By Adele Lafrance, PhD & Reid Robison, MD
Clinicians working with eating disorders are well aware that these conditions can be the most difficult to treat. The stakes are high, as millions of individuals are affected, they have a significant impact on quality of life, and they can be lethal in some cases. While there are a variety of promising treatment options, despite everyone’s best efforts—clinicians, clients, and families alike—too many individuals continue to suffer, even after several courses of treatment. Pharmacotherapy options for eating disorders are also lacking—anorexia nervosa has no Food and Drug Administration–approved medications, and bulimia nervosa and binge eating disorder each have only one recognized option (fluoxetine and lisdexamfetamine, respectively). In severe and enduring cases of eating disorders, palliative care approaches are even considered. There exists an urgency to continue to develop treatment modalities to help address these unmet needs.
There has been a remarkable resurgence of research in the past two decades that supports the therapeutic use of psychedelic medicines in the treatment of emotion-based disorders including post-traumatic stress disorder (PTSD), major depressive disorder, and addictions, to name a few. Psychedelic-assisted psychotherapy is emerging as a promising new treatment paradigm, in which the use of psychedelics, paired with psychotherapy, has the potential to yield significant breakthroughs for individuals with difficult-to-treat mental health conditions, including eating disorders. A number of psychedelic clinical research studies for eating disorders are in preparation or have begun, including emotion-focused ketamine-assisted psychotherapy (EF-KAP) for anorexia nervosa (Cedar Psychiatry by Novamind), psilocybin-assisted psychotherapy for anorexia nervosa (Johns Hopkins University; Imperial College London; University of California, San Diego), and MDMA-assisted psychotherapy for anorexia nervosa and for binge eating disorder (Multidisciplinary Association for Psychedelic Studies).
How Might Psychedelics Help with Eating Disorders?
Though theoretical mechanisms of action of psychedelic medicines are still being investigated, a growing body of research points toward the following ways psychedelics might help individuals with eating disorders in particular: 1) the potential to alleviate symptoms that relate to serotonergic signaling and cognitive inflexibility, and 2) the induction of desirable brain states that might accelerate therapeutic processes.
Classic psychedelics—like psilocybin, LSD, and ayahuasca—are thought to interrupt what is called the default mode network (DMN), which is often considered the neurobiological seat of the “ego” in the brain. The DMN is a collection of pathways that govern our self-image, our autobiographical memories, and our deeply ingrained beliefs and thought patterns. While results from brain imaging studies in eating disorders are diverse, findings seem to converge on a common theme of overactivity in the DMN, showing up in our clients as rumination over caloric intake and food rules, compulsive exercise or eating behavior patterns, body checking, etc. And, like a ski slope, the mind develops and strengthens pathways as we repeat patterns. Every time the thoughts and actions are engaged, the grooves get deeper and deeper, and before long, no matter where we start, we’re likely to slip into the same ruts and end up following the same path down the mountain. When a psychedelic medicine is ingested, the DMN is downregulated, and it’s like the mind benefits from a fresh coat of powder. This fresh coat of powder provides a blank slate—offering a welcome break from the eating disorder patterns, allowing for increased connectivity between other neuronal networks, and creating the potential to move beyond self-imposed limitations that can be so debilitating in those affected. In other words, the individual has the opportunity to travel down a new set of tracks, allowing them to consciously chart a course that isn’t governed entirely by eating disorder thoughts and urges.
Image from: Petri, G., Expert, P., Turkheimer, F., et al. (2014). Homological scaffolds of brain functional networks. Journal of the Royal Society Interface, 11(101):20140873. (Side-by-side images showing the connections made between distinct areas of the brain on psilocybin compared with placebo.)
