Wednesday, December 6, 2017

Reliability

my brain
is not
reliable.

my thoughts
are not
reliable.

my feelings
are not
reliable.

i
am not
reliable.

some people
i named
'reliable'
turned out
to be
unkindable.

nothing
is set
in stone.

reliability
is
a falsity.


study notes

Tuesday, December 5, 2017

I'm way too good at goodbyes.

This is filed under Ranty Pants, but actually, it lies somewhere between Ranty Pants and Sad-dy Pants. I am sad today. Actually no. I am bitterly, painfully, heart-achingly depressed. But. Here are some thoughts. Because as we all know, if there's one thing that helps The Girl With Words, it's making words.


Something was said to me today that is really eating at me. And I want to talk about it, because this is a kind of epic bullshit way of thinking. This is the main Ranty Pants part, so brace yourself.

The comment was this:


"For someone who claims to hate themselves,
you can sure defend yourself."




Some thoughts on this:

Screw that noise. I mean it. I am in therapy because of all the times I DIDN'T defend or protect myself or say a word when people hurt me. I am mentally damaged from that and have been in treatment for years to try to overcome it. And you want to throw that in my face like standing up for yourself is a bad thing? Mind you I don't even mean standing up for myself in the sense that I swore at this person. I just defended myself by saying, Actually no, I don't accept that because it's unfair and untrue and here's some empirical evidence proving why. I call this, Exhibits A through Z.


Bye Felicia. Ain't nobody got time for that nonsense

Guys. Do NOT let people make you think you have to accept their shitty behaviour. If someone makes you feel bad, or small, or worthless, or useless, or says things that aren't true, or makes you hate yourself more, YOU ARE ALLOWED TO CALL THEM OUT. Or even cut them out of your life entirely if it's a consistent pattern that is not getting any better.

Please don't swear at them [I didn't FTR, I said, basically, That's super unfair because I AM ALLOWED TO DEFEND MYSELF WOW WHAT A REVELATION] but please, PLEASE don't let people make you feel like you're a bad person for standing up and saying, Actually no, I deserve better than your bullshit treatment of me. Because you know what? You do. You do deserve better. And some days you can't see that or fight for it, but damn, on the days that you do see it and can fight for it, FIGHT YOUR LITTLE HEART OUT. Three years of treatment with a magical unicorn has taught me nothing else if it hasn't taught me this: When you feel anger, direct it where it belongs. At the perpetrators.* Do not curl up with it and let it fester and grow and poison you from the inside out. Don't swear at people. Don't yell. Don't be unkind. But DAMMIT FIGHT and DEFEND YOURSELF because YOU ARE ALLOWED TO STAND UP FOR YOURSELF.  YOU ARE WORTH IT. I promise you are. It doesn't invalidate your feelings or your struggles or magically make your struggles with a lack of self-worth disappear. It means, in my eyes in this instance, that I'm getting better. 12 months ago I would have just accepted the hurtful words thrown at me as gospel truth. Not today, Sunshine. So yeah, to that person [theoretically, as they won't see this]: HELL YES I WILL STAND UP FOR MYSELF WHEN UNFAIRLY ATTACKED WHEN I FEEL STRONG ENOUGH TO DO SO, because maybe if I did the first time, I wouldn't be here now. 

Please guys, if you take nothing else away from this post, take on the words of the Magical Unicorn and direct your anger and frustration where it belongs: Towards the person or people who are hurting you. I know this is FAR easier said than done, but think of it as a muscle. The more you use it, the stronger it will get.




However. That being said. I'll be honest. The events of today have been awful. Words said that have carved themselves into my skin. Burned into me forever. Once close friends now turned into strangers I don't recognise. Heart racing with fear and panic and anxiety. Tachy spikes of 219 beats per minute. A heavy stomach weighed down with dread and sadness and guilt. But. Here are some things that I know:

1. If a person asks you what you've done to upset you and your answer is, "I don't know, I'm just so angry and it's your fault [somehow?¿]" chances are, the problem lies elsewhere. Look for that trigger. Locate it. Identify it. Name it. And deal with it without putting it on someone else. Putting it on someone else is not fair.

2. If you tell a person that they refuse to accept blame when they've repeatedly apologised for hurting you, and they then further ask you what they've done wrong that they didn't apologise for in an effort to make it right or avoid it future, and again your answer is, "I don't know", see point 1. You are projecting. We all do it. It's human. But recognise it and take steps to rectify it. Do not attack others for something they had nothing to do with, and do not attack others for the pain you hold inside yourself for things they are not involved in.

3. If a person consistently makes you feel worse about yourself, no matter how much you care about them, it might be time to consider taking a step back or perhaps ending the relationship entirely. Not all relationships are built to last. It sucks, but it's true.

4. Throwing someone's illness/es in their face is a really fucking shitty thing to do. Don't do it, kids.

• •••

Honestly, I am really, bitterly, painfully depressed and hurt about certain events. I'm going to retreat for a while. Be safe, lovebugs xxx

••• •



You must think that I'm stupid
You must think that I'm a fool
You must think that I'm new to this
But I have seen this all before

I know you're thinking I'm heartless
I know you're thinking I'm cold
I'm just protecting my innocence
I'm just protecting my soul

I'm never gonna let you close to me
Even though you mean the most to me
'Cause every time I open up, it hurts
So I'm never gonna get too close to you
Even when I mean the most to you
In case you go and leave me in the dirt

But every time you hurt me, the less that I cry
And every time you leave me
the quicker these tears dry
And every time you walk out, the less I love you
Baby, we don't stand a chance, it's sad but it's true

I'm way too good at goodbyes



sometimes, we need to let things go




* Direct quote from The Unicorn. He's Magical.

Monster.

[TW for depressing themes, and vague talk of self injurious behaviour. Be safe xx]

[More of my fiction can be found here]



***



"I'll-I'll do better," she stammers. She lowers her eyes to avoid the hatred radiating out of the dark pupils fixated on her.

She can still feel them.

Its disgust is palpable.

It speaks without making a sound.

//There is no better. There is no Good Enough. No rest. No respite. No relief.//

She nods like a puppet on a string. Head bouncing on cue. Empty-headed bobble doll. No longer in mint condition. Tainted. Dirty. Damaged.

"Yes," she whispers. "Yes."

She senses its eyes flicker towards the bathroom drawer. She doesn't need to look to be sure. She doesn't need proof. She knows.

She knows.

Her heart sinks into her stomach and lodges itself there. Bricks upon bricks upon bricks stack their way into her throat.

