The Vicious Cycle of Loneliness: Social Functioning in Eating Disorders – A Qualitative Study

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Elif Ergüney-Okumuş² This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7759539/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Eating disorders are serious psychiatric conditions with increasing prevalence, typically characterized by chronicity and substantial impairment in physical and psychosocial functioning. This study explores the role of social functioning in eating disorders, aiming to identify the roots of its impairment, examine its influence on illness progression, and understand how loneliness perpetuates the disorder, while also investigating the role of social support in recovery. Methods Using an interpretative phenomenological approach, semi-structured interviews were conducted with eight participants diagnosed with Anorexia Nervosa, Bulimia Nervosa, or Binge Eating Disorder. Interviews explored personal experiences of social functioning, loneliness, and recovery. Data were analyzed to generate themes that captured both shared and individual experiences. Results Four superordinate themes were identified: Roots of Impaired Social Functioning – Adverse childhood experiences, including neglect, abuse, early social isolation, and a pervasive sense of being a “lonely child,” shaped participants’ early interpersonal patterns. The Worsening Spiral: Impaired Social Functioning and Illness Progression – A perceived lack of family care and the tendency to interact from behind a “social mask” deepened interpersonal disconnection and exacerbated illness severity. The Self-Perpetuating Cycle of Loneliness and Eating Disorders – Loneliness emerged as a catalyst for symptom escalation, while deliberate withdrawal and self-imposed isolation formed a “closing circle” that reinforced the disorder. Reconnecting and Recovering: The Healing Role of Social Support – Improvements in family, peer, or therapeutic relationships were linked to symptom reduction, highlighting the centrality of sustained social support in the recovery process. Conclusions The findings illustrate that impaired social functioning often originates in adverse early experiences and contributes to the development and maintenance of eating disorders. Loneliness plays a pivotal role in intensifying symptoms, while self-imposed isolation further entrenches the disorder. Conversely, meaningful social connections act as a protective factor, facilitating recovery. These results underscore the importance of integrating social functioning enhancement and sustained support networks into eating disorder treatment and prevention strategies. Eating disorders Anorexia nervosa Bulimia Nervosa Binge Eating Disorder Loneliness Social Functioning Family Functioning Interpersonal Functioning Adverse childhood experiences Plain English summary This study looked at how social life and relationships affect people with eating disorders such as anorexia, bulimia, and binge eating disorder. Eight eating disorder patients took part in interviews where they spoke about their personal experiences. Four main findings emerged: Many had difficult childhoods, including neglect, abuse, and feeling alone from an early age. Problems with family support and difficulties trusting others made their illness worse. Loneliness often made symptoms more intense, and many chose to spend time alone, which kept the illness going. Support from family, friends, or therapy helped reduce symptoms and encouraged recovery. The study shows that loneliness and poor social connections can make eating disorders worse, but good relationships and support can help people get better. Building and keeping strong support networks should be an important part of treatment for eating disorders. Background Eating disorders (EDs) are severe psychiatric conditions characterized by pronounced disturbances in eating attitudes and body image, accompanied by maladaptive compensatory behaviors—such as self-induced vomiting, excessive exercise, and the misuse of laxatives or diuretics—intended to prevent weight gain. These disorders adversely affect emotional, physical, and psychological functioning [ 3 ]. Among the various ED subtypes, this study focuses on Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED). AN is marked by severe energy restriction and low body weight; BN by recurrent binge-eating episodes followed by compensatory behaviors; and BED by recurrent binge-eating episodes in the absence of such behaviors [ 3 ]. Epidemiological data indicate that the lifetime prevalence of EDs is approximately 2.5% [ 68 ]. AN affects an estimated 0.5–1% of the population, BN 0.5–4.2%, and BED 1.1–4% [ 35 , 68 ]. BN is reported to be roughly four times more prevalent than AN, while BED is considered the most common ED subtype [ 54 , 61 ]. These prevalence patterns underscore the public health significance of EDs and the necessity of examining factors that contribute to their onset, persistence, and recovery. The etiology of EDs is widely acknowledged to be multifactorial, encompassing biological, sociocultural, and psychological determinants [ 24 ]. Alongside genetic vulnerability, adverse relational experiences within family and peer contexts during early life have been identified as key psychosocial risk factors [ 9 , 36 ]. Family dynamics characterized by emotional over-involvement, emotional distance, and deficits in affection and empathy—as well as negative parental attitudes toward eating and derogatory comments about weight—can shape maladaptive eating behaviors [ 33 , 77 ]. Childhood trauma, particularly emotional abuse and physical neglect, has been consistently linked to the development of EDs [ 16 , 81 ]. Neglected individuals often report pervasive feelings of loneliness and exclusion, difficulties in establishing interpersonal boundaries, and a tendency toward social withdrawal [ 59 ]. Experiences of being bullied—or engaging in bullying—during childhood are also associated with ED pathology [ 12 ], all of which can contribute to heightened loneliness [ 26 ]. Attachment theory offers a useful framework for understanding these patterns, positing that early relational experiences shape interpersonal behaviors and expectations in adulthood [ 85 ]. Insecure attachment styles are more prevalent among individuals with EDs, with anxious attachment particularly associated with increased symptom severity and less favorable treatment outcomes [ 50 , 78 ]. Social functioning—defined as the ability to initiate and sustain meaningful relationships, participate in community life, and maintain self-care [ 22 ]—is a critical yet often underexamined aspect of EDs. In this study, social functioning is conceptualized to include both family and interpersonal dimensions [ 2 ]. Impairments in social functioning can precede illness onset, exacerbate symptom severity, and impede treatment progress [ 4 , 9 ]. Even after physical and behavioral symptoms improve, difficulties in family and social relationships frequently persist, and inadequate social support alongside continued isolation significantly increases relapse risk [ 5 , 60 , 76 ]. Despite this, existing ED treatments tend to prioritize the resolution of physical and behavioral symptoms, with comparatively limited emphasis on restoring social functioning [ 25 , 64 ]. While prior research has examined the domains of impaired social functioning, their contribution to illness maintenance, and variations across ED subtypes, the reasons for such impairments from the lived perspective of individuals remain insufficiently explored [ 64 ]. Qualitative methodologies, by privileging subjective accounts, allow researchers to address “why” and “how” questions, offering nuanced insights into the lived challenges of EDs and informing the design of more tailored and effective interventions [ 15 , 18 ]. This is particularly relevant given that quantitative studies may be influenced by self-report biases [ 57 ]. Accordingly, the present study aims to explore the lived experiences of individuals with EDs to understand the domains in which social functioning is impaired, the mechanisms through which these impairments contribute to illness maintenance and treatment challenges via social isolation and loneliness, and the cyclical interplay between social functioning and ED pathology. Specifically, the study addresses the following research questions: What role do early life experiences play in the development of EDs? What types of difficulties