Category Archives: Eating disorders

The Therapeutic Alliance: The Essential Ingredient for Psychotherapy



 I am currently writing on the ‘therapeutic alliance’ – its relation to mindfulness, psychotherapy, understanding, and ‘being listened to…’   What follows is an interesting article that I came across that may interest some of you…


Have you ever tried to change the way you do something? It could be anything — the way you hold your tennis racket, blow into a flute, meditate — you name it. If so, think about that experience. No matter how motivated you were to change, and no matter how much you knew that it would help your serve, musicality, or sense of inner peace, it can be difficult and scary to change even the smallest thing. In order to change, you have to give up your old way of doing something first and then try the new way. That means that for a while you’re in a free fall — you no longer have your old habit to rely on and you don’t yet have the new one.

The anxiety of trying to change something as complex and entrenched as how you relate to people close to you or manage stress takes the feeling to a whole new level. Yet, that’s just what you do when you enter psychotherapy. Just as you had to put yourself into the hand of your teachers and coaches, in therapy you need to gradually do just that with your therapist to help you through what can be a harrowing adventure. The foundation for therapy is called the therapeutic alliance (1, 2). When it’s there, you know that your therapist is there to help you, no matter how hard the going gets.

The therapeutic alliance might be the most important part of beginning a psychotherapy. In fact, many studies indicate that the therapeutic alliance is the best predictor of treatment outcome (3-5).

See entire article:


A mad world A diagnosis of mental illness is more common than ever – did psychiatrists create the problem, or just recognise it?


Unfortunate Events

When a psychiatrist meets people at a party and reveals what he or she does for a living, two responses are typical. People either say, ‘I’d better be careful what I say around you,’ and then clam up, or they say, ‘I could talk to you for hours,’ and then launch into a litany of complaints and diagnostic questions, usually about one or another family member, in-law, co-worker, or other acquaintance. It seems that people are quick to acknowledge the ubiquity of those who might benefit from a psychiatrist’s attention, while expressing a deep reluctance ever to seek it out themselves…

…While a continuous view of mental illness probably reflects underlying reality, it inevitably results in grey areas where ‘caseness’ (whether someone does or does not have a mental disorder) must be decided based on judgment calls made by experienced clinicians. In psychiatry, those calls usually depend on whether a patient’s complaints are associated with significant distress or impaired functioning. Unlike medical disorders where morbidity is often determined by physical limitations or the threat of impending death, the distress and disruption of social functioning associated with mental illness can be fairly subjective. Even those on the softer, less severe end of the mental illness spectrum can experience considerable suffering and impairment. For example, someone with mild depression might not be on the verge of suicide, but could really be struggling with work due to anxiety and poor concentration. Many people might experience sub-clinical conditions that fall short of the threshold for a mental disorder, but still might benefit from intervention.

See link for interesting article on psychiatry…and bits about the importance of psychotherapeutic intervention…

BB Barbie


Plus Size Barbie

I stumbled upon something very interesting considering all the time I spend writing about self-image and weight issues. I found it on Facebook of all places on a page about Plus Size Modeling.

It seems a debate has sprung up about creating a Plus Size Barbie doll. There are many people voicing their thoughts and adding their opinions about the need for a plump partner to the traditional slim and sexy gal next door that Ken knows and loves.

All in all, I consider myself a pretty decisive person and it usually doesn’t take me very long to make up my mind, but I have to admit, I’m on the fence about this one. My initial reaction to the thought of Barbie packing on a few pounds and still being an icon appealed to me because I instantly thought about how much more accepting girls might become of their own bodies and imperfections. But then I thought that maybe it would send the message of being too accepting of a habit and behavior that was not healthy and could lead to even more severely unhealthy habits and behaviors later on in life. I certainly don’t want to encourage being overweight either.

I see it as a pretty fine line between being okay with our imperfections and encouraging harmful behaviors. Perhaps if Plus-Size Barbie comes with running gear, a sweat suit and a treadmill so she can work out and maintain healthy habits I would be more likely to see it as a good thing. But no matter how hard I try, I can’t feel good about advocating behaviors that cause a person to become overweight.

Very Underweight Model

Very Underweight Model

It is not right to advocate underweight either and I know that historically and even currently, our society still pushes our women to achieve the ideal look which tends to be too thin and unhealthy. It also has been the catalyst of many young girls harming themselves by eating too little and emotionally scarring themselves by failing to accept themselves and their bodies.

Mayo Clinic Health Food Pyramid

Mayo Clinic Health Food Pyramid

Why do we have to go to extremes? I would feel much better about this if we could find the middle of the road somewhere, not advocating too much of anything. Maybe I will start a group on facebook where we could develop a “Healthy-Weight Barbie.” I wonder if that would have a lot of followers. Who’s with me?

Judy is a licensed clinical social worker and has worked extensively as a counselor with children, adolescents, couples and families. Judy’s professional experience in the mental health field along with her love of writing, provide insight into real-life experiences and relationships. Her fresh voice and down-to-earth approach to living a happier, more meaningful life are easy to understand and just as easy to start implementing right away for positive results!

Have a Jolly Healthy Christmas

Struggling with Weight Loss

Struggling with Weight Loss

Although my intention is to be helpful and provide useful simple break-downs to eating healthier and losing weight in a healthy way, it seems I ruffle more feathers whenever I write about weight loss and attempt to simplify things.
It seems many people who struggle with weight take issue with keeping it simple. Having spent a good portion of my life significantly overweight myself, I realize the amount of personal responsibility and accountability it takes It is very easy to discount a lot of the grazing type of eating that occurs frequently and to minimize the true amount of calories that we consume in the course of any given day.

