• Research article
  • Open access
  • Published: 02 April 2015

Comparison in decision-making between bulimia nervosa, anorexia nervosa, and healthy women: influence of mood status and pathological eating concerns

  • Junko Matsumoto 1 , 2 , 3 , 4 ,
  • Yoshiyuki Hirano 1 , 2 ,
  • Noriko Numata 2 , 6 ,
  • Daisuke Matzuzawa 1 , 6 ,
  • Shunichi Murano 4 ,
  • Koutaro Yokote 7 ,
  • Masaomi Iyo 5 , 8 , 9 ,
  • Eiji Shimizu 1 , 2 , 6 &
  • Michiko Nakazato 1 , 2 , 5  

Journal of Eating Disorders volume  3 , Article number:  14 ( 2015 ) Cite this article

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Decision-making is reported to be impaired in anorexia nervosa (AN) and bulimia nervosa (BN), but the influence of mood status, pathophysiological eating, and weight concerns on the performance of decision-making ability between AN and BN is still unclear. The aims of this study were to investigate differential impairments in the decision-making process between AN, BN, and healthy controls (HC), and secondly, to explore the role of mood status, such as anxiety, depression, pathological eating, and weight concerns, in decision-making ability.

Patients suffering from AN (n = 22), BN (n = 36) and age-matched HC (n = 51) were assessed for their decision-making abilities using the Iowa Gambling Task (IGT). Self-reported questionnaires including the Eating Disorder Examination Questionnaire (EDE-Q), the Bulimia Investigatory Test, Edinburgh (BITE), the Eating Disorders Inventory, the Maudsley Obsessive-Compulsive Inventory measuring obsessive-compulsive traits, the Hospital Anxiety and Depression Scale, and the Toronto Alexithymia Scale were used to assess pathological eating concerns and attitude to feelings.

Significant differences in IGT performance were observed between BN and HC. Significant negative correlation was found between IGT performance and the BITE symptom subscale in AN. In BN, there was a negative correlation between the EDE-Q weight concerns subscale and IGT performance. It was also found that increased anxiety, depression, and eating/weight concerns predicted poorer decision-making.

Different patterns of association between pathological eating concerns/behaviors and performances in decision-making ability were found between AN, BN, and HC. Anxiety, depressive mood status, and eating/weight concerns were related to decision-making ability.

Eating disorders (EDs) are severe and enduring psychiatric disorders of eating behavior, including extreme, unhealthy decreases in food intake as well as severe overeating, accompanied by feelings of distress or excessive concern about body shape or weight [ 1 ]. Three types of eating disorders are recognized by the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) [ 2 ]: anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS).

Decision-making is affected by the combination of emotional representations, sensitivity to immediate reward and long-term outcome according to the somatic marker hypothesis (SMH) [ 3 - 5 ]. Multiple cognitive functions such as attention, memory, learning [ 6 , 7 ], risk-taking, and obsessive-compulsive traits [ 8 ] have been suggested as being involved in performances in decision-making [ 9 , 10 ]. A previous study by Tchanturia et al. found impairment of emotional signal by skin conductance (SCR), showing the lowest emotional signal by demonstrating a lack of ability to be aware of emotional signal during decision-making task [ 11 ]. In BN, a previous study showed no significant correlation between SCR and performance in decision-making [ 12 ]. For this reason, it is unclear whether the AN and BN groups have different deficits in emotional skills during decision-making.

The role of emotion, specifically anxiety or worry, may influence the decision-making process [ 13 ]. High levels of worry may have expected consequences of future events that influence the performances of decision-making [ 14 ]. The majority of people with EDs have high levels of anxiety [ 15 ], worry, a defining cognitive feature, and a maintenance factor of anticipatory anxiety [ 16 ]. Heightened anxiety levels may affect the process of decision-making in AN or BN patients. However, few studies have focused on the effect of mood status on a prospect during the decision-making process in AN compared with BN. Two studies showed that decision-making in patients with AN may be related to anxiety [ 17 , 18 ], whereas other studies showed that they were unrelated [ 7 , 19 ]. Some studies suggested significant associations between measures of depressive disorder and decision-making [ 20 , 21 ], but a number of other studies have indicated that depressive symptoms did not significantly influence decision-making ability in patients with EDs [ 7 , 12 , 22 - 24 ].

Alexithymia is commonly described as consisting of four features: (1) difficulty identifying and describing subjective feelings; (2) difficulty distinguishing between feelings and the bodily sensations of emotional arousal; (3) lack of fantasy; and (4) an externally orientated cognitive style [ 25 ]. Previous studies demonstrated that patients with EDs use maladaptive eating behaviors (e.g., binging, purging, or dietary restriction) as a way to avoid or cope with their emotions [ 26 , 27 ], with many clinical studies suggesting that eating disorder symptoms are associated with emotional dysfunction [ 28 , 29 ], with clear functional links expressed between emotional states and both bulimic and restrictive pathology. It has been suggested that patients with EDs tend to show alexithymia, but only one study has examined the relation in EDs in comparison with healthy controls (HC), showing that alexithymia was unrelated to decision-making in AN [ 30 ].

The Iowa Gambling Task (IGT) is a neuropsychological task that tests the decision-making ability to sacrifice immediate rewards in order to achieve long-term gain [ 3 ]. IGT assesses set-shifting ability, reaction to reward and punishment, and learning ability to decide advantageous over disadvantageous choice under uncertainty [ 31 ]. IGT is underpinned by SMH, a theory that, in essence, posits that decision-making under uncertainties is guided by emotional responses to anticipated positive and negative consequences [ 5 , 6 ]. Neuroimaging findings suggest that activation of the mesolimbic pathway during wins and decreased activation of the inferior frontal gyrus during losses lead to repeated selections in reward and punishment in IGT [ 32 ]. IGT was developed for functional assessment, given that patients with ventromedial prefrontal cortex (vmPFC) and limbic system dysfunction show severe impairments in decision-making.

Increasing evidence suggests neuropsychological traits such as poor set-shifting ability [ 19 ], weak central coherence [ 19 , 33 ], a dysfunction of the reward circuit, including a preference for immediate reward despite long-term adverse consequences [ 15 ], higher sensitivity to punishment [ 34 ], and poor insight into illness [ 35 , 36 ] in AN. In previous studies, memory function [ 37 ], skin conductance response [ 11 ], body mass index (BMI) [ 38 ], anxious mood [ 18 ] and impaired decision-making ability were indicated in AN. Regarding the domain of decision-making ability, several studies have reported that individuals with AN show impaired decision-making ability as reflected by poorer performance on IGT [ 11 , 22 , 39 - 41 ].

In BN, decision-making ability was impaired in some studies [ 12 , 22 , 41 ], showing that obsessive-compulsive traits [ 42 ] and pathological eating symptoms may be related to impaired decision-making ability, which in turn may lead to real-life risk-taking and immediate reward-seeking behavior such as binge eating and purging.

Thus, in total, relatively few studies have been conducted concerning the decision-making ability between AN, BN and HC [ 12 , 37 , 43 , 44 ]. In addition, it has remained unclear whether the performances of decision-making are distinguished by pathological eating concerns/behaviors, mood status (anxiety, depression), and attitude to feelings such as alexithymia between AN, BN, and HC.

The hypotheses of this study were: 1) decision-making performances can be distinguished in AN, BN and HC, and 2) decision-making deficits are related to mood status such as anxiety, depression, alexithymia, and pathological eating symptoms.

The aims of this study were to investigate differential impairments in the decision-making process between AN, BN, and HC, and secondly, to explore the role of mood status such as anxiety, depression, attitudes to feelings, and pathological weight concerns in decision-making ability.

Participants

The patients of this study were 58 females recruited from Chiba University Hospital, Japan (22 AN; 36 BN). They were interviewed by a senior psychiatrist assessing criteria for AN and BN as defined by DSM-IV [ 2 ]. In addition, the M.I.N.I. International Neuropsychiatric Interview translated into Japanese (M.I.N.I.) [ 45 ] was applied. Exclusion criteria for patients with AN and BN were a history of brain injury, epilepsy, psychosis or drug dependence. The AN group included restrictive (n = 9) and binge eating/purging (n = 13) subtypes. The BN group included purging (n = 34) and non-purging (n = 2) subtypes. A total of 7 females (2 AN and 5 BN) had the following comorbidities: dysthymia (5%; 3 with BN), panic disorder (2%; 1 with BN), somatoform disorder (2%; 1 with AN), anxiety disorder (2%; 1 with AN), and alcohol dependence (2%; 1 with BN). Seventeen percent of all patients were taking serotonergic drugs (SSRIs) (Table  1 ).

HC (n = 51) were recruited through local advertisements and a website from a potential pool of university students and volunteers. Age-matched HC underwent an interview by a senior psychiatrist using M.I.N.I. [ 45 ], and they were determined to have no family history of psychiatric conditions, history of brain injury, epilepsy, psychosis, current substance abuse or dependence, risk of suicide, mental retardation, autistic spectrum disorders, comorbid depression and bipolar disorders, and that their BMI (body mass index) was between 19 and 25 kg/m 2 .

All participants, female native Japanese speakers, were between age 18 and 38 (mean = 24.92, SD = 5.83 years). After the study had been described to the participants, their written informed consent was obtained. The ethics committee of the Chiba University Graduate School of Medicine approved the study protocol.

Measurements

Instruments, toronto alexithymia scale (tas-20).

The Toronto Alexithymia Scale [ 46 , 47 ], Japanese version with established validity and reliability [ 48 ], is a 20-item self report questionnaire measuring alexithymia. It includes three subscales: difficulty identifying feelings, difficulty describing feelings, and externally oriented (concrete) thinking. Cut-off scores for TAS-20 are equal to or less than 51 for non-alexithymic individuals, and equal to or greater than 61 for alexithymia. Scores of 52–60 indicate possible alexithymia.

Hospital Anxiety and Depression Scale (HADS)

The Hospital Anxiety and Depression Scale [ 49 ], Japanese version established as valid and reliable [ 50 ], is a widely used self-report scale developed to detect states of depression, anxiety and emotional distress among patients being treated for a variety of clinical problems. The scale consists of eight questions assessing depression (HADS-d) and eight assessing anxiety (HADS-a). The optimal cut-off point is said to be greater than or equal to 8 for the identification of suspicious cases and greater than or equal to 11 for safe cases on both subscales [ 49 ].

Eating Disorder Examination Questionnaire (EDE-Q)

The Eating Disorders Examination Questionnaire [ 35 ], Japanese version, which was established for its validity as well as reliability [ 51 ], is a widely used 36-item self-report questionnaire that assesses the eating disorders-related level of symptoms over the past 28 days. EDE-Q generates two types of data. First, 22 scaled items plus one unscaled item (items 1–15 and 29–36) provide subscale scores reflecting the severity of aspects of the ED psychopathology. Second, 13 more items (items 16–28) provide data on six key behavioral features of ED in terms of presence/absence and frequency with which the behavior occurred, and loss of control. EDE-Q includes four subscale scores, Restricting (EDE-Qr), Eating concern (EDE-Qe), Shape concern (EDE-Qs) and Weight Concern (EDE-Qw), which are included in this assessment, the response format of which is a 7-point Likert-type scale (0: never; 6: every day). The subscale scores are obtained by calculating the average of the items forming each subscale, and the global score (EDE-Qg) is the average of the four subscale scores.

Bulimia Investigatory Test, Edinburgh (BITE)

The Bulimia Investigatory Test, Edinburgh [ 52 , 53 ], Japanese version, recognized for its validity and reliability [ 54 ], is a 33-item self-report measure designed to identify individuals with symptoms of bulimia or binge eating. BITE consists of two subscales: the symptom scale (BITE-sas), which measures the degree of symptoms present, and the severity scale (BITE-ss), which provides an index of the severity of binging and purging behavior as defined by their frequency.

Eating Disorders Inventory-2 (EDI-2)

The Eating Disorder Inventory-2 contains 91 items and is a self-report questionnaire designed for use with those aged 12 years or older. This measure assesses features commonly associated with anorexia nervosa and bulimia nervosa but does not provide diagnoses for eating disorders [ 55 ]. EDI-2 consists of 11 subscales including bulimia, body dissatisfaction, drive for thinness, perfectionism, ineffectiveness, interpersonal distrust, interoceptive awareness, maturity fears, asceticism, impulse regulation and social insecurity. The Japanese version of EDI-2, which has been established as valid and reliable [ 56 ], was used to assess the presence of eating disorders.

Maudsley Obsessive-Compulsive Inventory (MOCI)

The Maudsley Obsessive-Compulsive Inventory [ 57 ], Japanese version, recognized as being valid and reliable [ 58 ], is a true-false format self-report questionnaire developed for evaluating obsessive-compulsive symptoms to discriminate obsessive patients from other neurotic patients and nonclinical individuals. The test is composed of 30 dichotomous items, such that the total score for a participant will range between 0 (absence of symptoms) and 30 (maximum presence of symptoms).

The levels of psychopathology in eating disorders were measured using the scores of BITE, total scores of EDI-2, and EDE-Q subscores.

Neuropsychological assessment

Iowa gambling task [ 3 , 59 ].

Decision-making ability of participants was evaluated using IGT, which is a neuropsychological task based on emotion-guided evaluation. Participants are required to choose one card at a time from four available decks of cards (100 trials) in this task. The goal of the task is to win as much money as possible. To accomplish a task, participants have to detect, from a long-term perspective, which are the most advantageous decks. First, participants were given both the task instructions and 200,000 Japanese yen (approximately US$1,666) of play money. Each time participants choose a card, they will win some money; however, on turning over each card they also will, seldom or sometimes, have to pay a penalty according to a pre-programmed schedule of reward and punishment. Gains and losses differ for each card selected from the four decks. Decks A and B are “bad decks (disadvantageous)”, and the other decks, C and D, are “good decks (advantageous)”, because, in the former, while participants receive 10,000 Japanese yen (approximately US$83), the losses are also higher, such that these decks cost more in the long run. In contrast, the latter will lead to overall gains in the long run (receiving less money, but punishments are also smaller). The 100 choices were divided into five blocks of 20 choices each. We calculated the number of advantageous cards (decks C and D) selected in total.

Statistical analyses

All statistical analyses were performed using SPSS 21.0 (IBM Corp., Armonk, NY). Demographic and clinical variables for ED and HC groups were compared using one-way analyses of variance (ANOVAs).

IGT scores were defined as the number of choices from the advantageous decks (C and D) minus the number of choices from the disadvantageous decks (A and B) for all 100 trials. This net score (decks[C + D] - decks[A + B]) calculated for each 20-choice time block enables the assessment of learning during the task. A total net score for the 100 selections is also calculated. A score of <10 was established by Bechara et al. as the threshold for deficit of decision-making on IGT, given the maximum net score achieved by vmPFC patients was <10 [ 9 ]. A 5 × 3 repeated-measures ANOVA was carried out with the net scores of the five blocks [C + D]-[A + B](1–20, 21–40, 41–60, 61–80, 81–100) as the repeated-measures variable and the three diagnostic groups (AN, BN, and HC) as a between-subjects variable. Effect size was calculated using Cohen’s d , with d  = 0.2 regarded as a small effect, d  = 0.5 as a medium effect, and d  = 0.8 as a large effect [ 60 ]. Pearson’s correlations were used to examine the relationship between IGT performance and demographic and clinical variables in the whole sample and in each group, respectively. Finally, multiple regression analysis was performed for all participants to detect the best predictors of IGT performance, using IGT performance as the dependent variable and all questionnaire scores and subscale scores showing significant relationships as independent variables. In all analyses, the statistical significance level was set at p  < 0.05 (2-tailed tests).

Sample characteristics

Demographic and clinical characteristics are summarized in Table  1 . The three groups did not differ in terms of age ( F (2,106) = 1.71; p =0.19) and education ( F (2, 65) = 1.24; p  = 0.30). In addition, no significant difference between the patient groups in terms of illness duration was found ( F (1, 52) = 0.003; p  < 0.096). On the other hand, significant differences were obtained for BMI and clinical self-report measures (TAS-20, EDE-Q, HADS, BITE, MOCI, and EDI-2). Post hoc t tests revealed that AN and/or BN differed from HC for most of the dimensional assessments, while no significant differences were found with respect to the overall questionnaires between AN and BN.

Decision-making performances

Group comparisons in igt total net scores [c + d]-[a + b](1–100 choices).

Results from IGT are presented in Table  2 . The prevalence of decision-making impairment (IGT < 10, [ 9 ]) was approximately 45% in AN, 44% in BN patients, and 45% in HC. No significant group differences were found in the mean IGT total net scores ( F (2,103) = 1.06; p  = 0.35), indicating that the decision-making abilities of the three groups were quite similar.

