Eating disorders are pernicious. People suffering with anorexia or bulimia nervosa have the
highest risk for death of any mental illness – from starvation or heart
failure. I move in and out the
circle of researchers and clinicians treating ED patients or conducting research
on prevention and intervention. At
this year’s conference of the Academy for Eating Disorders (AED) there were some
very interesting developments.
Because I’m intrigued in the workings of the teen brain and adolescent
development, I attended a talk: “The Neurobiology of Eating Disorders” by
Walter Kaye, MD, and Laura Hill, PhD.
The intricacies of the brain systems studied are a bit complex, but
here’s my takeaway.
The symptom of anorexia and bulimia are puzzling and often
fraught with stigma. For
instance, the perception exists that anorexics may have a personality flaw, are
willful in their restriction of food, or that there may be a parenting problem
that is the cause of their child’s psychological issues. So, patients just need to change
their eating behaviors and work through their psychological issues, and parents
need to change their styles, to get well.
If it were that easy! But
as we know, blaming the patient is not uncommon, even with the most biological
of mental illnesses.
Eating disorders are indeed complex. Medications don’t seem
to work that well. Yet, there are various characteristics that are fairly
consistent and are more manageable with interpersonal, cognitive and
family-based therapies. These
similarities are found in many patients and as such suggest some sort of
biological influence. With eating
disorders, young women and girls (as well as boys) have certain characteristics
that are apparent early on: childhood anxiety, perfectionism, obsessive
tendencies, and a drive for achievement and self-control. Add to this puberty, major
physiological shifts, as well as psychosocial transitions – peer pressure,
academic demands, media messages on beauty ideals – you have yourself the
makings of complex syndrome that can persist over the lifespan.
What the emerging brain research suggests is quite
fascinating and potentially important in the treatment of the illness. One of
the mainstays of treatment is getting girls to a weight that reduces their risk
for illness and death. But eating
food seems to have a neuro-physiological response of skyrocketing anxiety.
Anorexics seem to have a blunted signal in the brain, almost like a “food
blindness,” per Dr. Kaye. The
reward system in the brain that tells healthy people, “I’m hungry” or “This
food tastes delicious!” does not work this way. Anorexics do not have “intuitive
eating” and may never have this ability.
With both anorexics and bulimics there is an altered modulation of the
reward and emotion systems in the brain.
Their emotional states get heighted with the prospect of food but their
higher order cognitive functions go into an exaggerated state of self-control.
Feeding causes anxiety. Staving oneself reduces it. (Bulimics, one the other hand, seem to have a diminished
inhibition for food that leads to binging as a way to reduce anxiety).
Here enters into the discussion Dr. Laura Hill, CEO of the
Center for Balanced Living, in Ohio. She challenges us to ask: How might eating
disorders be any different from childhood (type I) diabetes? How do you think of that disease and
the treatment of it? It’s clearly both medical and behavioral. As a medical diagnosis, it also reduces
blame on the child and the family. Perhaps we should consider eating disorders
as a biologically-influenced illness.
From the psychological side – which is so potent in eating
disordered patients, she posits that since the neurobiological system is
thwarted but the cognitive side – decision making planning part the brain is in
over drive – health professions should consider targeting that part of the syndrome.
Picture anxiety as a “noisy brain” with layers of noise that
make it impossible to think or to calm oneself. Dr. Hill demonstrated this with the high frequency sounds of
a tape recorder while she was delivering her talk. It was distressing to listen and concentrate as an audience
member. Thus, her point was well taken.
People with ED are largely managing anxiety through
food. If these young women are so
rule-bound and excel at following their own regimes for eating, then work with
their fine-tuned ability to set the rules that will help them recover. What does this mean in practice? It
means when it comes to meal management and self-care, patients and families can
plan meals where there are a fewer options rather than more. Do not give too
many options or open-ended questions with the idea you are empowering her with
choice, “Well honey, what carbs would you like to have today?” This will spin her into anxiety and
she’ll shut down from eating.
This is intriguing. It shifts the paradigm to one of
hope. It means bringing in the
education of how the brain works into the intervention picture. This emerging
research broadens the context for an illness that shatters many lives. It may
be just one piece of the puzzle to the etiology of eating disorders, but alike
all puzzles, each piece brings the bigger picture into closer view.
