Approximately 80% of all severe cases involving anorexia or bulimia have a coexisting major depression diagnosis. Depression is a very painful and all consuming disorder in and of itself. However, in combination with an eating disorder, depression is beyond devastating and is often masked within the eating disorder itself. Depression in eating disorder clients looks different than it does in clients who have mood disorder alone. One way to describe how depression looks in someone who is suffering with an eating disorder is: hidden misery. For eating disorder clients, depression takes on a heightened quality of hopelessness and self-hatred, and becomes an expression of their identity, not a list of unpleasant symptoms. The depression becomes intertwined with the manifestations of the eating disorder, and because of this interwoven quality, the depressive symptoms are often not clearly distinguishable from the eating disorder. One purpose of this article is to highlight some of the distinctions and differences in how depression manifests itself in someone suffering with anorexia or bulimia. Another purpose is to provide suggestions that will begin to foster hope for these hopeless clients within the therapy setting.
When dealing with eating disorder cases, it is important to understand that if major depression is present, it is most likely present at two levels. First, it will be evident in a history of chronic, low level, dysthymic depression, and secondly, there will be symptoms consistent with one or more prolonged episodes of acute major depressive disorder. The intensity and acuteness of the depression is not always immediately recognizable in how the client is manifesting their eating disorder. Clinical history taking will reveal chronic discouragement, feelings of inadequacy, low self-esteem, appetite disturbance, sleep disturbance, low energy, fatigue, concentration troubles, difficulty making decisions, and a general feeling of unhappiness and vague hopelessness. Since most eating disorder clients do not seek treatment for many years, it is not uncommon for this kind of chronic dysthymic depression to have been in their lives anywhere from two to eight years. Clinical history will also reveal that as the eating disorder escalated or became more severe in its intensity, there is a concurrent history of intense symptoms of major depression. Oftentimes, recurrent episodes of major depression are seen in those with longstanding eating disorders. In simple words, eating disorder clients have been discouraged for a long time, they have not felt good about themselves for a long time, they have felt hopeless for a long time, and they have felt acute periods of depression in which life became much worse and more difficult for them.
One of the most unique characteristics of depression in someone who is suffering with an eating disorder is an intense and high level of self-hatred and self-contempt. This may be because those who have these major depressive episodes in conjunction with an eating disorder have a much more personally negative and identity-based meaning attached to the depressive symptoms. The depressive symptoms say something about who the person is at a core level as a human being. They are much more than simply descriptive of what the individual is experiencing or suffering from at that time in their life. For many women with eating disorders, the depression is broad evidence of their unacceptability and shame, and a daily proof of the deep level of "flawed-ness" that they believe about themselves. The intensity of the depression is magnified or amplified by this extreme perceptual twist of the cognitive distortion of personalization and all-or-nothing thinking. A second symptom of major depression shown to be different in those who suffer with severe eating disorders is that their sense of hopelessness and despair goes way beyond "depressed mood most of the day, nearly every day." The sense of hopelessness is often an expression of how void and empty they feel about who they are, about their lives, and about their futures. Up until the eating disorder has been stabilized, all of that hopelessness has been converted into an addictive attempt to feel in control or to avoid pain through the obsessive acting out of the anorexia or bulimia.
Thirdly, this hopelessness can be played out in recurrent thoughts of death, pervasive suicidal ideation, and suicidal gesturing which many clients with severe anorexia and bulimia can have in a more entrenched and ever-present fashion than clients who have the mood disorder alone. The quality of this wanting to die or dying is tied to a much more personal sense of self-disdain and identity rejection (get rid of me) than just wanting to escape life difficulties. Fourth, the feelings of worthlessness or inadequacy are unique with eating disorders because it goes beyond these feelings. It is an identity issue accompanied by feelings of uselessness, futility, and nothingness that occur without the distraction and obsession of the eating disorder.
A fifth, distinct factor in the depression of those with eating disorders is that their excessive and inappropriate guilt is tied more to emotional caretaking issues and a sense of powerlessness or helplessness than what may typically be seen in those who are suffering with major depression. Their painful self-preoccupation is often in response to their inability to make things different or better in their relationships with significant others.
A sixth factor that masks depression in an eating disorder client is the all consuming nature of anorexia and bulimia. There is often a display of high energy associated with the obsessive ruminations, compulsivity, acting out, and the highs and lows in the cycle of an eating disorder. When the eating disorder is taken away and the individual is no longer in a place or position to act it out, then the depression comes flooding in, in painful and evident ways.
