That's right, everybody. It's the return of the weekly smorgasbord of eating disorders research and news from the past week that didn't make it into my blog. Some of these tasty tidbits might not have had enough information to warrant their own post; others were neglected because I got sidetracked, busy, or otherwise preoccupied. If you follow me on Twitter (you do follow ED Bites on Twitter, right?), I probably will have mentioned some of these links, but this is my time to provide a little insight and discussion using more than 140 characters.

Attitudes of patients with anorexia nervosa to compulsory treatment and coercion

The topic of coercion and force in the treatment of eating disorders is rather contentious; for my previous thoughts on the subject, click here, and Dr. Sarah Ravin recently addressed the topic as well. Some interesting research has been going on in recent years to determine how people with AN ultimately feel about compulsory treatment and coercion. The answers are a bit surprising. Although people tend to have a negative view of compulsory treatment in the moment (which really is to be expected), this view changes as time passes and many patients recognize the necessity of hospital care.

In this study, the researchers interviewed a group of women who were currently suffering or had recently suffered from AN and found that:

Compulsion and formal compulsory treatment of anorexia nervosa were considered appropriate where the condition was life-threatening. The perception of coercion was moderated by relationships. What mattered most to participants was not whether they had experienced restriction of freedom or choice, but the nature of their relationships with parents and mental health professionals.

Explicit vs. implicit body image evaluation in restrictive anorexia nervosa

First off, we need to understand the exact difference between explicit and implicit (Note: do not just Google explicit and hope for a definition...you will find a different kind of "explicit" waiting for you). According to the About.com Grammar Guide,

Explicit means clearly expressed or readily observable. Implicit means implied or expressed indirectly.

This study looked at whether the preference for an ultra-thin shape stemmed from a desire to be ultra-thin, or more of a fear of overweight. The researchers found that it seemed the latter was the most true for people with AN. Not that all anorexics are fat-hating monsters, but fat phobia is a feature of a sizable portion (though not 100%) of those diagnosed with anorexia.

In contrast to the control group, the patients did not show a positive attitude toward the ultra-thin body shape on the automatic level. The AN group both on the automatic and the self-reported levels evaluated the overweight body as negative. Depression and anxiety did not influence body evaluation. Strong negative evaluation of overweight appears to be a key issue in AN rather than positive evaluation of ultra-thin role models.

Day hospital programmes for eating disorders: a review of the similarities, differences and goals

I'm a big supporter of evidence-based treatment, whether for eating disorders or cancer. Evaluating ED treatment has its difficulties, some of which include treatment dropout, and the difficulties in comparing apples to apples. This review of day hospitalization (DH) programs (also known as partial hospitalization programs, PHP) found that it's very difficult to evaluate treatment programs since they are all so different--and this is with nationalized health care, so I can imagine that doing these comparisons in the US would provide even more disparate results.

The researchers found that most day treatment programs seemed "largely experimental" due to the large number of differences in programming.

Briefly, the shared elements are: biopsychosocial model as reference frame; cognitive-behavioural model or techniques; behavioural contract; patients' selection; body image therapy; involvement of family; weight normalisation/weight gain and modification/normalisation of eating behaviour as objectives. Nonetheless, shared opinions concerning inclusion criteria are lacking; the duration of DH treatment is surprisingly different among centres (from 3 to 39 weeks); the approach to eating and compensation behaviours ranges from control to autonomy; followup and psychometric assessment can be either performed or not; psychological and behavioural objectives can be different. This review suggests the existence of two different DH models: the first has a shorter duration and is mainly symptom-focused; the second is more individual-focused, has a longer duration and is focused on patients' relational skills, psychodynamic understanding of symptoms and more gradual changes in body weight. Further investigation is required to make DH treatment programmes measurable and comparable.

This study only underscores the difficulties in not only designing evidence-based treatment programs for EDs, but then being able to evaluate different treatment modalities for efficacy. But not doing this job would be a disservice to millions of people.

When I was taught about avoiding ED triggers in treatment, I learned a lot of the usual: stay away from fashion magazines, the crazy aunt/sister/cousin/uncle who's always on a diet, throw out your "sick" clothes, etc. All of these are very good things to do, and I've made changes in all of these areas in my life to avoid being bombarded with the same messages that I'm trying to convince myself aren't true.

Where I'm at in recovery now is a little different from when I was first hospitalized almost 9 years ago. Sure, my body image may take a hit if I look at a fashion magazine, and nothing sets my teeth on edge quite like discussion of what I "should" be eating. It's irritating and uncomfortable, but it's not triggering. It doesn't make the ED sound all rosy and happy and maybe breakfast really isn't such a good idea after all.

This is not to say that I'm without my triggers, however. They're just a lot different than some of the ones I learned so long ago.

My biggest trigger, without a doubt, is anxiety. The more anxious I get, the more I feel compelled to return to my routines and rigid ways of living. It makes me want to do an impromptu ultra-marathon and run until I'm too physically exhausted to be wound up and anxious. It's what ultimately prompted this last relapse: heaps of unchecked anxiety that I "managed" by exercising and creating more and more rules for myself until I was sucked back in.

I've been making a lot of progress recently with feeling more free to eat when I'm at home. The AN isn't gone, but I can exhale just a little bit. I don't get the insane metabolic hiccups anymore (as in needing nearly twice the daily recommended intake just to maintain), and my body is beginning to trust that food will be there again in a few hours. Part of the exhalation is my routine. What I do, when. Particular combinations of foods. Even just the types of food that are generally on hand. When I arrive in a different environment--even a comfortable, different environment--I get all shook up. And those nagging fears creep back in, fears about whether I'm eating too much in general, I'm consuming too many "added sugars," I'm exercising enough, what will be served in a few hours.

Right now, it's a fine line between finding security in the routines that I psychologically crave, and not getting so wrapped up in them that it ends up hindering my recovery. These routines do help dramatically decrease my anxiety, which then helps me stay in recovery. On the other hand, if the slightest deviation in my routine causes me to freak the hell out, this isn't good, either.

I think tackling my longstanding anxiety and depression will be one of the last major hurdles for me in recovery. I'd love for it to be short and easy and simple, but I have a strange feeling that's not going to happen. But until I do, those triggers will always be waiting for me.

Remember that no matter how your holiday turns out, at least you're not Big Bird.

Companies that are hawking diets and other weight loss products claim to be interested in your health. Really? They're interested in your wallet. Ditto for "reality shows" that feature competitive weight loss. And there is a growing awareness that these products and programs are futile at best and dangerous at worst.

A great editorial titled "Weight-loss industry masks its economic interests with bogus health concerns," writes about the realities of our thin-is-in culture, with a focus on the new academic field known as fat studies.

For several decades, scholars in the social sciences have shown that when it comes to people’s attitudes about weight in the United State, thin is good and fat is bad. Fat people suffer from harassment and discrimination; thin people live in fear that they will gain weight and lose status...Fat studies scholars ask why we oppress people who are fat and who benefits from that oppression, arguing that weight, like height, is a human characteristic that varies across any population. Fat studies, then, resembles other academic disciplines that question discriminatory practices based on race, ethnicity, gender or age.

