The role of science
This third post in my 2010 ICED Conference series also has to do with Dr. Kelly Vitousek's keynote address (which is also the source for my AN and Competitive Scrabble post). The title of her talk was "Coming Together Without Losing Our Way," and the best succinct summary I can give of her talk was: controversial. Although I don't personally like controversy (can't everyone just play nice and get along?), it can also be useful because it forces people to clarify their thoughts and positions on certain subjects. Dr. Vitousek's talk did that for me.
Much of Dr. Vitousek's talk focused on the difficulties with identifying eating disorders (specifically anorexia) as brain diseases. Her first point was, in my opinion, a fantastic one: what do we mean when we say "brain disease"? Are we all referring to the same thing?
After hearing Dr. Vitousek speak, I can assure you that we're not.
Dr. Vitousek said that there are three main arenas in which people talk about "brain disease" related to anorexia (the commentary underneath each point is quoted from Dr. Vitousek's talk- I can't promise that every word is exactly as she spoke since I was taking notes via typing and not recording, but it's pretty accurate):
1) The acute brain disorder brought on by semi-starvation
However, starvation brain disorder isn't anorexia, and a person can have severe starvation but not AN. It could be that anorexia causes the brain disorder, but semi-starvation itself isn't a brain disorder.
2) The temperamental traits linked to anorexia, but still not anorexia.
Except that traits are not brain diseases, they're not specific to AN, not uniform in AN, and not essential for AN. They are also not all bad, and they're not going away. Some traits may be tweaked or worked around or invested elsewhere. We think that people are "less to blame" if their brains are at fault. (This next is a direct quote that Dr. Vitousek said should be on a bumper sticker). "Traits don't kill people. AN kills people." It's where traits are put that's the most serious problem. Some traits that help keep EDs running can be drafted to work towards recovery. Increasingly experts who study these issues underscore the powerful potential of these traits.
3) It's some variant on a more specific model of AN brain disorder. Hard wired appetitive dysregulation? Anomalous response to starvation? Problems perceiving body size and shape? Cluster of disordered beliefs?
In my own thinking, option #3 seems to make the most sense. Starvation isn't a brain disorder (though it can trigger one if you have the genetic predisposition to anorexia), nor are the temperamental traits linked to anorexia. These traits can be tremendously adaptive, as Dr. Vitousek pointed out. I think these traits can be markers for having a predisposition to anorexia, but that's far from saying "Here's what anorexia is." Frankly, I think the brain disorder called anorexia is a combination of all of the aspects of option #3. My reading of Dr. Walt Kaye's research on interoceptive awareness (and I will talk more about interoceptive awareness from another ICED talk by Bryan Lask) seems to indicate that this could be one of the lynchpin features of anorexia.
After making these three points, Dr. Vitousek began to deconstruct the use and meaning of the word "brain disorder" with respect to anorexia.
[The use of the term] Brain disorder somehow makes patients' suffering is more "respectable" and more sympathetic if symptoms are seen as wholly beyond their control. Neuroimaging has offered some great PR of learning models and psychotherapy. There have been changes in brain scans due to psychotherapy in anxiety disorders. Treatments for EDs can be psychological even when we use a brain disorder model.
What I'm uncertain of is where Dr. Vitousek got the idea that the brain disease model means that psychotherapies for eating disorders are useless. All the evidence shows that they're very much not useless. Secondly, we shouldn't use the term brain disorder because it's less stigmatizing and gives patients that warm fuzzy feeling. I use the term because I think it's the most accurate description for what is actually happening in anorexia nervosa. Is the fact that it helps us waste less time on the Blame Game an advantage? Yep. But that doesn't have any effect on how accurate or true the brain disease model is. Some people respond to the brain disease model with a "screw it" attitude, because if it's biology, then they're well and truly screwed. Is that a disadvantage to the model? Yep. But that's not a problem with the model, it's a problem with how we are interpreting it.
Nor by saying that eating disorders are brain disorders am I trying to erase the influence of environmental factors, both the larger cultural factors at play and the individual life events that work to increase or decrease our risk for developing an eating disorder. Some of us are at higher risk than others for developing an eating disorder, and there is no doubt that environment plays a role. But I also firmly believe that biology is a HUGE predisposing factor to determining our risk for developing an eating disorder.
