Thread by @AnorexiaMyths

Okay, let’s go…

#ancelkeys #minnesotastarvationexperiment

The first chapter looks at psychological problems in starvation. Should be relevant to anorexia. Let’s see…

Keys says that while there have been previous, controlled studies into the physical aspects of starvation, never before has anyone scientifically studied the psychological effects.

I suspect they never will again, so this information is invaluable

#minnesotastarvationexperiment

Both overt behaviour and and bodily sensations show marked alterations in starvation. ‘They are repeatedly mentioned in accounts of famine’.

‘…the bond between the physiological status of the organism and the “psyche” is closer than is sometimes realized. The dominance of the “body” becomes prominent under severe physical stress.’

Great quote. Bookmarking that one for later use.

‘In a few variable, such as performance in intellective tests, there was no important relationship to loss of body weight, within the range of semi-starvation in the ME’

This is reflected in people with AN, who often achieve highly academically despite being malnourished.

The changes in the depression score on Keys’ tests ‘during the period of rehabilitation were substantially in direct proportion to the level of caloric supplementation’

Keys caveats all this by saying that personalities differ, every man is shaped by different experiences etc

‘We were surprised again and again to discover how stable the intellective test scores were in the face of severe environmental or metabolic stresses resulting in marked changes in the personality and the emotional status of the subjects.’

‘This indicates… the high resistance of the central nervous system to deterioration’

(This is giving me a lot of food for thought for an article I’m writing on received wisdom.)

Behaviour: Keys again talks about studies into animals and activity, which has been shown time and again to increase just prior to feeding. So hunger makes animals more active. Interesting when we consider compulsive movement in anorexia…

In the next chapter Keys and co talk about behaviour. He notes that ‘in some primitive [direct quote] societies anxiety about food is a potent and persistent cultural factor’.

Keys cites a study from 1939 when Kardiner analysed a particular form of hypochondriasis in the Marquesan Islanders. This was traced to a chronic type of hunger anxiety.

I believe hypochondria is linked to AN in some.

Famine alters behaviour. Keys refers to Morgulis, 1923, who quotes a C13th Russian chronicle:

‘A brother rose against his brother, a father had no pity for his son, mothers had no mercy for their daughters… There was no charity left among us, only sadness, gloom and mourning…’

In Man and Society in Calamity (1942) Sorokin ‘noted that the cognitive processes, beginning with perception, became directed more and more to objects and thoughts connected with the calamity’. In a famine, food became the main topic of writing and conversation.

Cont…

‘It intrudes constantly into the consciousness of the starving and disturbs the association of images and the flow of ideas… The amount of time and energy spent in seeking food increases until the major part of the waking hours are so engaged, directly or indirectly’

So people in a famine spent all their time thinking about food…

Not unlike people with anorexia.

Migration and famine go hand in hand, Keys notes.

There is, of course, a theory that the compulsive movement and exercise some with AN experience is an ancient migration response to starvation.

Keys refers to a study by Benedict et al in 1919 on 12 young men. In a semi-starved state they all had poor tolerance to cold and had to be relieved of swimming exercises because the water in the pool was intolerable.

My daughter loves to swim in cold water. Anyone else?

In the Carnegie Experiment the men ‘became irritable and were easily annoyed’ and were ‘bothered by persistent thoughts about food and eating’.

So persistent thoughts about food and eating are not unique to anorexia. This is normal in starvation.

Now on to the MSE. Each man was given a standardised set of questions. He had to rate eg his irritability from 0-5, 0 being absent, 5 extreme. There was also a complaint inventory, with 53 items eg ‘do you find that you do not particularly desire to mix socially with people?’

The CI required only yes or no answers. The individual score was the number of undesirable responses and the average gave an idea of the overall change for the group. Diaries kept by the subjects were another source of information.

The self eating items that deteriorated the most were:

Tiredness
Appetite
Muscle soreness
Irritability
Apathy
Hunger pain
Ambition
Self-discipline
Concentration

It’s not clear to me if appetite lessened or increased.

After 12 weeks rehab there was a marked improvement in all symptoms.

