Psychiatry starts to lose its grip on anorexia nervosa

[Hutan]

I heard on the radio this morning about this genetic study of anorexia nervosa. Basically it seems that there is preliminary evidence that anorexia nervosa has an autoimmune/biomedical basis.

https://www.sciencedaily.com/releases/2017/06/170612094212.htm

A large-scale, international whole-genome analysis has now revealed for the first time that anorexia nervosa is associated with genetic anomalies on chromosome 12. This finding might lead to new, interdisciplinary approaches to its treatment. The study was led by the University of North Carolina and has been published in the American Journal of Psychiatry.

This revealed that the significant locus lies on chromosome 12, in a region associated with Type I diabetes and autoimmune disorders, as well as insulin metabolism.

I'm not surprised, as I have heard people with anorexia nervosa speak of how eating makes them feel physically ill. The researcher I heard was hopeful that biomedical treatments would eventually be developed.

Disappointingly however, she said that psychotherapy was still very important 'as we don't have any other treatment yet, and it's crucial that these people eat'. If I was a young woman with anorexia nervosa and was told 'you aren't eating because you don't want to grow into an adult or you are reacting to your family over-controlling you', I'd be thinking 'rubbish, you have no idea what you are talking about, go away'. I wish people understood that psychotherapy is not necessarily a benign treatment and can cause all sorts of new problems for the patient and their family.

 

[Jeckylberry]

That's a valid point I think. The sweetness of psychotherapy as some sort of safety net or 'the best we have' could be just a lazy solution to something not understood. Is it better to have psychotherapy than nothing? Is haspitalisation and tube feeding nothing? What is seen as a temporary fix (hospitalisation) vs long term (psychotherapy) may be an illusion.

 

[Woolie]

Its really hard to get your head around anorexia nervosa, and if anyone here has had it, it would be good to hear your thoughts. My understanding from speaking to people who had it is that there are lots of pathways, but common themes are control and self-control. The cycle often starts because losing weight can be really rewarding. You diet, you get slimmer, people compliment you. This feels really satisfying, especially if other things in your life aren't going well.

So you keep going. Its hard because you love food and feel hungry all the time, but harder still is the worry that if you relax even a bit, you'll pile all that weight back on, or even more. And all your achievements - which are really keeping you going right now - will be lost. And anyway, you don't trust yourself to relax just a bit. You think once you loosen the strings just a little, you'll lose complete control.

There's other stuff in there too for some, feeling the way you look is never really good enough. You're still fat, ugly. You have to be slimmer, better, prettier.

Who hasn't felt some of these things before? Or even all of them? I'm lucky to have never had anorexia, but that's most likely because I lack the necessary strength of will!

 

[Valentijn]

I wouldn't be surprised if there's multiple causes. But an autoimmune disease wouldn't really explain the "thinspo" (thin inspiration) sites that many anorexics use to help encourage themselves to stick to starvation. So it sounds like those ones at least are trying to suppress their biology, rather than being the victims of their biology.

 

[Woolie]

The paper's interesting in that it suggests the "anorexia" gene profile might operate by enhancing the risk that a person will suffer from anxiety (Figure 2). But the same gene profile also seems to have positive benefits - people with the profile tend to be high achievers in education.

 

[Manganus]

The paper's interesting in that it suggests the "anorexia" gene profile might operate by enhancing the risk that a person will suffer from anxiety (Figure 2). But the same gene profile also seems to have positive benefits - people with the profile tend to be high achievers in education.

I would guess this is a fairly common pattern.

My hunch is that certain genetic profiles functions this way also for other psychiatric symptoms (including autism-spectrum disorders). While working in psychiatric care, I think I've met surprisingly many relatives to prominent persons. With "prominence" I think of bishops, CEO:s, community leaders, etc., etc., i.e high achievers in life.

 

[Woolie]

My hunch is that certain genetic profiles functions this way also for other psychiatric symptoms (including autism-spectrum disorders). While working in psychiatric care, I think I've met surprisingly many relatives to prominent persons. With "prominence" I think of bishops, CEO:s, community leaders, etc., etc., i.e high achievers in life.

That's interesting, @Manganus. I do think that the way we think about psychology is very value laden. Some traits are seen as overwhelmingly good, while others are totally bad. In reality, there's a good side and a bad side to every trait. A good dose of trait anxiety gives you the drive to achieve (I have always thought I wasn't anxious enough to ever be really successful at what I do). But then at its worst, it can send you into a bad place.

