Second Helpings: AEDP Accelerated Glucose regulation challenges Dynamic Psychotherapy in the Treatment of Eeating Psychological approaches to eating Eating Disorders Natasha C. What psychological approaches are used to treat the eating disorders? Severe or life-threatening physical health problems that occur with anorexia can be a medical emergency. Perey I, Cook-Cottone C.

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This cognitive-over-behavioral hierarchy in core CBT texts — the behaviors must be addressed, but only in service of addressing the cognitions that are the true causes — perhaps helps explain why in the translation of theory and guidelines into clinical practice, a cognitive- before -behavioral approach is so widespread.

After all, if the primary point is really to change the cognitions, why not just start with them? The cognitive-before-behavioral practice goes directly against treatment guidelines for eating disorders, which often encourage a behavioral focus designed to effect physical rehabilitation, especially at the start of treatment.

The recommendations for BN also emphasize the importance of early behavioral normalization around binge and purge habits. This advice is striking for originating in a psychiatric setting, but it is even more striking that these guidelines are not widely followed.

Mainstream treatments are often unsuccessful in treating either the disordered eating behaviors or the psychological problems associated with them.

Outcome studies and systematic reviews of psychotherapeutic and inpatient treatments some also including drug treatment for eating disorders typically show that although some patients may experience symptomatic improvement in the short term, dropouts from treatment are high, many patients relapse after the end of treatment, long-term outcomes are often unknown, and deaths during or after treatment are not uncommon, especially in AN Steinhausen, , ; Lock et al.

A recent review of five trials in which a non-specific treatment protocol was used as a placebo found that the placebo performed as well as the specialized eating-disorder treatments, which included enhanced cognitive behavior therapy for eating disorders CBT-E and the Maudsley model for AN in adults MANTRA Gutiérrez and Carrera, A meta-analysis of treatments for AN Murray et al.

Current specialized treatments are more adept than comparator interventions at imparting change in weight-based AN symptoms at EOT [end of treatment], but not at follow-up. Specialized treatments confer no advantage over comparator interventions in terms of psychological symptoms p.

There is a problem, then, with the status quo. The second observation may give us indirect insight into why the clear explication called for in the first remains elusive. Psychological symptoms are thought to be central maintaining mechanisms in AN psychopathology, and this cluster of cognitions e.

Instead of drawing the obvious conclusion from their findings — that more specialized targeting of psychological symptoms yields no benefits — they instead conclude that even more focus on the psychology is needed:. Future treatment development efforts ought to adopt a specific focus on the more rapid relief of psychological AN pathology, such that the mechanisms by which they drive behavioral symptoms may be targeted and ameliorated throughout treatment , p.

Behaviors are a key mechanism by which body affects mind and vice versa. For instance, malnutrition directly increases the attentional salience of food-related stimuli in a physiology-to-psychology dopamine-mediated effect for an overview, see Troscianko, , p.

However, the cumulative effects of this heightened salience on everyday life are all mediated by changed behaviors: seeking out recipes, restaurant reviews, and food-related materials as replacements for or enhancements of actual eating; spending a long time shopping for food; cooking for other people without eating; and so on.

These behaviors have powerful twofold effects: intensifying the psychological salience distortion while also exacerbating the physiological aspects of malnutrition. These effects may in turn have further effects such as the generation of cognitive dissonance, whose reduction may often involve post hoc alignments of cognitions with behaviors: for example, discounting the negative effects of secretive and restrictive eating for mind and body to justify continuing to eat in a disordered way.

Thus, the vicious circle tightens. In line with this pivotal role for behavior within the pathology of eating disorders, behavior-focused treatments seem to be as effective as those with extensive cognitive elements Waller and Raykos, ; they are also much simpler and cheaper to provide, meaning that more patients have the chance to benefit from them.

Accordingly, the case has recently been made from within the community of CBT researchers and practitioners Waller and Raykos, and from outside it Södersten et al.

In this paper, we present the hypothesis that effectively treating eating is the key to treating eating disorders effectively: that behavior must be restored to the center of eating disorder treatment and research.

We also propose, however, that the most meaningful model for both understanding and treating eating disorders is a dynamical systems model in which the interconnections between mind, body, and behavior are understood as structurally integral to the whole.

Put simply: the eating has to be treated, but what shapes and is shaped by the eating cannot be ignored. It is supported by, and has in turn generated, a large amount of research aimed at uncovering correlations amongst eating disorders and other psychological disorders and traits, such as maladaptive perfectionism Dahlenburg et al.

