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I'm Dr. Jeffrey Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

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(gentle music) Today on Healthy Minds: How does self-control either too much or too little, affect people who are living with an eating disorder?

Today I speak with leading expert, Dr. Laura Berner, about self-control and eating disorders.

That's today on Healthy Minds.

This program is brought to you in part by The American Psychiatric Association Foundation, The John & Polly Sparks Foundation and The Woodnext Foundation.

(gentle music) Laura, thank you for joining us today.

- Thanks so much for having me.

- I wanna jump right in and talk about an area related to eating disorders that's been a focus of yours, both clinically and in terms of research, which is the issue of self-control.

Tell us about it.

- It's an area of my research for several reasons.

First, self-control is really key to some of the main symptoms that we see in folks with eating disorders.

Much of my research focuses in on folks with bulimia nervosa and binge eating disorder, and the symptom that these eating disorders share is binge eating.

Now, binge eating is really importantly different from just overeating that we regret or mindless eating that we don't feel good about.

It's really critically defined by a sense of loss of control.

So, a lot of people describe this as feeling like a ball rolling down a hill that they just can't stop or feeling this drive or compulsion to keep eating once they've started.

It seems really clear that self-control processes are probably pretty important in understanding what's happening with folks with binge eating.

But on the flip side, many folks with both bulimia nervosa and anorexia nervosa, which is probably the eating disorder that a lot of people think about first when they think about eating disorders, these folks have periods of really rigidly controlled eating, fasting behavior, dietary restriction that's over controlled.

And even outside of the eating domain, in patients with eating disorders, we often see behaviors like substance use or shoplifting behavior that can be under controlled as well as more rigidly over-controlled behavior in how people approach work or school.

That can cause problems for them as well.

So both within and across these diagnoses, we see these extremes of over control and under control that really tell us that it's probably quite important to understand if we're trying to understand the mechanisms that underpin eating disorders.

The psychotherapies that we have for eating disorders and that are really the leading treatments for eating disorders right now, really try to tap into and focus on self-control in many different ways.

So for example, in cognitive behavioral therapy for somebody with a binge type eating disorder, we would focus in on helping them restructure some of their unhelpful thoughts and get and develop a pattern of regular eating.

These are both two things that really require the enhancement of self-regulation in a pretty major way.

And in addition to being a neuroscientist, I'm also a licensed clinical psychologist.

The ultimate goal of all of our work is to really identify targets for new interventions for folks.

And we think that we have a likely ability to be able to do that in a helpful way if we can better understand what might be going awry specifically with self-control in these patients.

And then we can develop treatments that better help folks enhance their self-control in ways that we think will specifically be helpful for them.

- A very good overview and I wanna just bring up the term self-control sometimes could elicit a feeling amongst people, well, you know, just get in control of this, stop it, and it's really much more complicated than that and I'd like you to speak towards that.

- Yes, it's far more complicated than that.

I also think folks a lot of times think about self-control as sort of a binary process, like almost like a red light, green light kind of process where you either go or you stop.

You've either done it successfully or you haven't done it successfully.

And we know from a lot of research actually that it's a lot more complex than that.

I kind of like to ask folks to think about it the same way that you would think about what it would take for you to drive successfully or control a car successfully on a really windy, dark road at night.

Of course, yes, you would need an accelerator that works well, you would need breaks that are responsive, but you would also need what app-based alerts help us do and signs on the road help us do, which is an ability to sort of build up a map or a model of the road in our brain to help us anticipate what's coming next to help us figure out how expensive making a decision to go one way instead of another is going to be and to ultimately help us adapt our behavior accordingly.

And it turns out that the process of adaptively engaging control is quite similar to this.

It's this a moment to moment kind of process where we're constantly taking in new information and having to make decisions about whether we need to exert control, whether it's worth it to try to spend effort on exerting control, and ultimately then finally, what behavior we're going to enact and some newer methods allow us to sort of quantify these more precise processes and measure them in healthy people and in folks with eating disorders.

- I wanna ask you about that because I know that you use mathematical models in better understanding this.

So tell us, how does math help us with an understanding of these complicated behaviors?

- A lot of the work in my lab uses, a method called computational cognitive modeling, which is essentially, it sounds very technical, but it's just a fancy way of saying that we're applying mathematical models to understand how people go about making decisions and how they learn.