Essays like this have helped open my eyes to the fact that most diets really aren't about health, they're a form of status-seeking. And this status-seeking can only exist if larger people are considered second-class citizens. It's no different than discrimination based on gender or skin color.

Of course, there's a lot of money to be made in keeping people as second class citizens, as long as they can strive to become like the "rest" of us. And one of the most onerous examples of this is the show "The Biggest Loser." I've never seen the show and have no real desire to see the show- I've lived it. Basically, the show is based on the notion of "competitive weight loss," and shaming and starving people into losing weight. A great article in the New York Times took a long, hard look at whether this show was endangering the health of the contestants.

The series also highlights the difference between the pursuit of engaging television and the sometimes frenzied efforts of contestants to win, perhaps at the risk of their own health. Doctors, nutritionists and physiologists not affiliated with “The Biggest Loser” express doubt about the program’s regimen of severe caloric restriction and up to six hours a day of strenuous exercise, which cause contestants to sometimes lose more than 15 pounds a week.

At least one other contestant has confessed to using dangerous weight-loss techniques, including self-induced dehydration. On the first episode of the current season, two contestants were sent to the hospital, one by airlift after collapsing from heat stroke during a one-mile race.

{snip}

Medical professionals generally advise against losing more than about two pounds a week. Rapid weight loss can cause many medical problems, including a weakening of the heart muscle, irregular heartbeat and dangerous reductions in potassium and electrolytes.

“I’m waiting for the first person to have a heart attack,” said Dr. Charles Burant, a professor of internal medicine at the University of Michigan Health System director of the Michigan Metabolomics and Obesity Center.

“I have had some patients who want to do the same thing, and I counsel them against it,” Dr. Burant said. “I think the show is so exploitative. They are taking poor people who have severe weight problems whose real focus is trying to win the quarter-million dollars.”

The contestants were also required to sign waivers that said "no warranty, representation or guarantee has been made as to the qualifications or credentials of the medical professionals who examine me or perform any procedures on me in connection with my participation in the series, or their ability to diagnose medical conditions that may affect my fitness to participate in the series."

What perhaps absolutely gobsmacked me (though really isn't that surprising, when you think about it) is how the show essentially muzzles any prior contestants who might criticize the show.

Shortly after a reporter started contacting former contestants to interview them about their experiences, a talent producer on the series sent an e-mail message to many former contestants reminding them that “serious consequences” could ensue if they ever talked to a reporter without the show’s permission.

To do so could subject them to a fine of $100,000 or $1 million, depending on the timing of the interview, according to the e-mail message, which was obtained by The New York Times. The show’s producers did provide an opportunity to interview several former contestants, but the interviews were conducted with an NBC publicist listening in.

I don't know about any of you, but this sure sounds like a cult to me. Each time we watch the show or buy the products, we're encouraging such insanity. And I think it's high time that we stopped.

I hadn't planned on doing a "holiday survival" post this year, but after seeing some of the great advice on the Center for Eating Disorders blog, I decided I really should post it.

Tips for Overcoming Holiday Stress and Anxiety Part One: The Food

Tips for Overcoming Holiday Stress and Anxiety Part Two: The Stress

May you have a good Thanksgiving and remember to keep your recovery a priority.

Last week, two interesting research papers were published that looked at the neurological origins of body image distortion in anorexia nervosa. And what researchers found was rather interesting.

The first article looked at not only how people with AN process body image, but it broke down that processing into two different steps: attitudes towards their body and how they experienced their own size (Mohr et al, 2009). Using fMRI, the researchers

"further demonstrated stronger activation of the insula and lateral prefrontal cortex during the satisfaction rating of thin self-images. This indicates a stronger emotional involvement when patients are presented with distorted images close to their own ideal body size. Patients also overestimated their own body size."

Furthermore, the researchers found a complex pattern of activation of the precuneus, an area of the brain that is thought to contain a sensory-based map of the body. Scientists hypothesized that people with AN have a deficit in their ability to pull up an accurate map of their bodies, leading to the body size overestimation so prevalent in AN.

I think it would be fascinating to compare fMRI scans of people with non-fat-phobic anorexia to those with AN and body dysmorphia. Perhaps this would help confirm that these different patterns are specific to body image and not related to anorexia in some other way.

The second paper looked at the role of the right parietal lobe in the formation of body image in people with AN (Nico et al, 2009). Part of the parietal lobe's job is to integrate sensory information from different points in the body, and stroke patients who have damaged right parietal lobes have difficulties with body representation and schema. Whereas people without AN and those with stroke damage to the left parietal lobe were able to estimate their bodies accurately, those with AN and stroke damage to the right parietal lobe were not. The researchers concluded that these results

"support the possibility for a neuropsychological component in the pathogenesis of anorexia, offering alternative approaches to treatment of the disorder."

Together, this research indicates that the body image difficulties in eating disorders go beyond seeing skinny models in magazines (though this doesn't help) and these neuropsychological differences play a role in the development of EDs.

An interesting allegory is being passed around at the Around the Dinner Table Forum, about parents coming to grips with the fact that their child's eating disorder has changed the family. It's called "Welcome to Holland," and it was originally written for parents of kids with disabilities. Basically, you plan on a trip to Italy all your life, only to find that you are now stuck in Holland. You will miss Italy, of course, but it's also important to find good things about Holland. It's said much more eloquently than that, but this is the gist of it.

I know this piece was written more for parents, but to be honest, I relate to it, too--quite a bit. My life now, with the eating disorder, is so different than I ever thought it would be. I never thought that I would likely be turning 30 while still living with my parents. I never thought that I would live to 30, to be totally honest. I never thought things would be this hard. And I see my friends, who are getting married, having kids, climbing the ranks at their jobs, and I get a little bit irked. I know life isn't fair and the fastest path to unhappiness is trying to make it so. But I can't let go of wanting to see Italy.

There are some good things that have come out of the eating disorder. I don't know if I would have discovered my love of writing, for starters. I've met some awesome people. And I have a lovely kitty. Which is all well and good, but it's like being crowned Miss Congeniality. It is, perhaps, better than nothing, but dude, it's not the prize you worked so hard for.

Holland has many nice things--tulips, legal marijuana, and lots of tall, thin blonde people to give me a massive complex. It's not Italy and it's never going to be Italy. I want to be okay with that. Just like in the article, I'll probably never stop wanting that trip to Italy, but I'm in Holland now, and I need to make the best of it.

My life itinerary got massively changed, and I hope to simply accept that there's nothing I can do about the change and move on the best I can.

I got an email request from my good friend June Alexander, asking me to post this notice:

ED sufferers and caregivers have an opportunity to share their experience in a new international textbook aimed at educating primary care health practitioners. The book, co-authored by June Alexander and Professor Janet Treasure, will be published by Routledge (UK) in 2011. Carrie is among those contributing their story in this exciting new book.

June particularly would like to hear from you if you:

--have experienced DBT or know a family member who has;
--have experienced CBT;
--are an elite female athlete who has suffered AN;
--are an Hispanic family, or black family, whose child developed AN and the family assisted recovery through FBT; or
--are a sufferer of bulimia who has experienced/is experiencing a drug therapy strategy.

