The link between decision-making and eating disorders

Some fascinating research – funded by the Medical Research Council and UCL – has  looked at the connection between eating disorder symptoms and decision-making.

What was found is that that people who make disadvantageous decisions are much more likely to have eating disorder symptoms than those who make advantageous decisions.

In this post, Dr Amy Harrison, Senior Psychologist with Altum Health and Associate Professor at UCL, takes a deeper look into this research, helping to explain the link we’ve discovered between decision-making and eating disorders, and the potential benefits this could offer.

A little on decision-making

Looking broadly at decision-making, this is something we all have to do, hundreds of times a day. These decisions range from what to wear, which route to take to work, and what to eat, to which subjects to study at college, or which universities to apply to. 

Some decisions are easy to make because you have all the information you need in order to make the decision and there are limited options to choose from. 

However, some decisions are more difficult because, perhaps, you don’t know all the parameters and you don’t have enough information. There may be things you don’t yet know or understand and you might not know what (if any!) the solutions are.

The psychology of decision-making

A typically-developing person will acquire and learn decision-making skills throughout childhood and adolescence and well into their adulthood. It’s a complex cognitive skill and is one of the key things that sets us aside from other animals.

It requires us to weigh up what we’ve learnt from past experiences and use that knowledge to gauge what to do next. However, we don’t all share the same decision-making ability.

There is a new idea in psychiatry that disadvantageous decision-making underpins all forms of psychological distress. Part of the solution is to teach people to make more advantageous decisions so they can lead happier lives. 

How does disadvantageous decision-making affect everyday life?

Making a judgement or interpretation about something involves an element of decision-making. 

In depression, for example, someone might wake up in the morning and feel really low. The decision they make is to stay in bed and not do anything. The problem is, that person will then have no opportunity for reward or pleasure and their mood will get lower. If they made a decision to go and do something – however hard that decision is to make – it would be more advantageous than the decision to do nothing. 

In the development of an eating disorder, people may make disadvantageous decisions about how much or how little food they’re eating. They might think, “My body doesn’t look the way I want it to look”. They then make a decision about what to do about that. Some people will make a decision to go on a diet whereas other people will think, “That’s how my body looks. I’m still a good person. I can still do nice things.”

What do we know about decision-making and eating disorders?

There’s lots of research that helps us to better understand the link between how those with eating disorders react to rewards and punishment, and also how conditions of risk impact their decision-making.

Punishment sensitivity

We know that people who experience eating disorders – in general – are more punishment sensitive than peers without eating disorders. 

This means that when someone living with an eating disorder has to make a decision, they’ll often choose the course of action that avoids the possibility of getting something wrong. Because for these people, to fail at something feels so horrible that they’ll do anything to protect against it. 

Therefore eating disorder sufferers are often withdrawn, isolated, and may avoid certain experiences because they don’t want to risk getting things wrong. 

This has the added impact of also limiting their opportunities to learn from experiences, which is a natural part of developing our cognitive skills. This can lead to others making decisions on their behalf.

Reward sensitivity  

In addition to high punishment sensitivity, people with bulimia nervosa also have a high reward sensitivity. 

They might be more impulsive, have lots of urges and cravings, and be drawn to more addictive behaviours. 

In this situation, the underlying feeling of not wanting to make the wrong decision can jar with the impulsive thoughts, creating a stressful experience for the sufferer.

Conditions of risk

When it comes to making decisions under conditions of risk, people with an eating disorder – particularly those with anorexia nervosa – are typically cautious. 

Studies based on gambling tasks, with the element of risk being that you could either gain or lose money, showed that when those with an eating disorder experience a loss, their decision is to ‘batten down the hatches’ and not to take any further risk.

We see this in the everyday lives of people living with eating disorders. They can be quite frugal and they often avoid putting themselves out there. For example, it can feel like a big risk to try a new food. Situations such as this can be really anxiety provoking.

