EDITOR IN CHIEF
Walter H. Kaye, MD Director, Eating Disorders Program Professor, UCSD
Department of Psychiatry
Laura Collins Lyster-Mensh, MS
F.E.A.S.T. Executive Director
Kelly L. Klump, PhD
Professor and Co-Director of the Michigan State University Twin
Registry, Department of Psychology, Michigan State University
Richard E. Kreipe, MD, FAAP, FSAM, FAED
Director of the Child and Adolescent Eating Disorder Program University of
Rochester Medical Center School of Medicine and Dentistry
Dr Sloane Madden, MBBS(Hons), FRANZCP,CAPcert, FAED
Child and Adolescent Psychiatrist, Co-Director Eating Disorder Service, Head
of Department, Psychological Medicine, The Children’s Hospital at Westmead
James E. Mitchell, MD
President and Scientific Director Professor and Chairman Department of
Neuroscience University of North Dakota School of Medicine and Health
Sciences University of North Dakota
Janet Treasure, PhD, MD
Kings College London , South London and Maudsley NHS Trust
Mary Beth Krohel
F.E.A.S.T. Advisory Panel
EATING DISORDERS AND THE BRAIN
OUR LOVED ONE HAS AN EATING DISORDER. WHAT DOES THIS
HAVE TO DO WITH THE BRAIN?
Although people with eating disorders struggle to eat normally, this is only a
part of the problem. This is a disorder that affects thinking, mood, behavior,
and relationships. We now believe that part of the problem has to do with
how our brains process information about the environment and the body.
CAN THIS PROBLEM BE FIXED?
Yes. With appropriate professional and family assistance these processing
problems can be addressed and improved – even normalized. The brain is
remarkably good at learning and developing in response to a supportive
environment, skills-training, psychological therapy, and good physical
health. Moreover, many of the traits that make a person vulnerable to an
eating disorder are very useful and helpful to that person in recovery and
WHAT IS WRONG WITH THE BRAIN WHEN SOMEONE HAS AN
Our knowledge is evolving as we learn more about brain function and
development. Often, a young person has certain traits since early childhood that
had nothing to do with food or eating that are early signs. Looking back, most
families will remember that the patient had one or more of the
following traits even as a young child: anxious, sensitive, obsessive,
perfectionist, impulsive, difficult to soothe. These personality traits may indicate
differences in brain function that put young people at special risk of developing
There may also be differences in how certain young people’s brains do not
receive enough nourishment. Unfortunately, for these individuals if they stop
eating enough for their growth needs or activity level, their restricted eating can
lead to dramatic changes in the brain. Once started, it can be difficult for the
young person to get “back to normal” without help. Because of the unique way
the person’s brain and body responds to limited nutrition, the longer they are
malnourished, the harder it becomes to eat normally again. For some young
people a cycle of delaying meals, over-eating, and purging also sets in.
Researchers do not yet have all the answers, but it is believed that eating
disorders involve disturbances in the pathways of the brain. There may be
several ways for things to malfunction, but we know that pathways involved
are those that manage mood, emotions, reward, memory, fear, and
Adolescence is a time of dramatic physical, emotional, social change, and
growth towards becoming independent. For those who have problems with
rigid thinking or impulse control, this time of transition is particularly
challenging. This can make adolescence a period of vulnerability where
normal brain development can be disrupted. This vulnerability makes it all
the more urgent that eating disorder behaviors and thinking be addressed as
early as possible to prevent changes to the brain that are hard to reverse and
that can have life-long effects on the individual’s thinking, feelings, and
HOW DO WE KNOW ALL THIS?
Recent work using brain imaging, cognitive testing, and studies of the brain
nerve cell functioning has harnessed new technology to begin to identify
some of the key brain mechanisms, pathways and chemical signals
(neurotrans- mitters) underlying eating disorders. While individual
pathways to the development of eating disorder are many and may vary
from person to person, the key similarities in thoughts and behavior seen in
eating disorder patients seem to indicate similar brain disturbances.
WHY DOESN’T MY CHILD UNDERSTAND THAT THIS IS
It is so important for families to know that their loved one is in an altered
state even when they may seem otherwise quite bright and rational. The
brain is a complex network of systems and one system can be
malfunctioning without affecting the others. People with eating disorders
often manage to get excellent grades in school and perform well in jobs. It
is not uncommon for patients to argue forcefully about their reasons for
their behaviors, even believing they do not need to eat, gain weight, or
engage in treatment. This lack of insight often gets better with treatment.
