Bryan LaskBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i29 (Published 05 January 2016) Cite this as: BMJ 2016;352:i29
- Janet Fricker, Hemel Hempstead
Bryan Lask, a child psychiatrist who worked at London hospitals Great Ormond Street, and St George’s, did much to reduce the stigma associated with anorexia nervosa by promoting his theory of neurobiological deficits. Lask also established the first European clinic dedicated to the treatment and research of childhood onset eating disorders, described the natural history of anorexia in children, and was the driving force behind defining a battery of neuropsychological assessments for anorexia.
“Bryan had a pivotal role in the generational shift in thinking that took eating disorders away from being a psychosocial problem,” said Ian Frampton, Lask’s research collaborator for many years. The movement took the blame away from parents who had been held responsible for causing anorexia by the way they fed or looked after their children. Lask and his collaborators (including Frampton, Isky Gordon, and Ken Nunn) believed that children developed anorexia not because of anything they or the family had done, but because of an underlying neurological disposition.
Lask was a born communicator, memorably describing the insula (also known as the insular cortex, a brain structure featuring prominently in his anorexia research) as the “Clapham Junction of the brain”—that is, the structure affecting all the different brain areas involved with anorexia. “His strength was the fact he wasn’t an academic neuroscientist. He’d tell us when we were talking complete gobbledygook and articulate theories in language everyone could understand,” said Frampton, now a clinical psychologist at the University of Exeter.
Rachel Bryant-Waugh, another long term collaborator at Great Ormond Street, said, “Bryan had an extraordinary knack to make things happen. His enjoyment of the pursuit of knowledge was infectious, and at times he was like a child in a sweetshop cramming too many sweets into his mouth.”
Lask’s interest in eating disorders started in 1975, when he was appointed as a consultant at Great Ormond Street on the Mildred Creak unit for children with mental health problems. It was here in the early 1980s that he encountered Bryant-Waugh, then a junior psychologist, who had the temerity to challenge his dictatorial approach to families. “When I asked why he was so bossy he replied he wasn’t sure, and we agreed we should do some research,” she remembered.
Together Lask and Bryant-Waugh described the first large series of 48 children younger than 14 years with anorexia nervosa, including 15 boys.1 The existence of the condition in children before puberty gave lie to the idea that this was a disease of adolescence. The following year the team described the long term follow-up (mean 7.2 years) of a different cohort of 30 children and showed that 10 remained moderately to severely impaired, and two had died.2 “It highlighted that children could and did get serious eating disorders,” said Bryant-Waugh.
In 1985 Lask and Bryant-Waugh established the first clinic specialising in childhood eating disorders and went on to collaborate on books for clinicians and parents including Eating Disorders in Childhood and Adolescence (currently in its fourth edition) and Eating Disorders—A Parent’s Guide (currently in its third edition). “Bryan has probably treated and helped more young people with eating disorders than anyone else in the UK,” said Bryant-Waugh.
Around the same time Lask—with Isky Gordon, a paediatric radiologist—embarked on a series of brain imaging studies of children with anorexia. Although Lask initially dismissed the project as “a waste of time,” they were able to demonstrate with positron emission tomography that specific regions of the temporal lobe had less blood flow.3 When rescanned 18 months later (after gaining weight) the children showed the same blood flow abnormalities.4 “It’s a testament to the quality of the relationships Bryan had with these families that he ended up with more than 40 families willing to have their children scanned,” said Frampton.
