Wednesday, November 26, 2014

Treatment Resistance in Eating Disorders

Clinicians treating patients with eating disorders find the challenge great with many treatment-resistant cases.

To some extent, this is true of any clinical disorder. Outpatient treatment rolls and inpatient samples are over-represented by those failing to respond to initial interventions.

A medical example is helpful here. Endocrinologists specializing in diabetes see more complicated cases where glucose control is difficult and diabetic complications are common.

Diabetics with easy glucose control and no complications do not need to see an endocrinologists. To an endocrinologist, clinical practice seems to point to the disease as a treatment-resistant and clinically challenging disorder.

Nevertheless, treatment resistance in eating disorders is a significant issue that has been recently summarized in a nice review by Dr. Katherine Halmi.

Here are my notes from review of the Halmi manuscript using her key headings:

Core eating disorder psychopathology

  • Adolescent eating disorder subjects lack insight into the seriousness of illness
  • Many do not acknowledge need for treatment
  • Body weight, exercise and dieting provide a distraction from other life problems
  • Malnutrition in eating disorders contributes to cognitive impairment, treatment engagement problems
  • Bulimia treatment resistance has been linked to greater depression, lower BMI and social adjustment problems

Psychiatric and psychological comorbidity

  • U.S. National Survey found high rates of psychiatric comorbidity in eating disorders (56% in anorexia nervosa, 95% in bulimia nervosa and 79% in binge eating disorder)
  • Anxiety disorders rates are elevated in eating disorders with obsessive compulsive disorder and social anxiety disorder two common conditions
  • Anxiety disorders can contribute to resistance of treatment of eating disorder symptoms
  • Cluster B personality disorders are elevated in bulimia nervosa and appear related to higher rates of substance dependence in this disorder
  • Perfectionism is common in anorexia nervosa. Early onset and high perfectionism traits contribute to higher treatment resistance

Biological features

  • Serotonin receptor and transporter function appear to influence course of illness in eating disoders
  • GABA receptor genotype appears to be related to level of trait anxiety in both bulimia nervosa and anorexia nervosa
  • GABA receptor abnormalities are also possibly related to treatment resistance

Treating refractory patients

  • Quetiapine, olanzapine, haloperidol and duloxetine are drugs with some promise in treatment resistant anorexia nervosa
  • Novel psychotherapies including CBT and the Maudsley Model  target key features of resistance in anorexia nervosa
  • Treatment resistant bulimia nervosa may respond to sequential treatment strategies that include partial hospitalization, selective serotonin reuptake inhibitor (SSRI) drugs and cue exposure
  • Binge eating disorder may respond to high dose SSRI therapy or topiramate in a graduated dosing schedule

This review points to the key elements for treatment of the difficult eating disorder patient.

This population needs access to specialized hospitalization units, psychopharmacology expertise and specialized psychotherapy services.

Dr. Halmi notes advances in the treatment of this population may require advances in understanding the neurobiology and neurocircuitry for the disorder.

Readers with more interest in this summary can find the free full-text manuscript by clicking on the DOI link in the citation below.

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Halmi, K. (2013). Perplexities of treatment resistence in eating disorders BMC Psychiatry, 13 (1) DOI: 10.1186/1471-244X-13-292

Monday, November 17, 2014

Eating Disorders in Obesity: DSM-IV and DSM-5

The recent revision of the American Psychiatric Associations Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) altered several eating disorder diagnostic criteria.

Some have expressed concern that these revisions are overly broad and may result in over diagnosis in some clinical populations. One clinical population where this is a concern is obesity.


A research study has been recently published addressing this issue.


Jennifer Thomas and colleagues at Harvard University and Massachusetts General Hospital recruited a series of subjects from an obesity program for eating disorder diagnostic assessment.


All subjects completed an assessment for presence of an eating disorder 

diagnosis using both DSM-IV and DSM-5 criteria.

For DSM-IV eating disorder diagnoses, the research team used a validated module from a validated measure known as SCID-IV. For DSM-5 eating disorder diagnosis an early structured interview developed by the DSM-5 Eating Disorders Task Group was used.

The key findings from the study included:
  • Prevalence rates for eating disorders using DSM-5 criteria did not increase compared to DSM-IV criteria
  • Bulimia nervosa prevalence rates were 2% in both interviews
  • Binge eating disorder prevalence rates were 9% in both interviews
  • An additional 20% of the obese sample met residual eating disorder criteria in both interviews

Obese individuals with a formal eating disorder diagnosis endorsed higher rates of psychological impairment, depression and anxiety validating the impact of eating disorder comorbidity.

Assessment for the presence of eating disorders is an important part of treatment planning. Eating disorders are more prevalent in obese populations are relatively easy to diagnose.

Some studies have found poor outcomes in obese populations with severe binge eating behaviors.

Treatment of a comorbid eating disorder in obese populations may improve weight and psychological outcomes.