So for example, we might ask someone to complete a decision making task on the computer and we can take the information from the choices that they make on each trial of that task and how quickly they make choices on each each trial of that task to help us really understand how exactly is this person going about this, what are all the different pieces going into this final product, this end behavior that we see.

So we could figure out, for example, how quickly are they learning from new information that they're getting within the context of the task?

How much influence does reward value have on the choices that they make?

Or how much influence, for example, does their perceived tastiness or healthiness of a food that they're making a decision about influence their ultimate choice?

So applying these mathematical models really allows us to put numbers on these sort of sub components of decision making and specifically in our research on these little sub components of all the little pieces that go into an ultimate decision about whether or not someone is going to exert self-control.

- In using these models, how were you able to figure out what's the best approach for an individual person?

- Some of our findings can help us kind of better understand how it is that folks with Bulimia nervosa might have trouble engaging self-control in an adaptive way if something changes in their environment.

So, a lot of what we ask people to do in treatment is to stop doing behaviors that they were doing before, that they are doing now because there's new information about what they should be doing instead, maybe we want them to use a therapeutic skill instead of engaging in binge eating and purging.

And this can be really difficult for a lot of people.

So, in one of our studies, we applied one of these mathematical models to show that folks with Bulimia nervosa, when we give them new information about the fact that they should inhibit a behavior to particular cues that they had learned specific responses to, they have trouble adjusting their behavior to do this successfully.

So they continue to do the old behaviors that they did, they continue to respond to cues that they initially learned that they were supposed to respond to.

And when we apply the mathematical model, we can understand a little bit more about why that might be.

So we found that people with Bulimia nervosa have a slower pace of belief updating in context where they're getting new information about particular stimuli or cues in their environment and whether they should respond to them or not or how they should respond to them.

So, that would suggest that maybe if we can design treatments that better help people learn and update beliefs more quickly about whether or not they should be responding to particular cues that might be really helpful for folks with this disorder.

So, it gives us a more kind of nuanced understanding of exactly what might be going on that contributes to problems with self-control.

- Are there ways to make use of this type of information to sort of help prevent the onset of an eating disorder before it really grow to a full eating disorder?

- Yeah, I think that's a really important question and we don't yet know the answer.

A lot of the research that's been done has been focused on folks who already have symptoms of an eating disorder.

There are a few studies that have focused in on adolescents with eating disorders to try to understand early in the course of illness what might be contributing to symptoms when they're at that early stage or might even put people at risk for the development of eating disorder symptoms.

There are some data to suggest, not from studies necessarily using mathematical models, but from brain imaging studies to suggest that there are altered responses in the brains of folks who ultimately go on and develop binge type eating disorders or binge eating and purging behaviors, specifically when we ask them to try and control their behavior in brain scanners.

So, on again, sort of computerized tasks where on specific trials, people have to either inhibit a response or engage a response and press a button on a keypad that we give them.

We see this altered pattern in self-control circuits in folks who ultimately go on to develop binge type eating disorders.

So, it may be that there's sort of different functioning in these brain circuits that help us control our behavior even before eating disorder behaviors have specifically developed, but we need really large data sets and longitudinal studies to help us better understand exactly what might be going awry or might be functioning differently in these circuits that ultimately leads to the development of these symptoms.

- So down the road there may be a way to, in particular if somebody may be at higher risk of developing an eating disorder, really looking at these issues to see if they really are at higher risk and then taking some proactive measures to reduce that risk.

- Yes, absolutely.

- Laura, I'd like you to speak a little bit more about the use of brain imaging in understanding these conditions.

- We use a couple of different modes of brain imaging in my lab.

One is called Functional magnetic Resonance Imaging or FMRI.

So we can tell, are we seeing overactivity or underactivity in these self-control circuits while folks are trying to make these decisions or engage in these behaviors that really helps us understand at a biological level what might really be going awry.

And that gives us a really good sense of what might our treatment need to change.

We can also look at how different parts of the brain that make up these self-control circuits are connected to each other.

How are they "talking to each other" while folks are trying to engage control, are monitoring the need for control, are making decisions about whether they should or shouldn't engage control.

We can also look at how parts of the brain that process things like hunger and satiety might be interacting with those control related circuits to get a more nuanced understanding about problems related to state specific control engagement and decisions when people are in specific states.

So, the method really helps us understand a little bit more about what's going on under the hood, not just what are the different aspects of control that might be functioning differently in people with eating disorders, but what's sort of the brain basis of that alteration in behavior and decision making that we see.

