Eating disorder recovery: Understand & treat with Dr. Shan Guisinger's approach

Transcript for this video:

Hi, I’m Michelle Cen. I had a life-threatening eating disorder for 5 years. I never wanted to be so skinny that my organs were wasting away. Quite the opposite; I wanted to gain weight but couldn’t. I never understood why I rejected food or compulsively exercised. And standard medical treatments made my eating disorder worse.

I never really recovered until I discovered the work of Dr. Shan Guisinger. She's a clinical psychologist and evolutionary biologist who has researched and treated anorexia for over 30 years.

Dr. Guisinger created the Adapted to Flee Famine Hypothesis (AFFH). This is not a new concept, but Dr. Guisinger is the first to extensively research and apply it to humans. Many including me have finally recovered thanks to the theory.

The theory explains that anorexia is caused by weight loss, not the other way around. It’s weight loss that causes the neuroendocrine changes which trigger anorexia symptoms. These symptoms, like abstaining from food and moving constantly, are all evolutionary adaptations to flee famine.

In this video I’ll paraphrase Dr. Guisinger’s explanations. I’ve linked to her website in the video description, which you can visit for details. I’ll weave in my personal experiences which corroborate her theories.

I’m studying to become a mental health therapist but am not a medical professional.

My understanding of anorexia is informed by my years of personal experience, research, and undergoing medical treatments that backfired. Those treatments triggered serious relapses which could’ve killed me.

I’m creating this video because the current model of anorexia causality and treatment can be harming patients like me.

Dr. Guisinger’s approach helped me more than any of the hundreds of books I’ve read or many doctors, therapists, and nutritionists I’ve seen.


In the Pleistocene era which was about 2.5 million years ago, anorexia was an advantage. During famine, starving people needed to move from depleted environments to find places with more resources. Those who couldn’t ignore their hunger cues, and instead conserved energy, were the ones who perished.

Dr. Guisinger writes: "Anorexics report feeling they are not supposed to eat. They feel ashamed of giving in to hunger. It feels right to them when they restrict food and exercise, and it is difficult to reason with them about their beliefs.”

These beliefs aren’t chosen by the patients, unlike what conventional psychology purports. Instead, “patients talk of being “taken over” by the anorexia. It is striking that people as different as… middle school girls, underweight boys, and elderly women express the same bizarre thoughts and feelings when they develop anorexia."

Anorexia's symptoms are consistent across people, historical era, sex, age, and culture. This wouldn't be the case if anorexia was a response to personal psychological conflicts or societal pressure. Instead, the consistency of the anorexic symptoms, such as difficulty eating, hyperactivity, and distorted body image, suggests they are a biological response to starvation.

Anorexia is likely genetic. It seems highly heritable, suggesting that natural selection helped shape its traits. Research has identified many gene changes linked to anorexic behaviors, genes which turn on when weight drops.

Dr. Guisinger even cites why the typical first-time anorexic is a 14-year-old girl who has always been lean and active. I encourage you to visit her website to learn more about that. Her theory fit me like a glove. The first time I lost my period was when I was 15. I was always naturally lean. On top of that, I had started running 2 hours a day on my school’s cross country team.

After reading Dr. Guisinger’s reasoning, I finally understood why so many anorexics tend to be teenage girls.

Even medical professionals shame anorexics. Most think that people with anorexia could recover if they simply wanted to. They believe anorexics deliberately refuse to gain weight. They believe anorexics are vain, obsessed with body image, and have a problem with control.

I faced all these stereotypes when at 17 I entered an eating disorder treatment program. This program was at one of the top children’s hospitals in the country. Ironically, this program made my eating disorder worse.

In my case, I’d lost weight by accident. I was overexercising and accidentally under-fueling. I also had undiagnosed food allergies that were giving me complications.

Unfortunately, because the doctors believed in the stereotypes about what causes anorexia, they never investigated the true causes of my weight loss. They never believed I wanted to gain weight. Foods I was allergic to, they labeled my “fear foods” and forced me to eat more of. My painful physical reactions they dismissed as mental hysteria. A lot of anorexics, like I was, get used to being told we’re crazy. We stop believing ourselves and are basically told to shut up.

The doctors never fixed the cause of my food problems and in fact worsened them. For years later my eating disorder grew increasingly severe.

An eating disorder therapist who empathized with my story said that “when the only tool we have is a hammer, we might treat everything as if it were a nail.” This quote references a cognitive bias sometimes known as Maslow’s hammer. It points out we might overly rely on a tool if it’s the only one available. If we’re to cure more patients of the mental illness with the greatest mortality rate, anorexia, then we need more eating disorder treatment tools such as Dr. Guisinger’s methods.

Here’s the reality: many people with anorexia do not lose weight on purpose. Many who were anorexic are like me. They never wanted to lose weight nor cared about body image. One such person is Tabitha Farrar. Tabitha is an eating disorder recovery coach who writes of Dr. Guisinger's Adapted to Flee Famine theory. She’s also shared her own story of losing weight due to sports, which spiraled into over a decade of anorexia – I’ve linked to her website in the video description.

