Treating eating disorders: Findings from the latest brain function research

Contents

• What is an eating disorder?
  • Anorexia nervosa
  • Bulimia nervosa
  • EDNOS (Eating Disorders Not Otherwise Specified)
• What causes an eating disorder?
  • The two pathways for processing emotions
  • Why one pathway rather than the other?
• Who gets an eating disorder?
• How brains develop
  • The adolescent brain
• How to open up the symbolic pathway and reduce the use of the body pathway
• A new treatment - Internal Language Enhancement

What is an eating disorder?

Three categories of eating disorder have been described and these are anorexia nervosa, bulimia nervosa and a catch-all category called EDNOS, or eating disorder not otherwise specified.

Anorexia nervosa

Anorexia is the deliberate maintenance of an abnormally low weight (15% below the expected weight), the loss of three menstrual cycles when they should have occurred, and over-concern about weight and shape which becomes central to how a person views themselves. Some sufferers binge, vomit and use laxatives and some just restrict their intake of food. The average length of an episode of anorexia is six years.

Bulimia nervosa

Bulimia is the maintenance of normal weight but with recurrent episodes of binge eating, self-induced vomiting, misuse of laxatives or diuretics, excessive exercising and extreme dieting or fasting along with an over-concern with weight and shape.

EDNOS (eating disorder not otherwise specified)

EDNOS makes up 80% of eating disorders and include binge eating disorder (BED), which covers uncontrollable episodes of binge eating without purging. Usually over-concern with weight and shape is present but generally none of the symptoms reach the criteria for a diagnosis of anorexia or bulimia. 

What causes an eating disorder?

You might think that an eating disorder has something to do with food or at least body shape but this is not the case. Whilst western societies certainly admire thinness, the people who starve themselves into emaciation, are not striving to be models but are trying to rid themselves of something “horrible” that they locate in their bodies rather than in their emotions. Research that has been carried out into how the brain deals with emotions suggests that the thinking about calories and shape of the body that is typical of eating disorders occurs as a result of changes in the brain pathways that we use for dealing with our emotions. 

The two pathways for processing emotions

We have two different pathways for dealing with our emotions: the ‘thinking’ pathway and the ‘action’ pathway.  What normally happens is that when we experience an event that provokes an emotional reaction, the brain decides whether it is something we have the luxury to take our time to think about. If the brain decides that the situation is life-threatening, it shuts down the thinking pathway in favour of the action pathway. The difference between these two pathways is that the thinking pathway allows access to what is called the ‘executive functions’ - we can take stock, look at potential merits and problems and imagine different solutions before taking considered action. This kind of thinking is called ‘symbolic’ thinking. The action pathway only allows for ‘concrete’ thinking where feelings are experienced in the body. The logical action, if the problem is experienced in the body, is to do something to the body to ‘get rid’ of the discomfort, which leads to the behaviours typical of eating disorders. If the problem feels like there is something horrible inside the body then the logical ‘concrete’ solution is to get it out by vomiting or starving or punishing the body in some way.

In evolutionary terms we need to be very alert to danger in the environment and our brains are wired to react to danger by either fighting or running away. This was essential for survival. However, if our brains over-react to danger and trigger action responses when not necessary, we might not survive. Alternatively, if we do not react to a danger, then we were made short work of by the nearest lion! It might be argued that the brains of eating disorder sufferers are too easily triggered to experience danger. When this happens and the ‘symbolic’ pathway is shut down ready for action, then the eating disorder patient is unable to make sense of the emotional world and their anxiety is increased, leading to more anxiety and danger signals, resulting in more triggering of the fight or flight response.

Why one pathway rather than the other?

When we are highly anxious, our brains can react as if there is danger in the environment and they will shut down that part of the brain that thinks in a symbolic way about the problem at hand (in metaphoric language - ‘I’ve got a lot on my plate this week and I cannot manage to do it all’). Instead the brain opens the pathway to action by the body and releases adrenaline, ready either to stand and fight or to run away. So if we are faced with a dangerous situation - say a snake - we cannot afford to hang around and wonder what kind of snake we are facing; we just run. To do this, our bodies are primed for action and not thought. Our thinking in this situation is concrete (‘there is too much food on my plate and I cannot put it into my stomach’). 

