Anorexia Nervosa

Causes & Risk Factors

There is no one-size-fits-all explanation of Anorexia Nervosa. Rather, researchers agree that Anorexia Nervosa is the product of a complex interaction of various psychosocial, sociocultural, familial, biological, and risk factors that collide at a vulnerable time in a person’s life. Below, we will summarize some of the major etiological factors that may play a role in the onset and maintenance of Anorexia Nervosa.

There is a strong tendency to blame the media and our Western culture of unachievable beauty ideals for the development of Anorexia Nervosa. Researchers suggest that the media does play a substantial role in the development of body dissatisfaction, particularly in young women. The media influence on our body image has led to a phenomenon that researchers refer to as “normative discontent,” the term used to describe the unsettling finding that most women in Western societies are dissatisfied with their bodies. It is important to point out, however, that most young women are exposed to the same media images and not all women develop Anorexia Nervosa equally. Similarly, the billion dollar diet industry is practically force-fed on everyone via television, radio, the internet, and print, yet not everyone will go on a diet, and not all dieters progress to the severe self-starvation seen in of Anorexia Nervosa. So, it seems as though the current cultural ideals of thinness and media perpetuated by the media industry are likely to be necessary, but not sufficient, for the development of eating disorders. Media influence precipitates eating disorders by contributing to women feeling bad about their bodies and inadequate in regards to their appearance. Additional factors, such as genetic predispositions, psychological tendencies, family dynamics, and life events converge to create the disorder.

Psychosocial Factors
Certain personality factors such as perfectionism or overachieving tendencies may increase the risk of developing Anorexia Nervosa. Persons with Anorexia Nervosa are often “people-pleasers.” They are overly critical and judgmental towards themselves. With perfectionistic thinking there is a tendency to engage in all-or-nothing or black-and-white thinking. If they are not perfect, they may feel as though they are a total failure. Similarly, anxious or obsessive-compulsive tendencies may put individuals at greater risk of developing Anorexia Nervosa. Additionally, anxious or obsessive-compulsive thinking can be a side effect of starvation. Difficulty with emotional expression, poor interpersonal effectiveness, and poor coping skills all have been cited as risk factors for Anorexia Nervosa.

In the face of stressful life events such as a romantic breakup, parental divorce, or a sudden change in schools, those with poor coping skills and difficulty obtaining support are at greater risk for the onset of an eating disorder. Strong self-esteem seems to be a powerful protective mechanism against the development of eating disorders, with low-self esteem making an individual more vulnerable to eating disorders. Individuals with low self-esteem tend to be more susceptible to teasing or weight/shape related criticisms. They also may put undue importance on body size and shape as a way to distract themselves from underlying causes of negative emotions. The eating disorder may also be a maladaptive attempt to regulate negative affect and cope with poor self-esteem. The underlying thought being that “If only I was thin and beautiful, then I would be happy, accepted, loved, valued, etc.,” may precipitate and maintain the eating disorder. Peer influence and choice of extracurricular activities (e.g., competitive running, gymnastics, dance, etc.) becomes critically important in the development of eating disorders, particularly when combined with any of the aforementioned risk factors.

Familial Factors
Research on the familial factors associated with Anorexia Nervosa is wrought with methodological issues such as correlation design (looking only at association between variables, rather than causation), or retrospective design (i.e., having individuals and families recall aspects of their development history after the onset of eating disorder), and focus largely on case studies in absence of controls. That said, there are important aspects of families and familial patterns that have been associated with Anorexia Nervosa, however, readers are cautioned not to interpret these factors as causative mechanisms of eating disorders.

There is a tendency for families of an individual with Anorexia Nervosa to be more likely to hold high expectations, be rigid with rules and standards, and have difficulty resolving conflict. “Expressed Emotion” (EE) is a qualitative psychiatric construct that refers to high levels of hostility, criticism, and emotional overinvolvement typically among caregivers. There has been an association found between high parental EE (particularly criticism and hostility), poorer recovery, and premature dropout from treatment. Some forms of family based therapy (FBT) have been effective in reducing parental EE. Parents who make critical comments about weight and shape and inadvertently encourage Anorexia Nervosa by praise of perfectionism and slimness. The majority of researchers tend to agree, however, that while certain family factors may perhaps increase the risk of developing Anorexia Nervosa and help maintain the illness, that additional vulnerabilities (such as genetic tendencies, low self-esteem, and perfectionism) must also exist for Anorexia Nervosa to occur.

Biological Factors
Research using family and twin studies has suggested that genetic factors may contribute to up to 50% of the variance in the development of Anorexia Nervosa. Within the past decade there has been a dramatic increase in research funding to investigate the specific genetic basis of eating disorders. Research to date suggests that a few certain genes line up to create a genetic predisposition for the development of Anorexia Nervosa. This research proposes that some individuals, mostly women, have a latent vulnerability to eating disorders which can only be “turned-on” by certain environmental triggers. These findings help to explain why 100 women may go on a diet and yet only 1-2 of those women will develop Anorexia Nervosa. The research also suggests that certain personality characteristics that are highly heritable, such as perfectionism, obsessionality, and anxiety, put individuals at the highest risk for Anorexia Nervosa and that these personality traits could be targeted early as a means of prevention.

Neurobiological theories of Anorexia Nervosa suggest that abnormalities in the neurotransmitter 5HT (serotonin) in certain regions of the brain play a major role in Anorexia Nervosa. One variant of this research has shown excesses of one form of serotonin in certain regions of the brain associated with anxiety. This has led to one hypothesis that starvation is the brain’s attempt at decreasing anxiety by lowering serotonin in these particular brain regions. Another variant of this research shows deficits of another form of serotonin in regions of the brain associated with mood and appetite. One difficulty with this area of research is determining whether or not these neurobiological abnormalities are a cause or an effect of the disease. However, some research has shown that these brain abnormalities exist even after recovery from Anorexia Nervosa suggesting that perhaps, these abnormalities existed prior to the onset of the illness.

Other biologically based theories of Anorexia Nervosa have highlighted changes in basic biological factors that may maintain Anorexia Nervosa. When the body is not used to have “normal” amounts of food, increasing dietary intake can be accompanied with bloating, gas, pain, and constipation. Therefore, increased gastric distress has been implicated as one of the potential biological factors thought to maintain the illness. Another potential biological factor that has been noted in Anorexia Nervosa is altered olfactory senses. Some research has found that very low weight anorexics have severe deficits in their ability to detect and identify odors and that these deficits do not always improve with weight restoration. These deficits are compounded by the presence of cigarette smoking. Some studies have found that a lack of interoceptive awareness (IA) is associated with Anorexia Nervosa. IA refers to an individual’s ability to notice and detect internal cues, in particular hunger and satiety. Lack of IA has been implicated in a biological factor that may maintain Anorexia Nervosa.

Summary of Causes and Risk Factors
There is no single causal mechanism that has been identified in the development of Anorexia Nervosa. Rather, research suggests that Anorexia Nervosa typically develops and is maintained by a genetic susceptibility either to the disorder itself or certain personality characteristics that are risk factors for the disorder combined with certain sociocultural, familial, environmental, and biological factors. In the future, it seems unlikely that we will come upon a single cause of Anorexia Nervosa, be it genetic or environmental, rather researchers are likely to perhaps tease apart the relative importance of specific contributory factors.

Article by Lindsey Ricciardi, Ph.D
Licensed Clinical Psychologist &
Eating Disorders & Obesity Specialist

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