do individuals with EDs encounter in social interactions, and how do these difficulties contribute to illness maintenance? How do family and social relationships change following the onset of EDs, and how do these changes affect the treatment process? Methods Design This study employed Interpretative Phenomenological Analysis (IPA), a qualitative research methodology designed to provide an in-depth understanding of human experiences and to explore complex psychological phenomena [ 38 , 65 ]. Developed specifically within the discipline of psychology, IPA investigates how individuals make sense of their core life experiences, treating the person who has lived the experience as the primary authority on its meaning [ 38 ]. This approach requires the researcher to bracket personal preconceptions (epoché) and to understand the phenomenon from the participant’s perspective. IPA involves detailed, idiographic case analysis in which conceptual themes are derived from individual accounts before moving toward cross-case analysis. The decision to employ IPA in the present study was guided by its capacity to explore subjective experiences in depth and to shed light on participants’ thoughts, emotions, and behaviors [ 10 ]. Specifically, IPA was deemed appropriate for examining the lived experiences of individuals with EDs in relation to social functioning, interpersonal relationships, and family dynamics. Participants and Sampling Purposeful and homogeneous sampling strategies were employed. In accordance with purposive/criterion sampling, a relatively small number of participants were recruited to enable detailed exploration of the shared experiences of individuals diagnosed with EDs. Prior to interviews, participants completed a set of relevant assessment scales [ 65 ]. Following the principles of homogeneous sampling, the participant group consisted of individuals with similar demographic characteristics [ 75 ]. Three inclusion criteria were established: Gender – Participants were required to be female. Age – Participants were required to be between 18 and 30 years of age. Diagnosis – Participants must have been diagnosed with an ED by a psychiatrist or clinical psychologist according to DSM-5 criteria. Although qualitative studies in the literature range from single-case designs to samples of up to 64 participants, smaller samples of 1–15 participants are generally preferred for IPA, as they allow for more in-depth engagement with each participant’s account [ 38 , 65 , 75 ]. In the present study, interviews were conducted with eight female participants aged between 18 and 29 years. Demographic characteristics of the study group are presented in Table 1 . Table 1 Demographic Characteristics of the Study Group Participant Age Diagnosis BMI EDE-Q-13¹ SFS² Marital Status Education Level Employment Status G1 18 AN 23.7 14.0 159 Single High school graduate Student G2 18 BN 30.5 13.8 146 Single High school graduate Student G3 19 BED 38.8 8.0 123 Single High school graduate Student G4 25 BN 35.2 11.8 128 Single University graduate Employed G5 26 BED 25.7 9.0 129 Single University graduate Employed G6 21 BN 27.3 5.8 131 Single University graduate Employed G7 23 AN 31.2 9.2 115 Single University graduate Unemployed G8 29 AN 17.5 12.8 88 Divorced Primary school graduate Unemployed Note. AN = Anorexia Nervosa; BN = Bulimia Nervosa; BED = Binge Eating Disorder; BMI = Body Mass Index; EDE-Q-13 = Eating Disorder Examination Questionnaire–Short Form; SFS = Social Functioning Scale. ¹ Eating Disorder Examination Questionnaire–Short Form. ² Social Functioning Scale. Data Collection and Analysis Context and Data Collection Participants were recruited from individuals who had sought treatment at the psychiatry outpatient clinic or inpatient unit of Başakşehir Çam and Sakura City Hospital in Istanbul between 2021 and 2023. Following ethical approval, 14 potential participants were contacted via the hospital’s telephone system. Of these, three declined participation, two repeatedly postponed scheduled appointments and were therefore not interviewed, and one was excluded after the interview upon determining that diagnostic criteria were not met. After the informed consent process, eight participants meeting the inclusion criteria were enrolled in the study. Interviews were conducted either face-to-face (n = 3) or online (n = 5), based on participant preference. Face-to-face interviews were held in the hospital outpatient clinic, while online interviews were conducted via WhatsApp or FaceTime. All participants received an informed consent form and were informed of their right to withdraw from the study at any time. The Demographic Information Form, the Eating Disorder Examination Questionnaire–Short Form (EDE-Q-13), and the Social Functioning Scale (SFS) were completed either in person (paper format) or online (Google Forms). These instruments were used solely for participant selection and diagnostic confirmation and were not included in the qualitative analysis. Each participant took part in a single interview lasting between 45 and 65 minutes. The researcher took notes on key observations during the sessions, and all audio recordings were transcribed verbatim. Participant identities were anonymized to ensure confidentiality. Data collection was completed between October 2023 and February 2024. Data Analysis Data collection and analysis were carried out concurrently. Interview audio recordings were first transcribed verbatim and then integrated with the researcher’s field notes. The analytic process followed the standard IPA procedures outlined by [ 74 ]. Initially, transcripts were read and re-read to ensure familiarity with the data. For each interview, an individual coding table was created to capture initial codes. The coding process involved identifying and categorizing descriptive units in the data [ 14 ]. After initial coding, similar codes within each interview were grouped into categories. In the context of this study, the term “category” was used to refer to early thematic groupings rather than final superordinate themes [ 14 ]. Categories generated from each interview were then compared across participants. The analysis process was conducted under the supervision of two researchers and independently reviewed by two doctoral-level clinical psychologists. Feedback from these reviews informed subsequent revisions. The results, including participant quotations and interpretative commentary, are presented in the following section. Results In this study, the influence of social functioning–related factors on the course of eating disorders was examined using the Interpretative Phenomenological Analysis (IPA) approach. In-depth interviews were conducted with eight participants, and analysis of the interview data led to the identification of four overarching themes: The analysis yielded four superordinate themes. Roots of Impaired Social Functioning reflected adverse childhood experiences—such as neglect, abuse, early social isolation, and a pervasive sense of being a “lonely child”—that shaped early interpersonal patterns. The Worsening Spiral: Impaired Social Functioning and Illness Progression captured how a perceived lack of family care and reliance on a “social mask” deepened disconnection and intensified illness severity. The Self-Perpetuating Cycle of Loneliness and Eating Disorders described loneliness as a driver of symptom escalation, with deliberate withdrawal and self-imposed isolation creating a “closing circle” that reinforced the disorder. Reconnecting and Recovering: The Healing Role of Social Support highlighted that improved family, peer, or therapeutic relationships were associated with symptom reduction, underscoring the importance of sustained social support in recovery. The sub-themes and their corresponding subthemes are presented in Table 2 . Table 2 Themes and Subthemes Emerging from the Analysis Themes Sub Themes Roots of Impaired Social Functioning Adverse Childhood Experiences Loneliness as an Early and Persistent Experience The Worsening Spiral: Impaired Social Functioning and Illness Progression Feeling Unseen: Lack of Family Care Living Behind a Social Mask The Self-Perpetuating Cycle of Loneliness and Eating Disorders Loneliness as a Catalyst for Symptom Escalation The Closing Circle: Choosing Solitude and Losing Connection Reconnecting and Recovering: The Healing Role of Social Support Roots of Impaired Social Functioning Participants shared experiences of childhood loneliness, neglect, and abuse. Such experiences