REVIEW

A Three-phase Model of the Social Emotional Functioning in

Eating Disorders
Janet Treasure*, Freya Coreld & Valentina Cardi
Eating Disorders Unit, Institute of Psychiatry, London, UK

Abstract
Background: Problems with social emotional functioning are an important part of eating disorder psychopathology.
Aim: This study aimed to propose a model of social emotional functioning before and during the illness and to explain the consequences
for those involved.
Method: We propose a three-phase model of social and emotional processes as both causal and maintaining factors in anorexia nervosa.
The predictions from this model are examined, and we consider the relevance for treatment.
Results: The evidence base for the theoretical model is presented: Phase 1 describes causal predispositions and environments, Phase 2
notes the way in which the symptoms themselves impact on brain function and social cognition and Phase 3 explains the reactions of
close others.
Conclusions: A three-phase model including interpersonal and socio-emotional elements can be used to shape and plan treatment
interventions. Understanding causal chains and consequences can give a rationale for change and frame therapeutic interventions.
Copyright 2012 John Wiley & Sons, Ltd and Eating Disorders Association.
Keywords
anorexia nervosa; socio-emotional functioning; perinatal environment; emotional recognition; emotional regulation; attachment; temperament; attentional bias;
carers response; treatment implications

*Correspondence
Janet Treasure, PhD, FRCP, FRCPsych, Eating Disorders Unit, Institute of Psychiatry, Box P059, De Crespigny Park, London, SE5 8AF, UK. Tel: 020 7848 5969;
Fax: 020 7848 5967.
Email: janet.treasure@kcl.ac.uk

Published online 27 April 2012 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/erv.2181

Introduction Socio-emotional difculties also manifest within the families

Several aspects of impaired emotional functioning in eating
disorders have been synthesised into systematic reviews
(Oldershaw et al., 2011; Zucker et al., 2007). Difculties within
the socio-emotional domain have been found both premorbidly
(Anderluh, Tchanturia, Rabe-Hesketh, & Treasure, 2003) and
during the acute phases of the illness. In particular, high levels
of social anxiety (Tiller et al., 1997; Zucker et al., 2007) and low
sensitivity to reward (Zucker et al., 2007) have been reported.
Experimental data suggest that people with eating disorders
show abnormal attentional processing to social stimuli, with dif-
culties attending to positive facial expressions (Cardi, di Matteo,
Coreld, & Treasure, 2012; Cserjesi, Vermeulen, Lenard, &
Luminet, 2011), a bias towards angry faces (Cardi et al., 2012;
Harrison et al., 2010) and less eye gaze directed at the face and
eyes (Watson, Werling, Zucker, & Platt, 2010). Moreover, people
with eating disorders reported and displayed less positive affect
when watching lms clips depicting positive social interactions
(Davies, Schmidt, Stahl, & Tchanturia, 2011).
Clinical markers of a decit in the social hedonic system are
also conrmed by low sexual functioning and desire found in
people with eating disorders (Pinheiro et al., 2010) and high levels
of social anhedonia found in people with anorexia nervosa (AN)
(Tchanturia et al., Submitted).
of the patients as well. Family members often report high levels
of stress, depression and anxiety as a result of the illness
(Haigh & Treasure, 2003; Zabala, Macdonald, & Treasure,
2009). This is possibly due to the importance placed on
interpersonal behaviour during and surrounding meal times.
A patient, reecting on her own illness, described how social
factors were intertwined with her eating disorder: nobody
could convince me to eat normally, because I was getting so
much enjoyment [and contact time] from conversations in
which they expressed their worries. . .doing things like crying,
getting angry, or refusing food started off a conversation with
a familiar and predictable script [whats wrongoh, its
justwhy dont youyes butetc.] I gained control of my
interactions with other people.
Experimental data and clinical observations suggest that socio-
emotional functioning is both a causal and maintaining factor.
However, there is not an explicit aetiological or causal model to
synthesise this evidence and guide the development of interventions
targeting this domain. Based on a review and recent experimental
ndings of Oldershaw et al. (2011), the aim of this paper was
to propose a three-phase, empirically based explanatory model
of socio-emotional functioning in AN. Table 1 presents the con-
tent and stages involved in the model, which are described in de-
tail in the remainder of the paper.

