Bringing the Magic of the Mind to Treatment of Eating Disorders
The International Association of Eating Disorders Professionals (iaedp) 2018 Symposium, held in Orlando from March 22-25, began with multiple sessions on the many advances in neuroscience of the mind and, fittingly, ended by pairing the new with a time-honored approach, using hope in therapy. Nearly 900 eating disorders professionals from the US and abroad attended.
The Symposium’s theme, “Focus on Neuroscience: Magic of the Mind, Language of the Body,” was reflected in courses, sessions, and plenaries that examined ways that advances in brain and genetic technology are improving the detection and outcome of eating disorders. In seminars, comprehensive training sessions, and keynote speeches attendees also heard new and time-honored applications of therapy. Other sessions addressed some of the most difficult parts of therapy, such as how to break bad news to parents and how to deal with acute food refusal.
Plenaries: Spotlight on practical and technological treatment
At a special plenary session, six leading eating disorders specialists addressed “Making Sense of the Complex Eating Disorder.” Dr. Ovidio Bermudez, Senior Medical Director of Childhood and Adolescent Services and Chief Education Officer at the Eating Recovery Center, Denver, served as moderator. Dr. Bermudez was awarded the iaedp Foundation Lifetime Achievement Award at the conference.
The Challenging Task of Defining Recovery
“Recovery” does happen, it is really messy, and is still largely misunderstood, Dr. Beth Harman McGilley told the audience. While we have quantitative definitions of recovery and outcomes supply extensive data, the data often overlook the nuances involved, she said. For example, some groups of patients are not included. Thus, an analysis of the AN literature suggests that everyone recovers from anorexia and that no one recovers from anorexia, she said. Adding to the problem of are major differences in the definitions and criteria found in different versions of the DSM-III through DSM-5. Study lengths can vary widely as well, from as little as 6 weeks to 20 years.
Recovery from an ED also has familial, psychosocial and spiritual underpinnings, she said. Dr. McGilley pointed out that there is a “diversity deficiency,” and praised the work of researchers such as Dr. Cynthia Bulik, whose work reflects that EDs can affect people of all genders, races, ages, body shapes, sexual orientations, and socioeconomic groups.
Dr. McGilley noted that treatment is often a labor of love, and urged the audience to “keep the lights on” for patients’ recovery. In a 22-year follow-up study of women with AN or BN conducted by Dr. Kamryn T. Eddy and colleagues, two-thirds of the women had recovered by the end of the study (J Clin Psychiatry. 2017; 78:184). Eddy and colleagues’ study also reinforced the idea that recovery continues over the long term; approximately half of those with AN who had not recovered at the 9-year follow-up point progressed to recovery at 22 years.
Dr. McGilley also challenged clinicians to actively seek social justice, for example, not remaining silent about weight stigma found in treatment centers. Finally, she said recovery is a misnomer. Instead, she added, what is really being described is inspiration transference; that is, the boundaries of the body no longer define where the self begins and ends.
Eating Disorders at Midlife
Dr. Margo Maine told the audience that eating disorders are major public health problems for women at midlife and beyond. In a recent study in the United Kingdom, for example, while 12.4% of women at midlife had breast cancer, a larger number, 15.3%, had an eating disorder. Of this group, only about 20% got help for their eating disorder. Dr. Maine also noted that the period from1999 to 2000 showed the greatest upsurge in admissions for EDs for women at midlife and beyond.
We are living in a globalized culture and exposure and cultural shifts are producing nearly a perfect storm for disordered eating, she said, adding that disordered eating is equally common among African American and Caucasian women in midlife.
Dr. Maine said that our species need to know the relationship between the pain of an eating disorder and what is causing the pain. She said that therapists have to help patients understand what is causing their pain. “We need to think more about relationships and spirituality,” she added, pointing out that neuroscience says the human brain is hard-wired but it also says that the psychic need is as real as the physical need. She also reminded the audience members that patients at midlife suffer as much as younger patients do, with menopausal symptoms and muscle aches, for example. Older patients also often have a degree of shame about their eating disorder and don’t want their children to know about their eating disorder. They also must face natural aging and the overall loss of power. Underweight women die earlier, too, she added. The key is education, she said, which will help challenge distorted ideas.
DBS: A New Tool for Seriously Ill Patients
Dr. Craig Johnson praised developments in brain science, especially tools that can be helpful and even lifesaving for seriously ill ED patients. Deep brain stimulation (DBS), for example, “sets an example of the importance of such developments for all of us in the audience who are psychotherapists to pay attention to brain science,” he said.
