eating disorders origin?

[Chrismander]

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hi all--i'm a 3rd year med student, more interested in neurology than psych, but i love your forum. one of the few on here that's active and lively. thanks to all you residents who keep the discussions going!

So here's my discussion question for y'all, partly inspired by the last post on eating disorders. Based on your clinical experience with anorexics and your knowledge of the literature, what do you feel the origin of the disease to be? One of my professors in the first 2 years (she was a practicing shrink at an eating disorders center, don't know if she was solely clinical or a research person too) told us in our lecture on eating disorders that 1) anorexics seem to genuinely have a form of body dysmorphic disorder, in which they look into a mirror and inaccurately judge their own weight, seeing fat and chubby thighs where there are none, despite their ability to accurately guess the weight of other women and 2) that their brains are somehow "immature".


Does this "primary body dysmorphic disorder" framework strike you out in the clinical world as having truth to it when you talk to anorexics and see their psychodynamics in action? or is this just a smokescreen they throw up to justify their behavior? So if an anorexic with visible ribs looks into a mirror, does she see the ribs and herself as she really looks (and then just make a value judgement that that person with visible ribs is still too fat) or does she see that image in the mirror as fatter than normal and is she just reacting to an abnormal precept?

This second point this lecturer fascinated me since i'm a neuro dude at heart, but i can't remember what she said when our class pressed her on it--but she seemed to be saying that the brain itself in some measureable way was more like a pre-adolescent's than someone of the patient's own age, but i don't know what she was talking about--white matter, sizes of various regions, cortical thickness, or what.

what's your feelings on the role of genetics in the origin in the disorder? were there anorexics before Cosmo? were the medieval monks and nuns who starved themselves carriers of the same genes modern anorexics have, who just had a social excuse to do what they wanted to do? impossible to answer, i know. 😉 but i'd love to hear your speculation.

Thanks for your 2 cents!

Chrismander

 

[PublicHealth]

Check these out:

http://www.ncbi.nlm.nih.gov/entrez/...uids=16448703&query_hl=23&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/...uids=14599241&query_hl=23&itool=pubmed_docsum

http://www.ncbi.nlm.nih.gov/entrez/...uids=16259854&query_hl=23&itool=pubmed_docsum

 

[Psyclops]

I want to preface my observations by saying taht I am not familiar with the literature on AN, nor have I had experrience with many AN clients. So if my speculations are off base (likely) I don't need to have how big an idiot I am pointed out.

This second point this lecturer fascinated me since i'm a neuro dude at heart, but i can't remember what she said when our class pressed her on it--but she seemed to be saying that the brain itself in some measureable way was more like a pre-adolescent's than someone of the patient's own age, but i don't know what she was talking about--white matter, sizes of various regions, cortical thickness, or what.

I would be very careful about assuming that the "immature" brain (if it exists) was premorbid to the onset disorder. My ignorant guess would be that if there were any grand deficits in size or development, it might in some way be due to the lack of nutrients someone with AN might have. Similar to the degeneration of cortical matter seen in an alcoholic with Korsakoffs.

what's your feelings on the role of genetics in the origin in the disorder? were there anorexics before Cosmo? were the medieval monks and nuns who starved themselves carriers of the same genes modern anorexics have, who just had a social excuse to do what they wanted to do? impossible to answer, i know. 😉 but i'd love to hear your speculation.

Again, I don't know the literature, but the fact that this disorder is not often observed outside of developing nations would make a genetic component dubious in my opinion.

 

[Poety]

PH do you ever discuss anything or just put up links? 🙄

Thanks for contributing Psy, I have nothing to contribute OP, since I have zero experience in this category 😳


Psy, they don't see Anorexia in underdeveloped countries OR is it that its not possible because of the lack of influencing factors like scales, mirrors, etc? hmmmm 😴

 

[Psyclops]

Well, that was kind of my point P-digity, it would seem to be externally influenced as opposed to internally. Putative biologically oriented MIs tend to conform to the diathesis stress model, right? Correct me if I'm off base there. But, these stressors tend to be lacks such as how there are higher rates of MI among the poor who have less access to care of various types. Or from those who have been placed under stress (PTSD, trauma, etc). But what would the stress be in AN? I'm just rambling here but could it be the stress of intense pressure to conform, succede, belong?