Eur. Eat. Disorders Rev. 20 (2012) 431438 2012 John Wiley & Sons, Ltd and Eating Disorders Association. 431
Social Emotional Functioning in Eating Disorders
Table 1 The contents of the three-phase model of social and emotional
functioning in eating disorders
Phase Content of phase Events effecting socio-emotional functioning
Phase 1 Predisposing factors Adverse perinatal events
Birth complications
Attachment style
Early temperament style: shyness and isolation
Early temperament style: social and
communication difculties
Early temperament style: shame proneness
Phase 2 The illness The impact of anorexia nervosa symptoms on
emotional recognition and regulation
The impact of anorexia nervosa symptoms on
vigilance to social cues
The impact of anorexia nervosa on
social comparison
Phase 3 The consequences of the Anorexia nervosa symptoms create a
illness on close others vicious circle of deteriorating social
emotional functioning
Phase 1: Predisposing factors and social
emotional functioning
Phase 1 includes some of the risk factors involved prior to the
onset of the illness. These factors are specically related to the
following: adverse perinatal events, birth complications, abnormal
attachment patterns and temperament characteristics.
Adverse perinatal events
Social emotional functioning is shaped by both genetic and
environmental effects.
The mechanisms underpinning the link between adverse
perinatal events and later suboptimal functioning have been
delineated in animal models (Tarantino, Sullivan, & Meltzer-
Brody, 2011). Environmental events, particularly those in the
perinatal period, such as exposure to maternal anxiety, are known
to impact on attachment and on hypothalamic pituitary adrenal
(HPA) regulation (Glover, 2011; OConnor, Heron, Golding,
Beveridge, & Glover, 2002; OConnor et al., 2005). This may be
relevant to eating disorders, considering that they retrospectively
report a heightened exposure to antenatal stress (Shoebridge &
Gowers, 2000; Taborelli, Krug, Karwautze, Haidvogle, Wagnere
et al., submitted). Retrospective accounts may be coloured by a
search for meaning.
Birth complications
Birth complications increase the risk of developing AN (Andrews
& Brown, 1999; Cnattingius, Hultman, Dahl, & Sparen, 1999;
Favaro, Tenconi, & Santonastaso, 2006; Foley, Thacker, Aggen,
Neale, & Kendler, 2001; Lindberg & Hjern, 2003; Micali et al.,
2007) and the sensitivity to later childhood adversity (Favaro,
Tenconi, & Santonastaso, 2010). This may be mediated by anxiety
(Favaro et al., 2006).
432 Eur. Eat. Disorders Rev. 20 (2012) 431438 2012 John Wiley & Sons, Ltd and Eating Disorders Association.
J. Treasure et al.
Attachment style
Insecure attachments that have been noted to be common in
eating disorders (Illing, Tasca, Balfour, & Bissada, 2010; Ward
et al., 2001) are a central feature of the neurodevelopmental
explanatory model of AN (Connan, Campbell, Katzman,
Lightman, & Treasure, 2003). This model proposes that insecure
attachments, submissive behaviours, suboptimal emotional and
stress regulation contribute to a chronic stress reaction (Connan,
Troop, Landau, Campbell, & Treasure, 2007).
Individuals with the short allele variation of the 5-HTTLPR
transporter appear to be more sensitive to variations in attach-
ment style, such as high parental control, and this increases the
risk of AN (Karwautz et al., 2011). Insecure attachment and
anxiety may increase the vulnerability to fat talk and to being
bullied, teased or criticised (Jacobi et al., 2011; Keery, Boutelle,
van den, & Thompson, 2005; Taylor et al., 2006).
Early temperament style: Shyness and isolation
Several markers of social difculties, including loneliness, shyness
and feelings of inferiority (Fairburn, Cooper, Doll, & Welch,
1999; Fairburn et al., 1998) and a tendency to engage in solitary
pursuits (Krug et al., in press), predate the onset of the illness.
Also, some of the traits observed in AN (e.g. low novelty seeking
and self directness; high harm avoidance) (Fassino et al., 2002)
may contribute to the development of the socio-emotional dif-
culties and predispose to the onset of the illness.
Early temperament style: Social and
communication difculties
Approximately a fth of eating disorder cases can be considered
to lie within the autistic spectrum (Gillberg, Rastam, &
Gillberg, 1994). This group have continuing pronounced pro-
blems with social communication and empathy during their
lifetime. A study by Anckarsater et al. (2011) explored socio-
communicative problems corresponding to autism spectrum
disorders in AN. They found that those with AN plus autism
spectrum disorder traits had the highest prevalence of personal-
ity disorders, compared with those with AN without autism
spectrum disorder traits and healthy controls. Moreover, indi-
viduals with AN without autism spectrum disorder traits
demonstrated less-adaptive personality traits, in terms of inter-
personal functioning and on the neurocognitive tests, compared
with healthy controls.
Early temperament style: Shame proneness
The pre-morbid difculties observed within the socio-emotional
domain in people with AN may be linked to a heightened sensi-
tivity to shame. The evolutionary model of shame proposed by
Gilbert (1998, 2007) posits that shame proneness is rooted in
early experiences and involves two components. The rst one
(external shame) is marked by thoughts and feelings that others
view the self negatively, and this is associated with unfavourable
social comparison and submissive behaviours. The second one
(internal shame) is associated with feelings and evaluations of self
as inadequate, awed, or bad (Gilbert, 1998). The emotion
of shame is related to actual or possible detrimental changes
J. Treasure et al.
in status (e.g. loss of social attractiveness), with the potential
consequences of attack, rejection or disengagement from others
(Gilbert, 1998, 2007).
The onset of eating disorder symptoms may be associated with
the use of mechanisms to cope with shame. Attempting to control
eating and lose weight have been described as attempts to respond