"Please."

It's not a question. Or a plea. Just a word.
A word.
A word.

Empty laughter fills the cavern inside her head. Her hands automatically open the drawer. Stumble. Fumble. Tumble. Fingers over thumbs over fingers over thumbs over over over.

It grows impatient.

Her spine stiffens. She grips the tool she knows it wants. And atones for her daily sins.

//one. two. three.//

She risks a glance in its direction.

It seems bored. Uninterested. Waiting. Watching. Waiting.

She hesitates.

The does three more.
Just to be safe.

She lets the damage coagulate and congeal before making any effort to clean it. Wash it. Fix it. Seal the edges where the pain leaked out.

Its eyes stay trained on her.

She avoids them like her life depends on it. 'Oh,' she thinks idly as she unwinds a wad of gauze. 'My life DOES depend on it.' When it is clean and bandaged, she takes a deep breath and holds it. Holds it. Holds it. And raises her gaze to the mirror.

Their eyes meet. Darkness on darkness. Reflection in a mirrored surface. It barks a dry laugh inside her head. And speaks without a sound.

//Tomorrow will be better.//


Not a question.
Not a statement.
A warning.
A warning.
A warning.

She nods. Puppet on a string. And drops her gaze as she backs away from her own reflection.

She is the monster inside the mirror.

She is the monster inside her head.

I am the monster inside my head.


Sunday, November 12, 2017

Talking To Anorexia


Oooh guys look out, my Ranty Pants are firmly on.

Those of you who follow my private Instagram accounts are quite familiar with my rants by now, as they happen quite frequently. I’m a passionate and opinionated person, okay, and I like to fight for what I believe in. Voice my thoughts. Write epic essays. Rant my pants clean off. By popular demand, there’s a new section here on my blog called RANTY PANTS, and this, my friends, is the first of what I’m sure will be many, many posts in this section.



I apologise if my views offend you, and if you want to rant back or challenge me, I welcome it. You can find me on Instagram, Twitter, the comments here, or askFM if you want to be anonymous. Rant away. I love a good passionate discussion, but friendly reminder that hateful vitriolic personal attacks get you blocked and mocked. No apologies. Speak freely, but also speak kindly. We learn this in kindergarten. It is not rocket science xo



So. On to today’s topic of RANTY PANTS.

Friendly warning that this DOES come with some numbers, behaviours, and may be triggering for some readers. Please keep yourselves safe.



Talking To Anorexia.

Louie Theroux.




Let me start with the disclaimer that I love Louie Theroux and I am a big fan of his documentaries. I am a documentary AND mental health information junkie, so when I heard this was coming out, I thought, in no uncertain terms: YASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSS!!



However, while I think the documentary did do an excellent job in focusing on the thoughts and feelings surrounding the development of and attempt to recovery from an eating disorder, there are some things that irked me something chronic. And given that my ranty pants are on, get ready for a list of things to remember if/when/while you watch this documentary:



1.       It is a documentary. It designed to intrigue and draw in viewers. This means that, much like every documentary about basically anything, it IS going to disproportionally focus on the “worst” or “most severe” cases or behaviours. Why? Because it lures you in. Increases viewership. Who wants to watch an hour-long documentary about the anorectic person who eats 1500-2000 calories a day and goes for a moderate walk? That just sounds like regular old dieting, right? And yet I PERSONALLY know individuals with CRITICALLY LOW BMIs who got there doing exactly that.  One person I personally know got to a deadly [and I mean DEADLY] BMI on 1300-2100 cals a day and 45 minutes of walking her dog each day. Her doctors didn’t believe that to be true so they put her on 2:1 special obs, yet she didn’t gain on their meal plan because it was no more than her normal amount of calories. Yes, some people DO go to the extreme and eat one cheerio a day, or three peas, or something similar, but you have to remember: chances are, that’s not what they do EVERY day. These documentaries hone in on the most extreme things for the sake of viewership. That’s show business, guys. I cannot confirm this happened in this documentary, nor am I suggesting it did, but I do know of cases where individuals have been directed to only talk about their worst times, and anything “not disordered enough” was edited out. I am uncertain about the ethics of outing people, but there are videos available on YouTube where participants of documentaries  such as this one have expressed distress over how their segments were edited to make them seem "sicker" or "worse" or "hopeless." Again I don't want to name these individuals as that is not my story to tell, but if I can find them on YouTube, you can, too.

My point is, please, PLEASE don’t think you’re a “failure” or “not sick” or "not sick enough" if your behaviours don’t match those shown in this documentary or others like it. Nine times out of ten, the behaviours shown represent the worst days and moments of the people being interviewed. Their day to day lives, I’m sure, have similar elements, but it’s unlikely that what you see in these documentaries is what happens 24/7 in most cases. Not all. But most.


2.      There was a heavy focus on white females. Boys get EDs too, you guys. As do people of colour. Older people. Young children. EDs are not bound by age, nor gender, nor shape, nor race, nor culture, nor religion, nor faith, nor culture. Louie Theroux was better at capturing this than some other documentaries I’ve seen, but it’s worth repeating. You can develop an ED at any age, at any weight, any gender, any race, culture, ethnicity, religion, or sexuality. It is not a “privileged white girl disease” as it is SO often portrayed [side-eyes To The Bone -- which I did enjoy mind you, but still]. NOTE that this refers to what is available as a whole, rather than this particular documentary, which did show a slighter greater diversity than some of what is available.


3.      NOT ALL EDs PRESENT THE SAME. Not every anorexic exercises for hours every day, or even at all. Not every anorexic eats exclusively healthy food. What is a fear food for some is a safe food for others, and vice versa. Some people have no fear or safe foods at all. You are not “fake” if you can eat chocolate, cookies, cake, cheese, butter, or anything else typically portrayed as a "fear food" or "challenge". Mental disorders have elements of uniqueness and should be treated as such. We all vary in our behaviours. There is no right way to be "sick."  Yes, there are overarching similarities that allow for these labels for treatment purposes as I mentioned in this post, but we are individuals. Treatment should be tailored on an individual level to meet the specific needs of each patient.


4.      When I did my research for my paper on the neurobiology of anorexia [the blogger friendly version of which can be found here], I found a vast body of literature that indicated the average caloric intake of chronic, severe, and long-term anorexia suffers with critically low BMIs. I AM going to trigger warning this, so brace yourself. I won’t mention the exact average number, but this was mentioned time and time and time again in my research, across several papers. Actual proper scientific peer-reviewed research that I used to write that assignment -- which was graded highly by the way, not to sound braggy, but to demonstrate it can be reasonably assumed my information and interpretation was correct. You ready for it?

