According to the National Eating Disorders Association, 20 million women and 10 million men in the United States have a clinically significant eating disorder during their lifetime. In recognition of Eating Disorder Awareness Month, we spoke with Allegra Broft, assistant professor of psychiatry at Columbia University Medical Center, who has been researching eating disorders and treating patients for more than a decade. Her research suggests that the underpinnings of eating disorders may lie in altered brain circuits similar to those in people with substance abuse problems.
What are some prevalent misconceptions about eating disorders?
The most common misconception is that these disorders are just dieting gone awry, that they are trivial problems, rather than complex disorders with strong biological, psychological, and cultural components. Although dieting does seem to be a precursor to eating disorders, the majority of people who diet do not go on to develop eating disorders.
But for those who may be vulnerable, behaviors that start out as reasonable may become compulsive. A person with anorexia may say, “I want to stop dieting but I can’t.” A person with bulimia nervosa may try to exert dietary restraint but be unable to maintain it.
What makes someone vulnerable? Can you predict beforehand who is at risk?
There is still much that we do not know, but female gender is the strongest predictive factor in anorexia nervosa and bulimia nervosa. It’s likely that many other genetic and environmental factors are involved, but we are still a long way from understanding how they interact to cause an eating disorder.
What’s the best way to respond when a friend or loved one has an eating disorder?
First of all, urging someone to eat, or drawing attention to shape and weight, is unlikely to be helpful. Supporting a person in the process of moving toward treatment is one of the most concrete ways a loved one can help.
Are there any effective treatments?
We have some good evidence-based treatments for certain eating problems, but more work is needed. Cognitive behavioral therapy, a type of psychotherapy, works well in treating bulimia nervosa and binge-eating disorder. Some medications are also effective.
Treating anorexia nervosa is more difficult. Inpatient and residential programs can improve weight and medical status, but we do not know as much about how best to treatment people in an outpatient setting.
Our clinic has investigated new psychotherapies, and we are actively enrolling patients with anorexia nervosa in a clinical trial of a medication that looks promising.
How long do people generally suffer from eating disorders?
Those with eating disorders fall roughly into three groups. Those in the first group can bounce back—with treatment or almost spontaneously—and put much of it behind them, although they may have a lifelong vulnerability to relapse. Those in the second group remain quite ill and may be in and out of hospitals their whole lives; some may die from their eating disorders. Those in the third group fall in between; they don’t need specialty care, but may struggle all their lives.
Please tell me about your research and how it relates to the understanding and treatment of eating disorders.
There are likely to be genetic components and neurobiological differences in the brains of people with eating disorders that are as important to recognize and understand as psychological and culture factors. I have been looking at possible similarities in the brain circuitry of patients with eating disorders and of those with substance use problems such as alcohol or cocaine dependence. In patients with substance-use problems, we see low levels of dopamine and certain dopamine receptors in the striatum, a brain region known to influence reward-related behaviors.
It’s too early to draw any conclusions, but we have some hints, particularly in bulimia nervosa, that the dopamine reward circuitry is different in people with eating disorders than in those without such disorders. These differences seem to parallel the findings seen in substance-use problems, although they are subtler. Such findings could have implications for future treatment and research, though they are likely to have limitations.
How did you become interested in eating disorders?
I decided that I wanted to become a psychiatrist when I was a medical student, and at the time, I was involved in using brain-imaging techniques to study substance-use disorders. Two or three years later, while a resident at Columbia, I rotated on the eating disorder unit, which we were all required to do, and it captured my interest. We were working with young women who were so articulate and intelligent in so many ways and yet struggling profoundly. I wanted to know how those things could fit together, and I realized that some of the work I had done on addictive problems might be relevant to eating disorders.
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