Such correlations have indeed been found. Along with self-starvation, individuals with AN, for instance, may show florid psychological symptoms: depression Voderholzer et al. Patients with eating disorders have also been found to have problematic personality traits such as perfectionism, neuroticism, obsessionality, negative emotionality, harm avoidance, low self-directedness, low cooperativeness, avoidant personality disorder, high constraint, high persistence, low novelty-seeking, high impulsivity, sensation-seeking, and borderline personality disorder Vitousek and Manke, ; Cassin and von Ranson, The disordered eating behavior seems like one more comorbid symptom of a complex psychological disorder.

Of course, psychological factors matter. It is trivial to acknowledge that behavioral disturbances like eating problems may sometimes arise in response to complex or stressful situations which also generate psychological disturbances. It is equally obviously true that an individual will not engage in treatment at all without making a decision to pursue recovery, and that this decision-making is in part a psychological act.

Given the ambivalence with which most people with eating disorders view both their illness and the possibility and desirability of recovery Williams and Reid, , this decision must not be taken for granted, either prior to the start of behavior change in treatment or at any point in the ongoing decision-making required to sustain change through treatment and in post-treatment life.

As described above, the stronger claim has not yielded effective psychologically based treatments. In the rest of this section, therefore, we investigate five specific forms of reasoning that underpin it, and what makes these approaches both attractive and problematic.

One reason why the psychological story persists despite its failure to generate effective treatments may be a confusion of correlation and causation.

As noted, a multitude of correlations have been observed between eating disorders and other psychological problems. Once a correlation has been observed, a sensible next step is often to investigate possible causal links. Anxiety in general, and obsessive-compulsive disorder OCD as a specific expression of anxiety, are amongst the most common focal points for research on the causes of eating disorders Matsunaga et al.

That is, the temporal relationship is the wrong way around for the AN to be an effect of the OCD. Similarly, when considering social anxiety disorder SAD , some retrospective studies suggest that SAD often starts before an eating disorder e.

Indeed, Buckner et al. In simple terms, too, the general idea that anxiety causes eating disorders needs to account for the far greater incidence rates of anxiety compared to the incidence of eating disorders.

Levinson et al. Similarly, investigating the relationships between eating disorders and OCD, Wu found that once a confounding general distress variable had been removed, apparent correlations between three OCD scales and eating disorders disappeared for AN, and only compulsive washing remained a correlate with BN, though a less powerful one than separate measures of panic and depression.

Adding in a temporal element, in a 6-month prospective model Levinson and Rodebaugh found no prospective predictive power of SAD for the development of eating disorders, but they did identify maladaptive perfectionism as a shared prospective vulnerability for symptoms of both eating disorders and SAD.

Social appearance anxiety also prospectively predicted eating disorder symptoms here measured on three scales: drive for thinness, bulimia, and body dissatisfaction but not did not predict social anxiety symptoms more generally.

This kind of reorientation does not rule out the potential value of well-targeted psychological interventions: the causal relations between psychological and behavioral variables can and do flow both ways. But we will argue that such interventions must always be attuned to the elucidation and resolution of current behavioral dynamics rather than being oriented around etiological history.

As we have shown and see also Södersten et al. The conclusions generated by these increasingly sensitive observational data are also supported by experimental findings in which causation can be directly inferred. High dietary restraint is an unstable state in which disinhibition and loss of control over eating is a likely result of changes in external food-related cues Herman and Mack, Dietary restraint has been found to be directly modifiable by eating behavior, specifically eating rate Zandian et al.

Similarly, the chronic anxiety associated with starvation in AN is reversible with appropriate short-term Heruc et al. These findings suggest that at least some psychological problems are not causes of eating disorders, nor even comorbid correlations with eating disorders, but are actually caused by eating disorders.

The idea that starvation triggers psychological symptoms is supported by a detailed experimental study of starvation and refeeding conducted during World War II, the so-called Minnesota starvation study Keys et al. Here, young men selected for their robust good health were subjected to systematic semi-starvation, which induced in them severe psychological problems strikingly similar to those displayed by people with AN.

Moreover, systematically refeeding the starving volunteers for 12 weeks, and allowing them subsequently to eat ad libitum , eliminated these problems within a year.

However, in both cases, semi-starvation results in similar emotional and cognitive abnormalities that, along with the physiological damage, are reversed when eating behavior is fully normalized. The Minnesota study remains a critical piece of evidence in the field despite its age because arguably few more recent clinical studies have encouraged patients to regain enough bodyweight to make full physical, behavioral, and psychological recovery viable Troscianko, , Most psychologically oriented therapies take roughly this approach.

For example, in a randomized controlled trial comparing psychoanalytic psychotherapy with CBT for BN Poulsen et al. This kind of therapeutic orientation may involve long-term often years-long or even life-long psychiatric excavation of past interpersonal trauma, sometimes in total absence of structured support for either changing eating behavior or weight restoration e.

As we have seen, however, this hope is not borne out by the evidence. In general, we can observe slippage between two meanings of primary : as an etiological starting point for a disorder, and as its most significant component, which deserves to be the focus of treatment.

