A few days ago a paper describing the theory that anorexia may be more of a biological disorder than a psychological condition was disseminated in the media. The general gist as I understood it was that when the majority of people become malnourished the response of their body is to try to make them eat more, whereas when people predisposed to anorexia become malnourished, biological changes occur which serve to keep them acting in a way which perpetuates their malnourishment. In this theory, it’s this “broken” response to starvation which stops a person from recovering, not anything to do with personal choice or motivation. Sounds like my sort of thing, right? I thought it was interesting – I’m not entirely sure that I understood all of the ins and outs, but it seemed to be a variation of the type of research that I think explains eating disorders better than any of the old school psychological theories – and so decided to post it on the twitter feed I run for the ED charity. But however hard I looked, I could NOT for the life of me find an article on the theory which wasn’t full of ignorant/offensive/triggering comments. The comments on the Jezebel article were probably the best of the bunch, but some commenters still seemed determined not to get the point of the article. “So if I diet hard enough I’ll get anorexia?” one person wrote with obvious disbelief. A couple of people (ahem…I might have been one of them) replied saying that no, you need the right biological make up for weight loss/malnutrition to turn into full blown anorexia, but she replied again a few hours later saying “I was just following what the article said to the logical conclusion”. No you weren’t!

This, similar comments and far worse on other articles made me wonder why people are so resistant to scientific explanations for mental health problems. I can think of a few reasons. There’s fear and scepticism about the marketing of mental illness by drug companies, for a start. There’s an attachment to the theories you’ve learned and subscribed to for years too – for example, some people REALLY want to believe that eating disorders are caused entirely by the media’s emphasis on thinness because that’s what they’ve always been told, whereas others are certain that mental illness as a whole is an affliction of the weak and selfish. Even when presented with hard evidence otherwise, people who are truly wedded to a certain belief will find some way to discount everything else. I’m a nerd so I love scientific theories. It would take a lot to convince me that there was NO biological component to eating disorders – but if it could be proved, I like to think I would be open minded enough to change my ideas. It is painful to backtrack on deeply held beliefs, so I am glad that all the evidence points in the other direction at the moment.

From this point of view it makes sense that often the people who are most afraid of this kind of research are those suffering from mental illnesses themselves. Eating disorders are all consuming and the way the illness affects a person can make them deeply attached to the behaviours – becoming terrified of change and/or seeing the behaviours as having benefits which are too important to lose. Being told that this entrenchment in the disorder is a product of biology is kind of like explaining the biological mechanisms behind love to a besotted couple. It can seem reductive and dismissive – if you feel your eating disorder had a justifiable trigger you might feel offended by the growing evidence that the biggest risk factor is genetic. Someone who developed anorexia after dieting due to peer pressure might understandably believe that they had a clear and obvious reason for becoming unwell, as might someone who was abused and sees their restriction as a coping mechanism.

I used to feel that way. I went through a lot during my adolescence, and I felt that biological theories of eating disorders and other mental illnesses somehow suggested that my experience didn’t matter or didn’t harm me at all. Of course this isn’t true – mental illnesses require environmental triggers as well as a biological predisposition, and even if I hadn’t been vulnerable to any type of mental illness I would still have been traumatised by being bullied and raped. I just wouldn’t have developed anorexia regardless of how traumatic my past had been. Also, “environmental” encompasses more than just trauma. For instance, someone with the right biological make-up might develop anorexia after not eating properly for a few weeks due to a physical illness. A teenager who is prone to anxiety and loses their appetite before important exams might first unintentionally under-eat and then begin to starve themselves as the predisposition kicks in, despite the fact that exam stress is a normal part of growing up which many people go through without getting ill. It doesn’t mean that person is weak, it just means their brains react in a certain way to not eating enough.  And if you take a hundred people on a diet, ninety nine of them will a) give up after a few weeks, b) lose weight healthily and maintain, or c) go overboard but eventually be forced to eat more by their body (yo-yo dieting anyone? Bodies don’t like being starved). But that final person with the right biology will be the only one to develop full blown anorexia in response to dieting.

That doesn’t mean that the media has a free pass to be as worshipful of emaciation as they like. It doesn’t mean that bullying or abuse doesn’t deeply scar people. It also doesn’t mean that anorexia is the only true eating disorder, and that bulimia, EDNOS and BED are lesser forms of disordered eating. People react in different ways to chaotic or insufficient diets, and there’s no reason why genetic predisposition couldn’t account for why, for any given scenario involving under-eating, some people become anorexic whereas others develop bulimia or a combination of ED symptoms, and the rest of the population escape scot free.

It does complicate things if your eating disorder began while you were going through a lot of stress or trauma. The behaviours seem to take on deeper meanings. Much of that disappears with weight restoration and/or cessation of behaviours – most of my eating disordered beliefs seem downright illogical now, but once I was convinced they were true and no amount of therapy could change my mind. Even so, I think that working out which fears were just part of the illness and which were more than that can be invaluable. For example, in recovery I had a big problem with adjusting to being female-shaped again, because it triggered memories of being raped. That was something I had to work on in therapy after I was weight restored, otherwise it might have caused enough stress to make me stop eating properly again. That doesn’t mean that being raped caused my anorexia, just that it complicated it and that the PTSD had to be resolved to make my recovery more stable.

