case study for eating disorders alexis

• Open access
• Published: 13 October 2021

Stressful life events among individuals with a history of eating disorders: a case-control comparison

• Selma Ø. Lie 1 , 2 ,
• Cynthia M. Bulik 3 , 4 , 5 ,
• Ole A. Andreassen 6 , 7 ,
• Øyvind Rø 1 , 2 &
• Lasse Bang 1 , 8  

BMC Psychiatry volume  21 , Article number:  501 ( 2021 ) Cite this article

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Experiencing stressful life events (SLEs) can negatively impact mental health and increase risk for psychiatric disorders including eating disorders (EDs). Previous research has shown that childhood sexual abuse is associated with some EDs, but less is known about the association between other non-sexual SLEs and EDs.

A case-control study of individuals with ( n  = 495, age mean ± SD = 29.1 ± 9.8 years) and without ( n  = 395, age = 30.2 ± 11.7) self-reported lifetime history of EDs was conducted to compare history of self-reported SLEs. Participants reported history of sexual (e.g., rape, other sexual assault) and non-sexual (e.g., emotional abuse, assault, bereavement) life events using an adaptation of the Stressful Life Events Screening Questionnaire. Individuals with EDs were divided into ED subtypes along the restricting – binge eating/purging spectrum to examine subtype differences. Logistic regressions were conducted for each SLE and ED subtype to obtain odds ratios (ORs). We report p -values corrected for multiple comparisons.

Exposure to any SLE was significantly more common in individuals with EDs than in controls (OR = 2.47, p  < .001). Specifically, rape, other sexual assault, and emotional abuse were significantly more common among individuals with a history of binge-eating/purging ED subtypes (ORs = 2.15–3.58, p ’s < .01) compared with controls. Furthermore, history of life-threatening disease and loss of a close relative/partner/friend were associated with some ED subtypes. The association between SLEs and EDs was stronger for individuals who had experienced multiple SLEs.

By investigating a range of different SLEs, we showed that both sexual and non-sexual SLEs were more common in individuals with a history of EDs (binge-eating/purging subtypes) than controls. Results highlight the importance of assessing a variety of past SLEs in risk assessment for different EDs.

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Introduction

Anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) are eating disorders (EDs) characterized by dysregulated food intake. Both genetic and environmental risk factors have been implicated in the development and maintenance of EDs [ 1 , 2 ]. Negative or stressful life events (SLEs) are among many environmental risk factors that have garnered interest in the ED field. In the context of this paper, we consider all negative and potential stressful life events together, including various forms of abuse, assault, bereavement, car accidents, being threatened, been diagnosed with a serious disease, etc. Many of these events are commonly referred to as ‘traumas’, but considering the diversity of events included we collectively refer to these as SLEs. Childhood maltreatment, particularly sexual abuse, is among those most studied and has been implicated as a risk factor for the development of EDs [ 3 , 4 , 5 ], and a predictor of treatment dropout [ 6 , 7 ]. A meta-analysis by Molendijk and colleagues [ 4 ] found that childhood maltreatment was two to four times more common among individuals with EDs than healthy controls, and was associated with more severe ED symptoms, earlier onset age, and more frequent binge-eating and purging behaviours.

To date, associations between SLEs and EDs are more consistent for binge-eating/purging subtypes (i.e., BN and BED) than restricting (i.e., AN) subtypes [ 3 , 4 , 8 , 9 , 10 , 11 , 12 ]. A recent review of published risk factor meta-analyses investigating a range of risk factors found evidence for childhood sexual abuse as a risk factor for BN, while the evidence was weaker for the other ED subtypes [ 13 ]. A stronger association between adverse events and binge-eating/purging behaviors has also been reported in individuals with AN, where both childhood and adult sexual abuse were more commonly associated with the binge-eating/purging subtype (AN-BP) than the restricting subtype (AN-R), and was associated with more posttraumatic stress disorder (PTSD) symptoms, emotion dysregulation, and treatment dropout [ 14 , 15 , 16 ]. Thus, converging evidence suggests that SLEs, both in childhood and later in life, may be selectively associated with binge-eating/purging EDs. The evidence is more mixed for AN, and few studies directly address differences between AN-R and AN-BP.

Although the majority of research on SLEs in EDs has focused on childhood sexual abuse [ 5 , 17 , 18 , 19 ], other types of childhood SLEs have also been associated with EDs, including physical and emotional abuse [ 4 , 20 , 21 ]. Studies investigating lifetime SLEs in different populations have found increased risk of ED symptoms in victims of sexual assault [ 22 , 23 , 24 ] and in female war veterans who have experienced traumatic events and/or assaults [ 25 ]. A range of relatively common childhood events such as parental illness, parental divorce, changing schools, and bullying, have also been asociated with EDs [ 26 , 27 , 28 ]. Despite a rich literature highlighting many different types of traumatic or stressful events as significant predictors of risk for mental problems [ 29 ], we know little of how common various SLE exposures are among individuals with EDs.

As such, exisiting research supports an association between different SLEs and some EDs, with the most conclusive evidence available for highly traumatic experiences such as sexual abuse. Less is known about other stressful life experiences, and studies investigating other types of SLEs throughout life and their potential associations with different EDs are scarce. Also, few studies have directly investigated how different SLEs are associated with specific EDs (including the two AN subtypes). This has been identified as an important topic for research in recent literature [ 13 , 30 ], and could have implications for our understanding of the etiology and treatment strategies for EDs.

The current study explored history of SLEs in individuals with a lifetime history of EDs and controls. Specifically, we investigated a) whether exposure to a variety of SLEs differed between individuals with a history of EDs and controls, and b) if the association was stronger for individuals who had experienced multiple types of events. Moreover, we explored differences in SLE exposure across different ED subtypes and report results separately for each subtype compared with controls. The main hypothesis was that SLEs would be more prevalent in individuals with EDs than in controls. We also hypothesised that the association between SLEs and EDs would be stronger for binge-eating/purging subtypes than restrictive subtypes, and that it is more common for individuals with EDs to experience multiple types of SLEs.

The present study used data from the Eating Disorders: Genes & Environment (EDGE) project; a cross-sectional study of Norwegian adults investigating a variety of risk factors for EDs. The study was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (#2017/0606), and all procedures were performed in accordance with ethical guidelines and regulations. All participants provided written informed consent.

Participants and procedures

Norwegian residents over the age of 16 were invited to participate in the study by completing an online test battery including questions regarding ED history and experiences of SLEs. Individuals with and without lifetime EDs were invited to participate, and recruitment was targeted at user organisations for EDs and specialised ED treatment units in Norway to reach individuals with a lifetime ED. Recruitment through online/social media platforms (e.g., websites, Facebook), and flyers and posters at Norwegian universities targeted both case and control participants. Data were collected between June 2019 and January 2020.

The ED100K (see below) was used to classify cases and controls according to the presence or absence of lifetime DSM-5 EDs [ 31 ]. A total of 890 participants were classfied as either cases ( n  = 495) or controls ( n  = 395) according to DSM-5 criteria. Individuals with BN and/or BED (BN/BED n  = 180) were combined in one group due to the considerable overlap between the two subtypes in lifetime diagnoses. In addition, previous research has found associations between SLEs and the shared symptomatology of these subtypes (i.e., binge-eating), suggesting that there may be underlying processes that are distinct for binge-eating/purging type disorders when compared to EDs characterised by restricting behaviours [ 4 , 32 ]. AN was divided into the two subtypes (AN-R n  = 65 and AN-BP n  = 114) to further explore this hypothesis. A mixed ED group (AN/BN/BED n  = 133) included all individuals who at some point in their life had met criteria for both AN and BN and/or BED, further emphasising the high crossover between the ED diagnoses over time. We were unable to determine subtype for three individuals in the ED group who were excluded from the subtype analyses. We also calculated the ED onset age, defined as the earliest age of clinically significant symptoms (e.g., low weight, frequent binge eating, compensatory behaviours such as purging, etc.).

ED100K . The self-report measure ED100K (version 2) was used to assess lifetime history of AN, BN, and BED according to DSM-5 criteria [ 33 ]. The ED100K has shown good predictive validity for the different ED types when validated against the Structural Clinical Interview (SCID) for DSM-5 [ 33 ], The measure was adapted to fit the study design and was translated into Norwegian (then back-translated to ensure correspondence). The ED100K contains questions about frequency, duration, and severity of core ED features (e.g., weight history, binge eating, compensatory behaviors) and the age of onset for these features. This enabled us to distinguish between ED cases and controls as well as assigning the individuals with EDs to different subtypes.

Stressful life events screening questionnaire - adapted (SLESQ). The SLESQ is a validated instrument to assess history of different types of stressful events in clinical and non-clinical populations [ 34 ]. The current study used an adapted version of the Norwegian translation developed by Thoresen and Øverlien [ 35 ]. Twelve different items (SLEs) were included in the current study; disease (serious/life threatening), accident (serious/life threatening), assault (e.g., physical attack or robbery), bereavement (loss of a close relative, partner, or friend), rape, other sexual assault (unwanted sexual contact/touching), childhood physical abuse (before 18 years of age), adulthood physical abuse (after 18 years of age), emotional abuse, threatened (with a weapon or by threat of force), witnessed (witnessed a situation where another person was hurt, died, or was abused), and other (any other situations of serious threat to life, health, or safety; this item was not specified further). The complete list of questions is included in Table  1 . For each of these items, the participants indicated whether they had experienced the event (“yes” or “no”), and at what age (first occurrence). For some items (rape, other sexual assault, adulthood physical abuse, childhood physical abuse, emotional abuse, threatened), we also asked how many times the event in question had occured. In addition to the individual items, all participants who responded “yes” to one or more events were coded as “yes” on an overall “Any SLE” variable.

Eating disorder examination-questionnaire (EDE-Q). The EDE-Q is a self-report measure assessing ED psychopathology in the past 28 days [ 36 ], and a Norwegian translation has been previously validated [ 37 ]. For the present study, only the global EDE-Q sum scores were used to compare current ED symptoms and behaviours in cases and controls. The measure demonstrated good internal consistency: α  = .96 for controls and α  = .95 for the ED group.

For the main analysis, logistic regressions were performed for SLEs comparing each of the ED diagnostic groups with the control group. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported as a measure of effect for each comparison. In all regression models, ED outcome (subtype) was the dependent variable, and the specific SLE (e.g., rape) was entered as a dichotomous predictor (independent variable). We added gender, age, and education as covariates in all models as these variables have been associated with EDs [ 1 ], and to reduce recall bias. Unadjusted regression models were conducted without covariates, but these are not reported as the overall pattern of results was similar to the adjusted model.

To investigate whether individuals with EDs had experienced a higher number of SLEs than controls, three levels of SLE exposure were defined: none, one or two types, three or more types. As the measure of SLE number was heavily skewed (majority, > 75%, of participants had experienced between zero and four SLE types), this categorisation was preferred over the continuous measure to specifically compare low (0), medium (1 or 2), and high (≥3) exposure to SLEs while securing relatively even numbers in all groups. This variable was then used to perform logistic regressions comparing the different levels of SLE exposure as predictors for ED outcome (with gender, age, and education as covariates).

Separate analyses of variance (ANOVAs) were used to compare differences in continous variables between case and control groups.

In all models, alpha levels were adjusted using the Bonferroni-Holm correction for multiple comparisons within each family of tests. To ease interpretation, we report corrected p -values and p  < 0.05 was considered statistically significant. All analyses were conducted using R version 4.0.3 [ 38 ].

Participant characteristics

Table  2 shows sample characteristics. The sample comprised individuals between the ages 16–78 years (M = 29.5 ± 10.6), and was predominantly female (95%). The lifetime ED group did not differ from controls on age or current body mass index (BMI, kg/m 2 based on self-reported weight and height). The majority (89%) of the ED group reported having received treatment for an ED, and they had a higher EDE-Q global score than controls ( p  < .001). The control group had significantly higher completed education ( p  = .002); more individuals had completed university education ≤4 years in the control group (28.9%) than the ED group (18.4%). The average age of ED onset was 15 years, and the average age reported for any SLE was between 10 and 14 years for the dfferent ED subtypes. Frequency and age for the different SLEs are listed in Table  3 .

Are SLEs more common in individuals with EDs than controls?

A total of 81% of all individuals with lifetime EDs had experienced one or more SLEs, compared to 65% in the control group. Many of the SLEs assessed were events that are commonly experienced throughout a lifetime (e.g., bereavement) and we therefore expected the majority of both cases and controls to report at least one SLE. Of the total ED sample, 56% had experienced one or more SLEs prior to ED onset. Of all the individuals in the ED group who reported a history of SLEs, 68% reported that at least one of the SLEs had occurred prior to ED onset age. The overall case-control comparison of exposure to any SLE in individuals with and without lifetime EDs yielded an OR of 2.47 (95% CI 1.80–3.40, p  < .001). Individuals in the AN-BP, BN/BED, and AN/BN/BED groups had significantly higher frequency of any SLE than individuals in the control group (all p’ s < .05; see Table  4 ). Individuals with AN-R did not differ significantly from controls in overall SLE history ( p  > .05).

What types of SLEs are associated with the different EDs?

The most commonly reported specified SLE in both ED and control groups was emotional abuse (43 and 21%, respectively). The second most common was other sexual assault (35% of ED group, 19% of controls), followed by rape for the ED group (28% of ED, 14% of controls) and child physical abuse for the controls (22% of ED, 16% of controls). This pattern was similar for each of the ED subtypes, except for AN-R where other sexual assault (26%) was more common than emotional abuse (23%). This is shown in Table 3 .

Of all the specified SLEs in the study, three events reached significance (all p  < .05) for the three groups AN-BP, BN/BED, AN/BN/BED compared with controls: rape, other sexual assault, and emotional abuse (Table 4 ). Disease was significant for the AN-BP ( p  = .029) and the AN/BN/BED ( p  = .018) groups, and bereavement was significant for the BN/BED group only ( p  = .038). In addition, individuals in all ED groups (including AN-R) scored significantly higher than the control group on the SLE category “other”, which was also the most commonly reported of all the SLE items across all groups.

Follow up analysis for the SLEs reaching significance for the three binge/purge ED groups (rape, other sexual assault, and emotional abuse) revealed no significant differences in age of event between groups except for a slightly lower age for rape in the mixed AN/BN/BED group (M = 12.3 ± 6.2) than controls (M = 16.3 ± 6.0; p  = .028). The frequency of sexual assault was also higher in the BN/BED (M = 2.5 ± 1.19) group than in controls (M = 1.59 ± 0.86; p  < .001). No other group differences in frequency were significant. In the ED sample as a whole, the proportion of reported SLEs that had occurred prior to ED onset age was 43.1% for rape, 56.6% for emotional abuse, and 49.4% for other sexual assault.

Is the association between SLEs and EDs stronger for individuals with a history of multiple SLEs?

Individuals with EDs reported experiencing a higher number of different SLEs (M = 2.6, M dn  = 2) than individuals in the control group (M = 1.6, M dn  = 1; p  < .001). The overall case-control comparison showed that individuals in the ED group were significantly more likely to have experienced three or more SLEs (OR 2.08, 95% CI 1.49–2.90), than one or two SLE types (OR 1.82, 95% CI 1.30–2.57) compared with controls (see Table  5 ). Apart from the AN-R subtype, a pattern emerged that was consistent with a cumulative effect of multiple SLE types for all subtypes (AN-BP, BN/BED, AN/BN/BED). Thus, there was support for an association between binge-eating/purging EDs and SLEs that was stronger for individuals with more extensive SLE history.

The current study investigated the history of a variety of different lifetime SLEs in individuals with and without lifetime EDs, differentiated by subtype. Individuals with binge-eating/purging subtypes of EDs had experienced SLEs more often than controls, and it was more common for these groups to be exposed to multiple types of events. Rape, other sexual assault, and emotional abuse were significantly more common in the ED group as a whole than in the control group, and this held true for all ED subtypes with the exception of AN-R. This is consistent with previous research reporting a stronger association between a range of SLEs and binge-eating/purging EDs than restrictive AN [ 4 , 12 , 26 , 39 , 40 ]. The event category “other SLE” was significantly more common in all ED groups, and certain SLEs (bereavement and life-threatening disease) were more common for only some ED subtypes. The average onset age for both ED onset and SLE was during adolescence, and the majority of SLEs in the ED group occurred prior to ED onset. More than half of the ED group had experienced at least one SLE prior to developing significant ED symptoms, which raises the possibility that such events can be a trigger contributing to the onset of EDs. By assessing a number of different SLEs throughout life, we showed that both non-sexual and sexual SLEs are associated with binge-eating/purging EDs and thus add to the growing knowledge of sociocultural factors in EDs.

