Depression and Eating Disorders
Spring 2006, Vol 5, Issue 2
A. David Wall, PhD, Department of Psychological Services
Edward J. Cumella, PhD, Department of Research and Education
Remuda Ranch Programs for Eating Disorders
How long must I wrestle with my thoughts and every day have sorrow in my heart? (Psalm 13:2)
Depression is eating disorders’ (EDs) most common co-occurring psychiatric problem (Bulik, 2002). Across studies, between 20 and 98% of ED patients have been diagnosed with some form of depression (Blinder, Cumella, & Sanathara, 2006). At Remuda, 90% of adults and adolescents, and 81% of children, have a depression diagnosis at admission. Because depression is so common with ED patients, ED practitioners need to understand the relationship between depression and ED and how to treat co-occurring depressive symptoms.
Many see depression primarily as sad or blue feelings. Although sadness is often at depression’s core, it does not in and of itself define depression. In depressed adolescents, irritability rather than sadness is often the primary mood. On the widely-used Beck Depression Inventory-II (Beck, Steer, & Brown, 1996), people can indicate that they do not feel sad and still achieve scores indicative of depression, even extreme depression. Hence, depression manifests in a range of symptoms in addition to or even in lieu of sadness. These symptoms include anhedonia, weight fluctuations, fatigue, guilt, concentration and sleep problems, indecision, and others.
Depression can be primary or secondary. Both primary and secondary depression are typically diagnosed in DSM-IV as major depression, dysthymia, or depression not otherwise specified. In primary depression, no other mental or physical disorder plays a significant etiological and/or maintaining role in the depression. The depression stands alone, or without significant relation beside another condition. However, in secondary depression persons become depressed because of their emotional and mental reaction to another physical or mental condition. For example, someone just diagnosed with progressive vision loss may sink into deep depression due to impending blindness. People with obsessive compulsive disorder often experience extreme depression because they are overwhelmed by the pervasive anxiety of their obsessions and the tyranny of having to engage in compulsive behaviors. Even when depression is secondary, it still requires treatment, because the triggering condition may
not be fully treatable or, even if it is, the depression may not resolve when the triggering condition resolves.
Two additional DSM-IV variants of secondary depression include depression due to the direct physiological effects of a medical condition and substance-induced mood disorder. In these situations, the individual manifests symptoms of depression, but the symptoms are definitively explainable by physiological mechanisms associated with the underlying medical condition. Common medical conditions that lead to such secondary depression are malnutrition, degenerative neurological illnesses, strokes, endocrine and autoimmune disorders, certain cancers and viral infections, and the use of a range of prescription and illegal substances. It is important to understand these forms of secondary depression when working with EDs because ED patients often abuse substances and may be chronically malnourished—both of which can produce secondary depressive symptoms. Screening for these conditions, especially for substance abuse, is therefore essential with ED patients.
One preliminary study suggested that many ED patients develop depression at some time after they have first developed their ED (e.g., Yaryura-Tobias et al., 2000). Thus, depression may often be a secondary condition caused by EDs or associated malnutrition. In other ED cases depression may come first and be primary.
A Synergy of Problems
In addition to high co-occurrence, there is also symptomatic overlap between depression and EDs. For comparison, the table below lists the DSM-IV features of major depression and dysthymia juxtaposed with the primary features of EDs.
Depressed mood is not, in and of itself, a feature of EDs. Thus, when present, it indicates possible co-occurring depression. To help differentiate primary from secondary depression, it is useful to determine whether ED patients’ depressed mood is chiefly in response to their being prevented from practicing their ED or is a more general experience that occurs even when they are able to engage in ED behavior.
