Two current Kartini parents handed me an excellent article the other day whose lead author, Walter Kaye, is likely well known to our readers. The article, Temperament-based Treatment for Anorexia Nervosa, appeared in the European Eating Disorders Review.
I was especially pleased to see this article, although many of us have heard Walt speak about meal planning and the latest neuro-biological and neuro-radiological evidence before. Neuro-biological and neuro-psychological evidence has shown that the temperament of a patient with anorexia nervosa is usually characterized by anxiety, reward insensitivity, altered interoceptive awareness and cognitive inflexibility/rigidity. These temperament and personality traits, which are related to neural circuit functions, according to the study’s authors, are important in the development and maintenance of anorexia nervosa. And in addition to predating the disease, these traits often persist to a mild-to-moderate degree after recovery.
That makes perfect sense, as temperament traits are known to be strongly heritable and basically difficult to alter; they are part of a person's “personality makeup” and style of adapting to the environment. I think we can all think of ways in which these traits could be advantageous under certain circumstances as well as highly disadvantageous under others.
Patients with anorexia nervosa experience exaggerated levels of anticipatory anxiety. There is evidence that individuals with anorexia nervosa, after eating, may experience dopamine release in the brain which (in them) is anxiety-causing rather than hedonic (pleasurable), which may explain their avoidance of eating when the rest of us enjoy it. Of intense interest to us at Kartini Clinic are Dr. Kaye’s suggestion that this temperament type can be successfully managed by reducing food choices and thereby reducing anxiety-provoking uncertainty. Such a reduction takes advantage of such patients’ tendency to stick to rules and structure and allows the clinician to ensure sufficient caloric intake and hence weight restoration. Further recommendations in the article for treating patients with anorexia nervosa involve engaging the support of carers – in our case, parents – in successful food strategies.
I titled this blog “Connecting the Dots” because I fear that many people who are enthusiastic about Dr. Kaye's work in general, are not connecting the dots, as it were, between research and treatment. His research supports the use of a structured meal plan, such as the Kartini Meal Plan, with simplified choices. Far from “making the patient dependent on a meal plan" or "supporting anorexic-style eating", a meal plan such as ours takes advantage of the known neurobiological substrate/temperament of our patients in order to ensure their weight restoration, despite their intense anxiety around food. In my view, this research shows us why food paradigms such as "intuitive eating" -- irrespective of the their efficacy for others -- cannot work in this specific population. If the patient were able to eat intuitively, they would not have this eating disorder! Structured meal plans allow us to draw on the strengths of individual temperament styles (and the emerging scientific understanding of them) and allow those strengths to show us the way forward in effective, evidence-based treatment. Supporting parents in their attempts to do this is the essence of all forms of family-based treatment.
I read Dr. Kay's article with some amusement as well. The reason for this amusement lies in the past. In the early 2000's I attended more than one international conference where Walt and I seemed to be the only two people in the room who believed that anorexia nervosa was a medical disorder, with its feet firmly in the neurobiological substrate we call "our brain". I remember one conference in particular, in Italy, where Walt turned to me and said, following a lively discussion where pretty much everyone in the room thought we were crazy, extreme reductionist biologists: "we will prove them wrong someday, Julie."
I am not the research scientist Walt Kaye is. I am a clinician and clinical scientist. When it came time for me to design a program that I felt fit the science, I designed our Meal Plan and Kartini’s version of family-based treatment, which we feel has given more than one pediatric patient a roadmap for healing, despite the frequent criticism of its ordered eating plan. I am grateful to Dr. Kaye and his colleagues for “proving them wrong".