It is above 1200 calories per day.

That, my friends, is the cold hard truth. I have no doubt that some days people do eat an apple a day, or nothing at all. Hell, I’ve had days like that. Weeks like that. But when we’re talking long-term, that just simply is NOT the case for any extended period of time. You know why? I’ll give you the top three reasons:

a)      Binges. They happen. You eat a cheerio a day for a week and see what happens. Hello out of control binge eating. It’s called survival. This even happens in rats. The Minnesota Starvation Experiment does a great job of explaining this.

b)     Medical intervention. You ain’t gonna be stable for long, petal. Someone WILL intervene. Someone will stop you and force you into treatment. Or else, we have option c.

c)      Death. That is the cold hard truth. I heard an amazing slam poem that contained the line, if you are not recovering, you are dying. You can die of an eating disorder at ANY weight. Please do NOT listen to the bullshit in your brain that says I don’t look like the girls in the myriad of ED docs out there, so I don’t deserve help. That is a lie your sick brain is telling you to keep you sick.

I don’t mean this rant to undermine the bravery of those who featured in the documentary, or the hard work of Louie Theroux and his team in putting together a raw and heart wrenching documentary. Overall, it was very well done and should be commended. However, as I stated here, every research article, documentary, blogpost, textbook, article -- whatever -- has its limitations and flaws. Nothing is perfect. It is vital that we approach these things with an open and critical thinking mind.

To conclude, I’ll leave you with this example.
I have OCD, right. You guys all know that, I’m sure.
Recently I posted this in my story on my private Instagram account.



Yep I did this.


Now, do I break a door lock EVERY day due to obsessive compulsive locking and unlocking and locking and unlocking? No. Of course not. But did I break it that day due to the compulsions being bad? Yes. It’s not a lie or exaggeration for me to share that event, but it IS important that I balance out that information by explaining that it doesn’t happen every day. It was a bad day, but not every day is a bad day. Or the same level of bad. A hypothetical documentary about my OCD may use this example as though it is standard. It may not. It may be more balanced than that. Yet unfortunately, most of these eating disorder and other mental health documentaries are filmed in such a way that provide the impression that every day is the worst day. That’s not a negative thing. That's not a deceitful thing. That is the nature of docutainment. But it is something that we need to be aware of when viewing the material that is out there.

And that, my friends, is worth ranting about.

Take care of your precious selves.

Xoxo
For more of my blog posts on disorderly eating, look here.


Saturday, November 11, 2017

Hunger Hurts But Starving Works: Part Five


F I N A L L Y



The last instalment of my AN series. I swear I normally write much faster that this; my brain is full of white noise these days. But. I made it. Thanks for sticking with me, if you did.






As always, the information here comes with a TRIGGER WARNING. Please be safe as you read it, and don’t be afraid to ask for help if you need it. If you have questions or comments, you can leave them below, message me on Instagram, on Twitter, or leave me a question on askFM – which is blowing up like crazaaaaaay so if I don’t get to your question and it is pressing, don’t be afraid to resend in a couple of days as I cannot keep up with my real life and my online life at times.



Be safe.



As usual, black text is verbatim from my original paper, and purple italics is my added commentary or explanation.

Hunger Hurts But Starving Works: Part Five

Thus far we have examined the role of 5-HT and dopamine in AN-R individually; however, the interaction between the 5-HT and dopamine systems is equally as important in the neurobiology of AN-R as their individual mechanisms (Frank, 2014). For example, one study found that the interaction between 5-HT and dopamine D2/D3 receptor binding is related to increased anxiety and harm avoidant behaviours in AN-R (Bailer et al, 2013). Remember: harm-avoidant means avoiding the things that cause anxiety by engaging in ritualistic behaviours or coping in a way that numbs the pain. Further, medications that act on these neuronal systems such as serotonin reuptake inhibitors (SSRIs) and the dopamine reuptake inhibitor methylphenidate show little effect on the core symptoms of AN-R, suggesting that pharmacotherapies need to target both these systems and the interaction between them in order to improve treatment outcomes (Frank, 2014; Kaye et al., 2009). This is why antidepressants do NOT tend work on EDs unless the ED is caused by depression. Also a future rant will explain that there is no such thing as a chemical Imbalance as there is no such thing as a chemical BALANCE. These drugs CAN and DO work in some cases, but not all, and science literally cannot explain how or why they work in many cases. Biopsych 466, yo. These drugs work by trial and error. Kinda scary, right? But I digress.  There is preliminary evidence that atypical antipsychotics such as olanzapine, which targets both 5-HT and dopamine, may assist in reducing anxiety and promote weight gain, but this is widely debated as treatment with these drugs has yielded mixed results (Frank, 2014; Kaye, 2009; Kaye et al., 2013). Personal anecdote: I was on olanzapine. It was not a good time. These drugs are SO tetchy. Some work brilliantly for some people and completely mess with another. It’s really about finding the RIGHT drug for YOU at the RIGHT time. This can take years. This is also why there about 50 million options available. I won’t go into this too deeply, but they are apparently trialling DNA testing to give you your best shot at finding a drug that works for you, so that is promising.


THE FOLLOWING PARAGRAPH CONTAINS BMI NUMBERS. TRIGGER WARNING.


Although the literature reviewed provides substantial evidence for the role of 5-HT and dopamine in AN-R, it is important to note the limitations of the research presented. ALL studies have limitations. Even what I’ve written has limitations: the most important of which being that I am not qualified. I am just a student and this was just an assignment for university. I am no expert and I am NOT a therapist [yet, hehe].  The studies reviewed, like many of the studies on AN-R, have taken place during or following weight restoration (Bosanac et al., 2007; Broft et al., 2015). Participants often no longer have a critically low BMI—defined by the DSM-V as below 15kg/m2—and due to the process of refeeding, are often no longer in a dire malnourished state (Broft et al., 2015; Sodersten et al., 2016). I’ll tell you what shocked me: A BMI below 15 is considered critically low. Below 13, organ failure is imminent without intervention. Below 12, death is imminent without intervention. Terrifying. Additionally, while in treatment, individuals with AN-R have restrictions imposed on their exercise behaviour (Zunker, Mitchell, & Wonderlich, 2011). These factors could impact findings and mask potential differences between individuals with AN-R and healthy controls. However, it is difficult to overcome this as safety concerns make it problematic to study severely underweight individuals, and it is unethical to study unwell individuals without offering support and treatment. Nevertheless, despite these limitations, the studies reviewed provide an insight into the neurobiology of AN-R.