Now, in a lot of the work that we're doing now in my lab, we're actually combining the computational modeling method with the neuroimaging method so that we can see what's exactly going on in terms of how the brain is encoding different specific aspects of self-control.

Is there sort of an altered signal that's tracking these different aspects that helps us better understand what's exactly contributing to symptoms?

People with bulimia nervosa kind of exhibit both of these extremes of control at different times.

So we know that these people engage in binge eating, they have trouble controlling their eating behavior during binge eating episodes by definition, but they also often between these binge eating episodes engage in pretty prolonged periods of fasting behavior or dietary restriction where there will often go for a long period of time eating very little or maybe even not eating anything at all.

And it's sort of puzzling to think about that because we don't really know how to make sense of the fact that these two extremes of control are coexisting within the same person.

It's not that they're just dysregulated in every way, sometimes they're over-controlled, sometimes they're under-controlled.

And we thought, okay, a really important signal that helps us switch between over-control and under-control is how we track these control related surprises.

And could it be that when people move from a fasted to a fed state, they need to adjust that tracking to help them be better at control once they've started eating something and help them be more disinhibited when they're in a fasted state so that they're in a state where they might end up eating more and be sort of not as likely to try to control their behavior if they're in a fasted state.

So that's sort of the the optimal pattern that we would look for in a healthy person.

In folks with bulimia nervosa, we thought the opposite might actually be happening where when they're in a fasted state, they're sort of over tracking these control related surprises and when they're in a fed state, they might not be tracking these control related surprises as well.

And that's in fact what we found evidence for.

In healthy people, we see a strong signal tracking control related surprises when they're in a fed state.

So, after they've eaten something and a weak signal tracking it when they're in a fasted state.

That kind of tracks with this idea that, and you might identify with this, if you've ever tried to focus on something or make a big decision right before you've had lunch, it can feel difficult to do that effectively and it might feel easier to do that and to engage control and think flexibly after you've eaten something.

For somebody with Bulimia nervosa, we see that their brains are actually showing the complete opposite pattern.

So, the brain signal that's tracking these control related surprises is amplified in a fasted state.

So their brain is sort of in an optimized state for self-control when they haven't eaten anything and then after they eat something, we see a blunted signal tracking these control related surprises.

So, we think, especially because that blunted signal tracked with symptom severity, that it may be that this sort of completely opposite response to tracking control related surprises might be part of what helps contribute to this sort of oscillation between over-controlled eating and under-controlled eating in bulimia nervosa.

And we're testing that idea a bit more thoroughly now in folks who have current symptoms of bulimia nervosa.

So these past findings were in people who had a history of bulimia nervosa.

Now we're tracking, we're seeing how do these sort of same patterns potentially contribute to the severity of current symptoms of bulimia nervosa and can we also measure these control related surprises and the states that people are in when they experience them in people's everyday lives by leveraging another form of technology.

In my lab, we also use something called, Ecological Momentary Assessment or EMA where people respond to questions that they get on their phones throughout the day.

And that really allows us to measure not only what is happening with tracking control related surprises or making control related decisions in the lab when we have them in a very controlled environment and it probably doesn't look anything like what their everyday looks like, but also how does what we see in the lab when we measure what's happening in their brains in the lab, relate to what we see in terms of their behavior in their everyday lives when they're in a real world state of being fasted and a real world state of just having eaten something.

Do we see the same altered pattern?

So, our hope is that we can really bring some of what we're finding in these controlled environments outside of the lab and into people's everyday lives and that would allow us to even better draw conclusions that would help us treat these symptoms as they're occurring in folks' everyday lives and in their natural environments.

- I wanna ask you about some of the newer medications, the GLP-1 medications and how they fit into these issues.

- Yeah, it's a great question.

There's definitely a lot more work to be done to understand exactly how it is that signals from the gut to the brain might influence self-control and a whole range of other processes that are probably relevant for folks with eating disorders like appetite, reward processing, other sort of elements of decision making.

Some of our work is actually focusing in on that right now, trying to better understand not GLP-1 signaling, but signaling in other pathways that involve gut brain signals that might alter decision making specifically around self-control.

When it comes to GLP-1, there's not much research that's been done in terms of their use for folks with binge eating.

The small studies that have been done suggest that they may be promising, there's some reduction in binge eating that seems to occur and certainly anecdotally, folks with binge eating who have taken GLP-1 seem to report that it might help with sort of quieting inner chatter about food and help them find that fewer of their thoughts are consumed by food throughout the day.

