Why Would a Person Choose to Starve?

"Nothing tastes as good as skinny feels" as an articulation of pathophysiology.

Photo by K8 on Unsplash

Why would a person choose to starve?

Narrow body standards create a harmful world for folks with diverse body types to live in. Albeit mentally and physically harmful, many Americans restrict their caloric intake in an attempt to cope with the oppressive nature of the thin ideal. One might diet in an attempt to fit into physically defined spaces such as clothes, chairs, seats, doorframes, and even beds. Shrinking ones body mass might help protect them from harm and discrimination. The pursuit of thinness has helped some women exert a sense of agency over their life in a culture that permits them little to none.

But some folks seem equipped to take dieting too far. So far that the pursuit may inflict permanent bodily harm. Often we sum up their extreme behavior to a traumatic past because of course only a person who is suffering from debilitating pain could go to such lengths¹.

We seemed to have answered the question as to why a person would starve themselves, but have we asked why the body would let a person starve? How do some bodies permit their humans to wither away while the rest of us are unable to fight through the physical pain induced by hunger? For most of us, pushing off a meal puts our caveman brain in the drivers seat, making us fumble through our pantries to find whatever will restore our blood sugar the quickest. Yet folks with Anorexia Nervosa (AN) are somehow able to maintain “self-control” and abstain from eating in the midst of the chaos hunger creates.

When our stomach empties and our blood sugar dips, the hunger hormone ghrelin is created by the stomach to alert our brain that it’s time to eat. Our brain becomes more interested in food and deploys the eyes, nose, and ears to seek it out. Dopamine is created in anticipation of the meal to motivate you to seek out food.

When you eat in response to increased levels of ghrelin, the brain creates more dopamine to reward you for eating, establishing a connection that eating in response to hunger will make you feel good. The first crunch of your meal is the most exciting. The combination of flavors and textures in your mouth is the most pronounced. As you continue eating and your stomach recognizes that it’s being filled with food, your brain mutes your senses making each bite less and less interesting.

When hunger feels good

The AN brain seems to have a different relationship with hunger. Although it still creates dopamine in response to being hungry, the AN brain does not receive much of a reward for actually eating food. As a result, the brain associates hunger with feeling good. The End.

Although short-term caloric restriction triggers dopamine production, long-term caloric restriction leads to decreased dopamine production. In an effort to seek it out, the AN brain continues to engage in caloric restriction. It can’t recognize that the behavior isn’t working and keeps returning to the behavior inappropriately expecting a reward- what some researchers call “entrenchment”.

This behavioral inflexibility is not only seen in AN, but in other disorders in which the brain lacks sufficient dopamine production such as ADHD and substance disorders. On a smaller scale it’s likely that some of you can relate. Have you ever tried fixing a problem having very few tools to do so? If you don’t know any better, the tool you’re using might make the problem worse until someone shows you another option. This is how the Anorexic brain views caloric restriction - a solution to the problem it’s perpetuating.

“Nothing tastes as good as skinny feels”

A universal experience among folks with Anorexia Nervosa is the sensation that “hunger feels good”, like a “reward”, or even “a drug”. It’s no wonder considering the AN brain has come to associate hunger with dopamine.

To challenge these feelings, a common treatment approach is to explore how this association may have developed. Many well-meaning providers (including myself), will use a narrative-based approach to help an individual trace back to what made them need such an extreme tool to feel good in the first place. Maybe hunger is associated with a period in time in which caloric restriction made them feel safe- such as losing weight to protect their body from abuse. Restriction could have also stopped their body from developing secondary sex characteristics that did not align with their gender identity. Or it could have numbed their body from experiencing intense emotions inflicted by environmental harm. With repeated use, restriction becomes associated with safety and the individual may go back to it to feel good even when the initial threat is no longer present.

There’s no doubt that acknowledging one’s lived experience can help an individual feel seen and validated. Observing the meaningful associations with one’s eating disorder behaviors can help them process feelings necessary to heal. But what I often notice in eating disorder (ED) treatment is that the cause of the ED thoughts is often reduced to fabrications of the conscious mind as opposed to inappropriate signaling from the brain. Could this contribute to the defeat some patients feel when processing said associations don’t seem to help ED thoughts go away?

Although the personal associations that develop with ED behaviors have a significant impact on an individual, the pathophysiology of eating disorders helps explain why some folks working toward recovery struggle to progress. We tend to solely blame social factors for causing eating disorders but not everyone who diets becomes Anorexic and not everyone who develops Anorexia initially did so to pursue thinness. Some researchers believe that entering a prolonged caloric deficit during adolescence, whether intentional or not, triggers the gene for Anorexia Nervosa to “turn on”. In other words, the pathophysiology of eating disorders exists regardless of whether or not the social pressure to be thin is present at onset.

