A Conversation with Dr. B. Timothy Walsh
I recently had the privilege to sit down with B. Timothy Walsh, MD, the founding director of the Columbia Center for Eating Disorders (then called the Eating Disorders Research Unit) at the New York State Psychiatric Institute. A research psychiatrist who’s currently in charge of the Division of Clinical Therapeutics in Columbia University’s Department of Psychiatry, Dr. Walsh has been studying eating disorders and related conditions for over three decades.
His perspective on the field of feeding and eating disorders (past, present, and future) is invaluable as we – clinicians, researchers, patients, and families – seek to raise awareness about these conditions, particularly this week, and strive for answers to questions that remain unanswered.
Part 1 of the interview broadly addresses the topics of eating disorders research and treatment.
Part 2 provides an overview, in historical context, of research on anorexia nervosa, including a description of our latest studies.
Part 3 will cover research on bulimia nervosa, binge eating disorder, and obesity. In this segment, Dr. Walsh will also weigh in on DSM-5 (the most recent version of the diagnostic manual for mental disorders used by clinicians nationally) and make some predictions for DSM-6.
ON RESEARCH
Why does scientific research matter? It’s a basic question, certainly, but for those of us at the Columbia Center for Eating Disorders dedicating our energy to the pursuit of answers for all kinds of questions, it’s absolutely where we must start.
According to Dr. Walsh, there are two fundamental reasons that research matters. First, “knowledge is important and provides power.” And second, “knowledge about illnesses should improve their treatment.” He elaborates:
The more we know about our world and the things that afflict us, the smarter we are and the smarter the world is. Pragmatically, when it comes to human disease, the more we know, the more able we should be to make the illness go away, to help people get better. We will not get to effectively treat the most serious of mental illnesses, including anorexia nervosa, unless we understand them better.
Persuading patients to seek help from a research program is not always an easy sell. While many patients welcome the opportunity to make a contribution to science and help further our knowledge about eating disorders, others are concerned about what it will mean to participate in this mission.
If someone is need of treatment, why should he or she consider going to a research hospital?
Dr. Walsh worries that a lot of the treatment currently provided is based more on “what feels good, instead of data—of evidence it really works.” Such an approach to treatment, though not without value, may “burn time and money” for individuals in need of help.
Clinicians at a specialty research program, according to Dr. Walsh, uniquely focus on both what is known and what is unknown. He explains, “These clinicians know what’s known…They are very well equipped to deliver treatments that are known to be useful and to be honest about the approaches that we think may be useful despite not yet having proof.”
ON TREATMENT
To patients or families of individuals suffering from an eating disorder seeking treatment, Dr. Walsh offers a hopeful message:
These are absolutely treatable disorders. They are primarily behavioral disturbances, and humans are capable of changing behavior. It’s hard, a lot of work, but absolutely possible. The brain is not broken – it may have become accustomed to do things in a certain way, molded to fixed patterns of behavior, but with training, humans can be flexible.
Eating disorders treatment research, which according to Dr. Walsh has historically borrowed ideas from other areas of mental health, has been critical in building an evidence base for some therapeutic approaches and in demonstrating that other approaches aren’t actually all that helpful.
For bulimia nervosa and binge eating disorder (which will be discussed in more detail in Part 3 of this series), Dr. Walsh explains, “when researchers began to apply treatments for anxiety and depression it directly led to the knowledge we now have that cognitive behavioral therapy is a good treatment, interpersonal psychotherapy is not a bad treatment, and antidepressants can be very helpful medications.”
Anorexia nervosa treatment research, to be described in depth of Part 2 of this series, has taken a less linear path. Dr. Walsh offers an example of one important bend in the road:
Does Prozac help treat anorexia nervosa? That was a very important treatment research question and we got an answer. A negative answer – that it neither helped folks during weight gain nor in preventing relapse once weight-restored – but that was a very important negative answer. It should mean that doctors should not get excited about prescribing antidepressants for this illness. You can if you want to–there’s no evidence that it hurts– but no evidence that it helps either.
So how can people with eating disorders overcome their illness?
According to Dr. Walsh, the particular components of a helpful treatment will vary by diagnosis and circumstance but targeting behavior will be a critical piece of the puzzle. He explains that psychotherapy, especially behavioral approaches, “allow people to come aware of things that they do that are not good for them and give them the chance to develop alternatives. And it helps them understand what factors cue up the behavior – sadness, a bad day, a drink. Awareness and insight are critical.”
Dr. Walsh believes that by being encouraged to imagine other possible reactions to cues, individuals are brought a critical step closer to making changes. “It’s not complicated,” he states, “it’s just difficult.” Fortunately, Dr. Walsh and other researchers nationwide are dedicated to learning how to make it easier.
For more information on taking a step forward towards recovery at our research program, please call us at 646-774-8066.
Photo Credit (front): Creative Commons by Pixabay (Geralt)
I agree with much of what you have said–particularly the part about many treatments having lack of evidence. What I am unclear about is your feeling about the brain not being “broken.” How does this jibe with the emerging genetic evidence and what we are learning from Functional MRI studies?
A perceptive question… We thank you. Dr. Walsh’s response:
“The ‘broken brain’ term was probably not ideal. But, here’s how I tend to think about Anorexia Nervosa. People develop this disorder for reasons we do not understand well at all. However, it seems likely that innate psychological and behavioral tendencies are predisposing factors, like a tendency to be a bit obsessional. And, it is likely that some of these tendencies are genetically determined and therefore ‘hard-wired’ in the brain.
But, I don’t think Anorexia Nervosa is similarly hard-wired. Certainly, brain activity is different from normal, but my hunch is that such differences are malleable with enough effort. The only way to change behavior is to change brain activity, and folks with Anorexia Nervosa can change their behavior, and how they view food and weight. The crude contrast would be to an illness such as Alzheimer’s Disease where there are structural changes in the brain that cannot be changed.
Hope that clarifies.”
[…] Although anorexia nervosa, bulimia nervosa, and binge eating disorder are the most well-known eating disorder diagnoses, many people struggle with eating problems that fall into an ‘other’ eating disorder category (referred to as OSFED, which stands for other specified feeding and eating disorder). In fact, historically, most people with eating disorders have fallen under this classification. To have an ‘other’ eating disorder does not mean that your symptoms are not significant, potentially dangerous, or worthy of clinical attention. It simply means that not quite as much is known about these conditions and that more research is needed. […]
[…] written previously about Dr. Walsh’s distinguished career and the evolution of his thinking about eating […]