 

[PublicHealth]

PH do you ever discuss anything or just put up links? 🙄

The abstracts state the hypotheses well. They're not my hypotheses, so why plagiarize them in this thread? If the OP is interested in the topic, s/he can track down the articles and read them. Others may do the same. The abstracts are worth reading for a quick synopsis. Don't think there's any harm to this method. If you'd prefer, I'll copy and paste the abstracts. Sheesh! 🙄

 

[MBK2003]

From out in left field, my take on "immature brain" was more along the lines of the immature/primitive defense mechanisms and identity diffusion, which are developmentally appropriate at 13-16 but less so at 26+. Too much Kernberg and too little neurobiology I guess.

MBK2003

 

[Psyclops]

From out in left field, my take on "immature brain" was more along the lines of the immature/primitive defense mechanisms and identity diffusion, which are developmentally appropriate at 13-16 but less so at 26+. Too much Kernberg and too little neurobiology I guess.

MBK2003

Kan you eve have too much Kernberg? I suppose for this forum you kan.

 

[MBK2003]

Kan you eve have too much Kernberg? I suppose for this forum you kan.

I'm not sure anyone can have too much Kernberg. His TFP primer is the most fascinating book I've read in some time. I know I never could get away with saying some of those things to my borderlines, but it makes me smile to think that Dr. K can get away with it at least.

MBK2003

 

[Poety]

From out in left field, my take on "immature brain" was more along the lines of the immature/primitive defense mechanisms and identity diffusion, which are developmentally appropriate at 13-16 but less so at 26+. Too much Kernberg and too little neurobiology I guess.

MBK2003

Ok just one minute here - were you a psychologist or something in a previous life? OR, how about a therapist, errr psych major in undergrad? Why do I not know anything about what you're talking about 😳

 

[MBK2003]

Ok just one minute here - were you a psychologist or something in a previous life? OR, how about a therapist, errr psych major in undergrad? Why do I not know anything about what you're talking about 😳

No, actually hard core bench science until I "discovered" my true calling. I am in proximity to Dr. Otto Kernberg and his object relations theory and transference focused psychotherapy permeates our residency training. You'll get there, Poetry, be patient young grasshopper. That which they let the medical students in on is only the tip of the proverbial iceberg of psychiatry. There are many more fascinating layers beneath the DSM-IV and psychopharmacology. 🙂

MBK2003

 

[Poety]

No, actually hard core bench science until I "discovered" my true calling. I am in proximity to Dr. Otto Kernberg and his object relations theory and transference focused psychotherapy permeates our residency training. You'll get there, Poetry, be patient young grasshopper. That which they let the medical students in on is only the tip of the proverbial iceberg of psychiatry. There are many more fascinating layers beneath the DSM-IV and psychopharmacology. 🙂

MBK2003

Thanks MBK, thats encouraging 🙂

 

[Doc Samson]

Thanks MBK, thats encouraging 🙂

You should learn about Kernberg in residency Poety.

I just posted a (very) basic version of my thoughts on the etiology of AN on the other thread, but ultimately it's about control of self and others.

 

[Poety]

You should learn about Kernberg in residency Poety.

I just posted a (very) basic version of my thoughts on the etiology of AN on the other thread, but ultimately it's about control of self and others.

I just looked him up and talked to Psy about him - apparently hes the new Freud, I better learn about him 🙂 THere are a lot of books I'm going to get so I can expand my knowledge base - I'm getting a excited to start! I really hope I get great training

 

[PublicHealth]

I just looked him up and talked to Psy about him - apparently hes the new Freud, I better learn about him 🙂 THere are a lot of books I'm going to get so I can expand my knowledge base - I'm getting a excited to start! I really hope I get great training

Ah, why bother learning about psychotherapy? I thought you just wanted to push drugs, Poety. What happened? Are you getting soft on us? 🙄

 

[Poety]

Ah, why bother learning about psychotherapy? I thought you just wanted to push drugs, Poety. What happened? Are you getting soft on us? 🙄

I'll never be soft on you you link freak 😱 😎 😳

 

[PublicHealth]

I'll never be soft on you you link freak 😱 😎 😳

It's called literature. And it's the reason you do what you do clinically.

