1976 Soviet naval study came to similar conclusions.

Roth and Slater concluded “the treatment of such a personality is almost hopeless under the present ordering of society. Any treatment would…present difficulties…beyond the powers of these patients. The prospects of psychotherapy are forlorn and the best that can be obtained will be reached through social control.”

Some researchers suggest their moods and insufficient motivation will lead them to “vague feelings of fear and calamity…turning every little thing into big things, excitement, misinterpreting every harmless word, criticizing everything and commiting hostile acts”, and in some cases they look back with hindsight and regret the injustices they did. However Kramer held that when caught in wrongdoing, “we find them contrite, self-accusing and assuring that they will improve – but on closer inspection it is feigned and not sincere”.

Upon being confronted with their misdeeds, the Haltlose respond “with more or less superficial reasons to excuse them, they claim that their parents treated them incorrectly, that they were the victim of adverse circumstances, seduced by other people and misled. Other Haltlose, especially those with a strong intellect, make up a theoretical schema that would justify their actions.”

Examples

  • Kielholz, Arthur, Internationale Zeitschrift für Psychoanalyse XIX 1933 Heft 4, “Weh’dem der lugt! Beitrag zum problem der pseudologia phantastica”, an article on pathological lying in the Haltlose patients Max Specke, a Swiss charlatan with a penchant for melodramatic flair and Emil Schuldling, a habitual criminal with childhood sexual perversions
  • Story of Robert Wenger, who was diagnosed Haltlose and spent 54 years between institutions and prison for minor crimes until the documentary series Quer exposed his case, leading to an apology from politician Samuel Bhend in 1999.
  • Karl Hager, a habitual criminal diagnosed Haltlose who was frequently jailed for homosexual acts and was ultimately killed in Sachsenhausen concentration camp (in German)
  • Biography of a man diagnosed Haltlose in 1936 (in German)
  • Berlit, Berthold (December 1931). “Erblichkeitsuntersuchungen bei Psychopathen”. Zeitschrift für die gesamte Neurologie und Psychiatrie. 134(1), pp.382-498.
  • Article referencing Hermann Lederman, discharged from the Wehrmacht in 1940 having been diagnosed with Haltlose personality disorder and sent to Wehrmachtgefängnis Torgau
  • Article about Karl Sieger, a chronic drunkard diagnosed with Haltlose personality disorder in 1936 by Dr. Ferdinand Rechberg of Konstanz
  • Thomas Leveritt’s novel “The Exchange-Rate Between Love and Money” contains a character, Frito, who has Haltlose personality disorder.

What is Hysteroid Dysphoria?

Introduction

Hysteroid dysphoria is a name given to repeated episodes of depressed mood in response to feeling rejected. It bears similarities to Haltlose personality disorder from which it must be distinguished.

Hysteroid dysphoria has been described in outpatient populations and is thought to be a subtype of atypical depression involving rejection sensitivity (see below) and therapeutic response to monoamine oxidase inhibitors (MAOIs).

While some research shows that hysteroid dysphoria responds well to MAOIs, other research has suggested that the difference actually comes from the condition being less sensitive to tricyclic antidepressants.

Other studies have examined the symptoms associated with hysteroid dysphoria and found that while the symptoms are observable, they are not unique or distinct enough to be considered their own condition.

Rejection Sensitivity

Karen Horney was the first theorist to discuss the phenomenon of rejection sensitivity. She suggested that it is a component of the neurotic personality, and that it is a tendency to feel deep anxiety and humiliation at the slightest rebuff. Simply being made to wait, for example, could be viewed as a rejection and met with extreme anger and hostility.

What is Depressive Personality Disorder?

Introduction

Depressive personality disorder (also known as melancholic personality disorder) is a psychiatric diagnosis that denotes a personality disorder with depressive features.

Originally included in the American Psychiatric Association’s DSM-II, depressive personality disorder was removed from the DSM-III and DSM-III-R. Recently, it has been reconsidered for reinstatement as a diagnosis. Depressive personality disorder is currently described in Appendix B in the DSM-IV-TR as worthy of further study. Although no longer listed as a personality disorder, the diagnosis is included under the section “personality disorder not otherwise specified”.

While depressive personality disorder shares some similarities with mood disorders such as dysthymia, it also shares many similarities with personality disorders including avoidant personality disorder. Some researchers argue that depressive personality disorder is sufficiently distinct from these other conditions so as to warrant a separate diagnosis.

Characteristics

The DSM-IV defines depressive personality disorder as “a pervasive pattern of depressive cognitions and behaviours beginning by early adulthood and occurring in a variety of contexts.” Depressive personality disorder occurs before, during, and after major depressive episodes (MDE), making it a distinct diagnosis not included in the definition of either MDE or dysthymic disorder. Specifically, five or more of the following must be present most days for at least two years in order for a diagnosis of depressive personality disorder to be made:

  • Usual mood is dominated by dejection, gloominess, cheerlessness, joylessness and unhappiness.
  • Self-concept centres on beliefs of inadequacy, worthlessness and low self-esteem.
  • Is critical, blaming and derogatory towards the self.
  • Is brooding and given to worry.
  • Is negativistic, critical and judgmental toward others.
  • Is pessimistic.
  • Is prone to feeling guilty or remorseful.

People with depressive personality disorder have a generally gloomy outlook on life, themselves, the past and the future. They are plagued by issues developing and maintaining relationships. In addition, studies have found that people with depressive personality disorder are more likely to seek psychotherapy than people with Axis I depression spectra diagnoses.

Recent studies have concluded that people with depressive personality disorder are at a greater risk of developing dysthymic disorder than a comparable group of people without depressive personality disorder. These findings lead to the fact that depressive personality disorder is a potential precursor to dysthymia or other depression spectrum diagnoses. If included in the DSM-V, depressive personality disorder would be included as a warning sign for potential development of more severe depressive episodes.

Millon’s Subtypes

Theodore Millon identified five subtypes of depression. Any individual depressive may exhibit none, or one or more of the following:

SubtypeDescriptionPersonality Traits
Ill-Humoured DepressiveIncluding negativistic features1. Patients in this subtype are often hypochondriacal, cantankerous and irritable, and guilt-ridden and self-condemning.
2. In general, ill-humoured depressives are down on themselves and think the worst of everything.
Voguish DepressiveIncluding histrionic and narcissistic features1. Voguish depressives see unhappiness as a popular and stylish mode of social disenchantment, personal depression as self-glorifying, and suffering as ennobling.
2. The attention from friends, family, and doctors is seen as a positive aspect of the voguish depressive’s condition.
Self-Derogating DepressiveIncluding dependent features1. Patients who fall under this subtype are self-deriding, discrediting, odious, dishonourable, and disparage themselves for weaknesses and shortcomings.
2. These patients blame themselves for not being good enough.
Morbid DepressiveIncluding schizoid and masochistic features1. Morbid depressives experience profound dejection and gloom, are highly lugubrious, and often feel drained and oppressed.
Restive DepressiveIncluding borderline and avoidant features1. Patients who fall under this subtype are consistently unsettled, agitated, wrought in despair, and perturbed.
2. This is the subtype most likely to commit suicide in order to avoid all the despair in life.

Not all patients with a depressive disorder fall into a subtype. These subtypes are multidimensional in that patients usually experience multiple subtypes, instead of being limited to fitting into one subtype category. Currently, this set of subtypes is associated with melancholic personality disorders. All depression spectrum personality disorders are melancholic and can be looked at in terms of these subtypes.

DSM-5

Similarities to Dysthymic Disorder

Much of the controversy surrounding the potential inclusion of depressive personality disorder in the DSM-5 stems from its apparent similarities to dysthymic disorder, a diagnosis already included in the DSM-IV. Dysthymic disorder is characterised by a variety of depressive symptoms, such as hypersomnia or fatigue, low self-esteem, poor appetite, or difficulty making decisions, for over two years, with symptoms never numerous or severe enough to qualify as major depressive disorder. Patients with dysthymic disorder may experience social withdrawal, pessimism, and feelings of inadequacy at higher rates than other depression spectrum patients. Early-onset dysthymia is the diagnosis most closely related to depressive personality disorder.

The key difference between dysthymic disorder and depressive personality disorder is the focus of the symptoms used to diagnose. Dysthymic disorder is diagnosed by looking at the somatic senses, the more tangible senses. Depressive personality disorder is diagnosed by looking at the cognitive and intrapsychic symptoms. The symptoms of dysthymic disorder and depressive personality disorder may look similar at first glance, but the way these symptoms are considered distinguish the two diagnoses.

Comorbidity with other Disorders

Many researchers believe that depressive personality disorder is so highly comorbid with other depressive disorders, manic-depressive episodes and dysthymic disorder, that it is redundant to include it as a distinct diagnosis. Recent studies however, have found that dysthymic disorder and depressive personality disorder are not as comorbid as previously thought. It was found that almost two thirds of the test subjects with depressive personality disorder did not have dysthymic disorder, and 83% did not have early-onset dysthymia.

The comorbidity with Axis I depressive disorders is not as high as had been assumed. An experiment conducted by American psychologists showed that depressive personality disorder shows a high comorbidity rate with major depression experienced at some point in a lifetime and with any mood disorders experienced at any point in a lifetime. A high comorbidity rate with these disorders is expected of many diagnoses. As for the extremely high comorbidity rate with mood disorders, it has been found that essentially all mood disorders are comorbid with at least one other, especially when looking at a lifetime sample size.

What is Bipolar Disorder Not Otherwise Specified?

