 Dear colleagues, welcome to the Third International Conference on Neurology and Brain Disorders in Dublin, June 2019. My name is Sam Battening. I'm the author of Malignan Self-Lab, Narcissism Revisited and Other Books on Personality Disorders. I'm a professor of psychology in Southern Federal University, or Stovon Dome, Russian Federation, and a professor of finance and a professor of psychology in CSCFs, the Center for International Advanced and Professional Studies. Today, I would like to discuss the issue of eating disorders. Sufferers of eating disorders tend to be fearful and anxious, specifically about gaining weight and being fat. Some anorexics and rectics admit to being perfectionists or wanting to punish themselves. Many say that they are addicted either to food or to the euphoric feeling they derive from starving. They report enjoying exerting control over food and figure and watching the effect that their condition has on people around them. This is from the book Sobequity by Barbara Nettison-Porbis, Vintage Books, 2020. Patients sufferings from eating disorders either binge on food or refrain from eating. Sometimes they are both anorectic and polemic. This is an impulsive behavior as defined by the Diagnostic and Statistical Manual. It is sometimes comorbid with cluster B personality disorders, particularly with borderline personality disorder. Some patients develop eating disorders as the convergence and confluence of two pathological behaviors. Self-mutilation or self-harm and an impulsive rather obsessive compulsive or ritualistic behavior. The key to improving the mental state of patients who have been diagnosed with both a personality disorder and an eating disorder lies in focusing at first upon their eating and sleeping disorders. Why is that? Why shouldn't we treat the fundamental core problem of personality disorders first? By controlling his eating disorder, the patient reasserts control over a life. This newfound power is bound to reduce depression or even eliminate it altogether as a constant feature of her mental life. It is also likely to ameliorate other facets of her personality disorder. It's a kind of chain reaction, virtual cycle. Controlling one's eating disorders leads to a better regulation of one's sense of self-worth, enhanced self-confidence and self-esteem. Successfully coping with one challenge, the eating disorder, generates a feeling of inner strength that results in better social functioning and an enhanced sense of well-being. When a patient has a personality disorder and an eating disorder, a dual diagnosis, the therapist would do well to first tackle the eating disorder. Personality disorders are intricate and intractable. They are rarely curable, though certain aspects like obsessive-compulsive behaviors or depression, this can be ameliorated with medication and certain abrasive and antisocial behaviors can be modified. Still, the core, the nucleus, the kernel of personality disorder is usually untouchable. The treatment of personality disorders requires the norms, the systems and continuous investments of resources of every kind, but everyone involved not least the patient. Depleted by the eating disorder, such a patient is unlikely to invest in these resources or to have their world middle. From the patient's point of view, the treatment of her personality disorder is not an efficient allocation of scarce mental resources. Neither are personality disorders the real threat. If one's personality disorder is cured, but one's eating disorders are left untouched, one 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 also a message. I think I lost control, I'm very afraid of losing control, I will control my food intake and discharge, this way I can control at least one aspect of my life, my nutrition. This is where we can and should begin to help the patient, by letting her regain control of her life. The family or other supporting figures must think what they can do to make the patient feel that she is in control, that she is managing things her own way, that she is contributing, has her own schedules, her own agendas, and that she, her needs, preferences, wishes, will, and choices matter. Eating disorders 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, her eating disorders are in effort to exert and reassert mastery over her own life. At this early stage, the patient is unable to differentiate her own feelings and needs from those of others, her cognitive and perceptual distortions and deficits, for example regarding her body image. This only increases her feeling of personal ineffectualness and her need to exercise even more self-control via her diet. So, so much of all disorders, body image disorders, usually accompanying eating disorders, there's a misreading, misjudgment, wrong assessment and wrong evaluation of everything about the body, starting with its dimensions and ending with its aesthetics. The patient does not trust herself in the slightest. She rightly considers herself to be her worst enemy, a mortal adversary. Therefore, any effort to collaborate with the patient against her own disorder is perceived by the patient as self-destructive. The patient is emotionally invested in her disorder. This is her vestigial mode of self-control, the only thing she controls. The patient views the world in terms of black and white, she has dichotomous thinking, a kind of splitting of absolutes. Thus, she cannot let go, even to a very small degree. She is constantly anxious, and this is why she finds it impossible to form relationships. She mistrusts herself and by extension others. She does not want to become an adult. She does not enjoy sex or love, which both entail a modicum of loss of control and some kind of positive attitude to one's body, positive relationship with one's body. All this leads to a chronic absence of self-esteem. These patients like their disorder. Their eating disorder is their only accomplishment. Otherwise, they are ashamed of themselves and they are disgusted by their shortcomings, as expressed via the distaste with which they hold their bodies. Eating disorders are amenable to treatment, though comorbidity with a personality disorder presages a poorer prognosis. The patient should be referred to talk therapy, possibly be put on medication and enrolled in online and offline support groups such as overeaters anonymous. Recovery prognosis is good after two 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, so the family must be involved. In short, medication, cognitive or behavioral therapy, psychodynamic therapy and family therapy, family systems therapy, for example, ought to do it, ought to demonstrate some progress. The change in the patient following a successful course of treatment is very marked. Her major depression disappears together with her sleeping disorders. She becomes socially active again, she gets a life. Her personality disorder might make it difficult for her, but in isolation, without the exacerbating circumstances of her other disorders, she finds it much easier to cope with. Patients with eating disorders may be immortal aging. Their behavior is ruining their bodies