Episode 230: This is a solo episode looking at how restriction and eating disorders affect the brain. I look at how the structure and function of the brain changes, the phenomenon of anosognosia and how long it takes for repair to occur.
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Chris Sandel: Welcome to Episode 230 of Real Health Radio. You can find the show notes and the links talked about as part of this episode at seven-health.com/230.
Just a note before we get started. I’m currently taking on new clients. At the time of recording this, I have just five spots left.
I specialise in helping clients overcome eating disorders and disordered eating, chronic dieting, body dissatisfaction and negative body image, overexercise and exercise compulsion, and dealing with irregular cycles or cycles that have ceased altogether.
If these are areas you struggle with and you’d like help to make them a thing of the past, then please get in contact. You can head over to seven-health.com/help, and there you can read about how I work with clients and apply for a free initial chat. The address, again, is seven-health.com/help, and I’ll also include that in the show notes.
Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I am a nutritionist that specialises in recovery from disordered eating and eating disorders and really just helping anyone who has a messy relationship with food and body and exercise.
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This week on the show, I’m back with another solo episode. This is actually a topic I’ve been wanting to cover for a number of years. While it’s clearly something that I see as an important topic, I have to give credit to a past client for suggesting it. She made the suggestion a couple of years ago and said that she thought it would be helpful to do an episode on brain changes that occur due to restriction – changes that affect perception and beliefs and cognitive functioning.
In the intervening years since she made that suggestion, I’ve seen how important it is to cover this topic. When working with clients, I think about things from two sides. One is the nutritional rehabilitation and how the physical body is working versus where they would like it to be, and we can use various symptoms as indicators as to how things are functioning. Then the other side is more the mental/emotional and psychological side. This is looking at thoughts and beliefs and identity and values and those kinds of things. It’s how someone perceives the world and perceives their place in the world.
While I can talk about these as being two sides, they are completely interlinked. Your nutritional status and your physiology impacts on your psychology and your beliefs and how you see the world. In fact, if you’re trying to do psychological work while in a depleted state, it’s really difficult or maybe impossible, even.
I’ve made reference to the Israeli judge study on the podcast before. This was a study done in 2011, and it looked at the decisions of judges in Israel who presided over parole hearings. The paper looked at over 1,000 rulings made in 2009 by eight judges. The judgements are meant to be based on the facts of the case, but what they found in this study was something interesting. They found that the probability of a favourable decision dropped during sessions. At the start of the session, there was a 65% chance of a favourable ruling, and this then dropped to almost 0% by the last ruling within each session. Then the rate of favourable rulings returned to 65% again following a food break and then headed back down to basically 0% by the end of the session.
Basically, if the judge was full and had good energy, a favourable judgement was likely, and as time went on and they became hungry and low in energy and more mentally depleted, they saw defendants in a different and more negative light and were less favourable in their judgements.
If we were to pull the judges aside first thing in the morning and ask why they’d made the decision, they’d be able to give an explanation, and if we pulled them aside just after their last decision before lunch and asked them why they made the decision they did, they’d be able to give a reason for that. They’d be able to in both scenarios explain why they decided how they did, and in both instances, they would’ve felt that their decision was based on the merits of the case, not because of their physiology.
But in fact, the level of blood sugar and how long they’d been continuously concentrating for was having an impact on the thoughts they had and therefore the decisions they made based on those thoughts.
This is an example of what happens in the short term when energy levels drop, but in this example, it’s temporary and it’s transitory. By eating, cognitive function changes. But with ongoing restriction, this then becomes more of the norm, and rather than just a dip in glucose in the brain having an impact, the brain actually starts to change. It degrades, and certain regions of the brain cease working as they should.
What’s most troubling about this shift is that you are unaware of it happening. Rather than feeling like your thoughts and your beliefs and your mood are being altered, it just feels like you. It feels like this is who you are. This is really the Catch-22 with recovery. After ongoing restriction, you’re cognitively impaired; your brain has become impaired, and you require weight gain and a sustained time even after reaching a healthy weight for cognitive impairment to fully improve. And yet it’s the cognitive impairment and the accompanying systems that then make you believe that either nothing is wrong or create the terror at the thought of gaining weight.