Introduction

Bipolar disorder not otherwise specified (BD-NOS) is a diagnosis for bipolar disorder (BD) when it does not fall within the other established sub-types.

Bipolar disorder NOS is sometimes referred to as subthreshold bipolar disorder.

Classification

BD-NOS is a mood disorder and one of three subtypes on the bipolar spectrum, which also includes bipolar I disorder and bipolar II disorder. BD-NOS was a classification in the DSM-IV and has since been changed to Bipolar “Other Specified” and “Unspecified” in the 2013 released DSM-5.

Diagnosis

Bipolar disorder is difficult to diagnose. If a person displays some symptoms of bipolar disorder but not others, the clinician may diagnose bipolar NOS. The diagnosis of bipolar NOS is indicated when there is a rapid change (days) between manic and depressive symptoms and can also include recurring episodes of hypomania. Bipolar NOS may be diagnosed when it is difficult to tell whether bipolar is the primary disorder due to another general medical condition, such as a substance use disorder.

Treatment

Individual approaches to treatment are recommended, usually involving a combination of mood stabilisers and atypical antipsychotics. Psychotherapy may be beneficial and should be started early.

Epidemiology

The prevalence of BD-NOS is approximately 1.4%.

What is an Eating Disorder?

Introduction

An eating disorder is a mental disorder defined by abnormal eating habits that negatively affect a person’s physical and/or mental health.

Types of eating disorders include binge eating disorder, where people eat a large amount in a short period of time; anorexia nervosa, where people have an intense fear of gaining weight and restrict food or over-exercise to manage this fear; bulimia nervosa, where people eat a lot and then try to rid themselves of the food; pica, where people eat non-food items; rumination syndrome, where people regurgitate food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons (see below); and a group of other specified feeding or eating disorders. Anxiety disorders, depression and substance abuse are common among people with eating disorders. These disorders do not include obesity.

The causes of eating disorders are not clear, although both biological and environmental factors appear to play a role. Eating disorders affect about 12% of dancers. Cultural idealisation of thinness is believed to contribute to some eating disorders. Individuals who have experienced sexual abuse are also more likely to develop eating disorders. Some disorders such as pica and rumination disorder occur more often in people with intellectual disabilities. Only one eating disorder can be diagnosed at a given time.

Treatment can be effective for many eating disorders. Treatment varies by disorder and may involve counselling, dietary advice, reducing excessive exercise and the reduction of efforts to eliminate food. Medications may be used to help with some of the associated symptoms. Hospitalisation may be needed in more serious cases. About 70% of people with anorexia and 50% of people with bulimia recover within five years. Recovery from binge eating disorder is less clear and estimated at 20% to 60%. Both anorexia and bulimia increase the risk of death.

In the developed world, anorexia affects about 0.4% and bulimia affects about 1.3% of young women in a given year. Binge eating disorder affects about 1.6% of women and 0.8% of men in a given year. Among women about 4% have anorexia, 2% have bulimia, and 2% have binge eating disorder at some time in their life. Rates of eating disorders appear to be lower in less developed countries. Anorexia and bulimia occur nearly ten times more often in females than males. Eating disorders typically begin in late childhood or early adulthood. Rates of other eating disorders are not clear.

Classification

ICD and DSM Diagnoses

These eating disorders are specified as mental disorders in standard medical manuals, including the ICD-10 and the DSM-5.

  • Anorexia Nervosa (AN):
    • This is the restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
    • It is accompanied by an intense fear of gaining weight or becoming fat, as well as a disturbance in the way one experiences and appraises their body weight or shape.
    • There are two subtypes of AN:
      • The restricting type; and
      • The binge-eating/purging type.
    • The restricting type describes presentations in which weight loss is attained through dieting, fasting, and/or excessive exercise, with an absence of binge/purge behaviours.
    • The binge-eating/purging type describes presentations in which the individual suffering has engaged in recurrent episodes of binge-eating and purging behaviour, such as self-induced vomiting, misuse of laxatives, and diuretics.
    • Severity of AN is determined by BMI, with BMIs below 15 noted as the most extreme cases of the disorder.
    • Pubertal and post-pubertal females with anorexia often experience amenorrhea, or the loss of menstrual periods, due to the extreme weight loss these individuals face.
    • Although amenorrhea was a required criterion for a diagnosis of anorexia in the DSM-IV, it was dropped in the DSM-5 due to its exclusive nature, as male, post-menopause women, or individuals who do not menstruate for other reasons would fail to meet this criterion.
    • Females with bulimia may also experience amenorrhea, although the cause is not clear.
  • Bulimia Nervosa (BN):
    • This is characterised by recurrent binge eating followed by compensatory behaviours such as purging (self-induced vomiting, eating to the point of vomiting, excessive use of laxatives/diuretics, or excessive exercise).
    • Fasting may also be used as a method of purging following a binge.
    • However, unlike anorexia nervosa, body weight is maintained at or above a minimally normal level.
    • Severity of BN is determined by the number of episodes of inappropriate compensatory behaviours per week.
  • Binge Eating Disorder (BED):
    • This is characterised by recurrent episodes of binge eating without use of inappropriate compensatory behaviours that are present in BN and AN binge-eating/purging subtype.
    • Binge eating episodes are associated with eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, and/or feeling disgusted with oneself, depressed or very guilty after eating.
    • For a BED diagnosis to be given, marked distress regarding binge eating must be present, and the binge eating must occur an average of once a week for 3 months.
    • Severity of BED is determined by the number of binge eating episodes per week.
  • Pica:
    • This is the persistent eating of non-nutritive, non-food substances in a way that is not developmentally appropriate or culturally supported.
    • Although substances consumed vary with age and availability, paper, soap, hair, chalk, paint, and clay are among the most commonly consumed in those with a pica diagnosis.
    • There are multiple causes for the onset of pica, including iron-deficiency anaemia, malnutrition, and pregnancy, and pica often occurs in tandem with other mental health disorders associated with impaired function, such as intellectual disability, autism spectrum disorder, and schizophrenia.
    • In order for a diagnosis of pica to be warranted, behaviours must last for at least one month.
  • Rumination Disorder:
    • This encompasses the repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out.
    • For this diagnosis to be warranted, behaviours must persist for at least one month, and regurgitation of food cannot be attributed to another medical condition.
    • Additionally, rumination disorder is distinct from AN, BN, BED, and ARFID, and thus cannot occur during the course of one of these illnesses.
  • Avoidant/Restrictive Food Intake Disorder (ARFID):
    • This is a feeding or eating disturbance, such as a lack of interest in eating food, avoidance based on sensory characteristics of food, or concern about aversive consequences of eating, that prevents one from meeting nutritional energy needs.
    • It is frequently associated with weight loss, nutritional deficiency, or failure to meet growth trajectories.
    • Notably, ARFID is distinguishable from AN and BN in that there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
    • The disorder is not better explained by lack of available food, cultural practices, a concurrent medical condition, or another mental disorder.
  • Other Specified Feeding or Eating Disorder (OSFED):
    • This is an eating or feeding disorder that does not meet full DSM-5 criteria for AN, BN, or BED.
    • Examples of otherwise-specified eating disorders include individuals with atypical anorexia nervosa, who meet all criteria for AN except being underweight despite substantial weight loss; atypical bulimia nervosa, who meet all criteria for BN except that bulimic behaviours are less frequent or have not been ongoing for long enough; purging disorder; and night eating syndrome.
  • Unspecified Feeding or Eating Disorder (USFED):
    • This describes feeding or eating disturbances that cause marked distress and impairment in important areas of functioning but that do not meet the full criteria for any of the other diagnoses.
    • The specific reason the presentation does not meet criteria for a specified disorder is not given.
    • For example, an USFED diagnosis may be given when there is insufficient information to make a more specific diagnosis, such as in an emergency room setting.

Other

  • Compulsive Overeating:
    • This may include habitual “grazing” of food or episodes of binge eating without feelings of guilt.
  • Diabulimia:
    • This is characterised by the deliberate manipulation of insulin levels by diabetics in an effort to control their weight.
  • Drunkorexia:
    • This is commonly characterised by purposely restricting food intake in order to reserve food calories for alcoholic calories, exercising excessively in order to burn calories from drinking, and over-drinking alcohol in order to purge previously consumed food.
  • Food Maintenance:
    • This is characterised by a set of aberrant eating behaviours of children in foster care.
  • Night Eating Syndrome:
    • This is characterised by nocturnal hyperphagia (consumption of 25% or more of the total daily calories after the evening meal) with nocturnal ingestions, insomnia, loss of morning appetite and depression.
  • Nocturnal Sleep-Related Eating Disorder:
    • This is a parasomnia characterised by eating, habitually out-of-control, while in a state of NREM sleep, with no memory of this the next morning.
  • Gourmand Syndrome:
    • This is a rare condition occurring after damage to the frontal lobe.
    • Individuals develop an obsessive focus on fine foods.
  • Orthorexia Nervosa:
    • This is a term used to describe an obsession with a “pure” diet, in which a person develops an obsession with avoiding unhealthy foods to the point where it interferes with the person’s life.
  • Klüver-Bucy Syndrome:
    • This is caused by bilateral lesions of the medial temporal lobe and includes compulsive eating, hypersexuality, hyperorality, visual agnosia, and docility.
  • Prader-Willi Syndrome:
    • This is a genetic disorder associated with insatiable appetite and morbid obesity.
  • Pregorexia:
    • This is characterised by extreme dieting and over-exercising in order to control pregnancy weight gain. Prenatal undernutrition is associated with low birth weight, coronary heart disease, type 2 diabetes, stroke, hypertension, cardiovascular disease risk, and depression.
  • Muscle Dysmorphia:
    • This is characterised by appearance preoccupation that one’s own body is too small, too skinny, insufficiently muscular, or insufficiently lean.
    • Muscle dysmorphia affects mostly males.
  • Purging Disorder:
    • This is recurrent purging behaviour to influence weight or shape in the absence of binge eating.
    • It is more properly a disorder of elimination rather than eating disorder.

