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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

At the Margins: What Patients and Parents Are Not Being Told

Exactly what are parents and patients being told about the ‘‘new’’ paradigms for understanding AN? Well, they certainly hear more about genes and the brain; but unfortunately, without much clarification or context, the result of which has been no small measure of confusion and misunderstanding as they are to wonder in private if they were just told they/their child has ‘‘brain damage’’ or a ‘‘genetic defect.’’ It goes without saying that explanations serve a clinical purpose only if they are authoritative and complete; if not, they do harm since fragments of truth are never a good substitute for no explanation at all.

This is why it is not a good thing for patients and the public to be told that AN is a genetic disorder, but little else; not to be told: obstacles stand in the way of identifying causative genes and determining how genes, brain physiology, and behavior interrelate; what genetic risk actually means; that stress in the environment can worsen vulnerabilities by programming anxiety proneness and negative reactions to later occurring stressful events; what connection causative genes may have to core features of the illness (anxiety and fear proneness, compulsiveness of habits, and low appetitive motivation); that genetic effects are not necessarily permanent; that predisposing genes can also have positive adaptive effects—i.e., discipline and regimentation are virtues, but in AN these virtues are ‘‘hijacked’’ in an effort to restore a veneer of competence as the strains of maturation become too much to live with; that behavior is shaped by environment too, because genes, biology, and the social context, which includes family life, are interdependent.

On top of these omissions, we now hear therapists insist that giving credence to environmental influences in AN is outdated, a theory refuted long ago, and that doing so amounts to unjustified scolding of parents for being malevolent and causative. This is so patently at odds with science it suggests that the BBMI and FBT paradigms’ most ardent defenders know the least about it (again, we are not referring to any of the authors of the BBMI and FBT papers1,2). It’s another oddly inverted, contradictory logic—pitting a general premise (genes and biology play a role in risk; FBT can be effective) against others also well supported by elegant research (how natural processes inevitably link genes, brain function, and environmental adversity together; FBT is not universally effective).

Our point is that a growing, integrative science convincingly shows there is no basis whatsoever to claim that reference to environmental conditions is resurrecting outdated theories of psychogenic etiology. Rather, it argues:

1. AN frequently involves more (in psychological terms) than what is transmitted by heredity.

2. Invoking an interplay of biology and environment does not vilify families any more than it argues family disturbance is a causal prerequisite.

3. The notion of stress engendered vulnerability is not at odds with treatment models that see families as critical partners in care; it argues that broad attention must be given to sources of intrafamilial strain and the need for other forms of therapeutic dialogue to reduce it. Ignoring the potential adverse effects of environments that can increase childhood anxiety is not helpful to families or patients given current scientific data showing these effects can be long lasting, and that changing a rearing environment’s emotional tone can be beneficial.

Importantly, our experience has been that nearly every family who has heard this broadly sketched viewpoint has been entirely receptive to the concepts outlined, did not feel vilified, and welcomed knowing about their implications. So from the clinical perspective, the message that modern neuroscience underscores is: (1) that an invigorated focus on therapy skill is warranted, addressing not only the individual’s belief structure, but also the social context in which they live; and (2) applying technique, whether in manual form or instructed, can be valuable, but more is needed, especially when it comes to work with difficult cases. In our view, the further needed element is not easily measured, but patients and families feel its presence and they speak of it often. It is not one single thing, but rather a set of skills with different facets: the uniquely refined ability of the therapist to sit long hours sifting patiently and thoughtfully through strains and secrets the human psyche can easily cloak; insight into what this messy tangle of conflicting tensions, puzzling emotions, and disparaging self-beliefs reveals about a patient’s (and family’s) misery; the ability to translate this understanding into prose eloquent enough, and delivered with the strength of conviction needed, for our patient (and family) to ‘‘feel’’ they best give it deeper thought; and then to steer the treatment in the direction needed and escalate its intensity should progress lag. To appreciate science is one thing, but in the clinical realm there is no substitute for well-honed skills, intuitiveness, and decisiveness when facing AN’s challenge.