Obesity*, Mental Disorders … and the DSM-VI?

In my freshman year of college (before cell phones, the internet and electricity were invented), to satisfy required science credits, I took Philosophy 101. Our introduction to deductive reasoning included the following :

P1). All mammals have lungs.

P2). All dogs are mammals.

C). Therefore, all dogs have lungs.

The conclusion necessarily followed from Premise 1 and 2. IF P1 and P2 are true, and the subject matter is common, then it follows that C must be true. This is a prime example of deductive reasoning. But, is that always the case? For example:

P1). All dogs are mammals.

P2). All cats are mammals.

C). Therefore, all dogs are cats.

In this case, unquestionably Premise 1 and 2 are both correct. Both involve a common subject matter, that is, mammals. But, the conclusion does NOT necessarily follow even though Premise 1 and 2 are correct and the subject matter of the premises is similar. This illustrates the only instance in which deductive argument is invalid, that is, when a faulty conclusion is drawn from two premises, which when viewed in isolation, are accurate.

Which brings us to issues involving Obesity, eating disorders and mental disorders.  *To begin with, I am aware that the terms “Obese” or “Obesity,” have become  almost terms of derision amongst a growing number of people. They postulate that these terms reflect outdated and inaccurate measures by which a diagnosis is based. And yet, to facilitate easier understanding of this article, I will use this term as it is defined by a number of authoritative entities. For example, the National Institutes of Health, define Obesity as someone having a Body Mass Index of 30 and over.   So, let us commence.

The Deductive Argument Analysis

P1). Obesity has a biological, genetic, environmental and/or psychological component to it.

P2) All mental disorders have a biological, genetic, environmental and/or psychological component to them.

C). Therefore, Obesity is a mental disorder.

In this example, Premise 1 and 2 are correct. Both involve a common subject, that is, a biological, genetic, environmental or psychological component. But, the conclusion does NOT necessarily follow even though Premise 1 and 2 are correct and the subject matter of the premises is similar. However, if this deductive argument is accurate, then an evolution in the manner in which Obesity is defined, researched and treated is necessary.

This brings us to our essential inquiry: Does sufficient evidence now exist supporting the premise that Obesity should now be classified as a mental disorder and included as such in the next DSM-VI?

What is a Mental Disorder?

In the DSM-V, published in 2013, “mental disorder” was defined as:

“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”

This definition seems to be a bit wordy. As previously note, Albert Einstein is on record as saying, “If you can’t explain it to a six year old, you don’t really understand it.” This definition is broad, yet vague, expansive yet finite. It expands on the definition of “mental disorder” as defined in previous DSMs. And yet, in an article published in the July 2013 edition of Psychology Today  authored by Eric Maisel, PhD, Dr. Maisel stated: “The very idea that you can radically change the definition of something without anything in the real world changing and with no new increases in knowledge or understanding is remarkable, remarkable until you realize that the thing being defined does not exist. It is completely easy—effortless, really—to change the definition of something that does not exist to suit your current purposes. In fact, there is hardly any better proof of the non-existence of a non-existing thing than that you can define it one way today, another way tomorrow, and a third way on Sunday.” The foundation for Dr. Maisel’s opinion is based in his disbelief in the existence of God.

This definition has been widely criticized for a number of reasons. The newer definition greatly expanded previous definitions although critics could find no scientific breakthroughs supporting this expansion. It has been called overreaching. Other justified criticism exists as well.

So, as unsatisfying as this definition may be, at this point, let us work with what we have and toddle on to the next inquiry.

What is Obesity?

In 2010, the National Institutes of Health defined Overweight as persons with a BMI of 25.0 – 29.9; Obesity as persons with a BMI over 30.0, and; Severe Obesity as persons with a BMI exceeding 35.0. [And yes again, I am aware of the arguments against using BMI as an accurate measure of health and that persons in larger bodies can enjoy “good health.” But, that is the subject for another article].

In general, Obesity refers to an excess of body fat. In the broadest sense, Obesity results from an imbalance between energy intake and energy expenditures.

So, whether its definition is limited to this definition of BMI as set forth by the NIH, or involves a more expansive and all encompassing definition, the fundamental issues remains; Is Obesity a mental disorder and should it be included in the next DSM-VI?

Historical Perspective

Previously, the Eating Disorder Work Group of the DSM 5th Edition Task Force was given the responsibility for determining whether Obesity was a mental disorder that should be included in the DSM-V.

Ultimately, the Work Group did not find compelling, sufficient evidence to support establishing Obesity as a mental disorder and concluded that Obesity would not be included in the DSM-V. The Work Group reasoned that Obesity is a heterogeneous condition with a complex and incompletely understood etiology. Since that time, more research and study have been conducted on Obesity and its etiology.

In 2013, just after the DSM-V was published, the American Medical Association’s House of Delegates voted overwhelmingly to “recognize Obesity as a “disease state” with multiple pathophysiology aspects requiring a range of interventions to advance obesity treatment and prevention.”

We must still go further.

Is Obesity a Mental Disorder?

To conduct this analysis, we turn to the works of Dr. Jerome C. Wakefield. Dr. Wakefield has been a university professor at NYU since 2003. His areas of expertise include conceptual foundations of clinical theory and the philosophy of psychopathology.

Professor Wakefield’s definition of mental disorder focuses on “harmful mental dysfunction” and was proposed for inclusion in the DSM-V. Although ultimately, his definition was not included, Professor Wakefield believes his alternative definition improves the validity and diagnosis of mental disorder constructs.