Readers with more interest in this research can access the free full-text manuscript by clicking on the PMID link below.

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Thomas JJ, Koh KA, Eddy KT, Hartmann AS, Murray HB, Gorman MJ, Sogg S, & Becker AE (2014). Do DSM-5 eating disorder criteria overpathologize normative eating patterns among individuals with obesity? Journal of obesity, 2014 PMID: 25057413

Wednesday, November 12, 2014

Binge Eating Linked to Risk for Irritable Bowel Syndrome

Binge eating is defined as the recurrent rapid consumption of high calorie meals accompanied by a feeling that eating is out of control.

Bulimia nervosa is an eating disorder characterized by binge eating paired with a purging behavior such as self-induced vomiting.

Binge eating without purging is receiving increased clinical and research attention.

Binge eating is a relative common component in elevated body mass index and obesity. Successful behavior and drug treatment for obesity often includes a significant reduction in the frequency of binge eating.

Binge eating is frequently accompanied by symptoms of gastrointestinal disorders such as gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS). However, these GI symptoms and disorders are also increased in obesity

These relationships have made it difficult to determine the specific effects of binge eating on GI symptoms as it is possible these effects may occur through an obesity mechanism.

Christine Peat along with colleagues from the University of North Carolina and Sweden recently published a study teasing out relationships between binge eating, BMI and GI symptoms.

This study used data from the Swedish Twin Study of Adults: Genes and Environment (STAGE). For the current study, over 23,000 twin pairs were interviewed for presence of lifetime history of binge eating, weight history and presence of gastrointestinal symptoms.

The key findings from this study included the following:

  • Gastrointestinal reflux symptoms were present in 15.7% of men and 28.9% of women
  • Irritable bowel syndrome (broad definition) was present in 3.7% of men and 8.1% of women
  • Binge eating was linked to to higher rates of GERD and IBS
  • However, when BMI was controlled binge eating was independently related to IBS but not related to GERD

The authors propose three potential mechanisms for this link between binge eating and IBS.

  1. Stress may be a common factor as it is known that stress can precipitate bingeing episodes and increase IBS symptoms
  2. IBS may cause dietary restriction including periods of fasting. Fasting is known to increase later risk for binge eating as the body attempts to compensate via a strong hunger mechanism
  3. Binge eating of large quantities of high fat foods may directly produce IBS symptoms as the GI system responds to a feeding load

The take home message for clinicians treating IBS is that it is important to assess for the presence of binge eating. Successful reduction in the frequency of binge eating may contribute to a successful reduction in IBS symptoms. 

Readers with more interest in this study can access the free full-text manuscript by clicking on the PMID link in the citation below.

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Peat CM, Huang L, Thornton LM, Von Holle AF, Trace SE, Lichtenstein P, Pedersen NL, Overby DW, & Bulik CM (2013). Binge eating, body mass index, and gastrointestinal symptoms. Journal of psychosomatic research, 75 (5), 456-61 PMID: 24182635

Tuesday, November 11, 2014

Anorexia Nervosa: Brain Connectivity Abnormalities

Functional magnetic resonance imaging is providing a new tool for understanding brain circuitry in normal brain development and in brain disorders. 

Anorexia nervosa is an restrictive calorie eating disorder often resistant to treatment.

No effective drug treatment for anorexia nervosa currently exists and psychotherapy is often only partially effective. A better understanding of the brain pathophysiology in anorexia nervosa is needed to aid in treatment development.

Stephanie Kullman along with colleagues at the University of Tubingen recently published a study of brain connectivity in twelve women with anorexia nervosa.

This study used a resting state functional connectivity approach with magnetic resonance imaging. In functional connectivity studies, the brain is studied during rest and levels of coherent activity between brain regions measured. 

The authors of this study noted anorexia nervosa commonly includes motor hyperactivity and so they used both a non-athlete and athlete female control group for comparision.

The primary findings from this study included the following:

  • The brain inferior frontal gyrus (IFG) in both the left and right sides demonstrated reduced effective connectivity 
  • Decreased effective connectivity was noted between the right IFG and the cingulate
  • Increased effective connectivity was noted between the right IFG and the bilateral orbitofrontal gyrus region
  • Increased effective connectivity was noted between the left IFG and the bilateral insular cortex

The authors note the inferior frontal cortex is a key region for executive functions, or control of complex cognitive functions. Disturbance of executive function in anorexia nervosa may contribute to food consumption and activity decision making.

The authors note their study found a link between level of physical hyperactivity in individual patients with anorexia nervosa and reduced IFG connectivity. Women with the highest level of physical activity had the lowest levels of IFG connectivity.

The areas of increased connectivity in this sample of patients with anorexia contribute to processing of the salience of stimuli. The authors note the insular cortex is a "multisensory neural node" involved in integration of "perception, emotion, interoceptive awareness, cognition and gustation". 