to the threat of social exclusion, by regaining attractiveness
(Goss & Gilbert, 2002) or demonstrating status and control
(Gatward, 2007).
Also, Schmidt and Treasure (2006) pointed out that self-
starvation in AN is a manoeuvre with complex defensive
functions, which has the effect of reducing social threat.
Subordinate status may be directly related to symptoms of AN,
such as low weight, through its effects on serotonin, the HPA
axis and appetite (Connan et al., 2003). Alternatively, there
may be an indirect relationship occurring through, for example,
personality features. Subordinate status has been related to
higher levels of perfectionism and particularly to socially
described perfectionism in which attitudes are attributed to
others regarding the expectation of high standards in oneself
and where a lack of control in the social domain is perceived
(Wyatt & Gilbert, 1998).
Once developed, the dynamics related to shame proneness
become maintaining factors of the illness (Burney & Irwin, 2000).
Phase 2: The impact of anorexia nervosa
symptoms on social emotional functioning
As a secondary consequence of starvation or of irregular nutri-
tion, impaired brain function can accentuate underlying dif-
culties in social cognition. The individual becomes ever more
isolated, and this denes the illness (McKnight & Boughton,
2009). The consequences of starvation and nutritional imbal-
ance can be expected to resolve after nutritional recovery. This
makes it possible to estimate the impact that the symptoms
themselves have on social emotional functioning by comparing
functioning in both the acute and recovered states. Here, we
present research investigating social emotional functioning in
both the acute state and after recovery state and in rst-degree
relatives, wherever possible.
The impact of anorexia nervosa symptoms on
emotional recognition and regulation
Emotional recognition, as assessed by the Reading the Mind in
the Eye task, has been found to be impaired, particularly in AN.
In a meta-analysis of several studies, effect sizes in the acute
phase of the illness were moderate to large (d = 0.51, 95%
CI 0.73 to 0.28) (Oldershaw et al., 2011). Monozygotic
twins are more concordant than dizygotic twins for this trait
(Kanakam, Raoult, Collier, & Treasure, submitted), and the im-
pairment remains after recovery (Harrison et al., 2010), which
suggests that it might be an endophenotype.
The ability to perform on a variety of theory of mind tasks
was impaired in the acute state of AN (Oldershaw, Hambrook,
Tchanturia, Treasure, & Schmidt, 2010). Those who are recov-
ered from the illness also show differences in activation of
the large right temporal lobe region in the ability to take the
Eur. Eat. Disorders Rev. 20 (2012) 431438 2012 John Wiley & Sons, Ltd and Eating Disorders Association.
Social Emotional Functioning in Eating Disorders
perspective (e.g. understand anothers feelings and thoughts,
social hierarchy) (McAdams & Krawczyk, 2011), whereas no
signicant differences were found in the ofine version of the
task, suggesting that theory of mind may still be at least partly
impaired at the neurocognitive level.
Individuals with AN demonstrate difculties with affect regula-
tion; they show higher levels of emotional dysregulation
(distraction) and lower levels of emotional self-efcacy (sense of
competence in using various strategies for negative mood regula-
tion) (Gilboa-Schechtman, Avnon, Zubery, & Jeczmien, 2006).
There is evidence to suggest that emotional regulation may be
impaired during the acute phase of the illness, where self-
starvation serves as a dysfunctional behaviour to regulate aversive
emotions (Brockmeyer et al., 2011). Uncertainty exists as to
whether emotional regulation actually improves following
recovery (Brockmeyer et al., 2011; Harrison et al., 2010).
Problems with frustration may be a precursor for difculties
with emotional regulation. Adolescent women with AN have been
shown to be more likely to perceive hostile intent from a peer
provocateur (McFillin et al., 2012). Intrapunitive avoidance
coping strategies are used more in these circumstances (Harrison,
Genders, Davies, Treasure, & Tchanturia, 2011).
The impact of anorexia nervosa symptoms on
vigilance to social cues
People with eating disorders [particularly in those with
bulimia nervosa (BN)] show an attentional bias towards angry
faces, using Emotional Stroop (Harrison et al., 2010) and dot
probe paradigms (Cardi et al., 2012). This vigilance toward
angry faces remained even after recovery. Likewise, vigilance
to social rank cues (dominant and submissive faces) is present
in the acute state and remained after recovery (Cardi et al., 2012).
Vigilance to threat and rank is associated with early adversity such
as separation from parents in childhood (Cardi et al., 2012). Thus,
anxiety and vigilance to threat and rank may both be causal and
maintaining risk factors.
The impact of anorexia nervosa on social comparison
Problems associated with shame have been found in people with
eating disorders. Troop, Allan, Treasure, and Katzman (2003)
showed that patients with eating disorders displayed more
unfavourable social comparison and reported more submissive
behaviours than age-matched controls. Connan et al. (2007)
replicated these results in patients with AN, nding that women
who were currently ill and those who had recovered reported
more submissive behaviours and a tendency towards more
unfavourable social comparison relative to healthy controls. A
more recent study (Troop, Allan, Serpell, & Treasure, 2008)
found that women in remission reported signicantly lower levels
of both internal and external shame than women who were
currently ill, but they continued to report signicantly higher
levels of external shame than a non-clinical sample.
These ndings show that people with eating disorders have
high levels of shame proneness and that issues associated with
rank, unfavourable social comparison and submissive behaviours
may persist after recovery.
433
Social Emotional Functioning in Eating Disorders J. Treasure et al.

