Tobacco Documents Online

I I I I I I I I I I I I I I I I I I The Clinical Phases of Anorexia Nervosa and Their Relevance to Endorphin Addiction T HE TERM "ADDICTION" usually refers to a process in which the use of certain substances leads to a compelling habit of in- creasing use, resulting in successive changes in mind and body. The progression of these changes follows an orderly and predict- able path from health to mental and physical devastation. In this chapter we will examine the clinical evidence for the notion that the self-starvation process in anorexia nervosa is iden- tical to the behavior and psychology of drug addiction. This im- plies, of course, that there is a substance to which a person with anorexia nervosa becomes addicted. It further implies that this substance plays an essential role in causing the behavioral and mental changes characteristic of this condition. Third, it implies that this substance is singularly responsible for perpetuating and maintaining anorectic behavior throughout all stages of the addict- ive process. We are not talking about a substance that the anorectic is taking into her body. The substance I am referring to is secreted by the body as a result of starvation. In this chapter I am inviting the reader to just imagine that there is such a substance or physiolog- ical mechanism to which the anorectic has become addicted by 16 I

I I I i I I I I I i I I I Clinical Phases of Anorexia Nen,osa 17 simply going on a diet and starving herself. Would such a mecha- nism explain many of the behavioral features and changes that have been widely described in the literature and that have re- mained an enigma? I am appealing especially to clinicians who have watched the progression of this condition and have been frustrated in their treatment efforts. Identifying these features as the orderly manifestations of an addictive process may answer some of the questions that have continued to puzzle them, as well as anorectics and their families. This substance is actually a group of substances, called endor- phins. Their biochemical nature and the evidence for their role in anorexia nervosa will be extensively addressed in Chapter 3. For our discussion here it is sufficient to know that endorphins are a group of highly addictive substances which play an important role in the regulation of many functions of the body. These substances have much in common with opiates, drugs that have been used against pain since antiquity. Therefore, they are called endoge- nous opioids, a name indicating that these substances produce opiate-like effects (opioids) and are generated within the body (endogenous). Similarly, the name "endorphin" stands for "en- domorphine" or internal morphine, a term usually used in the plural to reflect the inclusion of many structurally related mole- cules in this family of compounds with opiate-like activity. In ac- cordance with this general concept of endogenous opioids, I will refer to the substance that underlies the self-starvation addiction of anorexia nervosa simply as "endorphins." Central to the addiction concept of anorexia nervosa are two principles that merit special emphasis because they diverge from established approaches to the understanding of this condition. One is the principle that much, if not all, behavior and thinking in anorexia nervosa are governed by the mechanism of reward (and nonreward). Also called reinforcement, this mechanism re- fers to the unique property of all addictive substances: that is, humans (as well as animals) will engage in behavior or actions to self-administer these substances once they have been exposed to them. In contrast, a non-addictive substance will not cause a

I I I I I I I I I I I I I I I I l8 Endorphins, Eating Disorders and Other Addictive Behaviors person to automatically continue self-administration. In short, hu- mans will not stop wanting addictive substances, whereas they mav lose interest in non-addictive substances. The reason for this is that addictive substances affect certain brain centers in ways that are pleasing or rewarding to the individual, so much so that the individual wants more of this effect. What is experienced as rewarding need not be always euphoria, an elevation of one's mood, or a "high"; it can be simply a reduction of anxiety or improvement of a depressed mood. The second principle is that there is a direct causative relation- ship between the state of eating (or non-eating), on the one hand, and the state of mood and feelings, on the other. The endorphins form the physiological link in this interaction. Non-eating and weight loss promote a sense of well-being or improvement of de- pressed mood via release of endorphins. Eating and weight gain lead to a reduction of endorphins, resulting in increased anxiety andlor depression. This acute and immediate interaction between the state of food intake and mood has been neglected by most research in the field, which has focused primarily on advanced weight loss states. One reason may be the wide use of Feighner et al.'s (1972) diag- nostic criteria for anorexia nervosa, which specify a weight loss of at least 25% from ideal body weight, thus taking a rather static view and missing out on the dynamic relationship between acute eating state and mood. As a consequence, to this day research is mostly conducted on emaciated patients and their course of recovery. In my opinion, more important information can be gained from studies that investigate the progression of symptoms and biochemical abnormalities from the onset of this condition to emaciation, as we will do here. We can extend this study even further back, to the years pre- ceding anorexia nervosa, and look closely at the early develop- mental stages and the personality structure of the anorectic, as well as the family dynamics she grew up with, as has been done by many researchers. Then, if we integrate findings from the