PATHWAYS INVOLVED ARE THOSE THAT
MANAGE MOOD, EMOTIONS, REWARD,
MEMORY, FEAR, AND ATTENTION.
WHY DO PATIENTS BELIEVE THEY ARE OVERWEIGHT WHEN THEY
The sense of feeling “fat” is perhaps the most puzzling eating disorder
symptom, and remains poorly understood. While sociocultural inﬂuences
are thought to play a role, these body image symptoms are so persistent –
even in very underweight individuals with anorexia nervosa – this raises the
question of whether there is a biological cause. How big we feel not only
depends on our physical senses but also on our beliefs, memories and
emotions. It is possible that this information may not be being processed
accurately by the brain.
In fact, some recent imaging work tends to show altered function of the
parietal, and related regions of the brain, which are known to regulate body
Recent work on how eating disorder patients sense temperature and their
own heartbeat also indicate problems in self-perception of the body that
may play a role.
Still, relatively little research has investigated possible biological
contributions to body image in those with ED, so this remains an area with
more questions than answers.
HOW DO YOU FIX THE BRAIN PROBLEMS IN EATING DISORDERS?
The brain is constantly learning and changing. Restoring healthy eating and
weight, along with psychotherapy, skills-building, and a supportive environment, can help eating disorder symptoms improve or go away.
While many underlying traits present since childhood, such as
perfectionism or anxiety, may still exist after recovery, they are often
manageable, or respond to specific psychotherapy or drug treatments.
In some cases, especially in individuals with bulimia nervosa, medication
can assist in recovery. The good news is that the majority of eating disorder
patients, even quite severe cases, can recover and go on to lead a healthy,
productive life. The earlier the intervention, the higher the chance of
success, but there is always hope for successful recovery.
THE EARLIER THE INTERVENTION,
THE HIGHER THE CHANCE OF SUCCESS, BUT
THERE IS ALWAYS HOPE FOR SUCCESSFUL
THERE ARE MORE THAN ONE KIND OF EATING DISORDER. ARE
THERE DIFFERENT BRAIN PROBLEMS INVOLVED?
This is a question that is currently under debate. We know there is a
relation- ship between the different eating disorders because of the high
rates of people who “cross over” to other eating disorders over time. While
it is likely that similar regions of the brain are involved in all eating
disorders, it is also likely that different mechanisms and pathways are
involved. Research is still in the early stages of understanding the
connections among the different disorders. At this time, we know more
about changes in the brain in anorexia nervosa than the other eating
WHAT PARTS OF THE BRAIN ARE INVOLVED?
There are two pathways of particular interest, especially in anorexia
nervosa. These are the limbic pathway, and the cognitive pathway. Both
affect appetite and emotion and thinking. The limbic pathway includes
several areas of the brain including the amygdala, insula, ventral striatum,
and ventral regions of the anterior cingulate cortex (ACC) and orbital
frontal cortex (OFC); these areas seem to help people see what is important
and rewarding, and then how to respond.
The cognitive pathway is involved with deciding what to pay attention to,
how to plan, what to avoid, and how to self-control. The parts of the brain
in this circuit pathway are the hippocampus, dorsal regions of the
accumbens (ACC,) the dorsolateral prefrontal cortex (DLPFC), and parietal
cortex. For example, brain imaging studies have shown that people who had
restricting- type anorexia nervosa may have a different balance between
these pathways, so that they tend to worry about planning and self-control
and long-term consequences, making it difficult to enjoy immediate
DOES FOOD PLAY A ROLE?
We know that starvation and weight loss have powerful effects on the body
and the brain. Malnutrition impacts on the brain’s capacity to think, manage
emotions and process information from its environment. Starvation often
exaggerates an individual’s personality traits and ways of thinking.
Malnutrition may lead to changes in brain development even after they
have restored normal eating and weight. We also know that the brain
responds to, and has an effect on, hormones and other body systems that
are undernourished. Food certainly plays a major role; the most urgent task
of early recovery and maintenance is restoring the patient’s normal weight
with adequate daily nutrition. An undernourished individual’s brain cannot
DOES DIETING CAUSE EATING DISORDERS?