Anhedonia, like depressed mood, is not in and of itself a feature of EDs. Thus, when present, it indicates possible co-occurring depression. It is important and often difficult, however, to differentiate whether the anhedonia is merely apparent or real. Apparent anhedonia can occur because the ED has so absorbed patients’ time and mental energy that they have let go of other interests they once had. Upon probing, individuals with merely apparent anhedonia often state that they would still like to engage in various activities and express hope that these activities will one day be part of their lives again. In true anhedonia, patients more clearly indicate that they have lost interest in, or express a blasé attitude about, activities from which they once gained satisfaction.
Major Depression Dysthymia Eating Disorders
Depressed Mood Depressed Mood
Anhedonia/Loss of Interest or Pleasure in Most Activities ED absorbs time, leading to removal from other activities
Weight Loss/Gain Weight Loss/ Gain
Decreased or Increased Appetite Decreased or Increased Appetite Eating Less or More
Insomnia or Hypersomnia Insomnia or Hypersomnia
Psychomotor Agitation or Retardation Psychomotor Agitation or Retardation
Fatigue/Loss of Energy Fatigue/Loss of Energy Fatigue/Loss of Energy (when severe malnutrition is present)
Concentration Problems Concentration Problems Concentration Problems (related to malnutrition)
Feelings of Worthlessness Low Self-Esteem Body Hatred/Negative Body Image
Excessive Guilt
Indecisiveness Indecisiveness
Recurrent Thoughts of Death
Suicidal Ideation/Plan/
Attempt Hopelessness Hopelessness as ED gets out of control
Weight loss/gain as well as changes in appetite and eating are part of both depression and EDs. In both disorders weight loss or gain can be excessive. However, since weight loss/gain and appetite changes are the core symptoms of EDs, in practice it is difficult to use these symptoms to make a depression diagnosis in ED individuals. It may be useful to note that when appetite and weight changes are present in depressed individuals who do not have EDs, these patients are not obsessed with weight, calories, and food; they do not fear food; they do not have a desire for excessive weight loss or extreme fear of gaining weight; and they do not use compensatory behaviors to eliminate calories consumed.
Insomnia and hypersomnia are primarily features of depression and not EDs. Thus, when present, they often indicate co-occurring depression.
It is often difficult to differentiate whether psychomotor agitation/retardation, fatigue/loss of energy, and concentration problems are the result of depression or of the anxiety and/or metabolic changes secondary to an ED. As such, in practice it may be difficult to base a depression diagnosis on these symptoms. A careful, longitudinal history can sometimes assist with this differential.
Indecisiveness is not ordinarily a feature of EDs. Therefore, when present, it is a good indicator of co-occurring depression. Differential diagnosis can be complicated, however, when dealing with patients who are ambivalent about ED recovery. Their ambivalence may manifest as indecisiveness, but usually in these cases the indecisiveness pertains mainly to the issue of whether to engage in the recovery process. More generalized indecision likely suggests depression.
Recurrent thoughts of death also do not typically characterize EDs. Therefore, when present, they are good indicators of co-occurring depression. Differentiating primary from secondary depression can be difficult, however, for ED patients with severe medical complica-tions or protracted EDs, especially those who have had multiple medical hospitalizations and/or treatment failures for their ED. These individuals may no longer deny that they may die from their ED. As such, they may be thinking regularly about death.
Excessive guilt about past actions or inaction is a DSM-IV feature of depression. When such guilt predated the ED, or covers a range of past behaviors, it suggests co-occurring depression. But even when patients feel guilty chiefly about their ED behaviors, excessive guilt is, in and of itself, suggestive of depression. Likewise, hopelessness and suicidality are not ordinary aspects of EDs and are inherently suggestive of co-occurring depression. Even when patients’ are mostly hopeless about ever recovering from their ED, hopelessness, in and of itself, suggests depression secondary to the ED.