Phase 3: Anorexia nervosa symptoms
create a vicious circle of deteriorating
social emotional functioning
The next layer of difculty in social emotional functioning
involves the interpersonal reactions between close others who
respond to the changes brought about by the illness. These
interactions are challenging to the individual, who as we have
seen, have their social and emotional resourcefulness compro-
mised by the illness (Phase 2). Those close to the individual may
react to the illness with intense anxiety and anger. The latter can
be shaped by unhelpful carer appraisals, such as believing that
the illness is caused by vanity or vengeance (Whitney et al.,
2005). Interactions high in expressed emotion (overprotection,
criticism, hostility) are common (Kyriacou, Treasure, & Schmidt,
2007; Kyriacou, Treasure, & Schmidt, 2008). Also, as the patient
described in the introductory paragraph, interactions may
be shaped by the need of the person with AN for control
and sameness.
Poor emotional regulation on the part of the patients often
leads to bullying, verbal and physical abuse. Family members
may react to this aggression with anxiety and avoidance,
and accommodating and enabling behaviours (Treasure et al.,
2008). This occurs when carers tacitly allow eating disorder
behaviours to continue or shield the individual from the conse-
quences. These reactions to the illness are seen in professional
carers as well as family carers (Treasure, Crane, McKnight,
Buchanan, & Wolfe, 2011; Waller, 2009). They allow the symp-
toms to ourish by reinforcing illness behaviours, reducing
caregiving efcacy and mirroring and, hence, escalating emo-
tional arousal. Moreover, they can lead to an irretrievable
breakdown in relationships. This Phase 3 cognitive interpersonal
model is shown in Figure 1.
Symptoms of AN steer a carers threat-laden appraisals,
which lead to anxiety and anger and unhelpful interac-
tions between patient and carer (overprotective and hostile,
respectively). In turn, these responses can lead to an exagger-
ation of illness behaviour and resistance, which entrench
the illness. The emotional reaction in the carer is mirrored
by the patient, who has limited ability to regulate their
emotion and hence uses starvation, self-harm or exercise as
maladaptive strategies.
Targeted treatments
Interventions targeting the components of this model can change
these interpersonal behaviours and have been shown to reduce
both carer (Goddard et al., 2011) and patient distress (Goddard,
Macdonald, & Treasure, 2011). The hypothesis that this, in turn,
will improve patient eating disorder symptoms and long-term
relationships has not been tested.
Discussion
In this review of the literature, we have considered how difculties
with social emotional functioning and interpersonal relationships
may be both risk and maintaining factors for AN. Social emotional
difculties (insecure attachment, shyness, interpersonal anxiety)
are primary risk factors, the nutritional consequences on the brain
produces secondary changes in social emotional functioning
(impairment in theory of mind and emotional regulation), and
nally, there are the tertiary consequences caused by the reaction
of carers or close others to the illness. The next question to
consider is how to apply this theoretical understanding to a
clinical setting.
It is easier to address maintaining factors as, by denition, they
are overt in the clinical process. This therefore means treatments
targeted at Phase 2 and Phase 3 are of interest. Interventions for
Phase 2 involve symptom change (i.e. eating), whereas interven-
tions for Phase 3 involve optimising the social environment to
produce change.