Cognitive reframing can be used as a tool to change ones feelings and behaviors. But since our culture values mind-body dualism, many of us confuse cognitive reframing as a way to simply intellectualize our thoughts away. If we want cognitive reframing to be helpful, it should actually align with our experience (including physiology) as opposed to a tool to “grin and bear it”. Since many thoughts and feelings are created by aberrant neurotransmitter activity, the activity needs to change in order to effectively change the associated thoughts. Sometimes, the activity can be influenced by thinking differently. But typically it changes by incorporating new behaviors that establish healthier neurotransmitter activity.

Those who know Anorexia personally know that trying to get an Anorexic to “think differently” about food is rarely if ever enough to help them eat. Entrenchment cannot be fixed by reason. Give a person with Anorexia Nervosa the list of reasons in which the disorder makes them feel bad and they will not believe that it outweighs the perceived benefits of restriction. Trust me, I’ve done it at least a hundreds of times before. Why would they believe it when their brains reward-response is telling them that it feels good?

I’ve had many clients tell me something along the lines of, If I waited to develop the motivation to eat to actually start eating, I would end up dying from starvation. And that sums up Anorexia Nervosa recovery. In order to heal, patients simply need to start eating even if they don’t believe that they need to.

Cognitive inflexibility associated with the disorder is caused by the chronic restriction. So in the case of AN recovery, cognitive reframing is not necessarily a useful tool until the brain is adequately nourished and has established healthier reward pathways. Tools that can help one do so include but are not limited to adequate nourishment, pharmacological support, distress-tolerance skills, increased community support, and more. Healthy brain chemicals = healthy thoughts.

If it’s still not making sense why cognitive reframing is not always enough to change ones thoughts and feelings let’s use an example we can all relate to. Has a hungry friend or family member every been angry and inpatient with you? Try telling them that they should just calm down and be patient. They’re likely just going to get angrier at you because their low blood sugar has shortened their fuse. Thus regulating their blood sugar will do the best job at resolving their anger. Our feelings work the same way. We have to resolve the actual cause of the dysregulation as opposed to trying to intellectualize it away.

Treating the brain as an organ

A person doesn’t simply choose to starve. Inappropriate brain patterns make them believe that it is truly the right thing to do. In my sessions, every client I have with Anorexia vocalizes a universal experience: I know logically I need to eat, but it feels so wrong. It does. We shouldn’t underestimate the power of our feelings, but if we seek to understand them we will learn that sometimes they are in fact just feelings. Not to be avoided, but understood to find appropriate tools to help one transform.

Instead of trying to convince patients to feel good when they eat food, focusing on providing education to help them learn why certain treatment tools will help in the long-run is likely more useful. Providing education as to why adequate caloric intake, dietary variety, exposure-response-prevention, anti-depressants, RO-DBT, CBT, ACT, will change their reward processing might be useful. Even if using these tools doesn’t provide the same immediate reward that restriction does, it will lead to steady production of dopamine and new routines for achieving such.

What could we all learn from AN recovery?

We live in a culture in which it’s assumed that our thoughts can be changed simply by thinking differently, but this doesn’t work for Anorexia nor a variety of mental conditions. Instead, we must teach that thinking differently often requires doing differently to create an alternative outcome that brings us reward. What would happen if we took the lessons from AN and applied them to how we understand our thoughts and feelings in general? Many of us mistaken our feelings for fundamental truths, making us reinforce evidence of those truths by avoiding situations that make us feeling uncomfortable. What would happen if instead of trying to just think differently, we did differently?²

A person who has never run before might feel the aches and pains of the muscles and joints warming up their first time. But with consistency will get more comfortable with running and eventually experience a runner’s high.

A person who rarely leaves their house might be overwhelmed by the scents, sounds, and lights outside. But being outside consistently will help with senses adjust and eventually lead to joy in doing so.

A person who has never been on a plane before might be afraid that flying would compromise their safety. But if they flew regularly would learn that it’s actually quite safe, and pilots are highly skilled to appropriately navigate any situation that could compromise safety.

Sometimes thinking differently simply requires experience, and experience requires doing the thing that we think is scary. Cognitive flexibility does not solely depend on thinking differently but also doing differently to teach our body that there are other possibilities.

1. This is sarcasm directed towards how our culture overgeneralizes the factors attributing to the development of eating disorders.

2. In dialectical behavioral therapy, this is called “opposite action”. At Nike, this is called “just do it”.