Tolerance to heat was increased with semi-starvation. Eg ‘subjects could hold hot plates without discomfort’.

I’d be very interested to hear if this is true in general of people with AN. I suspect not from anecdotal evidence.

If there is a difference, why is that?

In the MSE gastrointestinal symptoms were rare. Again, this is very different from people with AN, who often suffer badly in this area.

Some men exhibited anorexic behaviour:

‘Some of them attempted to lose weight in order to obtain increased bread rations… or to avoid reduction in rations…’

They were doing this because of the rules on the MSE, much like someone with AN with AN’s rules.

Super interesting!

The men in the MSE drank a lot of coffee and demanded that food and beverages be very hot.

‘Aristotle reported that warm food was more effective than cold food in counteracting the sensation of hunger’

The men in the MSE ‘attempted to keep the stomach full by consuming large amounts of liquids and felt they were less hungry as a result’

It’s often said that people with AN don’t get hunger cues but I’ve observed my daughter drinking a lot of coffee and water so perhaps they do

Chewing and making inhibited hunger contractions. ‘Both were indulged in by a large number of the Minnesota subjects.’

The hunger drive is not the result of gastric motility, Keys says, as experiments on rats with the stomachs removed show. These animals ‘exhibit behaviour indicative of the strength of the hunger drive which is not different from that of control animals’.

‘…it is certain that the factors stimulating the ebb and flow of food intake must be related to the changing metabolic state’

In fact, Keys differentiates between hunger (‘a dull, aching, gnawing sensation localised roughly in the region of the stomach’) and the ‘appetite’ (‘a craving for food, not referred to any special region of the body’).

Interesting thought.

‘As the starvation progressed, the number of men who toyed with their food increased.’

In one historic example (Freidrich, 1950), the POWs in the Russian hospital where he was sent ‘played with their food for hours’.

This behaviour is common in anorexia.

‘Towards the end of starvation some of the men would dawdle for almost two hours over a meal… To increase the pleasure of eating, they would do much planning as to how they would handle their day’s allotment of food’

The men became intolerant of food waste.

Again this is something I’ve noticed in my daughter.

They quickly became tolerant of previously disliked food and the taste of the v restricted diet ‘increased rather than diminished’ during the 6 months of semi-starvation.

‘Food… became the principle topic of conversation, reading, and daydreams for almost all of the Minnesota subjects… Cookbooks, menus and information bulletins on food production became intensely interesting to many of the men…’

Some of the men changed career plans, making plans to become cooks or to go into agriculture. Keys notes that the men in Greely’s expedition of 1881 expressed a similar desire.

Some men drank 15 or more cups of coffee per day before a limit was set of 9.

‘The cumulative stresses of semi-starvation resulted in emotional instability.’ This included periods of depression which got worse as their weight fell.

Things that lifted their spirits included: good weather, anticipation of an outing.

Curiously ‘feeling “high” was sometimes attributed by the men to a “quickening” effect of starvation or to success in adjusting to the semi-starvation diet.’

This was inevitably followed by a low.

The men became hyper irritable with weight loss. ‘A few has strong urges toward violence, but these were controlled.’

The men became less sociable, spending more and more time alone. They also became self-centred.

The men made odd purchases like old books, second hand clothes they didn’t need and other ‘junk’. They were puzzled by these purchases.

‘Several subjects insisted that they had grown unusually anxious to save money for a “rainy day”…’

Hoarding is normal in a famine.

In the first 6 weeks of rehab the spirits of the men, especially those in the lowest calories, were low. Some became more depressed and irritable than in semi-starvation.

Perhaps the lesson for AN recovery is: dive in. Don’t go slow.

‘Humor, enthusiasm, and sociability progressively reappeared’ with renourishment.

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Sexual feelings declined until they were entirely absent in all but a few men. They stopped dating. After 12 weeks of rehab, these feelings were still low.

