Most abide by the belief that some combination of genetics, culture, and family dynamics contributes to the development of eating disorders: society is the gun, genetics loads the gun, and the family pulls the trigger. Unfortunately, many afflicted individuals and their families have lived with a negative stigma associated with this disorder. Until recently, most research had been devoted to the sociological contributing factors to the disorder, highlighting the role that family can play in the development of eating disorders. Consequently, too much blame has been unduly placed on families. Leading research in the field is now turning towards genetic and neurobiological contributing factors.

Researchers at the University of California, San Diego Medical Center are looking at how the brain may contribute to the development of the disease Anorexia Nervosa (AN). Walter Kaye, Director of the Eating Disorders Program at UCSD, and his colleagues found that behavioral commonalities amongst those affected point to the possibility of underlying neurobiological factors: “They often become sick around the same time (early adolescence), show similar symptoms and behaviors, and are mostly females. They typically resist eating and engage in a powerful pursuit of weight loss, yet paradoxically are obsessed with food and eating rituals. Even when underweight, they tend to see themselves as fat and deny being underweight. They tend to resist treatment and lack insight about the seriousness of the medical consequences of AN.”

So is this eating disorder really a brain disorder? Anorexia patients exhibit reduced brain volume, altered metabolism of brain regions known to modulate thought and emotion, and a return to childhood levels of female hormones. These disruptions tend to normalize with weight restoration, suggesting that they are consequences of AN rather than causes.  Furthermore, AN patients demonstrate that their higher brain regions, such as the frontal cortex, are able to override or ignore signals sent from the lower brain regions such as the hypothalamus which signal starvation and the need for food intake. These higher brain regions play a critical role in emotions, personality, and rewards, all important components in AN.

Genes play a huge role in causing eating disorders, contributing to certain personality traits that increase the risk of developing AN. People who develop AN tend to possess similar characteristics even in childhood, including anxiety, depression, perfectionism, people-pleasing behaviors, obsessiveness, and a drive for thinness.  These traits also tend to persist after recovery. Kaye et. al. point out “they tend to be rule abiding, rigid, and anxious children who are high in harm avoidance, a personality trait characterized by a tendency to criticize and doubt past thoughts and behaviors, worry about the future, and struggle with uncertainty.” Studies have shown that these traits are heritable and found in family members of AN patients irregardless of weight. Because these personality traits persist into recovery, it is suspected that they reflect underlying traits rather than consequences of anorexia.

Appetite is regulated by a complex system of nerve signals and hormones in the brain, gut, and fat and sugar stores throughout the body. Imaging studies show that higher brain structures in those with AN are used to override signals and to cognitively control and restrict eating. Brain scans show distinct differences between the brains of those with AN and the brains of those without it. Many of these differences are found in the insula. During a sweet-perception task, people without AN are given sugar and the more they report that they enjoy the sugar, the more activity shows up in their insula, striatum, and ACC.  Thus, these regions of the brain are important for sensing reward.  When given the same test, people recovered from AN show less activity in these areas when given sugar.

Similarly, when looking at pictures of food, both ill and recovered anorexics show altered activity in the insula, OFC (orbitofrontal cortex), mesial temporal and parietal cortex, and the ACC (anterior cingulate cortex). Furthermore, people recovered from AN show less activity in the insula and other parts of the neural network.  This suggests that the “ability to perceive palatable taste is fundamentally altered in AN, even after recovery, and that people with AN have a reduced incentive and/or motivation to approach food.” Overall, these imaging studies suggest that people with AN have a reduced drive in several systems associated with hunger and appetite, which explains how it’s possible for many to pursue emaciation even to the point of death. Unlike those without the disease who experience food as more rewarding when hungry because of neural pathways in the brain becoming more active, driving the motivation to eat, those with AN seem to received mixed messages from various parts of the brain. This may explain why food and cooking obsessions are paired with lack of motivation to eat.

Lastly, recent studies have assessed reward processing in AN. The neurotransmitter dopamine is involved in reward and affect, decision-making, and executive control. There is much evidence that alterned function of dopamine occurs in AN. Kaye and his associates conducted a study in which healthy controls and those with AN were assessed for brain activity response to winning or losing money. In controls, the neural activity for winning was very different from that of losing. But in people recovered from AN, the brain activity in the ACC and its ventral striatal target was similar whether they won or lost. “This suggests that people with AN might have trouble discriminating between positive and negative feedback and identifying the emotional significance of stimuli, which in turn could help explain why it is so tough to motivate them to go into treatment or to appreciate the consequences of their behaviors.”