relentlessly and inexorably. They might attempt suicide. They might do drugs. It is only a question of time. The therapist's goal is to buy them that time. The older they get, the more experienced they become. The more their body chemistry changes with age, hormonally and otherwise, the better their chances are to survive and to thrive. Eating disorders, notably anorexia nervosa and bulimia nervosa, are complex phenomena. The patient with eating disorder maintains a distorted view of her body as too fat or as somehow defective. She may have, as I said, a body dysmorphic disorder. Many patients with eating disorders are found in professions where body form and body image are emphasized, such as ballet dancers, fashion models, actors. The Diagnostic and Statistical Manual, edition 4, text revision, says on pages 584, 585 the following. Patients with eating disorders exhibit feelings of ineffectiveness, a strong need to control one's environment, inflexible thinking, limited social spontaneity, affectionism and overly restrained initiative and emotional expression. Bulimics show a greater tendency to have impulse control problems, abuse alcohol or other drugs, exhibit moodlability, have a greater frequency of suicide attempts. The current view of orthodoxy is that the eating disorder patient is attempting to reassert control over her life by ritually regulating her food intake and her body weight. And in this respect, eating disorders resemble obsessive-compulsive disorders. One of the first scholars to have studied eating disorders, Raj, described the patient state of mind as a struggle for control for a sense of identity and effectiveness. In works written in 1962 and 1974, he kept emphasizing this theme. In Bulimia nervosa, protracted episodes of fasting and purging, induced vomiting and the abuse of laxatives and diuretics, they are precipitated by stress, usually fear of social situations akin to social phobia. There is a breakdown of self-imposed dietary rules, which leads to heightened anxiety and self-medicating via the eating disorder. In this sense, eating disorders seem to be life-long attempts to relieve anxiety, to ameliorate it. Ironically, binging and purging render the patient even more anxious, and provoking her of overwhelming self-loathing and guilt. Eating disorders involve masochism. The patient tortures herself and inflicts on her body great harm by aesthetically abstaining from food, or by purging. Many patients cook elaborate meals for others and then refrain from consuming the dishes they had just prepared. Perhaps there is a sort of self-denial, self-punishment or spiritual purging and cleansing. The Diagnostic and Statistical Manual comments on the inner mental landscape of patients with eating disorders. Weight loss is viewed as an impressive achievement, a sign of extraordinary self-discipline, whereas weight gain is perceived as an unacceptable failure of self-control. But the eating disorder is an exercise in self-control hypothesis, maybe a bit overstated. If it were true, we would have expected eating disorders to be prevalent among minorities, the lower classes, people whose lives are controlled by others, people with an external focus of control. Yet the clinical picture is totally reversed. The vast majority of patients with eating disorders, 90 to 95%, are actually white, young, mostly adolescent women from the middle and upper classes. Eating disorders are rare among the lower and working classes and among minorities and non-Western societies and cultures. So perhaps we should look at eating disorders as a kind of refusal to grow up. Some scholars believe that the patient with eating disorder refuses to become an adult. By changing her body and stopping her menstruation, a condition known as aminorrhea, the patient regresses to childhood and she avoids the challenges of adulthood, loneliness, interpersonal relationships, sex, of legal job and child rearing. There are similarities between eating disorders and personality disorders. Patients with eating disorders maintain great secrecy about their condition, not unlike narcissists or paranoics, for instance. When they do attend psychotherapy, it is usually going to tangential problems, having been called stealing food and other forms of antisocial behaviors such as ranger ties. Clinicians who are not trained to diagnose the subtle and deceptive signs and symptoms of eating disorders often misdiagnose eating disorders as personality disorders or esmood or affective or anxiety disorders. Patients with eating disorders are emotionally led by, frequently suffered from depression, are socially withdrawn, lack sexual interest, and are irritable. Their self-esteem is low, their sense of self-worth fluctuates, they are perfections. The patients with eating disorders derive narcissistic supply from the praise that they garner for having gone down in weight. The eating disorder patient kind of demonstrates the way she looks post-dieting. Small wonder that eating disorders are often misdiagnosed as personality disorders, borderline, schizoid, avoidant, antisocial, or narcissistic. Patients with eating disorders also resemble subjects with personality disorders in that they have primitive defense mechanisms, most notably the aforementioned splitting. The review of general psychiatry, page 356 says, individuals with anorexia nervosa tend to view themselves in terms of absolute and polar opposites. Behavior is either all good or all bad, the decision is either completely right or completely wrong. One is either absolutely in control or totally out of control. Patients with eating disorders are unable to differentiate their feelings and needs from those of others, adds the author. To add confusion, both types of patients with eating disorders and with personality disorders share an identically dysfunctional family background. Manchin and allies described it in this way in 1978, in measurement, overprotectiveness, rigidity, and lack of conflict resolution. Both types of patients are reluctant to seek help. The diagnostic and statistical manual says, individuals with anorexia nervosa frequently lack insight into or have considerable denial of their problem. A substantial portion of individuals with anorexia nervosa have a personality disturbance that meets criteria for at least one personality disorder. In clinical practice, comorbidity or dual diagnosis of eating disorders and a personality disorder is very common. About 20% of all anorexia nervosa patients are diagnosed with one or more personality disorders, though mainly cluster C, avoidant, dependent, compulsive, obsessive, but also cluster A, schizoid, and paranoid. At whopping 40% of anorexia nervosa and bulina nervosa patients have comorbid personality disorders of cluster V type, narcissistic, histrionic, antisocial, or borderline. Pure bulimics tend to have borderline personality disorder. Binge eating is included in the impulsive behavior criterion for borderline personality disorder. And such rapid comorbidity raises the question whether eating disorders are not actually behavioral manifestations of underlying personality disorders. Thank you for listening.