The recognition of the extent of the situation becomes apparent once recovery has happened. Clients feel like they were in a cult. They feel like they were brainwashed once they’re out the other side. But they could really use this insight at the start, not at the end, and instead they get the opposite. The deeper the hole that someone is in, the more they’re unable to see how deep they are in and how much is being lost because of it.
As part of this episode, I want to go through a number of papers that look at the changes that occur due to restriction and looking at the brains of those who are suffering with anorexia, mostly. There are some that are looking at bulimia as well, and they then compare this to either healthy counterparts who have never had an eating disorder, or those who’ve had an eating disorder but have now recovered.
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Anosognosia is a term that is really at the root of everything I’m going to cover here with these papers. Truthfully, it’s a term that I’ve recently come across as part of doing the research for this episode. Anosognosia is a term originally used by neurologists who describe a neurological syndrome in which people with brain damage have either complete or partial lack of awareness of their different neurological or cognitive dysfunctions.
Previously, this would’ve been talked about as denial, that the person was in denial of what was really going on. But it’s not the same as denial. Denial is psychological in reason. We all have the ability to live in denial, and we also all have the ability to overcome the denial. But with anosognosia, it’s caused by physical changes to the brain and thus is anatomical in origin. The changes in the brain are what is altering the thoughts; it’s not simply someone’s psychology.
It can be difficult or it can feel strange to comprehend how or why a person who is sick can’t understand that they are sick ,and this is especially the case when someone’s symptoms just seem so obvious that it’s hard to believe that this person is unaware.
Oliver Sacks, who was an incredible writer, wrote a book called The Man Who Mistook His Wife for a Hat, and he talked about this problem: ‘It is not only difficult, it is impossible for patients with certain right hemisphere syndromes to know their own problems. And it is singularly difficult for even the most sensitive observer to picture the inner state, the situation of such patients, for this is almost unimaginably remote from anything he himself has ever known’.
So while it can feel baffling that someone can’t see what’s really going on, this is the case, and it’s not about denial; it’s about brain impairment.
Thankfully with something like anorexia or with an eating disorder, anosognosia is temporary. It is caused by restriction and it abates with weight restoration and with recovery. But without this occurring, there isn’t really logic or insight-focused therapy that can make much of an impact, which is why nutritional rehabilitation is always the starting place with recovery. Without it, there isn’t a proper functioning brain to be receptive to other forms of therapy.
I will say that this isn’t a binary thing. As I said in the description of anosognosia, it can be complete or it can be partial in terms of its lack of awareness. In terms of anorexia, it’s more likely to be at the partial end of the spectrum. So it’s not like therapy is completely useless until full recovery has occurred, and a big part of therapy can be about building trust and having someone start to share their fears and their concerns and being able to be compassionate and model this for someone else.
In the early stages of working with a client, it’s not like my only role is to say ‘just eat the food’. It is to look for chinks in the eating disorder armour and where we can start to look for points of leverage to assist recovery or where someone can start to see how untrue a belief may be. This is incredibly useful, even in the early stages; it’s just that it becomes easier to do and sticks more as nutritional rehabilitation progresses more.
This for me can also be a good yardstick for how someone is doing and if they’re potentially relapsing or restricting again, even if it’s unintentional restriction, because people’s awareness will fluctuate over time. They will be more aware when they’re doing better, but lose that awareness when they’re restricting or relapsing. They won’t actually notice that difference, but I can then notice it in the consults, and this can be in terms of their level of awareness but also in terms of their mood and the kinds of thoughts that are coming up and the kinds of struggles they’re having and the kinds of questions they start asking that they weren’t asking before when they were doing better.
What makes this whole situation especially difficult is society and what we’ve come to value in society. Society values so much of what an eating disorder values in terms of the pursuit of thinness and self-control and discipline. These can easily then be seen as healthy impulses. So to say that someone who’s having these thoughts has anosognosia and they have cognitive impairment can seem strange, because if they have this issue, then so does the rest of society.
This is equally difficult as well because these thoughts and beliefs can predate the eating disorder. For most, it’s not like they loved their body and felt completely comfortable in their own skin and then the disorder happened. It was already there, and now it’s still there. But there’s a difference between beliefs that someone holds because of society, which can be changed with enough talking and with enough therapy, versus beliefs that someone holds because of changes to the structure and the functioning of their brain that will never change unless the brain is able to heal and rewire – which is what the studies I’m going to go through look at.
