“Why did you eat that? You better go for a jog and eat less for the rest of the day! There’s still time to compensate. Let’s total everything you’ve eaten today….”
I know cognitively that I would be calmer without the constant chatter in my head. I would be more productive: connected without the distraction. I want desperately to live without that unbearable berating.”
Denise is tormented. She has been struggling with anorexia nervosa for years. And she’s ready to change… as she has been many, many times. Why can’t eating disorders’ sufferers recover? The answer is complex but extremely perplexing and frustrating for those who are ready to change and are unable to. It feels like a pit bull that just won’t let go.
Denise’s angst is not an uncommon scenario in my office. Whether it is someone struggling with a full-blown eating disorder or from a lifetime of fad diets; or a teen that is struggling with her body’s transition to adulthood – at a certain point in their recovery, they agree that the preoccupation with food and body weight is negative…. If they’re ready to move on and be done with the obsession, why don’t they change? Eating disorders are renowned to be one of the most intractable mental illnesses. There have been decades of research and treatment options including medications and brain surgery, and yet the disease still persists.
A recent study by B. Timothy Walsh revealed that the brains of women struggling with anorexia nervosa show move activation in an area known as the dorsal striatum. This area of the brain contributes directly to decision-making, especially to action selection and initiation. In other words, higher activation in the dorsal striatum is suggestive of habitual behavior. Instead of weighing the pros and cons of eating, people with anorexia act automatically based on past learning. Walsh’s study suggests that anorexia is a habit. In addition, starvation makes the brain less flexible and threat-avoidant, hence reinforcing the habits.
Growing up in South Africa, I am familiar with a recreational activity called ‘bundu bashing’. In essence, it’s the act of going off the beaten path, into the long grass filled with unknown and danger. I think of the brain networks of all of our behaviors like the well-treaded footpaths, familiar and safe. In anorexia, those ‘safe’ pathways are actually very dangerous. If you continue on those pathways, your intake will continue to be inadequate and you may end up malnourished or even dead. Alternately, the pathways are so rigid that deviating even a little, result sin guilt and shame. The scary part of eating disorders is that eating normally, which is imperfect and varied, fires up the amygdala – the most primitive part of the brain that elicits the fight/flight response. Eating normally is reason for extreme, irrational danger. So of course, habits are reinforced.
It’s interesting that clients like Denise are able to jump off the path if there’s a pull for another motivation – but only temporarily. It may be a restaurant meal, a brief vacation or weekend away with a boyfriend. But as soon as the environment reverts back to the familiar work, home, routine… the eating disorder rules jump right back in. This phenomenon could perhaps explain the reason that intensive, inpatient treatments are often unsustainable. Relapse is common. When you go back to the environment filled with all the cues for old, destructive behaviours, the loud voice of an eating disorder returns. While drug or alcohol addiction can be treated by abstinence, we can’t avoid food. Part of the treatment of eating disorders includes avoidance of triggers such as those friends that talk about diets, visiting websites and social media that promote thinness and reading fashion magazines. That’s a far cry from a recovering alcoholic not going to her favourite pub or a drug addict severing ties with his dealer. Our physiological needs require that we face decisions about food consumption 5 to 6 times a day. That’s exhausting, especially when it requires bundu bashing!
If you want to create an alternate pathway, it needs to be a desirable one. Just eating more for the sake of not being on the familiar, is not a strong enough motivator. Full recovery requires energy, perseverance, resilience and creativity. So how do you undo these entrenched habits?
(1) It starts with visualizing another way of eating, of being… another food identity. Is there a desire to eat freely at a restaurant and with friends? Do you like eating spicy, exotic foods? Or is it grandmother’s recipes from the old country that are your favourite? If calories didn’t count, would you choose poutine or gelato, or both? Is sustainability a factor in your food choices? Do you have religious or cultural influences? Does your food identity look flexible and varied? Will you be able to eat socially – with food set into the context of the bigger picture of life?
(2) The next step is to expect anxiety and accept that it is a very unpleasant, yet necessary part of recovery. Accept that your perception of food sufficiency is most likely false and outside help is needed. Planned food exposure is the cure. Make a list of all the foods you’re afraid of and commit to include them… again, and again and again.
(3) Create new positive memories by eating with people and in environments that are comfortable, loving and supportive.
Finally, a good deal of patience, strength and faith is required… it takes 66 days to change a habit. That’s an awful lot of eating – almost 400 eating challenges to break it.
So Denise is surrounding herself with her loved ones, friends and family that enjoy food. She ‘gives the finger’ to the ED voice as she takes a bite into a freshly baked almond croissant. She doesn’t expect to have pleasure from her croissant just yet. With each moutful she is re-wiring her brain. We’re extremely proud of each and every bite of her journey! It’s well worth it! She will get to enjoying her food, trusting her body, free of the constant chatter of a bully in her head.