It is perhaps more accurate to say that a person’s response to a diet can
reveal an eating disorder. Most children and adolescents can diet and then
go back to their normal eating behaviors. When two young women decide
to lose a few pounds together, and one gives up after a week and the other
not only continues but becomes underweight and obsessive, it is likely that
the difference between them is a difference in how their brains respond to
inadequate nourishment. The one who ends the diet is responding to the
biological need to eat normally. Neuroimaging studies indicate that
anorexia nervosa patients are able to ignore urgent signals from the brain to
eat that most people cannot resist. There is also evidence that anorexia
nervosa patients may feel less reward from eating and feel some relief from
anxiety when under-eating.
AN UNDERNOURISHED INDIVIDUAL’S
BRAIN CANNOT RECOVER.
MY SON IS ASHAMED TO HAVE AN EATING DISORDER BECAUSE
EVERYTHING HE HEARS OR READS IS ABOUT GIRLS.
Rates of eating disorders are higher in girls than boys, especially for
anorexia nervosa and bulimia nervosa. This does not mean, however, that
the diseases are less severe in male patients. Just as with other illnesses
where males are more likely to be affected, like heart disease and autism,
there is no reason to refer to eating disorders as female problems.
...THERE IS NO REASON TO REFER TO
EATING DISORDERS AS FEMALE
During adolescence, male and female children develop differently. Girls
and boys have different changes in the hormones in their body and these
affect metabolism and body shape. For example, estrogen affects chemicals
in the brain, like serotonin, that have a strong inﬂuence on appetite and
emotions. Puberty brings dramatic changes in certain areas in parts of the
brain that may contribute to excessive worry and increased perfectionism.
Changes in the body also bring changed interactions with the environment
including a pressure to diet for girls and to appear athletic for boys.
Romantic interests and social pressures bring stresses to the brain as well.
Treatment for both boys and girls involves restoring the brain’s functions,
providing a supportive environment, and good mental health care.
HOW ABOUT MEDICATIONS?
In eating disorders “food is medicine.” So far, there are no psychiatric
medication that cure eating disorders, but several may help with symptoms,
or with the distress at certain stages of treatment. In addition, because many
people with eating disorders also have other disorders they may be treated
with psychiatric medications.
WE RAISED OUR KIDS IN THE SAME WAY: WHY DID ONE GET AN
EATING DISORDER AND THE OTHER DID NOT?
All individuals, including identical twins, have unique brain development.
Starting in the womb, brains are affected by hormones, nutrition, and
experience. Even virus exposure may play a role. We know, for example,
that being born in certain seasons or with an opposite sex twin can affect
the risk of an eating disorder. While two people may be born with an equal
disposition for an eating disorder, many factors may determine whether the
disorder occurs or what form it takes. We also know that each person is
born with tendencies for personality traits, like perfectionism or anxiousness
that last their whole lives and seem to be associated with eating disorder
risk. Two siblings might react to the same situation – a family crisis, for
example – in very different ways, which tells us something about their
lifelong traits. Two siblings may become anxious about an event, but one
calms down when the danger is gone (state), and the other might remain
anxious regardless of the situation (trait).
OUR DAUGHTER DOES SO WELL IN SCHOOL: IT SEEMS TO BE THE
ONLY THING THAT MATTERS TO HER
For those with eating disorders, it is common to have traits that are
obsessive. This can be good, as when it helps with schoolwork or other
detailed work, or bad, as when it limits one’s activities or makes normal life
unpleasant. Other common traits are a strong sense of right and wrong,
following rules, caring about others, and worry about the future. Because
these qualities are often highly valued in society those who recover from
eating disorders are also often quite successful in their careers, relationships,
OUR SON SAYS HE’S NOT HUNGRY, BUT HE MUST BE. WHAT’S
For healthy people, appetite seems to work in a very simple way: eat when
you’re hungry, stop when you’re full. In fact, appetite is complex and
involves not only the senses but also emotions, hormones and levels of
the bloodstream – all coordinated by the brain which has other competing
functions. The person’s history with food also matters, as does the ﬂavor
and availability of food.
People with eating disorders may also have a disturbance in appetite.
Hunger feels different, fullness feels different, and eating less than needed
actually can feel calming, and relieve anxious and depressed feelings, for
young people with this predisposition.