Symptoms and Long-Term Effects

Symptoms and complications vary according to the nature and severity of the eating disorder.

Associated physical symptoms of eating disorders include weakness, fatigue, sensitivity to cold, reduced beard growth in men, reduction in waking erections, reduced libido, weight loss and growth failure. Frequent vomiting, which may cause acid reflux or entry of acidic gastric material into the laryngoesophageal tract, can lead to unexplained hoarseness. As such, individuals who induce vomiting as part of their eating disorder, such as those with anorexia nervosa, binge eating-purging type or those with purging-type bulimia nervosa, are at risk for acid reflux.

Possible Complications

  • Acne.
  • Xerosis.
  • Amenorrhoea.
  • Tooth loss.
  • Cavities.
  • Constipation.
  • Diarrhoea.
  • Water retention and/or oedema.
  • Lanugo.
  • Telogen effluvium.
  • Cardiac arrest.
  • Hypokalaemia.
  • Death/suicide.
  • Osteoporosis.
  • Electrolyte imbalance.
  • Hyponatraemia.
  • Brain atrophy.
  • Pellagra.
  • Scurvy.
  • Kidney failure.

Frequent vomiting, which may cause acid reflux or entry of acidic gastric material into the laryngoesophageal tract, can lead to unexplained hoarseness. As such, individuals who induce vomiting as part of their eating disorder, such as those with anorexia nervosa, binge eating-purging type or those with purging-type bulimia nervosa, are at risk for acid reflux.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder to affect women. Though often associated with obesity it can occur in normal weight individuals. PCOS has been associated with binge eating and bulimic behaviour.

Other possible manifestations are dry lips, burning tongue, parotid gland swelling, and temporomandibular disorders.

Pro-Ana Subculture

Pro-ana refers to the promotion of behaviours related to the eating disorder anorexia nervosa. Several websites promote eating disorders, and can provide a means for individuals to communicate in order to maintain eating disorders. Members of these websites typically feel that their eating disorder is the only aspect of a chaotic life that they can control. These websites are often interactive and have discussion boards where individuals can share strategies, ideas, and experiences, such as diet and exercise plans that achieve extremely low weights. A study comparing the personal web-blogs that were pro-eating disorder with those focused on recovery found that the pro-eating disorder blogs contained language reflecting lower cognitive processing, used a more closed-minded writing style, contained less emotional expression and fewer social references, and focused more on eating-related contents than did the recovery blogs.

Psychopathology

The psychopathology of eating disorders centres around body image disturbance, such as concerns with weight and shape; self-worth being too dependent on weight and shape; fear of gaining weight even when underweight; denial of how severe the symptoms are and a distortion in the way the body is experienced.

The main psychopathological features of anorexia were outlined in 1982 as problems in body perception, emotion processing and interpersonal relationships. Women with eating disorders have greater body dissatisfaction. This impairment of body perception involves vision, proprioception, and tactile perception. There is an alteration in integration of signals in which body parts are experienced as dissociated from the body as a whole. Bruch theorised that difficult early relationships were related to the cause of anorexia and how primary caregivers can contribute to the onset of the illness.

A prominent feature of bulimia is dissatisfaction with body shape. However, dissatisfaction with body shape is not of diagnostic significance as it is sometimes present in individuals with no eating disorder. This highly labile feature can fluctuate depending on changes in shape and weight, the degree of control over eating and mood. In contrast, a necessary diagnostic feature for anorexia nervosa and bulimia nervosa is having overvalued ideas about shape and weight are relatively stable and closely related to the patients’ low self-esteem.

Causes

Many people with eating disorders also have body dysmorphic disorder, altering the way a person sees oneself. Studies have found that a high proportion of individuals diagnosed with body dysmorphic disorder also had some type of eating disorder, with 15% of individuals having either anorexia nervosa or bulimia nervosa. This link between body dysmorphic disorder and anorexia stems from the fact that both BDD and anorexia nervosa are characterised by a preoccupation with physical appearance and a distortion of body image. There are also many other possibilities such as environmental, social and interpersonal issues that could promote and sustain these illnesses. Also, the media are oftentimes blamed for the rise in the incidence of eating disorders due to the fact that media images of idealised slim physical shape of people such as models and celebrities motivate or even force people to attempt to achieve slimness themselves. The media are accused of distorting reality, in the sense that people portrayed in the media are either naturally thin and thus unrepresentative of normality or unnaturally thin by forcing their bodies to look like the ideal image by putting excessive pressure on themselves to look a certain way. While past findings have described eating disorders as primarily psychological, environmental, and sociocultural, further studies have uncovered evidence that there is a genetic component.

Genetics

Numerous studies show a genetic predisposition toward eating disorders. Twin studies have found a slight instances of genetic variance when considering the different criterion of both anorexia nervosa and bulimia nervosa as endophenotypes contributing to the disorders as a whole. A genetic link has been found on chromosome 1 in multiple family members of an individual with anorexia nervosa. An individual who is a first degree relative of someone who has had or currently has an eating disorder is seven to twelve times more likely to have an eating disorder themselves. Twin studies also show that at least a portion of the vulnerability to develop eating disorders can be inherited, and there is evidence to show that there is a genetic locus that shows susceptibility for developing anorexia nervosa. About 50% of eating disorder cases are attributable to genetics. Other cases are due to external reasons or developmental problems. There are also other neurobiological factors at play tied to emotional reactivity and impulsivity that could lead to binging and purging behaviours.

Epigenetics mechanisms are means by which environmental effects alter gene expression via methods such as DNA methylation; these are independent of and do not alter the underlying DNA sequence. They are heritable, but also may occur throughout the lifespan, and are potentially reversible. Dysregulation of dopaminergic neurotransmission due to epigenetic mechanisms has been implicated in various eating disorders. Other candidate genes for epigenetic studies in eating disorders include leptin, pro-opiomelanocortin (POMC) and brain-derived neurotrophic factor (BDNF).

Psychological

Eating disorders were classified as Axis I disorders in DSM-IV. There are various other psychological issues that may factor into eating disorders, some fulfil the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 “clusters”: A, B and C. The causality between personality disorders and eating disorders has yet to be fully established. Some people have a previous disorder which may increase their vulnerability to developing an eating disorder. Some develop them afterwards. The severity and type of eating disorder symptoms have been shown to affect comorbidity. The DSM-IV should not be used by laypersons to diagnose themselves even when used by professionals as there has been considerable controversy over the diagnostic criteria used for various diagnoses, including eating disorders. There has been controversy over various editions of the DSM including the latest edition (then DSM-V).

Comorbid Disorders

Cognitive Attentional Bias

Attentional bias may have an effect on eating disorders. Attentional bias is the preferential attention toward certain types of information in the environment while simultaneously ignoring others. Individuals with eating disorders can be thought to have schemas, knowledge structures, which are dysfunctional as they may bias judgement, thought, behaviour in a manner that is self-destructive or maladaptive. They may have developed a disordered schema which focuses on body size and eating. Thus, this information is given the highest level of importance and overvalued among other cognitive structures. Researchers have found that people who have eating disorders tend to pay more attention to stimuli related to food. For people struggling to recover from an eating disorder or addiction, this tendency to pay attention to certain signals while discounting others can make recovery that much more difficult.

Studies have utilised the Stroop task to assess the probable effect of attentional bias on eating disorders. This may involve separating food and eating words from body shape and weight words. Such studies have found that anorexic subjects were slower to colour name food related words than control subjects. Other studies have noted that individuals with eating disorders have significant attentional biases associated with eating and weight stimuli.

Personality Traits

There are various childhood personality traits associated with the development of eating disorders. During adolescence these traits may become intensified due to a variety of physiological and cultural influences such as the hormonal changes associated with puberty, stress related to the approaching demands of maturity and socio-cultural influences and perceived expectations, especially in areas that concern body image. Eating disorders have been associated with a fragile sense of self and with disordered mentalisation. Many personality traits have a genetic component and are highly heritable. Maladaptive levels of certain traits may be acquired as a result of anoxic or traumatic brain injury, neurodegenerative diseases such as Parkinson’s disease, neurotoxicity such as lead exposure, bacterial infection such as Lyme disease or parasitic infection such as Toxoplasma gondii as well as hormonal influences. While studies are still continuing via the use of various imaging techniques such as fMRI; these traits have been shown to originate in various regions of the brain such as the amygdala and the prefrontal cortex. Disorders in the prefrontal cortex and the executive functioning system have been shown to affect eating behaviour.

Celiac Disease

People with gastrointestinal disorders may be more risk of developing disordered eating practices than the general population, principally restrictive eating disturbances. An association of anorexia nervosa with celiac disease has been found. The role that gastrointestinal symptoms play in the development of eating disorders seems rather complex. Some authors report that unresolved symptoms prior to gastrointestinal disease diagnosis may create a food aversion in these persons, causing alterations to their eating patterns. Other authors report that greater symptoms throughout their diagnosis led to greater risk. It has been documented that some people with celiac disease, irritable bowel syndrome or inflammatory bowel disease who are not conscious about the importance of strictly following their diet, choose to consume their trigger foods to promote weight loss. On the other hand, individuals with good dietary management may develop anxiety, food aversion and eating disorders because of concerns around cross contamination of their foods. Some authors suggest that medical professionals should evaluate the presence of an unrecognised celiac disease in all people with eating disorder, especially if they present any gastrointestinal symptom (such as decreased appetite, abdominal pain, bloating, distension, vomiting, diarrhoea or constipation), weight loss, or growth failure; and also routinely ask celiac patients about weight or body shape concerns, dieting or vomiting for weight control, to evaluate the possible presence of eating disorders, specially in women.

