My latest story for Scientific American, More Than Meets the Mirror, is actually relevant to this blog (it doesn't happen very much!).  It's about the relationship between body image and what's known as interoceptive awareness.

Are you cold?  Thirsty?  Hungry?  Short of breath?  Whatever your answer, you used interoceptive awareness to answer the question.  Previous research has linked interoceptive awareness to the insula, and people with eating disorders have been shown to have deficits in both of these areas.  But that didn't mean the two were necessarily related.  After all, I have red hair and green eyes, but my green eyes didn't cause my red hair (for that, I thank Garnier Nutrisse Honeydip).

So a neuroscientist at the University of London devised an experiment where he tested students' interoceptive awareness by having them measure their heartbeat without taking their pulse.  Then he used a trick known as the rubber hand illusion to trick the students into thinking that a rubber hand was actually a part of their body.  Those students with low interoceptive awareness were more susceptible to the rubber hand illusion.

From the story (I do feel a little weird quoting myself, but whatever):

"People with low interoceptive awareness might have a less strict distinction between what is 'my body' and what is the external world," Tsakiris says. "They might be ruled more by vision, rather than by internal sensation." Previous studies have also found that people with anorexia have an impaired ability to sense internal cues, making the results of this new work useful for understanding and potentially treating severe body-image disturbance.

To be sure, the study used a small sample size and has not yet proved causation, but "if we can train people to sense their interoceptive states," Tsakiris says, "it might make a change in their body image. An interesting avenue for future research would be to see if improving interoceptive awareness impacts different areas of these disorders."

New research on people with body dysmorphic disorder shows that their brains focus on the details of their faces, rather than taking in the face as a whole. The study, titled "Abnormalities of Visual Processing and Frontostriatal Systems in Body Dysmorphic Disorder," was published in the most recent issue of Archives of General Psychiatry.* CNN covered the story, an excerpt of which is below:

It turns out that people with this condition have abnormal brain function when it comes to looking at pictures of their own faces, according to a new study led by Feusner and published in the Archives of General Psychiatry.

When viewing themselves in photographs, patients with BDD underutilize parts of the brain used in seeing the face's overall shape and size, he said.

"If you just see the pieces of your face, and not seeing how they fit into the whole, then it's going to look distorted," he said. "That's how we interpret the findings."

What is especially interesting are the similarities between BDD and anorexia. Similar to what this study found in people with BDD, previous research has found that people with anorexia tend to focus on the details, which leads to a trait known as Weak Central Coherence (Southgate, Tchanturia, and Treasure, 2008). People with AN also show abnormalities in neural functioning when looking at images of themselves, but not other people (Sachdev et al, 2008).

More from the CNN story:

"...the part of the brain that helps guide behavior and maintain emotional flexibility, the frontostriatal systems, had unusual activation patterns.

"What we think may be happening is that they may be seeing details, perhaps even seeing details normally, but that they're not able to contextualize it," [Fuesner] said...The study is "groundbreaking" in its demonstration that patients with BDD are too focused on the details aren't able to see the whole picture when they see themselves, said Sabine Wilhelm, director of the BDD Clinic and Research Unit at Massachusetts General Hospital, who was not involved in the study. This can be observed anecdotally in treatment, but this study confirms it at the level of brain processing, she said.

Feusner's previous research found that when BDD patients viewed the faces of other people -- not their own faces -- the brain's left hemisphere, associated with categorization and details, was more more active. Healthy individuals used the right hemisphere, the part of brain that processes more holistically.

It is too early to directly apply the findings to treatment, but one possibility is that patients with BDD could be retrained to see their own faces, he said.

Considering that people with BDD show many of the same difficulties in executive functioning (i.e., "a loosely defined collection of brain processes which are responsible for planning, cognitive flexibility, abstract thinking, rule acquisition, initiating appropriate actions and inhibiting inappropriate actions, and selecting relevant sensory information.") as people with AN, perhaps the underlying neurological similarities shouldn't be surprising.

The Semel Institute at UCLA is currently recruiting subjects for a study to compare neural processing in people with BDD, people with AN, and healthy controls. Click here for more information- I will phone the study site tomorrow as I am interested in participating and I will post more information as I get it.

*I haven't yet been able to get ahold of the full-text of this study- my alumni association dues need to be updated before I can get a copy, so I apologize.

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!

Perhaps, if the folks at the Great Ormond Street Hospital in London are right. New research, which will be presented at the Institute of Education conference this week, sheds light on the brain changes that accompany anorexia. Rather than a size zero fad or an overcontrolling mother, anorexia may be caused by changes to the brain that occur in the developing fetus.

In an article in the UK's The Guardian titled "Anorexia risk 'could be predicted'," lead researcher Ian Frampton says that

"Our research shows that certain kids' brains develop in such a way that makes them more vulnerable to the more commonly-known risk factors for eating disorders, such as the size-zero debate, media representations of very skinny women and bad parents."

Slight quibble: those are stereotypical risk factors. The first two may cause people to diet, which would then trigger an eating disorder, but in and of themselves, they don't have a whole lot to do with EDs. The last has been thoroughly debunked- bad parents don't help you in life, but they don't cause eating disorders, either.

And these brain changes--whatever they may be--don't make you more vulnerable to "the size zero fad and the cult of the super-thin celebrity," as the author writes. Anorexia is deadly, not a fad a little too far by a bunch of vapid teenage girls. The brain changes make you more likely to develop a serious mental illness that might look like a fad, but let me tell you: it ain't about celebrities.