appear to have negatively influenced their ability to establish and maintain healthy social relationships later in life, thereby deepening feelings of social isolation and loneliness. Two interrelated subthemes emerged: Adverse Childhood Experiences and Loneliness as an Early and Persistent Experience Adverse Childhood Experiences Participants described experiences of neglect from an early age, as well as emotional or physical abuse, and exposure to bullying. These accounts suggest that impairments in social functioning are closely linked to the development of eating disorders, with adverse childhood experiences acting as a significant precipitating factor in this relationship. One participant reflected on the violence, insecurity, and loneliness she experienced: “ My father, yes, he was bad—he would hurt us and speak harshly—but my mother would never respond to it. She would not protect us, stand by us, or be there for us. I remember crying alone; when I was beaten, I remember being beaten alone…” (Participant 4) Bullying, as a form of emotional and/or physical abuse, was also frequently mentioned: “As I said before, people always focus on flaws—they would always focus on some flaw of mine. Either my arm, my weight, a spot on my face, or a pimple. It’s been that way since childhood. I was always bullied, or I always felt like I was being bullied. And the main bullying was always about my weight…” (Participant 2) Loneliness as an Early and Persistent Experience Across participants, early life was characterized by a pervasive sense of loneliness that often coexisted with neglect, abuse, and limited social connection. This loneliness emerged not only from the absence of supportive family relationships but also from difficulties forming and maintaining peer relationships during childhood and adolescence. Participants described growing up largely in isolation, engaging in solitary activities, and lacking positive social memories from early life. One participant explained: “I remember always doing things on my own. I don’t remember having happy memories from childhood—none at all. I remember my mother and father always being in a rush.” (Participant 7) For some, loneliness was tied to unmet emotional needs, even when basic material needs were met. One participant reflected: “In childhood, I didn’t have much of a relationship with my family. Whenever I needed something—and I mean emotional needs, not material ones—and those needs went unmet, the more I realized my family was never there for me, the lonelier I felt. I had a lonely childhood. My mother and father were hardly ever around when I was a child—I don’t remember them being at home at all.” (Participant 4) This early sense of disconnection often extended into the school environment, where participants described minimal engagement in friendships and social activities: “I didn’t have any friends. I wouldn’t go anywhere with friends. I wouldn’t join trips. I didn’t do anything related to friendship.” (Participant 6) Collectively, these accounts highlight how early-onset loneliness may have laid the groundwork for long-standing social difficulties, fostering patterns of isolation that persisted into adulthood and influenced the course of eating disorder development. The Worsening Spiral: Impaired Social Functioning and Illness Progression This theme reflects the role of impaired social functioning in intensifying and perpetuating eating disorder symptoms. Pre-existing deficits in family functioning and interpersonal skills appeared to exacerbate relational difficulties following the onset of the disorder, further deepening both social and emotional disconnection. Two interrelated subthemes emerged: Feeling Unseen: Lack of Family Care and Living Behind a Social Mask . Feeling Unseen – Lack of Family Care All participants reported receiving little to no effective support from their families during their struggle with the eating disorder. Even before the onset of symptoms, participants described minimal emotional sharing with family members, and during the illness, most continued to refrain from disclosing their difficulties. Nearly all expressed that speaking openly about their condition was challenging and that, when they did, their experiences were often dismissed or trivialized: “I wanted them to see me, and when they finally noticed, I was actually a little happy because I thought they would stop me. But they didn’t care at all… I mean, if I had a child who ate and vomited, I would take them to a psychologist, ask what’s wrong. But nothing like that happened.” (Participant 2) “I made some comments about my parents’ neglect, and they didn’t care much. My father even laughed and said, ‘What were we supposed to do—stand next to you all the time?’ He mocked me. That really made me angry. That was probably the last straw for me.” (Participant 4) Living Behind a Social Mask – Distrust and Avoidance in Relationships A reluctance to form close relationships emerged in all interviews. Most participants reported a deep-seated mistrust of others, coupled with intense anxiety about being judged in social settings. A recurring belief was that people are inherently “bad,” which contributed to patterns of devaluing social interaction, approaching social situations with extreme caution, or engaging through a socially constructed “mask” rather than authentic self-expression. Ultimately, these patterns served to maintain distance from meaningful relationships. The impact of judgment-related anxiety on withdrawal was vividly illustrated in the following account: “After a while, I didn’t want to see people’s faces, hear their voices, or be around them, because I thought they were judging me and only saw my flaws.” (Participant 2) Some participants linked lifelong trust issues directly to an inability to form friendships: “I think I just don’t trust people, so I don’t make friends with anyone. I don’t trust easily… I guess I’ve had this mistrust for as long as I can remember.” (Participant 7) Others described maintaining a socially competent but emotionally distant presence: “On the surface, in class, I was known as the funny, joking person everyone talked to and liked. But once I left class, I wouldn’t talk to anyone, wouldn’t do any activities outside of school with them… I can communicate easily, but I can’t really form strong bonds or deepen friendships.” (Participant 4) The Self-Perpetuating Cycle of Loneliness and Eating Disorders Loneliness as a Catalyst for Symptom Escalation Participants described engaging in binge–purge behaviors primarily as a means of achieving emotional relief. They reported that feelings of distress and the need for such relief were most intense during times of solitude. The direct link between loneliness and eating disorder symptoms was evident: “The emergence of these symptoms is somewhat related to me being alone. For example, even if I’m not feeling bad, when I’m home alone on the weekend, I constantly feel the need to eat something.” (Participant 4) Loneliness was perceived as a driver of symptom severity, as illustrated in the following accounts: “Then, when I stopped going out, I realized that I was eating more at home and vomiting more.” (Participant 2) “When I stay home on weekends, I binge again and say to myself, ‘I’ll throw up.’ The idea comes to my mind again… Binges happen when I’m at home. Even now, when I’m upset, I still eat like that.” (Participant 6) The Closing Circle: Choosing Solitude and Losing Connection As noted in previous themes, all participants had a limited social network. However, they often framed their solitude as a personal preference, explaining that they typically chose solitary activities and struggled to build or sustain adequate social connections and support systems. One participant linked the progression of their illness to increased isolation, noting that they withdrew to prevent others from discovering their condition, turning it into a “huge secret”: “After my illness progressed, I started to become more and more alone. I had always felt lonely deep down, but I had never truly felt it like that. When I saw that no one was by my side, I felt startled and scared. It made me feel even more terrible. My communication with my family collapsed… I stopped eating with them. I stopped eating outside. Only in my room… I was already making my own meals after I started vomiting, because I was afraid they might notice if I went to the bathroom right after eating with them. And they did notice. Communication with them broke down even more… Nobody knew I was vomiting. It was such a hard thing to say—it was one of my most hidden secrets.” (Participant 2) Internalized loneliness was expressed even more starkly by another participant: “After a certain age, I think I will commit suicide because I will always be alone, and at a certain point, I won’t want to continue alone anymore. I already have a plan in my mind about it.” (Participant 4) Reconnecting and Recovering: The Healing Role of Social Support All participants reported that their eating disorder was ongoing. While most had previously received psychiatric treatment, they had discontinued medication; three participants were still engaged in psychotherapy. Across interviews, individuals indicated that when family relationships improved or when they received support from parents, friends, or romantic partners, their symptoms diminished. Conversely, when social support was withdrawn, illness severity tended to increase. These narratives suggest that establishing a consistent and effective social support network is vital in eating disorder treatment. A participant with historically distant family relationships described how reconnection brought notable improvement: “The reason my depression somewhat ended, and I became motivated again, more eager and excited to participate in life, was because I repaired my relationship with my family. I visited them during the holiday. When things got better with my family, I automatically became more motivated. I started caring about my appearance again, cooking at home, and feeling better.” (Participant 4) Some described times when shared dietary efforts with mothers or friends marked their healthiest eating patterns: “At school, I started dieting together with the other teachers in the room, and we began supporting each other. During that period, I was doing better.” (Participant 5) One participant attributed symptom reduction to improved social functioning during psychotherapy: “Since starting therapy, I began to improve. In the first six months, I didn’t see results, but later, I began to get better, and I’ve become more social. I think I’ve started to overcome that anxiety, but from time to time, I still fall into three-month periods of depression. Right now, I’m fine… I think. Lately, I’ve become more sociable with my friends. Before that, I wasn’t this social… Because I’ve been able to push myself outside more, but when I can’t get myself outside, I stay home and binge a lot again.” (Participant 3) Discussion This study was conducted to explore the role of factors associated with social functioning in the onset of eating disorders (EDs), as well as the bidirectional interaction between social functioning and eating disorders, and its influence on illness trajectories and treatment processes. Employing a qualitative approach, the analysis drew on in-depth accounts from participants’ lived experiences. The findings indicate that impairments in social functioning often originate from early-life traumatic experiences, neglect, and abuse, which initiate processes of social withdrawal in childhood and lead to persistent difficulties in establishing and maintaining interpersonal relationships. From these early disruptions onward, the deterioration of social functioning and the ensuing loneliness emerge as significant contributors to the development of eating disorders. Moreover, the results suggest a cyclical interplay between eating disorders and social functioning, in which impaired family and interpersonal functioning drive individuals toward deeper loneliness and social isolation. Within this cycle, social support networks tend to be weak or insufficient, and help-seeking behaviors are limited. The study highlights the critical importance of both the continuity and quality of social support in the recovery process. Support derived from family, friends, or romantic relationships was found to facilitate substantial symptom improvement, whereas the withdrawal of such support was associated with a resurgence in illness severity. Overall, these findings suggest that the relationship between loneliness-fueled social dysfunction and eating disorders is multidimensional, cyclical, and persistent. Roots of Impaired Social Functioning The data indicate that impairments in social functioning most frequently stem from early-life traumatic experiences, including emotional and physical neglect, abuse, and peer bullying, which create enduring challenges in social relationships later in life. Participants reported experiences of neglect and abuse during childhood, as well as peer victimization. Such adverse childhood experiences are known to hinder the development of social skills and to precipitate early withdrawal from social contexts. Research consistently shows that childhood trauma histories are prevalent among individuals with eating disorders, with emotional neglect emerging as the most frequently reported subtype [ 32 , 66 ]. Emotional and physical neglect undermine self-esteem, heighten body dissatisfaction, and disrupt eating patterns, often triggering weight-related anxieties and compensatory behaviors [ 20 , 31 , 73 ]. Children deprived of adequate care and emotional support from parents often struggle to communicate effectively within their families, further exacerbating maladaptive weight-control behaviors and body image concerns [ 1 ]. Neglected individuals frequently experience intense feelings of familial loneliness, a sense of exclusion, and difficulties in establishing healthy interpersonal boundaries [ 59 ]. Emotional neglect is associated with limitations in recognizing, experiencing, and expressing emotions, with disordered eating sometimes serving a compensatory role in emotion regulation [ 53 ]. The literature also points to strong associations between childhood trauma and later social functioning deficits, showing that neglect and abuse erode trust, foster avoidance of interpersonal relationships, and weaken social networks [ 51 , 55 ]. Emotional abuse is another prevalent childhood trauma linked to eating disorders [ 82 ]. Such experiences are associated with heightened concerns about appearance and weight, increased disordered eating, and the use of compensatory strategies [ 73 ]. Furthermore, emotional abuse is linked to reduced self-esteem, interpersonal difficulties, and impaired daily functioning [ 32 , 58 ]. Growing up in families characterized by low emotional connectedness, fractured unity, and invalidating parenting practices often fosters abandonment fears and avoidance of intimacy [ 29 , 43 ]. In addition to family-based neglect and abuse, peer bullying represents another critical form of childhood trauma. Evidence indicates that individuals with eating disorders are more likely to experience peer victimization, particularly weight-related bullying, which exacerbates unhealthy weight-control behaviors and deepens body dissatisfaction [ 19 , 27 , 62 ]. Peer bullying may leave victims feeling more vulnerable in interpersonal contexts and weaken their social bonds [ 11 ]. Taken together, the findings underscore the high prevalence of adverse childhood experiences among individuals with eating disorders, positioning these experiences as significant risk factors for both ED onset and social functioning impairment. Neglect, abuse, and bullying erode family functioning, interpersonal competence, and trust, leading to narrower social networks. However, the limited number of qualitative studies directly examining the impact of childhood trauma on social functioning development highlights the need for more in-depth research. The present study contributes to the literature by providing insight into the subjective experiences of individuals with eating disorders regarding their childhood trauma and its repercussions for social functioning. In this study, early-onset loneliness emerged as a shared experience among nearly all participants. Emotional or physical absence of caregivers, inadequate family communication, and exclusion in peer relationships contributed to the multidimensional entrenchment of loneliness. Prior research similarly indicates that early loneliness not only increases the risk of psychopathology but also disrupts the developmental trajectory of social functioning [ 70 ]. Studies examining the relationship between eating disorders and loneliness have found that loneliness-related difficulties are common across all ED subtypes (AN, BN, BED), with negative interpersonal experiences and perceptual distortions reinforcing the sense of