Written by Monte Nido & Affiliates East Coast Medical Director Dr. Molly McShane, MD, MPH
Dr. McShane is a board certified psychiatrist and practices psychotherapy and medication management for a range of psychiatric conditions. Dr. McShane dives into the neurobiology and genetics of mental health disorders in this week’s blog post.
It is an exciting time in the world of brain and mental health research. Over the past few years, there has been an exponential increase in research findings in the neurobiology and genetics of mental health disorders. While we have known for decades that mental disorders are related to dysfunction in brain pathways, we are now able to say that mental illnesses are brain diseases.
Most diseases develop, progress and/or resolve due to a number of factors including biology, genetics, psychological co-morbidities and environmental exposures. Like most diseases, eating disorders typically occur in individuals with a genetic predisposition, meaning they born with genes inherited from their parents, which are associated with eating disorders. Data shows that 50 to 80 percent of the risk of developing an eating disorder is related to genetics. Clinically, we know this. It is very common for my patients to tell me they have family members with eating disorder histories. In fact, first degree relatives of patients with eating disorders are over eleven times more likely to have anorexia nervosa compared to controls. There are over forty genes involved in the regulation of eating disorder behaviors, motivation, reward, personality traits and emotions. The relationship between the genes and environment is complex. These genes may be turned on or off by environmental triggers. Of course, environment (exposure to social media that over-emphasize image, involvement in certain activities like dance, modeling or wrestling, etc.) can play a significant role in the development of an eating disorder.
Certain temperaments are associated with the development of eating disorders. While specific genes have not yet been identified with temperament, we do know that temperament traits are often constant throughout life, before, during and after experiencing an eating disorder. The temperament traits commonly seen in individuals with eating disorders include harm avoidance, perfectionism, neuroticism, compulsivity, dysphoric mood, low self-directedness, impulsivity, sensation seeking, lack of planning and lack of persistence. Individuals with eating disorders may experience one or more of these temperament traits throughout life, while the eating disorder symptoms often change over time. It can be helpful to address the management of temperament traits in therapy.
Brain research has revealed that neurochemistry is disrupted in individuals with eating disorders. Serotonin and dopamine are neurotransmitters that are involved in complex signaling pathways. These pathways are dysregulated in eating disorders, mood and anxiety disorders. Dopamine is involved in functions related to reward, pleasure, movement, compulsion and perseveration. Serotonin is involved in functions related to mood, memory processing, cognition and sleep. Considerable evidence suggests that altered serotonin and dopamine functions contribute to dysregulation of appetite, mood, impulse control and temperament in individuals with eating disorders. Restriction causes reduced plasma levels of tryptophan, the precursor to serotonin, which modulates serotonin activity and therefore symptoms of anxiety and depression. In individuals without eating disorders, dopamine is associated with a positive reinforcement effect in feeding. In other words, eating feels good.
In anorexia nervosa, dopamine dysregulation diminishes the reward effects of food, so that eating does not necessarily feel good. Data suggests low levels of dopamine receptors and weakened responsivity of dopamine is associated with increased eating and weight. We also know that appetite-regulating hormones, like leptin and ghrelin, may affect dopamine functioning. Leptin is an appetite suppressing chemical, and ghrelin stimulates the appetite. In patients with anorexia nervosa, ghrelin is abnormally low. In patients with binge eating, leptin is abnormally low. These findings help confirm that eating disorders are not due to “lack of will power”. There are chemical alterations in the brain that affect the development and persistence of eating disorder symptoms.
The more we as providers understand the biological basis of eating disorders, the better equipped we are to provide effective treatments. Based on new research in the field, novel medications are being studied that may help us better treat eating disorders. Psychiatric medications that target serotonin and dopamine pathways, such as SSRIs, can be very helpful in the treatment of eating disorders and co-morbid anxiety and mood disorders. Usually, the best treatment for eating disorders is a multidisciplinary approach involving a therapist specializing in eating disorders, a psychiatrist, nutritionist and primary care physician.