Environmental Influences

Child Maltreatment

Child abuse which encompasses physical, psychological and sexual abuse, as well as neglect has been shown to approximately triple the risk of an eating disorder. Sexual abuse appears to about double the risk of bulimia; however, the association is less clear for anorexia.

Social Isolation

Social isolation has been shown to have a deleterious effect on an individual’s physical and emotional well-being. Those that are socially isolated have a higher mortality rate in general as compared to individuals that have established social relationships. This effect on mortality is markedly increased in those with pre-existing medical or psychiatric conditions, and has been especially noted in cases of coronary heart disease. “The magnitude of risk associated with social isolation is comparable with that of cigarette smoking and other major biomedical and psychosocial risk factors.”

Social isolation can be inherently stressful, depressing and anxiety-provoking. In an attempt to ameliorate these distressful feelings an individual may engage in emotional eating in which food serves as a source of comfort. The loneliness of social isolation and the inherent stressors thus associated have been implicated as triggering factors in binge eating as well.

Waller, Kennerley and Ohanian (2007) argued that both bingeing-vomiting and restriction are emotion suppression strategies, but they are just utilised at different times. For example, restriction is used to pre-empt any emotion activation, while bingeing-vomiting is used after an emotion has been activated.

Parental Influence

Parental influence has been shown to be an intrinsic component in the development of eating behaviours of children. This influence is manifested and shaped by a variety of diverse factors such as familial genetic predisposition, dietary choices as dictated by cultural or ethnic preferences, the parents’ own body shape and eating patterns, the degree of involvement and expectations of their children’s eating behaviour as well as the interpersonal relationship of parent and child. This is in addition to the general psychosocial climate of the home and the presence or absence of a nurturing stable environment. It has been shown that maladaptive parental behaviour has an important role in the development of eating disorders. As to the more subtle aspects of parental influence, it has been shown that eating patterns are established in early childhood and that children should be allowed to decide when their appetite is satisfied as early as the age of two. A direct link has been shown between obesity and parental pressure to eat more.

Coercive tactics in regard to diet have not been proven to be efficacious in controlling a child’s eating behaviour. Affection and attention have been shown to affect the degree of a child’s finickiness and their acceptance of a more varied diet. finickity

Adams and Crane (1980), have shown that parents are influenced by stereotypes that influence their perception of their child’s body. The conveyance of these negative stereotypes also affects the child’s own body image and satisfaction. Hilde Bruch, a pioneer in the field of studying eating disorders, asserts that anorexia nervosa often occurs in girls who are high achievers, obedient, and always trying to please their parents. Their parents have a tendency to be over-controlling and fail to encourage the expression of emotions, inhibiting daughters from accepting their own feelings and desires. Adolescent females in these overbearing families lack the ability to be independent from their families, yet realize the need to, often resulting in rebellion. Controlling their food intake may make them feel better, as it provides them with a sense of control.

Peer Pressure

In various studies such as one conducted by The McKnight Investigators, peer pressure was shown to be a significant contributor to body image concerns and attitudes toward eating among subjects in their teens and early twenties.

Eleanor Mackey and co-author, Annette M. La Greca of the University of Miami, studied 236 teen girls from public high schools in southeast Florida. “Teen girls’ concerns about their own weight, about how they appear to others and their perceptions that their peers want them to be thin are significantly related to weight-control behavior”, says psychologist Eleanor Mackey of the Children’s National Medical Centre in Washington and lead author of the study. “Those are really important.”

According to one study, 40% of 9- and 10-year-old girls are already trying to lose weight. Such dieting is reported to be influenced by peer behaviour, with many of those individuals on a diet reporting that their friends also were dieting. The number of friends dieting and the number of friends who pressured them to diet also played a significant role in their own choices.

Elite athletes have a significantly higher rate in eating disorders. Female athletes in sports such as gymnastics, ballet, diving, etc. are found to be at the highest risk among all athletes. Women are more likely than men to acquire an eating disorder between the ages of 13-25. 0-15% of those with bulimia and anorexia are men.

Other psychological problems that could possibly create an eating disorder such as Anorexia Nervosa are depression, and low self-esteem. Depression is a state of mind where emotions are unstable causing a person’s eating habits to change due to sadness and no interest of doing anything. According to PSYCOM “Studies show that a high percentage of people with an eating disorder will experience depression.” Depression is a state of mind where people seem to refuge without being able to get out of it. A big factor of this can affect people with their eating and this can mostly affect teenagers. Teenagers are big candidates for Anorexia for the reason that during the teenage years, many things start changing and they start to think certain ways. According to Life Works an article about eating disorders “People of any age can be affected by pressure from their peers, the media and even their families but it is worse when you’re a teenager at school.” Teenagers can develop eating disorder such as Anorexia due to peer pressure which can lead to Depression. Many teens start off this journey by feeling pressure for wanting to look a certain way of feeling pressure for being different. This brings them to finding the result in eating less and soon leading to Anorexia which can bring big harms to the physical state.

Cultural Pressure

Western Perspective

There is a cultural emphasis on thinness which is especially pervasive in western society. A child’s perception of external pressure to achieve the ideal body that is represented by the media predicts the child’s body image dissatisfaction, body dysmorphic disorder and an eating disorder. “The cultural pressure on men and women to be ‘perfect’ is an important predisposing factor for the development of eating disorders”. Further, when women of all races base their evaluation of their self upon what is considered the culturally ideal body, the incidence of eating disorders increases.

Socioeconomic status (SES) has been viewed as a risk factor for eating disorders, presuming that possessing more resources allows for an individual to actively choose to diet and reduce body weight. Some studies have also shown a relationship between increasing body dissatisfaction with increasing SES. However, once high socioeconomic status has been achieved, this relationship weakens and, in some cases, no longer exists.

The media plays a major role in the way in which people view themselves. Countless magazine ads and commercials depict thin celebrities like Lindsay Lohan, Nicole Richie, Victoria Beckham and Mary Kate Olsen, who appear to gain nothing but attention from their looks. Society has taught people that being accepted by others is necessary at all costs. Unfortunately this has led to the belief that in order to fit in one must look a certain way. Televised beauty competitions such as the Miss America Competition contribute to the idea of what it means to be beautiful because competitors are evaluated on the basis of their opinion.

In addition to socioeconomic status being considered a cultural risk factor so is the world of sports. Athletes and eating disorders tend to go hand in hand, especially the sports where weight is a competitive factor. Gymnastics, horse back riding, wrestling, body building, and dancing are just a few that fall into this category of weight dependent sports. Eating disorders among individuals that participate in competitive activities, especially women, often lead to having physical and biological changes related to their weight that often mimic prepubescent stages. Oftentimes as women’s bodies change they lose their competitive edge which leads them to taking extreme measures to maintain their younger body shape. Men often struggle with binge eating followed by excessive exercise while focusing on building muscle rather than losing fat, but this goal of gaining muscle is just as much an eating disorder as obsessing over thinness. The following statistics taken from Susan Nolen-Hoeksema’s book, (ab)normal psychology, show the estimated percentage of athletes that struggle with eating disorders based on the category of sport.

  • Aesthetic sports (dance, figure skating, gymnastics): 35%.
  • Weight dependent sports (judo, wrestling): 29%.
  • Endurance sports (cycling, swimming, running): 20%.
  • Technical sports (golf, high jumping): 14%.
  • Ball game sports (volleyball, soccer): 12%.

Although most of these athletes develop eating disorders to keep their competitive edge, others use exercise as a way to maintain their weight and figure. This is just as serious as regulating food intake for competition. Even though there is mixed evidence showing at what point athletes are challenged with eating disorders, studies show that regardless of competition level all athletes are at higher risk for developing eating disorders that non-athletes, especially those that participate in sports where thinness is a factor.

Pressure from society is also seen within the homosexual community. Gay men are at greater risk of eating disorder symptoms than heterosexual men. Within the gay culture, muscularity gives the advantages of both social and sexual desirability and also power. These pressures and ideas that another homosexual male may desire a mate who is thinner or muscular can possibly lead to eating disorders. The higher eating disorder symptom score reported, the more concern about how others perceive them and the more frequent and excessive exercise sessions occur. High levels of body dissatisfaction are also linked to external motivation to working out and old age; however, having a thin and muscular body occurs within younger homosexual males than older.

Most of the cross-cultural studies use definitions from the DSM-IV-TR, which has been criticised as reflecting a Western cultural bias. Thus, assessments and questionnaires may not be constructed to detect some of the cultural differences associated with different disorders. Also, when looking at individuals in areas potentially influenced by Western culture, few studies have attempted to measure how much an individual has adopted the mainstream culture or retained the traditional cultural values of the area. Lastly, the majority of the cross-cultural studies on eating disorders and body image disturbances occurred in Western nations and not in the countries or regions being examined.

While there are many influences to how an individual processes their body image, the media does play a major role. Along with the media, parental influence, peer influence, and self-efficacy beliefs also play a large role in an individual’s view of themselves. The way the media presents images can have a lasting effect on an individual’s perception of their body image. Eating disorders are a worldwide issue and while women are more likely to be affected by an eating disorder it still affects both genders (Schwitzer 2012). The media influences eating disorders whether shown in a positive or negative light, it then has a responsibility to use caution when promoting images that projects an ideal that many turn to eating disorders to attain.

