Episode 246: Today on Real Health Radio, I'm speaking with Dr. Sasha Gorrell. We talk about the question of is anorexia nervosa an anxiety disorder. We spend a lot of time speaking about the brain and other topics like anxiety, compulsive exercise, the microbiome, and reward and fear circuitry.
Dr. Sasha Gorrell earned a Bachelor’s degree in Psychology from Columbia University and a Masters in Psychology from New York University. She completed her doctorate in Clinical Psychology at the University at Albany in New York and then joined the University of California, San Francisco (UCSF) Eating Disorders program as a T32 postdoctoral scholar, sponsored by the National Institutes of Health.
She is now an Assistant Professor in the UCSF Department of Psychiatry and Behavioral Sciences, where her clinical focus is in the treatment of adolescents with restrictive eating disorders, and specifically in supporting their recovery in family-based treatment. Her current NIMH-funded research leverages behavioural data and neuroimaging to investigate specific neurobiological risk and maintenance factors for problematic exercise behaviour in the context of eating pathology. Her overall research interests include exploration of biobehavioral mechanisms that promote our understanding of motivated behaviour. This work includes better characterizing maintenance mechanisms and shared features of anxiety and eating disorders, and using this knowledge to adapt and develop evidence-based treatment for eating disorders.
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Chris Sandel: Welcome to Episode 246 of Real Health Radio. You can find the show notes and the links talked about as part of this episode at www.seven-health.com/246.
Before we get started, I want to mention that I’m currently taking on new clients. I specialise in helping clients to overcome eating disorders, disordered eating, chronic dieting, body dissatisfaction and poor body image, exercise compulsion and overexercising, and also helping clients to regain their periods. If you want help with any of these areas or you simply want support to improve your relationship with food and body and exercise, then please get in contact. You can head to www.seven-health.com/help, and there you can read about how I work with clients and apply for a free initial chat. The address, again, is www.seven-health.com/help, and I’ll also include that in the show notes.
Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I’m a nutritionist that specialises in recovery from disordered eating and eating disorders, or really just helping anyone who has a messy relationship with food and body and exercise.
Today on the show, it is another guest interview. Y guest today is Dr Sasha Gorrell. Sasha earned a bachelor’s degree in psychology from Columbia University and a master’s in psychology from the New York University. She completed her doctorate in clinical psychology at the University Albany in New York and then joined the university of California-San Francisco eating disorders programme as a T32 postdoctoral scholar sponsored by the National Institute of Health. She is now an assistant professor at UCSF Department of Psychiatry and Behavioural Sciences, where her clinical focus is in the treatment of adolescents with restrictive eating disorders and specifically in supporting their recovery in family-based treatment.
Her current NIMH-funded research leverages behavioural data and neuroimaging to investigate specific neurobiological risk and maintenance factors for problematic exercise behaviour in the context of eating pathology. Her overall research interests include exploration of bio-behavioural mechanisms that promote our understanding of motivated behaviour. This work includes better characterising maintenance mechanisms and shared features of anxiety and eating disorders and using this knowledge to adapt and develop evidence-based treatments for eating disorders.
I became aware of Sasha when a past client of mine shared a talk of hers. This is something I cover in my intro when chatting with Sasha, so I won’t duplicate it here; all I want to add is to say thank you to Annie for sharing it with me.
As part of the conversation, we talk about how Sasha got into working in eating disorders, and we talk about her past life as a ballet dancer and how this has impacted upon and influenced some of her ideas. We talk about the idea of eating disorders being anxiety disorders and what this would mean for treatment. We spend a lot of time talking about the brain, going through the reward-deficit model and the habit-centred model, looking at dysregulation and reward in fear circuity. We go through some rat studies looking at dopamine and its impact on food consumption and exercise activity. And we also talk about compulsive exercise and some of the studies that Sasha has done and is hoping to do in this area.
This is a fairly science-heavy episode, so it may feel a little dense in parts, but part of the reason I invited Sasha on the show is because of her ability to talk about this stuff in a way that’s easy to understand. I think she does a very good job with this, and if you are someone who is living with an eating disorder, I predict that there will be many ‘aha’ moments when listening to this episode.
So let’s get on with the show. Here is my conversation with Dr Sasha Gorrell.
Hey, Sasha. Thanks for joining me on the show today. I’m really excited to be chatting with you.
Sasha Gorrell: Thanks, Chris. Thank you for having me.
Chris Sandel: How we come to be talking today is that towards the end of last year, one of my clients, a past client of mine, shared a YouTube recording of a live webinar that you’d done for the University of California-San Francisco Department of Psychiatry and Behavioural Sciences. The topic of the talk you did was ‘Is Anorexia Nervosa an Anxiety Disorder?’ I watched the video and I thought it was great. It definitely contained information that was new to me. I also really loved your ability to explain science and complex ideas and research in simple and digestible ways and thought this would be something that the listeners would appreciate, and I think the idea of anorexia being an anxiety disorder is an interesting topic to have a discussion on.
So I think what I would like to do today is use that talk as a bit of a jumping-off point for us to have a discussion, but I also know you have lots of other areas of interest and expertise and knowledge, so I want to cover those as well. Does that sound good?
Sasha Gorrell: That sounds fantastic, yeah.
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Chris Sandel: Just as a start, would you be able to give the listeners a bio of sorts in terms of what training you’ve done, your areas that you work in, how you’ve come to doing the work that you’re doing?
Sasha Gorrell: Absolutely. By training, I’m a clinical psychologist, so I have a PhD in clinical psychology from the State University of New York at Albany. I had an almost 18-year professional career as a ballet dancer, so this is really my second career. I think if you look at the work that I’ve done, the things I’m really passionate about, looking to my history as a professional athlete explains a lot about how I arrived where I am.
Currently, I’m an assistant professor at the University of California San Francisco, here in the Bay Area with our eating disorders team. I feel very fortunate to be working with people who are at the top of their field, embedded within a team where we principally treat adolescents, but that does range up to age 26. We have as our director of our team Dr Daniel Le Grange. He’s one of the originators of family-based treatment, which is our current first line treatment for treating adolescents with restrictive eating disorders. When I wound up here at University of California San Francisco, it really felt like a dream job to be working with people that really do the work that I wanted to be doing.
Throughout my whole life as a dancer, I think I was struck with the level of adaptive disordered eating, if you will, that so many people were engaging in – manipulating what they were eating and how they were exercising to have a certain look about them. I think looking at how some people were deeply impacted by that and yet others seemed to come out of that completely unscathed, I was sort of fascinated. Like, for whom and why is this environment potentially dangerous?
I think when I first retired from dancing and went to more formal education with college and graduate school, psychology was a natural path and inroad for me. I was fascinated by the human condition and particularly by that interface of exercise and eating, both the more under the skin, neurobiological and biological reasons for eating disorders, in conjunction with the dynamic interplay of environmental factors as well.
So it’s been a passion project for me. I think it’s always really nice to say that you love what you do. [laughs] Work doesn’t feel like work so much on most of my days, which I feel very fortunate to say. I’ll stop there. I think that gives people an idea of where I come from and where I am now.
00:08:25
Chris Sandel: You said as a dancer, you noticed that some people would be quite impacted by either the exercise or the eating or both, and others were much more unscathed. Where would you put yourself in that category? How much of an impact did this have on you?
Sasha Gorrell: I had a really comparatively long career. I started my career dropping out of high school, actually. My parents were super supportive. I think because I had a long career, it felt like I retired when I wanted to. I never had any major injuries. I don’t want to paint an unrealistic picture of the idyllic experience I had with it, but the first half of my career was spent at Boston Ballet and the second half was at American Ballet Theatre. I was fortunate to dance with two companies where it was the best choreography. I toured all over the world.
Looking back on that, it’s hard to imagine I even had a pair of point shoes on my feet at some point, it feels that far away. But I think in terms of my experience with it, maybe because I was able to grow up within that environment and had the opportunity to mature into an adult in that environment in a way where – I don’t know, I had a lot of social support. I had a lot of people that were helping me to stay grounded and maybe less pulled toward the more insidious disordered eating pattern.
So yes, I dieted. I did the things to make sure I looked the way I needed to when I was in that environment. But I feel very fortunate, I guess, that I came out of it intact, if you will.
Chris Sandel: Do you think differently of that environment now that you’re out of it? Now that you do the kind of work that you do, do you see things in a different light?
Sasha Gorrell: That’s a good question. Some of the work that I was doing in graduate school was actually helping to run some programming that would prevent eating disorders or disordered eating among dancers. So we had the opportunity to dip in and dip out from a more intellectual perspective, to assess what I saw and what I heard. Lots of qualitative interviews. It was such a privilege, in a way, to be able to go back in and look at it with a different lens.
