Melissa M. Gonzalez, Psy.D.

We all know what starvation looks like on the outside, whether we envision some child in a poverty-stricken, third-world country or a teenage girl with Anorexia Nervosa (AN). When most of us think about severe AN, we have visions of painfully thin girls and women with protruding bones, thinning hair, sunken eyes, and hollow cheeks. We can look at her and see what AN looks like, but what we don’t see is the damage being done on the inside. Today, I want to talk specifically about the impact of starvation on the brain and brain functioning. A starving brain operates very differently from a normal, well-fed brain; and changes in physiology and metabolism often result in distorted thinking. Such consequences may exacerbate the existing symptoms of eating disorders, create new challenges, or make treatment even more difficult. Therefore, it is important to understand this process and the changes that occur.

When the body begins to experience starvation, as is the case in AN, the body makes every effort to preserve the brain and provide it with the nutrients it requires to continue functioning. The idea here is to keep the brain going so it can direct the body to go seek out food and nutrients. So, in the initial stages of starvation, our bodies convert glycogen in the liver into more user-friendly glucose. However, after a short time, our bodies begin burning fat reserves. When our fat is metabolized into nutrients useable by the brain, Ketone bodies are produced resulting in a state of Ketosis. Eventually, after a more extended period of starvation, the body begins to run out of excess fat and must, instead, turn to muscle and connective tissue. Finally, when all else fails, the brain begins to break down neurons, reducing the volume of the brain and thereby “shrinking” the brain. While some studies suggest that brain volume can be restored after starvation ceases, other studies are beginning to find that recovery may not be so simple. It is also interesting to note that male brains seem to begin breaking down neurons more quickly in the starvation process than female brains.

What happens next? Malnutrition or starvation often results in difficulties with attention and concentration. The limbic system, which controls many aspects of our emotional response, attachment, and memory, is also impacted. Additionally, when the frontal lobes are involved, deficits in judgment, insight, and impulse control are often noticed. Brain imaging studies have noted an imbalance between the circuits that regulate our reward systems, emotions, the ability to plan ahead, and our understanding of consequences. The pleasure response often associated with food and eating may be blunted so that those who suffer with AN do not feel pleasure when eating. Instead, they may begin to experience fear, stress, or anxiety in response to food rather than feeling anxious or fearful when food is scarce or unavailable. The anorexic brain may no longer be able to signal the individual to eat in response to hunger – the message just doesn’t get through. Changes in the metabolism of neurotransmitters such as serotonin and dopamine are likely instrumental in the changes described above. So now, when we begin to treat the individual with AN, we must not only overcome the mind, but also the brain and the changes that have occurred as the result of malnutrition and food restriction. Finally, it is also important to note that in measuring the electrical activity of the brain using EEG, we find that those with AN and other eating disorders have a higher prevalence of EEG dysrhythmia. Even in those individuals without an eating disorder, EEG results showed anxiety and slow thinking in those who did not eat. When foods high in sugar or carbohydrates were consumed, slow processing speed and an inattentive pattern emerged. However, when individuals consumed a balanced, nutritious meal prior to being tested, a more normalized EEG pattern with less anxiety, impulsivity, and distractibility was observed.

So what does it all mean? First, early intervention is especially important in order to interrupt the loss of brain volume experienced by many anorexics; and the treatment of chronic eating disorders becomes more complex due to physiological and metabolic changes in the brain. Second, in assessing individuals with eating disorders, especially AN, an EEG may be useful in addition to a comprehensive psychological evaluation in order to determine the impact on the brain. Then, perhaps neurotherapy could be utilized as part of a treatment strategy if indicated. Third, in psychotherapy, distorted thinking must be understood within the context of a starving brain as well as the mental illness itself. Finally, psychiatric intervention is often an essential element of treatment in order to better regulate the neurotransmitters in the brain. Here at the Tarnow Center for Self-Management, we provide all of the services necessary to assess and treat the impact of eating disorders on the mind and the brain including psychological assessment; QEEG studies; individual, group, and family therapies; and psychiatric services. Please call us if you or someone you know is suffering with disordered eating.

If you suspect that your chld may suffer from an eating disorder or may be developing patterns of disordered eating, express your concerns difectly and privately in a kind, empathic, calm and supportive manner. Be able to ask educated questions. Do not try to force your child to eat. Engaging in a power struggle will not help. Providing advice about dieting or nutrition commenting positively about appearance, or attempting to solve your child's problems is not recommended. Do not agree to keep disordered eating habits a secret. Finally, do not let fear prevent you from confronting your child. EDs have the highest mortality rate of any psychiatric illness. Intervening and seeking help may save your child's life. We here at the Tarnow Center for Self-Management believe in a comprehensive approach to the treatment of eating disorders. This "attack n all fronts" often includes family therapy; and parents become an important part of the treatment process. Additionally, parents are encouraged to seek support, for themselves during this challenging process and that may take the form of support groups including other parents of children with EDs, use of online resources, or even individual therapy.