Finally, there are the issues of low self-esteem and feelings of worthlessness. When negative feelings about oneself are long-standing, predate the ED, and generalize to contexts beyond eating and body image, we are more likely looking at symptoms of depression. When negative feelings about oneself are confined to body image and failure to adhere to strict, self-imposed dietary or exercise rules, we are more likely dealing primarily with an ED. Sometimes, however, perceived failure to achieve one’s ED goals, other losses related to the ED’s absorption of personal time, and negative experiences with other people who are judgmental or distraught about the patient’s ED, collectively diminish the patient’s self-esteem across multiple domains. In such cases, the ED has contributed to a genuine depressive symptom.
Clearly, depression and ED symptoms have a complex and even confusing relationship. One disorder feeds the other. For example, individuals with a history of low self-esteem are vulnerable to develop EDs, in part because their generalized self-esteem deficits lead them to negative views of their bodies. The malnutrition associated with EDs can exacerbate depressive symptoms such as poor concentration and anergia. The loss of dreams and narrowed focus associated with severe EDs often lead to hopelessness and despair. There is evidence of a common biological vulnerability that predisposes some people to both depression and ED (Mangweth et al., 2003; Silberg & Bulik, 2005). We also outline below a prominent approach to depression called learned helplessness that further underscores its interweaving with EDs.
In addition, recent studies (Cooper, 2005; Cooper & Hunt, 1998; Waller et al., 2001; Waller, Kennerley, & Ohanian, 2005) suggest that the core cognitions of patients with both depression and ED overlap substantially, such that there is a common set of distorted attitudes, beliefs, and perceptions that predispose individuals to both depression and EDs. These include self-perceptions of personal defectiveness, shame, vulnerability to harm, abandon-ment, failure to achieve, and social isolation. It is important to note, however, that one study (Cooper, Rose, & Turner, 2006) found a relatively small subset of cognitions that may distinguish ED patients from depressed patients. Self-perceptions that may be relatively unique to ED patients include expectations of betrayal, feeling unintelligent, dependent, and as though no one has ever cared deeply for them, and a perceived need to caretake others.
There is also the psychoanalytic concept of anaclitic depression. This term describes depression beginning early in childhood, related to separation or neglect from primary caregivers. It indicates a deep, forlorn experience of being alone in the world with no one to meet one’s needs. In recent days, aspects of anaclitic depression are addressed at least partially in the literature on attachment disorders. We have seen ED patients with severe attachment issues and concomitant (anaclitic) depression that appear to be etiologic of the ED. In such cases, the ED offers a sense of control to replace unstable and unpredictable relationships; it garners attention; it provides options for emotion regulation through the numbing and euphorogenic effects of starvation, bingeing, purging, and exercise; it fills the void of loneliness by occupying the person’s time and attention; and it prescribes rewards and punishments based on clear, concrete behaviors in the absence of external feedback. A deeper exploration of attachment issues, anaclitic depression, and EDs is not possible in this article. Those with greater interest in this topic can consult attachment resources, such as Cassidy and Shaver (2002).
In sum, depression and EDs intensify one another, have overlapping symptoms and cognitions, and at some points their features blend and can no longer be differentiated with confidence. In a practical sense, then, it is often prudent to treat ED patients’ depressive symptoms rather than assume that they are secondary to the ED and would spontaneously resolve when the ED or its physiological components resolve. Antidepressant medication in combination with cognitive behavioral interventions for depression may at a minimum assist patients to develop more rational and positive thinking, self-esteem, and coping skills. At a maximum, they will address a true depressive disorder in need of appropriate treatment.
Learned Helplessness and Depression
Depression is frequently conceptualized within the learned helplessness model derived from the work of psychologist, Martin Seligman (Seligman, 1975). In Seligman’s experiments, dogs received electric shocks while restrained. Later, even though no longer restrained and able to run away, the dogs stayed put and accepted the shocks. The principle was clear: Repeatedly experi-enceing an unavoidable aversive situation caused dogs to passively accept it, even when it could be easily escaped. The dogs had "learned helplessness."
This principle explains the helplessness that often accompanies depression in human beings. Those with histories of painful experiences over which they have had little or no control develop a pervasive sense of hopelessness and helplessness, manifested in the symptoms of clinical depression.