I think from that experience, one of the things I took away that was particularly poignant for me was thinking about this from the dancer perspective. I was going in saying, “Hey, I want to help you to be able to prevent these things.” So many of them said, “Hey, nice idea, Sasha, but I feel kind of hopeless in a sense because I can change all I want, but I can’t change the system. I can’t change the broader historic sociocultural environment.”
It was interesting in the sense of we can do as much as we want to on the athlete level, but it really does need to, at a certain point, be top-down. It has to involve all the players, all the stakeholders in the system. I don’t know if I answered your question. [laughs]
Chris Sandel: I wonder, then, is that starting to happen? Is there starting to be pressure put on or top-down change that is coming and they want to be doing that? It’s an area that I know so little about, so I’m just interested to see how it is now versus 10 or 15 years ago.
Sasha Gorrell: I’d say in the last couple of years particularly, there’s a lot of rumbling. There’s people that are passionate about this. Maybe it’s what you’d call a small but mighty group, trying to change at least one or two institutions at a time. It feels like it’s going to be part of a broader effort. As you might imagine, I join those people when I can in whatever ways I can in terms of sharing resources or doing some kind of consulting work or trying to improve the climate.
I think to make a longer story short, I do feel optimistic about it, that there is much more awareness, particularly with diversity, equity & inclusion movements. There’s been a movement to say, “Hey, what about body types? That’s also inclusion. What can we think about changing some of these traditional ideals within those environments?” So yes, I do feel a little bit hopeful. There’s still a lot of work to do, but it is changing.
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Chris Sandel: When you first started studying as a psychologist, did you know this was the area you were going to go into? Or it was just “psychology, that sounds interesting to me, let me just get started”?
Sasha Gorrell: I didn’t really choose it. When I was in college, I was interested in everything psychology, and then I had an externship at New York University that was more on the “Let’s look at the impact on the brain from metabolic dysfunction. How do the mind and the body relate in terms of the impact of weight?”
I think from that experience, I started to dip a little bit more into weight and eating disorders and it started to spark my interest in research as well. When I applied for graduate school, for listeners who are less familiar with the clinical psychology graduate path, you apply for the lab that you want to work in. You don’t really apply for the institution; you apply for the graduate advisor who’s doing the work that you can imagine that you want to be doing, too. So as I was applying, I applied for – it wasn’t half and half, but some schools that were more anxiety-centred and others that were much more eating disorder-centred. And I wound up in an eating disorder one, and very, very happy about that, obviously.
I think that speaks to my longstanding interest in that overlap, since as I was approaching “Who do I want to be with this doctoral degree?”, I think I was really genuinely interested in both.
Chris Sandel: Do you have also a particular interest in working with adolescents? Is that it as well, or that’s just the population that you’re serving, but it’s not something that was like “I need to work with this age group”?
Sasha Gorrell: I think I have that problem where I’m interested in everything. [laughs] I would say I would not rule out a deep interest in eating disorders across age. With that said, when we intervene early, across any research, if you look at duration of illness or the length somebody has been ill, if we catch it sooner we have such a better chance of getting in and getting out faster and just getting that person back to life sooner.
So I’ve found working with adolescents, the brain has plasticity. Imagine that somebody in mid-life gets a concussion versus a child getting a concussion. Who has a better chance of quickly jumping right back into their life? From that perspective, I find the more people I can help at a younger age, the more I feel like I’m preventing longer term quality-of-life costs. I think intervening at any age, I have a lot of hope for most people to have full recovery, and yet I also know if I can make that process faster, easier, it’s something. I care about intervening earlier.
Chris Sandel: Which makes total sense. How much of your time is spent as a clinician versus as a researcher? Is research a big part of your day to day?
Sasha Gorrell: It is. On any given week, I’d say I spend probably three afternoons seeing patients, and the rest of my time is really devoted to research. I am funded by the National Institute of Mental Health right now for what’s called a Career Development Award. That does allot a good deal of my work to research, which I feel very fortunate to have that time. And yet at the same time, I deeply love my clinical work. I feel like not a week goes by that I don’t feel that the clinical work inspires some thoughts about my research or draws the two worlds closer together for me.
So it’s something where, as much as I appreciate the luxury of time to be able to read and to write and to contribute to research, I also know that I could not be doing that work as effectively if I didn’t also have the counterpoint of actually engaging with the patients themselves.
Chris Sandel: How much leeway do you have to come up with the kind of research you’re doing? Are you able to be noticing things in a clinical perspective and think, “It would be great if I could do some research on that” and then you just do it? Or it’s not quite that flexible?
Sasha Gorrell: It’s all about time and funding. Those of us who are in this position, we are writing grants. We write many more grants than those that actually get funded. So all the ideas I have, I try to whittle out the ones that I think are the most interesting, the most compelling, and as calls for grants come up, rallying the energy and time to put those calls in. Then of the ones that do end up getting funded, I think sometimes we hear that the pace of science is pretty slow. Many of these projects that we have great ideas take a few years to get funded and then they take a few years to actually collect the data and then they take another few years to publish the data.
It’s a process, and I love it. It’s something where I do really genuinely enjoy writing grants and thinking about the ways in which I can disseminate the ideas and the work that I do. But it does take quite a bit of lag time.
Chris Sandel: I can definitely understand that.
00:19:27
Just so I know, what levels of care have you worked in and are you working in? Where you’re seeing clients, is that inpatient, is it outpatient?
Sasha Gorrell: Our clinic is actually one of the rare opportunities that patients have to have a really comprehensive – the multidisciplinary nature of our team I think is really special. There’s not too many centres like us, at least in the United States. We have an adolescent medicine team who are exquisitely trained in eating disorders, so we have a dedicated inpatient unit. Many of our patients that we see in the outpatient setting do come directly from our inpatient unit, so it’s a direct referral.
I have spent time working within our inpatient unit here at UCSF; however, my current caseload is all outpatient. I think we identify primarily as an outpatient team, although we have half of our team spending half of their time on the inpatient unit as well. We do really interface with not only adolescent medicine and the inpatient unit really tightly, but we also have a full-time nutrition team who are also, to use the same word I did, exquisitely trained in eating disorders as well.
I feel so fortunate that whenever I have questions or I’m coordinating care, I know the people I’m working with are really good at what they do and can fully support, in a scaffolding way. So even if I’m seeing my outpatients, should I have any concerns about their vitals or anything that I feel like I need somebody to keep an eye on their suitability for readmission, then I have that right there at my fingertips.
Chris Sandel: With the family-based treatment, are you just doing the sessions with the adolescents, or there’s times where it’s with the parents there as well?
Sasha Gorrell: Some of my patients I’m actually seeing as individual clients, where I do cognitive behavioural therapy for eating disorders. Depending on the specific eating disorder presentation, the level of motivation, their age, family factors, making those clinical decisions about whether they’d be more suitable for CBT or for FBT.
For those with eating disorders where they do need family support, the adolescent typically checks in with me for anywhere from 10 minutes to probably 30 minutes. In that time, depending on their willingness to engage with me about their eating disorder, or about anything else that’s going on for them, some of my patients really use that time, and some are less willing.
And then the remainder of the session typically is with the family all together, so one or both parents, depending on the family structure, and the child. Sometimes I will meet with parents individually if there’s things that I think are more appropriate to be addressed individually with them. So it’s a little bit flexible in that sense, where I think once I’ve established care with a family, we fall into a rhythm of what seems to work best for them.
Chris Sandel: I was just going to say, with the people who are there, how much is it they are there and they want to recover and they are very much on board versus “I’m here because my parents are putting me here and this is being forced upon me”? For me, I’m in private practice; majority of the people who are coming to see me want to be recovering. And that’s not to say there isn’t ambivalence, that’s not to say that there aren’t people who really struggle with getting on board, but people are self-selecting and saying, “Hey, I want to do this.” But I imagine that’s not always the case with the people you’re working with.
Sasha Gorrell: Yeah, the fancy word for that is ‘egodystonic’ or ‘egosyntonic’. The disorder itself, some adolescents really don’t want to give it up. That fear of engaging in treatment or envisioning what the other side of recovery looks like is terrifying. I think most people entering eating disorder treatment, whether it’s self-selection or not, there’s that level of fear, of uncertainty about what not having the eating disorder would be like. So just acknowledging that that’s across the board for everybody.
And then I think within each individual patient, the variability can happen almost session to session. When they come in one day, they might be kind of pumped that they had just celebrated a birthday and been able to eat some birthday cake and they’re sort of ambivalent about that but also sort of proud of themselves. And then the next time I see them, they’ve had a ‘setback’ where they’re really bummed and they feel hopeless and don’t want to engage very much in the idea of recovery that day.
So I think like all of us, there’s differing levels of willingness to engage. I’d say for the most part, treatment is something that people consent for, so we would never actually force a child into treatment. For the most part, I don’t want to give myself too much credit, but I think I try to make my work with them not too painful, that they feel engaged and they do feel like it’s helpful.
