Some people think that anorexia nervosa is just about food, body shape, or weight. But the reality is much more complicated. Anorexia is caused and sustained by a complex interplay of factors that lead to a dangerous preoccupation with body shape and weight – and the harmful behaviours that result from it.
The cognitive interpersonal maintenance theory of anorexia helps us to understand these factors and how they combine to maintain the condition. In particular, it emphasises the key role of interpersonal factors (the way someone with anorexia nervosa interacts with other people) in maintaining anorexia.
But the cognitive interpersonal maintenance theory of anorexia nervosa isn’t just about understanding the illness. It also has hugely important implications for treatment. Once we recognise the role of cognitive and interpersonal factors in sustaining the condition, we also expose the key to treatment and recovery.
What Is Cognitive Interpersonal Maintenance Theory?
The cognitive interpersonal maintenance theory of anorexia says that anorexia is caused and maintained by a combination of interpersonal, socio-emotional, and cognitive factors.
- Interpersonal factors refer to a person’s relationships with others. This includes things like social isolation and avoidance of close relationships. Interpersonal factors are influenced by both a young person’s own personality traits and the reaction of other people to their illness.
- Socio-emotional factors describe emotional and social traits such as sensitivity to stress and social anxiety.
- Cognitive factors are about the way that a young person thinks or ‘thinking styles’. This might include difficulties shifting attention from one task to another or seeing the ‘big picture’.
Cognitive-interpersonal maintenance theory is based on the idea that anorexia is not just about food or eating. Instead, a complex relation of social, emotional, and cognitive factors underpin the disorder. This means that treatment for anorexia – especially when the illness has gone on for some time – needs to address all of these factors, rather than focusing on eating patterns and routines.
Predisposing Factors and Maintaining Factors
The cognitive-interpersonal maintenance model refers to both predisposing and maintaining factors for anorexia nervosa.
- Predisposing factors are emotional, social, and cognitive factors that make a young person more likely to develop anorexia.
- Maintaining factors cause disordered eating attitudes and behaviours to keep going. This includes predisposing factors – personality traits and behaviours that were present before the onset of an eating disorder – but also those that develop later as a result of the illness.
Predisposing factors – such as personality traits and ways of thinking – make young people more vulnerable to developing eating disorders. They contribute to the development and continuation of eating disorder attitudes and behaviours and cause problems in relationships with others. Interpersonal problems, in turn, often play a key role in the development and maintenance of eating disorders.
At the same time, the reactions of other people to eating disorder symptoms and behaviours make interpersonal difficulties even worse. They may increase social isolation and perceptions of being judged by others.
As young people withdraw even more socially, eating disorder thoughts and behaviours increasingly dominate their inner and outer world.
What Are Some Predisposing Factors for Anorexia Nervosa?
Cognitive-interpersonal maintenance theory describes several key traits that make young people more likely to develop anorexia and help maintain it. This includes obsessive-compulsive traits, avoidance of close relationships with others, and anxieties about expressing emotions.
Obsessive-Compulsive Traits
Obsessive-compulsive traits are a set of character traits related to intrusive, reoccurring thinking patterns and compulsive behaviours that seek to resolve obsessive thoughts. Disordered eating attitudes and behaviours typically resemble obsessive-compulsive behaviours. For example, young people with anorexia are preoccupied with thoughts about body shape and weight. They may use disordered eating behaviours to try and alleviate anxieties or distress connected to their bodies.
Some experts suggest that obsessive-compulsive traits are rooted in certain cognitive tendencies. In particular, they refer to ‘set-shifting’ and ‘central coherence’.
- Set-shifting is the ability to move back and forth between different tasks unconsciously. People with anorexia may struggle with set-shifting, instead focusing on rigid thought patterns, such as preoccupations with weight and shape.
- Central coherence is the ability to step back and see the bigger picture. Young people with weak central coherence may be more likely to focus on details of eating and exercise patterns or aspects of their body shape or weight.
Some evidence suggests that cognitive functions like central coherence become weaker as eating disorders progress. This might happen because of the effects of malnutrition and starvation on the brain. As a result, recovery can become even more difficult.
Avoiding Emotions and Social Situations
The cognitive interpersonal maintenance theory of anorexia emphasises the interpersonal difficulties that often exist before someone develops the disorder. Traits like shyness, feelings of inferiority, and high levels of social anxiety can result in a lack of close friendships, loneliness, and limited social support.