isolation [ 46 ]. Childhood adversity appears to play a critical role in the formation of loneliness. Öz and Saltukoğlu (63) found that while neglect and abuse are linked to ED development, not all trauma experiences result in EDs; instead, deficits in mentalization, social isolation, and loneliness operate as additional risk factors. Accordingly, the present findings suggest that impairments in social functioning are not merely byproducts of the eating disorder process but rather phenomena shaped from early life onward, fostering isolation and subsequently influencing illness development. The Worsening Spiral: Impaired Social Functioning and Illness Progression Findings reveal that eating disorders deepen existing deficits in family and interpersonal functioning, gradually weakening social ties. Social dysfunction emerges not as an accompanying feature but as a core driver in both the escalation and maintenance of eating disorder symptoms. The results indicating that participants felt they did not receive adequate care from their families are consistent with the widely emphasized view in the literature that family functioning plays a critical role in the maintenance and exacerbation of eating disorders [ 6 , 23 , 45 ]. In particular, limited emotional sharing appears to contribute to the concealment of struggles and the avoidance of help-seeking. In this way, a lack of intrafamilial support not only prevents the visibility of symptoms but also reinforces the process of social withdrawal. Prior research has shown that families’ difficulties in communication and conflict resolution increase interpersonal emotional distance and thereby fuel eating disorder symptoms [ 23 ]. In line with this, participants in the present study reported that their illness became more invisible and intensified when they were unable to receive support from their families. However, the current findings add an additional dimension to existing literature. Specifically, participants’ accounts suggest that families’ inability to make sense of the eating disorder was experienced as “not being cared for” and “not being understood,” highlighting a vulnerability rooted not only in functional deficits but also in emotional invisibility. In this respect, the study demonstrates that family support is critical not only at the behavioral level but also in recognizing the illness and validating the individual’s lived experiences. Furthermore, the alignment between participants’ narratives and the literature emphasizing “supportive but non-controlling” parental attitudes [ 17 ] underscores the importance of the quality of family support. Thus, the study reaffirms the multidimensional need for family support among individuals with eating disorders, while its unique contribution lies in showing that experiences of “being unseen” and “being misunderstood” are not merely consequences of insufficient support but also factors accelerating the course of the illness. A lack of trust in social relationships and heightened fears of being judged led participants to develop a “social mask” as a self-protective strategy. While this strategy appeared to reduce anxiety about negative evaluation in the short term, it ultimately hindered the formation of genuine relationships, increased social isolation, and contributed to the maintenance of the disorder. Within this framework, adopting a masked identity emerged as a factor negatively influencing not only interpersonal connections but also engagement in the recovery process. The findings largely converge with existing literature demonstrating impaired interpersonal functioning in eating disorders [ 34 , 39 , 56 ]. Previous studies have shown that interpersonal distrust [ 33 , 36 ] and avoidance of self-disclosure, commonly observed among individuals with eating disorders, hinder the establishment of close relationships and exacerbate loneliness, thereby maintaining symptoms [ 31 , 36 ]. The present study supports this framework, as participants reported adopting social masks due to difficulties in trust, fear of judgment, and challenges in developing intimacy. At the same time, the research extends existing findings by identifying three distinct social attitudes—devaluing relationships, setting cautious boundaries, and adopting a masked identity. Notably, even participants who attempted to socialize more through a masked identity were unable to establish authentic relationships in the long term, resulting in deepening isolation. This aligns with Brown and Levinson’s [ 30 ] argument that while avoidance may temporarily reduce anxiety, it reinforces fear over time and creates a vicious cycle. Accordingly, this study expands the perspective on interpersonal difficulties in eating disorders, which have often been explained primarily through distrust and fear of judgment, by highlighting the masking strategies individuals adopt in social interactions. This finding is significant in showing that the maintenance of eating disorders is influenced not only by withdrawal from relationships but also by the ways in which individuals participate in them. The Self-Perpetuating Cycle of Loneliness and Eating Disorders The findings of this study demonstrate that loneliness is not only confined to early life experiences but rather functions as a reinforcing factor in the course of eating disorders. Participants reported that feelings of loneliness, rooted in adverse family and interpersonal experiences since childhood, evolved into social isolation following the onset of illness, with binge–purge behaviors becoming closely intertwined with loneliness. In an attempt to cope with the destructive effects of loneliness, individuals appeared to develop strategies of struggling with the illness on their own. These results highlight that loneliness operates as a central mechanism that both exacerbates symptoms and contributes to the chronicity of eating disorders. Participants frequently described binge–purge behaviors as a means of emotional relief, typically engaged in when alone. This finding parallels prior research demonstrating a direct link between loneliness and the severity of AN, BN, and BED symptoms [ 46 , 49 ]. As Levine [ 46 ] emphasized, childhood trauma and emotional abuse erode self-confidence, increasing vulnerability and obstructing help-seeking. This process contributes to interpersonal difficulties, loss of trust, and a deepening sense of loneliness, while low levels of social functioning further accelerate illness progression and intensify feelings of isolation. Previous studies have also established the reciprocal relationship between loneliness and eating disorders, showing that they mutually trigger and reinforce one another [ 30 , 72 ]. Consistent with Kinnear and colleagues [ 41 ], participants in this study indicated that binge–purge behaviors became nearly synonymous with loneliness, serving as an escape from overwhelming negative affect. However, the findings also illustrate that although disordered eating behaviors may appear to function as a form of emotion regulation, in the long term they perpetuate both loneliness and illness symptoms. The data suggest that participants, having encountered loneliness since early life through problematic family and social relationships, became increasingly isolated as anxiety and mistrust escalated during the illness, and ultimately sought refuge in eating disorder symptoms to alleviate loneliness. Within this cycle, individuals became trapped in solitude and unable to establish effective social support networks. This theme illustrates how loneliness, often perceived as a personal choice, is in fact socially constructed, reinforcing social withdrawal and contributing to the chronicity of illness. Previous studies have shown that individuals with eating disorders already had limited social networks before illness onset and that these networks shrink further as the disorder progresses [ 79 , 84 ]. Moreover, a tendency toward solitary activities beginning in childhood and persisting into adulthood has been documented [ 42 , 84 ]. Our findings extend this perspective, demonstrating that such tendencies toward loneliness are not simply personal preferences but rather processes intertwined with mistrust and impaired social functioning. The literature also emphasizes that high levels of interpersonal distrust and poor social functioning increase social isolation and restrict access to support resources [ 71 ]. Our findings corroborate this view, as participants described both limited existing