00:25:08
Chris Sandel: Let’s start chatting about some of the stuff that you mentioned as part of your talk. As I said at the beginning, the talk title was ‘Is Anorexia Nervosa an Anxiety Disorder?’ How long had you been thinking about anorexia or eating disorders as an anxiety disorder? What led to this line of thinking?
Sasha Gorrell: That’s a good question. I think looking back, in my graduate training, the programme I went to at University of Albany, we had really solid training in CBT and exposure-based treatment. I think I just started to think about most things through that lens. Almost, if you put it in quotes, like ‘everything is exposure’. [laughs] Everything that we do is exposure. Whether that’s planned exposures and then we’re trying to learn from those exposures – but I think just the nature of eating disorder treatment is exposing somebody to something that terrifies them.
So I think from that base philosophy, I really thought about things that way. And I really have an interest in that application. We know so much about exposure-based treatments from the world of anxiety. It’s only within really the last five years or so, maybe six years, that we’re really starting to think about making this more mainstream within eating disorders. These things work. These treatment approaches work. So turning the tide of our willingness to use those as more of a first line approach – of course, depending on the patient and the situation.
Chris Sandel: If you think of a continuum where at one end you have exposure and at the other end you have avoidance, the more exposure, the better; the more avoidance, the worse.
Sasha Gorrell: Exactly.
00:27:10
Chris Sandel: You started out as part of the talk saying that it’s often useful to think about the similarities with eating disorders. So rather than thinking about the differences between all the different eating disorders, thinking about some of the similarities with them. Do you want to talk a little about this?
Sasha Gorrell: Sure. This is something where if you are actually treating people with eating disorders, you realise that some of these differential diagnostic details are really not that important. Whether somebody is discretely definitely underweight matters less than how distressed they are right now, what are their behaviours right now. If you think about these arbitrary definitions of “How many times do you need to engage in a specific behaviour per week, per month to meet diagnostic criteria?”, it’s less important than, how is that person’s quality of life? How much are they impaired or distressed?
I think the more I’ve been working with individuals with eating disorders – not the less concerned I am about these discrete categories we make, but I think the idea that every single eating disorder has a fear deep down inside of the consequences of eating. Not necessarily a fear of weight gain, but a fear of “What’s going to happen to me if I eat whatever is in front of me that’s scaring me for whatever reason?” Whether that’s weight gain, it could be social judgment, it could be identity, holding on to the eating disorder. Whatever it is. It could be emetophobia. It could be all of these things.
So I think thinking more about the causal mechanisms behind these symptom presentations is really where some of our more effective thinking and therefore treatment development could lie.
Chris Sandel: Definitely. One of the other ones you mentioned as part of this was also weight suppression and looking at where the person has been historically, and that this again, across the board, irrespective of what eating disorder someone has, is also something that has an impact.
Sasha Gorrell: Absolutely. Again, to think about those criteria of “Are you underweight?”, why are we calling atypical anorexia ‘atypical’, when really they’re weight-suppressed from where their body needed to be or had been historically. I think whenever you take the body below whatever weight it had been historically, there’s going to be physiological changes, biological changes.
In some ways, I think every eating disorder we’re talking about, even, surprisingly – sometimes people assume that somebody in a larger body couldn’t possibly be underweight, but they are for them. I think Michael Lowe at Drexel probably has written the most about weight suppression. There are some fascinating longitudinal studies through Harvard MGH that have shown 20+ years later that there’s impacts of weight suppression on retention of symptoms in an eating disorder.
It’s something I think is worth paying attention to rather than separating these diagnoses by weight status currently, but just thinking about them as being impacted across the board by weight suppression.
Chris Sandel: What percentage of the people that you’re seeing or that are coming to where you work would fall into that category of atypical anorexia? Again, I’m on board with you; I think it’s a terrible definition and it does a lot of disservice to people who are not matching up to the stereotypical view of anorexia. But I’d just be interested in terms of how many people are actually coming and getting help even though they’re not matching up to that stereotypical view.
Sasha Gorrell: You’re asking me for a pinpointed number and I wish I had it for you. I would say anecdotally, I feel like it’s higher than maybe people would expect. I would also say I do believe that even in the last maybe five to eight years, I’m seeing more of it. Take that for what you will.
Eating disorders in general, people tend to think of them as low base rate disorders. I am in the opposite camp; I say they’re everywhere. There’s disordered eating everywhere. There’s not a low base rate here. But I think within that, the people who do actually present for treatment, the number who are by definition, if you will, atypical is considerably higher than people would assume.
Chris Sandel: That’s both good and bad. But I’m glad that they’re being able to get treatment and get help. And then the third area you said where there are similarities with the eating disorders is the behaviours that maintain the eating disorders.
Sasha Gorrell: Yeah, and I think you were just talking about this a few moments ago, this idea of avoidance of the things that scare us. We all do it, myself included. But as we’re avoiding certain things, if you think about the parallel to anxiety disorders, engaging in behaviours that make us feel safe. It could be avoidance, but they could also be things that we engage in that prevent the perceived outcomes that we fear. For any given individual with an eating disorder, that might be something compensatory – either restriction before or after or engaging in exercise.
Once you engage in those behaviours, for most people there’s a sense of reinforcement. It’s either taking away the anxiety or the negative affect they were feeling, and initially making them feel better. Of course, sometimes that can be a pendulum swing to then go into ultimately feeling guilty or regret that they had done whatever they did because then they feel like, for any number of reasons, they’re setting themselves back.
It sets up this pattern of feeling the discomfort, engaging in the behaviour that initially takes away that feeling of discomfort, but then feeling like it continues. Then you feel like you need to engage in that behaviour again when that feeling comes up. I think that’s part of where I see some parallels between anxiety and eating disorders in terms of the patterns of either positive reinforcement or negative reinforcement that people get into that keep those behavioural patterns stuck.
Chris Sandel: And unfortunately, it doesn’t often keep it stuck at the same level that it started. What I notice is it used to be this amount of exercise and then it increased to this amount of exercise and then increased to this amount of exercise, and it just goes in one direction where it very quickly then becomes the new normal and “I can’t do any less than this thing.” The same can be true with eating as well; “I’ve taken out this snack, so I now can no longer bring that snack back in.” So it’s not that the avoidance stands still. It’s this constant ratcheting up.
Sasha Gorrell: Yeah. I think, too, sometimes for an individual who has perhaps a little bit more insight, if you ask them, “Why are you doing that? You know that’s not helpful”, sometimes they’ll say something like, “I know, but that’s just what I do. I’ve got to do it because that’s what I do.” It’s almost like it reaches a point where they understand that it’s not rational why they’re feeling that they have to continue doing these ratcheted-up things, and yet, I don’t know, it becomes so entrenched or so much a part of their daily life that it is really hard to back down or backtrack from that.
Chris Sandel: Yeah, which we’ll get into a little more when we talk about some of the things you mentioned in terms of changes to the brain and the different models that can have an impact on that, because that explained how that process can continue on.
00:36:03
You also talked about the different comorbidities that can come alongside anxiety disorders or eating disorders and looking at this both ways, in terms of the percent of those who have anxiety disorders who also have eating disorders and then the percentage of people who have eating disorders but also have comorbidity with other things.
Sasha Gorrell: Starting with the individuals who have eating disorders as a primary presentation, I think it’s really the norm and not the exception now that there is comorbidity there, just simply because of the impact of malnutrition. Most individuals who present for treatment do have some level of depression and anxiety, and whether that’s just because their life is so deeply impacted by the eating disorder is one thing, but it can also be because they are, as we mentioned, weight-suppressed. So getting proper nutrition for some people does a little bit of mitigation of that depression.
But for others who either had a premorbid presentation of depression, or it seems as if anxiety is a lot harder to actually move within the context of eating disorder treatment, many individuals start off eating disorder treatment with both anxiety and depression, and what we seem to see is that depression remits a little bit more easily than the anxiety. So they might be towards the end of a standard course of eating disorder treatment but still have strikingly high levels of anxiety.
And it seems as if, if you have a more severe presentation of an eating disorder, then the prevalence rates of generalised anxiety disorder, other anxiety disorders like social anxiety – even though we’re not calling OCD an anxiety disorder as of 2013 in the DSM, we would call that an anxiety-related disorder – those rates of having that comorbid presentation are quite high. So thinking about how we’re conceptualising treatment, there’s many things to address all at once.
Chris Sandel: It also doesn’t surprise me that there are certain things that get better as part and parcel of the eating disorder recovery, and then there’s certain things that don’t. When I watched this in the presentation, the thought that someone who goes on to develop an eating disorder may historically, and as a trait more than a state, have higher anxiety – there’s nothing surprising about that because it then makes sense – and this could be from a genetic predisposition perspective that an eating disorder is more likely, or it could be, as we talked about before, they find this thing in terms of avoidance that starts to work for them, and that increases the susceptibility of that thing and then it goes from there.