Our findings support the observation that exposure to SLEs is more prevalent among individuals with binge-eating/purging EDs than controls. These individuals were between two and three times more likely than controls to have experienced any SLE, with the highest individual associations being for sexual and emotional abuse. The association was also stronger for those with a higher number of different SLEs. This finding is consistent with other research showing a cumulative effect of multiple adversities on a range of negative health outcomes [ 41 ]. The strength of the associations in the present study is comparable to previous studies finding OR’s in the range of 2–3 for different types of adversities including emotional, physical and sexual child abuse, sexual assault, family disruption, parental psychiatric illness, parental teasing, and bullying [ 3 , 26 , 40 , 42 , 43 , 44 , 45 ]. We have previously reported associations between school-age bullying and EDs in the same sample as the present study, with a similar pattern of results [ 28 ]. Together, these findings indicate that history of SLEs is common among individuals with EDs, underscoring the importance of environmental factors in these patient groups.

Various SLEs were more common in individuals with AN-BP, BN/BED, and AN/BN/BED than controls, whereas this was not the case for the AN-R group. While we note that these analyses could be underpowered due to a relatively small sample size for the AN subtypes ( n  = 65 for AN-R, n  = 114 for AN-BP), other studies have found similar subtype differences regarding AN-R [ 14 , 16 ]. Why individuals with restricting ED subtypes would be less likely to have experienced SLEs is unclear. One interpretation is that SLEs and traumas cause behaviors that are characterized by impulsivity, as many studies have found associations between SLEs and other impulsive behaviours and maladaptive coping such as suicide attempts [ 46 ] and substance abuse [ 47 , 48 ] in addition to the more ED specific behaviours binge eating and purging [ 4 , 10 , 49 ]. Behavioural impulsivity has also been shown to mediate the relationship between childhood abuse and binge eating and purging in non-clinical populations [ 50 , 51 ]. Relatedly, personality traits such as sensation seeking and disinhibition have been associated with both BN/BED and victimisation experiences [ 52 ]. In addition, SLEs might differentially affect BN and BED – and different types of SLEs could be related to specific types of binge/purge symptoms. This would be obscured due to the combination of BN and BED in one group in the current study, and would need to be explored in future research.

In line with findings implicating an association between impulsive psychopathologies and SLEs, it has been suggested that AN-R in particular might have a different etiology than other EDs [ 1 , 26 , 53 ]. Different genetic pathways and interactions between genetic profile and traumatic events could thus account for the observed difference between restricting and binge-eating/purging EDs [ 54 , 55 , 56 ]. Genetic research on AN has also found both psychiatric and metabolic genetic correlations [ 57 ], and it is noteworthy that heritability estimates are higher in restricting than binge-eating/purging EDs, possibly suggesting a more biological etiology [ 58 ]. These observations along with the findings in the present study, may indicate that environmental stressors and triggers are more important in the etiology of binge/purge ED subtypes than restricting subtypes, which could have clinical implications for prevention and treatment.

In terms of specific SLEs, our results highlight that a range of SLEs are commonly experienced by individuals with EDs. This is in line with previous findings (e.g., [ 4 , 59 ]). Sexual traumas (rape and other sexual assault) were significantly associated with binge-eating/purging ED subtypes in the current study. This is consistent with previous literature highlighting sexual abuse in childhood [ 3 , 4 , 5 ] and sexual assault and harassment in adulthood [ 23 , 42 , 60 , 61 , 62 , 63 ] as risk factors for ED psychopathology and diagnosis. We also found that emotional abuse was significantly associated with binge-eating/purging EDs. This was common for both cases and controls (20–45%), and resulting ORs were particularly high (2.54–3.27). Emotional abuse has previously been studied mainly in childhood and adolescence and although fewer studies are available than for sexual abuse, the research supports a role of childhood emotional abuse in EDs [ 4 , 16 , 20 , 21 ]. Additionally, bereavement was significantly associated with BN/BED, which is consistent with a recent review highlighting non-abusive family-related risk factors [ 64 ]. Having a serious or life-threatening disease was significantly associated with AN-BP and AN/BN/BED. This could be consistent with previous research implicating immune system disturbances as risk factors for EDs [ 13 , 65 , 66 ], but we cannot rule out the possibility that some participants might have responded “yes” to this item because of their ED—for example in the case of somatically unstable AN or other complications. The final SLE category “other stressful life events” was also significant for all ED groups. This could include a range of different life experiences (for example divorce, financial difficulties, etc.), and indicates that there could be many more SLEs other than «typical» traumatic experiences that could be of interest to investigate in ED populations.

On average, most of the significant events occurred during early to middle adolescence in the present study. Thus, the average age for the significant SLEs associated with EDs was between 10 and 21 years for the different diagnostic groups, indicating that many of these events would have coincided with ED onset age (average 15 years). Indeed, in 68% of the individuals with EDs who reported SLEs, at least one event occured prior to our calculated ED onset age based on presence of symptoms. This is consistent with the notion that these events could be risk factors for the development of EDs [ 2 ], and in line with a handful of longitudinal studies finding increased risk of disordered eating in individuals who have experienced childhood maltreatment or other traumas [ 67 , 68 , 69 , 70 ]. Moreover, in a study by Brewerton et al. [ 71 ], history of victimisation and PTSD symptoms were associated with child onset binge eating, as opposed to adult onset. Thus, the timing of ED onset and SLE occurrence is an important factor to include in future studies. As there are still unanswered questions regarding the mechanisms of the associations between EDs and SLEs, further prospective studies are needed to explore this and extend to a wider range of lifetime experiences.

Although childhood physical abuse has previously been linked to EDs [ 3 , 4 ], both childhood and adulthood physical abuse were among the SLEs not significicantly associated with EDs in the present study. Some of these non-significant associations could be due to low power, as some events were infrequent in both ED and control groups. For example, being threatened was only experienced by 3–9% of individuals in all groups. The low prevalence for some events can be due to cultural and societal factors, as for example childhood maltreatment is less common in Scandinavian countries compared to the US and many other countries [ 72 , 73 , 74 ]. As such, we contribute to the current understanding of stressful life events and EDs by highlighting the role of sexual and emotional stressors, while not ruling out the possibility that other types of events may be important.

The current study used a convenience sample, and recruited participants mainly through online channels. Many of the participants were reached through ED-specific social media accounts and user-forums. This might have biased our sample towards more severe ED presentations, with a higher proportion of AN in the ED case group than what we would expect in the general population. In addition, this sampling method is likely to reach predominantly younger participants, and the sample had an average age of ≈ 30 yrs. (Mdn = 27). We therefore acknowledge that the ED case groups in the current study may not be representative of the ED population at large. However, as previous research has also found, there seems to be a subgroup of individuals with EDs who have a history of SLEs that may be related to the development, maintenance, severity, or clinical presentation of their symptoms. The co-occurrence and relationship between ED symptoms and SLE history has implications for treatment strategies for this group, and we refer to other studies providing in-depth discussions and experiences about the clinical interventions and treatment delivery for these individuals [ 75 , 76 , 77 ].

Our study has a number of limitations. First, we used self-report measures both for establishing ED status and for documenting SLEs. However, we used a comprehensive and previously validated measue (ED100K) for ED assessment and a validated measure for SLEs. Second, the retrospective nature of our study may introduce recall bias, which we attempted to account for by controlling for current age. This design also precludes us from drawing causal inferences, and further studies are needed to explore potential bi-directional relationships or third-variables that could affect the associations between SLEs and EDs. For example, we did not measure PTSD symptoms in the current study and we cannot determine whether the observed differences were influenced by such symptoms. Third, we did not consider events such as for example military experiences or natural disaster, and there could be other events that are associated with EDs not explored in the current study. Fourth, we did not include a psychiatric control group, and the sample was predominantly female. We also lack information regarding race or ethnicity of our sample, but note that the population of Norway is primarily of Northern European descent. Last, we did not directly compare ED subtypes as these comparisons would likely suffer from low power, and we combined BN and BED into one group which prevented us from investigating potential differences in SLE history for these two subtypes.

Conclusions

The current study showed that SLEs were more frequently reported by individuals with binge-eating/purging EDs than controls. While previous studies of SLEs have typically focused on sexual abuse, we queried a number of different events and found that both sexual (e.g., rape, other sexual assault) and non-sexual (e.g., emotional abuse, bereavement) events were more common among individuals with a history of EDs. These events may consistute risk factors, but prospective studies are needed to establish this further. Future studies are also needed to explore if timing of events is important, and whether there is a dose-response relationship between SLEs and EDs. In addition, an interesting avenue for further research is the exploration of potential gene – environment interactions, which may be relevant in the study of risk factor assessment for EDs [ 78 ]. Our results highlight that one or more SLEs are more commonly reported in individuals with ED subtypes marked by binge eating and purging than in controls, and encourage thorough assessment of SLEs to inform case conceptualization, treatment strategies, and risk assessment for this patient group.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Anorexia nervosa binge-eating/purging subtype

Anorexia nervosa restricting subtype

• Binge-eating disorder
• Bulimia nervosa
• Eating disorders

Stressful life event

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Acknowledgements

The authors would like to thank all the participants for their willingness to contribute to this study, and to the Norwegian user organizations ROS and SPISFO for their support and assistance.

This study (via Dr. Bang) is funded by the South-Eastern Norway Regional Health Authority (#2017083). Dr. Bulik acknowledges funding from the Swedish Research Council (Vetenskapsrådet, award: 538–2013-8864). None of the funding bodies had any role in the design, data collection, data analysis, interpretation of data, or drafting the manuscript.

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Selma Ø. Lie, Øyvind Rø & Lasse Bang

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Selma Ø. Lie & Øyvind Rø

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SØL contributed to data collection, data analysis, interpretation of results, and drafted/revised the manuscript. CMB contributed to the conception and planning of the study, interpretation of results, and in revising the manuscript. OAA contributed to the conception and planning of the study, interpretation of results, and in revising the manuscript. ØR contributed to the conception and planning of the study, interpretation of results, and in revising the manuscript. LB secured funding for the study, and contributed to the conception and planning of the study, data collection, interpretation of results, and in revising the manuscript. All authors read and approved the final manuscript.

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Affiliations: Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway (Selma Øverland Lie, Øyvind Rø, and Lasse Bang); Division of Mental Health and Addiction, Institute of Clinical Medicine, University of Oslo, Oslo, Norway (Selma Øverland Lie and Øyvind Rø); Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (Cynthia M. Bulik); Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA (Cynthia M. Bulik); Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA (Cynthia M. Bulik); NORMENT, Institute of Clinical Medicine, University of Oslo, Norway (Ole A. Andreassen); Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway (Ole A. Andreassen); Norwegian Institute of Public Health, Oslo, Norway (Lasse Bang).

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The study and all procedures were approved by the Regional Ethics Committee in Norway, South-East region (REK sør-øst, project id# 2017/1606). All participants signed informed consent to participate. All procedures were performed in accordance with ethical guidelines and regulations.

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CM Bulik reports: Shire (grant recipient, Scientific Advisory Board member); Idorsia (consultant); Lundbeckfonden (grant recipient); Pearson (author, royalty recipient). OA Andreassen received speaker’s honorarium from Lundbeck and Sunovion. Consultant to HealthLytix. The other authors have no conflicts to declare.

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Lie, S.Ø., Bulik, C.M., Andreassen, O.A. et al. Stressful life events among individuals with a history of eating disorders: a case-control comparison. BMC Psychiatry 21 , 501 (2021). https://doi.org/10.1186/s12888-021-03499-2

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Antonella: ‘A Stranger in the Family’—A Case Study of Eating Disorders Across Cultures

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The story of Antonella illustrates the way in which cultural and other values impact on the presentation and treatment of eating disorders. Displaced from her European home culture to live in Canada, Antonella presents with an eating disorder and a fluctuating tableau of anxiety and mood symptoms linked to her lack of a sense of identity. These arose against a background of her adoption as a foundling child in Italy and her attachment problems with her adoptive family generating chronically unfixed and unstable identities, resulting in her cross-cultural marriage as both flight and refuge followed by intense conflicts. Her predicament is resolved only when after an extended period in cultural family therapy she establishes a deep cross-species identification by becoming a breeder of husky dogs. The wider implications of Antonella’s story for understanding the relationship between cultural values and mental health are briefly considered.

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Overlaps and Disjunctures: A Cultural Case Study of a British Indian Young Woman’s Experiences of Bulimia Nervosa

René girard and the mimetic nature of eating disorders, the rise of eating disorders in asia: a review.

• Eating disorders
• Anorexia multiforme
• Cultural values
• Uniqueness of the individual
• Role of animals
• Cross-species identification
• Cultural family therapy

1 Introduction

Eating disorders are a potentially fruitful area of study for understanding the links between values—in particular cultural values—and mental distress and disorder. Eating disorders show widely different prevalence rates across cultures, and much attention has been given to theories linking these differences with variations in cultural values. In particular, the cultural value placed on ‘fashionable slimness’ in the industrialised world has for some time been identified with the greater prevalence of eating disorders among women in Western societies [ 1 ]. Consistently with this view, the growing prevalence of eating disorders in other parts of the world does seem to be correlated with increasing industrialisation [ 2 , 3 ]. In my review of cultural distribution and historical evolution of eating disorders , I was so struck by its protean nature and its variability of clinical presentations of anorexia nervosa that I renamed this predicament ‘anorexia multiforme’ [ 4 , 5 ].

The story of Antonella that follows illustrates the potential importance of contemporary theories linking cultural values with eating disorders though also some of their limitations.

2 Case Narrative: Antonella’s Story

Ottawa in the early 1990s. Antonella Trevisan, a 24-year-old woman, was referred to me by an Italian psychiatrist and family therapist, Dr. Claudio Angelo, who had treated her in Italy [ 6 ] . When Antonella came to Canada to live with a man she had met through her work, Dr. Angelo referred her to me. Antonella’s presenting problems concerned two areas of her life: her eating problems, which emerged after her emigration from Italy, and her relationship with her partner in Canada.

2.1 Antonella’s Predicament

My initial psychiatric consultation (conducted in Italian) revealed the complexities of Antonella’s life. This was reflected in the difficulty of making an accurate diagnosis. Her food-related problems had some features of eating disorders , such as restriction of intake, the resulting weight loss, and a history of weight gain and being teased for it. What was missing was the ‘psychological engine’ of an eating disorder: a drive for thinness or a morbid fear of fatness. Her problem was perhaps better understood as a food-related anxiety arising from a ‘globus’ sensation (lump in the throat) and a learned avoidance response that generalized from one specific situation to eating in any context.

Although it was clear that her weight gain in late adolescence and the teasing and insults from her mother had sensitized her, other factors had to be considered. Antonella showed an exquisite rejection sensitivity that both arose from and was a metaphor for the circumstances of her birth and adoption. Her migration to Canada also seemed to generate anxieties and uncertainties, and there were hints of conflicts with her partner. Was she also re-enacting another, earlier trauma? In the first journey of her life, she was given up by her birth mother (or taken away?) and left on the steps of a foundry. In the first year of her life, Antonella had shown failure to thrive and developmental delays. And she had, at best, an insecure attachment to her adoptive family, predisposing her to lifelong insecurities.

2.2 A Therapeutic Buffet

After my assessment, we faced a choice: whether to treat the eating problem concretely, in purely behavioral terms, or more metaphorically, with some form of psychotherapy. Given the stabilization of her eating pattern and her weight and the larger context of her predicament, we negotiated to do psychotherapy. There were several components to her therapy. Starting with a psychiatric consultation, three types of therapy were negotiated, with Antonella sampling a kind of ‘therapeutic buffet’ over a period of some 2 years: individual therapy for Antonella, couple therapy for Antonella and Rick, and brief family therapy with Antonella’s adoptive family visiting from Italy.

The individual work with Antonella was at first exploratory, getting to know the complex bicultural world of the Italian Alps, how she experienced the move to Canada, examining her choices to move here and live with Rick. Sessions were conducted in a mix of Italian and English. At first, the Italian language was like a ‘transitional object’ in her acculturation process; slowly, as she gained confidence in her daily life, English began to dominate her sessions. Under stress, however, she would revert to Italian. I could follow her progress just by noting the balance of Italian and English in each session. This does not imply any superiority of English or language preferences; rather, it acknowledges the social realities of culture making its demands felt even in private encounters. This is the territory of sociolinguistics [ 7 , 8 ] . Like Italian, these individual sessions were a secure home base to which Antonella returned during times of stress or between other attempts to find solutions.

After some months in Canada and the stabilization of her eating problems, Antonella became more invested in examining her relationship to Rick. They had met through work while she was still in Italy. After communicating on the telephone, she daringly took him up on an offer to visit. During her holiday in Canada, a romance developed. After her return to Italy, Antonella made the extraordinary decision to emigrate, giving up an excellent position in industry, leaving her family for a country she did not know well. Rick is 22 years her senior and was only recently separated from his first wife.

In therapy she not only expressed ambivalence about her situation with Rick but enacted it. She asked for couple sessions to discuss some difficulties in their relationship. Beyond collecting basic information, couple sessions were unproductive. While Rick was frank about his physical attraction to her and his desire to have children, Antonella talked about their relationship in an oddly detached way. She could not quite articulate her concerns. As we got closer to examining the problems of their relationship, Antonella abruptly announced that they were planning their wedding. The conjoint sessions were put on hold as they dealt with the wedding arrangements.