Seligman elucidated learned helplessness further by exploring the attributions of depressed persons (Alloy et al., 1988). When something painful happens individuals seek to determine why it happened; i.e., they seek to attribute a cause to the event. For example, people who have been abused often wonder, "Why me?". Attribu-tional answers to the "why" question can be:
• Internal: Something in me is the cause OR
• External: Something in the environment is the cause
• Specific: The cause is limited to this situation OR
• Global: The cause is will manifest in many situations
• Temporary: The cause won’t continue OR
• Permanent: The cause will always exist
Let us consider an example. If I receive an “F” in a class, I may conclude:
• I failed because I am not good at math (internal)
• I am not good at math because I am stupid (global)
• I will always be stupid (permanent)
I may alternately conclude:
• I failed because I did not study enough (internal)
• I am fairly good at math (specific)
• I won’t fail next time because I will study harder (temporary)
Or I may conclude:
• I failed because the teacher was unfair (external)
• Most teachers are fair (specific)
• I won't have this problem once I get rid of this unfair math teacher (temporary)
There are other combinations. Each possible set of attributions may be healthy or unhealthy, depending on its correspondence to reality.
Research demonstrates that when depressed people explain aversive experiences, they tend to make internal, global, and permanent attributions. The learned helpless-ness model purports that this is due to a history of painful events over which depressed individuals have had little or no control. Depressed persons’ attributions may run thus:
• I am helpless (internal)
• In all situations (global)
• There is nothing I can do to change this (permanent)
Attribution research also considers how people explain positive experiences, such as good grades in school or a work promotion. When something positive occurs in the lives of depressed individuals, they make the opposite kinds of attributions—external, specific, and temporary—the least optimistic attributions possible. To wit:
• I got an “A” because it was an easy class (external)
• It was just one class; most classes are hard (specific)
• I received an “A” this time, but won’t in the future (temporary)
Finally, depressed individuals also perceive their environ-ment as negative in a global and permanent way. For example:
• People are mean (external)
• Nobody accepts me (global)
• No one will ever accept me (permanent)
Depressed persons’ negative attributional styles reinforce a bleak view of their lives. They have determined that they have no control over negative or positive events—leading to an experience of helplessness. Negative events are likely to occur across life situations, while positive events are limited in scope; negative events recur, while positive events are occasional at best—leading to an experience of hopelessness. The primary cause of these problems is internal to the person him or herself—leading to an experience of worthlessness. Depression is built on this punishing triad of perceived helplessness, hopeless-ness, and worthlessness.
Aaron Beck, another renowned authority on depression, has a similar conceptualization involving self, world, and future (Clark, Beck, & Alford, 1999). In his view, individuals with a negative view of themselves (internal), the world at large (global), and the future (permanent) are prone to depression. Because Beck’s perspective can be seen to correspond closely to Seligman’s, it will not be addressed further in this overview article.
Learned Helplessness and Eating Disorders
In ED patients, a multi-faceted relationship exists between depression and the ED. For many ED patients, secondary depression arises after the ED (Godart et al., 2000; Yaryura-Tobias et al., 2000). In these cases, negative attributions about the ED are often the source of the depression. These negative attributions manifest chiefly in two ways, with some variant of the following cognitions:
• Factors outside of myself (e.g., my parents) caused me to have an ED (external)
• I cannot escape these factors (global)
• I am helpless to change because these factors won't go away (permanent)
• I am a horrible person because I have this ED that is hurting my body and my family (internal)
• I cannot do anything right (global)
• I am so messed up that I am beyond hope and can never change (permanent)
In these cases, because individuals attribute their ED to global and permanent factors, they feel helpless and hopeless to change their lives and they become clinically depressed.