We don't really know what the mechanisms of that might exactly be and lots more research is needed.

I think it's particularly tricky in the case of these kinds of medications because the goal in treatment for somebody with binge eating is not to indiscriminately reduce all eating.

The goal is to specifically reduce binge eating and these medication have much more broad based effects than that.

The effects so far are not super precise and a lot of times they can have some side effects of nausea that can be pretty unpleasant for folks who are taking these medications.

And it's not clear yet to what extent that nausea actually might be one of the sort of main mechanisms of the treatment effect in some folks who take those medications.

A lot more research needs to be done to figure out how it is that we might target and leverage what's going on in the GLP-1 system to specifically reduce binge eating and not indiscriminately reduce all types of eating in folks who have eating disorders.

We certainly don't wanna be introducing a new eating problem in somebody who's already coming and seeking help for one eating behavior that they're struggling with.

So, lots more research to be done and for sure, I think any ultimate answer is going to involve lots of training for folks who are prescribing these medications in the assessment and the monitoring and the treatment of eating disorder symptoms more broadly so that any problematic behavior should they arise, could be detected and managed really quickly and that we aren't putting folks at more risk by prescribing these kinds of medications.

- Very important point, that really more research needs to be done, the jury is still out in terms of whether or not these medications are useful for the issues of binge eating.

- Yeah.

- Laura, one of the challenges for families if they have a loved one with an eating disorder is what can they do to help their loved one?

And I'd like you to speak toward that.

- I think first, and since we're talking about self-control, from a self-control perspective, families and even support people, if they're not necessarily family members can be incredibly helpful in thinking about the treatment of eating disorders.

I'll just speak to this from the perspective of somebody who might have binge eating disorder or Bulimia nervosa, even for adults, family members can be incredibly helpful.

In part, that's because we can almost think about it as like a surrogate prefrontal cortex, right?

So, an extra sort of brain circuit with extra self-control that we can bring online to help out when somebody who's actively struggling with eating disorder symptoms might not yet have a self-control circuit that is helping them behave the way that they'd like to be behaving.

For example, family members and support people can help out by helping the food environment at home be controlled for somebody with an eating disorder.

So that might involve a skill that we call stimulus control, which involves just keeping stimuli that might be more likely to prompt a binge eating or purging episode out of the way, not bringing binge foods into the home, making them less accessible, decreasing access to ways that people might engage in compensatory behaviors.

Just sort of restructuring the world that people have to make maps of and adjust to in complex ways so that it puts less stress on the self-control circuit that we already know is having some trouble functioning in the way that a person might optimally want it to.

So that's one way that in particular parents and people who live with somebody with an eating disorder can be helpful provided that the person with the eating disorder has agreed that, that they think that that would be helpful for them.

From a broader perspective, I think just having somebody in your corner and advocating for you when somebody is struggling with an eating disorder can be incredibly helpful.

I think sometimes part of what can keep eating disorders going is that a lot of the symptoms feel reinforcing to the person.

So unlike other disorders where the symptoms are pretty much just uniformly distressing to the person, there are some aspects of eating disorder behaviors that don't feel as distressing and actually feel reinforcing to the person.

And so, the more that sort of non-eating disorder behaviors can be reinforced by a support person, by that person either cheering them on or giving them other sort of rewards or celebrations with them of meeting other milestones that are in line with recovery can be incredibly powerful for folks.

And I think in general, if a support person is feeling like they're not really sure how to help, the best way to figure it out is to ask the person themselves directly and to say, "You know, without judgment I've noticed this.

Is this something that I might be able to help with or what could I do that might be, feel supportive to you or feel helpful to you?"

And getting their take on what they think would be helpful for them is a great first place to start.

- Very good advice.

You know, people for all issues in life, whether it be medical, psychiatric, other challenges.

Better to get a little help from friends and loved ones than to try to go it alone.

- Yeah.

- Well, Laura, the work that you are doing and the folks in your lab are doing and others really brings great hope to people who are living with eating disorders.

And I want to thank you for the work that you've been doing and continue to do.

And thank you for joining us today.

- Thanks so much for having me.

(gentle music) - If you or a loved one are living with an eating disorder, don't suffer in silence, seek help.

Remember with help, there is hope.

(gentle music) Do not suffer in silence.

With help, there is hope.

This program is brought to you in part by: The American Psychiatric Association Foundation, The John & Polly Sparks Foundation and The Woodnext Foundation.

(gentle music)