Identifying a plausible ultimate origin or proximate trigger, for example through first-person testimony, however, is not the same as identifying a neurobehavioral control mechanism for eating disorders. In many contexts of human endeavor, all-or-nothing thinking seems more appealing than careful exploration of the middle ground.

In practice, by contrast, debates about eating disorder treatment methods often involve statements to the effect that because one extreme of treatment is ineffective, the solution must be sought at the other extreme.

At the other end of the scale, the inhumanity of enforced refeeding protocols in some inpatient settings is an easy extreme to reject, especially since as we discuss below they are ineffective. Yet as we have begun to suggest, the zero-sum physical versus psychological stalemate may be broken by a conception of behavior as mediating between the two extremes.

This applies as much in research as in treatment. Many research papers, particularly those on AN, are concerned ultimately with the meaning of the disorder e. Whether in the service of research or treatment, storytelling about a difficult childhood or disentangling phenomenological anomalies offers easier footholds for complex interpretive activity than discussion of whether breakfast time should be moved forward by an hour.

Psychological concerns may often be perceived as simply more interesting than physical or behavioral matters; it may disappoint the therapist that what really needs to be done this week is helping someone to include more fat in their diet. Intellectual appeal may be one side of the coin in the therapeutic encounter; anxiety is probably the other.

The likelihood of an ineffectually accommodating dynamic arising is increased by presence of mistaken beliefs about the power of the therapeutic alliance Mulkens et al.

The first of these beliefs is supported by various reviews suggesting that therapeutic alliance can contribute to the efficacy of treatment for eating disorders Antoniou and Cooper, ; Puls et al. However, the second belief is not substantiated.

A meta-analysis conducted by Graves et al. This implies that whatever is needed to bring about symptom change must be prioritized if the therapeutic alliance and its feedback benefits on further symptom change are to be fully exploited.

Dropout is also a key mediating factor here Graves et al. Overall, then, there is no reason to treat the therapeutic alliance and a behavioral focus as at odds with one another.

Other factors are doubtless at play, but these may be some of the primary contributors to how the behavioral gets sidelined in favor of the psychological in the treatment of eating disorders. In the following section, we propose a theoretical and practical model that offers a direct response and alternative to all these reasons for adherence to psychology-focused treatment protocols: the feedback model of pathology.

Feedback influences the dynamics of almost every natural and artificial process, from homeostatic temperature regulation to the flow of traffic through the internet. This problem persists until negative feedback intervenes, or the feedback loop is interrupted by an external force.

Feedback systems are best modeled by dynamical systems theory, which describes how any property of a system evolves over time. Such systems may be deterministic, in which case, if the initial conditions are specified, the full trajectory can be uniquely determined.

In most real-world cases, disturbances that cannot be predicted act upon the system. In this case the system is said to be stochastic, and only the average trajectory can be determined, since each specific trajectory is subject to an unpredictable set of disturbances.

In general, however, one is interested not in a specific trajectory, but in all trajectories initiated within a set of initial conditions. Even more important than any specific trajectory, though, is long-term behavior: Systems may be stable trajectories tend to a fixed point , periodic trajectories oscillate infinitely, neither dying out nor blowing up , or unstable trajectories continue to deviate from the initial condition at an increasing rate.

Identifying long-term patterns of this kind allows for powerful predictions about, and interventions into, the dynamics of any system, including a human illness.

Eating disorders have long been understood as unstable feedback systems Zeeman, ; Minuchin et al. Treatment is successful when it characterizes the feedback dynamics accurately enough to intervene in a way that disrupts them by introducing a source of stabilizing negative feedback.

It is possible to apply feedback principles at any level of specificity: in eating disorders, for instance, one might focus solely on hormonal imbalance.

However, the structural principles of dynamical systems encourage awareness of the multiple levels at which system dynamics interact, for instance of the fact that the hormonal system is coupled with the reward and stress systems, the wider metabolic system, etc.

Equally, important feedback loops within the cognitive-emotional system may be identified, but it will rapidly become clear, when investigating them from a feedback perspective, that making sense of those dynamics requires insight into other factors driving and being driven by the cognitive-emotional patterns.

The quest for ultimate causal origins becomes insignificant relative to the question of how the current feedback dynamics are maintaining the problem 2.

The decision about where to intervene in a pathological feedback system is determined by pragmatic considerations focused on the present and the future, not the past. Such considerations include: 1 which factor is demonstrably maintaining most other factors and 2 which factor is most practically feasible to alter given the current circumstances.

In AN, malnutrition tends to fulfill both criteria, since 1 it brings with it a vast cascade of cognitive, physical, and behavioral problems that create further cascading causal instabilities for the system, and 2 it is remedied with simple if not easy changes to eating habits.

