Food Restriction in Anorexia Nervosa in the Light of Modern Learning Theory: A Narrative Review

Abstract

Improvements in the clinical management of anorexia nervosa (AN) are urgently needed. To do so, the search for innovative approaches continues at laboratory and clinical levels to translate new findings into more effective treatments. In this sense, modern learning theory provides a unifying framework that connects concepts, methodologies and data from preclinical and clinical research to inspire novel interventions in the field of psychopathology in general, and of disordered eating in particular. Indeed, learning is thought to be a crucial factor in the development/regulation of normal and pathological eating behaviour. Thus, the present review not only tries to provide a comprehensive overview of modern learning research in the field of AN, but also follows a transdiagnostic perspective to offer testable explanations for the origin and maintenance of pathological food rejection. This narrative review was informed by a systematic search of research papers in the electronic databases PsycInfo, Scopus and Web of Science following PRISMA methodology. By considering the number and type of associations (Pavlovian, goal-directed or habitual) and the affective nature of conditioning processes (appetitive versus aversive), this approach can explain many features of AN, including why some patients restrict food intake to the point of life-threatening starvation and others restrict calorie intake to lose weight and binge on a regular basis. Nonetheless, it is striking how little impact modern learning theory has had on the current AN research agenda and practice.

Testing the role of associative learning in evidence‐based treatments for anorexia nervosa

“…A number of existing theoretical accounts highlight the relevance of associative learning to the onset and maintenance of AN, conceptualizing AN symptoms as learned responses that emerge and are maintained through associations with positive and/or negative outcomes (Garcia‐Burgos et al, 2023; Melles et al, 2021; Pallister & Waller, 2008; Steinglass & Walsh, 2006; Strober, 2004). For instance, food avoidance may emerge through direct or vicarious experience of positive outcomes (e.g., weight loss; social praise; feelings of pride) or escape from/avoidance of negative outcomes (e.g., decreased anxiety; avoidance of weight gain) (see Table 2).…”

“…For instance, food avoidance may emerge through direct or vicarious experience of positive outcomes (e.g., weight loss; social praise; feelings of pride) or escape from/avoidance of negative outcomes (e.g., decreased anxiety; avoidance of weight gain) (see Table 2). Because many individuals are exposed to information that could result in food‐ and body‐related learning, theoretical models often hypothesize that individuals with AN may have unique risk factors that interact with this learning history or demonstrate alterations in associative learning that result in learning occurring more readily, becoming overgeneralized, or being more change resistant (Christian & Levinson, 2022; Garcia‐Burgos et al, 2023; Murray et al, 2018; Schaefer & Steinglass, 2021; Schaumberg et al, 2021).…”