Keys muses on this topic:

‘The loss of the sex drive in semi-starvation is not an unmixed “evil”. Biologically it may be considered one of the adaptive mechanisms protecting the individual organism from nonessential energy expenditure’

12 of the men were given a ‘banquet’, on 20 October 1945, after 12 weeks of rehab. They were warned against ‘overeating’, but all couldn’t wait to eat freely. The majority found they could eat far less than expected. Several has stomach pains.

The following week the men ate and slept. Some ate three lunches. They became experimental with their food. The free eating in some led to headaches, gastrointestinal distress and ‘unusual sleepiness’.

Several had spells of nausea and vomiting.

The men continues to obsess about food waste, licking their plates to get every crumb. They showed ‘an irrational fear that food would not be available…’

‘Many Minnesota subjects commented that they were still “hungry”, though incapable of ingesting more food… All the men ate snacks between meals and in the evening’

There wasn’t any particular foods they craved, ‘though milk in one form or another was taken in remarkable quantities’.

The gastrointestinal complaints listed for several weeks. Sleepiness too. Edema was observed in some. By the 20th week of rehab 13 of 28 men had no complaints.

1 man was almost back to normal but still “nervous”.

The men’s hair, which had thinned, was beginning to grow more abundantly’ by week 33 of rehab.

By week 13 of rehab, table manners were returning.

Keys has very high standards: who doesn’t mop up with their bread? Or gnaw meat from the bones? Come on! This is a very English/American view if what’s acceptable!

Cravings after the 12th week of rehab: 10 men craved sweets (ice cream, pastries) and dairy (milk, eggs, cheese) and nuts.

Milk was most frequently mentioned.

‘The men frequently found it difficult to stop eating.’ They ate and ate and ate, especially at weekends, when they had complete freedom.

By the 15th week, the insatiable hunger began to subside a little, although their appetites ‘remained keen’.

By the 20th week ‘the men who remained at the Laboratory were rapidly approaching normal food intakes and were satisfied with progressively less food.’

After week 12 of rehab the men started to obsess less about food. It was no longer the main topic of conversation. One man still hoarded food but another said food waste no longer bothered him.

But by week 15 one said he still felt a “slave” to food, one was still ‘nearly obsessive’ about food waste.

10 subjects reported normal or nearly normal attitudes to food.

By week 20, though, ‘food was still a vital concern and centre of interest for 11 of the 27 men’.

Why are we surprised, then, when someone with anorexia is still engaged in anorexic thinking months after they have put on weight and are eating a proper amount? Physical recovery is slow. And treatment needs to reflect this. And reassurance must be given.

Many people say to me ‘Weight gain made it worse’; ‘I reached a healthy weight but I didn’t get better’ etc.

We are serially neglecting the Time element of the recovery equation.

Time. Time. Time.

By week 33 (so 6 months) ‘the attitude to food has returned in general very close to normal. Food was no longer the significant factor in life.’

Never in my life did I expect to be spending my Saturday mornings reading about starvation…

It is fascinating though.

By week 33 the men reported that their sex drive had returned to normal.

Although a large proportion of men in the MSE felt their judgement had been impaired by semi-starvation, ‘the intellective capacity was essentially unchanged’.

Keys concludes: ‘It was the narrowing of interests, apathy, and lack of initiative in carrying on conversation and study which led the men to conclude that they had suffered actual loss in intellective powers.’

Chapter 40: Personality

This was measured via statistical analysis of questionnaires.

Scores showed a marked increase in hypochondriasis, depression and ‘hysteria’.

‘There was statistically significant elevation of the Psychasthenia* and Schizophrenia scores.’

*phobias, compulsions, excessive anxiety

In semi-starvation ‘the striking feature is the general elevation of the “neurotic” end of the profile’

All changes were reversed with rehab.

Although not entirely at the end of 12 weeks. They were better but the scores were still higher than in the control period.

In the first 12 weeks the men were still in a restricted diet, though higher in calories.

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One case study is of a 24-year-old who had a high standing in the group at the start. By the ninth week he couldn’t stop ‘the whirling ideas going through his mind about “food, food, food” and began to display other signs of a serious personality disturbance.

He tried to turn to God and it helped for a few days. He developed insomnia, shoplifted (stealing trinkets).