Content originally posted on October 5, 2017 at http://www.oliverpyattcenters.com/part-one-mental-illnesses-are-brain-diseases/
Written by MEDA Graduate Clinical Interns, Molly Curcio & Rachael Trotta in response to the Boston Globe Article “After patients’ weight loss surgery, her work really begins” published on September 15, 2017
There are a number of factors that influence food choice and body size. The general public has a tendency to focus on the notion of “self-control” and dieting rather than underlying invisible influences. Those struggling with disordered eating are often stigmatized, shamed, and told they lack self-discipline. Too often, people think that weight loss is solely about “willpower”. This misconception ignores the fact that there are neurological pathways and responses that have significant unconscious power over our decision making regarding food and exercise. Additionally, all bodies react differently to the stimuli of nutrition and movement; we are literally not in control of how the body responds.
Beyond biology, there are emotional components that play a part in why people make certain food choices. There are a number of reasons that extend beyond hunger that influence a person’s choice; these can include feelings of loneliness, anger, sadness, guilt, boredom, and frustration. Eating can become a way to cope with distressing emotions, take care of oneself, and survive difficult situations. For many, there is no longer a trust in the body to regulate itself. Instead, external cues and rules regarding food cloud the innate ability to respond to biological prompting. To only address weight loss ignores the root of the behavior, the purpose it serves, and sets up a system that will likely fail and lead to a harmful restrict/binge cycle. It also ignores the simple truth of body diversity- not all bodies are meant to be thin.
Societal influences also play a role in an individual’s beliefs and behaviors around food.
On a daily basis the public is constantly bombarded with subliminal messages that reinforce unrealistic beauty standards. Simultaneously, industry conglomerates invest millions of dollars in media campaigns that promote illusions that eating certain products will cure any life stressor. These conflicting forces can create an environment in which it is difficult to intuitively eat rather than follow “food rules” that are ineffective and harmful.
Making assumptions based on appearances ignores the truth about an individual’s health–both physiological and psychological. It ignores the reality that there are many factors that influence each food choice and the body’s response. Perpetuating the misconceptions associated with disordered eating hinders the desire to seek treatment, as our society has conditioned the public to believe that particular external factors signify health. There is no quick fix or easy solution to address disordered eating. Moving forward, it is critical to establish a community of treatment providers and medical professionals who have sufficient knowledge on the multifaceted nature of disordered eating and the various treatment options available.
If you are struggling with your weight and suspect you may have a disordered relationship with food and/or exercise, do not hesitate to reach out to MEDA for help at 617-558-1881 or firstname.lastname@example.org
For more information on our services, see our website here: www.medainc.org
Written by MEDA Undergraduate Intern, Gabrielle Silva
Fall has finally made its return, and though the temperatures remain high, all of the traditional Fall favorites are in full swing. From pumpkin spice to Halloween decor, people are embracing the season. For many, Fall also brings the long awaited return of football season. Whether you’re a fan or not, you can’t help but notice its return. Football season is almost like a part of our culture. For the next few months it will dominate the media, and we’ll hear about players, games, wins, losses, injuries, scandals, and more, but there’s one thing most won’t be talking about, and that’s football, and the high prevalence of fat shaming against players that occurs.
In a recent article on ESPN, Eddie Lacey, from the Seattle Seahawks opens about the chronic fat shaming he has endured throughout his career as professional football player. Lacey describes the constant barrage of fat jokes, and body comments he faces every day through social media, and interviews, and even in public appearances. Throughout the article he opens up about feeling like his weight is all people focus on, and how that has affected him emotionally. Despite being a very successful athlete, Lacey discusses feeling like his talent and success are often overlooked because of the public’s fixation on his weight. He goes onto to talk about how he can’t even post on social media without getting at least a few fat jokes in response. Lacey says, “Like I could tweet, ‘Today is a beautiful day!’ and someone would be like, ‘Oh yeah? You fat.’ I sit there and wonder: ‘What do you get out of that?’”
