4.3.6 - Psychological explanations for anorexia nervosa

Family systems theory

Family systems theory proposes that patterns of relationships can affect autonomy and the meaning of control over eating.

Anorexia nervosa is a serious eating disorder involving restriction leading to significantly low body weight, fear of weight gain or behaviour preventing restoration, and disturbed experience of weight or shape. Psychological theories aim to explain how a problem may begin or persist; a symptom description alone is not an explanation. People of different genders can experience the disorder, and no short scenario establishes a diagnosis or its cause.

Salvador Minuchin, Bernice Rosman and Lester Baker developed a family systems account of anorexia nervosa in Psychosomatic Families (1978). They argued that some families with psychosomatic symptoms, including anorexia nervosa, show interaction patterns that make separation and open conflict difficult.

Minuchin's account is often summarised through four features of the psychosomatic family:

Hilde Bruch's work on anorexia nervosa also fits this route. Bruch argued that the disorder can involve problems with identity, autonomy and recognising internal states. If a young person feels that ordinary independence is blocked, controlling food intake may become a visible way of saying, "This is mine to control."

These are historical theoretical proposals, not diagnostic descriptions of every family. Close relationships or parental concern alone do not establish enmeshment. The proposed chain is:

1. Enmeshment and overprotectiveness reduce privacy and independence.
2. The young person struggles to develop autonomy.
3. Restricting food intake becomes a behaviour that appears controllable.
4. The family may then focus on the symptom, which can maintain the wider pattern.

Research support: Strauss and Ryan (1987) administered autonomy, object-relations and family-environment measures to 19 restrictive anorexia nervosa participants, 14 bulimic anorexia nervosa participants and 17 controls. The anorexia nervosa groups showed more autonomy-related difficulties, poorer self-concept and more disturbed family interactions than controls. This supports the idea that autonomy problems can be prominent in anorexia nervosa.

Latzer and Gaber (1998) compared 40 family triads with daughters diagnosed with anorexia nervosa and 40 matched control triads. The anorexia nervosa families had more difficulty choosing a conflict topic, staying with it, exploring it and reaching a solution. This is consistent with conflict difficulties in this sample. Because families were studied after diagnosis, increased concern or conflict could also be a response to illness; it does not establish a pre-existing family cause.

AO3 caution: Family systems concepts can be difficult to define and measure. Enmeshment, rigidity and control may be interpreted differently across studies. The theory can also become gender biased if it focuses too heavily on mothers and daughters while ignoring fathers, siblings, culture, biology and the young person's own thinking.

AO2 example: Anoushka is 16. Her parents expect to know where she is at all times, her mother enters her room without knocking, and family arguments are quickly shut down. A family systems answer would identify enmeshment and conflict avoidance. It would then explain that food restriction could become one of the few ways Anoushka feels able to assert autonomy and control.

Social learning theory

Social learning theory explains how observing valued models and their rewards can influence eating-related behaviour.

Social learning theory applies Bandura's ideas to anorexia nervosa. A person may observe food restriction, dieting, body-checking or the pursuit of thinness in a parent, sibling, peer, celebrity or influencer. If the model is admired, similar, attractive or high status, the observer is more likely to pay attention and imitate them.

In this explanation, reinforcement can be direct or vicarious. A person may be directly praised for weight loss. They may also observe someone else being praised, followed, admired or treated as disciplined because of thinness. This can make restrictive eating seem socially valuable.

Media matters because it provides symbolic models. A celebrity, edited image or fitness influencer does not need to be physically present to shape norms. The learner may identify with the model and internalise the idea that thinness brings beauty, status, control or success.

Research support: Dittmar et al. (2006). Helga Dittmar, Emma Halliwell and Suzanne Ive studied 162 British girls aged 5 to 8. Girls were exposed to images of Barbie dolls, Emme dolls or neutral control images. In the younger girls, exposure to Barbie images was associated with lower body esteem and a greater desire for a thinner body shape than the comparison conditions; the effect was not uniform across age groups. This supports the idea that thin-ideal models can influence body dissatisfaction, although the study measured immediate body image effects rather than clinical anorexia nervosa.

Research support: Becker et al. (2002). Anne Becker and colleagues studied ethnic Fijian adolescent girls around the introduction of television in Nadroga, Fiji. In 1995, soon after television arrived, 63 girls were assessed; in 1998, after three years of exposure, 65 girls were assessed. High EAT-26 scores increased from 12.7% to 29.2%, and self-induced vomiting to control weight rose from 0% to 11.3%. This supports a media-influence explanation, especially because traditional Fijian culture had valued a more robust body shape.

AO3 caution: Becker et al. used two different samples, so the 1998 group was not individually measured before television exposure. Concurrent social change and differences between samples are alternative explanations; neither television nor modelling was isolated by random allocation. High screening scores are not diagnoses of anorexia nervosa. A further limitation is that almost everyone is exposed to media thin ideals, but only a minority develop anorexia nervosa. Social learning is therefore better seen as a risk or trigger process, not a complete explanation.