Her parents did not approve of the marriage and boycotted the wedding. Her paternal aunt, however, agreed to come to Canada for the wedding. Since I was regarded by Antonella as part of her extended family support system, she brought her aunt to meet me. It gave me another view of Antonella’s family. Her aunt was warm and supportive of Antonella, trying to smooth over the family differences. A few months later, at Christmas time, her parents and sister visited, and Antonella brought them to meet me. To understand these family meetings, however, it is necessary to know Antonella’s early history.

2.3 A Foundling Child

Antonella was a foundling child. Abandoned on the steps of a foundry in Turin as a newborn, she was the subject of an investigation into the private medical clinics of Turin. This revealed that the staff of the clinic where she was born was ‘paid off to hide the circumstances of my birth.’ As a result, her date of birth could only be presumed because the clinic staff destroyed her birth records. She was taken into care by the state and, as her origins could not be established, she was put up for adoption.

Antonella has always tried to fill in this void of information with meaning that she draws from her own body. She questions me closely: ‘Just look at me. Don’t you think I look like a Japanese?’ She feels that her skin tone is different from other Italians, that her facial features and eyes have an ‘Asian’ cast. With a few, limited facts, and some speculation, she has constructed a personal myth: that she is the daughter of an Italian mother from a wealthy family (hence her hidden birth in a private clinic) and a Japanese father (hence her ‘Asian’ features). It is oddly reassuring to her, but also perhaps a source of her alienation from her family.

At about 6 months of age, Antonella was adopted into a family in the Italian Alps, near the border with Austria. This is a bicultural region where both Italian and German are spoken and services are available in both languages (much like Ottawa, which is bilingually English and French). Her father, Aldo, who is Italian, is a retired FIAT factory worker. Annalise, her mother, who is a homemaker, had an Italian father and an Austrian mother. About her family she said, ‘I had a wonderful childhood compared to what came afterwards.’ Years after her adoption, her parents had a natural child, Oriana, who is 15.

She describes her mother as the disciplinarian at home. Her mother, she said, was ‘tough, German.’ When she visited her Austrian grandmother, no playing was allowed in that strict home. Her own mother allowed her ‘no friends in the house,’ but her father ‘was my pal when I was a kid.’ Although she had a good relationship with her father, he became ‘colder’ when she turned 13. Her parents’ relationship is remembered as cordial, but she later learned that they had many marital problems. Mother told her that she married to get away from home, but in fact she was in love with someone else. Overall, the feeling is of a rigid family organization. Her father is clearly presented by Antonella as warmer and more sociable. She experiences her mother as being ‘tough’. But she is crying all the time, feeling betrayed by everybody.

2.4 A Family Visit from the Italian Alps

When her family finally came to visit, Antonella brought them to see me. At first, the session had the quality of a student introducing out-of-town parents to her college teacher. They were pleased that I spoke Italian and knew Dr. Angelo, who they trusted. I soon found that the Trevisans were hungry to tell their story. Instead of a social exchange of pleasantries, this meeting turned into the first session of an impromptu course of brief family therapy.

Present were Antonella’s parents, Aldo and Annalise, and her sister, Oriana. Annalise led the conversation. Relegating Aldo to a support role. Oriana alternated between disdain and agitation, punctuated by bored indifference. Annalise had much to complain about: her own troubled childhood, her sense of betrayal and abandonment, heightened by Antonella’s departure from the family and from Italy. I was struck by the parallel themes of abandonment in mother and daughter. Mother clearly needed to tell this story, so I tried to set the stage for the family to hear her, what narrative therapists call ‘recruiting an audience’ [ 9 ] . I used Antonella, who I knew best, as a barometer of the progress of the session, and by that indicator, believed it had gone well.

When I saw them again some 10 days later, I was stunned by the turn of events. Oriana had assaulted her parents. The father had bandages over his face and the mother had covered her bruises with heavy make-up and dark glasses. Annalise was very upset about Oriana, who was defiant and aggressive at home. For her part, Oriana defended herself by saying she had been provoked and hit by her mother. Worried by this dangerous escalation, I tried to open some space for a healthy standoff and renegotiation.

Somehow, the concern had shifted away from Antonella to Oriana. Antonella was off the hook, but I waited for an opening to deal with this. I first tried to explore the cultural attitudes to adolescence in Italy by asking how the Italian and the German subcultures in their area understood teenagers differently. What were Oriana’s concerns? Had they seen this outburst coming? The whole family participated in a kind of sociological overview of Italian adolescence, with me as their grateful audience. The parents demonstrated keen insight and empathy. Concerned about Oriana’s experience of the session, I made a concerted effort to draw her into it. Eventually, the tone of the session lightened. Knowing they would return to Italy soon, I explored whether they had considered family work. Since they had met a few times with Dr. Angelo over Antonella’s eating problems, they were comfortable seeing Dr. Angelo as a family to find ways to understand Oriana and her concerns and for Oriana to explore other, nonviolent ways to be heard in the family. I agreed to meet them again before their departure and to communicate with Dr. Angelo about their wishes. On their way out, I wondered aloud about the apparent switch in their focus from Antonella to Oriana. The parents reassured me that they were ready to let Antonella live her own life now.

When they returned to say goodbye, we had a brief session. Oriana and Antonella were oddly buoyant and at ease. The parents were relieved. Antonella had offered the possibility of Oriana returning to spend the summer in Canada with her. I tried to connect this back to the previous session, wondering how much the two sisters supported each other. I was delighted, I said emphatically, by the family’s apparent approval of Antonella’s marriage to Rick. It was striking that, even from a distance of thousands of miles away, Antonella was still a part of the Trevisan family. And Rick was still not in the room.

3 Discussion

In this section, I will consider the impact of cultural and other values on Antonella and those around her and then look briefly at the wider implications of her story for our understanding not only of eating disorders but of mental distress and disorders in general.

3.1 Antonella: Life Before Man

The key to understanding Antonella’s attachments was her passion for her Siberian huskies. In the language of values-based practice , it was above all her huskies that mattered or were important to her. And it is not hard to see why. From the beginning of her relationship with Rick, she used her interest in dogs as a way for them to be more socially active as a couple, getting them out of the house to go to dog shows, for example. As her interests expanded, she wanted to buy bitches for breeding and to set up a kennel. Rick was only reluctantly supportive in this. Nonetheless, they ended up buying a home in the country where she could establish a kennel. Her haggling with Rick over the dogs was quite instrumental on her part, representing her own choices and interests and a test of the extent to which Rick would support her.

Yet the importance to Antonella of her huskies rests I believe on deeper cultural factors, both negative and positive. As to negative factors , these are evident in the fact that from the first days of her life, Antonella was rejected by her birth parents, literally abandoned and exposed, and later adopted by what she experienced as a non-nurturing family. Positive cultural factors , on the other hand, are evident in the way that having thrown her net wider afield, she looked initially to Canada, and to Rick, for nurturance and for identity. Then, finding herself only partly satisfied, she turned to the nonhuman world for the constancy of affection she could not find with people. Her huskies gave her pleasure, a task, and an identity. She spent many sessions discussing their progress, showing me pictures of her dogs and their awards. As it happened, my secretary at the time was also a dog lover who raised Samoyed dogs (related to huskies) and the two of them exchanged stories of dog lore.

As to positive factors , again, is there something, too, in the mythology of Canada that helps us understand Antonella? Does Canada still hold a place in the European imagination as a ‘New World’ for radical departures and identity makeovers? Or does Canada specifically represent the ‘malevolent North,’ as Margaret Atwood [ 10 ] calls it in her exploration of Canadian fiction? Huskies are a Northern animal, close to the wolf in their origins and habits. Bypassing the human world, Antonella finds her identity within a new world through its animals. If people have failed her, then she will leave not only her own tribe (Italy), but skip the identification with Canada’s Native peoples, responding to the ‘call of the wild’ to identify with a ‘life before man’ (to use another of Atwood’s evocative phrases, [ 11 ]), finding companionship and solace with her dogs.

3.2 Wider Implications of Antonella’s Story

Antonella may seem on first inspection something of an outlier to the human tribe. Orphaned from her culture of origin, she finds her place not in another country but by identification with another and altogether wilder species, her husky dogs. Yet, understood through the lens of values-based practice Antonella’s story has, I believe, wider significance at a number of levels.

First, Antonella’s story is significant for our understanding of the role of values – of what is important or matters to the individual concerned – in the presentation and treatment of eating disorders , and, by extension, of perhaps many other forms of mental distress and disorder. Specifically, her story provides at least one clear ‘proof of principle’ example supporting the role of cultural values.

As noted in my introduction, much attention has been given in the literature to the correlations between the uneven geographical distribution of eating disorders and cultural values. Correlations are of course no proof of causation. But in Antonella’s story at least the role of cultural values seems clearly evident. They were key to understanding her presenting problems. And this understanding in turn proved to be key to the cultural family therapy [ 12 ] through which these problems were, at least to the extent of her presenting eating disorder, resolved.

The cultural values involved, it is true, were not those of fashionable slimness so widely discussed in the literature. But this takes us to a second level at which Antonella’s story has wider significance. For it shows that to the extent that cultural values are important in eating disorders , their importance plays out at the level of individually unique persons. In this sense, social stresses and cultural values are played out in the body of the individual suffering with an eating disorder, making her body the ‘final frontier’ of psychiatric phenomenology [ 13 ]. Yes, there are no doubt valid cultural generalisations to be made about eating disorders and mental disorders of other kinds. And yes, these generalisations no doubt include generalisations about cultural values—about things that matter or are important to this or that group of people as a whole. Yet, this does not mean that we can ignore the values of the particular individual concerned. It has been truly said in values-based practice that as to their values, everyone is an ‘ n of 1’ [ 14 ]. Antonella, then, in the very idiosyncrasies of her story, reminds us of the idiosyncrasies of the stories of each and every one of us, whatever the culture or cultures to which we belong.

Antonella’s identification with animals , furthermore, to come to yet another level at which her story has wider significance, was a strongly positive factor in her recovery. As with other areas of mental health, it is with the negative impact of cultural values that the literature has been largely concerned: the pathogenetic influences of cultural values of slimness being a case in point in respect of eating disorders . Antonella’s story illustrates what has been clear for some time in the ‘recovery movement’, that positive values are often the very key to recovery. Not only that, but as Antonella’s passion for her husky dogs illustrates, the particular positive values concerned may, and importantly often are, individually unique.

Not, it is worth adding finally, that Antonella’s values were in this respect entirely unprecedented. Animals , after all, are widely valued, positively and negatively, and for many different reasons, in many cultures [ 11 ]. Their healing powers are indeed acknowledged. Just how far these powers depend on the kind of cross-species identification shown by Antonella, remains a matter for speculation. But, again, her story even in this respect is far from unique. Elsewhere, I have described the story of a white boy with what has become known as the ‘Grey Owl Syndrome’ , wishing to be native [ 12 , chapter 5 ]. Similarly, in Bear , Canadian novelist Marion Engel [ 15 ] portrays Lou, a woman who lives in the wilderness and befriends a bear. Lou seeks her identity from him: ‘Bear, make me comfortable in the world at last. Give me your skin’ [ 15 , p. 106]. After some time with the bear, the woman changes: ‘What had passed to her from him she did not know…. She felt not that she was at last human, but that she was at last clean’ [ 15 , p. 137]. It was perhaps to some similarly partial resolution that Antonella came.

4 Conclusions

Antonella’s story as set out above goes to the heart of the importance of cultural values in mental health. Her presenting eating disorder develops when, displaced from her culture of origin in Italy, and in effect rejected by her birth family, she finds healing only through cross-species identification with the wildness of husky dogs in her adoptive country of Canada. Although somewhat unusual in its specifics, her story illustrates the importance of cultural values at a number of levels in the presentation and management of eating and other forms of mental distress disorder.

And Antonella? I met her again in a gallery in Ottawa, rummaging through old prints. She was asking about prints of dogs; I was looking for old prints of Brazil where my father had made a second life. How was she, I asked? ‘Well …,’ she said hesitantly. Was that a healthy ‘well’ or the start of an explanation? ‘Me and Rick are splitting up,’ she said without ceremony, ‘but I still have the huskies.’ For each of us, the prints represented another world of connections.

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Acknowledgements

The story of Antonella was first published in reference [ 12 ] (pp. 214–220) and presented at the Advanced Studies Seminar of the Collaborating Centre for Values-based Practice in Health and Social Care at St Catherine’s College, Oxford in October 2019. The names and other details of the case have been altered to maintain confidentiality. Parts of the discussion are adapted from that publication and the Oxford seminar. I am grateful to the publishers for permission to reproduce these materials here and to Professor Fulford and the members of the Advanced Studies Seminar for their stimulating exchanges. The subheading to the discussion of Antonella’s story (‘Life before Man’) was inspired by Margaret Atwood’s novel, Life Before Man [ 11 ].

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Vincenzo Di Nicola

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Drozdstoy Stoyanov

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Bill Fulford

Department of Psychological, Health & Territorial Sciences, “G. D’Annunzio” University, Chieti Scalo, Italy

Giovanni Stanghellini

Centre for Ethics and Philosophy of Health Sciences, University of Pretoria, Pretoria, South Africa

Werdie Van Staden

Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China

Michael TH Wong

Guide to Further Sources

For a more extended treatment of the role of culture in eating disorders and family therapy see:

Di Nicola VF (1990a) Overview: Anorexia multiforme: Self-starvation in historical and cultural context. I: Self-starvation as a historical chameleon. Transcultural Psychiatric Research Review, 27(3): 165–196.

Di Nicola VF (1990b) Overview: Anorexia multiforme: Self-starvation in historical and cultural context. II: Anorexia nervosa as a culture-reactive syndrome. Transcultural Psychiatric Research Review, 27(4): 245–286.

Di Nicola, V (1997) A Stranger in the Family: Culture, Families, and Therapy . New York & London: W.W. Norton & Co.

Nasser M and Di Nicola, V. (2001) Changing bodies, changing cultures: An intercultural dialogue on the body as the final frontier. In: Nasser M, Katzman M A, and Gordon R A, eds. Eating Disorders and Cultures in Transition . East Sussex, UK: Brunner-Routledge, pp. 171–193.

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Di Nicola, V. (2021). Antonella: ‘A Stranger in the Family’—A Case Study of Eating Disorders Across Cultures. In: Stoyanov, D., Fulford, B., Stanghellini, G., Van Staden, W., Wong, M.T. (eds) International Perspectives in Values-Based Mental Health Practice. Springer, Cham. https://doi.org/10.1007/978-3-030-47852-0_3

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Eating disorders and psychosis: a review and case report

Affiliations.

• 1 Department of Psychiatry and Mental Health, Baixo Vouga Hospital Centre, Aveiro, Portugal.
• 2 Psychiatry and Mental Health Clinic, São João University Hospital Centre, Porto, Portugal.
• PMID: 33331586
• DOI: 10.1590/1806-9282.66.12.1736

Introduction: The interplay between eating disorders and psychosis is a challenging field to which little attention has been paid. Its study raises conceptual and methodological questions in both areas, making the diagnosis and management of patients difficult. Such questions are addressed and illustrated with a review and case report.

Methods: The authors present the case of a woman with Anorexia Nervosa and with comorbid Shared Psychotic Disorder, based on a literature review regarding the comorbidity between eating disorders and psychosis. The authors conducted a non-systematic review by searching the PubMed database, using the Mesh Terms "anorexia nervosa", "bulimia nervosa", "comorbidity" and "psychotic disorders".

Results: The findings suggest that studies on the subject are limited by issues regarding data on the prevalence of comorbidities, phenomenological aspects of eating disorders, and the interface and integration with psychotic symptoms.

Conclusions: The case presented illustrates the difficulties in managing a patient with a comorbid eating disorder and psychosis. In order to ensure a rigorous assessment of both psychotic and eating disorder symptoms, the focus should be on the pattern of appearance or emergence of symptoms, their phenomenology, clinical and family background of the patient, and clinical status on follow-up.

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Family sues Meta, blames Instagram for daughter’s eating disorder and self-harm

A preteen girl’s “addictive” use of Instagram resulted in an eating disorder, self-harm and thoughts of suicide over several years, according to a lawsuit against the platform’s parent company, Meta. 

The lawsuit, which was filed in U.S. District Court for the Northern District of California late Monday, heavily cites the Facebook Papers , a trove of internal Meta research documents leaked last fall that revealed that the tech giant knew Instagram was worsening body-image and other mental-health issues among teenage girls in particular .

The case was filed on behalf of Alexis Spence, who was able to create her first Instagram account at the age of 11 without her parents’ knowledge and in violation of the platform’s minimum age requirement of 13. The complaint alleges that Instagram’s artificial intelligence engine almost immediately steered the then-fifth grader into an echo chamber of content glorifying anorexia and self-cutting, and systematically fostered her addiction to using the app. The lawsuit was filed by the Social Media Victims Law Center , a Seattle-based group that advocates for families of teens harmed online.

Now 19, the formerly “confident and happy” Spence has been hospitalized for depression, anxiety and anorexia and “fights to stay in recovery every day” as a result of “the harmful content and features Instagram relentlessly promoted and provided to her in its effort to increase engagement,” the lawsuit states.

