The Heart is a Lonely Hunter

Respighi: Fountains of Rome

Carson McCullers wrote The Heart is a Lonely Hunter when she was 23. It became a literary sensation, though she was already suffering from rheumatic fever and would live most of her remaining life handicapped by a series of strokes. She wrote most often of love, loneliness, and empathy for the human condition.

I haven�t written a philosophical post in a while. Maybe because I�d done enough public searching for meaning in the first years. Maybe because so many read the blog now. And sometimes when I am busy, meaning is lost in the day to day of clinical medicine. In pain, addiction, success, coping, transcendence�but mostly pain, loss, and suffering. That is what people bring to me on a daily basis. And of all my elixirs to offer the most powerful is empathy.

Maybe when people longed for a thing that bad the longing made them trust in anything that might give it to them.

A psychiatrist�s job is a strange one. I sit with people as they cry. I try to sort out the influences of biological and psychologic pathology. I attempt to buttress the strengths and soothe and repair the weaknesses. And I never know what will happen, though I may have seen a similar patient walk through my door a hundred times, say a middle aged man drinking twelve beers a day. One of them gets worse, loses his family, the next one finds his path, quits drinking, and yet another sticks with six beers a day from here on out. Ten thousand variables walk in with every patient and we try to predict the possibilities.

It was funny, too, how lonesome a person could be in a crowded house.

I hate people, sometimes, their selfishness and my own. Our weakness and blindness. The mistakes we make over and over. And I love people, as they push through. It is a great gift that they will share with me all these daily despairs and victories. Sometimes I wish I could be more specific, but another part of my job is the vault of secrets, whether they are fantastic or heart wrenching.

One of the things I struggled with, initially, was a great sense of loneliness. Here I was with so many psychiatrists dismayed by my elixirs and not entirely sure the answer could be found by reading enough Kohut, Winnicot, or Freud. But the blogosphere is plentiful, the world of interested people almost limitless, despite the limitations of the medium and the egos and the foolishness.

I do not have any home. So why should I be homesick?

Our brittle weaknesses almost always come from places of pain. If someone is arrogant, outrageous, narcissistic, or lost, or too easily hurt�at the heart of it is insecurity and the ever-present pain. And where does the wish for finding some truth in the evolutionary medicine come from but dismay and pain? How many people have I seen die from heart disease or complications of diabetes? How many disabled from multiple sclerosis or lupus? And then the daily complaints of fatigue, depression, or constipation. I have few cures and far more questions to ask. 

The modern human race is a dysfunctional, limping family with awesome powers of energy and information. Here on the interweb we strike out and rant and rave and post pictures of our cats.

It was like they waited to tell each other things that had never been told before. What she had to say was terrible and afraid. But what he would tell her was so true that it would make everything all right.

When I sit with people who are dying, they tell me of their families. Their children and lives, and the people they meet on the street, and the color of the air at their favorite summer place. And when I sit with people who are living, they speak of the same, but hardly ever mention the color of the air.

Pain is the currency of my profession. For all doctors, perhaps, and all nurses. The rants, always, the raves, sometimes, and rarely, we hear about the cat pictures, which are, of course, the most important things. When you go out tomorrow try to remember to notice the colors in the sky and the crispness of the wind, because within those small details are serenity. The past is gone, the future is not here. The present is all we will ever hold and experience.

I�m a stranger in a strange land.

I am filled with stories, with sorrows and secrets. Carson McCullers knew these things at 23, and I am much older yet am still figuring them out. When do you call out the brutes, the proud, and the misguided? When do you succor their misery? What is the greater good? Is it silence and a smiling face, or a bitter cut, or perhaps manipulating a character weakness to serve a common end.

Some will benefit from the succor, others the cut. Some won�t learn, ever, and can only serve the good with the benign manipulation. All the terrible and glorious people and their ten thousand variables.

The most fatal thing a man can do is try to stand alone.

It seems like a long time ago that I wrote The Glorious Cause. And I still believe in it, that we have to move forward with open minds, honest skepticism, and a common respect for each other, for science, and for human health. But there are no seekers without flaws, no truths without pain, and no consensus without compromises. The question is are the compromises we make and the new friends we keep worth the cost? Each day those variables change, and the question differs, and the air carries a new scent and a new hue.