Sasha Gorrell: I think what you’re speaking to are some of the neurocognitive traits that we often see with individuals with eating disorders. Some of those, talking about being achievement-oriented or detail-oriented, conscientious. Some of my patients refer to as being ‘stubborn’. [laughs] It’s like, no, actually, you’re just really dedicated or whatever it is. Some of my patients are some of the best students.
While every person is different and everybody has a different personality profile, we do see those similarities across many individuals with eating disorders. It does speak to underlying genetic predisposition for this neurocognitive profile. So to your recent point, Chris, I think it’s really not surprising that that would be an underlying thread that is part of the presentation, but it also is premorbid and continues throughout.
Chris Sandel: With your patients, is there a disappointment with this in terms of “I thought I was going to recover and then all my anxiety was going to go away and this hasn’t happened, and I’m bummed”?
Sasha Gorrell: What I’ve found is that most people, when they’re engaging in treatment, it can be profoundly wonderful in a strange way that they are now talking about their mental health in a different way. They’re more accepting of what they’re experiencing and their feelings. So I don’t know. I feel like most people, even though, yes, there’s still work to do once they start to feel better at least with their eating disorder, I think they have more energy or willingness to engage in treatment for it or to think about even accepting those quirks about themselves. Like, “Okay, this is part of what makes me potentially vulnerable for relapse, but at least I know that about myself now.” I wouldn’t say they’re bummed. It’s more curious and actually more accepting, I think.
Chris Sandel: I would also think as well that even if someone’s baseline anxiety isn’t decreased, what you learn through the eating disorder recovery is so many of the skills in terms of “How do I not do avoidance? How do I have better coping skills?” So even if it hasn’t taken away the baseline, it’s still given you the tools to be able to deal with that.
Sasha Gorrell: Yeah. I can’t tell you how many people, at some point we have those discharge conversations where they say, “Hey, my body image still isn’t great” or “Yeah, I still have all the thoughts, but I have the tools. I have a toolbox now. I know not to respond to those thoughts in the same way, or I can distract myself and move beyond that to focus on things that matter more to me than my eating disorder.” I think there’s an engagement with the cognitions and the feelings in a way that feels much more adaptive and empowering.
00:42:20
Chris Sandel: You then talked about how anxiety interacts and maintains the eating disorder and the loop that people get into. We’ve kind of touched on this, but I think it would be useful to sharpen it up and explain it again.
Sasha Gorrell: I tend to think a little bit like a behaviouralist. I love the cognitive piece of CBT, but I like to think about that ‘B’ like a ‘cBt’. If we’re thinking about an example of somebody who has an eating disorder or subclinical at least, and there’s a trigger, a stimulus that somehow clues them into “Okay, this is something that in my learning history has been associated with something that’s not a great outcome.” It’s something that signals this is something to avoid or something that’s not great. Or it brings up an emotional response, it brings up something that – we could call it anxiety, but sometimes it’s guilt, sometimes it’s shame, sometimes it’s sadness. Take any panel of negative emotion and you can pop it in there as a response.
And then oftentimes individuals with eating disorders learn that engaging in an eating disorder behaviour decreases that negative emotion. So thinking about “If I go for a run later, I will feel a little bit less uncomfortable with the fact that my parents made me go out to brunch with them.” That can be anticipatory, too, in the sense of if you know you’re going to brunch with your parents and you know you’re going to be having to eat more food than your eating disorder is comfortable with, then you can say, “I’ll go but I’ll feel better because I know I can go running later.” So not even engaging the behaviour, but just knowing that the opportunity is there, the promise to yourself.
As you might imagine, if you either are engaging in that behaviour or anticipating it, you have that out for your eating disorder, if you will, then there’s the idea that “Hey, I avoided that negative outcome. Maybe I don’t feel so bad. I took care of the problem. I don’t feel as bad as I thought I would.” So then it takes tend to make it more likely that you’ll engage in that behaviour again, because you’re like, “That was my solution last time, so I’ll do it again because it’s going to make it less uncomfortable for me.”
As I mentioned, there’s fallout from that. Oftentimes people, when they have gotten stuck in a pattern of compensatory behaviour, they start to feel really bad about it after a while and frustrated that they can’t break the cycle. “I know I shouldn’t and I did.” So there’s lots of other negative emotion that comes up, but then it keeps getting in a cycle where it continues.
I think one of the things I spoke about in the talk, and I wanted to highlight too here, is that the individuals with whom we interact – for my particular clinical population, it would be adolescents within their family structure – oftentimes loved ones don’t want to see their loved one in distress. They’ll inadvertently say, “It’s okay. You don’t have to go and do that thing that scares you. I’ll make it easier for you” or whatever it is. So inadvertently, it’s almost like the parents or family members accidentally, by way of trying to do a good thing and reducing distress, actually end up accommodating that eating disorder or keeping it something where everybody feels like they can collude with it, or not quite challenge the eating disorder because they want to keep the negative reactions and distress lower.
It’s a natural thing that I think happens across the board for any parent with a child with an anxiety disorder and any parent with a child with an eating disorder.
Chris Sandel: Definitely. I’m blanking on it – I had a recent conversation with Adele Lafrance and she was talking about this same situation, and what can often go through the parent’s mind is lots of different fears. There’s the fear of “I’m worried that they may end up killing themselves”, and suicide is a real big risk. So they weigh up “Okay, I think it’s better to let them not have to eat as much at this brunch or to be able to go for that run afterwards because an alive son or daughter feels like the better option.”
Sasha Gorrell: Yeah. Even if we’re not talking about suicide, we’re talking about acute food refusal. Like, “I’m going to let them eat what they want to because if I don’t let them eat what they want to, then they won’t eat at all.” It’s this idea of, what do you do if a child says “I’m absolutely not going to eat”? That’s also terrifying in the sense of, as a parent, those stakes are so high. The medical acuity is so high for many people.
Chris Sandel: Is that when you’re having the conversations with parents and maybe the conversations you’re having with parents on their own? Is this some of the stuff that is coming up more often?
Sasha Gorrell: Absolutely. That’s the beauty of the work, helping parents to feel more empowered that they can make headway against the eating disorder without – I think a tagline would be “You will not ruin your relationship with your child. We’re helping you to ruin your relationship with the eating disorder.” [laughs] It’s so cliché and so basic, but I think so many parents believe that they will permanently alienate their child, or this conflict that they’re bringing up – the conflict is inevitable, but just reminding parents, hey, if you see that reaction from your child, that means we’re challenging the eating disorder. That’s good. If that child is quiet and happy, we know that the eating disorder is at work.
So yeah, it’s tricky. I think parents also oftentimes arrive at treatment feeling tremendously guilty. Like, “How did I let it get this bad? I should’ve seen it sooner.” So again, helping parents to understand that these disorders thrive in silence. They thrive in secrecy. I don’t know if I’ve actually met a parent who knew what was happening right at the beginning.
Chris Sandel: I would say guilt and/or burnout, like they’ve been trying to do this on their own, and the frustration of that and the fear. It’s just this horrible melting pot of all these things.
Sasha Gorrell: Yeah, it’s exhausting. I think reminding people, too, that their ability to support their child is only as good as their ability to take care of themselves as well, in the sense of trying to help parents to bolster their social support because it’s this intensive caretaking, intensive work to fight the eating disorder. It takes a lot of energy.
00:50:04
Chris Sandel: You then talked about the key differences between anxiety and anorexia and looked at it in different contexts and different ways. I think this would be useful to talk about. I’ve got it as a screenshot from the talk, but if you can remember it, that would be great.
Sasha Gorrell: I think there’s a couple of really key differences, and I think it’s a little ironic that I have thought so much about how similar they are and yet there’s really key differences that I think are important in thinking about particularly treatment approaches.
One of them we were just talking about, suicidality. I think sometimes people believe that it’s not okay to talk about the eating disorder or ask questions about it, mostly for fear of making it worse. That’s something that’s really different for anxiety. Most people in a colloquial sense joke about being anxious or call themselves some derogative whatever, and there’s a more popular belief that talking about anxiety makes it better. It’s the opposite for eating disorders, typically.
What I would say is just remember that actually talking about eating disorders is really important and necessary to override that misperception – myth-busting, if you will – that talking about it makes it worse.
Going along with that, I think so much of the way we think about mental health, depending on the circles that you run in, it’s maybe more acceptable for individuals to talk about having certain kinds of mental health challenges, and yet having an eating disorder is still really uncomfortable to talk about. It’s something where our societal attitude about it is really different. So that’s tricky in the sense of most people will be more forthcoming about other mental illness. It’s just different for a lot of people with eating disorders.