Dr. Vitousek then went on to critisize science as a tool for learning more about eating disorders--specifically neuroimaging--and how to treat them. I didn't take too many notes on this particular segment because I was too busy personally seething. Neuroimaging is a new field, and it looks a rather lot like a bunch of pretty pictures of brains. The subject is usually covered in the media along the lines of "such-and-such made the brains light up!" Which isn't accurate- our brains (sadly) don't glow. Neuroimaging studies determine the rate at which certain areas of the brain use oxygen, which is a proxy for their metabolic activity. High oxygen use means high metabolic activity means lots of neurons firing. The levels of oxygen use are color-coded, hence the pretty pictures.
Dr. Vitousek rightly pointed out that people are unduly swayed by pretty pictures of brains. Again, this is a problem with how we interpret these studies rather than an inherent problem with the studies themselves. And there are certainly other problems that neuroimaging studies have, such as small sample sizes and the fact that the scans aren't as sensitive as we would like them to be. Much of the time in eating disorder research, however, the neuroimaging studies have simply confirmed what we already suspected, only now we had actual hard data rather than a hunch or information from a few little mousies.
Should we rely solely on neuroimaging studies to teach us more about eating disorders? Nope, and not even Walt Kaye (Dr. Anorexia Neuroimage himself) would say so. Nor is science the only way of learning more about eating disorders. But it does provide the clearest path forward.
9 comments:
The director of NIMH published a nice article recently, "Disruptive Insights in Psychiatry: Transforming a Clinical Discipline" The full text is here and well worth reading. http://bit.ly/9fgHct
Eating disorders aren't mentioned, but he says that mental illnesses brain disorders (and defines what he means), and also emphasizes that they are developmental disorders (this is hugely important IMO), and that they are complex genetic illnesses. The article makes some other terrific points and is one of the best things I've read recently.
(Others may disagree, but I think that saying eating disorders are brain disorders and leaving it at that isn't especially illuminating.)
Jane,
You raise a really good point, and I think your thinking is more highly evolved than many in the field whom I've talked to (who even doubt whether AN is a brain disorder). Because Alzheimer's disease is also a brain disorder and it's rather different than AN.
I think in general what "brain disorder" implies is that eating disorders have a biological basis--they aren't rooted in culture or family pathology. Although most people give lip service to this idea, I don't think it has really altered the way many professionals think of eating disorders (at least in the more generalist ranks).
Thanks for the link- I will check it out tomorrow when I have more time!
OOOOOOO
My psychologist was telling me about this exact talk yesterday. . .
I was talking to her yesterday about anorexia as a brain disease. My issue about this is that AN is not wholey influeced by genetics to the extent the Huntingtons or MS is. But I think you addressed it in your blog post.
I like the defination of anorexia as a NEURODEVELOPMENTAL brain disorder because it allows for development/environment AND genetics which are both necessary components to become ill. No one is born with anorexia -- one is born with a predisposition.
I agree with you about the first definition. I think that would be the defination of starvation's affect on the brain, but I don't now if AN is simply starvation.
It would be wrong and cruel to call the traits related to AN a "brain disorder." They are simply a cluster that tends to indicate increased risk for AN. And as you mentioned these traits can be worked on in recovery to minimize the risk of relapse.
Number three does make the most sense, but I think it is going to be very difficult to tease out just what constitues the brain disorder and what is starvation or inherent traits. . . For example: What if the anomalous respone to starvation and appetite dysfunction are predisposing tendecies as well? Is it only a brain disorder when these "systems" become active (such as during an anorexic episode?)
The neuroimaging studies are fascianating. They aren't useless but I do think she is correct in that there is the tendency to draw too much from them. I recently attended as Neuroscience week at my university and many professors (also principle researchers) seemed to hail fMRI, PET and other imaging techniques as the holy grail and answer to everything. . .
What did Kelly Vitousek conclude was HER defintition of a brain disorder? Which point did she agree with?
It would be a bit silly to adopt it simply because it makes sufferers/families feel less responsible. . .