We learn so much when we go to those places that cause us pain, yet it sticks to us like glue, and we cannot be free, and we make the same foolish mistakes when we are beset by pain. I hope we can transcend and write and learn and move forward and break through. I hope we can do such a thing together, brute, nerd, narcissist, seeker, mother, warrior, and all the elements of the human family.

Perhaps we cannot get along. Perhaps the compromises we make are not honorable or worthy enough. Perhaps we are too small, too vulnerable, to make it work. That is the human condition, and it is not shameful.

I will not be hurried�kindly allow me to sit in peace a moment.

Every day we are dying. And every moment we live. Every moment there is an opportunity for weakness or triumph or love or serenity. Everything risks pain except perhaps serenity, and that may be why it is the nirvana of choice in lieu of happiness for the wise. The heart is a lonely hunter. We know so little, and expect so much.

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Malnourishment in Infancy and Adult Personality Traits

I could have sworn I�d written about the Barbados long-term malnutrition follow-up study before, but I could not for the life of me remember the context or the name of the article. That�s the problem with having over 350 articles since 2010�I tried looking for the similarly-designed Mauritius study and found it at the bottom of this breezy post from last summer, Mainstreaming. In that study, poor nutrition in early childhood correlated with low IQ at age 12 and schizotypal personality traits at age 23. (Schizotypal traits in the Five Factor model include low self-directedness, introversion, and some distorted perceptions of reality, though an increased openness to new ideas).  It was felt the malnutrition resulted in poor development and functioning of the frontal lobes.

This week a new study came out from Barbados (1). 77 children who were admitted to the hospital at age 7 months for malnutrition were matched with 57 controls. All the malnourished children were subsequently enrolled in an interventional program from infancy until age 12. All 77 malnourished infants were otherwise healthy and achieved complete catch-up of growth by the end of puberty. The children and their matched classmates with no hospital admissions have been followed pretty much ever since. What is interesting about the original cohort is that malnutrition was a �reportable� disease in Barbados, so every child on the island who presented with malnutrition was subsequently enrolled in the same program. That means there is not extra "selection bias" in the malnourished cohort, besides the obvious that they were malnourished in the first place. In addition, on Barbados, education is compulsory until age 16, and 99% of the population is literate.

New Politics: Harlem

As children, the malnourished cohort had impaired IQ and poorer grades than their peers. They also had poorer attention and behavior, even after controlling for socioeconomics and family background. These problems persisted through adolescence, along with a greater tendency to be depressed. At age 40 years, both groups were given personality testing, measuring the tendency of the person to be open or withdrawn, altruistic or suspicious, angry, depressed, hopeful, and other measures such as whether the person tends to have irrational ideas, poor planning abilities, or brittle coping skills. All adults with IQ less than or equal to 70 were taken out of the sample, and a number of other measures that had been taken over the years, including questionnaires completed by their parents, were used to sort out other factors that might cause certain personality traits in mid-adulthood.

After all the data-crunching, the personality testing showed some significant differences between the previously malnourished cohort and their classmates. The malnourished cohort was more likely to have more negative feelings such as anxiety, anger and depression, seemed more vulnerable to stress, were less warm and gregarious, less trusting and less altruistic. They were less likely to consider new ideas and try to experience new things, and they also reported being less able to carry out plans, less punctuality and reliability. These significant differences remained after controlling for IQ and socioeconomic status in adulthood and childhood.

The malnourishment itself could have affected the brain, of course, particularly the frontal lobe and hippocampus, where it is known that early protein malnutrition can cause changes. In addition, maternal depression is associated with malnourishment in children, and maternal depression is known to affect childhood behavior and coping. Also, it is clear the early malnutrition was associated with other problems in childhood (behavioral issues, less ability to achieve in school) and these childhood experiences could have contributed to the adult personality differences as well.

Children born during the Dutch Famine in WWII were found to have an increased prevalence of antisocial and schizoid personality traits (which would include some of the traits studied here, such as decreased trust of others). In a Finnish study, children with slow growth in the first 6 months of life were more likely to be hospitalized later for personality disorders, particularly borderline and antisocial personality (2). No study had examined the personality particular traits in a Five Factor Personality questionnaire after 40 years of follow-up as was done in the Barbados cohort.

These are interesting studies and fascinating cohorts, and I think it is very plausible that early malnutrition would affect personality development and coping skills. It is also plausible that other kinds of maltreatment in early infancy could be factors as well. 

