Eating disorders can affect people of all ages, racial/ethnic backgrounds, body weights, and genders. Eating disorders frequently appear during the teen years or young adulthood, but may also develop during childhood or later in life. These disorders affect both genders, although rates among women are higher than among men. Like women who have eating disorders, men can also have a distorted sense of body image. It is important to seek treatment early for eating disorders. People with eating disorders are at higher risk for suicide and medical complications. Some people with eating disorders may also have other mental disorders (such as depression or anxiety) or problems with substance use.

Researchers are finding that eating disorders are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors. This research has lead to many different and integrative approaches and techniques for treating eating disorders. It is important to also note that eating disorder treatment is highly influenced by the individual patient and the effectiveness of treatment plans varies, depending on a wide variety of factors. Some treatment plans include medications, psychotherapy, nutritional counseling, medical care, or some combination of these approaches. Treatment location also varies, as the levels of care provided for the patient depend on their medical and psychiatric stability; there are inpatient, residential, partial hospitalization, intensive outpatient, and outpatient options.

Let’s examine a few of the psychological perspectives related to eating disorders and examine treatment options from several of these perspectives.

Biological Approaches

Eating behavior is a complex process controlled by the neuroendocrine system, of which the hypothalamus-pituitary-adrenal-axis (HPA axis) is a major component. Dysregulation of the hypothalamus-pituitary-adrenal-axis (HPA axis) has been associated with eating disorders, such as irregularities in the manufacture, amount, or transmission of certain neurotransmitters, hormones, or neuropeptides and amino acids such as homocysteine, elevated levels of which are found in anorexia and bulimia, as well as depression. Some of the neurotransmitters and hormones linked to eating disorders include

• serotonin: a neurotransmitter, known for being involved in depression, that has an inhibitory effect on eating behavior.
• norepinephrine: both a neurotransmitter and a hormone; abnormalities in either capacity may affect eating behavior.
• Dopamine: in addition to being a precursor of norepinephrine and epinephrine also regulates the rewarding property of food.
• neuropeptide Y (also known as NPY): a hormone that encourages eating and decreases metabolic rate. Blood levels of NPY are elevated in patients with anorexia nervosa, and studies have shown that injection of this hormone into the brain of rats with restricted food intake increases their time spent running on a wheel. Normally the hormone stimulates eating in healthy patients, but under conditions of starvation it increases their activity rate, probably to increase the chance of finding food. The increased levels of NPY in the blood of patients with eating disorders can in some ways explain the instances of extreme over-exercising found in most anorexia nervosa patients.
• leptin and ghrelin: leptin is a hormone produced primarily by the fat cells in the body; it has an inhibitory effect on appetite by inducing a feeling of satiety. Ghrelin is an appetite-inducing hormone produced in the stomach and the upper portion of the small intestine. Circulating levels of both hormones are an important factor in weight control. While often associated with obesity, both hormones and their respective effects have been implicated in the pathophysiology of anorexia nervosa and bulimia nervosa. Leptin can also be used to distinguish between constitutional thinness found in a healthy person with a low BMI and an individual with anorexia nervosa.
• Gut bacteria and immune system: studies have shown that a majority of patients with anorexia and bulimia nervosa have elevated levels of autoantibodies that affect hormones and neuropeptides that regulate appetite control and the stress response. There may be a direct correlation between autoantibody levels and associated psychological traits.

Genetic influences

While past findings have described eating disorders as primarily psychological, environmental, and sociocultural, further studies have uncovered evidence that there is a genetic component related to a predisposition toward eating disorders.^[1] Twin studies have found slight instances of genetic variance when considering the different criterion of both anorexia nervosa and bulimia nervosa as endophenotypes contributing to the disorders as a whole. A genetic link has been found on chromosome 1 in multiple family members of an individual with anorexia nervosa. An individual who is a first-degree relative of someone who has had or currently has an eating disorder is seven to 12 times more likely to have an eating disorder themselves. Twin studies also show that at least a portion of the vulnerability to develop eating disorders can be inherited, and there is evidence to show that there is a genetic locus that shows susceptibility for developing anorexia nervosa.

People with gastrointestinal disorders may be at greater risk of developing disordered eating practices than the general population, principally restrictive eating disturbances; there is an association of anorexia nervosa with celiac disease.