Interpersonal maintenance model of anorexia nervosa.

Anorexia nervosa
symptoms

Patients' emotion

Low Care-Giving Carers anxiety

Mirroring emotion
Self Efficacy Carers appraisals

Carers emotion

Interactions
Carer/Patient

Figure 1 Interpersonal maintenance model of anorexia nervosa

434 Eur. Eat. Disorders Rev. 20 (2012) 431438 2012 John Wiley & Sons, Ltd and Eating Disorders Association.
J. Treasure et al.
Treatment implications for Phase 2
and Phase 3
Therapeutic alliance
The therapeutic alliance is a core element of all psychotherapeutic
approaches, and this will be shaped by the social emotional biases
of both parties in the relationship. The closest and most sustained
relationships are those with the families, and strengthening the
alliance between family members and the individual with an
eating disorder is an important rst step. Sharing information
about the illness with carers (families and professionals) can help
them steer a balanced course between the tendency to be over
protective, accommodating to the illness and angrily trying to
coerce change.
Individuals with an eating disorder have heightened vigilance
for threat and/or dominance (Cardi et al., 2012), and this
may lead to an approach/avoidance conict, a lack of trust and
ambivalence within the relationship. This may lead to problems
with treatment adherence that have been reported (Halmi et al.,
2005). Signals of care and compassion appear to be ignored,
making it more difcult for the individual to regulate emotions
(Cardi et al., 2012). Family members and clinicians need to be
mindful of this possible biased style. An analogy that may help is
that of colour blindness comparing (i) an inability to see the
positive to an inability to recognise green and red colours and (ii)
the heightened sensitivity to focus on the negative produces a black
sombre context. This explains why one of the rst steps is for carers
(professionals and family) to regulate their own emotional response
and be calm and warm rather than dominant and critical. Good
communication is a key component of care and can be a model of
procient social cognition skills.
Motivational interviewing
An exemplar of a communication style that includes these
elements is motivational interviewing. Motivational interviewing
emphasises the importance of afrmation, warmth and accurate
listening (adaptive theory of mind skills). Moreover, this commu-
nication style emphasises the need to side step resistance and
conict, minimising criticism and dominance within the relation-
ship. Motivational interviewing has been used in a variety of
eating disorder contexts. It is noteworthy that three out of the ve
randomised controlled trials, which used motivational interview-
ing as a component of treatment, found that it resulted in higher
readiness to change (Dean, Touyz, Rieger, & Thornton, 2008;
Dunn, Neighbors, & Larimer, 2006; Wade, Frayne, Edwards,
Robertson, & Gilchrist, 2009). Teaching parents and other carers
how to use motivational interviewing skills seems to be highly
valued by carers (Whitney, Currin, Murray, & Treasure, 2011),
and studies are underway to establish whether it is of benet.
Therapeutic approaches
The use of interpersonal psychotherapy in eating disorders has
showed comparable recovery rates to cognitive behavioural
therapy (CBT), both in patients with BN (Agras, Walsh, Fairburn,
Wilson, & Kraemer, 2000; Fairburn et al., 1991) and patients with
AN (McIntosh et al., 2005; McIntosh et al., 2006). However,
limitations have been highlighted (Rieger et al., 2010), and new
Eur. Eat. Disorders Rev. 20 (2012) 431438 2012 John Wiley & Sons, Ltd and Eating Disorders Association.
Social Emotional Functioning in Eating Disorders
interpersonal formulations of the illness have been developed
(Ansell, Grilo, & White, 2012; Rieger et al., 2010).
Other therapeutic approaches also use strategies to enhance
social cognition. The circular questioning used in family therapy
fosters theory of mind thinking. Mentalisation-based treatment
specically focuses on social cognition, with the aim of improv-
ing interpersonal functioning (Bateman & Fonagy, 2004). Inter-
ventions directly targeting the vigilance to threat have also been
developed for conditions such as anxiety (Wilson, MacLeod,
Mathews, & Rutherford, 2006). Cognitive bias modication
for attention (MacLeod, Rutherford, Campbell, Ebsworthy, &
Holker, 2002) has been used to good effect in anxiety (Hakamata
et al., 2010) as well as alcoholism (Schoenmakers et al., 2010).
Also, cognitive bias modication for interpretation, in which
participants are trained to interpret emotionally ambiguous
information in a positive way (Mackintosh, Mathews, Yiend,
Ridgeway, & Cook, 2006) has also been found to be effective
in socially anxious individuals (Beard & Amir, 2008; Brosan,
Hoppitt, Shelfer, Sillence, & Mackintosh, 2010). It is possible
that these training approaches may benet people with eating
disorders. Yet another approach to improve emotional regula-
tion and social engagement is to build a foundation of positive
emotions (Wood, Froh, & Geraghty, 2010; Wood & Tarrier,
2010).
Pharmacological approaches
An alternative approach is to consider pharmacological
approaches. Oxytocin improves many aspects of social emotional
functioning (reviewed in Bos, Panksepp, Bluthe, & Honk, 2011)
promoting trust (Baumgartner, Heinrichs, Vonlanthen, Fischbacher,
& Fehr, 2008), afliative behaviour (Zak, 2008), empathy and
generosity (Zak, Stanton, & Ahmadi, 2007), positive communication
(Ditzen et al., 2009; Gouin et al., 2010), secure attachment (Buchheim
et al., 2009), decreasing social stress (Heinrichs, Baumgartner,
Kirschbaum, & Ehlert, 2003), improving eye gaze and empathy
(Guastella, Mitchell, & Dadds, 2008) and facial emotional recognition
(Domes, Heinrichs, Michel, Berger, & Herpertz, 2007). Moreover,
oxytocin has been used to treat several psychiatric conditions in
which social problems dominate (see reviewed Striepens, Kendrick,
Maier, & Hurlemann, 2011). However, this form of treatment has
not been explored.
Does the social emotional functioning impact on
prognosis and outcome?
If social and emotional difculties are risk or maintaining factors,
then they would be expected to impact on prognosis and
outcome. This has been found. Wentz and colleagues examined
the longitudinal course of a cohort of patients ascertained at age
15 years and found that the group with antecedent of social
communicative problems and obsessive compulsive disorder traits
had a less favourable outcome (Wentz, Gillberg, Anckarsater,
Gillberg, & Rastam, 2009). Also, a study from Canada found that
attachment insecurity predicted a poor outcome (Illing et al.,
2010) as did interpersonal difculties (Tasca et al., 2011). The
latter group tested Fairburns enhanced CBT model for eating
disorders and found that low self-esteem mediates the relation-
ship between interpersonal difculties and eating symptoms
435
Social Emotional Functioning in Eating Disorders J. Treasure et al.