Lets say I have a tendency to fail to recap that handful of peanuts I grabbed when my husband left them open on the counter just as I was walking through the kitchen before lunch. Or what if I totally forgot to consider the spoonfuls of dinner I “tasted” while I was preparing it?

As much as I hate to admit it, that could account for an addition 400 or 500 calories at the end of the day. If I multiply that by each day of the week (the likelihood of me doing it habitually is quite high) then that may add up to 3500 calories during the week that contribute to my gaining a pound while I am totally baffled at my weight gain.
So, while the calorie counting thing is a real pain in the excess flab department, it is entirely mathematical (unless I have some rare disorder that doctors haven’t determined).

If this sounds like gloom and doom, think again…because depending on the way I approach it psychologically, this can be the HOLY GRAIL to my losing weight without tons of stress and strain.

Low Calorie Foods

Low Calorie Foods

Since it is mathematical and since 3500 calories is the magic number of additional calories that equal a pound, it is also the magic number of fewer calories that equal a pound. If I can find a way to have 3500 fewer calories stick to my ribs during any given period of time, then that is 1 pound less that I weigh.

Here are a few very basic – but hopefully not too basic ideas and tips that can make this upcoming year’s weight-loss goals a reality.

• Avoid skipping any meals – even if you are in a hurry and can’t sit down to a complete meal, make sure you consume something with a good amount of sustaining protein. This will make sure you keep your energy up and will also help keep you from overeating later on because of being extra hungry.

• Get into the water-drinking habit – there are times when thirst masquerades as hunger. There are many positive benefits to drinking a lot of water. Weight loss gets a boost when we make drinking plenty of water a regular habit.

• Devote eating time to your food – although many of us develop the habit of eating while standing up or while working or watching TV, make it a habit to sit quietly and calmly at the table and take the 20-30 minutes to make your meal last and enjoy it.

• Journal your eating and exercise – it is much too easy to minimize or forget what we eat during the day. Journaling is one of the only ways to honestly account for what we are doing.

• Veggies are our friend – by filling half our plate with veggies (especially at dinner time) and avoiding coating them with dressings and unhealthy oils and fats, we will teach ourselves how to eat healthier and not feel hungry.

• Keep active – not only regarding exercise, but because many of us eat when we feel bored. By keeping busy and avoiding boredom, we can more easily avoid snacking because we think we are hungry.

• Re-invent your kitchen’s inventory – Emptying cupboards and refrigerators of unhealthy and unfriendly to weight-loss foods is a win-win situation. The tempting foods you want to avoid will be gone, making it easier for you to stick to your plan, and you can donate the excess bounty to an organization that will make sure those in need get the food, for an added feel-good benefit, especially this time of year.

Happy Weight-Loss

Happy Weight-Loss

Focusing more on all the benefits to eating better, it is easier to stick with it. Most people actually feel more energy with every few pounds lost, not to mention the emotional/psychological feel goods like endorphins from exercise and esteem from knowing we look better and are taking better care of ourselves.

There’s an week worth of eating between Christmas and New Years – why not get a jump start on your resolution and be on your way to a healthier 2014 before all the diet commercials start?

Judy is a licensed clinical social worker and has worked extensively as a counselor with children, adolescents, couples and families. Judy’s professional experience in the mental health field along with her love of writing, provide insight into real-life experiences and relationships. Her fresh voice and down-to-earth approach to living a happier, more meaningful life are easy to understand and just as easy to start implementing right away for positive results!

The First Step in the Fight Against Obesity

Obesity's Negative Effects

Obesity’s Negative Effects

By now, many of us are inwardly responding with “blah, blah, blah” when we hear all the hype about the epidemic of obesity. We see it all around us in our daily lives because obesity is one of those disorders that is out there in plain sight. It is worn out for the world to see.

There is a strong emotional component to obesity that often gets less attention because of how at risk an obese person’s health becomes. But prior to all the physical harm which takes its toll over time, there is the teasing and taunting and the battering of self-esteem and of self-regard. There is the endless inner berating that comes from wondering ‘what is wrong with me?’ ‘why can’t I control myself?’ ‘why can’t I be more like everybody else?’ ‘why am I so broken?’

It doesn’t take rocket science to realize the detrimental impact this type of self talk does to a person’s sense of worth and esteem. Not only does this cause the emotional torment, but where is a person who has turned to food for emotional reasons in the past going to go when they feel emotionally battered? Right back to the food, their solace; their safe haven. And so the cycle continues.

According to present-day research, there are more than 90.5 million (that’s MILLION) Americans who meet the medical diagnosis of obesity. 12.5 million are children. THAT is why there is so much talk about the obesity epidemic. The research proving the connection between obesity and increased heart problems and diabetes is overwhelmingly indisputable.

Spending Money

Spending Money

The out of pocket costs of obesity are insane, justifying in excess of $3 million dollars annually for celebrity endorsements of major weight-loss programs. But the macro concern is that of health costs of obesity to insurances and the government. Predictive costs are through the ceiling and needless to say, that gets people’s attention.

I have to wonder, how many people who suffer from being overweight keep track of what they eat during the day. Although there are so many different plans and programs available, I don’t think any one of them works more effectively than mindful accountability.

