Affect, reward, and punishment in anorexia nervosa: a narrative overview

  • Margarita SalaEmail author
  • Amy H. Egbert
  • Jason M. Lavender
  • Andrea B. Goldschmidt



Anorexia nervosa (AN) is a serious psychiatric disorder that is difficult to treat and often follows a protracted course. A number of theoretical models have been proposed for the etiology and maintenance of AN. Two domains that have received substantial attention in the literature on AN are affect and reward/punishment processes. However, despite an overlap in the nature and implications of these processes, studies of AN addressing these constructs have typically investigated them independently.


The purpose of this narrative review is to integrate the literature on the role of affect, reward, and punishment in AN.


We provide a focused narrative overview of the literature relating to the affect, reward, and punishment in AN via a synthesis of recent reviews and meta-analyses.


We first describe several prominent affect and reward/punishment-based conceptualizations of AN, followed by a brief overview of the existing empirical literature in these domains.


We provide a critical discussion of the disparate nature of these literatures in AN, including associated limitations. We then conclude with an extensive discussion of directions for future research that integrate the study of affect and reward/punishment processes in AN.

Level of evidence

Level V, narrative review.


Reward Punishment Affect Emotion Anorexia nervosa 



Margarita Sala is supported by the National Science Foundation (NSF) Graduate Research Fellowship under Grant No. DGE-1645420. Amy H. Egbert is supported by the National Science Foundation (NSF) Graduate Research Fellowship. Jason Lavender is supported by National Institute of Health (NIH) grant K23MH101342. Andrea Goldschmidt is supported by NIH grant K23DK105234. Any opinion, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the NSF or NIH.

Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study, formal consent is not required.


