Why Eating Disorders Return
A Clinical Review of Habit Learning, Relapse, and Recovery
Keywords:
Eating disorders, Behavioral persistence, Habit learning, Relapse, Action control, Treatment resistance
Abstract
Eating disorders are often described in terms of their symptoms; however, the feature that actually defines them is the duration of their symptoms. Despite the awareness, motivation, and symptom-focused treatment individuals receive, eating disorder behaviors frequently recur, showing that existing models are not capable of comprehensively explaining why these behaviors are so challenging to change. This narrative review approaches eating disorders from an action-control perspective, separating goal-directed and habit-like forms of behavior. Using this framework, restrictive binge-eating and compensatory behaviors are viewed as learned action patterns. This review integrates research theories, transdiagnostic models of compulsivity, and clinical outcome studies to explain why eating disorder behaviors are challenging to modify and prone to relapse. Clinical findings related to ambivalence, limitations in evolutionary control, relapse patterns, comorbidity, and generalizations in treatment demonstrate why short-term, symptom-based treatment methods are ineffective. Viewing eating disorders as habitual behaviors is crucial for relapse prevention, long-term monitoring, and identifying behaviors, context, and clinical factors that need to be addressed in treatment.
References
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Bulik, C. M., Sullivan, P. F., Fear, J. L., & Pickering, A. (2000). Outcome of anorexia nervosa: eating attitudes, personality, and parental bonding. The International journal of eating disorders, 28(2), 139–147. https://doi.org/10.1002/1098-108x(200009)28:2<139::aid-eat2>3.0.co;2-g
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Everitt, B. J., & Robbins, T. W. (2005). Neural systems of reinforcement for drug addiction: from actions to habits to compulsion. Nature neuroscience, 8(11), 1481–1489. https://doi.org/10.1038/nn1579
Fairburn, C. G., Cooper, Z., Doll, H. A., Norman, P., & O'Connor, M. (2000). The natural course of bulimia nervosa and binge eating disorder in young women. Archives of general psychiatry, 57(7), 659–665. https://doi.org/10.1001/archpsyc.57.7.659
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment. Behaviour research and therapy, 41(5), 509–528. https://doi.org/10.1016/s0005-7967(02)00088-8
Fichter, M. M., Quadflieg, N., & Hedlund, S. (2008). Long-term course of binge eating disorder and bulimia nervosa: relevance for nosology and diagnostic criteria. The International journal of eating disorders, 41(7), 577–586. https://doi.org/10.1002/eat.20539
Foerde, K., Steinglass, J. E., Shohamy, D., & Walsh, B. T. (2015). Neural mechanisms supporting maladaptive food choices in anorexia nervosa. Nature neuroscience, 18(11), 1571–1573. https://doi.org/10.1038/nn.4136
Gillan, C. M., Kosinski, M., Whelan, R., Phelps, E. A., & Daw, N. D. (2016). Characterizing a psychiatric symptom dimension related to deficits in goal-directed control. eLife, 5, e11305. https://doi.org/10.7554/eLife.11305
Godier, L. R., & Park, R. J. (2014). Compulsivity in anorexia nervosa: a transdiagnostic concept. Frontiers in psychology, 5, 778. https://doi.org/10.3389/fpsyg.2014.00778
Gowers, S. G., Clark, A., Roberts, C., Griffiths, A., Edwards, V., Bryan, C., Smethurst, N., Byford, S., & Barrett, B. (2007). Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised controlled trial. The British journal of psychiatry : the journal of mental science, 191, 427–435. https://doi.org/10.1192/bjp.bp.107.036764
Graybiel A. M. (2008). Habits, rituals, and the evaluative brain. Annual review of neuroscience, 31, 359–387. https://doi.org/10.1146/annurev.neuro.29.051605.112851
Grilo, C. M., Masheb, R. M., & Wilson, G. T. (2005). Efficacy of cognitive behavioral therapy and fluoxetine for the treatment of binge eating disorder: a randomized double-blind placebo-controlled comparison. Biological psychiatry, 57(3), 301–309. https://doi.org/10.1016/j.biopsych.2004.11.002
Grilo, C. M., White, M. A., & Masheb, R. M. (2009). DSM-IV psychiatric disorder comorbidity and its correlates in binge eating disorder. The International journal of eating disorders, 42(3), 228–234. https://doi.org/10.1002/eat.20599
Halmi, K. A., Agras, W. S., Crow, S., Mitchell, J., Wilson, G. T., Bryson, S. W., & Kraemer, H. C. (2005). Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Archives of general psychiatry, 62(7), 776–781. https://doi.org/10.1001/archpsyc.62.7.776
Hambleton, A., Pepin, G., Le, A., Maloney, D., National Eating Disorder Research Consortium, Touyz, S., & Maguire, S. (2022). Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature. Journal of eating disorders, 10(1), 132. https://doi.org/10.1186/s40337-022-00654-2
Herzog, D. B., Keller, M. B., Sacks, N. R., Yeh, C. J., & Lavori, P. W. (1992). Psychiatric comorbidity in treatment-seeking anorexics and bulimics. Journal of the American Academy of Child and Adolescent Psychiatry, 31(5), 810–818. https://doi.org/10.1097/00004583-199209000-00006