It is of course possible that some specific psychological component may satisfy both criteria, but if the question is asked and answered honestly, psychological therapeutic work in a malnourished state is rarely a feasible option, while behavioral work, such as modifying eating behavior, usually is.

Therapy addressing the behaviors that maintain the starvation is far more likely to be effective. A feedback model also addresses the problem of intellectual appeal [point 3 above]: once the pivotal role of behavior is understood in its theoretical context, it stops being boring.

Sensitive modeling of pathological dynamics, including psychological states, allows the dynamics to be made predictable and hence tractable. This shift provides intellectual satisfaction for both clinician and patient. This perspective also at least begins to change the dynamics of anxiety and safety behavior within the clinical encounter [point 4 ], both by making them explicit, precisely as a conspicuous and significant example of feedback dynamics in action, and by making unavoidably clear the impossibility of meaningfully disrupting the disorder while ignoring the eating behaviors.

CBT is the best-known therapeutic instantiation of feedback principles. For some individuals, CBT provides a helpful contribution to a recovery effort from an eating disorder.

But if the feedback model is so powerful, and CBT is a direct formalization of it into therapeutic protocols, why are global remission and recovery rates so unimpressive? The first problem comes back to the question of priority amongst the components at play in the feedback system.

We discussed in the introduction, and can now reconsider through a feedback lens, the tension between cognitive and behavioral emphases. Continuing to use Fairburn as our case study, we find several feedback diagrams exemplifying the theory that guides the practice. In these diagrams p. In investigation of natural systems, it is common to speculate that one component is the controller and another is the thing being regulated.

This is reverse engineering: given the full existing system, what are the components and how, when integrated, do they produce the overall behavior one has observed? But to move from speculation to demonstration requires extensive testing of the system dynamics to assess the relative strengths of multiple feedforward and feedback channels, eliminate confounds, etc.

This type of research is highly compatible with more standard clinical testing. Indeed, the meta-analyses on treatment efficacy cited earlier suggest that to the extent that we have made progress in identifying the controller of the eating disorder system, we can be fairly confident that it is generally not the cognitions: the evidence we have suggests that creating ever more specialized psychological treatments will be ineffective.

When asking why this evidence is often not acted on, it is worth noting another ambiguity in presentations of CBT methods and theory. It is easy to conflate the two, and the conflation is also manifest in the repeated use of the ambiguous term secondary , which can refer to both chronology and importance.

This lack of clarity may in turn generate the impression that a search for origins can stand in for a search for the appropriate target for treatment.

These unresolved internal tensions at the heart of CBT for eating disorders can be added to the list of reasons we offered earlier for the wider clinical privileging of cognitive over behavioral treatments. The inconsistencies help explain why CBT has so far not fully capitalized on its dynamical-systems inheritance.

Perhaps this decision is not surprising if the cognitive overvaluation is presented as ontologically and clinically, if not etiologically, primary for the disorder.

CBT is working poorly, we suggest, in part because its tenets are poised uneasily between its cognitive and behavioral foundations, without a full espousal of the feedback principles that could resolve the tension. It is also the case that many clinicians do not provide true CBT and focus on the cognitive issues at the expense of the behavioral issues.

Waller and Turner offer suggestions for countering this second problem at the individual level and at higher levels of practice in the field. But theoretical inconsistency and therapist drift are not the only factors involved in the relatively low efficacy of CBT for eating disorders.

Many implementations of it and of other non-CBT treatments fall into other avoidable traps that systematically reduce its efficacy. We suggest that the most common additional problems are as follows:. In restrictive eating disorders where patients are underweight, therapists may insist on weight gain at all costs, including strategies for intensive nutritional rehabilitation such as nasogastric tube feeding that involves no behavioral learning and may actually impede such learning.

A review of the efficacy of tube feeding in AN suggests that short-term weight gain is generally achieved without concurrent improvement in psychiatric symptoms or evidence of long-term sustainability Kells and Kelly-Weeder, A comparison of feeding methods in anorexia found no advantage in efficacy for tube feeding over ordinary oral intake of food or liquid supplements, and a wide range of disadvantages Hart et al.

Meanwhile, in eating disorders where some patients are overweight, for example BED, recommended procedures might include energy restriction based on calorie-counting, even though such practices are well known to promote disordered eating Simpson and Mazzeo, The urgent need for meaningful and standardized definitions of remission and recovery has been acknowledged Khalsa et al.

Overemphasis on short-term bodyweight normalization, especially in AN, may also entail using inadequate follow-up protocols for tracking remission and recovery rates beyond end of treatment: follow-up beyond a year or two is rare. Short follow-up protocols have often been flagged as a problem, as they prevent accurate relapse estimates e.