Taking Baby Steps

Taking Baby Steps

None of us is being force fed. We are eating because we choose to eat. And while economics play a huge factor in the healthfulness of the types of food we can afford, the portions can always be smaller. We don’t have to eat as much today as we did yesterday and for many of us, that can be the first step to taking control back over something that we have given up control to.

Judy is a licensed clinical social worker and has worked extensively as a counselor with children, adolescents, couples and families. Judy’s professional experience in the mental health field along with her love of writing, provide insight into real-life experiences and relationships. Her fresh voice and down-to-earth approach to living a happier, more meaningful life are easy to understand and just as easy to start implementing right away for positive results!

When Ignorance Begets Confidence



“There are few people whom I really love, and still fewer of whom I think well. The more I see of the world, the more am I dissatisfied with it; and every day confirms my belief of the inconsistency of all human characters, and of the little dependence that can be placed on the appearance of either merit or sense.”  Pride and Prejudice by Jane Austen

I begin with this quote to convey the feelings evoked in a recent exchange with a neighbor, one in which surprise (and some horror) was felt during the course of the conversation.  Logic and ‘reasonableness’ had little place in the interchange. I had just been reading a short article that looked at particular German words that gave expression to complex emotional states. An excerpt is as follows: 

“Fremdschämen describes embarrassment which is experienced in response to someone else’s actions, but it is markedly different from simply being embarrassed for someone else….Fremdscham (the noun) describes the almost-horror you feel when you notice that somebody is oblivious to how embarrassing they truly are.” Further…”Fremdscham-inducing events…usually cause one to ask this question: “how on earth can these people be unaware of how stupid they are being right now?”.

I invite you to read this short article on the cognitive bias created in the Dunning Kruger effect – an effect that causes one to be unaware of their performance – and their incompetence.

New Hope For Eating Disorders



I’m not a scientist. Heck! I don’t even play one on TV. But I most definitely can attest to the fact that almost all aspects of mental illness can be found to have some genetic component to them. When a child is born with ADHD, we would be hard-pressed to find that there is not some type of mental health issues effecting one or both of the child’s biological parents that attributed to the ADHD in the child.

So, it is no surprise that the more studies that are done with genetics, the more we are finding things like the newest information regarding genetics and eating disorders. We already know that the tendency for eating disorders has been found to run in families, however, we have not been able to identify the specific genes directly related to putting people at greater risks because of their familial connection.

At least not up until now. Two groups of scientists, one from the University of Iowa and the other from the University of Texas Southwestern Medical Center, have been researching two families that have been very negatively impacted by eating disorders, because of two totally different gene mutations.



What makes these finding unique, is that although the two families are not connected and the two gene mutations are totally different, there is interaction in the same signaling pathway in the brain that produce the same effect biologically.

Karen Carpenter

Karen Carpenter

Let me back up for a moment. About one in every thousand women will die from anorexia. With that fact as the stimulus for these scientists, the study which can be found in the Journal of Clinical Investigation, published October 8, 2013, the mutations that decrease activity in a protein in the brain that turns on expression of other genes, increases the risk of eating disorders.

Again, I’m no scientist, but to me this means that when our brains don’t get enough of a certain type of activity due to some type of defect, it causes an increased in the chances of there being eating disorders.

Large families have to be studied in order to get strong statistics to conclusively back up the differences. The genetics have to indicate what people with the disorder have in common that people without the disorder don’t have.

This study permitted researchers to work with two families, one with 20 members from three generations and one with eight members. Half the individuals in the first family were affected by the disorder and six of the eight in the second family were affected. The results led to the identification of two new genes now associated with eating disorders and more research to come that might help lead the way in working with people who suffer with them.

Although the combinations are pretty much endless, when there is a hit; when two genes like these show similar results, it really makes tremendous progress in learning more about and treating the problems.

Now that is productive research!

Judy is a licensed clinical social worker and has worked extensively as a counselor with children, adolescents, couples and families. Judy’s professional experience in the mental health field along with her love of writing, provide insight into real-life experiences and relationships. Her fresh voice and down-to-earth approach to living a happier, more meaningful life are easy to understand and just as easy to start implementing right away for positive results!

I can`t stop binge eating



It Happened to Me: I Can’t Stop Binge Eating

No matter how careful I am during the day, in a cubicle, or in with a group of girlfriends at dinner, there is some part of me that knows when I am alone and I can and will buy and eat an entire box of Fig Newtons and a whole sack of Cheeze-Its.

Apr 30, 2012 at 1:00pm | 200 comments


This is how I see myself. It’s probably how a lot of people see me, too.

If you’ve read a magazine intended for women in the past decade, you’ve probably come across an article by Geneen Roth. A smiling blonde rarely photographed below the shoulders (and always in a black, figure-concealing turtleneck so you aren’t tempted to compare your body against hers), she’s the print publishing world’s go-to expert in binge eating.

In the article I first (sorry for the word choice) devoured, Geneen talked about the broad spectrum of women she’d met in her workshops for binge eaters: wealthy women, broke women, fat women and women of average weight, happy women and depressed women, all of whom had realized that this one part of their lives was not healthy.

There were single women who didn’t date because they were afraid it would hamper their ability to binge, and married women who put locks on their refrigerators and begged their husbands to hide the key at night to prevent them from sneaking out of bed to binge.

I’d never thought I had an Eating Disorder before, but I suddenly saw myself in both of these scenarios.

