In our society, in which obesity is variously considered a sign of the person's lack of self-discipline or self-respect, or a manifestation of self-loathing, it is rare to encounter people who are called obese but feel happy about their bodies.

The Diagnostic and Statistical Manual of Mental Disoders-5 authors proposed adding Obesity as a mental illness to the next edition of their manual. Although it appears that they have withdrawn this specific proposal, it may reappear (as often happens with DSM proposals), and in any case the fact that it was even submitted reflects a strong tendency for both therapists and laypeople to consider obesity a sign of mental illness. As Kara Massie, Amy Cavanagh, Julie Davis, and Aleta Storch [1] explain, this raises many questions. For one thing, since obesity is so harshly judged, would not, for instance, shame and fear about being obese be understandable feelings about one's body in reaction to that judgment, rather than problems that simply spring on their own from within the individual's psyche? For another thing, what is the point of considering this physical condition a mental illness, when few other physical conditions are so classified?

One answer to the latter question would be to claim that, because obesity is simply a consequence of ingesting too many calories and/or exercising insufficiently, it is obvious that obesity must result from some disordered emotion(s) driving the person to eat too much and/or exercise too little. However, there are known physiological conditions, such as Chronic Fatigue Syndrome, that often - and usually for reasons not yet understood - make it difficult if not impossible to lose weight and extremely easy to gain. Furthermore, relatively little is known about physical conditions that can lead to obesity, so it is currently virtually impossible to rule out physiological causes of extreme weight gain. Another way to say this is that obesity is a result of something or some things, but to call it a mental illness is to convey the message that it is always caused by the individual psychological problems of the obese person.

It is ironic that, as described in my previous essay, many psychiatric drugs cause weight gain in significant percentages of the people who take them, because we then have this vicious cycle: A professional assumes that a mental illness causes Ellen's obesity and prescribes a drug that is supposed to cure that mental illness. If Ellen is one of the people whose weight skyrockets because of taking the drug, she is likely to become sad, ashamed, or anxious, maybe even agoraphobic, so that if she did not actually have a mental illness (however you choose to define it) before taking the drug, she ends up with serious emotional problems because of it. [2] And what do we do when that happens? Add yet another drug or two to treat the resulting emotional problems? One reader of this blog wrote of "gaining 35 pounds in a year of taking Lexapro. For the past years of my life I had been at a healthy weight" and on Lexapro had continued the previous schedule of exercise and eating." Now says, the reader, "I am no longer depressed, but I am stuck with a poor body image."

On a recent email list, someone sent a request for treatment resources for a young woman she described as engaging in "emotional eating." Despite the public announcement some months ago that obesity itself would not go in DSM-5, the writer described the young woman as having "EDNOS," which stands for "Eating Disorder Not Otherwise Specified." This illustrates how easy it will be to diagnose obesity as a mental illness under a different name. The writer of the email said that the young woman works with a trainer, sees a counselor, and is substantially overweight, but she did not say whether she had been checked for any of a great many metabolic or other known physiological causes of weight gain, nor did she say whether or not she was taking psychiatric drugs. Since in a culture obsessed with physical appearance and especially with thinness in women, as well as obsessed with food in often unhealthy ways, it is often hard to find young women for whom eating is not associated with troublesome emotions; thus, it is particularly important not to jump to the conclusion that obese people are obese because of disordered emotions. As with anything regarded as a problem, the full range of possible causes should be considered. Calling obesity a mental illness is likely to reduce the chances of such full exploration.

A reader who identifies herself or himself as a psychiatrist but posts as Anonymous on this site raised a number of concerns about my "Elephant in the Living Room: Obesity Epidemic and Psychiatric Drugs" essay. Anonymous asked whether anyone has researched the connection between obesity and drugs, but I had provided some of the extensive documentation of that very connection. The reader suggested that "elephant in the living room" was an inappropriate metaphor, because such weight gain is more like the squirrel on the coffee table. But the reader who gained 35 pounds in a year on Lexapro does not consider that change to be a minor irritant, nor, I suspect, do the one in six people taking Zyprexa who gain an average of 33 pounds during their first two years on the drug.

And though Anonymous pointed out that "Weight gain is listed as a possible side effect on pretty much every psychotropic drug I've ever seen" (thus in part answering her/his earlier question about documentation), it is simply untrue that this "is common knowledge": Patients often report that the prescribing professionals actually failed to alert them to the substantial probability of major weight gain from the drug. Many have made remarks to me along the lines of, "I might even have gone ahead and taken the drug, but it would have been nice to know ahead of time that I might gain 30 pounds and be unable to take it off, and I might get diabetes or serious heart disease or both, so that I could at least make an informed decision." Informed choice is my primary concern here.

Anonymous proposes that we need to ask is not how many psychiatric patients are obese but rather how many obese people are taking such drugs. That is an interesting question but not germane to the point I was making, which was that, however much of obesity is caused by psychotropic medication, the well-established connections between weight gain and the drugs is virtually ignored in popular media and even to a great extent in scholarly publications.

Finally, Anonymous expresses alarm that if patients were told about these connections, they might suddenly stop taking their drugs, with serious ("potentially fatal") consequences. It is alarming that some professionals who write these prescriptions withhold warnings about negative effects, lest the patients refuse to take or stop taking the drugs. Patients have the right to be offered all available information, if we are not to infantilize them and deprive them of the opportunity to make educated decisions about their bodies and their lives. Indeed, Anonymous' implication that patients should not have this information or are likely to base rash decisions on it is an illuminating example of one danger of psychiatric diagnosis, i.e., that some therapists use the fact that a person has received a label to justify choosing what to tell them and what to conceal from them. This is all the more worrying, given that the effects of some of these drugs has been shown to shorten the life span. [3] Decisions about their health and sometimes literally about life-and-death matters should not be taken from people just because they have been classified as mentally ill. But since that happens, we must take all the more care to avoid overusing psychiatric categories and inventing new ones without careful consideration.

©Copyright 2011 Paula J. Caplan All rights reserved

[2] In this connection, see Comment on this site posted by Tricia on May 15, 2011.
[3] As just a few examples, see:
Colton C. "Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states," Preventing Chronic Disease 3 (April 2006)
Jourkamaa M. "Schizophrenia, neuroleptic medication, and mortality," Br J of Psychiatry 1888 (2006):122-27.
Morgan, M. "Prospective analysis of premature mortality in schizophrenia in relation to health service engagement," Psychiatry Research 117 (2003):127-35.
Saha, S. A systematic review of mortality in schizophrenia: is the differential morbidity group worsening over time? Arch Gen Psychiatrty, 2007, 64(10):1123-31.

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