Where remission and recovery are explicitly defined, and where BMI is used as a criterion, it is often a primary criterion. However, indefensibly low BMI thresholds are often set for end of treatment for AN, and avoidance of higher BMI values is often prioritized during treatment for BN, despite the fact that many patients with bulimia may present with suppressed bodyweight Butryn et al.

The goal weight of AN treatment should be the weight at which physical and psychological symptoms are or can be resolved, but there is no agreed-upon BMI level at which this reliably occurs for all individuals Lebow et al.

This is partly thanks to the fact that BMI is a crude measure, which has some use as a rough proxy for physical restoration following malnutrition but is ill-suited to its common roles as an index of fatness either overall body fat mass or its distribution and as an index of health Nuttall, These interrelated problems may be caused in part by the institutional and funding pressures to which both clinical practice and academic research are subject.

Whatever their causes, the adverse consequences for treatment success of a focus on normalizing BMI without altering eating behavior may be profound. In theoretical terms, each of these three problems can be parsimoniously framed as deriving from an underestimation of the feedback interactions at work in eating disorders devaluing the importance of normalizing all components of the mind—body—behavior system as well as from misidentifying the controller of the feedback system assuming it to be bodyweight.

The second issue offers an interesting counterpoint to the general privileging of the cognitive components in eating disorders: here we see the physical issue bodyweight acquiring undue priority in significance and in treatment time-course.

Almost nowhere in the treatment of eating disorders is eating behavior given priority — which, we argue, is the heart of the problem. Of course, all aspects of eating behavior are not equally important.

As we have seen, the implementation of cognitive-behavioral feedback principles in mainstream eating disorder treatments often emphasizes improvement in cognition or bodyweight at the expense of lasting behavioral change. But if a reorientation toward the improvement of abnormal eating behaviors were to happen, we would face the choice of which behavior it is most important to change first.

One largely overlooked factor for whose relevance there is accumulating direct and indirect evidence across the eating disorder spectrum is rate of eating. Some of this evidence comes from obesity-oriented research.

For example, rapid food intake is a strong risk factor for higher BMI Leong et al. A slow eating rate has been shown to be associated with lower energy intake and higher perceived satiety Andrade et al.

Moreover, interventions to reduce eating rate have resulted in reduced energy intake and increased satiety amongst normal-weight participants Shah et al. Slowing the rate of food intake also reduces energy intake without satiety change amongst those who previously had voluntarily eaten a large meal Scisco et al.

Mealtime feedback on eating speed helps obese children and teenagers to slow the rate at which they eat, reduce their energy intake while maintaining satiety levels, and allow them to lose bodyweight and fat and maintain that loss in the long term Ford et al.

The mechanisms by which eating more slowly causes people to eat less food seem to be:. As noted earlier, there is also evidence that eating rate directly affects psychological variables like dietary restraint: shifting a linear eating rate to a decelerated one reduced dietary restraint and broke the link between disinhibition and overeating amongst healthy women Zandian et al.

Thus eating rate seems a promising starting point for interventions to effect both psychological and physiological change. They suggest a simple hypothesis accounting for etiology, progression, and effective treatment across the full spectrum of eating problems, as follows.

Those who will develop the restrictive subtype of AN do not experience satiety during or after meals. Unlike most people, they are able to continue this behavior until they experience profound weight loss, deterioration of their physiological status, and deterioration of their psychiatric status.

Many factors may contribute to this capacity, from a heightened sensitivity to the mood-enhancing effects of hunger to a greater concern with physical appearance as status marker: as ever, feedback dynamics mean that the effects of any such difference in initiating conditions may be rapidly amplified.

Those with BN eventually become very hungry, binge, and then purge. Those with BED replicate this strategy without purging. A further extension to the case of obesity may also be possible: individuals who will become obese eat too quickly to reliably experience satiety, so they continue to be hungry and continue to eat in excess of their metabolic needs Ford et al.

All of these eating problems are driven by an inability to experience satiety due to rapid food consumption precluding the gut hormone changes that mediate satiety Galhardo et al.

Therefore, all eating-disorder patients can be effectively treated via a behavioral intervention that normalizes eating rate and thus satiety signaling. All additional aspects of the intervention should be tailored to support the normalization of eating behavior. We acknowledge that our hypothesis may seem provocative.

The question is, does the existing evidence support it? We believe that it does. As described earlier, global remission and recovery rates for CBT and other standard treatments are not good.

In addition, they do not include individuals who were not treated because standard-care clinics often reject potential patients with AN if they have a very low BMI; their outcomes would not be reflected in these data.

Much better outcomes are seen with a treatment method focused on mealtime feedback. The Mandometer clinics originating at the Karolinska Institute in Stockholm, Sweden provide treatment in both inpatient and outpatient formats centered on a small device under a plate to measure food consumption and provide visual feedback to the eater on normal changes of eating rate and satiety over the course of the meal.