At the time, I was co-habitating with a nice, slacker guy, one who wasn’t so much enabling as clueless. We moved in together after college, into my first real apartment, and it was the first time I ever really made food choices for myself. (In college, I was always broke, and on a meal plan. Even if I wanted to binge eat, it would be hard to do with $20 in my checking account and having to swipe my card at the commissary at prescribed mealtimes. )

I usually ate healthy, but he ate whatever he wanted. And when he was sleeping or out of the house, I would find myself consuming things like a woodchipper, feeding pretzel rods and barbecue potato chips into my mouth as fast as my teeth could make them into pulp.

When an entire box of Toaster Strudels or Girl Scout cookies went missing in the night, he would either not notice or make a joke of it. I think maybe he thought that this was just something women did, occasionally plunging face first into a Whitman’s Sampler in a tornado of chocolate wrappers and hands, like in the Cathy comics.

It didn’t happen every night — probably once every 10 days or so, depending. I was a careful eater, living in the big city where a size six was still not considered very “thin,” and always one week of low-fat cheese and controlled portions away from my “goal weight.” After a week of savoring vegetarian sushi and making elaborate, healthful salads, I might find myself in Whole Foods, knowing my boyfriend would be out for the night with his friends, and suddenly start filling my basket with wedges of brie, a loaf of zucchini bread, a bag of chocolate covered pretzels, peanut butter, and those Paul Newman cookies that taste extra good because the proceeds are going to charity.

Immediately following a binge, I’m filled with guilt over what I’ve just done to my body, but also because there are people out there who are starving and I have this horrendous compulsion to shove mac and cheese into my face so quickly I can’t taste it. I begin fantasizing about living in a place where somebody was making all  of my food choices for me — like jail.

It is a weird, automatic feeling — TV makes me think of someone having a “substance abuse episode” as something that happens suddenly, brought on my some inciting emotional incident. But like other “scoring,” binging often involves a certain amount of planning. I might have zero junk food in the house, and put off a binge as long as I could, reading quietly with a mug of tea, while secretly thinking Pizza, Pizza, Pizza knowing that in the next hour I would probably order an extra large pie and finish the whole thing.

When I lived with my boyfriend, I would put the evidence in a trash bag and take it to the dumpster behind my house, burying the whole thing under another bag in case my he should happen to go back and dig through the trash (not that he would, but you never know.)

While I had the vague feeling that this was all Bad, I never really thought of it as disordered eating. There wasn’t necessarily something that made me binge (a breakup or a bad week at work), I never thought, “I’m an emotional eater” or “I’m using food to cope.” I have the same kind of changeable moods and free-floating anxiety that all people in the world have. But I also have this habit, a routine I can’t seem to break even though it makes me feel sick and awful.

It’s also hard for me to say I have A Problem because like I said, it doesn’t happen all the time. And I never purge, which would be Really Bad instead of just Bad-Bad. I just feel like shit afterward, emotionally and physically. Sometimes, I never feel full, even after taking down eight tacos from the delivery Mexican place and washing them down with that old binger’s standby, a carton of ice cream.

If you’ve ever eaten too much candy too fast, you know the physical sensation. You can practically feel your organs trying to frantically keep up. I usually get headaches and intense nausea. I worry that this is actually bad for my body, that I’m going to get pancreatic cancer or Type II diabetes or just permanently “break” my body’s ability to feel normal feelings of hunger and fullness.

Then there is also The Guilt. I feel fat, disgusting and gluttonous. I feel like the Cathy comic, shoving food in my mouth until I physically cannot eat any more. I don’t have a bad life — I have friendly co-workers and good parents and lots of nice, supportive friends. If you met me and knew, you would wonder why I am doing this. I’m not the Type-A eating disordered girl from the studies and books who uses food to feel in control of her life.

Some of it is probably emotional, that I’m unthinkingly medicating with sugar and fat the same way some girls enjoy three glasses of wine in a bubble bath after a long week. I’m sure another part of it is my body craving this toxic crap when I’m being so good to give it its calories through stuff like tofu cutlets and baked yams.

I am hungry all the time, whether I’m watching what I eat or not. I grew up eating a mix of healthy and processed foods, begging for cookies but resigned to having a reasonable amount of them doled out by my parents after a balanced dinner. But left to my own devices, I can’t self-regulate. I might eat a nutritionist-approved breakfast of yogurt and fruit, a lunch of kale and brown rice and an orange, and grilled seitan and broccoli for dinner. Maybe my body gets scared that it’s never going to have a Dorito again, because after a week of being “good,” I’ll often find my face in a full-sized bag of Cool Ranch.

It’s a testament to the power of the pure-need part of the brain over the reasonable, thinking part that it is nearly impossible to say to myself, “Stop this. Don’t go to the store. Don’t buy the cookies. Don’t even put on your shoes to do it.”

No matter how careful I am during the day, in a cubicle, or in with a group of girlfriends at dinner, there is some part of me that knows when I am alone and I can and will buy and eat an entire box of Fig Newtons and a whole sack of Cheeze-Its.

I’ve been binging for several years now, and I probably won’t stop until someone figures out what I do and is horrified by it, too. I have told myself again and again that I’ll quit, that I’ll go to a Geneen Roth workshop, that I’ll start a journal, but I always go back. I wish it were as simple as filling the fridge with healthy alternatives, or freezing my credit card in a bowl of water, but somehow I always find a way around it, and there I am, a whole pizza gone, wanting to cry.

