Is Anorexia a Mental Illness?
Anosognosia:
(uh-naa-suh-NO-zhuh)
A neurological condition in which the patient is unaware of their neurological deficit or psychiatric condition. It is associated with mental illness, dementia, and structural brain lesion.
Anorexics often refuse to acknowledge that they are unwell. But society isn’t much better. We’re quick to characterize anorexics as affluent attention-seekers, acting out in reaction to years of poor parenting. It’s a sort of social anosognosia that’s reflected most clearly in our treatment of the disease: long therapy sessions, journalling, analyzing feelings, and decrying the insidious toxicity of twiggish fashion models glisteningly displayed on the cover of every pop culture magazine.
As expected, success rates for the usual treatment modalities are paltry: only 21 percent of us are estimated to reach full remission. Turns out, social workers vent-vomiting all over social media about the Machiavellian effects of colonialism, white supremacy, and structural racism on our impressionable tweenage self-regard isn’t effectively rescuing anyone from the depths anorexia. That’s because anorexia isn’t caused by the current zeitgeist of Facetune and ozempic. Nor is it ameliorated by blaming your mother for buying whole grain pop tarts. Which begs the question…
What causes anorexia?
For lack of a well-fitting description, what anorexics are able to do is egregiously phenomenal. It’s normally impossible for people to keep their weight 15% or more below normal for long. I’ve gone over this in detail here and here. But have you ever wondered how 14-year-old girls can willfully resist hunger when adults cannot? After all, the part of the brain that helps us delay gratification and exert self-control isn’t yet fully developed until we’re in our mid-twenties. So how can young anorexics exert such self control?
Here’s the thing: anorexia isn’t a hobby.
Contrary to popular belief, anorexia doesn’t feel like a choice because it isn’t. Which is why, when people with anorexia try to recover, they find that their body and mind fight against them.
“There are a number of other facts that do not square with the idea that anorexia nervosa really is caused by “nervosa”, that is, psychological illness.”
Dr. Shan Guisinger is an evolutionary biologist and clinical psychologist specializing in eating disorders. She’s the only clinical practitioner that has authored theoretical articles on the evolution of anorexia nervosa and interpersonal relatedness for both The American Psychologist and Psychological Review. She’s currently at work on a treatment manual for anorexia nervosa, but the reason she’s appearing in this post is for what she is most well known for: The Adapted to Flee Famine Hypothesis.
The Adapted to Flee Famine Hypothesis (AFFH) proposed that hunter-gatherer ancestors who were able to forego their hunger in favor of continuous movement, the ancestors of today’s anorexia patient, could have scouted ahead for food in the Pleistocene.
Anorexia is highly heritable, indicating that genes make a significant contribution to anorexia. This supports the theory that natural selection may have been involved in the development of anorexic traits. The AFFH builds on this, positing that eating disorders are heritable adaptations that once served a very practical purpose. In other words: controlling hunger, denying starvation, and moving makes sense in the context of a desperate journey. But what would influence anorexics to behave this way? Turns out, the answers are found in one small region of the body: your hypothalamus.
Hypothalamus is the anatomical name for a region of your brain whose main function is to maintain homeostasis. It does this by controlling and coordinating two things: your autonomic nervous system (the group of nerves which regulate involuntary physiological processes like your heartbeat), and your hormones. Long story short, among the plethora of responsibilities designated to this region, your hypothalamus also monitors your nutritional status.
Here’s where it gets interesting:
Most people’s hypothalami have a two-pronged approach to surviving starvation:
First, it increases hunger signals, which renders that person unable to think of little else until their hunger is satisfied.
And second, it lowers satiety signals so that when and if food does become available, they gorge.
But if an anorexic is starving, their hypothalamus has a shockingly different set of cascading reactions.
Inside the anorexic brain, starvation triggers the hypothalamus to simultaneously decrease hunger signals and increase satiety signals. The resulting two-pronged effect is that a starving anorexic becomes repelled by food, and when they do eat, they’ll feel more full than they should.
Taking a closer look at the mechanisms behind this, Dr. Guisinger found that satiety signals in the gut are ramped up so that people with anorexia feel full more quickly than they should. And in their brain, dopamine reward receptors are decreased so that food tastes dull and eating is unrewarding. Additionally, anorexia physically increases a fear response when a person is faced with food. This misidentification of food as a threat leads people with anorexia to deduce that it’s vitally important to control their appetite.
The brilliant paradox of an eating disorder brain is that it rewards food-seeking behavior, punishes you for eating, and rewards you for starving. Anorexia is the ultimate trait of a leader whose primary responsibility is rallying her tribe to safer lands.
More to Guisinger’s point is this: prehistoric hunter-gatherers originated in Africa, and travelled outward. Amazingly, as few as 500 of the people who left Africa gave rise to the modern populations of the rest of the world. According to molecular geneticists, the founding population of American Indians may have only been 70 people. All this to say: anorexia nervosa is extremely rare in Africans, it is more common in Europeans and Asians, and appears to be most common in Native Americans who have traveled the furthest from Africa.