The athlete has been dealing with comments like those for years. Internet trolls would scroll through his twitter looking for places to slip in a fat joke. Others actually made several very hurtful memes about Lacey and circulated them across the internet. He shares he feels as if the fat shaming he faces is inescapable, it seems to follow him wherever he goes, or whenever he opens up an app on his phone there’ll be a new comment about his weight from yet another person. Though Lacey’s struggle with fat shaming has been so public, it’s not a subject that is ever talked about in the football world. Though it should be, because sadly, Lacey is not the only pro football player to experience brutal fat-shaming on a daily basis. However, because society puts a certain pressure on players to be tough, and never show their true feelings, the harm and hurt that comes with fat shaming gets swept under the rug, and these players are forced to deal in silence with the negativity they face from the public everyday.
From high school to the pros fat-shaming is an unfortunately common experience. In my high school days, I was a member of the color guard, and I was expected to be at every home football game. At those games, I remember witnessing many instances of fat-shaming against our school’s players. They were expected to laugh it off, and be unperturbed by the unwarranted comments about their bodies. Players literally grow up with this fat-shaming culture, and often come to expect it as part of playing football. This shouldn’t be the case. Players should not have to undergo bullying and body-shaming while playing the sport they love. Just because these athletes are often perceived as emotionless, and immune to the negativity doesn’t mean they actually are.
Fat-shaming hurts no matter who you are, which is why it’s so great that Lacey chose to open up about it. Hopefully, his candidness with ESPN will spark a much needed discussion about the undue prevalence of fat-shaming in the sport of football. It is also a hope that more athletes from school age to the pros will be able to speak out and share their experiences to begin to create a more accepting culture. One that focuses on the whole person, and not their weight, because after all, weight does not equal worth.
Van Valkenburg, K. (2017, September 20). ‘You Just Can’t Shake It’. ESPN. Retrieved from http://www.espn.com/espn/feature/story/_/id/20756278/seattle-seahawks-eddie-lacy-opens-public-struggle-weight
written by Monte Nido & Affiliates Vice President of Admissions Dr. Melissa Spann, PhD, LMHC, CEDS
Dr. Spann discusses the difficult decision of entering into eating disorder treatment during the school year.
As the summer ends and the crisp fall air approaches, the season of back to school is upon us. While this time of year can excite some, for others, the beginning of school is coupled with feelings of anxiety and stress. For those individuals considering going away from home for school for the first time or leaving home once again to return to college, this time can be fraught with decisions around lack of parental involvement which can lead to struggles with schedule, sleep, study, exercise and food.
I recently spoke with a client regarding a “quick admission” to residential treatment so she could return to college for her junior year. During the course of the conversation, this lovely, articulate and bright twenty-year-old told me every summer for the previous three years she had been in treatment. When we explored those treatment stays, she reported she consistently discharged to “get to school on time”. We discussed what it would mean for her to commit to being present in treatment for the recommended length of stay, rather than entering treatment for a specified period of time to engage in minimal weight restoration, receive a quick tune-up and brainstorm potential pitfalls for her return.
This conversation is one many professionals have during this time of year. When is it time for our clients to remain in a higher level of care and when is it time to return to their college campus? College students are left to cope with high-pressure academic environments, navigating complex social nuances and trying to engage in self-care; even in the best of circumstances this is challenging. Add an eating disorder to the mix and an individual is left to manage feeding themselves, self-monitoring exercise and managing substances which can significantly increase engagement of eating disorder symptoms, anxiety and depressive symptomatology.
The National Eating Disorder Association (NEDA) conducted a Collegiate Survey Project in which they reported:
The increased pressure and stress of school and leaving home may lead to mental health problems among college students and a greater need for campus services. This is also a period of development in which disordered eating is likely to arise, resurface or worsen for many young men and women. Full-blown eating disorders typically begin between 18 and 21 years of age (Hudson, 2007). Although some students will experiment with dieting and escape unscathed, 35 percent of “normal” dieters progress to pathological dieting. Of those, 20 – 25 percent progress to partial or full-syndrome eating disorders (Shisslak & Crago, 1995).