There are also various childhood personality traits associated with the development of eating disorders. During adolescence, these traits may become intensified due to a variety of physiological and cultural influences such as the hormonal changes associated with puberty, stress related to the approaching demands of maturity, and socio-cultural influences and perceived expectations, especially in areas that concern body image. Eating disorders have been associated with a fragile sense of self and with disordered mentalization. Many personality traits have a genetic component and are highly heritable. Maladaptive levels of certain traits may be acquired as a result of anoxic or traumatic brain injury, neurodegenerative diseases such as Parkinson’s disease, neurotoxicity such as lead exposure, bacterial infection such as Lyme disease or parasitic infection such as Toxoplasma gondii as well as hormonal influences. While studies are still continuing via the use of various imaging techniques such as fMRI, these traits have been shown to originate in various regions of the brain such as the amygdala and the prefrontal cortex. Disorders in the prefrontal cortex and the executive functioning system have been shown to affect eating behavior.

Biological Treatments

Depending on the medical stability of the patient, in general, medical treatment plans for eating disorders include medical care and monitoring, nutritional counseling and interventions, medications, or a combination of these approaches. Typical treatment goals include restoring adequate nutrition, bringing weight to a healthy level, reducing excessive exercise, and stopping binge-purge and binge-eating behaviors.

Two pharmaceuticals, prozac and vyvanse, have been approved by the FDA to treat bulimia nervosa and binge-eating disorder, respectively. Olanzapine has also been used off-label to treat anorexia nervosa. Studies are also underway to explore psychedelic and psychedelic-adjacent medicines such as MDMA, psilocybin, and ketamine for anorexia nervosa and binge-eating disorder.

Cognitive Approaches

Cognitive attentional bias may have an effect on eating disorders. Attentional bias is the preferential attention toward certain types of information in the environment while simultaneously ignoring others. Individuals with eating disorders can be thought to have dysfunctional schemas and knowledge structures that may bias judgment, thought, and behavior in a manner that is self-destructive or maladaptive. They may have developed a disordered schema that focuses on body size and eating. Thus, this information is given the highest level of importance and overvalued among other cognitive structures. Researchers have found that people who have eating disorders tend to pay more attention to stimuli related to food. For people struggling to recover from an eating disorder or addiction, this tendency to pay attention to certain signals while discounting others can make recovery that much more difficult.

Studies have utilized the Stroop task (which measures reaction time to different stimuli) to assess the probable effect of attentional bias on eating disorders. This may involve separating food and eating words from body shape and weight words. Such studies have found that anorexic subjects were slower to color name food-related words than control subjects. Other studies have noted that individuals with eating disorders have significant attentional biases associated with eating and weight stimuli.^[2]

Cognitive treatments

Figure 1. The biopsychosocial model emphasizes the interplay between biological, psychological, and sociocultural forces. Research on eating disorders indicates that there is a strong sociocultural influence.

Cognitive treatment approaches focus on helping patients with eating disorders shift the way that they think about eating and their eating behaviors. The primary form of cognitive treatment comes in the form of psychotherapy, the most common of which for treating eating disorders include acceptance and commitment therapy (ACT), CBT, enhanced CBT, and cognitive remediation therapy.

Acceptance and Commitment Therapy

The goal of ACT is to focus on changing your actions rather than your thoughts and feelings. Patients are taught to identify core values and commit to creating goals that fulfill these values. A popular metaphor for ACT has us compare the journey through life as driving a bus full of noisy passengers (or thoughts), but ignoring unwanted or negative thoughts by still purposefully driving to the destination. For someone with an eating disorder, negative thoughts may be related to their body, appearance, or self-worth. Through ACT, they can learn to be mindful of these thoughts but not act on them.^[3]

Cognitive Behavioral Therapy

CBT is a relatively short-term, symptom-oriented therapy focusing on the beliefs, values, and cognitive processes that maintain the eating disorder behavior. It aims to modify distorted beliefs and attitudes about the meaning of weight, shape, and appearance, which are correlated to the development and maintenance of the eating disorder.