For satiety, the eater is prompted to input current satiety at intervals, and the resulting readings are likewise visualized relative to the normal satiety development for such a meal. Regular use of the device is complemented by restricted exercise and warm rest after eating in a warm room or with a thermal blanket.

Furthermore, the standards for remission and recovery are detailed and ambitious. These high standards have been met by a strikingly simple implementation of feedback principles: normalizing the rate of eating and normalizing satiety regulation with mealtime feedback Bergh et al. As noted, in the case of AN, the rate of eating needs to be increased, and for BN eating rate needs to be slowed; in both cases a constant eating rate needs shifting to a decelerated pattern.

In all eating disorders, awareness and responsiveness to the progressive transition from hunger to satiety during the course of a meal is also impaired Halmi et al.

All these changes can be achieved by means of the Mandometer device. Importantly, after normalization of only eating behavior, without formal psychiatric therapy or drugs all patients taking psychoactive drugs on admission are gradually withdrawn from them , all the psychological symptoms of AN and BN resolve.

It is no accident that treating eating disorders as disorders of eating in this way should involve more robust criteria for remission and recovery than are typically employed.

Both approaches create ideal conditions for relapse Tomba et al. If, on the other hand, the psychological problems are understood to arise as a direct consequence of disordered behaviors resulting in physiological destabilization, and are understood to contribute to sustaining that instability, then complete normalization of the physical, behavioral, and psychological issues must be required to signify remission, let alone full recovery.

This therapeutic model makes it reasonable to require an absence of all symptoms associated with the dynamical system of the eating disorder.

Indeed, the importance of how weight is normalized as well as that it is normalized is also testified to by patients who acknowledge that what they really need is to relearn how to eat. A statement to this effect was in fact the inspiration for the development of the Mandometer mealtime feedback method Södersten et al.

Despite the success of this approach to behavioral normalization, however, not all the factors on which the eating-rate hypothesis depends have been tested. For example, no prospective studies have been conducted to find out whether every eating disorder is preceded by rapid eating and lack of satiety, nor whether everyone who has anorexia eats too slowly or everyone who is obese eats too quickly and all at a linear rate.

We do not know what the most crucial differences are between people who keep eating less and exercising more and so develop AN and those who do not and so develop obesity or another eating disorder , or between any of these cohorts and those who maintain healthy eating habits and bodyweight throughout their lives.

It will be important to determine under what circumstances this idea holds. We suggest that the most effective next step for testing our hypothesis would be to conduct fine-grained treatment research to establish the relative significance of eating rate normalization versus other aspects of the Mando treatment method, initially by separating out eating rate from satiety regulation training, exercise abstention, warm rest after meals, and verbal encouragements to behavioral change see more on these latter in the next section.

The first step in this testing could be to use a simple 2 × 2 design balancing eating rate ER against the four other covariates 4CoV , and so including four conditions:. Involving a clear prediction as to the ranking of efficacy by condition in the order presented and disambiguating between eating rate and the other components, this design would provide newly structured evidence on Mando efficacy, and would set the stage for testing each of the covariates in order to assess their inner structure.

An external comparator e. This research would have practical and theoretical benefits as regards the interrelations between Mando and CBT. It would ideally be conducted by teams including specialists in CBT as well as the Mando practitioners and researchers.

At present all Mando evidence has been gathered by the Mando teams in their own clinics, and most research publications on the Mando method have been published by the developers of the method with the exception of one problematic study, van Elburg et al.

This research would thus help expand the research on the Mando method in scope and disciplinary grounding.

It would also shed light on the specifics of practitioner engagement with the patients, to address the question of precisely what overlap exists between the forms of interpersonal support offered in CBT and Mando.

This in turn would broach the broader question of whether the model we propose here is best thought of as a new alternative to CBT or a return to the behavioral foundations of CBT. Both methods emphasize the significance of behavioral normalization in the treatment of eating disorders, and CBT involves some acknowledgment of the importance of feedback dynamics.

But it is only through careful explorations of the details of how both methods operationalize these principles that we will arrive at a meaningful characterization of the similarities and differences between them, and an answer to the question of how exactly the present theory relates to the theory and the practice of CBT.

This interventional study focused on the treatment and recovery process could be complemented by a prospective observational study in which eating rate were tracked at regular time points against satiety regulation, dietary intake, exercise habits, bodyweight changes, and ED onset where applicable , around the mid-adolescent phase where ED onset is most common, to assess the prospective predictive power specifically of eating rate in the etiology of eating problems.

Studies of these kinds would contribute to modeling the feedback dynamics of health and illness and of successful and failed recoveries. As such, they would enrich the existing evidence base for the treatment of eating problems, which currently suggests that eating disorders and other problems with bodyweight and eating can be effectively treated using protocols that focus on the simple behavioral retraining of eating rate.