Frampton and his colleagues conducted in-depth neuropsychological testing on more than 200 people in the UK, America and Norway who suffer from the condition...They found that about 70% of the patients had suffered damage to their neurotransmitters, which help brain cells communicate with each other, had undergone subtle changes in the structure of their brains, or both.

One in every few hundred girls may be affected in this way, according to Frampton, who said the condition was random and not the result of poor maternal diet or environmental factors, such as widespread use of chemicals. Imperfect wiring in the brain's insular cortex that may lead to dyslexia, ADHD or depression in other children produces what he calls "an underlying vulnerability" among some young people that makes them more likely to develop anorexia.

This research is, of course, preliminary, and there are many questions I would like to see answered, such as:

• How do you know these brain changes aren't a result of malnutrition? If the girls being studied are currently in the hospital for AN, they're malnourished, which we know changes the brain. I'm assuming they authors have an answer for this and I am all ears.
• How do you intend to show that these brain changes came first?
  
• Are there other people with these brain changes that don't develop AN? In other words, are these brain changes diagnostic, or just suggestive?
  
• If the process is random, why does AN run in families? Did you look at siblings?

These studies are absolutely important, and I'm glad they're being done, but I'm not sold that this study will "revolutionize" anorexia treatment. Yet.

The authors of the study naturally mention screening and prevention, efforts that are no doubt important. However, dieting is ineffective for everyone, and malnutrition is dangerous for everyone. There should be a zero-tolerance for it across society, not just for those with EDs. The stakes are almost certainly higher for those with the genetic wiring for EDs, but that doesn't mean everyone else has a "get out of jail free" card, either.

Still, the take-home message is this: anorexia is the result of differences in neurobiology and neurochemistry that is triggered by things in the environment.

EDITED: I found another story in the Sydney Herald-Sun that had a few slightly different quotes and seemed to portray the research just a bit better, without some of the dodgy paraphrasing by the writer. See the story here. I'm still waiting for the American newsmedia to weigh in (no pun intended).

Recent research from the Basque region in Spain found that boys have greater psychological well-being than girls because they have a better physical self-concept.

First off, some definitions. A person's self-concept is "the totality of perceptions that each person has of themselves," which doesn't help a whole lot. I think a lot of your self-concept has to do with the adjectives you use to describe yourself, and what talents and traits you value in yourself. But the author here looked at one specific aspect of self-concept: how you perceived yourself physically. In other words: body image.

The author looked at the relationship between physical self-concept and general psychological well-being, depression and anxiety, and eating disorders. The study found that

the more one is happy with one’s physique, the more psychological well-being one has, with less levels of anxiety and depression and less risk of suffering from an Eating Behavior Disorder.

Now, in general, I think the results make a lot of sense, especially now that your weight isn't just about being "thin" or "pretty." People can and do equate your weight with your moral worth. Though this is catching up for men and boys, I think it's safe to say that women and girls get it worse. I also think that if you have major body image issues, you're less likely to be happy with yourself. This leads, not surprisingly, to increased rates of depression and anxiety.

But I read this research summary shortly after I read something that Laura had posts on how childhood balance problems could be linked to anxiety disorders. This got me thinking about how your physical self-concept extends far before the window of time when one is most prone to developing an eating disorder. And maybe that a poor physical self-concept may not cause an eating disorder, but rather be a side effect of the genetic wiring that makes you prone to such disorders.

To be fair, the author never implied that poor physical self-concept caused eating disorders, but the timeline was clear: poor physical self-concept can lead to an eating disorder down the line. But the genetic predisposition to an eating disorder happens long before a child has a chance to develop a concept of body image, and indeed, research has shown that people with eating disorders perceive their own bodies differently.

It could also be true that those teens with depression and anxiety think negatively about everything, including their bodies. The author didn't, I don't think, separate these out in time (as in the chicken or the egg kind of thing). Nor does it have to be one or the other. Likely things like risk factors for EDs, depression and anxiety, and physical self-concept interact with each other, ebbing and flowing, waxing and waning over time.

So it could very well be that this negative physical self-concept is a symptom of something else going on deep in the brain, just as it is a symptom of a society that places exceptionally high value on appearance.

I met with my dietician this afternoon, and my weight is finally coming up. I swear, I thought I was going to have to start raising my own cows. To eat. Whole. Several times a day. Well, breathe easy, Bessie. There may be hope yet.

My secret weapons? Peanut butter and ice cream. If I can combine them, all the better!

I've been calorie-counting free for a week as of first thing tomorrow morning. Yikes! I haven't managed that in several years! I'm kind of proud of it, but I also have to stay on guard. I can't count just once. I fall right back in. Ditto for weighing myself. I've finally gotten to the point where I've realized that these behaviors are very counterproductive. I always think I've consumed too many calories. I always think I can shave a few pounds off my current weight. It makes me miserable! So why do I do it?

Habit. Decrease in anxiety (very short term). Hell if I know.

I've been using a technique I heard about in the movie What the Bleep do we Know? where I'm actually visualizing the changes in my brain as I continue to refeed and recover. I picture the neurons in my brain that are attached to things related to the anorexia (calorie counting, weighing, restricting my food, exercise) withering and dying. At the same time, I'm picturing the neurons towards healthy and positive activities (writing, beading, crochet, etc) strengthening. With food and thought, I'm actually changing the structure of my brain.

Mind-boggling. I love neuropsychology. If I ever got a PhD, it would be in that. Instead, I'm just going to write about stuff like that as a profession. Easier and more interesting.

So Bessie, I'll see you tomorrow. Though watch out- I've been having quite a hankering for hamburgers!