Cognitive Dissonance and Anorexia Nervosa: How They Play Out

"27.75 calories too many, but I’m meant to be gaining weight. I shall look better when I do." (Diary entry, in recovery, 2008)

In the first two posts in this series, I sketched out the basics of cognitive dissonance theory and the direct evidence of its efficacy in eating disorder prevention. How might we extrapolate from here to think more broadly about cognitive dissonance as a principle relevant to anorexia and recovery from it?

The main reason I’m drawn to cognitive dissonance as a concept for understanding anorexia nervosa and recovery better is just how suffused anorexia is with dissonances. (I focus on anorexia here, as ever, because I know it best, but similar considerations probably apply with other kinds of eating disorders.) Living with anorexia means living in an ongoing state of multiple dissonances and only partially successful attempts to reduce them.

What form do the dissonances take? Well, you’ve achieved the thinness that’s meant to make you happy and yet you’re miserable; you’re excellent at the things so many people seem to struggle with health-wise and yet you understand that you’re more seriously ill than most; you’re exercising intense levels of control over lots of things in your life yet feel your life is out of your control; you’re saying you’ll eat a bit more tomorrow and not doing it; you’re telling your children to be body-acceptant and not diet while modeling the exact opposite… And so you find little or not-so-little ways to make this OK: upselling the happiness; downplaying the physical damage; denigrating other people’s alternatives to control; eating tiny enough bits extra that they make no difference but also aren’t nothing; acting out little relaxed-eating charades for the kids…

The dissonances and the reduction tactics are deeply personal. They’re also social: the inconsistencies are internal to your belief system, experience, and actions, but they also implicate the broader sociocultural values that you’ve tried to live by and been failed by, and keep being failed by, over and over. You started dieting because you’d grown up learning that slimmer is better; you kept dieting because people were paying you more compliments; you know where all this has got you, yet you’re responding with something closer to Stockholm syndrome than countercultural rejection. The sharpness of this conflict is readily enough reduced into something approaching consonance by invocations of normality (if that many people think dieting is standard, they must be right; or if normal = daily cardio, there’s no way I could do differently and be happy) or by pretence of helpless inevitability (the system is too powerful for me), or any other means by which the broader dynamics are both legitimized and made the unavoidable reason for your misery.

Both personally and socially, the dissonances also continue into recovery, indeed are often exacerbated there. For example: I’m acting as if I wanted to gain weight but I don’t—or I want to gain weight but I don’t seem able to act that way (or both at once). I want to get better but I don’t want to perform any of the actions needed to get better. I'm trying to learn to honour my hunger but I keep finding reasons to distrust it. I envy my slim friends but I seem to be trying hard to make myself less slim… And, later in the process, especially once conspicuous thinness is going or gone, the social dissonances may grow stronger: I’m aiming for a “normal” relationship with food but the normality I see around me seems nothing to aspire to. Why am I eating so much more than my friends even though I already weigh more than them? And so on. The dissonances may even extend, interpersonally, into the treatment we receive: when a clinician is trying to help you get over a restrictive eating disorder but suggests you start to restrict your eating when you reach a certain weight, for instance, or conversely when they encourage you to get fatter than they would themselves be comfortable with, they are exhibiting and responding to their own dissonances, and the ways they do so may not work out in your favour, despite everyone’s best intentions.

And when it comes to that fragile extended moment of choosing to begin recovery or not, or choosing (or not) to restart it after it’s ground to a halt or after a relapse, dissonance is at play in the fragility. In an early study on what they called the "don't remind me" effect, Elkin and Leippe (1986) found that high dissonance (as measured physiologically) remained heightened when an attitude change opportunity was given, but declined when no opportunity was given, i.e. when participants were left to forget about the dissonance. In general, being confronted with opportunities for dissonance reduction may maintain the dissonance until one or more are selected. And given that any strategy has its costs, avoidance of all of them may seem the appealing option. So we throw ourselves into work or a relationship or anything else that can distract us from the problem.

All these kinds of fact about the experience of anorexia would more traditionally be framed as forms of “paradox”:

For example, pre-morbidly our patients have been conscientious and compliant but during the illness they are rebellious and resistant; they see themselves as fat when they are thin; feel well when they are ill; feel full when they are empty. They starve themselves but sometimes binge; they are obsessed with food but avoid it. They tend to be popular and successful but have low self-esteem; they appear to be in control and controlling but feel they have no control or are out of control. They look fragile but behave with extraordinary strength and determination; they perceive their tormenting and destructive illness as a friend and a comfort. In the depths of the illness they can see only advantages and rarely any disadvantages. At times they appear to have insight but can switch instantly to a state of illness denial (anosognosia). (Lask and Frampton, 2009)

But there’s a danger, in the terminology of paradox, of mystifying something that isn’t actually at all mysterious. None of the contradictions or contrasts inherent to anorexic experience are much of a challenge to make sense of once you try. Cognitive dissonance offers an immediately less inert way of understanding the paradoxes, since dissonance is understood as an inherently unstable state. This offers a natural frame for asking the question of what dissonance reduction strategies get wheeled out, and when, and why, in an effort to restore stability. Crucially, the theory also helps us answer those questions.

Turning back to the modulating factors we considered in Part 1, the theory helps us see, for example:

• Why partial recovery can be even harder to get out of than acute illness (because the dissonances are too low to demand drastic reduction)
• How depression contributes to stasis (by limiting the sharpness of the dissonance we’re capable of experiencing and hence the reduction strategies we’re willing to bother with)
• Why the specifics of social context have so much power to amp up or dial down personal and vicarious dissonances and the reduction strategies that do or don’t result
• How the need to change everything paralyzes the conviction to change anything
• How, in a meta sense, the most potently destructive actions can embed themselves so easily as habits as long as they sweeten themselves with some dissonance reduction benefits.

Cognitive Dissonance Essential Reads

The Effects of Cognitive Dissonance on Romantic Relationships

Why Do People Double Down?

In all these contexts and many others, cognitive dissonance theory is certainly not the whole story. A lot of it is also simple physiology and behaviour. But this angle does offer a parsimonious way of understanding many of the tradeoff dynamics that can come to feel enough like progress to last a lifetime.

In the last two parts of this post, I’ll expand on these concluding ideas by pairing cognitive dissonance with the concept of optimization, in order to offer some suggestions for how to mitigate the damage and harness the positive potential of cognitive dissonance in illness and recovery.

Read on here.