relationships and a tendency to choose solitude. Furthermore, as noted by Makri and colleagues [ 49 ], the reduction of social support contributes to increased loneliness and depression, thereby laying the groundwork for chronicity. In this context, the present study underscores that loneliness in eating disorders should not be conceptualized merely as an emotional state or the passive outcome of diminished social networks. Rather, it emerges as a defensive mechanism shaped by adverse early experiences, impaired social functioning, and illness symptoms, which is perceived as an “individual choice.” This socially constructed choice legitimizes social withdrawal while simultaneously deepening it, thereby reinforcing chronicity. By framing loneliness as an active and sustaining factor, this study provides a more nuanced understanding of its role in the persistence of eating disorders. Reconnecting and Recovering: The Healing Role of Social Support All participants reported that their eating disorders were ongoing. Although most had previously received psychiatric treatment, many had discontinued pharmacotherapy, and only three were still engaged in psychotherapy. The most striking finding regarding treatment processes was the direct influence of social support on symptom severity: as support from family, friends, or partners increased, symptoms diminished; when support was withdrawn, the illness intensified. This underscores the vital role of a consistent social support network in recovery. The present findings are consistent with studies emphasizing the critical importance of social support in the treatment of eating disorders [ 7 , 44 ]. While participants had discontinued medication and experienced only partial benefit from psychotherapy, existing research has shown that pharmacological interventions have limited effects, and that standard approaches such as Cognitive Behavioral Therapy achieve only moderate success with high relapse rates [ 13 , 80 ]. Taken together, prior research and current findings suggest that therapy alone, medication, and limited social support are insufficient for recovery. Therefore, the role of interventions targeting social functioning—such as interpersonal psychotherapy (IPT), family-based therapies (FBT), and group psychotherapy—requires greater attention in eating disorder treatment. Interpersonal Psychotherapy (IPT) focuses on fostering healthy relationships, enhancing the use of social support networks, and developing skills to manage interpersonal deficits. Research has shown IPT to be effective particularly in the treatment of Bulimia Nervosa (BN) and Binge Eating Disorder (BED) [ 47 , 67 ]. While IPT aims to reduce bulimic attitudes and behaviors in BN [ 34 ], in BED it improves interpersonal functioning and assists in managing emotional eating and weight control [ 52 ]. Considering the interpersonal difficulties reported by participants in this study, IPT appears especially relevant due to its potential to intervene directly in these dynamics. Family-Based Therapies (FBT) have proven efficacy, particularly in cases of AN and severe BN [ 40 , 83 ]. This study highlights that problematic family relationships pose a risk for the development of eating disorders and that inadequate family support exacerbates the illness. By aiming to enhance parental involvement and strengthen family dynamics [ 48 ], FBT may offer a promising approach to addressing family-related difficulties identified among participants. Group Psychotherapies, which emphasize interpersonal development and allow simultaneous access to multiple clients at relatively low cost, also present an effective alternative [ 28 ]. Given the prevalence of interpersonal dysfunction in eating disorders and its role in the onset, exacerbation, and chronicity of the illness [ 21 ], group therapies may be particularly beneficial. The findings of this study, showing that few participants had access to therapy and that full recovery was not achieved when interpersonal difficulties were unaddressed, further support the value of group therapies. By enhancing interpersonal skills, reducing treatment costs, and improving accessibility, such interventions could play a critical role in clinical practice. In conclusion, the present findings suggest that adverse childhood experiences may hinder the development of social functioning, fostering early isolation and constituting a major risk factor for the onset of eating disorders. Furthermore, the illness appears to further impair social functioning, making it increasingly difficult for individuals to maintain existing relationships, establish new ones, and sustain daily functioning. As a result, participants became socially isolated, entrenched in loneliness, and relied on binge–purge behaviors as a maladaptive coping strategy. Consequently, their illnesses intensified, and access to social support remained extremely limited, with symptoms worsening when support was withdrawn. Throughout this process, impaired social functioning and eating disorders appear to exert a mutually reinforcing influence, trapping individuals in a vicious cycle of deepening loneliness. The findings emphasize that disturbances in social functioning and loneliness not only contribute to the onset of eating disorders but also drive their exacerbation and chronicity. Strengths and Limitations One of the main limitations of this study is the sample size. Interviews were conducted with eight female participants, a number lower than that typically reported in similar studies. Furthermore, the inclusion of only female participants restricts the generalizability of the findings to male populations. In addition, although the study involved individuals diagnosed with AN, BN, and BED, diagnostic differences were not examined separately. While the overall aim was to illuminate the shared experiences of individuals with eating disorder diagnoses, future research may benefit from addressing intergroup differences to provide a more nuanced understanding. Nevertheless, the originality of the study is noteworthy. In the literature, there are very few qualitative studies exploring social functioning in adults with eating disorders across both family and interpersonal dimensions. By addressing this gap, the present research highlights that adverse childhood experiences play a critical role not only in the development of the illness but also in the early disruption of social functioning. Focusing on participants’ subjective experiences makes visible the long-term impact of trauma and family attachment difficulties on social functioning, emphasizing the need to systematically consider these factors in clinical assessment and intervention. The most significant contribution of this study lies in its conceptualization of loneliness not as a passive outcome of eating disorders, but as an active mechanism shaped by the interaction of adverse early experiences, impaired social functioning, and illness symptoms. This perspective suggests that loneliness is not a matter of individual choice but gradually becomes legitimized as a defensive strategy, playing a sustaining role in the chronicity of the illness. Moreover, by showing that experiences of “being unseen” and “being misunderstood” function not only as indicators of insufficient support but also as factors accelerating symptom severity, the study offers an original contribution to the literature. Implications for Intervention and Future Research The findings of this study underscore the importance of early identification and intervention for individuals exposed to adverse childhood experiences, with a particular focus on mitigating the long-term impact of neglect, abuse, and peer victimization on social functioning. Interventions should prioritize strengthening emotional literacy, enhancing interpersonal skills, and fostering trust in relationships, alongside addressing core eating disorder symptoms. Clinicians may benefit from incorporating targeted modules on social reconnection and loneliness reduction into treatment programs, as sustained and high-quality social support emerged as a pivotal factor in recovery. Furthermore, longitudinal research is needed to disentangle the temporal dynamics between social functioning impairments and ED symptom progression, as well as to evaluate the efficacy of early preventive programs designed to disrupt this self-perpetuating cycle. By integrating relational rehabilitation into both prevention and treatment frameworks, it may be possible to reduce the