I I I I I I I I I I I I I I Clinical Phases of Anorexia Neraosa 19 anorectic's early life and family setting with the events taking place during her progressive weight loss, many of the bewildering ieatures of anorexia nervosa become comprehensible and even logical. ,As a reference for the clinical features of drug addictions I will use a review, article by Jaffe and Clouet (1981), which summarizes some 130 research papers in the field of opiate addiction. This paper was helpful to me at the time it was published and, I am certain, it still is valid as far as general concepts of addiction are concerned. Jaffe and Clouet describe as central clinical features of the addictive process the phenomena of reinforcement and re- ward, tolerance, dependence, as well as withdrawal and absti- nence, and craving associated with withdrawal. The authors also discuss two factors that are important precursors of addiction: (1) the mood state of depression and demoralization that precedes the use of drugs and makes an individual vulnerable to addiction, and (2) the social acceptability of the use of a particular addictive substance. In examining the addictive features of anorexia nervosa let us start with these latter features. VULNERABILITY Addicts do not become addicted for fun. Depression, social and personal demoralization, low self-esteem, as well as biological sensitivities ezisting since birth, are typical precursors of drug addiction. Similarly, depression and distress have been widely recognized as precipitating states of anorexia nervosa. For exam- ple, Warren (1968) found depression in 85% of his sample of 20 anorectics, and Cantwell, Sturzenberger, et al. (1977) found a high percentage of affective disorder upon long-term follow-up of ano- rectics and a high incidence of depression in their families, thus establishing an associational link between depression and anorex- ia nervosa. Using larger samples, Eckert, Goldberg, et al. (1982) and Hendren (1983) confirmed and elaborated on this link, as did many studies thereafter. I

I I I I I I I I I I I I I I ~ I 20 Endorphins, Eating Disorders and Other Addictive Behaaiors Similarly, if one takes a careful history, one always finds states ' of serious depression and distress in anorectics prior to dieting. '°' Often going on for years and associated with anxiety, worry, and low self-esteem, depression and distress are states of nonreward that cause the pre-anorectic to cry out for something that will make her feel less depressed and balance her mood. In other words, she reaches out for a compensatory reward. For the pre- anorectic this compensatory reward is food, and eating becomes an irresistible preoccupation not only for its gustatory pleasures but also in response to a biological signal to eat given by the dis- tressed brain. The widely discussed "addictive personality" is nothing but the outcome of this chronically depressed mood and the constitu- tional inability to maintain an internal equilibrium. While most people might reach out for ways of reducing distress and anxiety without going to extremes, people with addictive personalities tend to seek more rewards and become addicted to whatever re- wards they pursue. Going back to Tascha, we are able to identify factors that would make any person in her situation insecure and depressed. She was a very sensitive child who had difficulties keeping up with her peers and her brothers. This feeling of being different from others was made worse by her parents' attempts to help her, no matter how good their intentions were. Somehow she got the message that her slowness was not acceptable. When she became chubby in early adolescence, like many teenagers, or because she overate to compensate for her unhappiness, her mother's overt disapproval made her feel truly ostracized. Her acceptance of the abusive and self-destructive relationship with Jack reveals how desperately she wished to be accepted by her peers. In view of these background experiences and her personality marked by sensitivity and low self-esteem, it is not difficult to imagine that a major setback or distress would make her highly vulnerable to developing anorexia nervosa should she decide to go on a diet. © C32 c,o ~ w

