Anyone who’s ever had an eating disorder or supported a loved one knows one thing for certain: there is no shortage of misinformation out there. Some people still believe that eating disorders are rooted in vanity or that these illnesses are a choice—but neither of these beliefs could be further from the truth. Myths like these are pervasive, and continue to distract from the truth about eating disorders like anorexia, ARFID, bulimia, and binge eating disorder: eating disorders are brain disorders.
But what, exactly, does that mean?
When someone is in the throes of an eating disorder, their brain is undergoing various chemical and physiological imbalances that drive them to act, think, and behave outside of their norm. This is especially true if they’re also malnourished, as malnutrition can significantly affect normal brain functioning.
Here are four ways in which eating disorders affect the brain, all of which make it incredibly difficult for someone to stop eating disorder behaviors without outside help:
- Eating disorders can often cause malnourishment
- Eating disorders can alter the reward system in the brain
- Eating disorders can cause dysregulation of serotonin levels
- Eating disorders can make it difficult for the brain to read hunger cues
The good news is that the brain is incredibly resilient and capable of change, a phenomenon known as neuroplasticity. Just because someone’s brain is altered by an active eating disorder, it doesn’t mean those changes are permanent. In eating disorder recovery, both the brain and body get the opportunity to heal.
Let’s dive a bit deeper into why eating disorders are brain disorders, and why evidence-based treatment is so important.
Why eating disorders are not a choice
Research has shown time and time again that eating disorders are not one-dimensional; they're rooted in biological, psychological, and social risk factors and triggers. Above all, eating disorders are not a choice. Here are three ways that eating disorder behaviors stem from changes happening in the brain, not from personal choices or a desire to look a certain way:
1. Eating disorders often cause malnourishment
Many eating disorder patients are below their optimal weight when they begin treatment (even if they don’t “look” underweight). When a person is below their optimal weight, their brain is likely malnourished, and if the brain is malnourished, it’s not receiving the fuel it needs to carry out its many functions correctly. A malnourished brain is also more susceptible to feelings of fear, anxiety, and depression. Often in the case of eating disorders, these feelings become closely associated with worries about body image, weight, and food habits.
During malnourishment, the brain has a hard time making rational decisions, thinking clearly, and regulating emotions. For these reasons and for the general well-being of the patient, weight restoration is always the first goal of eating disorder treatment (when it’s needed). Only once their brain regains nourishment can the patient take on the psychological and emotional elements of recovery.
2. Eating disorders can alter the reward system in the brain
The reward system, also known as the mesolimbic system, is an incredibly powerful driver of our behaviors. In this system, the hypothalamus and amygdala receive a stimulus, and send signals to release dopamine. This dopamine, in turn, binds to neurons and creates a sense of pleasure. The prefrontal cortex remembers the good feelings that came from that stimulus, and then reinforces the brain to repeat it. When functioning correctly, this reward system is especially important in reminding us to eat.
Research has shown that this system is altered in patients with eating disorders. While most people naturally avoid the unpleasant feelings that can arise from eating too little or expending too many calories, people with certain eating disorders may actually find these feelings calming. In the case of anorexia, hunger and overexercise can trigger feelings of pleasure. Alternatively, in the case of binge eating disorder, eating may feel overly rewarding, causing people to engage in binges where they eat a large amount with a feeling of being out of control.
How eating disorders impact the reward system is also important to keep in mind during treatment. For example, mounting research has shown that people with anorexia specifically have a tough time learning from reward but too easy of a time learning punishment. Understanding this and working with it (such as emphasizing a negative consequence of disordered behavior) can lead to lasting, positive change.
3. Eating disorders can cause dysregulation of serotonin levels
People with eating disorders tend to have dysregulated levels of serotonin, which is the neurotransmitter associated with feelings of happiness and calm. Serotonin is released in our gut, which means our eating habits can have a strong effect on serotonin levels. Many people are also naturally born with high or low levels of serotonin, which can affect how susceptible they might be to an eating disorder.
People with eating disorders like anorexia and bulimia tend to have higher than normal serotonin levels, while those with binge eating disorder tend to have lower than normal serotonin levels. In either case, dysregulated serotonin can cause anxiety, depression, mood swings, and hyperactivity. These effects can all be underlying factors driving eating disorder behaviors, which makes them essential to address during treatment.
4. Eating disorders can make it difficult for the brain to read hunger cues
Eating disorders can impair the functioning of the hypothalamus and prefrontal cortex, which regulate hunger signals and impulse control. When these brain areas are affected, it’s especially difficult to maintain regular appetite and eating patterns. Someone with an eating disorder may feel physically less hungry, even if it’s time for their body to eat. They may also feel more impulsive around food, without knowing why.
As a result of their unique neurobiology, people affected by eating disorders can also experience something known as impaired interoceptive awareness. This means their subjective perception of internal body sensations is altered, making it difficult for them to connect to their physical bodies. This can also impair their ability to read hunger cues.
People can be born with these neurological differences, or develop some of them as a consequence of the eating disorder. Either way, full recovery—and a return to normal, healthy brain function—is entirely possible for everyone.
How to treat eating disorders like brain disorders
Eating disorders are complex and varied, and require personalized, targeted treatment strategies that are backed by solid science. That’s why Equip believes in and practices evidence-based modalities tailored to each patient’s unique needs.
For young people, this usually means using family-based treatment (FBT). FBT is considered the gold-standard treatment for eating disorders and makes family members active participants in their loved one’s recovery. FBT allows families to lean into the unique variability of their loved one’s neurobiology and truly customize treatment so that it works.
For adult patients, enhanced cognitive behavioral therapy (CBT-E) and dialectical behavioral therapy (DBT) are some of the leading evidence-based treatment approaches. These modalities help the patient establish regular eating patterns and address underlying issues such as co-occurring anxiety or depression.
No matter what treatment modality is used, weight restoration is always the first priority in eating disorder treatment. This allows the brain to recover from the effects of malnourishment before attempting deeper therapeutic interventions.
At Equip, we empower patients and their loved ones to do the hard work necessary to achieve real results in recovery. We’re particularly sensitive to the ways a patient’s brain chemistry can and does affect their ability to heal, and we use their unique neurobiology to our advantage.