 

[Doc Samson]

It's called literature. And it's the reason you do what you do clinically.

Not really... the "evidence base" of psychiatry is really quite abysmal, even the best studies are inherently flawed because what we're treating/measuring is so nebulous. "anecdotal" clinical experience (especially when those anecdotes repeat themselves again and again over decades) is much more the reason we do what we do clinically.

 

[PublicHealth]

Not really... the "evidence base" of psychiatry is really quite abysmal, even the best studies are inherently flawed because what we're treating/measuring is so nebulous. "anecdotal" clinical experience (especially when those anecdotes repeat themselves again and again over decades) is much more the reason we do what we do clinically.

Hinging an entire medical specialty on anecdotes has not really served psychiatry well: http://www.ncbi.nlm.nih.gov/entrez/..._uids=16677777&query_hl=2&itool=pubmed_docsum

 

[Doc Samson]

Hinging an entire medical specialty on anecdotes has not really served psychiatry well: http://www.ncbi.nlm.nih.gov/entrez/..._uids=16677777&query_hl=2&itool=pubmed_docsum

That link seems to support my statement. I'm confused about the point you're trying to make.

 

[Psyclops]

I disagree with your introduction to that article PH. That article is an indictment of the current trends in psychiatric research, which I agree are abysmal. When asked, many clinicians (I seem to recall the intrepid sazi even) agree that the DSM is of limited clinical utility. Trends in psychological research, especially large epidemiological studies, show that empirical evidence supports a dimensional or factor system of psychopathology. The APAs are responding to this and moving forward. As for the clinical trials of psychopharmacueticals, well, what can I say, it's a dirty business. I think that's the case regardless of medical specialty.

 

[Psyclops]

That link seems to support my statement. I'm confused about the point you're trying to make.

I agree it doesn't refute your statement DS, but I do think that these things can be measured.

 

[Doc Samson]

I agree it doesn't refute your statement DS, but I do think that these things can be measured.

Can be measured? Sure. Currently being measured to any reliable degree in any of the studies that "evidence" based psychiatry hangs its hat on? Not so much.

For now, I still trust my own clinical experience (brief though it is) and the recommendations of my supervisors (with decades of practice under their belts), before I buy into the ersatz picture of treating psychopathology provided by research.

BTW, thanks for that link though... a hard copy of that article is being printed as we speak.

 

[PublicHealth]

BTW, thanks for that link though... a hard copy of that article is being printed as we speak.

De nada. 😉

 

[Poety]

Can be measured? Sure. Currently being measured to any reliable degree in any of the studies that "evidence" based psychiatry hangs its hat on? Not so much.

For now, I still trust my own clinical experience (brief though it is) and the recommendations of my supervisors (with decades of practice under their belts), before I buy into the ersatz picture of treating psychopathology provided by research.

BTW, thanks for that link though... a hard copy of that article is being printed as we speak.

AMEN BROTHER!!! And with my 8+ years psych experience, and med training, I can only HOPE that people like PH start to get what EXPERIENCE is really worth. Its SOOOOO not about just STUDIES which are dubious anyway, especially in psychiatry - its all about intuition (which can actually be argued in our specialty ie being a better predictor than STUDIES)

PH I'm sure you'll learn this lesson soon enough and see why people are a bit more reserved about your links - but in psych, a lot is to be said for gut feelings. All your research is fine and whatever, but the best psychs I know work on following instinct, not text.

 

[Poety]

That link seems to support my statement. I'm confused about the point you're trying to make.