chronicity of EDs and improve long-term recovery outcomes. Conclusion This study underscores the central role of impaired social functioning in the onset and maintenance of eating disorders, showing how individuals become increasingly isolated and trapped in a vicious cycle throughout the illness process. By foregrounding the lived experiences of individuals with eating disorders, the study emphasizes that loneliness is not merely a by-product of the disorder, but rather an active, self-reinforcing mechanism shaped by adverse early life experiences, disrupted interpersonal functioning, and illness-related symptoms. These findings extend the current literature by demonstrating that impaired social functioning is both a precipitating and sustaining factor in eating disorders, and they highlight the necessity of addressing interpersonal and family contexts in clinical interventions. Ultimately, this research contributes to a more comprehensive understanding of the onset, chronicity, and high relapse rates characteristic of eating disorders, while underscoring the importance of integrating social functioning into assessment and treatment strategies. Abbreviations AN Anorexia Nervosa BED Binge Eating Disorder BN Bulimia Nervoza ED Eating Disorder FT Family Therapy IPA Interpretative Phenomenological Analysis IPT Interpersonal Psychotherapy Declarations Ethics approval and consent to participate This project has been approved the University of Sabahattin Zaim Research Ethics Board (REB) (Number:2023/07). All participants signed a written consent form prior to the interviews. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This research received no external funding. Conflict of Interest The authors declare that they have no competing interests. Acknowledgments The authors would like to thank Dilara Eren for the preparation of the manuscript and all participants for their valuable contributions. Author Contribution SCA conducted the interviews, transcribed the material, conducted the analysis, and wrote the article. Both authors discussed the analytical approach and manuscript structure. EEO translate the article, reviewed the manuscript and made improvements to the article several times. Both authors made substantial contributions and has approved the submitted version. Acknowledgement The authors would like to thank Dilara Eren for the preparation of the manuscript and all participants for their valuable contributions. Data Availability Because this article includes personally identifiable information that may compromise individual privacy, data sharing is not applicable. The supporting data are presented within the article. References Ackard DM, Neumark-Sztainer D, Story M, Perry C. Parent–child connectedness and behavioral and emotional health among adolescents. Am J Prev Med. 2006;30(1):59–66. https://doi.org/10.1016/j.amepre.2005.09.013 . Altshuler L, Mintz J, Leight K. The life functioning questionnaire (LFQ): A brief, gender-neutral scale assessing functional outcome. 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Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta-analysis. Int J Eat Disord. 2015;48(7):946–71. https://doi.org/10.1002/eat.22411 . Westwood H, Lawrence V, Fleming C, Tchanturia K. Exploration of friendship experiences, before and after illness onset in females with anorexia nervosa: A qualitative study. PLoS ONE. 2016;11(9):e0163528. https://doi.org/10.1371/journal.pone.0163528 . Widom CS, Czaja SJ, Kozakowski SS, Chauhan P. Does adult attachment style mediate the relationship between childhood maltreatment and mental and physical health outcomes? Child Abuse Negl. 2018;76:533–45. https://doi.org/10.1016/j.chiabu.2017.05.002 . Additional Declarations No competing interests reported. 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Elif Ergüney-Okumuş²","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYHACZjDJz8yG4BCnRbIZpoWNWC0GB4jVws/AfNiYN+ewvfFxtjQJhgrrxAb53gd4tUg2sCUn8247nLjtMNsxCYYz6YkNbOwGeLUYHOAxPgzUkmB2mL1NgrHtMFALAZfZQ7XYGzeDtPwjQosBA48xyGGMG5iBDmNsIEKLxGG2ZMO529ITZwAZFgnH0o3b2NLwa+Fvbz4s8XabtT1//zHDGx9qrGX7mY/h14Ia3QkMRMXkKBgFo2AUjAJCAAAZzjjJl1k+HAAAAABJRU5ErkJggg==","orcid":"","institution":"Istanbul Kültür University","correspondingAuthor":true,"prefix":"","firstName":"F.","middleName":"Elif","lastName":"Ergüney-Okumuş²","suffix":""}],"badges":[],"createdAt":"2025-10-01 12:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7759539/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7759539/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95292227,"identity":"527692bd-d609-4c38-b189-ba1b241d22c3","added_by":"auto","created_at":"2025-11-06 11:21:58","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":70520,"visible":true,"origin":"","legend":"","description":"","filename":"manuscriptfulltext.docx","url":"https://assets-eu.researchsquare.com/files/rs-7759539/v1/6bb857ef30283ae8e238be27.docx"},{"id":95314831,"identity":"b0febf66-0225-4c10-b1aa-d3a58ff8d4a7","added_by":"auto","created_at":"2025-11-06 15:53:22","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5604,"visible":true,"origin":"","legend":"","description":"","filename":"38a144c554574fe98f7840d9fd2f9cfb.json","url":"https://assets-eu.researchsquare.com/files/rs-7759539/v1/7a15096055aa34a2583c0bc1.json"},{"id":95292228,"identity":"b9e19968-9697-4a88-b550-a6bcb8841522","added_by":"auto","created_at":"2025-11-06 11:21:58","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":26972,"visible":true,"origin":"","legend":"","description":"","filename":"TitlePage.docx","url":"https://assets-eu.researchsquare.com/files/rs-7759539/v1/0b7ed78287e1e2cf5bd66afe.docx"},{"id":95314456,"identity":"bd3f243c-8400-451b-a01f-d1e1f8f968b3","added_by":"auto","created_at":"2025-11-06 15:52:53","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":206151,"visible":true,"origin":"","legend":"","description":"","filename":"38a144c554574fe98f7840d9fd2f9cfb1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7759539/v1/300a091d8104598ccabfe2ce.xml"},{"id":95292230,"identity":"5cd12292-ebf1-424f-acec-2061ad6d71ae","added_by":"auto","created_at":"2025-11-06 11:21:58","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":202194,"visible":true,"origin":"","legend":"","description":"","filename":"38a144c554574fe98f7840d9fd2f9cfb1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7759539/v1/a8a5ade5e03738d20102664e.xml"},{"id":95292232,"identity":"918d5e8c-d8d9-42e9-ba5b-04f06d1fe20e","added_by":"auto","created_at":"2025-11-06 11:21:58","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":221677,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7759539/v1/43225f281f6d8d1ad3f60e5e.html"},{"id":96918574,"identity":"97aa4abc-cc73-443c-866c-2061ba77544c","added_by":"auto","created_at":"2025-11-27 14:12:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1318587,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7759539/v1/1e999776-8cf6-4cd5-9deb-56e4bc366784.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Vicious Cycle of Loneliness: Social Functioning in Eating Disorders – A Qualitative Study","fulltext":[{"header":"Plain English summary ","content":"\u003cp\u003eThis study looked at how social life and relationships affect people with eating disorders such as anorexia, bulimia, and binge eating disorder. Eight eating disorder patients took part in interviews where they spoke about their personal experiences. Four main findings emerged:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eMany had difficult childhoods, including neglect, abuse, and feeling alone from an early age.\u003c/li\u003e\n \u003cli\u003eProblems with family support and difficulties trusting others made their illness worse.\u003c/li\u003e\n \u003cli\u003eLoneliness often made symptoms more intense, and many chose to spend time alone, which kept the illness going.\u003c/li\u003e\n \u003cli\u003eSupport from family, friends, or therapy helped reduce symptoms and encouraged recovery.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe study shows that loneliness and poor social connections can make eating disorders worse, but good relationships and support can help people get better. Building and keeping strong support networks should be an important part of treatment for eating disorders.