Chris Sandel: I would say as well with that, there’s probably an added layer of uncomfortableness depending on where someone falls within the stereotypical view. If someone’s in a larger body, to say they’ve got an eating disorder, a lot of the time they’re going to feel like “I’m not being heard here” or “Someone’s going to assume that what I’m saying isn’t true and I’m eating more than I’m letting on” or all of these things. Or for a man to admit that they have an eating disorder has a different weight to it than a woman admitting that they have an eating disorder. So I think there are differences here as well.
Sasha Gorrell: Yeah, the misperception of what somebody with an eating disorder actually should look like or act like or talk like. I think that’s part of building awareness around how widespread eating disorders are and that they come in all shapes and sizes and presentations.
One thing that’s really taking a quick detour into the clinical realm – I’ve already talked about how exposure treatments are historically not as widespread in the eating disorders field, and I think some of that is related to what we were just talking about. It’s this fear of the fragility of an individual with an eating disorder. Like if I push them, addressing that eating disorder directly with an exposure approach or something that’s a little bit more aggressive, if you will, is somehow going to backfire or not be helpful.
I think what we’ve found is that individuals with eating disorders are not fragile at all. They’re actually pretty tough. I think obviously – big caveat here – if somebody has deep medical acuity and they should really be not engaging in anything that challenges them, that makes sense. But I think this reversal of exposure is really the first line gold standard treatment for anxiety disorders, and it’s only now recently coming into play as something we’re really thinking about as being important for eating disorders as well.
But with that, I think the last thing I’ll highlight is that when you’re talking about exposure-based treatment for anxiety, oftentimes one of the things you can leverage as a clinician is the distortion of the fear or the unreasonableness of that anxiety. Like, do you actually think that’s going to happen? Getting somebody to think about “Yes, I have this fear, but what are the odds of it actually coming true?”
But with eating disorders, whenever you’re starting treatment with somebody – hearken back to this idea that most people are weight-suppressed – one of their key fears is gaining weight, for many people. So thinking about, actually, within the context of treatment, your worst fear that you’ve identified is actually going to come true. And I think it’s part and parcel of treatment. Like, yes, you have to actually confront that main fear head on, and that’s tricky to think about. There’s no way of helping somebody to think about it being irrational because it’s something that will actually manifest.
Chris Sandel: I guess the thing I would add to that is it’s not a fear of weight gain in a vacuum; it’s a fear of weight gain and then what’s going to happen as part of that, which is mostly going to be “I won’t be able to tolerate this” or “I won’t be able to have a good life” or “I won’t be able to meet a partner.” So I think that piece, you can start to show someone, isn’t necessarily true. But I also do agree with you that yes, there is a weight gain that is going to have to happen as part of recovery, so that part can’t be avoided.
But it’s not that fear in and of itself. There’s all these other things, the layer down that is connected to that fear.
Sasha Gorrell: Chris, I think you just blew your cover that you clearly work with people that have eating disorders. [laughs] Because you understand that piece in such an articulate, eloquent way.
I’m teasing you; I think you’re right, that it’s really not that simple. I think if we rely on this fear of weight gain as a diagnostic criterion for some eating disorders, that doesn’t give it any credence or service for what it actually means for many people. It’s oftentimes not even about the weight gain but it’s about all of the other things that are associated with it. So I agree with you wholeheartedly. I think there are ways in which you can leverage that fear, but I also think it’s also something that oftentimes people want to feel better, but they don’t want to have the larger weight body compared to where they are when they first start.
Chris Sandel: Definitely. I’m trying to have a look here to see if there were any others here as part of it. You said that these were the key differences, but when I look down, they’re actually not different. It’s more like the misconceptions of anorexia and eating disorders versus what we do know about anxiety.
Sasha Gorrell: Yeah. It’s almost like our societal perception or a shift of thinking about it. If you are somebody who is embedded in this way of thinking, then none of these things are surprisingly different. Just the way maybe some individuals who are less in the know about certain aspects of eating disorders would see it differently.
00:57:57
Chris Sandel: You then talked about the reward deficit model versus the habit-centred model. Do you want to explain a little about what these two are?
Sasha Gorrell: Yeah. We’re taking a dive into the brain. Just to start off by saying that oftentimes there’s this discomfort with talking about the neurobiological bases for some people and the genetic bases for some people. I think framing this idea that we know eating disorders are not a choice – nobody would ever choose to have an eating disorder before they’re diagnosed with it. So I think just putting them alongside all other psychiatric illnesses, there are clear underlying things that come from both genetic and also neurobiological bases that drive the risk for these illnesses.
I think sometimes people, when they hear that there’s a huge genetic basis for eating disorders, they’re like, “What do you mean? I caused it for my kid?” That’s not the case. We’re talking about this very complex foundational risk, that if you do have some of these underlying differences, then potentially you are more at risk for dive of an eating disorder. So just to lay that groundwork.
My interest and fascination with it is that perhaps if we understand what happens underneath the skin, we’re going to be able to be more effective with our treatment, to think about our treatments a little more subtly, a little bit more individualised, potentially a little more effective.
There are two main neurobiological models of anorexia nervosa right now. There’s lots of literature on this, and I’m going to do them a quick disservice by saying anything about them, because there’s lots of reading to do.
The reward deficit model derives from individuals from the University of California San Diego. The habit-centred model derives from individuals who have been working on this at Columbia University. They’re not in any way opposing; in fact, they’re very complementary models. I can talk a little bit about why that’s the case. They both circle around striatal dysfunction or dysregulation. Your striatum is a part of the brain that does regulate reward response; it also regulates behavioural response and reinforcement, the things I was talking about before.
What we see is that across lots of neuroimaging studies, there are differences in the circuitry both in the dorsal and the ventral striatum, and they each correspond to where some of the habit-based behaviour would get entrenched and where some of the reward dysregulation would be associated with. No matter how much you know about the brain, there’s not one brain part that corresponds to any one behaviour; it’s much more complex. It’s about the communication between different brain regions. So again, just taking this with a grain of salt. I’m definitely oversimplifying by saying that there’s one area of the brain that’s responsible for most of this thinking.
Where should I go from here, Chris? What else would be helpful to know about these models and how they might be implicated?
Chris Sandel: You talked about how these can look different with someone with an eating disorder, or it might’ve been specifically with anorexia, in terms of how they can relate to something that would otherwise be considered a reward or a disorder-specific stimuli. I thought that was really helpful.
Sasha Gorrell: It’s again something that I’m wary of oversimplifying, but I think what the literature shows is that there’s mixed findings in reward response across individuals with eating disorders. In some imaging, in some paradigms, you see normative reward response – like if you present somebody with a cue that you would expect to be rewarding, then you do see the neural response that you would expect. Whereas in other studies, depending on what that cue is, you don’t see the same reward response.
At first people were puzzled. They’re like, wait a minute, is there a problem with reward response or not? I think where the reward deficit model landed was this idea that primary reward value – primary rewards would mean things that typically would be rewarding. Oftentimes people would say food for most people is rewarding, whereas for an individual with an eating disorder, it’s almost like the absolute opposite. The brain response to something that’s typically rewarding would actually be in areas that are associated with fear. Again, even if you don’t know anything about the brain, you might be aware that the amygdala is really associated with fear response. So if you would show in a scanning paradigm a picture of something that’s high fat, high calorie food, you wouldn’t see any reward response from somebody with an eating disorder. In fact, you’d see the opposite. You’d see a fear response.
However, when that cue that you present to somebody with an eating disorder is more aligned with the disorder – let’s say a really low calorie food or something that elicits the idea that there’s a very thin body that’s shown – then there’s actually a normative reward response in the brain. It’s almost like depending on the cue and the stimulus and how that learning has been implanted – ‘implanted’ is not the right word, but how it’s been consistently historically learned over time, the reward response is totally on board if the cue is disorder-related.
Chris, you were talking about this earlier. You were talking about this ratcheting up of needing more of whatever behaviour it is to feel the satisfying reaction to it. So the overtraining of those reward responses over time actually diminishes in some ways their effectiveness. So then over time, that behaviour becomes more habitual. It becomes more automatic that people engage in those behaviours regarding of whether they’re rewarding it anymore or not.
Chris Sandel: I think that’s probably a function of someone getting more and more into a depleted state.
Sasha Gorrell: Exactly.
Chris Sandel: You then have less energy to be able to do the thing that you’re doing, but it’s like “I’m doomed if I do, I’m doomed if I don’t, and I’m so used to doing this thing that it just happens automatically.”
Sasha Gorrell: I’ll add that it doesn’t even seem to be weight dependent or depleted. It can just be over time that the longer we have these pairings of things that we’re learning – a certain cue and then a certain consequence or response – the longer you learn these relationships between things, the more entrenched that pattern of learning becomes.
Chris Sandel: That’s how humans are able to do what humans do. That’s how someone is able to get better at swinging a golf club through to basically everything we learn to do. The more we do it, the better we get.