He's link obsessed, he's going to need an intervention soon 😡

 

[Doc Samson]

He's link obsessed, he's going to need an intervention soon 😡

Link

 

[Chrismander]

thanks to everyone who posted their replies to my thread, whether from clinical experience/intuition to pubmed links. all very interesting and thought provoking, and why this forum is so much fun to read--almost enough to make me wanna head into shrinkdom. 😀

Mind if i tack on a follow up question? For those of you (i think it was doc samson, i'd have to take a look though) who were posting based on clincial experience with anorexics and who felt strongly that anorexia is about psychodynamic issues like control vs. primary metabolic/brain abnormalities, do you feel that body dysmorphic disorder falls into a similar category? Does a guy who's obsessed with his muscles to the point of using steroids or lifting until his body is grotesque have similar psychodynamics to an anorexic when you're up close and personal, or is the smiliarity only apparent at a distance?

 

[Demosthenes]

I would be very careful about assuming that the "immature" brain (if it exists) was premorbid to the onset disorder. My ignorant guess would be that if there were any grand deficits in size or development, it might in some way be due to the lack of nutrients someone with AN might have. Similar to the degeneration of cortical matter seen in an alcoholic with Korsakoffs.

I'd have to agree. The Minnesota study showed so many of the classic symptoms of AN that it's hard to know how much of the symptomology is related to the psychiatric illness, and how much is simply the physical effects of starvation. On the other hand, the question of how much really is premorbid sure is interesting, huh?

Again, I don't know the literature, but the fact that this disorder is not often observed outside of developing nations would make a genetic component dubious in my opinion.

Except there are some retrospective studies from, I think it was Fiji? Wherever it was, the retrospective studies, based on symptomology rather than diagnosis, found about .8% of the population showed up in psychiatric wards with AN symptomology. They may not have used the name, but long before television hit their island, they had women who starved themselves. I can't remember who did the study, but I think it was in Acta Psychiatr Scand? Maybe two years ago?

My own thought, though, is that the environmental factors that trigger AN in susceptible individuals are absent in the non-developed nations. And I am firmly convinced that without a genetic susceptibility, there will not be AN. There'll be other MI, perhaps, but it will take a different form than AN.

Mind if i tack on a follow up question? For those of you (i think it was doc samson, i'd have to take a look though) who were posting based on clincial experience with anorexics and who felt strongly that anorexia is about psychodynamic issues like control vs. primary metabolic/brain abnormalities, do you feel that body dysmorphic disorder falls into a similar category? Does a guy who's obsessed with his muscles to the point of using steroids or lifting until his body is grotesque have similar psychodynamics to an anorexic when you're up close and personal, or is the smiliarity only apparent at a distance?

I feel very strongly that AN is not simply psychodynamics. While I've heard some AN say that it's about control, there's not a lot of buy in from them when they say it. Much more as though they've been taught that that's what caused it. I am a geek, though, and do believe that we don't give enough credit to mammalian biology when we're talking about MI in general. Maybe I'm wrong, maybe it is just psychodynamic, but I don't think so.

For whatever it's worth, I have a long history of AN and have never felt that it was about control, per se. In my case, I wasn't diagnosed until long into adulthood, so my lack of eating certainly didn't give me any control over the people around me -- they never even noticed, as far as I know. Restrictive eating did "control" my emotions, in a sense, but only because it did seem to reduce anxiety, to focus my mind, to focus my energies.

And it's also too simplistic to say that people with EDs don't know what they look like. Is it BDD? Probably not. The two have similarities, but they don't look too much the same close up -- depending on how you're looking. There have been some studies that show something akin to depressive realism in AN: people with AN have a much more accurate view of their physical appearance than the average member of the control groups. (Watch some mirror exercises sometimes -- it can be hard to watch someone try to reconcile their feeling "fat" with the reality that they are too thin. And many, many of them do know that they are too thin. They may not be able to express it, but many of them do know.)

I can't address teh question of men who lift, because that's not a population I have much experience with. I've known one or two, who seemed to have lost sight of reality on that one topic. But I don't think it was as visceral a need for them as for most women with EDs that I've come across.