Compassion for the Hopelessness
The reality of working with people who are suffering in the throws of depression and an eating disorder is that it is difficult not to feel hopeless for their hopelessness. Their hopelessness is extremely painful. It is an inner torture and misery, and it is encompassed by intense feelings of self-hatred and self contempt. For many, their emotional salvation was going to be the eating disorder. It was going to be thinness, physical beauty, or social acceptability. Many come to feel that they have even failed at the eating disorder and have lost the identity they had in the eating disorder. Hence, the hopelessness goes beyond hopeless, because not only is there nothing good in their lives, there is nothing good in them. Not only is there no hope for the future, there is nothing hopeful at the moment but breathing in and out the despair they feel. It feels to them like the suffering will last forever. Therapists who work with eating disorders need to be prepared for the flood of depression that pours out once the eating disorder symptoms and patterns have been stabilized or limited to some degree.
It is my personal observation that clinicians need to change what they emphasize in treating depression in those engaging in recovery from eating disorders compared with those for whom depression is the primary and most significant disorder. Therapists need to find ways to foster hope for the hopeless, much more so for someone with an eating disorder because oftentimes these clients refuse comfort. They refuse solace. They refuse support. They refuse love. They refuse encouragement. They refuse to do the things that would be most helpful in lifting them out of the depression because of their intense inner self-hatred.
For the therapist, the pain that fills the room is tangible. Clients are often full of sorrow and anger for who they are, which takes the symptoms of depression to a deeper level of despair. In working with eating-disordered clients with this level of depression, it is important for the therapist to show a deep sense of respect, appreciation, and love for those who feel so badly about themselves and who are suffering so keenly in all aspects of their lives. In spite of all the suffering, these people are still able to reach out to others with love and kindness and function at high levels of academic and work performance. They are still able to be wonderful employers, employees, and students, but they are not able to find any joy in themselves, or in their lives. These clients tend to carry on in life with hidden misery, and a therapist's compassion and respect for this level of determination and perseverance provides a context for hope. As therapists it is important that a sense of love and compassion grows and is evident in these times when the client feels nothing but hopeless and stuck.
Separating Depression from Self-hatred
One of the key components of working with the depression aspects of an eating disorder is to begin to separate the depression from the self-hatred. It is important to help the client understand the difference between shame and self-hatred. Shame is the false sense of self which leads someone to believe and feel that they are unacceptable, flawed, defective, and bad, an inner sense that something is wrong with their "being." They feel unacceptable to the world and to themselves, and feel that somehow they are lacking whatever it is they need to "be enough." Self-hatred is the acting out of that shame within and outside of the person. The self-hatred can be acted out in the negative mind of the eating disorder, that relentless circle of selfcriticism, self-contempt, and negativity that is a common factor in all who suffer with eating disorders. The shame can be acted out through self-punishment, self-abandonment, emotional denial, avoidance, minimization, self-harm, self-mutilation, and through impulsive and addictive behaviors both within and outside of the eating disorder. Self-hatred is the ongoing gathering of evidence within the client's own mind that they are broken, and unacceptable. In time, the eating disorder becomes their main evidence that there is something wrong with them and that they are unacceptable. And so, in a sense, the eating disorder is their friend and their enemy. It is a source of comfort and it is the reason they will not be comforted, and until they can achieve perfection in the mind-set of an eating disorder, they have great cause to hate themselves for who they are and who they are not.
All of these examples of self-hatred become intertwined with the symptoms and the expression of the depression, and so it becomes important in therapy to help the client to separate what depression is and what self-hatred is for them. It has been my experience that focusing on the aspects of shame and self-hatred has been more helpful to those who have eating disorders than focusing only on the depression itself. The self-hatred amplifies the intensity and the quality of the depressive symptoms. By focusing on the self-hatred aspects we begin turning the volume down on how the depressive symptoms manifest themselves with the client.
I have found that emphasizing the separation of self-hatred from the depression and its symptoms, and then beginning to change and soften the expressions of self-hatred fosters hope and generates hopefulness. Clients begin to see and sense that maybe the problem is not entirely who they are. Some hope comes from knowing that the feelings and the sense of self they have may not be accurate and true. They may recognize that some of what they have done forever and what has felt very much a part of their identity is really a chosen and acted out pattern of self-hatred. Somewhere in this separation of self hatred and depression they begin to feel hope in themselves, hope in letting go of pain, and hope in having their life feel, look, and be different.