With the papers, I’m not going to go through all the different brain regions in detail. I want to go through the papers at a practical level rather than a granular level. For one of the papers, it does make sense to discuss a particular region, as this is what the paper is all about and it’s pretty eye-opening with how connected it is to eating disorder thoughts and behaviours, but mostly I’m going to give a basic overview of the papers, and I’ll include links to all of them in the show notes, which you can find at seven-health.com/230.
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The final thing I want to mention before going through the first paper is how revealing these papers are about the weight biasness within recovery – and biased in thinking if we can get someone to the very bottom of the healthy BMI category, this is considered weight-restored. This really is a travesty, and it’s something I’ve talked about recently in a number of my articles – the one on anorexia recovery, on binge eating disorder. I talked about it as part of the Minnesota Starvation Experiment podcast.
Weight restoration hasn’t occurred just because you’ve crept into the healthy BMI range and you were previously below it. For most people with eating disorders, they’re never at this low a weight and still suffer and still have the same symptoms and still have the same brain changes. So long-term recovery rates would be much higher if we weren’t falling for this trap that weight restoration means someone’s hit a BMI of 18.
The reason this is so important is because if someone is being told that they don’t need to gain any more weight or they don’t need a higher amount of calories and the reality is different, this is going to have a really big impact. Without the further weight gain and without the further energy intake, the brain degradation that has occurred just never recovers. You get stuck in this same hellscape of thoughts and judgements and beliefs, and you think that this is as good as it’s going to get and this is how things will be for the rest of your life. And if you spend the rest of your life with this same level of obsessiveness and worry and you’re on this knife-edge, then relapse is going to be very likely.
I do really wish that recovery was focused on what the body truly needed to get better rather than getting someone to some arbitrary weight and then saying that they’re better and that’s the end of it.
I would say that that is one of the limitations with these papers. While they do look at different types and subtypes of anorexia and they also include bulimia, they are all focused on those with eating disorders at a low weight. But I can tell you from my experience that this isn’t just a problem if someone is at a low weight. This happens across the weight spectrum if someone is restricting and it sitting at a weight lower than their body wants to be.
So just because your BMI doesn’t fall below the normal range, doesn’t mean that what I’m going to cover as part of this podcast can’t be a problem, because it can be and it definitely is the case with the clients that I see.
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Let’s look at the first paper. It’s called ‘Brain tissue volume changes following weight gain in adults with anorexia nervosa’, and it appeared in the International Journal of Eating Disorders in June 2011.
The study was looking at how brain volume changes for adults with anorexia. Interestingly, the reason for doing this study was because there’d been many done in the same area, but with adolescents, and they’d shown that adolescents had decrease in their brain volume with anorexia. They wanted to see if the same changes occurred with adults.
The first aim of the study was to examine changes in brain volume accompanied by weight restoration among adult inpatients who met the criteria for either the restricting subtype of anorexia or the binge/purge subtype of anorexia. The second aim of the paper was to examine how brain volume in patients with anorexia at lower weight and normal weight compared to brain volumes of healthy control patients.
There were 40 patients who were recruited to participate. It was a functional magnetic resonance imaging study (an fMRI study) looking at their response to food. To be eligible for the study, you had to meet the criteria for anorexia, except for amenorrhea. You had to have no other Axis I disorders other than major depression, be women between the ages of 18 and 45, be free of psychotropic medication, not be pregnant or lactating, not have any non-removable metal on the body or other contraindications for MRI, be medically stable, and have no history of suicide attempt or other self-injurious behaviour within the previous six months.
There were 26 healthy women who were used as control participants who matched up in a similar way in terms of weight and age.
What the study found was that underweight individuals with anorexia had significant deficits in brain grey matter volume compared to healthy controls. There was also an inverse correlation between the duration of illness and the lower volumes of grey matter. This meant that greater brain volume deficits were experienced the longer a patient had anorexia.
These deficits in grey matter volume improved with short-term weight restoration, but they didn’t fully normalise over the course of the 51-week study. This could be a reflection in that it takes more than a year to fully recover brain matter, or that those in recovery still hadn’t gained enough weight to have this recovery occur over the time of the study. It could be argued that these changes are permanent, that once grey matter is lost, it can never fully heal, but let’s look at another study to see if this is actually true.
The next paper is ‘Normal brain tissue volumes after long-term recovery in anorexia and bulimia nervosa’, and it appeared in the Journal of Biological Psychiatry in 2005.