Group comparisons in IGT block net scores [C + D]-[A + B](1–20, 21–40, 41–60, 61–80, 81–100)

Figure  1 shows the mean IGT scores for the three groups over the five blocks of 20 trials each. A 5 (IGT block) × 3 (group) repeated measures ANOVA was performed on net scores for all five blocks. Mauchly’s test indicated that the assumption of sphericity had been violated (χ 2 (9) = 51.51, p  < 0.0001), and therefore the degrees of freedom were corrected using Greenhouse-Geisser estimates of sphericity (ε = 0.78). There was no significant main effect of group ( F (2, 103) = 1.06, p  = 0.35, ηp 2 = 0.02), but there was a significant main effect of block ( F (3.14, 57.48) = 14.53, p  < 0.0001, ηp2  = 0.12), and a significant group × block interaction ( F (6.28, 57.48) = 2.63, p  = 0.02, ηp2  = 0.05) over the IGT blocks. In the HC group, IGT performance showed a gradual increase across blocks. There was a significant task-related learning effect, as performance improved during the task for BN and HC (BN: F (4, 32) = 2.69; p  = 0.04; HC: F (4, 47) = 15.24; p  < 0.0001). A post-hoc least significant difference test indicated that there was a significant difference between the BN and HC groups in the final block [C + D]-[A + B](81–100), that is, performance in BN was significantly worse than in HC ( p  = 0.02). On the other hand, although no significant difference was observed between AN and HC in the final block [C + D]-[A + B](81–100), performance in AN was marginally deficient compared to HC ( p  = 0.054). The two clinical groups were not significantly different from each other in any other block. Effect sizes for between-groups differences in IGT net scores were measured using Cohen’s d (block 1: AN vs. HC, d  = 0.20; BN vs. HC, d  = 0.11; block 2: AN vs. HC, d  = 0.36; BN vs. HC, d  = 0.36; block 3: AN vs. HC, d  = 0.13; BN vs. HC, d  = 0.30; block 4: AN vs. HC, d  = 0.35; BN vs. HC, d  = 0.42; block 5: AN vs. HC, d  = 0.50; BN vs. HC, d  = 0.56).

Strategy of Iowa Gambling Task, as total number of “Advantageous” minus “Disadvantageous” cards selected in each block of 20 cards; anorexia nervosa (AN), bulimia nervosa (BN), and healthy control (HC). A significant difference between BN and HC was indicated ( p   < 0.05).

Group comparisons controlling for covariates

We demonstrated the same group comparisons analysis, controlling for the use of SSRIs in the IGT block net scores [C + D]-[A + B](1–20, 21–40, 41–60, 61–80, 81–100). We not only detected remaining significant differences in the IGT net scores in the final [C + D]-[A + B](81–100) choices ( p  = 0.01), but also found significant differences between BN and HC in the fourth [C + D]-[A + B](61–80) choices ( p  = 0.01).

Association between decision-making and clinical variables

Correlation analysis.

We explored correlations among clinical measures including all scores such as TAS-20, EDE-Q, BITE, EDI-2, HADS, MOCI and IGT performance (both IGT total net scores: [C + D]-[A + B](1–100 choices) and block net scores: [C + D]-[A + B](1–20, 21–40, 41–60, 61–80, 81–100) ) in AN and BN females, respectively. Performance in the first block [C + D]-[A + B](1–20) of the IGT was negatively associated with BITE-sas in the AN group ( r  = −0.73, p  = 0.04) (Figure  2 ). In the BN group, as shown in Figure  3 , the IGT performance in the third block [C + D]-[A + B](41–60) was also negatively correlated with EDEQ-w ( r  = −0.47, p  = 0.02). Therefore, we detected different patterns of association between pathological eating concerns/behaviors and the performances of decision-making ability between AN and BN.

Scatter plot shows the scores of the first block on IGT (1–20 within 100 trials) and the bulimia investigatory test, edinburgh symptom subscale (BITE-sas) for AN, BN, and HC. Negative correlation was found in AN ( r  = −0.73; p  = 0.04).

Scatter plot shows the scores of the third block on IGT (41–60 within 100 trials) and the eating disorder examination questionnaire weight concern subscale (EDE-Qw) for AN, BN, and HC. Negative correlation was found in BN ( r  = −0.47; p  = 0.02).

Regression analysis

Multiple regression analysis was performed for all participants using demographic and clinical scores such as TAS-20, EDE-Q (four subscales: restricting, eating concern, shape concern, weight concern), HADS (depression and anxiety), EDI-2, MOCI, and BITE (symptoms and severity) as independent variables and IGT net scores [C + D]-[A + B] (1–20, 21–40, 41–60, 61–80, 81–100) as dependent variables. As shown in Table  3 , the analyses revealed seven predictive factors for the third block of IGT [C + D]-[A + B](41–60): years of education ( β  = 0.77, p  = 0.0001), EDEQ-r ( β  = 1.58, p  = 0.0001), HADS-a ( β  = −0.69, p  = 0.01), HADS-d ( β  = 1.44, p  = 0.0001), EDI-2 ( β  = −0.81, p  = 0.01), BITE-ss ( β  = −0.51, p  = 0.03), and BITE-sas ( β  = −1.80, p  = 0.0001). In contrast, no significant predictive factor was highlighted for the AN and BN groups, suggesting that mood status (anxiety or depression), in addition to the pathological eating/weight concerns for the prospect of decision-making were detected.

In the present study, we found different profiles in IGT performance between BN, AN, and HC. As shown in Figure  1 , a comparison of the performance curves of the three groups revealed that the individuals with AN and BN, as opposed to HC, failed to learn advantageous decision-making until the end of the task. Although no significant difference between AN and HC was observed, a difference between BN and HC (BN < HC, p  = 0.02) was detected in the final block [C + D]-[A + B](81–100). Regarding total net scores, the prevalence of decision-making impairment (IGT < 10) was reported to be approximately 61% in AN and 77% in BN by Brogan et al. [ 44 ], but our data showed lower percentages. Secondly, only in the BN group, there was a significant negative correlation between the weight concern subscales and the performances of decision-making ability. These findings may be strongly confirmed by the fact that in the BN group, pathological weight concern affected the impaired decision-making ability.

A previous study has reported that patients with BN were significantly different from the HC group in blocks 3 [C + D]-[A + B](41–60) and 4 [C + D]-[A + B](61–80) [ 44 ]. In contrast, we found that BN made fewer advantageous choices than HC in the final block [C + D]-[A + B](81–100) of the task. This would suggest that pathological concerns affect ignored long-term negative consequences, which may have led to impaired decision-making ability in the final block [C + D]-[A + B](81–100) in the current study. There is a striking resemblance between the IGT performance of the patients and their real-life pathological behaviors, in which they have a tendency to reduce their food intake and/or refuse to eat, or in contrast to this pattern, repetitively overeating and purging, ignoring long-term negative consequences. In a previous study, BN subjects failed to learn an advantageous decision-making strategy by choosing immediate rewards (high gains) despite the long-term negative consequences (loss of money) as compared to HC, showing that sensitivity to gains affect these findings [ 23 ], results consistent with the current study. Boeka and Lokken [ 22 ] suggested that there are links between decision-making, weight, and eating concerns/restricting behavior in BN, and thus the authors argued that the severity of bulimic symptoms as measured by the Bulimia Test-Revised [ 61 ] and the severity of EDE-Q (restraint, eating concerns and weight concerns) contribute to decision-making ability. These data were consistent with the findings in the BN group in the current study. Brand et al. suggested that performance in decision-making was related to executive functioning but not to other neuropsychological functions, personality, or disease-specific variables in the BN group [ 41 ]. Regarding the task, in comparison to HC, the patients with BN tended to choose disadvantageous alternatives more frequently, possibly due to a tendency to fail to learn from the anterior half of the task, which might be linked to real-life pathological behaviors.

On the other hand, although performance in AN was marginally deficient compared to HC ( p  = 0.05) in the last trial [C + D]-[A + B](81–100) of the IGT, the current study does not support results from other studies [ 11 , 39 , 40 ], showing that AN patients failed to reach a significant difference in decision-making compared to HC. One explanation for this is the small sample size of the current study. Additionally, the fewer comorbidities (AN, 2 with comorbidities; BN, 5 comorbidities) in AN might have led to better decision-making compared to BN. Interestingly, in the AN group, there was a significant correlation between bulimic symptomatology measured by the BITE symptom subscale, which measures the degree of present symptoms, and the poor performance of IGT in the first block [C + D]-[A + B](1–20). 59.1% (13/22) of the AN group had binge eating/purging subtype, which may have affected the poor performance of IGT. Thus, our first hypothesis, that the AN and BN groups present a different pattern in decision-making ability, was confirmed.

The second aim of this study was to explore the links between decision-making ability and mood status, weight/eating concerns of pathological symptoms. Using multiple regression analysis, we found that EDI-2 and BITE-ss measures predicted decision-making. These data are in line with previous investigations concerning this subject [ 18 , 22 ].

Both the states of anxiety and depressive mood were found to be predictors of better decision-making. These data suggest that emotional states may impact decision-making in EDs [ 11 ] as well as in HC [ 62 - 64 ]. Zeeck et al. reported that the urge to eat is significantly higher under negative-emotional states; negative emotions such as sadness or disappointment correlated significantly with the number of binges, whereas positive emotions did not [ 65 ]. Thereby, the ‘Network Theory of Affect’ [ 66 ], that is, affective nodes (central units), can be semantic (with straightforward meaning) or affective (with emotional meaning), which may confirm the findings of the previous study. One recent study of binge eating disorders was in line with this view, proposing that the emotional state may have a direct experience that is similar to its emotion [ 67 ].

Alexithymia, as measured by TAS-20, did not affect decision-making ability in the current study, although a higher level of alexithymia compared with HC was observed. Miyake et al. reported that there was no correlation with decision-making ability using emotional decision-making task and alexithymia in EDs [ 30 ], a result consistent with the finding of our study.

In the current study, controlling for the use of SSRIs as covariance, we detected significant difference in IGT performances between BN and HC in the fourth block [C + D]-[A + B](61–80) and the final block [C + D]-[A + B](81–100), which suggested the influence of the serotonin system in decision-making. In the previous study by Tchanturia et al. [ 11 ], 44% of AN patients were taking SSRIs, but no difference between medicated and non-medicated patients was found. Emerging data have suggested that dysregulation of serotonin circuits in cortical and limbic structures are related to anxiety, eating behaviors and body image symptoms [ 68 ]. Alterations of this system may influence mood status and decision-making process in EDs, which may lead to insights into potential treatment approaches. The question of whether cognitive impairment in EDs is an endophenotype and risk factor or whether it is a correlate of illness remains unclear from the findings in the current study. It may be suggested that the relationship of symptomatology and emotional functioning to decision-making performance improves with recovery of illness.

There are some limitations to this study. First, it should be noted that a single task such as IGT is limited in examining decision-making impairments comprehensively, and this is true for the other clinical scales as well. Second, the results are generalizable for females only, and the sample sizes were not large enough compared to previous studies [ 12 , 37 , 43 , 44 ], indicating that a replication with a larger group that includes males is desirable. Finally, other variables such as impulsivity, central coherence, set-shifting, and inhibitory control-confounding factors associated with decision-making deficits or emotional dysregulation should be considered in the future.

Future study should evaluate how some different emotional variables such as sadness and fear may influence the decision-making process in patients with EDs. A longitudinal study is required to investigate changes in decision-making ability in accordance with emotional states and recovery of symptomatology of illness.

Conclusions

In conclusion, we found different profiles in IGT performance between BN, AN, and HC. Different patterns of association between pathological eating concerns/behaviors and the performances of decision-making ability were found between AN, BN, and HC. Individuals with BN, compared to HC, have a different processing pattern of decision-making ability that may be linked to pathological eating/weight concerns. Anxiety, depressive mood status, and pathological eating/weight concerns are linked to decision-making ability.

Abbreviations

  • Anorexia nervosa

One-way analyses of variance

Bulimia Investigatory Test, Edinburgh

Bulimia Investigatory Test, Edinburgh symptom scale

Bulimia Investigatory Test, Edinburgh severity scale

Body Mass Index

  • Bulimia nervosa

Diagnostic and Statistical Manual of Mental Disorders

Eating disorders

Eating Disorder Examination Questionnaire

Eating Disorder Examination Questionnaire eating concern

Eating Disorder Examination Questionnaire global score

Eating Disorder Examination Questionnaire restricting

Eating Disorder Examination Questionnaire shape concern

Eating Disorder Examination Questionnaire weight concern

Eating Disorders Inventory

Hospital Anxiety and Depression Scale

Hospital Anxiety and Depression Scale anxiety

Hospital Anxiety and Depression Scale depression

Healthy controls

  • Iowa Gambling Task

Maudsley Obsessive-Compulsive Inventory

Somatic Marker Hypothesis

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Acknowledgements

We would like to thank the Research Center for Child Mental Development and the Department of Psychiatry, Chiba University Hospital, for their help with recruitment. The authors are also grateful to the participants for their co-operation in this study. A summary of this study was presented at the 43rd Annual Congress European Association for Behavioral and Cognitive Therapies, 2013.

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Junko Matsumoto, Yoshiyuki Hirano, Daisuke Matzuzawa, Eiji Shimizu & Michiko Nakazato

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Junko Matsumoto, Yoshiyuki Hirano, Noriko Numata, Eiji Shimizu & Michiko Nakazato

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Conceived and designed the experiments: JM, MN, SM, KY, MI, ES. Performed the experiments: JM, MN, YH, NN. Analyzed the data: JM, MN, YH. Contributed reagents/materials/analysis tools: JM, MN, NN, DM, MI. Wrote the paper: JM, MN, YH. All authors read and approved the final manuscript.

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Matsumoto, J., Hirano, Y., Numata, N. et al. Comparison in decision-making between bulimia nervosa, anorexia nervosa, and healthy women: influence of mood status and pathological eating concerns. J Eat Disord 3 , 14 (2015). https://doi.org/10.1186/s40337-015-0050-6

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DOI : https://doi.org/10.1186/s40337-015-0050-6

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The Outcome of Bulimia Nervosa: Findings From One-Quarter Century of Research

  • Hans-Christoph Steinhausen M.D., Ph.D., D.M.Sc.
  • Sandy Weber Cand.Phil.

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Objective: The present review addresses the outcome of bulimia nervosa, effect variables, and prognostic factors. Method: A total of 79 study series covering 5,653 patients suffering from bulimia nervosa were analyzed with regard to recovery, improvement, chronicity, crossover to another eating disorder, mortality, and comorbid psychiatric disorders at outcome. Forty-nine studies dealt with prognosis only. Final analyses on prognostic factors were based on 4,639 patients. Results: Joint analyses of data were hampered by a lack of standardized outcome criteria. There were large variations in the outcome parameters across studies. Based on 27 studies with three outcome criteria (recovery, improvement, chronicity), close to 45% of the patients on average showed full recovery of bulimia nervosa, whereas 27% on average improved considerably and nearly 23% on average had a chronic protracted course. Crossover to another eating disorder at the follow-up evaluation in 23 studies amounted to a mean of 22.5%. The crude mortality rate was 0.32%, and other psychiatric disorders at outcome were very common. Among various variables of effect, duration of follow-up had the largest effect size. The data suggest a curvilinear course, with highest recovery rates between 4 and 9 years of follow-up evaluation and reverse peaks for both improvement and chronicity, including rates of crossover to another eating disorder, before 4 years and after 10 years of follow-up evaluation. For most prognostic factors, there was only conflicting evidence. Conclusions: One-quarter of a century of specific research in bulimia nervosa shows that the disorder still has an unsatisfactory outcome in many patients. More refined interventions may contribute to more favorable outcomes in the future.

The introduction and definition of bulimia nervosa were presented only 30 years ago. In his salient publication, Gerald Russell (1) emphasized the dread of overeating, various compensatory measures, and the morbid fear of gaining weight and getting fat. Within this relatively short period of time, a remarkably large number of outcome studies have been published. Early reviews included one review based on eight studies (2) and another on 24 follow-up studies (3) . The latter found a mean recovery rate of 47.5% and mean rates of 26% for both improvement and chronicity. Shortly before the turn of the century, Keel and Mitchell (4) analyzed the course of 56 patient series and found a recovery rate of 50% and chronicity in 20% of the patients. The mortality rate of 0.3% was slightly lower than that reported in the prior review of 24 studies (3) . The review by Vaz (5) concentrated on prognostic factors only, and Quadflieg and Fichter (6) reviewed various outcome measures in a total of 33 studies. Finally, a recent, more selective review based on very rigorous inclusion criteria by Berkman et al. (7) provided findings from 13 patient series. Steinhausen’s analysis (8) of the outcome of anorexia nervosa in the second half of the last century served as a model for the present review.

