The Myth of Recovery Through Therapy

https://opinionabouted.wordpress.com/author/amazonialove/

The underlying aim of psychological interventions in ED is to assist the person to form new patterns of behaviour, particularly normalising eating, followed by gaining a conscious awareness of the triggers and stressors that someone with ED will manage by starving – because there is a neurobiological payoff from getting into and staying in a calorie deficit/negative energy balance – ED people have a unique neurobiological response to a neuropeptide that is secreted when a person is in a calorie deficit, and that has a powerful numbing-down effect on emotional responses.

To form new behaviours, there is a physical process of neurogenesis and synaptogenesis – as in building complex physical structures, and then reinforcing these with repetition.

It is impossible to effectively build new brain structures in a catabolic state, where the body is not taking in enough energy to maintain their body weight, regain lost body weight (which has been shown by peer reviewed research to at first preferentially increase fat mass levels).

It is IMPOSSIBLE to restore the fatty tissues of the brain when the body is in a state where it must consume its own tissue to sustain life. Not from a psychological viewpoint, but from a physiological viewpoint. You cannot, CANNOT, effectively build new tissue and maintain full body function in a calorie deficit.

Catabolism means that the body consumes its own tissues in order to get the nutrients it needs in order to stay alive. The brain, being one of the fattiest organs in the body, has been shown through MRIs to lose mass when a person is starving. Until that mass can be restored, with enough energy coming in to restore all of the other catabolised organs and systems, as well as enough energy coming in to allow the body to prioritise brain function, then it is nigh impossible for someone with ED to get to a remitted state.

As well, there are a serious of critical processes in puberty and where the brain structure changes dramatically, and where new white matter, and myelin, is laid down at a great rate. This is dependent on nutrition – and actual calories. We have this great urban myth that a healthy enough diet will ensure healthy development – but unless there are enough calories coming in consistently – it physically cannot happen.

Also, there is a changeover period in late young adulthood where the functioning shifts from being processed by the amygdala to instead being processed in the prefrontal cortex. Again, this CANNOT happen if the person is in a catabolic state. It requires a surplus of calories to happen. It also requires reproductive hormones to be at specific levels in order to happen. Starvation negatively impacts the production of those hormones, and makes that impossible.

People with long term ED can be stuck in a state of perpetual puberty, and never learn to regulate their emotions or behaviour in an adult manner because that changeover has not happened. Some will be diagnosed with MH disorders as a result. There are many in the ED remission community whose MH issues dissipated, or at least greatly lessened, once their intake was high enough for a consistent period.

One reason that we have such high levels of relapse, and a terrible attrition rate with deaths in the ED community, is that the data first gathered in the only longitudinal study on starvation to date – the Minnesota Starvation Experiment – has not been assimilated into the ED recovery narrative.

Yes, it is an old study – but it is the only one of its kind. And its data are STILL being referenced by people who research in this area. There are three aspects in particular that are very relevant in ED.

1. The findings Ancel Keys presented in Chicago in the 50s, on that experiment, that the men were unable to restore their bodies back to their normal set point until their intake was at least 4,000 calories. He made the observation that until the calorie intake was high enough, nutritional elements (we call them macros) were of little to no use.

2. In the early stages of refeeding, the bodies of the men preferentially increased the ratio of fat mass to lean mass. I.E they gained fat FIRST – with some overshooting their previous weight by 100 lb. Then lean mass was increased and the fat mass was lowered – without exception, all tapered back WITHOUT lowering intake or exercising to lose weight.

3. The mental health issues that developed during the study, and these encompassed a vast range, ALL dissipated with sustained refeeding. They were understood to be a side effect of starvation. This viewpoint has been since reinforced with MANY studies on the impact of starvation in other populations.

The parent’s groups that use FBT and similar at home, or in conjunction with formal treatment have had many hundreds of children and adolescents get to remission have seen the recoveries of those children follow the trajectory of the Minnesota Experiment. And in the adult recovery community, many hundreds of people – if not thousands – in recovery have followed the same trajectory to achieve remission successfully.

Most have had psychological help of some kind. All, without exception, have been refed to the point where they overshot an original weight, and tapered back to a lower weight WITHOUT reducing intake.

The men in the Minnesota Experiment would have been considered overweight or obese today. They, if in recovery from ED now, would have likely had their intake reduced when they hit a certain weight, and would have been told to avoid obesoegenic foods. They would have been encouraged to lose weight by exercising if they hit a certain point – depending on who their recovery team were. We have generations of young people, and adults also, stuck in a state of suspended animation – all too often as a direct result of our societal narrative against weight gain, overweight and obesity. Many are stuck in a state of extremely poor MH also, because they simply are not getting the calories they need in order to restore their physical brain along with their body. And many of these are in therapy – whether as outpatients, inpatients, or in PHP. Some do therapy a few times a week. And yet their intake is all too often less than a small child’s because of absolutely rigid attitudes about weight and body size, and the fat mass/lean mass ratio in relation to recovery.

How can those people recover fully while their intake is suppressed? From a purely physiological viewpoint, taking weight bias out of the equation, and shutting down the incessant societal yapping about overweight and obesity which has pervaded the ED world and continues to poison it, they CANNOT recover fully. That is a physiological impossibility because of how catabolism works.

