Tuesday, October 13, 2015

The Bad Habit of Anorexia

Back in the day therapists, especially those of the Freudian persuasion, assumed that anorexia was the product of an unresolved developmental conflict. They believed, because their theory told them so, that anorexia represented a fixation at the oral stage of development. Perhaps these patients had been starved for nourishment when they were infants. Perhaps they were overnourished. Perhaps they were weaned incorrectly and were trying to master their anguish by willfully choosing not to eat.

It sounded great on paper, but it failed to produce good clinical results. It produced no clinical results at all. Thus, therapists moved on to other treatments.

Where psychoanalytically influenced therapy assumed that symptoms were expressions of unresolved mental conflicts, cognitive and behavioral therapists believed that symptoms were bad habits. Those who took their cues from Aristotle asserted that the best way to treat bad habits was to replace them with good habits.

I had assumed that this was established within the field. Apparently, not as well as I had thought. Now, researchers have announced that anorexia has nothing to do with willpower, but is really a bad habit. A summary article appears in the New York Times.  I am not sure who thought that the problem was willpower, but I am happy to see that the research has gotten to a more solid theoretical ground. If I had to guess I imagine that therapists who believe that their work on the mind could teach patients how to control their impulse to starve themselves were calling it a question of willpower.

The new research explains that once anorexics develop the habit of eating low calorie and diet foods, to say nothing of not eating at all, they keep doing it without thinking about what they are doing. They do it automatically, even if they have pledged to stop doing it, even if they really, really want to stop doing it.

This ought not to be very surprising. Addictions like alcoholism and drug abuse have long been considered to be bad habits. When alcoholics are treated by 12 Step programs they learn to replace bad habits with good habits. That means, instead of going to the local bar they go to an AA meeting.

Beyond being a bad habit, alcoholism involves behaviors. The alcoholic might belong to a social scene where others drink. He organizes his time to ensure that he can participate in the scene. If he drinks alone at home, he will work to hide his drinking from others. The genius of 12 step programs is that it attacks the behaviors that constitute the illness and does not just limit itself to self-discipline. In fact, it begins by saying that willpower is for nothing in the fight against alcoholism. It even suggests that the intervention of a higher power is required. Unless a therapist can figure out how to break down the different behaviors that constitute the habit, he will not be very successful treating alcoholism.

And now that we have learned that alcohol produces feelings that are akin to empathy, the problem will be more difficult to treat in a culture that has mistakenly made empathy into the psychotropic medication of choice.

Of course, you can live without alcohol or gambling or many kinds of illicit drugs. You cannot live without food. Thus, anorexia is a special kind of addiction.

Many clinics today use a modified version of the approach developed by the England’s Maudsley Hospital. They force anorexics to eat, often large quantities of food. By definition, the treatment modality assumes that these patients do not have the willpower to choose to eat the right foods. Thus, they are fed, whether they like it or not.

I would add, for my part, and without pretending to possess anything like knowledge about the matter, that anorexia must also compromise the body’s biochemistry, the digestive system, metabolism,the way that the digestive system sends to the brain, and perhaps even the structure of the brain and its ability to process information.

Without knowing how chronic malnourishment affects those aspects we will still have a great deal of difficulty understanding the illness.

It is also true that the habit of anorexia is sustained and supported by cultural cues, by the media and by friends and family. In a culture that obsesses over eating disorders the anorexic will find herself the center of a great deal of attention and worry. She might even find the illness empowering. In a culture that bombards people with messages about weight loss, diet foods, calorie counts, the virtue of thinness… the anorexic will find her choices affirmed. Obviously there are websites encouraging anorexia; women who become skeletal do receive reinforcement from fellow sufferers who will stop them on the street to tell them how good they look.

The Times explains the problem that therapists face:

In the case of anorexia, therapists often feel helpless to interrupt the relentless dieting that anorexic patients pursue. Even when patients say they want to recover, they often continue to eat only low-fat, low-calorie foods.

Therein lies the problem. Whatever techniques therapists have do not seem to work. When these patients are allowed to choose what they will or will not eat, they will choose salad and turkey breast. If we assume that they do not lack the will to recover, they must lack the good habits that constitute good health.

If this is the case, as sad as it is to say, treatment should limit the anorexic’s ability to choose what she will or will not eat. She should eat at a dinner table where everyone eats what he or she is served. To some this will sound quaint.  To others it will be commonplace.

How many children today sit down to family dinners where they are obliged to eat what they are served? How many of them—called picky eaters-- are allowed to choose what they will or will not eat? How many of them request special orders? How many of them eat alone, from a take-out menu?

Treating anorexia means creating a social context in which people sit down together to eat dinner (or breakfast or lunch) and feel obligated to eat what everyone else is eating. Hopefully, the dinner table will be a place where people eat a balanced diet, in moderation.

