The other day a young patient of mine asked me “which is more important: psychological remission or physical remission?” Of course she was asking because she wanted to know how she could get out of the DTU most quickly, but it was a good question nonetheless.
Which is more important? Well, let’s see…which is more important: breathing or heart beating? Yes, it’s just like that. There is no psychological remission without physical remission. That’s been tried. In fact, we spent most of the 20th century treating patients as if their psychological issues could be treated in the absence of adequate weight restoration. Therapists and doctors claimed that a patient could not get better “until they were ready” or until they “bought into their treatment”. And so many patients were allowed to remain in a limbo of under-nutrition and all of its consequences inlcuding lack of menstruation with subsequent poor cognition and weak bones.
At an AED conference a few years ago Debra Katzman of the University of Toronto presented some of her work showing that amenorrhea (lack of periods) had a greater impact on cognition (intellectual ability, mental processing) than low weight itself.
Clearly if one is cognitively impaired there can be no psychological recovery/remission. And this deficit will impact not only general clear thinking and coping with stress and the demands of life, but school performance, career success and interpersonal relationships.
While reading around in Pubmed on the subject of hormonal effects on cognition (thinking) I came across a study of female patients with MS and the effects of estrogen and estrogen withdrawal on their cognition. As an explanation for why estrogen can affect thinking and processing, an article called Estrogen’s impact on cognitive function in multiple sclerosis in the International Journal of Neuroscience, discussed the fact that “Serotonin (5-HT) mechanisms have been implicated in memory functions and estrogens modulate these functions through an interaction with 5-HT2 receptors in the cerebral cortex and limbic system. It is suggested that estrogen withdrawal induces impairment in cognitive functions through dysregulation of 5-HT2 receptor activity and 5-HT neurotransmission.”
So, no weight restoration, no periods. No periods, no brain recovery.
Which is more important, physical or psychological restoration? You be the judge.
No Weight Restoration, No Periods! Estrogen’s Role On Cognitive Function And Recovery
posted by Julie O'Toole on June 10, 2011 at 2:56pm17 Comments
on 06/11/11
Hi. Such a timely piece!!!! I think you’re right on. We are on the cusp, I think, of huge breakthroughs in the understanding of eating disorders. Thank you!
on 06/11/11
PS to my previous remark. If eating disorders as a group could be termed 5-HT disorders or something along those lines to promote better cooperation from the insurance industry to the point that these disorders are rooted in the physical body, perhaps our society could _finally_ understand why these disorders need covered medical intervention. Thank you again for this post.
on 06/13/11
Oh I love it: 5HT disorders!
Something of this nature will doubtless come to pass. This is why I find it liberating to describe EDs as “brain disorders”. No more and no less.
on 06/12/11
I absolutely agree that psychological recovery is dependent on physical recovery, but I am a little wary of the idea that weight restoration = periods. I have two friends who still got their periods at BMIs of 14, and one who got pregnant at a BMI of 16. It seems more and more common for girls to continue menstruating at low weights. Mine returned at a BMI of 18, but I would have had to restrict to maintain that weight and I definition [sic] still had a lot of the psychological symptoms of an eating disorder there. I didn’t consider myself weight restored until I’d gained 15lbs on top of regaining my periods.
Another thing which has worried me in the past is the suggestion that weight restoration determination could be based on ultrasound scans of ovaries. Again - what about all the women whose hormones seem to defy the odds? Too many people are told they are weight restored at low weights already, and suffer the consequences for it. I wouldn’t like this to happen with scientific backing.
on 06/13/11
You are absolutely right Katie. This is why I say: “a woman’s ideal body weight is that weight at which she can have normal periods and which she can maintain when not engaged in eating disordered behaviors.”