Selection criteria for the inclusion of studies in the present review were 1) data on at least one out of five outcome measures for bulimia nervosa after a minimum follow-up evaluation period of 6 months following the treatment episode and/or 2) data on any prognostic factor of the disorder. The aforementioned reviews consisted of a total of 141 studies. A systematic search with various databases was performed using the terms “bulimia nervosa,” “outcome,” “follow-up,” and “prognosis.” A search using PubMed led to an additional 60 studies, and a search using PsycINFO resulted in 19 studies. Thus, before applying any exclusion criteria, a total of 220 published studies were available. As a result of duplicate or review-type studies, 68 studies were excluded. Furthermore, 26 studies did not include sufficient information on the duration of follow-up evaluation or provided pre-post measures only or were based only on follow-up periods <6 months. In another 21 studies, information on the course of the disorder was insufficient (e.g., no information on sample size or no independent assessment of anorexia and bulimia nervosa patients was provided). Finally, there were 14 studies dealing with prognostic factors only, and another 12 studies presented additional data based on the same patient cohort. Thus, at the end, a total of 79 patient series were entered into the analyses for the outcome of bulimia nervosa in the present review. Findings were published between 1981 and 2007. Data based on reports from a total of 32 studies were extracted by the expert senior author. Decisions on the inclusion of the remaining studies were jointly made by both the junior and senior authors.

Study Characteristics

The 79 published reports (9 – 87) were composed of 5,653 patients (group mean size=71.6 [SD=113.4], range=4–884). There were considerable differences in design, group size, methods, duration of follow-up evaluation, and missing data. Diagnostic classification changed considerably over the period in which the studies were conducted. Since the 1990s, there has been an increasing reliance on DSM-IV and ICD-10 criteria. In 46 studies consisting of 2,508 patients, the mean age at onset was 17.2 years (SD=1.7, range=4.3–23.2), and the mean age at follow-up assessment was 28.4 years (SD=4.3, range=16.6–38.0) in 39 studies consisting of 2,478 patients. The mean duration of follow-up evaluation varied between 6 months and 12.5 years (mean=3.2 months [SD=3.3]) in 77 studies of 5,239 patients. In 66 studies of 3,830 patients, a total of 75 men (1.9%) were included.

A minority of studies used combined intervention and follow-up evaluation, whereas the majority of studies used only limited evaluation of treatment effects. The available information on treatment was classified as 1) nonbehavioral psychotherapy, 2) unspecified medical intervention, 3) cognitive-behavioral therapy (CBT), 4) family intervention, or 5) mixed or uncontrolled intervention.

In the analyses for prognostic factors, 35 studies included information on prognostic factors in addition to data on outcome (10 , 14 , 15 , 17 , 21 , 24 , 25 , 30 , 34 – 36 , 40 – 44 , 52 , 54 , 55 , 57 , 61 , 63 , 65 , 68 , 71 – 73 , 75 , 76 , 83 , 88 – 92) , and 14 studies (93 – 106) dealt exclusively with prognostic factors. The total sample of these studies on prognosis consisted of 4,639 patients (mean=94.62 [SD=133.76], range=4–884).

Outcome Measures

The five central outcome criteria for the present analyses were recovery, improvement, chronicity, mortality, and crossover to other eating disorders. In addition, information on comorbid mental disorders was collected. Information on recovery was provided in the studies as part of 1) a three-level classification in combination with improvement and chronicity, 2) a two-level classification mostly in combination with chronicity, or 3) a single criterion. There were 22 synonyms of recovery (e.g., “abstinent”). Improvement was most commonly used as a medium category of a three-level classification. In a few instances, rates of improvement were reported in combination with recovery only. Among the 27 synonyms of improvement were terms such as “intermediate course,” “some remaining symptoms,” or “partial remission.” Finally, among 21 synonyms of chronicity, the most common were “bulimia nervosa,” and “poor course.” Some studies used crossover to another eating disorder according to DSM-IV criteria as an outcome category in addition to recovery and chronicity. All mortality rates represented crude mortality rates. None of the studies reported standardized mortality rates.

Statistical Analyses

The five outcome measures were calculated in percentages that were rounded to the nearest whole value. In order to take into account the large variation in sample sizes, weighted percentages were calculated by weighting each reported rate with the size of the study group. Data for all studies were converted into individual data for performance of statistical analyses using SPSS 14 (SPSS, Chicago).

All analyses were based on adjusted sample sizes at follow-up assessments rather than actual sample sizes after patient recruitment. Differences between these two figures were considered the dropout rate. The latter was dichotomized into high (≥16% of the original sample) and low (0%–15% of the original sample) categories and served as a first independent effect variable. In accordance with previous analyses (8) , the duration of follow-up evaluations was the second independent effect variable and categorized as <4 years, 4 to 9 years, or ≥10 years. Studies with a variable length of course were not considered for analyses of effect. In case there was more than one report based on the same cohort, only the last report with the longest duration of follow-up assessment was considered for the analyses. The third independent variable was represented by the type of intervention. Because of limited data, the aforementioned classification of available information on treatment into five types was restricted to the following three types: nonbehavioral psychotherapy, unspecified medical therapy, and CBT.

Effects of these three variables for treatment type on four outcome measures were analyzed using multivariate analyses of variance. In addition, effect sizes were calculated using partial eta-squared (η 2 ) as a measure of association between independent and dependent variables. According to Cohen (107) , η 2 =0.01–0.059 represents a small effect, η 2 =0.06–0.13 represents a median effect, and there is a large effect starting with η 2 =0.14. Furthermore, the frequencies of positive, negative, and insignificant prognostic factors were calculated.

Main Outcome Findings

Detailed information on crossover diagnoses was available in 23 studies. As shown in Table 1 , more than one-fifth of the patients fulfilled this criterion, with a majority of 16% on average crossing over to eating disorder not otherwise specified, which in most cases was a subclinical manifestation of bulimia nervosa, and nearly 6% on average developed full anorexia nervosa. A few patients developed binge eating disorder.

Seventy-six studies reported on mortality, and there were 14 deaths among 4,309 patients, leading to a crude mortality rate of 0.32%. For two patients, car accidents were the cause of death, four deaths were the result of suicide, one death was the result of a drug overdose, two deaths were caused by an eating disorder, and no causes of death were given for two subjects.

There was a large list of reported comorbid mental disorders. At follow-up assessments, patients most frequently suffered from affective disorders, followed by neurotic disorders (mostly anxiety disorders). Nonspecific personality disorders and borderline personality disorder were also frequent. Substance use disorders were less frequently seen, and obsessive-compulsive and schizophrenia spectrum disorders were described only in a single study.

Findings From Repeated Follow-Up Assessments

A few studies shed some light on the differential course of bulimia nervosa across time. Fichter and Quadflieg (91) published findings after 2-, 6-, and 12-year follow-up evaluations (34) and found substantial improvement in patients who completed longer follow-up assessment periods. Similarly, in the study by Herzog et al. (42) , recovery rates increased between the first follow-up assessment after 2 years and the second follow-up assessment after 7 years, but rates of improvement and chronicity declined correspondingly. Another study on intervention (59) found that the reduction of binge eating episodes and compensatory vomiting and laxative abuse remained constant between the 6- and 12-month follow-up evaluations. A change in outcome rates was observed in two smaller studies. Nevonen and Broberg (64) found a decreased recovery rate and an increased improvement rate between 1 and 2.5 years of follow-up evaluation when comparing individual and group psychotherapy. Similarly, in a very small sample of six patients, Toro et al. (80) observed that all patients were recovered at the first follow-up evaluation, but only four patients remained recovered after 25 years.

Intervention Effects on Outcome

There are various intervention studies on bulimia nervosa that include follow-up assessments. Two studies (28 , 30) compared three types of interventions and found that both interpersonal therapy and CBT were superior to behavior therapy without cognitive components. Other studies reported that CBT was superior to interpersonal therapy (29 , 84) or found no significant differences in the effects of either CBT or the combination of behavior therapy and hypnotherapy (40) . In another study (12) , more patients became symptom-free by the use of a self-help manual rather than CBT. Physical activity, but not diet counseling, was shown to be superior to CBT in one report (78) .

In a study on the optimization of CBT (82) , one group of patients used a self-help manual and received additional CBT when necessary. The other patients received behavior therapy only. There were no significant differences between these two approaches. In a study on the effectiveness of either the antidepressant fluoxetine or interpersonal therapy after a first inefficient phase of CBT (62) , no significant differences between the two approaches were found.

When comparing the effects of the antidepressant desipramine, CBT, or a combination of both measures (11) , CBT or the combined intervention resulted in stronger reduction of symptoms after 24 weeks relative to the pure antidepressant treatment. Adding exposure and response prevention to CBT did not result in improved results (19) . Another study (59) revealed that relative to a coping with stress program, diet counseling led to a more rapid improvement of eating behavior and to reduction and abstinence of binge eating episodes.

Two studies on the effects of family therapy revealed contradictory findings. One study (74) found that family intervention was inferior to individual psychotherapy, whereas family therapy was found to be superior in another study (39) . No significant differences were found in the effectiveness of group versus individual psychotherapy (64) . Finally, a positive effect of after-treatment control visits on the course of bulimia nervosa has been documented (58) .

Effect Variables

As a result of methodological restrictions, the presentation of findings based on effect analyses was limited to the set of 27 studies that used the three-level classification with recovery, improvement, and chronicity, supplemented by the smaller number of studies that provided additional information on rates of diagnoses for crossover to other eating disorders. There were no missing data in this data set.

Dropout rate

Duration of follow-up evaluation.

in comparing anorexia nervosa to bulimia nervosa research shows that

Long-term outcomes in treated males with anorexia nervosa and bulimia nervosa-A prospective, gender-matched study

Affiliations.

  • 1 Schön Klinik Roseneck Affiliated with the, Medical Faculty of the University of Munich, Ludwig-Maximilians-University, Prien, Germany.
  • 2 Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany.
  • PMID: 31444805
  • DOI: 10.1002/eat.23151

Objective: We report on the long-term outcome of males compared to females treated for anorexia nervosa (AN) or bulimia nervosa (BN).

Methods: A total of 119 males with AN and 60 males with BN were reassessed 5.8 ± 4.6 and 7.5 ± 5.9 years (respectively) after treatment and compared to matched female patients.

Results: At follow-up, males with AN had a higher body weight than females. For AN, remission rates (40% males vs. 41% females) did not differ at follow-up. And at follow-up, more males (34%) than females (19%) had an eating disorder not otherwise specified (ED-NOS; p < .01). At follow-up of AN, there was no binge-eating disorder (BED) and obesity was rare. For BN, remission rates (44% males vs. 50% females) and frequency of AN, BN, BED and ED-NOS did not differ at follow-up. Males with AN scored lower than females at follow-up on most subscales of the Eating Disorder Inventory (EDI) and on somatization, obsessive-compulsive symptoms, and depression (Brief Symptom Inventory). Males with BN scored lower than females with BN on perfectionism and higher on interpersonal distrust (EDI) at follow-up.

Discussion: Results from the scarce literature on males with ED are inconclusive regarding longer term outcome. In the present study, males with AN showed a slightly better outcome than females. In BN, outcome was about the same in males and females. According to our study, existing treatment is equally effective in both males and females. Additional research on the need of gender-specific diagnosis and therapy is required.

Keywords: anorexia nervosa; bulimia nervosa; course; eating disorder; females; long-term; males; outcome.

© 2019 Wiley Periodicals, Inc.

Publication types

  • Research Support, Non-U.S. Gov't
  • Anorexia Nervosa / therapy*
  • Bulimia Nervosa / therapy*
  • Gender Identity
  • Prospective Studies
  • Treatment Outcome

The transition from restrictive anorexia nervosa to binging and purging: a systematic review and meta-analysis

  • Open access
  • Published: 05 June 2021
  • Volume 27 , pages 857–865, ( 2022 )

Cite this article

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  • Riccardo Serra   ORCID: orcid.org/0000-0003-4105-5078 1 , 2 , 5 ,
  • Chiara Di Nicolantonio 1 ,
  • Riccardo Di Febo 1 ,
  • Franco De Crescenzo 3 , 4 ,
  • Johan Vanderlinden 2 ,
  • Elske Vrieze 2 ,
  • Ronny Bruffaerts 2 , 5 ,
  • Camillo Loriedo 1 ,
  • Massimo Pasquini   ORCID: orcid.org/0000-0003-3959-8137 1 &
  • Lorenzo Tarsitani 1  

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A Correction to this article was published on 02 July 2021

This article has been updated

Numerous studies addressed the topic of behavioral and symptomatic changes in eating disorders. Rates of transition vary widely across studies, ranging from 0 to 70.8%, depending on the diagnoses taken into account and the study design. Evidence shows that the specific transition from restrictive-type anorexia nervosa (AN-R) to disorders involving binging and purging behaviors (BPB) is related to a worsening of the clinical picture and worse long-term outcomes. The aim of this systematic review and meta-analysis is to focus on this specific transition, review existing literature, and summarize related risk factors. Medline and PsycINFO databases were searched, including prospective and retrospective studies on individuals with AN-R. The primary outcome considered was the rate of onset of BPB. Twelve studies ( N  = 725 patients) were included in the qualitative and quantitative analysis. A total of 41.84% (95% CI 33.58–50.11) of patients with AN-R manifested BPB at some point during follow-up. Risk factors for the onset of BPB included potentially treatable and untreatable factors such as the family environment, unipolar depression and higher premorbid BMI. These findings highlight that patients with AN-R frequently transition to BPB over time, with a worsening of the clinical picture. Existing studies in this field are still insufficient and heterogeneous, and further research is needed. Mental health professionals should be aware of the frequent onset of BPB in AN-R and its risk factors and take this information into account in the treatment of AN-R.

Level of evidence

Evidence obtained from a systematic review and meta-analysis, Level I.

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Introduction

Drifting of behavioral and psychopathological patterns can lead to permanent or temporary switches in eating disorder (ED) diagnoses over time [ 1 , 2 , 3 ]. While ED diagnoses are useful for describing and managing a patient’s current condition, frequent diagnostic transitions could limit their validity and utility in clinical and research settings. Reported rates of transition between ED diagnoses vary widely across studies, ranging from 0 to 70.8% [ 4 , 5 ]. The reasons for this high variability are still unclear. Inclusion of patients with different clinical and socio-demographic characteristics and from different settings (e.g., in-patients or out-patients services) could contribute to the variance. Another factor could be the inclusion of patients with anorexia nervosa (AN) without a sub-sample analysis of patients with restrictive-type anorexia nervosa (AN-R) and binge–purge subtype anorexia nervosa (AN-BP), potentially leading to inaccurate estimates. The changing of diagnostic criteria over time (e.g., amenorrhea criterion for AN was removed in DSM-5) might also be a confounding factor. All things considered, existing literature is heterogeneous and does not allow for clear-cut conclusions to be drawn on the subject of diagnostic transition in EDs. Although some research has been conducted, this subject still needs further investigation.

The transition from AN-R to cases involving binging and purging behaviors (BPB) offers an interesting perspective on the subject of diagnostic transition in ED. This specific transition has been shown to entail a worse clinical picture with a longer duration of illness and worse outcomes [ 6 , 7 , 8 ]. In line with this, when compared to AN-R, cases involving BPB are associated with a higher prevalence of past traumatic experience [ 9 ], comorbid mental disorders [ 10 , 11 ], maladaptive personality traits [ 12 ], suicidality [ 10 ], as well as higher levels of somatic and dissociative symptoms (i.e., an interruption in consciousness, identity, environmental awareness, or memory—which is normally well integrated in a healthy person) [ 1 , 13 ]. From a purely behavioral point of view, AN-R is characterized by a focus on weight loss (accomplished primarily through dieting, fasting and/or excessive exercise) while AN-BP, bulimia nervosa (BN) and binge–eating disorder (BED) are characterized by recurrent episodes of binging (eating large amounts of food in relatively short time while experiencing a sense of loss of control). Furthermore, in AN-BP and BN, binging behaviors are usually followed by a variety of harmful behaviors aimed at regaining control of weight such as vomiting, the use of laxatives and diuretics or excessive physical activity (purging behaviors) [ 1 ]. Interestingly, although the behavioral difference is pronounced, no significant differences were found when objectively measuring behavioral impulsivity in patients with different ED diagnoses [ 14 ]. Furthermore, some studies focused specifically on patients with AN-R transitioning to BPB (e.g., [ 8 ]) and it has been reported that 36% of patients with AN-R develop BN over time [ 15 ].

Relevantly, risk factors for transitioning between EDs have been highlighted. Physiological and environmental factors, such as higher premorbid body mass index (BMI) [ 4 ] and conflictual family environment [ 15 ], as well as depression, substance abuse, panic disorder and obsessive–compulsive disorder [ 2 , 3 ], have been associated with transitions between ED diagnoses. However, scarcity and heterogeneity of available evidence might prevent this clinically notable information from reaching mental health professionals. Accessibility to an organic source of knowledge on these data could be of clinical relevance, especially in the management of first onsets and younger patients.