With every client, parent and provider I speak with, I encourage them to dig deep in consideration around the return to school. The idea of taking a semester off may be a painful one; however, the ultimate benefits may far outweigh the potential challenges.
I believe it is more beneficial for an individual to engage in treatment fully and completely, rather than potentially need to reenter in the future.
For questions or more information on supporting your client or loved one in the transition from treatment to school, please email us directly.
Content was originally posted on http://www.oliverpyattcenters.com/3084-2/ and is re-posted here with permission.
Written by MEDA Undergraduate Intern, Alexa Riobueno-Naylor
This summer, the eating disorder community has had the opportunity to engage in both educational and challenging public conversations about eating disorders. The release of the film To the Bone at the beginning of the summer caused many to speak out about the positive and negatives aspects of the film. Some pointed out how triggering the film was, criticizing it as an unnecessary misrepresentation of eating disorders, while others lauded the film for its honesty. In the end, it seemed as though the film raised more questions than it answered.
As discussions of To the Bone abated, another film based on the experience of a young woman with anorexia was released. In early July, Troian Bellesario released a film that she wrote and starred in called Feed – a film informed by her own experiences with anorexia and mental illness. Troian Bellesario has been a long-time advocate for mental health awareness and has participated in eating disorder advocacy through the National Eating Disorders Association (NEDA). Her willingness to speak openly and honestly about her own struggles with mental illness inspires many. She has successfully used her platform as a well-known actress to bring attention to issues of mental illness. The eating disorder community has been lucky to have such an outspoken celebrity representative such as Bellesario.
In an article written for NEDA about the film, Bellesario writes that, “I wanted to write a film that opens up the conversation about eating disorders and tells the people who are listening to that horrible voice in their head that it’s not the way their life has to be.” Bellesario created a film that complicates our understanding of eating disorders. She accomplished this by focusing less on eating disorder behaviors, and more on the trauma and anguish that lies behind the illness.
It is unfortunate that there seems to have not been as much attention put on Bellesario’s film as was put on To the Bone. Maybe it is because we are all still recovering from To the Bone, or maybe it is because the film wasn’t released on an accessible streaming site such as Netflix. However, it may have to do with the fact that Feed was not as much of a visually provocative story. The film doesn’t include multiple close-ups of Bellesario’s body, although there are some instances in which the camera highlights her body in order to emphasize how sick she is. The film doesn’t show Bellesario fixating on the scale, or focusing on numbers. Instead, the film is centered around the psychological and emotional pain that Bellesario’s character (Olivia) endures. It focuses on the complexity of her grief, and the horror that she experiences as a result of her mental illness. In other words, it isn’t the romanticized, body-focused eating disorder narrative that we are all used to.
There are other positive aspects of the film, including the fact that the plot did not revolve around depicting Olivia’s eating disorder behaviors. However, it must be noted that the film does include some depictions of Bellesario’s character hiding food and over-exercising. In an article she wrote for NEDA, Bellesario speaks to this point:
“And for the people who think that eating disorders are just about being skinny, or a choice? For people who don’t think they are a serious problem? I wanted to put those people inside one experience of an eating disorder and have it scare the hell out of them. I wanted to convey how uncomfortable it was, not only for me, but for my family and friends, too. I wanted them to understand that eating disorders aren’t about vanity—they’re rooted in pain and a sense of hopelessness and, as you see in the film, often tied to trauma.”
As Bellesario mentions, the film provides space for other characters, such as Olivia’s parents, to experience complex emotional pain, highlighting the many ways in which individuals cope with grief and trauma. Olivia has a complicated relationship with her parents, in that they are supportive, but also sometimes triggering. Olivia’s dad often encourages her to exercise, and focuses on food rather than his daughter’s emotional turmoil. Her mother tries her best to take care of her daughter, eventually realizing that her daughter needs professional help. All the while, the parents’ relationship becomes strained, as they are forced to deal with multiple tragedies throughout the film.