So your example of menstruating at a BMI of 16, yet needed to restrict in order to maintain your weight there, is perfect. Ergo: whatever weight is associated with a BMI of 16 for you is not your ideal weight—and you would not be considered weight restored.
on 07/25/11
Dr. O’Toole, I have a question for you concering this article. You link, in your title and also in the article, the lowering of estrogen with cognitive processing issues. What about those girls who still have their periods and have memory issues. For example: forgetting what has been learned, and testing lower than their age, after a year of low weight? I see, in your reply to Kate, that you do mention that having a period is not the only way to define weight restored, but I am asking spacifically about memory issues and estrogen. Are there any studies that link memory issue to weight loss alone, not just lowering estrogen?
on 07/27/11
I’m confused: are you asking about someone with persistent low weight and normal estrogen?
on 09/12/11
I am asking about my daughter that has been diagnosed as having restrictive anorexia with purging. She started restricting at about age 10 and now is 15. She insists that she has been having her period, but also admits to going to pro-ana websites, so I am not 100% sure about that. In any case, she went from being able to work algebraic math problems to barely understanding a number line. So I was wondering if a person could still be having her period, but have the cognitive issues. She does display several of the ED behaviour, too.
on 09/13/11
If she is active in her eating disorder there are likely several reasons, including lack of estrogen, for this inability to concentrate. One of the main reasons is that her brain is so taken up with thinking about—perseverating on—weight, food, calories, fat etc that there is no room for anything else. What is happening to her weight? 15 is not very old, do you eat with her? What kind of treatment is she getting Deb?
on 09/13/11
It is a LONG drawn out, sad tale, but my daughter isn’t living with me right now, so I can’t answer your questions. In fact I go to court in less than 12 hours to try to convince a judge that re-feeding isn’t a form of child abuse and that letting my child choose her own food is not how to help her. Of course there much more to the story, and I would be willing to share it privately, but not on here. I was asking because one of the ways that I was accused of “harming” my child was educational neglect. (I home school) But I knew that my child could do higher math one year, and barely anything the next… so I wanted to see what I could find to use in court. If this is too much information or inapropriate for this site, please feel free to remove it.
on 09/13/11
It’s not clear to me, too, if your daughter has lost a lot of weight. You seem to be implying this while noting that your daughter claims to still have her period. If your daughter is restricting then she probably is not getting enough calories for her brain to function. For example, research has shown that the brain needs 500 calories a day in the form of glucose just to do the functions you and I would ordinarily do. So if she is exercising and being somewhat active AND only taking in e.g. 1000 or fewer calories a day, her brain just isn’t getting fed. And if her brain isn’t getting the nourishment it needs, she isn’t going to be able to think well.
on 09/15/11
Deb, no amount of pain caused by this illness is “inappropriate” for our website. Try looking at this poster by Debra Katzman’s team.
on 09/15/11
Well, the court hearing is over. I agreed to a compromise, kind of a “lesser of two evils” thing. I met with the guardian ad litem appointed for my daughter. Her points of contention were that they were going to have my daughter tested in the public school they put her in to confirm whether or not I have neglected her education (a strike against me). My daughter has been restricting for a while now (five years) and after her local threapist suggested that she keep track of her calories (yeah, I know) we saw that she was eating a weekly average of 750 calories a day. She was also purging by vomiting into containers, and excessive exercise. There is NO surprise to me that she couldn’t think.
The biggest contention from the guardian ad litem was that I was not doing what the doctor reccomended for my daughter. See, I felt that for my daughter’s height of 5’ 1”, her weight should be between 105 and 110. I came to this number based on Dr. O’Toole’s information posted on the F.E.A.S.T. website. But the hospital decided that 96 lbs was a healthy enough weight to let her start making her own food choices, and only eat 85% of the 2000 calories that they suggest in her meal plan. They did ammend this in an email they sent to the local therapist that at the time I thought was going to be part of our treatment team. In the email they did say that an ideal weight would be 105, but that “this could be a goal for B for her high school carreer.“But I was stupid enough to share my concerns with the IP therapist and of course she and the psychiatrist took offense. There were accusations of me having Munchausen’s Syndrome by Proxy, and I was turned in to the child abuse authorities once by the IP hospital and once by the local threapist.