(Tasca et al., 2011). These ndings suggest that strengthening or Conclusion

repairing ruptures in relationships may be a critical therapeutic goal.
Limitations
The three-phase model of socialemotional processing heavily
relies on a vulnerability to anxiety as a basis for social and
emotional problems. An alternative explanation is that communi-
cation problems stem from characteristics related to rigidity and
perfectionism, similar to autism spectrum disorders. The majority
of the evidence presented to substantiate the model is based on
behavioural tasks, which is problematic when considering the
integrated model of brain organisation in AN. Social and
emotional processing occur at different levels. Emotional
processing occurs at a subconscious level, with thinking/feeling
and self-regulation occurring later at the conscious level (Hatch
et al., 2010). Key elements may be missed at the behavioural level.
In conclusion, we have outlined a three-component model of
social emotional factors as risk and maintaining factors associ-
ated with eating disorders. Adverse perinatal events, attachment
problems and temperamental characteristics seem to predispose
the development of the illness. Abnormal socio-emotional
functioning (emotional recognition and regulation, attentional
bias and social comparison) serve to maintain the illness.
These symptoms have consequences on close others, creating
a vicious cycle of deteriorating socio-emotional functioning.
A coherent approach to the illness would involve treatment
interventions focused on these three different facets. Carers
(professionals and families) need to model a high level of
emotion regulation and social emotional skills in order to be
effective therapy guides.

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