Disturbance of connectivity balance between the IFG and insular cortex may contribute to anxiety and fear related to somatic sensations.

The findings in this imaging study occurred in the context of active illness in anorexia nervosa. It would be interesting to follow these findings with recovery and weight restoration.

Additionally, modification of functional connectivity disturbances in anorexia may hold promise for new drug development and more effective psychological interventions.

Readers with more interest in this study can access the free full-text manuscript by clicking on the citation link below.

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Kullmann S, Giel KE, Teufel M, Thiel A, Zipfel S, & Preissl H (2014). Aberrant network integrity of the inferior frontal cortex in women with anorexia nervosa. NeuroImage. Clinical, 4, 615-22 PMID: 24936412

Monday, November 10, 2014

Eating Disorders Linked to Higher Autoimmune Disease Rates

There is increasing evidence for inflammation contributing to risk for a variety of psychiatric disorders.

I previously summarized research supporting use of anti-inflammatory drugs in the treatment of depression.

A recent study from Finland supports an inflammation link to the eating disorder categories.

The key elements of the design of this study included:

  • Subjects: 2342 subjects admitted for treatment in the Eating Disorders Unit at the central hospital in Finland. Four controls were identified for each case matched by age, gender and place of residence
  • Identification of presence for autoimmune diseases: Cases and controls were examined for the presence of one of 30 autoimmune diagnoses in their Hospital Discharge Register
  • Statistical analysis: Period and lifetime rates for autoimmune disorders were compared between eating disorder cases and control using logistic regression modeling with calculation of odds ratios and 95% confidence intervals.

Here are the important findings from the study:

  • Eating disorders subjects had a 5.6% rate for presence of any autoimmune disease compared to only 2.8% of controls (Odds ratio 2.13, 95% confidence interval 1.71-2.65)
  • Rates for autoimmune disorders were increased across all eating disorder diagnostic categories including anorexia nervosa, bulimia nervosa and binge eating disorder
  • Within autoimmune disease subtypes, endocrinological and gastroenterological diseases were statistically increased in eating disorders
  • Type I diabetes and Crohn's disease were individual autoimmune disorders found at higher rates in eating disorders

The authors note there are several methods that could explain the association between autoimmunity and eating disorder risk. Higher rates of autoantibodies against peptides that control appetite and stress response could contribute to eating disorder risk.

Additionally, the authors note disturbed eating may contribute to disturbance of the microbiome of the gut. Gut microbiome is a known regulator of autoimmunity and a contributor to allergies and type I diabetes risk.

The authors noted additional specific autoimmune disorders may be increased in eating disorders but due to small sample size their study may have not found a statistical association.

Systemic lupus erythematosis rates were increased in the eating disorder group but this was one of the individual disorders that failed to reach statistical significance.

The take home message for clinicians treating eating disorder patients is to be vigilant for the presence of autoimmune medical disorders in this population. Accurate and early detection of autoimmune disorders in those with eating disorders may contribute to improved medical outcomes.

Readers with more interest can access the free full text manuscript by clicking on the PMID link below.

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Raevuori A, Haukka J, Vaarala O, Suvisaari JM, Gissler M, Grainger M, Linna MS, & Suokas JT (2014). The increased risk for autoimmune diseases in patients with eating disorders. PloS one, 9 (8) PMID: 25147950

Friday, November 7, 2014

Eating Disorders: Weekend Reading Links

I am focusing on recent research in eating disorders this month on Brain Posts.

Here are some of the research abstracts I will be reviewing for upcoming posts.

Clicking on the title will take you to the PubMed abstract and also to a link for the free full-text manuscript.

Higher parental education as a risk factor for eating disorders
This study of the Swedish population examined the effect education and social class on risk for eating disorders. Individuals diagnosed with an eating disorder were more likely to have higher educational levels in their parents. This is an interesting finding as educational typically reduces rates for many psychiatric disorders. 

Increased rates of autoimmune diseases in patients with eating disorders
A study of a large cohort from Finland found higher rates of a variety of autoimmune disorders in a sample of patients treated for eating disorders. Type I diabetes and Crohn's disease were two of the disorders that were more likely to be seen in eating disorder patients compared to controls.

Epidemiology of eating disorders
This literature examined 149 studies on the epidemiology of eating disorders. The review found evidence for genetic and environmental factors as risk factors for eating disorders. Additionally, the review found support for esthetic or weight-oriented sport participation also as risk factors for eating disorders.

Evidence for effective treatment options of eating disorders in young people
This review examined evidence for effective prevention and treatment of eating disorders in adolescents and young adults. The authors note the paucity of large well-designed clinical trials for the treatment of most eating disorders and make recommendations about directions for future research. 

Inferior frontal cortex network abnormalities in anorexia nervosa
This study examined resting functional connectivity in 12 subjects with anorexia nervosa compared to controls. The study found impairment in connectivity in the inferior frontal cortex in those with anorexia nervosa.