Ah, maybe there's nothing in there. Maybe I'm entirely wrong about all of this. I will say, though, that my own experience looking for treatment was pretty appalling -- there just aren't a lot of people with much talent for treating EDs. The stories I've heard from the women in my groups have been pretty terrible, too. In fact, in a couple of cases, the treatment these women have received has made them much worse -- I've even suggested a couple of them file reports with the licensing boards. Part of the problem seems to be a one size fits all approach, that all EDs are caused by the same thing; that all EDs will respond to CBT/DBT and if they don't, it's the pt's fault; etc.

 

[Doc Samson]

Restrictive eating did "control" my emotions, in a sense, but only because it did seem to reduce anxiety, to focus my mind, to focus my energies.

That's one heck of an "only."

 

[Doc Samson]

thanks to everyone who posted their replies to my thread, whether from clinical experience/intuition to pubmed links. all very interesting and thought provoking, and why this forum is so much fun to read--almost enough to make me wanna head into shrinkdom. 😀

Mind if i tack on a follow up question? For those of you (i think it was doc samson, i'd have to take a look though) who were posting based on clincial experience with anorexics and who felt strongly that anorexia is about psychodynamic issues like control vs. primary metabolic/brain abnormalities, do you feel that body dysmorphic disorder falls into a similar category? Does a guy who's obsessed with his muscles to the point of using steroids or lifting until his body is grotesque have similar psychodynamics to an anorexic when you're up close and personal, or is the smiliarity only apparent at a distance?

Control can be an issue in BDD, but mostly as a secondary process. BDD is about displacement. Anxiety/anger/depression about whatever is displaced onto body part X which seems significantly easier to think about/change than the outside world.

 

[PublicHealth]

AMEN BROTHER!!! And with my 8+ years psych experience, and med training, I can only HOPE that people like PH start to get what EXPERIENCE is really worth. Its SOOOOO not about just STUDIES which are dubious anyway, especially in psychiatry - its all about intuition (which can actually be argued in our specialty ie being a better predictor than STUDIES)

PH I'm sure you'll learn this lesson soon enough and see why people are a bit more reserved about your links - but in psych, a lot is to be said for gut feelings. All your research is fine and whatever, but the best psychs I know work on following instinct, not text.

If it's all about intuition and experience, then why go to medical school where you learn from text? I understand that one must be sensitive to efficacy vs. effectiveness, but you cannot discount protocol, standards of practice, etc.

 

[Psyclops]

My own thought, though, is that the environmental factors that trigger AN in susceptible individuals are absent in the non-developed nations. And I am firmly convinced that without a genetic susceptibility, there will not be AN. There'll be other MI, perhaps, but it will take a different form than AN.

I feel very strongly that AN is not simply psychodynamics. While I've heard some AN say that it's about control, there's not a lot of buy in from them when they say it. Much more as though they've been taught that that's what caused it. I am a geek, though, and do believe that we don't give enough credit to mammalian biology when we're talking about MI in general. Maybe I'm wrong, maybe it is just psychodynamic, but I don't think so.

For whatever it's worth, I have a long history of AN and have never felt that it was about control, per se. In my case, I wasn't diagnosed until long into adulthood, so my lack of eating certainly didn't give me any control over the people around me -- they never even noticed, as far as I know. Restrictive eating did "control" my emotions, in a sense, but only because it did seem to reduce anxiety, to focus my mind, to focus my energies.

Ah, maybe there's nothing in there. Maybe I'm entirely wrong about all of this. I will say, though, that my own experience looking for treatment was pretty appalling -- there just aren't a lot of people with much talent for treating EDs. The stories I've heard from the women in my groups have been pretty terrible, too. In fact, in a couple of cases, the treatment these women have received has made them much worse -- I've even suggested a couple of them file reports with the licensing boards. Part of the problem seems to be a one size fits all approach, that all EDs are caused by the same thing; that all EDs will respond to CBT/DBT and if they don't, it's the pt's fault; etc.

I want to be cautios in my responses Demos, seeing as you have experienced AN, so please don't take anything as offensive as it is not intended to be.

