Traditional understandings of anorexia nervosa focus on the role of body shape and weight concerns in causing and maintaining disordered eating behaviours. However, recent research shows us that anorexia is caused by an interplay of interpersonal, socio-emotional, and cognitive factors. More young people relate to relationship challenges than food, body, or shape concerns in the onset and maintenance of anorexia.

Relational challenges require relational solutions. When eating disorder symptoms are rooted in interpersonal difficulties, addressing these challenges should be a core element of treatment. Traditional care for anorexia nervosa that focuses only on refeeding and weight restoration often leaves the causes of disordered eating behaviour untouched, preventing any meaningful measure of recovery.

In this article, we look at the connection between relationship challenges and anorexia nervosa, referencing ideas from the cognitive interpersonal maintenance model of anorexia. We explore what trauma-focused, relationship-centred treatment might look like, and the principles it should follow.

The Cognitive Interpersonal Maintenance Model of Anorexia Nervosa

The cognitive interpersonal maintenance model of anorexia nervosa (Treasure and Schmidt, 2013) describes how an interplay of interpersonal, socio-emotional, and cognitive factors causes and maintains anorexia nervosa. 

Treasure and Schmidt identify certain social and emotional traits and behaviours that may be more pronounced among people with anorexia. These include limited expression of emotion, a focus on social threats rather than social reward, feelings of inferiority, and high levels of social anxiety. These traits impact the way individuals form relationships with others, often leading to loneliness and social isolation.

Research has found that some of these traits are still present in people who have recovered from anorexia, but they are most pronounced during acute stages of the illness. Some traits are also present among close family members.

These observations suggest that such traits may be pronounced in young people before the onset of anorexia, contributing to the development of the disorder. However, malnutrition also accentuates these effects, profoundly impacting how our brains and bodies function. For example, the production of the hormone oxytocin – a key facilitator of emotional communication – is significantly altered in acute stages of anorexia. 

Treasure and Schmidt also highlight the role of interpersonal relationships and bidirectional interactions in maintaining anorexia. In acute phases of anorexia, relationships with family members and carers can become hostile, critical, or overprotective, as other people react to eating disorder symptoms and behaviours. These reactions may be more likely when family members share some of the same socio-emotional and cognitive traits that make a person vulnerable to eating disorders.

Social Processes and Relationships Challenges

The anxious avoidance of emotions and social interactions is often present before the onset of anorexia nervosa. People with anorexia nervosa are more likely to have fewer close friends, take part in fewer social activities, and have weaker social support than others, even before the disorder develops. 

These interpersonal problems may partly stem from traits that make it more difficult to build close, trusting friendships. For example, young adults with anorexia may be less likely to express their own emotions or understand the emotions of others through facial expressions or body language. 

Other studies have found that people with anorexia have an attentional bias towards negative facial expressions, but not positive ones. This may focus on social threats rather than social reward, creating social anxiety and discouraging the formation of close relationships. People with anorexia are also often sensitive to criticism, rejection, and negative evaluation by others.

These traits and social experiences can both contribute to and maintain anorexia nervosa. Sensitivity to criticism and a focus on social hierarchies may make a person more likely to perceive inadequacies in their body, shape, and appearance, especially if they have experienced negative comments from others about their weight or appearance. 

When a person has fewer close friends and spends more time alone, it’s easier for these ideas to dominate their thoughts and daily life. As anorexia develops, intensified interpersonal difficulties exacerbate social isolation, leading to a vicious cycle of social withdrawal and intensifying eating disorder symptoms.

The reactions of other people to anorexia nervosa are also important. Criticism and over-protection from family and friends can make relationships even more distant. On the other hand, showing warmth and listening to a person can help bring them closer.

Abandoning Medical Nutrition-Only Treatment Plans

Unfortunately, despite clear evidence that eating disorders are closely related to interpersonal relationships and social skills, many treatment programs for anorexia nervosa continue to focus on eating patterns and weight restoration. These programs fail to address the underlying causes of disordered eating behaviours, preventing meaningful recovery.

Research suggests that while focusing on changing eating patterns can be effective for some adolescents in the early stages of anorexia, less than half may still be in remission a year later. As the duration of illness increases, change becomes more difficult, especially more than three years after the onset of anorexia.

Treatment plans that focus only on medical nutrition often leave individuals with ongoing psychological distress, even when they are labelled as ‘recovered’. Without whole-person healing that addresses cognitive, emotional, and social factors, disordered eating symptoms frequently return, creating the perception of anorexia as a chronically relapsing condition. This outlook causes hopelessness and exhaustion within families and constructs further barriers to treatment.

In some contexts, incentives within the public and private healthcare systems encourage a focus on weight restoration in anorexia nervosa recovery, despite evidence that contradicts its effectiveness. Understanding body weight as a measure of recovery enables treatment programs (that may have long waiting lists) and insurance companies to deny access or coverage to individuals above a certain body weight, regardless of the severity of their psychological, emotional, and behavioural symptoms. This body weight criterion is normally very low. Unfortunately, these policies reinforce a culture of treatment that leaves many individuals without access to effective recovery programs.

Prioritising Relationships within a Trauma-Focused Care Model for Anorexia Nervosa

Instead of focusing on weight restoration and medical nutrition, effective treatment for anorexia nervosa should address the thoughts, emotions, and experiences that contribute to and maintain disordered eating behaviours. This includes interpersonal relationships with friends and family members and the socio-emotional skills that underpin them.

Experiences of trauma are common among people with anorexia nervosa. A 2022 study found that a majority (75%) of adolescents who entered residential treatment for eating disorders had experienced at least one type of childhood trauma, while 38% met the criteria for PTSD. These traumas affect relationships, trust in others, perceptions of threat, and the processing and management of emotions.

Some core principles of treatment for anorexia nervosa should include:

• Recognising that anorexia nervosa is not about the body a person lives in, but their emotions, thoughts, and experiences
• Integrating trauma therapy from the very start of a treatment program
• Understanding recovery as a psychological, social, and physical process of healing that is experienced in different aspects of a person’s life

Following these principles requires the provision of evidence-based treatment modalities that address different aspects of a person’s experience. This includes prioritising both trauma-based therapies and interpersonal approaches. Treatment programs should be adapted to suit each person’s individual needs and experience.

Some examples of treatment modalities include:

• Interpersonal therapy
• Trauma therapy, such as cognitive-processing therapy or EMDR
• Enhanced cognitive-behavioural therapy (CBT-e)
• Radically open dialectical behavioural therapy (RO-DBT)
• The Maudsley model of anorexia nervosa treatment for adolescents and young adults (MANTRa)
• Family therapy

In most situations, prioritising interpersonal relationships also means including a person’s social systems – particularly their family – in a treatment program. Treatment approaches like family therapy facilitate the development of warm, empowering and supportive relationships that encourage positive change and overcome loneliness and isolation, promoting long-term recovery from eating disorders.