So rather than treatment for an eating disorder addressing either food or body obsessions, if we reverse the overuse of the ‘body’ emotional brain pathway, people with an eating disorder can return to ‘normal’ symbolic thinking about their emotions rather than ‘feeling’ their emotions in their bodies. When this happens the need to find a ‘body’ solution to an emotional problem fades.

Who gets an eating disorder?

New research tells us that, on the whole, people who go on to have an eating disorder have difficulty in putting their emotions into language. They often find difficult emotional situations and relationships quite overwhelming and become very anxious. 

When we feel very anxious, the brain shuts down our higher functions that, in normal circumstances, allow us to plan for the future (leave enough time to get to our destination), check reality (can we really get to both parties in one night on opposite sides of London?) and remember things we have learned, so that we do not keep repeating the same mistakes. However, quite a lot of boxes need to be ticked for an eating disorder to develop and it might be helpful to understand how our brains are built and develop so that we can understand where things can go awry and what we can do to put ourselves back on track. 

How brains develop

When we are first born we are completely helpless - we do not know where our arms and legs are, and we cannot see further than about 10 inches. Our cry is undifferentiated and it is up to our mothers to try to decipher what it is we are communicating. Mothers have to guess and work out what their babies need. On the whole mothers get it right more times than they get it wrong. However, if the mother is under stress (she might have been bereaved or abandoned or perhaps is mentally unwell following the birth or maybe she just feels a failure if she does not understand her baby’s cry first time or perhaps she is just very anxious), she might be unable to do this. This happens quite frequently and does not cause an eating disorder. What does happen is that the baby fits to the mother, rather than the mother to the baby. Thus, the baby’s sense of itself is a bit weakened as it waits for things to occur that are not a consequence of it seeking to communicate its needs. This might seem very subtle - and it is - but it can be the beginning of a feeling of being out of control of what happens to us and perhaps lead to an automatic response of allowing others to think about our needs rather than doing it for oneself. Such problems in this period of ‘maternal preoccupation’ can result in difficulty in bringing down our anxiety (self-soothing) and also in ‘mentalising’ (thinking about our feelings in language).

People who go on to have an eating disorder often have difficulties in other areas. There is evidence that difficulties in executive functioning (higher planning, reality functions, and memory in language) may lead to misinterpretation of other people’s body language, which in turn will affect the understanding of our own and other people’s minds.

Allowing others to think for us does not present too much of a problem when we are children, but once we hit adolescence (the age when the majority of eating disorders start to show themselves), if we cannot make emotional sense of our environment, we run into a lot of difficulties. During this important time of our lives we have to come to terms with our sexuality, choose what we want to study and what we want to become, negotiate friendships and develop a social life - quite a tall order. All this happens against a background of changes in the brain that hamper these developmental tasks.

The adolescent brain

At around two years of age the frontal lobes (where the executive functions live) pare down the connections that are needed in the brain during infancy. We no longer need these connections but they disappear randomly and result in the typical two-year-old tantrums. When we get to adolescence the same thing happens to the brain. We become monosyllabic teenagers who seemingly are unable to plan, assess risk or express our feelings in language.

Those young people who already have weakened executive functions find that once they hit adolescence they are really at a loss to understand their emotional environment. They have relied on the minds of others and have tremendous difficulty in discovering their own minds. If we do not know what we feel, it is very difficult to know who we are, or what our opinions are. It is at this point that anxiety becomes abnormally raised, shutting down the weakened emotional pathway to the planning, reality and symbolic language part of the brain and opening up the body pathway. The more we use a pathway the stronger it becomes; conversely the unused pathways weaken. 

