On the Wrong Track: A Layperson’s Explanation of Brain Reward System Malfunction in Anorexia Nervosa
Updated: Aug 9, 2019
-JD Ouellette, JD Ouellette Peer Coaching
-Illustrated by Lilac Vylette Maldonado
This is the explanation I use with families to give a short primer on how anorexia nervosa would be better labeled a brain reward center malfunction disorder, and explain the role of nutritional rehabilitation, as well as the unlikelihood that “willpower” can surmount the malfunction without substantial help. The best one -sentence explanation I have heard to explain anorexia nervosa came from my youngest son several years ago, when I asked him how he explained anorexia to his friends: “When the brain processes food as a threat to survival rather than necessary for it” was his insightful response.
Genetic Vulnerability and Temperament
A large part of the risk factor for anorexia is genetic, and the genetic vulnerability is often indicated by temperament. Not everyone has all of these traits, though most impacted people have some. Anorexia is positively correlated with high intelligence and these people are often. Common temperamental traits are:
¨ Excellent student
¨ High Achiever
¨ Rules follower
¨ Black-and-white thinker
¨ Enjoys practicing to perfection (a draw for athletic and artistic pursuits)
¨ Drive for order and symmetry
¨ Emotionally over-regulated
¨ Frugal with money
Co-occurring anxiety, obsessive-compulsive disorder, and other mental health issues are common
Anorexia and ARFID are common in those with autism, and autism in girls is often missed
Anorexia is often secondary to health issues like Celiac, other GI issues, autoimmune disorders, and more, so full medical screening by an informed clinician is important
Self-harm and suicidal ideation may occur with anorexia
The Brain’s Food Reward System Explained (by a layperson)
When things are working optimally, our stomachs and brains work together to get our physical and mental health nutritional needs met. In terms of eating, the stomach, when empty, will send a signal to the brain to get the eating process going, the food goes into the stomach and a signal goes to the pleasure center of the brain, in in the amygdala, and the message is hopefully something like, “yum, tasty, let’s have some more.” I visualize the pathway on which that message is conveyed, as a train track. When the stomach is full, a message is sent to the satiety center of the brain to stop the eating. The signals are supposed to chug up and down the track, seamlessly, back and forth.
Anorexia Nervosa and the Trigger of
Negative Energy Balance
When a genetically-vulnerable person (this occurs in all demographics) experiences an energy deficit state (intentional or unintentional), the brain goes haywire and something deadly happens: the railroad track has been hijacked and the signal from the stomach when eating no longer goes to the please center of the brain, but the anxiety center. The impact of this is that eating then causes tremendous anxiety and not eating relieves anxiety.
The brain processes food as a threat to survival rather than necessary for it. The “Adapted to Flee Famine Theory” posits it once served societies well to have people who could have relative physical and mental stamina while malnourished and who, during times of famine, could gather food and feed others without eating, or eating much, themselves, and for whom desire for movement was high.
As restriction to relieve anxiety begins to take its toll, the brain actually shrinks from the impacts of malnutrition. Many of the signs of anorexia are also behaviors people who are malnourished will exhibit; intense fascination with food and obsessive interest in food is often expressed through voyeuristic behavior like watching cooking shows. Even when sick, people with anorexia can continue to perform well in many parts of their lives, especially work and school.
Getting Back on Track
In order to get the signals between stomach and brain on a track that supports physical and mental health, full nutritional rehabilitation to a brain restored intake and weight is necessary – the bad track has to be torn up and the good track shored up.
In family peer support and recovery communities those who are doing well often report feeding/eating high fat and high calorie foods, restricting exercise if it is at all problematic, not arbitrarily limiting weight gain, embracing a health at every size perspective, monitoring against relapse for an extended period, and practicing a relapse prevention lifestyle, to guard against a negative energy balance.
The time it takes for the reward center train to get back on track ranges from really long to even longer than that, and that’s an important truth everyone should be prepared for – there is no express train for this journey, derailments are common (and sometimes unavoidable even with all the best interventions). Recovery is possible at every age and stage, and early detection and appropriate intervention are the best routes to decreasing suffering and increasing recovery/remission rates.