Eating disorders are a significant health problem but effective treatment may be hampered by flawed theories of the disease, research by Dr Hannah Hawkins-Elder suggests.
Dr Hawkins-Elder recently completed her PhD at Te Herenga Waka—Victoria University of Wellington, investigating whether the theories behind eating disorder treatments may be limiting their effectiveness.
“Compared with treatments for medical conditions and other mental health problems, current treatments for eating disorders are falling short,” she said.
“Treatments for anorexia nervosa typically produce poor results, with a significant number of cases never fully recovering or becoming chronic. Treatments for binge-eating and bulimia show comparatively more promise, but evidence suggests approximately 30 to 50 percent of cases will remain symptomatic or relapse down the line.”
In her PhD research, Dr Hawkins-Elder examined several prominent theories underlying treatment approaches to eating disorders and concluded they had “fundamental problems”.
These shortcomings may help to explain why treatments for eating disorders often have poor or only moderate efficacy, she said.
One previously influential theory (the so-called psychosomatic family theory) assumed anorexia was caused by “dysfunctional” family dynamics—specifically, growing up in an overprotective family that had a rigid structure and didn’t cope well with conflict.
However, evidence doesn’t support this theory. “Research shows families of people with anorexia are incredibly diverse, both in their demographics and how they interact,” Dr Hawkins-Elder said.
“Theories such as this, which are outdated and based on poor quality evidence, still problematically inform some eating disorder treatment today. They can also contribute to harmful stereotypes about the families of those suffering, and thereby cause stigma and shame.”
More recent theories focus on psychological factors—such as low self-esteem, perfectionism, responses to stress, difficulty dealing with relationships, or emotional instability—to explain eating disorders.
These theories have contributed significantly to our understanding of eating disorders, Dr Hawkins-Elder said. However, they tend to lump a large number of factors together without always providing robust cause-and-effect reasoning to explain different behaviours—for example, why a particular factor, or factors, leads to a specific pattern of disordered eating.
The theories also frequently fail to acknowledge and incorporate biological factors that may be contributing to a person’s eating behaviour, she said.
“In some cases, the development of disordered eating may involve biological factors, such as imbalances in appetite hormones or disturbances in metabolic or neurochemical systems.”
Dr Hawkins-Elder argues eating disorder explanations need to look more closely at specific disordered eating behaviours—dietary restriction, binge eating or purging—rather than broader diagnostic categories, such as anorexia nervosa, which tend to delineate poorly between cases.
“These behaviours need to be examined in detail to better understand them and the factors that may be causing and maintaining them.”
Worldwide, it’s estimated 8.4 percent of women and 2.2 percent of men will experience an eating disorder within their lifetime.
Recent research suggests the number of people seeking treatment for eating disorders has increased since the COVID-19 pandemic.
Dr Hawkins-Elder wants to continue researching eating disorders as she begins clinical practice.
She was awarded her Doctorate of Philosophy in Psychology from Te Herenga Waka—Victoria University of Wellington in December 2021. Her PhD was supervised by Professor Tony Ward, director of clinical psychology training in the School of Psychology at Te Herenga Waka—Victoria University of Wellington.