To research this, scientists have studied the brain response to sweet drinks,
comparing people with anorexia nervosa with others. In both groups, the
tongue tasted the sweetness, but as the signal passed to the primary taste
center in the anterior insula of the brain, individuals with anorexia nervosa
processed the taste differently. This even occurred when they looked at
pictures of food while having their brains imaged. Something was different
in the anorexia nervosa patients, and between current patients and
IN EATING DISORDERS “FOOD
THOSE WHO RECOVER FROM EATING
DISORDERS ARE ALSO OFTEN QUITE
SUCCESSFUL IN THEIR CAREERS,
RELATIONSHIPS, AND INTERESTS.
The conclusion? Those with anorexia nervosa had brains that experience altered
reward from food. This helps us understand the struggle with decisionmaking around food choices. Without the positive reward that comes from
eating, it is possible that patients have a greater ability to ignore hunger
cues, yet still display great interest in food and cooking because at some
level they know they are hungry.
The insula, a part of the brain that processes taste, is also important to
keeping us aware of our body, and any changes going on. If the insula is not
giving us those messages, it could help explain why patients “feel fine”
despite being quite ill, and may contribute to the distorted sense of body
shape and size so common to these patients.
IT’S NOT JUST THE EATING, OUR SON WON’T STOP EXERCISING
Although patients give many reasons for “needing” to exercise, some of this
drive may also be explained neurologically. Studies with rats have shown
that the drive to exercise even when exhausted and underfed can be so
strong that animals might run until they die. Dopamine, a chemical in the
brain (neurotransmitter), may play a role. Leptin, a newly discovered
hormone that affects the brain’s hypothalamus, is believed to contribute to
hyperactivity in starving mice.
SHE THINKS WE’RE GOING TO MAKE HER FAT.
Eating disorders are perplexing and difficult to understand, for both the
family and the patient. Fears, sometimes irrational ones, can take hold and
be impossible to argue away. Some of these fears have to do with what
others are doing and saying. Eating disorder patients are often on high alert
and struggle to take in compassion while ill: as their attention is very
focused on the immediate concerns of the eating disorder. Patients often
report feeling disconnected and distrustful of family and friends. Some of
these symptoms may be worsened by altered brain function and
malnourishment. Repairing relationships with family is an important aspect
I DON’T WANT TO TELL ANYONE THAT MY DAUGHTER HAS
SOMETHING WRONG WITH HER BRAIN. I’M AFRAID SHE’LL BE
STIGMATIZED AND FEEL BAD ABOUT HERSELF.
This is unfortunately true: there is stigma around psychiatric illnesses, including
eating disorders. The stigma is based on ideas that are mostly unfounded: for
example that brain problems can’t be fixed, that patients don’t recover, or that
they are permanently “broken” or strange. In any case, hiding from the truth
may lead to poor care decisions and lower the chance of full recovery. It is
important for parents to know that mental illness is quite common, and a new
era of thinking about the brain and psychiatric disorders is under way. Like
breast cancer, eating disorders need not be something that is whispered about
and the end of stigma begins with how each of us addresses it.
HOW DOES NEUROSCIENCE HELP WITH TREATMENT?
The most important lesson from neuroscience is that eating disorders are
treatable. Second, knowing that the brain is operating differently in eating
disorder patients can help families respond with less frustration: it can help to
understand that this is not a set of choices or lack of motivation to change. No
one, including the patient, is at fault. Finally, parents and families need to focus
on helping the patient regain their health through normal eating, providing a
warm and supportive family environment, and working with
a clinical team with the most recent training and expertise.
In addition, new advances in understanding eating disorders are leading to new
therapies – psychological and medical – that target the specific pathways that
have gone awry for the patient. For example, treatment may help people learn to
use constructive coping strategies for traits such as anxiety or perfectionism,
rather than engage in unhealthy or destructive behaviors.
An eating disorder diagnosis is an opportunity to begin treatment that can free a
loved one to go on with their life. Modern neuroscience has a great deal to offer
families doing what they do best: supporting a loved one!
(Families Empowered and Supporting Treatment of Eating Disorders)
Academy for Eating Disorders
111 Deer Lake Road, Suite 100 Deerfield, IL 60015 USA
TREATMENT OF EATING DISORDERS
P.O. Box 11608
Milwaukee, WI 53211 US
FAMILIES EMPOWERED AND SUPPORTING