Starving Emotions into Submission

Anyone who seeks treatment with Patrick Pasi has already taken the biggest step toward possible recovery: acknowledging that they’re sick. This isn’t as simple as it sounds, as people with eating disorders are often convinced nothing is wrong. Quite the opposite: “They tell themselves that exercising is healthy, and everyone wants to lose weight. I’m just doing it especially well – so why would I need to see a doctor?” Pasi says. The nutrition psychiatrist heads the Eating Disorders Center at the University Hospital Zurich, where conditions such as anorexia, bulimia and binge-eating disorder are treated. Between one and four percent of the population suffer from the conditions, most of them women. Those who seek psychiatric help often do so because of pressure from family members or their family doctor. That’s why Pasi’s treatment includes work on patient motivation, because recovering from a severe eating disorder is a long, demanding process that requires resilience.

At the beginning of treatment, the goal is to restore a regular eating pattern, something that most patients have lost. With inpatient treatment, this means three main meals and three snacks a day. Patients must sign an agreement to eat them and keep them down. A regular eating structure, Pasi says, strengthens the body and clears the mind: “People with eating disorders think of nothing else but how to control what they eat. When we relieve them of that burden, it creates space for other subjects in their life that we can work through in psychotherapy.”

This includes exploring the causes of the eating disorder, which are highly complex. On the surface, anorexia often appears to revolve around being thin and conforming to an idea of beauty reinforced by social media. “It’s part of the drive toward self-improvement that’s so common in today’s society,” Pasi says. “People believe they have to enhance themselves to be of value. And the first thing they see is their own body, so that’s where many start.”

But the desire for self-improvement is only the most obvious explanation – and doesn’t automatically lead to an eating disorder. Deeper causes are usually at play: a mix of personality traits and biological, family-related and social factors. Pasi lists traits such as perfectionism, the drive to achieve, a desire for harmony or persistent negative thoughts and feelings about self-image. “We often see patients having difficulties in recognizing and regulating their emotions.”

These traits then collide with delicate family and social situations – such as separating from parents, entering adulthood and accepting life’s responsibilities. Pasi calls this the autonomy-dependence conflict: “A young person wants to be autonomous and tries to prove their power by controlling their body and food intake. At the same time, they’re still young enough to require protection, and don’t yet need to take adult responsibility.” Anorexia can also become a way of keeping the body childlike and avoiding adulthood, he notes. “That also means sexuality, which is often rejected.”

Rigid control over eating gives patients a sense of agency at a time when so much –physically and socially – feels beyond control. But starvation is a dysfunctional coping mechanism, Pasi says: “You can’t starve negative emotions into submission.” And the illusion of control, the compulsion to “get a grip on things,” takes a profound toll on the body.

Insufficient weight and malnutrition weaken the body and makes people with anorexia sick – mentally and physically. The long list of comorbidities – sicknesses that accompany or result from eating disorders – range from mood disorders, depression, anxiety, and sleep problems to digestive issues, osteoporosis, metabolic disorders, and cardiovascular problems.

At the root of it all is the way starvation causes natural bodily mechanisms to malfunction or even flip into their opposite. Normally, we experience natural feelings of hunger that tell the brain we need food. The act of eating then activates the brain’s reward system. “In anorexia, however, the reward doesn’t come from eating – but from not eating,” Pasi explains.

Food deprivation also affects the gut, which produces chemical messengers key to metabolism. It not only disrupts communication between the gut and the brain, which regulates hunger and food intake through hormones like leptin and ghrelin, but upsets the balance of the gut microbiome too.  “As a result, fewer chemical messengers and more inflammatory cells end up in the brain. These inflammatory signals then reinforce the anorexia.” In short, eating disorders throw the body seriously off balance – mentally and physically. Restoring equilibrium is extremely difficult.

The fact that eating disorders often occur alongside other conditions makes treatment all the more complex. Psychotherapy remains the “gold standard,” as eating disorders begin in the mind and must also be resolved there. Parallel interventions include art and movement therapy, medication for psychiatric comorbidities and nutritional counseling.

But first comes what Pasi calls “the practical part”: the body needs to gain weight. Patients are given weight-gain goals – for example, about 700 grams per week. The target is a body mass index (BMI) of 18.5, the threshold between normal weight and underweight. For someone 1.65 meters tall, that means 50.5 kilograms. Many patients start far below this, so treatment often takes time.

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Once eating patterns stabilize, Pasi can begin addressing psychological issues. If parents and family play a role, they’re included. A key focus is improving how patients perceive and process emotions. This includes learning to distinguish true hunger from emotions that pose as hunger – anger, disappointment, frustration, loneliness, boredom, or the fear of not being good enough. “We also work on building autonomy and personal responsibility, alternative coping strategies and a positive self-image,” Pasi says. Over time, eating should once again be something pleasurable. To recover, patients need to break the vicious cycle that’s holding them captive and causing their sickness.

Psychedelic substances such as psilocybin, ketamine and LSD – which have shown good results in studies on other psychiatric conditions – may also help. They increase cognitive and emotional flexibility and could help break through the rigid thinking that prevents people with anorexia from responding flexibly to their environment or treatment, especially when sensitive issues are raised. “Initial studies suggest they could help patients with chronic eating disorders too,” Pasi says. Other experimental treatments that may support psychotherapy include transcranial magnetic stimulation, which activates specific regions in the brain. Results here are encouraging, Pasi notes, but the benefits don’t yet appear to be long-lasting.

Virtual reality is another emerging tool. Patients can gradually become accustomed to a stronger, healthier image of themselves through an avatar created in VR. “This helps the brain gradually adapt to and accept a new appearance,” Pasi explains.

Exploring new treatment options is essential to improving outcomes. Most people with eating disorders recover over time. But in around 20 percent, the sickness becomes chronic, and 5 to 10 percent may die as a result. Specialized centers like the one at USZ – which offer tailored treatment at each stage of sickness – are essential for “lowering mortality and improving recovery rates,” Pasi says. It’s also important not to wait, but to seek help as early as possible: “Prognoses improve when the sickness is recognized and treated early.” Early intervention can also prevent the sickness from becoming chronic.