Sasha Gorrell: Exactly. Tightening up the communication between those neurons, and the behaviour becomes – I don’t want to say easier, but a lot more automatic.
Chris Sandel: Yeah. When I heard this part of the talk, those two models don’t feel like they’re in competition but are more like these two things happen together, and in some people one happens more than the other, but I don’t imagine the people who have come up with the reward deficit model are telling the people who’ve come up with the habit-centred model that they’ve got it all wrong.
Sasha Gorrell: No, not at all. I think the differences or the interesting parts come in in terms of thinking about the more subtle aspects of learning. How do we learn and what keeps some of these behaviours in maintenance? They are complementary models, but I think if you took a little snapshot of where somebody was cognitively and where they are in their state of illness and where they are in their state of treatment, we might think that some aspects of these models are more salient at any given time.
01:07:08
Chris Sandel: Then sticking with the brain, you talked about the reward prediction error and some of the studies that have been done on this. Do you want to speak about this?
Sasha Gorrell: Sure. This is some recent work. Dr Guido Frank at UCST. Reward prediction error refers to a classic task where if you’re presented with a reward and you didn’t expect it, like it’s surprising to you, then you’re going to have a brain response. The opposite is also true: if you expected a reward but you didn’t get it, you’re also going to have a brain response. So the reward prediction error refers to that absolute value of how surprised you are, or how salient is the degree to which you’re surprised, how much that shows up in your brain activity.
Some of the more recent work that Dr Frank has been doing has been looking at this reward prediction error response in individuals with transdiagnostic eating disorders as well as comparing them to healthy controls.
Chris Sandel: For the listeners, what does ‘transdiagnostic’ mean?
Sasha Gorrell: Oh sorry, yeah, thanks for pointing that out. Transdiagnostic means they’re not limiting it to only people with anorexia nervosa. They would include OSFED, binge eating disorder, bulimia nervosa, anorexia nervosa. So looking at it, hearkening back to our earlier thoughts about these disorders have more similarities in some ways than they do differences. Highlighting that that’s a slightly unusual approach sometimes, because I think oftentimes individuals who are doing this research, there’s a push to keep the samples more homogeneous. The argument would be like “Just test it in individuals with anorexia because then you know that there’s less potential differences across your sample.” I think, though, that I would applaud this approach to be transdiagnostic because then it becomes more real world. It becomes something you can generalise across eating disorders.
Chris Sandel: Definitely. I think this is important as well because often there’ll be research with anorexia and it’s only with people who are underweight anorexia. Then I try and share that with someone and they’re like, “That obviously doesn’t apply to me.” It’s like, no, it can still be applied to you even though your body weight is not the same as this person’s. So I think having research where it has much more breadth in terms of where someone’s at from a size perspective and can still show these same findings has a lot of weight.
Sasha Gorrell: Yeah, it has so much more value. So this particular line of research was finding that those with lower weight actually had a different brain response to this reward prediction error. It was basically that restriction that would lead to weight loss would end up altering your brain response, particularly in an area that’s associated with food intake.
So thinking about if you engage in restriction, which leads to weight loss, this actually would have an impact on your brain. I hate to simplify it and say it’s like chicken and egg, but it’s almost like your brain didn’t lead you to have the restriction weight loss, but if we think about did that restriction weight loss actually inspire the brain change – when you inspire that brain change, then talking about reinforcing, going backwards and keeping those eating disorder behaviours in place. It’s really important.
I think some of our listeners might have taken Psychology 101 way back in the day in some high school or college environment, and there’s often a case – Ansel Keys was the researcher who did the study. It was in the 1940s, and it basically showed that when you have men – these were men that I think were either associated with the military or something that they were normal civilians. They were not a psychiatric sample, necessarily. But they were given a six-month low calorie diet. Enforcing what happens when we give people restriction. Of course, nowadays that would never be approved by Institutional Review Boards. We would never be able to voluntarily give a bunch of people a really low calorie weight loss diet just to see what happens.
Chris Sandel: Two things I will say on this. One, I’ve done a really long podcast on the Minnesota Starvation Experiment.
Sasha Gorrell: You did? Okay, never mind, great.
Chris Sandel: I’ll put that in the show notes so that people can listen to it. And two, I made the same statement a while ago of no-one would ever be able to do this again – and I was proved wrong, because in Australia they’re trying to get something off the ground – and this was with kids – where they were giving something like an 800- or 1200-calorie diet. Something insanely low. There was a lot of pushback, and I don’t know if the study has started, if they’re still recruiting or what’s happened, but I was shocked that this kind of research does appear that it can still be done in this day and age.
Sasha Gorrell: Wow. Thank you for enlightening me, and I’m sorry to hear that that is the case. I would’ve assumed, as you just said, that that would not be allowed.
In any case, the idea that that actually would lead potentially to brain changes, that it would then circle back and keep the eating disorder in place. So it’s an important line of research to think about how these behaviours potentially impact the brain once they’re already in place, and how that explains maybe a more maintenance type of model.
Interesting stuff that seems to implicate dopamine response. Dopamine is a neurotransmitter that’s most commonly associated with reward. Again, thinking about we know from those two models of anorexia nervosa I was talking about earlier that the striatal dysregulation is circling around reward response generally. So again, the study thinks about a mechanism that might implicate a little bit more of a causal mechanism. Like, how do we wind up changing the brain just simply by the physiology?
01:13:55
Chris Sandel: You mentioned there about dopamine. As part of the talk, you made reference to some rat studies. I know this is also quite a classic study to talk about, rats that were able to run themselves to death and proving that anorexia isn’t about how you look; it can be given to other animals. But it was great to hear about this addition where they looked at the knockout mice with the dopamine receptors or transporters. Do you want to talk about that?
Sasha Gorrell: Sure. The activity-based anorexia model is this paradigm in rodents where if rats are restricted in their food, so not given as much food as they normally would be, but they’re also given access to a running wheel, they end up really prioritising running and not eating as much at all. And then if they’re not removed from the paradigm, they actually will expire. That’s a fancy word where they’ll run themselves to death.
It’s a fascinating physiological model, but it really doesn’t seem to map on so well to humans. I think there’s lots of different reasons why. I think one of the more recent studies, the one you referred to, Chris, was a model where they took this paradigm and they compared mice that had had dopamine receptors knocked down so that they had excess dopamine. Receptors would take up that dopamine and take it away, where if you knock down that receptor, then the dopamine is much more likely to be free-flowing. Basically, high dopamine mice and then mice that didn’t have this knockdown.
They gave them the paradigm where they didn’t give them access to the wheel. In that, if they gave them a restricted calorie diet, turns out there was really no difference between the two groups of mice in terms of their ability to survive. But as soon as they gave them the running wheel, the ones that had the dopamine knockdown, so the ones that had that excess dopamine, ended up not surviving very long at all. In fact, they survived half the number of days that those without that knockout did. A striking difference in their ability to succumb, if you will, to this paradigm. They’re much more likely to engage in that exercise than those without the dopamine knockdown.
I think one of the neatest things about this study was that they looked at even within the two groups, within the group that had the knockdown versus someone that didn’t, there were still some mice within that knockdown group that were more ‘resilient’. Even though they had the knockdown, they could fight the paradigm. They could actually not succumb to it the way some of their peers did.
The question that’s now burning is, why are some of these mice more resilient? If they’re all given the same treatment where they’re given this knockdown, even within that group, some of the mice didn’t actually end up running themselves to death. So again, a hint at future research. Not surprising that there’s individual variability. I think humans and animals, we are not the same across groups or across treatments. But just some really neat work about thinking about a more positive idea of can we build resilience to this presentation of compulsive exercise within the context of eating disorders? That’s really the take-home.
Chris Sandel: When you say resilience, when I think about it from that study, is resilience about the things that someone is doing? Or do you mean resilience in terms of some other biology that is then countering the issue that dopamine has? When I heard you talk about it, I thought it’s dopamine is having an impact, but it’s not the defining impact, or it’s not doing absolutely everything, and that’s why there can be this variation. I just want to get a sense of, when you say resilience, what do you mean?
Sasha Gorrell: You’re absolutely right. You’re dead on with that. Even though they all had the same, if you will, impediment of having the dopamine knocked out, clearly there is something else that’s functioning within their neural activity that’s helping them to either retain weight even though they’re exercising more or eating less, or that they’re not going to be engaging in the exercise as much. This idea that maybe resilience means being able to survive longer because they’re able to retain weight even though their exercise level would not suggest that. Or they are just engaging in less of that ‘deadly’ behaviour, which in this case would be the wheel running.
Chris Sandel: Did they have some kind of mini rat pedometer so they could answer some of that question? [laughs]
Sasha Gorrell: It’s a good question. I think they probably monitor these guys overnight with video cameras. They probably know every little last detail of their activity. That is the beauty of doing any animal models. There is increased control that you really do know exactly what the animals are doing and when.
