Let’s fine tune CBT and psychodynamic approaches with biology

A dear and respected colleague wrote me, “I of course get the survival mechanisms but I also hear the wrenching confessions from my patients about how much they hate their bodies…My approach is focused more on helping patients and other patients understand the famine concepts without directly finding fault with well accepted and researched approaches like CBT-E.”

She gave me permission to post her comment and my response:

Yes, dear colleague,

“They overvalue body size for self-esteem” is like fingernails on the blackboard to an old feminist like me. Do you think if we had a disorder caused by adaptations to life in the Pleistocene that was choosing some of our best and brightest young men, something that made them willing to sacrifice their health and their future health to an abstract idea, we would be so ready to call them vain?

Wait! We do have such a thing. We call it love of sports. And we call them heroes.

“I am afraid of getting fat,” the explanation that anorexia nervosa sufferers readily give us today for their fear of eating and hyperactivity was not given by patients before 1960s. They said they felt full, that their stomach was sensitive. All these explanations are confabulations; artifacts of the way the mind makes sense of urges from the hypothalamus, insula and prefrontal cortex to ignore hunger.

In the early Middle Ages pious Catholics with anorexia nervosa said they wanted to be less led by carnal appetites. Then observers admired their Chirst-like abilities to work tirelessly and live with little food. St Gregory of Nyssa marveled, “What human words can make you realize such a life as this, a life on the borderline between human and celestial nature? That nature should be free of human weakness is more than can be expected from mankind, but these women fell short of the angelic and unmaterial only in so far as they appeared in bodily form, were contained in a human frame, and were dependent on the organs of sense” (AD 378).”

Contrast this with Vitousek, Watson and Wilson (1998) observation, “Accurate empathy is unusually difficult to sustain with anorexic clients….  Many clinicians dislike working with anorexia patients because of the perception that clients habitually deny, deceive, and rationalize to protect their symptomatology” (p. 392). They continue, “anorexics’ denial and sometimes defiant stance can adversely affect the therapeutic relationship, and may contribute to punitive treatments, patient abandonment and intense emotional reactions by professionals” (p. 394).

This is why I think contemporary CBT-e, psychodynamic and interpersonal conceptualizations that anorexia nervosa is a due to a personal conflict or values are pernicious. Anorexia nervosa is caused by an ancient famine-selected agenda that is as impersonal and strong as the one that makes some store extra pounds.

Understanding the brain’s hiccups and ancient agendas can relieve people of unfair self-attributions. For example, I once saw a new mother who was tormented by the thoughts that she would take a sharp knife and stab her baby. She told me she used to have such thought about the family dog and her husband. She had never hurt the baby, had never harmed any one.

She explained that she and her husband had been unable to conceive and then with help they had had this precious child. She said that she loved him unbearably, but these thoughts intruded and she couldn’t trust herself. She was distraught and miserable.

I consulted with an OCD expert and he told me this terrible symptom is well known to those who work with OCD. It generally doesn’t mean the mother is a danger to her child; rather it’s an artifact of the way the brain works. Because one must think of the dangers one needs to guard against, for people with certain kind of an overactive amygdala the thought gets stuck. They are so appalled that they could even think of such a vile act, they think it means they will do it, so they have to remind themselves to never do it, and then they think, why would that thought come into my mind? and it spirals on.

For this young mother, simply explaining how the checking part of the brain works, that it didn’t mean she was a danger to her child, dog or husband, resolved the symptom. Now when such thoughts come to her she simply says, oh, that’s my amygdala checking, and can move her thoughts along.

Haven’t we all had patients who claim they never knew or cared what they weighed and never cared about fashion, but now find the thought of gaining a pound unbearable? They are ashamed of caring so much because it makes them look vain. Nisbet said we observe our behavior and derive self-attributions. Thus, “I am behaving vainly” becomes “I am vain.”

