Why Cognition Only Goes So Far

http://www.latimes.com/news/opinion/commentary/la-oe-wood-neal-habits-dieting-bloomberg-20130809,0,5731193.story

“Habitual behavior implicates parts of the brain that have relatively sparse connections to other brain areas involved in conscious decision-making (willpower) and goal setting. In effect, our bad habits represent neural islands, pretty much cut off from our thoughtful planning. We really can be of two minds — knowing and wanting to do the right thing but also unconsciously driven by habits triggered by the everyday contexts in which we live. In other words, willpower has limited command over our habitual mind. On top of that, exerting it is arduous, unpleasant and hence typically short-lived.”

Behavior is multi-determined. We can know what to do and then not do it. This applies to eating, relationship choice, and career decisions. Today’s LA Times Op-Ed article about changing eating patterns by Wendy Wood and David Neal outlines this issue. Understanding the depth of the human brain allows us to appreciate the complexity of behavior change. Merely understanding that eating too much sugar is “bad for your health” does not address the other brain structures which trump this understanding. These other brain areas can be habit areas, where our brains work on auto-pilot, or they can be in deep emotional areas where we want immediate satisfaction at the expense of long-term problems. Our brain is in constant conflict with itself, thereby giving us conflict in decision-making. We must balance out routines that are familiar, with the anxiety of a new activity. For some, this anxiety is coded as excitement and so fresh experiences are constantly wanted. For others, the comfort of sameness is more important than a new adventure. For most of us, we seek a balance, but finding this balance is the art of living. How do we enjoy food, without eating to excess? How do we not use food, as an outlet for sensual gratification? Understanding the basics of nutrition does not address the deeper meanings we attribute to the act of eating. These “neural islands” as stated above, describe how a person can be at war with himself. Psychotherapy attempts to bring these islands together to form a continent of understanding and awareness. Behavior can change, but not quickly, and not without harnessing all of the factors that go into that behavior. Cognition is only one piece.

Re-Posting Since I Did A Repeat Performance: Teaching about Anorexia Nervosa

        “The young woman is looking for some sort of control over her life,” I say to fourth-year medical students, as a way to help explain the self-destructive behavior that might underlie Anorexia Nervosa. “What does she say when you ask her about how it feels to have control over her life by not eating,” an eager, soon to be primary care physician asks me. “Well, she would deny the experience. She would say that she does not have a problem; that her parents are overly concerned and they always have been. Her denial of her problem, stimulates a question about what is going on, on a deeper level of her brain. This leaves us, the clinician, to speculate that it is possible that on an unconscious level, there is a positive affirmation in her starvation, in her ability to control her bodily urges.” I say, wondering if these future physicians are looking at me glassy-eyed because they are tired or because I am not explaining the unconscious very well, or both. “So, what is a primary care physician supposed to do?” Another eager and enthusiastic fourth-year medical student, interested in Internal Medicine, asks me. “Well, as with so many complicated diseases, the primary care physician, needs to shepherd the patient through the health care system. The patient will need monitoring of her electrolytes, her weight, her blood pressure. She will also need to see a nutritionist, along with, a mental health provider. The primary care doctor needs to coördinate care; provide the patient with a “medical home,” the new buzz phrase. The student looks at me with recognition, maybe a little embarrassment that the answer was obvious, and yet because we are dealing with mental health issues, the clarity of the situation gets blurred.

      I am back to wondering my age-old question. Do medical students, our future physicians, need to understand human behavior? If so, what is the best way to teach them? If not, should their psychiatry curriculum be limited to psychopharmacology? My answer is clear. A major challenge in being a physician is to help people, help themselves. Understanding how patients get in their own way is critical to helping all patients stay on a good path. This seems both obvious and neglected.

Weight Watchers

  Theresa, seventy, fifty pounds overweight, the subject of Friendly Fire,https://shirahvollmermd.wordpress.com/2010/01/23/friendly-fire/, seeing me consistently for ten years, says “I don’t know why I resisted weight watchers for all these years. I am doing it now and it is the best part of my life.” “No kidding,” I reply, thinking over the numerous discussions we had about how she can help herself with her weight problem.  “I go there,” she continues enthusiastically, “and I feel like I have a loving family.” Fellowship, I think, is the strength of these meetings.

   Blue, fifty-three, a patient of mine for three years, seventy pounds overweight, refuses to go to weight watchers, saying “I know what to do, I just don’t do it.” “Yes,” I respond, ” but Weight Watchers can help keep you focused.” “Well, I don’t think so,” she responds, as if we are in an argument. Persuasion, the art of it, is not often my job, but sometimes I think about how people can help themselves if they become more open to new experiences. Pre-conceived notions, resistances, get in the way, and sometimes these resistances are more rigid; other times there is an opening. I recognize with Blue that the feeling of being in a fight signals that the resistances are strong in this moment. I wonder if Blue will be like Theresa, wondering ten years from now, why she did not go sooner.