The goal of this study was to assess brain tissue abnormalities in a large sample of individuals who had long term recovered from eating disorders, including the different subtypes of anorexia as well as bulimia. They used MRI and it was performed on 40 women who were long term recovered. How they defined long term was greater than one year with no binging, purging, or restricting behaviours, at normal weight, having menstrual cycles, and not being on medication.
The length of recovery for the participants wasn’t just a year. It actually ranged between 29 months and 40 months, so much greater than a year. That looks more like two and a half to three and a half years that these people had been recovered. They also then had 31 healthy control women to compare against. With the 40 women who’d had previous eating disorders, 14 of them met the criteria for restricting type of anorexia, 16 met the criteria for the binge/purge subtype of anorexia, and 10 for bulimia.
What did the study find? All the brain structures in the recovered women were normal in volume and similar to those of the control subjects. So while the previous study showed that partial recovery happened with initial weight restoration, this study suggests that structural brain abnormalities are reversible with long-term recovery.
What is important to keep in mind here is the timeframe. Complete healing hadn’t happened after a year in the first study, but had by two and a half years in the second study. I’m using two and a half years in terms of the person who had the least amount of recovery time. I just want to say that recovery takes time. Even if the weight restoration process takes a handful of months, this doesn’t mean that all healing is done.
I think this is really important because you can notice that you’ve gained weight, that some symptoms have improved, but you still struggle with feelings around food and fear of weight gain and struggling with body acceptance. It’s easy to think, ‘Well, if this is as good as it’s going to get and I’m going to have to struggle like this all the time, then I prefer to struggle like this and do so at a lesser weight’, or you can feel short-changed: ‘If this is all recovery is delivering for me, why did I put in all this effort?’
But that is not actually the case. With time, this does change. Full recovery is possible; it just takes time for the brain recovery to catch up.
00:22:17
The next paper is called ‘Cognitive function and brain structures in females with a history of adolescent onset anorexia nervosa’, and it appeared in the Journal of Paediatrics in 2008. There were 66 female subjects in their early to mid twenties who had a diagnosis of adolescent onset anorexia nervosa and had been treated five to eight years earlier in a tertiary care hospital. They had 42 healthy female control subjects who were in the same age bracket.
As part of this study, they looked at weight restoration as well as menstrual function. I made the comment earlier that I think there can be a rather biased and skewed perception of recovery weights and recovery restoration, and I want to quote something from this article to highlight this.
‘Although weight restoration is an important goal of treatment and one indicator of recovery from anorexia, menstrual function may remain abnormal in some weight-recovered patients and normal in some low weight patients. These observations highlight the possibility that weight and menstrual function have independent effects on brain structure and cognitive function in anorexia’.
Menstrual function is impaired by undernutrition. If someone is supposedly weight-restored but is still not menstruating, I question how weight-restored they really are. For me, I feel like this is less about weight and menstrual function having independent effects and more that full weight restoration and recovery hasn’t happened yet.
For this study, as I mentioned, the subjects had been treated previously for adolescent onset anorexia nervosa. At the time of the study, 10 clinical participants continued to meet the criteria for anorexia; 6 were restricting and 4 were binge-eating subtype. One clinical participant had binge eating disorder, and then 30 were in partial remission, showing residual psychological and physiological symptoms, and 25 were free from any symptoms of anorexia. None of the control subjects had an eating disorder.
So what did the study find? Subjects with anorexia who remained at a low weight had abnormal MRI scans, weight-recovered patients had normal brain volumes, and patients who currently had lost their menstrual cycles or had irregular menses showed significant deficits across a broad range of many cognitive domains, including verbal ability, cognitive efficacy, reading, math, and delayed verbal recall.
This final point is really important. Weight restoration leads to structural improvements, but abnormal menstrual function was associated with cognitive deficits even if the structural brain changes had resolved. Part of this, I think, is because of the crudeness of MRIs. Just because an MRI shows structural improvements, it doesn’t tell you that this area is now working exactly as it should be or as well as it could be. This extra layer of information using the menstrual cycle can then be really helpful.
Research has shown that low circulating oestrogen levels coupled with amenorrhea have been associated with cognitive impairments in animals and in humans, and this can be the case irrespective of what structural changes to the brain have occurred or not. Again, this just points to the fact that it takes time for full healing to occur and that rather than just looking at whether someone is supposedly weight-restored, there are other factors that should be taken into consideration.