The link between decision-making skills in adolescence and the development of eating disorder symptoms  

The research…

The Millennium Cohort Study, which follows the lives of more than 6,000 children born in the year 2000, formed the basis of our research. As part of this study, participants were given a gambling-style task at ages 11 and 14 where they could win or lose points under conditions of risk. In order to get a high score, they had to make more advantageous decisions. 

Alongside this, the children were asked a series of questions, including whether they were restricting how much they were eating, or whether they intended to do that, whether they were excessively exercising, and how satisfied or dissatisfied they were with their body. 

The results…

We’ve looked at the data collected by the Millennium Cohort Study and have found that the participants who made less advantageous decisions on the task at ages 11 and 14 were much more likely to have eating disorder symptoms at ages 14 and 17. 

What’s more, because the study was also done at ages 14 and 17, we were able to see that those who showed eating disorder symptoms ,at 14 and 17 improved less on the task between the ages of 11 and 14 compared to those who did not show eating disorder symptoms

  • The people without eating disorder symptoms did show an improvement in their decision-making skills. 
  • The decision-making skills of those with eating disorder symptoms changed less. 

In simple terms, advantageous decisions are more likely to create a favourable outcome, while disadvantageous decisions make a successful outcome less likely.

We can’t use these results as a predictor of whether or not someone will develop eating disorder symptoms. However, we can say there’s an association, a relationship, between more disadvantageous decision making in childhood and early adolescence and developing eating disorder symptoms in middle to late adolescence.

One of the implications of this work is that, potentially, if we can teach advantageous decision making skills early on, we might be able to help people develop the skills that will help to protect against eating disorder symptoms.

Decision-making skills when living with an eating disorder

When living with an eating disorder, it might be that you are able to make advantageous decisions in some areas, but with decisions related to your eating disorder, you’re really affected by what the illness wants you to do and therefore those skills don’t transfer. You may feel paralysed by this situation. It can be incredibly distressing.

For anyone experiencing this scenario, the solution could be to practise, so that they can get better at making the most advantageous choices. 

For example: choosing to follow your meal plan even when you’re having a bad day, your friends are skipping lunch, and you’re stressed. That would be an advantageous decision because you’re standing up to the eating disorder by saying, “I will still eat this food even if it’s really difficult”. The more you do that, the easier it will get. 

When your brain is starved, whether it’s chronically starved by undereating or intermittently starved perhaps through bingeing and purging, some cognitive skills – such as decision-making – are sub-optimal. You simply don’t have the cognitive resources to do it effectively. 

This, coupled with the fear of making the wrong choice (as mentioned earlier), can make decision-making really overwhelming. 

Broadly speaking, can decision-making skills be improved?

There are a number of ways to help someone’s ability to make advantageous decisions. One being to practise set decision-making tasks – similar to what you would find in the previously mentioned cohort study.

There are also techniques that can be used to help improve decision-making. For example, if someone has suffered from a brain injury or substance-abuse, there are strategies that can be used to help compensate for the challenges of not being able to use their cognitive skills in the same way as others. 

This could involve breaking down the task into more manageable chunks. Looking at the different factors involved, the options available, and the pros and cons of those options. And empowering the person to make the right choice for them. 

Planning is also a major factor in helping to make advantageous decisions. In our post on going on holiday with an eating disorder, we spoke to the importance of having plan A, B, C, D etc… In fact, expert decision makers spend much more time on planning than executing their choice. 

Social support is also key. Getting others to help you in your decision-making, as well as modelling how to weigh something up to make an informed decision.

Learning from others’ experience can also be useful to improve decision-making skills. Many people living with an eating disorder are quite isolated and alone, however, your therapist can help to model those skills so you can start to practise them for yourself.

If you’re living with an eating disorder and would like to understand how our licensed and trained professionals can support you to develop your decision-making skills, please do reach out. You can book a free, 20-minute consultation with us by clicking here.

Take care,

Dr Amy Harrison

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