To try to address unhealthy body image in the fashion world, in 2015, France passed a law requiring models to be declared healthy by a doctor to participate in fashion shows. It also requires re-touched images to be marked as such in magazines.

There is a relationship between “thin ideal” social media content and body dissatisfaction and eating disorders among young adult women, especially in the Western hemisphere. New research points to an “internalisation” of distorted images online, as well as negative comparisons among young adult women. Most studies have been based in the US, the UK and Australia, these are places where the thin ideal is strong among women, as well as the strive for the “perfect” body.

In addition to mere media exposure, there is an online “pro-eating disorder” community. Through personal blogs and Twitter, this community promotes eating disorders as a “lifestyle”, and continuously posts pictures of emaciated bodies, and tips on how to stay thin. The hashtag “#proana” (pro-anorexia), is a product of this community, as well as images promoting weight loss, tagged with the term “thinspiration”. According to social comparison theory, young women have a tendency to compare their appearance to others, which can result in a negative view of their own bodies and altering of eating behaviours, that in turn can develop disordered eating behaviours.

When body parts are isolated and displayed in the media as objects to be looked at, it is called objectification, and women are affected most by this phenomenon. Objectification increases self-objectification, where women judge their own body parts as a mean of praise and pleasure for others. There is a significant link between self-objectification, body dissatisfaction, and disordered eating, as the beauty ideal is altered through social media.

Although eating disorders are typically under diagnosed in people of colour, they still experience eating disorders in great numbers. It is thought that the stress that those of colour face in the US from being multiply marginalised may contribute to their rates of eating disorders. Eating disorders, for these women, may be a response to environmental stressors such as racism, abuse and poverty.

African Perspective

In the majority of many African communities, thinness is generally not seen as an ideal body type and most pressure to attain a slim figure may stem from influence or exposure to Western culture and ideology. Traditional African cultural ideals are reflected in the practice of some health professionals; in Ghana, pharmacists sell appetite stimulants to women who desire to, as Ghanaians stated, “grow fat”. Girls are told that if they wish to find a partner and birth children they must gain weight. On the contrary, there are certain taboos surrounding a slim body image, specifically in West Africa. Lack of body fat is linked to poverty and HIV/AIDS.

However, the emergence of Western and European influence, specifically with the introduction of such fashion and modelling shows and competitions, is changing certain views among body acceptance, and the prevalence of eating disorders has consequently increased. This acculturation is also related to how South Africa is concurrently undergoing rapid, intense urbanisation. Such modern development is leading to cultural changes, and professionals cite rates of eating disorders in this region will increase with urbanisation, specifically with changes in identity, body image, and cultural issues. Further, exposure to Western values through private Caucasian schools or caretakers is another possible factor related to acculturation which may be associated with the onset of eating disorders.

Other factors which are cited to be related to the increasing prevalence of eating disorders in African communities can be related to sexual conflicts, such as psychosexual guilt, first sexual intercourse, and pregnancy. Traumatic events which are related to both family (i.e. parental separation) and eating related issues are also cited as possible effectors. Religious fasting, particularly around times of stress, and feelings of self-control are also cited as determinants in the onset of eating disorders.

Asian Perspective

The West plays a role in Asia’s economic development via foreign investments, advanced technologies joining financial markets, and the arrival of American and European companies in Asia, especially through outsourcing manufacturing operations. This exposure to Western culture, especially the media, imparts Western body ideals to Asian society, termed Westernisation. In part, Westernisation fosters eating disorders among Asian populations. However, there are also country-specific influences on the occurrence of eating disorders in Asia.

China

In China as well as other Asian countries, Westernization, migration from rural to urban areas, after-effects of sociocultural events, and disruptions of social and emotional support are implicated in the emergence of eating disorders. In particular, risk factors for eating disorders include higher socioeconomic status, preference for a thin body ideal, history of child abuse, high anxiety levels, hostile parental relationships, jealousy towards media idols, and above-average scores on the body dissatisfaction and interoceptive awareness sections of the Eating Disorder Inventory. Similarly to the West, researchers have identified the media as a primary source of pressures relating to physical appearance, which may even predict body change behaviours in males and females.

Fiji

While colonised by the British in 1874, Fiji kept a large degree of linguistic and cultural diversity which characterised the ethnic Fijian population. Though gaining independence in 1970, Fiji has rejected Western, capitalist values which challenged its mutual trusts, bonds, kinships and identity as a nation. Similar to studies conducted on Polynesian groups, ethnic Fijian traditional aesthetic ideals reflected a preference for a robust body shape; thus, the prevailing ‘pressure to be slim,’ thought to be associated with diet and disordered eating in many Western societies was absent in traditional Fiji. Additionally, traditional Fijian values would encourage a robust appetite and a widespread vigilance for and social response to weight loss. Individual efforts to reshape the body by dieting or exercise, thus traditionally was discouraged.

However, studies conducted in 1995 and 1998 both demonstrated a link between the introduction of television in the country, and the emergence of eating disorders in young adolescent ethnic Fijian girls. Through the quantitative data collected in these studies there was found to be a significant increase in the prevalence of two key indicators of disordered eating: self-induced vomiting and high Eating Attitudes Test-26. These results were recorded following prolonged television exposure in the community, and an associated increase in the percentage of households owning television sets. Additionally, qualitative data linked changing attitudes about dieting, weight loss and aesthetic ideas in the peer environment to Western media images. The impact of television was especially profound given the longstanding social and cultural traditions that had previously rejected the notions of dieting, purging and body dissatisfaction in Fiji. Additional studies in 2011 found that social network media exposure, independent of direct media and other cultural exposures, was also associated with eating pathology.

Hong Kong

From the early- to-mid-1990s, a variant form of anorexia nervosa was identified in Hong Kong. This variant form did not share features of anorexia in the West, notably “fat-phobia” and distorted body image. Patients attributed their restrictive food intake to somatic complaints, such as epigastric bloating, abdominal or stomach pain, or a lack of hunger or appetite. Compared to Western patients, individuals with this variant anorexia demonstrated bulimic symptoms less frequently and tended to have lower pre-morbid body mass index. This form disapproves the assumption that a “fear of fatness or weight gain” is the defining characteristic of individuals with anorexia nervosa.

India

In the past, the available evidence did not suggest that unhealthy weight loss methods and eating disordered behaviours are common in India as proven by stagnant rates of clinically diagnosed eating disorders. However, it appears that rates of eating disorders in urban areas of India are increasing based on surveys from psychiatrists who were asked whether they perceived eating disorders to be a “serious clinical issue” in India. 23.5% of respondents believed that rates of eating disorders were rising in Bangalore, 26.5% claimed that rates were stagnant, and 42%, the largest percentage, expressed uncertainty. It has been suggested that urbanisation and socioeconomic status are associated with increased risk for body weight dissatisfaction. However, due to the physical size of and diversity within India, trends may vary throughout the country.

