Anorexia nervosa is considered one of the most difficult psychiatric disorders to treat1.
Another way of saying this is that anorexia nervosa is one of the most difficult psychiatric disorders to recover from.
Having lived 15 years of my life with anorexia nervosa evidently there is little room for me to argue the contrary and if you’re living with anorexia nervosa first and foremost my heart truly goes out to you.
I know what a psychological and physical hell that is.
I also, thankfully now know what is possible in terms of full recovery and a fulfilling and meaningful life on the other side of the eating disorder and this is what I want for you.
There are many reasons why anorexia nervosa is traditionally thought of as an incredibly difficult, if not impossible illness to recover from and and in today’s post I am going to cover just 3 of these reasons which are all directly related to brain changes at the structural level2.
I do this not with the purpose of despairing over what makes recovery hard but instead to highlight the opposite.
Each of these 3 neurocognitive characteristics of anorexia I’m about to share with you as bad as they may at first seem can also be reframed and used as powerful allies to actually help you fast track your recovery.
I want you to walk away from having read this post with both a deeper understanding of what is going on as well as how you can work with rather than against the manifestations of the illness because what we know with as much certainty as we know these brain changes occur within the illness is that these changes are reversible in people who achieve an adequate level of nutritional and weight restoration3,4.
So, let’s take a look at 3 Reasons why anorexia nervosa is considered so hard to recover from and how you can use these very same reasons to instead fuel your recovery…
Reason #1 Cognitive Inflexibility
What It Means
If you are living with, have lived with or have a loved one living with anorexia nervosa you will know exactly what I mean when I say there is a profound level of rigidity associated with this illness.
Rigidity in thinking and behaviours may manifest as an excessive focus on maintaining an unrealistic level of certainty or micromanaging certain aspects of life (including food) which leaves very little, if any room for flexibility, adaptation or spontaneity.
What It Means in Day to Day Life
For me rigidity meant I wanted to know ahead of time those things which in a life full of variables (which is the case in the life of all human beings wishing to live a high quality existence) you simply cannot know.
I wanted to know exactly how the day would go, what everyone else would be thinking and doing and what I would be doing and of course eating came into this because when everything else felt out of control that was something I could control (and when I say “control” this is an unconscious pursuit of control because consciously I would have had no clue that this was what I was doing. I felt out of control).
I planned and stressed excessively over details. I tried to condense my days into less and less so they would feel manageable or bearable.
Unexpected changes to plans made me feel as though I was dying (no exaggeration).
When I was sick I never would have spoken this to anyone because like everything to do with anorexia nervosa I was too ashamed to admit what I truly felt, believing it was “crazy” and that I “shouldn’t” be feeling that way. Also, in the midst of the delusion I did not have the understanding to fully grasp what was going on.
I knew what I felt, I knew what was true for me but I also thought willpower and determination were the ways in which I was going to get better and if I just tried harder I’d recover. I thought a lot of things that I can only see in hindsight were never true (they were my truth, a version of the truth but not “the truth”).
Why It Happens?
Rigidity in thinking and behaviours can be viewed as a protective mechanism or means of self-soothing.
When everything feels out of control there is a need to gain some level of certainty.
This isn’t a choice or something unique to anorexia nervosa, but rather a fundamental human need each and every one of us has and which your unconscious mind goes about attempting to get met in the best way it knows how.
Furthermore, rigid thinking is a direct result of starvation and a brain getting stuck on “safe patterns” i.e. if you’ve done things one way and you’re still alive it is best not to change that because back in our past when we were living out in the wilderness a change in what “works” could mean death.
Remember your unconscious processes aren’t too concerned with your quality of life, just that you are alive.
What to Do Now (aka How to Transform Cognitive Inflexibility into the Superpower of Single Minded Determination)
Make a clear decision to commit to recovery no matter what.
Do this and your rigidity and stubbornness to stick to this decision will ensure there is nothing and no one who can stop you from reaching it.
I have no doubt about that.
Also, consider beginning to look to other things to channel your energy into because if you can invest this amount of energy into something you hate, be so “good” at it and obtain such phenomenal results imagine, just imagine for a moment what you could do if you devoted the same level of commitment and energy to something you actually did love?…
Reason #2 Compromised “Big Picture” Thinking
What It Means
Compromised (or lack of) big picture thinking or what is more scientifically termed “central coherence” means a focus on the details at the expense of taking into account the broader picture.
