Tracey Wade from the Flinders University Institute for Mental Health and Wellbeing outlines several key issues to consider in developing successful early intervention approaches for people with disordered eating and who are at risk of developing an eating disorder
Several key issues outlined below should be considered in developing effective early intervention approaches for individuals with disordered eating who are at risk of developing an eating disorder.
Account for ambivalence
Eating disorders are associated with a high level of both denial and ambivalence. Denial that the problem exists can be observed across other mental health problems. It can often be unwelcome news to accept that one has a mental health problem. It does, however, form a potent barrier to help seeking in eating disorders. (1)
In contrast, ambivalence is unique to eating disorders. On one hand, the person recognises that aspects of the disorder are hijacking their pathway away from a life worth living. On the other hand, the person also believes: “Aspects of this disorder work for me and achieve what I need out of life, and I am not willing to surrender it”. It is hard to imagine anyone saying this about depression, anxiety, substance dependence, or psychosis. This is described as the ego-syntonic nature of eating disorders, as it represents values that are in harmony with valued aspects of one’s sense of self. (2) In particular, dietary restriction is highly valued in society and represents a pathway to building self-worth for individuals who value simplicity, control, and predictability. It conveys the illusory promise that a lower number on the scales will equate to the person being more valued by others and feeling better about themselves. Ultimately, of course, the eating disorder results in the person feeling out of control, being socially isolated, and having their self-worth constantly undermined by a relentlessly critical “eating disorder voice.”
Successful positioning of early intervention for eating disorders needs to bypass this denial and ambivalence to present a way of changing that is consistent with the person’s values and provides a pathway to building self-worth. This can be achieved using testimonials from peers who share similar values but model helpful, simple and accessible ways to manage difficult emotions that are consistent with self-care rather than self-harm.
Recognise the transdiagnostic nature of eating disorders
Eating disorders often grow out of pre-existing depression or anxiety disorders, and it is the rule rather than the exception that eating disorders co-exist with other mental health problems. Genome-wide association studies have shown that anorexia nervosa has significant genetic correlations with obsessive-compulsive disorder, major depressive disorder, anxiety, neuroticism, depressive symptoms, and schizophrenia. (3)
When developing effective early interventions for eating disorders, we need to include recognition of this complex interaction with other mental health disorders and avoid simplifying the central message to a focus only on food and eating.
Target transdiagnostic processes that lead to an eating disorder
It is commonly considered that eating disorders are a symptom of a problem and not the problem themselves. It is helpful to consider the processes or mechanisms common across different mental health problems that contribute to a person’s vulnerability to developing a mental illness. Acknowledgement of these processes and targeting them in an engaging and affirming way will increase the likelihood that a young person with disordered eating will try the suggestions offered in the early intervention.
We have suggested 38 hypothesised psychological transdiagnostic processes across anxiety disorders, depression and eating disorders for consideration. (4) These include psychophysiological processes (e.g., anxiety sensitivity), external exposures (e.g., trauma), cognitive processes (e.g., repetitive negative thinking) and other psychological processes (e.g., low self-compassion).
Consultation with people with lived experience, families, clinicians and researchers suggests that the nine critical processes to target in early intervention are: expanding judgment of self-worth beyond just one or two aspects of oneself; modifying excessively high and unrealistic standards; improving distress tolerance skills and emotion regulation; reducing self-criticism; improving body image; improving ability to cope with developmental life transitions; self-compassion; self-worth and self-acceptance; constructive social media use. (5)
Functional eating
While processes are important to target in early intervention, it is also commonly accepted that even modest dietary restriction adversely impacts the brain neuroplasticity and epigenetic functioning, making it more difficult for a person to effectively learn and use techniques to improve mood and behaviour.
Hence, the inclusion of some information on functional eating in early intervention is important. Functional eating uses science to explain why adequate nutrition is necessary for optimal brain function, as shown in the box. We avoid using a healthy eating message because it is so prone to misinterpretation. It can trigger and reinforce behaviours that strengthen risk factors for an eating disorder, including dietary restriction, rigid and perfectionistic rules for eating, and attempts to lose weight. An example of a simple message on functional nutrition for young people can be found in the box.
Remember
Research has shown that brain activity is affected by even modest dieting, and a young person’s developing brain is particularly vulnerable. A starved brain shrinks and makes it more difficult to think, process information, manage our emotions, and change behaviours. Someone with a starved brain will struggle to make decisions, solve problems, regulate their emotions, and learn new behaviours. Serotonin is decreased when dieting, particularly when we try to reduce carbohydrates. Serotonin depletion is associated with more depression. To start to feel better, the brain needs to be nourished. This enables your brain to form new neural pathways to support new behaviours that can make you feel better. Adequate nutrition also provides an environment for genes to function optimally and helpfully.
Summary
Consideration of how to navigate the obstacles to engagement in early intervention to prevent the development of eating disorders in youth requires a thoughtful response to the evidence. Partnerships with experts in youth mental health and eating disorders, including people with lived experience, are also essential for the optimal positioning of such interventions. Our research, funded by a National Mental Health and Research Council Investigator Grant 2025665, evaluates early intervention for eating disorders based on the key principles outlined in this paper.
References
- Radunz, M., Ali, K., & Wade, T. D. (2023). Pathways to improve early intervention for eating disorders: Findings from a systematic review and meta-analysis. International Journal of Eating Disorders, 56(2), 314–330. Doi: https://doi.org/10.1002/eat.23845
- Vitousek, K., Watson, S., & Wilson, G. T. (1998). Enhancing motivation for change in treatment-resistant eating disorders. Clinical Psychology Review, 18(4), 391–420. Doi: https://doi.org/10.1016/S0272-7358(98)00012-9
- Watson, H. J., et al. (2019). Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa. Nature Genetics, 51(8), 1207–1214. Doi: https://doi.org/10.1038/s41588-019-0439-2
- Wade, T. D., Pennesi, J-L., & Pellizzer, M.L. (2025). Identifying transdiagnostic psychological processes that can improve early intervention in youth mental health. Australian & New Zealand Journal of Psychiatry. doi: https://doi.org/10.1177/00048674241312803
- Pennesi, J-L., Pellizzer, M. L., & Wade, T. D. (2024). A multi-stakeholder Delphi consensus study on transdiagnostic processes that can inform early intervention and augmentation therapy for eating disorders. Manuscript submitted for publication.
