Table 2 ED function themes, frequency counts, and example quotes

Alleviating shape, weight, and eating concerns

To control shape and weight

Not so much now, but when I was younger, I definitely used my eating disorder to control my weight (ED Group Participant #9)

Surface level ones would be managing weight, and I think that that’s, if you would ask anybody who’s kind of dealing with ED stuff and views of body image that would probably be on the top of their mind like, ‘I restrict because I want to be thin or I purge because I want to be thin’ and so that’s certainly like a very, like surface level reason people do it but I think that there's a lot more under that (Clinician #9)

To meet societal expectations/avoid fat stigma

It feels like I have to do it…I do have this huge fear of being overweight or obese, like I just, I do. I don't want to ever admit that, but I have that fear (ED Group Participant #15)

It’s just external versus internal, so there’s internal reasons that someone would want to lose weight, but then also people can have external. So by like parents, family members, partners telling them they should lose weight or saying disparaging comments about their weight and so by doing things like restricting or vomiting or exercise or laxatives they feel that like relief by kind of doing what other people and kind of want or expect or, or what they think they should do (Clinician #1)

To regulate physiological responses

But the bingeing that came afterwards, like it really was just a matter of like a consequence of the restricting…it’s like, your body is saying like ‘we need this food, like we, it’s been way too long’ (ED Group Participant #13)

It may look like the binge eating is driven by stress or you know, ‘I'm an emotional eater or I had trauma when I was three.’ I don't actually agree with those. In most cases, I don’t agree that that's the cause. I think …it’s starvation, that then makes you susceptible to…not requiring many triggers…to binge eat (Clinician #6)

To compensate for other behaviors or lack thereof

So, instead of restricting for so long it was like, ‘Great I can eat this at dinner time and just throw it back up’ or ‘I can eat the food that I was restricting for so long that I didn’t allow myself to have and then just purge it right back up’ (ED Group Participant #13)

They perceived to have eaten too much, and lost control of their eating, so they’re going to make up for it by getting rid of the food to compensate for that (Clinician #3)

To cope with fears of food insecurity

Growing up, if food was restricted or…if you were food insecure and food was not readily available, those are big precursors to eating disorders, because just the thought of not having food and then having it in abundance can be really hard to handle. Or if you were always told like you can't eat or when to eat or what to eat, it's really hard to manage that once you’re on your own and have food available (Clinician #11)

Emotion regulation

To decrease negative emotions

Typically, I binge and purge for stress related reasons. So, when I was younger when I first started being bulimic like when I was in middle school it was primarily because of stress at home, and then when I got a little older it was because of school stress, and then as I got even older now it's work stress that kind of feeds my—it's kind of like the relief of it…it's a bad coping skill, but it's like, it's the most effective coping skill for me, even though I’ve like tried to break this habit and gone to treatment (ED Group Participant #9)

I think that people are more likely to talk about [anger] at themselves, but sometimes, sometimes they'll say it's just about others, like you know a family member, or person that has a relationship with… or it could be something, you know it could just be their situation (Clinician #8)

To increase positive emotions or self-soothe

I felt incredible when I was restricting and when I was bingeing or had to use laxatives, I felt weaker (ED Group Participant #7)

They can count on [the eating disorder], and it's hard for people to relinquish that, and to lose it can feel like a real significant loss to people when they decide to work on their eating disorder (Clinician #7)

To avoid emotions

I need to slow my brain down, like nothing else is working to do this. So, I can completely numb out by like bingeing and purging my face off (ED Group Participant #8)

As long as someone is thinking about calories or ‘Should I have eaten this?’ or ‘Should I not have eaten this?’ or ‘Should I have thrown up?’ or ‘Will I throw up?’ all those things, they aren't thinking about other issues (Clinician #10)

To replace other forms of self-harm

Originally, when I first started, it wasn't the case. But now, it’s the case that it also helps prevent me from relapsing into drug use…And it's come back periodically but this latest one is absolutely driven partly, like, as a way to cope with life without going into drugs (ED Group Participant #12)

Self-regulation/maladaptive schema response

To achieve and maintain control or to satisfy a compulsion

It just feels like I couldn't, I tried to imagine not, and I just can't (ED Group Participant #15)