01:19:33
Chris Sandel: You then also talked about traits and neurocognitive features of anxiety, and I think this would be useful to go through as well.
Sasha Gorrell: I spoke about it a little bit earlier. I think harm avoidance – most people would say they don’t love change, but just this aversion to change or novelty. Oftentimes, individuals with eating disorders will be more sensitive to punishment or criticism. They’ll be more rigid in their thinking. Perfectionism is a quality that’s often studied within eating disorders. I mentioned this already, but this idea that many individuals are very achievement-oriented, so sometimes the dark humour is that they’re so invested in doing well at something that they even want to do well at their eating disorder.
I think across the board, the takeaway for me as I’m starting to think about this a little bit more from parallels with obsessive-compulsive disorder or something where there’s a rigidity that feels like it’s outside of voluntary control. It feels like it’s a little bit more neurobiological. So if you’re looking at the brain circuitry, the front part of our brain, our prefrontal cortex, is involved largely speaking in decision-making and guiding our more rational control over our behaviour.
Thinking about if that part of our brain is overactive – which is the case, we’ve found, with individuals with OCD – that orbitofrontal cortex is really strong and really active in terms of tamping down on the more emotive side of our brain, the limbic system. So that circuitry is enhanced in individuals with OCD, and some preliminary work has also shown that that connectivity is also enhanced in individuals with anorexia nervosa. So maybe it’s a shared feature of both OCD and anorexia nervosa. Actually, some of the more recent genetic studies that are looking at shared polygenic risk for eating disorders, specifically anorexia and OCD, some pretty compelling work in the last year or two confirming that.
Chris Sandel: I haven’t done a huge amount of research on this or looked into it, but I did do a podcast on brain changes in restriction and also brain changes after someone recovers, and one of the things that came up as part of that was that a lot of the regions that are affected with anorexia are also affected with OCD, and also seem to improve as well as part of recovery. And again, it might be, like we talked about earlier with the anxiety, that it’s still higher than the population average, but through recovery, that does seem to improve. Am I right with that? Or would you look at it differently?
Sasha Gorrell: Absolutely. I think some of the behaviours – a good part of my work is really focused on studying exercise, and I see that as a discretely compulsive behaviour. But I think if we also think about rigidity, about needing to have certain foods at certain times or eating in certain orders or calorie counting, these are all behaviours that are obsessive in their quality. Those do really improve in the course of treatment. Typically making those behaviour changes really does seem to be a lynchpin for improving the overall eating disorder presentation as a whole.
01:23:21
Chris Sandel: You mentioned there about work and research you’ve done on compulsive exercise. What can you mention about that? And I know that is a very broad question. [laughs]
Sasha Gorrell: One of the things I’ll start off by saying is that I’m calling it compulsive exercise here, but there’s at least three, probably four decades of research that have called it all different things. I think the most common terms for it would be either addictive or dependent exercise. There’s also obligatory exercise. Depending on the research group and the measures used. But what they’re all getting at is this driven experience of exercise, whether it’s a direct eating disorder behaviour or developed as a compensatory behaviour within the context of the eating disorder.
It’s interesting thinking about, is excessive exercise a problem? I think the short answer is no, because there’s people that train for marathons. The duration, the frequency of the exercise that one is engaging in can actually be super adaptive depending on the context. Any elite athlete will tell you that. So just to specify that it’s not the duration or the frequency, necessarily, or the excessive nature of exercise that’s problematic; it’s really the motivation for it. It’s the context in which the individual is engaging in it.
And I think primarily, the most commonly correlated factor would be exercise for weight and shape control. If that is your primary motivation for engagement in any exercise, then obviously that could be problematic, no matter how much exercise you’re doing. If it’s something where you feel like you have to do it, you’re guilty if you don’t do it, you do it despite being injured, you do it at the consequence of other socially normative behaviours. The way we’re thinking about it and defining it, I just wanted to start with that, because I think sometimes people just think about it as more simply excessive. I think it’s more the motivation or the quality of it that is problematic.
Chris Sandel: I would also add, excessive also depends on the amount of food someone’s eating and the amount of rest that someone’s getting. Going for something that’s half an hour for some person might be very excessive because of how little they have coming in, while for someone else, that’s not excessive because they’re actually getting the nourishment to do the repair, they’re getting the rest to do the repair, and their body truly is adapting and benefitting from that exercise versus someone else, it’s just pushing them further and further into a hole.
Sasha Gorrell: I’m preaching to the choir here, but thinking about relative energy deficiency in the sense of, are you eating adequately, nourishing your body for the amount of activity you’re doing? You are wise to put that in an individual context, that for everybody it looks really different.
And it can have downstream effects on bone health and endocrine function. Again, I’m preaching to the choir because I know you know all this, but I think it’s relevant to think about whether exercise is problematic has a lot of different tangents and things that are important to consider as well.
Chris Sandel: Definitely. I’ve done an article and a podcast or two on that, so I will add stuff on this topic to the show notes as well. What else would you mention on compulsive exercise from your research?
Sasha Gorrell: It’s something where I think historically, people have not really studied it so much, mostly because the clinical advice, to this day for many individuals who work with people with eating disorders, is just don’t do it. Don’t exercise. Some of that is very wise because any amount of activity is going to undermine any attempts at needed weight restoration.
But it can also, depending on the individual – it’s complicated in the sense of let’s say the individual that you’re talking about is an elite athlete. Telling them not to exercise makes sense maybe in the very acute phases of illness, but in reality, their identity, their life is so involved in exercise, it’d be really hard to imagine that person completely stopping.
So that’s one facet of the complicated nature of exercise within the context of treatment, but another piece of it is this idea of, because we’ve always told people to stop it and just not do it, we know so much more about eating behaviour in the context of eating disorders and we know so little about exercise behaviour in the context of eating disorders, simply because we decided collectively as a field not to engage with it as much.
I think we’re at the point now where there really is no model that the field agrees on for what determines whether somebody with an eating disorder actually presents with the symptom versus not. So I think a large part of my work is just to try to unpack some of that. There’s so many different angles to think about it through. Anecdotally, if you work with individuals with eating disorders, it’s very common that somebody either presents with this symptom or they don’t.
At the risk of oversimplifying and to feel like it’s dichotomous, it’s like, okay, some people are more at risk for this than others. Why? That’s been swirling around my brain with all the work that I’m doing, and some of the current work I’m doing is looking at reward learning. Are these individuals who present with this symptom somehow different in the way that they respond to reward? Do they learn differently? Are they more habit-based in their general learning rather than reward responsive, or is it the opposite?
With great humility, I’ll say I’m making hypotheses based on what I’ve seen with other bodies of literature. But I think part of the fun of it is simply it’s a little bit like an uncharted territory. We really don’t know. Hopefully some of the work I’m doing – I’m looking at both behavioural tasks, which are computer tasks that gauge somebody’s reward response as they’re making decisions within this task, but I’m also looking at neuro-correlates, so doing some functional imaging to see what’s underlying some of those behavioural choices and looking at group differences between people who present with the symptom versus those who don’t within a clinical population.
But then also looking at activity-matched controls, because potentially if we have teenagers who exercise a lot, are they going to have a similar response to those who have this presentation within anorexia nervosa? Again, hypothesize as I might, I really don’t know. So that’s exciting.
Chris Sandel: I will be really interested to hear more about what the research shows up, because even a couple of things that came up when you were talking there – anecdotally, what I’ve noticed with clients is for a lot of clients, they might not start with exercise and exercise might not start as being a big part of it, and often it ends up being a bigger part when they feel that they’re no longer able to restrict in the way that they were before. So it comes in because it’s now needed in a way that it wasn’t needed before.
Another one was, thinking again from a genetic standpoint, I remember some of the research from Cynthia Bulik looking at some of this, that there’s a predisposition towards someone who wants to move and exercise more in certain populations that is also then predisposed to having eating disorders. So it’s the thing of that’s already there, but it then becomes a problem when it’s put into the context of someone who is dieting or restricting. Then it morphs into something that’s more sinister.
Sasha Gorrell: I couldn’t say that any more eloquently than you did. That’s exactly what I’ve seen anecdotally, and also the idea that the compelling research from Cynthia Bulik and others that she works with – the polygenic risk for anorexia and OCD – there was a really recent paper that showed the one symptom, the one anxiety-related phenotype that seemed to cross both, was compulsive exercise.
Again, not surprising to those of us who have seen this in the clinical realm. But I think helping to explain some of that and then hopefully, if we can understand the symptom a little bit better, than thinking about how we might target our treatment a little bit differently. Or even explain it to people in a way where it’s a little bit more understandable to them.