CBT-Enhanced

A common form of CBT that is used to treat eating disorders is called CBT-enhanced (CBT-E) and was developed by Christopher G. Fairburn throughout the 1970s and 1980s. Originally intended for bulimia nervosa specifically, it was eventually extended to all eating disorders. Within Fairburn’s enhanced CBT is CBT-Ef, designed to deal particularly with eating habits, and CBT-Eb for other issues that do not directly involve eating. It is described as “enhanced” because it uses a variety of new strategies and procedures to improve outcomes and because it includes modules to address certain obstacles to change that are “external” to the core eating disorder, namely clinical perfectionism, low self-esteem, and interpersonal difficulties.

Although CBT-E uses a variety of generic cognitive and behavioral interventions (such as addressing cognitive biases), unlike some forms of CBT, it favors the use of strategic changes in behavior to modify thinking rather than direct cognitive restructuring. The eating disorder psychopathology may be likened to a house of cards with the strategy being to identify and remove the key cards that are supporting the eating disorder, thereby bringing down the entire house.^[4]

Cognitive Remediation Therapy

For individuals with anorexia nervosa, CRT is an interactive treatment that combines practical exercises with discussions about their relevance to the patient’s everyday life. Cognitive remediation therapy was adapted for anorexia nervosa by Professor Kate Tchanturia and colleagues at the Institute of Psychiatry, Psychology, and Neuroscience to address the process rather than the content of thinking, thus helping patients to develop a metacognitive awareness of their own thinking style. The treatment is hypothesized to work by strengthening and refining neural circuits, and by learning and transferring new cognitive strategies to appropriate situations. The aim is to identify and target the cognitive impairments specific to each patient, and to motivate the patient to engage in meta-cognitive processes, i.e., to consider their cognitive/thinking styles and to explore alternative strategies, which in turn might lead to behavioral changes. By becoming aware of problematic cognitive styles, the patient can reflect on how these affect everyday life and learn to develop new strategies. The intervention was originally developed for adults with chronic anorexia nervosa, but it has been explored for younger patients as well.

Behavioral Approaches

Behavioral theories about eating disorders related to ways that behavior is learned and reinforced. For example, if someone who loses weight is praised or rewarded for their appearance but took extreme measures to look that way, this praise could contribute to the development or maintenance of an eating disorder. What types of behaviors are rewarded and encouraged are strongly influenced by sociocultural factors, which we’ll examine soon. Another behavioral connection to eating disorders is the way in which anxiety or stress become associated with eating or overeating; efforts to avoid that anxiety may result in starvation or binging, and the reduction of anxiety acts as a reinforcer for the behavior.

Treatments: Dialectical Behavior Therapy (DBT)

Dialectical behavior therapy assumes that the most effective place to begin treatment is with changing behaviors. Treatment focuses on developing skills to replace maladaptive eating disorder behaviors. Skills focus on building mindfulness skills and becoming more effective in interpersonal relationships, emotion regulation, and distress tolerance.

Sociocultural Approaches

Media Influences

Figure 2. Diet culture is prevalent on social media and can have a negative influence on an individual’s body image.

There is a strong sociocultural influence on the development of eating disorders.
Western society especially places a cultural emphasis on thinness that can influence how people view their bodies. A child’s perception of external pressure to achieve the ideal body that is represented by the media predicts the child’s body image dissatisfaction, body dysmorphic disorder, and an eating disorder.^[5] “The cultural pressure on men and women to be ‘perfect’ is an important predisposing factor for the development of eating disorders”.^[6] Further, when women of all races base their evaluation of themselves upon what is considered the culturally ideal body, the incidence of eating disorders increases.

While there are many influences to how an individual processes their body image, the media does play a major role. Along with the media, parental influence, peer influence, and self-efficacy beliefs also play a large role in an individual’s view of themselves. The way the media presents images can have a lasting effect on an individual’s perception of their body image. Countless magazine ads and commercials depict thin celebrities who appear to gain nothing but attention from their looks. Unfortunately, this has led to the belief that in order to fit in, one must look a certain way. Televised beauty competitions such as the Miss America Competition contribute to the idea of what it means to be beautiful because competitors are evaluated on the basis of opinions about idealized beauty standards.

To try to address unhealthy body image in the fashion world, in 2015, France passed a law requiring models to be declared healthy by a doctor to participate in fashion shows. The law also requires re-touched images to be marked as such in magazines.

