They should know better

This study just irritated me: Psychiatric 'diseases' versus behavioral disorders and degree of genetic influence

The study's premise was that

"Psychiatric conditions in which symptoms arise involuntarily ('diseases') might be assumed to be more heritable than those in which choices are essential (behavioral disorders). We sought to determine whether psychiatric 'diseases' (Alzheimer's disease, schizophrenia, and mood and anxiety disorders) are more heritable than behavioral disorders (substance use disorders and anorexia nervosa)."

...And what do they think drives behaviors? Have these researchers even thought about what anorexia actually is? No, it's not a bunch of skinny dieting champs. It's about being scared to eat. Which strikes me as less of a behavior and more of something arising "involuntarily."

I've heard some people say that they chose to be anorexic, but I would say that for the vast majority of people, they didn't choose their eating disorder. I know I didn't. Did I make the choice to lose a few pounds and exercise more? Yes, I'm not denying it. But choosing to head to the gym regularly is totally different than choosing to be anorexic. The first I will concede; the second I most definitely will not.

It frustrates me. It really does, especially because this is a scientific study carried out by actual professionals. I can grit my teeth and try and explain to Jim Bob that I wasn't randomly deciding to live on Diet Coke and look like a model because he very well might not know better. But psychiatric specialists? Seriously?

Interestingly, they didn't consider OCD in their spectrum of diseases, which would be interesting since it involves what they would term "involuntary" symptoms (obsessions) as well as chosen behaviors (compulsions). Nor did they address how people with depression are often told to cheer up and snap out of it, which implies that it really is a choice.

There are endless choices I've had to make as I've recovered from my eating disorder, although many of them were a choice amongst lack of alternatives. I've been told recovery is a choice, and although I don't think that's wrong, I don't think it's that simple. It's not as if recovery is one single choice, and it's not as if our brains always have the same capacity to make these choices as we move through recovery. There is some small amount of choice when my brain is compelling me to engage in ED behaviors or OCD behaviors, and I can see that now that I'm no longer in it on a minute to minute basis. But in the moment? I didn't see a choice, and my brain chemistry tipped the scales so heavily in favor of the disordered behaviors that I couldn't un-choose my disorder without a serious amount of support.

Ultimately, the study didn't find that "behavioral disorders" were any less heritable that psychiatric "diseases." They found a 60% heritability rate for anorexia, although other studies have found rates of 70% and Walt Kaye frequently uses an interval of 60-84% heritability (I believe this can be found in his Maudsley Parents lecture here).

The authors concluded:

No systematic relationship exists between the disease-like character of a psychiatric disorder and its heritability; many behavioral disorders seem to be more heritable than conditions commonly construed as diseases. These results suggest an error in 'common-sense' assumptions about the etiology of psychiatric disorders. That is, among psychiatric disorders, there is no close relationship between the strength of genetic influences and the etiologic importance of volitional processes.

Maybe that's because these "behavioral disorders" really are diseases...

5 comments:

Cathy (UK) said...

I actually think this paper is interesting. I didn't find it disheartening. I tried to download the whole paper, but couldn't access it. Therefore, my interpretations are based solely upon the Abstract.

The genetic basis for the aetiology of AN is based upon data from twin studies. Twins, including identical twins with identical genetic profiles, are usually raised in the same family and comparable environment (i.e. they often attend the same schools and are exposed to comparable interpersonal and social influences). For that reason it is difficult to separate out the effects of genes from environment. The most interesting data would arise from studying the psychological profiles and behaviours of identical twins separated at birth and raised in different environments; however, there are few such data.

The heritability factor in AN doesn't mean that a person is pre-programmed to develop the illness and so will automatically develop it at a certain point in their life, or even if they go on a diet. They will only do so if subjected to potent environmental triggers - be these social, environment, traumatic (etc.) which influence the individual's sense of self.

Genetic influences within the brain impact on temperament, information processing, thinking styles etc. At present, no researcher has ascertained a specific genetic profile for the risk/development of AN. In fact, despite the data suggesting 60-85% genetic vulnerability, the underpinning evidence and theoretical base relating to genetic factors is actually quite weak.

Having said all that, I didn't choose to develop AN either. Also, I do see common familial traits which increased my risk of developing the illness. All my family have suffered depression, we are all obsessive and perfectionistic, and my father and brother (like me) have many high functioning autistic characteristics. However, I am the only person in my family who developed AN. Furthermore, what triggered my anorexic behaviours were definite social and interpersonal factors which led to depression and a negative sense of self.