To this end, Professor Wakefield wrote:

“A condition is a mental disorder if and only if:

(a). the condition causes some harm or deprivation of benefits to the person as judged by the standards of the person’s culture, and;

(b). the condition results from the inability of some mental mechanism to perform its natural function, wherein a natural function is an effect that is part of the evolutionary explanation of the existence and structure of the mental mechanism.”

In short, the Wakefield approach focuses on the concept of harmful mental dysfunction. And dysfunction exists when a person’s internal mechanisms are not able to function in the range of environments for which they were designed.

Is Obesity Harmful?

Again, we are using (without commenting on the accuracy, inaccuracies or shortfalls) the NIH’s definition of Obesity. If the NIH’s definition of Obesity is adopted, most medical professionals assert that Obesity is harmful for most individuals. Obesity has been recognized as a base condition that could lead to or worsen cardiovascular disease, diabetes, hypertension, kidney disease, obstructive sleep apnea, and osteoarthritis.

Obesity also is associated with significant psychosocial impairment. Persons with a higher BMI have been subject to weight-based stigma and discrimination, generally report poorer quality of life and are subject to stressors and derision that low BMI persons do not experience. That there is weight discrimination is not debatable.

At a societal level, there are profound economic consequences associated with persons with a higher BMI in the form of fewer economic opportunities, increased medical costs and a medical community which languishes in past beliefs and who have not studied not embraced the many societal obstacles placed before persons with a higher BMI and the manner in which those obstacles psychologically impact persons with a higher BMI.

Accordingly, few could argue that Obesity clearly satisfy the first element in the Wakefield Mental Disorder Concept.

What evidence exists establishing that Obesity is Caused by Mental Dysfunction?

This issue stymied the Eating Disorder Work Group and formed the basis for their denial of inclusion. Subsequent to that decision, evolving times have given greater clarity,

As previously stated, the AMA classified Obesity as a disease.

In the last 10 years, genetic research has made tremendous leaps forward. Studies indicate that gut microbiome influence metabolism and energy extraction from food. One research study involving family history and twins documented that 40% – 70% of the variance in Obesity can be accounted for by genetic factors.

Dr. Joseph M. Pierre, a Health Sciences Clinical Professor at the School of Medicine at UCLA stated: “Highlighting the behavioral core of obesity is not to be equated with saying that freely-willed choices about eating are the root-cause of obesity. On the contrary, it would be more correct to say that obesity, just like any other psychiatric disorder, represents a dysfunction involving genetics, anatomy, physiology, and environmental factors that results in an inability of the brain to properly regulate behavior. In the case of obesity, the brain must ultimately decide whether to eat based on hunger, satiety, and other factors, but that decision is an action influenced by things going on in other places in the body.”

In the same article, Dr. Pierre categorized Obesity as a possible addiction issue. He stated: “Still, we now have compelling animal models for addiction, with reasonably clear outlines of the neural pathways in the brain that govern behaviors associated with reward and loss of control. This has helped to build a strong case for modeling addiction as a psychiatric disorder, a viewpoint that is now widely embraced by the medical community, if still debated in other circles including the legal system. Just so, best practice addiction therapy now involves the combination of psychotherapy as well as pharmacotherapy, with several medications now approved by the Food and Drug Administration (FDA) for the treatment of alcohol dependence. 

He further opined: “Many researchers have applied an addiction model to at least some forms of obesity, noting similarities in terms of the immediate psychological rewards one derives from eating, a loss of behavioral control, and overlapping neural systems underlying “appetitive and consummatory behaviors.” Again then, adopting a psychiatric model for obesity hardly seems a stretch.”

The progress made in the genetic and biological understanding of Obesity warrants a serious, long look as to whether thew scientific and medical communities are now able to satisfy the definitions of “mental disorder” or mental dysfunction. And if Obesity falls under the umbrella of mental disorders, then the rules of the game will dramatically change.

RAMIFICATIONS OF THE REDEFINING OF OBESITY

Assuming the latest research studies support the finding that Obesity is in fact, a mental disorder, the benefits and positive aspects of this classification are many and varied. First, it could be argued that Obesity would garner renewed attention and study from psychiatrists in a more objective manner. These medical professionals seek to understand behavior from both psychological and medical perspectives and routinely combine behavioral interventions with somatic therapies.

Recognizing Obesity as a mental disorder could result in greater public understanding of Obesity. This could lead to more federal and state funding for public health programs and greater financial reimbursement by insurance companies for treatment. On the issue of stigma, a disease model could temper stereotypes about laziness and lack of self-control resulting in greater acceptance of the complex etiology of obesity. 

From a legal perspective, in general, courts have held that Obesity is not a disability under the Americans with Disabilities Act. (“ADA”) Under the ADA, to qualify as a disability, a physical or mental impairment must substantially limit a major life activity. If Obesity was determined to be a mental disorder, courts would be forced to reassess future cases in which the claimant claimed protection under the ADA. 

Weight discrimination would no longer just be a rallying cry by those who have been oppressed. Now, they would have legal ammunition to strike back against those entities which have historically practiced weight discrimination.

CONCLUSION

A greater understanding of all aspects of “Obesity” is long past due. And assuming that the studies being conducted and continued biological and genetic research support such conclusion, we would have to rethink the conclusion from our prior deductive argument:

P1). All mental disorders have a biological, genetic, environmental and/or psychological component to them.

P2). Obesity has a biological, genetic, environmental and/or psychological component to them.

C). Therefore, Obesity is a mental disorder.

Based upon a greater medical, scientific and psychological understanding and the breakthroughs in the last ten years, this conclusion could necessarily follow. This in turn, would necessarily supply the groups like HAES with legal ammunition to better spread their message and bring strength and clarity to their vision.

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