I I I I I I I I I I I I I I I I I I Cltntcal Phases of Anorexia Nervosa 21 FfRST EXPOS[;RE: LOSING WEIGHT AS A SOCIALLY ACCEPTABLE WAY OF FEELING BETTER In order to become addicted to a drug an individual has to be etiposed to it. ~ti'hile the avenues of initial exposure may be multi- ple, the social and cultural availability and acceptability of a partic- ular addictive substance is an important factor in this process. In this regard there is a parallel to anorexia nervosa as well. %%'ithout dieting in pursuit of slimness for social reward or for other reasons, the addictive cycle leading eventually to anorexia nen'osa is not initiated. Slimness is highly rewarded in our cul- ture, and even more so in farnilies of anorectics. The extraordinary %,alue placed on a slim and trim body sets the stage for the anorec- tic-to-be when she finds herself overeating and gaining weight. Instead of a socially available drug she chooses dieting because of its social acceptability. Thus, dieting as an avenue to a positive feeling state constitutes the first motive for the decision to diet, and a very powerful motive in families where slimness is highly valued. For the same reasons, the incidence of anorexia nervosa varies greatly in different societies, and in our society within different sociocultural groups. I have had the opportunity to treat women with anorexia nervosa from other countries that are known to have attitudes towards slimness very different from ours, coun- tries in which-being fat is considered a sign of wealth and sex appeal. Without fail, it has turned out that these women have lived their lives outside of the prevailing social attitudes and stan- dards of their country. Some have frequently traveled to Westem countries or adopted Western middle- and upper-class standards from exposure to Western magazines and movies. The Decision to Diet Tascha's decision to diet in her junior year was made under quite dramatic circumstances that eventually led her to succumb to anorexia nervosa. After having had two reasonably happy years, I

I I I I I I I I I I I I I I I I 22 Endorphins, Eating Disorders and Other Addictive Behaviors Tascha's world seemed to cave in when she had to meet an aca- demically demanding schedule. Furthermore, her brother's arrivaI' on campus brought the troubling family dynamics of her child- hood right into the college, which she had thought of as her terri- tory. In her distress she started to overeat again to give herself some form of reward, and this time found herself getting totally out of control. It is no surprise that she decided to go on a diet again, as she had done successfully earlier. Only this time the decision was reached while being desperately depressed and dis- satisfied with herself and feeling agitated, nervous, and confused. The decision to diet is not always made under circumstances as dramatic as Tascha's. Especially in younger girls a seemingly unremarkable event often leads to the decision to diet. Sometimes a pediatrician has told the anorectic-to-be to lose a few pounds, or a certain special dress does not fit anymore, or a boyfriend, a parent, or a sibling has made offhand remarks about her weight. Sometimes, reasonably slim adolescents find themselves sud- denly gaining weight during a time of loneliness, separation, or distress due to altered life circumstances. Even the natural change of figure that occurs with sexual devel- opment during puberty poses a threat to some girls that they feel must be counteracted. In some of these cases, the girl's body develops sexually before those of her peers, or she has a petite body that suddenly becomes quite rounded. Sometimes a viral illness or other discomfort leads to a loss of appetite, allowing the potential anorectic to experience what it is like to weigh a few pounds less and giving her hope that she can realize her long- held, often secret dream of being slimmer. It is easy to underestimate the power of this wish to be slim, especially when the precipitating event for the decision to diet seems relatively unremarkable. Similarly, it is easy to underesti- mate the severity and duration of the underlying distress and depression that resulted in the decision to diet. In cases in which the distress appears to be of short duration, closer analysis often reveals that long-lasting but very tenuous patterns of coping have suddenly failed as the individual has been confronted with a new I

I I I I I I I I I I I Ciinual Phases of Anorexia Neroosa 23 ,,;uation or has entered a new phase o life, like college. Actually, ;,n~:z the premorbid distress determines the need for social reward ,, dieting, «'e can estimate the degree of pre-anorectic distress ,na depression from the intensity of anorectic's dieting efforts. PHASE I, THE EARLY WEIGHT Loss PHASE „hrptation to Starvation The early weight loss phase is marked by a series of physical and mental changes that together constitute the body's adapta- tional changes to promote survival. Mediated by endorphins, these adaptive responses of the organism are universally found in starvation states of any cause. They are triggered within a few days of serious dieting and continue to be active as long as the bodv is deprived of food. Anorectics-to-be adapt to a reduced diet during this phase like everybody else. However, anorectics respond to and experience these natural changes in a unique way, so that they are powerfully influenced by these changes and eventually controlled by them. For the discussion of the addictive process here, we will confine ourselves to the mental features of adaptation to starvation. Rein forcement and Reward Of the mental changes, the most important phenomena are re- inforcement and reward, two terms that are sometimes used inter- changeably and constitute the core of the addictive process. Hu- mans, once exposed to addictive substances, will not stop wanting them and will keep doing things to get them (reinforcement). This is so because these substances give a pleasing feeling to the person (reward); this can be elation or a "high" but is often just a reduc- tion of depressed feelings or anxiety. Reinforcement and reward-and for that matter nonreward- come into play during this phase in several ways. First, there is the experience of nonreward caused by giving up the rewarding . I

