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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A fundamental attribution error in CBT-e for eating disorders

There is something fundamentally wrong with Cognitive Behavioral Therapy (CBT-E) for anorexia nervosa and other eating disorders. I want to be clear that I think that some form of CBT is useful in treating eating disorders. After all, anorexia nervosa (AN) and bulimia nervosa (BN) are characterized by dysfunctional cognitions and behaviors that maintain the disorders and a CBT approach can profitably focus on changing these cognitions and behaviors.

My concern is with that Fairburn and his colleagues’ CBT-(enhanced) believe the core psychopathology of eating disorders is the “overevaluation of shape and weight”(1). (I think we agree on the behavioral part, people must normalize eating and stop purging.)

This conceptualization ignores history (2) and biology (3). Moreover, it can interfere with recovery (4) and contribute to sufferers’ and observers’ blaming victims for their plight.

History: Before the 1960s people with anorexia nervosa did not give fear of getting fat as their reason for eating little. They said they were full, their stomach was upset, they were not hungry. St Catherine of Siena thought she had difficulty eating earthly food because God had prepared a heavenly table where she would be able to eat. She died of malnutrition at 33 but not before shaking up the Catholic Church. Eleanor Roosevelt, Simone Weil and Virginia Woolf struggled with AN all their lives. They were not trying to be thin.

“Fear of being fat” is the culture-bound explanation that people have given since the 1960s for the chaotic and confusing signals welling up from the ancient, nonverbal hypothalamus. Signals that, in the case of AN, make it hard to eat and drive them to move, and in the case of BN drive them to bingeing and purging. People automatically search for an explanation for any mysterious feelings and readily agree to the currently popular psychological explanations.(5)

Biology: eating disorders are caused by powerful survival mechanisms that will not change as long as the body fears famine. Trad CBT for eating disorders does not reflect what biological researchers have learned about what causes eating disorder symptoms and how to heal them. It treated the brain as a black box, but it shouldn’t.

CBT was developed originally to treat depression. With depression, viewing the brain as a black box was necessary because little was known about the neurophysiology of depression and we have no natural animal model. This is not the case with eating disorders. Many other species spontaneously develop animal anorexias where they stop eating and start moving when starved. Binge eating can be induced in normal weight mice in the lab if they are dieted, refed, stressed and then given access to sugar water. The brain systems that are in charge of eating are highly conserved in mammals so there is no reason not to learn from animal neuroendocrine research.

Neuroendocrine researchers have teased out how ED behaviors are caused by changes in appetite and activity regulators and reward pathways in animals and people(6). This information provides the explanation that patients need for why certain behaviors lead to feeling out of control of binge eating, and why weight loss in people genetically vulnerable to AN can lead to restricting and exercising.

People need to know that only a tiny fraction of the brain is conscious and it cannot take care of deciding most of what we do. Nonconscious brain algorithms initiate most of our eating behavior, but, knowing nothing of that, we automatically assign agency to the conscious part we know.

CBT for eating disorders focuses on the wrong underlying cognitions. An underweight person with AN does not run and restrict because she is vain, but because of same neuroendocrine changes that cause rats, mice (7) and pigs (animals that like humans evolved as opportunistic omnivorous nomadic foragers) to run and restrict. These behaviors would remove them from a food-depleted environment. I believe that these behaviors, as well as binge eating, are adaptations that helped our ancestors from survive famines(3).

Recovery: And treatments based on the conventional CBT assumptions have a dismal success rate. In fact McIntosh and colleagues (4) found that patients in what was supposed to be the control group, given only nutritional counseling and emotional support, did better than those given CBT that assumed anorexia is caused by overvaluing body size.

Our updated CBT for eating disorders explains the powerful compulsions as adaptations to flee famine that borrowed from their body’s future to save their life today. Their body is trying to migrate. It feels so wrong to give up anorexia today because they were selected to persevere through pain and hunger.  I suspect that when they found better lands the band members helped them recover.


  1. C. G. Fairburn, Z. Cooper, R. Shafran, Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour research and therapy 41, 509-528 (2003).
  2.  P. K. Keel, K. L. Klump, Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology. Psychological bulletin 129, 747-769 (2003).
  3.  S. Guisinger, Adapted to flee famine: adding an evolutionary perspective on anorexia nervosa. Psychological review 110, 745-761 (2003).
  4.  V. V. McIntosh, J. Jordan, F. A. Carter, S. E. Luty, J. M. McKenzie, C. M. Bulik, C. M. Frampton, P. R. Joyce, Three psychotherapies for anorexia nervosa: a randomized, controlled trial. Am J Psychiatry 162, 741-747 (2005).
  5.  P. G. Zimbardo, in Advances in experimental social psychology, M. P. Zanna, Ed. (Academic Press, San Diego, CA 1999), vol. 31, pp. 345-486.
  6.  J. Hebebrand, T. Muller, K. Holtkamp, B. Herpertz-Dahlmann, The role of leptin in anorexia nervosa: clinical implications. Molecular psychiatry 12, 23-35 (2007).
  7.  W. F. Epling, W. B. Pierce, Activity based anorexia: A biobehavioral perspective. Int J Eat Disord 5, 475-485 (1988).


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