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Folate and Negative Symptoms in Schizophrenia

The psychiatric symptoms of schizophrenia are defined in two major categories, "positive" and "negative." So-called positve symptoms are called so because they are an addition that people without psychosis don't experience, such as hallucinations and delusions and disorganized behavior. The negative symptoms represent functions being taken away from the brain and can be apathy, social withdrawal, and loss of motivation and emotional expressiveness.

Earlier today, a paper (free full text) was released from JAMA Psychiatry detailing a multi-center trial of placebo vs 2 mg folate and 400 micrograms of B12 for folks diagnosed with schizophrenia.  All the patients (140, aged 18-68)  had residual symptoms but were stabilized on antipsychotic medications for at least 6 months and on a stable dose for at least 6 weeks.

HAIM: Forever

All the patients had genetic evaluations of their folate systems and measurements of red blood cell levels of folate. Red blood cell levels of folate don't necessarily correlate with levels in the central nervous system, which is just something to keep in mind. However, in other studies, folate metabolite measurements in the central nervous system seem to flatten and be maintained at a relatively moderate level of red blood cell folate, and levels correlate more closely at lower levels of folate.

The folate cycle is complicated. Please see this article� and several articles linked from that one for more detail. However, in short, folate is an important nutrient necessary to make neurotransmitters, DNA, and also to help with the activation or deactivation of DNA via a process called methylation (which is basically just adding groups of -CH3 molecules).

Folate deficiency has long been linked to schizophrenia. Certain groups of people with hereditary deficits in their folate cycle metabolism are more likely to be schizophrenic than the general population, and cohorts of babies born during famines are more likely to develop schizophrenia a few decades later.  A few of the particular genes include the C77T variant of the MTHFR gene (the young man in the case study of B12 deficiency and psychosis had this variation of this gene). MTHFR is needed to make folate from food into the kinds of folate we use in the body, and many of us have a less efficient version of this enzyme. Each copy (we have two) of the C77T version (rather than C77C, the more typical version) reduces MTHFR activity by 35%. Other missense variants in genes coding for FOLH1 (a peptide that sits on the intestinal brush border and helps dietary folate be absorbed into the body), COMT, and methionine synthase also confer a higher risk of schizophrenia. More interestingly, problems with these genes will predict a greater negative symptom burden in schizophrenia but seem to have no relationship to the positive symptoms.

Back to the current study. Folate (in rather large doses, 2mg) and B12 were used together as the B12 would facilitate the action of the folate in helping the folate cycle� cycle through. In more biochemical terms, B12 is a cofactor for methionine synthase (MTR), which remethylates homocysteine into methionine, which is then converted into the universal methyl donor S-adenosylmethionine (SAMe). 

The long and the short of it�supplementation failed to separate from placebo for the general study group. HOWEVER, among those with the (more efficient) version of the FOLH1 gene and to a lesser degree among other folate cycle genetic variants, folate and B12 supplementation did seem to significantly help negative symptoms in schizophrenia, but not the positive ones.

An important point to make is that negative symptoms are extremely difficult to treat. It is, relatively speaking, fairly straightforward to decrease positive symptoms of hallucinations and disorganized behavior with medications in most people with psychosis. Apathy, social withdrawal, and flattened emotions tend to remain and be very debilitating. (In addition, the medicine can also cause a flattened affect). Therefore finding any intervention, particularly one with presumably far fewer side effects than antipsychotic medication that might help the negative symptoms is an exciting finding.

Genetic testing in psychiatry is still in its infancy. In many cases (such as finding if someone is a rapid metabolizer of certain antidepressants) the tests have modest usefulness in the Real World where such tests are generally paid for out of pocket. But with this study we are really starting to unlock some real clinical utility, and as genetic testing becomes cheaper and more readily available, it might help us design personalized treatments. 

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The Grand Theory

Last week there was a bit of hubbub as a new paper was printed in The Lancet, Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. 