If you fit any of the above criteria, and are willing to share your story, please contact June who will arrange to collect your story via email, Skype or phone. Anonymity is assured unless specifically stated. Write to June Alexander at june@junealexander.com or Carrie at carrie@edbites.com

For more details about June go to www.junealexander.com

I just noticed this little magnetic notepad that is hanging on the side of my computer. I remember picking it up several years ago at a NEDA conference because I needed to write something down when I was near the exhibit booths. So I picked up the notepad and ultimately stuck it to my computer when I got home. And there it has stayed. I neither thought about it or really used it since.

Today, however, I was on hold and found myself staring at this little notepad, which said:

Food is not the problem, therefore it can never be the solution.

I confess, I'm a little stymied by this. To say that food isn't the problem for someone with an eating disorder strikes me a vaguely ridiculous. Of course food is a problem- either you can't eat enough, or you can't stop eating. Food isn't necessarily at the root of an eating disorder, any more than being sad is at the root of depression. It's our attitude towards food, and our ability to consume and digest appropriate amounts of it that ultimately are the problem.

To some degree, I have found food to be the solution to my eating disorder. Eating is not a cure, not by a long shot. But re-learning how to eat and maintain a healthy body weight has been one of the big challenges of recovery. The rest of recovery--coping skills, emotions, therapy--doesn't mean a whole lot if you haven't addressed the eating part of the eating disorder.

I was always told that my eating disorder wasn't about the food. I'm realizing now that my eating disorder was about the food. It wasn't solely about the food, as a lot of my anorexia had to do with my anxiety and fears around food, as well as perfectionism, etc. Not that clinicians should focus on the food to the exclusion of everything else, but you have to start somewhere.

(On a side note, the other phrase from treatment that still makes me cringe is "fat is not a feeling." Fat is too a feeling--a physical feeling. It's not an emotion, but you can, in fact, feel fat.)

I understand that food (whether consuming it or restricting it or purging it) will never be a solution to emotional problems. I've learned that the hard way. But to say that food isn't a problem, period, and food isn't part of the solution seems a little ludicrous when it comes to eating disorders.

How do you interpret this notepad? What do you think?

I used to think that eating disorders were an extreme diet (this was a very long time ago). I thought there were people who didn't diet, people who dieted, and people with eating disorders, all arrayed on a nice little continuum, one blending seamlessly into the next. I've since learned that scholars are still considering this question, albeit in a more academic, less hand-waving sort of way.

Eating disorders are currently classified into three major categories: anorexia nervosa, bulimia nervosa, and eating disorder- not otherwise specified. What we don't know is whether these categories are just humanity's attempts to corral people with eating disorders into three categories, or if these are, in fact, three different eating disorders. Nor do we know if eating disorders are dimensional (ie, they exist along a continuum) or they are taxonic (ie, they have their own category, sort of like humans are a separate species from chimps. We don't have a human-chimp continuum, the behavior of several of my relatives notwithstanding). Perhaps a better analogy would be the difference between a light on a dimmer switch (dimensional model) and a light with an on/off switch (taxonic model). The methods for determining the difference between these use a lot of advanced mathematical models and some really fancy words--I'm not especially concerned in understanding precisely how the determination is made. Rather, I intend to look at whether we can make a distinction, and what that distinction is.

Like many new ideas in science, there is evidence in favor of both views. So let's start with a brief review of the evidence.

Eating disorders are dimensional

Thus far, one study has evidence that restricting anorexia exists along a continuum with "normal eating," although this study also found that bulimia and binge eating disorder do not exist along a continuum (Gleaves et al, 2000a). Perhaps one of the reason why restricting anorexia didn't appear quantitatively different from "normal eating" has to do with the prevalence of dieting behavior, which is more common than not in the college students surveyed in the study. In general, dieters have higher scores on the restraint/weight subsection of the EDI-2, but have similar psychopathology scores as non-dieters (Lowe et al, 1996), which really helps muddy the waters.

Interestingly, the Gleaves study found that the binge/purge subtype of anorexia was much closer to bulimia nervosa than the restricting subtype of anorexia, indicating that binge eating and purging is, in fact, taxometric, whereas restrictive behaviors are more dimensional.

When looking at nonbehavioral eating disorder symptoms (such as fear of fatness, obsession with food/calories), researchers failed to find any sort of eating disordered category, which would indicate that yes, indeed, eating disorders exist along a continuum (Tylka and Subich, 2003). A more recent study, building on this one, found that although eating disordered thoughts are common among people without clinical eating disorders, eating disordered behaviors are rather uncommon (Miller, Vaillancourt, and Hanna, 2009), which has implications on what, precisely, is measured on future studies.

Eating disorders are taxometric

The evidence for both binge eating disorder and bulimia nervosa seem to indicate that these disorders exist as their own categories; that is, either you have them or you don't (Lowe et al, 1996, Gleaves et al, 2000a, Gleaves et al, 2000b). Of course, a diagnosis is rarely as simple as one of those notes you likely received in sixth grade that said "Do you like me? Check yes or no."* There are lots of issues still to be worked out, not the least of which is where do we draw the line?

Perhaps one of the most interesting studies found a middle of the road for this discussion: some eating disorder symptoms existed on a continuum, and some, such as binge eating, fear of fatness/compensatory behaviors, and drive for extreme thinness, did not (Williamson et al, 2003).

Conclusion

At this point, the only consensus on the issue of eating disorder taxometry is the need for more research. Preliminary evidence suggests that bulimia and binge eating disorders are discrete symptoms; the evidence is less suggestive for restrictive anorexia. That being said, eating disordered thoughts are quite common, even if the behaviors are not, which could have significant implications on what is measured and studied in the future.

With the upcoming (and much-heralded) publication of the DSM-V in several years, these seemingly esoteric ideas could have a large impact on how we diagnose, treat, and prevent eating disorders.

Coming tomorrow: Classifying eating disorders, part two (What's temperament got to do with it?)

*Full disclosure: I neither sent nor received any of these notes.

Remember when food was just food? I don't. But I try to imagine it sometimes. I grew up in the throes of fast food, Halloween candy, and plates of bacon at breakfast buffets only to learn that I was just another victim of the food processing industry. Food issues are fascinating if for no other reason that they instill a constant sense of humility.

With all this information about food, I have been compelled toward ambivalence. On the one hand, the issues are compelling and require large-scale change. On the other hand, the potential obsession about what we put in our bodies can lead to a sophisticated brand of narcissism.

So writes Jennifer Jacquet, in a post titled "Use the Force against the Dark Side of Food" on her blog Guilty Planet. I haven't read many other of her posts, but she used the term "eco-douchebag," so it has to be good.

Thoughts on this?

(Today's post on eating disorders vs. disordered eating has been postponed because I ended up at TJ Maxx for quite some time and uh, Aria needs a bath. The details are a little gross for the blog, but needless to say, her hindquarters need a good scrub. ATDT ladies, any virtual strap-on gonad donations will be greatly appreciated...)