One look at Wikipedia and you’ll see why my problem is such a grey-area when it comes to treatment. The entry on binge eating disorder (or BED) begins by stating that it’s the most common eating disorder in the United States, and then the very next sentence admits that it’s not officially classified as an eating disorder.

I’ve considered OA and support groups, there’s still part of me that thinks I’m not “that bad,” and that I would feel like an interloper. I picture the people who are there who are actually killing themselves with food, and worry that all I could say would be, “I normally eat pretty healthy but every two weeks or so I eat so much I stand in front of a mirror calling myself a fucking fatass or dump dish soap into a box of brownie bites.”

I’d like to see a psychiatrist and a nutritionist and one of those hormone specialists who promises to test your blood and fix you with shots and patches and a custom diet. But right now, my insurance doesn’t cover mental health care, and I can’t afford to pay for excess private treatment.

It doesn’t help that I’ve known women who were anorexics or bulimics (who have an officially classified ED) who were turned away from private facilities for not being “severe” enough. So for now, it seems unlikely that I’ll seek treatment aside from being careful not to diet so severely that I “trigger” a binge, and to try not to be alone too much with the contents of my cupboards.

Because binge eaters aren’t always visibly affected weight-wise (mine falls someplace in the upper register of the “healthy” BMI for a 30-year-old woman of my modest stature), it’s unlikely that anybody will know unless I tell them or they look through my trash.

But I hope if you’re like me, this at least helps you to know that there are others of us out there, hiding their garbage, feeling equally clueless about the next step.

Where There’s A Will


Thanks to new research in an emerging field of study called prospection, that studies the way people project themselves into the future, by mentally stimulating future events; there is new hope for developing behavioral interventions that can help overweight women thanks to a new study from the University at Buffalo. In last month’s journal Appetite, research has been published that disagrees with previous studies regarding different levels of difficulty for obese and lean women when it comes to delaying gratification and impulse control.

Emotional Eating

Emotional Eating

Previous studies historically led researchers to conclude that overweight and obese people are more likely to forego health and more normal weight bodies in the future, in order to eat more desired, calorie-dense foods now.

But this new study shows that whether obese, overweight or lean, women who thought about future scenarios were able to postpone gratification, and were equally capable of the impulse control that lean women exhibit.

Put into everyday language, delayed gratification equals willpower. And it involves being able to delay immediate results for a better reward in the future. In the past, studies indicated that obese and overweight people found it more difficult to delay their gratification; to display willpower.

This has very long-lasting and significant implications for people who took on the findings as part of how they saw themselves; weak willed, possessing poor impulse control, not having the will-power or control over themselves that ‘normal’ people have with regards to food and eating.

Leonard H. Epstein, PhD, SUNY Distinguished Professor in the UB School of Medicine and Biomedical Sciences, who was senior author on the research and renown obesity specialist notes that many people find it hard to resist impulses and opt for immediate gratification, and it has no connection to whether they are overweight, slender or obese.
The wonderful part is that it is likely to prove that if people can modify delay discounting, and delayed discounting can be taught. It is possible to teach how to mentally simulate the future in order to moderate present behaviors and this type of intervention can help people become more successful at losing weight.



“This research is certainly welcome news for people who have struggled to lose weight, because it shows that when people are taught to imagine, or simulate the future, they can improve their ability to delay gratification,” says Epstein.

Judy is a licensed clinical social worker and has worked extensively as a counselor with children, adolescents, couples and families. Judy’s professional experience in the mental health field along with her love of writing, provide insight into real-life experiences and relationships. Her fresh voice and down-to-earth approach to living a happier, more meaningful life are easy to understand and just as easy to start implementing right away for positive results!

The anorexic brain


The Anorexic Brain

Neuroimaging improves understanding of eating disorder

By Meghan Rosen

Web edition: July 26, 2013
Print edition: August 10, 2013; Vol.184 #3 (p. 20)

A+ A- Text Size


Luke Lucas

In a spacious hotel room not far from the beach in La Jolla, Calif., Kelsey Heenan gripped her fiancé’s hand. Heenan, a 20-year-old anorexic woman, couldn’t believe what she was hearing. Walter Kaye, director of the eating disorders program at the University of California, San Diego, was telling a handful of rapt patients and their family members what the latest brain imaging research suggested about their disorder.

It’s not your fault, he told them.

Heenan had always assumed that she was to blame for her illness. Kaye’s data told a different story. He handed out a pile of black-and-white brain scans — some showed the brains of healthy people, others were from people with anorexia nervosa. The scans didn’t look the same. “People were shocked,” Heenan says. But above all, she remembers, the group seemed to sigh in relief, breathing out years of buried guilt about the disorder. “It’s something in the way I was wired — it’s something I didn’t choose to do,” Heenan says. “It was pretty freeing to know that there could be something else going on.”

Years of psychological and behavioral research have helped scientists better understand some signs and triggers of anorexia. But that knowledge hasn’t straightened out the disorder’s tangled roots, or pointed scientists to a therapy that works for everyone. “Anorexia has a high death rate, it’s expensive to treat and people are chronically ill,” says Kaye.

Kaye’s program uses a therapy called family-based treatment, or FBT, to teach adolescents and their families how to manage anorexia. A year after therapy, about half of the patients treated with FBT recover. In the world of eating disorders, that’s success: FBT is considered one of the very best treatments doctors have. To many scientists, that just highlights how much about anorexia remains unknown.