This next part was a requirement of the assignment that asked us to suggest what can be done to better treat the condition we chose. I was like, lemme hit these fools with some knowledge, lol:

The bolding was added for this blog post because SAY IT LOUDER FOR THE PEOPLE AT THE BACK.

Based on the evidence presented, it becomes clear that the next step in treating AN-R is to target both the cognitions and behaviours present and the underlying neurobiology. To do so requires research into the potentially opposing functions of 5-HT and dopamine; if an increase in intrasynaptic 5-HT causes a reduction in food intake while an increase in stress-related dopamine stimulates food foraging, one must ask how these work together to create the pathophysiology seen in AN-R. It is evident that simple weight restoration is not enough, yet unfortunately, current treatment systems appear to mainly focus on restoring the weight of malnourished individuals (Sodersten et al., 2016). SAY IT LOUDER FOR THE PEOPLE AT THE BACK. While this can be life-saving, it sets sufferers up for relapse as the underlying causes have not been addressed. PREACHING IT OH LORDY YEAH I WROTE THIS YEAH I’M PRAISING MYSELF DON’T CARE I SPEAK THE TRUTH, lol. This could arguably explain the high relapse rates seen following inpatient hospitalisation. Treatment should focus on assisting individuals with AN-R to develop healthy coping strategies for overcoming dysphoria and anxiety while simultaneously restoring weight and treating the underlying neurobiology; focusing on one of these aspects alone is not sufficient. SO STOP REDUCING PEOPLE TO A NUMBER, K?! Moreover, greater emphasis needs to be placed on early intervention, as there is evidence that the symptoms of AN-R can become almost addictive due to the rewarding nature of dopamine, and so like an addiction, AN-R becomes harder to treat as time goes on. Indeed, studies have shown that the dopamine interactions present in AN-R facilitate conditioned learning (Volkow, Fowler, Wang & Swanson, 2004). This is the reward response I wrote about in part three. Future studies could investigate potential neurological risk factors in the development of AN-R, and ways to intervene and counteract them. The next step, therefore, is to investigate pharmacotherapies that target the specific implicated neurotransmitters and the interaction between them, while improving the cognitive and behavioural aspects of treatment such as cognitive behavioural therapy and other psychological approaches. AND ALSO: QUIT WAITING UNTIL PEOPLE’S BMIs DROP “LOW ENOUGH” TO PROVIDE HELP BECAUSE BY THEN THE PATHWAYS ARE BECOMING SO DEEPLY FORMED THAT THEY ARE HARD TO TREAT; QUIT REDUCING PEOPLE TO A SIMPLE SERIES OF NUMBERS AND VITALS; QUIT ASSUMING THAT WEIGHT RESTORED = BETTER; QUIT MAKING PEOPLE WEIGHT RESTORE WITHOUT SIMULATANEOUSLY HELPING THEM ADDRESS THEIR UNDERLYING PROBLEMS BECAUSE HEY GUESS WHAT THAT MAKES THINGS WORSE AND GOSH DAMMIT TREAT PEOPLE LIKE PEOPLE AND NOT WALKING DIAGNOSES DEAR LORD. ALL mental health issues present specific to the individual, and while there ARE common symptoms, cognitions, and behaviours -- hence the need for these overarching labels -- people are unique and SHOULD BE TREATED AS SUCH.

In closing, AN-R has been shown to be more than a simple desire to be thin. It is entrenched in the neural pathways of the brain, making it a self-perpetuating, complex, and difficult disorder to treat. A dysregulation of 5-HT and dopamine neurotransmitters has been shown to underpin the typical behaviours and cognitions exhibited in AN-R, as these behaviours are the result of an attempt to reduce the distress and dysphoria caused by disturbances in these pathways. Future studies could investigate the root cause of these disturbances, and examine how they develop, be it through a genetic vulnerability; environmental factors and experiences; if they are the result of self-starvation and malnutrition; or if the cause lies somewhere in between.



*mic drop*



I hope you guys enjoyed or learned something from my series on the neurobiology of AN-R! Please do let me know what you think because comments help me improve. The full series can be found here. Remember, I’ve only addressed restrictive anorexia here due to the word constraints of the assignment; however, OTHER EDs EXIST AND ARE JUST AS VALID, PAINFUL, LONELY, ISOLATING, and WORTHY OF HELP.



Take care of your precious selves.

