Exercise very often plays a role in the development of restrictive eating disorders, particularly Anorexia Nervosa (AN). Some people view exercise as “a form of purging” or “a way to get rid of calories.” These explanations seem to make sense in light of modern western society’s views on exercise, similar to the theory that people with AN restrict their calories in order to conform to society’s thin ideal. But like the thin ideal theory, the “exercise purging” theory is an erroneous attempt to make sense of a puzzling symptom in the context of modern society.
In AN, excessive exercise, just like food restriction, is a biologically-based symptom, driven by something beyond conscious control or awareness. Patients do not exercise “to burn calories,” although they may insist that burning calories is their motivation. Consider, for example, the fact that even patients who know they are too thin are motivated to gain weight (yes, such patients do exist), often cannot stop themselves from moving unless they are forced to do so. Young children with AN are especially susceptible to the drive to exercise even though they have no idea what calories are or how to burn them.
A little history may help to put this into context. People did not really exercise for the purposes of physical fitness and attractiveness prior to the “exercise boom” of the 1970’s and 1980’s. However, hyperactivity was a symptom of AN long before Jane Fonda’s exercise videos found their way into American living rooms.
The nineteenth-century British Physician William Gull, the first clinician to describe AN medically, was surprised by the seemingly boundless energy that his anorexic patients possessed despite their emaciated state. In his 1874 paper entitled Anorexia Nerovsa, he wrote the following description of a young anorexic girl: “The patient complained of no pain, but was restless and active…it seemed hardly possible that a body so wasted could undergo the exercise which seemed agreeable.” Clearly, this young woman was not motivated by the pursuit of a thinner body, as the idea of exercising to “burn calories” would not emerge until a century later.
Animal research has shown that the hyperactivity commonly associated with AN is rooted in neurobiology and may serve an adaptive evolutionary purpose. For example, activity-based anorexia can be experimentally induced in rats which, like humans, evolved as opportunistic omnivorous foragers. When food-deprived lab rats are given free access to a running wheel, they become hyperactive, lose large amounts of weight, and will often die unless they are removed from these experimental conditions. I highly doubt that these rats were running excessively to purge calories, ward off obesity, or pursue some unrealistic standard of rodent beauty.
So why would AN, which leads to numerous health problems, infertility, and death, remain in our gene pool for tens of thousands of years? Shan Gusinger, an evolutionary biologist and a psychologist, posits that AN has evolved in humans as a means of helping us flee from food-depleted environments. The restless energy, grandiosity, and lack of awareness of one’s starved body allowed prehistoric anorexics to lead their tribes in migrations from food-depleted areas to plentiful ones.
Once the anorexic leader and her tribe arrived in a plentiful environment, the tribe feasted, pressuring the anorexic leader to indulge in food with them. In the absence of modern society’s thin ideal and without our modern obesity hysteria, prehistoric anorexics may have been able to allow their families to feed them, restoring their health and fertility. Even if the anorexic herself died of her condition or was rendered infertile, her close genetic relatives survived and reproduced, thus ensuring the continuity of AN into the next generation.
In our modern world, where children are encouraged to exercise more and make “healthy” (e.g. lower calorie) food choices as early as kindergarten, it is no wonder that AN is still around. During the pre-teen years, when rapid vertical growth and pubertal development demand extra energy, girls and boys are hit hard with the social pressures to be thin (for girls) or lean and ripped (for boys). The rapid weight gain that is necessary for growth and development is feared and despised in these growing children (and often, sadly, in their parents and pediatricians).
Adding add fuel to the fire, the pre-teen years are when intense and time-consuming athletic training begins. Competitive sports provide socially-applauded outlets for the young anorexic’s hyperactivity. No one bats an eye at the 12-year-old dancer who spends hours each evening at her studio in preparation for her next audition, or the 11-year-old boy who plays multiple back-to-back games each weekend with his elite travelling soccer team. Meanwhile, these children are making “healthy food choices,” consuming too few calories and fats to keep up with normal growth, let alone intense daily exercise.
In these vulnerable children, their vertical growth is stunted, their pubertal development is halted, and their intense athletic drive is praised by adults. And before you know it, they have fallen down the rabbit hole and developed full-blown AN. In this way, hyperactivity serves as both a precipitating factor and a perpetuating factor in the development of AN.
In my next post, I will discuss the role of exercise in eating disorder recovery.
High levels of physical activity coupled with restricted intake of food also explain, in many individuals, the psychological symptoms associated with anorexia nervosa, including sleep disturbance, fatigue, loss of vigor, loss of self-confidence, irritability, depression, anxiety, confusion, emotional and motivational imbalance, anger, hostility, mood swings, and loss of appetite. For a review of this body of research, read the free online full text of the paper A Review of Overtraining Syndrome — Recognizing the Signs and Symptoms,
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1317287/ That’s why most people recover from activity-based anorexia, including the psychological symptoms, when their parents take charge, refeed them, and help them return to a healthy weight, regular patterns of sleep, and normalized patterns of eating. Unfortunately, many athletes with Overtraining Syndrome/ Activity Based Anorexia are misdiagnosed. They are given a diagnosis of one or more mental illnesses or psychiatric disorders. This typically results in the use of ineffective psychotherapies and psychiatric medications. For these individuals, however, the best medicine is food and rest, which together tend to reverse the psychological symptoms described above. FBT tends to work well. Keeping these individuals and their families out of the psychiatric system is generally a good idea.
