While society as a whole may be familiar with the concept of eating disorders, less is broadly understood about the psychology behind them—namely, what is happening inside a person’s brain who is struggling with an eating disorder.

Many people with eating disorders develop various coping mechanisms to manage overwhelming emotions, such as stress, anxiety, depression, or unresolved past trauma.

"Eating disorders can develop without any identifiable triggers,” explained Leah Pickett, DNP, CRNP, Advanced Practice Provider in the UAB Department of Psychiatry and Behavioral Neurobiology. “This is why it’s important to have open and nonjudgmental conversations about anything concerning body size, appearance, and food choices."

Pickett offers valuable insights into the psychological factors involved in eating disorders, exploring how societal pressures, co-occurring mental health conditions, and stigma contribute to their development and treatment.

Societal pressures and their impact on eating disorders

Constant exposure to societal views on food and body weight can significantly impact individuals dealing with eating disorders.

“We receive significant cultural messaging about food and weight on a daily basis,” Pickett explained. “For those who harbor even a small amount of body dissatisfaction, this messaging can be incredibly harmful.”

Furthermore, she stated that terms like "good," "bad," "clean," and "healthy" used to describe food choices and eating habits can damage self-esteem and promote unhealthy behaviors.

"Sadly, the stigma surrounding eating disorders, much like other psychiatric conditions, persists due to widespread misunderstanding,” she said. According to Pickett, when combined with society's fixation on thinness and a narrow view of health and fitness, these factors can contribute to the development of disordered eating patterns.

In addition, social media has reinforced unrealistic body standards, particularly with the ease of manipulating photographs and videos through filters and Artificial Intelligence (AI). Pickett added that an even greater concern is the prevalence of hateful body-shaming comments and widespread nutrition misinformation.

"Even well-educated people may struggle to filter out evidence-based nutrition guidance and misleading information," she explained. She further noted that cultural conversations around food and body weight have focused on a narrow body ideal, ignoring the diversity of body shapes and sizes.

Key signs and behaviors for identifying eating disorders

There are several hallmark symptoms of disordered eating, including food restriction, food rituals, overexercising, eating in secret, unexplained weight changes, excessive body checking or comparisons, and negative body comments. However, Pickett pointed out that eating disorders often thrive in secrecy, making these symptoms difficult to detect until the condition becomes severe.

“A helpful approach is to routinely ask patients about their eating behaviors and body image while assessing their nutritional status during each visit,” Pickett advised. “I've learned so much about my patients simply by asking about their typical eating habits, food preferences, access to food, and feelings about their bodies.” Questions as simple as, "What did you eat yesterday?" or "How do you feel about your body?" can open the door to important conversations with patients.

Psychological barriers to eating disorder treatment

Perfectionism and unresolved trauma are two significant barriers to overcoming eating disorders. These psychological factors can cause individuals to set unrealistically high standards for themselves and may stem from past experiences that are never fully processed. Pickett shared that society's fixation on physical appearance presents a major challenge to recovery, as it reinforces the false belief that a smaller body size equals better health.

"In reality, the relationship between body size and health is far more complex and nuanced than suggested," Pickett explained.

Impact of coexisting mental health conditions on treatment

It can be increasingly difficult to address eating disorders when co-occurring mental health conditions are not simultaneously managed. Conditions such as depression, anxiety, OCD, PTSD, ADHD, and other co-occurring mental health conditions must be addressed alongside eating disorder treatment for patients to achieve the best outcomes.

“For example, if someone is struggling with depression, managing those symptoms can take much of their energy and focus, leaving little capacity to address disordered eating,” Pickett said.

She emphasized the importance of treating the underlying mental health disorder, adding, “One of my initial steps is to assess for any co-occurring psychiatric illness and create a treatment plan that includes both medication and individual therapy.”

Health care providers as advocates in eating disorder recovery

Health care providers play a crucial role as advocates and allies for their patients.

"Building rapport, asking about their concerns related to body image or nutrition, and providing unconditional positive regard is invaluable in supporting their recovery,” Pickett said.

She shared an example: "I’ve heard from patients who were advised to lose weight during their eating disorder recovery, which was counterproductive to their recovery efforts."

Pickett suggested that providers embrace the principles of precision medicine, including nutrition, when making patient recommendations.

"This may require us to confront our own biases about weight and body size, but it will help us better address the needs of our patients in the long run," she added.

In treating eating disorders, it is essential to tailor approaches to each patient's unique needs and circumstances. Pickett emphasized the importance of individualized care, explaining that while each patient is unique, she generally uses affirming techniques to boost self-esteem. She incorporates principles from Dialectical Behavior Therapy, Acceptance and Commitment Therapy, and Intuitive Eating to guide the process.

"These approaches help identify and address problematic eating behaviors while enhancing coping skills," she said.

It is important for Advanced Practice Providers to reassure patients that healthcare providers are partners and advocates in their treatment, Pickett added.

"Building trust takes time, so we can nurture that trust with every interaction," she explained.