For those that had ED from before their teens hit, and who have never gone into full remission, there is the added issue of delayed development from the adolescent brain to the adult brain. And that all too often manifests as MH problems – some of which dissipate after a sustained period of refeeding. Not all, with comorbids being possible. But there are many many who end up with an MH diagnosis (or diagnoses) without ever being given the chance to refeed at a high enough intake for a long enough period of time.

I am sure we all know the stories of many of these. The ones who move from admission to admission, to this therapist and that clinic, and on and on. The ones who take meds on a list as long as your arm; the ones who end up in restraints and on an NG tube for years and years. The ones I know of personally, and that is in the hundreds now, are without exception on an intake below that mentioned by Ancel Keys, and below that stipulated by clinics and clinicians who have been highly successful in getting people into remission, including Rebecca Peebles of CHoP and USCD. I see all too many of these people, subsisting, hovering on the brink of life for all too long, only allowed to reach a certain weight – for most this is a very low BMI, a BMI that only 4% of the population will be at naturally – and being trained to active suppress weight gain above that point. These are often dismissed as being beyond help, and as chronic sufferers. I call bullshit on that; and so dies current peer-reviewed practice and research.

And they have complex and varied MH issues. Do they what.

There is that old saying: The definition of insanity is doing the same thing over and over again and expecting different results. The long term chronicity of ED by now surely informs us that there is no way of “therapying” someone out of the condition. SURELY. And yet, because “this is the way we have always done it” – that is the way it keeps getting done.

And children are dying; teenagers are dying; adults are dying. The ones who don’t die live in some half life, propped up erroneous attitudes about body weight, lurching from one crisis to another. Then there are the invisible ones; the ones who will never have babies; the ones who will never hold down a career that inspires them; the ones who will never manage to have a function relationship with an S.O. The ones who will deteriorate as they get to middle age, with health issues directly relating to a sustained history of sub-clinical starvation mounting up as the years go by. Not to mention the ones who will suffer premature onset of degenerative neurobiological disorders even as their bones crumble and their heart and other major organs start to falter.

We have to change the narrative. ED is an eating disorder. People are unable to eat in a way that allows them to thrive. No amount of therapy will change that without also disallowing any form of weight suppression, or the prescription of (and it staggers me that this is even a thing) DELIBERATE WEIGHT LOSS. The Minnesota Experiment is the only study to date that informs us so profoundly about recovery from starvation. It is absolutely relevant in terms of explaining and predicting the physicality of a robust recovery. The trajectory it spells out for physical recovery from starvation MUST be more widely embraced as a model if we are to move on from the current appalling mortality rate and chronicity levels.


ASHLEY says:
November 19, 2018 at 2:32 pm
Fantastic article! I developed an ED in adolescence, was in some degree of remission for years, relapsed after a tbi. Can you share your background and\ or references?


AMAZONIALOVE says:
November 20, 2018 at 9:31 am
Hi Ashley, thanks for commenting. The original Minnesota Experiment is detailed in a fairly hefty volume, but worth the effort if you are interested: Keys, A., Brozek, J., Henshel, A., Mickelson, O., & Taylor, H.L. (1950). The biology of human starvation, (Vols. 1–2). Minneapolis, MN: University of Minnesota Press.

Keys in 1945 made the comment about “4000 calories” being necessary: “Enough food must be supplied to allow tissues destroyed during starvation to be rebuilt … our experiments have shown that in an adult man no appreciable rehabilitation can take place on a diet of 2000 calories [actually 2000 kcal (8368 kJ)] a day. The proper level is more like 4000 [4000 kcal (16,736 kJ)] daily for some months. The character of the rehabilitation diet is important also, but unless calories are abundant, then extra proteins, vitamins and minerals are of little value. 1945 ‘U’ Experiment Proves Starved People Can’t Be Taught Democracy. Minneapolis Star-Journal September 26, 1945:18.

My background is a 44 year history of ED, starting with ARFID as a young child and then moving in and out of remission and relapse through my adulthood. For the majority of my adulthood I returned time and time again to a state of sub-clinical starvation. Until I read the research of Gwyneth Olwyn of The Eating Disorder Institute https://edinstitute.org in 2013 (at the age of 52) I thought that I was a naturally “slim person”, that I had “recovered permanently from ED when I was 20, and that I was an expert in eating healthy and weight management. Turns out I had Anorexia Nervosa and went into recovery – and because Gwyneth’s method of recovery (HDRM) is weight neutral and focuses on normalising eating and letting go of all ED behaviours I was able to start practising remission at that moment. I have run a recovery support group on FB for 4 years, and contribute in a number of other forums for people in recovery and carers. I have seen hundreds of people reach remission using this paradigm as a basis. I have also seen many people who are still being treated in weight centric and weight biased ways die, or become semi invalid with long term hospitalisation and never able to get far enough into recovery to see progress.

Gwyneth has a book that I highly recommend = stacked with references, and covering off ED with really broad strokes. It is available on Amazon “Recover from Eating Disorders: Homeodynamic Recovery Method, A Step-by-Step Guide”. However, Gwyneth also recommends that people MUST receive medical monitoring and not recover without that help – ideally a size accepting Dr who can supervise and monitor someone all the way through a recovery.