The second theorized mechanism in support of psychedelics as a treatment tool for eating disorders involves the way in which psychedelics can help foster desirable brain states that might accelerate therapeutic processes. Specifically, the increased neuroplasticity observed with classic psychedelics and ketamine can also be leveraged in the context of psychotherapy. For example, when we use ketamine as a treatment for eating disorders, we schedule psychotherapy sessions within the 24- to 48-hour window of potential for neurogenesis to optimize outcomes. Also facilitative in the therapy setting, MDMA, while not a classic psychedelic, is unique among consciousness-altering substances in its ability to promote acceptance of and empathy for self and others. In addition to elevating oxytocin levels, MDMA stimulates the release of the monoamines serotonin, norepinephrine, and dopamine, resulting in an improved mood and increased sociability. Brain imaging after being administered MDMA shows decreased amygdala activation, and the reduced fear response that follows allows the client to emotionally engage in therapy without becoming overwhelmed by anxiety or negative affective states. As of September 2020, the Multidisciplinary Association for Psychedelic Studies is conducting phase 3 trials of MDMA-assisted psychotherapy for treatment-resistant PTSD, under the FDA’s breakthrough therapy designation, and the results are quite striking. An analysis of phase 2 data showed that at 12-month follow-up, 67 percent of participants no longer met criteria for PTSD.
“I’m tempted to say MDMA gave me ‘hope,’ but that word isn’t right—the insight was more substantive than hope. I’d held the sensation in my body; I understood, at a visceral level, what might someday be mine: the sense of peace and joy within my body. For me, the therapeutic process could unfurl from there.” —MDMA participant
We’ve also been analyzing data gathered from interviews of individuals with eating disorders who participated in ceremonial ayahuasca use. When asked to describe the positive effects of this traditional Amazonian tea, similar themes emerged in that individuals shared that participation led to an ability to face and work through challenging emotions and memories. They also reported decreases in symptoms of anxiety and depression, including urges to self-harm and suicidal ideation.
“I still experience periods of feeling anxiety, but I feel like they don’t last as long, whereas before, I would spiral downward and get depressed and then start to restrict and start to purge and binge and all of that. I feel like I can notice when my energy is changing, and then I am more able to be with it and sort of resist it, and then it moves after.” —Ayahuasca participant
Several respondents also shared that they benefited from increased capacities for mindfulness, improved body image, and strengthened relationships with important others, including a new or deeper connection with nature and/or God or Spirit. Participants even described an “embodied knowing” of self-love, where they were able to recognize from a deeper place that: “I am worthy. I am beautiful as I am inside and out”—a powerful antidote to the harsh inner critic so common in eating disorders.
“I seem to think about myself and talk about myself a lot more kindly than I previously did. And I’m a lot gentler [to myself].” —Ayahuasca participant
Family-Based Psychedelic Medicine for Eating Disorders
One of the unique facets of treatment in the field of eating disorders is the recognition of the importance of caregiver involvement. Thanks to several different lines of research, and the tireless efforts of parent advocacy groups, contemporary approaches to eating disorder treatment have evolved to include families as active supports in the recovery process. Recent research outcomes have confirmed the benefits of carer involvement, including improved outcomes for both the sufferer and their family members, and it is our goal to continue this important work in the context of psychedelic psychotherapies for eating disorders.
To do so, we propose three models of family-based psychedelic medicine. The first model involves the recruitment of caregivers who learn specific skills to support their loved one throughout the course of psychedelic-assisted psychotherapy, creating an optimal home environment for healing and growth, and reducing the likelihood of problematic interactional patterns that could inadvertently maintain symptoms. For example, in the context of our study examining the safety, feasibility, and preliminary outcomes of EF-KAP, an identified caregiver (partner or parent) attends the preparation session with their loved one to learn about the model, and offers support during the medicine sessions. They also learn skills to assist their loved one with emotion processing throughout the treatment protocol and beyond. We are using a similar protocol in the context of MDMA-assisted psychotherapy for eating disorders, in which caregivers will learn emotion coaching skills and participate in preparation and integration sessions to create a bridge from the therapy session to life at home.
