What We Mean By “Eating Disorders Are Brain Disorders”
Michelle Konstantinovsky

Anyone who’s ever dealt with an eating disorder or supported a loved one as they’ve navigated the challenging, frustrating, and potentially life-threatening journey through eating disorder recovery knows one thing for certain: there is no shortage of misinformation out there.. People still believe eating disorders are rooted in superficiality or that these illnesses are a choice—neither assertion could be further from the truth. The myths around anorexia, bulimia, binge eating disorder, and other eating disorders are pervasive and persistent and they continue to detract from the reality of these illnesses: eating disorders are brain disorders.

Many people may not realize that the majority of existing eating disorder treatment programs simply aren’t grounded in the powerful neuroscience of the diseases. 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. We know that people with eating disorders, as well as their loved ones, often experience guilt and shame around the illness and question what could have possibly caused it. We want to make it clear that eating disorders are complicated and layered and are influenced by a range of genetic and environmental factors—no single person, experience, or issue is to blame for a person’s eating disorder. They’re complex, nuanced, and diverse, and therefore require personalized, targeted treatment strategies that are backed by solid science. That’s why Equip believes in and practices evidence-based modalities that acknowledge this reality. For young people, this usually means using family-based treatment (FBT).

Once known as the Maudsley Approach, family-based treatment (FBT) is considered a gold-standard treatment for eating disorders and it’s the first line evidence-based treatment for adolescents with anorexia specifically. While individual therapy can also lead to improvements in adolescents with eating disorders, FBT has been shown to be the most effective evidence-based treatment.

FBT is rooted in a few key tenets:

  1. It recognizes that the resulting malnourishment of an eating disorder can and does affect thoughts and behaviors, so nutritional rehabilitation is a priority and families are expected to be involved in that process.
  2. The treatment itself is “theoretically agnostic” and makes no assumptions about the origin of the disorder.
  3. It separates the individual from their illness — a person is not their eating disorder
  4. Family members are considered important treatment resources who can empower their loved one with an illness to pursue recovery.
  5. Parents and guardians are empowered to act as leaders in their child’s recovery and work with the care team to address the thoughts and behaviors driving the disease.

Aside from its clear demonstrated effectiveness, FBT allows families to lean into the unique variability of their loved one’s neurobiology and truly customize treatment so that it works. Each eating disorder is unique, but many individuals who cope with eating disorders share similar, powerful temperament traits like perfectionism and achievement orientation; FBT, allows families in recovery to capitalize on this neurobiology to help loved ones achieve their recovery goals.

Take for example, the concepts of reward and punishment. For most people, if something is rewarding, they learn to do more of it, and if something is punishing, they learn to do less of it. However, mounting research has shown that people with anorexia specifically have a tough time learning from reward but too easy of a time learning punishment. For people with anorexia, criticism can feel debilitating and crushing in ways that people without eating disorders don’t experience or understand. While parents may be tempted to use reward systems to encourage their child’s weight restoration or recovery journey, these strategies usually don’t work, precisely because of the way their child’s brain is wired—their sensitivity to rewards just isn’t there. Understanding this and working with it (rather than resisting it) can lead to lasting, positive change. In some cases, this might mean emphasizing a negative consequence of disordered behavior (i.e. requiring a higher level of inpatient care if nutrition goals aren’t met).

As a result of their unique neurobiology, people affected by eating disorders often 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. Understanding this neurobiological nuance can empower families to encourage healthy behaviors like conscious breathing and yoga practices — both of which can help individuals better align their brains and bodies and start to feel more comfortable in their own skin.

Using neurobiology-informed FBT strategies can also go a long way in helping to prevent relapse. Since people affected by eating disorders are neurologically wired for achievement orientation and perfectionism, we can empower them to use those traits for self-improvement over self-harm, applying their personality traits to sustained recovery and avoiding relapse at all costs.

One example of this is understanding the realities around negative energy balance (i.e. expending more energy than is consumed) for people 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 eating disorders may actually find these feelings calming. Armed with that information, families can move through recovery empowered by the awareness that dieting, restricting, or over-exercising in any way must be avoided at all costs — not just because these behaviors are inherently problematic, but because for people with eating disorders, they can trigger a slippery slope that leads directly to a full relapse. Understanding the neurobiology underpinning that reality can guide families in constructive, life-saving ways.

At Equip, we empower family caregivers and support loved ones in the hard work necessary to produce 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.

Michelle Konstantinovsky
Equip Contributing Editor
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