I have a number of clients right now who feel almost restriction in other areas, like they have very domineering parents, for example, very domineering partner, but [the ED behavior] is something that they believe is within their control, even though psychologically it often is outside of their control, once they begin (Clinician #2)

To respond to trauma

Part of it could be just, feeling small, wanting to be small… it just matches the mental like, playground of the world that I have…like I, if you don’t feel significant, then and part of like I guess an almost OCD reaction is like if I'm not going to feel significant, I'm gonna go all the way (ED Group Participant #12)

Trauma is a huge part of it too right, like that feeling of lacking safety or autonomy or control of your own body can certainly lead to ED behaviors, because you know restricting, purging, bingeing, all these different things can totally numb us so it’s a protective way of managing our trauma (Clinician #9)

To give oneself a sense of identity and self-worth

Staying small or not eating it—turned very competitive. Where if it was me hanging out with some friends at school and one of them was complaining about being so hungry because they haven't eaten all day, in my head, I would either feel bad because I did eat that day, or I'd feel proud because I didn't eat at all that day and I feel fine…I would feel better than them to an extent because I had the willpower not to eat (ED Group Participant #7)

I'm not good at anything else, but I can sure count calories well (Clinician #12)

To regulate self-hatred

I’m just generally always feeling like an extremely ugly person and thinking that I like deserve to not eat because I'm that ugly kind of thing (ED Group Participant #10)

I think that [the eating disorder] sort of plays out different maladaptive schemas. So, if I feel like I am defective… it could be that I…punish myself with behaviors or that it somehow compensates for those maladaptive schemas. Then I also think that those, those cognitions sort of…in a cognitive behavioral way, perpetuate… ‘I'm not good enough,’ that may perpetuate the cycle of, ‘so therefore I shouldn’t eat this meal, because I, my body doesn't look good,’ I don't know and, ‘and then I feel better about myself’ (Clinician #12)

Interpersonal regulation and communication

To seek help

The um, external appearance of like, ‘I'm not okay,’… can be a way to try and breakdown that barrier of like, ‘I don't know how to ask for what I need, but my body will ask for it without me having to use my words’" (ED Group Participant #8)

Restriction…I think it can also be a way of trying to subconsciously influence relationships so…wanting to maybe, again subconsciously play the sick role in order to have people maybe engage with them more or control kind of a relationship by kind of subconsciously engaging in symptoms in order to manage that relationship (Clinician #5)

To avoid social interactions or other commitments

Sometimes I use it as an excuse of like well like I'm crazy and like super eating disordered, so there's no reason for me to bring another person into a relationship (ED Group Participant #8)

Especially in university, people use the eating disorder behaviors to procrastinate (Clinician #10)

To communicate emotions

If it’s like, ‘Well I want to eat here,’ and they’re like, ‘No’, then I can just be like, ‘Well fine, since you make me feel fat for wanting to eat there, I just won't eat at all’ (ED Group Participant #7)

I think it's a way to communicate anger and sort of an ‘eff you’ to people, and so if I sort of binge and purge in my spouse's bathroom or something like that, you know, it's a way to kind of communicate that message and push them away in that way. Or I guess it could activate them…I think that…it is a form of communication, and with that form of communication it can either pull people in or push them away (Clinician #12)

To prove oneself to others

I felt like in that relationship I consistently had to like prove that like I had some sort of like self-control and like maturity because I was dating somebody older than me and like I felt like he…was like testing my ability to like be ready to date a man his age. And he never like specifically said those things…but he was like very obvious and like the way that things went down (ED Group Participant #11)

I don’t need anything, I am self-sufficient, not only do I not need people and help but I don’t even need food, and I don’t even want it like you guys do" (Clinician #13)

To punish or push others away

They would make me feel worthless, so I want to punish them by punishing myself, because I knew they would feel guilty over me punishing myself (ED Group Participant #7)

I think I often see, thinking about attachment, there can often be like a kind of a push–pull dynamic of interpersonal communication with individuals. We actually see a lot of this play out in the treatment world …There’s kind of like a push, you know, ‘I want to be loved so much so like eating disorder brings people in but then as like when people get too close there’s like a push away of like please don’t come near me,’ and the eating disorder kind of ends up being like an ‘eff you’ or a way to create distance relationally. So there’s kind of a push–pull pattern interpersonally with the client with an eating disorder and the function of like negotiating safety in relationships (Clinician #14)