Received Wisdom: What do we Really Know About Anorexia?
Anorexia Myths takes a look at some of the known knowns, known unknowns and unknown unknowns of anorexia nervosa
It was a tweet that got me thinking about received wisdom and anorexia nervosa. These aren’t myths, in that we know for sure that they’re wrong. These are more the assumptions we all make that, if scrutinised, may not be quite as true as we thought.
On the face of it, the irksome tweet doesn’t seem particularly controversial. In fact, most people would probably read it, nod and move on. Quite right. That’s doubtless a normal, healthy response. But for some reason, this tweet got under my skin and I couldn’t get it out of my mind. For hours. In fact, I spent a whole night tossing and turning after I’d read it, thinking about what the writer had said and why the contents of that tweet just didn’t quite add up. Anyway, here it is:
…anorexia requires long term intensive treatment & is obviously not solved by eating and weight gain. Therapy is more effective when the brain is no longer in a starved state & the person wants to attend and engage in therapeutic sessions which can be extremely difficult.
It’s the word ‘obviously’ that pushed my buttons, of course. Because is it really obvious that anorexia nervosa isn’t solved by eating and weight gain? Is this an indisputable fact, or is it just something that we all assume to be true? Is there any solid evidence to back this up? This is the first piece of received wisdom that I’d like to look at:
Anorexia is not Solved by Eating and Weight Gain
There are many different treatments for anorexia nervosa, but the most successful ones, as far as I am aware, all contain three basic elements, which makes this the equation for recovery:
Weight Gain + Therapy + Time = Anorexia Recovery
What’s curious to me is that only two of those elements are truly measurable, yet it’s the third, the intangible therapy, that most seem to believe is the lead actor, the star of the show, the one that truly matters; the other elements are there merely to facilitate it.
Now, don’t get me wrong, I’m not saying that therapy doesn’t have a place in treatment, nor that it is not important in recovery for many people. There is some evidence, like this study, that patients who receive certain types of therapy do better than those who don’t receive any psychological help. But do we truly know whether the therapy’s function lies merely in keeping someone at their brain-healthy weight long enough for the physical repairs to take place, or whether it is actually altering the person’s thinking?
I’m not sure that we’ll ever know the truth of this, but I believe it is dangerous to put too much emphasis on this part of the equation because if we neglect the biological aspects of recovery, it’s probable that recovery just won’t happen.
Most clinicians now understand that weight gain needs to happen for recovery to take place, although far too many are still undershooting wildly. Time is normally the lowest rated element of the Recovery Equation, but it is no less important than weight gain. The Minnesota Starvation Experiment showed that it can take months, if not years, for the body to fully repair after starvation, and as the brain is part of the body why should it be any different? Almost all treatments support their patients for far too little time, and I believe this is one of the major reasons why relapse is so common.
Therapy, then, is important for many in supporting them while their brains are still not functioning at full capacity, in offering practical ways to address the issue of eating when eating is so difficult, and in ensuring that they maintain a weight that is healthy for them. (And this weight may well be higher than predicted by the BMI chart.) But although therapy is extremely helpful for many, it is variable, there are numerous different types, and they differ widely depending on the therapist.
The other two elements in the Recovery Equation — Weight Gain and Time — are immutable, measurable and, most importantly, essential. Because while these two elements are common to everyone who has truly recovered from anorexia nervosa, not all people who have recovered from anorexia nervosa have had therapy. Some, like eating disorders expert by experience Tabitha Farrar, have never been near a therapist’s office yet have still managed to reach full freedom from the tyranny of anorexia nervosa.
So if those two elements of the equation are essential, and the other is not always present, why do we believe that anorexia is obviously not solved by eating and weight gain? If proper, healthy (for that person) weight gain occurs and is somehow maintained for a substantial period of time, could that be enough on its own?
Given the evidence, we would perhaps be wise not to assume that the magic of talking is more important than the magic of biology.
A Malnourished Brain isn’t Capable of Rational Thought
This brings me to the second part of the tweet in question: Therapy is more effective when the brain is no longer in a starved state. Look, this is true, of course. First and foremost, you have to eat. Behaviour change and weight gain does have to occur before any meaningful changes in thinking around food and weight can take place.
But that’s the bit that intrigues me: the irrationality of anorexia nervosa is highly specific. The brain of someone with anorexia normally only struggles to think rationally about food and weight gain. In all other areas, a person with anorexia, even if physically very unwell, is normally capable of absolute rationality, even creativity.
When people have anorexia nervosa, or any kind of malnutrition, the rest of the brain’s functioning seems largely unaffected. In tests on the men in the Minnesota Starvation Experiment on intellectual function, there was no noticeable difference in the men’s intellectual abilities when they were malnourished. Many people with anorexia achieve highly in education, my daughter being a case in point. Many gain top-class degrees, write academic papers, speak eloquently on all manner of topics.