I got invited to join a Facebook group of this name late last night, and I spent part of the day contemplating my response. I hesitated in writing for several reasons, not the least of which were that I don't have time right now to be responding to a lot of potentially irritated people, and also because I wanted to frame my thoughts properly. After a while, I figured what the hell- I'll bite. I decided to blog my thoughts here and post a link to the group so I didn't have to check two places for comments.

I searched through my blog archives and was astonished to discover that I had never answered this question head-on, in its own post. So, here it is.

To me, the question of "Does media play a role in eating disorders?" is usually asked in a sense of "Does media play a role in causing eating disorders?" And that answer, I would have to say, is pretty minimal. Media provides lots of context, and more than enough triggers, but to say that people with eating disorders are "dying to be thin" minimizes the seriousness of the illness and does everyone a disservice.

I was flipping through a copy of The Handbook of Treatment for Eating Disorders and I stumbled across an article that looked at the Three Ps of eating disorder onset: Predisposing factors (ie, genetics and other neurobiological factors), Precipitating factors (ie, culture, dieting, "healthy eating," etc), and Perpetuating factors (ie, what keeps the illness going). The role of the media certainly fits in the category of "precipitating factors," but although these factors are important, they seem more incidental than causative. Predisposing factors are largely homogeneous; precipitating factors can vary widely.

Finding yourself afraid to eat is a rather bizarre phenomenon. Our brains need to explain it somehow--so we turn to the vocabulary we know. I did blog about this almost two years ago now, rather briefly, and I think I shall plagiarize myself a bit:

Could eating disorders be women and men trying to be perfect? To live up to society's expectations? To look like models? I doubt it. That's part of it. It's the cultural context of the illness. In the Middle Ages, women (most of the recorded cases were in females) who starved themselves were considered saints. They fasted to get closer to God. Some, like Catherine of Siena, got hooked. It felt good. Her explanation was of faith. Ask a sufferer today, and a lot of it seems to be 'healthy eating' and images of supermodels and the idea that you can Have It All. It's no more a reason than faith. But it is a context. It does explain the triggers, the psychological environment from which an eating disorder develops.

One of my OCD fears was that I was going to catch AIDS from someone, or that I already had AIDS and was going to give it to someone else. Regardless, it was OCD. But if I was about 15 years older (the OCD AIDS stuff started in about 1993-1994, when I was 13-14), AIDS wouldn't have been on the radar. It might have been another disease. It might have been something else entirely. A person with schizophrenia would not have feared the CIA listening in on phone calls 100 years ago. First off, they probably wouldn't have had a phone, nor would there have been wire taps, and lastly- there was no CIA. Diseases have a context. But that doesn't mean that AIDS fear mongering caused my OCD, nor that the CIA causes schizophrenia.

Or, for that matter, that the media caused my eating disorder.

Much of the debate about media and eating disorders boils down to this: do eating disorders exist along a continuum with more normalized eating (that is, are eating disorders an extreme version of a diet and common body image issues?), or are eating disorders a separate entity. The answers aren't all in, and I won't pretend to understand all the answers that we do have (but I'll pretend enough to do a more in-depth blog tomorrow- stay tuned!), but I believe that eating disorders are a distinct entity separate but similar to our obsession with dieting and thinness.

Let's compare eating disorders to depression. Saying eating disorders are just a really whacked out diet is like saying depression is just a really bad mood. Most people with depression are in a really bad mood--that's kind of the definition of depression, really. And many people with eating disorders appear to be dieting and have body image distortion. But depression isn't a really bad mood that won't go away. When the weather sucks or the store is out of eggs or the car won't start, people will often say, "Ugh- I'm so depressed!" Not really. You're pissed off, sad, annoyed, whatever, but that's not depression. Both eating disorders and depression frequently pass through stages of seeming like just another diet or a really bad mood that lasts for-freaking-ever, but they then take on a life of their own. They stop becoming a choice and become an illness.

I thought for a long time that the thinness ideal had a lot to do with eating disorders, and I've since changed my mind, especially in light of the emerging research that suggests that up to 82% of eating disorder risk is genetic.* Eating disorders existed long before supermodels and they'll probably exist long after. And I think we are missing so many opportunities for prevention and education by focusing on the media aspect and leaving so many other areas out in the cold.

*A, this wasn't the study that I was referring to in a previous post (the study is too new), but it does confirm the numbers in the talk that I scribbled down.

...it'll really float my boat!

SO MANY of you have shown your support and voted for ED Bites for the People's HealthBlogger Awards 2009- I can't tell you how much I appreciate it. However, I know many of you have busy lives and may not have gotten around to voting yet. If you haven't yet voted, please do so now! You will need to sign up for Wellsphere, but it's really easy and they won't flood your inbox with lots of spam. All you need is a valid email address. Click on the widget below or the link above to get started with voting. Thanks!

Carrie A. http://www.wellsphere.com/linkOut.s?link=http%3a%2f%2fwww.edbites.com

One of the questions I get a lot when people hear about my eating disorder history is usually some variant on: but how did you resist all of that tempting food? (This is usually said dripping with the unsaid phrase of "please teach me how you did this.") My answer is that anorexia made me afraid of food. Not that I wasn't hungry or wasn't utterly obsessed with it, just that the prospect of facing food gave me that deer-in-the-headlights feeling.

Now, if we want to talk about temptation, we can talk about the allure of the anorexia symptoms. I'm not so delusional as to think that losing weight will be a cure-all for everything that is wrong in my life, but I have been so delusional as to think I wouldn't become addicted to exercise, or that I could lose five pounds and be absolutely fine, dammit. Uh, not so much. Eating dinner every day really does matter, and so does making sure I have at least one rest day each week from exercise.

Which is why this study on restraint bias (called The Restraint Bias: How the Illusion of Self-Restraint Promotes Impulsive Behavior really interested me: it seemed to echo my own thoughts that I really wasn't all that vulnerable to relapse. I mean, hey- I've written two books on eating disorders. Surely I'd know the danger signs.

Except that it doesn't work that way.

Ed Yong, in his blog Not Exactly Rocket Science, has a great explanation of this study, and summarizes the study as follows:

The restraint bias stems from the fact that we're generally bad at predicting the future and how we'd feel in circumstances that are different to our current ones. When we're full, we underestimate the powerful pangs of hunger. When we're cold, we can't imagine what it's really like to be sweltering. Addicts underestimate the pull of their drug-of choice when they try to quit.

{snip}

The restraint bias could also help to explain why people willingly take up activities they already know to be addictive - they simply believe that they're strong enough to resist the addiction. As a powerful example of this, one study showed that heroin users are less willing to pay for the substitute buprenorphine if they weren't currently experiencing cravings. If experienced users underestimate their urges, imagine how monumentally more difficult it would be for a naive person to do so.

Restraint bias is the idea that we often think we are better at resisting temptation than we really are. A smoker may underestimate the strength of their cigarette cravings when they're in a smoky bar. Someone with binge eating behaviors may take home leftover cake for their family to enjoy, pretty sure that they won't be tempted to eat it. Or, like me, you may think you can skip dinner once and it won't become a habit. Or that you will pack your schedule full of activities and jobs, positive that you will still find time to eat.