So, in summary, the paper you highlight doesn't imply that AN and its behaviours are 'chosen'. Rather, it emphasises the complex association between genetic influences + environment on the aetiology and maintenance of AN.

A:) said...

Hey Cathy, when I read this post last night, I was trying to think of something to say. I think you put it much more eloquently than I ever could!

In my understanding, a person inherits a predisposition and not an illness. The illness is triggered and maintained by environmental factors. Percipitating factors may be different than perpetuating factors.

Therapy can help to unravel these different environmental factors, distorted beliefs, etc that maintain the illness.

Genetics interact with environment in a complex two-way relationship and this is why it is so difficult to seperate one from the other. The environment can influence gene expression and genetics can shape the environment. . .

I thought the paper was heartening because it is clear that all psychiatric illnesses have some genetic component.

I'm wondering if by behavioural disorder they simply meant that the illness had specific behavioural components (restriction, b/p, drug use) as opposed to purely psychiatric components. This may not necessarily mean that researchers considered AN or substance abuse to be voluntary.

A:)

Cathy (UK) said...

A:) - Thanks..

You wrote:

"I'm wondering if by behavioural disorder they simply meant that the illness had specific behavioural components (restriction, b/p, drug use) as opposed to purely psychiatric components. This may not necessarily mean that researchers considered AN or substance abuse to be voluntary."

That is my understanding; however it would have been helpful to read the whole paper, which probably would have explained the terms used in more detail. I tried to download the whole paper, but the library I use doesn't subscribe to this journal.

I think it's helpful to view AN as having a genetic and biological basis, and I know that when my AN began it felt as though my brain had almost been 'hijacked'. Even when I tried to eat I found I couldn't do so easily, without experiencing disabling anxiety. Similarly, if I missed a planned exercise work-out I felt equally panic stricken. That is why I felt I had a mental illness that was not borne out of 'choice'.

Not everyone experiences AN in the same way, and even if the behaviours are similar between individuals, different individuals may attach different personal meanings to those behaviours. For some people the desire/need is to be thin; for others it is to feel 'in control' (etc.).

However, what does seem to be a 'common denominator' amongst all individuals with AN is anxiety, and AN behaviours are compulsive and quite similar to OCD or autistic routines/special interests. Starvation also plays a huge role in food obsessions.

I'm not a big fan of DSM and I question the extent to which some of the listed diseases ARE actually diseases/disorders - or whether they simply arise from extremes of temperament/unusual neurophysiology which make life in certain environments (+ all life's complexities) difficult to cope with for certain individuals. In other words: environmental influences play a huge role.

Anonymous said...

Thanks for pointing out an important study. A little peeved that they referred to anorexia as a "behavioral" disorder, but that is just an indication of the education that needs to be done. Probably has to do with the ways that illnesses were commonly conceptualized, with schizophrenia, depression and bipolar as the "serious mental illnesses." I am pleased their study showed high heritability. Wish the other eating disorders were included.

Alley Cat said...

Thanks for this entry! I was just thinking about this, and you have a way of putting some of my thoughts to words better than I can. I absolutely did not ever choose the disorder, and it also stemmed from disabling anxiety. I definitely emphasize with, "I've been told recovery is a choice, and although I don't think that's wrong, I don't think it's that simple. It's not as if recovery is one single choice, and it's not as if our brains always have the same capacity to make these choices as we move through recovery. There is some small amount of choice when my brain is compelling me to engage in ED behaviors or OCD behaviors, and I can see that now that I'm no longer in it on a minute to minute basis. But in the moment? I didn't see a choice, and my brain chemistry tipped the scales so heavily in favor of the disordered behaviors that I couldn't un-choose my disorder without a serious amount of support."

My therapist has said that more than once, and she's very helpful in many ways, but I can't stand the simple "answers" to my problems (like pampering myself before bed to cure my insomnia). I've struggled with insomnia my whole life and have also done so many different things to tame it, but it's just not simple. Similarly, other struggles that tend to come back as our environments change and we keep combating them must be biological.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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nour·ish: (v); to sustain with food or nutriment; supply with what is necessary for life, health, and growth; to cherish, foster, keep alive; to strengthen, build up, or promote



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