Another reason for the emphasis on self-hatred is to help clients begin to recognize and challenge the unique quality of the all-ornothing thinking that leads them to filter everything about their lives in this most negative, personal, and self-contemptuous way. Hope is generated by learning that everything does not say something bad about who they are, that normal life experiences are not evidence that there is something wrong with them, and that negative feelings do not prove as true, what they have always felt about themselves. The unique perfectionism inherent in this all-or-nothing thinking allows no room for anything but perfection in any area of thought, feeling, or behavior. To be able to let go of the self-hatred filter and begin to see many of these thoughts, feelings, and behaviors they experience every day as typical, usual, and acceptable begins to foster hope, more importantly the kind of hope that is not tied to the false hopes of the eating disorder itself. Part of what has made the eating disorder so powerful is that clients put all of their hope in the eating disorder itself. Eating disorders are hopeless because after clients have done everything in their power to live them perfectly, they have only brought misery, despair, dysfunction, and more hopelessness. The attempt to generate hope through anorexia and bulimia has failed. By focusing on the self-hatred, they begin to separate their eating disorder from themselves. They also begin to separate the eating disorder from their source of hope. They begin to recognize that hope is within themselves and hope is within reach if they will soften how they view themselves and if they will change how they treat themselves internally and externally. Separating the depression from the self-hatred can help clients see the eating disorder for what it really is, with all its lies and consequences, and can help them begin to see who they are in a more honest and accurate way.
Renaming the Depression
I have also found it helpful in working with this clientele to rename or re-frame the depression and its symptoms within some kind of specific pain they are experiencing. I emphasize the pain aspects because part of what makes the depression so painful for those with eating disorders is the internalization of hopelessness. We can remove the global, ambiguous, and future sense of the depression, and break it into smaller pieces, more specific, immediate, and emotionally connected to their experiences rather than to their identity. We talk a lot about their feelings of hurt and sadness, and explore and deepen their understanding about their sense of feeling unloved, or their sense of inadequacy, or their feelings of rejection and disapproval, etc. I try to underpin the depression in very specific and emotionally-connected understandings and expressions. Rarely do I talk to them about their depression explicitly while we are trying to understand, validate, and generate hope in specific areas of their pain. I have found it more helpful to spend sessions talking about how to generate hope for themselves over a sense of loss, a sense of powerlessness, a sense of disappointment, etc., rather than to keep talking about depression and what to do to help lessen it. The realization is that in the process of fostering hope by focusing on and discussing the different kinds of pain, we are also de-amplifying and de-escalating the depression. It is impossible to get to the bottom of depression and avoid the specific pain, since avoiding the pain is what clients have been trying to do through the eating disorder.
It is important to note here that there certainly can be, and usually is, biochemistry involved in the quality, intensity, and type of depression they are experiencing, and that careful evaluation and utilization of antidepressant medications is strongly encouraged as an active part of the treatment. It is also important to remember that clients with severe eating disorders often resist the notion of medication or sabotage use of the medication as an attempt to control their body and weight, and to foster a sense of control. It is important to be very attentive and regularly follow up on taking medication and continue to help them in the positive interpretation of the use of medication. Too often, medicine represents weakness and becomes evidence to again engage in self-hatred rather than being viewed as one more piece of the puzzle that will help generate hope in their recovery. It is my experience that clients often respond to and benefit from medication if we can reframe the medicine as a hopeful part of their healing and their recovery from both the depression and the eating disorder.
When dealing with eating disorders it is also important to continue to evaluate and recognize the impact of malnourishment on clients' ability to process and/or modify the way they process information about themselves and about their lives. It is important to stabilize the eating disorder as a primary intervention and to emphasize renourishment before there will be a lot of success in treating the depression. Renourishing the brain and body is an important early framework for fostering hope.
Another important component in treating depression among eating disorder clients is moving them out of isolation. It is often a very powerful intervention for clients to re-engage and reconnect with other people. Moving out of isolation and reconnecting with others in their lives generates hope. Pursuing a re-connection with others emphasizes opening themselves up to feel connected, to feel the love, compassion, and interest from others towards them and in expressing their own compassion and love toward family members, friends, other clients or patients, etc. Involving families in family therapy, partners in couple therapy, and friends in the treatment are often very powerful ways to lessen the depression and increase hope for clients because they feel comforted and supported by those who love them and care for them. Helping clients to communicate again with people in their lives brings hope and renewed ability to feel something different than self-hatred. To receive expressions of someone else's love, concern, and genuine caring is hopeful and becomes a very important part of treatment for the depression.
