Obesity-Related Anxiety: A Me-Too Disease?

Psychiatry seems to have a strange fascination with labels.  (I would say it has an obsession with labels, but then it would be labeled OCD.)  We’re so concerned with what we call something that we sometimes ignore the real phenomena staring us in the face every day.

Consider social anxiety disorder (SAD).  Some have argued that this is simply a technical, high-falutin’ label for general shyness, which even “normal” people experience in varying degrees.  There are indeed cases in which someone’s shyness can be horribly incapacitating—and these cases usually benefit from specialized treatment—but there also exists a broad gradient of social anxiety that we all experience.  If I spend too much time worrying about whether the shy patient in my office meets specific criteria for SAD, I might lose sight of why he came to my office in the first place.

So a news story this week caught my eye, with the headline “Obese People Can Suffer From Social Anxiety Due to Weight Alone.”  To a non-psychiatrist, this statement probably seems self-evident: people who are overweight or obese (just like people with any other aspect of their physical appearance that makes them appear “different from normal”) might be anxious or uncomfortable in social settings, simply because of their weight.

This discomfort doesn’t meet criteria for a DSM-IV diagnosis, though.  (At this point, you might ask, but who cares?  Good question—I’ll get to that below.)  The DSM-IV specifies that the symptoms of social anxiety must be unrelated to any medical condition (of which obesity could be considered one).  So if you’re overly self-conscious in social situations due to your weight, or due to an unsightly mole on your face, or due to a psoriasis flare-up, or because you’re a dwarf, sorry, you don’t “qualify” as SAD.

Apparently some researchers want to change this.  In a study to be published this month in the journal Depression and Anxiety, researchers at Brown University and Rhode Island Hospital investigated a large number of obese individuals and found that some of them have social anxiety due to their weight and nothing else, resulting in “greater impairment in social life and greater distress about their social anxiety” than those obese patients who had been diagnosed with (non-obesity-related) SAD earlier in life.  They argue that we should expand the diagnostic criteria in the upcoming DSM-5 to include these folks.  (Indeed, the subtitle of the article in question is “Implications for a Proposed Change in DSM-5.”)

An investigation of their methods, though, reveals that their key finding may have been a foregone conclusion from the start.  Here’s what they did: They interviewed 1,800 people who were being evaluated for weight loss surgery.  (A pre-op comprehensive psychiatric evaluation is often a requirement for bariatric surgery.)  616 people had no psychiatric history whatsoever, while 135 of them had been diagnosed with SAD at some point in their lives.  But then they found 40 additional people whom they labeled as having something they called “modified SAD,” or “clinically significant social anxiety … only related to weight concerns.”  The paper demonstrates that this “modified SAD” group had psychosocial characteristics (like work/social impairment, past/current social functioning, etc) which were strikingly similar to patients with SAD.

But wait a minute… they admit they “labeled” a subset of patients with something that resembled SAD.  So in other words, they pre-selected people with SAD-like symptoms, and then did the analysis to show that, sure enough, they looked like they have SAD!  It’s sort of like taking all the green M&Ms out of a bowl and then performing a series of chemical and physical tests to prove that they are green.  OK, maybe I shouldn’t have used a food analogy, but you get my point…

I don’t mean to be weigh too heavily (no pun intended) on study’s authors (for one thing, the lead author shared a draft of the article with me prior to publication).  I know why articles like this are written; I’m aware that the medical exclusion has made it impossible for us to diagnose SAD in many people who actually have debilitating anxiety due to some obvious cause, like obesity or stuttering.  And this is relevant because we have to give a DSM code in order to be paid for the services we provide.  As with much in life, it’s often all about the money.

But if that’s the only reason we’re squabbling over whether obesity-related anxiety deserves the DSM seal of approval, then I’m sorry, but it’s another example of psychiatrists and psychologists missing the point.  Whether we call something SAD—or depression, or panic disorder, or ADHD, or bipolar disorder, or whatever—means less to the patient than what he or she actually experiences.  Admittedly, we do have to give a “diagnosis” at some point, but we need to ensure our diagnoses don’t become so homogenized that we end up looking at all of our patients through the same lens.

The 40 obese Rhode Islanders who are socially distressed due to their weight probably don’t care whether they’re labeled “SAD,” “modified SAD,” or anythingelse, they just want help.  They want to feel better, and we owe it to them to get our heads out of our DSMs and back into the therapeutic setting where they belong.

25 Responses to Obesity-Related Anxiety: A Me-Too Disease?

  1. leejcaroll says:

    There is too much effort spent trying to pigeonhole people. I understand the payment issue but as a person living with chronic pain I get tired of reading/listening to medical and adjunct medical people trying to get us to fit into their preconceived notions. It is as you say. Often those with chronic pain are disbelieved because pain is subjective; so instead of treating us as individuals with medical complaints we are sent to psychiatrists’ offices where we do not usually fit a DSM Dx. Yes like obese people we are often anxious. They may have a social concern, we have a pain concern but anxiety, as a result, is usually not to a DSM level.
    author A PAINED LIFE, a chronic pain journey

  2. moviedoc says:

    Much ado about nothing (or barking up the wrong tree):

    First, SAD is seasonal affective disorder. The correct term for what you discuss here is Social Phobia, not social anxiety disorder. The key criterion in DSM is “The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.” ACT! not look.


    Exclusionary criteria don’t apply because the criteria don’t apply:

    G. refers to physiological effects, so not applicable here.
    H. refers to ACTION related to a medical condition, not appearance. Again, not applicable.

    For appearance, including obesity, Body Dysmorphic Disorder would seem to apply, and there are NO exclusionary criteria:


    Better comparisons would be neurofibromatosis, phocomyelia or elephantiasis, or disfiguring injuries like burns or lost limbs.

  3. stevebMD says:

    md, thanks for the details & links — agree that social phobia = social anxiety disorder and the SAD acronym usually refers to seasonal affective d/o. Nevertheless, the article used the term SAD; there must be something more palatable about reading “modified SAD” than “modified SP.”

  4. Having visited many psych professionals for help with my SAD/SP I can really relate to this. In the search for a psychologist to suit my needs I encountered many a label happy counsellor. I was labelled with all sorts of mental health issues before I finally found someone who could look behind the labels and actually help me. Only then did I find out that I had SAD/SP, but like you said that wasn’t the significant part. There is definitely too much effort used trying to label rather than help or treat, good post.

  5. leejcaroll says:

    i have a facial paralysis from medical malpractice. I was embarrassed and upset by how I looked, and worried becauee I was under repeated threat of needing my eye sewn shut because of it.
    In the hospital a psychiatric resident, already well learned in naming regardless of reality, wrote in the chart I had ‘body dysmorphic disorder’ (which as you may know is when you do not have a defect but think you do -oversimplified, I know).
    They learn from the earliest on you need a name no matter what the symptoms (or lack thereof).

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