This systematic review and meta-analyses aims to compare contents and provide clearer figures of available data on the transition from AN-R to BPB. It also aims to provide a unified, structured source of information on risk factors for this specific transition. This could hopefully foster further studies on the topic of diagnostic transition in EDs and ultimately push toward effective prevention strategies and specific early interventions for avoiding chronicization in the treatment of AN-R. In pursuit of its aims, this review tried to answer the following research questions: “what is the number of patients with AN-R who undergo an onset of BPB?” and “is it possible to predict which patients are at high risk for a transition from AN-R to BPB?”.

Materials and methods

Data sources.

We developed our review and meta-analysis according to the PRISMA statement [ 16 ]. The primary search strategy involved exploring databases (Medline, PsycINFO) through December 2020, to identify relevant, peer-reviewed, articles in English on long-term outcomes of patients with AN-R. The final search syntax was the following: (anorexia nervosa) AND ((follow-up study) or (course) or (predictors) or (evolution) or (crossover) or (transition) or (prediction)) AND ((bulimia) or (vomiting) or (binging) or (purging)). A filter for English language was applied. Gray literature was searched using multiple resources such as Scopus and reference tracing.

Eligibility criteria

Selection of the evidence was structured in three progressively more selective phases:

Phase 1—Title screening including only studies on the long-term outcome of patients who received the diagnosis of AN at admission.

Phase 2—Abstract screening applied all criteria of phase 1 and, in addition, only included studies on patients with a specific diagnose of AN-R.

Phase 3—Full-text screening applied all criteria of phase 2 and included only studies reporting data on the transition from AN-R to BPB that used validated diagnostic instruments.

Two authors (Serra & Di Nicolantonio) independently reviewed titles and abstracts of retrieved references. Then, the same two researchers independently reviewed the full-text versions of the articles to confirm their eligibility for inclusion. The age of participants, study setting, design and sample size were not criteria for exclusion. All disagreements were resolved in a consensus meeting with the team. Each included study was assessed using the Newcastle Ottawa Scale, an instrument developed to assess the quality of non-randomized studies on three broad perspectives: the selection of the study groups; the comparability of the groups; and the ascertainment of either the exposure or outcome of interest for case–control or cohort studies, respectively [ 17 ].

Data extraction

Two authors (Serra & Di Nicolantonio) independently extracted data from each of the included references: authors’ names , year of publication , sample size , drop-out rate , diagnostic criteria , mean BMI , rates of BPB onset , outcome criteria , therapeutic regimen (in-/out-patients/other), assessment tools , risk factors , mean age , mean age at onset and duration of illness , duration of follow-up , year and country of the study. Primary outcome was the rate of onset of BPB during follow-up for a AN-R diagnosis (i.e., the proportion of participants that engaged in BPB at some point during follow-up).

Statistical analysis

Analyses were performed using the “metaprop” command of STATA 16. We calculated pooled incidence of BPB onset with its 95% confidence interval (CI) using a random effects meta-analytic model. We also quantified heterogeneity using the I-squared measure.

A total of 1975 records were identified through database search, with 1722 remaining after duplicate removal. The screening of titles and abstracts led to 23 studies. The full-text evaluation led to the exclusion of 11 studies (Fig.  1 ). Reasons for non-inclusion in the review were diagnostic instruments not fitting inclusion criteria ( n  = 1), report from the same sample of another included study ( n  = 3), sample not fitting inclusion criteria ( n  = 6) and sample and outcome not fitting inclusion criteria ( n  = 1). The twelve studies included accounted for a total of 725 patients with a baseline diagnosis of AN-R. Table 1 summarizes results and characteristics of the included studies. All but three of the retrospective studies had a prospective design, [ 15 , 18 , 19 ]. The mean study sample size consisted of 60.41 patients (SD = 24.25) with only three studies having a sample size lower than 50 [ 4 , 20 , 21 ] and only one with less than 30 [ 22 ]. All patients were women and the mean age at baseline was 22.02 years (SD = 5.08). Reports were gathered from many different areas of the globe, improving generalizability of the findings: a total of five studies recruited patients from the USA [ 8 , 10 , 15 , 20 , 22 ], three from Italy [ 2 , 11 , 18 ], while the remaining four studies were respectively from Germany [ 21 ], Japan [ 19 ], Sweden [ 4 ] and the UK [ 23 ]. Only two studies enrolled adolescents [ 4 , 8 ]. As shown in Table 1 , six studies used DSM-IV diagnostic criteria [ 10 , 11 , 15 , 18 , 19 , 21 ], three studies used DSM-III [ 8 , 20 , 22 ], one study used both DSM-III and DSM-IV [ 4 ], and one used ICD-10 [ 23 ]. Three studies enrolled in-patients [ 8 , 20 , 21 ], three enrolled out-patients [ 2 , 11 , 19 ] and two studies enrolled patients from mixed settings [ 4 , 23 ]. Four studies did not report the specific setting of recruitment [ 10 , 15 , 18 , 22 ]. Outcome criteria used were the onset of BN [ 15 , 18 , 22 ], the onset of BPB with a specified frequency [ 10 , 11 , 23 ], the onset of BPB with no frequency cut-off [ 2 , 4 , 20 ], the onset of any BPB disorder [ 19 , 21 ], and the onset of objective binge-eating only (defined as having eaten more than other people would consider normal, as opposed to the subjective sensation of having eaten excessively) [ 8 ]. The mean age at onset of the AN-R was assessed in eight studies and was 17.44 years (SD = 2.52); mean duration of illness was 5.12 years (SD = 3.59). Average baseline BMI was 16.63 kg/m 2 (SD = 2.59). The follow-up duration of studies was long with an average of 9.05 years (SD = 6.59), ranging from a minimum of one up to 20 years. In two studies, patients died during follow-up [ 10 , 20 ], with a mean mortality rate of 2.5%. The NOS evaluation revealed good quality level and the absence of substantial source of bias in the selected studies (data available upon request).

figure 1

Flowchart of the screening and selection of literature included in qualitative and quantitative analysis

The pooled rate of AN-R patients who underwent an onset of BPB was 41.84% (95%CI 33.58–50.11). The pooled remission rate was 41.91% (95%CI 15.96–67.85; I 2  = 97.23%).

A total of seven of the studies identified risk factors for the onset of BPB in AN-R (Table 1 ) [ 2 , 4 , 8 , 11 , 15 , 18 , 19 ]. Two studies presented results from bi-variate models [ 18 , 19 ]. All other studies reported results from multivariate models and are presented in Table 2 , according to their potential treatability (modifiable/unmodifiable).

This is the first systematic review and meta-analysis of available evidence on the onset of BPB in AN-R patients. The review also includes a synopsis and categorization of reported risk factors for the onset of BPB. The onset of BPB in AN-R is consistently reported across studies, with a pooled 41.84% of the patients undergoing this transition at some point during follow-up. The pooled remission rate of 41.91% suggests that the vast majority of non-remitting patients will eventually undergo a transition to BPB. It is hard to define a specific, single psychopathological phenomenon underlying cross-over in eating disorders. Many factors are surely involved and, as for the onset of BPB in AN-R patients some of these factors were highlighted in seven of the included studies (Table 1 ).

Compared to patients with stable AN-R, undergoing an onset of BPB was consistently related to a higher premorbid BMI in well-designed bivariate and multivariate models [ 2 , 4 , 15 , 18 ]. Although further research is needed to explain this finding, researchers have hypothesized that a higher premorbid BMI could be the sign of a greater pre-existing appetitive drive or a weaker appetitive inhibition potentially facilitating the onset of binging and/or purging (the latter with the aim of weight control) while on a restrictive diet [ 4 ]. This hypothesis is also in line with genetic studies showing how obesity-related genes such as the chromosomal region 10p and the preproghrelin gene single nucleotide polymorphisms are recognized susceptibility factors for the development of bulimia [ 24 , 25 ]. Higher premorbid BMI could also be related to higher levels of body dissatisfaction, which was also correlated to higher risk of BPB onset in AN-R [ 11 ].

Another strong finding across multivariate models is the association between onset of BPB and various aspect of familial relations such as patients’ hostile attitude towards their family, high parental criticism and lack of parental expressed empathy/affection towards the patient [ 8 , 15 , 19 ]. It is important to notice how many studies in the field have shown an association between BPB and the presence of a history of trauma [ 9 , 15 , 26 ] and that, while psychological trauma is associated to diagnostic instability and BPB [ 27 , 28 ], it is not associated to AN-R [ 29 ]. In line with clinical theories such as the theory of “escape from self-awareness” [ 30 ] or the theory of “complex relational trauma” [ 31 ], given the available evidence, it is possible to state that a tense and conflictual family environment implies a higher risk of BPB onset in AN-R. Interesting in this regard, is the emerging evidence of the role of emotional dysregulation and depression in the relation between past traumatic experiences and EDs [ 32 , 33 ]. More specifically, emotional dysregulation and depression seem to have a mediating effect-linking trauma and emotional overeating, which is commonly reported by patients with eating disorders involving BPB [ 33 , 34 ]. This is in line with the presented evidence on unipolar depression, which showed a strong prospective association with the onset of BPB [ 2 ]. Further research is needed to understand whether there is a causal relation between unipolar mood disorders and the onset of BPB in AN-R. The presence of unipolar depression could, in fact, be a sign of severity or have a unique role in the onset of BPB in patients with AN-R.

One last factor to keep in mind when studying this phenomenon is starvation itself. In fact, re-nourishing after prolonged food deprivation is associated with binging, food hoarding, depressive mood and other impulsive behaviors, leading to the hypothesis of a causal link between starvation and the development of BPB [ 35 , 36 ]. As highlighted in the milestone Minnesota semi-starvation experiment and later confirmed in non-experimental conditions, binging and purging behaviors can also emerge during nutritional rehabilitation of individuals constrained to protracted dietary restriction [ 37 , 38 , 39 ].

Overall, highlighted predictors for the onset of BPB in AN-R seem to point at a biopsychosocial model involving psychological, familial and metabolic factors. In line with this, we hypothesize that no single cause can lead to such a complex transformation, rather a concausal chain pushing against the single patient’s will and psychological resources.

Limitations and future research directions

Present results should be interpreted in consideration of several limitations. First, some characteristics limit the generalizability of available data: three studies had a sample size lower than n  = 50 [ 20 , 21 , 22 ]; reports only considered women; and ten of the studies included patients regardless of current age and age of onset in spite of the early onset of AN. Second, the specificity of our research question led to the inclusion of a low number of studies, potentially limiting the generalizability of our findings. However, we believe that the focus on AN-R rather than a general group of patients with AN increases the strength of our findings. The proportion of AN-R patients undergoing an onset of BPB in any given study is related to the specific definition of “transition” and its measurement in a given study, limiting the availability of data fit for a meta-analysis. However, results showed a narrow 95% CI proving adequate homogeneity of included studies. Nevertheless, although the selection was strict it is possible that the samples include non-homogeneous clinical presentations, diagnosable as AN-R, of which slight differences are understandably not reported. Future studies in this field should apply more reliable criteria for the definition of BPB onset. In our opinion, despite seemingly different criteria used to assess the transition to BPB, the onset of any impulsive behavior (i.e., isolated binging, diagnosis of AN-BP, any BPB with a low frequency or others) is the lowest common denominator of a dramatic change in the clinical course of AN-R. Risk factors identified in included studies should be considered in future research examining predictors, mediators and moderators of the onset of BPB in AN-R patients. Given the ego-dystonic nature of binging behaviors, it is possible that sharing with patients the information that fasting may lead to BPB could increase motivation and adherence to nutritional rehabilitation and therapeutic plans. Future research could test this hypothesis to help clinicians in the management of this critical aspect of AN-R therapy.

Conclusions

Almost half of the patients with a diagnosis of AN-R will eventually undergo an onset of BPB, marking an evolution of their clinical condition with longer duration of illness and reduction of their possibility for a sustained recovery [ 7 , 8 , 40 ]. As highlighted in a recent study [ 41 ], general practitioners, nutritionists and mental health professionals have a key role in rapidly directing patients to specialist care settings to provide appropriate care. This is critical in the prevention of the permanent risks associated with starvation, the onset of BPB and the general worse outcomes related to a late diagnosis [ 6 , 42 , 43 ]. Confirmed risk factor for the onset of BPB should be systematically assessed by clinicians in patients AN-R and specific treatments (such as family therapy) should be considered in patients at high risk for the onset of BPB, especially in the evaluation and treatment of first onsets. This could lead to more prompt interventions for preventing chronicization and the evolution of the clinical picture.

What is already known on this subject?

Rates of diagnostic transition in ED vary widely across studies, ranging from 0 to 70.8%. Heterogeneity of existing research makes it hard to interpretate available data. The specific transition from restrictive-type anorexia nervosa to disorders involving binging and purging behaviors has been related to a worse long-term prognosis. Over the years, some risk factors for this transition have been identified.

What this study adds?

This study focuses on the literature from a neglected area of research, suggesting that the transition from restrictive-type anorexia nervosa to disorders involving binging and purging behaviors is common. Results are consistent across country of origin, decade when the study was performed, design of the study and clinical/nonclinical settings. Some established risk factors for the transition could be targeted in therapy.

Data availability

A database containing data from the different phases of the selection of articles was shared during the submission process (as additional material was not for review). The database will be shared upon request.

Code availability

Code will be shared upon request.

Change history

02 july 2021.

A Correction to this paper has been published: https://doi.org/10.1007/s40519-021-01244-y

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Serra, R., Di Nicolantonio, C., Di Febo, R. et al. The transition from restrictive anorexia nervosa to binging and purging: a systematic review and meta-analysis. Eat Weight Disord 27 , 857–865 (2022). https://doi.org/10.1007/s40519-021-01226-0

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Comparing Bulimia and Anorexia Psychopathology

This article provides a comprehensive examination of the psychopathology associated with Bulimia Nervosa and Anorexia Nervosa within the framework of health psychology . The introduction contextualizes the prevalence and significance of eating disorders, emphasizing the necessity of understanding the psychopathological nuances of both Bulimia and Anorexia. The body of the article consists of three main sections: an individual overview of each disorder, a comparative analysis of their shared and distinguishing features, and a discussion of treatment approaches. The third section delves into therapeutic modalities, challenges in treatment, and the implications of psychological and physical health. The conclusion summarizes key findings, underscores implications for research and clinical practice, and advocates for enhanced prevention and education strategies. This article contributes to the field by offering a detailed exploration of the psychological underpinnings of Bulimia and Anorexia, thereby facilitating a deeper understanding of these complex disorders for both researchers and practitioners in the realm of health psychology.

Introduction

Eating disorders constitute a category of mental health conditions characterized by persistent disturbances in eating patterns, body weight, and shape perception. The most prevalent among these are Bulimia Nervosa and Anorexia Nervosa, each presenting distinctive psychopathological features. While Bulimia involves episodes of excessive food consumption followed by compensatory behaviors, Anorexia is marked by severe restrictions in food intake, leading to significant weight loss. Understanding the psychopathology of these disorders is essential for clinicians, researchers, and policymakers, given the rising global prevalence of eating disorders and their profound impact on individuals’ physical and mental well-being.

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Delving into the intricacies of Bulimia and Anorexia psychopathology is of paramount importance due to the severe health consequences and societal implications associated with these disorders. Individuals grappling with these conditions often experience profound emotional distress, impaired social functioning, and physical health complications. Moreover, the societal burden extends to healthcare systems and economies. A nuanced understanding of the psychopathological aspects of Bulimia and Anorexia is imperative for developing effective prevention strategies, informing targeted interventions, and promoting public awareness to mitigate the pervasive impact of these disorders.

The primary purpose of this article is to provide a comprehensive examination of the psychopathology inherent in Bulimia Nervosa and Anorexia Nervosa within the domain of health psychology. By exploring the unique features and shared characteristics of these disorders, the article aims to contribute to the existing body of knowledge, offering insights that can inform clinical practices, therapeutic approaches, and public health initiatives. Additionally, the article seeks to underscore the significance of continued research and education in advancing our understanding of these complex conditions and enhancing the overall mental health landscape.

This article contends that a meticulous exploration of the psychopathology inherent in Bulimia Nervosa and Anorexia Nervosa is crucial for elucidating the complexities of these eating disorders. By examining their shared and distinguishing features, this article aims to contribute to a comprehensive understanding of the psychological underpinnings of Bulimia and Anorexia, providing valuable insights for clinicians, researchers, and policymakers alike. Through this exploration, the article endeavors to underscore the necessity of informed intervention strategies, preventive measures, and public health initiatives to address the multifaceted challenges posed by these debilitating conditions.