   Like antidepressant medication does not help every depressed person, Weight Watchers is not  helpful for everyone with a weight problem. Yet, everyone with a weight problem could go once to see  how it feels; to see if they think it is worth their time and money. Having said that, I am mindful of the emotional risk of trying to lose weight; fearing that a failed attempt will just make things worse psychologically speaking. Like a child who does not study for a test so that he does not feel bad if he does not do well, many people with weight problems prefer to avoid their food issues, rather than chance feeling like a failure. Appetite suppressanst and/or liposuction can be attractive because with these interventions, it is the procedure that failed, not the person.

    Weight is so interesting to me-the obvious mind/body connection. The meaning of food, the meaning of eating, is so rich with conscious and unconscious experiences. Food is an personal experience, a family experience and a social experience. The value we place on eating, the types of foods, the portions of food are all driven by biology, culture and emotional states. How these three factors are woven together define our relationship to our body and to our mind.

    Theresa knew that she would feel better if she lost weight. She also felt lonely and food gave her comfort. Simplistically speaking, now that she has found comfort with her new “family” she has less of a need to comfort herself with large portions of food. I say simplistically speaking because on the one hand I know it might be more complicated than that, but on the other hand, I wonder if it is as simple as that. In other words, Theresa needed a “family” to motivate her to take better care of herself. For reasons that are not clear to me, she joined Weight Watchers at a time in her mental life where she was open to having a new “family”. By contrast, Blue is in a scared place, a closed mental space, such that she is not emotionally ready to try new ways to tackle her weight problem. How much I wait for her to open up in her own time, and how much I push her to reconsider her decisions is the art of my job. Seeing Theresa’s turn with her eating, along with a turn in her mental state, makes me want to push Blue a little harder. At the same time, maybe I should let Blue change the subject; maybe I should respect her resistance. Dilemma.

Feeling Stuffing

   Peter, https://shirahvollmermd.wordpress.com/2010/02/28/seeming-sad/http:/ /shirahvollmermd.wordpress.com/2010/03/09/seeming-scared/, a sixty-four year teacher, with chronic weight issues returns to his weekly appointment. “You know, you said something last week which was so obvious, and yet for the first time in my life, I really began to understand what it meant.” I look at him, not sure what he is referring to. He continues. “You told me that I stuff my feelings, quite literally. I use food to avoid my feelings. I know that, but somehow last week that really began to mean something to me.” I feel good that my words had an impact, but I am also confused about exactly what made my words stick like that.

    Peter has multiple health problems, many weight-related. To be a healthy weight, Peter needs to lose about forty pounds. Yet, talking about weight is very delicate. The edge of shame is close to the surface. I have tried behavioral recommendations such as weight watchers or consulting with a nutritionist  but Peter says “I know all that.” Looking for the underlying dynamics of eating seems ripe for a deep understanding of Peter’s mind, if we can find a way to think about his eating together without increasing his defensiveness.

    We talk about his childhood as a military brat, moving around a great deal; always having to make new friends. “When you moved, did you tell anyone how hard that was for you?” I wonder aloud. Peter looks at me, as if surely I have no idea where he comes from, and says “are you kidding, it was hard on all of us, but we could never talk about it.” “I suppose your family was concerned that talking about losing relationships would make people sad or lonely and so in your family, as in many military families, the general belief is that if you don’t talk about it, then you won’t feel it.” “Yes,” Peter says “we had to stuff our feelings.”

    “‘ When you say ‘stuff’ your feelings, that  reminds me of stuffing food down, where eventually you just feel physically sick,” I say. “You go from feeling emotionally ill-at-ease to physically ill,” I continue. Peter stares at me, as if I had said something interesting, but he is not sure how to respond. “I will see you next week” I say. The mind/body connection strikes me. Eating issues is the arena where this connection is so obvious. Hunger changes our mental state, as does eating. Our mental state influences our eating behaviors. The bidirectionality is clear, and yet, easy to forget.

      For Peter, connecting his overeating with his history of multiple losses associated with his family moves, along with his inability to express his feelings to his family of origin, seemed to lead to a pattern of behavior where difficult feelings had to be “stuffed.” In this context, Peter was not ashamed of his weight; rather, he could understand how despite his good judgment in most areas of his life, when it comes to eating, he was responding to his emotional state and not to his frontal lobes; the area of the brain responsible for thought and executive decision making. Harnessing his frontal lobes in his food choices is his goal. Understanding his emotional state, not “stuffing”,  is the first step.