Perfectionism or cognitive rigidity may serve as both a risk factor and a maintenance factor for anorexia nervosa. This includes obsessive-compulsive traits, all-or-nothing/black-or-white thinking, excessive attention to detail, and fear of making mistakes. In children, these traits lead individuals to be more influenced by societal rules and appearance norms, and thus more likely to develop obsessive-compulsive dieting behaviors once they have begun following a trigger event. Perfectionism and OCPD traits are associated with adverse outcomes for patients. Obsessive-compulsive spectrum disorders are present in 50% of ED patients, while other ED patients often have obsessive-compulsive or anxious traits. Obsessive thoughts and compulsive behaviors are often worsened as a result of starvation, leading to increasingly strict dieting rules.

Perfectionism/Cognitive Rigidity in Anorexia Nervosa

Anorexia nervosa patients are often temperamentally avoidant, displaying a sensitivity to negative stimuli, which 25% of anorexic individuals meeting criteria for avoidant personality disorder, including issues with intimacy, emotional expression, and identity. Intimacy and close relationships are often avoided in anorexia nervosa patients prior to onset of the disorder but avoidance is typically worsened following onset, making avoidant traits both a risk factor and maintenance factor for AN.
Experiential avoidance includes refusal to maintain contact with certain experiences/events and taking of measures to reduce their frequency/form/prerequisites. In anorexia nervosa patients, this may include repressing negative emotions and personal needs to cope with resultant stress. Patients are often shy, have few friends, avoid intimate relationships, and display psychosexual inhibition. They are also more likely to struggle to detect emotional signals from themselves and others, retrieve emotional autobiographical memories, and struggle with defensive emotions such as shame, guilty, and jealousy. Starvation worsens and is used as a mechanism for avoidance of emotions, relationships, etc.. Avoidant traits (low novelty seeking, high interpersonal distrust, anxiety disorders, avoidant-dependent personality disorder, OCPDs) are associated with poor outcomes and are common among anorexia nervosa patients, and thus treatments that focus on emotional processing rather than food and weight alone may show more success. 

Avoidance in Anorexia Nervosa

Pro-anorectic beliefs are perceived positive values of functions of anorexia nervosa or its symptoms. These beliefs often make patients reluctant to seek treatment or contribute to denial of the illness. In the early pre-contemplation stage of the disorder, patients perceive more positives than negatives to anorexia nervosa, but in the later action stage, the opposite is true. Some positives described by patients are that their disorder brings them feelings of safety, allows them to indirectly communicate distress, helps them to stifle negative emotions, and makes them feel special. While reducing pro-anorectic beliefs is associated with good outcomes, there is little data to support the relationship between pro-anorectic beliefs and outcomes, and its role as a maintenance factor is thus unclear.

Pro-Anorectic Beliefs in Anorexia Nervosa

Interpersonal factors like the intense emotional responses of close others may be a causal maintaining factor of anorexia nervosa, especially for patients with high levels of contact with their relatives. Expressed emotions (EE) measure criticism, hostility, and emotional over-involvement toward psychiatric patients from relatives, and high EE predicts relapse across numerous psychiatric illness. In cases of conflict with family members, anorexia nervosa patients may feel empowered by thwarting caregivers' attempts to intervene. This feeling of victory over logic and parental authority may reinforce beliefs and behaviors of anorexia nervosa by creating feelings of self-esteem derived from food restriction. On the other hand, excessive reassurance and support by caregivers may also reinforce the disorder by demonstrating that it elicits sympathy, care, and kindness, and may contribute to resentment toward the patient by other family members. High EE is thus correlated with distress among family members as they are unsure how to help and may have difficulty meeting other responsibilities outside of supporting the patient. For patients, having high EE relatives is associated with poorer outcomes, but these outcomes can be modified with family-based interventions. Some traits associated with anorexia nervosa are inherited, such as obsessive-compulsive traits and social impairment which can lead caregivers and family members to be excessively controlling or withdrawn toward the patient, contributing to inflexibility and miscommunication that can worsen the disorder. Instead, caregivers should focus on educating themselves about the nuances of anorexia nervosa's impacts on social cognition and communication, learning skills to support behavioral changes, and modeling a calm, compassionate, and collaborative environment. 