It is the first lawsuit of its kind to draw from the Facebook Papers while exposing the real human harm behind its findings, Spence’s attorneys say. The suit also features previously unpublicized documents from the leaks, including one in which Meta identified “tweens” as “herd animals” who “want to find communities where they can fit in.” The attorneys argue that such documents demonstrate Meta’s efforts to recruit underage users to its platforms.

“If you look at the extensive research that it [Meta] performed, they knew exactly what they were doing to kids, and they kept doing it,” said the founder of the Social Media Victims Law Center, Matthew P. Bergman, who is representing Spence and her family. “I wish I could say that Alexis’ case is aberrational. It’s not. The only aberration is that she survived.”

Bergman is also representing Tammy Rodriguez, an Enfield, Connecticut, woman who filed a lawsuit in January against Meta and Snap, the parent company of Snapchat, over the companies’ alleged roles in her 11-year-old daughter’s suicide last summer.

Liza Crenshaw, a spokesperson for Instagram, declined to comment on the Spence lawsuit, citing that it is “active litigation.”

But in a Facebook post that Meta CEO Mark Zuckerberg published on Oct. 5, 2021, following the early release of the Facebook Papers, he wrote, “I’ve spent a lot of time reflecting on the kinds of experiences I want my kids and others to have online, and it’s very important to me that everything we build is safe and good for kids.”

He also specifically referred to reporting that showed teenagers suffered more from “anxiety, sadness and eating issues” and noted that “more teenage girls who said they struggled with that issue also said Instagram made those difficult times better rather than worse.”

Katie Derkits, a spokesperson for Snap, said in part in a statement, “While we can’t comment on the specifics of active litigation, nothing is more important to us than the well-being of our community.” She added, “We work closely with many mental health organizations to provide in-app tools and resources for Snapchatters as part of our ongoing work to keep our community safe.”

At the height of her addiction to Instagram, Spence said she had had multiple accounts and would access them for hours in the middle of the night so as not to alert her parents, who had grown concerned by her increasingly hostile and uncharacteristic behavior. One time, she punched a hole in the wall when they tried to take away her device, noted the suit, which attributed her conduct to Instagram’s “addictive design and product features.”

In an interview, Spence recalled how her algorithmically curated Instagram Explore page was brimming for years with “thinspo,” or “thin-spiration,” photos of emaciated young girls and models, which she would then save to look at for “motivation” whenever she was feeling hungry. Instagram also algorithmically recommended accounts for her to follow, including many offering instructions for bulimic purging and extreme dieting, the suit said.

At age 12, Spence drew a picture of herself crying on the floor next to her phone with the words “stupid ugly fat” on the screen and “kill yourself” in a thought bubble. By the time she was 15, she was receiving emergency psychiatric treatment for her anorexia, purging and suicidal ideation, according to the lawsuit.

“It was definitely really traumatizing,” Spence said in an interview. “It’s all images that are now ingrained into my head.”

The Facebook Papers, leaked by former Facebook product manager Frances Haugen, made public internal studies that Meta had conducted over the preceding three years. Meta conclusions contained in the documents included that Instagram makes 1 in 3 female teenage users feel worse about their bodies; the app is addictive by design; and it algorithmically drives vulnerable users toward pro-eating-disorder content. 

Sen. Richard Blumenthal, D-Conn., reported similar findings amid the leaks when his office used a fake Instagram account to pose as a teenage girl.

“Our research has shown, in real time, Instagram’s recommendations will still latch on to a person’s insecurities, a young woman’s vulnerabilities about their bodies and drag them into dark places that glorify eating disorders and self-harm,” Blumenthal said at the time. “That’s what Instagram does.”

Haugen has argued that Instagram’s promotion of harmful content is part of what makes it so addictive.

“What’s super tragic is Facebook’s own research says as these young women begin to consume this eating-disorder content they get more and more depressed, and it actually makes them use the app more,” she said during a "60 Minutes" interview on CBS in October 2021, days before addressing Congress to warn of the damage Instagram has allegedly wrought on the mental health of its younger users. 

Her testimony made Spence’s parents realize that Meta was driving their daughter toward this content. The Spences, who are both teachers, said they had long struggled to understand what had happened to her. The teen now lives with them on Long Island along with her therapy dog, Draco, who alerts them to her self-harm and disordered eating behaviors, and ensures that she is never alone. 

“We started losing her slowly, piece by piece by piece,” Spence’s mother, Kathleen, said in an interview. “There was nothing that we could have done because we were fighting a multibillion-dollar corporation and we have two different interests at heart, and their interest is not my daughter.”

Jesselyn Cook is an investigative tech reporter for NBC News.

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Clinical Case Discussion: Binge Eating Disorder, Obesity and Tobacco Smoking

Marney a. white.

1 Department of Psychiatry, Yale University School of Medicine

Carlos M. Grilo

2 Department of Psychology, Yale University School of Medicine

Stephanie S. O'Malley

Marc n. potenza.

3 Child Study Center, Yale University School of Medicine

This clinical case involves an obese woman requesting treatment for her binge eating and obesity. The information is presented to expert clinicians who provide their thoughts regarding the case, assessment, treatment formulation, and associated clinical and research issues.

Case Description

A 48-year old African American woman presented for treatment for binge eating and weight loss. She presented for treatment following a recent routine physical examination during which her primary care physician noted concerns about her increasing weight. The physician recommended that she try to lose weight but did not provide any specific or further guidance. In light of her previous “failed” experiences with commercial weight loss programs, she decided to seek treatment at a university-based program. At initial evaluation, she was 64 inches tall and weighed 230 pounds yielding a body mass index (BMI) of 39.5, which reflects obesity. She had moderately elevated blood pressure and high cholesterol but was otherwise in good health. The patient completed college and a master's degree in education and had been employed as a special education teacher in the same job for 11 years. She lived with her husband of 24 years, and one of her two adult children. She reported that her relationships with her husband and family were good, that her job was enjoyable and rewarding, and that she had a good circle of close relationships.

Weight and dieting history

The patient reported an onset of overweight during adulthood. She reported having been involved in sports throughout childhood, and although she viewed herself as ‘big-boned’, she did not have body image concerns nor did she recall feeling dissatisfied with her weight or shape when younger. She denied any significant dieting behaviors until age 29. She reported maintaining a weight of approximately 150 pounds (BMI = 25.7) until age 28, at which age she became pregnant with her second child. She reported that she never fully lost the ‘baby weight’ and subsequently began to gradually gain weight throughout her 30s despite numerous dieting efforts. She reported a rapid weight gain of approximately 25 pounds in the past 6 months.

Binge eating

The patient reported an onset of “eating binges” at approximately age 16. The binge eating began soon after she began babysitting for neighborhood children. She estimated that she would engage in binge eating approximately 1-2 times per month which occurred during times that she babysat at night and had access to assorted snack foods. During those times she would ‘load up on junk food’ that the family had provided. She recalled that she would eat chips, cookies, and brownies “non-stop,” and that these eating episodes often lasted throughout the evening. She recalled feeling a loss of control during these episodes and stated that she would continue to eat despite not feeling physically hungry and that she would not stop until feeling physically ill. She reported that she was very embarrassed and secretive about these eating behaviors. She also recalled feeling embarrassed when worried that it was likely that the missing food was apparent to the family for whom she was babysitting. She denied any history of extreme inappropriate weight control or purging behaviors such as self-inducing vomiting or misusing laxatives.

The patient reported infrequent and sporadic binge eating throughout her late teens and early 20s, estimating a frequency of once per month which tended to correspond with social functions. During her 30s, however, the frequency of her binge eating increased considerably and became more regular except during periods of dieting efforts. The patient reported that she had enrolled in commercial weight loss programs approximately five different times, and had, in addition, tried to follow multiple self-help diets. She reported that when she was following a weight loss plan, she could successfully lose approximately 10 pounds, but that she would ‘hit a wall’ and discontinue after about one month of dieting. She reported that in-between diets, her binge eating would resume at a frequency of 2 to 3 times per week, and persist at that level until the next dieting attempt. The patient reported that she had not engaged any formal dieting in the past 18 months, although she frequently skipped meals in an effort to reduce her weight.

Recent course

The patient noted an increase in binge eating frequency approximately six months ago, corresponding with her mother's hospitalization and rapid physical decline. The patient was the primary caregiver for her mother, and noted that the months preceding her mother's death were extremely stressful. She reported that her binge eating increased in frequency to 3 to 4 times per week during her mother's illness, and increased to 6 to 7 times per week following her mother's death.

The patient described her typical binge episode as starting with an evening meal and extending for several hours. Her daily pattern of eating was to skip breakfast, and to consume a standard school cafeteria lunch at 11:30 a.m. She would then not eat again until preparing the evening meal, at which point she would ‘graze’ while cooking. The patient reported that most nights she would eat a ‘normal’ meal with her family, consisting of 5-6 ounces of meat, 2 or 3 types of vegetables, and bread. However, she would then eat the ‘leftovers’ while cleaning up after the meal, such that overall she would have consumed the equivalent of two full meals. She would then eat various foods throughout the rest of the evening until bedtime. During these episodes, she would alternate between salty and sweet snacks. One example binge episode, occurring approximately 30 minutes after the evening meal and spanning the two hours before bedtime, included: a roll of Ritz crackers with 6 ounces of cheese, 2 doughnuts, 4 handfuls of Chex mix, and ½ of a large (12 oz.) Cadbury candy bar.

Smoking History and Cessation

The patient reported that she had recently quit smoking ‘cold turkey’ and had successfully maintained abstinence for four months. She reported quitting smoking following the death of her mother because she died of cancer. She quit smoking without any professional help and without the use of any nicotine replacements or medications to assist with the smoking cessation.

In terms of her smoking history, the patient reported that she began smoking at age 18, that she had successfully quit smoking upon becoming pregnant at age 24, but resumed when she returned to work 11 years ago. She reported a daily smoking frequency of 15 to 20 cigarettes per day. She reported no serious efforts to stop smoking during the past 11 years prior to this recent period of complete abstinence. The patient reported that since quitting smoking, she has experienced more frequent and intense urges to binge eat, and that in the few weeks prior to intake the urges to smoke had increased in frequency and intensity. She reported urges to smoke primarily in the evenings.

Diagnostic Instrument

In addition to a standard intake history, the patient was administered the Eating Disorder Examination (EDE; Fairburn and Cooper, 1993 ). The EDE is a semi-structured investigator-based interview that evaluates current eating behaviors and eating disorder psychopathology. The EDE focuses on the previous 28 days, except for diagnostic items – such as binge eating behaviors - which are assessed for the duration stipulations for each ED. More specifically, the EDE assesses the frequency of different forms of overeating, including objective bulimic episodes (binge eating defined as unusually large amounts of food with a subjective sense of loss of control) and various inappropriate weight control methods (e.g., purging, laxative abuse, etc). The EDE contains four scales reflecting different aspects of ED psychopathology (dietary restraint, eating concerns, weight concern, and shape concern). The EDE is considered the best-established method for assessing and tracking over time the behavioral and cognitive features of EDs and has psychometric support specifically with BED ( Grilo, Masheb, Lozano-Blanco, & Barry, 2004 ; Grilo, Masheb, & Wilson, 2001 ). The interview was administered before treatment and at treatment conclusion to evaluate treatment gains.

The patient was treated with 12 weekly individual sessions of cognitive behavioral therapy (CBT) for binge eating. Expert opinion ( Wilson, Grilo, & Vitousek, 2007 ) and quantitative meta-analytic reviews ( NICE, 2004 ) conclude CBT is the best-established and treatment-of-choice for BED. CBT, a focal and structured treatment, consists of three overlapping phases conducted in a collaborative and interactive method with patients. The first phase focused on educating the patient about the nature of binge eating. Standard behavioral strategies such as self-monitoring and record keeping were used to help the patient identify better her disordered eating patterns while working towards the central goal of normalizing and achieving a structured regular pattern of eating (i.e., not skipping meals). The second phase integrated cognitive procedures to help the patient identify and challenge maladaptive cognitions regarding her eating, possible triggers for dyscontrol, and associated eating/shape concerns. The final phase focuses on consolidating and maintaining the changes and relapse prevention issues.

During the overview of treatment and the ‘meal pattern prescription,’ the patient became tearful, stating that she is not organized enough to follow a meal pattern consisting of three meals and three snacks. She expressed a fear that eating more frequent meals would result in more weight gain, and stated that she was fearful of failing at another weight loss effort. The patient was encouraged to follow the meal and snack pattern as an ‘experiment’ for the first week of treatment. When the patient's fears were alleviated (i.e., disproved owing to weight maintenance during the first week of treatment), she moved through the treatment steps without difficulty. Although she initially voiced concern about the self-monitoring she eventually regarded it as one of the most essential tools that she gained during the treatment.

Overall, at treatment completion the patient's binge eating had remitted fully. She reported no objective bulimic episodes in the last 4 weeks of treatment. Her weight remained relatively stable, with a post-treatment weight loss of five pounds (final weight = 225; BMI = 38.6). Although the patient was pleased to have stopped binge eating, she reported continued distress over her weight and a persisting desire to lose weight.

Carlos M. Grilo, Ph.D.

This clinical case involves a combination of a behavioral (BED) and a physical medical problem (obesity) that often co-occur. This case is also notable for a positive lifetime history of a pharmacological addiction (nicotine) despite not being “active” at the time of presentation for treatment for the eating/weight concerns might nonetheless have important implications. In several respects, this case is fairly typical of BED in obese persons and serves to illustrate a number of important issues facing clinicians and researchers.

Background: Diagnosis, Distribution, and Clinical Features of BED

BED is a specific example of eating disorder not-otherwise-specified (EDNOS) and was included as a “research category” with provisional research diagnostic criteria in Appendix B of the DSM-IV ( American Psychiatric Association, 1994 ). BED is defined primarily by recurrent episodes of binge eating without the regular use of inappropriate compensatory weight control methods (such as purging) that characterize bulimia nervosa (BN). Binge eating is defined as eating unusually large amounts of food while experiencing a subjective sense of loss of control. The research criteria require marked distress about the binge eating and that the binge eating occurs on at least two days per week over the past six months. Unlike the two “formal” eating disorders (anorexia nervosa and bulimia nervosa), the DSM-IV does not include a cognitive criterion pertaining to disturbed body image (i.e., overvaluation of shape or weight) for the diagnosis of BED although such disturbances are present in many patients with BED ( Grilo, Hrabosky, White, Allison, Stunkard, & Masheb, 2008 ). Research has supported the distinctiveness of BED from both other eating disorders (BN) and from obesity without co-existing binge eating (Grilo, Crosby et al., in press; Grilo, Masheb, & White, in press ). A recent critical review of the literature concluded that there exists sufficient empirical evidence to support the inclusion of BED as a distinct and formal ED diagnosis in the DSM-V ( Striegel-Moore & Franko, 2008 ).

Recent epidemiological research has reported a prevalence rate for BED of roughly 3.5% in adult women, which is greater than anorexia nervosa and bulimia nervosa combined ( Hudson, Hiripi, Pope, & Kessler, 2007 ). The distribution of BED is much broader and more diverse than that of the other eating disorders. BED is evenly distributed throughout adulthood and is common in both men and women as well as across ethnic and racial groups ( Hudson et al., 2007 ; Grilo, Lozano, & Masheb, 2005 ). BED is strongly associated with obesity (which is not a required criterion) ( Hudson et al., 2007 ) and therefore with substantially increased morbidity associated with excess weight (e.g., diabetes, metabolic problems). The excess weight in patients with BED is attributable to a combination of binge eating in the absence of weight compensatory behaviors in addition to a general lack of dietary “restraint” that is salient and characteristic of the other eating disorders ( Grilo, 2010 ). Patients with BED who seek treatment are typically older than patients with other eating disorders despite the fact that many report a longstanding duration of the binge eating often dating back to adolescence ( Reas & Grilo, 2007 ). Moreover, unlike the case for the other eating disorders, which most frequently begin following intensive dieting attempts, nearly half of patients with BED report that the onset of their binge eating preceded their first diet ( Reas & Grilo, 2007 ). Regardless of the exact longitudinal sequence, the binge eating and the associated weight gain over time motivate multiple diet attempts over time many of which are not successful ( Reas & Grilo, 2007 ; Roehrig, Masheb, White, & Grilo, 2009 ).

Observations About the Specific Case

I will offer a number of observations regarding this specific case that are illustrative regarding selected issues of relevance to clinicians and researchers. This case is typical in a number of important respects yet it differs in several important ways that I will note with a view of characterizing the heterogeneity of this behavioral disorder. Evolving research has identified a number of treatments that have efficacy for a majority of such patients although two major challenges remain. First, many patients with BED do not get accurately identified, and few receive empirically-supported treatments ( Wilson, Grilo, & Vitousek, 2007 ).