Binge eating and risk for gastrointestinal disorders
The Swedish Twin Study of Adults: Genes and Environment (STAGE) cohort was used to look for associations between binge eating and gastrointestinal disorders. Binge eating was found to be increased in irritable bowel syndrome and may be important in effectively managing this disorder. 

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Wednesday, November 5, 2014

Anorexia Nervosa as a Disorder of Perception

A key feature in anorexia nervosa is the disturbance in perception of the body.

This perceptual disturbance is encapsulated in criteria 3 from DSM-5:
 "Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape evaluation, or denial of the seriousness of the current low weight"
 Santino Guadio from Italy and colleagues recently published a nice summary of the support for body image disturbance in anorexia nervosa. This study focused on research in the neuropsychology of anorexia nervosa.

This review is informative in outlining the components involved in sensory perception.

Here are the key findings from their review following their perception components outline.

Tactile perception
What it is: identifying touch stimuli and discriminating differences in stimuli
How it is tested: finger identification test, tactile estimation task (estimating distance between two tactile stimuli in different body sites
Findings in anorexia nervosa: Patients with anorexia nervosa perform poorly on identifying finger perception when blindfolded and two fingers are stimulated. Anorexia nervosa is also associated with overestimation of distance between stimulation sites over multiple body parts

Haptic perception
What it is: ability to identify shapes by touch when no visual input is available
How it is tested: Identifying figures and shapes with eyes closed using hands for sensory input
Findings in anorexia nervosa: Patients with anorexia nervosa perform more poorly than controls on correctly identify shape and form when unable to see an object. This deficit appears to be present during both active illness with weight loss and persists following weight restoration.

Propioception
What it is: identification of body and limb position in space
How it is tested: identification of right-left orientation, ability to place a rod in a vertical postion as body position is modified and no visual sensation is provided
Findings in anorexia nervosa: Patients with anorexia nervosa show impaired spatial orientation perception as well as deficits in correctly identifying right-left orientation.

Haptic-visual-proprioception integration:
What it is: Ability to estimate correct physical properties using both haptic and visual stimuli
How it is tested: Two objects of identical weight but difference size are presented for touch and sight input. Subjects estimate weight of two objects relative to each other
Findings in anorexia nervosa: Subjects with anorexia nervosa show reduction in size-weight performance and reduction integration of visual and haptic information.

Visual-tactile-proprioception integration:
What it is: use and integration of three sensory modalities, sight, touch and body position
How it is tested: rubber hand test where subjects estimate position of left index finger before and after visuotactile stimulations.
Findings in anorexia nervosa: Patients with anorexia nervosa show impairment in two components of visuo-tactile-propioception integration

Interoceptive perception:
What it is: ability to identify and process internal bodily sensations such as heartbeart, intestinal activity, hunger, pain
How it is tested: participants are asked to count their own heartbeats and this count is compared to actual heart rate. 
Findings in anorexia nervosa: Patients with anorexia nervosa show impaired perception of heartbeat compared to controls

The authors note they found a relatively few well-designed studies of perception in anorexia nervosa. 

Although the number of studies is small, this review supports a multi-modal impairment in perception in patients with anorexia nervosa compared to controls.

The authors note perception is known to be processed through the brain parietal lobe. They propose that parietal lobe dysfunction may impair perception in anorexia nervosa. This perceptual impairment may contribute to the body image disturbance found in the illness.

Look for an expansion of studies of perception in anorexia nervosa. Pairing neuropsychological perception studies with advanced brain imaging research techniques may be powerful strategy.

Readers with more interest in this topic can access the free full-text manuscript by clicking on the citation link below.

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Gaudio S, Brooks SJ, & Riva G (2014). Nonvisual multisensory impairment of body perception in anorexia nervosa: a systematic review of neuropsychological studies. PloS one, 9 (10) PMID: 25303480

Insightful Thinking 101

Genius is defined by creativity. Albert Einstein is often regarded as the epitome of genius. Nobody seems to understand his genius other than to say that it bubbled up like uncorked champagne. But the story of his work paints a different picture. His discovery of Special Relativity, for example, came as a stepwise series of small insights spread over many years of incubation.

Einstein used systematic ways of thinking to unleash his creativity. His success was not magic. There was method to his genius. First, Einstein relied heavily on thinking with visual images rather than words. Many famous scientists claim that their best thinking occurs in the form of visual images, even at the level of fantasy. Words and language, according to Einstein, had no role in his creative thought and math was used mainly to express the ideas quantitatively. Einstein, for example, in one of his fantasies visualized himself riding on a beam of light, holding a mirror in front of him. Since the light and the mirror were traveling at the same speed in the same direction, and since the mirror was a little ahead of the light's front, the light could never catch up to the mirror to reflect an image. Thus Einstein could not see himself. Another example of his use of imagery is his thought experiments visualizing train movements. Although fantasy, such thinking is not the product of a hallucinating mind; there is clear logic and order embedded in the fantasy.