Xx



The Girl With Words

Artwork from my journal

Quote from Marya Hornbacher's WASTED


References
Avena, N. M., & Bocarsly, M. E. (2012). Dysregulation of brain reward systems in eating disorders: Neurochemical information from animal models of binge eating, bulimia nervosa, and anorexia nervosa. Neuropharmacology, 63(1), 87-96. doi:10.1016/jneuropharm.2011.11.010
Avena, N. M., Rada, P., & Hoebel, B.G. (2008). Underweight rats have enhanced dopamine release and blunted acetylcholine response in the nucleus accumbens while bingeing on sucrose. Neuroscience, 156(4), 865-871. doi:10.1016/j.neuroscience.2008.08.017
Bailer, U. F. (2007). Exaggerated 5-HT1A but normal 5-HT2A receptor activity in individuals ill with anorexia nervosa. Biological Psychiatry, 61(9), 1090-1099. doi:10.1016/j.biopsych.2006.07.018
Bailer U. F., Frank, G. K., Price, J. C., Meltzer, C. C., Becker, C., Mathis, C. A., … Kaye, W. H. (2013).  Interaction between serotonin transporter and dopamine D2/D3 receptor radioligand measures is associated with harm avoidant symptoms in anorexia and bulimia nervosa. Psychiatry Research: Neuroimaging, 211(2), 160-168. doi:10.1016/j.pscychresns.2012.06.010
Berridge, K. C. (2009). 'Liking' and 'wanting' food rewards: Brain substrates and roles in eating disorders. Physiology & Behavior, 97(5), 537-550. doi:10.1016/j.physbeh.2009.02.044
Broft, A., Slifstein, M., Shingleton, R., Kenney, L., Attia, E., Martinez, D., . . . Osborne, R.. (2015). Striatal dopamine type 2 receptor availability in anorexia nervosa. Psychiatry Research: Neuroimaging (233)3, 380-387. doi:10.1016/j.pscychresns.2015.06.013
Bosanac, P., Kurlender, S., Stojanovska, L., Hallam, K., Norman, T., McGrath, C., . . . Olver, J. (2007). Neuropsychological study of underweight and “weightrecovered” anorexia nervosa compared with bulimia nervosa and normal controls. International Journal of Eating Disorders, 40(7), 613-621. doi:10.1002/eat.20412
Carter, J., Blackmore, E., Sutandar-Pinnock, K., & Woodside, D. (2004). Relapse in anorexia nervosa: A survival analysis. Psychological Medicine, 34(4), 671-679. doi:10.1017/S0033291703001168
Chowdhury, T. G., Chen, Y.-W., & Aoki, C. (2015). Using the activity-based anorexia rodent model to study the neurobiological basis of anorexia nervosa. Journal of Visualized Experiments: JoVE, (104), 52927. Advance online publication. doi:10.3791/52927
Compan, V. (2013). Under- to over-eating: How do serotonin receptors contribute? Future Neurology, 8(6), 701–714. doi:10.2217/fnl.13.54
Corwin, R. L., Avena, N. M., & Boggiano, M. M. (2011). Feeding and reward: Perspectives from three rat models of binge eating. Physiology & Behavior, 104(1), 87-97. doi:20.2026/j.physbeth.2011.04.041
Darcy, A. M., Doyle, A. C., Lock, J., Peebles, R., Doyle, P., & Le Grange, D. (2012). The eating disorders examination in adolescent males with anorexia nervosa: How does it compare to adolescent females? International Journal of Eating Disorders, 45(1), 110-114. doi:10.1002/eat.20896
Deep, A.L., Nagy, L.M., Weltzin, T.E., Rao, R., & Kaye, W.H. (1995). Premorbid onset of psychopathology in long-term recovered anorexia nervosa. International Journal of Eating Disorders, 17, 291–297. doi:10.1002/1098-108X(199504)17:3<291::AID-EAT2260170310>3.0.CO;2-#
Frank, G. K. W. (2014). Could dopamine agonists aid in drug development for anorexia nervosa? Frontiers in Nutrition, 1(19), 1-9. doi:10.3389/fnut.2014.00019
Frank, G. K., Bailer, U.F., Henry, S. E., Drevets, W., Meltzer, C. C., Price, J. C., …  Kaye, W. H. (2005). Increased dopamine D2/D3 receptor binding after recovery from anorexia nervosa measured by positron emission tomography and [11C] raclopride. Biological Psychiatry, 58. 908–912. doi:10.1016/j.biopsych.2005.05.003
Godier, L. R. & Park, R. J. (2015). Does compulsive behaviour in anorexia nervosa resemble an addiction? A qualitative investigation. Frontiers in Psychology, 6(1608), 1-12. doi:10.3389/fpsyg.2015.01608
Hudson, J.I., Hiripi, E., Pope, H. G. Jr., & Kessler, R.C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry 61(3), 348–58. doi:10.1016/j.biopsych.2006.03.040
Kalm, L. M., & Semba, R. D. (2005). They starved so that others be better fed: Remembering Ancel Keys and the Minnesota experiment. The Journal of Nutrition, 135(6), 1347-1352. Retrieved from http://search.proquest.com.ezproxy.une.edu.au/docview/197463003
Kaye, W. H. (2008). Neurobiology of anorexia and bulimia nervosa. Physiology & Behavior, 94(1), 121-135. doi:10.1016/j.physbeh.2007.11.037
Kaye, W. H., Bailer, U. F., Frank, G. K., & Wagner, A. (2006). Persistent alterations of serotonin and dopamine activity after recovery from anorexia and bulimia nervosa. International Congress Series, 1287, 45-48. doi:10.1016/j.ics.2005.12.038
Kaye, W. H., Barbarich, N. C., Putnam, K., Gendall, K. A., Fernstrom, J., Fernstrom, M., . . . Kishore, A. (2003). Anxiolytic effects of acute tryptophan depletion in anorexia nervosa. International Journal of Eating Disorders, 33(3), 257-267. doi:10.1002/eat.10135
Kaye, W. H, Frank, G. K., Bailer, U. F., Henrya, S. E., Meltzera, C. C., Priced, J. C., … Wagner, A. (2005). Serotonin alterations in anorexia and bulimia nervosa: New insights from imaging studies. (2005). Physiology & Behavior, 85(1), 73-81. doi:10.1016/j.physbeh.2005.04.013
Kaye, W. H., Fudge, J. L., & Paulus, M. (2009). New insights into symptoms and neurocircuit function of anorexia nervosa. Nature Reviews. Neuroscience, 10(8), 573-84. doi:10.1038/nrn2682
Kaye, W. H., Wierenga, C. E., Bailer, U. F., Simmons, A. N., & Bischoff-Grethe, A. (2013). Nothing tastes as good as skinny feels: The neurobiology of anorexia nervosa. Trends in Neurosciences, 36(2), 110-120. doi:10.1016/j.tins.2013.01.003
Lak, A., Stauffer, W. R., & Schultz, W. (2014). Dopamine prediction error responses integrate
subjective value from different reward dimensions. Proceedings of the Natural Academy of Sciences of the United States of America, 111(6), 2343–2348. doi:10.1073/pnas.1321596111
O’Hara, C. B., Campbell, I. C., & Schmidt, U. (2015). A reward-centred model of anorexia nervosa: A focussed narrative review of the neurological and psychophysiological literature. Neuroscience and Biobehavioural Reviews, 52, 131-152. doi:10.1016/j.neubiorev.2015.02.012
O'Hara, C.,B., Keyes, A., Renwick, B., Leyton, M., Campbell, I. C., & Schmidt, U. (2016). The effects of acute dopamine precursor depletion on the reinforcing value of exercise in anorexia nervosa. PLoS One, 11(1), 1-16. doi:10.1371/journal.pone.0145894
Schwartz, M.W., Woods, S. C., Porte, D., Seeley, R. J., & Baskin. D. G. (2000). Central nervous system control of food intake. Nature, 404(6778), 661-671. doi:10.1038/35007534
Sodersten, P., Bergh, C., Leon, M., & Zandian, P. (2016). Dopamine and anorexia nervosa. Neuroscience And Biobehavioral Reviews, 60, 26-30. doi:10.1016/j.neubiorev.2015.11.003
Stengel, A., & Taché, Y. F. (2014). CRF and urocortin peptides as modulators of energy balance and feeding behavior during stress. Frontiers in Neuroscience, 8(52), 1-10. doi:10.3389/fnins.2014.00052
Trainor, B. C. (2011). Stress responses and the mesolimbic dopamine system: social contexts and sex differences. Hormones and Behavior, 60(5), 457–469. doi:10.1016/j.yhbeh.2011.08.013
Treasure, J., & Campbell, I. (1994). The case for biology in the aetiology of anorexia nervosa. Psychological Medicine, 24(1), 3-8. doi:10.1017/S0033291700026775
Via, E., Soriano-Mas, C., Sanchez, I., Forcano, L., Harrison, B., Davey, C., . . . Cardoner, N. (2015). Abnormal Social Reward Responses in Anorexia Nervosa: An fMRI Study. PLoS ONE, 10(7), 1-20. doi:10.1371/journal.pone.0133539
Volkow, N. D., Fowler, J. S., Wang, G-J., & Swanson, J. M. (2004). Dopamine in drug abuse and addiction: Results from imaging studies and treatment implications. Molecular Psychiatry, 9(6), 557-569. doi:10.1038/sj.mp.4001507
Volkow, N., Wang, G., Maynard, L., Jayne, M., Fowler, J., Zhu, W., . . . Pappas, N. (2003). Brain dopamine is associated with eating behaviors in humans. International Journal of Eating Disorders, 33(2), 136-142. doi:10.1002/eat.10118
Walsh, B. T. (2011). The importance of eating behavior in eating disorders. Physiology & Behavior, 104(4), 525-529. doi:10.1016/j.phybeh.2011.05.007
Zunker, C., Mitchell, J. E. & Wonderlich, S. A. (2011), Exercise interventions for women with anorexia nervosa: A review of the literature. International Journal of Eating Disorders, 44(7), 579–584. doi:10.1002/eat.20862

