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Ambivalence to Recovery: What Does the Brain Have to Do With It?

Ambivalence to Recovery: What Does the Brain Have to Do With It?

by Dr. Alice Ely and Dr. Walter Kaye

One of the greatest challenges about treating eating disorders is what is frequently described as apathy or ambivalence about recovery. In the case of anorexia nervosa (AN), people seem to be indifferent to activities and rewards that others might consider to be enjoyable and motivating, while individuals with bulimia nervosa (BN) may impulsively value instant gratification over more long-term goals. While we are still learning about these relationships to reward, recent research in neurobiology suggests that they may be two sides of the same coin.

Most people tend to prefer positive, rewarding stimuli or experiences rather than punishment (e.g., unpleasant events) or loss, especially when they’re hungry.1 This is evolutionarily useful—if we were too worried about possible consequences, then we might never risk leaving the cave to find food. However, recent studies suggest that the brains of people with eating disorders seem to respond similarly to both positive and negative feedback. This suggests that these people may have difficulty, at least in a neural sense, telling them apart.

In AN, we see elevated brain activation in response to reward and to punishment, but not in the area that is typically involved in motivating or important stimuli, a brain region called the ventral striatum.2 Instead, the activity is in areas of the brain linked to planning and consequences.3 Those with AN may rely on these cognitive processes to compensate for an altered reward response when evaluating choices or making decisions. Thus, they may be more likely to consider consequences than to respond to immediate gratification.

The brain response in BN is a little different. Brain imaging research has shown that, like in AN, the response to reward and punishment is similar, but individuals with BN don’t have the same exaggerated activity in the areas of the brain related to inhibition.4 In fact, some studies suggest that they may have less inhibitory control. They do, however, have an elevated reward response to food in the ventral striatum.5,6

We know that individuals with eating disorders have some dysfunction in how they process rewards, particularly when it comes to food. The findings suggest that people with AN may be experiencing a perpetual state of satiety, while individuals with BN may be feeling chronically deprived.7 Moreover, difficulties in evaluating important information—whether good or bad—may contribute to patients’ ambivalence toward treatment and recovery.

So how can we make treatments better, given what we know about the neurobiology of people with AN and BN? There is some evidence that these differences in reward are temperament traits,8 so we might have more luck working with them as opposed to against them. Psychoeducation about these neurobiological differences with individuals with eating disorders and those who care about them is especially important, both to depersonalize symptoms of the disorders and to reduce blame. Moreover, our group9 is developing a treatment that teaches skills to allow people to constructively use their temperament to recover. Beyond this, we will need to work to develop treatments or treatment packages that can best allow us to support recovery, even when there is ambivalence.

About the Authors:

Dr. Alice Ely is a postdoctoral research fellow at the UC San Diego Eating Disorders Center for Treatment and Research. She received her BA in psychology from the University of Pennsylvania and her PhD in clinical psychology from Drexel University in Philadelphia, completing her clinical internship at UCSD and the San Diego VA Healthcare System. She has clinical experience working with adults and adolescents with eating disorders, as well as anxiety, depression, substance use, and chronic medical conditions. Her research interests focus on the neurobiology of eating disorders and risk factors for eating problems.

Dr. Walter Kaye is a professor and Director of the Eating Disorders Program at UCSD Department of Psychiatry



1.         Wang K, Zhang H, Bloss C, Duvvuri V, Kaye W, Schork N, et al. A genome-wide association study on common SNPs and rare CNVs in anorexia nervosa. Molecular Psychiatry. 2010;Epub ahead of print.

2.         Yin H, Knowlton B. The role of the basal ganglia in habit formation. Nature Neuroscience Rev. 2006;7(6):464-476. 16715055.

3.         Konishi S, Nakajima K, Uchida I, Sekihara K, Miyashita Y. No-go dominant brain activity in human inferior prefrontal cortex revealed by functional magnetic resonance imaging. Eur J Neurosci. 1998;10:1209-1213. 9753190.

4.         Wagner A, Aizeinstein H, Venkatraman V, Bischoff-Grethe A, Fudge J, May J, et al. Altered striatal response to reward in bulimia nervosa after recovery. Int J Eat Disord. 2010;43(4):289-294. 19434606.

5.         Bohon C, Stice E. Reward abnormalities among women with full and subthreshold bulimia nervosa: a functional magnetic resonance imaging study. Int J Eat Disord. 2011;44(7):585-595. 21997421.

6.         Oberndorfer T, Frank G, Fudge J, Simmons A, Paulus M, Wagner A, et al. Altered insula response to sweet taste processing after recovery from anorexia and bulimia nervosa. Am J Psychiatry. 2013;170(10):1143-1151. 23732817.

7.         Wierenga C, Bischoff S, Melrose J, Irvine Z, Torres L, Bailer U, et al. Hunger does not motivate reward in anorexia nervosa. In Press. Biological Psychiatry. 2014.

8.         Kaye W, Wierenga C, Bailer U, Simmons A, Wagner A, Bischoff-Grethe A. Does a shared neurobiology for foods and drugs of abuse contribute to extremes of food ingestion in anorexia and bulimia nervosa? Biological Psychiatry. 2013;73(9):836-842. 23380716.

9.         Kaye W, Wierenga C, Knatz S, Liang J, Boutelle K, Hill L, et al. Temperament Based Treatment (TBT) for Anorexia Nervosa. In Press. European Eating Disorders Review. 2014.



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