“Dear eating disorder,
When I was irreparably lonely, you made me feel safe from failure, from social rejection, and from the uncertainties of life. You gave me a sense of control over my body and my world, and for that—I thank you. But I realize now that I was controlled by you all these years. So, it’s time to part ways. I hope we never meet again.”
These words were written in my journal during my struggle with anorexia nervosa—an eating disorder defined by extreme restriction of food intake, intense fear of weight gain, and a distorted body image (American Psychiatric Association, 2013). Public understanding of anorexia nervosa often reduces it to a desire to be thin or look “pretty.” In popular discourse, it is framed as the result of too much scrolling on Instagram, a side effect of having an “almond mom,” or just a teenage phase. However, it is actually a complex psychiatric illness rooted in deep psychological, neurobiological, and personality-based factors. In the same vein, Professor Laura Hill emphasizes that effective treatment requires shifting focus away from meal plans and calorie counts toward addressing the root causes that trigger and perpetuate the illness.
While sociocultural pressures play a role, this is only one piece of the puzzle. As Professor Walter Kaye contends, although “many people diet, only a few develop an eating disorder.” Through considering other factors, research has pointed to anorexia brain differences and personality traits such as perfectionism traits, risk-aversion, and inflexibility as key vulnerabilities. Professor Hill’s Temperament-Based Treatment with Supports (TBT-S therapy) approach builds on this insight, encouraging individuals to understand the traits that sustain the disorder and channel them in more positive ways.
The Eating Disordered Personality
Suppressing hunger for prolonged periods requires extraordinary restraint, often reinforced by social praise. From a young age, individuals rewarded for their willpower and discipline may come to see self-denial as a virtue. But when self-control crosses a certain threshold, when flexibility gives way to rigidity, it can become debilitating.
Perfectionism, defined as the pursuit of unrealistically high standards despite negative consequences, appears to be one of the most influential personality traits linked to the development of anorexia nervosa (Shafran et al., 2002). Retrospective studies show that many with the disorder recall childhood traits of perfectionism and high self-discipline (Anderluh et al., 2003). Such traits may be intensified in individuals with anorexia and contribute to the disorder’s development. These traits can create ground for anorexia: when life feels uncontrollable, dietary restriction offers a sense of mastery.
According to Professor Christopher Fairburn (1999), individuals with high perfectionist tendencies may experience profound distress when confronted with situations they cannot control and often turn to dietary restriction to reestablish mastery over their environments. Early weight loss reinforces this sense of mastery and temporarily relieves anxiety. Over time, restraint becomes a measure of self-worth, and any challenge to it—a “sugary” cookie—only strengthens the resolve to restrict.
In addition to perfectionism, individuals with anorexia often show heightened sensitivity to risk and punishment (Harrison et al., 2010). Thus, when one breaks a rigid food rule, they might experience a heightened sense of intense guilt, fostering a fear of certain “risky” or “tempting” foods that might trigger a sense of failure or loss of control. This hypersensitivity often extends beyond food, reducing motivation to pursue rewarding activities in general (Zastrow et al., 2009).
Should We Change Traits?
Approaches to treatment increasingly focus on these underlying temperamental factors. Temperament-Based Treatment with Supports (TBT-S therapy), for example, aims to shift traits, that exist on a spectrum, from a place of dysfunction toward functionality. For instance, maladaptive perfectionism may appear as excessive self-criticism, while adaptive perfectionism involves high but realistic goals and resilience in the face of setbacks (Stolz et al., 2017). This approach helps individuals recognize different aspects of their traits and reframes them as tools that support, rather than hinder, well-being.
Targeting these underlying factors has shown promise in reducing relapse. In a study by Knatz-Peck and colleagues (2021), over half of participants undergoing TBT-S therapy showed significant improvement after 12 months. The approach affirms that the same traits that once fueled discipline can, if unbalanced, keep someone sick. Instead of fighting against who a person is, TBT-S seeks to guide traits toward balance and health.
The words once written in my journal—“Dear eating disorder, when I was irreparably lonely, you made me feel safe … but I realize now that I was controlled by you all these years. So, it’s time to part ways”—began as an attempt to imagine life beyond the disorder. Letting go of the eating disorder does not mean losing control but reclaiming yourself in healthier, more life-affirming ways. And in that shift, a different kind of strength emerges: one that allows for growth, connection, and the possibility of joy.