Saturday, October 7, 2017

Hunger Hurts, but Starving Works: Part Four  

This is part four in my series on the neurobiology of restrictive anorexia nervosa. As a reminder, the following information may be triggering or difficult for some readers. Please keep yourselves safe.

If you need to catch up, you can find parts one, two, and three here.


I apologise for the MASSIVE delay in getting this next instalment out to you all. As I explained in this post, I’ve been having a rough time and a lot of things were put on hold. This blog and this series was one of those things. However, I always intended to finish it because I know it can be so helpful to understand the science of these things, so by golly, finish it I shall.

We last left off [In July, Y I K E S] talking about dopamine. You can have a refresher of that post here.
As with the previous posts, the black is verbatim from my original paper, and the purple is my added blogger-friendly breakdowns. Some parts of my original paper have been omitted because they don’t add anything in the context of this blog post. Friendly reminder that this is all secondary research and there if a full reference list behind the spoiler if you want to read up on anything I’ve discussed. I am a student, not a psychologist, and I can only assume my information is correctly interpreted due to the grade I received for this paper. I am no expert so if you see an error, please do let me know.

Alright. Brace for impact.


Hunger Hurts But Starving Works: The Role of Serotonin and Dopamine Anorexia Nervosa [Part Four: Dopamine, Rats, Binge Eating, and Food Hoarding]

Food intake is dictated by a complex interaction between the brain and body (Lak, Stauffer, & Schultz, 2014). The overarching neurobiology is the brain reward system, which integrates hunger signals with cognitive and emotional factors to regulate eating behaviour (Berridge, 2009). In the context of AN-R, research suggests that extreme eating and exercise behaviours can modulate the brain regions involved in reward processing, thus mediating the dopamine system (Frank, 2014). Extreme terms of either restricting relative to energy requirements or overeating. This process has consistently been modelled by animal studies, and perhaps the most well-known of these is activity-based anorexia in rats. In this model, first demonstrated by Routtenberg and Kuzzesof in 1967, rats on a severely restricted diet are given free access to a running wheel. Within a few days, the rats exhibit excessive exercise and a decline in body weight so severe that without experimenter intervention, it leads to death (cited in Avena & Bocarsly, 2012). Who knew that you could create anorexic rats, right? It raises some extremely interesting questions, which were unfortunately beyond the scope of this paper. There are a number of possible explanations for the over-exercise exhibited by the rats in this model, and by extension, individuals with AN-R. Two such explanations are that this behaviour is due to stress, or that it is a form of foraging or food-seeking behaviour (Adan, 2011; Gutierrez, 2013, cited in Chowdhury, Chen, & Aoki, 2015). Meaning we are hungry, so we are subconsciously exercising [eg running or walking] in an effort to seek out food. This implicates the mesolimbic dopamine neurons, as food restriction and excessive exercise can lead to a stress response mediated by these neurons (Trainor, 2011). This stress response increases cortisol and corticotrophin releasing factor, which results in a surge of dopamine that consequently rewards food restriction and exercise behaviour (Sodersten et al., 2016). Basically this means, it messes with the wiring in your brain so that restricting and over exercising are rewarding by a reduction in dysphoria or other unpleasant feelings. It numbs you out, reduces your stress, and helps you cope. This creates a feedback loop not unlike those seen in drug dependent individuals, whereby engaging in the behaviour results in a surge of dopamine, which in turn creates a habit or compulsion and increases the likelihood of engaging in that behaviour again, which causes a surge in dopamine and so on (O'Hara et al., 2016). This is exactly what happens to those addicted to substances. Interestingly, it occurs also in those addicted to sugar, such as chronic over eaters, binge eaters, or those with AN-BP or bulimia. I want to do a shorter post on this in future as there are some fascinating studies out there. One such study indicates that sugar targets the same brain areas as cocaine. Biopsych [the unit I wrote this paper for] was SUCH a fascinating subject, honestly. As a sidenote, my original paper idea was going to be based on the notion that eating disorders are an addiction, but the word limit meant I wouldn’t have been able to discuss it in the level of detail that I wanted. Each eating disorder has a different pattern of brain chemistry changes, and so I had to focus on only one ED. I chose AN-R because although I deeply contest it, it is in my diagnosis list and therefore is of personal interest to me. But I digress



