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Thursday 2 February 2012

Extinction Burst

I have recently been asked to review an advance copy of :

The Need for Complex Ideas in Anorexia Nervosa: Why Biology, Environment, and Psyche All Matter, Why Therapists Make Mistakes, and Why Clinical Benchmarks Are Needed for Managing Weight Correction by Michael Strober and Craig Johnson

due to be published in the IJED and, I believe, is the last article that Dr Strober has written before retiring.

The abstract reads like this:

Anorexia nervosa remains an enigma and its clinical challenge is intimidating. But the potential for new insights has been advancing, largely as a result of elegant research in the neurosciences that has modeled behavioral processes resembling key features of the illness. Unfortunately, many in the eating disorder field seem to know little of this work or the implication it holds for treatment philosophy. Instead, the knowledge void has been taken up recently by a host of misguided notions about etiology, blatantly dismissive attitudes toward psychological concepts, and ill-conceived beliefs about therapy priorities. This article is a clinical perspective on these issues

So far, so good.  However, when reading the full paper, Strober appears to contend that FBT advocates are a radical bunch of contentious people, who are young and would benefit from his worldly wisdom about how treatment should be.

But as we began to write, we felt that a discussion focused on benchmarks alone would not suffice because while they can be plausibly described, implementing them at a point in treatment when symptoms are worsening or progress has stalled is a unique challenge; and as our key point argues, not many challenges in AN can be managed without convincing insights and strong clinical skills.  We wanted our younger  colleagues to understand this;

It’s when it comes to the question of what specific elements of AN and its outcome are encoded in the genome and where other sources intervene that we are at a loss. Indeed, if there is a single, overarching seminal idea emerging from recent neuroscience research it is that psychiatric illness reveals processes more elusive than the effects of vulnerability genes alone. So we turn next to the striking contrast between this body of new knowledge and what many in the Academy deem to be justified beliefs. Some of the statements listed below were made at the 2010 and 2011 Academy meetings, others we picked up from the AED List Serve. They are paraphrased—some are embellished—but only to make the point that it has become easy in our field for misunderstanding, misattribution, and plain lack of knowledge to stand in for clinical wisdom.

1. It now proven that AN is a brain disease; this explains why patients behave strangely and say illogical things—their actions, perceptions, and utterances are irrational because their brain is.

2. AN is a genetic disorder; this is why you have it forever and why psychosocial factors are less relevant in causation or in determining outcome; features once thought to be part of its psychological realm are really effects of its genetic underpinnings, having no unique significance of their own.

3. The BBMI model doesn’t deserve the strong attention it is receiving because the methods now used to study brain biology are prone to over-interpretation.

4. Because AN is a brain-based illness, family turmoil should be viewed only as a byproduct of the frustration the illness sows; weight correction needs to take priority for these tensions to resolve; things said by patients about their relationships, family ones included, should not to be taken too seriously.

5. Psychotherapy cannot, and should not, take place until the brain is mended by restoring weight to normal.
6. Family-based behavioral therapy is the only acceptable method for treating young patients.

7. The FBT approach to weight restoration is crude and atheoretical, unjustly diverting attention away from critical psychological needs of the patient; it disparages psychotherapy.

Would it surprise you to know that Dr Strober is in charge of a huge inpatient treatment facility?........


  1. May all these oldies have a long and hopefully early retirement and let the 'younger colleagues' get on with the work. Then, maybe, these IP facilities can become much, much smaller.

    And can clincians start to write in plain English, please, instead of academic-babble.

    Charlotte, I love your 7 points. A true case for 'Out with the Old and In with the New'...

  2. Confusion here surely, the 7 points are contradictory and cited by the author as such - they don't define his opinions and presumably some clash with the opinions expressed in this blog too.
    As to whether his views can be discounted because he has a potential bias? No more than the views of a parent can on this topic surely. I found his article a massive breath of fresh air, the first academic publication I've read on AN in years that I've agreed with every word of...

  3. Anonymous 1, I am interested that you found the article a breath of fresh air - indeed I am interested that you found the article at all as I don't think it's been published yet. Where did you find it? Can we all read it so that we can make up our own minds? If so where?

  4. It's prereleased on Wiley Online Library but I had to sign in through my university :)

  5. Ah thanks. I hope that eventually it will be available to those of us not in academia so that we can can all join in a hopefully rational and helpful debate on the real issues that appear to have been raised.

  6. I have been able to access a copy but it must be a draft version as it obviously requires much editing before publication.

    Because of the format and extreme length I have not yet managed to read the whole article, but what I have read so far perplexes me.

    This paper appears to be simply an attack on the work and perceived threat of that work on Dr Strober and his colleagues, of ONE person "the founding member of a parent advocacy group". While that one person should be extremely flattered to have generated so many words from so great a figure as Dr Strober, at present I cannot see that the paper has brought any clarity to the field or answered any of the questions currently being asked within it.

    Strober states, without references, that the main points of debate in the field at present are biological explanations of cause and the value of Family Based Treatment. He lumps these in together. As far as I am aware there is little overlap between the questions other than within the parent activist movement. He also makes no mention of other important questions such as whether or not a trans diagnostic approach is appropriate in eating disorders or the debate between those who take a motivational stance and those who take a more behavioural one. This in a document that in its present form is over 19,000 words long.

    By contrast in this article Stephen Touyz, despite using up some of his word count with a quote from Strober about AN which I, as a carer, find offensive and emotive, manages to discuss all of these in a tenth of the time. I don't find his article a breath of fresh air either, but at least it isn't enough hot air to fill Branson's entire balloon fleet and it shines some useful light on a difficult and complex subject.