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 addressed 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 ANOREXIA NERVOSA
First introduced to anorexia nervosa during his psychiatry residency, Dr. Walsh describes being instantly struck by the mind-body problem experienced by those suffering from this condition. He has focused much of his career on trying to figure out “the enigma that is anorexia nervosa.“
While there is a lot that remains mysterious anorexia nervosa, scientific understanding of the disorder has certainly developed over time in no small measure due to Dr. Walsh’s scientific contributions. By investing in asking clear research questions, he has unearthed some important answers. “The first grant I had, which I brought here [to Columbia], was to look at the biological characteristics of reproductive functioning in folks with anorexia and bulimia nervosa. With others, I was trying to parse out if it was weight, behavior, or psychological state that led to a disruption in biology.”
Data from this study contributed to the field’s understanding that the simplest explanation for the biological abnormalities evident in anorexia nervosa was starvation. “You fix that [starvation],” Walsh explains, “and this other biological stuff eventually goes away.” Indeed, scientific research has played a large role in the evolution of theories explaining the development and persistence of anorexia nervosa.
Dr. Walsh describes that when he founded our program in the late 1970s, what existed was largely good descriptive research on the illness (an illness whose presentation, he adds, has not changed in hundreds of years). During the initial ‘psychoanalytic era,’ Dr. Walsh recalls that it was suggested that the cause of anorexia was ‘how mothers brought up their kids very early in life,’ a theory that he found rather farfetched. The ‘hypothalamic era,’ during which a theory of biological abnormality prevailed, was discounted by research studies (including Dr. Walsh’s) indicating that most physiological features of anorexia nervosa could be corrected by refeeding to normal weight.
The next phase was the ‘comorbidity era,’ during which it was believed that eating disorders reflected a unique way of dealing with other problems like depression and anxiety. “It was a reasonable guess because many of these people have symptoms of depression and anxiety, but when we tried to treat patients with anorexia nervosa in particular with psychotherapies or drugs that worked for those others problems, it didn’t keep them well.” Negative findings did not discourage Dr. Walsh. In fact, quite the opposite: “We just had to keep digging, hoping it would help people.”
What was dug up – resurrected, really, from earlier days of researching eating behavior in the laboratory in those with other types of eating disorders – was an interest in eating behavior in anorexia nervosa. Dr. Walsh explains:
I always assumed we couldn’t study eating behavior in anorexia nervosa because these patients were not eating. How can you study what people are NOT doing? But that was naive. It turns out that studying eating behavior is a gold mine – there are a million ways to not do it, and by asking patients to eat you can capture the core of the disorder right in front of you. That’s astounding.
Applying eating behavior theory to anorexia nervosa is how Dr. Walsh arrived at the latest ‘habit hypothesis:’
After 35 years at this, the habit idea is new and compelling. The evidence our group has collected so far suggests that it may well be right. (And if it’s not right, I want to be the one to figure it out.) What’s wonderful is that it’s both psychological and biological – we are trying to determine what part of the brain is engaged by individuals with anorexia nervosa that’s not engaged by other people, but we are assessing this as we look at habits, which are by definition behavioral. Put it another way: we want to understand the basic pattern of how the brain controls behavior in anorexia nervosa.
We’re now attempting to bring the habit hypothesis to life, working with patients with anorexia nervosa in our inpatient program using a therapy that focuses on specific behavior routines and on the emotions that are involved when trying to change these fairly automatic routines. Participants in this study work one-on-one with a study therapist to learn more about their routines and how to change them over the first several weeks of hospitalization. To learn more about the REACH (Regulating Emotions and Changing Habits) approach and our other current research studies, check out the descriptions here.
Photo Credit (front): Creative Commons by Pixabay (johnhain)