Kaye et. al. also found that women who were recovered from AN showed increased activity in certain areas of the brain (DLPFC and the parietal cortex). These regions are activated when there is a perceived connection between action and outcome and when there is some uncertainty about whether the action will lead to a desired outcome. Healthy controls were able to live in the moment, make a guess, and then move on. However, those recovered from AN “tended to worry about the consequences of their behaviors, looking for “rules” when there were none, and feeling overly concerned about making mistakes.”

In conclusion, AN is a very complex disorder with etiology stemming from the interaction of genetic, biological, psychological, and sociological factors. More and more research is finding that there are actual brain and neurological changes that occur in those with AN. It is not in their head! (Well, actually it is…literally… in their brain chemistry and anatomy) It’s an actual, real life disease, and it’s my hope that those who suffer from the disorder can find some solice in knowing that they are not somehow defective and that it’s very difficult to “just get over it.” When they are feeling disconnected from their feelings, for example, there are actual neurobiological reasons for this in their brains. My hope is that as new information continues to surface, the shame and guilt can be removed from the disorder and we can respect it like we do any other disease.

Source:

Kaye, Walter H, et. al. Is Anorexia Nervosa An Eating Disorder? How neurobiology can help us understand the puzzling eating symptoms of anorexia nervosa.
http://eatingdisorders.ucsd.edu/research/biocorrelates/PDFs/Kaye2010NeurobiologyofAN.pdf

Glamour conducted a survey of more than 300 women of all sizes. They found that, on average, women have 13 negative body thoughts daily. Some women even attest to having 50 or 100 hateful thoughts about their bodies each day. Cultural ideals about weight and beauty certainly play a part. But we’ve also trained ourselves to think this way. Neuroscience has actually shown that whatever we focus on shapes our brain. Neural pathways form according to what we habitually think about. Unfortunately, this training begins very early. A study conducted at the University of Central Florida shows that, of three to six year old girls, nearly half were already worried about being fat and about a third stated that they wanted to change something about their body.

When Glamour went to analyze their data in efforts to find a cause for these negative thoughts, an interesting trend emerged: They found that participants who were unsatisfied with their career or relationship tended to report more negative body thoughts than women who were content in those areas. In fact, uncomfortable emotions of any kind, such as stress, l0neliness, or even boredom, influenced women to start berating their bodies.

I often talk with my patients about “fat attacks”. This is what I call that sudden, out of the blue fear and panic associated with feeling incredibly huge. It can seem to come out of nowhere. One minute, you’re feeling fine, and the next, you can feel as big as a blimp.  Nothing changed in the last few moments about your body. It’s the same one you had when you feeling fine about it. The only thing that changed was an emotional state. Perhaps you’re feeling overwhelmed about all of the things you have to do that day. Or perhaps you’re angry with your boss, or frustrated with the mess the dog has made in the living room. These emotions can come so quickly, and people with eating disorders are so disconnected from their emotions, that all of this gets channeled into body image. However, all the dieting in the world won’t make you feel better, because the issue was never about that in the first place.

In her article “Body Talk: The Use of Metaphor and Storytelling in Body Image Treatment”, Anita Johnston writes, ” A woman who struggles with body image issues tells herself a story (“I’m too fat” or “I am ugly”) but fails to question what is real and true. She is not conscious of the inner stories that are causing her great suffering… Because her physical appearance is the first thing that appears to her when she looks at herself, the first thing she sees when she senses something is wrong, she turns the full force of her fear, disgust, and rage against it.” As Anita so powerfully articulates, a woman who does not pause to examine the full picture of her life responds instead to the initial thought that comes into her mind. For example, “He doesn’t like me because I’m too fat.” She immediately assumes that the culprit is her body, which houses her appetites and desires, which has now become the enemy that has caused her all of her pain and anguish.

If we would pause long enough to assess the real issues and concerns in our lives, we would realize that the problem is not our bodies. It’s our inner critic. Our bodies are nearly messengers alerting us to the real issues: pain of divorce, loneliness of being rejected, worry about being our of a job etc. Negative body image is merely a red herring, convincing us that the problem is that we’re too fat, and deterring us from the real issues causing the pain. As long as we persistently focus on changing our bodies, the real underlying issues never get addressed and resolved. I ran across a quote somewhere that has stuck with me: “In order to see the moon, you must allow your gaze to go beyond the finger pointing to it.”