Dr. Guisinger argues there's no scientific evidence to show that anorexia is linked to pursuing thinness or refusing to gain weight, nor that the parents of anorexics are overbearing. Research shows no evidence for emotional problems that correlate with anorexia in affected families.

Most anorexics are actually hardworking, conscientious, and high-achieving. They are perfectionists. This description rings true for me and when I was a student at Stanford University, I noticed fellow students who struggled with eating disorders.

One time when I was in class, the girl next to me on her laptop was Googling "how much is too little to eat" and recording calorie counts. The people I knew who calorie-counted tended to be valedictorians. I considered them to be detail-oriented about all aspects of their lives. OCD and anorexia are linked, too.

Social theories about body image pressure only partly explain why females have higher rates of anorexia. Social theories don’t explain why anorexia’s symptoms are consistent across people, sex, age, time, and culture. They also don’t explain why one of anorexia’s symptoms is hyperactivity – I’ll later explain how the Adapted to Flee Famine theory addresses this.

Regardless of the initial cause of weight loss, weight loss triggers anorexia. Anorexia then makes someone feel proud for not eating.

This is because in the environment of our ancestors, during famines, it was evolutionarily beneficial for people to restrict food intake.

Anorexics feel they must sacrifice themselves. It’s like how a person may feel they must sacrifice for their team or country. To some anorexics, it gives their life meaning to restrict food to “save” others. They don’t consciously realize it – they just know that eating food feels like a sin, and abstaining from consumption feels heroic.

Until I heard Dr. Guisinger explain this, I never understood why I felt virtuous when I denied myself food despite intense hunger. Or why I felt so anxious when eating, as if I were committing a dirty crime.

Anorexics by definition have lost at least 15% of their body weight, yet they consume little and feel they have endless energy.

Dr. Guisinger’s theory explains why anorexics are hyperactive and don’t even understand why they deny their hunger. In the Pleistocene, these behaviors kept them moving toward finding more resource-rich environments.

Only after I lost weight did I start feeling restless all the time. I paced all the time, even when I ate. The urge to move was overwhelming – I would exercise, at least walk, before and after each meal. This wasn’t because I felt I had to “undo” the meal or burn calories. I just felt a restless obligation to move.

Dr. Guisinger’s theory helped me ignore my brain’s screams at me to move. I felt calm knowing that I was doing the right thing by resting, even when it went against my instinct.

Before then though, I exercised round-the-clock for years. My brain told me I brimmed with energy, but in reality I was digging myself into a deeper and deeper deficit. My body couldn’t escape the laws of thermodynamics. With no food to consume, it ate itself. I lost my fat, muscles, and bone. I was in such an energy deficit that I lost my period for years. My organs weren’t functioning well.

People with anorexia can succumb to kidney failure, heart failure, and seizures. Their bones become so brittle that they break while stepping off curbs.

I was in trouble but couldn't see it in the mirror, literally. I thought I looked average. At the same time, I became so thin that my friends couldn’t recognize me at first glance and my bony appearance frightened strangers.

There’s research to back up why anorexics seem blind to their own thinness. It turns out, they actually are blind to it. Brain scans show that they anorexics see themselves as fat even when they're dangerously thin. This image shows activation in the visual cortex of women looking at themselves, one with and one without anorexia. The person with anorexia has little activation in their visual cortex. They literally can't see their own body as well, and this suppressed visual cortex activation only happens when they look at themselves.

This selective blindness is another evolutionary adaptation. People fleeing famine must ignore their desire to conserve energy. Their brains delude them into thinking they have enough body fat to keep going. If they could see how thin they were, like if I had realized how thin I was, then I would've stopped to rest and eat.

As Dr. Guisinger explains, people who are anorexic are like "super athletes." They have increased pain tolerance, muscle capacity, ability to delay gratification, and decreased hunger drive. All these adaptations help them flee famine.

I felt this myself - the more I exercised, the less hungry I felt, and numbing out hunger almost seemed to numb out pain.

One of the most famous examples of someone with anorexia was Joan of Arc. She never got her period, rarely ate, and seemed to have boundless energy. She and her soldiers traveled 350 miles in 11 days to elude enemies. Even when shot in the chest by an arrow, she kept fighting as if it didn't hurt. Her extraordinary physical energy probably came from anorexia.


It's not true that different personality types lead to bulimia or anorexia, either. Dr. Guisinger explains that if anorexia persists for too long, binging and purging will occur. These normal adaptations to starvation will break through sometimes. It also makes perfect sense for someone to want to binge on food if they’ve been starving.

What’s more, people rarely binge on salad. They binge on calorically-dense and processed food like candy. All my cravings were for processed food. This easy-to-digest, energy-packed food was exactly what my starving body needed.

I developed bulimia after the third time I lost so much weight that I’d lost my period. I was so weak that doctors wanted to hospitalize me and put me on a 24/7 feeding tube to force-feed me. I was bedridden for months.

When I sometimes ate sweet and processed food, it was like a dam broke in me. I couldn’t stop eating, and after eating I couldn’t stop purging because of the intense shame I felt about eating.