But I agree with DSs comments about the italysized material. Maybe you could illustrate how that owuld be considred control. Including the part abou them not noticing - would they have noticed had you not engaged in X, Y & Z?

Also, I find the comments about biology bases and the fact that people whould be treated individually somewhat disinchronous (I can't spell), or maybe that's only in light of PHs comments about SOCs. Currently as a student, I am trying to reconcile the idiographic and nomothetic approaches in my own understanding of disorders and treatment, it's something I give alot of thought to. Anyone else have any thoughts on this?

Additionally, if you are correct, and that there is an underlying genetic diathesis, and only with the stressors of a developed nation does it manifest istself as AN, what would it manifest itself as in other cultures? I would imagine that it would be highly comorbid with such a disorder even here in the US, but I don't know the AN literature, do you know? And if so, one would imagine that it would resopnd to similar treatmetns, right? I'm oeversimplifying I know but somethng to think about

 

[Demosthenes]

I want to be cautios in my responses Demos, seeing as you have experienced AN, so please don't take anything as offensive as it is not intended to be.

Hey, I've only experienced it and read about it and run groups for it -- which truly does not make me much of an expert. And I'm still curious about it all, including why it still comes back periodically for me, no matter what treatment I've received, how hard I've worked, and how successful those treatments have seemed. As away, and if I'm offended, I'll just tell you. Sound fair? (Trust me -- if I'm offended, I'll get over it. And you haven't come close to offending me so far.)

Additionally, if you are correct, and that there is an underlying genetic diathesis, and only with the stressors of a developed nation does it manifest istself as AN, what would it manifest itself as in other cultures? And if so, one would imagine that it would resopnd to similar treatmetns, right?

My own thinking, frankly, is that AN is not expressed in developing nations solely because there is not the leisure for it to be. As long as energies are mainly directed towards survival, I don't believe AN will be expressed. Similarly, I wouldn't expect to see quite as much depression or anxiety in developing nations, for similar reasons. ('Though I haven't read up on the stats there, so maybe I'm completely wrong, as well as completely ignorant.)

I've read a few things written by people who came to America after growing up in places like Viet Nam, Cambodia, etc, who were shocked by AN and BN when they were exposed to them. All said similar things, largely that it seemed sinful to reject the adequate food supplies, and that growing up starving innoculated them against it. My guess is that that, combined with having a productive focus for energy, protects against AN in many developing nations. Just having something to do, truly, might make a world of difference.

Then again, I'm a biogeek, and I guess some sort of evolutionary psychodynamicist...

 

[Demosthenes]

And I'm still curious about it all, including why it still comes back periodically for me, no matter what treatment I've received, how hard I've worked, and how successful those treatments have seemed.

One reason I'm so convinced there's some biological element to AN has to do with my own recurrences. One happened when there were no real stresses in my life, things were going very well, but I got sick -- mononucleosis, which is pretty debilitating for an adult. (I was in my 30s, my stepson was sick for a day, I was in the hospital for nearly a week. Advice: don't get childhood illnesses after the age of 12.) My weight dropped, and despite all the good things in my life at the time, I proceeded to starve myself again. It truly seems as though AN kicks in as soon as my weight drops below a specific point, no matter what's happening in my life. Similarly, when my weight is over another point, I have no symptoms of AN.

An n of one is meaningless, but it's hard for me to say that there's nothing to it, since it's my own experience I'm looking at.

 

[Psyclops]

Mononucleosis = stressor in my book. Although, I'm sure there are some biological correlates of the disorder, I'm not sure what weight to give to it.

 

[Poety]

Link

I can't access it, was it a sexy picture of you?

 

[Poety]

If it's all about intuition and experience, then why go to medical school where you learn from text? I understand that one must be sensitive to efficacy vs. effectiveness, but you cannot discount protocol, standards of practice, etc.

Ofcourse you can't but here again, you're thinking in absolutes. Perhaps you should think about surgery as a specialty - since there really are no absolutes in psych (or medicine for that matter)