A proposal for the inclusion of obesity dysmorphia in the Diagnostic and Statistical Manual of Mental Disorders

Larkin and coauthors (2017) propose that obesity dysmorphobia be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM). They list a number of psychiatric comorbidities including anxiety, obsessive-compulsive disorder (OCD) and depression and state that certain criteria would need to be met and confirmed by research. It was stated that stigma would thereby be reduced, research more focused and treatment more appropriately designed for individuals presenting with obesity dysmorphia, which is judged to be somehow more than normative discontent.

Much depends on the issue of distorted reality as the basis for obesity dysmorphia. Western society has become increasingly obsessed with appearance and images thanks to social media and advertising to sell the glut of unnecessary products created through globalization and what Robert Reich has termed, ‘supercapitalism’. When normal-weight individuals despair because they do not conform to contemporary media promoted images, be these tall, lean, muscular, emaciated or excessively developed in certain regions, for example, breast, buttocks, ‘abs’, biceps and so on, but invariably unattainable without genetic endowment or at least effort, surgery, suffering and expense incompatible with normal life, what hope do the frankly overweight or obese have?

This is particularly the case when the ‘thrifty metabolism’ of the genetically overweight or obese reacts adversely with an environment where food and high energy food in particular is so readily accessible (and persuasively advertised) with extra calories hidden in seemingly ‘healthy’ food items. Throw stress into the mix with its effects on eating habits and abdominal adiposity, and overweight and obese individuals might be seen to require more than an ordinary sense of self worth and equanimity along with a more robust body image to cope with the inevitable negative evaluation and criticism. The unsolicited advice from those less genetically blighted and the well-meaning but often misdirected efforts of the medical profession do not help either.

Will the epidemiological studies of Flegel et al. (2014), in adults aged 25–60, demonstrating that all-cause mortality is in fact lowest in the overweight body mass index (BMI) category (25–30), change how we rate the upper end of the weight scale? Will this put the fitness industry, cosmetic surgery, weight loss organizations and the like out of business? Unfortunately, this does not seem to have happened yet and it is the overweight and obese who remain most vulnerable to exploitation by the push to sell remedies which fail.

Without research proof of cognitive distortion or propensity to overestimate size, the criteria listed namely dissatisfaction, impairment, affective component and avoidance would be just as much in keeping with atypical depression occurring in overweight or obese individuals. Cognitive distortion and a propensity to overestimate body size would then be seen to distinguish the group who would be diagnosed with obesity dysmorphia. Do they in fact display cognitive distortion in overestimating their body size and unstable body image in the way that patients with anorexia nervosa have been shown to do (Keizer Smeets et al., 2014)? Could this be demonstrated by the aperture test or other psychological instruments? How overweight or obese does one have to be to included in this category particularly in view of the work of Flegel’s group?

Milaneschi et al. (2017) have demonstrated that patients meeting criteria for atypical depression are more likely to be overweight or obese and to have higher leptin levels for weight, suggesting leptin resistance. Leptin exerts a positive effect on mood so dysregulation could lead to depressed mood and an atypical pattern of vegetative symptoms. Could obesity dysmorphia then be more properly labelled as an atypical depression?

Food addiction would also have to be considered diagnostically in that there is positron emission tomography (PET) scan evidence of reduced D2 receptors in the striatum and reduced orbitofrontal cortex metabolism in obese human subjects (Volkow et al., 2013) in keeping with an addictive disorder. Increased functional connectivity of the dorsal striatal networks has also been correlated with food craving and weight gain (Contreras-Rodriguez et al., 2017). Obesity and overweight in the food addicted is most likely to be accompanied by depressed mood with associated negative self-evaluation and a sense of despair and futility around the elusive goal of weight loss.

Thus, the currently available evidence offers more support for the contention that obesity dysmorphia be classified as an atypical depression or an addictive disorder, that is, food addiction. The cause and effect relationship of the latter to obesity is more complex than might appear and has been shown to involve cognitive deficits (Volkow et al., 2013). Treatment pathways for these conditions have already been developed including effective pharmacological interventions. Neurocognitive strategies and endocrine treatment aimed at increasing leptin sensitivity also offer promise. Even if the proposed research were to demonstrate evidence of body image distortion in some overweight or obese individuals, it might still be difficult to differentiate the condition from atypical depression or an addictive disorder. More importantly, would this improve the lot of the obese dysmorphic?

See Debate by Larkin et al., (2017) 51: 1085–1086.