I would add with this, though, that getting a period back shouldn’t be overvalued as a marker for recovery. Some people get a period early on in the process, and for other people it takes a long time of restriction for their period to disappear in the first place. So while getting a period is important and obviously has an impact on cognitive functioning, just because a period has returned or it never stopped, doesn’t mean that everything is okay.
00:26:40
The last paper that I want to go through is called ‘Implications of starvation-induced change in right dorsal anterior cingulate volume in anorexia nervosa’ – a really snappy title. It appeared in the International Journal of Eating Disorders in November 2008.
Up until this point, I haven’t talked about specific brain regions, but with this one I think it’s relevant and helpful – one, because this paper looked at a particular region, and two, because this region is connected with both cognitive ability and with eating disorder thoughts and behaviours.
The brain region, as I mentioned as part of the name of the paper, is the right dorsal anterior cingulate. This is abbreviated to right dorsal ACC. Let me quote the paper as it talks about the region: ‘Dorsal ACC activity has been implicated in the reward circuit for food intake and is linked to several aspects of cognitive functioning and motor activity. Patients affected by starvation from active anorexia have decreased blood flow in the dorsal ACC. Decreased dorsal ACC activity is associated with increased motor activity and abnormal food intake behaviours in people without anorexia as well. Since blood flow changes have been related to volume changes, decreased volume in the right dorsal ACC may be related to increased drive to exercise and decreased appetite’.
Then there is another section that states: ‘Right dorsal ACC volume reduction and dysfunction also have been found in patients with high alexithymia scores. High alexithymia scores, which indicate impairment in one’s ability to express emotions and how one is feeling, also have been reported in patients with anorexia and may be related to outcome. Similarly, abnormal function and reduced volume in the dorsal ACC is also found in patients with OCD and may be related to food and body image obsessiveness and compulsions in patients with anorexia. Patients with OCD and anorexia also have similar deficits in executive function tasks. Although none of the patients in this study had a comorbid diagnosis of OCD, right dorsal ACC volume reduction in patients with anorexia may help explain why obsessions and compulsions related to food and weight are known to increase as a function of decreasing weight in patients experiencing starvation with active anorexia’.
Then one more section: ‘Most people who develop anorexia typically have above average IQ. However, during the active phase of anorexia, 50% of individuals with anorexia have been found to have mild cognitive impairment on two or more neuropsychological tasks, and one-third outright fail two or more tasks. Although there is usually no generalised intellectual compromise as evidenced by premorbid estimates on the wide range achievement test reading levels, several areas of verbal and non-verbal memory were significantly lower. Impairments have also been found in several other areas of cognitive functioning, including verbal and visual memory, visuospatial ability, attentional skills, and executive functioning’.
I think those three paragraphs really sum up the importance of the right dorsal ACC and how it can impact on the changes seen in an eating disorder. It’s not like it’s just the right dorsal ACC and that is the only location that helps these different areas of functioning. Undoubtedly there are other areas that are also impacted in a similar way; it’s simply that this is where this paper was focusing.
In fact, when I looked up anosognosia through the Treatment Advocacy Centre, they have links to many papers looking at studies connected to different areas of the brain. They can then say this brain region is corelated or this brain region is not correlated with anosognosia. There are many, and the same will be the case with the functions connected to the right dorsal ACC.
But what I find so striking is how much the paragraphs I just quoted match up with what I’ve seen in practice and what I’ve experienced in practice. Clients that I work with are highly intelligent. Many are working in jobs that require this level of intellect, whether they are doctors or engineers or lawyers or are working in finance, or even those who aren’t working in this kind of work, it’s very apparent that they are smart and well-educated.
This then is the added wrinkle. While the eating disorder is clearly having an impact on their thoughts and cognitive functioning to me, to them it can seem hard to see or to feel, and they’re able to have intelligent conversations and they’re able to lead lives that require technical knowhow and they’re able to do this. So it can be easy to think that they’re not cognitively impaired, this isn’t affecting their brain. And for many, many areas of their life, this may be true, but there are areas where this is not the case. For things like food and exercise and body image and weight, there clearly is an impairment.
