RESEARCH SHEDS NEW LIGHT ON THE NEUROBIOLOGY OF DISORDERED EATING

High-fashion models are an unhealthy 23% thinner than the average woman – while research shows girls as young as five on diets to achieve the same image. On top of this, people with eating disorders are at higher risk for substance-use disorders. Kathleen Parrish and Kim Sines report on the science and treatment.

A CULTURE OF THINNESS

The media images are wearily familiar—stick-thin models, beautiful, indifferent and fashionably emaciated, exuding power and chic that speaks the last word in cutting-edge fashion. The banks of cameras lining the catwalks of Milan, London and New York lend an air of importance to their poses. Interviewers sit rapt while models share their secrets for a waistline unattainable for most women. And, where high-fashion models were once 8% thinner than the average woman, today’s models are an unhealthy 23% thinner.

These powerful images can leave suggestible young minds with the clear impression that personal value is a byproduct of outward appearance. Some clinicians familiar with disordered eating worry that these images and inferences contribute strongly to a culture in which eating disorders easily take root.

The fashion industry has, in recent years, been taken to task for promoting a distorted but revenue-friendly ideal of waif-like femininity and airbrushed perfection which fills the glossy magazines featured in the racks of supermarket check-out aisles. The popular media also seem determined to foster a culture of weight loss. A recent review of print media found that women’s magazines feature 10 times the number of ads and articles devoted to weight loss than magazines targeted to men. And over 75% of the covers of women’s magazines promise advice on how to change the shape and size of readers’ bodies. The message that skinny-is-good has become a central theme in media targeted to women, and this message is usually accompanied by ever-thinning images of the perfect female body.

To make matters worse, the internet has joined the print media and airways in bombarding us with images of starlets checking themselves in and out of rehab for treatment of anorexia and bulimia, all the while being followed by eager paparazzi and applauded in the fashion magazines. Many young viewers can already think of disordered eating as the trendy and hip behavioural health issue of the 21st century; their chance to bask in the spotlight, being, at once, pitied and envied.

The obsession with thinness is now affecting populations previously spared, with reports of weight-control measures being taken by girls as young as five and six years old.

NEUROBIOLOGY AND GENETICS

While it is important to appreciate the role of society, culture and media in the development of eating disorders, new research has begun to shed the hard light of science on neurobiological contributors to the development of disordered eating. Many neuroscientists now believe that genetics and neurobiology could be more strongly implicated in the development of eating disorders than the influence of society, media, or culture.

This new focus on the neurobiology and genetics of disordered eating helps behavioural health clinicians to understand why some people develop eating disorders while others do not.

Recent data suggest that both anorexia nervosa and bulimia nervosa are highly heritable disorders with documented histories of disordered in 50-80% first-degree relatives. Some research seems to indicate that people can have specific genetic traits which predispose them to developing an eating disorder. A recent neuroimaging study found that, compared to control subjects, people with anorexia nervosa showed a significantly lower activation of the brain’s primary cortical taste region when administered both sucrose and water.

Personality traits that seem to dispose some people toward disordered eating include perfectionism, performance anxiety, novelty seeking and harm avoidance. Among these susceptibility traits, anxiety appears to be one of the strongest predictors of disordered eating.

Both anxiety and perfectionism are identified as potential risk factors for developing bulimia nervosa, and anxiety disorders appear to be more prevalent among those with anorexia nervosa.

Anxious symptoms often predate the onset of an eating disorder and routinely persist long into recovery. Interestingly, the most common types of comorbid anxiety disorders among those with anorexia nervosa or bulimia nervosa is obsessive-compulsive disorder and social phobia.

CO-OCCURRING MOOD AND ADDICTIVE DISORDERS

Other mood disorders also affect the dynamics of disordered eating. Recent research found increased levels of depression in patients who suffer from anorexia and bulimia. In one study, 83% of patients treated for some form of disordered eating reported depressive symptoms. The usual factors contribute to this, including trauma, hormonal imbalances, and significant life loss, such as the death of a loved one.
To further complicate the diagnostic picture, symptoms of depression like weight loss and lack of appetite often mimic the symptoms of an eating disorder. This reality underscores the need to treat eating disorders thoughtfully and from a multidisciplinary perspective.

Anorexia nervosa and bulimia are complex and tenacious disorders which often require prolonged, intensive treatment. The mortality rates for anorexia alone are a staggering 10% – the highest mortality rate of all psychiatric disorders. And people suffering from anorexia are at heightened risk for suicide, with attempts occurring in 3-20% of those studied. Over half of the disordered eaters who attempt suicide die from the attempt.

Although those who suffer from anorexia nervosa have the highest suicide rate, suicide attempts among those with bulimia nervosa are also substantial.

On top of this, research suggests that those who suffer from eating disorders are also at higher risk for substance use disorders. The National Center on Addiction and Substance Abuse at Columbia University in New York reports that almost a third of women who abuse substances (both alcohol and illicit drugs) suffer from some kind of eating disorder.  Substances commonly used by disordered eaters include alcohol, tobacco, diuretics, cocaine, amphetamines, heroin, laxatives, emetics, and caffeine – substances known to have anorexic or purgative effects.

People in treatment for comorbid eating and substance-use disorders often struggle to balance recovery, typically experiencing a rise in the symptoms of one disorder while managing the recovery of the other. This dynamic is well known to clinicians familiar with disordered eating: someone with a history of bulimia nervosa and cocaine addiction might maintain abstinence from their drug of choice, but struggle with a resurgence of bingeing and purging. The converse also holds true: an individual who is using cocaine might experience a reduction in eating disorder symptoms while their use is active.