Django Django Default

The paper is a dense discussion of the higher maths of a large genome-wide association study. There�s all sorts of statistical wizardry going on with triple pseudocontrols and a number of things that are a bit above my pay grade, with my single statistics class from medical school and my genetics knowledge from the 20^th century. But the gist of the paper is the following: after hacking the genome (using variations in genome markers, called SNPs, or �snips� to use the genetic parlance, meaning �genome-wide single nucleotide polymorphisms�) of many tens of thousands of cases and controls for people with autistic spectrum disorders, schizophrenia, bipolar disorder, major depressive disorder, and attention deficit hyperactivity disorder, several gene clusters were found that seemed to increase the risk of ALL FIVE of those disorders. Most of the genes found to increase the risk of these disorders were located within the coding for two L-type voltage-gated calcium channel subunits.

What? Okay, so we know that psychiatric diagnosis is a mess. We have the DSM (soon to be in its 5^th iteration) which is basically a recipe list of symptoms. Find enough of your symptoms on the list, and voila, a diagnosis. The DSM is atheoretical ON PURPOSE. They make no pretensions at looking for pathology or brain chemistry issues or whatnot because, for the most part, back in 1980 when the DSMIII came out no one knew what the heck the actual pathology was. The earlier renditions did have some �causes� which led to some gems like the �schizophrenogenic mother,� and so instead of making horrible gaffes, the psychiatrists writing the DSMIII (and IV and V) really strove to see if there were clusters of symptoms that seemed to have some diagnostic validity without venturing into causes at all, so that researchers and clinicians and everyone could more or less speak the same language when talking about patients and trying to come up with evidenced-based treatments. The first MRI was built in 1977, and it�s only been since then (and really, since the invention of functional MRIs, advanced genetics with rapid PCR and PET scans and SPECT scans and the like) that we�ve really been able to see a bit more what is going on in a human brain in a living, thinking subject.

One of the frustrating (and great) things about psychiatry (and, frankly, medicine in general) is that you will almost never see a textbook case of anything. Most of my patients who show up at my office for the first time meet criteria for several diagnoses simultaneously. It�s easier to use symptoms as a benchmark rather than the full diagnoses, though for FDA purposes, treatments are researched based on diagnosis, not symptom. More recently genetic studies have shown links between various diagnoses (most notably, I think, bipolar disorder and schizophrenia, and schizophrenia and autism). While the diagnostic categories are quite clear, sometimes it can be quite difficult in practice to distinguish schizophrenia from bipolar disorder (so much so that there is a midway in between diagnosis called schizoaffective disorder), and many antipsychotic medications are approved for both treating the psychosis of schizophrenia and treating the manic episodes of bipolar disorder.

So what the new paper tells us is that these 5 different disorders of adult and childhood-onset diseases may well all be related. Voltage-gated calcium channels are little places in the cell membrane that decide, based on the voltage of the membrane at the time, whether to let a parade of positively charged calcium ions through the membrane. We need the particular calcium channel subunits coded by the genes found in the study for many brain processes, including functions involved with memory, planning, emotional processing and regulation, and attention. Another one of the calcium channels identified by the study helps other calcium channel subunits be turned on and off, whether by helping them travel to the membrane to set up shop, assist in their regulation by other molecules, or increase their function in other ways. 

A commentary on the study published at the same time in The Lancet spoke to the methods used in the study (and some of the weaknesses, geneticists, by all means, pull the papers and have a look). But it also tried to make some sense of the overall picture here. Basically we have many, many interacting factors that convey risk for psychiatric disorders.  

Prenatally, we have infectious disease, drugs, alcohol, nicotine, nutritional deficiencies, maternal stress and disease interacting with the genetic make-up of the baby. The postnatal environment of trauma, living conditions, nutrition, disease, etc can effect epigenetic changes which interact with brain plasticity to influence, along with the genetic make-up, disease vulnerability. So someone with an abnormal calcium channel gene in the wrong place at the wrong time (along with some other genetic and environmental issues) will get symptoms of ADHD. Another person (with the same calcium channel gene issue but different other genes, environment, etc.) will end up with schizophrenia.  Some with the gene will have no psychiatric disorder at all, I�m sure. 

Are we getting closer to upending the DSM? To define disease from the pathology upwards rather from the symptoms down? I hope so.

See also: Toward a Grand Unified Theory of Psychiatry

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The Dark Side of Food Addiction

When it comes down to it, what is the difference between enjoying a terrific meal and the dangerousness of hyperpalatable foods? 

(If you haven�t seen it, go read the Extraordinary Science of Addictive Junk Food recently in the New York Times.) 