Overview of Bulimia Nervosa

Bulimia Nervosa is a complex eating disorder characterized by recurrent episodes of binge eating, which involves consuming an excessive amount of food within a discrete period, accompanied by a perceived lack of control. These episodes are followed by inappropriate compensatory behaviors, such as self-induced vomiting, misuse of laxatives, fasting, or excessive exercise, to prevent weight gain. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the diagnostic criteria for Bulimia Nervosa include the occurrence of binge-eating and compensatory behaviors at least once a week for three months, along with an undue emphasis on body shape and weight in self-evaluation.

Bulimia Nervosa affects individuals across diverse demographic groups, with prevalence rates varying globally. Research indicates a higher incidence among females, but a significant number of males also experience this disorder. The onset of Bulimia typically occurs in late adolescence or early adulthood. Societal factors, such as cultural emphasis on thinness and body image ideals, contribute to the development of Bulimia. The prevalence of this disorder is influenced by factors such as socioeconomic status, ethnicity, and urbanization.

The psychopathology of Bulimia Nervosa encompasses a range of cognitive, emotional, and behavioral features. Individuals with Bulimia often exhibit intense concern about body shape and weight, coupled with a distorted body image. This preoccupation can lead to repeated cycles of binge eating and purging, perpetuating a sense of guilt, shame, and distress. The disorder is associated with impulsivity, low self-esteem, and mood fluctuations. The secrecy surrounding binge episodes and compensatory behaviors further complicates the psychopathological profile. Additionally, individuals with Bulimia may experience comorbidities, such as depression, anxiety disorders, and substance abuse, emphasizing the need for a holistic understanding of the disorder’s psychopathology.

Overview of Anorexia Nervosa

Anorexia Nervosa is a severe eating disorder characterized by an intense fear of gaining weight and a distorted body image that leads to self-imposed starvation and excessive weight loss. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), outlines specific diagnostic criteria, including restriction of energy intake relative to requirements, an intense fear of gaining weight, and a persistent lack of recognition of the seriousness of low body weight. Individuals with Anorexia often have a distorted perception of their own body size and shape, viewing themselves as overweight even when underweight.

Anorexia Nervosa is prevalent across various demographic groups, though it is most commonly diagnosed in females during adolescence and young adulthood. The disorder can also affect males, with an increasing recognition of its occurrence in diverse gender identities. The prevalence of Anorexia varies globally, and cultural factors play a significant role in its manifestation. Societal pressures, such as the idealization of thinness, contribute to the development of Anorexia. It is noteworthy that Anorexia has one of the highest mortality rates among psychiatric disorders, emphasizing the severity of its impact on physical health.

The psychopathology of Anorexia Nervosa is characterized by a complex interplay of cognitive, emotional, and behavioral factors. Individuals with Anorexia often exhibit an obsessive preoccupation with food, weight, and body image, leading to strict dietary restrictions and rituals surrounding eating. The fear of gaining weight may be so pronounced that it results in self-imposed starvation, extreme dietary measures, and excessive exercise. The psychopathology also includes an impaired ability to recognize the severity of low body weight, contributing to the maintenance of the disorder. Individuals with Anorexia may experience cognitive distortions related to body image, perfectionism, and a persistent drive for thinness, further complicating the psychopathological profile. Comorbidities such as depression, anxiety, and obsessive-compulsive traits are common, underscoring the need for a comprehensive understanding of Anorexia’s psychopathology.

Comparative Analysis of Bulimia and Anorexia Psychopathology

Both Bulimia Nervosa and Anorexia Nervosa share a fundamental characteristic: a distorted body image. Individuals afflicted by either disorder often perceive themselves as overweight despite evidence to the contrary. This distorted self-perception becomes a driving force behind disordered eating behaviors and contributes to the maintenance of the psychopathology inherent in both conditions.

A profound fear of gaining weight is another shared feature between Bulimia and Anorexia. Individuals with both disorders exhibit an intense preoccupation with body weight and shape, and this fear becomes a central focus in their daily lives. The fear of weight gain acts as a powerful motivator for various disordered eating behaviors, influencing both the onset and perpetuation of these conditions.

The psychopathology of both Bulimia and Anorexia significantly impacts cognitive functioning. Cognitive distortions related to body image, self-worth, and control over eating are common in individuals with both disorders. These distortions contribute to maladaptive thinking patterns, reinforcing disordered behaviors and perpetuating the cycle of the eating disorder.

While both disorders involve disordered eating, the specific patterns and behaviors differ. Bulimia is characterized by recurrent episodes of binge eating followed by compensatory behaviors, such as vomiting or excessive exercise. Anorexia, on the other hand, involves severe dietary restriction leading to self-imposed starvation. Distinguishing the specific eating patterns is crucial for accurate diagnosis and tailored treatment.

The physical consequences of Bulimia and Anorexia vary due to differences in their respective eating behaviors. Bulimia’s frequent purging behaviors can result in electrolyte imbalances, gastrointestinal issues, and dental problems. In Anorexia, severe malnutrition and weight loss can lead to a range of physical complications, including cardiovascular issues, osteoporosis, and hormonal imbalances.

Although both disorders are associated with comorbidities, the nature of these additional mental health challenges differs. Individuals with Bulimia may commonly experience comorbidities such as depression, anxiety, and substance abuse. In Anorexia, comorbidities may include obsessive-compulsive traits, depression, and heightened levels of anxiety.

Cultural factors play a significant role in the development and manifestation of both Bulimia and Anorexia. Societal ideals regarding body image, beauty standards, and thinness contribute to the onset of these disorders. Cultural influences shape individuals’ perceptions of an ideal body, impacting their attitudes toward food, weight, and appearance.

Familial and environmental factors contribute to the development of both disorders, albeit in unique ways. Family dynamics, interpersonal relationships, and environmental stressors can influence the onset and maintenance of Bulimia and Anorexia. Understanding these factors is crucial for developing effective interventions that address the multifaceted nature of eating disorders.

The role of psychological trauma in the etiology of eating disorders is significant. Both Bulimia and Anorexia may be associated with past traumatic experiences, such as abuse, neglect, or other adverse events. Exploring the impact of psychological trauma is essential in understanding the complexity of the psychopathology inherent in these disorders and tailoring therapeutic approaches accordingly.

Treatment Approaches for Bulimia and Anorexia

Cognitive-Behavioral Therapy (CBT) stands as a cornerstone in the treatment of both Bulimia Nervosa and Anorexia Nervosa. CBT aims to identify and modify dysfunctional thought patterns and behaviors associated with disordered eating. In the context of Bulimia, CBT addresses the cycles of binge eating and purging, focusing on breaking these patterns and fostering healthier coping mechanisms. For Anorexia, CBT targets distorted cognitions related to body image, perfectionism, and fear of weight gain, encouraging individuals to challenge and modify maladaptive thoughts. The structured and goal-oriented nature of CBT makes it an effective intervention for altering the psychopathology inherent in these disorders.

Particularly effective in the treatment of adolescents and young adults, Family-Based Therapy (FBT) recognizes the role of the family in the development and resolution of eating disorders. FBT involves active family participation in the treatment process, with a focus on restoring normal eating patterns and addressing familial dynamics that may contribute to the maintenance of the disorder. In the case of Anorexia, FBT often involves parents taking a central role in overseeing the individual’s eating and weight restoration. For Bulimia, FBT may include family involvement in addressing underlying psychological factors contributing to binge eating and purging.

Pharmacotherapy plays a supplementary role in the treatment of Bulimia and Anorexia. While medications are not standalone solutions, they can assist in managing specific symptoms and comorbidities. For Bulimia, selective serotonin reuptake inhibitors (SSRIs) have shown efficacy in reducing binge-eating episodes and improving mood. In Anorexia, medications may be prescribed to address comorbid conditions such as depression or anxiety. However, the use of medication should be carefully monitored, and its effectiveness is often enhanced when integrated with psychotherapeutic interventions.

Resistance to treatment is a common challenge in the management of Bulimia and Anorexia. Individuals may resist therapeutic interventions due to the strong attachment to disordered eating behaviors, fear of weight gain, or underlying psychological factors. Overcoming this resistance requires a collaborative and empathetic approach, emphasizing the importance of building trust between the individual and treatment providers. Tailoring interventions to the individual’s specific needs and addressing the root causes of resistance are essential components of successful treatment.

Preventing relapse is a crucial aspect of the long-term management of eating disorders. Individuals recovering from Bulimia or Anorexia may face triggers and stressors that can lead to a recurrence of disordered behaviors. Comprehensive relapse prevention strategies involve ongoing psychoeducation, the development of coping skills, and addressing underlying psychological factors that may contribute to relapse. Regular follow-up and support from mental health professionals, as well as the involvement of family and support networks, play pivotal roles in maintaining recovery and preventing relapse.

Individuals with Bulimia and Anorexia often experience co-occurring mental health disorders, such as depression, anxiety, or substance abuse. Treating these comorbidities concurrently with the eating disorder is essential for comprehensive care. Integrated treatment approaches that address both the eating disorder and co-occurring conditions are crucial for achieving sustained recovery. Coordination among different healthcare providers, including mental health professionals and medical practitioners, is necessary to ensure a holistic approach that considers the complex interplay of psychopathological factors.

Psychological and Physical Health Implications

The psychological impact of Bulimia and Anorexia extends to profound effects on emotional well-being. Individuals grappling with these eating disorders often experience heightened levels of anxiety, depression, guilt, and shame. The cyclical nature of disordered eating behaviors, such as binge eating, purging, or self-imposed starvation, contributes to emotional turbulence. The persistent preoccupation with body image and weight, coupled with the internalized societal expectations, exacerbates negative emotions, leading to a profound toll on overall emotional well-being.

Both Bulimia and Anorexia exert significant cognitive consequences on affected individuals. Distorted thought patterns related to body image, self-worth, and control over eating behaviors are prevalent. Individuals may engage in black-and-white thinking, perfectionism, and obsessive thoughts about food and weight. Cognitive distortions contribute to the maintenance of the disorders, hindering adaptive coping strategies. The cognitive consequences underscore the need for therapeutic interventions that target maladaptive cognitions and promote healthier thought patterns.

The psychopathology of Bulimia and Anorexia can strain interpersonal relationships. Social withdrawal, secrecy surrounding disordered eating behaviors, and the emotional toll of the disorders can lead to strained relationships with family, friends, and romantic partners. The focus on food, weight, and body image may divert attention from meaningful social interactions, contributing to social isolation. Addressing the impact on interpersonal relationships is integral to the holistic treatment of eating disorders, emphasizing the need for psychoeducation and family involvement in the recovery process.

Both Bulimia and Anorexia lead to significant malnutrition, with profound implications for physical health. In Anorexia, severe caloric restriction results in emaciation and nutritional deficiencies, impacting organ function, bone health, and hormonal balance. Bulimia’s cycles of binge eating and purging contribute to nutritional imbalances, electrolyte disturbances, and the erosion of dental health. Malnutrition poses severe risks to overall well-being, affecting immune function, reproductive health, and contributing to long-term complications.

Gastrointestinal issues are prevalent in individuals with Bulimia due to the recurrent episodes of purging. Frequent vomiting can lead to esophageal damage, gastric ulcers, and electrolyte imbalances. The gastrointestinal consequences underscore the need for medical monitoring to address and prevent complications arising from purging behaviors. In Anorexia, the gastrointestinal system may also be affected, leading to issues such as constipation and gastroparesis as a result of reduced food intake.

Cardiovascular complications are common in both Bulimia and Anorexia and pose significant health risks. Anorexia’s impact on the cardiovascular system is characterized by bradycardia, low blood pressure, and a risk of heart failure. In Bulimia, electrolyte imbalances resulting from purging behaviors can lead to cardiac arrhythmias and other cardiovascular issues. The compromised cardiovascular health underscores the necessity for regular medical monitoring and intervention to mitigate the risk of life-threatening complications associated with eating disorders.

In summary, the examination of the psychopathology of Bulimia Nervosa and Anorexia Nervosa reveals a complex interplay of cognitive, emotional, and behavioral factors. Both disorders share fundamental features, such as distorted body image and a pervasive fear of weight gain, while also presenting distinguishing characteristics in terms of eating patterns, physical consequences, and comorbidities. The treatment landscape involves evidence-based modalities like Cognitive-Behavioral Therapy (CBT) and Family-Based Therapy (FBT), alongside pharmacotherapy. Despite therapeutic advancements, challenges in treatment persist, including resistance, relapse prevention, and addressing co-occurring disorders.

The exploration of Bulimia and Anorexia psychopathology highlights the ongoing need for research to deepen our understanding of these complex disorders. Further investigations into the genetic, neurobiological, and environmental factors contributing to their development can inform targeted interventions. In clinical practice, the emphasis should be on personalized and integrated approaches, considering the unique features of each individual’s psychopathology. Clinicians must remain vigilant to challenges in treatment, adapting strategies to address resistance and enhance relapse prevention. Additionally, a multidisciplinary approach, involving collaboration between mental health professionals, medical practitioners, and families, is vital for comprehensive care.

As we navigate the intricate terrain of Bulimia and Anorexia, a proactive call to action emerges for prevention and education. Public health initiatives must target the societal factors influencing body image ideals, fostering a culture that promotes diverse definitions of beauty and emphasizes health over unrealistic standards. Educational programs should focus on early recognition of eating disorder signs, reducing stigma, and encouraging help-seeking behaviors. Collaboration between schools, communities, and healthcare systems is crucial to create environments that support positive body image and mental health. By investing in prevention and education, we can aspire to reduce the prevalence of Bulimia and Anorexia and cultivate a society that values mental and physical well-being.

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Stigmatization toward People with Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder: A Scoping Review

Lisa brelet.

1 Pôle R&D Santé, Jeolis Solutions, 63000 Clermont-Ferrand, France

Valentin Flaudias

2 Pôle Psychiatrie B, CHU Gabriel Montpied, 63003 Clermont-Ferrand, France; rf.dnarreftnomrelc-uhc@saidualfv

3 EA 780 NPsy-Sydo, Université Clermont Auvergne, 63001 Clermont-Ferrand, France

Michel Désert

4 Laboratoire de Psychologie Sociale et Cognitive (LAPSCO), Centre National de la Recherche Scientifique (CNRS), Université Clermont Auvergne, 63003 Clermont-Ferrand, France; [email protected]

Sébastien Guillaume

5 Département des Urgences Psychiatriques, Hôpital Lapeyronie, CHRU Montpellier, 34295 Montpellier, France; rf.reilleptnom-uhc@emualliug-s

6 Institut de Génomique Fonctionnelle (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Montpellier, 34094 Montpellier, France

Pierre-Michel Llorca

7 CMP-B CHU, Clermont Auvergne INP, Institut Pascal, Centre National de la Recherche Scientifique (CNRS), Université Clermont Auvergne, 63000 Clermont-Ferrand, France; rf.dnarreftnomrelc-uhc@acrollmp

Yves Boirie

8 Centre Troubles des Conduites Alimentaires (TCA), Service de Nutrition Clinique, Unité de Nutrition Humaine, CHU Gabriel Montpied, CRNH, Université Clermont Auvergne, 63003 Clermont-Ferrand, France; rf.dnarreftnomrelc-uhc@eirioby

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Research about stigmatization in eating disorders (EDs) has highlighted stereotypes, prejudices, and discrimination against people with EDs, as well as their harmful effects on them, including self-stigma and a difficult recovery process. Whereas a recent review focused on the consequences of ED stigma, our work aimed to provide a broader synthesis of ED stigma, including its consequences, but also its content and distribution. More precisely, we focused on three EDs—namely, anorexia nervosa, bulimia nervosa, and binge eating disorder. Based on a systematic search of four major databases in psychology, the present scoping review includes 46 studies published between 2004 and 2021. We did not conduct any quality assessment of the studies included, because our aim was to provide a wide-ranging overview of these topics instead of an appraisal of evidence answering a precise research question. The review confirmed the existence of a common ED stigma: all individuals affected by EDs reviewed here were perceived as responsible for their situation, and elicited negative emotions and social distance. However, our review also depicted a specific stigma content associated with each ED. In addition, the demographic characteristics of the stigmatizing individuals had a notable influence on the extent of ED stigma: men, young adults, and low-income individuals appeared to be the most stigmatizing toward individuals with EDs. It is important to note that ED stigma had a negative effect on individuals’ eating disorders, psychological wellbeing, and treatment-seeking behavior. There is an urgent need for further research on the adverse effects of ED stigma and its prevention.

1. Introduction

According to the American Psychiatric Association ( https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders , accessed the 29 July 2021), eating disorders (EDs) are behavioral conditions characterized by severe and persistent disturbance in eating behaviors, affecting physical, psychological, and social functions. In addition to physical and medical health considerations, researchers have recently focused on stigmatization against individuals affected by an ED [ 1 , 2 , 3 ], because of its multiple negative consequences, (e.g., increased ED symptoms, decreased treatment-seeking behaviors, etc.) [ 4 , 5 , 6 ]. More precisely, those works have also investigated the content and the distribution of ED stigma [ 7 , 8 ].

