The question, “What causes and cures eating disorders” has been replaced in the last decade or so by, "What are the variables that contribute to the development of eating disorders and what does recovery look like." Treatments for eating disorders vary in efficacy. Variability and inconsistencies in research outcomes are more usual than not. There is no one size fits all treatment, and standardizing treatment is no longer the goal. Relapse rates are high, and many are on board that this is because treatment approaches have not been guided by an understanding of the etiology of each specific eating disorder.
In order to understand how to treat, understanding what we are treating makes sense.
What are the contributing factors to eating disorder causation presents many challenges. Opposing and competitive opinions and theoretical perspectives in conjunction with discrepancies and inconclusive outcomes in quantitative and qualitative research continue to make it difficult to understanding causation and therefore in establishing solid treatment protocols.
The lack of seriousness taken by many patients regarding the medical sequeale of Anorexia and Bulimia, contributes to the inability to choose the best protocol for care and therefore increases the likelihood of treatment failure. Because patients deny the severity of their condition they cannot accept the effects of malnutrition on heart, brain, organ and bone health. Sometimes the thinking by patients and family members is that if the effects of the illness are not overt, then how can a problem exist. This line of thinking is akin to the faulty perception regarding patients’ refusal to accept the realities of looking in the mirror and seeing low body weight or emaciation. Denying the problem and thereby denying its effects are not uncommon. Patients sometimes lie also about the severity of their condition, further hampering the selection of appropriate treatment options.
Ends of the spectrum understandings
Most clinicians agree that focussing on pre-disposing biological factors, neurobiology and psychology offer great promise in understanding and detailing causation. For many patients, a combination of all factors contribute. Most in the eating disorder professional community agree that to some extent, nature, and indeed nurture and environment are significant contributors and all together they provide a more well rounded opportunity to figuring out causation. (see Scheel. December, 5,2016. psychologytoday.com)
As we progressed from the false assertion that genes cause eating disorders, to possibly there is a genetic link based on a series of potential genes and traits, the field of eating disorders began to explore biologic determinants contributing to causation. Significant studies on depression and anxiety as pre-determining factors proved reliable and gave and continue to give reason to be hopeful for patient recovery and in pursuing efficacious treatment protocols. (see Kaye, Strober, Fairburn)
Many patients with eating disorders have depression and/or anxiety prior to the development of the eating disorder. In this way, symptoms of the disorder can elevate mood as the sufferer relies on restriction or weight control to compete or fit in to the cultural norm and media expectations. Anxiety can also be controlled through food restriction and purging, both in terms of psychological and emotional buoying and as a physiological release of stress. (Scheel. December 2016. psychologytoday.com)
First, what does neurobiology mean?
Neurobiology is the study of cells of the nervous system and the organization of these cells into functional circuits that process information and mediate behavior. It is a branch of biology that is concerned with the anatomy and physiology of the nervous system. (sciencedaily.com)
Eating Disorders and Neurobiology
Research has shown that dysregulation of our brain’s reward and inhibitions systems may contribute to disordered eating. When looking at Anorexia Nervosa, when severe food intake occurs, it over activates the inhibition control networks and under activates the reward networks.
When looking at Bulimia Nervosa (BN), there seems to support for the dysregulation of both inhibition and reward pathways due to the characteristics of bulimia symptoms. (Beneath the Surface: The neurobiology of eating disorders. www.eatingdisorderhope.com)
Many people who read about depression, anxiety and eating disorders are familiar with the term neurotransmitter. Neurotransmitters (i.e. Serotonin, Norepinephrine, Dopamine) are chemicals that are released from a nerve cell which thereby transmits an impulse from a nerve cell to another nerve, muscle, organ, or other tissue. A neurotransmitter is a messenger of neurologic information from one cell to another. (medicinenet.com)
The neurotransmitter dopamine enables us to stop eating and resist the urge to eat a second helping of dessert and conversely Dopamine triggers when to eat when we are indeed hungry. Dopamine function is altered for patients with Bulimia and Anorexia.
With respect to brain function, the Orbital Frontal Cortex signals when to stop eating and the Dorsal Striatum is linked to habitual behavior. Research has found, based on brain scans, that people with Anorexia and Bulimia have structural and functional differences in these areas. Also, the part of the brain known as the Right Insula, which enables us to process taste as well as body sensations and signals, are altered in people with Anorexia. (eatingdisorderhope.com)
Viewing the development of eating disorders through the lens of Neurobiology creates difficulty in determining whether brain differences are the cause or result of having an eating disorder. Whether brain alterations are the result of “trait” (pre-existing features) versus “scar”(results of eating disorders on the brain and brain activity) remain unanswered. There is agreement among researchers and clinicians that being severely malnourished can cause changes to the brain. Brain scans have shown that many of these changes do return to normal after a person’s neutron and weight stabilizes. Perhaps, this leans more toward brain scarring versus trait based.
The Psychology of Eating Disorders
Needless to say, there are countless references in my Blog posts which address the psychological issues of eating disorders. See, “Mending the Eating Disorder Fence: Neither this Nor That.” (June 28, 2016. psychologytoday.com) Most clinicians and researchers agree that eating disorders are and shall remain Psychological disorders with co-occuring conditions.
Psychological theories regarding the causes and contributions to the development of eating disorders include intra-psychic, familial, relational, cultural and social. These include:
Psychoanalytic: S. Freud, A.Freud
Modern Psychoanalytic: Bruch, Palazzoli
Interpersonal: H.S. Sullivan
Attachment Theory: Bowlby
Object Relations: Mahler, Winnicott, Kohut, Kernberg), Bowlby,)
Psychodynamic and Feminist Psychoanalytic: Zerbe
Family Systems Theory: Fairburn, Minuchin
Many of the psychological theories are and can be operationalized in to treatment strategies and approaches.
Some treatment approaches are not solidly based on any theoretical framework, but rather focus on behavioral and cognitive changes like Cognitive Behavioral Therapy (CBT,) Dialectical Behavioral Therapy (DBT,) Family Based Treatment (FBT,) Interpersonal Psychotherapy (IPT,) Experiential (Art, Movement, Mindfulness,) Motivational Treatment and others.
Focussing on treatment rather than cause continues to demand further research, both quantitative and qualitative. What works and does not are hot questions. Greater learning opportunities are needed for professionals who treat eating disorders about the breath and variety of theoretical understandings. Practicing within one or two frameworks is never wise because eating disorder patients’ issues and needs tend to be complex.
Additionally, greater training and educational opportunities for patients and family members is always helpful. I have found over the course of many years of practice that educating patients and family members about the tenants and utility of varying theories and the practical application of theory i.e. treatment has enabled family members and patients to make sense of conditions that are complex and confusing. Determining which theory and which treatment approach applies is to be determined on a case by case basis.
Removing the Professional White Coat
Some eating disorder organizations and residential treatment facilities that are dedicated to professional development and training are moving in the direction of including patients and family members in their annual conferences. (see ANAD 2017 conference - www.anad.org) Though didactic learning can be tailored to each group during a conference weekend, joining together and simplifying theory and treatment so that it is digestible by all enables a shared experience and meeting of all minds - team treatment made possible. Ultimately, theory and treatment can be utilized by professionals in their practices and demonstrate to family members how they can implement theory and treatment at home. Everyone can practice on the same page, utilizing a similar language. Recovery increasingly made possible!
Judy Scheel, Ph.D., LCSW, CEDS