Dr. Johnson first saw the effectiveness of DBS when a friend who had Parkinson’s disease underwent the procedure. The surgical implantation procedure dramatically reduced the symptoms of Parkinson’s, including tremors, and improved speech and movement. It saved the friend’s life, Dr. Johnson said. DBS, which has been approved by the US Food and Drug Administration for 20 years, now has a real application for some more seriously ill AN patients, he said. The results of a small study in China are a case in point. In the study of 4 teens with an 18-month history of AN, use of DBS led to a 65% increase in body weight. Dr. Johnson was at first shocked when he learned that the average age of the teens was 16 to 17 years, since the guidelines are that DBS be performed only in those 18 years of age or older. However, when he considered that the procedure could produce such positive results, he decided it might be worth it, he said.
Positive results were also seen from a second study of DBS among older women with AN reported by Dr. Blake Woodside and colleagues at the University of Toronto (The Lancet Psychiatry. 2017; DOI:10.1016/S2215-366 (17)30076-7). Among 16 patients with an average age of 34, and 18-year duration of illness, only 2 withdrew (13%). Average dropout rates during treatment for AN are 30% to 45%, he noted. To qualify for the study the patients also had to demonstrate a 3-year history of unsuccessful admissions for treatment. The electrodes were placed into the patients’ subcallosal cingulate, the area the center of the brain shown to have altered serotonin binding in patients with anorexia. The average body mass index (BMI) at DBS implantation was 13.83 mg/kg2 and mean BMI after 12 months was 17.34. Use of DBS was associated with significant improvement in measures of depression, symptoms of obsessive-compulsive disorder, anxiety and affect regulation. The researchers also detected significant clues in cerebral glucose metabolism in key AN-related structures at 6 and 12 months of ongoing brain stimulation. Dr. Johnson added that the patients also showed remissions of binge eating (3 of 8) and remission of purging behavior in 4 of 11, and the psychology of the illness was receding. This offers hope for patients with AN and before the disease becomes more serious. ‘Not just the behaviors but the psychology was also remitting,” he added.
DBS offers hope for severe and enduring anorexia nervosa (SEED-AN) and for patients before they become more severely ill, he said. Dr. Johnson said, “I say to my families, routinely, that from a scientific perspective, without question our best discoveries for eating disorder treatment are ahead of us and not behind us.”
Focusing on the Mind as Well as the Body
Dr. Phil Mehler said that although he has spent much of his career studying the medical issues of eating disorder patients [see article elsewhere in this issue], at the symposium he wanted to consider whether clinicians need to spend more time on the mind and a little less on the medical aspects of treatment for eating disorders.
In AN, the GI tract is key to a successful refeeding programs, he said, adding that AN patients have gastroparesis, or slowed emptying of the stomach, that is hard to explain. Perhaps the cause is more in the mind than the gut, he said. Heartburn may not improve with weight gain or with improvement in psychological scores but if these patients with AN are not purging or never have purged, how can their heartburn be explained? Long periods of malnutrition may in the end cause problems in the integrity of the gut wall and as kilocalories are increased this may cause distress.
Many questions about the new microbiome and the mind-gut axis await answers, he said, and added, “If we are not paying attention to chemicals affecting the brain we are missing the boat.” The first scientific article, published in 1996, suggested that alterations in the microbiome are increasingly associated with diseases such as Crohn’s and celiac disease, as well as irritable bowel syndrome, and with cognitive sensations and pain. Patients with these illnesses have a higher perception of pain. The sense of satiation, and levels of the gut hormone glucagon-like peptitide 1 (GLP-1)peak 20 minutes after finishing eating, but satiety factors do not peak until 2 hours later, leaving patients to wonder whether they are full or not. Esophageal symptoms also do not correlate with manometric tests, he said.
Dr. Mehler noted there is not only an intricate interplay between true organic gut pathology and real alterations affected by the even bigger effects of the mind on the gut. He called for a thoughtful approach to testing and avoiding unnecessary and “overly enthusiastic workups,” which can be costly and ineffective in the long run. While the field is just evolving and there is much to learn, he cautioned that there is a dangerous proclivity among under informed and unseasoned care providers to injudiciously test patients and to use fancy terms and to use new, costly and ineffective medications. Instead, he called for taking time, listening respectfully to patients and providing respectful care, including using less unnecessary testing and medication. He said, “Sustained recovery is a reality, and we need to be more circumspect as we explore the mind-gut axis. Less is indeed more” he said.
Growing Knowledge, Changing Therapy
As Dr. Kronberg summed up the panel’s comments, she said there are many more questions than answers in treatment and recovery of clients with complex eating disorders. Dr. Kronberg related that 30 years ago she was an anomaly as a nutritionist who wanted to learn more about the field of eating disorders. The emphasis then was on the psychosocial and physiologic aspects of treatment, including getting enough but not too many calories, and living with the cultural influence of emphasis on body weight. Now the science is much more complicated, including new information on different parts of the brain being stimulated, neurotransmitters, and conductivity, she said. In addition, genetic influences on disease, how the GI tract works, and pleasure seeking, are just a few of the elements now involved in treatment.