1.1. Stigma and Mental Disorders

Stigmatization of social groups is common worldwide [ 9 , 10 ]. Stigmatized individuals are treated differently, excluded, or even socially rejected because they do not meet specific societal standards (e.g., skin color, physical disability, or age) [ 11 ]. Since EDs are mental disorders, one could argue that the stigma of EDs could be addressed through the mental illness stigma [ 12 , 13 ]. The scientific literature on mental disorders suggests that stigma associated with mental illness is prevalent [ 12 , 13 ].

Social psychologists distinguish between three stigma components: a cognitive, an emotional, and a behavioral component. To be more precise, stereotypes constitute the cognitive component of stigma. They are either positive or negative beliefs shared by individuals about social group members (e.g., believing that all online gamers are socially incompetent, lazy, and unattractive) [ 14 ]. Prejudice is the emotional component of stigma, comprising unfavorable attitudes (e.g., anger, fear, disgust, pity) toward someone because of their social group membership [ 15 ]. Finally, discrimination refers to the behavioral component of stigma. Discrimination is traditionally defined as negative behaviors directed toward individuals because they belong to a specific social group. Such actions serve to disadvantage people in many contexts [ 16 , 17 ]. The general term stigma typically indicates that at least one of these components is present.

Regarding mental illnesses, studies have highlighted the presence of stereotypes, prejudices, and discrimination against people with these disorders. For example, individuals with mental disorders are stereotyped as dangerous, childish, incompetent, weak, and responsible for their condition [ 18 ]. Concerning prejudice, Angermeyer and Dietrich [ 12 ] observed prosocial reactions toward people with mental disorders (e.g., feeling sorry for them, expressing the desire to help), but also discomfort, feelings of uncertainty, and fear reactions. In the same way, Corrigan and Watson [ 19 ] found that individuals with mental disorders were less appreciated than individuals with physical illnesses. Hipes et al. [ 20 ] highlighted discriminatory behaviors showing that fictitious job applicants described as fully recovered from a mental health condition received fewer call-backs than fictitious candidates who had recovered from a physical injury.

As shown above, people with mental illness—and, thus, people with EDs—can be stigmatized by others, with detrimental consequences to them [ 18 ]. Additionally, the experience of stigma can lead people with mental disorders to self-stigmatize; many consider themselves weak and incompetent, experience low self-efficacy and low self-esteem, and do not pursue work or other independent-living goals [ 19 ]. Moreover, those who had the most stigmatizing experiences were also the most reluctant to seek professional support, and had the poorest treatment adherence. This reluctance to seek help appeared to be more prominent among men, seniors, African Americans, and Hispanics than women, young people, and Caucasians experiencing mental disorders [ 18 ].

While these previous studies highlight a general stigma against all mental illnesses, there are also differences and specificities depending on the mental illness involved. For instance, unpredictability and dangerousness were traits explicitly associated with individuals affected by schizophrenia or alcoholism [ 12 , 13 ]. Avoiding personal contact with individuals with a mental disorder was also more often observed in schizophrenia, alcoholism, or drug addiction, compared to depression or anxiety disorders [ 12 ]. In addition, there is interindividual variability in the prevalence of mental illness stigma and, more specifically, in the occurrence of prejudice. For example, Angermeyer and Dietrich [ 12 ] found that age, education level, and familiarity with mental disorders played a role in the extent of mental illness stigma. Therefore, although EDs are mental illnesses, it seems important to specifically address ED stigma—namely, its content, distribution (i.e., prevalence in different social groups), and consequences.

1.2. Stigma and Eating Disorders

Eating disorders are recognized as stigmatized mental disorders [ 12 , 13 ]. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5 ) [ 21 ] defines three specific EDs—namely, anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Two additional categories of ED are also included in the DSM-5 : other specified feeding and eating disorders (OSFED, e.g., atypical anorexia; night eating syndrome, etc.), and avoidant restrictive food intake disorder (ARFID). However, we have chosen to focus on AN, BN, and BED as the main EDs investigated in the literature [ 4 , 22 , 23 , 24 ].

Regarding ED stigma, Crisp et al. [ 13 ] examined perceptions of various mental disorders, including EDs (with no distinction between AN, BN, and BED). They observed that more than a third of respondents blamed people with EDs for their situation, thought that people with EDs would be able to pull themselves together if they wanted to, and found communication with them challenging. Nevertheless, the study demonstrated that stigmatizing attitudes toward people with EDs were less common than toward people with schizophrenia, alcoholism, and drug addiction. Negative beliefs shared by the general public engendered negative emotions (anger and fear) toward people with EDs and avoidant behaviors (e.g., withholding assistance with work or housing opportunities) [ 18 ]. Since then, some experimental studies have specifically investigated the content of ED stigma, showing the existence of negative beliefs, e.g., responsible for their condition [ 25 , 26 ], negative attitudes [ 27 , 28 , 29 ], and social distance toward people with EDs [ 25 , 30 , 31 , 32 ].

Other work has focused on the distribution of ED stigma. It was found that men are the most stigmatizing toward people with EDs [ 26 , 33 ]. Importantly, Thompson-Brenner et al. [ 34 ] found that clinicians themselves also expressed negative beliefs (e.g., holding people with EDs responsible for their condition) and negative emotions (e.g., frustration, anger) toward people with EDs. The extent of ED stigma in clinical staff was also linked to individual characteristics, such as their clinical discipline, professional experience with EDs, and gender. More precisely, inexperienced clinicians, nurses compared to physicians, and men compared to women were more likely to show adverse and stigmatizing reactions to people with EDs.

Concerning the consequences of ED stigma, Foran et al. [ 4 ] conducted a recent systematic review of nine studies and found that ED stigma predicts negative outcomes for people with EDs on multiple levels: psychological, social, physical, and health behaviors. Indeed, the review indicated that ED stigma can lead to depressive and self-esteem symptoms, social alienation and social withdrawal, poor physical health, and greater ED symptoms, but also greater avoidance of treatment-seeking behaviors, increasing the physical (e.g., cardiac issues), psychological (e.g., distress), and social (e.g., poorer quality of life) complications associated with EDs [ 35 , 36 ] Consequently, by highlighting these negative consequences of ED stigma, this review and related works shed light on the importance of studying ED stigma to better understand and act on it.

Finally, one could expect that individuals with EDs would also be affected by weight-related stigma, which refers to any situation where a person feels treated differently, rejected, or excluded because their weight differs from cultural norms [ 37 , 38 , 39 , 40 ]. Indeed, people with a visible stigma (e.g., obesity) are more likely to be discredited than those with a non-visible stigma [ 11 ]. However, EDs do not necessarily involve physical changes; thus, ED stigma and weight stigma are only partially correlated [ 22 , 41 ]. Consequently, the present scoping review focuses specifically on ED stigma, but not weight stigma.

Empirical studies and reviews have demonstrated variation in the content and consequences of stigma associated with different mental disorders. One criticism is that most of this work has concentrated on psychotic or mood disorders such as schizophrenia or depression, while EDs have been relatively overlooked. The scarce research that has recently focused on ED stigma typically either examined just one ED (e.g., AN) [ 27 , 28 ]; did not necessarily distinguish between AN, BN, and BED; or addressed only a single aspect of ED stigma: either its content, its stigmatizing sources, or its consequences [ 4 , 7 , 42 ]. For example, the recent systematic review conducted by Foran et al. [ 4 ] only investigated the consequences of ED stigma.

Focusing on the consequences of ED stigma is crucial because of its severe impact on people with EDs (e.g., depressive symptoms, increased ED symptoms, decreased treatment-seeking behaviors). Nevertheless, we thought it was important to go further in describing the content and the distribution of this stigma, as this may be useful in understanding these consequences and identifying ways to reduce them. We therefore conducted a scoping review [ 43 ] of all recent articles to provide a broader overview of ED stigma, addressing all of its dimensions—namely, its content, distribution, and consequences.

We believe that a new review on this topic will be helpful to increase healthcare professionals’ awareness and understanding of EDs in order to improve their treatments [ 36 ]. An overview of the recent literature about ED stigma can also help to identify research gaps and ways to address ED stigma.

Thus, the purpose of this scoping review was to (a) synthesize current knowledge on common and specific stigma content of AN, BN, and BED in the form of stereotypes, prejudice, and discriminatory behaviors against people with EDs; (b) identify the sociodemographic characteristics (i.e., age, gender, education, income, etc.) associated with increased stigmatization against people with EDs; and (c) summarize the impact of ED stigma on individuals with EDs in terms of self-stigma, eating disorders, psychological disorders, treatment-seeking behavior, and therapeutic compliance.

In accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Review (PRISMA-ScR) 2018 statement [ 43 ], this scoping review systematically searched for all recent studies investigating ED stigma toward people with AN, BN, or BED, including its content, distribution, and consequences.

2.1. Eligibility Criteria

Inclusion criteria: All experimental studies included were written in English and published in peer-reviewed scientific journals. We included only studies investigating AN, BN, or BED. Because ED stigma is a novel area that has only begun to be explored [ 4 , 22 ], we searched for studies published from 2000 onwards.

Regarding the content of ED stigma, we included studies that looked at the stereotyping of, prejudice against, and discriminatory behaviors toward people with AN, BN, and BED. With regard to the distribution of ED stigma, we included studies that examined the degree of stigma toward people with EDs according to participants’ social category (e.g., age, gender, income, education level, etc.). Concerning the consequences of ED stigma, we included studies that examined the physical, psychological, medical, and social impacts that ED stigma can have on people with EDs. Participants in these studies could be of any age, gender, or nationality, and could come from the general population, health professionals, or ED patients themselves. Moreover, we made no restrictions on the method used to assess ED stigma (e.g., self-administered questionnaires, structured interviews, vignette paradigm).

Exclusion criteria: We excluded literature reviews, commentaries, papers describing psychometric scale validation, academic theses, books, articles with no English language version, and any work published before 2000. Moreover, this review does not include phenomena related to but different from ED stigma, such as mental illness stigma and weight stigma. Finally, we focused only on studies dealing with stigma toward people with EDs and its impact on them. Stigma can also exist toward the family and relatives of people with mental illness [ 44 , 45 ], but this review did not address this topic.

2.2. Information Sources, Search, and Study Selection

A computerized search of the PsycINFO, PubMed, ScienceDirect, and Google Scholar databases was conducted to identify studies published on ED stigma. We successively searched in Title the different combinations of the following terms: “eating disorder” OR “disordered eating” OR “anorexia” OR “bulimia” OR “BED” OR “binge eating disorder”, AND “stigma” OR “stigmatization” OR “stereotype” OR “opinion” OR “prejudice” OR “attitude” OR “discrimination” (for example, in PsycINFO one combination was: anorexia nervosa (Title) “AND” Stereotype (Title)). No term was excluded (i.e., no use of the “NOT” option). No reference lists were consulted. Thus, no additional studies to the selected paper were added.

These data sources, searches, and study selection were carried out by one researcher (L.B.) in November 2019, with an update in May 2021.

2.3. Data Extraction

At this step, the total of included studies ( n = 46) was classified according to the type of ED concerned—AN, BN, and/or BED—and the dimension of stigma studied: content, distribution, and/or consequences. Information on study location, participants, and ED stigma measures used were extracted (see Table 1 and Appendix A ). The main results of the 46 studies included in this scoping review are reported in a narrative manner. For the content of ED stigma, the data of articles included were grouped into three sections—stereotypes, prejudice, and discrimination—that concern, respectively, the beliefs, the emotions/affect, and the behaviors toward people with EDs. Regarding the distribution of ED stigma, the results were reported in 2 sections: the social categories that are most stigmatizing toward people with EDs, and those that are least stigmatizing. We categorized people/groups as “the most” and “the least” stigmatizing according to the authors of studies included in our review. These categories include gender, age, socioeconomic status (e.g., education and income levels), weight, and ethnicity, but also people who are familiar/unfamiliar with EDs, people who are informed/uninformed about EDs, and people who believe/do not believe in a “just world”. Individuals familiar with EDs are defined as people who have experienced or are currently experiencing an ED, or they may have an acquaintance (e.g., relative, friend, patient) with an ED or a history of ED [ 26 , 46 ]. People who are informed about EDs are individuals who have knowledge about the disease, its symptoms, and/or its treatments without necessarily being familiar with it [ 47 ]. People who believe in a just world represent individuals who think that we get what we deserve, and we deserve what we get [ 48 ]. Studying the disparities in ED stigma among these groups would be helpful to determine which populations require anti-stigma intervention, and to guide the content of these programs (e.g., increasing knowledge, decreasing belief in a just world, etc.). Finally, concerning the consequences of ED stigma, articles that examined similar outcomes related to ED stigma experiences and recovery were grouped into 3 sections: the patients’ stigma perception, self-stigma, and the impact on ED symptoms and severity.

Summary of studies included in the scoping review.

Note: EDs: eating disorders; AN: anorexia nervosa; BN: bulimia nervosa; BED: binge eating disorder.

2.4. Risk of Bias

As mentioned earlier, our study selection was not strictly limited to a specific assessment method of ED stigma. Moreover, we did not conduct a quality assessment to critically appraise the quality of evidence provided by the primary studies. Therefore, the studies included in our review might suffer from some heterogeneity regarding their methodological design and their respective quality.

3.1. Characteristics of Included Studies

In total, the search produced 570 articles published between 2000 and 2021. Of these, 143 occurred in more than one database; thus, 377 studies remained after duplicates were manually removed. Of the remaining articles, 228 were removed for improper topics (mainly assessment of participants’ attitudes to eating disorders and assessment of eating disorders in response to weight stigma). After screening the remaining 149 abstracts, a further 94 articles were excluded based on the inclusion/exclusion criteria mentioned above. Most were excluded for improper topics, e.g., studies on weight stigma, the relationship between EDs and body shape concerns, the effectiveness of anti-stigma interventions, ED treatments, etc. None were removed due to low quality of outcomes, low quality of study design, or wrong population of interest. Following full-text examination, 46 relevant studies were selected for this review (see Figure 1 for a PRISMA diagram summarizing our inclusion procedure) [ 76 ].

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Flowchart of the inclusion procedure for the review.

The included studies were published between 2004 and 2021, and just over half (27/46) had been published since 2015s (see Table 1 for the main information about the included studies, and see Appendix A for more details on the tools used). Twenty-nine studies examined the content of ED stigma. Some studies reported stigma content for a specific ED: eight focused on AN, six on BN, and one on BED. Other studies compared stigma content between different EDs: five contrasted AN and BN, one AN and BED, one BN and BED, and seven analyzed differences between all three EDs. Twenty-three studies examined the distribution of ED stigma. Most studies focused specifically on AN ( n = 6), on BN ( n = 4), on both AN and BN ( n = 7), or on all three EDs ( n = 4). Only one study examined AN and BED, and one for BN and BED. None of the studies focused uniquely on BED. Ten studies investigated the consequences of ED stigma; half of these discussed repercussions for all three disorders. The remaining studies focused specifically on AN ( n = 3), BN ( n = 1), or AN and BN combined ( n = 1).

Most studies explored stigma among the general population, patients with EDs, and healthcare professionals. It is worth noting that sampling bias is likely, as many studies (20/46) included college students—particularly psychology students ( n = 12), where women are overrepresented compared to men.

The selected studies used the vignette paradigm ( n = 26), questionnaires ( n = 39), and semi-structured interviews ( n = 6) to investigate ED stigma. In the vignette paradigm, participants read one or more fictional stories about targets with a specific ED and answer open-ended questions or complete validated standardized questionnaires about the target. These questions assess recognition, perception, and knowledge of EDs, and beliefs, attitudes, and behaviors toward persons with EDs to examine stereotyping, prejudice, and discrimination toward this population—for a vignette paradigm example, see [ 1 ].

3.2. Content of Stigma

As stereotypes, prejudice, and discrimination are established factors contributing to stigma, we explored these three dimensions to characterize ED stigma. The following section provides a synthesis of those findings (see Appendix B for an overview of stigma content for each ED).

3.2.1. Stereotypes

The selected studies focused on five aspects of ED stereotyping: the notion of responsibility, character traits, gender attribution, disease severity and control, and supposed causes.