 

[TiredSam]

Some traits are seen as overwhelmingly good, while others are totally bad.

"High achievers" regularly come in for a good kicking, which I suspect a certain type of psychologist must find particularly satisfying.

 

[Hip]

Catching a Streptococcus infection may be a triggering factor for anorexia nervosa:

Infection-triggered anorexia nervosa in children: clinical description of four cases

Strep Throat Can Cause Anorexia Nervosa, OCD : Rarely, group A β-hemolytic streptococcal infection can lead to sudden onset of psychiatric symptoms

In such cases, anorexia nervosa would come under the PANDAS umbrella (PANDAS = Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections).



It's interesting that there is a high statistical comorbidity of anorexia nervosa and obsessive-compulsive disorder (OCD); OCD is another condition that can in some cases be triggered by a Streptococcus infection.

For me, viewing anorexia nervosa through the lens of OCD makes sense, as anorexia nervosa seems to be a sort of OCD-type behavior: there may some psychosocial factors involved in originally setting the focus on body thinness (ubiquitous photographs of thin models in the media); but then after this focus is set, some OCD-type brain disposition (possibly caused by infection or autoimmunity) may take over, thereby creating an obsessive-compulsive mental focus on thinness.

 

[trishrhymes]

I think it's possible that nutritional deficiencies kicking in pretty quickly at the start of anorexia may have physiological effects that compound the problem. For example, I think zinc deficiency messes up taste and smell.

 

[Art Vandelay]

I've known a few anorexia sufferers and have never doubted that the illness had a biological basis.

As others have already noted, while there are some psychological payoffs from anorexia (compliments, losing weight etc) and that may have been behind some of initial motivation not to eat, it seemed to me that eating made them feel physically ill, and/or, they found that not eating gave them some control over their anxiety. (Sidenote: I also think that anxiety has a biological basis).

In any case, it's good news for those with anorexia and yet more bad news for the pseudo-scientists.

 

[NL93]

Interesting. I have a friend who had anorexia for years and has completely recovered with psychological treatment. She has a normal weight and eating pattern now. In her case it seemed to be mainly psychological.

 

[Hutan]

"High achievers" regularly come in for a good kicking, which I suspect a certain type of psychologist must find particularly satisfying.

(This gives me vindictive pleasure
https://finance.yahoo.com/news/least-valuable-college-majors-list-143543989.html )

The most and least valuable college majors — is yours on the list?

If you want to pick a major that pays big, consider the STEM fields — science, technology, engineering and math.
Pharmaceutical sciences and administration ranked second on the list. Pharmacists have a median income of $116,642.

Geological/geophysical engineering, the study of extracting the Earth’s natural resources, came in third. People employed in this field have a median salary of $94,060 per year. Mining engineering and Naval architecture rounded out the top five most valuable majors.

On the opposite end of the spectrum is clinical psychology, which came in as the least valuable college major. In addition, clinical psychologists have a high unemployment rate of around 8% and make a median salary of $43,092, about 31% less than the average.

 

[Mij]

I would imagine a lack of proper Omega 3 intake would affect the brain/nervous system function too.

 

[Hutan]

I found this article interesting.

A fundamental attribution error in CBT-e for eating disorders
http://www.adaptedtofamine.com/study/eating-disorders/

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.
....
“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,
....
People automatically search for an explanation for any mysterious feelings and readily agree to the currently popular psychological explanations.
....
Many other species spontaneously develop animal anorexias where they stop eating and start moving when starved.
....
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.
....
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 ... 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.

The two people I have known who had anorexia nervosa seemed psychologically normal, and with normal families, before becoming ill. The one treatment I have heard of that seems to work well is having patients eat quickly rather than nibble on food - maybe that helps to reset things. Therapy that helps people understand that there is a physiological reason for their condition probably helps too as opposed to that which blames the patient and family.

A pathway to anorexia nervosa that involves an autoimmune condition that makes eating unpleasant, followed up by an innate response to starvation and compounded by the resulting nutritional deficiencies sounds pretty plausible to me.

 

[Woolie]

A pathway to anorexia nervosa that involves an autoimmune condition that makes eating unpleasant, followed up by an innate response to starvation and compounded by the resulting nutritional deficiencies sounds pretty plausible to me.

Technically, that's not anorexia nervosa, its anorexia linked to another disease.