Mechanisms

  • Biochemical:
    • Eating behaviour is a complex process controlled by the neuroendocrine system, of which the Hypothalamus-pituitary-adrenal-axis (HPA axis) is a major component.
    • Dysregulation of the HPA axis has been associated with eating disorders, such as irregularities in the manufacture, amount or transmission of certain neurotransmitters, hormones or neuropeptides and amino acids such as homocysteine, elevated levels of which are found in AN and BN as well as depression.
      • Serotonin: a neurotransmitter involved in depression also has an inhibitory effect on eating behaviour.
      • Norepinephrine is both a neurotransmitter and a hormone; abnormalities in either capacity may affect eating behaviour.
      • Dopamine: which in addition to being a precursor of norepinephrine and epinephrine is also a neurotransmitter which regulates the rewarding property of food.
      • Neuropeptide Y also known as NPY is a hormone that encourages eating and decreases metabolic rate.
        • Blood levels of NPY are elevated in patients with anorexia nervosa, and studies have shown that injection of this hormone into the brain of rats with restricted food intake increases their time spent running on a wheel.
        • Normally the hormone stimulates eating in healthy patients, but under conditions of starvation it increases their activity rate, probably to increase the chance of finding food.
        • The increased levels of NPY in the blood of patients with eating disorders can in some ways explain the instances of extreme over-exercising found in most anorexia nervosa patients.
  • Leptin and ghrelin:
    • Leptin is a hormone produced primarily by the fat cells in the body; it has an inhibitory effect on appetite by inducing a feeling of satiety.
    • Ghrelin is an appetite inducing hormone produced in the stomach and the upper portion of the small intestine.
    • Circulating levels of both hormones are an important factor in weight control.
    • While often associated with obesity, both hormones and their respective effects have been implicated in the pathophysiology of anorexia nervosa and bulimia nervosa.
    • Leptin can also be used to distinguish between constitutional thinness found in a healthy person with a low BMI and an individual with anorexia nervosa.
  • Gut bacteria and immune system:
    • Studies have shown that a majority of patients with anorexia and bulimia nervosa have elevated levels of autoantibodies that affect hormones and neuropeptides that regulate appetite control and the stress response.
    • There may be a direct correlation between autoantibody levels and associated psychological traits.
    • Later study revealed that autoantibodies reactive with alpha-MSH are, in fact, generated against ClpB, a protein produced by certain gut bacteria e.g. Escherichia coli. ClpB protein was identified as a conformational antigen-mimetic of alpha-MSH.
    • In patients with eating disorders plasma levels of anti-ClpB IgG and IgM correalated with patients’ psychological traits
  • Infection:
    • PANDAS, is an abbreviation for Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections.
    • Children with PANDAS “have obsessive-compulsive disorder (OCD) and/or tic disorders such as Tourette syndrome, and in whom symptoms worsen following infections such as “strep throat” and scarlet fever”.
    • There is a possibility that PANDAS may be a precipitating factor in the development of anorexia nervosa in some cases, (PANDAS AN).
  • Lesions:
    • Studies have shown that lesions to the right frontal lobe or temporal lobe can cause the pathological symptoms of an eating disorder.
  • Tumours:
    • Tumours in various regions of the brain have been implicated in the development of abnormal eating patterns.
  • Brain calcification:
    • A study highlights a case in which prior calcification of the right thalumus may have contributed to development of anorexia nervosa.
  • Somatosensory homunculus:
    • This is the representation of the body located in the somatosensory cortex, first described by renowned neurosurgeon Wilder Penfield.
    • The illustration was originally termed “Penfield’s Homunculus”, homunculus meaning little man.
    • “In normal development this representation should adapt as the body goes through its pubertal growth spurt.
    • However, in AN it is hypothesized that there is a lack of plasticity in this area, which may result in impairments of sensory processing and distortion of body image”. (Bryan Lask, also proposed by VS Ramachandran).
  • Obstetric complications:
    • There have been studies done which show maternal smoking, obstetric and perinatal complications such as maternal anaemia, very pre-term birth (less than 32 weeks), being born small for gestational age, neonatal cardiac problems, preeclampsia, placental infarction and sustaining a cephalhaematoma at birth increase the risk factor for developing either anorexia nervosa or bulimia nervosa.
    • Some of this developmental risk as in the case of placental infarction, maternal anaemia and cardiac problems may cause intrauterine hypoxia, umbilical cord occlusion or cord prolapse may cause ischemia, resulting in cerebral injury, the prefrontal cortex in the foetus and neonate is highly susceptible to damage as a result of oxygen deprivation which has been shown to contribute to executive dysfunction, ADHD, and may affect personality traits associated with both eating disorders and comorbid disorders such as impulsivity, mental rigidity and obsessionality.
    • The problem of perinatal brain injury, in terms of the costs to society and to the affected individuals and their families, is extraordinary.
  • Symptom of starvation:
    • Evidence suggests that the symptoms of eating disorders are actually symptoms of the starvation itself, not of a mental disorder.
    • In a study involving thirty-six healthy young men that were subjected to semi-starvation, the men soon began displaying symptoms commonly found in patients with eating disorders.
    • In this study, the healthy men ate approximately half of what they had become accustomed to eating and soon began developing symptoms and thought patterns (preoccupation with food and eating, ritualistic eating, impaired cognitive ability, other physiological changes such as decreased body temperature) that are characteristic symptoms of anorexia nervosa.
    • The men used in the study also developed hoarding and obsessive collecting behaviours, even though they had no use for the items, which revealed a possible connection between eating disorders and obsessive compulsive disorder.

Diagnosis

The initial diagnosis should be made by a competent medical professional. “The medical history is the most powerful tool for diagnosing eating disorders”. There are many medical disorders that mimic eating disorders and comorbid psychiatric disorders. Early detection and intervention can assure a better recovery and can improve a lot the quality of life of these patients. All organic causes should be ruled out prior to a diagnosis of an eating disorder or any other psychiatric disorder. In the past 30 years eating disorders have become increasingly conspicuous and it is uncertain whether the changes in presentation reflect a true increase. Anorexia nervosa and bulimia nervosa are the most clearly defined subgroups of a wider range of eating disorders. Many patients present with subthreshold expressions of the two main diagnoses: others with different patterns and symptoms.

It is essential to develop specific scales for people under 18 years of age, given the increasing incidence of ED among children and the need for early detection and appropriate intervention. Early detection of ED in children implies a simple and accurate evaluation at the primary care level or in schools, as the course of the disease can be sub clinical for several years. Moreover, the need for accurate scales and tele-medicine testing and diagnosis is of high importance during the COVID-19 pandemic as youth are at particular risk being psychologically affected due to disrupted education and social interactions – at a critical time.

As eating disorders, especially anorexia nervosa, are thought of as being associated with young, white females, diagnosis of eating disorders in other races happens more rarely. In one study, when clinicians were presented with identical case studies demonstrating disordered eating symptoms in Black, Hispanic, and white women, 44% noted the white woman’s behaviour as problematic; 41% identified the Hispanic woman’s behaviour as problematic, and only 17% of the clinicians noted the Black woman’s behaviour as problematic.

Medical

The diagnostic workup typically includes complete medical and psychosocial history and follows a rational and formulaic approach to the diagnosis. Neuroimaging using fMRI, MRI, PET and SPECT scans have been used to detect cases in which a lesion, tumour or other organic condition has been either the sole causative or contributory factor in an eating disorder. “Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders, we therefore recommend performing a cranial MRI in all patients with suspected eating disorders”, “intracranial pathology should also be considered however certain is the diagnosis of early-onset anorexia nervosa. Second, neuroimaging plays an important part in diagnosing early-onset anorexia nervosa, both from a clinical and a research prospective”.

Psychological

After ruling out organic causes and the initial diagnosis of an eating disorder being made by a medical professional, a trained mental health professional aids in the assessment and treatment of the underlying psychological components of the eating disorder and any comorbid psychological conditions. The clinician conducts a clinical interview and may employ various psychometric tests. Some are general in nature while others were devised specifically for use in the assessment of eating disorders. Some of the general tests that may be used are the Hamilton Depression Rating Scale and the Beck Depression Inventory. longitudinal research showed that there is an increase in chance that a young adult female would develop bulimia due to their current psychological pressure and as the person ages and matures, their emotional problems change or are resolved and then the symptoms decline.

Several types of scales are currently used:

  • Self-report questionnaires – EDI-3, BSQ, TFEQ, MAC, BULIT-R, QEWP-R, EDE-Q, EAT, NEQ – and other;
  • Semi-structured interviews – SCID-I, EDE – and other; and
  • Clinical interviews unstructured or observer-based rating scales – Morgan Russel scale.

The majority of the scales used were described and used in adult populations. From all the scales evaluated and analysed, only three are described at the child population – it is EAT-26 (children above 16 years), EDI-3 (children above 13 years), and ANSOCQ (children above 13 years). It is essential to develop specific scales for people under 18 years of age, given the increasing incidence of ED among children and the need for early detection and appropriate intervention. Moreover, the urgent need for accurate scales and telemedicine testing and diagnosis tools are of high importance during the COVID-19 pandemic.

Eating Disorder Specific Psychometric Tests

  • Eating Attitudes Test.
  • Body Attitudes Test.
  • Eating Disorder Inventory.
  • SCOFF Questionnaire.
  • Body Attitudes Questionnaire.
  • Eating Disorder Examination Interview.

Differential Diagnosis

There are multiple medical conditions which may be misdiagnosed as a primary psychiatric disorder, complicating or delaying treatment. These may have a synergistic effect on conditions which mimic an eating disorder or on a properly diagnosed eating disorder.

  • Lyme disease is known as the “great imitator”, as it may present as a variety of psychiatric or neurological disorders including anorexia nervosa.
  • Gastrointestinal diseases, such as celiac disease, Crohn’s disease, peptic ulcer, eosinophilic esophagitis or non-celiac gluten sensitivity, among others.
    • Celiac disease is also known as the “great imitator”, because it may involve several organs and cause an extensive variety of non-gastrointestinal symptoms, such as psychiatric and neurological disorders, including anorexia nervosa.
  • Addison’s disease is a disorder of the adrenal cortex which results in decreased hormonal production. Addison’s disease, even in subclinical form may mimic many of the symptoms of anorexia nervosa.
  • Gastric adenocarcinoma is one of the most common forms of cancer in the world.
    • Complications due to this condition have been misdiagnosed as an eating disorder.
  • Hypothyroidism, hyperthyroidism, hypoparathyroidism and hyperparathyroidism may mimic some of the symptoms of, can occur concurrently with, be masked by or exacerbate an eating disorder.
  • Toxoplasma seropositivity: even in the absence of symptomatic toxoplasmosis, toxoplasma gondii exposure has been linked to changes in human behaviour and psychiatric disorders including those comorbid with eating disorders such as depression.
    • In reported case studies the response to antidepressant treatment improved only after adequate treatment for toxoplasma.
  • Neurosyphilis: It is estimated that there may be up to one million cases of untreated syphilis in the US alone.
    • “The disease can present with psychiatric symptoms alone, psychiatric symptoms that can mimic any other psychiatric illness”.
    • Many of the manifestations may appear atypical.
    • Up to 1.3% of short term psychiatric admissions may be attributable to neurosyphilis, with a much higher rate in the general psychiatric population.
  • Dysautonomia: a wide variety of autonomic nervous system (ANS) disorders may cause a wide variety of psychiatric symptoms including anxiety, panic attacks and depression.
    • Dysautonomia usually involves failure of sympathetic or parasympathetic components of the ANS system but may also include excessive ANS activity.
    • Dysautonomia can occur in conditions such as diabetes and alcoholism.