What It Means in Day to Day Life
The most powerful memory I have of how I experienced this was my inability to fully conceive the future.
As far as I was concerned, I basically didn’t have a future.
I was living day to day.
Therefore, my action or inaction was fully caught up in the now and I wasn’t able to alter what I did based on future consequences.
I lived in the moment and the pain in the moment always outweighed the intellectual understanding of long-term gain or threat.
Theoretically, logically I knew all the consequences of starving, treating my body terribly and all the other reckless behaviours I did and yet I wasn’t able to fully connect to the feeling of that.
Why It Happens?
There are many reasons for this, of which I’ll briefly explain just one because at the end of the day it comes down to priority.
When we are under stress, of which there really is no equivalent in terms of both mental and physical stress than the stress of starvation, your brain recognises there is no use in basing your actions in the here and now on their long-term consequences.
This is because stress is registered as an immediate threat to survival and the stress response is designed to increase your chances of survival now, not in 2 years or 50 years.
When you are under stress your body is far more concerned with keeping you alive in the here and now because ultimately why alter your actions for a future in which it doesn’t know if you’ll be around to experience or not?
Doing the anorexia nervosa behaviours in the here and now is a very real means of diminishing the inner turmoil (stress), even if the reprieve they offer is pathetically short lived and even if the doing of them has incredibly harmful future implications it does not matter.
As far as your automatic responses are concerned it is better you are alive now with no future planned than dead with a great future planned.
What to Do Now (aka How to Transform Compromised Big Picture Thinking into the Superpower of Mastery)
Rather than try to do everything at once and recover overnight focus on one thing per day, week or even month.
This could be as simple as having a nutritionally adequate breakfast every morning or bringing in an extra snack a day for a week.
Get that one thing on track and only then move on to the next.
With a few repetitions of this way of doing things (and I really mean giving yourself permission to do just one thing) your brain will get faster at doing it and start to automatically generalise to other areas of your life. Until it becomes habit rather than conscious effort. Which to me this is the difference between “behaviour free” and recovered.
“Behaviour free” is when you’re just stopping yourself from doing the eating disorder behaviours but still feeling the urge to do them and recovered is when the urge simply no longer comes up.
In every case, without exception we are going for the later.
But remember there is no mastery without first mastering the fundamentals.
Reason #3 Impaired Decision Making
What It Means
Impaired decision-making means you have difficulty making decisions and also trusting your decision once you’ve made it.
How long does it take you to make a decision? Do you make a decision and move on or do you ruminate over it for hours or weeks after making it?
What It Means in Day to Day Life
Once upon a time I struggled to make even the simplest of decisions.
I remember joking to my boyfriend at the time that I’d love to have someone just make all decisions for me.
The weight of making the “wrong” decision may have prevented me from making the “wrong” decision but it also prevented me from making a lot of the right decisions or from learning from the “wrong” decisions.
I was perpetually stuck in analysis paralysis.
I remember the hours, days and to be honest years I’d spend deliberating over making one decision.
From micro to macro they all took monumental effort.
I wanted ALL the evidence and information before choosing and in real life this is never the case. At any point in time, you only have the information you have and you have to make many decisions based off not knowing everything or exactly how it will turn out.
More often than not my decisions were made for me when it would eventually come to the point where circumstance, time or somebody else had to make the decision for me.
I thought I was bad at making decisions.
I thought that struggling to make decisions was an inherent part of me in the same way that I had blue eyes.
I’d honestly fully accepted that I was just a “bad decision maker” and I was because I didn’t know most of the time what I truly wanted.
There were many skills and internal resources I was lacking including a strong sense of self-identity, self-worth and boundaries that prevented me from making decisions, let alone making decisions with ease.
However, none of these skills and resources were unlearnable.
In fact, I’ve learnt them all now and I can tell you I’ve never struggles over a decision in quite the same confusing, visceral and all-consuming way I once did when I was living with anorexia nervosa.
Why It Happens?
When a human brain is starved of nutrients the first part of the brain to be “sacrificed” is your prefrontal cortex (PFC).
Why? Because unlike many other regions of your brain including your brain stem which coordinates vital processes such as your breathing and temperature regulation your PFC is not involved in your immediate survival.
This means its receiving peak nutrition when resources are in scarce supply isn’t a priority.
This is a problem because what your PFC is involved in is your higher order, logical, deductive and longer term, decision making processes. Evidently a problem to have this all go offline if you want to be a calm, compassionate and successful human being.