Responsibility: The general population and most healthcare professionals perceived people with EDs as blameful and responsible for their situation [ 25 , 26 , 28 , 29 , 31 ], for studies on healthcare professionals see [ 46 , 52 , 63 , 66 ]. This trend was especially notable for BN compared to AN [ 66 ], and for BED compared to AN [ 33 ] and AN/BN [ 2 , 63 ]. Individuals with EDs were more likely to be associated with personal responsibility than those with depression or a major depressive episode (MDE), but less so than those with obesity [ 1 , 2 , 28 , 32 , 52 ]. Indeed, an obese individual without BED was more likely to be blamed for his or her situation than an obese individual with BED [ 51 ]. In addition, one recent study found that a target with no mental disorder or weight-related problems was blamed more for their situation (i.e., eating more fast food during stressful times and spending money on these foods) than a target with AN, BN, or BED [ 2 ]. Patients’ age seemed to moderate this responsibility belief. For instance, participants rated a fictitious 12-year-old boy less responsible for the onset of his BN than the same boy aged 24 [ 50 ]. Thörel et al. [ 2 ] found no significant effect of target ages on stigmatizing attitudes, but the ages used were older: 19 and 39 years, respectively.

Character traits: Studies in the general public found that participants attributed negative traits to people with EDs, but less so for those with BED [ 1 , 54 ]. However, targets with BED have been described with less desirable personality traits (e.g., weak, lazy, and careless) than targets without BED [ 51 ]. The general population associated people with BED with a larger body [ 51 ], and rated people with AN as dangerous, incompetent, able to pull themselves together if they chose to, hard to talk to [ 25 , 29 , 52 , 58 ], and considerably attention-seeking [ 28 , 29 , 52 , 59 ]. The perception of people with EDs as self-destructive was also commonly held, especially for those with BN [ 58 , 66 ]. Healthcare professionals demonstrated similarly negative beliefs about people with EDs—e.g., that they are manipulative, disrespectful, deceitful, and non-compliant with treatment (for a study on nurses, see [ 55 ])—and people with AN, i.e., unreliable (for a study on nursing students, see [ 26 ]).

Finally, some studies noted that targets with other mental or physical disorders elicited a more favorable personality trait assessment than targets with EDs [ 56 ], AN, [ 27 , 29 , 32 , 59 ] or BED [ 1 ]. However, this trend does not appear to be uniformly held across all personality traits. Some studies found that targets with AN were rated more negatively than those with other mental disorders on some dimensions (i.e., intelligence and communication), but more positively on others (e.g., dangerousness, motivation, enthusiasm; for a comparison with schizophrenia, see [ 29 ]; for a comparaison with depression, see [ 27 , 59 ]).

Gender attribution: AN was perceived to primarily affect women [ 3 , 63 ], as was BN [ 66 ], but for non-significant results see [ 34 , 51 ]. For BED, the reverse trend was observed, although the association with men was not statistically significant [ 3 , 63 ]. In a recent study on Turkish school counselors, all three EDs were more associated with women than men compared to other disorders. Female counselors made this assumption more than male counselors [ 56 ].

Disorder severity and control: The general public recognized BN as a severe and disabling condition that is difficult to treat [ 31 , 60 ], and perceived it as more serious than BED [ 62 ]. People rarely minimized BN or perceived it as beneficial [ 25 , 26 ]. In general terms, this was also true in AN [ 25 ]; however, some participants still praised people with AN for their ability to control and lose weight [ 30 ]. Overall, the general public appeared optimistic about people’s ability to control and recover from EDs. Compared to individuals with other mental or physical disorders, AN and BED were perceived more as psychopathological [ 33 ], and EDs as a long-term illness where individuals affected by these disorders have less control [ 56 ]. In contrast, some studies have shown that those with BED were thought to have more personal control over their condition [ 63 ]. People with AN were perceived as more capable of composing themselves and recovering [ 36 ], but for contradictory results in athletes, see [ 47 ].

Supposed causes: EDs’ causes are mainly internalized (i.e., perceived to be the result of personal responsibility). Lack of self-discipline was noted as a common cause for all three disorders [ 1 , 29 , 57 , 68 ], although this was less pronounced for AN [ 1 , 2 , 66 ], and more for BED [ 1 , 2 ]. BED was linked to a lack of self-control and willpower [ 1 , 62 ]. In some studies, participants attributed distinct and specific causes to AN and BN. Vanity and the desire for attention were noted as the leading causes of AN [ 28 , 29 , 30 , 52 ]. Conversely, BN was linked with low self-esteem [ 61 ].

When external causes (i.e., context-related influences) were noted, participants mainly mentioned a lack of social support [ 29 , 57 , 68 ]. Media was also reported as a main causal factor in AN and BN, while genetic factors were not perceived as being involved [ 26 ]. Family problems were also mentioned for EDs [ 56 ]. Specifically, parents’ role was also considered in AN and BN [ 29 , 57 , 68 ], but not for BED [ 68 ]. The general public also associated AN and BN with specific external causes: AN with social influences [ 29 ], and BN with sexual abuse and being overweight or obese during childhood or adolescence [ 61 ].

Compared to other mental or physical disorders, AN was more likely to be linked with low self-discipline [ 29 , 32 , 57 ], lack of social support, and poor parental support [ 29 , 32 ]. AN was rarely attributed to genetic or biological factors [ 29 , 32 , 57 ]. For BN, the desire for attention was more widely reported [ 56 ].

3.2.2. Prejudice

The studies we reviewed indicated that the general public feels conflicting emotions about people with AN. Study participants expressed negative emotions such as irritation and anger, lacked sympathy, and felt uncomfortable in personal interactions with people with AN [ 28 , 29 , 30 , 32 ]. On the other hand, people with AN aroused admiration and inspired a degree of willingness to imitate them [ 28 ], but for contradictory results see [ 27 ]. Imitation was also reported for BN targets [ 52 ], although BN was not perceived as admirably as AN [ 31 , 60 ]. People with BN seemed to inspire sympathy [ 60 ] and more friendly attitudes [ 52 ]. People with BED received equal or more negative attitudes, e.g., compared to those with AN and BN [ 54 , 63 ]; and people without BED [ 51 ]. However, AN and BN elicited more distrust than BED [ 2 , 33 ]. AN was also subject to more distrust than other eating problems (i.e., restrictive eating, emotional eating, picky eating, and ARFID) [ 33 ].

Studies on healthcare workers indicated that professionals might share the public’s negative emotions about EDs. They reported a loss of motivation to deliver or manage care to these patients and expressed negative emotions such as discomfort, frustration, fear, stress, anger, exasperation, and displeasure [ 46 , 53 , 55 ].

Overall, compared to other mental or physical disorders, the reviewed research demonstrates that EDs provoke fewer positive reactions in both the general population [ 2 , 28 , 57 ] and healthcare professionals [ 49 ]. Nevertheless, individuals affected by EDs elicited less distrust than those with an MDE [ 2 ]. In addition, people with AN inspired more admiration, and people with BN more friendly attitudes, than those with depression [ 28 , 52 ], and study participants reported feeling more comfortable interacting with people with AN than those with schizophrenia [ 29 ].

3.2.3. Discrimination

At the behavioral level, there is some evidence that people maintain social distance between themselves and people with EDs. Study participants reportedly avoided personal contact with people with AN [ 25 ], and were reluctant to interview them for a job [ 30 ]. A desire for social distancing was also expressed toward people with BN [ 31 , 32 ]. For BED, participants’ desire for social distance from targets with BED was low, and not significantly different when compared to targets without BED [ 51 ]. Study participants were more likely to want to interact with people with BED than those with AN or BN [ 63 ], and expressed less desire for social distance from them [ 2 ], but for no significant difference in social distance assessment for all three ED populations, see [ 54 ].

The public’s tendency to socially distance seems to be a common finding for a range of mental disorders, e.g., AN, schizophrenia, depression, see [ 2 , 57 ]. One study reported that people with AN produced less social distance than people with depression in the general public [ 28 ], while the opposite was found among healthcare professionals [ 3 ]. Compared to physical disorders, the general population reported more social distance from targets with AN [ 32 ] and all three EDs [ 2 ]. Similarly, McNicholas et al. [ 3 ] found that healthcare professionals preferred to manage people with type 1 diabetes rather than those with AN. Finally, Lupo et al. [ 26 ] showed that nursing students reported a high level of social distance from people with AN, while that for people with BN was low.

3.3. Distribution of Stigma

Some studies included in the review found that ED stigma is more likely to be expressed in some populations than others (see Table 2 for details).

Distribution of ED stigma.

3.3.1. Most Stigmatizing Individuals

Men held stereotypes and prejudice against people with EDs to a greater extent than women [ 26 , 33 ]. Men were more likely than women to have stereotypes such as believing in patients’ responsibility [ 7 , 31 , 33 , 47 ] and attributing the condition to internal causes, e.g., narcissism, lack of willpower, attention-seeking, [ 7 , 58 , 59 , 66 , 67 ]; for one study on BED see [ 62 ]. They were also more likely to minimize the challenge and severity of AN and BN [ 27 , 31 , 33 , 47 , 58 , 66 ]. Men also expressed more prejudice than women, exhibiting less prosocial and friendly attitudes toward people with EDs [ 65 , 66 , 67 ]. However, the findings on discriminatory behaviors are inconclusive. Some studies found no gender difference in ED stigma [ 25 , 31 ], but Makowski et al. [ 67 ] found that women reported more social distance from people with EDs. A recent study found that AN stigma was not predicted by gender per se , but rather by compliance with masculine gender norms, which resulted in more stigmatizing behavior toward people with AN [ 8 ].

A few studies examined the influence of age, educational background, and income on ED stigma. Overall, young adults were more likely than older adults to express stigma or seek social distance from people with AN or BN [ 25 , 31 , 61 , 64 ]. The same pattern of results was observed for individuals with low income compared to those with high income [ 31 , 64 ]. Results were mixed for educational background. Two studies found that individuals with a low education level were more stigmatizing than those with a high education level [ 31 , 64 ], but in two others, the effect of education on stigma was not statistically significant [ 60 , 61 ].

Finally, one study observed that individuals who strongly believed in a “just world” were more stigmatizing toward people with EDs than those who did not share this belief [ 68 ].

3.3.2. Least Stigmatizing Individuals

Several studies have examined the impact of familiarity with EDs on stigma. The studies included in this review indicated that individuals familiar with EDs held few stigmatizing attitudes toward people with EDs (for AN and BN, see [ 25 , 26 , 46 ]). Research also suggested that familiarity was associated with less discomfort and greater sympathy toward patients with EDs [ 27 , 32 , 60 ], but for a non-significant finding see [ 46 ]. At the behavioral level, Caslini et al. [ 25 ] observed that people with EDs themselves were less likely to desire social distance from people with BN. Nevertheless, one study indicated that those familiar with EDs were more likely than those unfamiliar to think that BN is caused by low self-esteem and sexual abuse. Individuals familiar with EDs were also more likely to minimize BN and identify benefits associated with the condition [ 61 ]. Only one study found no impact of familiarity on the extent of stigmatizing attitudes against people with BN [ 47 ]. Caslini et al. [ 25 ] offer one potential explanation for this disparity in the literature, noting that the influence of familiarity might depend on the proximity to the individual with an ED. Stigma was less prevalent if the person with AN or BN was a close relative (e.g., boyfriend or girlfriend vs. cousin).

A small number of studies focused on people with significant ED symptoms (but without a formal diagnosis) or on people who were knowledgeable about EDs. These two populations attributed fewer negative stereotypes—such as selfishness, lack of self-control, and responsibility—to people with EDs compared to people with few ED symptoms or limited knowledge about EDs [ 30 , 47 , 66 ]. At the emotional and behavioral levels, people with significant ED symptoms also reported less irritation and less desire for social distance than people with few ED symptoms, demonstrating a stronger inclination to befriend people with AN [ 30 ].

Finally, a handful of studies focused on factors like participants’ degree program, ethnic group, and weight category. Psychology students, Caucasian participants, and underweight individuals had less stigmatizing attitudes toward people with EDs than students in other degree programs [ 7 , 25 ], African-American participants [ 66 ], and normal-weight or overweight individuals [ 25 ].

3.4. Consequences of Stigma

Compared to studies on ED stigma content and distribution, very few studies have examined the consequences of ED stigma ( n = 10). The reviewed research suggests that people with EDs often experience ED stigma, and that stigmatization can have significant impacts (see Figure 2 ).

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Consequences of stigma against people with eating disorders (EDs).

3.4.1. Stigma Perception

Few studies have examined ED stigma from the patient’s perspective. The studies included in this review mainly focus on female patients with AN. Most women with AN reported ED stigmatization by the general public [ 6 ]. People with AN felt that they were stereotyped in public opinion, and that others blamed them for their situation and attributed negative characteristics to them, such as incompetence, lack of self-control, and manipulative personality traits [ 6 , 69 , 73 ]. People with AN also found that others proposed superficial causes to explain AN [ 69 ], and trivialized their disorder, as well as their treatment and their recovery [ 69 , 73 ]. People with AN noted discriminatory behavior, finding that people distanced themselves from them [ 6 , 69 ]. Finally, Bannatyne and Stapleton [ 71 ] highlighted that people with AN also experienced negative beliefs (e.g., blame, trivialization) and negative reactions (e.g., frustration, no empathy) from healthcare professionals.

3.4.2. Self-Stigma

ED stigma seems to lead to self-stigma among people with EDs. Maier et al. [ 6 ] found high rates of internalization of others’ negative beliefs (e.g., blame, attention-seeking, the ability to pull themselves together if they wanted) in women with AN. Self-stigma was found to be an independent predictor of having an undiagnosed ED [ 74 ], and has been linked to reduced treatment-seeking and a more negative attitude toward recovery [ 72 ]. Among patients with AN, Dimitropoulos et al. [ 42 ] found that high self-stigma and perceived stigma toward family members were negatively correlated with recovery attitudes. Griffiths et al. [ 73 ] reported that greater resistance to stigma (i.e., being able to counteract stigma or remain unaffected) was associated with less severe depressive symptoms, enhanced self-esteem, and a more positive attitude toward treatment-seeking.

3.4.3. Impact on ED Symptoms and Severity

ED stigma can have harmful psychological consequences, such as low self-esteem and feelings of shame and culpability (for a study on BN, see [ 70 ]). In addition, stigma can affect the course of the ED itself. Griffiths et al. [ 5 ] found that more frequent experience of ED stigma was associated with higher levels of ED psychopathology. A further study examining the underlying mechanism for this association demonstrated that ED stigma led to greater alienation and social withdrawal which, in turn, predicted greater symptom severity [ 75 ]. A third potential adverse effect of stigma is its impact on the treatment of EDs. Griffiths et al. [ 5 ] observed that the experience of stigma was associated with longer illness duration and reduced treatment-seeking. Maier et al. [ 6 ] noted that a substantial proportion of people with AN waited a long time before visiting a physician and starting treatment because they were afraid of being stigmatized. The average period between disease onset and the first medical consultation or treatment initiation was around 8–9 months.

4. Discussion

The primary aim was to review and synthesize the evidence on ED stigma, producing a comprehensive update on stereotypes, prejudice, and discriminatory behaviors toward people with EDs. We examined ED stigma in a broad sense and explored stigma content associated with specific EDs (i.e., AN, BN, and BED). The second objective was to describe the distribution of ED stigma—specifically, to understand which groups were more likely to stigmatize people with EDs and which groups were more tolerant. The final objective was to summarize the known consequences of ED stigma—specifically, the impact on the healthcare of people with EDs.

4.1. Present Contributions and Future Research

Regarding the content of ED stigma, there is strong evidence of stigma against patients with AN, BN, and BED. Overall, people with EDs were perceived by the public as being responsible for their disorder. Causal attributions included a lack of self-discipline (dispositional cause) and a lack of social support (situational cause). Examination of the affective and behavioral dimensions revealed that negative attitudes and social distance toward patients with EDs are also common.

These data are consistent with findings on mental illness stigma in general. Indeed, previous studies have shown that the general public believe people with mental illnesses are responsible for their condition [ 13 , 18 ], display adverse reactions like discomfort or fear [ 12 , 77 ], and avoid personal contact with them [ 12 , 20 ].

This review has also highlighted that some beliefs and attitudes were more strongly associated with specific EDs. First, AN was generally perceived as a way of garnering attention from others and considered easy to overcome. Only people with AN provoked both irritation and a desire to imitate. Secondly, self-destruction, low self-esteem, sexual abuse experience, and being overweight or obese in childhood or adolescence were uniquely associated with individuals affected by BN. This disorder was rated severe and generated more sympathy. Thirdly, people with BED were less likely to elicit negative character assessments than those with AN or BN, but were nevertheless associated with equally or more negative attitudes, except for distrust. People with BED were more likely to be held responsible for their condition. Lack of self-control as well as lack of willpower were also strongly associated with BED.

These data support previous findings of variation in stigmatizing content between different mental health conditions. For example, unpredictability and dangerousness were uniquely associated with people with schizophrenia compared to people with other mental illnesses [ 12 , 13 , 78 ]. However, above all—as mentioned in the introductory section—the difference in stigma content between AN, BN, and BED could be explainable by their differences in stigma visibility and conformity to cultural norms [ 11 ]. One could hypothesize that people with BN may have engendered more sympathy because BN is sometimes less visible than AN and BED. People with AN may have triggered more admiration because their body shape could be more consistent with the predominant ideal of thinness [ 79 , 80 ]. Conversely, people with BED may have been the target of blame attribution because their body shape might differ from cultural weight standards.