Chris Sandel: Another thing I’ve noticed in practice with exercise – I’m working very much in an outpatient setting in terms of I’m seeing clients online; I’m not there making sure that they’re eating certain things. I’m not there making sure they’re not doing this amount of exercise. So there is some level of flexibility in that the best plan is the plan that someone will follow. I’m always up front in saying, if I’m thinking purely from a physiology standpoint, the best thing you can do is to not exercise. As you said earlier, that’s energy that could be used for recovery. So that is the best thing you could do if I’m thinking purely from a physiological standpoint. But not everyone is ready to get on board with that either immediately or even long term, and it has to be then, okay, let’s look at how you can reduce it, etc.
But what I have found is that when someone does actually stop exercising, it is way less difficult than they imagined, and is way less of a challenge than other changes they make, even though if they were to have to rate this before they made that change, they would say “This is the most difficult thing I have to do.” I don’t want to give everyone false hope of like after a day it gets better, but it’s amazing how much this change is easier than people imagine it to be, and in a much quicker time than any other improvements, this thing changes. Is that something you’ve noticed?
Sasha Gorrell: I have, completely, and I appreciate you pointing that out. I think especially when you’re saying the anticipation of giving it up is uncomfortable, and yet for some people, I feel like they’re reporting that it’s almost a relief that they don’t have to do it.
Chris Sandel: Definitely.
Sasha Gorrell: Maybe that relief helps it to feel like it’s actually easier to give up once it’s been given up.
I think there’s a crazy part of this, though. This is the counterpoint. There’s a beautiful body of literature about the benefits of exercise, where it can actually help to restore some aspects of BDNF, which is a really important biomarker that’s associated with depression and anxiety. So this irony that we’re telling people that have high rates of depression and anxiety to take away something that ultimately, if they could have a healthier relationship with it, at some point might be adaptive, might be actually helpful – it’s just that how to reintroduce it within the context of treatment in a way where it’s actually helpful and adaptive. And that’s really different for each person that I’ve spoken and worked with. There’s no right way to do it.
Chris Sandel: Definitely. I do agree, I think exercise can be a really helpful thing to do, depending on the context that that exercise is being done. I would also be interested with that research in that I wonder how much of it isn’t just the exercise, it’s the “I’ve had time outside, I’ve had fresh air, I’ve had sunshine, I’ve given myself this act of a break, of self-care”, of all these other things where it feels like you’re starting exercise, but it’s actually a proxy for something else.
Sasha Gorrell: I do think it’s interesting that there are certain individuals for whom exercise is really fun and rewarding, and obviously the stereotypical runner’s high and endocannabinoid release. For some people, they really do get that buzz or, if you will, a natural reward response from it, where others really don’t. Again, thinking about, is that something that defines collective risk for this behaviour within the context of an eating disorder more so than for others?
01:37:07
Chris Sandel: I want to finish off our chat today kind of in the same way you finished off the talk, which was looking at some potential new treatments that could be available for eating disorder recovery. I know you shared a couple in the talk, but if there’s others that come to mind as well, what are some of the things you’re thinking about, future-facing?
Sasha Gorrell: There’s a whole frontier of looking at the gut-brain access, thinking about so much of eating disorders involves what you’re eating. The way in which we’re studying microbiome within eating disorders is really not developed yet. There’s pockets of people looking at this throughout the world, but really putting some energy and dedicated research time to not just looking at the diversity of the gut microbiota, but looking at its function.
So many of the studies even outside of eating disorders are general look at what’s happening in the gut. It’s much more about the variety or the diversity of what shows up in the gut instead of looking at, hey, there’s a whole world of the function of these microbiota in terms of how that also relates to changes in the brain. I’m talking about decades of work that will be done long after I’ve retired, so I recognise that even if I have any interest in microbial therapeutics, who knows where that might go.
Something that I am a little bit more hopeful that I might see in my span of research time is repetitive transcranial magnetic stimulation (RTMS). It’s non-invasive, but it’s basically this ability to go in and target a certain brain region or connectivity. To oversimplify it, it gives this idea that we can actually turn symptoms on and off. There’s been some really neat work with craving and with particularly in depression.
I think where I’ll pull in this idea is that there’s also some compelling work in OCD to really dampen down on some of that rigidity or inflexibility with some of the behaviours. We’ve done a handful of studies with RTMS and neuromodulation in anorexia nervosa. Probably 10 or so published RCTs or small pilot trials right now. Most of that has looked at dorsolateral prefrontal cortex – here I am throwing out brain jargon, but it’s looked at a specific brain area, and for good reason. It’s implicated.
But I think where I’m hoping to see this go is that if we’re thinking more through how OCD can inform how we might target the same regions in those with anorexia nervosa, could we see a reduction in those compulsive symptoms if we’re applying a different region than we would with OCD to those with anorexia nervosa?
Some of the people I’m working with here at UCSF, we’re working on the pilot data for that, and so far I’m really excited about it and I think it might be one of those things where maybe it takes a while to become more mainstream, because I think it sounds, legitimately, like it’s a little bit more – it’s something where people would perceive it as more expensive, maybe it’s not covered by insurance across the board, maybe it would only be for people that were treatment nonresponsive to start off with. But I do think there’s some promise for individuals particularly with a more severe and enduring presentation of eating disorders. This might be a new frontier.
Chris Sandel: The two things that come up with both of those – the first is your comments about the microbiome. I totally agree with you, and when you talked about this as part of the presentation, it was really interesting to hear how that could affect tryptophan and the downstream effect that had. I’m totally on board with it. My fear is that for someone in recovery, hearing the kind of cliff notes of that could be the “and this is why I need to eat really healthy, and this is why I need to be doing” –
Sasha Gorrell: Which is the opposite of what I would actually say. Yeah, I appreciate that. It’s not something that you can change the gut to change the brain. It doesn’t work that simply. But I do feel like the interaction between the function of some of the microbiota will be helpful, potentially, in helping to alleviate symptoms. That might be where it goes.
Chris Sandel: In terms of the RTMS, the region you mentioned that you were focusing on or some of the research has been done on – how much of this overlaps with some of the research around psychedelics and the brain regions that are being impacted with that? This is an area that I’m quite excited about. I’ve had a number of people on the podcast talking about it, so I’m just wondering, is there an overlap in terms of you’re doing a similar thing but with a different tool?
Sasha Gorrell: I have to say I do not know. I think that’s something where psychedelics are something that there’s a chance it feels more unregulated in that sense, where it’s a more global effect on the brain, whereas I think one of the benefits of RTMS is it’s pointed specificity. You can actually go in and stimulate an area of the brain very, very specifically. In some ways I think there’s a certain beauty, an elegance to that, and there’s also a certain confidence that you can look at causality or something that would be a preliminary signal of being a therapeutic target, actually, rather than this more diffuse effect on the brain, if that makes sense.
Chris Sandel: It does, and it sounds very Bladerunner-ish futuristic to be able to shoot a laser at a very specific point of the brain and change a behaviour. [laughs]
Sasha Gorrell: And there’s still other work in context to do. Even just targeting a certain brain area, I would be naïve to say that would be curative. I think just recognising that when we’re treating individuals with eating disorders, we’re treating the whole person and we’re treating within their life and all of the beautiful things they bring with, all the challenges and strengths as well. All of these precise treatments are only as good as the way in which we frame, deliver and use them.
Chris Sandel: It’s part of the therapeutic treatment. It’s not the be all and end all. It’s not the only thing that’s happening.
Sasha Gorrell: Exactly. It’s one of the many tools we have in our toolbox to help people with.
Chris Sandel: Yeah. Sasha, this has been incredible. I’m so glad I got to chat with you, and I really loved your presentation on anxiety. We’ve covered a lot of it, but I’ll also include it in the show notes because there is more to it, and if people want to be able to watch it, I highly suggest that they do.
Where can I be pointing people towards for you if people want to find out more about you or about where you’re practicing from?
Sasha Gorrell: I am at University of California San Francisco. My contact information is freely searchable on my UCSF profile. I also don’t spend a lot of time on Twitter, but if people do want to message me on Twitter, I am on Twitter as well. I think those are probably the easiest ways to get in touch. I’m happy to follow up with any future questions. This is a dialogue that I love having. So ask away.
Chris Sandel: Perfect. I will put those things in the show notes. If they want to reach out, they can. Thank you so much for doing this. This is great.
Sasha Gorrell: Thank you.
Chris Sandel: So that was my conversation with Dr Sasha Gorrell. I really loved this conversation and think Sasha is doing incredible work, so I hope you got a lot out of it, too.
That’s it for this week’s episode. As I mentioned at the top, I’m currently taking on new clients. If you want help with eating disorders or disordered eating, with chronic dieting, poor body image, exercise compulsion, getting your period back, any of the topics that I cover as part of this show, then please reach out. You can head over to www.seven-health.com/help and there you can find out more information.
I will be back next week with another episode. Take care, and I’ll catch you then.
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