In some ED cases depression arises before the ED (Godart et al., 2000; Yaryura-Tobias et al., 2000). These patients may actually experience the ED as an escape from their learned helplessness/depression. Instead of “I am helpless (internal), in all situations (global), and there isn’t anything I can do to change this (permanent),” ED patients may conclude: “I am helpless, except over what I eat; although I cannot control the world around me, I can control what I eat; controlling what I eat is the only thing I can do to change my experience of helplessness.” Through these ED attributions, the ED modifies the crushing experience of helplessness and hopelessness by opening a door through which the individual can make an impact on the world. For those who live in controlling families or have experienced years of peer rejection and ridicule, the ED may therefore paradoxically express an impulse toward health and freedom inherent in the human spirit—an effort to preserve and express the spirit in very limiting circumstances.
Whether depression precedes or follows ED, treatment is similar. The best treatment for depression in ED usually involves cognitive behavioral therapy combined with antidepressant medication. The cognitive behavioral approach begins by helping people recognize their thinking style. It can be useful to validate individuals’ histories of uncontrollable situations to help them understand how their thinking patterns developed. Validation is not a syrupy, "you are a wonderful person!" approach. Although positive regard, genuine concern, and acceptance are critical, true validation comes when we listen to patients’ stories and develop an understanding of how they became negative and helpless. We enable patients to see how their unhealthy patterns developed by pointing out significant themes from their lives and demonstrating how these experiences understandably led to their current ways of thinking and behaving.
Validation helps patients to feel better, but does not change their thinking patterns. Thus, we must next confront individuals with their ability to make new choices. They need to make conscious attempts to move beyond the past and elect new ways of thinking and behaving. Counselors help patients to see that, “Although you adapted the best you could back then, now you can make changes;" or, "You may have been helpless then, but you are not helpless now." Counselors then assist patients to frame more accurate and positive cognitive interpretations of their life circumstances and events.
As patients begin to change their perceptions, they are held to increasing responsibility for more changes. Of course, responsibility must be distinguished from blame. Helpless patients were often subject to constant berating and abuse in the name of making them more responsible. This history would cause most anyone to become responsibility-avoidant and perceive calls for responsi-bility as an attack. This issue must be raised and clearly addressed. Responsibility is a call to take control; blame is a call for punishment. The patient can be helped to see the difference. At this juncture, therapy for depressed ED patients will often need to include skill building to help individuals make continuing positive changes.
With validation and confrontation combined, patients recover. But therapists must work to balance validation and confrontation in the proper amounts for each patient; significant clinical error lurks at the extremes. One error is to constantly validate: "Of course you react negatively, who wouldn't given what you've been through”. If therapy stays here, patients do not improve and will likely become dependent on therapy. In addition, continual empathic responses to negative thinking reinforce such thinking. When patients say, "I am the worst person in the world," therapists may naturally respond, "No, you are wonderful, look at all of your wonderful qualities in spite of how mean people have been to you." If therapists do little more than respond in this manner, patient will remain stuck, repeating the refrain, “I am the worst person in the world,” to receive more validation. Therefore, therapists cannot allow patients to constantly pull out the "horrible past" card, even when the past was truly horrible. If this continues, patient remain helpless.
The other extreme ignores the difficult real-life forces that have shaped individuals’ current presentation. If thera-pists say: "You are engaged in negative thinking. All we need to do is change that and you'll be fine," such confrontation without validation will be experienced by patients as an attack and will demoralize them. They are unlikely to continue in treatment.
Many resources (e.g., Clark, Beck, & Alford, 1999) pre-sent greater detail on the cognitive-behavioral approaches described herein.
Biblical Understanding
At cursory reading, the Bible actually appears to endorse a posture of learned helplessness.