I tell such patients: “Your fear of eating is not because you are vain. Of course you care about your appearance. All women do, but your weight suddenly feels like life and death because once it was for your ancestors. You have anorexia genes because your ancestors survived by resisting their hunger and moving. Gaining a pound means you have failed to resist your hunger and move enough. Anorexia makes gaining a pound feel like the worst thing. It steals your future to help you migrate today because it was migrate or die in the Pleistocene. That’s why it feels so important, not because you are more vain than women at their normal weight.

When you are normal weight it won’t feel like life and death anymore. You will be able to use your energy for your own life, for your own agenda instead of anorexia’s.

It is true that some food phobias persist because they get wired into the brain’s primitive fear center. But we can work on those just as we do any phobia. And it’s true that we live in a fat phobic culture that taunts women to lose weight, and you will have to strengthen your spine to resist going on fad diet, but the crazy, vehement feeling that it would be dangerous and terribly wrong to eat fades with weight restoration.

I believe that cognitive behavioral, as well as psychodynamic therapists, DBT, Compassion focused therapy, ACT, etc can be very helpful with AN patients. But let’s fine-tune these approaches with what we are learning about how AN works. It’s busy at the most primitive levels of the brain and that makes a difference in interpreting a person’s anorexic behaviors and urges.

In my next post: An evolutionary reason that women care so much about meeting the current beauty ideal.

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Competing Paradigms for Anorexia Nervosa

The contributors to the April 2007 American Psychologist special issue on eating disorders are to be commended for acknowledging lack of progress in understanding, classifying, and treating anorexia nervosa (AN). They highlighted the acute need to refine diagnosis (Wonderlich, Joiner, Keel, Williamson, & Crosby, 2007), understand comprehensive causal mechanisms to tune treatments and transcend “hodgepodge diagnoses” (Striegel-Moore & Bulik, 2007, pp. 181–182), study functional neural circuits and link behavior with “genomic, cellular, and systems data” (Chavez & Insel, 2007, p. 164), and develop effective treatments (Wilson, Grilo, & Vitousek, 2007, p. 201). Specifically, Chavez and Insel (2007) wrote that “present-day treatments are significantly limited” and that identifying underlying pathophysiology “will be critical for developing more effective treatments and preventive strategies” (p. 160). This state of the field could suggest that a new paradigm is needed, but new paradigms are often resisted by the established scientific community (Kuhn, 1962), of which the contributors to the special issue are internationally recognized leaders.

Link to Full letter:

Guisinger AP Comment 2008

Guisinger, S. (2008). Competing paradigms for anorexia nervosa. The American Psychologist, 63(3), 199-200.

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Modeling the heritability of Anorexia Nervosa


Shan Guisinger, Ph.D

David Schuldberg, Ph.D.

The University of Montana– Missoula

Growing genetic evidence indicates that symptoms of anorexia nervosa (AN), representing illness today, were selected in the past. Eight genes have been identified in AN individuals that decrease appetite and increase activity, triggered by falling weight. The adapted-to-flee-famine hypothesis (Affh) has proposed that abilities to ignore hunger, deny starvation, and move energetically are remnants of archaic adaptations that helped some in starving hunter-gatherer bands lead others from depleted home range. Yet, only 1-2% carrying the genes develop the disorder, which also exhibits sex differences. Maynard Smith clarified when natural selection results in stable polymorphisms; density-dependent selection describes how net individual benefit depends on behavioral strategies of others. We model effects of a variety of variables — including number of potential leaders, survival of those leaving home, refeeding success, reproductive outcomes for “successful” anorectics, and syndrome lethality — evaluating effects on the prevalence and sex distribution of AN.

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Monitor on Psychology

An evolutionary explanation for anorexia?

by Karen Kersting

Monitor, Vol. 35, No. 4, page 22 | April 2004

Modern anorexia may stem from an adaptation that helped ancient nomadic people find food, according to a recently proposed theory.

An evolutionary instinct that told members of migrating populations to move along when their food supply ran out may be a major contributor to modern anorexia nervosa, according to a new theory.

When food is scarce and starvation begins, most animals and people demonstrate intense hunger, low activity levels and a single-minded search for food. But, when starved, individuals with a genetic tendency toward anorexia feel sated, full of energy and unfazed by starvation–a set of symptoms described in the DSM-IV, says psychologist and Missoula, Mont. private practitioner Shan Guisinger, PhD, in an article published last year in Psychological Review (Vol. 110, No. 4).