Those who treat AN, BN, or BED often regard these conditions as arising primarily from either a personality problem or a psychological problem.

Treatment often proceeds on this basis, or else focuses on weight normalization at the cost of all other factors. However, there are good reasons for thinking that normalization of eating behaviors, rather than of bodyweight per se , is the key driver of recovery.

The main driver of improvement in all of these problems may be the normalization of eating behavior, rather than nutritional rehabilitation e. A common principle for all these eating problems is that the rate at which food is consumed is a strong contributor to regulating the amount of food that is eaten and the experience of eating it.

Standard care could be enhanced by a changed behavioral focus in treatment, accompanied by improved standards for remission and recovery.

Overall, we propose that a shift away from the extremes of physiology bodyweight or psychology toward eating behavior as their structural intermediary may resolve many of the problems manifest in eating disorder treatment today. There is substantial evidence for the success of a behavior-focused treatment of eating disorders that normalizes both 1 eating rate and 2 experiences of mealtime satiety.

This treatment protocol, as implemented over more than 20 years, has also involved two additional behavioral practices: 3 restricted exercise and 4 warm conditions in which to rest after eating. Both strategies help retain calories for weight gain in patients with AN, rather than losing them to heat production or exercise; warm rest after meals also helps counters post-prandial anxiety in all patients Bergh et al.

The four elements have not been separated out for individual efficacy tests such as could be initiated via the protocol we set out in the previous section , and they have been implemented in concert only in specific clinics although enforced rest is widespread in inpatient treatment for anorexia, and ambient warmth may be a feature of some.

These clinics may be distinct from others in ways that are easily quantifiable or not. But the strikingly improved remission and recovery rates for the full spectrum of eating disorders suggest that the dual-track eating-speed-plus-satiety mealtime feedback, with or without warm rest and exercise restriction, is what makes the difference.

These findings could generate a strong claim that psychological therapy is not needed to successfully treat an eating disorder. However, this conclusion may be going too far. Much of this type of treatment, of course, is also common sense, but CBT, too, works not least by appealing to common sense.

Encouraging a patient not to take every sensation or emotion at face value, but to interrogate its possible causes and effects and challenge it where appropriate, is a common-sense way of proceeding. Expertise in providing CBT consists not least in anticipating likely patterns of cause and effect, and in encouraging the appropriate conclusions to be not just drawn but acted on.

These therapeutic goals are also common sense that has been formalized into therapeutic method. Just as with the four behavioral components of the Mando method, this fifth element will require in-depth descriptive and efficacy analysis to clarify the nature of its role in generating lasting behavior change as part of an effective mind—body—behavior intervention.

Minds are always embodied, and no solution to a problem involving embodied minds in action can ignore any part of the mind—body—behavior constellation. The question is how to balance their requirements effectively at different phases of treatment. As we have seen, however, approaches that put specific eating behaviors center-stage while acknowledging realities that are also partly psychological, such as the need to relearn how to eat and feel hungry before eating and full after eating, show the most promise for success.

It may also be worthwhile looking further afield for ways to maximize therapeutic efficacy — and to increase uptake of and full engagement with therapeutic support. After all, as we noted earlier, any change in behavior must be preceded by a decision to change.

The effects often manifest via contributions to usually harmful positive feedback loops or usually beneficial negative feedback dynamics, via a wide range of intermediary mechanisms.

The wide-ranging effects of reading literature are just one example of the power of cultural phenomena to intervene at every point in the mind—body—behavior feedback systems of disordered eating.

The things people read, watch, listen to, and are confronted with on their way to work or their time on Instagram all have the potential to make part of the difference between spiraling further into illness or understanding that the time has come to leave illness behind.

Thus they can all be part of the motivation to seek out treatment in the first place, to persevere through the physical and mental discomfort of recovery, and to maintain and build on the resulting good health — or to espouse disordered habits and retreat back into seductive but damaging exercises of self-control or self-objectification.

Crucially, it is wrong to see cultural, social, or aesthetic factors as widely divergent from physiological or behavioral ones. The bottom line is that no eating treatment works if people do not accept or adhere to it, and cultural, social, and aesthetic factors always play a role in determining this, just as physiological or behavioral factors do.

Take food choice as an example. While eating rate may be a critically important mechanism for the control of eating, and overall energy intake is central to the development of malnutrition and its reversal, specific food choices also play a role in eating disorders and recovery.

Causality is not always easily established, but lack of dietary fat, for instance, has been repeatedly associated with specific physical and cognitive deficits found in underweight or post-underweight individuals Mayer et al.