In the same way, therapists know that  food is an integral part of the recovery process for an anorexic. But their anorexic patients don’t want to get better. They won’t take the “pill”. This disease is particularly difficult to treat because, while the patients are dying before their very eyes, they want to keep their disease. It works for them. The psychological term for this is “ego-syntonic”. It means that the behaviors and effects of their anorexia make them feel good. While the feeling of hunger for a “normal” person is unpleasant, it feels good, even euphoric, for an anorexic. While lethargy and sluggishness is a drag for most people, these feelings are reward and reassurance for someone with anorexia. Most females are concerned when they are a-menstrual for several months.  An anorexic likes this because it tells her that her starvation is working and she is still underweight.

Rather than feel calm and safe when satiated, anorexics feel extremely anxious and fearful; like crawling out of their skin. Hunger does not create a feeling of anxiety like it does for those who respond to our instinctual need to find food when hungry. Instead, it actually creates a feeling of calm and numbness. Not eating for an anorexic makes them feel victorious. The behaviors of this disease cause someone to feel competent, in control, even invincible. Who would want to give that up!?

This is why suggestions such as “just eat” or “why don’t you have a sandwich” don’t work for someone suffering from this disease. Recovery is not as quick as just popping a pill. It requires long and tedious work of meeting the underlying emotional needs until the behaviors are no longer needed. It also requires working with the afflicted to help them also see how their disease is not working for them. Until this realization breaks through the heavy denial, treatment will most probably be unsuccessful. Once someone realizes, at least on some level, that their disease is no longer accomplishing for them all that it originally did, change and recovery is much more possible.

“I really want to keep the weight off this year.”

“I know, but I always just give up after Thanksgiving and figure that my new year’s resolution will be to lose all the weight I gained.”

They were gone in a flash, but they left behind with me the realization they we are in full swing of holiday “fat talk”. This term, first coined by Mimi Nichter who wrote Fat Talk: What Girls and Their Parents Say about Dieting, is that conversation that plays out ad nauseum whenever a group of females get together. This discourse reaches an all-time roar around the holidays, starting around Halloween with all of the candy and continuing well past New Years as everyone sets their New Year resolution on losing weight.

Unfortunately, fat talk is an accepted part of our culture. It can even be a distorted way for women to bond by finding some kind of common ground by degrading their bodies. I’d like to pause here and just reflect on how absurd it is that we, as a culture, endorse this cultural value and teach our children that being a woman means that you are constantly dissatisfied with your body. Why couldn’t we just as easily shift our conversations to ones of thanks and acceptance for our bodies? Can you imagine how this would shift our entire culture?

Anyways, holiday fat talk is extremely difficult for those who struggle with an eating disorder. The holidays evoke extreme anxiety for many, particularly those who suffer with food and body obsessions. Imagine running 2 hours a day on perhaps 500 calories for weeks prior to Thanksgiving in preparation for this national binge day (that’s basically what it is). And then you timidly fill your plate with salad and vegetables when someone next to you says, “oh my gosh! These mashed potatoes are going to have me working out at the gym for weeks!” Or imagine that you’ve just spent the last month paralyzed with the anxiety of eating in front of people when someone serving the gravy makes a comment on what this will do to her hips. Or imagine that the thought of seeing family has had your stomach in knots and mom says, “gosh, honey. Have you been watching your figure? Maybe you should pass on the pumpkin pie this year.” The shame and embarrassment now triggers you to hide yourself in gallons of ice cream after everyone has finished the Thanksgiving feast and left for the night. Comments like these are enough to send someone into a tailspin, or straight to the bathroom to purge. What might seem like benign comments to some, may be enough for someone’s eating disorder to feast on for days, a set up for a regression deep into eating disorder behaviors.

I caution all of us to be mindful of our attitudes and words this year. We never know who around us may be  struggling with an eating disorder. And derogatory comments aren’t good for anybody’s soul, mind, or self-esteem. What if we focused on being thankful rather than on escaping the meal without any added pounds?  What if the holidays were really about family, friends, and spiritual celebration rather than food? Let’s make this season fat talk free.

My friend and colleague, Nicole Cruz, Registered Dietitian, writes an excellent article that speaks to this exact phenomenon.  She writes:

“As a society, how have we come to the idea that food is something we don’t need and that we should actually try to avoid? How have we gotten to the point that a store like Home Goods, selling just that, “home goods”, is using weight loss to sell it’s unrelated products? We’re obsessed. We’re obsessed with the idea of losing weight and obsessed with ways to make it happen. We treat food like the enemy rather than the nourishment that it is…”

Check on the rest of her article at http://www.nicolecruzrd.com/apps/blog/show/8571275-zero-calorie-lunch.

This phenomenon is called body dysmorphia and it runs rampant among individuals who suffer from eating disorders. Body dysmorphia is when an individual obsesses over some “flaw” in their appearance.  This can be over a specific body part or over one’s overall weight and shape.  This “flaw” is typically over-exaggerated or not even present at all. If left untreated, body dysmorphia usually worsens over time and leads to compulsive behaviors such as body checking, eating disorder behaviors, excessive grooming, comparisons to others, social avoidance, low self-esteem, and numerous cosmetic surgeries with little satisfaction.