Kaye and others are looking to the brain for answers. Using brain imaging tools and other methods to explore what’s going on in patients’ minds, researchers have scraped together clues that suggest anorexics are wired differently than healthy people. The mental brakes people use to curb impulsive instincts, for example, might get jammed in people with anorexia. Some studies suggest that just a taste of sugar can send parts of the brain barrelling into overdrive. Other brain areas appear numb to tastes — and even sensations such as pain. For people with anorexia, a sharp pang of hunger might register instead as a dull thud.

The mishmash of different brain imaging data is just beginning to highlight the neural roots of anorexia, Kaye says. But because starvation physically changes the brain, researchers can run into trouble teasing out whether glitchy brain wiring causes anorexia, or vice versa. Still, Kaye thinks understanding what’s going on in the brain may spark new treatment ideas. It may also help the eating disorder shake off some of its noxious stereotypes.

“One of the biggest problems is that people do not take this disease seriously,” says James Lock, an eating disorders researcher at Stanford University who cowrote the book on family-based treatment. “No one gets upset at a child who has cancer,” he says. “If the treatment is hard, parents still do it because they know they need to do it to make their child well.”

Pop culture often paints anorexics as willful young women who go on diets to be beautiful, he says. But, “you can’t just choose to be anorexic,” Lock adds. “The brain data may help counteract some of the mythology.”


View larger image | Studies of the brains of people with anorexia have revealed a number of complex brain circuits that show changes in activity compared with healthy people.
Medical RF, adapted by M. Atarod

Beyond dieting

A society that glamorizes thinness can encourage unhealthy eating behaviors in kids, scientists have shown. A 2011 study of Minnesota high school students reported that more than half of girls had dieted within the past year. Just under a sixth had used diet pills, vomiting, laxatives or diuretics.

But a true eating disorder goes well beyond an unhealthy diet. Anorexia involves malnutrition, excessive weight loss and often faulty thinking about one of the body’s most basic drives: hunger. The disorder is also rare. Less than 1 percent of girls develop anorexia. The disease crops up in boys too, but adolescent girls — especially in wealthy countries such as the U.S., Australia and Japan — are most likely to suffer from the illness.

As the disease progresses, people with anorexia become intensely afraid of getting fat and stick to extreme diets or exercise schedules to drop pounds. They also misjudge their own weight. Beyond these diagnostic hallmarks, patients’ symptoms can vary. Some refuse to eat, others binge and purge. Some live for years with the illness, others yo-yo between weight gain and loss. Though most anorexics gain back some weight within five years of becoming ill, anorexia is the deadliest of all mental disorders.

Though anorexia tends to run in families, scientists haven’t yet hammered out the suite of genes at play. Some individuals are particularly vulnerable to developing an eating disorder. In these people, stressful life changes, such as heading off to college, can tip the mental scales toward anorexia.

For decades, scientists have known that anorexic children behave a little differently. In school and sports, anorexic kids strive for perfection. Though Heenan, a former college basketball player, didn’t notice her symptoms creeping in until the end of high school, she remembers initiating strict practice regimens as a child. Starting in second grade, Heenan spent hours perfecting her jump shot, shooting the ball again and again until she had the technique exactly right — until her form was flawless.

“It’s very rare for me to see a person with anorexia in my office who isn’t a straight-A student,” Lock says. Even at an early age, people who later develop the eating disorder tend to exert an almost superhuman ability to practice, focus or study. “They will work and work and work,” says Lock. “The problem is they don’t know when to stop.”

In fact, many scientists think anorexics’ brains might be wired for willpower, for good and ill. Using new imaging tools that let scientists watch as a person’s mental gears grind through different tasks, researchers are starting to pin down how anorexic brains work overtime.

Control signs


Images of high-calorie foods (left) switched on a self-control center in the brains of anorexic women. Pictures of objects on plates kept the control center quiet.
Courtesy of S. Brooks

To glimpse the circuits that govern self-control, experimental neuropsychologist Samantha Brooks uses functional magnetic resonance imaging, or fMRI, a tool that measures and maps brain activity. Last year, she and colleagues scanned volunteers as they imagined eating high-calorie foods, such as chocolate cake and French fries, or using inedible objects such as clothespins piled on a plate. One result gave Brooks a jolt. A center of self-control in anorexics’ brains sprung to life when the volunteers thought about food — but only in the women who severely restricted their calories, her team reported March 2012 in PLOS ONE.

The control center, two golf ball–sized chunks of tissue called the dorsolateral prefrontal cortex, or DLPFC, helps stamp out primitive urges. “They put a brake on your impulsive behaviors,” says Brooks, now at the University of Cape Town in South Africa.

For Brooks, discovering the DLPFC data was like finding a tiny vein of gold in a heap of granite. The control center could be the nugget that reveals how anorexics clamp down on their appetites. So she and her colleagues devised an experiment to test anorexics’ DLPFC. Using a memory task known to engage the brain region, the researchers quizzed volunteers while showing them subliminal images. The quizzes tested working memory, the mental tool that lets people hold  phone numbers in their heads while hunting for a pen and paper. Compared with healthy people, anorexics tended to get more answers right, Brooks’ team wrote June 2012 in Consciousness and Cognition. “The patients were really good,” Brooks says. “They hardly made any mistakes.”

A turbocharged working memory could help anorexics hold on to rules they set for themselves about food. “It’s like saying ‘I will only eat a salad at noon, I will only eat a salad at noon,’ over and over in your mind,” says Brooks. These mantras may become so ingrained that an anorexic person can’t escape them.