Furthermore, high corticotrophin releasing factor appears to increase dopamine responses that supress food intake while simultaneously stimulating food seeking behaviour (Stengel & Taché, 2014). This provides one possible explanation for the high levels of food preoccupation seen in AN-R; rather than eating, suffers become obsessed with food, perhaps preparing elaborate meals for others, collecting cookbooks, or even hoarding food without eating it (Thurston, 1999, cited in Sodersten et al., 2016). I myself am a MASSIVE food hoarder. I know many of you reading this are too. You’re not alone and you don’t lack self-control. Part of the reason we hoard food is that our bodies and brains want it and so we feel compelled to have it around. That doesn’t make you a bad person. It’s biologically driven. Animals do it too, as do individuals who have their food restricted outside their control [eg, neglected children]. It’s almost to be expected when your intake is inadequate for your energy requirements. This may also explain the difficulties in the modulation of food intake experienced by both individuals recovering from AN-R and non-eating disordered individuals following a period of food restriction (Kalm & Semba, 2005). It is common for individuals with AN-R to experience binge-eating during weight restoration, as such dysregulated eating behaviour is related to altered dopamine receptors and reward sensitivity (Avena, Rada, & Hoebel, 2008). This means that again, the change in your food consumption changes your brain chemistry and your brain goes into survival mode, pushing you to eat as much as you can for fear that you may start starving again. Many people describe it as being physically full yet mentally hungry, and it is an absolutely accurate description. So next time someone tells you that extreme hunger or binge eating following a restrictive eating disorder is just a matter of self-control, or that you’re “pigging out on McDonalds” or that you’re acting like you're “on holiday from your ED” [both examples of things this borderline braindead MORON said to a friend of mine], I want you to pick up your laptop and slap them in the face with this paragraph. Extreme hunger is real. Extreme MENTAL hunger is real. Have you ever heard of the Minnesota Starvation Experiment? If not, you can read about it here. I would love to talk more about it, but this blog post is already so long, eeep. I don’t want to ramble too much. But do read up on it, if this is of interest to you. And remember, if you find yourself bingeing after a period of restriction, it doesn’t make you weak, greedy, pathetic, fake, or any of the nasty things your head says about you. It makes you human. Even if you’re weight restored. Even if you’ve overshot your ‘target’ weight. Your brain doesn’t know that you’d like to be XXkgs. All it knows is you’ve been starving it or restricting it and so now it wants food and it wants food NOW. That’s not your fault. And it doesn’t make you weak. Each of these explanations implicates the dopaminergic pathways and provides compelling evidence that dopamine plays a key role in the neurocircuit function of AN-R.

I wanted to combine all the remaining information into this post, but that took it to over 3000 words with my commentary. And so, although I am loathed to do it, I am going to stop here on this post. There’s one more post to go that looks at how the 5-HT and dopamine systems interact to create and regulate the symptoms of AN-R, treatment options, the limitations of the research presented, and where do we go from here*

Take care and please speak to your GP, therapist, dietician, or other healthcare professional if you are struggling with food or eating or exercise. Here are some resources that may be of use to you if you are struggling.

Be safe.
Xx

*This is largely influenced by the fact that my illness has me sitting on my butt all day watching Buffy, but all I can hear is,
Where do we go
From here?
Where do we go
From here?
The battle's done
and we kind of won
So we sound our victory cheer
TELL ME
Where do we go from hereeeeeeeeeee?





Screenshot from the Netflix film 'To The Bone'


<Can't get the spoiler to work and will come back to edit it later, but for now, here's the unspoilered reference list>

References

Avena, N. M.,& Bocarsly, M. E. (2012). Dysregulation of brain reward systems in eating disorders: Neurochemical information from animal models of binge eating, bulimia nervosa, and anorexia nervosa. Neuropharmacology, 63(1), 87-96. doi:10.1016/jneuropharm.2011.11.010




Avena, N. M., Rada, P., & Hoebel, B.G. (2008). Underweight rats have enhanced dopamine release and blunted acetylcholine response in the nucleus accumbens while bingeing on sucrose. Neuroscience, 156(4), 865-871. doi:10.1016/j.neuroscience.2008.08.017

Bailer, U. F. (2007). Exaggerated 5-HT1A but normal 5-HT2A receptor activity in individuals ill with anorexia nervosa. Biological Psychiatry, 61(9), 1090-1099. doi:10.1016/j.biopsych.2006.07.018

Bailer U. F., Frank, G. K., Price, J. C., Meltzer, C. C., Becker, C., Mathis, C. A., … Kaye, W. H. (2013).  Interaction between serotonin transporter and dopamine D2/D3 receptor radioligand measures is associated with harm avoidant symptoms in anorexia and bulimia nervosa. Psychiatry Research: Neuroimaging, 211(2), 160-168. doi:10.1016/j.pscychresns.2012.06.010

Berridge, K. C. (2009). 'Liking' and 'wanting' food rewards: Brain substrates and roles in eating disorders. Physiology & Behavior, 97(5), 537-550. doi:10.1016/j.physbeh.2009.02.044

Broft, A., Slifstein, M., Shingleton, R., Kenney, L., Attia, E., Martinez, D., . . . Osborne, R.. (2015). Striatal dopamine type 2 receptor availability in anorexia nervosa. Psychiatry Research: Neuroimaging (233)3, 380-387. doi:10.1016/j.pscychresns.2015.06.013

Bosanac, P., Kurlender, S., Stojanovska, L., Hallam, K., Norman, T., McGrath, C., . . . Olver, J. (2007). Neuropsychological study of underweight and “weightrecovered” anorexia nervosa compared with bulimia nervosa and normal controls. International Journal of Eating Disorders, 40(7), 613-621. doi:10.1002/eat.20412

Carter, J., Blackmore, E., Sutandar-Pinnock, K., & Woodside, D. (2004). Relapse in anorexia nervosa: A survival analysis. Psychological Medicine, 34(4), 671-679. doi:10.1017/S0033291703001168

Chowdhury, T. G., Chen, Y.-W., & Aoki, C. (2015). Using the activity-based anorexia rodent model to study the neurobiological basis of anorexia nervosa. Journal of Visualized Experiments: JoVE, (104), 52927. Advance online publication. doi:10.3791/52927

Compan, V. (2013). Under- to over-eating: How do serotonin receptors contribute? Future Neurology, 8(6), 701–714. doi:10.2217/fnl.13.54

Corwin, R. L., Avena, N. M., & Boggiano, M. M. (2011). Feeding and reward: Perspectives from three rat models of binge eating. Physiology & Behavior, 104(1), 87-97. doi:20.2026/j.physbeth.2011.04.041

Darcy, A. M., Doyle, A. C., Lock, J., Peebles, R., Doyle, P., & Le Grange, D. (2012). The eating disorders examination in adolescent males with anorexia nervosa: How does it compare to adolescent females? International Journal of Eating Disorders, 45(1), 110-114. doi:10.1002/eat.20896