Expressed Emotions in Anorexia Nervosa

Certain factors predispose individuals to greater risk of anorexia nervosa:

- Negative self-evaluation
- Internalizing strategies
- Reduced social processing skills
- Increased sensitivity to social hierarchy,/negative judgements
- Desire to belong or be accepted based on social norms
- Internalized idealization of thinness

Predisposing Factors to Anorexia Nervosa

Anorexia nervosa creates a vicious cycle as many of the traits that contribute to the development and maintenance of the disorder are further worsened by malnutrition and starvation as the illness progresses. The starved brain is less plastic and is thus more resistant to treatment and less responsive to therapy. Furthermore, malnutrition further impairs set shifting, global integration, central coherence, and social cognition and communication. This leads anorexic individuals to become even more isolated and avoidant, and worsens obsessive-compulsive traits that perpetuate dieting behaviors. 

Secondary Consequences of Malnutrition in Anorexia Nervosa

Behavioral consequences of severe and enduring anorexia nervosa can further perpetuate the illness by creating additional barriers to recovery:

- Neuroadaptation/habit-forming
- Food aversion

Behavioral Consequences of Severe and Enduring Anorexia Nervosa

Chronic stress is at once a predisposing factor to, a result of, and a perpetuating factor of anorexia nervosa. It can result from genetic susceptibilities, developmental trauma, emotional abuse, or starvation. The chronic stress profile of treatment-resistant depression mimics that of anorexia nervosa, causing hyperactivity of the hypothalamic pituitary adrenal (HPA) axis, immune system activation, microbiome anomalies, reduction of neurogenesis and brain volume, and reduced hippocampal volume, which is also associated with increased cortisol levels, anxiety, and depression. This stress response impairs resilience and may cause reduced mesolimbic dopamine function, anhedonia, and decreased motivation, causing or worsening depression. 50% of anorexia nervosa patients report at least one mood disorder episode in their lifetime, and depression often persists regardless of fluctuations in eating disorder symptomatology. Depression is common about anorexic patients but they often present with fewer somatic symptoms (low energy, reduced neural activation) and more severe cognitive symptoms (negative self-image). Patients with a history of depression prior to onset of anorexia nervosa have been found to have reduced recovery rates, and those struggling with mood comorbidities likewise show worsened long-term outcomes. Anxiety traits, such as obsessive-compulsive personality traits, OCD, and anxiety disorders, are also common in childhood prior to onset of anorexia nervosa. Polygenic risk correlations with anorexia nervosa are strongest with OCD, followed by half-sized correlations with neuroticism, depression, and anxiety. Patients with severe and enduring forms of anorexia nervosa may thus benefit from treatments originally targeted towards treatment-resistant depression and OCD.

Chronic Stress and Comorbidities in Severe and Enduring Anorexia Nervosa

A model explaining the intra- and inter-personal maintenance factors for the continued duration of anorexia nervosa, not bound by Western sociocultural limitations. Intrapersonal factors combine to predispose individuals to anorexia nervosa and contribute to its maintenance, eliciting strong reactions from close others which then create interpersonal factors that further perpetuate the illness:

- Perfectionism/cognitive rigidity
- Experiential avoidance
- Pro-anorectic beliefs
- Expressed emotions

Kalamazoo College

Anorexia nervosa is an eating disorder defined by maintaining a body weight significantly below average, which is achieved through methods like starvation or excessive exercise. A central characteristic of this disorder is a distorted body image, a form of body dysmorphia, where individuals perceive themselves as overweight despite being underweight.

Anorexia Nervosa

Schmidt, U., & Treasure, J. (2006). Anorexia nervosa: Valued and visible. A cognitive‐interpersonal maintenance model and its implications for research and practice. British Journal of Clinical Psychology, 45(3), 343-366. https://doi.org/10.1348/014466505X53902

Anorexia Nervosa: Valued and Visible. A Cognitive-Interpersonal Maintenance Model and its Implications for Research and Practice

Treasure, J., & Schmidt, U. (2013). The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors. Journal of Eating Disorders, 1, 1-10. https://doi.org/10.1186/2050-2974-1-13

The Cognitive-Interpersonal Maintenance Model of Anorexia Nervosa Revisited: A Summary of the Evidence for Cognitive, Socio-Emotional and Interpersonal Predisposing and Perpetuating Factors

Dialectical behavior therapy (DBT) has been shown to be effective in treating anorexia nervosa (AN), as patients with the disorder who underwent DBT saw low dropout rates and increased BMIs which were sustained 6 months later. While standard DBT has been shown to be effective, a DBT program that was augmented to focus on overcontrolled emotions and behaviors which contribute to AN was more helpful in encouraging long term results.

