Obesity: We Must Take the Lead
Clinical Psychiatry News - Volume 32, Issue 11, Page 27 (November 2004)
A few years ago, a 35-year-old patient I'll call Betty came to me because her weight had spiraled out of control. At 235 pounds, Betty found that even the simplest tasks—such as taking a 15-minute walk—were challenging because she got very tired despite having no medical illness other than obesity.
It quickly became apparent that Betty was filled with rage because she had been sexually abused as a child by her mother's boyfriend over many years. We identified the source of her rage through brief psychotherapy, using my learning, philosophizing, and action (LPA) technique.
This helped the patient to develop a better identity and image of herself. I also incorporated a behavior modification program for her weight control. Then I directed her to a diet and exercise program connected to a hospital. A year later, Betty was 105 pounds lighter.
Psychiatrists have long known that excessive eating is associated with emotional factors, including anxiety and identity issues. Domestic issues and financial problems, leading to confusion and frustration, also play a part in excessive eating.
Overeating has been associated with hostility that cannot be expressed and therefore gets directed into dysfunctional behaviors. Certainly, decreased self-esteem, poor identity, and sexual inadequacy many times lead to overeating. Food can be a substitute for a lack of attention—or even love. Some types of depression are also characterized by lethargy and excessive eating.
In Betty's case, her overeating appeared connected to unexpressed rage from feelings of decreased self-esteem secondary to the abuse. The rage was expressed in overeating and led to increased weight. Because of the extra weight, Betty was not particularly attractive and faced social rejection. That rejection validated her low self-esteem, which originated from the abuse.
This illustration clearly demonstrates how eating habits—good and bad—can develop through learning or intrapsychic processing.
In this country, obesity appears to be on the verge of being deemed a medical illness. This is good news, considering that obesity-related medical treatments improve physical health. Whether a person's corresponding mental outlook changes is variable and may be questionable.
Meanwhile, obesity and obesity-related illnesses continue to increase at a rapid pace. Those who need immediate help for severe weight problems are turning to bariatric surgery, an intervention that has had positive results for serious obesity. But bariatric surgery is expensive and not without risks.
Advances in surgery are models for those of us in psychiatry—another medical specialty—as we develop weight control programs. In many cases, obesity is the result of learned behaviors. We in psychiatry have the ability to help unscramble the negative lessons that can lead to unhealthy eating. And for many patients, our techniques would be just as effective and probably less expensive than bariatric surgery.
I have had moderate success in my weight control treatment work. In my private practice and at New York University/Bellevue Hospital Center, I used a hypnosis-cognitive approach substantially modified from the work of Herbert Spiegel, M.D., and David Spiegel, M.D., as described in “Trance and Treatment” (New York: Basic Books, 1978).
Some of those results, such as those with Betty, were quite positive. Whether we help our patients to relearn how to eat or explore other factors in their development that influence their eating habits, the biggest challenge is helping people like Betty realize that emotional issues affect what and how they eat.
Because the “craving” centers of our brain seem to share the same chemical mechanisms, we already have some excellent models in place for treating obesity. The data seem to point to similar mechanisms in brain activity in both behavioral addictions—such as gambling, sex, or eating—and chemical and alcohol dependencies.
I believe that a psychotherapeutic program tailored to each patient's emotional needs would be the best approach. Using these psychiatric concepts, plus diet and exercise in a hospital-based setting, might be ideal. Yes—I did say the program should be based in a hospital.
Now that bariatric surgery is establishing obesity as a medical illness, we can use medical treatment concepts—with psychiatry leading the way—in a comprehensive medical model to treat and control weight problems. And, like the noninvasive procedures that are among the brilliant medical advances developed over the last 30 years, treatments for obesity can involve medical interventions that are much less invasive than bariatric surgery. The medical model is useful because the health consequences of obesity go beyond what the gym or weight-control program can affect.
If we can make a good case for the health care reimbursement of medically approved weight-control programs, why not recommend basing these programs in a hospital setting? Hospitals have all the guidelines in place to monitor patients, to keep accurate records, and to deliver a full spectrum of care. We are, after all, caregivers.
I envision a 1-year plan of psychotherapy for these obese patients, who may not want bariatric surgery, who may be too heavy and thus a surgical risk, or who may not be heavy enough to qualify for the surgery. The patient might meet with a psychiatrist individually or in small groups.
Coupled with the psychiatric treatment plan would be a medically driven exercise and diet program based on sensible and tailored physiological guidelines. Included with the psychotherapy, diet, and exercise would be appropriate medications, when helpful. Adherence to all of the components of the program would be essential.
Using this noninvasive approach, I think we would see a dramatic improvement in many obese people. We already provide medical care for patients with the medical illness of obesity that is of such serious proportions that surgery is warranted. But for so many others, why not try a noninvasive approach under the hospital “roof”? We know that weight control programs in which participants spend a month or more at a center yield results that are initially positive but not long lasting.
For many patients, bariatric surgery has been a great breakthrough. But I expect the procedure to come under more cost scrutiny as demand increases and as longer term follow-ups come in, perhaps showing increased complications.
When I ran my idea past Wendy Z. Goldstein, president and chief executive officer of Lutheran Medical Center, New York, she agreed that behavioral interventions were worth examining from a medical point of view. And if they were cost effective, she pointed out, that would be a plus. “Our hospital and others should explore programs that focus on helping patients achieve noninvasive weight control,” said Ms. Goldstein, a longtime advocate of medically appropriate bariatric surgery. “This approach also might help us reach more patients and improve community health.”
I have seen these approaches work on a small scale with patients like Betty and others at the New York University/Bellevue Hospital Center in the short-term psychotherapy program that I ran. We need to be in the forefront of weight control treatment as part of our major contribution to health care. Feel free to write me at cpnews@elsevier.com, and let me hear about your ideas as mental health professionals about treating obesity. I'll try to pass them along to my readers.
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