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The Need for Complex Ideas in Anorexia Nervosa: Why Biology, Environment, and Psyche All Matter, Why Therapists Make Mistakes, and Why Clinical Benchmarks Are Needed for Managing Weight Correction

Michael Strober, PhD, ABPP1, 2* Craig Johnson, PhD3, 4

The Illusion of Consensus

It isn’t that consensus among us is completely lacking; it’s that it’s illusive. Witness any discussion of AN and points of agreement are many; or so it seems. Regarding psychopathology, we agree that its symptoms quickly assume a will of their own and that in its more severe form the consequences are grave. We also appreciate that the illness has a stubbornness so persuasive it brings patients to do things different from what we plan for them. Parents describe it best: a transformation of their child’s manner seemingly out of nowhere, as mystifying as it is frightening, often leaving them exhausted, in despair, and resentful. AN can not be explained simply, nor is the remedy predictable, because so many of its features—the suddenness of its onset, the rapidly peaking intensity, its ego-syntonic character—are inaccessible to single-focused ideas.

Also uncontroversial is that heritable factors operate at an important level in etiology. It’s when discussion turns to equally strong evidence from research outside of eating disorders that environmental factors also play a role in pathological behavior, sometimes enhancing, sometimes mitigating, the vulnerabilities conferred by genes that consensus frays. Why acrimony ensues as soon as this notion is introduced is an intriguing question, especially when evidence of gene-by-environment interaction in psychological development is incontrovertible, and given that the evidence is strongest for phenotypes having a plausible clinical parallel to AN: stress sensitivity, cognitive bias toward threat, neuroticism, anxiety—even activity-based anorexia.3,4 To frame the irony differently, here we are bickering about whether or not rearing influences should be included in causal and treatment paradigms, at the same time that neuroscience-based models of psychiatric disorder elegantly show why inheritance shouldn’t receive singular attention any more than early attachment deficits or family discord should. Simply put, the more we learn about molecular codes that play a role in vulnerability, the better is our appreciation that the origins of abnormal behavior travel a far distance from inherited variations of DNA.

Clinically, we easily agree that AN is an intimidating challenge and that therapists who take it on should have the highest level of skill development to help patients battle its emotional sway. But this is hardly the prevailing ideology in our professional dialogue. Instead, many in the field are attempting to reduce complex challenges to rudimentary ideas which then quickly take on such broad significance that a treatment model is born impromptu—some even insisting it should be adopted as our treatment of choice. Why? If complexity is bluntly etched not only in the psychopathology of AN but also in the challenges it creates, shouldn’t this very same notion be a constant thread in the ideas we introduce during treatment? And if narrow ideas sufficed, why does the treatment of AN often veer off course and prove disappointing? As an example, consider the notion that eating and restoring weight to normal weight while preventing compensatory behaviors models extinction learning; in the most rudimentary sense this is true, but to think this rises to the level of an explanatory paradigm is short-sighted.

So we are not saying that opinions about AN shouldn’t vary. It’s when the intensity with which they are defended rests on assumptions too narrow to represent a powerful conceptual principle that knowledge suffers, along with patient care. If clear thinking is what we want in our professional and public discourse—it’s certainly what our patients and families deserve—then entrenched viewpoints that ignore the many levels of analysis needed for explaining an illness layered in complexity must be set aside. And there is another point. Since errors in managing AN are sometimes set in motion before treatment actually begins (an assertion less incongruous than it sounds), modifying attitudes founded on sweeping generalizations may help to avoid these blunders from occurring in the first place. This article is, in effect, a dialectic that underscores why our field is wracked by confusion, mistrust, and divisiveness when it need not be.