In my opinion, body dysmorphic disorder falls in the camp of an anxiety disorder, and more specifically, an obsessive compulsive disorder (OCD).  OCD involves some sort of obsession which is followed by compulsions, attempts at reducing the anxiety produced by the stimuli, or obsession.  For example, in the case of body dysmorphic disorder, one’s obsession might be weight.  The stimuli is highly exaggerated and blown out of proportion so that the affected individual literally sees a much larger representation of themselves in the mirror than is reality.  A healthy person from the outside would be able to see that they are extremely thin, not fat at all.  But the affected person truly sees and feels fat. Consequently, this arouses extreme anxiety.  In attempts to lower the anxiety, the individual will engage in compulsions, most probably weight loss behaviors such as restriction, purging, and/or compulsive exercise.

As in any manifestation of obsessive compulsive disorder, the issue is not about the reported obsession.  The issue is about the underlying anxiety.  In other words, the issue is not about being overweight, no matter how much the individual feels it’s so.  The issue is about the underlying anxiety. In OCD behaviors, anxiety gets placed on, or manifested in, some sort of concrete worry, thought, rumination, or body obsession.  In the case of body dysmorphia, the underlying anxieties literally get embodied.  This is where therapists have to become detectives.  They have to uncode, so to speak, what emotions and beliefs are getting acted out in what the client sees reflected to them in the mirror.

As a therapist, my job is to help my clients extract their feelings from their body and free them up to experience their emotions for what they are.  Most of the time, body dysmorphia is caused by a mix of shame, low self-esteem and perfectionism.  Many times, there are feelings of fear and disgust.  Sometimes these feelings stem from a violation that has occurred against the body. Rather than confronting and experiencing these emotions, which may feel overwhelming and lethal, individuals have somaticized them into body obsessions.  It’s a way of saying “if I can change and perfect my body then I can change and perfect these feelings. I can make these feelings go away.” Of course this is not a conscious thought transaction, but it is an unconscious protective mechanism that may have served to help them survive a real or perceived threat.  With a lot of work and persistence, recovery is possible.

Many people who suffer from body dysmorphic disorder also suffer from anxiety, depression, obsessive compulsive disorder, or eating disorders.  Treatment includes a mix of cognitive behavioral therapy to change the negative thought patterns, exposure and response prevention (ERP) to treat the obsessive compulsive component, and medication.

“They say I’m supposed to recover.  But recover what? Recover whom? I have no idea who I was before my eating disorder.”

“How do I return to a life when I have no idea who I was?  As least with my eating disorder I have some sort of identity.  Without it I’m just a big blank.”

“Recover what?  There’s no way I’m going back to my life before this!”

These are all common sentiments I have heard from my clients.  What is recovery exactly?  It’s a word we through around all the time in the mental health community.  It’s supposed to be that thing we do when we’re trying to move past an addiction or a brokenness of some sort.  We have clinics and treatment centers named after this word. In the dictionary, I found definitions such as:

 ”a return to a normal condition”

“the regaining of something lost”

“restoration to a former or better condition”

Let’s take the first one: “a return to a normal condition”. That’s sounds good, but what if what was normal for someone before the eating disorder set in was horrific?  People don’t get eating disorders without a significant amount of pain.  Who would want to return to that? And for many people, their eating disorder is, in a bizarre way, their saving grace.  It has helped them cope with terrible circumstances and survive things that otherwise might kill them or literally drive them insane.  Who would want to return to that without some form of numbing agent?

How about the second definition: “the regaining of something lost”.  That’s all well and good if you know what you lost. Most people with eating disorders have no idea who they truly are inside.  They are completely disconnected from any core identity, thus turning to externals to define them (looks, numbers, measurements, calories, accomplishments, approval, etc.).  I have had clients who can’t tell me what their favorite color is or whether they want to turn right or left. The eating disorder takes on a life of it’s own, the sufferer merely the conduit.  One’s identity becomes the eating disorder, and without that, many fear they won’t have an identity at all.  