There are no incompatibilities that I can think of between science and the lived experience of an eating disorder – but I found that difficult to accept once, and it seems that a lot of other people do too. I am always sceptical of research which suggests that a specific drug is a miracle cure for a specific mental illness. But most research is just looking for the best way to explain and treat illnesses. Studies like these might eventually make the difference between a twelve year old with anorexia getting the right treatment first time and recovering within the first year – and the same person living with an eating disorder into their thirties because they received poor, outdated treatment time and again. How can science be a bad thing?


6 responses to “Resistance

  1. I like the combination of biology and phsycholgy and science combined.
    There is certainly a genetic/biological component to anorexia….
    Manytimes a decision to diet leads to disordered eating and anorexia. These women genertally get help when they start getting sad and weak. But serious full-blown anorexia requires something biological — severe cases (like the Isabel Caro types) are a bit different than dieting.
    (I know I am pushing the envelope of ED PC talk but I trust that you get what I am saying and I am not glorifying anything or making any person’s experience less serious or painful than any other …yaddayaad. Please tell me you get where I am coming from ?(0:)

    • I do get where you’re coming from, but that’s not exactly what I meant (or the study!). You don’t have to look like Isabelle Caro to be sick – as I’ve said before, bulimia and EDNOS have mortality rates comparable to anorexia, and 80% of people with full blown eating disorders are not underweight. Biology can account for people who have eating disorders but are not underweight as well. Anorexia is not the most serious or dangerous ED. Plus, unless you are quite a bit shorter than average the majority of adults would be pretty damn sick even in your dieting example! Context is everything.

      *ETA* Actually, I might get shouted at for this (censoring!) but I edited out the numbers you mentioned. I think they could have upset people and I really don’t want anything on my blog to do that. Sorry for messing with your comment ❤

  2. It is often is best to refer back to the original paper Katie: see:

    As you know, I am very much in favour of recognising and describing AN as a biologically based illness, wherein starvation plays a significant role and genetic factors likely play some sort of role – although as yet we do not know precisely how genetics influence the risk of developing AN. Neither do we know, for certain, what is happening in the brains of people with AN that causes them to develop the illness and remain within it. For example, techniques such as fMRI have enabled metabolic activity in various regions of the brain to be examined in response to various cues (e.g. food cues) in individuals with and without AN, and for comparisons to be made between ‘patients’ and ‘controls’; however, none of these data definitively account for the aetiology of AN. The recent paper by Dwyer et al. (which I have read in full) is hypothetical and draws together experimental data on a particular theme: the metabolic responses to starvation.

    Like many biomedical scientists I prefer hard, empirical data. It is what I am used to working with and makes the most sense to me. Yet, it is common for individuals who support the hypothesis that AN is a biologically based illness to dwell upon hard empirical data, describe such data as ‘evidence based’ (which it is), but discard data from qualitative research studies that investigate (e.g.) commonalities in the lived experience of the disorder. However, qualitative studies also count as evidence based and pass through a peer review process. Of course, it could be argued that interviewing patients who are sick with AN is merely listening to the anorexic voice, and that voice may change with weight gain and recovery.

    From a personal standpoint, I feel 100% confident that my AN was biologically based. I come from a loving family and I have never had any interest in thin models/celebrities or felt ‘triggered’ by thin images. I am totally turned off by the emphasis on such stuff. However, I also admit that it is not entirely clear how biology played a role in my illness. I will hazard a guess that the most likely genetic role has been through an influence on temperament, personality and cognitive processing. We have a lot of autism and OCD in my family. I, myself, have OCD (that existed loing before the onset of AN), significant autistic traits – primarily in the realms of attention to detail, poor set shifting and extreme systemising. Starvation accentuated these traits. Yet, I am also certain that environmental triggers – in the form of sexual abuse by an adult outside of my family and serial bullying by peers at school played a role. I became so depressed at age 10-11, one year before I developed AN, that I wanted to disappear. I loathed what was happening to my body at puberty (the change was frightening) and this loathing and depression preceded the onset of AN by a couple of years.

    Weight gain to a healthy weight for each individual is absolutely essential to the recovery from AN, and I remain ambivalent about the efficacy of the many forms of therapy. I don’t think we have reached a stage where we can categorically state that AN has a definitive biological cause, or is a ‘brain disorder’ – even though there is much evidence to support a biological basis. Neither do I think that there is an effective one-size-fits-all treatment for AN. But I think it is nihilistic to ignore the hard scientific data that are accumulating in relation to the aetiology of AN.

    • Thanks Cathy! You know I agree with you 😉 I saw the abstract for the paper somewhere last week but couldn’t find it again when I looked – and really it was the reaction to the write-ups of the paper which interested me more than the paper itself, if that makes sense.

      • Sorry I left you an essay above… I didn’t realise how long it was until the comment posted!

  3. Oof. Accidentally deleted my comment before I even sent it. Clever, me.

    Anyway, glad I finally got time to read this post properly. Whilst I don’t really have anything of any intellectual value to contribute, I really do appreciate when you do posts like this that comment on studies etc. I’ve learnt a lot through them – and they’ve proven quite eye opening in terms of unravelling my own understanding of stuff (‘scuse my use of technical terms ;)) and opened my eyes at various points that change is possible.

    I found this one really fascinating, and it’s given me a lot to chew over, so I think I’m going to go off and process for a while.

    And thank you again, for your posting stuff like this.

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