For we know that the law is spiritual; but I am made out of flesh, sold into sin's power. For I do not understand what I am doing, because I do not practice what I want to do, but I do what I hate. And if I do what I do not want to do … I am no longer the one doing it, but it is sin living in me. For I know that nothing good lives in me, that is, in my flesh. For the desire to do what is good is with me, but there is no ability to do it. (Romans 7:14-18; Holman Christian Standard Bible)
"There is no ability to do it!" That is indeed a statement of helplessness. Fortunately, Scripture doesn't leave us there. It continues: “… in all these things we overwhelmingly conquer through him who loved us” (Romans 8:37; New American Standard). We also read:
But he said to me, "My grace is sufficient for you, for my power is made perfect in weakness." Therefore I will boast all the more gladly about my weaknesses, so that Christ's power may rest on me. That is why, for Christ's sake, I delight in weaknesses, in insults, in hardships, in persecutions, in difficulties. For when I am weak, then I am strong. (2 Corinthians 12:9-10)
And finally we read, “In this world you will have trouble. But take heart! I have overcome the world” (John 16:33). These Scriptures validate our human struggles and feelings of helplessness—“there is no ability to do it!”, but also confront us with the possibility for change through a relationship with God—“we overwhelmingly conquer through him who loved us” and “when I am weak, then I am strong”. Scripture does not suggest that we simply tell depressed Christians to have greater faith and snap out of it, but rather that their feelings of hopelessness can be overcome with God’s help. Scripture also explains how God helps us to overcome the experiences of hopelessness and helplessness.
Because human beings interpret past events, we can learn to perceive past events in new ways and cope using new behaviors. God created us with the capacity to overcome painful histories and gain understanding within a much larger moral, existential, and spiritual framework. For example, the Apostle Paul states: “I consider that our present sufferings are not worth comparing with the glory that will be revealed in us” (Romans 8:18). He later indicates: “I have learned the secret of being content in any and every situation, whether well fed or hungry, whether living in plenty or in want. I can do everything through him who gives me strength” (Philippians 4:13). The Apostle James likewise instructs: “Consider it pure joy, my brothers, whenever you face trials of many kinds, because you know that the testing of your faith develops perseverance. Perseverance must finish its work so that you may be mature and complete, not lacking anything” (James 1:2-4).
These almost paradoxical spiritual exhortations underscore the human capacity for subtle understandings that allow us to transcend difficult experiences and benefit from them in ways that animals cannot. We as helping professionals can rely on this capacity to assist our patients to transform their depressive attributions into more accurate, positive, and freeing attributions by incorporating Biblical wisdom. This will assist them in developing a worldview that may help inoculate them against future depression by recognizing that their current pain is temporary and will produce something of lasting value in their lives. Scripture suggests a range of valuable gains that may come from suffering, including a deepened relationship with and reliance on God, greater compassion for others who are suffering, the ability to persevere and achieve long-term goals in spite of obstacles, stronger faith, and a heightened awareness of God’s ability to work good in the world even through difficult events and experiences. Books such as Willcox’s Feelings: Converting Negatives to Positives (2001), Yancey’s Where is God When it Hurts (1990), or Jantz’s Becoming Strong Again (1998) can help patients to mine their troubling experiences for spiritual gold and overcome depressive cognitions.
Personality Disorders, Eating Disorders, and Depression
Inasmuch as the human capacity for complex understand-ing and interpretation allows us to overcome problems in creative ways, it also opens the door to maladaptive coping that goes beyond simply giving up. In short, the human ability to contemplate and plan allows us to develop strategies for temporary relief that result in long-term problems. EDs are one such example. For instance, EDs may afford individuals escape from oppressively controlling environments, but they bring new dilemmas and threats to personal safety. In some cases, maladaptive coping strategies become so pervasive that they fully color an individual’s personality. Along with biological predispositions to certain maladaptive behaviors, the fact that these behaviors yield short-term gains reinforces these behaviors again and again to become the core of personality disorders. As such, we often see a triune diagnosis of personality disorder, depression, and ED.