This is really life's way of knocking you on your arrogant ass, over and over and over again. And the only way to deal with this restraint bias is to learn humility. To accept that one skipped dinner is never just one skipped dinner. To be always aware of the pull of this behavior. This is not to say that full recovery isn't possible. I know there are plenty of people who are completely free of eating disordered thoughts. But efforts to stay recovered and healthy are different than efforts of constantly fighting off an illness.

I never thought I couldn't relapse or wouldn't relapse, but I sure thought it would be more difficult than it was. Looking back, I can see that I was teetering on the edge of a relapse for a good long time, and that it didn't take much to push me over into the "let's starve!" mode. I underestimated how rapidly exercise would become addictive, and how difficult it would be to just stop. I didn't realize that I couldn't just flip a switch in my brain and start eating again. Which is restraint bias at it's finest.

My recovery journey has been humbling and, at time, humiliating. But I think that ongoing self-awareness will help keep me well, and keep me on my toes.

There was a brief but interesting research article this past week on Interesting practitioners in training in empirically supported treatments, published in the Journal of Clinical Psychology. Despite a growing recognition of the importance of empirically supported treatments (otherwise known as evidence-based treatments), not all therapists are aware of these treatments or are willing and able to provide them. A good blog post from the Cleveland Center for Eating Disorders explains some of the reasons why.

Of course, all the training in the world isn't useful unless a therapist is interested in receiving that training. Speaking as someone with a research-oriented background, not a clinical one (nor even a psychological one), my first instinct would be to start by showing people the strength of the research base behind the treatment. What this paper found, however, is that most therapists responded more favorably to case studies rather than larger research studies.

Which, when you think about it, does make sense. Most therapists are more oriented towards people than they are towards large research studies (I'm the opposite, which helps explain why I'm not a therapist and never will be). This is neither good nor bad, it's just a general trend I've observed. Furthermore, case studies can provide more practical information in explaining how the therapy is carried out, how the patient responded, and what are some common pitfalls. This isn't to say that case studies should replace large research trials, just that they interest therapists more in empirically supported treatments.

For more information on empirically supported treatments, see both the Psychotherapy Brown Bag blog and this explanation from the American Psychological Association (they have information specifically on empirically supported treatments for eating disorders here).

For carers of those with eating disorders, the line is often-repeated that you need to put your own oxygen mask on before you can help your child with theirs. And in that context, I read about An Encounter With Hypoxia. However, as I read it, I didn't think about caregiving, I thought about relapse and recovery.

Think of the hypoxia symptoms as a relapse or a slip. Sometimes these symptoms are straight out of the textbook; sometimes they're more unusual. Sometimes they come on slowly; sometimes they just give you a proverbial kick in the gut--you go from fine to f*cked in less than 10 seconds. In treatment, I was told what these symptoms were, and I could probably do a decent job at recognizing them in others. But when it came to me, I was clueless. Reading about relapse and then actually experiencing it are two different things.

This past spring, I was aware for a while that I might be getting into dangerous territory, but I felt fine, so I just kept living my life and flying the metaphorical plane. By the time I realized I was relapsing and needed my oxygen mask, I was too far gone to put it on myself. Looking back, I can see the signs and identify several places when I really should have stopped flying the plane and started making sure that I had enough oxygen.

Which is why slips and struggles can be beneficial: they help you begin to recognize when you might need to put on your oxygen mask. I'm not saying people should be thrown to the wolves or left to starve and then polled about their experiences. Nor should you necessarily try to relapse in order to pick up some of these valuable lessons. But there's also something to be said for experiencing recovery hypoxia while you are still in a position to have others quickly put your oxygen mask on. It's how they trained the Air Force pilots, so that when they were out solo, they could recognize the signs before the signs that told them they needed more oxygen.

Part of the hardest thing for me to grasp is just how quickly my symptoms arise and how I'm almost incapacitated even more quickly. How, like Student Number 5 at the beginning of the article, I can be in desperate need of oxygen and not even know it. I don't know what the solution is. Take regular puffs of recovery oxygen and monitor if I feel different? Don't get in an airplane? I don't know what the exact answer is, but I suppose there's no better time to start figuring that out.

I ran across a fantastic article in The Atlantic, titled The Science of Success, which examines the genetics of mental illness. Writes David Dobbs:

Of special interest to the team was a new interpretation of one of the most important and influential ideas in recent psychiatric and personality research: that certain variants of key behavioral genes (most of which affect either brain development or the processing of the brain’s chemical messengers) make people more vulnerable to certain mood, psychiatric, or personality disorders. Bolstered over the past 15 years by numerous studies, this hypothesis, often called the “stress diathesis” or “genetic vulnerability” model, has come to saturate psychiatry and behavioral science. During that time, researchers have identified a dozen-odd gene variants that can increase a person’s susceptibility to depression, anxiety, attention-deficit hyperactivity disorder, heightened risk-taking, and antisocial, sociopathic, or violent behaviors, and other problems—if, and only if, the person carrying the variant suffers a traumatic or stressful childhood or faces particularly trying experiences later in life.

This vulnerability hypothesis, as we can call it, has already changed our conception of many psychic and behavioral problems. It casts them as products not of nature or nurture but of complex “gene-environment interactions.” Your genes don’t doom you to these disorders. But if you have “bad” versions of certain genes and life treats you ill, you’re more prone to them.

Recently, however, an alternate hypothesis has emerged from this one and is turning it inside out. This new model suggests that it’s a mistake to understand these “risk” genes only as liabilities. Yes, this new thinking goes, these bad genes can create dysfunction in unfavorable contexts—but they can also enhance function in favorable contexts. The genetic sensitivities to negative experience that the vulnerability hypothesis has identified, it follows, are just the downside of a bigger phenomenon: a heightened genetic sensitivity to all experience.

(emphasis mine)

Dobbs explains that there are two differen types of children: "dandelions," those children with more reslient genes who will grow no matter where they are planted, and "orchids," those children who will wilt if neglected but will bloom magnificently in the right greenhouse.

"One lesson that geneticists know," writes evolutionary biologist jerry Coyne, "is that 'genetic' does not mean 'unchangeable.' "

Indeed it doesn't.

I was on the great Neuroscience and Society website at the University of Pennsylvania, looking up more information on the 2010 Neuroscience Boot Camp (which I really hope to attend, provided I can snag both an admission spot and a scholarship), when I checked out their full-text research articles published by members of the program. One, titled Denying autonomy in order to create it: the paradox of forcing treatment upon addicts, immediately caught my eye.

(Just to warn you: the article is full-text, but it's really blurry. It appears they scanned in printed pages to create the .pdf files, so you can't copy and paste the text into word to get a better look. And no, printing it doesn't help either. I apologize if there are any errors in my transcription of the text.)

The author, Arthur Caplan, writes:

People who are truly addicted to alcohol or drugs really do not have the full capacity to be self-determining or autonomous. Standard definitions of addiction cite loss of control, powerlessness and unmanageability. An addiction literally coerces behavior. And addict cannot be a fully free, autonomous agent precisely because they are caught up in the behavioral compulsion that is addiction. If this is so, at least for some addicts, then it may be possible to justify compulsory treatment involving medication or other forms of therapy, if only for finite periods of time, on the grounds that treatment may remove the coercion causing the powerlessness and loss of control.