Also, looks like a book will soon be out from which the article was taken: Sugar, Salt, Fat (just downloaded it to my kindle).

The Lumineers: Stubborn Love

Drug addiction has three phases. The introduction to amazing hyperpalatable something, the likes of which the brain is primed to find rewarding but has never seen before in such intense form. After the initial binge, there is a withdrawal phase of negative emotions associated with being without the rewarding taste, then the preoccupation and anticipation phase, and a ton of time and energy spent seeking the same sensation as before. In addicts, use changes from pursuing positive reinforcement (chasing the high) to forestalling negative reinforcement (to prevent getting sick from opiate withdrawal. I�ve heard that one a hundred times: �It doesn�t even make me feel good anymore, doc. I just don�t want to get sick.�) This last bit, the physical dependence, really means you have crossed the border from abuse to a true addiction. 

In �The dark side of food addiction� (sent to me by Dallas Hartwig, thank you very much!), the work of Dr. Hoebel is examined. He mostly considered sugar to be the hyperpalatable food du jour, and his views that one could be called �food addicted� are controversial. And in the pursuit of sugar, for example, there are some parallels to that shift from seeking the palatable to seeking an absence of negative, relieving the anxiety or sad feelings of being without the food, and a transition in the brain circuits with the downregulation of certain brain reward systems and amplification of stress or �antireward� systems in the brain.

Obesity, as I�ve said time and time again, does not overlap 100% with food addiction behaviors, and food addiction is not the entire story behind obesity. There are obese people who seem to demonstrate no characteristics of food addiction, and there are normal weight or even underweight people who have very troubling relationships with food. The �Yale Food Addiction Scale� is the main criteria used to gauge levels of food addiction in research. It is a series of questions meant to quantify how much someone overeats certain foods despite efforts to limit eating them, how much the eating interferes with functioning, and how much there are withdrawal symptoms if one abstains from the trigger foods.

The most likely to suffer from food addiction type behaviors are, obviously, the binge eaters and bulimics. This population has a high level of other psychiatric comorbidity, including depression, anxiety, and other substance abuse. In fact, 1/2 of teenage bulimics report suicidal ideation.  Interestingly, in most normal-weight individuals, stress and negative mood states are associated with decreased appetite, which is less true of overweight individuals. Is this little difference some of the reason behind the obesity epidemic? Is this difference why obesity tracks with depression, as does diabetes and the other metabolic disease? Or are there more complications to the comorbidities?* Bulimics have lower mood immediately prior to a binge than on says when no binges occur. So, we are talking vulnerable populations. Not everyone. Could explain while some people remain slender in the modern food environment where food scientists uses volunteers and supercomputers to calculate the perfect crispiness of a Cheeto and the �bliss point� of salt, sweet, and fat.

Who are these vulnerable populations? Scarily, as I�ve discussed before, it may be those who have started out dieting. Attempts to control body weight via exercise, dietary restriction, appetite suppressants, laxatives, etc are associated with increased weight gain in female adolescents, and dietary restriction is associated with long term weight gain in female adults. Drinking diet soda is also associated with weight gain. Self-reported �restrained eaters� tend to over eat more in stressful situations.

High carbohydrate foods (particularly bread, pasta, and sweets)(an aside, rice is almost never mentioned in these papers�is that because these aren�t papers written by Asian/Indian authors or because the rewarding properties of gluten and sugar are creepy? I don�t know) tend to reduce reports of anger, tension, and increase calmness for 1-2 hours after consumption. Thereafter, depending upon the person, you may have a rebound decrease in good feelings. The overconsumption of these foods may also prime the reward and addiction pathways to induce low mood and cravings for the foods when they are not available. I�ve discussed the downregulation of the dopamine receptor and decreased dopamine availability before. 

Unfortunately, a lot of the hard data associated with addiction and withdrawal syndromes to food is found in mouse and rat models. And mice and rats simply don�t crave and eat quite the same way we humans do, though they do appear to prefer that cafeteria diet and, I believe, chocolate ensure. But when you are on a diet or a detox or whatever it is� what do you crave the most, particularly if there is a stressful time of day, or you have a headache (I tend to eat far less when stressed, but I will crave Diet Coke during those times). And in those first days of your New Years� Resolution, what food do you dream about? Many report dreaming about chocolate, sweets, or cheese.