CB
Chris,
I do agree that most patients can recover at home with the help of their families, and that admission to hospital or residential treatment can and should be avoided in most cases, unless necessary for short-term medical stabilization.
I also agree that psychotropic drugs are overprescribed in this population and that food and rest are very effective in treating many symptoms of AN (which are actually symptoms of starvation).
I am puzzled, however, by your the last sentence, which seems to contradict the sentence before it. What do you mean by “the psychiatric system?” FBT, by definition, involves a psychologist or a psychiatrist who collaborates with the patient’s parents to help him/her recover.
The “psychiatric system” is the system of psychiatrists and related professionals who treat psychiatric disorders. This system assumes that the underlying cause of the sufferer’s problem is a psychiatric, or mental, illness. In my opinion, that system is not well designed to help teenage athletes who suffer from activity-based anorexia. We know from a fairly large number of studies that the psychiatric system results in success for only about 1/4 of people who are diagnosed with anorexia after two years of treatment, and about 1/2 within five years. This is true regardless of the specific psychiatric treatment model used. See, for example, the Gowers TOUCAN study, the ANDI study, the Godart paper on hospitalizing AN patients in France, the Freeman/Strober paper on outcomes, reports by Halmi on hospitalization of AN patients at Columbia University (only about 1/4 recover after 3.5 months of hospitalization) and the review of all studies on “systemic family therapy” by the Cochrane Collaboration (no evidence systemic family therapy is effective in treating AN). In short, the psychiatric system has been largely a failure in the treatment of anorexia nervosa generally, and therefore we can assume for the subclass of sufferers from activity based anorexia. For a further discussion of the flaws in the traditional psychiatric approach, see the recent paper by Bergh published in Behavioral Neuroscience, a journal issued by the American Psychological Association, which describes why so much of the psychiatric approach to AN is misguided and infeffective, and offers some pretty good data supporting a non-psychiatric approach, including impressive outcomes achieved by Mandometer. Bergh, Effective Treatment of Eating Disorders: Results at Multiple Sites, Behavioral Neuroscience 2013, Vol. 127, No. 6, 878-889, http://www.apa.org/pubs/journals/bne/index.aspx Attia and Bulik have both published papers in recent weeks acknowledging that the psychiatric system hasn’t been able to deal very well with anorexia nervosa. (See, for example, the recent issue of the Lancet reporting on the ANDI study.)
By contrast with psychiatric treatments, FBT does not assume that an underlying psychiatric disorder is causing or maintaining the symptoms of anorexia nervosa. In fact, FBT is completelyagnostic with regard to cause. Therefore, I don’t consider FBT a “psychiatric” model.
In my opinion, parents are well advised to first treat activity based anorexia in their teenager at home without professional involvement, if at all possible. If, after a reasonable period of time, they aren’t seeing weight gain, they might want to involve an FBT professional as a second-line treatment. If FBT isn’t working, then they have a real problem because it isn’t clear that the psychiatric system has any other treatments that will be able to help them. Mandometer might be the best third-line treatment.
I suffered from bulimia and excessive exercise for 13 years and also viewed exercise mainly as “a form of purging”. The most important thing to realize on my way to recovery was that exercise is not a way of keeping me thin and burning calories. I had to reprogram my mind and start thinking about it as of a way to maintain my physical and mental health. As something to keep me healthy, not thin, a strategy that together with quality food nurtures my body so that I can enjoy life. This point of view is crucial; it gives a whole new perspective and all of a sudden takes the pressure off. Finding balance in everything is the key. I went through a life overhaul and after 3.5 years of full self-recovery I decided to share it in my book The Most Honest Book About Eating Disorders: http://www.amazon.com/Most-Honest-About-Eating-Disorders-ebook/dp/B00HRWF15I, in a hope that it will help as many people as possible to heal and find themselves again.
So I apparently “over exercise” or “exercise compulsively” and restrict my food. While I was an athlete all my life, playing 2 division 1 sports in college, I believe my exercise is calorie driven. Even if I didn’t have an ED, I would still be exercising and playing sports, but I make sure I go to the gym and work out to burn calories. I wear my heart rate monitor, which keeps tracks of calories burned (even if it’s not 100% accurate, it’s something I can monitor and keep track of). My T keeps asking me to bring it to her because she wants me to stop using it. I feel like if I didn’t have it on, my workout “wouldn’t count” because I wouldn’t know how many calories I’ve burned. So for, me, I think it is mostly about burning calories. That’s what I’m keeping track of.