  1. 1.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. WashingtonGoogle Scholar
  2. 2.
    Katzman DK (2005) Medical complications in adolescents with anorexia nervosa: a review of the literature. Int J Eat Disord 37(S1):S52–S59. CrossRefPubMedGoogle Scholar
  3. 3.
    Kaye WH, Bulik CM, Thornton L, Barbarich N, Masters K (2004) Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am J Psychiatry 161:2215–2221. CrossRefGoogle Scholar
  4. 4.
    Papadopoulos FC, Ekbom A, Brandt L, Ekselius L (2009) Excess mortality, causes of death and prognostic factors in anorexia nervosa. Br J Psychiatry 194(1):10–17. CrossRefPubMedGoogle Scholar
  5. 5.
    Sullivan PF (1995) Mortality in anorexia nervosa. Am J Psychiatry 152(7):1073–1074. CrossRefPubMedGoogle Scholar
  6. 6.
    Bulik CM, Berkman KA, Brownley KA, Sedway JA, Lohr KN (2007) Anorexia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord 40(4):310–320. CrossRefPubMedGoogle Scholar
  7. 7.
    Culber KM, Racine SE, Klump KL (2015) Research review: What we have learned about the causes of eating disorders—a synthesis of sociocultural, psychological, and biological research. J Child Psychol Psychiatry 56(11):1141–1164. CrossRefGoogle Scholar
  8. 8.
    Lavender JM, Wonderlich SA, Engel SG, Gordon KH, Kaye WH, Mitchell JE (2015) Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: a conceptual review of the empirical literature. Clin Psychol Rev 40:111–122. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Oldershaw A, Lavender T, Sallis H, Stahl D, Schmidt U (2015) Emotion generation and regulation in anorexia nervosa: a systematic review and meta-analysis of self-report data. Clin Psychol Rev 39:83–95. CrossRefPubMedGoogle Scholar
  10. 10.
    Harrison A, O’Brien N, Lopez C, Treasure J (2010) Sensitivity to reward and punishment in eating disorders. Psychiatry Res 177(1–2):1–11. CrossRefGoogle Scholar
  11. 11.
    Keating C, Tilbrook AJ, Rossell SL, Enticott PG, Fitzgerald PB (2012) Reward processing in anorexia nervosa. Neuropsychologia 50(5):567–575. CrossRefPubMedGoogle Scholar
  12. 12.
    O’Hara CB, Campbell IC, Schmidt U (2015) A reward-centred model of anorexia nervosa: a focussed narrative review of the neurological and psychophysiological literature. Neurosci Biobehav Rev 52:131–152. CrossRefPubMedGoogle Scholar
  13. 13.
    Forbes EE, Dahl RE (2005) Neural systems of positive affect: Relevance to understanding child and adolescent depression? Dev Psychopathol 17(3):827–850. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Watson D (2000) Mood and temperament. Guilford Press, New YorkGoogle Scholar
  15. 15.
    Berridge KC, Robinson TE (2003) Parsing reward. Trends Neurosci 26(9):507–513. CrossRefPubMedGoogle Scholar
  16. 16.
    Berridge KC, Kringelbach ML (2008) Affective neuroscience of pleasure: reward in humans and animals. Psychopharmacology 199(3):457–480. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Gray J (1970) The psychophysiological basis of introversion-extraversion. Behav Res Ther 8(3):249–266. CrossRefPubMedGoogle Scholar
  18. 18.
    Watson D, Wiese D, Vaidya J, Tellegen A (1999) The two general activation systems of affect: structural findings, evolutionary considerations, and psychobiological evidence. J Pers Soc Psychol 76(5):820–838. CrossRefGoogle Scholar
  19. 19.
    Rolls E (2000) On the brain and emotion. Behav Brain Sci 23(02):219–228. CrossRefGoogle Scholar
  20. 20.
    Heatherton TF, Baumeister RF (1991) Binge eating as escape from self-awareness. Psychol Bull 110(1):86–108. CrossRefPubMedGoogle Scholar
  21. 21.
    Wildes JE, Ringham RM, Marcus MD (2010) Emotion avoidance in patients with anorexia nervosa: initial test of a functional model. Int J Eat Disord 43(5):398–404. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Fruzzetti AE, Shenk C, Hoffman PD (2005) Family interaction and the development of borderline personality disorder: a transactional model. Dev Psychopathol 17(4):1007–1030. CrossRefPubMedGoogle Scholar
  23. 23.
    Linehan MM (1993) Dialectical behavior therapy for treatment of borderline personality disorder: Implications for the treatment of substance abuse. In: Onken LS, Blane JD, Boren JJ (eds) National Institute on Drug Abuse research monograph: behavioral treatments for drug abuse and dependence. U.S. Department of Health and Human Services, pp 201–216Google Scholar
  24. 24.
    Haynos AF, Fruzzetti AE (2011) Anorexia nervosa as a disorder of emotion dysregulation: Evidence and treatment implications. Clin Psychol Sci Pract 18(3):183–202. CrossRefGoogle Scholar
  25. 25.
    Corstorphine E (2006) Cognitive–emotional–behavioural therapy for the eating disorders: working with beliefs about emotions. Eur Eat Disord Rev 14(6):448–461. CrossRefGoogle Scholar
  26. 26.
    Selby EA, Wonderlich SA, Crosby RD, Engel SG, Panza E, Mitchell JE et al (2014) Nothing tastes as good as thin feels low positive emotion differentiation and weight-loss activities in anorexia nervosa. Clin Psychol Sci 39:870–911. CrossRefGoogle Scholar
  27. 27.
    Schmidt U, Treasure J (2006) Anorexia nervosa: valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice. Br J Clin Psychol 45(3):343–366. CrossRefPubMedGoogle Scholar
  28. 28.
    Fairburn CG, Cooper Z, Shafran R (2003 May) Cognitive behaviour therapy for eating disorders: a “transdiagnostic” theory and treatment. Behav Res Ther 41(5):509–528. CrossRefPubMedGoogle Scholar
  29. 29.
    Bergh C, Södersten P (1996) Anorexia nervosa, self–starvation and the reward of stress. Nat Med 2(1):21–22. CrossRefPubMedGoogle Scholar
  30. 30.
    Park RJ, Godier LR, Cowdrey FA (2014) Hungry for reward: How can neuroscience inform the development of treatment for anorexia nervosa? Behav Res Ther 62:47–59. CrossRefPubMedGoogle Scholar