But as far as your body is concerned what’s the point of being smart and great at making decisions if you’re dead?
What to Do Now (aka How to Transform Impaired Decision Making into the Superpower of Action)
I highly recommend voluntarily putting decision making out of your hands.
If you are swamped and overwhelmed with the pressure and 24/7 exhaustion of trying to make decisions around food or other things. Hand over the “control” to someone you trust.
While it is preferable that this someone be a professional involved in your treatment it can also be your partner, parent, sibling, friend or other it does not truly matter. If there is someone in your life you trust to do the right thing by you let, go and let them make your decisions for a period.
This is not with the intention that this is a permanent situation and that the rest of your life is out of your hands but rather a period of time to take the pressure off you and see how that changes things.
You could, for example trial a month of taking the the pressure off the need to decide what, when, how much, with who and if you’ll eat by eating every day to a pre-planned meal plan (codesigned with your Dietitian). Decision made. No room for negotiation or exceptions.
This may sound extreme and to be honest it is the opposite of the long term goal of recovery (i.e. to have everything fully within your control) but it is as I said a solid place to start versus a place to live your life. The process of recovery has stages and steps and from my perspective there is definitely a time for decisions to be out of your hands so that later they can be in your hands.
Alleviating the excessive stress and overwhelm for even a solid month may be all you need to get to a stronger place where you can start to honestly take some of that control back for yourself and not the eating disorder.
The Bottom Line
For every reason you’ve ever been told be this by others or by yourself, that you are incapable of full recovery there is a reason why that thing you think is stopping you is actually a strength. A strength which you can transform into a very real superpower which may just be the very thing which changes everything.
There is a plethora of evidence to show many of the core psychopathological states of anorexia nervosa including anxiety, depression, rigid thinking, lack of ability to see the big picture, impaired decision making ability and obsessional behaviours are improved following nutritional restoration.
This is because each of these, rather than necessarily being inherently pathologic are simply symptoms of a starving but otherwise normal human brain doing what it is designed to do under the second to none stress of starvation.
However, what we now know is that these psychological “problems” do not entirely disappear with nutritional restoration.
That is, we know there is more to the process and achievement of full recovery than refeeding alone.
Having been there myself I can honestly say some of my most psychologically painful moments were the times I was in a “healthy” body and at a “healthy” weight with very little improvement in my ability to internally regulate my emotional state or behaviours.
Neurocognitive “deficits” are, without a shadow of a doubt a consequence of the illness but it is becoming evident that these traits were also often there to begin with and may have played a role or been a risk factor in the onset of the disorder.
Hence, any meaningful attempt at treatment if it is to contribute to full psychological freedom from the eating disorder must provide neurocognitive support and advancement alongside nutritional restoration.
If you are interested in the cognitive side of recovery and recognise within yourself or someone you love manifestations of the 3 psychological impairments I’ve described within this post there is more than hope to changing these both in order to recover and to live a higher quality life in general.
Clinical hypnotherapy (working alongside nutritional replenishment) is one such means of developing new skills and internal resources that ensure brain and mind development and not just a physical change in body size/weight/shape is achieved.
With my whole heart I hope you found this information useful and inspiring.
Become Great. Live Great.
Bonnie.
Reference
- Tone SF. Set-shifting, central coherence and decision-making in individuals recovered from anorexia nervosa: a systematic review. Journal of Eating Disorders 2019;7.
- CJ MA, Smith W. Neural correlates of eating disorders: translational potential. Neurosci Neuroecon. 2015;4:35–49
- McCormick LM, Keel PK, Brumm MC, Bowers W, Swayze V, Andersen A, Andreasen N. Implications of starvation-induced change in right dorsal anterior cingulate volume in anorexia nervosa. Int J Eat Disord. 2008;41(7):602–10.
- Owen I, Lindvall Dahlgren C, & Lask B. Cognitive Remediation Therapy. In B. Lask & R. Bryant-Waugh (Eds.), Eating Disorders in Childhood and Adolescence. New York: Routledge, 2013
1 thought on “3 Reasons Why Anorexia Nervosa Is Considered So Hard to Recover from and How You Can Transform These Reasons to Not Recover into Superpowers That Instead Fuel Your Recovery”
This is a great tip particularly to those fresh to
the blogosphere. Simple but very precise information… Thank you for sharing
this one. A must read article!