Addicts, just as many others with metal illnesses and disabilities, are not incompetent. Indeed, to function as an alcoholic or cocaine addict one must be able to reason, remember complex information, set goals and be oriented to time, place, and personal identity; but competency by itself is not sufficient for autonomy. Being competent is a part of autonomy, but autonomy also requires freedom from coercion. Those who criticize mandatory treatment on the grounds that an addict is not incompetent and thus ought not to be forced to endure treatment are ignoring this crucial fact. Addiction, bringing in its wake as it does loss of will and control, does no permit the freedom requisite for autonomy or self-determination.

The parallels to eating disorders are striking and, to me anyways, rather obvious. I believe that legal coercion should be a last resort measure. No one wants this- not the sufferer, not their family, and typically not society either. Buy-in is important in a therapeutic relationship, but if you never get sober, down from your Mt. Everest-level highs or begin a normal pattern of nutrition, "buy-in" is kind of irrelevant.

Coercion, even if it's not of the legal variety, is a commonly used tactic in both addiction treatment and eating disorders treatment. Done right, it can be seen as beneficial, even to the sufferer. Loving coercion could be financial ("I'm not paying for college if you're not healthy"), practical ("I don't think you should drive the car until you are doing better"), and even emotional (refusing to engage the person's disordered behaviors). Most sufferers, myself included, typically don't respond to these efforts with joy and praise, but that doesn't mean that they're not necessary. Many ED sufferers who felt they were coerced into inpatient treatment ultimately admitted they needed to be hospitalized.

In the end, what's worse: a few months of coerced treatment or a lifetime of an eating disorder?

There are, of course, plenty of issues surrounding the issue of gender and mental health, many of which I'm not qualified to discuss. There are issues with diagnosis and treatment, but there are also issues with how men and women experience mental illness.

A few weeks ago, the New York Times did a wonderful piece on PTSD in female combat veterans, and how their experiences differ from mens'. The disorder wasn't renamed PTSD-she and PTSD-he because men and women had different experiences coming home and living with their demons.

Very unlike the phenomenon of "manorexia." It's the same disease. Not that we shouldn't pay attention to and learn from men's expiences of eating disorders, but that doesn't mean their suffering is somehow different than a woman's. True, there hasn't been quite the same gender-based stigma in PTSD, which may account for some of the difference.

Two individuals are never going to have the exact same experience with an illness. That's not how life works. This doesn't mean that they don't have the same illness, just that we all experience things differently.

I hope the world out there can one day see the differences in EDs in men and women the same as they do with PTSD: same illness, different experiences.

...like a yummy root beer float!

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That's the question raised by researcher Rony Duncan. In his "News and Views" piece for the British Medical Journal, published this past September, Duncan argues that gyms do have some responsibility, and lays out three main areas in which this could be beneficial.

1) It provides a possibility for intervention.
2) It can help promote a healthy body image.
3) It can help break through the delusional thinking that accompanies EDs.

The possibility for intervention is well-intentioned and will probably fall on deaf ears. It would have for me. This isn't to say that people shouldn't speak up, just that speaking up will not necessarily produce a newly-converted couch potato. Frankly, if someone had spoken up to me, I would have just switched to a new gym. In fact, I was so paranoid about someone noticing that I took all sorts of steps to make sure I never exercise excessively in any one place at any one time. I spread my exercise sessions throughout the day and in several different locations: outside, my apartment, the gym at work, the gym at home. No one knew, of course, that I worked out several times each day.

The second point is almost laughable. First of all, Duncan is making the assumption that anyone who exercises excessively is visibly underweight. I rarely was. And many others aren't, either. Do we not have a problem until you can count our vertebrae? Secondly, preventing the visibly anorexic from exercising will probably not have a large impact on most people's body image, nor is that something that other people can control. Kicking someone out of a gym because they're very thin and giving other people a complex sounds more like playground logic.

There's also the problem that many men have exercise addictions, and also that someone can have a lower BMI (known as being constitutionally thin) and be perfectly healthy.

The third point is, perhaps, the most valuable. Writes Duncan:

...when gyms fail to intervene over members who are below a healthy body weight, they risk becoming complicit in the delusions held by these individuals, strengthening the perception that more exercise and weight loss are needed.


My long experience with anorexia has left me peeved at any number of things, including the paucity of good treatments (and treatment providers!). One of my other peeves is that, other than my mom, no one really spoke up and told me I was exercising too much or losing too much weight. Would the truth have made a bit of difference? Probably not then. But it's very hard to convince yourself you have a problem when everyone else seems to be living in the same delusional world as you are. If I were sick, I thought, surely somebody would say something.

And because they didn't, it only reinforced the idea that I was fine.

I don't necessarily think that speaking up to an exercise addict about his/her gym habits will magically take off the blinders. I don't know that it will decrease his/her overall exercise. I don't know that it will improve others' body image. I don't even know that it will break through the wall of delusion and anosognosia that comes along with eating disorders.

But there is value in speaking the truth, in saying what needs to be said whether the listener wants to hear it or is ready to hear it. I am incredibly angry that so few people said anything to me during my illness, when I ran to the bathroom after meals, when I basically moved into the gym, when I was using binder clips to keep my pants up. I was secretive, yes, but you would have had to be blind to miss some of this stuff.

Speaking up says one incredibly priceless thing to a sufferer: I care about you. And that is a message that sufferers need to hear, over and over and over again.

One of the side effects of eating disorders is a rapid sense of satiety; that is, you feel more full when eating less food. Some of this is strictly physical, as the stomach shrinks during starvation, and food empties into the digestive tract slower. The formal medical name for this is delayed gastric emptying or gastroparesis. It almost always reverses upon normalization of eating patterns, but it can take a while. Some of this satiety may be anxiety-based (that stomach-churning feeling really isn't condusive to eating lasagna, let alone with gusto), and sometimes, it was a matter of my believing my own BS. If I just ate X, I damn well better be full!

Then, of course, we have to add neurochemicals to the mix. I've blogged several times on leptin in eating disorders (What's Leptin Got to Do With It?, Leptin and You, and Food and Sex and Leptin- Oh My!), and the protein, which signals satiety, has been much researched in relation to both anorexia and obesity. Gina Kolata's book Rethinking Thin has a great chapter on the discovery of leptin and some of the interesting research going on about the protein.

Ghrelin is kind of the ugly stepsister to leptin--it has the opposite function (ghrelin signals hunger as opposed to satiety), and it's gotten the shorter end of the stick in terms of research (at least recently). Unlike leptin, which is primarily synthesized by adipose tissue, ghrelin is synthesized in the stomach upon eating. A drop in ghrelin levels typically happens after eating and is thought to be linked to the release of insulin, which tells the body's cells to absorb the glucose from the meal.

Considering that people with anorexia are objectively starving, they generally have high levels of ghrelin as their bodies signal them to go get some food, levels that return to normal upon refeeding. However, a new study suggests that the excessive release of insulin by people with AN (known as hyperinsulinemia) also blunts the hunger-signaling effects of ghrelin. That is, the sudden drop in ghrelin upon eating even small amounts of food tells the brain that the person is full and the meal is finished.

