(This blog isn’t mine but from my co-founder of the London Psychotherapy Network)
The Institute of Psychoanalysis held a forum on Eating Disorders on Saturday 25thFeb in two parts. The first presentation was Marilyn Lawrence’s paper entitled ‘The Obesity Epidemic’, which covered similar ground to Susie Orbach’s ongoing work on body image. Lawrence proposed that overeating is a disturbance in the early gaze relationship, rather than in the early eating relationship, with the primary carer, hypothesizing that when one is left with the feeling of being seen deeply, but not as being beautiful, what is left is shame.
Referring to Jamie Oliver’s school dinners programme and clinical work, she suggested the epidemic in obesity we have seen over the past 30 years has created a sub-culture of fatness, where families who are fat feel in conflict with the thin world. Being ‘forced to eat greens’ is then experienced as a deprivation and cruelty. A patient was described as “making the worst of herself, becoming morbidly obese, unacceptable. Like a monster.” Lawrence suggested this idea might have formed through the complex positive and negative self-image created in the mirroring/gaze relationship between infant and mother, whereby the anxious mother (herself obese) ambivalently projects fat, ugly into the baby. The baby is then felt to be loved, despite her unattractiveness.
In a strangely schizoid coupling this analytic musing was followed by a very different presentation on the neurobiology of Anorexia Nervosa (AN) by Professor Bryan Lask, psychologist and president of the Eating Disorders Research Society. He started off by stating firmly that the cultural & social influences on AN were a given, and he didn’t intend to go there in his talk, that “AN cannot only be explained by early infant experiences of feeding,” and that we have to look to brain dysfunction for possible answers.
In a refreshingly accessible presentation he went on to describe the neuroscience of AN to an audience I’d imagine more attuned to the previous speaker’s viewpoint. Using brain scans he showed the usual atrophy and ventricle enlargement associated with AN (starvation causes shrinkage and the space that’s left gets filled with spinal fluid). This is fully reversed once the patient starts eating again. What he and his colleagues have also discovered over more than a decade of research, is that there are other parts of the brain that are impaired in AN sufferers, that do not get reversed when nutrition is restored. This is unlikely to be a secondary effect caused by the AN, so they pursued the hypothesis that it is a possibly a genetic-related difference that primes some individuals to respond to the social & cultural triggers that can lead to developing AN. The part of the brain they have been looking at specifically is the ‘insula’, described as the ‘Clapham Junction’ of the brain, in other words the connecting structure between all the areas of the brain that affect the many different experiential aspects of AN. I had no idea that, apart from the obvious deficits in AN sufferers, they also show impairments in:
Visual and spatial processing and memory
Central coherence – they find it hard to see the wood for the trees
Cognitive inhibition – the ability to screen out intrusive thoughts
Cognitive flexibility – such as multi-tasking
Disturbance in reward regulation – they need a lot of praise to feel good
It is a sobering thought that full recovery in AN sufferers is at best one in two. Family therapy has been shown to get the best outcomes, says Lask (NICE recommends CBT related therapies however). Having worked in the field for the past 30 years Lask seems hopeful that his team’s research can begin to enable clinicians to improve this dire prognosis.
Referring to the well-known fact that taxi drivers who learn The Knowledge show huge increases in the part of the brain associated with memory, the hippocampus, he went on to suggest therapies and treatments that work towards increasing the size and capacity of the Insula which were as follows:
Relaxation & meditation – Buddhist monks have whopping Insulas
Bio-feedback and e-health techniques – stimulate the Insula
Trans-cranial magnetic stimulation – external, not invasive
Medications – aiming to target the correct neurotransmitter imbalance
Cognitive Remediation Therapy (CRT)
Lask ended his presentation with some techniques from CRT which looks at the process rather than the content of thought (not what we think, but how we think). He says this is a fun and stimulating activity-based therapy without the distress of trammeling over family stories/dynamics etc. The hope is to help the patient change their thinking strategies, which could, in turn expand the Insula.
Lask’s excitement about the possibilities the research and CRT had to offer was palpable and contagious. What he offered felt solid and hopeful, unfortunately rather to the detriment of the purely psychoanalytic approach of the previous speaker.
ellernmede.org (resource pack)
Lask, B & Frampton, I (2011) “Eating Disorders & The Brain” Wiley/Blackwell, UK
CRT – Tchanturia, K
Jane Edwards is an integrative psychotherapist and co-founder of London Psychotherapy Network