This shame is also predicted by Dr. Guisinger’s theory. If I were in an actual famine, indulging in calorically-rich food would have been like betrayal to my tribe.

Learning why I wanted to binge helped me forgive myself for it. The “all-in” method of eating disorder recovery, popularized by Dr. Nicola Rinaldi, also taught me that binging on food can be necessary for recovery.

Unfortunately, many anorexics get stuck in a vicious cycle of binging and purging. They purge by vomiting, fasting, and exercising in secret.

Even in 2020, before I discovered the fleeing famine theory thanks to Dr. Doug Lisle mentioning it in a Chef AJ interview, I binged and purged multiple times daily. I couldn’t sleep because I was so hungry. I felt constantly faint, had irregular periods, and developed heart arrythmias again. These were just some of the symptoms I’d battled for years. Nobody knew how serious it was and doctors trained in the traditional eating disorder treatment model couldn’t help me. I was used to them hurting me. I kept isolating myself, sinking deeper into shame.

Binging and purging is a cycle so miserable that the risk of suicide in people with bulimia is 50 times the norm.


The erroneous assumption that anorexics refuse to maintain a normal weight makes people blame them. Assuming an anorexic has a pathological "need for control" makes families distance from sufferers. Someone with anorexia will likely become lonely and secretive.

I hid my struggles and was always surprised myself when a friend revealed they had an eating disorder. I didn't want friends to assume I was obsessed with being thin. In fact, sports I’d joined, like weightlifting, were ones I did to get bigger and stronger.

Isolation is the opposite of what anorexics need. Anorexics need social support to help defeat such an addictive disorder.

Having relapsed multiple times into anorexia myself, I know how addicting this disorder is. It feels weirdly great to ignore my appetite until it disappears.

Here’s the biological reason for why. Typically a starving person's brain should turn up opiate, cannabinoid, and dopamine receptors when they eat. But in anorexics, their hypothalamus turns down reward receptors. Food to anorexics literally doesn't taste as good. Their brain also turns hunger signals down and satiety signals up, which is why anorexics feel full quickly.

Remember, our starving ancestors couldn’t afford to get addicted to food during a famine. They had to eat little and move on to find a better environment. Joan of Arc, traveling 350 miles in 11 days, wasn’t going to get distracted by feasting.

In the anorexic brain, two of the master hunger signals in the hypothalamus are also turned up just as high as in normal starvation. Therefore anorexics think constantly of food but can't bring themselves to eat.

This was also true for me. Starting in high school, when my weight first dropped, I fantasized all day about food. It was always food I never allowed myself to eat. I’d stare at the white walls of my classroom and dream about cake. I’d dream about my next carefully planned and timed meal. Yet when I sat down to eat, I could hardly take a bite. If I did, I felt full right away. Sometimes I brought the food near my mouth and then put it down, feeling like eating would be wrong.


It's not some psychological “power struggle” that causes the food issues. If parents understood that their underweight children had a hard-wired, compulsive drive to avoid food and exercise, then they could be more compassionate when their children refuse food.

Dr. Guisinger reports that many patients feel relieved when they hear these biological explanations for their behaviors. I felt great relief myself I discovered these explanations.

They made sense and finally I could ignore my anorexic brain's commands. For the first time in years, I didn’t feel like I was crazy.

Instead, I was normal. It made sense that I always wanted to exercise, felt so anxious when eating, and wanted to binge on food. It was all evolutionarily programmed in me to help my underweight body survive in an age of famine.

After learning this biological theory, I loved my body and brain for trying to protect me. For the first time in years, I loved myself.

And armed with this knowledge, I could finally solve my problems through rationalization.

As Dr. Guisinger recommends, when I feel I must exercise or purge after eating, I distract myself. I sit down. I engage in other things.

When struggling to eat, I remind myself of what she says: My anorexic behaviors saved my ancestors' lives in the Pleistocene, but do not help me in today's modern environment. I need food for energy. Food is medicine.

With greater understanding of Dr. Guisinger's theory, patients and their families can better treat anorexia. The current models of understanding and treatment of anorexia can hurt recovery, as it did in my case.

By understanding the Adapted to Flee Famine hypothesis, therapists won’t have to interrogate or gaslight their anorexic patients anymore. Or, worse, make their anorexic patients feel shame for their perfectly natural symptoms.

We need better treatments. Eating disorders are common and deadly. Before I got one, I didn't know that eating disorders have the highest mortality rate of any mental illness. Anorexia's mortality rate is 12 times higher than the death rate of ALL causes of death for females’ 15-24 years old. 20% of those with anorexia will prematurely die from complications such as suicide and heart problems. And almost half of all Americans know someone with an eating disorder.

If this video helped you or may help someone you know, please share it. And leave a comment telling me your thoughts.

I will create more videos about eating disorders since they’ve had such an impact on my life and those around me.

If you want to contact me or see more of my work, visit my website Michelle I’m always here for you – I know you can conquer whatever challenges you face.

I wish you the best on your journey toward living the life you deserve!