When I explained to the guardian ad litem that I felt that this doctor was wrong, she asked if I had gotten a second opinion. Sadly, there were no ED clinics in my state that would take my daughter’s state insurance. And the bottom line was that since we live on a fixed income, we can’t afford any of the other IP programs. But I did point out to her that I did have books and papers from some of the leading ED doctors. (Give Food a Chance, Help Your Teenager Beat an Eating Disorder, Brave Girl Eating, Eating with your Anorexic, etc.) and that they advocate a higher target weight and refeeding at home. Sadly, that wasn’t good enough. The doctor from the IP treatment hospital claims that I took my daughter out of their center against medical advice. So the guardian ad litem really wasn’t open to hearing much else. I did pick my daughter up on a Thrusday when they wanted to wait until a Saturday. That was because I was relying on a friend to drive me the six hour round trip, and my gut instinct was that my daughter was not getting the help she needed. But I was never advised that it was AMA.
So for me the bottom line now is that my daughter will live with my brother and his wife, because the consensus is that I can’t help her with her ED now and her hostility towards me. But my brother and his anorexic wife can help her despite her continueing to loose weight and the fact that they are a large part of the reason my daughter is hostile towards me in the first place. We will be required to attend family therapy and I will get visitation (any contact with her is considered visitation, BTW) once the family therapist decides I can.
Needless to say, I am still a bundle of emotions, but most of all I am very concerned for my daughter. I feel that if they would just let me care for her in the way that I KNOW will help her, she would get well. But that isn’t going to happen now. I want to thank you all for your input. I didn’t ask the questions quickly enough to help me in court, but I do feel better that I really was trying to help her.
on 09/16/11
That sounds like a nightmare. But now, having done all you could, it is time for you to take a step back, take a deep breath and focus intently on what really matters to you: a good outcome for your daughter. I would recommend that you resign yourself to the uncle and aunt and become the perfect, supportive parent and participant in family therapy and…wait. If we are lucky your daughter will do well and you will be glad; if we are less lucky she won’t (after six months trial or so) and you will have another shot at convincing the court’s guardian ad litem that there may be another way to do this. Meanwhile be calm and cooperative and loving. And begin to heal after this ordeal.
Focus on your daughter’s success, that’s all that matters.
on 09/17/11
Dr. O’Toole, thank you for your last post. You are right. Ok, two days of wallowing in self pity are enough. The situation is what it is, and there isn’t any changing what happened in the past. LIke you said, my daughter’s success is all that matters.
God bless you and yours
Deb
Add a Comment
Your comment may need to be approved before it will appear on the site. Thanks for waiting.
on 06/10/11
What is rather interesting about the link between estrogen (or oestrogen as we spell it in the UK) and my AN is that for many years, while underweight with AN (BMI < 16) I was treated on high does of oestradiol delivered through implants. The objective was to attempt to save my bones (it didn’t work… and I ended up with serious drug-induced gynaecological problems). Exogenous oestradiol didn’t help my AN, but I do wonder whether it sustained certain aspects of my cognitive function such as the ability to think and reason academically. I wrote some of my best research papers at a BMI of 14, which sounds totally crazy.
I am not suggesting, for one moment, that the treatment I had was the right choice. Instead of prescribing me hormones, the professionals treating me should have made more effort to ensure that the AN per se was treated. Oestradiol therapy trapped me in a sense of false security. I thought it was protecting my bones when in fact it was not. Moreover, my other organs were suffering simultaneously.
on 06/13/11
It’s incredible how resistant some professionals are to the concept that treating the underlying ED—otherwise known as REFEEDING—should precede other treatment attempts, and even makes many of them unnecessary. The “cure” for osteopenia is food and weight restoration. The fact that exogenous estrogen is not very helpful has been known for a long time. Experiments were also done on the use of alendronate without much success. And food is much safer than any medication.