But looking at subliminal images of food distracted anorexics from the memory task. “Then they did just as well as the healthy people,” Brooks says. The results suggest that anorexic people might tap into their DLPFC control circuits when faced with food.

James Lock has also seen signs of self-control circuits gone awry in people with eating disorders. In 2011, he and colleagues scanned the brains of teenagers with different eating disorders while signaling them to push a button. While volunteers lay inside the fMRI machine, researchers flashed pictures of different letters on an interior screen. For every letter but “X,” Lock’s group told the teens to push a button. During the task, anorexic teens who obsessively cut calories tended to have more active visual circuits than healthy teens or those with bulimia, a disorder that compels people to binge and purge. The result isn’t easy to explain, says Lock. “Anorexics may just be more focused in on the task.”

Bulimics’ brains told a simpler story. When teens with bulimia saw the letter “X,” broad swaths of their brains danced with activity — more so than the healthy or calorie-cutting anorexic volunteers, Lock’s team reported in theAmerican Journal of Psychiatry. For bulimics, controlling the impulse to push the button may take more brain power than for others, Lock says.

Though the data don’t reveal differences in self-control between anorexics and healthy people, Lock thinks that anorexics’ well-documented ability to swat away urges probably does have signatures in the brain. He notes that his study was small, and that the “healthy” people he used as a control group might have shared similarities with anorexics. “The people who tend to volunteer are generally pretty high performers,” he says. “The chances are good that my controls are a little bit more like anorexics than bulimics.”

Still, Lock’s results offered another flicker of proof that people with eating disorders might have glitches in their self-control circuits. A tight rein on urges could help steer anorexics toward illness, but the parts of their brain tuned into rewards, such as sugary snacks, may also be a little off track.


When an anorexic woman unexpectedly gets a taste of sugar (yellow) or misses out on it (blue), her brain’s reward circuitry shows more activity than a healthy-weight or obese woman’s. Anorexics’ reward-processing systems may be out of order.
G. Frank et al/Neuropsychopharmacology2012

Sugar low

For many anorexics, food just doesn’t taste very good. A classic symptom of the disorder is anhedonia, or trouble experiencing pleasure. Parts of Heenan’s past reflect the symptom. When she was ill, she had trouble remembering favorite dishes from childhood, for example — a blank spot common to anorexics. “I think I enjoyed some things,” she says. Beyond frozen yogurt, she can’t really rattle off a list.

After Heenan started seriously restricting her calories in college, only one aspect of food made her feel satisfied. Skipping, rather than eating, meals felt good, she says. Some of Heenan’s symptoms may have stemmed from frays in her reward wiring, the brain circuitry connecting food to pleasure. In the past few years, researchers have found that the chemicals coursing through healthy people’s reward circuits aren’t quite the same in anorexics. And studies in rodents have linked chemical changes in reward circuitry to under- and overeating.

anorexiaTo find out whether under- and overweight people had altered brain chemistry, eating disorder researcher Guido Frank of the University of Colorado Denver studied anorexic, healthy-weight and obese women. He and his colleagues trained volunteers to link images, such as orange or purple shapes, with the taste of a sweet solution, slightly salty water or no liquid. Then, the researchers scanned the women’s brains while showing them the shapes and dispensing tiny squirts of flavors. But the team threw in a twist: Sometimes the flavors didn’t match up with the right images.

When anorexics got an unexpected hit of sugar, a surge of activity bloomed in their brains. Obese people had the opposite response: Their brains didn’t register the surprise. Healthy-weight women fit somewhere in the middle, Frank’s team reported August 2012, in Neuropsychopharmacology. While obese people might not be sensitive to sweets anymore, a little sugar rush goes a long way for anorexics. “It’s just too much stimulation for them,” Frank says.

One of the lively regions in anorexics’ brains was the ventral striatum, a lump of nerve cells that’s part of a person’s reward circuitry. The lump picks up signals from dopamine, a chemical that rushes in when most people see a sugary treat.

Frank says that it’s possible cutting calories could sculpt a person’s brain chemistry, but he thinks some young people are just more likely to become sugar-sensitive than others. Frank suspects anorexics’ dopamine-sensing equipment might be out of alignment to begin with. And he may be onto something. Recently, researchers in Kaye’s lab at UCSD showed that the same chemical that makes people perk up when a coworker brings in a box of doughnuts might actually trigger anxiety in anorexics.

Mixed signals

Usually a rush of dopamine triggers euphoria or a boost of energy, says Ursula Bailer, a psychiatrist and neuroimaging researcher at UCSD. Anorexics don’t seem to pick up those good feelings.

When Bailer and colleagues gave volunteers amphetamine, a drug known to trigger dopamine release, and then asked them to rate their feelings, healthy people stuck to a familiar script. The drug made them feel intensely happy, Bailer’s team described March 2012 in the International Journal of Eating Disorders. Researchers linked the volunteers’ happy feelings to a wave of dopamine flooding the brain, using an imaging technique to track the chemical’s levels.

But anorexics said something different. “People with anorexia didn’t feel euphoria — they got anxious,” Bailer says. And the more dopamine coursing through anorexics’ brains, the more anxious they felt. Anorexics’ reaction to the chemical could help explain why they steer clear of food — or at least foods that healthy people find tempting. “Anorexics don’t usually get anxious if you give them a plate of cucumbers,” Bailer says.