He had violent outbursts, wept, talked of suicide and threatened violence. He was released from the experiment and admitted to a psychiatric ward.

‘At this time he presented the picture of a hypo manic: he was overly talkative, emotionally unstable, and somewhat elated.’

Within a few days his symptoms subsided.

Another subject ‘suffered a sudden “complete loss of willpower” while working in a grocery store. He ate several cookies, a sack of cookies and 2 bananas. He was immediately upset emotionally, with nausea, and vomited.

He was also released early.

Another subject showed the usual reactions to hunger at first. By the 9th week he was tense and worrying constantly. He confessed to eating the odd crust of bread which was big part of the experiment, and ‘this troubled him greatly’.

He began to chew gum, up to 50 packages a day. His finances couldn’t sustain this, and at one point he stole gum.

During the last 6 weeks of semi-starvation, his restlessness, guilt and nervousness increased dramatically.

He bought a $10 suit he didn’t need.

His ‘characteristic indecisiveness had become markedly aggravated.’

He developed a ‘compulsive attraction to refuse and a strong, almost impelling, desire to root in garbage cans… some of his behaviour was self-punishing:… he actually ate garbage, a sandwich he found…

on the ground, and a student’s lunch which he had stolen.’

He was released from the experiment at the end of the starvation period. His neurotic behaviour continued. He repeated the cycle of eating a lot, being sick and starting again. He sought psychiatric help.

After some weeks his problems subsided.

WARNING: DESCRIPTION OF SELF HARM

Another man has ‘a pronounced personality deterioration culminating in two attempts at self-mutilation’.

At the end of the first week of rehab he injured his left hand, almost cutting off a finger, and he confessed this was self inflicted.

WARNING: DESCRIPTION OF SELF HARM

He became very depressed. After a visit from his sister he chopped off 3 fingers on his left hand. This was not an accident.

Surprisingly he remained in the experiment

When the rules were broken ‘the subjects’ inefficient and neurotic approach to the solution of the problem of hunger is shown by the fact that those who broke diet are garbage, raw rutabagas, infinitesimal amounts of food, or in other ways attempted to minimise their behaviour…

… and expiate their guilt.

Keys notes that the MSE differs from other experiences of starvation, which are normally the result of war etc. ‘It can be argued… that the strain of starving voluntarily in a land of plenty produces an emotional conflict which in itself could act as a very powerful stress.’

‘Perhaps the outstanding feature in both famine and the Minnesota Experiment is depression and apathy.’

In the MSE ‘the personality alterations were induced by the starvation regimen and reversed by the diet therapy.’

Keys calls this a type of ‘experiental neurosis’.

‘In the rehabilitation phase of the Minnesota Experiment we were surprised at the slow rate of over-all recovery, including… the psychological aspects…’

Keys makes this assumption about anorexia nervosa, which I’d say was entirely wrong:

‘The only known invariable difference between the psychological characteristics of AN and famine is the latter’s continual hunger and absorption with food.’

I haven’t found anything noteworthy on the chapter in AN and most of the commentary seems very outdated. (Like the idea that v few men get AN and women with AN don’t lose breast tissue…)

The largest changes due to starvation in the MSE were observed as follows, in this order, greatest first:

Basal metabolic rate
Hemoglobin
Endurance time
Depression score
Body weight

Once again, the effects of starvation on mental health are shown to be dramatic.

In rehab the group given extra protein had a significant difference (5%) only on the depression score, but Keys dismissed this statistic for reasons I’m not entirely clear about.

In the last para Keys says:

‘In the great majority of starving patients simple foods, taken by mouth in small quantities at frequent intervals, are more than well tolerated; they are usually efficiently utilised and rapidly start the patient on the road to nutritional recovery’

He ends with four quotes on hunger, including this one from Seneca:

‘Non rationem patitur nec aequitate mitigatur nec ulla prece flectitur populus esuriens’

‘Hungry people will not endure reason, they will not listen to justice, nor will they bend to any prayer for mercy’

That concludes my reading of volume 2. I will write this up and post it on my site asap. Thanks for joining me!

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