Treatment-Seeking

Although obese patients with BED have elevated psychiatric and medical problems and greater health care utilization patterns relative to their obese peers who do not binge eat, they infrequently seek specialized psychological or psychiatric care for their binge eating. Obese persons who binge eat, along with many generalist health care providers, frequently see the binge eating problem as merely reflecting their obesity and need for better diet and weight loss. In this case, the patient and her physician discussed the need for weight loss, although her binge eating problem was not specifically addressed. Despite not being able to provide the patient with specific guidance, this interaction nonetheless represents an important first step. Many health care providers are uncomfortable in raising or discussing excess weight issues with their patients. This is likely due to a many reasons including, for example, negative biases or views about obesity, personal discomfort, perceived lack of expertise, and concerns about “harming” the therapeutic relationship ( Puhl & Heuer, 2009 ). The patient-physician interaction in this case seemed positive enough to support and motivate the patient to seek more specialized care. It is critically important for generalist health care providers to be receptive and open when discussing their patients' excess weight and potential treatment avenues.

Clinical Presenting Picture

This patient presented with co-occurring obesity and BED. Although she had moderately elevated blood pressure and high cholesterol, she had not yet developed metabolic syndrome although she was clearly at risk to do so along with other medical problems. Thus, her proactive treatment-seeking is certainly a very positive step. This is noteworthy because some research has suggested that black women who are obese and who binge eat are less likely to seek treatment than their white peers until both problems are substantially worse ( Grilo, Lozano, & Masheb, 2005 ; Pike, Dohm, Striegel-Moore, Wilfley, Fairburn, 2001 ). Her primary concern was her increasingly weight gain that started in her 30s despite numerous dieting attempts. More recently, her weight gain had increased markedly and this seemed related, in part, to her increased binge eating behaviors. Based on her clinical history, she did not seem to suffer from body image dissatisfaction or from body image disturbance that are characteristic of eating disorders. The EDE interview provides specific quantification of different aspects of body image disturbance and would yield detailed information regarding behavioral, affective, and cognitive aspects of body image to inform both treatment interventions and to assess changes over time ( Grilo et al., 2001 ). Although the absence of such body image problems in this specific patient signals a less disturbed variant of BED ( Grilo et al., 2008 ) with a positive prognosis ( Masheb & Grilo, 2008a ), treating the obese patient with BED will still remain challenging relative to treating obesity only ( Grilo et al., 2008 ). She did not appear to have significant psychosocial problems either independent or associated with the obesity and BED. Her psychosocial functioning seemed rather positive and this is not uncharacteristic of many patients with BED. Conversely, since it is not uncommon for many patients to have associated psychosocial problems, clinicians should routinely assess for any on-going difficulties as context for formulating and implementing treatment. Importantly, the patient did report a specific life stressor (her mother's death) which seemed associated with an intensification of her binge eating.

Psychiatrically, no additional lifetime or current problems were reported, although no formal structured diagnostic interview was administered. Patients with BED have elevated lifetime rates of psychiatric disorders, including most notably mood, anxiety, and substance use disorders ( Grilo, White, & Masheb, 2009 ), although roughly 25% have never experienced another psychiatric problem. For comprehensive treatment formulation and planning, the presence of other psychiatric disorders should be carefully ascertained. However, it is noteworthy that psychiatric co-morbidity has not emerged as a significant predictor or moderator of outcomes for BED treatments that have empirical support ( Masheb & Grilo, 2008b ; see Wilson et al., 2007 ).

The positive smoking history is especially noteworthy in this patient. Unfortunately, the significance of smoking in this patient group is still poorly understood and is often overlooked by clinicians and researchers alike. This case suggests some potentially important associations among smoking, eating, and weight domains. First, preliminary research suggests that smoking histories are not uncommon in patients with BED and, if present, signal increased risk for psychiatric problems, most notably anxiety disorders ( White & Grilo, 2006 ). Although this patient was not determined to have anxiety disorder co-morbidity, both binge eating and smoking may serve to regulate affect. The exacerbation of the patient's binge eating immediately following her mother's death and her smoking quit attempt can perhaps be conceptualized in this way (i.e., increased binge eating to cope with increased negative affect). Second, preliminary research also suggests that BED patients with smoking histories are characterized by heightened levels of maladaptive and rigid eating and dieting behaviors as well as heightened food “cravings” that must be addressed along with the binge eating ( White & Grilo, 2007 ). Third, weight gain following smoking cessation is common and may be especially problematic for obese patients with BED. A recent study found that obese patients with BED reported gaining significantly more weight following a smoking quit attempt than their non-binge-eating obese peers ( White, Masheb, & Grilo, in press ). This patient's rapid recent weight gain following her most recent smoking quit attempt is consistent with this finding and represents an important clinical challenge because it potentially represents a challenge to continued abstinence.

This patient's eating behavior and patterns are fairly representative of patients with BED. First, binge eating occurs most frequently during evenings, although many patients report having episodes at varying times throughout the day. The large amount consisting of mixed foods often based on availability and ease is typical. Also typical in this patient group is that the binge eating often follows eating behaviors or episodes that are occurring without a sense loss of control. Unlike bulimia nervosa where the binge eating episodes are very clear episodes following excessive restraint, patients with BED are characterized by a more chaotic and amorphous eating pattern. This patient attempts some dietary restraint (skipping breakfast, not eating for long period following lunch) but her eating is fairly continuous throughout the evening. Rather than eating a clear meal (dinner), she appears to eat continuously and during part of this time also experiences a sense of loss of control. Thus, these patients require assistance in several complex tasks including: normalizing and scheduling their eating (i.e., not skipping meals), lessening certain maladaptive restraint behaviors (i.e., not going long periods without eating), increasing certain adaptive restraint behaviors (i.e., not overeating during meals, not grazing or nibbling at odd times), in addition to eliminating the binge eating episodes (Allison, Grilo, Masheb, & Stunkard, 2006; Masheb & Grilo, 2006 ).

Treatment Options

Critical meta-analytic ( NICE, 2004 ) and qualitative reviews ( Wilson et al., 2007 ) of the treatment literature have concluded that cognitive behavioral therapy is the treatment of choice for BED. Studies of CBT for BED consistently report remission rates of 50% or greater along with broad improvements in associated psychological and psychosocial functioning, although weight loss tends to be minimal ( Wilson et al., 2007 ). Different research groups have documented that CBT is superior to other active treatments, including behavioral weight loss therapy ( Grilo & Masheb, 2005 ; Wilson et al., in press ) and pharmacotherapy with fluoxetine ( Grilo et al., 2005 ; Ricca et al., 2001 ), and that the benefits of CBT for BED are well-maintained through 24-months (Wilfley, Wilson, & Agras, 2008) following treatment. There is also some empirical support for two alternative psychotherapies (interpersonal psychotherapy and dialectical behavior therapy) which also produce substantial reductions in binge eating but, like CBT, fail to reduce weight ( Wilson et al., 2007 ). Finally, there is also empirical support for behavioral weight control therapy (structured manualized treatment delivered by professionals but not necessarily for the widely-available commercial programs or self-help diets) for reducing binge eating although findings regarding weight losses are also surprisingly mixed ( Grilo & Masheb, 2005 ; Wilson et al., 2007 ). Lastly, a critical meta-analysis of pharmacotherapy treatment research concluded that certain medications have a clinically significant advantage over placebo for producing short-term remission from binge eating and for reducing weight, although the weight losses tend to be quite modest and of uncertain clinical significance ( Reas & Grilo, 2008 ). The meta-analysis highlighted the potential efficacy of an anti-obesity agent (sibutramine) and anti-epileptic medications (particularly topiramate) but suggested more limited utility of SSRIs given their smaller effects on binge eating and essentially no effect on weight. Unlike the psychosocial treatments, the longer-term effects of these medications are unknown. The few available data from blinded ( Grilo, Masheb, & Wilson, 2005 ) and open-label ( Ricca et al., 2001 ) trials directly comparing the effectiveness of pharmacotherapy and psychological treatments indicate that CBT is significantly superior to SSRIs. In terms of combining approaches, most studies have found that adding pharmacotherapy to psychological approaches has generally not enhanced outcomes ( Reas & Grilo, 2008 ). Noteworthy exceptions are studies that reported adding orlistat ( Grilo, Masheb, & Salant, 2005 ) or topiramate ( Claudino et al., 2007 ) to CBT significantly enhanced the weight losses.

Treatment Course

Thus, it is fortunate that this patient sought treatment at a university-based program where she was offered an empirically-supported treatment. This patient's response to CBT was fairly typical in that she experienced an early and rapid response to the treatment ( Grilo, Masheb, & Wilson, 2006 ; Masheb & Grilo, 2007 ), stopped binge eating entirely by the end of treatment, but unfortunately did not lose weight. Many obese patients with BED fail to lose clinically meaningful amounts of weight despite the substantial reductions in binge eating achieved via CBT, which is not unlike the case for other psychological ( Wilson et al., 2007 ) and pharmacological treatments ( Reas & Grilo, 2008 ). Although the patient failed to lose significant weight (only five pounds), the CBT and presumably the cessation of binge eating were associated with a stabilization of weight. The patient entered treatment following a period of rapid and marked weight gain so the weight stabilization does represent a potentially important first step. Unfortunately, the failure to produce weight loss does leave this patient at risk for developing medical problems and given her frustration and distress about the weight may put her at heightened risk for relapse in both the binge eating and the smoking domains.

Future Directions

Finding ways to produce or enhance weight loss in obese patients with BED represents a major research priority ( Grilo, 2010 ). Interestingly, research has found that combining treatments, for example combining pharmacotherapy, has generally not enhanced outcomes ( Reas & Grilo, 2008 ). Possible notable exceptions have included findings from controlled trials suggesting that adding orlistat ( Grilo, Masheb, & Salant, 2005 ) or topiramate ( Claudino et al., 2007 ) may enhance weight losses achieved with CBT for BED. It has been suggested that greater attention to non-normative eating behaviors and patterns ( Masheb & Grilo, 2006 ) in addition to the CBT focus on normalization of eating meals and reducing binge eating may facilitate greater weight loss. Future treatment studies should include analyses of mediators of outcomes in order to guide the process of improving further our existing treatments ( Wilson et al., 2007 ).

Stephanie S. O'Malley, Ph.D.

This case history highlights the important interface between smoking and binge eating behavior and suggests how treatment of binge eating may have beneficial effects on maintenance of smoking abstinence.

Co-occurring Conditions and Complicating Factors

While smokers tend to be leaner compared to nonsmokers, a significant proportion of obese individuals smoke, placing them at increased risk of attendant health consequences such as diabetes and cardiovascular disease. Smoking related health consequences, experienced by the smoker or another family member, often motivate a smoker to quit as was the case for this patient. However, women compared to men are less likely to remain abstinent from smoking despite a motivating “health shock” for a variety of reasons, including concerns about weight gain. Smoking cessation can result in weight gain at one year of about 11 pounds on average, due to decreased energy expenditure, increased appetite and greater food intake. The degree of weight gain, however, is variable. Binge eating appears to be an important risk factor. In a retrospective study of overweight individuals who had quit smoking, those with significant binge eating problems gained substantially more weight in the year following smoking cessation (24.6 pounds) compared to those without binge eating (11 pounds) ( White, Masheb & Grilo, in press ).

Consistent with this report, this patient recently experienced rapid weight gain that initially began during the stressful period of her mother's illness and coincided with a four-month period of smoking abstinence. Her weight gain of 25 pounds over the recent six months, four of which followed smoking cessation, suggests that without intervention her binge eating is a major risk factor for continued weight gain.

Her maladaptive eating may also place her at risk of smoking relapse. Indeed, she reports that her urges to smoke had increased in recent weeks and were more intense in the evenings. Her pattern of depriving herself of food during the day and then binge eating in the evening could undermine maintenance of smoking abstinence in several ways. Food deprivation can increase the reinforcing effects of drugs, including nicotine, making any lapses to smoking more likely to promote continued smoking. Her efforts to resist eating may also tax her self-control resources and undermine her ability to resist smoking. The evening binge eating episodes she reports follow restricted eating during the day and may result in abstinence violation effects in which she experiences demoralizing recriminations over her loss of control. The resulting increase in negative affect and decreased self-efficacy could promote smoking urges and place her at risk of resorting to smoking to cope with negative affect, a common risk factor for smoking relapse. Finally, the expectation that smoking can limit binge eating is another risk factor for smoking relapse.

Treatment Considerations

Given this conceptualization, the treatment plan for her binge eating may help her also remain abstinent from smoking. The “meal prescription” of regular meals and several small snacks should prevent periods of food deprivation that could increase smoking urges, and diminished frequency of binge eating should increase feelings of self-efficacy and remove the compensatory need for smoking to limit binge eating. The remission of her binge eating and the resulting stabilization of her weight may remove the motivation to resume smoking in an effort to manage her weight.

Cognitive behavioral therapy for eating disorders, including binge eating, also addresses the development of alternative coping skills for handling negative affective states and other triggers of maladaptive eating patterns. Given that many smokers use smoking to cope with negative affective states, teaching her alternative coping skills for handling negative affect is likely to have benefits that generalize and help her maintain abstinence from smoking. The therapist could make this connection explicit by examining the circumstances that elicit the urge to smoke, noting any parallels with the circumstances that provoke binge eating as a coping strategy and emphasizing that the new coping skills learned as alternatives to maladaptive eating could serve as alternatives to smoking as a coping response. Evidence for coping skills therapy targeted to one maladaptive behavior generalizing to another behavior is evident in a study of cognitive behavioral therapy for alcoholism, in which improvements in eating disturbances occurred in addition to reductions in alcohol intake ( O'Malley et al., 2007 ). Learning new coping skills and introducing a regular pattern of eating during the day could ultimately minimize stress, a major precipitant of binge eating and smoking.

In the smoking literature, a recent meta-analysis concluded that smoking interventions that incorporate a weight control component result in short-term (< 3 months) improvements in smoking abstinence and reduced weight gain compared to smoking cessation interventions alone ( Spring et al., 2009 ). In one study, for example, a cognitive behavioral intervention designed to reduce over-concern with weight gain improved smoking quit rates and reduce weight gain compared to standard care or a weight control intervention ( Perkins et al., 2001 ). Further development of CBT interventions for weight concerned smokers may be well served by incorporating additional elements of CBT for binge eating, such as meal patterning, especially for those with a history of binge eating or other eating disorder that may predispose for the development or worsening of eating problems during a quit attempt. Likewise, the clinician should consider smoking history in the management of obese patients who present for treatment of binge eating disorder. As a group, these individuals have higher overall psychiatric co-morbidity and more severe binge eating pathology than overweight individuals without a history of smoking and may require specialized care ( White & Grilo, 2006 , 2007 ).

Marc N. Potenza, M.D., Ph.D.

Diagnostic considerations.

The current case describes the treatment of an individual who has demonstrated seemingly excessive engagement in two domains – tobacco use and food consumption. In anticipation of DSM-V, there exist discussions about how best to define and categorize disorders seemingly addictive in nature, and whether excessive engagement in non-drug behaviors (e.g., pathological gambling) might be grouped together with substance use disorders as addictions ( Petry, 2006 ; Potenza, 2006 ). The current case raises questions about whether excessive eating behaviors manifesting in BED and/or obesity might similarly be considered within an addiction framework, and, if so, how such a conceptualization might influence studies into the etiology, prevention and treatment of “behavioral” and drug addictions ( Grant et al., 2006 ; Holden, 2001 ).

Historically, the term “addiction” has undergone multiple changes in usage. Derived from the Latin word meaning “bound to” or “enslaved by”, the term was originally used independent of drug use. However, several hundred years ago the term became linked to excessive patterns of alcohol use and more recently drug use such that by the time when DSM-III-R was being generated, expert consensus was that “addiction” referred to compulsive drug-taking ( O'Brien et al., 2006 ). More recently researchers have proposed core elements of addiction (continued engagement despite adverse consequences, a compulsive quality, an appetitive urge typically preceding engagement in the behavior, and diminished self-control over the behavior) ( Potenza, 2006 ; Shaffer, 1999 ). If these features are seen as the defining qualities of addiction, then conditions like BED and obesity might be considered as addictions ( Volkow and O'Brien, 2007 ; Volkow and Wise, 2005 ).

Mechanisms and Treatment

Obesity, like addictions, appears to have multiple environmental and biological factors contributing to the disorder ( Gearhardt, Corbin, & Brownell, 2009 ; Gold et al., 2009 ). For example, food availability and advertising may increase the societal rates of obesity ( Brownell, 2004 ), and individual difference factors (e.g., specific genetic allelic variants) may predispose people to greater risks for obesity ( Paracchini et al., 2005 ; van Deneen et al., 2009 ). Arguably, a historical focus on the biological mechanisms underlying obesity has involved metabolism and imbalanced energy homeostasis (i.e., “energy in” and “energy out”) ( Abizaid et al., 2006 ). However, the application of motivational behavioral models to food consumption, like those that have been applied to drug use ( Chambers et al., 2003 ; Everitt and Robbins, 2005 ), may lead to identification of novel factors involved in the pathophysiology of obesity and BED ( Volkow and Wise, 2005 ; Hoebel et al.., 2009 ). Given that neurocircuity implicated in drug abuse appears similarly implicated in obesity (e.g., relatively diminished dopamine D2-like receptor availability in the striatum ( Wang et al., 2004 ; Wang et al., 2009 )), additional research is warranted to understand more completely the biological similarities and differences between drug addictions and obesity. The more complete and precise identification of these similarities and differences could help advance prevention and treatment strategies across disorders. Such a strategy has proven fruitful for pathological gambling, where proposed mechanisms underlying pathological gambling and substance addictions led to the hypothesis that opioid antagonists such as naltrexone, approved for the treatments of alcohol dependence and opioid dependence, would be efficacious in the treatment of pathological gambling ( Brewer et al., 2008 ; Grant et al., 2008 ; Tamminga and Nestler, 2006 ). Analogously, glutamatergic agents (e.g, N-acetyl cysteine) have demonstrated initial promise with respect to weight loss, tobacco smoking, pathological gambling and cocaine dependence ( Souza et al., 2008 ; Knackstadt et al., 2009; Grant et al., 2007 ; LaRowe et al., 2006 ), and further research is needed to further evaluate their efficacies and tolerabilities, particularly amongst dually diagnoses populations.