Beyond the anxiety finding, one other aspect of the study sticks out: Instead of examining sick patients, Bailer, Kaye and colleagues recruited women who had recovered from anorexia. By studying people whose brains are no longer starving, Kaye’s team hopes to sidestep the chicken-and-egg question of whether specific brain signatures predispose people to anorexia or whether anorexia carves those signatures in the brain.

Though Kaye says that there’s still a lot scientists don’t know about anorexia, he’s convinced it’s a disorder that starts in the brain. Compared with healthy children, anorexic children’s brains are getting different signals, he says. “Parents have to realize that it’s very hard for these kids to change.”

Kaye thinks imaging data can help families reframe their beliefs about anorexia, which might help them handle tough treatments. He thinks the data can also offer new insights into therapies tailored for anorexics’ specific traits.

Sensory underload

One trait Kaye has focused on is anorexics’ sense of awareness of their bodies. Peel back the outer lobes of the brain by the temples, and the bit that handles body awareness pops into view. These regions, little islands of tissue called the insula, are one of the first brain areas to register pain, taste and other sensations. When people hold their breath, for example, and feel the panicky claws of air hunger, “the insula lights up like crazy,” Kaye says.

Kaye and colleagues have shown that the insulas of people with anorexia seem to be somewhat dulled to sensations. In a recent study, his team strapped heat-delivering gadgets to volunteers’ arms and cranked the devices to painfully hot temperatures while measuring insula activity via fMRI.

Compared with healthy volunteers, bits of recovered anorexics’ insulas dimmed when the researchers turned up the heat. But when researchers simply warned that pain was coming, other parts of the brain region flared brightly, Kaye’s team reported in January in the International Journal of Eating Disorders. For people who have had anorexia, actually feeling pain didn’t seem as bad as anticipating it. “They don’t seem to be sensing things correctly,” says Kaye.

If anorexics can’t detect sensations like pain properly, they may also have trouble picking up other signals from the body, such as hunger. Typically when people get hungry, their insulas rev up to let them know. And in healthy hungry people, a taste of sugar really gets the insula excited. For anorexics, this hunger-sensing part of the brain seems numb. Parts of the insula barely perked up when recovered anorexic volunteers tasted sugar, Kaye’s team showed this June in the American Journal of Psychiatry. The findings “may help us understand why people can starve themselves and not get hungry,” Kaye says.

Though the brain region that tells people they’re hungry might have trouble detecting sweet signals, some reward circuits seem to overreact to the same cues. Combined with a tendency to swap happiness for anxiety, and a mental vise grip on behavior, anorexics might have just enough snags in their brain wiring to tip them toward disease.

Now, Kaye’s group hopes to tap neuroimaging data for new treatment ideas. One day, he thinks doctors might be able to help anorexics “train” their insulas using biofeedback. With real-time brain scanning, patients could watch as their insulas struggle to pick up sugar signals, and then practice strengthening the response. More effective treatment options could potentially spare anorexics the relapses many patients suffer.

Heenan says she’s one of the lucky ones. Four years have passed since she first saw the anorexic brain images at UCSD. In the months following her treatment, Heenan and her family worked together to rebuild her relationship with food. At first, her fiancé picked out all her meals, but step by step, Heenan earned autonomy over her diet. Today, Heenan, a coordinator for Minneapolis’ public schools, is married and has a new puppy. “Life can be good,” she says. “Life can be fun. I want other people to know the freedom that I do.”

Searching for treatments

The bowl of pasta sitting in front of Kelsey Heenan didn’t look especially scary.

Spaghetti, chopped asparagus and chunks of chicken glistened in an olive oil sauce. Usually, such savory fare might make a person’s mouth water. But when Heenan’s fiancé served her a portion, she started sobbing. “You can’t do this to me,” she told him. “I thought you loved me!”

Heenan was confronting her “fear foods” at the Eating Disorders Center for Treatment and Research at UCSD. Therapists in her treatment program, Intensive Multi-Family Therapy, spend five days teaching anorexic patients and families about the disorder and how to encourage healthy eating. “There’s no blame,” says Christina Wierenga, a clinical neuropsychologist at UCSD. “The focus is just on having the parent refeed the child.” Therapists lay out healthy meals and portion sizes for teens, bolster parents’ self-confidence and hammer home the dangers of not eating. Heenan compares the experience to boot camp. But by the end of her time at the center, she says, “I was starting to see glimpses of what life could be like as a healthy person.”

Treatment options for anorexia include a broad mix of behavioral and medication-based therapies. Most don’t work very well, and many lack the support of evidence-based trials. Hospitalizing patients can boost short-term weight gain, “but when people go home they lose all the weight again,” says Stanford University’s James Lock, one of the architects of family-based treatment. That treatment is currently considered the most effective therapy for adolescent anorexics.

In a 2010 clinical trial, half of teens who underwent FBT maintained a normal weight a year after therapy. In contrast, only a fifth of teens treated with adolescent-focused individual therapy, which aims to help kids cope with emotions without using starvation, hit the healthy weight goal.

Few good options exist for adult anorexics, a group notorious for dropping out of therapy. New work hints that cognitive remediation therapy, or CRT, which uses cognitive exercises to change anorexics’ behaviors, has potential. After two months of CRT, only 13 percent of patients abandoned treatment, and most regained some weight, Lock and colleagues reported in the April International Journal of Eating Disorders. Researchers still need to find out, however, if CRT helps patients keep weight on long-term. —Meghan Rosen


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