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.