So what is a solution? Clearly just eating whatever willy nilly doesn�t seem to work to keep the population healthy. And yet dieting induces unhealthy eating behaviors, and dieting that feels restrictive is doomed to failure, precisely because it seems to activate the negative side of these reward pathways, perhaps in response to starvation and stress. 

So one should (mostly) eat foods that one can eat to satiety. For the most part this will nix the designer processed foods meant to entice you to eat more. And many people can get away with special treats every once in a while, just as most people can have alcohol or even a cigarette or two without becoming addicted. The model of �intuitive eating� or mindfulness eating will apply to most people. If you want a special treat, enjoy the heck out of it. Smell it, enjoy the color, take a tiny bite and let the flavor melt on your mouth. Take five minutes to eat a single precious Ho-Ho. (You may find that plasticky chocolate shell and chemicalish cake not as enjoyable as you remembered from stuffing your face as a child). 

There�s a whole book about intuitive eating called �Intuitive Eating.�  I must admit I�ve tried to get a number of my binge eating patients to buy this book and practice the principals, but none of them seemed to take to it very much. I found it interesting that the documentary "Weight of the Nation" featured the mindfulness eating approach so much when I had so little luck with it (my medically compromised bingeing patients seem to do better with more drastic measures, such as weight loss surgery or pharmaceuticals that short circuit the reward pathways, and others seem to do better with a "rehab" abstinence approach.) I've had a great deal of luck prescribing mindfulness strategies and therapies to anxious or self-harming patients, but not to binge eaters.

Some people will be particularly vulnerable to certain trigger foods, and if they are indeed addictive, a rehab/recovery model suggests banning the foods altogether, for life. The problem is, in the short term, this method can increase the risk of further bingeing. But in the long term, with the appropriate support, abstaining from these foods may cause them to lose their seductive power.

In my experience there are two sorts of people. Those who can�t bear to be cut off from any particular foods and would rather count calories, and these folks love their fit bits and food scales and weight watchers apps. Then there are those who couldn�t be bothered, who find calorie counting a horrible nuisance, and prefer to avoid certain types of foods. In reality most people who maintain their weight in the modern foodscape are probably one of these sorts of people. Elderly women who�ve been thin their whole lives tell me how they never have dessert, or if they do, they share it with three other people at the table. Almost everyone is restricting in some way, but if they are doing it successfully, they are utilizing a way that complements their personality and hormonal profile, so they don�t feel deprived.

I think it wise to start children out eating real food (breastmilk) and transition them to real food (meat, fruit, veggies, fish, etc.) and limit their exposure to processed designer scary hyperpalatable crap as much as possible until they can be educated as to the dangers and make their own decisions. When they are hooked young, it is a difficult battle. If they are never overweight, they never have to go on a �diet� though like most people they will have to have some limitations on what they do (like most of us have limitations on the number of martinis we have during lunch). Dieting is not a risk-free endeavor and that should be acknowledged, though the most sensible course in my mind is always going for the nutrient rich, whole foods diet for the majority of what one eats, controlling portion size if you must. If your food needs a label to tell you what is in it or what it is, then you should probably be eating less of it. Makes calorie counting harder when the number isn�t printed right there where you can see it. 

Too simple? Probably. We haven�t talked about food intolerances, metabolic syndrome, or anything like that. Just as there are a raft of �paleo diets� from antiquity and we will never be able to copy them, there is no diet that is one size fits all. One can get most of the way and derive most of the benefit from cutting out processed foods (and I include bread and pasta as processed foods). The dark side of food addiction has to come with the acknowledgement that most people when exposed to addictive substances do not become raging, life threatened addicts. And for most, there is a place for some moderation.

*probably

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Brand New (Even to You) Post at Psychology Today

Head over there to see: Eat Your Egg Yolks about a new (groundbreaking) study from the American Journal of Psychiatry linking choline supplementation in pregnancy to better brain function in infants. You can also check out Zombieland and Zombieland II.