Specific aspects of the case also warrant mention as they relate to the relationship between disorders, like drug dependence, typically have been conceptualized as addictions and others, like obesity and BED, that typically have not. For example, it is noteworthy that the patient reports having recently quit smoking prior to entering treatment, as well as having had several periods of time of time when she was smoking regularly and others when she had quit for prolonged durations. This pattern raises questions about the natural history of smoking and eating behaviors, both individually and in conjunction. Addictions have historically been considered chronic relapsing conditions, a conceptualization based in considerable part on clinical samples. Epidemiological data suggest that both “behavioral” and drug addictions might follow less pernicious natural histories than originally thought, with many individuals recovering without formal interventions ( Slutske, 2006 ; Tamminga et al., 2006 ). Nonetheless, many individuals do require formal interventions, often on multiple occasions. Furthermore, how one behavioral domain might influence the other is incompletely understood. The phenomenon of “switching addictions”, as is suggested in other domains (e.g., alcoholism and problem gambling ( Potenza et al., 2005 )), may be reflected here in increased food cravings, food consumption and weight gain following smoking cessation, with multiple possible contributing mechanisms related to motivation, metabolic changes, stress reduction, or coping with uncomfortable or dysphoric states, as Dr. O'Malley indicates.

Life stressors appear to play an important role in the patient's clinical course, both with respect to smoking and eating. As such, therapies like CBT that include instruction in healthy coping strategies might be particularly relevant for the patient. From a biological perspective, the neural mechanisms underlying stress responses overlap with those implicated in impulse control and addiction ( Kalivas and Duffy, 1989 ; Piazza and Le Moal, 1996 ). Consistently, identification of specific intermediary phenotypes or endophenotypes in the domains of stress responsiveness and impulsivity would appear to have important implications across a broad range of disorders, including obesity, BED and nicotine dependence ( Blanco et al., 2009 ). As Dr. Grilo notes, combinations of pharmacological and behavioral therapies might be most helpful for BED, and consideration of pharmacological agents that target important intermediary phenotypes will represent important areas of future development.

Concluding Comments and Future Directions

The changes over time in the patient's smoking and eating behaviors highlight the importance of considering behaviors with addictive potential within a developmental framework, particularly as early problems have important implications for adult functioning ( Chambers et al., 2003 ). Early life interventions aimed at developing healthy eating, exercise, stress-coping skills, emotional regulation and general health behaviors at early ages, and particularly involving youth who might be considered high-risk, will be important in preventing the development of a broad range of addictive disorders including obesity ( Merlo et al., 2009 ). Public health interventions like those that appear effective in reducing youth smoking (e.g., increased taxation of cigarettes) warrant consideration for foods associated with obesity ( Brownell et al., 2009 ). It is likely that only through multiple interdisciplinary approaches will we be able to effectively target the public health concerns of obesity and drug addictions, ones that currently are estimated to cost US society hundreds of billions of dollars annually and impart significant personal and familial suffering ( Surgeon General, 2001 ; Uhl and Grow, 2004 ; Potenza and Taylor, 2009 ).

Acknowledgments

Acknowledgments and Disclosures: This work was supported by the NIH grants RL1 AA017539, UL1 DE19586, K23 KD071646, K24 DK070052, R01 DK49587, RC1 DA028279, P50 AA015632, NIH Roadmap for Medical Research/Common Fund, and the VA VISN1 MIRECC. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of any of the funding agencies. Dr. Potenza has received financial support or compensation for the following: Dr. Potenza consults for and is an advisor to Boehringer Ingelheim; has consulted for and has financial interests in Somaxon; has received research support from the National Institutes of Health, Veteran's Administration, Mohegan Sun Casino, the National Center for Responsible Gaming and its affiliated Institute for Research on Gambling Disorders, and Forest Laboratories, Ortho-McNeil, Oy-Control/Biotie and Glaxo-SmithKline pharmaceuticals; has participated in surveys, mailings or telephone consultations related to drug addiction, impulse control disorders or other health topics; has consulted for law offices and the federal public defender's office in issues related to impulse control disorders; provides clinical care in the Connecticut Department of Mental Health and Addiction Services Problem Gambling Services Program; has performed grant reviews for the National Institutes of Health and other agencies; has given academic lectures in grand rounds, CME events and other clinical or scientific venues; and has generated books or book chapters for publishers of mental health texts. Dr. Grilo has received research support from the National Institutes of Health, medical research foundations (Donaghue Foundation, American Heart Association, Borderline Personality Research Foundation), has delivered lectures and papers at scientific conferences, and has generated books and chapters for academic book publishers. Dr. O'Malley is a member of the ACNP workgroup, the Alcohol Clinical Trial Initiative, sponsored by Eli Lilly, Janssen, Schering Plough, Lundbeck, Glaxo-Smith Kline and Alkermes; a partner in Applied Behavioral Research; a Scientific Panel member, Butler Center for Research at Hazelden. Dr. O'Malley participates in studies in which Nabi Biopharmaceuticals and Sanofi Aventis donated medications, has given academic lectures at professional societies and has received grant support form the National Institutes of Health.

All authors report no conflicts of interest with the current manuscript.

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CASE STUDY Maria (binge eating disorder)

Case study details.

Maria is a 38-year-old divorced woman who works in a higher level administrative position for a large federal agency. She is well-established in her career and has several close friends with whom she enjoys spending time. She comes to you following years of unsuccessful attempts to get appropriate treatment for her binge eating. She reports a prior experience with counseling during college after she experienced a sexual assault. She shared with her counselor her concerns about binge eating but the counselor told her that they needed to remain focused on working through issues directly related to the sexual assault. Embarrassed for having brought up her binge eating behavior, she waited years to seek help again and, when she did on two other occasions, it was recommended that she meet with a dietitian to “learn how to eat healthily.” She explains to you that she needs help with binge eating and that it’s not a matter of knowledge – “I know what to do. I just can’t do it. I cannot control my eating.” She describes a pattern where she works hard to “get on track” with her eating but finds it difficult to maintain. She is 5’4”and weighs 180 lbs. She first started binge eating in college and her weight quickly increased from 135 lbs. as a freshman to 160 lbs. by graduation. She has been treated for hypertension and high cholesterol for the last 5 years. She is coming for help now at the recommendation of her physician after a recent visit where she reported increasing problems with back and knee pain due to her excess weight.

• Disordered Eating
• Obesity/Overweight

Diagnoses and Related Treatments

1. binge eating disorder.

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JSmol Viewer

An umbrella review of body image concerns, disordered eating, and eating disorders in elite athletes.

1. Introduction

2. materials and methods, 2.1. data extraction, 2.2. risk of bias assessment, 3.1. risk of bias assessment, 3.2. overlap analysis, 3.3. prevalence of disordered eating (including eating disorders) and body image concerns, 3.4. relative risk for disordered eating (including eating disorders) and body image concerns in elite athletes, 3.5. risk factors for disordered eating and body image concerns amongst elite athletes, 3.5.1. general risk factors, 3.5.2. sport-specific factors, 3.6. factors with emerging evidence, 4. discussion, 4.1. implications, 4.2. limitations, 4.3. conclusions, supplementary materials, author contributions, data availability statement, conflicts of interest.

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Fatt, S.J.; George, E.; Hay, P.; Jeacocke, N.; Gotkiewicz, E.; Mitchison, D. An Umbrella Review of Body Image Concerns, Disordered Eating, and Eating Disorders in Elite Athletes. J. Clin. Med. 2024 , 13 , 4171. https://doi.org/10.3390/jcm13144171

Fatt SJ, George E, Hay P, Jeacocke N, Gotkiewicz E, Mitchison D. An Umbrella Review of Body Image Concerns, Disordered Eating, and Eating Disorders in Elite Athletes. Journal of Clinical Medicine . 2024; 13(14):4171. https://doi.org/10.3390/jcm13144171

Fatt, Scott J., Emma George, Phillipa Hay, Nikki Jeacocke, Emily Gotkiewicz, and Deborah Mitchison. 2024. "An Umbrella Review of Body Image Concerns, Disordered Eating, and Eating Disorders in Elite Athletes" Journal of Clinical Medicine 13, no. 14: 4171. https://doi.org/10.3390/jcm13144171

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• Open access
• Published: 15 July 2024

A peer mentoring program for eating disorders: improved symptomatology and reduced hospital admissions, three years and a pandemic on

• Anita Raspovic 1 , 2 , 3 , 4 ,
• Rachael Duck 1 , 3 ,
• Andrew Synnot 1 ,
• Belinda Caldwell 1 ,
• Andrea Phillipou 5 , 6 , 7 , 8 , 9 ,
• David Castle 10 ,
• Richard Newton 11 ,
• Leah Brennan 12 ,
• Zoe Jenkins 9 ,
• Michelle Cunich 4 , 13 , 14 , 15 , 16 ,
• Sarah Maguire 2 , 4 , 17   na1 &
• Jane Miskovic-Wheatley 2 , 4 , 17   na1  

Journal of Eating Disorders volume  12 , Article number:  99 ( 2024 ) Cite this article

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Peer support involves people (mentors) using their own experiences to assist others (mentees). The impetus to include peer support in eating disorder recovery is high, however research on implementation of peer roles in eating disorder management is limited. A previous pilot study found positive but preliminary results for a Peer Mentor Program (PMP) for eating disorders. The PMP has since developed over time, including broadening its eligibility criteria and shifting to predominantly online delivery during COVID-19. This study aimed to evaluate the updated version of the PMP, on a larger and more diverse group of mentees.

Previously collected PMP service data from July 2020 to April 2022 (during COVID-19 lockdowns) was evaluated for fifty-one mentees using mixed methods. Data from program start (baseline), mid-point (3-months) and end (6-months) for measures of eating disorder symptoms as measured by the Eating Disorder Examination Questionnaire (EDE-Q) and psychological wellbeing as measured by the Depression, Anxiety and Stress Scale (DASS) was evaluated. Frequency of eating disorder-related hospital admissions during PMP participation versus the 6 months prior, direct program costs and qualitative mentee feedback were also analysed. One way ANOVA’s with post hoc tests were used to evaluate symptom change and thematic analysis was conducted on qualitative data.

Program attendance averaged 12.12 ( SD  ± 1.57) of a possible 13 sessions. Statistically significant and clinically meaningful improvements were demonstrated across all subscales of the eating disorder and psychological wellbeing symptom measures. EDE-Q Global score and DASS scores decreased significantly by program end. Fewer eating disorder-related hospital admissions were reported during PMP than the 6-months prior. Qualitative findings were positive and themed around the unique benefits of lived experience connection, a new kind of space for recovery, hope and motivation for change. Challenges with the time limited nature of the mentee-mentor relationship were expressed.

Conclusions

The important benefits of a PMP for individuals with eating disorders are further supported. There is a pressing need for high quality, co-produced research, utilising a mixture of designs and fidelity to core peer work principles, to inform further implementation of peer work into eating disorder policy and practice.

Plain English summary

Peer mentoring involves people using their personal lived experiences to support others. A pilot Peer Mentoring Program for eating disorders (PMP) offered through Eating Disorders Victoria (EDV) was evaluated previously, showing positive findings. Subsequent demand for the program was high. As a result, the PMP has been running and evolving over time. Key changes included a broadening of program eligibility to all individuals with an eating disorder (versus only people recently discharged from hospital), larger participant numbers and a shift to largely online delivery due to COVID-19. This study evaluated this current version of the PMP. Five rounds of anonymised PMP data, from July 2020 to April 2022, were evaluated with mentee prior consent. Individuals in recovery from an eating disorder (mentees), had been paired with individuals recovered from an eating disorder for 2-years minimum (mentors). PMP rounds were 6-months, with fortnightly meetings. Mentees overall showed improvements in eating disorder symptoms and psychological wellbeing. Fewer mentee eating disorder-related hospital admissions during PMP participation were reported, compared to the 6-months prior. Feedback from mentees identified many positive benefits and some challenges. Overall, the results provide further support for the use of peer mentoring in eating disorder recovery.

Eating Disorders are common, costly and disabling [ 1 , 2 , 3 ]. All eating disorder diagnoses are associated with elevated psychosocial and medical comorbidity, with anorexia nervosa having the highest mortality rate of all mental illnesses [ 4 , 5 ]. Eating disorders occur irrespective of age, gender, cultural background, sexual orientation and body size, with important groups being at elevated risk including Aboriginal and Torres Strait Islander Peoples (First Australians) [ 6 ], LGBTIQA + individuals [ 7 ], neurodiverse individuals [ 8 ] and people experiencing certain physical conditions such as diabetes [ 9 ]. As many as 80% of people with an eating disorder do not seek eating disorder-specific interventions, and for those who do, treatment can be substantially delayed, poorly co-ordinated, or inadequately aligned to individual needs [ 10 ]. Treatment relapse rates are high, averaging between 30% and 50% depending on diagnosis when followed for 10 years [ 11 ]. Taken together, there is a clear and urgent need for diversification, innovation and improved accessibility of person-focussed eating disorder treatments.

Peer support, the sharing of related lived experience in order to connect, support and learn with and from others, offers significant benefits within mental health [ 12 ]. Based on “a system of giving and receiving help founded on key principles of respect, shared responsibility and mutual agreement of what is helpful” [ 13 ], (p 135), peer support is relational in nature. Whilst underpinned by complex mechanisms, peer support operates through mutual challenge and personal growth, it mirrors naturally occurring peer support relationships and aims to build hope, empowerment, social inclusion and self-management [ 12 , 14 ]. Positive outcomes from peer support in mental health have been demonstrated, including in early psychosis intervention [ 15 ], for reducing psychiatric admissions [ 16 ] and assisting people with complex needs to engage in services [ 17 ]. With the current policy landscape advocating for lived experience in the co-production and co-delivery of eating disorder services, there is strong impetus to build an evidence base to support safe and effective implementation [ 18 ]. Eating Disorders Peer Workforce Guidelines have recently been released in Australia, which is a promising advancement [ 19 ]. Research in the context of peer support programs in eating disorders is, however, currently limited and outcomes have been mixed [ 18 , 20 ].

In terms of the extant literature, Ramjan et al. (2017) ran a proof-of-concept study on a mentoring support program for people with any eating disorder (n  =  10 mentees) [ 21 ] . They reported statistically significant improvements in hope for recovery in the domains of social relationships, romantic relationships, family life, work and overall scores. Ramjan et al. (2018) followed by using a mixed methods, participatory action research design to study a 13-week face-to-face community-based peer mentoring program for anorexia nervosa ( n  =  6 mentees ) [ 22 ]. They reported on the importance of connecting people in recovery with “someone who understands” to facilitate hope, grow relationships and build quality of life. A randomised controlled trial of a face-to-face hospital-based peer mentoring program for a range of eating disorder diagnoses (anorexia nervosa, bulimia nervosa and binge-eating disorder) ( n  =  60 ), showed reductions in body dissatisfaction, symptoms of depression and anxiety, and frequency of binge eating and restriction [ 23 ]. Peer-mentorship did not impact re-entry into higher level of care or body mass index. Finally, a 6-month community-based Peer Mentoring Program (PMP) in eating disorders was piloted by a research team in collaboration with Eating Disorders Victoria (EDV), the largest community-based organisation providing eating disorder specific services in Victoria, Australia [ 24 , 25 , 26 ]. A further evaluation of EDVs PMP is the focus of this current study.

The PMP was designed to address a service gap for people requiring additional support after an eating disorder-related hospital admission [ 24 ]. The PMP uses a peer support model, harnessing the experience of people who had recovered from an eating disorder (mentors) to support people in recovery (mentees) as an adjunct to their eating disorder treatment. The initial pilot PMP evaluation engaged mentees ( n  =  22 ) who had recently been discharged from a high acuity eating disorder-related admission and showed promising preliminary results, indicating “moderate feasibility” [ 25 ]. By program end, mentees demonstrated on average modest improvements in body mass index, quality of life, eating disorder symptomatology, depression, anxiety, stress and perceived disability. Important qualitative themes arose from program participation including hope for recovery, greater personal agency and inspiration from first-hand interaction with another person who had recovered from an eating disorder [ 26 ]. With additional funding, EDV went on to run their highly sought after PMP in the community for over four years with the current evaluation arm possible by translational research funding (MRFF Million Minds - MAINSTREAM).