A second reason for Einstein's creativity is that he was unafraid, even as an unimpressive student and a patent clerk without recognition as a scientist, to challenge no less an authority than James Clerk Maxwell when the thought experiment could not be explained by current electrodynamic dogma.

Third, Einstein thought long and hard on this problem for over seven years when he published his seminal paper in1905 at the age of 25.  Actually, he said in his autobiography that he started pondering the problem when he was 16. The point is that the revelation did not happen in an instant—it was the product of incubation. Actually, his ideas were fermenting for years, where he repeatedly thought about alternative possibilities and eliminated those that didn't add up. By the process of elimination incubated over a long time of thinking, the final solution became accessible.

This view of creativity is consistent with the view of Linus Pauling, who won two Nobel Prizes and came within a hair of decoding DNA structure that would have won him a third. He said, "To have a good idea, you have to have lots of ideas." All exceptional scientists generate lots of ideas, and then winnow out the ones that are practical for testing by experiment. In other words, Einstein and Pauling are proof that creativity is not as inaccessible for ordinary people as it seems. There are systematic ways for everyone to become more creative.

These ways of thinking can be taught and used by anyone. Young scientists aspire to have an early experience of working for a time in the lab of a famous scientist, in the hope of learning how to make discoveries. Many Nobel Prize winners have been students of other Nobel Prize winners. Consider the case of Hans Krebs, who discovered the energy-production process in cells. His "family tree" of scientists shows the following relationships of science teachers and mentors:

Berthollet (1748-1822)
   Gay-Lussac (1778-1850)
      Liebig (1803-1873)
         Kekule (1829-1896)
            von Baeyer (1835-1917)
               Fischer (1852-1919)
                  Warburg (1883-1970)
                             Krebs (1900- 1981)

All of these men were famous and each of the last four received Nobel Prizes, which began in 1901. A role model for Hans was Otto Myeroff, who worked in the same institute and who received the Nobel Prize in 1922. This tree is cultural, not biological. There was only one scientist in Hans' biological family tree, a distant cousin, who was a physical chemist.

In the years (1926-1930) Hans studied with Otto Warburg, where he learned the value of inventing new tools and techniques for conducting experiments to test ideas about energy transformation in living tissue. Another important lesson was the value of hard work on ideas. Warburg worked long and hard hours all his life; he was working in his lab eight days before he died, at the age of 81.

* * *

Creativity is a subset of a general learning competency that entails correct analysis, understanding, insight, and remembering. Here, I stress the importance of insight, often referred to as "thinking outside the box." Moreover, I make the claim that this competency can be taught and mastered through practice.

This mode of thinking goes by other names, such as lateral thinking or "thinking outside the box." Whatever you call it, such thinking requires breaking the constraints of predispositions, limiting assumptions, bias, mental habit, and rigid past learning.

See if you can solve the problem below, which is a simple illustration of the common problem of self-imposed limitation of thinking:

Problem: draw four straight lines that connect all dots without lifting the pencil off the paper. Each line starts where the other finishes. Can you do it?






In case you didn't figure it out, here is onesolution:



Many people can't do this task. Reasons for failure here and with other creativity challenges include:

  1. Improper understanding of the problem. Failure to recognize what is allowed and what is not.
  2. Failure to look beyond the ideas that first emerge.
  3. Being so close to a solution that you keep working with the same flawed approach.

Frame the Issue Properly

The sample dot-connection task above illustrates the problems you get into by the way you have framed the problem. When faced with any problem, it is natural to make certain assumptions about facets of the problem that were not explicitly stated. In the above, case, I didn't say that the lines had to stay within the borders of the dots, but many of you probably made that assumption. You were actually free to make the assumption that it was o.k. to do that.

The way we classify things creates a logjam to new ideas. For example, something in Newton's sensory or cognitive world caused him to see the similarity between an apple and the moon in a new way; of course they were both round, solid bodies. But it is not clear what caused him to perceive what is now obvious, namely that both are subject to the effect of gravity. Even seeing the apple fall from a tree would not be a meaningful mental cue for explaining moon motion to most people, because they are not used to thinking of the moon as "falling." Creative thought is affected by the ways in which we classify things. We put apples and moons into categories; but by insisting on describing and naming them, we restrict the categories to which they belong. Apples are supposed to be round, red, and sweet, while moons are large, yellow, rocky, and far away. The names themselves get in the way of thinking of either as a classless object that is subject to gravity. A lesser order of creativity is commonly seen in the simple realization of the significance of obvious associations. The associations may even be negative (e.g., if penicillin is present on a bacteriological plate, the organisms will NOT grow).

A question calls for an answer: a problem, its solution. The trick is not only to ask questions, but to ask questions or pose problems in the most effective ways. A question can easily limit creative thinking if it restricts the space of potential answers. It therefore is important to pose questions in open-ended ways and ways that do not make too many assumptions about an acceptable answer. A major part of the creativity task is proper formulation of the problem itself.