The increased insulin sensitivity makes sense from a biological standpoint: the body will want to make the most use out of limited energy intake, so cells would do well to become more sensitive to insulin to slurp up more glucose. Whether the drop in ghrelin is an abnormality completely separate from the insulin sensitivity, or just a really ironic side effect, has yet to be seen. However, it adds another piece to the puzzle of why people with AN find it so difficult to eat more: they really do feel full.

Today's edition of Psychotherapy Brown Bag deals with the efficacy for Equine-Assisted Psychotherapy (EAP), specifically in the realm of eating disorders. What did the author, Mike Anestis, find?

EAP does not appear to be harmful, but there is no evidence that it is efficacious in the treatment of mental illnesses. There is a paucity of research on the topic and the research that exists is so full of flaws that it is actually rather remarkable that it was published in the first place. Nonetheless, fancy treatment centers charge outrageous fees to provide this service and make grandiose claims regarding efficacy. Just as we covered in our article on touch field therapy (TFT), such behavior is a prime marker of pseudoscience.

I don't doubt that riding horses is nice and fun and pleasant, but that doesn't mean that it helps treat eating disorders (or any other illness, for that matter). I find many things nice and fun and pleasant and even, in a sense, therapeutic, but that doesn't make it a treatment. I'm a big believer in the power of animals to make us feel better- my cat does it all the time. Nothing beats snuggling her in my lap or watching her silly antics. Spending time with her is often the highlight of my day. But it doesn't help treat my eating disorder. There's a big difference.

I've done some equine therapy while in treatment and maybe I'm just bitter, but I'm not sure what the point of it was. I get the theoretical premises upon which EAP stands (as summarized by Anestis):

•Improving non-verbal communication skills through interactions with a non-verbal creature
•Improvement of acceptance skills and emotional expression through the realization that a person can not make the horse do things it does not want to do (e.g., lift its hoof)
•Improved mood due to positive interactions with an animal
•Increased awareness of connection to nature through outdoor experiences

Which is all well and good, and no doubt there can be valuable lessons learned from equine therapy. (Although I must say that my cat has taught me everything and more that I need to know about point #2. The horse might be larger, but my cat has claws! :) ) Yet that still doesn't mean that EAP is an empirically-supported treatment. I find valuable lessons in coloring mandalas, in watching Grey's Anatomy and House, in crochet, in Sudoku puzzles. Not that these things can't be helpful, but it's a long stretch to say that these actually treat eating disorder symptoms.

I do realize that places like Remuda Ranch don't rely on horses alone for their treatment. But you better believe that EAP is one of the reasons they charge so much. Why pay extra for something that doesn't really work? Why not let your kid take horseback riding lessons or go trail riding once their ED symptoms have improved?

Anestis sums up his thoughts as follows:

I like the idea of using animals to make people feel better. In fact, Joye and I may one day train our sweet playful golden retriever to visit hospital patients in order to provide them with an added moment of happiness. In doing so, however, we will not be under the illusion that such an action would constitute therapy or treat mental illnesses. Our dog would simply provide a positive experience, which can impact mood and perhaps motivate an otherwise ambivalent individual to pursue the type of help capable of addressing the actual problem. When animal-assisted therapy is couched in these terms, it sounds wonderful. When it is presented as a stand alone treatment, however, that is a problem.

I don't think, however, that Aria would be very good at visiting hospital patients. Hiding under their beds and peeing, yes. Therapeutic, not so much.

One of my friends was having a really bad day today, and sent me an email. I didn't really know how to provide email support, so I gave her a call. We talked for about 15 minutes, and I think I helped her feel at least a little bit better. She thanked me many times for calling, and I said I was glad to.

I'm not saying this because I want a pat on the back, or even that I feel that other people need to know how I occupied 15 minutes of my day.

I'm saying this because it's such a normal thing to do: be there for a friend. It's something I wouldn't have done when I was deep into the eating disorder because I wouldn't have had the energy, and I would have been afraid that my friend would end up suggesting we go out for dinner or something. It would have been much easier to write back and say "I'm sorry life sucks right now. Let me know if I can help." Which is fine, but I know when I'm drowning in anxiety and depression, a friendly voice can really help anchor me.

We used to be best friends until the usual time and distance separated us. In the past year or so, we've once again been closer geographically and have reconnected over numerous shared interests. I'm not totally positive why she wrote me, but I'm flattered that she did, and I'm glad the ED is out of my life enough that I was able to respond as a good friend and not a caring, starving anorexic.

I hate winter. First off, I hate the cold. I've never liked it, and my eating disorder history only makes my cold intolerance worse. I'm also not fond of the ice, seeing as five years ago, I slipped and fell on a patch of black ice and shattered all of the bones in my osteoporosis-riddled ankle that All the Kings' Horses and All the Kings' Men had to put back together surgically.

But the part about winter that really gets me down is the darkness. My depression tends to get worse in the winter, and I've had several meltdowns around December and January. It happens with such remarkable precision that I have to wonder. I have the little lamp that I try and sit in front of, and I'm not sure it helps, but it doesn't hurt. (Maybe it works because Aria treats it like her own personal kitty-sized tanning salon and basks in the light while it's on, which is hilarious).

However, after reading that CBT is more effective for seasonal depression than light therapy, and getting tired of the constant dread of winter, I thought I would try to find things about winter that don't suck.

1. The cold makes coffee taste better.
2. More darkness means better effects from my candles.
3. Scarves!
4. Wool socks.
5. Looking out the windows at the pretty snow.

Can anyone add to my list? I'm not looking to make winter my favorite season, but it would be nice not to start getting sad in August when I realize that all of this lovely daylight is going away.

I stumbled across an interesting article in The Behavior Therapist, published by the Association for Behavioral and Cognitive Therapies, titled On the Brain Disease Model of Mental Disorders, by Brett Deacon and James Lickel. The "brain disease" model holds that mental illnesses are biologically-based and are the result of underlying alterations in neurochemistry. I have used the terms somewhat interchangeably, and probably will continue to do so, although the semantics of the two terms are different.

In this article, the authors contend that the brain disease model has some drawbacks, namely:

We are concerned that the enthusiastic promotion of the brain disease model by NIMH and other prominent sources (e.g., National Alliance on Mental Illness, the pharmaceutical industry) has far outstripped the available scientific data and may actually be increasing the stigma associated with mental disorders.

For starters, they say, there are no diagnostic tests for mental illnesses based on abnormal brain circuitry. Secondly, although the acknowledgement that a mental illness is a brain disease decreases how much the sufferer blames him/herself, it also tends to make them view their situation as more hopeless. Furthermore, increases in our biological knowledge and understanding of mental illness have not yet resulted in better biological interventions.

...the intervening decades have not witnessed the expected advances in biological technology for diagnosing, preventing, treating, or eliminating common problems like mood and anxiety disorders.