Psychological disorders which may be confused with an eating disorder, or be co-morbid with one:

  • Emetophobia is an anxiety disorder characterised by an intense fear of vomiting.
    • A person so afflicted may develop rigorous standards of food hygiene, such as not touching food with their hands.
    • They may become socially withdrawn to avoid situations which in their perception may make them vomit.
    • Many who have emetophobia are diagnosed with anorexia or self-starvation.
    • In severe cases of emetophobia they may drastically reduce their food intake.
  • Phagophobia is an anxiety disorder characterized by a fear of eating, it is usually initiated by an adverse experience while eating such as choking or vomiting.
    • Persons with this disorder may present with complaints of pain while swallowing.
  • Body dysmorphic disorder (BDD) is listed as a somatoform disorder that affects up to 2% of the population. BDD is characterised by excessive rumination over an actual or perceived physical flaw.
    • BDD has been diagnosed equally among men and women.
    • While BDD has been misdiagnosed as anorexia nervosa, it also occurs comorbidly in 39% of eating disorder cases.
    • BDD is a chronic and debilitating condition which may lead to social isolation, major depression and suicidal ideation and attempts.
    • Neuroimaging studies to measure response to facial recognition have shown activity predominately in the left hemisphere in the left lateral prefrontal cortex, lateral temporal lobe and left parietal lobe showing hemispheric imbalance in information processing.
    • There is a reported case of the development of BDD in a 21-year-old male following an inflammatory brain process.
    • Neuroimaging showed the presence of a new atrophy in the frontotemporal region.

Prevention

Prevention aims to promote a healthy development before the occurrence of eating disorders. It also intends early identification of an eating disorder before it is too late to treat. Children as young as ages 5–7 are aware of the cultural messages regarding body image and dieting.[235] Prevention comes in bringing these issues to the light. The following topics can be discussed with young children (as well as teens and young adults).

  • Emotional Bites:
    • A simple way to discuss emotional eating is to ask children about why they might eat besides being hungry.
    • Talk about more effective ways to cope with emotions, emphasizing the value of sharing feelings with a trusted adult.
  • Say No to Teasing:
    • Another concept is to emphasize that it is wrong to say hurtful things about other people’s body sizes.
  • Body Talk:
    • Emphasize the importance of listening to one’s body.
    • That is, eating when you are hungry (not starving) and stopping when you are satisfied (not stuffed).
    • Children intuitively grasp these concepts.
  • Fitness Comes in All Sizes:
    • Educate children about the genetics of body size and the normal changes occurring in the body.
    • Discuss their fears and hopes about growing bigger.
    • Focus on fitness and a balanced diet.

Internet and modern technologies provide new opportunities for prevention. On-line programmes have the potential to increase the use of prevention programmes. The development and practice of prevention programmes via on-line sources make it possible to reach a wide range of people at minimal cost. Such an approach can also make prevention programmes to be sustainable.

Treatment

Treatment varies according to type and severity of eating disorder, and usually more than one treatment option is utilized.[241] Family doctors play an important role in early treatment of people with eating disorders by encouraging those who are also reluctant to see a psychiatrist.[242] Treatment can take place in a variety of different settings such as community programs, hospitals, day programs, and groups.[243] The American Psychiatric Association (APA) recommends a team approach to treatment of eating disorders. The members of the team are usually a psychiatrist, therapist, and registered dietitian, but other clinicians may be included.

That said, some treatment methods are:

  • Cognitive behavioural therapy (CBT), which postulates that an individual’s feelings and behaviours are caused by their own thoughts instead of external stimuli such as other people, situations or events; the idea is to change how a person thinks and reacts to a situation even if the situation itself does not change.
    • Acceptance and commitment therapy: a type of CBT.
    • Cognitive remediation therapy (CRT), a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning.
  • The Maudsley anorexia nervosa treatment for adults (MANTRA), which focuses on addressing rigid information processing styles, emotional avoidance, pro-anorectic beliefs, and difficulties with interpersonal relationships.
    • These four targets of treatment are proposed to be core maintenance factors within the Cognitive-Interpersonal Maintenance Model of anorexia nervosa.
  • Dialectical behaviour therapy.
  • Family therapy including “conjoint family therapy” (CFT), “separated family therapy” (SFT) and Maudsley Family Therapy.
  • Behavioural therapy: focuses on gaining control and changing unwanted behaviours.
  • Interpersonal psychotherapy (IPT).
  • Cognitive Emotional Behaviour Therapy (CEBT)u
  • Art therapyu
  • Nutrition counselling and medical nutrition therapy.
  • Medication:
    • Orlistat is used in obesity treatment.
    • Olanzapine seems to promote weight gain as well as the ability to ameliorate obsessional behaviours concerning weight gain. zinc supplements have been shown to be helpful, and cortisol is also being investigated.
  • Self-help and guided self-help have been shown to be helpful in AN, BN and BED; this includes support groups and self-help groups such as Eating Disorders Anonymous and Overeaters Anonymous.
  • Psychoanalysis.
  • Inpatient care.

Two pharmaceuticals, Prozac and Vyvanse, have been approved by the FDA to treat bulimia nervosa and binge-eating disorder, respectively. Olanzapine has also been used off-label to treat anorexia nervosa. Studies are also underway to explore psychedelic and psychedelic-adjacent medicines such as MDMA, psilocybin and ketamine for anorexia nervosa and binge-eating disorder.

There are few studies on the cost-effectiveness of the various treatments. Treatment can be expensive; due to limitations in health care coverage, people hospitalized with anorexia nervosa may be discharged while still underweight, resulting in relapse and rehospitalisation.

For children with anorexia, the only well-established treatment is the family treatment-behaviour. For other eating disorders in children, however, there is no well-established treatments, though family treatment-behaviour has been used in treating bulimia.

A 2019 Cochrane review examined studies comparing the effectiveness of inpatient versus outpatient models of care for eating disorders. Four trials including 511 participants were studied but the review was unable to draw any definitive conclusions as to the superiority of one model over another.

Outcomes

For anorexia nervosa, bulimia nervosa, and binge eating disorder, there is a general agreement that full recovery rates are in the 50% to 85% range, with larger proportions of people experiencing at least partial remission. It can be a lifelong struggle or it can be overcome within months.

  • Miscarriages:
    • Pregnant women with a binge eating disorder have shown to have a greater chance of having a miscarriage compared to pregnant women with any other eating disorders.
    • According to a study done, out of a group of pregnant women being evaluated, 46.7% of the pregnancies ended with a miscarriage in women that were diagnosed with BED, with 23.0% in the control.
    • In the same study, 21.4% of women diagnosed with Bulimia Nervosa had their pregnancies end with miscarriages and only 17.7% of the controls.
  • Relapse:
    • An individual who is in remission from BN and EDNOS (Eating Disorder Not Otherwise Specified) is at a high risk of falling back into the habit of self-harm.
    • Factors such as high stress regarding their job, pressures from society, as well as other occurrences that inflict stress on a person, can push a person back to what they feel will ease the pain.
    • A study tracked a group of selected people that were either diagnosed with BN or EDNOS for 60 months.
    • After the 60 months were complete, the researchers recorded whether or not the person was having a relapse.
    • The results found that the probability of a person previously diagnosed with EDNOS had a 41% chance of relapsing; a person with BN had a 47% chance.
  • Attachment insecurity:
    • People who are showing signs of attachment anxiety will most likely have trouble communicating their emotional status as well as having trouble seeking effective social support.
    • Signs that a person has adopted this symptom include not showing recognition to their caregiver or when he/she is feeling pain.
    • In a clinical sample, it is clear that at the pre-treatment step of a patient’s recovery, more severe eating disorder symptoms directly corresponds to higher attachment anxiety.
    • The more this symptom increases, the more difficult it is to achieve eating disorder reduction prior to treatment.

Anorexia symptoms include the increasing chance of getting osteoporosis. Thinning of the hair as well as dry hair and skin are also very common. The muscles of the heart will also start to change if no treatment is inflicted on the patient. This causes the heart to have an abnormally slow heart rate along with low blood pressure. Heart failure becomes a major consideration when this begins to occur. Muscles throughout the body begin to lose their strength. This will cause the individual to begin feeling faint, drowsy, and weak. Along with these symptoms, the body will begin to grow a layer of hair called lanugo. The human body does this in response to the lack of heat and insulation due to the low percentage of body fat.

Bulimia symptoms include heart problems like an irregular heartbeat that can lead to heart failure and death may occur. This occurs because of the electrolyte imbalance that is a result of the constant binge and purge process. The probability of a gastric rupture increases. A gastric rupture is when there is a sudden rupture of the stomach lining that can be fatal. The acids that are contained in the vomit can cause a rupture in the oesophagus as well as tooth decay. As a result, to laxative abuse, irregular bowel movements may occur along with constipation. Sores along the lining of the stomach called peptic ulcers begin to appear and the chance of developing pancreatitis increases.

Binge eating symptoms include high blood pressure, which can cause heart disease if it is not treated. Many patients recognize an increase in the levels of cholesterol. The chance of being diagnosed with gallbladder disease increases, which affects an individual’s digestive tract.

Risk of Death

Eating disorders result in about 7,000 deaths a year as of 2010, making them the mental illnesses with the highest mortality rate. Anorexia has a risk of death that is increased about 5 fold with 20% of these deaths as a result of suicide. Rates of death in bulimia and other disorders are similar at about a 2 fold increase.

The mortality rate for those with anorexia is 5.4 per 1000 individuals per year. Roughly 1.3 deaths were due to suicide. A person who is or had been in an inpatient setting had a rate of 4.6 deaths per 1000. Of individuals with bulimia about 2 persons per 1000 persons die per year and among those with EDNOS about 3.3 per 1000 people die per year.