Deep, A.L., Nagy, L.M., Weltzin, T.E., Rao, R., & Kaye, W.H. (1995). Premorbid onset of psychopathology in long-term recovered anorexia nervosa. International Journal of Eating Disorders, 17, 291–297. doi:10.1002/1098-108X(199504)17:3<291::AID-EAT2260170310>3.0.CO;2-#

Frank, G. K. W. (2014). Could dopamine agonists aid in drug development for anorexia nervosa? Frontiers in Nutrition, 1(19), 1-9. doi:10.3389/fnut.2014.00019

Frank, G. K., Bailer, U.F., Henry, S. E., Drevets, W., Meltzer, C. C., Price, J. C., …  Kaye, W. H. (2005). Increased dopamine D2/D3 receptor binding after recovery from anorexia nervosa measured by positron emission tomography and [11C] raclopride. Biological Psychiatry, 58. 908–912. doi:10.1016/j.biopsych.2005.05.003

Godier, L. R.& Park, R. J. (2015). Does compulsive behaviour in anorexia nervosa resemble an addiction? A qualitative investigation. Frontiers in Psychology, 6(1608), 1-12. doi:10.3389/fpsyg.2015.01608

Hudson, J.I., Hiripi, E., Pope, H. G. Jr., & Kessler, R.C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry 61(3), 348–58. doi:10.1016/j.biopsych.2006.03.040

Kalm, L. M.,& Semba, R. D. (2005). They starved so that others be better fed: Remembering Ancel Keys and the Minnesota experiment. The Journal of Nutrition, 135(6), 1347-1352. Retrieved from http://search.proquest.com.ezproxy.une.edu.au/docview/197463003

Kaye, W. H. (2008). Neurobiology of anorexia and bulimia nervosa. Physiology & Behavior, 94(1), 121-135. doi:10.1016/j.physbeh.2007.11.037

Kaye, W. H., Bailer, U. F., Frank, G. K., & Wagner, A. (2006). Persistent alterations of serotonin and dopamine activity after recovery from anorexia and bulimia nervosa. International Congress Series, 1287, 45-48. doi:10.1016/j.ics.2005.12.038

Kaye, W. H., Barbarich, N. C., Putnam, K., Gendall, K. A., Fernstrom, J., Fernstrom, M., . . . Kishore, A. (2003). Anxiolytic effects of acute tryptophan depletion in anorexia nervosa. International Journal of Eating Disorders, 33(3), 257-267. doi:10.1002/eat.10135

Kaye, W. H, Frank, G. K., Bailer, U. F., Henrya, S. E., Meltzera, C. C., Priced, J. C., … Wagner, A. (2005). Serotonin alterations in anorexia and bulimia nervosa: New insights from imaging studies. (2005). Physiology& Behavior, 85(1), 73-81. doi:10.1016/j.physbeh.2005.04.013

Kaye, W. H., Fudge, J. L., & Paulus, M. (2009). New insights into symptoms and neurocircuit function of anorexia nervosa. Nature Reviews. Neuroscience, 10(8), 573-84. doi:10.1038/nrn2682

Kaye, W. H., Wierenga, C. E., Bailer, U. F., Simmons, A. N., & Bischoff-Grethe, A. (2013). Nothing tastes as good as skinny feels: The neurobiology of anorexia nervosa. Trends in Neurosciences, 36(2), 110-120. doi:10.1016/j.tins.2013.01.003

Lak, A., Stauffer, W. R., & Schultz, W. (2014). Dopamine prediction error responses integrate

subjective value from different reward dimensions. Proceedings of the Natural Academy of Sciences of the United States of America, 111(6), 2343–2348. doi:10.1073/pnas.1321596111

O’Hara, C. B., Campbell, I. C., & Schmidt, U. (2015). A reward-centred model of anorexia nervosa: A focussed narrative review of the neurological and psychophysiological literature. Neuroscience and Biobehavioural Reviews, 52, 131-152. doi:10.1016/j.neubiorev.2015.02.012

O'Hara, C.,B., Keyes, A., Renwick, B., Leyton, M., Campbell, I. C., & Schmidt, U. (2016). The effects of acute dopamine precursor depletion on the reinforcing value of exercise in anorexia nervosa. PLoS One, 11(1), 1-16. doi:10.1371/journal.pone.0145894

Schwartz, M.W., Woods, S. C., Porte, D., Seeley, R. J., & Baskin. D. G. (2000). Central nervous system control of food intake. Nature, 404(6778), 661-671. doi:10.1038/35007534

Sodersten, P., Bergh, C., Leon, M., & Zandian, P. (2016). Dopamine and anorexia nervosa. Neuroscience And Biobehavioral Reviews, 60, 26-30. doi:10.1016/j.neubiorev.2015.11.003

Stengel, A.,& Taché, Y. F. (2014). CRF and urocortin peptides as modulators of energy balance and feeding behavior during stress. Frontiers in Neuroscience, 8(52), 1-10. doi:10.3389/fnins.2014.00052

Trainor, B. C. (2011). Stress responses and the mesolimbic dopamine system: social contexts and sex differences. Hormones and Behavior, 60(5), 457–469. doi:10.1016/j.yhbeh.2011.08.013

Treasure, J.,& Campbell, I. (1994). The case for biology in the aetiology of anorexia nervosa. Psychological Medicine, 24(1), 3-8. doi:10.1017/S0033291700026775

Via, E., Soriano-Mas, C., Sanchez, I., Forcano, L., Harrison, B., Davey, C., . . . Cardoner, N. (2015). Abnormal Social Reward Responses in Anorexia Nervosa: An fMRI Study. PLoS ONE, 10(7), 1-20. doi:10.1371/journal.pone.0133539

Volkow, N. D., Fowler, J. S., Wang, G-J., & Swanson, J. M. (2004). Dopamine in drug abuse and addiction: Results from imaging studies and treatment implications. Molecular Psychiatry, 9(6), 557-569. doi:10.1038/sj.mp.4001507

Volkow, N., Wang, G., Maynard, L., Jayne, M., Fowler, J., Zhu, W., . . . Pappas, N. (2003). Brain dopamine is associated with eating behaviors in humans. International Journal of Eating Disorders, 33(2), 136-142. doi:10.1002/eat.10118

Walsh, B. T. (2011). The importance of eating behavior in eating disorders. Physiology & Behavior, 104(4), 525-529. doi:10.1016/j.phybeh.2011.05.007

Zunker, C., Mitchell, J. E. & Wonderlich, S. A. (2011), Exercise interventions for women with anorexia nervosa: A review of the literature. International Journal of Eating Disorders, 44(7), 579–584. doi:10.1002/eat.20862