Anorexia nervosa patients struggle to interpret the emotions and intentions of others, impairing their communication. They often have difficulty in recognizing and identifying facial emotions, vocal emotions, and body language. Theory of mind, or the ability to understand others' mental processes, and social perception, or the ability to recognize social cues based on others' behavior in social contexts, is also somewhat impaired among patients. This trait is not present in first-degree relatives and improves after recovery, and is thus likely to be a result of starvation rather than an inherited vulnerability.

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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

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

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

An avoidant social phenotype predicts the onset and prognosis of anorexia nervosa, as difficulty relating to and connecting with others predates onset with anorexic patients having a greater risk of insufficient social networks (no childhood close friends, fewer social activities, less social support). People with certain temperamental characteristics such as shyness, internalizing problems, loneliness, feelings of inferiority, and social anxiety are more likely to develop eating disorders. Anxious avoidant behaviors of emotions, social experiences, and attachments are also associated with increased risk of anorexia nervosa development.  These issues are worsened by starvation with social avoidance becoming a core feature of eating disorder patients as their social network further shrinks upon progression of the illness. As the brain shrinks from food restriction, high-level functions that enable communication are impaired and oxytocin levels are drastically reduced, further damaging social connection. These traits sometimes persist after recovery from anorexia nervosa. For example, oxytocin levels continue to be reduced following recovery, but normal brain activation to emotional faces after full recovery indicates that some neurological issues impairing social processing in acute anorexia nervosa may be reversible.

Social Avoidance in Anorexia Nervosa

Individuals with anorexia nervosa tend to pay greater attention to social threats and less attention to social rewards. They often have automatic attentional biases towards negative (critical, domineering, angry) faces and away from positive (compassionate, happy) faces, in addition to generally gazing less at the face and eyes. While these traits are inherited and present in first-degree relatives, they are worsened by starvation in acute anorexia nervosa and persist to a lesser degree following recovery. 

Attentional Biases in Anorexia Nervosa

Interpretation of Social Signals in Anorexia Nervosa 

Signaling of emotions and intentions is impaired in anorexia nervosa patients. Many patients struggle with alexithymia, or issues identifying, expressing, and describing their own emotions, in addition to having generally impaired perceptions and understandings of themselves. They have been found to display reduced facial emotional expression, attentiveness, and reciprocity relative to self-reported actual intense emotions due to inhibited emotional expression and mirroring. This trait is present in first-degree relatives and may thus be an inherited endophenotype.

Social Signaling in Anorexia Nervosa

Set shifting, or cognitive flexibility from one mindset to another, is more difficult for people with eating disorders. This may be due to brain development-related genetic factors, as set shifting requires increased activation in the frontal and parietal regions but decreased activation in the striatal regions. Weak set shifting is an inherited vulnerability to anorexia nervosa that is also demonstrated in first-degree relatives, however it is worsened by starvation. Patients with less set shifting impairment are more likely to recover, and set shifting skills improve following recovery.

Set Shifting in Anorexia Nervosa

Central coherence, or the ability to see the bigger picture, is weakened in eating disorder patients due to an imbalance between global and detail processing. Strong focus on details is an inherited vulnerability to anorexia nervosa that is also demonstrated in first-degree relatives. Impaired set shifting contributes to weakened central coherence by making it difficult to alternate between global and detail processing. Although impaired central coherence is a result of food restriction in anorexia nervosa, it also serves to perpetuate the disorder by impeding environmental adaptation. 

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