  31. 31.
    Steinglass JE, Walsh BT (2016) Neurobiological model of the persistence of anorexia nervosa. J Eat Disord 4:19. CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Davis C, Woodside DB (2002) Sensitivity to the rewarding effects of food and exercise in the eating disorders. Compr Psychiatry 43(3):189–194. CrossRefPubMedGoogle Scholar
  33. 33.
    Zink CF, Weinberger DR (2010) Cracking the moody brain: the rewards of self starvation. Nat Med 16(12):1382–1383. CrossRefPubMedGoogle Scholar
  34. 34.
    Keating C (2010) Theoretical perspective on anorexia nervosa: the conflict of reward. Neurosci Biobehav Rev 34(1):73–79. CrossRefPubMedGoogle Scholar
  35. 35.
    Gross JJ (1998) The emerging field of emotion regulation: an integrative review. Rev Gen Psychol 2(3):271. CrossRefGoogle Scholar
  36. 36.
    Gratz KL, Roemer L (2004) Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess 26(1):41–54. CrossRefGoogle Scholar
  37. 37.
    Sala M, Heard A, Black EA (2016) Emotion-focused treatments for anorexia nervosa: a systematic review of the literature. Eat Weight Disord 21(2):147–164. CrossRefPubMedGoogle Scholar
  38. 38.
    Ohmann S, Popow C, Wurzer M, Karwautz A, Sackl-Pammer P, Schuch B (2013) Emotional aspects of anorexia nervosa: results of prospective naturalistic cognitive behavioral group therapy. Neuropsychiatr Klin Diagn Ther Rehabil Organ Ges Osterreichischer Nervenarzte Psychiater 27(3):119–128. CrossRefGoogle Scholar
  39. 39.
    Cook BJ, Wonderlich SA, Mitchell JE, Thompson R, Sherman R, Mccallum K (2016) Exercise in eating disorders treatment: systematic review and proposal of guidelines. Med Sci Sports Exerc 48(7):1408–1414. CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Diener E, Larsen RJ (1993) The experience of emotional well-being. In: Lewis M, Haviland JM, Lewis M, Haviland JM (eds) Handbook of emotions. Guilford Press, New York, pp 405–415Google Scholar
  41. 41.
    Myers DG, Diener E (1995) Who is happy? Psychol Sci 6(1):10–19. CrossRefGoogle Scholar
  42. 42.
    Kaye WH, Wierenga CE, Knatz S, Liang J, Boutelle K, Hill L et al (2015) Temperament-based treatment for anorexia nervosa. Eur Eat Disord Rev 23(1):12–18. CrossRefPubMedGoogle Scholar
  43. 43.
    Vitousek K, Manke F (1994) Personality variables and disorders in anorexia nervosa and bulimia nervosa. J Abnorm Psychol 103(1):137–147. CrossRefPubMedGoogle Scholar
  44. 44.
    Kaye WH, Barbarich NC, Putnam K, Gendall KA, Fernstrom J, Fernstrom M et al (2003) Anxiolytic effects of acute tryptophan depletion in anorexia nervosa. Int J Eat Disord 33(3):257–270. CrossRefPubMedGoogle Scholar
  45. 45.
    Fischer S, Breithaupt L, Wonderlich J, Westwater ML, Crosby RD, Engel SG et al (2017) Impact of the neural correlates of stress and cue reactivity on stress related binge eating in the natural environment. J Psychiatr Res 92:15–23. CrossRefPubMedGoogle Scholar
  46. 46.
    Monteleone AM, Cardi V, Volpe U, Fico G, Ruzzi V, Pellegrino F, Castellini G, Monteleone P, Maj M (2018) Attachment and motivational systems: relevance of sensitivity to punishment for eating disorder psychopathology. Psychiatry Res 260:353–359. CrossRefPubMedGoogle Scholar
  47. 47.
    Haynos AF, Berg KC, Cao L, Crosby RD, Lavender JM, Utzinger LM et al (2017) Trajectories of higher- and lower-order dimensions of negative and positive affect relative to restrictive eating in anorexia nervosa. J Abnorm Psychol 126(5):495–505. CrossRefPubMedGoogle Scholar
  48. 48.
    Selby EA, Cornelius T, Fehling KB, Kranzler A, Panza EA, Lavender JM et al (2015) A perfect storm: examining the synergistic effects of negative and positive emotional instability on promoting weight loss activities in anorexia nervosa. Front Psychol 31:6:1260. CrossRefGoogle Scholar
  49. 49.
    Matton A, de Jong P, Goosens L, Jonker N, Van Malderen E, Vervaet M et al (2017) Sensitivity for cues predicting reward and punishment in young women with eating disorders. Eur Eat Disorders Rev 25(6):501–511. CrossRefGoogle Scholar
  50. 50.
    Murao E, Sugihara G, Isobe M, Noda T, Kawabata M, Matsukawa N et al. Differences in neural responses to reward and punishment processing between anorexia nervosa subtypes: an f MRI study. Psychiatry Clin Neurosci 2017: 71(9): 647–658. CrossRefGoogle Scholar
  51. 51.
    Harney MB, Fitzsimmons-Craft EE, Maldonado CR, Bardone-Cone AM (2014) Negative affective experiences in relation to stages of eating disorder recovery. Eat Behav 15(1):24–30. CrossRefPubMedGoogle Scholar
  52. 52.
    DeGuzman M, Shott ME, Yang TT, Riederer J, Frank GKW Association of elevated reward prediction error response with weight gain in adolescent anorexia nervosa. Am J Psychiatry 2017:174(6):557–565. CrossRefGoogle Scholar
  53. 53.
    Lavender JM, Wonderlich SA, Crosby RD, Engel SG, Mitchell JE, Crow SJ et al (2013) Personality-based subtypes of anorexia nervosa: examining validity and utility using baseline clinical variables and ecological momentary assessment. Behav Res Ther 51(8):512–517. CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Wildes JE, Marcus MD, Crosby RD, Ringham RM, Dapelo MM, Gaskill JA et al (2011) The clinical utility of personality subtypes in patients with anorexia nervosa. J Consult Clin Psychol 79(5):665. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Department of PsychologySouthern Methodist UniversityDallasUSA
  2. 2.Department of PsychologyLoyola University ChicagoChicagoUSA
  3. 3.Department of PsychiatryUniversity of CaliforniaSan DiegoUSA
  4. 4.Department of Psychiatry and Human BehaviorAlpert Medical School of Brown University, Weight Control and Diabetes Research Center/The Miriam HospitalProvidenceUSA

Personalised recommendations