Together with Nunn, Gordon, and Frampton, Lask went on to develop the neurobiological theory focusing on the insula as central to the development of eating disorders. In 2008 they wrote a paper based on the hypothesis that anorexia was the result of an underlying dysfunction of neural networks converging on the insula.5 According to their model young people with suboptimal functioning of networks passing through the insula were predisposed to anorexia nervosa if they had underlying risk factors including sociocultural pressures. Towards the end of his life, Lask started to explore whether anorexia nervosa in children might be addressed through cognitive remediation techniques to strengthen and redefine neural circuits.6
Bryan Lask was born in Leeds in 1941, the oldest of three brothers in a Jewish family. His father, three paternal uncles, and one brother were all doctors. The family moved to Ealing, London, when his father Aaron—who was interested in psychosomatic medicine and wrote a book entitled Asthma, Attitudes, and Milieu—set up in general practice. Lask attended St Paul’s School, where he excelled in swimming and water polo but struggled with physics. He scraped into St Bartholomew’s medical school after achieving 49% on his third attempt at physics A level, and was admitted only on the seasonal good will of Joseph Rotblat, the professor of physics. “You obtained 49%, but as Christmas is approaching we’ll call it 50%,” the future Nobel laureate told him.
Academically Lask did not fare much better at medical school, where he had to re-sit finals in surgery, obstetrics, and gynaecology. “He wasn’t proficient in any subject and gravitated to psychiatry by default. To his complete surprise he turned out to be spectacularly good at it,” said his oldest son, Gideon.
It was while doing his specialist psychiatry training at the Maudsley in 1972 that Lask met his wife, Judith, a trainee social worker who later specialised in family therapy. In 1977—when Gideon was two years old and Judith pregnant with their second son, Adam—Bryan was diagnosed with bowel cancer. “His brush with mortality gave him a sense of purpose. He always assumed that he wasn’t going to live long and was determined to do as much as he could with the time he had left,” said Judith.
With his hectic schedule (travelling most weeks to meetings) and boundless energy, few colleagues appreciated Lask had a stoma and was living with the complications of radiotherapy. “Over the years he must have had at least 40 surgical revisions,” said Judith.
For Lask the experience prompted him to explore the psychological effects of stoma in children.7 He also looked at the psychological impact of cystic fibrosis and cardiac surgery in children, and undertook a controlled study showing family therapy benefited children with asthma. In 1991 he published the first clinical description of pervasive refusal syndrome, a condition in which children abandon their involvement in all functions of life including refusing to eat, drink, and talk.8 “Bryan always contended that you couldn’t separate the mind from the body and believed there was a need to provide psychiatric support to children with chronic diseases,” said Bryant-Waugh.
Lask wrote more than 10 books, edited the Journal of Family Therapy, founded the journal Clinical Child Psychology and Psychiatry, and cofounded Advances in Eating Disorders. He and Bryant-Waugh launched the London International Eating Disorders Conference, and in 1993 he was instrumental in persuading Princess Diana to address the meeting. It was after this event it became widely known that she had bulimia.
After retiring from the NHS (his last position was at St George’s) Lask was headhunted for the post of research director at the regional eating disorders service in Oslo in 2004, with the remit to set up an eating disorders service and associated research programme. “It was a really seductive offer with research money no object. It gave Bryan the luxury of taking an overview of the area and plenty of access to functional magnetic resonance imaging facilities,” said Frampton.
While in Oslo Lask became involved with the Ravello Profile to define a common shared neuropsychological assessment battery for children with anorexia, “Our concept was that if all researchers used the same psychometrics and tasks, it would be much simpler to compare results and establish patterns of difficulties,” explained Frampton.
Two years ago Lask’s bowel cancer returned. “Up until August he was still supervising research and doing Skype calls,” said Judith. In his last few months he was cared for at home by a palliative care team, his two sons, and Judith, whom he had divorced in 2007. In his valedictory editorial Lask railed against “the obligatory box ticking exercise,” and professional rivalry, when proponents of specific treatments criticised studies that did not support their own favoured modality. He ended by saying “compassion is a powerful component of our ‘pharmacopeia.’”9 That Bryan Lask had in spades. He leaves his ex-wife, and two sons.
Bryan Lask (b 1941; q St Bartholomew’s Hospital Medical School 1966), died from bowel cancer on 24 October 2015.
Cite this as: BMJ 2016;352:i29
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