Dr. Kronberg said she likes to use a mountain metaphor with clients, believing that metaphors and pictures might help patients better understand their eating disorders. The mountain metaphor is a way of coping and taking care of yourself, she added. For example, it is possible to explain to an anorexic patient that jumping off the mountain into an eating disorder might be a way to take care of herself. What creates the jump off into the ED? she asked. There are many elements, including the microbiome, the ability to get treatment, how to find help to stay on the mountain, and the physical elements that can impact the emotional side of the disorder.
Today, effective treatment involves more education and training than before, she said, and yet she added that therapy is really still in the early stages. In addition, full recovery is a messy definition, and there is no state of normality. The eating disorders have a social aspect and interpersonal aspect and a spiritual aspect, too, she said. Nutritionists have another large role in educating and training.
Dr. Kronberg also said that treatment still involves a type of bell curve. In the bell curve, most elements fall within or outside the curve. Variables that affect the percentage of clients who fall outside the normal range include genetics, GI traits, and having a compulsive or impulsive brain. We are treating the middle of the bell curve, but most eating disorders clients have problems that fall outside the curve, she said. Dr. Kronberg said that therapists need to be willing to change and to be open-minded and to appreciate the uniqueness of human potential. Referring to the 22-year follow-up study of anorexic patients, she commented that if two-thirds of patients have to wait 22 years for recovery, we know less than more. Therapists need to be open-minded to what is possible, and to understand the contributions each physical body brings to individual eating disorders, she said. Resistance perpetuates the status quo, she added. Finally, Dr. Kronberg said, we need to ask if therapists are certified and do they know what they are doing?
A Course in Brain Plasticity from Keynote Speaker Norman Doidge, MD, FRCPC
In a special 3-hour presentation, Dr. Norman Doidge, author of the best-seller, The Brain’s Way of Healing: Remarkable Discoveries and Recoveries from the Frontiers of Neuroplasticity), explained the new science of neuroplasticity, then applied principles to eating disorders. Dr. Doidge is a psychiatrist, psychoanalyst, and researcher on the faculty of Columbia University Center for Psychoanalytic Training and Research, New York City, and the University of Toronto Department of Psychiatry. His latest book, the Brain’s Way of Healing Itself, he describes natural avenues into the brain and the energy around us that can awaken the brain’s own capacity to heal itself.
According to Dr. Doidge, modern medicine began with modern science, viewed as a way to conquer nature—and the idea of conquest then gave rise to the many military metaphors used so commonly to describe treatment, such as “a battle” against disease, “the war against cancer,” and the “therapeutic armamentarium. In this view, the patient’s body is less an ally than a battlefield, and the patient is encouraged to become a helpless bystander. In contrast, the neuroplastic approach calls for the active involvement of the whole patient in his or her care. The therapist searches not just for the problem but healthy areas of the brain that may be dormant and for other existing capacities that may help recovery. Dr. Doidge views the discovery of neuroplasticity—or the thought that mental experience can change brain structure and function, as “the most important change in our understating of the brain in 400 years.”
Dr. Doidge explained the development of function in the right and left hemispheres, and noted that if trauma occurs before or around 3 years of life, sensory integration problems can arise. In the first 2 years of life, infants crave love and attachment, and gain this by eating, nutrition, nurturing, being held, gazing into their mother’s eyes. If the child feels unconsciously that for some reason his or her feelings are not reciprocated, dissociation can occur. In anorexia, a girl’s feelings dissociate from her body and are mostly processed by the right hemisphere.
To avoid development of a false self, an infant needs an age-appropriate omniscience—the true self is expressive, feels love and is loved. Dr. Doidge said that sometimes a struggling true self stays dormant and a false, superficially compliant, self appears. This persona or mask is not by itself pathological, he added. This can be a parent who confuses his feelings or is too accurate, too demanding, or actively rejects the child, or for example occurs when parents are conflicted about parenting.
Dr. Doidge said that while eating disorders behaviors and attitudes may be rigid, this does not automatically mean that brains of patients with disorders are too rigid or that they lack plasticity. He added that of being and doing, disturbances in being are more troubling than those in doing. For humans being is the primary capacity; this means having the sense it is okay to just be without having to perform. Doing too much too early can also lead to a false self, he said.
In the next issue, look for more highlights from the iaedp 2018 Symposium, including treatment of severe and enduring anorexia nervosa, breaking bad news to families; movement therapy for trauma, and nutritional approaches to EDs.