“It’s been really great to have him [spouse] involved. He’s using the techniques he learned, and it feels really good.” —EF-KAP participant
The second model involves the recruitment of caregivers who participate in medicine sessions alongside their loved one, thereby leveraging the neurobiological bond in order to deepen the process of healing and growth, including attending to problematic relational patterns and old injuries, if relevant. In fact, it is our hope that in the not-so-distant future, we can develop and research a treatment protocol where the family of an adult who is struggling with an eating disorder can participate in psychedelics-assisted family therapy to support the recovery process. Our colleagues who have had the opportunity to facilitate this type of treatment prior to the classification of MDMA as a Schedule I Controlled Substance have shared with us incredible stories of hope and healing. It also creates opportunities for systemic healing, including the transformation of intergenerational cycles of pain.
The third model involves caregivers who participate in psychedelic-assisted psychotherapy on behalf of their loved one, who, for medical or psychiatric reasons, cannot participate themselves. We’ve known of a woman (Anne) whose daughter (Heather) suffered from what would be considered a treatment-resistant eating disorder. They had participated in several specialized eating disorder treatment programs, at various levels of care, but with little improvement and growing despair. Anne thought that perhaps the plant medicine ayahuasca could help Heather get a break from the eating disorder—at least temporarily—and maybe even offer new hope for eventual recovery. Unfortunately, however, Heather was ineligible to attend the out-of-country retreat due to medical instability. Her mother made the decision to attend on her daughter’s behalf, as a surrogate healer. She shared that it was an incredibly powerful experience—that the ayahuasca ceremonies helped her to understand her daughter’s suffering in a new way, including what Heather needed from her to face her fears around food and weight. She went home with a new perspective and far more energy to keep up the fight for recovery, as the retreat also afforded her a much-needed opportunity to rest and recharge.
We’ve witnessed time and time again the extent to which the field is made up of caring, compassionate, and hardworking clinicians working hard on behalf of those suffering and their families. And one thing we can all agree on is that despite our best efforts, there remains a need for innovative treatment strategies to serve those for whom conventional treatments have been insufficient, ineffective, or even harmful. Although much more research is needed to better understand the safety and efficacy of psychedelic medicines in eating disorders, we feel it is a very worthwhile pursuit. One thing is clear to us, however, and that is the importance of coordinating these efforts with conventional treatment approaches. By doing so, we can build on the decades of research and clinical practice that have shaped treatment delivery across the spectrum of eating disorders, including psychedelic psychotherapy as another treatment ingredient for those for whom it might be appropriate. We have tremendous hope that psychedelic medicine can alleviate suffering for many along the continuum of recovery, as well as for their families, and we look forward to sharing the results of our studies as they become available.
About the authors:
Adele Lafrance, PhD, is a clinical psychologist, research scientist, and author. She is co-developer of Emotion-Focused Family Therapy. Adele is a leader in the research and practice of psychedelic medicine, with a focus on ayahuasca, MDMA, and psilocybin. She is the clinical investigator and strategy lead for the MAPS-sponsored MDMA-assisted psychotherapy study for eating disorders and a collaborator on the Imperial College study for psilocybin and anorexia nervosa. She is also co-developer of Emotion-Focused Ketamine-assisted Psychotherapy. Adele has a particular interest in mechanisms and models of healing, including spirituality, emotion processing, and couples and family therapy.
Reid Robison, MD MBA, is a board-certified psychiatrist and Chief Medical Officer at Novamind, an organization focused on evidence-based psychedelic treatments. Reid serves as Medical Director of Center for Change, an Eating Disorder treatment program in Utah. He is the co-developer of the Emotion-Focused Ketamine-assisted Psychotherapy model. Reid is currently the coordinating investigator for the MAPS-sponsored study MDMA assisted psychotherapy study of eating disorders. As an early adopter and researcher of Ketamine in psychiatry, Reid led a pivotal ketamine study leading up to the FDA-approval of Spravato. To date, Reid has guided thousands of ketamine therapy journeys and hundreds of Spravato dosing sessions and provides medical support and psychedelic therapy at plant medicine retreats abroad.
Buckner, R. L., Andrews-Hanna, J. R., & Schacter, D. L. (2008). The brain’s default network: Anatomy, function, and relevance to disease. Annals of the New York Academy of Sciences, 1124, 1-38
Carhart-Harris, R. L., & Friston, K. J. (2010). The default-mode, ego-functions and free-energy: A neurobiological account of Freudian ideas. Brain, 133, 1265-1283.