A:)
The thing that scares me is:
Will this be the end of talk therapy? I think therapy is very helpful in adjunct to medication and my therapist has been a lifesaver in simply talking about life problems, helping me think more logically, etc.
Fascinating post Carrie - and what sounds like a fascinating lecture.
Like you, I also firmly believe that biology is a HUGE predisposing factor to determining our risk of developing an eating disorder. For me this was AN.
Like you I have read extensively around the subject and related subjects on AN. However, the primary reason why I am convinced that AN is a brain illness is because of the way I experienced it and some other older women (i.e. in our 40s, who developed AN in the 70s) experienced it.
I developed AN in 1976. At that time there was virtually ZERO cultural pressure on girls to be thin/slim/'size zero' etc. And, as an 11-yr old, I had absolutely ZERO interest in fashion, or my weight and shape. I read kids' cartoon comics, and had intense interests in cars, animals and the music of Abba.
What triggered my food restricting and over-exercising was extreme anxiety and depression. The anxiety had always been there and I had had OCD + social anxiety from being 2-3 yrs old (probably some of the indicators of an ASD). The depression kicked in after bullying by a group of girls (not about my body: I had always been thin), but words that deeply affected my sense of self. I started to starve for self-punishment (for being such a 'useless' person) and exercise to relieve my anxiety. I lost weight inadvertently but became terrified of gaining it back, and terrified of changing my eating and exercise routines and rituals. It was the routines/rituals that felt safe; NOT my thin body. When a paediatrician asked me I restricting food I said "cuz this thing in my head won't let me stop". So my 12 yr old mind viewed AN as 'a thing in my head'.
*I'm glad Kelly Vitousek differentiated between the effects of semi-starvation and AN. Too often AN is compared to the Minnesota Starvation Experiment, but the two are not the same, not the least in that the men in the experiment didn't resist re-feeding and weight gain like someone with AN does.
*I dispute the fact that what underpins AN is body image distortion, because not everyone with AN has this.
*I do think that temperamental traits play a huge role, in combination with the way that the individual's brain processes information of internal states, the external environment and social interaction. (Please can you blog on Janet Treasure's lecture/workshops?).
*As for neuro-imaging: I also believe it's a valuable tool in detecting both hard-wired patterns of information processing, but also temporary, more plastic patterns of processing that can be corrected through various psychological therapies.
Finally, you write: ...."Nor is science the only way of learning more about eating disorders. But it does provide the clearest path forward". I 100% agree.
Great post... Thanks :)
From what I've read about it, I find Vitousek's talk to have been so abstract and metaphysical that it wasn't of much practical value. What I care about is 1) how, if possible, to prevent eating disorders from developing, and 2) how best to treat them if they do develop. I think the answers will appear not from abstract theorizing, but from large scale clinical trials. I'd like to see eating disorder professionals organize themselves and run those trials. Let's actually measure the effect of refeeding and weight gain on anorexic thinking and behavior. Let's measure and compare the effects of different kinds of talk therapy. Let's try prevention strategies on a large scale, develop data on outcomes, and measure whether any of them have a statistically significant effect. I think we'll learn more about the relative role of "biology" and other factors by studying what is most effective for prevention and treatment. The leaders in the eating disorders field were together in Salzburg. Was there any discussion about collecting outcome data in a systematic way?
Anon,
Sadly, the answer to your question is: nope. There is a much greater acknowledgement for the *need* for such data, and I think some people are starting to better articulate what questions need to be asked and how best to answer them.
I appreciate your observations on my talk at the Salzburg meeting, both favorable and un. I do want to address one point: my critique of neuroimaging research has nothing to do with doubting the value of science - quite the contrary - or, more narrowly, with disputing the potential contributions of neuroimaging research to our understanding of the eating disorders. The central message of that portion of my talk was that the principles of science should be applied MORE rigorously in the design and interpretation of neuroimaging studies - which, as I also noted in the presentation, do indeed have the potential to contribute to our knowledge of these disorders, in combination with other methods of investigation. If anything in my talk suggested that I think biological variables are unimportant, I miscommunicated my views - which attach considerable importance to biological factors on multiple levels. The message I intended was that we need to think about those multiple levels more rigorously, and be clearer on which we have in mind when we attribute specific aspects of the EDs to disordered biology/brains.
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