Epidemiology

In the developed world, binge eating disorder affects about 1.6% of women and 0.8% of men in a given year. Anorexia affects about 0.4% and bulimia affects about 1.3% of young women in a given year. Up to 4% of women have anorexia, 2% have bulimia, and 2% have binge eating disorder at some point in time. Anorexia and bulimia occur nearly ten times more often in females than males. Typically, they begin in late childhood or early adulthood. Rates of other eating disorders are not clear. Rates of eating disorders appear to be lower in less developed countries.

In the US, twenty million women and ten million men have an eating disorder at least once in their lifetime.

Anorexia

Rates of anorexia in the general population among women aged 11 to 65 ranges from 0 to 2.2% and around 0.3% among men. The incidence of female cases is low in general medicine or specialised consultation in town, ranging from 4.2 and 8.3/100,000 individuals per year. The incidence of AN ranges from 109 to 270/100,000 individuals per year. Mortality varies according to the population considered. AN has one of the highest mortality rates among mental illnesses. The rates observed are 6.2 to 10.6 times greater than that observed in the general population for follow-up periods ranging from 13 to 10 years. Standardised mortality ratios for anorexia vary from 1.36% to 20%.

Bulimia

Bulimia affects females 9 times more often than males. Approximately one to three percent women develop bulimia in their lifetime. About 2% to 3% of women are currently affected in the US. New cases occur in about 12 per 100,000 population per year. The standardised mortality ratios for bulimia is 1% to 3%.

Binge Eating Disorder

Reported rates vary from 1.3 to 30% among subjects seeking weight-loss treatment. Based on surveys, BED appears to affected about 1-2% at some point in their life, with 0.1-1% of people affected in a given year. BED is more common among females than males. There have been no published studies investigating the effects of BED on mortality, although it is comorbid with disorders that are known to increase mortality risks.

Economics

  • Since 2017, the number of cost-effectiveness studies regarding eating disorders appears to be increasing in the past six years.
  • In 2011 US dollars, annual healthcare costs were $1,869 greater among individuals with eating disorders compared to the general population.
    • The added presence of mental health comorbidities was also associated with higher, but not statistically significant, costs difference of $1,993.
  • In 2013 Canadian dollars, the total hospital cost per admission for treatment of anorexia nervosa was $51,349 and the total societal cost was $54,932 based on an average length of stay of 37.9 days.
    • For every unit increase in body mass index, there was also a 15.7% decrease in hospital cost.
  • For Ontario, Canada patients who received specialised inpatient care for an eating disorder both out of country and in province, annual total healthcare costs were about $11 million before 2007 and $6.5 million in the years afterwards.
    • For those treated out of country alone, costs were about $5 million before 2007 and $2 million in the years afterwards.

The Real Fear of Phobia

For many years psychologists have been aware that our minds are more than capable of producing a real biological reaction to any given situation.

And, so as long as the phobic person ‘believes’ that the object or situation they fear represents danger to them, then they will experience real fear.

The majority of people who do suffer with a phobia understand that their fear is ‘irrational’ but continue to experience it regardless of this knowledge. This is why simply being told to “snap out of it” rarely produces a solution!

What is Bathmophobia?

Introduction

Bathmophobia, or the fear of slopes or stairs, is a somewhat complicated phobia.

It is quite similar to climacophobia, or the fear of climbing stairs, except in its specific focus. If you have bathmophobia, you might panic when simply observing a steep slope, while people with climacophobia typically experience symptoms only when expected to actually climb or descend. The difference is subtle but important, and can only be accurately diagnosed by a trained clinician.

Definition

Bathmophobia is a specific phobia. The word itself defines what it means:

  • ‘Bathmo’ means step in Greek; and
  • ‘Phobia’ means fear in Greek.

Therefore, we have the meaning, which is a fear of steps.

Prevalence

According to the National Institute of Mental Health, approximately 12.5 % of the American population will experience a phobia at some point in their life. Bathmophobia is a specific phobia.

Symptoms

The symptoms of Bathmophobia are very similar to other specific phobias and will often include:

  • Feelings of Panic, Dread or Terror.
  • Inability to Relax.
  • An Impending Sense of Dread.
  • Problems Concentrating.
  • Being quick tempered.
  • Feelings of dizziness.
  • Difficulties in becoming motivated.
  • Prickly sensations like pins and needles.
  • Palpitations.
  • Aches & Pains.
  • Fatigued Muscles.
  • Dry and Sticky mouth.
  • Sweating Excessively.
  • Breathlessness.
  • Migraines and Headaches.
  • Poor Quality of Sleep.

Bathmophobia Symptoms are generally automatic and uncontrollable and can seem to take over a person’s thoughts which frequently leads to extreme measures being taken to avoid the feared object or situation, what are known as ‘safety’ or ‘avoidance’ behaviours. Unfortunately, for the sufferer, these safety behaviours have a paradoxical effect and actually reinforce the phobia rather than solve it!

Bathmophobia may be the result of negative emotional experiences that can be either directly or indirectly linked to the object or situational fear. Over time, the symptoms often become ‘normalised’ and ‘accepted’ as a limiting belief in that person’s life – “I’ve learnt to live with it.”’ In just as many cases, Bathmophobia may have become worse over time as more and more sophisticated safety behaviours and routines are developed.

Causes

Bathmophobia may be caused by a wide range of factors. A particularly common cause is an early negative experience with stairs or a steep hill. If you slipped or fell on steep stairs or watched someone else struggle with shortness of breath while climbing, you may be at a greater risk of developing bathmophobia.

Particularly in children, bathmophobia can also be triggered by negotiating or even just contemplating a particularly scary looking set of stairs. One example is a child involved in a local community theater with stairs leading to the backstage costume loft. The stairs were steep and open at the back so you could see down as you climbed them, and the child could imagine slipping through them, even though they did not ever climb them themself.

Memories of those stairs played into dreams that included struggling to cross a sloped floor that would tilt to near-vertical as they neared their destination in the dreams. They may continue to feel apprehension when confronted with a sloped floor or a tricky set of stairs.

Diagnosis

If your child has a fear of stairs or slopes, keep in mind that fears are a normal part of development. Bathmophobia, as with other phobias, is generally not diagnosed in children or adults unless it persists for more than six months.

Differential Diagnosis

In addition to the above-mentioned climacophobia, bathmophobia may be related to other disorders. Acrophobia, or the fear of heights, is exceptionally common. What appears to be a fear of stairs may, in fact, be a fear of the height that the stairs achieve. Illygnophobia, or the fear of vertigo, can also cause symptoms similar to those of bathmophobia.

Medical causes must also be considered. True vertigo is a medical disorder of the balance system that causes a feeling of spinning or dizziness. The term is also applied medically to similar symptoms that are not caused by a balance disorder. Both types can be worsened by even minor changes in height. By definition, a fear that is reasonable due to an existing medical condition cannot be called a phobia.

Treatment

The good news is that the vast majority of people who suffer from Bathmophobia will find a course of psychotherapy helps enormously. Almost every phobia responds well to psychological interventions.

If your clinician determines that your symptoms are caused by bathmophobia, you are likely to receive cognitive behavioural therapy (CBT). The goal of this type of therapy is to help you replace your fearful thoughts and behaviours with more rational alternatives. You will be taught relaxation exercises to help you remain calm, and slowly introduced to the object of your fear through a process known as systematic desensitisation.

Although it takes time, therapy has an excellent success rate in treating this type of phobia. Choosing a therapist that you trust is an essential component in working through your fear.

Did You Know?

  • Bathmophobia can be seen in both children and adults.
  • If you have medical vertigo, fearing that stairs and slopes may trigger your symptoms does not mean that you also have bathmophobia.
  • It is also fairly common among animals, particularly household pets.
  • Dogs trained as service animals may be rejected because of their fear of stairs.
  • Donald Trump has a fear of stairs.

Further Reading

Do Psychiatric Conditions Shift Over Time?

Diagnoses for mental health conditions often morph into each other, suggesting that psychiatry’s reliance on specific diagnoses may be misguided.

A team led by Avshalom Caspi and Terrie Moffitt (2020) at Duke University, North Carolina, analysed data from the Dunedin Birth Cohort Study, which follows a nationally representative group of more
than 1,000 New Zealanders born in 1972 and 1973.

As the participants in the Dunedin Study have grown up, they have been assessed nine times to measure aspects of their health and behaviour, including their mental health. Caspi and Moffitt’s team found that by the age of 45, 86% of participants had met the criteria for at least one psychiatric diagnosis in one assessment. This did not mean that they had received a psychiatric diagnosis, but if they had seen a psychiatrist, they could have been given one.

A third of the cohort met the criteria for a psychiatric diagnosis before they reached the age of 15. Yet over time, people’s mental health usually shifted into a different category of psychiatric conditions.

This could suggest that an excessive focus on a current diagnosis is short-sighted and that therapy should not just address the presenting disorder, but must build fundamental skills for maintaining general mental health.

However, one must caution against ditching diagnostic categories as some disorders are linked to specific causes and respond better to certain treatments than others. It could do harm to ignore these distinctions, at least in some cases.

Reference

Caspi, A., Houts, R.M., Ambler, A., Danese, A., Elliott, M.L., Hariri, A., Harrington, H., Hogan, S., Poulton, R., Ramrakha, S., Rasmussen, L.J.H., Reuben, A., Richmond-Rakerd, L., Sugden, K., Wertz, J., Williams, B.S. & Moffitt, T.E. (2020) Longitudinal Assessment of Mental Health Disorders and Comorbidities Across 4 Decades Among Participants in the Dunedin Birth Cohort Study. JAMA Network Open. 3(4), pp.e203221. doi:10.1001/jamanetworkopen.2020.3221