Improving Creative Thinking Ability

People who have looked carefully at the creative process have learned that everyone of ordinary intelligence has latent creative abilities that can be enhanced by training and by a favorable environment. But many of us have not developed our creative capacity. Our brains seem frozen in cognitive catalepsy, boxed in by rigid thinking.

One book that is dedicated to improving creativity is by D. N. Perkins, The Mind's Best Work. He finds that after-the-fact anecdotes about well-known examples of great leaps of creative thought have generally received little or no close scrutiny of the mental processes that led to them. There are too many opportunities for the real mental correlates of creativity to be lost through excitement and distraction (as part of the "eureka" phenomenon), lack of need or desire to reconstruct the thought processes, and faulty skill and memory in reconstructing the process. Experiments where people have been asked to think aloud or report their thoughts during an episode of invention led Perkins to conclude that creativity arises naturally and comprehensibly from certain everyday abilities of perception, understanding, logic, memory, and thinking style.

Generating Insight

As an indication that creativity can be taught and learned, I offer the following personal anecdote.

"Grade = C.  Klemm: Your work shows a lot of industriousness.  Strive for INSIGHT!"

That note was scrawled across an assignment paper I had turned in to my professor, C. S. Bachofer, at Notre Dame. I had worked very hard on that paper, was quite proud of it, and had expected an A. Decades years later, I could still see that message, seared into my memory like a brand on cow hide. It was as if he meant that I was not smart enough. If true, how was I supposed to make myself smarter?  Isn't that a born capacity? You either have it or you don't.

As the years went by, and I became a professor myself, I gradually came to realize that Professor Bachofer was really saying something else.  He was telling me to discover in my own terms and learning style the tactics and techniques that can develop insight capability.  I now know that it IS possible to learn how to become more insightful.  Some of this may be teachable to others.

Idea generation has little to do with intelligence. I remember a graduate student of mine who had great test scores and all As from six years of college work. As was my practice, I tried helping this student develop a thesis project by giving him a published research paper and asking him what ideas occurred to him? After the first paper, he said nothing particular came to mind other than what was reported in the paper. So, figuring I had just picked a paper that was too mundane, I gave him another paper. Again, the same result occurred.  After about four or five tries with the same result, I said, “I’m afraid this is not going to work. You really should not go into this line of work. In any case, if you persist in this ill-advised quest, you will have to find another major professor.”

So how could this student have generated ideas? First, he should have been looking for alternatives. In reading, for example, I focus on what the author did not say. This not only stimulates me to think of other possibilities but also improves my ability to remember what was written. Thinking about something is the best way to rehearse the memory of it.

Thinking of alternatives requires imagination. Young children have lots of imagination. Unfortunately, school tends to stamp that out in the first few years. This is one reason I like to use mnemonic devices to promote memory. All these devices require imagination, and the more you exercise this capability, the better you can get at it.

Idea generation needs to be valued. School tends to devalue creativity. Expectations are to learn what is dished out and pass a high-stakes test on it. What educators value most is understanding and remembering accepted knowledge. Do we believe students are too dumb for higher level thinking? Do we believe that these higher skills are innate and cannot be taught? Do we believe that maybe they could be taught if we only knew how?


The Creative Process

The literature on the creative process is vast, and I can only summarize it here. Have you seen the advertisement from IBM Corporation, in which there was a long alphabetized list of "old English" words? The ad's caption read, "Anyone could have used these 4,178 words. In the hands of William Shakespeare, they became King Lear." King Lear epitomizes the essence of creativity: to take commonly used and understood ideas and recombine them in elegant new ways. 


Some practical advice on how to think innovatively is provided by Beth Comstock, the CMO at General Electric. She was inspired by a brilliant boss who wasn't afraid to offer an idea before its time. Even though many of his ideas were absurd, many were also gems. None of these would have been born had he not been willing to "put it out there." As Einstein said, "If at first the idea is not absurd, there is no hope for it." The point is that creative ideas often come of the oven half-baked. Typically, the recipe has to be modified.

Comstock's advice includes:

1. Nurture the newborn idea. Absurd ideas are all too easy to dismiss. Be patient with them and protect them from early-stage critical analysis. This accepting attitude lies at the heart of effective brainstorming. Get the ideas out on the table. They often will grow or transform into better ideas. Sit on them. Let them incubate.

2.  Commit to a promising idea. Successful ideas are nurtured by passion. If you believe in the promise of an idea, noodle it to fit a meaningful problem. Do your homework. Smooth the rough patches. Ask others to help make the idea better.


3. Tell others, even when you feel embarrassed about how flakey the idea might be. This clarifies your own thinking and at least a few of your listeners may get intrigued and help you improve the idea.