Since the initial pilot, EDV’s PMP has evolved. Over 150 mentees have now completed the program. PMP improvements include enhanced mentor training and supervision, refined program systems and procedures, and greater staff expertise using intentional peer support in eating disorder recovery. PMP eligibility broadened to include anyone in the community 18 years of age or over seeking support for eating disorder recovery, rather than only those with a recent hospital stay only. Furthermore, the PMP shifted to predominantly online delivery (i.e., fully online or online with minimal in-person meetings outdoors) in response to COVID-19 lockdowns imposed by the Victorian State Government during the 2020–2021 pandemic years, which also increased geographical reach.

The primary aim of this study was to evaluate the updated PMP for eating disorders. We hypothesised that this program would be associated with reductions in mentee eating disorder symptomatology and lowered symptoms of depression, anxiety and stress, when delivered online as part of community-based eating disorder management. We further aimed to compare the frequency of mentee eating disorder-related hospital admissions in the 6-months prior to the PMP, versus during the PMP period, and to report direct program costs. A secondary study aim was to continue to build our understanding of mentee experiences of the PMP from their feedback, using qualitative thematic analysis.

Study design, time frame and setting

This study employed a single-site, retrospective, pre-post, uncontrolled, service evaluation design using mixed methods [ 27 ]. Retrospective ethical approval was granted by the Bellberry Human Ethics Research Committee (HREC 2022_04_374). Service delivery and evaluation data collected across 5 rounds of the PMP (from July 2020 to April 2022) were pooled for analysis. The PMP ran from the EDV offices in Melbourne, Australia and sessions were conducted across various formats and locations in keeping with COVID-19 lockdown rules, including online and at times suitable outdoors locations (e.g., parks). Meetings were not permitted in mentor or mentee homes.

Participants and procedures

Participants were mentees who undertook EDV’s PMP during the study timeframe. PMP recruitment was from a broad range of sources where the program was promoted, including hospital and medical/mental health practitioners, as well as EDV’s website, social media and newsletter. PMP staff, that is EDV staff who oversaw administration of the program, assessed program eligibility based primarily on verbal self-reported information from potential participants. PMP staff were all trained in mental health and eating disorders, with some having related lived experience. Mentors are not the focus of this current evaluation, however they were individuals who had recovered from an eating disorder for a minimum of two years duration and acted as peer mentors in the program. All mentors had undergone three days of intensive training and an induction run by EDV, prior to being matched with a mentee. EDV provided all mentors with regular de-briefing and bi-monthly group supervision throughout each of the rounds of the PMP in this study.

Inclusion criteria for PMP participation (and the study) were: being 18 years or older; a self-reported current eating disorder diagnosis as indicated by their health care team (including anorexia nervosa, bulimia nervosa, binge eating disorder, atypical anorexia nervosa or avoidant restrictive food intake disorder); and actively engaged in community-based eating disorder management including a treating general practitioner, a mental health practitioner and a personal support person for the duration of the PMP. A personal support person is someone who a mentee nominates that is aware of their diagnoses and who they would be comfortable with EDV contacting if there was a concern about their health or wellbeing. Once nominated, it was assumed that this person would be available for the mentee for the duration of the PMP . A personal support person can be a family member, loved one or friend. Exclusion criteria (for PMP enrolment and thus for this evaluation) were past participation in the program, serious acute risk of harm to oneself or another (e.g., individuals at high risk of suicide) and/or being a current inpatient at the time of program start. Mentees were not excluded from the PMP if they underwent a hospital admission during the program, mentees were offered the option to continue, or pause, mentor sessions whilst an inpatient.

In total, 117 people were assessed for eligibility for EDV’s PMP running between July 1, 2020 to April 31, 2022 (i.e., the five rounds of PMP being retrospectively analysed in this study) and 87 were deemed eligible and enrolled. Six people did not proceed, with baseline program data subsequently collected for 81 people (i.e., mentees). Seventeen mentees (21%) withdrew for a variety of personal, clinical and program reasons (e.g., insufficient time, alternative treatments or deeming program ‘fit’ was not right). One significant outlier was removed for analysis due to invalid questionnaire scores.

Of the remaining 63 mentees, complete data were available for 51 (81%) as primary outcome data were missing at either one or two time points for 12 (19%). A comparison between baseline characteristics of mentees with complete data ( n  = 51) versus missing data ( n  = 12) identified a possible difference in eating disorder diagnostic profile, suggesting data may not be missing at random. For example, in those with missing data there was a relatively higher rate of bulimia nervosa (25% compared to 7.8%) and eating disorder duration was on average five years longer. Data imputation was not deemed appropriate and therefore the 51 cases with full data on all primary outcome measures were included for analysis (Fig.  1 ).

Flowchart of mentees through the Peer Mentoring Program (PMP) across the study timeframe.*NB - 87 participants (mentees) in total were enrolled into the Peer Mentoring Program (PMP) between July 1 2020 and April 31, 2022. This flow chart shows the process followed for each of the 5 rounds over this time period, with total participants numbers (n) summed

Program details

EDV’s PMP involved fortnightly individual mentoring sessions over 6 months. Mentees attended an average of 12.1 ( SD  ± 1.6) PMP sessions out of a possible 13 sessions (range 6 to 13) indicating overall high attendance (87% attended over 75% of PMP sessions). A detailed program description is provided in Additional File 1 . Robust consent processes are in place at EDV for collection, analysis and reporting of service user data. Prior written approval was given by all mentees whose data was subsequently de-identified and pooled in the current analysis. Service data was not collected anonymously but was de-identified by EDV staff prior to analysis commencing. No mentees opted out, or requested withdrawal, of their de-identified data for service evaluation and publication. Program evaluation data was collected using FormAssembly, an online secure data storage system. All data were stored in EDV’s online, secure data storage system.

Program evaluation approach

Demographic and clinical information.

Demographic and clinical information, including age, identified gender, work status, education status and eating disorder diagnosis and duration, were collected via online self-report prior to PMP commencement.

Quantitative evaluation: eating disorder symptomatology and psychological wellbeing questionnaires

Mentees completed two questionnaires to evaluate change in eating disorder symptomatology and psychological wellbeing across PMP participation. These were utilised in two ways: (1) to monitor mentee wellbeing to guide if program modifications were needed, and (2) for program evaluation. Questionnaires were administered via automated email at program start, mid and end (i.e., baseline, 3-months and 6-months). The questionnaires were the Eating Disorder Examination Questionnaire (EDE-Q) [ 28 ] and the Depression, Anxiety and Stress Scale (DASS-21) [ 29 ]. Both have acceptable to good psychometric properties and are described elsewhere in detail [ 30 , 31 , 32 , 33 ]. Higher scores indicate higher symptomatology.

Eating disorder-related hospital admission data before vs during PMP

Self-reported, eating disorder-related inpatient hospital admission rates (medical or psychiatric admissions specific to the eating disorder) for the 6-months prior to PMP participation were collected during mentee online registration. Inpatient eating disorder-related admission rates during the 6-months of program participation were recorded by EDV program staff.

Peer mentoring program (PMP) direct costs

Direct costs of the PMP for the study period were derived from EDV operating budgets from July 2020 to April 2022. Expense categories included: general administration, infrastructure and information technology and program-related costs.

Qualitative evaluation: mentee feedback

Mentees provided online written feedback at mid-program and program end. The questions asked were what mentees (1) enjoyed most and found the least challenging, and (2) enjoyed the least and found most challenging, about PMP participation. Mentee feedback was used to optimise program responsiveness to their expressed needs and for service evaluation and quality improvement.

Statistical analysis

IBM SPSS Statistics (version 28.0) was used for quantitative analyses. Descriptive statistics were calculated. One-way repeated measures analyses of variance (ANOVA) tests evaluated change on EDE-Q and DASS scores across the 3 time points. Statistical assumptions were met for the one-way repeated measures ANOVA tests, except for the sphericity assumption for the EDE-Q Shape Concern and EDE-Q Weight Concern subscales, where a Greenhouse–Geisser correction was applied [ 34 ]. Bonferonni adjusted post-hoc tests evaluated specific time frames in which scores EDE-Q or DASS scores changed (i.e., baseline and 3-months or 3-months and 6-months). A t -test was used to compare differences in frequency of mentee eating disorder-related hospital admissions in the 6 months prior compared to during the PMP period. All tests were conducted using an alpha of 0.05.

Qualitative analysis

Qualitative analysis followed a six-stage approach of thematic analysis [ 35 ] to identify key themes in mentee feedback data. This analysis involves six phases: 1. familiarisation with the data, 2. generating initial codes, 3. searching for themes, 4. reviewing themes, 5. defining and naming themes and 6. producing the report. Qualitative analysis was overseen by the first author (AR) in collaboration with co-authors (RD & AS). Initial coding was undertaken manually by the first author on the entire data set, drawing on inductive approaches. This stage involved deep engagement with the data, to identify repeated patterns in mentee feedback. Codes were constructed around the two key feedback questions posed (i.e., 1. What were the most enjoyed/least challenging aspects of the PMP? and 2. What were the least enjoyed/most challenging aspects of the PMP?) and codes were generated in response patterns which were conceptualised from the data, strongly grounded in mentees’ accounts. Codes were grouped into themes and subthemes based on all feedback provided by the 51 mentees. The coding framework was refined over iterations in consultation between AR, RD & AS, as coded material was re-considered, similar codes merged and obsolete codes were deleted. Themes were therefore reviewed and amended to ensure they formed a consistent and authentic representation of both coded extracts and the entire feedback data set. This research was conducted primarily out of Eating Disorders Victoria (EDV), in conjunction with the MAINSTEAM collaboration and the research team, whom seek to improve care offered to people in recovery from an eating disorder. EDV’s vision is of “a future where individuals and communities thrive through empowered and safe relationships to food, eating, body and movement” and EDV’s services are strongly informed by people who have lived experienced of eating disorders and their loved ones.

First author AR, is a researcher, academic and mental health clinician working in the field, she did not work or have direct involvement with running the PMP at any stage of this evaluation (i.e., program delivery, data collection and analysis). AR contributed qualitative and quantitative research methods and service evaluation experience to the current study. As senior EDV staff members, authors RD and AS bought backgrounds in mental health work, including experience in peer work, program design & implementation and in overseeing the coordination of the PMP. They were both senior staff members in the PMP at the time of data collection, analysis and manuscript editing. Overall, the multidisciplinary research team broadly bring a range of different perspectives to this evaluation, including clinical, research, service provision (public community, hospital & private sector) and translation backgrounds. This is the first formal evaluation study of the PMP that AR, RD and AS have been involved in. Several of the authors were involved in the conduct and publication of the original PMP pilot studies (AP, DC, RN, LB, ZJ) [ 25 , 26 ].

Mentee baseline characteristics are provided in Table  1 . Mentees averaged 27 years of age ( SD  ± 8.7) and predominantly identified as women (94.1%). The primary self-reported eating disorder diagnosis was anorexia nervosa (AN; 76.5%), followed by binge eating disorder (BED; 11.8%) and bulimia nervosa (BN; 7.8%) being the next most frequent eating disorder diagnoses.

Quantitative evaluation: changes in eating disorder symptomatology and psychological wellbeing

Overall, there was a statistically significant decrease in scores (improvement) across the 6-months of PMP for all primary outcome measures - the Global EDE-Q score, as well as its constituent subscales Restraint, Eating Concern, Weight Concern & Shape Concern, and the Depression, Anxiety and Stress subscales of the DASS. Effects sizes found were mostly in the statistically large range according to Cohen (1988). Refer to Table  2 . The EDE-Q Global score and EDE-Q Restraint and Eating Concern sub-scale scores had decreased significantly by 3-months of the PMP and between baseline and 6-months. The EDE-Q Shape Concern sub-scale reduced by 3-months, between 3-months and 6-months and between baseline and 6-months. All three DASS subscales reduced significantly but only between baseline and 6-months (i.e., program end), except DASS-Stress which also decreased significantly between 3- and 6-months. DASS-Anxiety and DASS-Depression each reduced from the ‘severe’ to the ‘moderate’ category and stress scores changed from ‘moderate’ to ‘mild’ [ 36 ]. Refer to Table  3 and Fig.  2 a & 2b.

Change in eating disorder (EDE-Q) and wellbeing (DASS) symptoms across participation in the Peer Mentoring Program (PMP) (n = 51). a Changes in Eating Disorder Examination Questionnaire (EDE-Q) subscales and global score across PMP participation. b Changes in Depression, Anxiety and Stress (DASS) subscales across PMP participation

Eating disorder-related hospital admissions before v’s during PMP

Thirty-one eating disorder-related hospital admissions were self-reported in the 6 months prior to participation in the PMP across 25 individuals, with 21 mentees reporting one admission (41.2% of mentees) and the remainder reporting two or more admissions (7.8% of mentees). Fewer eating disorder-related hospital admissions occurred during PMP, with 11 admissions in total (i.e., 20 less admissions). Of those 11 admissions, nine mentees reported one admission (17.6% of mentees), and the remainder reported two or more admissions (2.0% of mentees). It was the first eating disorder-related admission for a small number of mentees and a re-admission for eight.

Regarding hospital admissions before versus during the PMP, twenty-four mentees (47.1%) did not report a hospital admission in either the 6-months before or during PMP participation and eight mentees (15.7%) reported a hospital admission in both the 6-months before and during PMP participation (i.e., no change). Two mentees (3.9%) had a hospital admission during PMP participation yet not before PMP (i.e., increase in hospital admissions), however, seventeen mentees (33.3%) reported a hospital admission in the 6-months before but not during PMP (i.e., decrease in hospital admissions). Overall, there were 31 admissions between 51 participants in the 6-months prior to PMP, (representing a 0.61 likelihood of hospital admission), however only 11 admissions during PMP (0.22 likelihood of hospital admission).

Direct costs of the PMP totalled $840,090 AUD across the study period. This equated to an average of $168,018 per round and $10,372 per mentee. Average cost per mentee was calculated for the 81 mentees who commenced the PMP in the study period, to also account for costs incurred by the service for those participants who withdrew from the program early (n = 17). This figure for direct costs included general administration costs, such as office costs, infrastructure and IT including rent and internet, program specific costs for mentees such as the costs of mentee-mentor activities undertaken and program specific costs for mentors including remuneration and supervision, staff costs and program administration. While the majority of the PMP was delivered online for the rounds of the PMP reported herein, office space, IT and internet costs for staff were still incurred. Of note is that the biggest expense of running the PMP, was for PMP staff (program & administrative), mentee and supervisor remuneration costs. A breakdown of costs for the Peer Mentoring Program according to key categories is provided in Table  4 . Additional costs (such as hospital stays) were beyond the scope of this study.

Below are findings and sample quotes from a cross-section of mentee responses (using initial-based pseudonyms), derived from the thematic analysis of PMP mentee written feedback. A summary of the feedback questions with a collated list of themes can be found in Table  5 .

Feedback Question 1 - Most enjoyed/least challenging aspects of the PMP

Theme 1.1: power of the lived experience connection.

Mentees reflected personal benefit from connecting first-hand with someone who had recovered from an eating disorder and was open to sharing their experiences.

“Hearing my mentor’s story helped me see that there is a life outside of an eating disorder and that full recovery is possible”(FT)

Mentees further described positive impact from feeling heard, understood, validated and guided in a nuanced way.

“Spending time talking to someone else who understands completely what I'm going through and is empathetic, sharing experiences, doing things that I would have been scared to try alone but have been really beneficial for me (e.g. yoga), having a supportive person who cares about me.”(DE).

Some mentees identified value in someone understanding and caring about their daily struggles with an eating disorder, and who in turn was there to support them trying new experiences.

“I enjoyed being able to talk to my peer mentor about struggles and difficulties I was experiencing and gaining support from a person with lived experience. I also enjoyed being able to try new things, challenge myself in a safe and supportive environment.”(NJ).

Theme 1.2: A new kind of recovery space

Mentees identified that the PMP offered a different kind of therapeutic space to explore recovery. This included authenticity from mentors and a safe space to explore any topic without fear of judgement or shame.

“Having someone with lived experience to talk to about my fears, concerns and eating disorder behaviours without fear of judgement. I felt as though I could ask anything and together we would work towards a solution.”(NY).

Mentees welcomed the opportunity to discuss experiences with someone who had firsthand experience of the challenges of living with an eating disorder.

“My mentor’s incredible understanding of living with an eating disorder. Laughing! The feeling of looking forward to our meetings and comfort, when I have felt hopeless, that I was not alone.”(TI).

More equal power dynamics, connecting with someone to whom mentees could relate (e.g., closer in age and interests), were reflected as helpful and additional to past treatment set ups.

“Having the opportunity to connect with a peer of similar age and positionality who also has the capacity and understanding to support me in the contexts of dining out and more day-to-day eating disorder recovery factors than I have had the opportunity to delve into in other treatment contexts.”(MH).

Theme 1.3: Strengthening the foundations for recovery

Themes of inspiration and hope for recovery were relayed by mentees.

