One patient we saw when she was in her early 30s had been treated for schizophrenia since her late teens. She began starving herself at age 6, and she has chronic existential conflicts, disabling perfectionism, and fluctuating auditory hallucinations that gradually develop from heightened sensory perceptions and that are reactive to emotions and stressors. She empathically embraces her diagnosis of schizophrenia and the accompanying sick role in an enmeshed family.
Another woman we met in her 40s had been treated for schizophrenia since adolescence. She has never experienced hallucinations but has had fluctuating delusions of a paranoid/grandiose nature. One feature that has not changed throughout the course of her illness is her fixation on wanting to weigh 101 lb. She had 2 psychiatric hospitalizations because of refusal to eat. Her weight has fluctuated some 70 lb during adulthood, and she has now accepted her current weight of 130 lb at a height of 5 ft 7 in. However, she wakes up some mornings and sees her reflection as being extremely fat and wonders whether her "eyes are playing tricks on [her] mind." Despite her verbalized approval of her current weight, she hoards pictures of stick figures, continues to count calories, and dreams and fantasizes about life at 101 lb.
Both women appear to have their illnesses correctly diagnosed under operationally defined DSM criteria for schizophrenia. But should their management include primarily antipsychotic medications (Figure)? Other examples of dimensional overlap and diagnostic questions are seen in firstperson accounts of schizophrenia10 and descriptive cases of anorexia nervosa.11
The degree of body image distortion in some anorexic patients may appear to be of delusional proportion, but the disturbance is circumscribed to areas central to the primary eating disorder.12Although there is a high prevalence of multiple comorbid conditions in patients with eating disorders,13 it is fascinating that such phenomena are restricted to themes of body image and eating. For example, patients with eating disorders showed normal responses on the traditional Stroop tasks14 but had selective processing of information related to eating and weight on a modified version of the Stroop task.15
The distinction between eating disorders and schizophrenia is unclear because the brain itself does not naturally make such artificial diagnostic divisions. As Maudsley16 put it in 1879:
[I]nsanities are not really so different from sanities that they need a new and special language to describe them; nor are they so separated from other nervous disorders by lines of demarcation as to render it wise to distinguish every feature of them by a special technical nomenclature.Metabolic implications
Whether eating disorders in patients with schizophrenia represent comorbid eating disorders or merely coexisting eating disturbances, the pathology influences metabolic health. Disinhibited eating was directly associated with metabolic changes such as increased triglyceride levels and body mass index.3 Cognitively restricted eating appears to be associated with disinhibited eating under various conditions.17 Within individual variability, we have also found and reported collective patterns of associations between medications and weight trends that are similar to those reported in the existing literature.18 However, such findings cannot adequately address how individual patient care can be optimized because medications appear to be only an additive factor to preexisting constitutional risks and multiple sociocultural stressors.19Acceptance and self-affirmation
Foods serve diverse purposes emotionally and cognitively. Addressing the maladaptive and simultaneously adaptive defenses of disturbed eating is challenging. Low-salt, low-fat diets; weight loss; and exercise can be preached, but there is a danger that the distinction between the illness and the patient can become blurred as the fight against obesity, diabetes, hypertension, and dyslipidemia takes on emotional tones such as disparagement. In a recent case of a physician who refused educational remediation following patient complaints, the physician saw nothing wrong with telling the truth: "I told a fat woman she was obese. I tried to get her attention. I told her you need to get on a program, join a group of like-minded people and peel off the weight that is going to kill you."20
Healing words are valuable remedies. Conversely, inconsiderate words can be as wounding as any physical insult. Moreover, people who use food to combat anxiety and loneliness are apt to become depressed when dieting is enforced,21 and human relationships with food are difficult to alter with obesity lectures. Attempts to address any illness in patients with schizophrenia, or in any population for that matter, must consider each patient's emotional assets and frailties. Without addressing the underlying psychosocial conflicts that manifest in disordered behaviors, lasting, healthful changes are difficult to achieve.
In our experience with group therapy in schizophrenia with a primary emphasis on self-acceptance and subsidiary themes of health and eating behaviors, we have noticed changes in behaviors as well as improvements in blood pressures after about 6 months without measurable changes in cognitive schemas or weights.22 During this extended phase of contemplation and experimentation with alternatives, we have observed that praising any and all attempts as "good" is more effective in bringing about change than debating cognitive distortions and confronting resistance. Perhaps with such affirmations, focusing contemplation on self-care and healthy behaviors becomes therapeutic in itself, even in the absence of obvious changes in body weight or shape.Conclusion
The heterogeneity of schizophrenia requires specific and individualized assessment and treatment approaches. With varied phenomenologic and clinical courses, identification and subsequent management of specific comorbid psychiatric syndromes are major determinants of outcome.23 Eating behaviors are complex reactive systems with multiple dimensions of phenomenologic variations, associated with various psychoneuroendocrine factors and dynamic in their progression. Further profiling of characteristic phenotypic patterns will help clarify the distinctions among eating behaviors that are part of the spectrum of schizophrenia, those that represent distinct coexistent entities, and those that represent overlapping comorbidity. These overlapping symptoms may then be studied for genetic causes. In addition, we should search for associations between behavioral phenotypes and genetic variability in psychotropic medication responses, including the effects on obesity. Such a need has recently assumed greater clinical importance with the increased prevalence of metabolic illnesses in schizophrenia that reflect both trait and state eating behaviors.
Dr Yum is affiliated with the New Jersey Veterans Affairs Health Care System, East Orange, NJ, and the Department of Psychiatry, University of Medicine and Dentistry of New Jersey–New Jersey Medical School in Newark. Dr Yum reports that he had support from the American Medical Association Foundation's "Fund for Better Health" public health grant for the group therapy discussed near the end of this article.
Dr Hwang is director of the Schizophrenia Program at the New Jersey Veterans Affairs Health Care System and associate professor of psychiatry at the University of Medicine and Dentistry of New Jersey—Robert Wood Johnson Medical School in Piscataway. Dr Hwang reports that he received project support from the American Medical Association.
Dr Halmi is professor of psychiatry and director of the Eating Disorder Program, Weill Medical College, Cornell University, New York. She reports that she has no conflicts to report regarding the subject matter of this article.