Psychodynamic theory asserts that symptoms do not happen by chance; symptoms are determined by contributing forces, including early childhood experiences, repressed sexual and aggressive drives, social, religious, and cultural dictates, and predisposing biological factors. Determining appropriate eating disorder treatment requires careful assessment of each individual’s needs, history, and challenges to select the most effective approach.
Adapting to evolving research and expanding theoretical approaches does not eliminate the need to recognize the core challenge: There is no single cause or solution. As health care trends have shifted over time, so too have approaches to eating disorders—driven by evolving knowledge and persistent misconceptions. This underscores the need for treatment to embrace complexity rather than rely on a single theory.
To understand these trends, consider the history of eating disorders. In the 14th and 15th centuries, restricted eating among young women in Catholic convents was seen as a form of spiritual devotion and control. In contrast, by the early 20th century, Freudian theories recast anorexia as a symptom of unresolved sexual fantasies—linking food, sex, and purity.
Despite Freud’s influence, his theories on anorexia received mixed reactions—they were obscure to some and preposterous to others. For example, he postulated anorexia to be a fear of pregnancy through the mouth, explained as stemming from unresolved sexual conflicts and impulses displaced on the oral pleasure of eating. Freud asserted that the fear of growing up, through curtailing menstruation, kept sexual wishes and realities of body changes at bay. Freud did pave the way for the idea that eating disorders partially involve seeking control when life feels unmanageable, but for Freud, this pertained exclusively to sex.
The refusal by many who were knee deep in treating patients to accept Freud’s conceptions led to an evolution that prompted clinicians to re-examine Freud’s conclusions. Freud’s essays on hysteria reflect fantasy wishes about sex, not actual events. He rationalized and sometimes denied that some patients were abuse victims; their stories were truly not fantasies. Salvatore Frenzci, a contemporary who disagreed with Freud, wrote extensively about reality versus fantasy regarding sexual trauma.
After Freud, Relational and Family Systems theories influenced how understanding was shaped. By the 1990s and 2000s, focus shifted toward patients’ experiences of loss, psychological injuries, and parental mishaps, such as narcissistic injury and empathic failures. During this period, qualitative treatment and research improved, and increasingly the field discovered that over half of eating disorder sufferers had experienced sexual or physical abuse before onset. Clearly, newer treatments could be tailored toward sexual abuse, trauma, and their impact on the development of eating disorders.
Treatments were improving, but clinicians were facing their own challenges and biases.
Despite advances in treatment, layers of issues persist among clinicians. Everyone has a viewpoint and something useful to add. Compared across regions, the key difference between my 20 years in New York and my 10 years in North Carolina is the provider hierarchy. I support a team approach with shared decision-making among providers, orchestrated by the primary mental health provider, who communicates with the patient and family. Where hierarchy exists, patient resistance increases because it reinforces patients’ prior sense of imposed control. Since the eating disorder serves as both a mechanism of defiance and autonomy, adopting a dogmatic approach often results in artificial compliance and thus recidivism or further defiance.
Treatment trends during the 1990s and 2000s included some embracing the “gene theory” for eating disorders, particularly among major research hospitals that received significant NIH and NIMH funding. To this date, no specific gene has been found. A global genomic study of 17,000 anorexia nervosa patients showed links to genetic factors like metabolism, brain development, and in utero gastrointestinal issues. Pursuing thinness may tragically reflect a medical predisposition (Watson).
Many candidate gene studies have been published, but none are conclusive (Gibson).
This uncertainty is reflected in real-life decisions around care. For instance, one family whose daughter had anorexia chose to send her to a major medical research recovery center for treatment. The recommendation was for a more residential, psychodynamic, and relational program with solid in-house medical care. Despite no proof, the family was convinced that their child’s anorexia was a biological condition determined genetically. The child returned subsequently to the same facility three times in the next two years.
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This raises the question: Might she have had a better treatment response at a differently oriented residential facility? There is no way to know for sure. However, the family refused to consider any other alternative facility. The reason for this steadfast preference remains unknown; however, the question of family resistance to looking beyond gene explanations was raised. For many, considering a psychological understanding versus a purely biological one is daunting; self-reflection is complicated. Family Systems approaches teach us that the person in the family with the eating disorder is “merely” the spokesperson for the illness that befalls the entire family system.
Clinicians have learned that replacing one theoretical approach with another does not guarantee better outcomes because eating disorders are a complex system, not a linear one. While evidence-based protocols help, they are typically effective for fewer than half of patients. Therefore, this highlights the need for an individualized, flexible approach that is open to integrating different models (Scheel).
If Freud offered a lasting lesson, it is the value of multi-determinism: Eating disorders, like most human struggles, have multiple causes and cannot be explained or resolved by a single theory or protocol. Consequently, the most effective treatment approach recognizes this complexity, prioritizing integration and flexibility to meet each patient’s needs.