I don't think anorexia nervosa is simply a disinclination to eat, its much more. People who don't enjoy eating can be thin, but they never reach the point of starvation. Anorexia nervosa is almost invariably more than not eating - its a goal-driven set of behaviours build around a central weight loss goal. Undereating is one such behaviour. Others are intense calorie counting, extremely intense exercise ( e.g., several runs/trips to the gym each day), and/or purging/laxatives. Its pretty common for ppl with anorexia to refuse meds (e.g. anti anxiety), if those meds are associated with weight gain. Many are even worried about having a drip put in, and will want to know how many calories it has.

There are pages on the internet designed to help those with anorexia manage their hunger and their temptations, about what to do to "burn off" a trangression. If they simply didn't enjoy eating, they wouldn't need such tips.

Sure, there are lots of pathways to anorexia, and I agree fear of being fat is not always a factor. The contributing elements seem to vary for each person. Some examples I've heard from talking with people: avoiding sexual attention from others, escaping greater fears (like not meeting parents' expectations), feeling less of a burden on their families, feeling unworthy. Some people describe it a little like self-harming, its a way of feeling something other than numbness. Some sufferers are very critical /demanding on themselves, and despise themselves when they don't meet their own standards. One personal account I read recently was a young male from a highly controlling family (abusive father) who couldn't come to terms with this homosexuality, and found that being really thin suppressed his sex drive.

What's changed since 1960 is the high social desirability of female thinness, I'd expect that nowadays, there'd be proportionally more cases where this type of reward played a role - at least in triggering the initial behaviours that led to the problem.

 

[Woolie]

The two people I have known who had anorexia nervosa seemed psychologically normal, and with normal families, before becoming ill.

Yea. Again, you've got to think multiple pathways. Most ppl with anorexia have lovely parents who have done nothing wrong. A small subgroup have the parents from hell. That famous model Isabelle Caro (who died from anorexia) was kept inside her house her whole childhood, because her mother feared that fresh air would make her grow big too soon.

The one treatment I have heard of that seems to work well is having patients eat quickly rather than nibble on food - maybe that helps to reset things.

That's interesting. I do wonder whether all the analysis of their thoughts, emotions, family relationships is a waste of time. Ppl with anorexia are often goal-oriented and driven, they were just unlucky to choose a goal that is potentially fatal. The ones I've spoken to didn't recover from therapy. They recovered when they found a new goal in life that was more important to them than weight, and were able to redirect their energies to that. Best still is when that new goal requires you to be a healthy weight - and most career, educational, sports or other goals do.

 

[duncan]

Ppl with anorexia are often goal-oriented and driven...The ones I've spoken to didn't recover from therapy

This sounds familiar.

 

[rosie26]

In my experience there is a risk of losing self perception after months of successfully losing weight. I was 15 years old when this happened to me. I had gained quite a bit of fat at puberty and didn't like it one bit. Determined to lose this weight I changed my eating to healthy food and exercised a lot. I lost the weight in around 3 months but I think I made a mistake by not setting a goal weight because I didn't adjust my eating at this stage to hold the ideal weight and so I got thinner than I should have. In other words I had lost the ability to see where I was in the whole process and continued on losing weight.

One day while I was at my friends house we walked past a full length mirror and when I saw myself all I could see was a fat person in the mirror, and I remarked to my friend that I was fat. This friend was shocked and told me I was thin and needed to put on weight.

After thinking about what my friend has said I slowly began to realise my perception was not correct. In all, it took another 2 years to slowly stop watching calorie intake and eat whatever.

 

[erin]

I believe I suffered from anorexia nervosa in my very early teens. This was many years ago and the disease was not in the media. I was taken to the doctor and had a lot of vitamin injections, force fed by mum. Then I left home at 18 and got a boy friend was kind of happy. Things were OK and I kept slim but not sickly slim. Then after ME, 2005 I started to put weight on. I became slightly plump. I needed energy and was eating a lot of sugary stuff. I could not help it. I found my self purchasing a big bag of haribo and eating the whole bag in the train on my return from a hospital visit. I felt I was going to pass out if I didn't do that.

Now it is a completely different story. this illness changes in time, I'm back to my sick feeling days. Loosing weight rapidly, like in my teens; I hate milk, eggs and bread. Not surprised I'm now allergic to gluten and lactose, not to eggs. But I feel sick if I have eggs. Maybe I was allergic to all these since I was born. I refused mother's milk after a month. I was fed with milk replacement.