Dialectical Behavior Therapy as Treatment for Anorexia Nervosa

While there is a long tradition of studying health inequalities between social classes, the standard approach does not apply for anorexia. The intersection of the social relations of age, gender, and social background, with which they are related, accounts sociologically for the disparities in the frequency of EDs.


Anorexia in Social Relationships

Diagnostic Criteria for Anorexia Nervosa (DSM-V)

1. The individual restricts their consumption of food such that it is significantly lower than their body's energetic demand, resulting in a dramatic reduction in body weight. This reduction is evaluated in reference to the individual's expected weight, which itself varies according to their age, sex, and developmental trajectory.

2. The extreme fear of gaining weight and/or subcutaneous fat, which prevents weight restoration and/or maintenance of a healthy weight.

3. The distortion of the individual's body-image due to the their perception their body's weight or shape, low sense of self-worth because of their body's weight or shape, or the absence of an acknowledgment that their body weight is lower than what is clinically considered to be healthy.

Diagnostic Criteria for Anorexia Nervosa (DSM-V)

Research unfortunately indicates that anorexia nervosa treatment outcomes are not always ideal. Although oftentimes significant weight is restored by the end of treatment, psychological symptoms frequently go largely unaddressed, indicating a gap in current treatment procedures that may leave patients more vulnerable to relapse.

Anorexia Nervosa Treatment Outcomes

Cognitive-Interpersonal Maintenance Model of Anorexia Nervosa

Individuals diagnosed with anorexia nervosa will typically have a distorted body image, which refers to when one feels they look overweight despite not being overweight. Distorted body image is a type of body dysmorphia.

Distorted Body Image

The gut microbiome is a diverse, abundant microbial ecosystem that helps modulate homeostasis via a symbiotic relationship with its host. It has implications in multiple complex diseases by facilitating interactions between genes and the environment, but it is vulnerable to chronic environmental disturbances, such as the dietary fluctuations and nutritional deprivation inherent to anorexia nervosa. It is likely involved in AN pathophysiology by affecting energy metabolism, intestinal permeability, immune function, appetite, and behavior, but complicated by genetic risk factors, eating patterns, etc.. Intestinal bacteria may be involved in appetite and weight regulation along with comorbidities such as mood changes and gastrointestinal symptoms by acting on metabolic, neuroendocrine, and immune pathways.

- Dysbiosis in anorexia nervosa 
- Gut microbiota adaptations to starvation 
- Microbiome-based anorexia nervosa symptom mechanisms 
- Microbiome-based interventions for anorexia nervosa

Anorexia Nervosa and the Gut Microbiome

Individuals with anorexia nervosa face an elevated risk of developing other psychological problems. Commonly co-occurring conditions include anxiety disorders, mood disorders, and issues with substance abuse.

Psychological Comorbidities of Anorexia Nervosa

The prevalence of anorexia nervosa is estimated to range from just under 1% to over 4% among women. The rates of this disorder are significantly lower for men.

Prevalence of Anorexia Nervosa

An example of a public health initiative is an Italian advertising campaign that was created to increase public awareness about anorexia nervosa. This campaign was highlighted in a news story to broaden its reach.

Italian Advertising Campaign for Anorexia Nervosa Awareness

A 19-year-old student is brought in for a consultation by her concerned parents. She is 5'7" tall and weighs 98 pounds. Despite her significantly low body weight, she expresses an intense fear of gaining weight and frequently states that she feels 'fat,' often pointing to her stomach and thighs. Her parents report that she eats very small portions, avoids high-calorie foods entirely, and engages in a rigorous two-hour exercise routine every day. Based on this information, which psychological disorder is most likely being described? Justify your answer by identifying at least two key features from the scenario that align with the typical presentation of this disorder.

Clinical Scenario Analysis

The medical consequences of anorexia nervosa are primarily caused by severe starvation, as well as purging behaviors.

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