...the notion that “mental disorders are brain disorders” represents an eliminative reductionistic perspective in which higher-level psychological processes such as thoughts, emotions, and behaviors are entirely explained by their putative biological causes. From this point of view, an association between biological variables and mental disorder symptoms may be interpreted as demonstrating the disease process that caused the disorder. This perspective leaves little room for the possibilities that apparent biological abnormalities might be the result of a mental disorder, a consequence of chronic psychotropic medication use (Leo & Cohen, 2003), confounded by affect-induced physiological changes during the biological test (Whiteside, Port, Deacon, & Abramowitz, 2006), or reflect a vulnerability for developing a mental disorder without directly causing it.

The authors do raise some important points, but many of the issues they raise have less to do with the brain disease model and more to do with our understanding of biology in general and the brain in particular.

Let's start by comparing neuroscience to physics. We've known from the time of Newton the forces that cause a planet to orbit a star, or a moon to orbit a planet. These rules have been the same for hundreds of years, rules that even today guide our ability to launch a satellite that enables me to Twitter on my Blackberry. Newton could have told us how to do it, but he wouldn't have been able to launch the satellite. Why? Technical difficulties. He simply didn't have the equipment and probably couldn't imagine the equipment. But that doesn't mean that his theories of gravity were wrong or that we were never going to send satellites into space.

Something similar is going on here. Just because we can't yet diagnose mental illness based on abnormalities in brain functioning doesn't mean that this differences aren't there. It means we can't measure them. Maybe we never will be able to measure them. But the evidence is pretty consistent in linking underlying neurochemistry to mental illness. The authors are right in pointing out that we don't know everything about these neural differences, and whether they are diagnostic, indicate increased risk, or are a scar from previous incidences of this mental illness. It's likely that a single brain scan looking at one single thing isn't going to be diagnostic of anything. Rarely does a single factor diagnose any disease, mental or otherwise. Usually, it's a combination of factors that lead us towards disease.

As much as we like to think of there being a "gene for" depression, bipolar disorder, eating disorders, schizophrenia, diabetes, obesity, cancer, that's just not how DNA works. It's not an on/off switch; rather, genetic risks function a lot like a dimmer switch. And determining how bright that light is also needs to account for the ambient light in the room, those environmental factors that interact with genes to help increase or decrease risk. If the room is dark, even a dim light will be obvious. At high noon, however, you might not even notice that the bulb is on.

We accept (however unwillingly) these biological complexities in illnesses like cancer and diabetes. There's a general understanding and acceptance that there will never be a "diabetes gene," that our treatments have improved over the past several decades, but we're still a long way from anything that could be called a "cure." That doesn't change the fact that diabetes is an endocrine disorder.

The other main issues that Deacon and Lickel raise has to do with an increase in the amount of hopelessness one feels when they are told that their illness is the result of biology. And perhaps the earth felt hopeless after they told it that it was no longer the center of the universe, but that doesn't make it any less true. Understanding science is a major issue in America, so it's no surprise that the more science-based explanations of mental illness have resulted in some misconceptions. Maybe it's because I have training as a biologist, but I found the knowledge that my eating disorder was the result of biology to be tremendously hopeful. I had plenty of insight, but I still wasn't getting better. I wasn't "choosing" recovery somehow. I thought my difficulties in recovery were my fault, rather than the result of a pernicious illness.

There is tremendous freedom in accepting the fact that, as far as ED biology goes, I'm f*cked. It's true. Dieting or even skipping a meal ends very, very badly for me. And if we're looking for treatment of mental illness to fundamentally change who we are as people, we're all f*cked. We can't do that. We don't know how to do that, and there's no reason that we should.

From a biological standpoint, my brain is high anxiety. I worry. A lot. I get depressed. A lot. Excessive exercise and starvation are strangely rewarding. There isn't much I can do about this. In fact, I've stopped trying. What I am doing, however, is learning how to live with my biology in the best way I know how.

This month's issue of Psychiatric Times contains the first of a two-part series on examining The Cellular and Molecular Substrates of Anorexia Nervosa. Although it's not a simple read (the author assumes some basic neuroscience knowledge, but it's nothing super-prohibitive), John Medina does a wonderful job of explaining some very complicated research results.

Research into the whats, wheres, hows, and whys of anorexia is a rather complicated matter. Compared to other brain diseases, Medina says, AN should be pretty straightforward. After all, age of onset and other characteristics of sufferers are almost stereotypical. Yet some of the research has been hampered by difficulties in discerning underlying neurologcal differences, those that are due to current malnutrition, and those that may be a neural "scar" from previous malnutrition. As well, appetite regulation is a very complex and convoluted process. There are signals for hunger, satiety, disgust, pleasure, to find food, to share food, to eat food, to digest food...you get the idea.

Moreso, says Medina,

there is a powerful chicken-and-egg issue to consider. Severe caloric restriction can cause equally severe changes in the functioning of the brain. Patients with AN usually experience profound alterations in the metabolism of specific regions in the parietal, temporal, frontal, and cingulate cortices. They tend to have reduced brain volumes. Many regress to preadolescent gonadal function. Did the changes in the brain lead to the symptoms? Did the symptoms lead to changes in the brain? Did they exaggerate a premorbid trait? Or cause the predilection to come into existence?

After discussing appetite signaling and regulation (be sure to click on the figure!), he then discusses two fascinating studies on reward regulation in people with AN.

The first set of experiments used classic “guessing game” behavioral protocols (usually involving positive and negative monetary reward exercises) while the participant’s brains were being imaged...Women who had recovered from AN...have an impaired ability to perceive the difference between positive and negative feedback information. Subsequent behavioral work using different protocols confirmed this finding. Interestingly, and for whatever reason, this impairment led to a negative bias.

The second set of experiments also used imaging in conjunction with behavioral tasks. These tasks involved measuring connections between actions and outcomes...Participants who had recovered from AN showed a greatly elevated response in the same experiments. Behaviorally, they appeared to be looking for “rules” in the tasks where there were none and were overly concerned—even obsessively concerned—with making errors. They appeared to be overdriving a broad spread of their executive functions, an insight consistent with the imaging data, as well as other behavioral experiments.

Combining these 2 sets of experiments has suggested to some researchers that a behavioral “perfect storm” is brewing in the brains of affected subjects. Anorexic patients display an absence of appropriate reward processing responses; at the same time, they possess an increased activity in the neural substrates that are concerned with the consequences of their behavior. Perhaps the latter exists in an attempt to compensate for a lack of appropriate perceptive rewards and punishment feedback loops in the former.

This has led directly to a testable hypothesis, which explains AN as a conflict between an acquired negative reaction to food and the biological need to have it. Patients with AN recruit cortical executive functions in an attempt to settle the bias, all the while carrying dysfunctional rewards and punishment systems. These modulatory circuits become consistently overstimulated, leading to high anticipatory behavior and obsessive concern with future events.

Indeed, the conflict between reward and punishment has been proposed as a hypothesis by researcher Charlotte Keating in a paper titled "Theoretical Perspective on Anorexia Nervosa: The Conflict of Reward," that I blogged about here.

Medina says that in next month's Psychiatric Times, he'll discuss the genetics and neurobiology of the origins of anorexia. I'll keep you posted!