Letting go of False Guilt
Another aspect of the treatment of depression relates to the intense and unrealistic levels of guilt. Again, the reason the guilt becomes unique for those with eating disorders is because of the self-hatred. The guilt tells them to feel bad and terrible about themselves because they are not perfect, or not in complete control, or not accomplished, or not accepted or liked by everyone, or because there are people in their lives who are unhappy. A pain that will not heal is the false guilt associated with untrue or inaccurate realities. It is helpful in working with eating disorder clients to help them clarify the difference between real guilt and false guilt. We can help them recognize that real guilt is associated with having literally done something wrong. Their recognition of that fact can lead them to correct it. False guilt tells them to feel bad and terrible about themselves, and whatever has happened becomes the evidence against them which supports the feeling of guiltiness. Oftentimes I try to help clients understand specific ways that false guilt enters the picture and feeds the self-hatred. It is frequently tied to areas of their lives where they feel or have felt powerless but have made themselves emotionally responsible. An example of this might be feeling bad about themselves because they feel responsible for a specific relationship outcome they do not really have the power to create on their own. They may feel badly about themselves because they cannot fix a situation or problem someone they love or care about is experiencing, or because they could not prevent a tragedy. False guilt is a sense of shame, feeling like they "should have known better" or had it "figured out" beforehand. False guilt is often an expression of what they are not, rather than who they are or what they are capable of doing. Sometimes the false guilt is just an active expression of the intense pattern of negative comparison between themselves and others that is so common with eating disorders. Eating disorder clients are constantly comparing themselves to someone else, both physically and behaviorally, and end up feeling a great deal of guilt about who they are because they do not match up in their comparison with someone else. Sometimes false guilt is an expression of self-hatred for some wrong done in the past, something they will not let go of or forgive themselves for. They continue to actively punish themselves for what happened or what they felt bad about doing, sometimes a very long time ago. They hold it against themselves mentally as support for their self-rejection.
Often the false guilt and feeling bad about themselves is tied directly to how important people in their lives are behaving or acting. They tend to somehow feel responsible or accountable for someone else's negative choices or behaviors. False guilt gives them a sense of hopelessness because their ability to change it or re-frame it differently is impeded by their all-ornothing filter of self-contempt. They may compare themselves to unreasonable self-standards that no one could live up to, and therefore they become the exception to all the rules of normalcy. Somehow they have to live above acceptable, and the sense of guilt is evidence that they are not living at that expected, higher level of performance. Oftentimes when they hear feedback from other people about their behaviors, in particular their eating disorder, it becomes another encouragement to feel false guilt. The problem with self-guilt is that it produces intense feelings of fault, blame, guiltiness, shame, anxiety, and sadness, but instead of moving them to correction and change, it moves them to selfhatred, self-criticalness, self-doubting, and self-punishment. False guilt always leads to more hopelessness. Releasing false guilt fosters hope because it leads to an increased sense of freedom and choices through the setting of clear emotional boundaries.
In conclusion, it is important to emphasize that in order to truly intervene in the area of depression with those who have an eating disorder, we need to first stabilize and lessen the intensity and the acting out of the eating disorder. Until we do that, we are probably not going to truly see the depth and the extent of the depression and the very personal nature of how the depression manifests itself in eating disorder clients. It is also important to increase our awareness and understanding of how depression is uniquely different in those who suffer with eating disorders because it gives us therapeutic options and a framework to intervene in a more compassionate and hopeful way with those who have these coexisting disorders. The most helpful thing we can do in every session with these clients is to generate hope. Nurturing hope is not always a clear-cut and obvious list of techniques or interventions, but rather a willingness by both client and therapist to face the hopelessness in a kind and loving context. I hope that these therapeutic distinctions and suggestions will begin to foster some hopefulness for clients suffering with a coexisting depression and eating disorder. In facing the hopelessness, pain, selfhatred, guilt, and isolation, we can, little by little, foster and generate hope and decrease the depression. New hope will lead to answers. Genuine hope will lead to something better. Honest hope will lead to change.