The patient is very knowledgeable about her condition and various treatment approaches. Among all the ‘facts’ she can rattle off, she says, “My therapist told me that eating disorders aren’t about eating.”

I have heard this phrase repeated so frequently about anorexia, bulimia, and other eating disorders; even among some professionals, it has achieved the status of clinical common sense: Eating disorders are not really about eating.

Admittedly, it sounds insightful. The danger is that it is also only partly true and, as in many other areas of life, half-true knowledge can sometimes be more dangerous than a false belief.

The aim of this statement is to correct a critical misconception: Eating disorders are not actually about making poor food choices or a lack of willpower. Empirical research and clinical observations show that people who suffer from these conditions typically have solid nutritional knowledge and strong willpower; they cannot simply decide to eat normally. Their struggles involve fear, perfectionism, self-perception, self-evaluation, self-regulation, emotion regulation, reward, habit, interpersonal experience, biological vulnerability, and, for some, trauma.

Anyone who has sat with a patient in the grip of one of these conditions knows that the food is never only food. But from there we tend to make a second mistake, and it is the more consequential one: We move from saying that an eating disorder is not only about eating to saying that eating is merely the surface expression of some deeper psychological problem. The food becomes a symptom screen. Underneath, we assume, hides the real disorder: trauma, low self-esteem, family conflict, personality disorders, and/or unmetabolized emotion (feelings that have not been fully processed).

I have to admit, it feels psychologically sophisticated. Scientifically, though, it is too simple and, hence, misleading.

Where a disorder lives is not why it started or how it was created

The main issue and misconception is not calling them eating disorders. The mistake is confusing the domain in which a disorder is expressed and maintained with a claim about what caused it: A disorder can be expressed through eating without having been caused by food. And eating behavior can become part of the machinery that keeps the disorder alive.

Let’s look at prolonged food restriction. Starvation does not simply make a person thinner. It also impacts and reshapes cognition, mood, attention, social behavior, reward processing, and preoccupation with, and rumination about, food. This is not uneducated speculation. The Minnesota Starvation Experiment, conducted by Ancel Keys and colleagues in the 1940s with 36 healthy male volunteers who had no history of disordered eating, produced depression, rigidity, irritability, social withdrawal, emotional lability, and an obsessive cognitive focus on food (Kalm & Semba, 2005).

The implication is challenging. Restriction can manufacture psychological features that we later read as evidence of a pre-existing personality problem. We meet the patient after the process has been running for months or years, and we mistake its products for its origins. That inference is plausible, but it goes further than the evidence settles: Recovered patients often perform much like acutely ill ones, and the unaffected sisters of patients show similar cognitive difficulties, which points toward trait as well as consequence (Holliday et al., 2005; Miles et al., 2020). Simply put, when you starve the brain, the brain behaves abnormally. We then look at that abnormal behavior and mistakenly say, “See, they were always like this.”

Bingeing can become self-sustaining in a parallel way. Eating may briefly reduce distress, shame, or emotional arousal, which makes the behavior more likely to recur. Purging and compulsive exercise can acquire similar reinforcing functions. This is the affect-regulation account, and it is contested: A meta-analysis of 36 momentary-assessment studies found negative affect rising before binge episodes but not reliably falling afterward (Haedt-Matt & Keel, 2011).

Once these cycles are established, whatever initially triggered the illness may no longer be sufficient to explain what is maintaining it. The disorder has become its own cause.

Why this is an important distinction at the bedside

If we believe eating is only the visible symptom of an underlying problem, a treatment sequence follows naturally: Uncover the deeper issue, resolve it, and normal eating will return.

Scientific evidence does not support that sequence.

In anorexia nervosa, nutritional rehabilitation is not something that can safely wait until the psychological work is finished. Restoring eating and reversing energy deprivation are themselves central components of treatment, not preconditions for the real therapy, and not a mechanical prelude to it. The American Psychiatric Association’s 2023 guidelines recommend that psychotherapy for adults with anorexia include normalizing eating, restoring weight, and addressing the psychological aspects of the illness together, rather than in sequence (Crone et al., 2023). A malnourished brain is not well positioned to do psychological work, which is part of why the order matters.

None of this diminishes the significance of trauma, relationships, identity, perfectionism, shame, or emotion regulation. For many patients these are profoundly important, and treatment that ignores them will fail in a different way.

It means something more precise: Causes, expressions, and maintaining mechanisms are three different things. What makes a person vulnerable may differ from what triggers the illness. What triggers it may differ again from what keeps it going. A model that collapses these into a single narrative will be wrong about at least two of them.

What a eating-disorder diagnosis can and cannot provide

Perhaps, then, we do not need to stop calling them eating disorders. The key is that we should stop using or hearing the name as an explanation.

Eating disorder tells us where an important part of the pathology occurs, and where a substantial part of the treatment must therefore go. It does not tell us why this particular person developed it.

That question is considerably harder.

If you or someone you know is struggling with an eating disorder, the National Alliance for Eating Disorders helpline offers free support. To find a therapist, visit the Psychology Today Therapy Directory.