4. Hang in there. Don't be intimidated by negative feedback. Use such feedback to improve the idea. If necessary, put the idea in storage until improvements come to mind, or new technology or resources become available or others people are more accepting. If you believe in your idea, don't give up.

A fundamental aspect of creative thinking is to be flexible in interpreting what you see or hear. Powers of observation include of course the ability to notice things. But just registering a visual or thought input is not enough. Creative brains see what others only look at. That is, creative brains look for implications.

A basic condition for a creative act is to combine known elements into new combinations or perspectives that have never before been considered. Perkins writes of the utility of deliberately searching for many alternatives so that many combinations and perspectives can be considered. Creativity is much more likely to emerge when a person considers many options and invests the time and effort to keep searching rather than settling for mediocre solutions.

The first and fundamental step in the creative process is to have a clear notion of what the problem is and to be able to frame it appropriately. Recall in the opening example how you framed the dot problem determined whether or not you could solve it. The effective thinker begins by first focusing on the structure of the problem rather than its technical detail.

Creative operations require conceiving alternative solutions. These come from each person's permanent memory store, his or her lifetime data base of knowledge and experience. Memorizing does not impair thinking ― it can empower thinking. Other potential alternatives are brought in from such external sources of input as reading, ideas from colleagues, data bases, and other sources. Next, these alternatives can be processed logically (by associating, sorting, and aligning into new or unusual categories and contexts) or more powerfully by the use of images, abstractions, models, metaphors and analogies.

Thus, knowledge is not the enemy of creativity. One's capacity for creativity depends on the store of knowledge. Einstein, for example, would not have discovered relativity if he had not known basic physics in general and Maxwell's ideas and equations in particular. As my friend, Ann Kellet has said, "To think outside the box, you have to know what is inside the box." The trick is to take a fresh look at what is inside the box.

The next stages involve noticing clues and potential leads, realizing permutations of alternatives that are significant, and finally selecting those thoughts that lead to a new idea. There are dozens of thinking tools that stimulate idea. Check out these tools at the Web sites ideaconnection.com, mindtools.com, and myucoted.com.

The process of considering and choosing among alternative approaches involves a progressive narrowing of options in the early stages of creation and a readiness to revise and reconsider earlier decisions in the later stages. Einstein ran into several blind alleys in his discovery journey. This narrowing process requires the creator to break down and reformulate the categories and relationships of thoughts and facts that are commonly applied to the problems and its usual solutions. The creative thinker examines all reasonable alternatives, including many which at first may not seem "reasonable." Each alternative needs to be examined, not only in isolation, but in relation to other alternatives—and in relation to the initial problem expressed in different ways. The practical problem then becomes one of reducing the size of the problem and alternative solution space to workable dimensions. That may well be why one has to be immersed in the problem for long periods, with subconscious "incubation" operating to help sort through various alternatives and combinations thereof.

Note that all of these operations must occur in the working memory, which unfortunately has very limited capacity. That is probably the reason why insight and creativity are so hard to come by. Researchers of the subject of creativity would do well to look for ways to create more capacity for our working memory and to make it more efficient. The most manipulatible factor would seem to be the mechanics of supplying information input from external sources.

The final stages of creativity are more straightforward. They involve critical and logical analysis, which typically forces a refinement of the emerging ideas. Analysis should force the refinement of premature ideas and re-initiation of the search and selection processes. Sometimes, analysis will force the realization that the wrong problem is being worked or that it needs to be reformulated.


If you have but one wish, let it be for an idea

                                                     ― Percy Sutton 

Further Reading

DeBono, Edward. (2009) Think! Before It's To Late. Vermilion. London.

Klemm, W. R. (1990).Leadership: Creativity and innovation, p. 426-439.Concepts for Air Force Leadership, ed. by R. I. Lester and A. Glenn Morton. Maxwell Air Force Base, Alabama: Air University.

Klemm, W. R. (2001)   Hans' Nobel Prize family. http://peer.tamu.edu/curriculum_modules/Cell_Biology/module_3/storytime3.htmAccessed Augst 15, 2014.

Michalko, Michaeal (2001) Cracking Creativity: The Secrets of Creative Genius. Ten Speed Press. New York.

Norton, John D. Einsteins pathway to special relativity. http://www.pitt.edu/~jdnorton/teaching/HPS_0410/chapters_2013_Jan_1/origins_pathway/index.html. Accessed Aug. 14, 2014.


Perkins, D. N. (1981). The Mind's Best Work. Harvard Univ. Press, Cambridge.  

Tuesday, November 4, 2014

Anorexia Nervosa: Fasting and Starvation Brain Effects

Brain research in anorexia nervosa presents several challenges.

Current knowledge of cognitive function in anorexia supports impairment in set shifting and global brain processing or central coherence.

However, there are two issues that complicate understanding the underlying brain effects in anorexia nervosa.