“In treating anorexics, I started to wonder if their symptoms could be something that was useful in the past,” Guisinger explains. “When nomadic foragers were starving, it wouldn’t make sense to hunker down and just not eat. If you’re starving it means that there’s no food there, and so you should move on–normal adaptations to starvation would get in the way.”

A problematic adaptation

In the nomadic groups that preceded modern civilization, members who were undeterred by hunger may have become leaders and moved the group to places where food was plentiful, Guisinger says. She argues that this ancient adaptation, which was likely an advantage at the time, today continues to cause anorexia in people who have a genetic predisposition to it.

But whereas food scarcity may have been the original catalyst for anorexia–which kicks in when genetically susceptible people lose 15 percent of their normal body weight through lack of food–intentional dieting related to societal fear of being fat is most often the cause in modern cases, Guisinger says.

“A lot of people have trouble with this theory because they think now, in modern times, when there’s so much food around, why don’t anorexics just start eating again?” she notes. “But the thing about the brain is that it simply responds to body fat levels, making automatic adjustments to hunger and satiety signalers. Evolution is not very elegant sometimes, and adaptations persist where they are not needed. In this case, the adaptation turns off hunger in modern women who diet.”

Making the case through research

Guisinger backs up her theory with evidence from myriad studies pieced together to show that the core symptoms of the disease make adaptive sense. For example, she references research by psychologists Nicholas Mrosovsky, PhD, and David F. Sherry, PhD, that describes food-restriction behavior across species when animals must migrate.

She also cites research by Leo Kron, MD, that illustrates anorexic patients’ tendency toward hyperactivity and compulsions to move. And she points to research by historian Rudolph Bell, PhD, that documents anorexia in medieval people who lost weight through religious fasting. They, too, demonstrated distorted body images, hyperactivity and food refusal.

Though Guisinger’s theory is carefully constructed through her presentation of such evidence, proving an evolutionary cause for a modern illness is tricky, says psychologist Jeanine Cogan, PhD, founder of the Eating Disorders Coalition for Research, Policy and Action. Because Guisinger is looking to the past for causation, proving her hypothesis through research is impossible, she adds.

“She’s made an interpretation that’s compelling,” Cogan says. “And what I found most useful is she raised some excellent points about the physiological and psychological effects of food restriction that may play an important role in causing anorexia.”

Guisinger, who has never published a research article on anorexia before, says she came to her evolutionary conclusion after years of observing patients who wanted to eat, but claimed to be stopped by their bodies. Now, she says the most important step in helping patients is getting their weight back to normal, which, she believes, will turn off their genetically programmed anorexic response. The hypothesis can serve as a basis for cognitive behavioral therapy and for enlisting the aid of loved ones to help keep body weight up, she adds.

“It doesn’t make psychotherapy irrelevant, but it means that more than anything, people are going to need all the help they can get from their therapist, family, doctor and dietician to fight against their body’s signals in, what is to them, a very unnatural way,” she says.

Find a copy of the article here.

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Adapted to Flee Famine: Adding an Evolutionary Perspective

Psychological Review 2003

Anorexia nervosa (AN) is commonly attributed to psychological conflicts, attempts to be fashionably slender, neuroendocrine dysfunction, or some combination of these factors. Considerable research reveals these theories to be incomplete. Psychological and societal factors account for the decision to diet but not for the phenomenology of the disorder; theories of biological defects fail to explain neuroendocrine findings that suggest coordinated physiological mechanisms. This article presents evidence that AN’s distinctive symptoms of restricting food, denial of starvation, and hyperactivity are likely to be evolved adaptive mechanisms that facilitated ancestral nomadic foragers leaving depleted environments; genetically susceptible individuals who lose too much weight may trigger these archaic adaptations. This hypothesis accounts for the occurrence of AN-like syndromes in both humans and animals and is consistent with changes observed in the physiology, cognitions, and behavior of patients with AN.

View the PDF version of this paper here .

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