There is a relationship between “thin ideal” social media content and body dissatisfaction and eating disorders among young adult women, especially in the Western hemisphere. New research points to an “internalization” of distorted images online, as well as negative comparisons among young adult women. Most studies have been based in the United States, the United Kingdom, and Australia; these are places where the thin ideal is strong among women as well as the strive for the “perfect” body.

In addition to mere media exposure, there is an online “pro-eating disorder” community. Through personal blogs and Twitter, this community promotes eating disorders as a “lifestyle,” and continuously posts pictures of emaciated bodies and tips on how to stay thin. The hashtag “#proana” (pro-anorexia) is a product of this community as well as images promoting weight loss, tagged with the term “thinspiration.” According to social comparison theory, young women have a tendency to compare their appearance to others, which can result in a negative view of their own bodies and altering of eating behaviors, which in turn can develop disordered eating behaviors.

Socioeconomic status (SES) has been viewed as a risk factor for eating disorders, presuming that possessing more resources allows for an individual to actively choose to diet and reduce body weight. Some studies have also shown a relationship between increasing body dissatisfaction with increasing SES. However, once high SES has been achieved, this relationship weakens and, in some cases, no longer exists.

Sports

Figure 3. A myth about ballet is that you need to be thin to be a successful ballerina. This notion, paired with the competitive nature of ballet has resulted in some dancers developing eating disorders.

Another risk factor for developing eating disorders involve participating in some sports. Athletes and eating disorders tend to go hand in hand, especially in sports where weight is a competitive factor. Gymnastics, horseback riding, wrestling, bodybuilding, and dancing are just a few that fall into this category of weight-dependent sports. Eating disorders among individuals that participate in competitive activities, especially women, often lead to having physical and biological changes related to their weight that often mimic prepubescent stages. Oftentimes as women’s bodies change, they lose their competitive edge, which leads them to take extreme measures to maintain their younger body shape. Men often struggle with binge eating followed by excessive exercise while focusing on building muscle rather than losing fat, but this goal of gaining muscle is just as much an eating disorder as obsessing over thinness. The following statistics taken from Susan Nolen-Hoeksema’s book, (ab)normal psychology, show the estimated percentage of athletes that struggle with eating disorders based on the category of sport:

• aesthetic sports (dance, figure skating, and gymnastics)—35%
• weight dependent sports (judo and wrestling)—29%
• endurance sports (cycling, swimming, running)—20%
• technical sports (golf and high jumping)—14%
• ball game sports (volleyball and soccer)—12%

Although most of these athletes develop eating disorders to keep their competitive edge, others use exercise as a way to maintain their weight and figure. This is just as serious as regulating food intake for competition. Even though there is mixed evidence showing at what point athletes are challenged with eating disorders, studies show that regardless of competition level, all athletes are at higher risk for developing eating disorders than non-athletes, especially those that participate in sports where thinness is a factor.

Pressure from society is also seen within the homosexual community. Homosexual men are at greater risk of eating disorder symptoms than heterosexual men.

Other Approaches

The psychodynamic view on eating disorders focuses on understanding the unconscious forces and motives that influence the disorder. Humanistic approaches take a positive approach to help the individual see themselves as more than their disorder. The humanistic approach attempts to take a positive lens during therapy. A therapist views their patient as an individual rather than a person who a member of a group that represents a category of an eating disorder. The shift in the individual focus allows the therapist and the client to take a holistic viewpoint to observe their behavior which allows for acknowledgment of their positive traits and behaviors, their ability to use their personal instincts to find healing, agency, and fulfillment within themselves. Humanistic therapy is beneficial to people with eating disorders because it is an effective therapeutic technique for people with depression, anxiety, addiction, and relationship issues including themselves. Given the positive focus and individualistic nature of the humanistic approach, people with eating disorders may be able to address their low self-esteem, lack of comfort with themselves or their lives, and a feeling of “wholeness,” and those who struggle with finding personal meaning in their lives.^[8]

Interpersonal psychotherapy (IPT) is humanistic therapy, originally created to treat depression, and is also effective in treating eating disorders. It is similar to CBT, but the therapist does not attempt to uncover distorted thoughts systematically by giving homework or other assignments. However, as evidence arises during the course of therapy, the therapist calls attention to distorted thinking in relation to significant others. The therapist is warm, empathetic, and positive, working to help the patient resolve interpersonal issues that can also reduce eating disorder behaviors.