Herzog, W., Wild, B., Giel, K. E., Junne, F., Friederich, H. C., Resmark, G., Teufel, M., Schellberg, D., de Zwaan, M., Dinkel, A., Herpertz, S., Burgmer, M., Löwe, B., Zeeck, A., von Wietersheim, J., Tagay, S., Schade-Brittinger, C., Schauenburg, H., Schmidt, U., & Zipfel, S. (2022). Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in female outpatients with anorexia nervosa (ANTOP study): 5-year follow-up of a randomised controlled trial in Germany. The lancet. Psychiatry, 9(4), 280–290. https://doi.org/10.1016/S2215-0366(22)00028-1
Kaye, W. H., Wierenga, C. E., Bailer, U. F., Simmons, A. N., & Bischoff-Grethe, A. (2013). Nothing tastes as good as skinny feels: the neurobiology of anorexia nervosa. Trends in neurosciences, 36(2), 110–120. https://doi.org/10.1016/j.tins.2013.01.003
Keel, P. K., & Brown, T. A. (2010). Update on course and outcome in eating disorders. The International journal of eating disorders, 43(3), 195–204. https://doi.org/10.1002/eat.20810
Keel, P. K., Mitchell, J. E., Miller, K. B., Davis, T. L., & Crow, S. J. (1999). Long-term outcome of bulimia nervosa. Archives of general psychiatry, 56(1), 63–69. https://doi.org/10.1001/archpsyc.56.1.63
Keel, P. K., Dorer, D. J., Franko, D. L., Jackson, S. C., & Herzog, D. B. (2005). Postremission predictors of relapse in women with eating disorders. The American journal of psychiatry, 162(12), 2263–2268. https://doi.org/10.1176/appi.ajp.162.12.2263
Keel, P. K., Brown, T. A., Holm-Denoma, J., & Bodell, L. P. (2011). Comparison of DSM-IV versus proposed DSM-5 diagnostic criteria for eating disorders: reduction of eating disorder not otherwise specified and validity. The International journal of eating disorders, 44(6), 553–560. https://doi.org/10.1002/eat.20892
Klein, D. A., & Walsh, B. T. (2004). Eating disorders: clinical features and pathophysiology. Physiology & behavior, 81(2), 359–374. https://doi.org/10.1016/j.physbeh.2004.02.009
Lowe, M. R., & Levine, A. S. (2005). Eating motives and the controversy over dieting: eating less than needed versus less than wanted. Obesity research, 13(5), 797–806. https://doi.org/10.1038/oby.2005.90
Nordbø, R. H., Espeset, E. M., Gulliksen, K. S., Skårderud, F., & Holte, A. (2006). The meaning of self-starvation: qualitative study of patients' perception of anorexia nervosa. The International journal of eating disorders, 39(7), 556–564. https://doi.org/10.1002/eat.20276
Patel, R. S., Olten, B., Patel, P., Shah, K., & Mansuri, Z. (2018). Hospitalization Outcomes and Comorbidities of Bulimia Nervosa: A Nationwide Inpatient Study. Cureus, 10(5), e2583. https://doi.org/10.7759/cureus.2583
Poulsen, S., Lunn, S., & Sandros, C. (2010). Client experience of psychodynamic psychotherapy for bulimia nervosa: an interview study. Psychotherapy (Chicago, Ill.), 47(4), 469–483. https://doi.org/10.1037/a0021178
Rangel, A., Camerer, C., & Montague, P. R. (2008). A framework for studying the neurobiology of value-based decision making. Nature reviews. Neuroscience, 9(7), 545–556. https://doi.org/10.1038/nrn2357
Robbins, T. W., Gillan, C. M., Smith, D. G., de Wit, S., & Ersche, K. D. (2012). Neurocognitive endophenotypes of impulsivity and compulsivity: towards dimensional psychiatry. Trends in cognitive sciences, 16(1), 81–91. https://doi.org/10.1016/j.tics.2011.11.009
Robinson, L., Flynn, M., & Cooper, M. (2024). Individual differences in motivation to change in individuals with eating disorders: A systematic review. The International journal of eating disorders, 57(5), 1069–1087. https://doi.org/10.1002/eat.24178
Serpell, L., Treasure, J., Teasdale, J., & Sullivan, V. (1999). Anorexia nervosa: friend or foe?. The International journal of eating disorders, 25(2), 177–186. https://doi.org/10.1002/(sici)1098-108x(199903)25:2<177::aid-eat7>3.0.co;2-d
Steinglass, J., & Walsh, B. T. (2006). Habit learning and anorexia nervosa: a cognitive neuroscience hypothesis. The International journal of eating disorders, 39(4), 267–275. https://doi.org/10.1002/eat.20244
Steinhausen H. C. (2002). The outcome of anorexia nervosa in the 20th century. The American journal of psychiatry, 159(8), 1284–1293. https://doi.org/10.1176/appi.ajp.159.8.1284
Strober, M., Freeman, R., & Morrell, W. (1997). The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. The International journal of eating disorders, 22(4), 339–360. https://doi.org/10.1002/(sici)1098-108x(199712)22:4<339::aid-eat1>3.0.co;2-n
Sysko, R., Walsh, B. T., Schebendach, J., & Wilson, G. T. (2005). Eating behavior among women with anorexia nervosa. The American journal of clinical nutrition, 82(2), 296–301. https://doi.org/10.1093/ajcn.82.2.296
Tozzi, F., Thornton, L. M., Klump, K. L., Fichter, M. M., Halmi, K. A., Kaplan, A. S., Strober, M., Woodside, D. B., Crow, S., Mitchell, J., Rotondo, A., Mauri, M., Cassano, G., Keel, P., Plotnicov, K. H., Pollice, C., Lilenfeld, L. R., Berrettini, W. H., Bulik, C. M., & Kaye, W. H. (2005). Symptom fluctuation in eating disorders: correlates of diagnostic crossover. The American journal of psychiatry, 162(4), 732–740. https://doi.org/10.1176/appi.ajp.162.4.732
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Published
2026-01-29
How to Cite
Korkut, B. (2026). Why Eating Disorders Return. International Journal of Social Science Research and Review, 9(1), 174-188. https://doi.org/10.47814/ijssrr.v9i1.3205
Section
Main Articles
Copyright (c) 2026 Bora Korkut
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