Dear Dr Ash,

I am one of six children (we’re now aged between 38 and 54) and we will all be hiring a house for the New Year with our partners and children. I know my wife and kids will have a great time, which is why I’m doing it, but I’m already worried that I’m going to fall into some unhelpful patterns with the doctor brother who’s next up from me in the pecking order – he’s number two in the family and I’m the third. He’s always been very competitive with me, making it clear he believes himself cleverer and more successful than I am, and even goes on about his general fitness – he’s a marathon runner. I work in the arts for a pittance, but I enjoy my life and feel lucky to have had so many blessings. Until I have to spend a weekend with my brother making me feel inadequate and probably even beating me at Monopoly. What can I do to try and make the situation less triggering?

Third-born
Edinburgh

Boasting is usually a marker of insecurity

Dear Third-born,

You write about wanting to break unhelpful patterns in your family, and I’m struck that your intention is nevertheless to play Monopoly. If there’s a game more calculated to throw discord and strife into an otherwise convivial gathering, I’ve not yet encountered it. So my first piece of advice is to immediately put down the dice and throw out the little top hat. Your healing starts here.

The next step is to try and understand a bit of what happens in the brain when we think about other people. Representations of mental states – our own or others’ – are formed in the medial parts of the brain’s prefrontal cortex. When we feel close to someone, our brain’s representation of their mental state looks similar to the way our brain represents our own mental state. When we feel distant, there is a bigger “self-other” distinction in the brain. This means our understanding of another person’s mental state is contingent on how we feel about that person – which is natural, but can cloud our ability to see others as they really are.

You feel somewhat estranged from your older brother, and it is likely that your brain is representing his mental state as very distinct from your own. But try making an intention to override that distinction. Imagine yourself saying and doing the things your brother does, boasting about your wealth and boring everyone about how many marathons you’ve run. If you were behaving like that, would you be feeling confident and at ease? Probably not. People who are really confident have no need to advertise it. Boasting is usually a marker of insecurity.

Imagining your way out of the “self-other” distinction in your brain can help you see the mental life of others much more clearly. Your brother is telling you that he needs your admiration or your envy, but giving him either will diminish your own feelings of self-worth. A better way is to offer him your compassion. Unlike envy or admiration, compassion empowers the person who feels it and nourishes the person who receives it. You write about feeling blessed, and so you are. Your brother’s behaviour suggests he doesn’t feel the same. That insight alone may let you see how much power you hold in this relationship. Your brother wants your approval, he is doing a ridiculous song and dance to win it, and it’s up to you to decide whether to reward him for that.

But ditch the Monopoly. Landing on Park Lane with a hotel and three houses has never led to a loving and happy family game night. My advice is to stick with charades.

Best wishes
Dr Ash

Dear Dr Ash,

At the risk of sounding like Scrooge, I dread the approach of Christmas. I’m not crazy about any of the enforced traditions but what really gets to me is the demand that everyone feasts and boozes for a fortnight. I had an eating disorder for three years in my teens (bulimia) and, even though I’m now 47 with two children, I feel massively stressed when people are trying to encourage you to eat lots of rich food, puddings, cheese and sweets – which seems to go on for a fortnight nowadays. It’s almost impossible to opt out, as it’s the only time I see my extended family and all my old friends. But it all instantly sets off a cycle where I eat too much and then feel disgusted, huge and lethargic for the rest of the winter. This isn’t just my imagination. I always seem to have put on around eight pounds by the beginning of January, which doesn’t sound a lot but is quite a bit for a small-framed woman who likes to wear skinny jeans. I’d be so grateful for constructive advice.

Fed-up and over-fed
Newmarket

The eating disorder becomes an extension of personality

Dear Fed-up,

I’ve just sat down to read your letter after a grey, drizzly morning spent clearing up the aftermath of a particularly boisterous Diwali party we gave for our local friends. Every year I order far more food than any group of human beings could possibly consume, every year I spend hours scraping half-eaten bits of laddoo and gulab jamun from between the floorboards, and every year I wonder why we do it at all.
Sweets have always been a big part of Diwali for my family, but as a child I found them overwhelmingly cloying, even sickening. I have strong memories of my mother and my aunts pushing bits of coconut burfi into my face, their beautifully thin and articulate fingers approaching like missiles laden with sticky, nuclear-pink payloads. For them, these sweets signified abundance and love and joy; for me, they signified a feeling of obligation and a horrible stomach ache.

In your case, the struggle with bulimia as a teenager might shed some light on how your body and your brain respond to food. Eating disorders like anorexia and bulimia are often “egosyntonic”, meaning they bolster a person’s identity. This is part of what makes them so hard to treat; the eating disorder becomes an extension of personality rather than strictly an illness. In both anorexia and bulimia, there’s a strong need for control and a dysregulation of the midbrain dopamine networks. For anorexics, this manifests as high levels of dopamine in the ventral striate pathway, enabling them to suppress the natural desire to eat even when they would otherwise feel hungry. By contrast, for bulimics the low levels of dopamine in the ventral striate pathway make it extremely difficult to resist impulsive behaviours, so control has to be regained in other ways.

Since both disorders involve disturbances to the ego and the need for control, treatment requires the development of healthy strategies for strengthening self-identity and controlling the environment. You have thankfully found strategies that work for you most of the time, but I’m guessing Christmas is a particular challenge. Whereas you might normally avoid endless buffets of food, during the holidays those heaving trays are placed right in front of you. Whereas you might normally limit your portions, your relatives are now piling food onto your plate. The strategies you’ve successfully adopted in the past as a way of counterbalancing your impulses are thwarted, and this leaves you feeling out of control.

So how can you communicate this to your family? In this case, invoking a diagnosis might be helpful. When someone has a gluten intolerance, for example, no one argues with them for declining a piece of cake. Even the pushiest Indian aunties I know wouldn’t force-feed a laddoo to someone with a nut allergy. If you could invoke a diagnosis, it might prove an effective shield against the onslaught of well-intentioned, ladle-wielding relatives. If bulimia itself is too specific and too intimate a diagnosis, you could simply say that you feel unwell when you eat too much. Express it in the language of a medical condition rather than as a personal preference and I think you will find people give you more space.

It will still be a challenge for you to resist the impulse to eat more than you want, so be gentle with yourself and remember that your brain may work differently. You may prefer to go for a walk when others sit down to a big meal, for example, or to leave the room when food issues become too difficult to navigate. Invoking a diagnosis can give you the social latitude you need to look after yourself in these ways.

I am aware that, as I’ve been writing this letter, I’ve been munching absent-mindedly on a silvered square of kaju katli. As a kid I couldn’t stand the stuff. As an adult, now that I have some choice in the matter, I really like having it once a year, to remind me of my childhood. Families and food are always intertwined; it can be a tangled relationship, but if you get it right it will fill you up in a way nothing else can.

Best wishes,
Dr Ash