“Getting out and about which I never really do, and having someone to chat to that has somewhat recovered from an eating disorder gives hope that it might be possible for me to improve my quality of life in that area too.”(TG).

Greater connection to others, belonging to a group, increased positive social engagement and reduced isolation, were factors identified in enabling positive change.

“It's also been really nice to feel part of something, and part of some kind of community through the program.”(OQ)

Key messages towards re-discovering sense of self-identity, self-worth and connecting with life motivations for recovery were relayed, for example, “finding myself again(WO)“ , “feeling like a normal person”(IY) and “seeing there is a life outside of an eating disorder”(FT).

Theme 1.4: Reaping the rewards of “going there”

Mentees commented on the power of mentor support to help drive positive change and the subsequent rewards, as akin to being pushed out of the comfort zone but in a helpful way.

“Getting to experience some real-world activities outside of my comfort zone with lots of support and having someone to share anything with and get advice without feeling like I am being forced to do anything.”(FF). “Having moral support and a friend for challenging situations outside of my comfort zone, which I never would have otherwise tried on my own.”(TU)

Help with goal setting and problem solving the ‘how to’ practical aspects of eating disorder recovery were valued by mentees (e.g., planning for social events, cooking together and help undertaking food challenges).

“Making challenges to complete between sessions became a really useful tool and accelerated my progress in recovery.”(NY)

Additionally, positive impacts of building motivation experientially, with persistence and help, was relayed as beneficial.

“The feeling of quiet accomplishment after trying something that previously scared me, like eating out socially in such a "normal" way.”(TU)

Feedback Question 2–Least enjoyed/most challenging aspects of the PMP

Theme 2.1: the double-edged sword of ‘going there’.

Whilst mentees clearly reported benefits from increased engagement with the tasks of recovery, this was also reflected as one of the greatest challenges of the PMP.

“Sort of the reverse of the above, pushing myself to open up has been incredibly challenging however, it's also been incredibly rewarding thus a huge positive for me.”(FJ)

Translating learnings into life, choosing recovery and doing the work were commonly relayed concepts that were expressed as very difficult, however potentially reflect a strength of the program in supporting individuals enact change.

“The parts that I enjoyed the least were the struggles of choosing recovery and doing activities that challenged my eating disorder, however it always ended up being beneficial.”(KI).

Theme 2.2: Trust and vulnerability

A consistent theme was around the challenges of allowing oneself to trust the program as a safe space to be open and vulnerable, despite a time limited arrangement.

“At first it was hard to be open and honest as we didn’t know each other”(KT) “It was challenging to open up because I hate being vulnerable.”(CU)”

Opening up to big emotions involving sharing feelings, values, fears and wants, came with trepidation, but also built hope for some mentees. Leaning into confronting experiences such as “ realising how far I had to go”(CO), managing “perfectionis tic personal challenges ”(UQ) and “ drawing comparisons to others in the program”(MQ) were reflected as valuable but challenging aspects of participation.

Theme 2.3: Navigating closeness with a trusted stranger

The unique mentee-mentor relationship was portrayed by mentees as a beneficial and fundamental program feature. This relationship, however, came with challenges around learning to navigate a new kind of relationship - one which was neither completely personal, nor clinical. Seeking to understand the boundaries of the mentee-mentor relationship (e.g., what can I ask, what can I say) and learning to maximise the available time, were two of the issues raised.

“I've found it a bit challenging to ask more personal questions, such as how to navigate an eating disorder in a relationship or how to talk about it with my partner, because it's a personal question and because I don't want to overstep my mentor's boundaries.”(TU). “Sometimes I feel I am imposing when I call or text at challenging times.”(WO)

The inevitable parting of ways with a mentor instilled sadness and a sense of vulnerability in some mentees, reflected in their feedback.

“The wave of sadness, grief and loss that has come with the end of the program and trying to navigate my way through these emotions.”(MQ)

Theme 2.4: Logistics matter

The shift to predominantly online delivery of the PMP due to COVID-19 raised a unique situation in the program’s history. No single preferred delivery mode was identified, but a greater variety of delivery options provided versatility to individual mentee needs and preferences. Some reported the online only mode reduced capacity for connection with their mentors, while others reported that flexible delivery enabled them to participate even if geographically constrained (e.g., if in hospital or outside of the metropolitan area).

“I found it challenging being confined to zoom and phone calls only. I would have loved to of met my mentor face to face but that didn't end up happening due to a variety of reasons.”(FT) versus “Flexibility of sessions and allowing it to fit into my lifestyle with work.”(FJ).

The overarching purpose of this study was to further build understanding of the effectiveness and acceptability of EDV’s PMP, a now well-established community program. We utilised a mixed method design, that is, an approach which utilised the available program quantitative and qualitative data [ 27 ], to gain a fuller understanding of the ways in which mentees experienced the PMP. An additional aim was to interpret the impact of a shift of PMP to online delivery, in context of the significant challenges of extended COVID-19 lockdowns on the physical and mental wellbeing of local communities [ 37 ]. The diversity of ages and eating disorder diagnosis duration in the mentees included is wider, suggesting good program adaptability and inclusivity. Acceptability of the program was high, as reflected by consistent mentee attendance, expressed program enjoyment and the range of benefits experienced.

The first study aim was to evaluate whether program participation was associated with changes in eating disorder symptomatology and psychological wellbeing. The EDE-Q Global score and the DASS subscales reduced around 20% on average, representing both statistically significant and clinically meaningful improvements [ 36 , 38 ]. These outcomes are particularly important given the data was collected across the very challenging time of COVID-19 lockdowns when the risk of eating disorder, depression and anxiety symptoms worsening was significantly elevated [ 39 ].

A further feature of this study was the access to three data points (i.e., baseline, 3-months and 6-months), providing information on the timing of symptom changes. Regarding the EDE-Q, the Restraint subscale showed the largest change particularly in the first 3-months, with the Eating Concern subscale changing in a similar pattern but to a lesser magnitude. It may be that eating concerns potentially reduced, as behavioural changes around restraint provided corrective experiences via challenging eating anxiety. The Shape Concern subscale appeared to improve a modest amount by 3-months and 6-months, but this equated to a statistically significant change by program end. The Weight Concern subscale demonstrated the least change and appeared to take longer to show improvements, albeit reaching significance by program end. This is not unexpected as body image often takes time to change particularly in clinical level eating disorders [ 40 ].

Statistically significant reductions in symptoms of depression, anxiety and stress, occurred in a pattern of reduction across the entire program. The exception was the Stress subscale, which also indicated a pattern of change between program mid-point and end. We interpreted this change as a clinically meaningful, as according to symptom severity scores for the DASS [ 36 ], depression and anxiety scores in the current study reduced from the ‘severe’ to the ‘moderate’ category and stress scores reduced from the ‘moderate’ to ‘mild’ category. Taken together, we believe these reductions in symptomatology are also likely to represent meaningful positive improvements to mentees lives and capacity for recovery, given there is a well-documented link between increased mental health concerns and eating disorder symptomatology, and consequently improved mental health with eating disorder recovery [ 41 ].

Of note is that the reported changes in eating disorder and psychological wellbeing symptom scores represent average improvements. There were a range of responses to the program; some participant scores did not improve to this degree, while others improved more (refer to Table  2 for 95% confidence intervals of the mean difference). Further research should seek to assess for whom this program works most effectively.

Eating disorder-related hospital admissions and costing data related to PMP adds another domain on which to evaluate the program. Fewer hospital admissions were reported during PMP participation, compared to the 6-months prior, which likely represents an important cost saving. We postulate that the intentional peer support offered during the PMP is likely to explain some of this marked decrease at a program level, but further research is required to confirm this and further explore individual variations in response to PMP participation, irrespective of hospital admission. Long hospital waiting lists during COVID-19 may also have had an impact on the lower hospital admission found [ 42 ]. This finding offers evidence however that hospital admissions may reduce during PMP, regardless of the broader eligibility criteria for the program from the original pilot which included only people transitioning out of intensive treatment programs [ 25 ].

The themes from the qualitative analysis of the PMP feedback questions helped to elucidate mentees experiences of intentional peer support within the current program, thereby improving fidelity of this evaluation. Researchers in the field have acknowledged the importance of using diverse methodology when seeking to understand the complex nature of peer work in recovery [ 14 ]. Past in-depth qualitative analysis has been conducted on the initial PMP pilot [ 26 ] and main themes were re-confirmed in the current version of the program. Mentees identified the therapeutic nature of empathy, validation, normalisation of experiences and feeling truly seen and understood by another who has ‘walked in their shoes’. The difficult nature of making changes, but the benefit accruing therefrom, highlights the juxtaposition of up and down sides. Similarly, the challenge of mentees allowing themselves to be vulnerable and open in order to benefit as much as possible from the mentor relationship, was also challenged by sadness when the relationship came to an end at program completion. The quantitative and qualitative findings from our current study, taken together, support contemporary dialogues that eating disorder recovery is personal and multi-dimensional, encompassing both the reduction of eating disorder symptoms and building psychological well-being though multiple avenues including fostering meaningful relationships, self-adaptability, resilience and positive personal growth [ 41 ]. The current study confirmed outcomes from the initial PMP pilot study [ 25 , 26 ] and shows efficacy for a broader group of individuals with eating disorder problems, at various stages of their wellness journey. The acceptability of the online delivery was made pressing by the COVID-19 pandemic but has longer-term applicability in expanding availability of the program. We provisionally conclude that peer support during eating disorder recovery can offer significant benefits towards symptomatic improvement, when the quantitative and qualitative data are considered together, and await this being examined in high quality research including embedded lived experience co-production.

Results of the study must be interpreted in light of key limitations. The absence of a control group is a key limitation for understanding whether and to what degree the improvements in symptoms and reductions in hospital admissions might be attributable to non-program effects. This issue should be addressed as a priority for studies moving forward considering a range of contemporary research methodologies and approaches to explore the mechanisms and effectiveness of peer mentoring given the complexities of eating disorder recovery [ 43 ]. Furthermore, the impact of prior hospitalisation and limited access to hospital during COVID may both be alternative explanations for our findings. It is also important to note that while average data are presented in this paper, there is inherent variation in the degree of symptom response from individual to individual. We do not yet know characteristics or predictors of whom will benefit significantly from engagement with a peer mentoring program. Other limitations include the potential for selection bias and lack of generalisability. The accuracy of self-reported data and recall bias is also a limitation. Further high quality, co-designed, prospective research utilising a range of study designs and long-term follow up is urgently required on a range of forms of peer support for eating disorder management, to inform implementation into policy and practice.

In conclusion, the findings of this work add to the under-researched but important area of peer mentoring programs in eating disorder management. The current research reports novel findings on the further evaluation of EDV’s PMP for eating disorders, as a matured program, with a larger and more diverse sample, adapted for online delivery. While participating in the program the mentees experienced a significant reduction in eating disorder symptomatology, improved psychological wellbeing and reduced hospital admissions. Thematic analysis showed key benefits experienced by mentees through connecting with people with lived experience of an eating disorder (the mentors), accessing a different kind of space for recovery, building hope, motivation and social engagement, and gaining practical help with the ‘work’ of recovery. Given growing research and anecdotal evidence for the benefits of peer support in eating disorder recovery, and wide-spread government and societal shifts calling for greater lived experience inclusion into mental health programs, targeted research in peer mentoring programs in eating disorder management is likely to have large-scale benefits for society.

Availability of data

The data are not publicly available due to privacy.

Abbreviations

Peer Mentoring Program

Eating Disorders Victoria

Eating Disorder Examination Questionnaire

Depression Anxiety Stress Scale - 21 (also known as Short Form)

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Acknowledgements

We wish to thank the myriad of people who have played a role in developing Eating Disorder Victoria’s (EDV’s) Peer Mentoring Program (PMP) since its inception. The authors would like to thank EDVs Board, Senior Management and PMP staff, for their commitment to facilitating lived experience eating disorder support for our communities and whose collaboration has allowed the conduct of this work. Importantly, we wish to thank and acknowledge the essential contributions of the mentees and mentors of the PMP, who make the program and this work possible.

Individual members of the Mainstream Center are: Associate Professor Sarah Maguire, Professor Stephen Touyz, Professor Natasha Nassar, Dr Michelle Cunich, Professor Ian Hickie, Professor Jan Russell, Associate Professor Sloane Madden, Associate Professor Warren Ward, Danielle Maloney, Claire Diffey, Dr Jane Miskovic-Wheatley, Dr Ang Li, Bronny Carroll, Genevieve Dammery, Belinda Caldwell, Belinda Chelius, Amanda Davis, Michelle Roberton, Dr Andrew Wallis, Dr Lyn Chiem, Rachel Knight, Dr Phillip Aouad, Dr Morgan Sidari, Dr Sumedha Verma, Dr Anita Raspovic, Dr Moin Uddin Ahmed, Dr, Lorraine Ivancic, Dr Diana Bond, Dr Francisco Schneuer Brahm, Amy Hannigan, Kelly Dann, Emma Bryant , Dr Shu Hwa Ong, Dr Sabina Vatter

This research is funded by the National Health and Medical Research Council Medical Research Future Fund Million Minds Mission Grant (APP1178922), grant activity coordinated by the InsideOut Institute for Eating Disorders, a partnership between the University of Sydney and Sydney Local Health District.

Author information

Sarah Maguire and Jane Miskovic-Wheatley have contributed equally to this work.

Authors and Affiliations

Eating Disorders Victoria, Abbotsford, Victoria, 3067, Australia

Anita Raspovic, Rachael Duck, Andrew Synnot & Belinda Caldwell

InsideOut Institute for Eating Disorders, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, 2006, Australia

Anita Raspovic, Sarah Maguire & Jane Miskovic-Wheatley

School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia

Anita Raspovic & Rachael Duck

MAINSTREAM The Australian Centre for Health System Research and Translation in Eating Disorders, Sydney, New South Wales, 2006, Australia

Anita Raspovic, Michelle Cunich, Sarah Maguire & Jane Miskovic-Wheatley

Orygen, Melbourne, Victoria, 3052, Australia

Andrea Phillipou

Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, 3000, Australia

Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, 3182, Australia

Department of Mental Health, St Vincent’s Hospital, Melbourne, Victoria, 3065, Australia

Department of Mental Health, Austin Health, Melbourne, Victoria, 3084, Australia

Andrea Phillipou & Zoe Jenkins

University of Tasmania and Tasmanian Centre for Mental Health Service Innovation, Hobart, Tasmania, 7000, Australia

David Castle

Peninsula Mental Health Service, Monash University, Frankston, Victoria, 3199, Australia

Richard Newton

School of Psychology and Public Health, La Trobe University, Wodonga, Victoria, 3689, Australia

Leah Brennan

Boden Initiative, Charles Perkins Centre, Faculty of Medicine and Health (Central Clinical School), The University of Sydney, Camperdown, New South Wales, 2006, Australia

Michelle Cunich

Sydney Health Economics Collaborative, Sydney Local Health District, Camperdown, New South Wales, 2050, Australia

Sydney Institute for Women, Children and Their Families, Sydney Local Health District, Camperdown, New South Wales, 2050, Australia

Cardiovascular Initiative, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, 2006, Australia

Faculty of Medicine and Health (Central Clinical School), The University of Sydney, Sydney, New South Wales, 2050, Australia

Sarah Maguire & Jane Miskovic-Wheatley

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Contributions

AR contributed to study conceptualisation, methodology, formal analysis, writing (original draft and review and editing), supervision and project administration. RD and AS contributed to conceptualisation, investigation, writing (review and editing) and project design and administration. BC, AP, RN, DC, LB, ZJ significantly and substantially contributed to conceptualisation and methodology, and contributed to writing (reviewing and editing). MC contributed to methodology, formal analysis and writing (reviewing and editing). JMW and SM contributed to conceptualisation, methodology, formal analysis, resources, writing (original draft and review and editing) and supervision. Four authors (AR, SM, JMW & MC) conducted the project under the auspices of the Mainstream Centre. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Anita Raspovic .

Ethics declarations

Ethics approval and consent to participate.

This study received ethical approval from the Bellberry Human Ethics Research Committee (HREC 2022_04_374) after a full board review (approval date 09-August-2022). This study analysed previously collected service evaluation data and prior written consent had been given from all people whose de-identified mentee data was pooled for analysis in the current study.

Consent for publication

Not applicable.

Competing interests

At the time of publication, Belinda Caldwell was Chief Executive Officer of Eating Disorders Victoria and Rachael Duck and Andrew Synnot were employed by Eating Disorders Victoria as Peer Mentoring Program (PMP) staff. Sarah Maguire and Richard Newton sit on the panel of Senior Editors for the Journal of Eating Disorders.

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Raspovic, A., Duck, R., Synnot, A. et al. A peer mentoring program for eating disorders: improved symptomatology and reduced hospital admissions, three years and a pandemic on. J Eat Disord 12 , 99 (2024). https://doi.org/10.1186/s40337-024-01051-7

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Received : 21 October 2023

Accepted : 19 June 2024

Published : 15 July 2024

DOI : https://doi.org/10.1186/s40337-024-01051-7

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