So it’s not a case of the brain being incapable of rational thought because of starvation. Yet someone who is malnourished because of anorexia struggles to think rationally about two very specific things — eating and body size — which are of course linked and just happen to be the source of the body’s current distress. Hmm…
But there’s more. What’s truly mind-blowing is that often a person with anorexia is perfectly capable of rational thought about someone else’s eating disorder. They are able to empathise with someone who is suffering from malnutrition and can identify in others that their self-starvation is a mistake that needs to be rectified. I have witnessed this in my daughter. Yet for some reason they just can’t apply the same logic and compassion to themselves. The irrationality, then, doesn’t extend to eating or body size in general. It is very specifically around someone’s own eating, someone’s own body, the very same body that is suffering from a lack of nutrition.
It seems to me very likely, then, that anorexia nervosa works as a kind of feedback loop. That the brain is giving messages about food because it is hungry, and it is hungry because of the messages it is giving about food. This gets worse and worse the more malnourished the body becomes. And so the reverse should be true. Eventually. Unfortunately, for some reason the anorexic thoughts often become louder with weight gain until you’re over the hump. Then slowly, with time, the brain is able to start thinking rationally about food again.
So, perhaps we need to reframe this idea: is it that weight gain is necessary for the brain to be able to engage in therapy, or is it that weight gain is necessary for the brain to think rationally about gaining weight?
Low Body Temperature is Just a By-product of Starvation
It is typical for someone who is malnourished to have a lower than normal core body temperature. The men in the Minnesota Starvation Experiment all complained of feeling cold as their body weight dropped. But, in treatment for anorexia, and research, the effects of a low temperature on the brain are rarely, if ever, considered.
This seems odd to me. After all, it’s accepted that people in the early stages of hypothermia, classified as a body temperature lower than 35 degrees Celsius, suffer some mental confusion, irritability and poor judgement — in other words it affects their brain. It seems to me that this 35 degree mark is a little arbitrary. Body temperature varies a fair amount from person to person and women, in general, have a higher temperature than men, so it stands to reason that some kind of hypothermic affect could be happening in the brains of some at a slightly higher temperature. What if the effects on the brain, in some people, kick in at 36 degrees, for example?
With this in mind, I can’t see the wisdom of not warming up patients with anorexia as a matter of course, whether or not they are officially suffering from hypothermia. This was never suggested to us in treatment. And it’s not something I ever thought about at the time. But looking back it seems like a very easy win. If a cold core temperature is worsening the brain symptoms, and it seems likely that it might, why not do something about that? Warming was used as part of the treatment for patients with anorexia by Sir William Gull, a physician to Queen Victoria and the man who coined the name ‘anorexia nervosa’, and it seems that he had some success. Isn’t it about time we looked at this again?
Of course, the only sustainable way to address a lowered core body temperature in anorexia is through re-nourishment. I’m not suggesting that a hot water bottle and a blanket could replace that. But if we could at least address the effects that cold may be having on the brain, perhaps some of the symptoms of anorexia might be lessened and re-nourishment might be a little easier.
Counting Calories is about Calories not Counting
It’s normally assumed that calorie counting in anorexia nervosa is all about weight loss. That the person is always just looking for the lowest possible number of calories. This fits neatly into the old idea that anorexia is just a diet gone wrong.
I don’t think it’s as straightforward as that.
Recently on Twitter I asked the question of people who have or have had anorexia in the past: is counting calories about the calories or about the counting? This question received a mixed response, but a number of people said that, for them, it was very definitely about the numbers rather than the calories.
Some people with anorexia say that the food they eat has to be a certain number of calories, or below a certain number. Some talk about numbers in terms of a timetable: they have to eat at or after a very specific time. Those with the compulsion to exercise talk about having to walk a prescribed number of steps or run a particular number of miles.
This may be caused by a similar mechanism that triggers the compulsive counting that is often experienced by people with obsessive-compulsive disorder, which we know has strong genetic links to anorexia. It might be helpful, then, to start looking at this aspect of anorexia in a slightly different way — and perhaps this could inform alternative treatments.
These are just a few examples of the received wisdom that is so prevalent in the world of anorexia nervosa and other restrictive eating disorders, but I’m sure there are many more.
It’s high time that we admitted that there are still a lot of unknowns, known or otherwise. Because using guesswork and blindly repeating ideas as though they are fact is not helpful if we are to make any progress in understanding this devastating disorder. Because making assumptions about anything about anorexia is not helping more people to get better, nor is it making treatments more effective. People are still dying of anorexia at an alarming rate. Even more are living a shadow life with the illness for decades.
So to those working in this field, and to anyone who writes about this topic, or who has a loved one with anorexia, it’s time to question the orthodoxy and think. And then think again.
Obviously.