Although not directly on the topic of Sarah’s blog post, I would like to add to the discussion of whether keeping anorexic teenagers out of the “psychiatric system” is a good idea, as I proposed, above.
I think it is.
First, the psychiatric system hasn’t given us good answers to date. One of the leading psychiatrists who studies AN, Walt Kaye, stated as recently as last year that “there are no proven treatments” for AN. Kaye, Nothing Tastes as Good As Skinny Feels: the Neurobiology of Anorexia Nervosa, Trends in Neurosciences, 36, 110-120 (2013) (Free full text available on the website of Trends in Neurosciences) Why would parents want to engage with a system that admits it has no proven treatments?
Second, the best available evidence shows that treatments targeting eating behaviors implemented by non-psychiatrists are more effective than psychiatric treatments. This includes Family Based Treatment (FBT) and Mandometer, both of which have relatively high rates of success. Neither one targets psychiatric disorders. Both target eating behaviors. Both are based on the idea that food is the best medicine. Both are premised on the idea that we should always give food a chance.
Third, Bergh and colleagues persuasively argue that the psychiatric symptoms sometimes associated with anorexia nervosa, including anxiety, depression, and perfectionism, are the consequence of AN and starvation, not the cause. Evidence for this includes the general failure of psychotherapy and pharmacotherapy to cure AN, as well as research into the effects of starvation, including the Minnesota Starvation Study. While it is argued by many psychiatrists that anorexics restrict food intake in order to relieve anxious mood, and therefore anxiety should be targeted in treatment, those efforts have not been successful. When anorexics are given anti-anxiety medications, for example, we know that their levels of anxiety drop. But they don’t suddenly start eating more. Instead, they continue to restrict, even when they aren’t feeling anxious. Given this, why would we expect talk therapies aimed at reducing anxiety, or targeting any othe psychiatric condition, such as depression or perfectinism for that matter, to be any more effective?
Fourth, calling anorexia a “mental disorder” or “psychiatric disorder” tends to give parents the false message that only experts can effectively treat it. This is disempowering and contrary to the best available evidence. Parents are not only competent, they are, as acknowledged by world-leading experts, more skilled than professionals are in treating anorexia nervosa in children and adolescents. Parents wouldn’t routinely call in a psychiatrist if their teenager began to smoke cigarettes or drink alchohol, even though both those behaviors have rates of mortality at least as high, or higher, than anorexia nerovsa. Why should they routinely call in a psychiatrist when their teenager begins to restict intake of food? If psychiatry had good answers, they might. But as Walt Kaye acknowledges, it doesn’t.
Finally, it is known that many of the “psychiatric” treatments for anorexia nervosa cause more harm than good. Institutionalizing teenagers in psychiatric hospitals, for example, is known to cause potentially severe psychological damage. It also does not lead to improvements in the rate of long term recovery from anorexia nervosa, as shown by several studies.
Only in the past few years has anorexia nervosa has been viewed as a psychiatric or “mental” disorder. Before that, it was treated by medical professionals and families. Perhaps it is time to return to that paradigm.
Dr. Ravin, your oversimplified explanation of anorexia’s persistence in our gene pool is as follows:
“Once the anorexic leader and her tribe arrived in a plentiful environment, the tribe feasted, pressuring the anorexic leader to indulge in food with them. In the absence of modern society’s thin ideal and without our modern obesity hysteria, prehistoric anorexics could finally relax and allow their families to feed them, restoring their health and fertility.”
The statement that “in the absence of modern society’s thin ideal… modern obesity hysteria… anorexics could finally relax and allow their families to feed them” doesn’t seem to connect. The nature of anorexia does not simply allow a sufferer to to “relax” after a task has been accomplished… thin ideals and obesity hysteria aside, this illness is not one that falls by the wayside when the future looks safe. I should think that it’s obviously a neurobiological happenstance that really isn’t going to be swayed one way or the other by modern cultural perceptions. Although I agree with part of your hypothesis, I urge you to reconsider the leverage you have put on the influences of our culture and media on the starving seven year old who really hasn’t lived all that long enough to really feel the need to “measure up.”
Carl,
I have considered your feedback carefully and have come to agree with you. Therefore, I have revised the text of my blog post slightly to reflect this.
I did not mean to imply that the prehistoric anorexic could totally relax, because, as you eloquently noted, their neurobiology would probably preclude that. Perhaps it would be more accurate to say that the prehistoric anorexic may have allowed her family to feed her, not necessarily willingly, and not without anxiety. This scenario would be analogous to the modern-day anorexic child feeling some sense of relief when her parents and treatment team take charge of her nutrition. Most people with AN have an extremely difficult time feeding themselves adequately, but they may allow (under duress, of course) others to feed them. This would explain why inpatient hospitalizations and FBT are effective at helping people with AN restore their weight.
For the record, the adapted to flee famine hypothesis is not mine; it is Shan Guisinger’s.
Thank you for your feedback.
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