First, individuals with anorexia nervosa often have additional anxiety and mood disorders. It can be difficult to tease out the specific effects of anorexia nervosa from the effects of these comorbid conditions.

Second, fasting and starvation are common metabolic issues in anorexia. These metabolic stresses can also influence brain function.

Sarah Pender and colleagues from University College London and Spain recently published a research study on the neuropsychology of starvation.

The key elements of their study included the following elements:

  • Subjects: Healthy females recruited by poster in a university sample. Subjects were required to not have a lifetime history of any psychiatric disorder including anorexia nervosa.
  • Measures: A test of set-shifting ability using a test called the rule-change task. A test of local versus global cognitive processing style. A second test of global processing known as the group embedded figures task.
  • Metabolic status: Each subject was studied on the above measures after eating and following a period of 18 hours of fasting. 

The authors then compared performance on these neuropsychology tests in the fasting versus satiated state. The main findings from the study included findings in set-shifting and central coherence.

Set-shifting: Performance on set-shifting was not slowed or impaired in the fasting state compared to the satiated state. However, fasting appeared to increase the difficulty (or effort) to set shift.

Central coherence: During the fasting state, subjects shifted processing to a stronger local processing style and a weaker global processing style. This is consistent with reduced central coherence with fasting.

A relevant potential confounding variable in this type of task is the contribution of anxiety and depression in neuropsychological task performance.

I previously collaborated with Dr. Rebecca Marshall and other colleagues at the Laureate Institute of Brain Research in a study of neuropsychological function in a group of women with a variety of eating disorders. In this study, we found subjective anxiety ratings contributed to a significant about of variance in neuropsychological performance in eating disorders. Additionally, we found executive function impairment, a component of central coherence in 30 % of the clinical sample.

Pender and colleagues looked for effects of anxiety and depression in their study and did not find any confounding effects. Obviously, their sample was likely to only have minimal sub-clinical levels of anxiety/depression given the requirement for no current or lifetime psychiatric problem for enrollment.

The authors conclude even short-term fasting "might trigger weak central coherence, and thus play a role in maintaining behaviors characteristic of AN". 

The authors also note the brain effects of fasting, starvation and anorexia nervosa may have difficulty participating in psychotherapy. Psychotherapy requires a more global processing style to be effective.

Readers with more interest in this research can access the free full-text manuscripts by clicking on the PMID link in the citations below.

Photo of brain corpus callosum activated during right-left brain coherence is from an iPad screen shot from the 3D Brain app.

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Pender, S., Gilbert, S., & Serpell, L. (2014). The Neuropsychology of Starvation: Set-Shifting and Central Coherence in a Fasted Nonclinical Sample PLoS ONE, 9 (10) DOI: 10.1371/journal.pone.0110743

Billingsley-Marshall RL, Basso MR, Lund BC, Hernandez ER, Johnson CL, Drevets WC, McKee PA, & Yates WR (2013). Executive function in eating disorders: the role of state anxiety. The International journal of eating disorders, 46 (4), 316-21 PMID: 23354876

Monday, November 3, 2014

Anorexia Nervosa Research Links

In November I will be looking at some research research in eating disorders.

On my first look at some of important research these five studies stood out for more review.

I will be posting more on several of these studies in the next few weeks.

You can click on the manuscript title to go to the abstract.  All studies have free full-text manuscripts that can be access through the abstract link.

The Neuropsychology of Starvation
One of the key problems in studying anorexia nervosa is the isolation of psychological effects from the effects of starvation on the brain. In this study, 60 healthy female subjects were studied after 18 hours of starvation and again when satiated. Short-term starvation was linked to changes in set-shifting and central coherence.

Resting State Connectivity in Anorexia Nervosa
In this study, 35 subjects with anorexia nervosa were studied using resting state functional magnetic resonance imaging. The study found increased connectivity between the angular gyrus and the fronto-parietal brain ciruit. Additionally, anterior insula connectivity was linked to deficits in interoceptive awareness.

Neuropsychology of Body Perception in Anorexia Nervosa
Patients with anorexia nervosa commonly display impaired perception of body shape and size. They often feel "fat" with body part size misperception. This manuscript reviews studies of nonvisual multisensory neuropsychological performance in anorexia nervosa. The review found support for deficits in tactile and proprioreceptive function in patients with anorexia nervosa.

Body Fat Distribution in Anorexia Nervosa
This literature review examined studies of body fat distribution before and during weight loss and with weight restoration. The authors found key differences between body fat distribution patterns in adolescents with anorexia nervosa compared to adult women with anorexia. The authors note body fat loss and re-accumulation may be an important metabolic and nutritional component of anorexia nervosa treatment.

Anorexia Nervosa Treatment Outcome After Urgent Hospitalization
This study examined the effect of several variables on outcome following urgent inpatient hospitalizations. Several psychological variables failed to contribute to poor outcome. However, lower BMI at admission was linked to several poor outcome measures.

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