More Resources for the Interested:
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More Anorexia Recovery Stories, Peace Meal Podcast Recovery Stories: https://emilyprogram.com/blog/episode-5-annas-recovery-story/
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More on Neurological Mechanisms of Anorexia by Dr. Laura Hill, Ted X Talk: https://www.youtube.com/watch?v=UEysOExcwrE&t=440s
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Information on How to Support Someone with an Eating Disorder: https://www.beateatingdisorders.org.uk/get-information-and-support/support-someone-else/tips-for-supporting-somebody-with-an-eating-disorder/
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More Information on Eating Disorders and Perfectionism in Young People by Psychologist Tasha Belix: https://www.youtube.com/watch?v=mX0e7dlQja4
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Information on Temperament-Based Treatment with Supports: https://insideoutinstitute.org.au/blog/in-brief-what-is-temperament-based-therapy-with-supports-tbt-s
References
AIM youth mental health. (2022, May 16). New discoveries and treatment for anorexia nervosa, Dr. Walter Kaye at AIM Scientific Symposium [Video]. YouTube. https://www.youtube.com/watch?v=M9Vs0Ff4HZQ
American Psychiatric Association. (2013). Feeding and Eating Disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
Anderluh, M. B., Tchanturia, K., Rabe-Hesketh, S., & Treasure, J. (2003). Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype. American Journal of Psychiatry, 160(2), 242–247. https://doi.org/10.1176/appi.ajp.160.2.242
Fairburn, C. G., Shafran, R., & Cooper, Z. (1999). A cognitive behavioural theory of anorexia nervosa. Behaviour Research and Therapy, 37(1), 1–13. https://doi.org/10.1016/S0005-7967(98)00102-8
F.E.A.S.T. Videos. (2019, May 29). Dr. Laura Hill: The new dance of temperament-based therapy with supports (TBT-S) [Video]. YouTube. https://www.youtube.com/watch?v=0n_HIbj4vcA&t=1908s
Harrison, A., O’Brien, N., Lopez, C., & Treasure, J. (2010). Sensitivity to reward and punishment in eating disorders. Psychiatry Research, 177(1-2), 1–11. https://doi.org/10.1016/j.psychres.2009.06.010
Kaye, W. H., Wierenga, C. E., Bischoff-Grethe, A., Berner, L. A., Ely, A. V., Bailer, U. F., … & Fudge, J. L. (2020). Neural insensitivity to the effects of hunger in women remitted from anorexia nervosa. American Journal of Psychiatry, 177(7), 601–610. https://doi.org/10.1176/appi.ajp.2019.19030261
Knatz Peck, S., Towne, T., Wierenga, C. E., Hill, L., Eisler, I., Brown, T., … & Kaye, W. (2021). Temperament-based treatment for young adults with eating disorders: acceptability and initial efficacy of an intensive, multi-family, parent-involved treatment. Journal of Eating Disorders, 9, 1–17. https://doi.org/10.1186/s40337-021-00465-x
Lampert, J. (Host). (2021, September). Temperament-Based Therapy with Support with Dr. Laura Hill (No. 60) [Audio podcast episode]. In Peace Meal. The Emily Program and Veritas Collaborative. https://emilyprogram.com/blog/episode-60-temperament-based-therapy-with-supports-tbt-s-with-dr-laura-hill/
Shafran, R., Cooper, Z., & Fairburn, C. G. (2002). Clinical perfectionism: A cognitive–behavioural analysis. Behaviour Research and Therapy, 40(7), 773–791. https://doi.org/10.1016/S0005-7967(01)00059-6
Stolz, K., & Ashby, J. S. (2007). Perfectionism and lifestyle: Personality differences among adaptive perfectionists, maladaptive perfectionists, and nonperfectionists. The Journal of Individual Psychology, 63, 414–423.
Zastrow, A., Kaiser, S., Stippich, C., Walther, S., Herzog, W., Tchanturia, K., … & Friederich, H. C. (2009). Neural correlates of impaired cognitive-behavioral flexibility in anorexia nervosa. American Journal of Psychiatry, 166(5), 608–616. https://doi.org/10.1176/appi.ajp.2008.08050775