In the last 50 years, the treatment community has made significant strides in the understanding of anorexia nervosa and bulimia nervosa. Although a stronger grasp of these behavioral illnesses has led to advances in therapeutic methodology, a substantial number of patients still do not respond to standard treatment.1
In these patients, traditional treatments such as cognitive-behavioral therapy (CBT), which aims to change mental content, are met with ambivalence and resistance. These methodologies simply will not spur lasting behavioral change in treatment-resistant patients. CBT's explicit cognitive processing approach might not work in an eating-disordered mind that is incapable of implicit processing.2 Another traditional approach-focusing on the cause of the eating disorder-will also have little impact. The fact is, what maintains an eating disorder may be quite different from what caused it.
When we instead take the time to comprehend the underlying temperament and neurocognitive processing deficits of an eating-disordered patient, and understand how they help the patient maintain an eating disorder, we can grasp the limitations of many current treatments and turn our focus to newer therapeutic methods addressing these maintaining factors.
Temperament and deficits in neurocognitive processing not only can set the stage for an eating disorder to manifest, but they also will act as catalysts for its maintenance.
Temperament refers to those aspects of an individual's personality, such as introversion or extroversion, that are regarded as innate rather than learned. Individuals with different temperaments see the world through different lenses. These innate personality traits can play a significant role not only in an individual's predisposition to an eating disorder, but also in his/her maintenance of an eating disorder. By understanding the specific temperamental traits that are common among individuals with eating disorders, clinicians can form a more targeted, informed approach to treatment.
Adapted from C. Robert Cloninger's Temperament Character Inventory,3 the four key temperament dimensions associated with eating disorders are described below.
The harm avoidance dimension of temperament, often intense in eating-disordered persons, is an expression of the brain's behavioral inhibition system. Those who are high in this temperament trait tend to overestimate the risk of hurt. They feel the somatic aspects of anxiety more intensely than the average person does. Consequently, they are more cautious, fearful, tense, timid, apprehensive, doubtful, passive, negative or pessimistic in situations that do not worry others. They tend to be inhibited in social situations. Their cautious nature has an adaptive advantage when there are real risks but can be an impediment to healthy change in treatment due to excessive avoidance of new experiences.
High harm avoidance contributes to a life centered on anxiety management by way of an eating disorder. Eating-disordered patients often report that they spend a major portion of their waking existence thinking about controlling their anxiety about eating, shape and weight. The eating disorder becomes the main tactic for mentally avoiding life's anxieties.
Novelty seeking is a pre-conceptual bias in the brain that relates to behavioral activation. Those who are high novelty seeking are drawn to the new and stimulating. Such individuals are quick-tempered, excitable, exploratory, enthusiastic, exuberant, curious, easily bored, impulsive and disorderly. It is not surprising that high novelty seeking is associated with binge/purge behavior. Higher novelty seeking is seen in bulimia nervosa cases and in anorexia nervosa cases with binge/purge behaviors, and is also associated with diagnostic cross-over from anorexia to bulimia.
On the other hand, individuals with low novelty seeking temperaments are slow-tempered, non-inquisitive, unenthusiastic, stoical, reflective, frugal, reserved, tolerant of monotony, systematic and orderly. In eating-disordered patients, low novelty seeking is seen in restricting anorexic patients. Such individuals tend to be slaves to routines and rituals because they like things to be orderly.
The behavioral maintenance system of the brain is represented by the temperament trait of
reward dependence. The reward dependence trait is manifested by individual differences in response to social reward. Those who are high in this trait are tender-hearted, sensitive, socially dependent, warm and sociable. They easily form emotional attachments. High reward dependence can be advantageous when sensitivity to social cues is needed and the capacity to understand the feelings of others is beneficial. A disadvantage of high reward dependence ensues from being easily influenced by emotional appeals. Reward dependence is not consistently associated with diagnosis but can significantly affect treatment issues, such as therapeutic alliance.
persistence is a bias in the brain that concerns maintenance of behavior in the face of frustration, punishment, fatigue and intermittent reward. Highly persistent individuals tend to be hard-working and ambitious overachievers. High persistence is associated with anorexia nervosa and consistent with these individuals' well-known perfectionism and inability to shift mental sets to a more healthy orientation.