I always remember the film Memento. I love the director, Christopher Nolan, and it was one of his first films. It’s about Leonard Shelby, who is played by Guy Pearce, and he’s trying to solve the murder of his wife, but he suffers with anterograde amnesia, which is the decreased ability to retain new information. So he keeps getting tattoos all over his body as a way of trying to remember the new information before it disappears from his mind. The whole film is actually shot in reverse order, so the start of the film is actually the end and the end of the film is actually the start. It’s incredibly well done, so if you haven’t seen it, I highly recommend checking it out.
But the reason I mention it is that for many clients, there are areas where it feels like they are suffering from some kind of amnesia. For certain topics in regards to food or exercise or body image or weight, it’s hard for this new information to stick. This is connected to the concept of anosognosia because this isn’t about denial, but it’s about the inability to actually grasp these ideas because of the changes to the structure and the function of the brain. But with nutritional rehabilitation and with time, this does change.
The alexithymia that the quote talked about is also something I’ve noticed as well. Alexithymia is defined by four things: (1) difficulty identifying feelings or distinguishing between feelings and the bodily sensations of emotional arousal; (2) difficulty describing feelings to other people; (3) a constricted imaginal process; and (4) a stimulus-bound, external-orientated cognitive style.
In some regards, alexithymia may make someone feel numb and shut down, which for many is part of the benefit of an eating disorder because it blocks out the pain and the noise and the emotions of real life. But in other ways, it makes emotions more heightened when things aren’t going to plan, which is basically always in the case of recovery, because recovery is messy and it never looks how you want it to.
One of the facets of alexithymia is the inability to identify feelings. This doesn’t mean that there isn’t discomfort or anxiety; it just means that this is more vague, and there’s this constant feeling of fear or anxiety that is just simmering away. You look for ways to turn down this anxiety, and this is where the eating disorder then comes in and can be so devastating, because it’s then able to create this narrative around why this feeling is occurring and it’s because of weight or the fear of weight or that you shouldn’t have eaten so much or you should’ve moved more. This then gives a reason for this feeling that someone is going through.
Alexithymia isn’t something experienced by everyone with anorexia or with an eating disorder, but it is something that I see fairly regularly, and again, it’s something that abates as time goes on as part of nutritional rehabilitation and as recovery gets further along.
Getting back to the actual study, the experimental group consisted of 18 patients. There were 6 males and 12 females, ranging in age from 15 to 41, who’d met the criteria of the DSM for anorexia and had received hospitalisation in an inpatient eating disorder unit between November 1992 and December 1995. Then there were 18 sex- and age-matched and height equivalent normal controls who were part of the study.
What did the study find? Let me read it in its own words. ‘Right dorsal ACC volume normalised after weight restoration in patients with anorexia. However, weight restoration itself as measured by change in BMI was not significantly correlated to restoration of right dorsal ACC volume. This suggests that there are other factors involved in restoration that occur independently of simple weight restoration. These factors may involve brain changes from psychotherapy or possibly a reduction of cortisol or something even simpler, such as thiamine replacement. Alternatively, it may reflect the extent to which neurological regeneration is impacted by the current energy balance such that regrowth is only possible once a positive energy state (e.g., more calories consumed than burned) is achieved’.
00:37:00
So right dorsal volume and function does improve as part of recovery and weight restoration. From my experience with clients, I tend to agree with the last sentence of that quote: the reason the full restoration hadn’t occurred in some is due to the fact that more calories are needed to facilitate this, and more calories as part of the restoration period to get someone to a higher level, but also more calories needed on an ongoing basis.
Something interesting that I’ve noticed with clients – and this isn’t anything I’ve found in the literature, but is just something through clinical experience – is that prior to many clients having an eating disorder, they needed higher than average calories. It’s common for clients to comment that before their eating disorder started, they used to eat lots of food, they used to eat much more than their friends, they used to eat more than their brothers, or they remember people commenting about how much food they could put away. They were doing this by simply responding to hunger. They were hungry for more food and they ate more food.
If this is the case before an eating disorder, it’s going to be the same after an eating disorder. They are simply wired in a way that means they need more food and they use more calories than the average person.
So if I have a conversation with a client and they remember that this was the case for them, I want them to keep this memory front of mind. It’s too easy to look around and think that they’re eating too much because they eat more than other people, or that they should simply use the eating of others as a guide for themselves. But the reality is that this is not going to work. For them to function correctly, they simply need more calories. It’s only the eating disorder and the meaning that is attached to eating more food than other people that makes this a negative thing. If that wasn’t there, eating more calories is just ‘that’s what my body needs’.