The limited social support that young people may have at the start of their eating disorder often becomes even less as their illness progresses.
Understanding Others Emotions
Young people who develop anorexia may find it more difficult than others to read facial expressions and interpret other people’s emotions. They may also be less able to understand emotional meaning from people’s voices or body language.
These traits may make it harder to form and maintain supportive friendships.
Expressing Emotions
Adolescents and young adults with anorexia may also be less likely to express their emotions through words, body language, or facial expressions. This can act as a barrier to meaningful, open communication with others.
Research suggests that some aspects of social communication improve when people recover from anorexia. When the brain is starved of nutrients and energy, it may lose some of its capacity for social connection. In particular, the production of the hormone oxytocin – a key facilitator of emotional communication – is noticeably altered in acute stages of anorexia.
How Do Interpersonal Difficulties Maintain Anorexia?
Evidence suggests that personality traits – that may be intensified during the course of the illness – cause interpersonal difficulties that contribute to and maintain anorexia.
When young people are sensitive to social hierarchies and criticism from others, they may be more likely to perceive inadequacies in their appearance, body shape, or weight. With limited social networks and social support, they may place increasing time and focus on their eating habits.
Without the perspective and distraction of friends and social activities, eating disorder thoughts are allowed to dominate a young person’s life. Young people may find themselves in a vicious cycle of fewer social skills, social withdrawal, and increased eating disorder symptoms.
The reactions of other people to a young person’s illness are also important. Both criticism and over-protection from family and friends can create even more distance in relationships. On the other hand, showing more warmth and listening to a young person can help to bring them closer.
What Does the Cognitive Interpersonal Maintenance Theory Tell Us About Treatment for Anorexia?
The cognitive interpersonal maintenance theory of anorexia shows us that treatment and recovery from eating disorders aren’t just about food or eating. Instead, treatment should also focus on building or rebuilding meaningful and supportive relationships with other people, helping them develop a more holistic and realistic view of the world and themselves.
Some treatment modalities that can support this process include psychoeducation, family therapy, and specific talking therapies.
Psychoeducation for Young People, Families and Friends
Understanding the complex interplay of factors that underpin anorexia can go a long way in the recovery process. It’s important to recognise that biological changes resulting from the illness can make overcoming harmful thoughts and behaviours more difficult. Not only does this understanding encourage compassion and patience, but it also offers hope that things will be easier in the future.
Recognising the importance of interpersonal relationships helps families and friends focus on creating warm relationships full of listening, attention when it matters, and respect. It also helps them understand why social communication may sometimes be strained – and develop ways to communicate better in the future.
Family Therapy
Family therapy sessions can teach loved ones the skills they need to build stronger relationships within the family, prevent isolation, and offer ongoing support. Families usually spend hours every day with a young person, so improving this time together can make a big difference.
Families of young people with eating disorders often share some of the social difficulties that predispose young people to the condition. In therapy sessions, they may learn skills that support better social communication – such as expressing emotions, understanding how other family members are feeling, and finding collaborative and inclusive approaches to care.
Family members may also learn the basic skills of motivational interviewing. This involves reflective listening and affirming a young person’s speech when necessary, such as when they are orientated towards positive change. This helps young people to have a positive self-image and drive for recovery.
Tailored Talking Therapy
Some researchers have developed talking therapy approaches that specifically address the cognitive functions that can lead to social isolation. For example, they may target complex forms of brain function that are affected by severe illness. This might include changing the way that young people perceive social situations so they are less threatening and anxiety-inducing.
There is some evidence to suggest that pharmaceutical treatment (medication) could also support the recovery process. For example, oxytocin may improve the effectiveness of social interventions and encourage positive bonding.
The Wave Clinic: Transformative Recovery Programs for Young People
The Wave Clinic offers specialist recovery programs for adolescents and young adults with eating disorders and other mental health concerns. We take a whole-person approach to mental health care, supporting young people to discover new life paths, build life-long friendships with others, and develop the skills they need to follow their dreams.
We place family and connection at the centre of our treatment programs. We involve family members collaboratively from the start of our treatment experiences, inviting them to our centre for a week of family therapy, new memories, and enriching adventures. We offer skills learning, psychoeducation, and family systems modules, nurturing close, caring, and mutually supportive family bonds that last.
The Wave is a Global Centre of Excellence for the treatment of eating disorders. We apply our exceptional expertise to every young person’s journey. If you want to find out more, get in touch today.