TREAT AN OFTEN-COMPLEX DISORDER

For such a complex behavioural health issue as disordered eating, treatment must not be done in a haphazard manner. A thoughtful, deliberate approach is advised, and we strongly believe that eating disorders are most effectively treated using a holistic perspective.

Holistic treatment derives its healing power from incorporating physical aspects of recovery with cognitive wellness and spiritual cultivation, helping people to learn to care for themselves compassionately and adaptively.

People entering treatment for an eating disorder should always consult a doctor for a thorough medical evaluation and possible management of physical health issues which often occur as an eating disorder progresses. In severe cases, people whose disordered eating is entrenched or whose health has been substantially compromised might need the structure of a hospital or residential treatment. This structure might be necessary to interrupt stubborn and dangerous behaviour around food while ensuring that physical health is not further compromised.

Education for people suffering from an eating disorder is crucial and a necessary part of any treatment programme. Education on the neurobiology of disordered eating and on a heritable predisposition for the development of eating disorders can help to reduce shame and guilt, powerful players in prolonging disordered eating. Psycho-educational activities can help patients to recognise the emotional and cognitive nuances of their disorder and separate themselves from disordered eating behaviour by practising new, more adaptive beliefs and behaviour. Treatment can result in informed and thoughtful, rather than impulsive and emotionally-driven, choices around eating.

Skillful nutrition, too, is crucial for those recovering from an eating disorder. Often, nutrition is severely compromised in those people whose eating behaviour is disordered. For those with active and entrenched anorexia, the risks to physical health, and even life, are high. Treatment can sometimes require tube feeding as a means to prevent severe illness or death.

Overall physical and cognitive functioning can also be compromised in people with a history of restricting food. Nutritional counselling is a powerful way to educate, helping to develop a healthy awareness of daily caloric and nutritional requirements and of specific foods to boost energy, sharpen focus and improve overall cognitive functioning.

Helping disordered eaters to develop new attitudes and behaviour round food is often a slow and bumpy process. This becomes most evident when newly recovering disordered eaters begin to gain weight when moving toward a more normal body composition. This might be a good opportunity for skilled counsellors to challenge negative thinking and body-image distortions.

Counsellors are advised to work hard at creating a therapeutic environment characterised by safety and the absence of judgment – an environment where disordered-eating clients can find the willingness to tolerate the risks inherent in examining feelings of anxiety and fear related to changes in their body shape, size and weight.

Counsellors should also invite honest conversation about relapse to disordered eating in early recovery – a likelihood for almost everyone. Clients who have insight into their own relapse dynamic will be more able to identify relapse triggers or unexpected barriers in their recovery. 
 
ENLIST THE FAMILY

Behaviour change is also slow and uneven for those who suffer from eating disorders, as they  relinquish control and turn a healing light on long-held secrecy and shame. Family and community support is not only helpful, it is necessary to the recovery process. Clients who have educated and supportive friends and family members stand a greater chance of achieving sustained recovery.

But creating positive family support is not easy. Family members of those who suffer from disordered eating can succumb to the temptation to limit their focus solely to the physical aspects of the disease, becoming controlling and hyper-vigilant, watching with hawk-eyes and trying to coerce their loved one into healthy eating habits. Family members and friends should be educated about how to support but not control, as attempts to control can often result in a family staying stuck in their own suffering.

Supporting open communication and appropriate boundaries among family members can help the recovering person to seek help when needed, and accept feedback and expressions of concern from loved ones.

Counsellors who treat disordered eating must be thorough and creative in their treatment interventions. At least some session time should be devoted to eradicating cognitive distortions associated with the eating disorder – and there are a myriad of these. Using proven counselling approaches, including cognitive behavioural therapy and dialectical behavioural therapy, a skilled clinician can help the disordered-eating patient to develop more rational thoughts and beliefs about eating and body image. Wellness resources which focus on the compassionate care of the human spirit are quite helpful here. Introducing mind/body therapies, like yoga, meditation and tai chi can foster the development of mindfulness as a means of managing emotional pain and self-defeating impulses.

While culture alone cannot be blamed for the proliferation of eating disorders, neither can the etiology of these illnesses be attributed exclusively to genetics or biology.

As with many other psychiatric disorders, the influence of both nature and nurture seem to be at work in the creation of disordered eating. People who suffer from eating disorders must recover with the genetic make-up with which they were born, and in a world where popular culture is what it is. A holistic approach to treatment including education, proper nutrition, a strong therapeutic alliance and appropriate family/community support can yield surprising results when applied to the treatment of disordered eaters.

Recovery is challenging and fraught with many barriers. People who are genetically susceptible to an eating disorder will almost surely find it hard to navigate recovery in a culture that screams thinness. Every mirror is a potential enemy and every size-zero dress mutely mocks from store windows. Approaching recovery from a holistic perspective carries the promise that disordered eaters can develop the necessary skills, self-care, and compassion necessary to begin the journey of healing and wellness.

Kathleen Parrish LPC has over 20 years’ clinical experience and  is clinical director of the adult and adolescent (female) units  at Cottonwood Tucson, a holistic behavioural health treatment facility in Arizona. She specialises in treating disordered eating, mood disorders and trauma. She can be reached through Cottonwood Centre London, 9a Wilbraham Place, London SW1X 9AE. 020-7229 0211 or kparrish@cottonwoodtucson.com.
Kim Sines LISAC is Cottonwood’s vice president for clinical affairs. He has been a behavioural health clinician for over 30 years and provides both education and psychotherapy to disordered-eating patients.

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