Patients suffering from eating disorders binge on food and sometimes are both Anorexic and Bulimic. This is an impulsive behavior as defined by the DSM (particularly in the case of BPD and to a lesser extent of Cluster B disorders in general). Some patients adopt these disorders as their way of self-mutilating. We may be witnessing a convergence of two criteria: self-mutilation and an impulsive (rather, compulsive or ritualistic) behavior.

The key to improving the mental state of patients with dual diagnosis (a personality disorder plus an eating disorder) lies in concentrating upon their eating and sleeping disorders. In my view, these disorders are a blessing in disguise.

It is very rarely, even in the lives of normal human beings, that they are faced with a veritable, identifiable enemy. By controlling their eating disorders, patients can assert control over their lives. This is bound to reduce their depression (even eliminate it altogether as a constant feature of their mental life). This is bound to ameliorate other facets of their personality disorders.

Here is the chain: controlling eating disorders = controlling my life = I am worthy, I have self-confidence, self-esteem and self-worth = I have a challenge, an interest, an enemy to subjugate = I am strong = I can Socialize = I feel better (I am a success) etc.

When a patient has a personality disorder and an eating disorder, I see no point in concentrating at first on anything but his eating disorder. Personality Disorders are intricate and intractable. They are rarely cured (though certain aspects, like OCD, can be dealt with using medication). It calls for the enormous, persistent and continuous investment of resources of every kind by every one involved. This is not realistic. Also this is not a realistic threat. If a personality disorder is cured but the eating disorders are aggravated, the patient might die (though mentally healthy)… An eating disorder is both a signal of distress (I wish to die, I feel so bad, somebody help me) and a message: “I think I lost control. I am very afraid of losing control. I will control my food intake and out-take. This way I control at least ONE aspect of my life”.

This is where we can and should begin to help the patient. Help him to regain control. The family or other supporting figures must think what they can do to make the patient feel that he is in control, that he manages things his own way, that he is contributing, has his own schedules, his own agenda, possesses both authority and responsibility.

BY FAR the most important element in such a patient’s mental abnormalcy is his eating disorders. He is usually right in emphasizing them over his personality disorders. They indicate the strong combined activity of an underlying sense of lack of personal autonomy and an underlying sense of lack of self-control. The patient feels inordinately, paralyzingly helpless and ineffective. His eating disorders are an effort to exert and reassert mastery over his own life. At this stage, he is unable to differentiate his own feelings and needs from those of others. His cognitive and perceptual distortions (for instance, regarding body image) only increase his feeling of personal ineffectiveness and his need to exercise even more self-control (of his diet, the only thing left).

The patient does not trust himself AT ALL, not in the slightest. He is his worst enemy, a mortal enemy and he knows it. Therefore, any efforts to collaborate with HIM against his disorder – will be perceived by him as collaboration with his worst enemy against his only mode of controlling his life to some extent.

The patient views the world in terms of black and white, of absolutes. So, he cannot let go even to a very small degree. He is HORRIFIED – constantly. This is why he finds it impossible to form relationships: he mistrusts (himself and by extension others), he does not want to become an adult, he does not enjoy sex or love (which both entail a modicum of a loss of control). All this leads to a chronic absence of self-esteem. These patients like only their disorder. Their eating disorder is their only successful feat in life. Otherwise they are ashamed of themselves and disgusted by their shortcomings (expressed through shame and disgust directed at their bodies).

There is a chance to cure the patient of his eating disorders (though the duality of eating disorder plus the existence of a PD is not favorable prognosticator of recovery). This – and ONLY this – must be done at the first stage. The patient’s family or closest should consider therapy AND support groups (the equivalent of Alcoholics Anonymous or a 12 step program for eating disorders). Recovery prognosis is good after 2 years of treatment and support. The family must be heavily involved in the therapeutic process. Family dynamics usually contribute to the development of such disorders.

Medication + cognitive or behavioral therapy + psychodynamic therapy + family therapy ought to do it.

The change in the patient IF the treatment of his eating disorders is successful is VERY MARKED. His major depression disappears together with his sleeping disorders. He becomes socially active again and goes on with the business of living. His personality disorder might make it difficult for him – but, in isolation, without the exacerbating circumstances of his other disorders – he finds it much easier to cope with.

Patients with eating disorders may be in mortal danger. Their behavior is ruining their bodies relentlessly and inexorably. They might attempt suicide. They might do drugs. It is only a question of time. Our goal is to buy them time. The older they get, the more experience they accumulate, the more their body chemistry changes with age – the better their prognosis.