Olivia’s parents are never blamed for their daughter’s eating disorder, and the film explores how they are struggling to find ways to effectively support their daughter as she enters residential treatment. The experience that Olivia has in residential treatment is highlighted in the film, which is important. Bellesario depicts how overwhelming residential treatment can feel to someone in the throes of an eating disorder, while simultaneously stressing the importance of residential treatment in achieving recovery. Her journey towards recovery only starts when she begins establishing a trusting and honest relationship with her therapist. In one of the final scenes of the film, the importance of their relationship is emphasized as the therapist provides Olivia with support as she challenges herself to have a meal outside of the treatment center walls.
I have mixed feelings about the end of the film, which closes with Olivia struggling to distance herself from the eating disorder voice inside her head, which communicates to her through hallucinations of her dead brother. To some degree, the ending is successful in depicting the difficulties of recovery, and the struggles that come along with relapse. Bellesario’s character inches towards recovery, while she is simultaneously struggling to keep moving in the right direction. This depiction is effective in that it makes it clear that recovery doesn’t happen overnight, or happen when a person all-of-a-sudden chooses that they want to be rid of their eating disorder.
In article Bellesario wrote for Lenny Letter, she discloses her struggles as someone living with mental illness:
“There is a part of my brain that defies logic… that part of my brain is my disease, and there was a time when it had absolute authority over me. It almost killed me, and you can see that even though I have lived in recovery for ten years now, it still finds loads of fun, insidious ways to thwart me to this day. It was a difficult journey finding my way back to health. Through hard introspection, intense medical and mental care, a supportive family, friends, and a patient and loving partner, I survived, which is rare.”
I applaud Bellesario’s ability to speak candidly about the work that goes into maintaining recovery. I applaud her dedication to mental health advocacy, and eating disorder awareness. I applaud her for making a film that challenges many of the stereotypes that are perpetuated in other eating disorder films. However, I still think we can do better when it comes to representing eating disorders.
Much like the majority of other films that depict a protagonist struggling with an eating disorder, Bellesario’s character is not diverse. She is depicted as a white, cis-gender, heterosexual, economically privileged, Christian, small-bodied, feminine, beautiful valedictorian with anorexia. This is what we are used to when it comes to representations of eating disorders, dating back to movies released about eating disorders in the early ‘80s. This film represents many people’s eating disorder story, including Bellesario’s. Therefore, the film includes aspects such as Bellesario’s weight loss to visually indicate that she has an eating disorder. Bellesario did not need to lose weight for the role, and the fact that she did emphasizes how individuals who may not “look like” they have an eating disorder continue to be ignored. The film also fails to represent many people, such as men, people living in larger bodies, people of color and folks who are LGBTQ, poor, disabled, or marginalized in other significant ways. These groups continue to not be represented in films and media about eating disorders, and we must continue to speak out about this issue until we begin to see the representation that these communities deserve.
With that said, I think Feed represents a move in the right direction. This film educates the public about how difficult it can be to have your brain taken over by an eating disorder. It also makes it clear that recovery from an eating disorder is possible, which is so important. If you want to watch a movie about eating disorders, out of all the movies that have yet been created, I’d recommend Feed. However, this recommendation does not come without trigger warnings for parts of the film that depict death, suicide, eating disorder behaviors, substance use, and shots of Bellesario’s emaciated body. The film doesn’t offer us a diverse perspective on the experience of an eating disorder, but it does venture away from many of the stereotypes we have become accustomed to seeing in other eating disorder films.
(1) A Dark Ride—On Writing What I Know. By Troian Bellesario, in the National Eating Disorders Association Blog July 2017.
(2) Troian Bellisarion Gets Real About Her Struggle with Mental Health. By Troian Bellisario, in Lenny Letter July 18th, 2017.