Carhart-Harris, R. L., & Friston, K. J. (2019). REBUS and the anarchic brain: Toward a unified model of the brain action of psychedelics. Pharmacological Reviews, 71(3), 316-344.
Collo, G., & Merlo Pich, E. (2018). Ketamine enhances structural plasticity in human dopaminergic neurons: Possible relevance for treatment-resistant depression. Neural Regeneration Research, 13(4), 645-646.
Duman, R. S., Li, N., Liu, R. J., Duric, V., & Aghajanian, G. (2012). Signaling pathways underlying the rapid antidepressant actions of ketamine. Neuropharmacology, 62(1), 35-41.
Goddard, E., Macdonald, P., & Treasure, J. (2011). An examination of the impact of the
Maudsley Collaborative Care skills training workshops on patients with anorexia nervosa: A qualitative study. European Eating Disorders Review, 19, 150-161. doi:10.1002/erv.1042
Griffiths, R. R., Johnson, M. W., Richards, W. A., Richards, B. D., Jesse, R., MacLean, K. A., Barrett, F. S., Cosimano, M. P., & Klinedinst, M. A. (2018). Psilocybin-occasioned mystical-type experience in combination with meditation and other spiritual practices produces enduring positive changes in psychological functioning and in trait measures of prosocial attitudes and behaviors. Journal of Psychopharmacology (Oxford, England), 32(1), 49-69.
Hysek, C. M., Schmid, Y., Simmler, L. D., Domes, G., Heinrichs, M., Eisenegger, C., Preller, K. H., Quednow, B. B., & Liechti, M. E. (2014). MDMA enhances emotional empathy and prosocial behavior. Social Cognitive and Affective Neuroscience, 9(11), 1645-1652.
Jerome, L., Feduccia, A. A., Wang, J. B., Hamilton, S., Yazar-Klosinski, B., Emerson, A., Mithoefer, M. C., & Doblin, R. (2020). Long-term follow-up outcomes of MDMA-assisted psychotherapy for treatment of PTSD: A longitudinal pooled analysis of six phase 2 trials. Psychopharmacology, 237(8), 2485-2497.
Lafrance Robinson, A., Dolhanty, J., Stillar, A., Henderson, K., & Mayman, S. (2016).
Emotion-focused family therapy for eating disorders across the lifespan: A pilot study of a two-day transdiagnostic intervention for parents. Clinical Psychology & Psychotherapy, 23, 14-23. doi: 10.1002/cpp.1933.
Ly, C., Greb, A. C., Cameron, L. P., Wong, J. M., Barragan, E. V., Wilson, P. C., Burbach, K. F., Soltanzadeh Zarandi, S., Sood, A., Paddy, M. R., Duim, W. C., Dennis, M. Y., McAllister, A. K., Ori-McKenney, K. M., Gray, J. A., & Olson, D. E. (2018). Psychedelics promote structural and functional neural plasticity. Cell Reports, 23(11), 3170-3182.
Müller, F., Dolder, P. C., Schmidt, A., Liechti, M. E., & Borgwardt, S. (2018). Altered network hub connectivity after acute LSD administration. NeuroImage: Clinical, 18, 694-701.
Palhano-Fontes, F., Andrade, K. C., Tofoli, L. F., Santos, A. C., Crippa, J. A., Hallak, J. E., Ribeiro, S., & de Araujo, D. B. (2015). The psychedelic state induced by ayahuasca modulates the activity and connectivity of the default mode network. PLOS One, 10(2), e0118143.
Steward, T., Menchon, J. M., Jiménez-Murcia, S., Soriano-Mas, C., & Fernandez-Aranda, F. (2018). Neural network alterations across eating disorders: A narrative review of fMRI studies. Current Neuropharmacology, 16(8), 1150-1163.
Originally appeared on Eating Disorders Resource Catalogue (01/23/2021).