Accordingly, BED stigma content showed overlap with weight stigma toward overweight people [ 15 , 81 , 82 ], which has negative psychological and behavioral consequences. Indeed, overweight people are victims of stereotypes. Horsburgh-McLeod et al. [ 83 ], for example, found that participants’ descriptions were more negative for an overweight target than for the same target with a normal weight. Obese people were also less valued. Using photographs of children, Musher-Eizenman et al. [ 84 ] found that child participants were less likely to choose photographs of overweight children as potential friends than photographs of thin or average weight children. Furthermore, this population is also disadvantaged in important areas of life. A field experiment demonstrated that hiring managers were less likely to invite obese individuals than normal-weight individuals to a job interview, even when applicants’ cover letters and curriculum vitae contained similar skills and qualifications [ 85 ]. Moreover, studies have shown that weight stigma has harmful consequences, e.g., depression, eating symptoms, [ 86 , 87 , 88 ]. However, a recent study found no evidence for additive effect of BED stigma and weight stigma [ 51 ]. The presence of BED limited and moderated weight stigma. Indeed, authors observed that an obese target with BED elicited fewer stereotyping characteristics (i.e., negative personality traits and blame) than an obese target without BED. Conversely, a study has shown that overweight people with BN received more blame and more weight problem attributions (compared to severe psychiatric disorder attributions) than underweight people with BN [ 89 ].

Our finding of public stigma around the causation of EDs is consistent with previous research demonstrating correlations between sociocultural factors and EDs. For example, one recent study found that peer pressure was a significant predictor of the risk of EDs [ 90 ]. Therefore, social causes are perhaps more likely to be associated with AN, because the body shape of people with AN might be more congruent with sociocultural weight and beauty standards.

Study participants’ gender attributions were consistent with ED prevalence statistics, which show a higher prevalence for women than for men, although this is less pronounced for BED. In 2017, the National Institute of Mental Health reported a male/female ratio of 1:3 for AN, 1:5 for BN, and 1:2 for BED [ 91 ]. However, those statistics should be treated with caution. Indeed, several studies have noted that men with EDs were underdiagnosed because they avoided care services out of shame of being affected by a “female disorder” [ 5 , 92 ], leading to the overrepresentation of females in ED prevalence. Redefinition of the ED diagnostic criteria in the DSM-5 , which now capture more male eating problems (e.g., removal of the amenorrhea criterion), might resolve this issue to some extent.

Our review has also highlighted that healthcare professionals were not immune to ED stigma and commonly endorsed public stigma, which is consistent with previous research indicating that healthcare practitioners were a source of mental illness stigma [ 78 , 93 ] and weight stigma [ 94 , 95 ]. The discomfort and reluctance of healthcare professionals to manage patients with EDs—especially patients with AN—is mainly explained by practitioners as a lack of knowledge, experiences, and equipment to treat them [ 3 , 46 ]. People with EDs have a higher risk of mortality than their counterparts in the general population [ 96 ], especially individuals with AN [ 97 ]. The latter also have the highest mortality risk compared to people with other mental disorders, such as schizophrenia, depressive episode, dementia, etc. [ 98 ]. This high risk of mortality in EDs may create prejudice among providers, but study of these links should be pursued.

Regarding the distribution of ED stigma, the past 15 years of research have principally shown that personal characteristics play a role in the extent of ED stigma. Most studies indicated that men tend to be more stigmatizing against people with EDs than women. However, this finding was qualified by a recent study that showed that stigmatization might be linked to compliance with masculine gender norms, and not gender per se . Several studies also noted an effect of age and income level on the extent of ED stigma. Young adults and low-income individuals were found to be more stigmatizing than older adults and those with higher incomes. The evidence for a link with educational attainment is mixed. Whereas some studies observed more stigmatization from individuals with less education, others found no significant difference based on education level. The effect of ED familiarity was less ambiguous. People who were familiar with EDs or knowledgeable on the topic and those who had experienced significant ED symptoms had fewer negative attitudes toward people with EDs. These findings are consistent with the contact hypothesis. This social psychology hypothesis, developed by Allport [ 99 ], argues that negative attitudes result from a lack of personal and positive contact with out-group members. This confirms the relevance of stigma reduction strategies that promote interpersonal or intergroup interactions with stigmatized people. A few studies included in this review highlighted the impact of other sociodemographic variables on the extent of ED stigma, such as a person’s ethnic group, weight category, and degree program. Future research would be helpful to replicate the impact of these variables on ED stigma.

Finally, the results on stigma distribution lead us to wonder what individual characteristics would protect one from ED stigma and self-stigma. Evans-Lacko et al. [ 100 ] found that having a university education or being employed resulted in less self-stigma about mental illnesses and more empowerment, as well as finding that women felt less empowered and perceived more mental illness discrimination. However, no specific work has been conducted regarding ED stigma.

Our review revealed that very few studies have focused on the consequences of ED stigma. Foran et al. [ 4 ] reviewed 9 studies on this dimension, and this present review examines 10; 7 of these studies are common to both works. The difference for the remaining texts can be explained by different choices in terms of keywords and inclusion criteria between our reviews. Nevertheless, despite these differences, our present review synthesizes similar negative impacts of ED stigma to those identified by Foran et al. [ 4 ]; namely, ED stigma precipitated negative emotions and decreased self-esteem in people with EDs, which is notable as these symptoms are already prevalent in EDs. Moreover, ED stigma exacerbated ED symptoms, specifically inducing more inappropriate eating behaviors and delaying treatment-seeking. Indeed, a recent meta-analysis [ 101 ] found a small-to-medium association between various combined discriminations (i.e., general, racial/ethnic, gender, LGBT, weight/obesity, and sexual harassment) and ED symptoms (e.g., general ED symptoms, body dissatisfaction, binge eating, restraint, night eating, etc.). The data of this meta-analysis and the present review are worrying because they indicate that discrimination increases the risk of developing an ED or maintaining an existing ED. Finally, these data raise questions about the impact of stigma on the eating behavior of people with multiple devalued attributes, such as a black woman with AN, but this topic seems still under-investigated.

In addition, people with EDs were notably aware of ED stigma. Stigmatization may therefore lead to self-stigma (e.g., people with EDs feeling they are responsible for their condition), which has been linked to negative emotions and reduced treatment-seeking. In short, ED stigma may lock people with EDs into a vicious circle that decreases the likelihood of recovery. The literature on mental illness has also demonstrated self-stigma among patients with mental illnesses [ 18 ]. If we apply the stage model of self-stigma developed by Corrigan and Rao [ 102 ] to the current evidence review, it would seem that people with AN have moved beyond the stage of “awareness” and “application”, and into “appropriation”. Future research should address whether people with AN might have reached the advanced level of “harm”; at that stage, individuals lack a sense of capability, which interferes with their life-goal achievement. As much of the research has focused on the perceptions of people with AN, it would be beneficial to assess self-stigma stages in people with BN and BED. An enhanced understanding of the self-stigma process in ED would enable more effective mitigation actions. Regarding mental illness, Rüsch et al. [ 103 ] have identified a range of factors associated with the emergence of self-stigma: the perception of others’ negative responses, belief in the legitimacy of others’ reactions, and a high degree of group identification. It would be interesting to establish whether these and other potential factors play a role in ED self-stigma.

4.2. Challenges and Opportunities in the Study of ED Stigma

Firstly, this review highlights a lack of diversity in methodological tools in the body of research on ED stigma. All of the studies included in this review exclusively used explicit measures. The use of such transparent measures to assess ED stigma may have elicited social desirability bias in study participants. This tendency to cast oneself, consciously or not, in a positive light, or present oneself in agreement with social expectations [ 104 ], may have motivated participants to report fewer stigmatizing behaviors and attitudes, leading to an underestimation of ED stigma prevalence. However, the two studies in this review that explicitly assessed social desirability effects found no significant association between participants’ “inclination to social desirability” and their stigmatizing attitudes [ 1 , 68 ]. Nevertheless, future research should include implicit measures to counteract the potential confounding effects of bias in the evaluation of ED stigma. Research on mental illness stigma has generally included both implicit attitude measures (e.g., a go/no-go task) and self-report measures [ 105 , 106 , 107 , 108 , 109 ]. Indeed, implicit and explicit attitude measures are not necessarily correlated [ 105 , 106 ], but could complement one another. Sometimes both types of attitudes are negative [ 107 ], but in other cases, only explicit [ 106 ] or implicit attitudes are negative [ 108 ]. Moreover, implicit and explicit attitudes do not necessarily predict the same consequences. In their study on decision patterns in healthcare professionals, Peris et al. [ 105 ] found that explicit negative attitudes significantly predicted more unfavorable prognoses for patients, while implicit attitudes were predictive of overdiagnosis (i.e., adding comorbidities). Teachman et al. [ 107 ] observed that in-group members possessed an implicit and explicit negative bias toward people with a mental illness. Future studies on ED self-stigma could likewise include implicit assessments [ 110 ].

Secondly, the review points to unequal research efforts in ED stigma, as the majority of studies focused on AN. The lack of interest in BED is one of the major limitations of the reviewed body of research. The recent inclusion of this disorder in the DSM-5 as a specific ED may explain this deficit.

Additionally, despite finding evidence of the harmful effects of ED stigma, this review reveals that very few studies to date have examined the consequences of ED stigma. The rare studies that have addressed this issue suggest that ED stigma adversely affects the medical treatment of people with ED. Further research is needed, in particular, to elucidate the mechanism that links stigma with treatment avoidance. The aim would be to establish whether stigma impedes treatment-seeking, and the extent to which people with ED might use stigma to rationalize treatment avoidance.

Finally, one included study highlighted that patients’ recovery attitude decreased when they perceived that their family members also experienced stigma. Apart from this study, we are not aware of any studies that have reported family stigma in the field of EDs. However, studies conducted on people (e.g., parents, sibling, etc.) who had a family member with a mental health issue found that they reported stigma experiences through their association with that family member [ 44 , 45 ]. Relatives reported experiences of overt stigma: blame, rejection, avoidance, embarrassment, verbal abuse, loss of status, and name-calling. They also reported psychological (i.e., stress, anxiety, lower self-esteem), social (i.e., avoiding situations, hiding their relative’s situation), and family consequences (i.e., seeing the relative as a burden, being stigmatizing) [ 44 , 45 ]. Considering these data, family stigma deserves special attention in the field of EDs. Research is needed to detect ED family stigma and its consequences on relatives (e.g., risk of developing their own mental issue) and patients themselves (e.g., shame, culpability, avoidance of treatment-seeking).

4.3. Clinical Implications

Considering the potential consequences of ED stigma, more work is urgently needed to reduce stigma. The review has highlighted that being familiar with or knowledgeable about EDs is associated with less ED stigma [ 25 , 26 , 32 , 46 , 47 , 60 ]. Therefore, improving public awareness about EDs may be an effective strategy to reduce ED stigma. Research on mental illness stigma has demonstrated that anti-stigma educational interventions and facilitating contact with people experiencing mental illnesses leads, in the short term, to knowledge gains and positive attitude changes [ 103 , 111 , 112 , 113 ]. However, evidence from the few programs specifically targeting ED stigma suggests that due consideration should be given to the exact messaging used in interventions. Reinforcing causal explanations for ED that focus on sociocultural influences could exacerbate stigmatizing attitudes [ 57 , 114 , 115 , 116 , 117 ]. Further work is required to determine the factors that contribute to public ED stigma in order to design suitable interventions that mitigate ED stigma and avoid disseminating information that could reinforce it.

The present review has revealed that each ED possesses unique stigmatizing content, and that some populations are more stigmatizing toward people with EDs (e.g., men) than others (e.g., psychology students). Thus, it also seems essential to tailor the intervention content to the specific ED, and adapt the design to the target audience. The existing research on mental illness stigma illustrates the utility of adapting strategies to particular groups. In their review, Thornicroft et al. [ 112 ] determined that adults were more responsive to education, while adolescents benefited from direct contact with stigmatized individuals. Our review indicates that young people are one of the most stigmatizing groups toward EDs. We hypothesize that contact-focused strategies would be the preferred choice to mitigate ED stigma in the least tolerant groups. Virtual and augmented reality (i.e., VR and AR) technologies offer a novel mechanism to simulate interpersonal and intergroup contact between stigmatizing groups and people with EDs. In this way, Christofi and Michael-Grigoriou [ 118 ] have reported promising effects of full-body VR illusion on empathy and prejudice toward minority people (e.g., black people or people with a disability).

Notably, while there is a clear need to reduce ED stigma in the general population, there is also a need to inform healthcare professionals who were found to hold similarly negative beliefs and attitudes toward people with EDs [ 3 , 46 , 49 , 53 , 55 , 116 ]. The effects of anti-stigma interventions for mental health professionals have received little attention to date [ 103 , 112 ]. Thornicroft et al. [ 112 ] reported positive attitude changes in practitioners, but these benefits did not necessarily translate to improved experiences for people with mental illness. As a first step toward designing effective anti-stigma programs for the medical community, future research should focus on identifying which comments, attitudes, or behaviors of healthcare professional patients experience as stigmatizing. More work is also needed to evaluate the effectiveness of interventions among healthcare professionals, and the indirect effects on patients’ motivation to engage in a caring process.

Finally, the review has demonstrated that, along with stigma, some people with EDs self-stigmatize. People with EDs must be protected from the potential additional harm of self-stigma. Programs based on cognitive behavioral therapies, acceptance and commitment therapies, psychoeducation, mindfulness, and peer support are already being used to effectively reduce self-stigma in people experiencing mental illness [ 119 , 120 ]. Future studies should evaluate the effectiveness and replicability of these interventions on self-stigma in people with EDs. Similarly, if there is evidence of family stigma among the relatives of patients with EDs, these different therapies should be proposed to help them cope. Indeed, a recent study showed that emotion-focused family therapy decreased parental fear and parental self-blame, consequently enhancing parental self-efficacy [ 121 ]. Moreover, this improvement in self-efficacy increased parental intentions to engage with supportive efforts in recovery and emotional coaching behaviors. If this therapy is useful for dealing with self-blame, perhaps it will be useful for dealing with the blame of others.

4.4. Limitations

Because our literature search was subject to some inclusion criteria (e.g., year of publication) and restricted to four major databases in psychology, this review on ED stigma might not be exhaustive. Indeed, a different choice of databases (e.g., Scopus or Web of Science) might lead to different results. Similarly, the choice of keywords may have reduced the number of studies included in the review process.

In addition, it should be noted that only the first author conducted this review process. Therefore, although we have clearly stated objective inclusion/exclusion criteria, some subjectivity may reside in this work, which may weaken its scientific value. However, it should be noted that in the event of uncertainty regarding the inclusion of an article, a second researcher (V.F.) was consulted.

Finally, we used a qualitative review approach, and the quality of each study was not assessed as part of the search process. Therefore, this review may include articles with methodological and other biases. A quantitative meta-analysis might be helpful to provide additional and novel insights. Because we did not restrict our inclusion criteria to particular methodological designs, the (presumed) methodological heterogeneity would hinder statistical comparisons, but meta-analysis could be used for subgroups of studies. This heterogeneity in the studies’ methods may also have constrained the conclusions that this review could draw. However, this variability is also emblematic of the recent interest in this topic, and indicates diverse engagement in ED stigma research.

5. Conclusions

This scoping review provides some evidence of ED stigma in the general public, as well as among healthcare professionals; it also highlights the harmful impacts of ED stigma on the psychological state (e.g., low self-esteem, self-stigma) and treatment-seeking behaviors of people with EDs. Educating the public and healthcare professionals on ED stigma seems necessary to avoid missed or delayed diagnosis and improve the care of patients with EDs.

Moreover, the review highlights the underrepresentation of research on BN and BED compared to the interest in AN, while also noting that stigma content differs between the three ED disorders (specifically for BED). The consequences of ED stigma are poorly studied and understood relative to ED content and distribution. Thus, more research is required to provide insight into ED stigma and improve the diagnosis and treatment of people with EDs.

Details of the tools used in the included studies.

Overview of stigma content for each eating disorder.

Please refer to Section 3.2 . “Content of Stigma” in the main text to find relevant references for each cell. Note: ARFID: avoidant restrictive food intake disorder; MDE: major depressive episode.

Author Contributions

Conceptualization, L.B.; methodology, L.B. and V.F.; investigation, L.B.; writing—original draft preparation, L.B.; writing—review and editing, L.B., V.F., M.D., S.G., P.-M.L., and Y.B.; supervision, Y.B. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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