Photo from Flikr Creative Commons

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Emotional Eating

First off, while a lot of the feedback from the Orthorexia series was quite positive (and here is a really thoughtful blog post offshoot from the series), I got some comments and emails accusing me of being silly and judgmental about people�s concern about their diets. So I do want to clarify one point: I care not one whit what you eat*. I do care about you as a human being, but I don�t judge whether you eat skittles for breakfast or you painstakingly raise and consume special pellets of moss species that flourish only on the carefully collected dung of endangered Himalayan goats. If any of those things makes you happy and productive and healthy and wonderful, I�m thrilled. My only concern was to suggest that some folks are trapped a bit by anxiety about what they eat, some to an extent that it negatively affects their lives and functioning. If you aren�t anxious about your Himalayan goat dung moss diet and you are happy and healthy, you do not have a problem. 

Bad Books: Forest Whitaker.

So let�s jump from the frying pan and right into the fire. �Emotional eating� is a soft phrase. There�s nothing to hold onto with it, no mineral deficiencies, no magnesium in receptors, no quick solution. It doesn�t hold the heaviness, wonder, despair and artistry of the human soul soaring in love, suffering in loss. There�s none of the poetry of nuzzling of a baby�s soft skin or hands caressing a loved one or the terror of violence in emotional eating. But I�ve sat with people in the midst of killing themselves with binging. I�ve sat with people who barely eat enough to survive and who can�t eat a meal without shame. Who are facing below the knee amputation for sores from diabetes but walk into clinic with a bag of candy. Emotional eating is an important thing to comprehend, but even the description of it brings along the dreaded spectre of �gluttony and sloth.� I don�t believe the entire Western human race was infected with a sudden onslaught of gluttony and sloth! But let�s look more at �emotional eating.� 

It�s just food. Food is life. Let food be your medicine�one of the reasons I like Dallas and Melissa Hartwig�s �It Starts With Food� so much is that they don�t begin with macronutrients, a long tale of a diet success story, or discussing the evils of different food toxins. No, the entire first section of the book is devoted to the psychology of food and eating, and one of the main criteria for an acceptable �Whole30� food is that it must promote a healthy psychological response. No weird cravings. No sweaty withdrawal dreams. Just eating for eating�s sake and enjoying the flavors, then letting it go and moving on to the next thing in life.

I�ve spent quite a bit of time on this blog discussing the parallels between addiction and binge eating. The book will have whole sections exploring that�but addiction is also a cold and measurable term. Use despite harm. Consuming more than intended. Spending a lot of time and resources finding and using. Using in secret. Sure, most people would agree that is a problem. 

But what about the plain old vanilla grazing and thoughtless eating while bored, or the friendship of a bowl of ice cream on a lonely Friday night? Grazing even though you don�t mean to at the holiday party. Not really a massive binge, no terrible secret, but over time these small overages seem to add up and have an unfair cost. So what does it mean to emotionally eat?

In the literature (1) �emotional eating� is equivalent to �comfort eating� or �stress eating.� Obviously, people who eat when stressed derive some sort of benefit from the eating, and for the most part, they are not eating celery sticks and steamed broccoli, or even a wholesome baked potato. When you are stressed or scared or bored what do you want to eat? Sugary snacks, cheesy bread, coffee, Doritos, or wine. Or sometimes the foods Mom used to make (which encode happy, secure memories, presumably).  �Comfort eating� is not clinically defined for happy situations, oddly enough. All the clinical scales refer to eating in response to stress.  However, there may well be sex differences in comfort eating, with men being more positively driven and craving familiar, savory foods, while women are more driven by negative emotions and crave sweets or wine. It shouldn�t surprise you that estimates of the incidence of emotional eating in the population are nebulous at best. Studies have used different questionnaires, different populations, different validities. Emotional eating does tend to happen more in women than in men, and more in adults than in children. Interestingly, in a general survey of the Dutch population taken 25 years apart, in 1983 23% of the population admitted to emotional eating. In 2009, 36% did so.

It is actually more common in these various studies for those under stress to report a suppressed appetite than a desire for comfort foods. Binge eaters are more likely to report cravings for food under stress, and non-binge eaters more likely to report decreased appetite under stress.

Emotional eating has long been used to try to define the cause of obesity in general, starting with Hilde Bruch, the psychiatrist who first wrote books on obesity and eating disorders as psychiatric phenomenon. Since obese individuals were seen more often in studies to eat when they were not hungry, or to have intake divorced from hunger, it seemed a logical conclusion that emotional factors were at play. Measures of dietary restraint (that is, the ability to turn down food even when hungry) are higher in those with high BMIs, and emotional eating (giving up dietary restraint) is seen much more often in people with higher levels of dietary restraint. As in restraint may beget emotional eating on the other side.  Of course, folks with higher BMIs are incentivized to attempt to turn down food, whereas many lucky folks with naturally low BMIs have never needed to exhibit much dietary restraint. It�s a messy business, trying to sort out natural food cues, hormonal dysregulation, and societal influence. But I do think it is a valuable exercise to determine how emotions cue us to want to eat, particularly unhealthy foods, even when we don�t need to.