How to open up the symbolic pathway and reduce the use of the body pathway 

Diagram of the emotional processing system of the brain  

When the brain processes emotions, it uses EITHER the pathway to the executive functions OR the one that goes back to the body. So if we make ourselves think in symbolic language about what is emotionally troubling us, we cannot also feel the problem as being in our bodies. If we identify the event that is upsetting us and think about it, we will not have the urge to eat/starve/binge/vomit etc.  

Just before feeling a ‘body’ or ‘concrete’ reaction the brain will have already assessed the environment for danger. If we look at the diagram we see something called the amygdala, which functions as a receiving station below our conscious awareness. It picks up information from both inside and outside the body, looking for danger in order that we survive. As explained above, during adolescence the ability to understand the emotional world diminishes. For some young people the emotional world becomes so anxiety-provoking that difficult mixed and negative emotions are labelled a danger signal. This makes the amygdala tell the insula (the gateway that decides which direction the information will go) that there is a danger. As a consequence the insula shuts down access to the higher functions, resulting in a lost opportunity to understand and learn from solving an emotional problem. This leaves the person in a weakened position, more prone to find emotional problems anxiety-provoking. And every time we use a pathway we strengthen it, meaning that the eating disorder will worsen. When we do not know what we think, we also weaken our sense of ourselves and so we react to the world via our bodies instead of our minds. 

A new treatment - Internal Language Enhancement

Following the logic of the neuroscience of emotional processing, if we identify and return to the trigger thought that made us go ‘body’ and think about the meaning it has to us - even if that is uncomfortable - we open up the symbolic pathway. At first it is the therapist who helps the patient identify the trigger and starts the process of thinking about the material, but the aim of the Internal Language Enhancement (ILE) treatment is to teach the method to patients so that they discover their own minds. 

ILE is a new way of treating eating disorders (the theoretical research behind it was awarded a PhD in 2010) by bringing together the well-accepted research into the neuroscience of emotional processing and applying it to eating disorders. It also utilises elements of psychoanalytic understanding and behavioural psychology to create a potentially powerful and successful short-term treatment to correct the underuse of the symbolic emotional processing pathway. The average treatment time is 20 sessions and the preliminary clinical trials indicate that this is sufficient to significantly reduce or eliminate eating disorder symptoms. Full clinical trials are in preparation in order to measure not only reduction in symptoms but the hypothesised change in neurological function. To date around 60 patients have been treated with ILE.  It was noted that initially there was a dramatic reduction in symptoms, often within the first 3 sessions, and then as the treatment progressed, a reduction to either a complete absence or occasional episodes under stress conditions.  It should be noted that patients frequently chose to continue with therapy following the initial 20 sessions as, being able to think more productively about their emotional experiences, they were keen to explore their emotional reactions. Only one patient, after an initial reduction in symptoms, returned to her previous symptoms. This patient had a severe and complex pathology, unlike other trial patients.

In the preliminary study the rate of relapse of symptoms has been very low. Rather, if the patient re-presented, it was because of a life event that might have triggered an episode or two. The symptoms then subsided as the difficulty was addressed. 

Because ILE addresses the ‘how’ of thinking rather than the ‘what’, patients have found the treatment very unthreatening and acceptable, as they go on their journey of finding out what it is that they are thinking. Because of the difficulty eating disordered patients have in making sense of their emotional world and experiencing their anxiety in their bodies, usual treatment approaches (psychodynamic or cognitive behavioural) can increase anxiety and exacerbate symptoms by either addressing the behaviour directly or offering complex emotional explanations beyond the capacity of the patient to understand.  

The major difference between ILE and standard treatments is that ILE proposes a discontinuous model of neural emotional processing (meaning that either we think symbolically OR concretely) rather than the accepted notion that we can be both symbolic AND concrete at the same time. It is suggested that by not understanding how our patients think has led to communication problems and the poor treatment results for eating disorders.

At present CBT is the ‘gold standard’ treatment for eating disorders but, by its own admission, only ‘cures’ 50% of sufferers. It is hoped that the clinical trials of ILE will offer a greater success rate.