I I I I I I I I I I I I I I I 1 24 EndOrphins, Eating Disorders and Other Addictive Behaviors substance food. This is a form of withdrawal, since forgoing food .. is experienced in many ways like the withdrawal from an addic- tive drug. Anorectics find the initial dieting just as difficult and unrewarding as anyone who is on a stringent diet, whether the deprivation is voluntary ("the woman next door" or the wrestler who "sucks" weight to have a competitive advantage in a lower weight class), or involuntary (the prisoner of war or the inhabitant of a famine-stricken country). The first hurdle to overcome is the feeling of deprivation from the universally rewarding substance, food, that will cause cravings and hunger pangs. If anything, the anorectic-to-be might find resisting food more difficult, since she opposes a stronger command, the impulse to eat excessively prior to her decision to diet. This phenomenon con- stitutes the key element in the differential diagnosis of weight loss in anorexia nervosa and severe clinical depression. Individuals suffering from depressive illness lose weight because of a true loss of appetite and interest in eating and food. Anorectics, on the other hand, resist with great effort a heightened appetite and in- terest in food. This resistance to a powerful wish to eat constitutes the essence of anorexia nervosa, which to this day some research- ers in the field seem to disregard when they are searching for a biochemical mechanism for the "loss of appetite." Second, soon the anorectic-to-be will, like any other person on a stringent diet, experience the reward she consciously has been aiming for, the societal reward. In Tascha's case friends and rela- tives commented that she looked more attractive and happier, and classmates who had never paid attention to her-even strangers- suddenly noticed her. The response to this societal reward, however, distinguishes the non-anorectic dieter from the anorectic. The non-anorectic di- eter will stop dieting at a reasonable goal weight; she will, if any- thing, be happy to increase her calories from a reduction level to a weight maintenance level. In contrast, the anorectic is not capa- ble of reverting to a maintenance diet at the goal weight and will continue to diet long after the societal reward for slimness has ceased because of her gaunt and emaciated look. W I "

I I I I I I I I I I I I I I I I I Ctinical Phases of Anorexia tiervosa 25 \,e,.ertheless, the anorectic continues to be aware only of this ~ ursuit of societal reward as reason for starving herself. It will i-aunt the anorectic throughout her illness, sometimes throughout ;;1e, and is typically expressed in her fear of getting fat whenever .he eats. However, the societal reward of slimness is not the true r,onvator, but constitutes the proverbial red herring of anorexia ren-osa. What the anorectic does not know is that her behavior is erned by a true and much more powerful motivator. This brings us to the third reward phenomenon, the key to the development of addiction. This is the reward provided by en- aorphins, a reward so powerful that the pursuit of it can carry the anorectic to extreme emaciation and even to death. The daily reduction of food intake below maintenance require- ments causes the body to switch to starvation mode by stimu- lating endorphin secretion. The physical condition under which this mechanism is triggered appears to be a switch by the body from burning carbohydrates to the use of fat stored in fat cells and does not depend on the person's weight. Someone weighing 300 lbs., let's say, and losing weight rapidly, will experience this mechanism as readily as a normal-weight or below-normal-weight person. As designed by nature, endorphin stimulation seems to serve as a master switch, causing most, if not all adaptational changes of the body and mind. Most important among the mental changes is the protection of the starving organism from the effects of star- vation by providing heightened coping power and a reduction of suffering. Therefore, strictly speaking, endorphins were not designed to be a reward-a substance that simply gives pleasing feelings. However, since it is rewarding to the mind to feel less anxiety and depression, the term reward is used appropriately. Endorphins benefit the voluntary and involuntary starver equal- ly. However, the beneficial effects of endorphin reward are expe- rienced differently, thus affecting the outcome in very different ways. The "woman next door" goes on a diet purely for the sake of social reward and does not suffer from depression or anxiety prior I