In animal studies, there are certain protections against stress-induced eating, such as cutting out the adrenal glands (not recommended) or lack of an �energy dense� diet (lack of sucrose or high fat diet availability). In rats, activation of the HPA axis in the stress response is associated with more cravings for sweet foods than for fat. In humans, stress (such as exams or higher workload) has, not surprisingly, been associated in many different types of studies with cravings for sweets and higher energy-dense foods. Fast food consumption and chocolate increases during high stress weeks, fruit intake seems unaffected. Cortisol levels and urinary cortisol excretion are correlated with energy intake, and in women given solvable or unsolvable puzzles along with snacks in a controlled trial, those with the unsolvable puzzles ate more M&Ms and fewer grapes than those who were given solvable puzzles. In a study of women in San Diego, those with higher depression rating scores ate twice as much chocolate as those with normal depression rating scores.

The obvious question when looking at all this negative mood leading to emotional eating data is whether or not comfort eating actually improves mood. Not surprisingly, the data is mixed and the data collection confusing. Binging might actually improve mood because it results in a parasympathetic rebound of digestion, sleepiness, and relaxation. However, in an emotional binge eater, feelings of guilt and shame are liable to come to the forefront as well. 

Chocolate is the most commonly craved food during negative affect, and the sugar, caffeine, and theobromine could actually directly lift mood. Chocolate, eaten on an empty stomach with the high fat content, low protein content, and sugar content could result in an increase of tryptophan being shuttled into the brain, increasing serotonin levels. In rats, craving for chocolate can be shut off with opiate receptor blockers. And in female students, the main food that has been shown to alleviate pain and the main food craved by emotional eaters during a stressful task is chocolate chip cookies. Chocolate could reverse the sad feelings induced by watching a tear jerking film, but the effect was short-lived, only 3 minutes. (I think a fun job would be to dream up stress eating measurement studies). 

More evidence that food can improve mood is found in following people with seasonal affective disorder, who eat and crave more sweet foods during the winter. The cravings are decreased with light therapy.  Per capita sugar consumption is highly correlated with depression rates in countries (Why might that be???  PLEASE someone do a large study on fructose malabsorption and depression.)

Does comfort eating cause harm? Among studies of obese patients, generally less than half consider themselves comfort eaters, suggesting that it is an issue in a minority of people. In several studies (including the Dutch one mentioned earlier), emotional eating has increased with the prevalence of obesity, suggesting a connection.  Emotional eating is also strongly correlated to increased incidence of depression, sensitivity to stress, and impulsivity.

Genetic studies have pointed to issues with dopamine, serotonin, and all the usual suspects with respect to appetite and reward in the brain, but the pathway forward so far as treatment is far from clear. In some emotional eaters, an SSRI is helpful and decreases BMI. In others there is insidious weight gain. Wellbutrin, naltrexone, and topamax have all had some evidence for binge eating reduction. Naltrexone blocks opiate receptors and thus some reward pathways. Wellbutrin modulates the dopamine system (and thus affects the reward pathways). No one is really sure how topamax works but it does seem to blunt appetite and reduce binge eating, and also reduce that tricky problem that some have of night eating. These are not FDA approved uses of these sorts of medications, but there is nothing FDA approved for �emotional eating.� And for some people, literally killing themselves with binges despite major cardiovascular risk factors, or binging and purging constantly, the benefit/risk discussion changes with respect to using medication.

So far as non-pharmacological approaches to emotional eating, I�m aware of two major contenders. One is mindful eating (described in detail in the HBO documentary �Weight of the Nation.�) The other is �Food rehab.� Almost every diet from Atkins to South Beach to Whole30 or 21 Day Sugar Detox has a strict �buy-in� period that is a kind of food rehab, blocking access to trigger foods. I think different sorts of people will benefit from different strategies, and will discuss this further in another post.

*unless you are a murderous cannibal. Then I disapprove.

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