Healing from an eating disorder involves intensive discovery of one’s self.  It is more than just returning to normal; it is a long and tedious journey of self-discovery.  It is a blossoming of life, purpose, and joy.  Many question whether it’s even worth it.  Perhaps they have never known life as it’s meant to be and doubt that things can get better.  It’s worth it!  Because it’s not just returning to a previous state.  It’s moving beyond that and going deeper than that.  It’s engaging on an ever-unfolding journey of living as who you are created to be.  And the work is never done.  It’s discovering what you like and dislike, your dreams, passions, desires. It’s finding one’s unique expression through voice, art, dance… It’s fully experiencing all of your minute emotions, the pain and heartache as well as the ecstatic joy and laughter.  It’s discovering where one begins and ends in relationship and knowing the joy of real connection with a friend.  It seeing the world in full color and being an alert and present participant in your own life and in the lives of others.  It’s not just about gaining weight; it’s gaining a life worth living.

It’s well-known that fashion and media play a huge part in the image obsession of our planet.  Throughout the generations, the female body has been treated as just another fashion.  What’s in?  Who has the latest trend in body shape.  Women’s bodies are expected to be changed and updated just like the latest trend of fashionable jeans. Recently, emaciated and androgynous looking women have flaunted the current fashion trend.  In centuries past, heavy and robust women were seen as desirable because their form indicated a lifestyle of wealth, ease, and abundance.  So what does the current trend in women’s fashion indicate?  Poverty, starvation, self-denial, masculinity, hatred of the feminine etc.? It’s about time for women’s bodies to be honored as they are.  Well, the editor of Vogue, Franca Sozinna, is taking a stand against pro-anorexia websites and reports that she is committed to including more “plus-size” models in her magazine.  Check out the article:

http://www.dailymail.co.uk/femail/article-1393482/Vogue-uses-plus-size-models-cover-bid-battle-anorexia.html

•  Being able to eat when you are hungry and continue eating until you are satisfied.
•  Being able to choose foods you like and eating them until you’ve had enough- not just stopping because you think you should.
•  Being able to use some moderate constraint on your food, but not being so restrictive that you miss out on pleasurable foods.
• Giving yourself three meals a day, or it can be choosing to munch along.
• Leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful.
• It includes overeating at times and feeling uncomfortable.  It is also under eating at times and wishing you had more.
• Trusting your body to make up for its mistakes in eating. 
• It takes up some of your time and attention, but keeps it’s place as only one important area of your life.

—  In short, normal eating is flexible.  It varies in response to your schedule, your emotions, your hunger, and your proximity to food. 

Looking around the room, I could have sworn I had somehow morphed into an alien talking about extraterrestrial TV dinners.  They looked at me as if I was crazy.  It was clear they didn’t buy it.  My explanation of normal eating was quickly followed by a barrage of questions and myths:

“But isn’t fried fish bad?”  “I heard that they put diet powder on Weight Watchers food.” ”Isn’t it bad to eat after 5 pm?”  “My dad says that if I just drink water during the day and then pig out at night, I’ll lose weight.”  “My sister uses diet pills and she lost a ton of weight.”  “But I thought cakes and ice cream made you fat.”  “Isn’t it true that if you starve yourself you actually get fatter?” “I heard that just eating protein gets you better abs.”                      

Wow.  It was obvious that normal eating was as foreign a concept as extraterrestrial TV dinners.  The feedback I received from the students was a direct reflection of the messages they see and hear every day from the media.  I realized that what they hear is all they know.  The disordered behaviors is what they know to be true and they have no idea that it could be, or ever has been, any other way.  They have no other construct from which to form their relationship with food and with their bodies.  Especially when they see the same beliefs and behaviors in their family members, friends, coaches, and teachers.  They have no idea that it could be any other way, because the disordered is their normal.   And how are these students to know any other way of relating to food and their bodies unless somebody tells them? 

I tried introducing the concept that there are no good or bad foods.  I explained that all foods can fit into a balanced diet.  I explained that restriction and control creates a feeling of deprivation and only leads to overeating or binging.  I introduced the idea that our bodies can tell us exactly what we need and that honoring our body signals also leaves room for enjoyable foods.  I was shocked that this seemed to be the first time they were hearing this. 

I left the campus saddened by the depth of our culture’s sickness and more deeply aware of the difficulties of growing up emursed in this pandemic.  The disordered has become the normal.  No wonder therapists and treatment centers are flooded with eating disordered clients professing that there is nothing wrong with them.  As far as they know, they’ve just perfected the cultural ideals.  When working with my clients, I find that I not only have to reduce the level of disorder, but I have to teach them how to live the rest of their lives in a counter-cultural way. Recovery for them will not be simply returning to a state of normal.  That just returns them to the normal insanity from which they developed their eating disorder.  They will have to take it a step further.  Recovery for them will be constantly choosing to live counter-culturally by choosing to make different choices than those professed by our society. 

Link to article: http://blogs.westmont.edu/horizon/2011/04/05/calorie-counters-in-the-dc/