If anorexia is so hard to treat, that is, if the habit of anorexia is hard to break, the reason must lie in the media discussions of eating disorders, the media obsession with diet and weight-loss, and the culture’s failure to foster stable families that have healthy social eating rituals.


Ares Olympus said...

I don't know anyone (to my knowledge) who has officially been diagnosed with anorexia, although such things may not be public knowledge. I have known people who are extremely skinny, and I've observed that many such people will eat minimally in public settings.

Stuart's suggestion "Treating anorexia means creating a social context in which people sit down together to eat ... and feel obligated to eat what everyone else is eating" seems problematic at least a majority of social meals would seem to be like restaurants where everyone can order different food.

Also perhaps coming from the "clean your plate" parental advice, it surprises me how many people will leave a good fraction of their plate uneaten, and a good fraction of those don't even bother taking home left-overs.

So anyway, its hard to believe that socialization can make people eat, and in fact the reverse may be true. People who like to talk will end up eating much less in social setting, again just leaving a plate full of uneaten food. I don't see adults being guilted by disapproving eyes into eating everything on their plates.

On the article it suggests:
NYT: For example, he said, one strategy might be to get the patient to look at entrees as well as at the salad bar, or to switch to eating with the left hand, as a reminder to think about eating different foods.

The left-hand suggestion is interesting, even if seemingly slower, but worth trying if we really believe its about habit rather than intention. That is to say, if "recovering anorexics" really say they want to eat more.

I recall a primary lesson I learned from ballroom dancing - doing new things is hard, and it takes time to get used to them, so you should keep trying something for a certain number of weeks (with periods of intentioned focus, and breaks where you don't think about it at all), and not prejudge failure just because it doesn't feel natural at first. So the reason knowing this helps is because it seems like a drag to imagine you'll always have to focus uncomfortably to act differently, but that's a false assumption.

Finally, we can't discount the compulsive exercise part of the anorexia. Maybe that's the easier part, since you don't need to exercise. In the running world, for example, there's the idea of "streaking", i.e. running every day, and they'll proudly tell you they've run every day for over 7 years or whatever. So that seemed unhealthy to me, and irrational, especially when they'll still run through injuries.

So that compulusion seems similar to the anorexia. I can't guess if this "dorsal striatum" is also related there.

Overall I still can't discount that it is important to identify a source for compulsion, something perhaps hidden by the habit, but still there when a bad habit is broken. Its like addicts who give up one addiction, and just get pulled into a different one. Patterns like that would suggest an underlying cause.

Ares Olympus said...

For reference, here's an article on question on how long it takes to form a new habit, with a "new" study that says 66 days were needed on average.

So I guess that means when we set our new year's resolutions, we might vow to keep them for 90 days and then allow ourselves the option to reassess, with the habitual behavior on our side.

And Stuart's advice is also helpful here - if you're going to compel yourself to a good habit, ideally you should find a group of people who want to learn the same good habit. It doesn't help if you have to guilt your family into communal meals which they believe don't want to do, although if you promise they can reassess after 3 months, perhaps they'll join your experiment?

These experiences prompted Maltz to think about his own adjustment period to changes and new behaviors, and he noticed that it also took himself about 21 days to form a new habit. Maltz wrote about these experiences and said, "These, and many other commonly observed phenomena tend to show that it requires a minimum of about 21 days for an old mental image to dissolve and a new one to jell."

Phillippa Lally is a health psychology researcher at University College London. In a study published in the European Journal of Social Psychology, Lally and her research team decided to figure out just how long it actually takes to form a habit.

The study examined the habits of 96 people over a 12-week period. Each person chose one new habit for the 12 weeks and reported each day on whether or not they did the behavior and how automatic the behavior felt.

On average, it takes more than two months before a new behavior becomes automatic -- 66 days to be exact. And how long it takes a new habit to form can vary widely depending on the behavior, the person, and the circumstances. In Lally's study, it took anywhere from 18 days to 254 days for people to form a new habit.

In other words, if you want to set your expectations appropriately, the truth is that it will probably take you anywhere from two months to eight months to build a new behavior into your life -- not 21 days.

Anonymous said...

I learned about anorexia in 1983 when it killed Karen Carpenter at 32. Shortly before she died, Petula Clark told her, "Girl, I don't know what the hell you're doing. But Stop It!"

Apparently it was news to her doctor(s) as well. And everybody else, including her family.

Heavens, what an angel voice. A music producer said, "People say The Carpenters are corny and crummy and intelligent folks don't listen to them. But the records fly off the shelves. I've seen them in homes where people say it!" -- Rich Lara

Margaretta Cloutier said...

If anorexia is a habit, then it needs to be broken like any other habit or addition. Supportive approaches to healthy eating, along with supportive coaches, can help. Just like alcoholics have a buddy to call when they think they are going to take a drink, anorexics should have a buddy when they think they should not eat. In addition, customized education about anorexia and its effects could also be helpful.

Margaretta Cloutier @ Aspire Wellness Center