Particularly in aversive and toxic environments, children develop maladaptive coping methods. These coping methods can be broadly categorized as flight, fight, or submit responses. Fighting involves the increasing development of defiant and rebellious behaviors. Flight or fleeing involves spending as much time out of the home as possible, isolation in the safest possible location, or mental escape through reading, music, the internet, or anything that decreases the frequency of aversive interactions. Submission is the strategy of the perfectionistic child who tries to avoid aversive situations by doing everything well and through submissive and placating behaviors designed to prevent hostility.
A fascinating aspect of EDs is that they are often a combination of all three coping methods—fight, flight, and submission. Many ED patients choose submit responses: they are perfectionistic and high achieving, meeting their parents’ and teachers’ expectations in every area except one, their ED. Through their ED, they fight against control by defying parental wishes and demands to eat or to stop bingeing and purging. This opposition often generalizes to healthcare providers. Finally, ED patients flee this irresolvable conflict between submission and rebellion by escaping into their ED world, where they are preoccupied with weighing and counting calories, fat grams, carbohydrates, and amounts of exercise; devising schemes to eat less or more, to hide food, and to increase their physical activity, each without being caught; reading, writing, and ruminating about ED behaviors; and so on. EDs are thus a paradox, a testimony to the complexity of the human mind and the spirit’s reach for mastery against difficult odds.
The more aversive a child’s environment, the more likely the range of maladaptive behaviors will expand. When these maladaptive coping behaviors are the only ones the person has found that work, they become deeply ingrained. Such pervasive, ineffective behaviors charac-terize the personality disorders. Repeated emotional pain from past abuse/neglect plus self-defeating behavioral patterns often comprise the core of a depressive disorder as well.
DSM-IV Cluster C personality disorders, the anxious-fearful type, may be the most common in ED patients (Westen, Thompson-Brenner, & Peart, 2006). But the single most common personality disorder associated with EDs, especially in patients with anorexia and bulimia who binge and purge, is in Cluster B, the dramatic-erratic type; it is borderline personality disorder (BPD). Perhaps as much as 25-50% of ED patients may have co-occurring BPD (e.g., Wonderlich, 1995). Depression is quite common in those with BPD. Therefore, ED practitioners are likely to see patients with all three diagnoses: co-occurring ED, depression, and BPD. Depression related to BPD has similarities to and differences from depression not associated with BPD. Depression related to BPD can be more complex to understand and treat.
First, depressive symptoms in BPD likely have secondary gain: they help the person obtain what they want and avoid what they do not want. For example, those with BPD may be self-deprecating, manifest helplessness and hopelessness, and mention suicide—all depressive symptoms—as a way of obtaining needed attention from other people. People see the depression and spend a lot of time cheering and building the person up. Those with BPD may also manifest social withdrawal, anhedonia, and anergia—additional depressive symptoms—in an effort to repel those at whom they are angry or of whom they are afraid. Depression symptoms without BPD rarely entail this degree of secondary gain.
Second, for many observers the depressive behaviors of those with BPD are often so irritating that judgmental and angry responses to these behaviors are, sadly, normal and understandable. These angry responses reinforce BPD patients’ perceptions that the world is threatening and unlikely to meet their needs, intensifying their depression and leading to more self-defeating, maladaptive behaviors aimed at garnering succor. Hence, in BPD, depression is likely to become a chronic condition characterized by chaotic interactions with others to meet needs in ways that are ultimately self-defeating. Here is an example. Josh has a strong need for approval coming from a childhood of parental neglect. He meets this need by people-pleasing. However, his need is so great that he requires constant affirmation. So Josh becomes ingratiating. This eventually wears on those around him. They pull back, reducing social affirmation. The decreased social affirmation causes Josh to use his maladaptive strategy even more to obtain approval—his people-pleasing intensifies. But this increase in ingratiating behaviors causes others to pull away even further. Josh becomes more depressed because his needs remain unfilled and because other people are now ignoring and ostracizing him. He re-experiences abandonment and neglect, changes his once positive perception of his friends, and now sees them as mean and awful people. So he moves onto new “friends”. But with them he repeats the same self-defeating pattern, with the same eventual consequence of abandonment.