This is why I think some people can get stuck, because they look at what they’re eating and they think ‘It must be enough because I’m eating so much food’. With this in mind, the paper then goes on to say: ‘With increasing pressure from insurance companies to discharge patients with anorexia before they are fully weight stabilised, inpatients may increasingly lack adequate time for the brain restoration that is needed to prevent rapid relapse and facilitate ultimate recovery from this often-chronic illness’.
Now, given the earlier papers that I went through that estimated that it takes over a year and potentially more like two or three years for brain structures to fully heal, it is impossible and unrealistic for someone to be an inpatient for all this time. I also think it would be counterproductive for that to happen, as part of the neural rewiring that is needed for full recovery happens when individuals are able to make the choices of their own accord to eat a particular food or eat a particular meal or to not exercise rather than simply eating what is put in front of them or abstaining from running because that is the rule of the facility they’re in.
So I don’t think the end goal should be that full recovery happens while someone is an inpatient, but I do think we need to do a better job with both managing weight restoration and with managing expectations. By this, I mean not just aiming for the lowest BMI within the normal range to tell someone that they are weight-restored and should be discharged, and also being explicit about brain changes taking a long time, and that this is dependent on adequate calories coming in as part of restoration and adequate calories coming in on an ongoing basis.
I do want to say that there are many components or drivers for eating disorders. I don’t want to simplify it and say that it is all biological, and if the right amount of calories come in, then everything is going to be repaired. There is a place for therapy, and for many or even most, it’s crucial to reaching a place of full recovery.
But if enough calories aren’t there to create the foundation for the physical healing to take place, it’s unlikely that other changes and forms of therapy will stick.
00:41:35
Those are the papers I wanted to go through and are what I wanted to cover as part of the show today. As part of the research for the show, I came across an article that I’ll also link to in the show notes. It’s aimed at parents with children or adolescents who are suffering with anorexia and are experiencing anosognosia. While it is directed at parents, I think it’s applicable to practitioners who work with eating disorders, and it’s something that I keep in mind when working with clients.
‘Parents usually find that anger doesn’t work. Logic and pleading and punishment doesn’t help. Compassion, commitment, and firm response can help, however – a lot. We can insist on restoring the brain, keeping the loved one going to treatment appointments, and providing an environment where recovery is the goal and optimism is the mood, even when they cannot. We can connect on an emotional level instead of a logical one by being unconditionally loving regardless of what the ill person does in response. We have to believe in the real person, the well person inside, and not allow ourselves to become embittered or defensive, even when our loved one is irritable or combative’.
Why I love this quote so much is that this is what I’m doing when working with clients. I am always focused on the true well person that is trapped inside – the one that I know doesn’t care so much about weight and exercise and numbers and cares a lot about many other aspects of their life.
Being able to help them escape that prison is what I’m wanting to do, and a prison that they might not even realise they are living in, or they realise it but don’t realise the extent to which they are constrained. Just helping clients get out of this hellhole is what keeps me doing what I do.
I hope you found this podcast helpful. I know that logic and science isn’t the best way to change someone’s mind when they have anosognosia and when it’s taken hold, but as I mentioned earlier, it’s often a partial issue, and hopefully there is enough of a crack that some of this information can get through. Or if you’re in a place of quasi-recovery, you can take even more of it on board.
That is it. As I mentioned at the top, I’m currently taking on clients. At the time of recording this, I have just five spots left. If you want help with recovery, with body image, getting your period back, exercise compulsion, being stuck in quasi-recovery, or any other areas that I cover as part of this show, then please get in contact. You can head to seven-health.com/help for more information.
I will be back next week with another episode. Stay safe, and I’ll catch you then.
Thanks so much for joining this week. Have some feedback you’d like to share? Leave a note in the comment section below!
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Do you have an ETA for the transcript? It is extremely difficult for me to process podcasts (same with audio books — I hear once upon a time and the next thing I know it’s happlily ever after and I couldn’t tell you one thing that happened in between; give me a print book/article and once I’ve read it I can answer anything you want to know about what I read). I so appreciate the written transcripts and I’ve been really looking forward to this one! 🙂
THANK YOU for the transcript! 🙂
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