Disorder:
(dis-OR-der)
In medicine, an abnormal condition that affects the body's function but may or may not have specific signs and symptoms. A disorder may indicate that a specific disease is present, but there is usually not enough evidence to make a diagnosis.
Labelling eating disorders as a mental disorder (or even, I’d argue, as a “disorder”) is reductive. Eating disorders aren’t mental illnesses any more than sickle cell anemia or fragile x syndrome are. The proof is in the pudding: researchers have found a genetic mutation on an estrogen receptor that turns on the capacity to develop anorexia at puberty.
I’m sorry, but eating disorders just aren’t a harbinger of a lifetime of struggle. They are a reaction to the very thing they perpetuate: starvation.
Our current milieu assumes that anorexia is caused by “successful pursuit of thinness.” This falsely attributes the cause of anorexia to faulty cognitions or disturbed relationships that lead someone to have excessive weight concerns.
Today’s anorexics often attribute their self-starvation to a desire to be thin, but medieval women with Holy Anorexia referred to their same behaviors with fervent piety. Humans try to make sense of their behavior post hoc, not recognizing that their anorexia emanates from sub-cortical structures. My point is that anorexia isn’t strictly volitional, and the symptoms of anorexia are in reality caused by weight loss.
Remember this:
Anorexia is a heritable metabolic condition which simultaneously is activated by, and perpetuates, undernourishment.
Read that again.
The study of epigenetics posits that your behavior and environment can change not only the way your genes work, but which of them is expressed or repressed. It’s essentially the plasticity of our DNA in response to our environment. Many things have been known to have phenotypical untoward effects, like microplastics and pesticides. One facet of epigenetics is nutrigenomics, or the way in which food alters our gene expression.
Thus far, eight genes have been identified in anorexic individuals that decrease appetite and increase activity. And guess what? They’re all triggered by decreasing body weight.
Anorexia does not cause your symptoms, it is the symptom.
The often-overlooked truth is this:
Refusal to eat and over-activity occur after weight loss.
In other words, for those with the genetic predisposition for anorexia, decreasing body weight signals for your genes to activate what we call ‘anorexia.’
So, what does this mean for you?
If you wish to reach remission, you need to remove the underlying cause: undernourishment.
But what the heck is undernourishment?
Undernourishment is an undesirable state in which there is not enough nutrition to maintain optimal health. It wears many different masks, most of which are sources of pride and symbols of moral superiority by today’s North American cultural standards. It can look like:
Energy suppression (not eating enough)
Physical illness (inability to eat for a period of time while you’re sick)
Overexertion and overexercise (marathons, long hikes, etc)
Cleanses
Fasting
High-vegetation diets (plant-based, vegan, vegetarian, you name it)
Low-fat diets
Animal food avoidance
ANY diet
Food insecurity, etc.
Basically, undernourishment is anything that causes enough of an energy deficit to trigger your brain’s famine response. It’s essentially why diets are so dangerous for those with an anorexia predisposition. In the same way that a recovered alcoholic would be remiss in their attempt to casually drink a Coors Light on the beach, avoiding gluten could just as likely send anyone with the genetic hardwiring for anorexia straight down the rabbit hole.
Anorexia is a genetic predisposition; you inherited your eating disorder. But just because “anorexia” is written in your genes doesn’t mean you have to be anorexic for the rest of your life. And if you take anything away from reading my article, let it be this:
Genes can be turned off.
How does knowing anorexia is heritable help with the treatment and prevention of eating disorders?
If anorexia is genetic, it’s triggered whenever body fat drops too low. This explains why so many cases of anorexia occur in adolescence and young adulthood. During puberty, girls attain their adult height more quickly than they can fill out. They’re typically leaner during this period than they will be at any other time in their lives. And these “beanpoles” are at a significant risk of developing anorexia. For those with the genetic code for anorexia, losing weight - for any reason - whether from illness, athletics, or dieting, can trigger anorexia.
Eating disorders are activated by the way in which we treat our bodies, and thus by the way in which our bodies perceive the world. Are you eating enough, or has your body been getting signals that it’s time to flee the famine? In agreement with all other effective treatments, the prescription remains the same:
In order to reach full remission, you must eat lots of food.
It takes a lot of effort to override your evolutionarily biological makeup. But remember that you are in full control of your future. All roads point to the same conclusion: eat lots of food, consistently and you will inevitably succeed in disengaging your anorexic adaptation.
Once your body gets the signal, it will realize that you don’t need to save all your kin by starving yourself so you can go forage further. You can just be you.
Remember that anorexia is a short-term Band-Aid for long-term happiness. Please don’t confuse the immediate and hardwired neurological rewards for starvation with what is true happiness. Your brain’s fear- and reward-systems have simply crossed wires. And it is totally within your ability to uncross them.
For more guidance, please read my full ebook by clicking below.
You’re stronger than you think.
Maria