Ultra-processed high-sugar foods are implicated in binging behaviors Ayton and Ibrahim, , while diets higher in fat and protein may offer psychological and physical benefits post-recovery from a restrictive eating disorder Troscianko, Higher-fat and -protein diets may also align neatly with the neural and hormonal mechanisms by which eating-rate interventions are effective for overweight, by modulating ghrelin and leptin levels Lomenick et al.

Yet the world is full of good reasons to eat sugar, from the social significance of a large family meal to the sensory and nostalgic pleasures of a chocolate Easter egg, and in an everyday sense as part of the wider importance of being relaxed and open about food during and after recovery from an eating disorder.

Thus food choices depend on, and in turn influence, multiple aspects of the dynamical eating disorder system, from social media habits to the experiences of hunger and satiety. No physiological or behavioral model can be meaningful if it ignores these complex interplays, of which we give a schematic outline in Figure 1.

Figure 1. Feedback interactions amongst cognitive, physiological, and behavioral components of the dynamics involved in eating.

The red dotted box indicates the controller of the system, here eating rate, which provides an effective means of intervention in the feedback system, e. The red dotted lines indicate the primary causal effects of controlling eating rate.

Specific intermediary mechanisms e. Other examples of the need for thinking in terms of dynamical feedback systems could be enumerated. Apparently trivial practicalities can also be make-or-break factors: in the trial of an eating-rate intervention for obese children Hamilton-Shield et al.

Of similar importance were more subjective failures of the device to engage young users, who complained about the voice commands being annoying, boring, robotic, and an American male adult voice; instead they wanted a cartoon voice, a range of voice options to choose from, the voice of another child, or their own voice.

Turning the device into more of an interactive game could have helped keep children and teens engaged for long enough for the benefits to become self-sustaining. It is easy to neglect the sheer complexity of the interactions involved in eating.

Any treatment model that ignores the cultural and the social worlds will fail at least some of the time. Eating disorders are sometimes defended as valuable manifestations of diversity or freedom of choice, despite the obvious forms of damage they involve — so the concepts of treatment and recovery are themselves controversial to some Fox et al.

But these apparently complex facts do not diminish the truth that the essence of a successful treatment for eating may be a resolute focus on simple, universal parameters of the eating itself.

A simple human—machine system — a small device under a plate providing visual feedback to the eater — is a microcosm of the feedback loops that spiral across the entire human world. This contribution to solving the problem of eating disorders is a long way from the divergent forms of apparent common sense encapsulated in the extremes of force-feeding or the unraveling of deep-rooted dysfunctions.

We suggest that the alternative to these demonstrably inadequate perspectives is a view in which the right behaviors, pinpointed and healed, act as a powerful fulcrum between world, body, and mind.

The original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding author. ET and ML contributed to the development of the ideas presented in this manuscript, as well as to drafting and revising it.

Both authors contributed to the article and approved the submitted version. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. We are grateful to James Anderson, Patrick Cane, James Carney, Paul Jenkins, and Per Södersten for extremely helpful comments on earlier drafts of this article.

In particular we thank James Anderson for guidance on dynamical systems theory, and James Carney for input on future empirical testing of the proposed model. We also thank our peer reviewers, MF-G and ML, for constructive criticisms that resulted in some important improvements to the manuscript, including on dynamical systems, testability, and the graphical illustration of our theory.

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Mainstream Effective hunger management Metabolism and exercise psychiatric talk therapy and Heart health professionals behavioral therapy CBT Psychological approaches to eating not reliably generate lasting recovery for eating disorders. We discuss widespread assumptions Effective hunger management the nature of eating esting Effective hunger management fundamentally psychological disorders and highlight the problems that approachrs these notions, as appraoches as related eatinf problems in Psychologucal implementation of mainstream treatments. We then offer a theoretical and practical alternative: a dynamical systems model of Appriaches disorders in which behavioral interventions are foregrounded as powerful mediators between psychological and physical states. We go on to present empirical evidence for behavioral modification specifically of eating speed in the treatment of eating disorders, and a hypothesis accounting for the etiology and progression, as well as the effective treatment, of the full spectrum of eating problems. A dynamical systems approach mandates that in any dietary and lifestyle change as profound as recovery from an eating disorder, acknowledgment must be made of the full range of pragmatic psychological, cultural, social, etc. factors involved. However, normalizing eating speed may be necessary if not sufficient for the development of a reliable treatment for the full spectrum of eating disorders, in its role as a mediator in the complex feedback loops that connect the biology and the psychology with the behaviors of eating. Learn Psychologicsl about how we Effective hunger management help. On a Psyvhological Start a chat Effective hunger management clicking the orange 'Let's Chat' button in the bottom right corner. On your phone or tablet device? Start a chat by clicking the purple 'Chat With Us' button at the bottom of the page.

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How an eating disorder affects the way a person thinks