Third, depression with BPD can be more profound than depression without BPD. Patients with BPD typically have early childhood histories of abuse and neglect, so they carry longtime wounds and profound unmet needs for love and affirmation. Their depression has also been intensified by other people's negative reactions to the frustrating behaviors they have used to meet their needs. Because of these continuing experiences of emotional deprivation, the wounding in persons’ with BPD is often lifelong. When such persons have an ED, they may cling to it tenaciously, because it may be the only reliable method they have found to meet their profound needs. EDs do significant harm to people, but they also soothe emotions, give purpose to life, and structure one’s time. EDs are there on demand, whereas other people may be unavailable.
Fourth, the attributions made by depressed persons with and without BPD also differ. Those with BPD may init-
ially sound like those with pure depression:
• I'm the problem in this relationship (internal)
• I have so many things wrong with me (global)
• I have always been this way, have failed at attempts to change, so I have no hope that I will ever be different (permanent)
But because their sense of reality and attributions are black-and-white and shift suddenly, they may also have the following set of near-contradictory attributions:
• People are rejecting (external)
• No one cares about me (global)
• I will never be able to count on anyone (permanent)
Let’s illuminate both sets of attributions. Such persons may say: "I am the worst person in the world. I hate myself." Then, 60 seconds later, they may cry out: "How can my boyfriend leave me?" These individuals do not see the logical inconsistency. If someone is the worst person in the world, why wouldn't her boyfriend leave her? Of course he would. People who completely hate themselves do not become demanding or feel they are being treated unfairly. Instead, they believe they deserve maltreatment. But inconsistent and oscillating attributions characterize depression with BPD and can be confusing for clinicians to deal with.
Finally, in depressed patients with BPD, there is a higher likelihood of self-injurious behavior. Such behavior can be life threatening and often derails therapeutic progress in other key areas because it rightly becomes the most pressing issue to treat.
When treating ED patients with depression and BPD, it is useful to rely on evidence-based methods established by Linehan (1993a, 1993b). Providers begin by collaborating with a psychiatrist to choose an appropriate antidepressant medication and dosage for the patient. Then, there is a hierarchy of interventions. First, providers focus on decreasing life threatening behaviors, such as severe self-mutilation with true suicidal intent. Second, providers focus on decreasing therapy-interfering behaviors, such as superficial self-injury or failure to complete therapy homework assignments. Finally, providers focus on quality-of-life interfering behaviors, such as lack of organization skills or anxiety. While pursuing these goals, therapists simultaneously teach patients new cognitive-behavioral skills, such as interpersonal effectiveness, emotion regulation, and distress tolerance. These skills supplant the older, maladaptive behaviors on which patients have been relying.
The diagnosis of BPD can also be openly discussed with patients in helpful and non-judgmental ways. Focusing on the wounds that patients almost certainly experienced earlier in life, validating their experiences, and presenting their symptoms as a valiant effort to survive in a painful environment is a key initial step. Both depression and ED can be framed in this context. Then, as described earlier, patients must be challenged to take responsibility for their current behaviors and develop new skills to cope more effectively. Treatment of both the depression and ED focus on patients’ choices, and not on the behaviors of other people, either past or present.
In summation, the relationship between depression and EDs can be complex and synergistic. When a personality disorder is present, such as BPD, the synergy grows in complexity. Co-occurring depression and EDs therefore require thoughtful assessment and sophisticated evidence-based tools to secure the best outcomes for patients with these co-occurring disorders.
References
Alloy, L.B., Abramson, L.Y., Metalsky, G.I., & Hartlage, S. (1988). The hopelessness theory of depression: Attributional aspects. British Journal of Clinical Psychology, 27, 5-21.
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