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eEating disorders (EDs) are severe psychiatric conditions characterized by pronounced disturbances in eating attitudes and body image, accompanied by maladaptive compensatory behaviors\u0026mdash;such as self-induced vomiting, excessive exercise, and the misuse of laxatives or diuretics\u0026mdash;intended to prevent weight gain. These disorders adversely affect emotional, physical, and psychological functioning [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Among the various ED subtypes, this study focuses on Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED). AN is marked by severe energy restriction and low body weight; BN by recurrent binge-eating episodes followed by compensatory behaviors; and BED by recurrent binge-eating episodes in the absence of such behaviors [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEpidemiological data indicate that the lifetime prevalence of EDs is approximately 2.5% [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. AN affects an estimated 0.5\u0026ndash;1% of the population, BN 0.5\u0026ndash;4.2%, and BED 1.1\u0026ndash;4% [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. BN is reported to be roughly four times more prevalent than AN, while BED is considered the most common ED subtype [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. These prevalence patterns underscore the public health significance of EDs and the necessity of examining factors that contribute to their onset, persistence, and recovery.\u003c/p\u003e\u003cp\u003eThe etiology of EDs is widely acknowledged to be multifactorial, encompassing biological, sociocultural, and psychological determinants [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Alongside genetic vulnerability, adverse relational experiences within family and peer contexts during early life have been identified as key psychosocial risk factors [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Family dynamics characterized by emotional over-involvement, emotional distance, and deficits in affection and empathy\u0026mdash;as well as negative parental attitudes toward eating and derogatory comments about weight\u0026mdash;can shape maladaptive eating behaviors [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e]. Childhood trauma, particularly emotional abuse and physical neglect, has been consistently linked to the development of EDs [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e]. Neglected individuals often report pervasive feelings of loneliness and exclusion, difficulties in establishing interpersonal boundaries, and a tendency toward social withdrawal [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Experiences of being bullied\u0026mdash;or engaging in bullying\u0026mdash;during childhood are also associated with ED pathology [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], all of which can contribute to heightened loneliness [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAttachment theory offers a useful framework for understanding these patterns, positing that early relational experiences shape interpersonal behaviors and expectations in adulthood [\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e]. Insecure attachment styles are more prevalent among individuals with EDs, with anxious attachment particularly associated with increased symptom severity and less favorable treatment outcomes [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSocial functioning\u0026mdash;defined as the ability to initiate and sustain meaningful relationships, participate in community life, and maintain self-care [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u0026mdash;is a critical yet often underexamined aspect of EDs. In this study, social functioning is conceptualized to include both family and interpersonal dimensions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Impairments in social functioning can precede illness onset, exacerbate symptom severity, and impede treatment progress [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Even after physical and behavioral symptoms improve, difficulties in family and social relationships frequently persist, and inadequate social support alongside continued isolation significantly increases relapse risk [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite this, existing ED treatments tend to prioritize the resolution of physical and behavioral symptoms, with comparatively limited emphasis on restoring social functioning [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. While prior research has examined the domains of impaired social functioning, their contribution to illness maintenance, and variations across ED subtypes, the reasons for such impairments from the lived perspective of individuals remain insufficiently explored [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Qualitative methodologies, by privileging subjective accounts, allow researchers to address \u0026ldquo;why\u0026rdquo; and \u0026ldquo;how\u0026rdquo; questions, offering nuanced insights into the lived challenges of EDs and informing the design of more tailored and effective interventions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This is particularly relevant given that quantitative studies may be influenced by self-report biases [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccordingly, the present study aims to explore the lived experiences of individuals with EDs to understand the domains in which social functioning is impaired, the mechanisms through which these impairments contribute to illness maintenance and treatment challenges via social isolation and loneliness, and the cyclical interplay between social functioning and ED pathology. Specifically, the study addresses the following research questions:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat role do early life experiences play in the development of EDs?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhat types of difficulties do individuals with EDs encounter in social interactions, and how do these difficulties contribute to illness maintenance?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHow do family and social relationships change following the onset of EDs, and how do these changes affect the treatment process?\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign\u003c/h2\u003e\u003cp\u003eThis study employed Interpretative Phenomenological Analysis (IPA), a qualitative research methodology designed to provide an in-depth understanding of human experiences and to explore complex psychological phenomena [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Developed specifically within the discipline of psychology, IPA investigates how individuals make sense of their core life experiences, treating the person who has lived the experience as the primary authority on its meaning [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This approach requires the researcher to bracket personal preconceptions (epoch\u0026eacute;) and to understand the phenomenon from the participant\u0026rsquo;s perspective. IPA involves detailed, idiographic case analysis in which conceptual themes are derived from individual accounts before moving toward cross-case analysis.\u003c/p\u003e\u003cp\u003eThe decision to employ IPA in the present study was guided by its capacity to explore subjective experiences in depth and to shed light on participants\u0026rsquo; thoughts, emotions, and behaviors [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Specifically, IPA was deemed appropriate for examining the lived experiences of individuals with EDs in relation to social functioning, interpersonal relationships, and family dynamics.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants and Sampling\u003c/h3\u003e\n\u003cp\u003ePurposeful and homogeneous sampling strategies were employed. In accordance with purposive/criterion sampling, a relatively small number of participants were recruited to enable detailed exploration of the shared experiences of individuals diagnosed with EDs. Prior to interviews, participants completed a set of relevant assessment scales [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Following the principles of homogeneous sampling, the participant group consisted of individuals with similar demographic characteristics [\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThree inclusion criteria were established:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e \u0026ndash; Participants were required to be female.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e \u0026ndash; Participants were required to be between 18 and 30 years of age.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDiagnosis\u003c/b\u003e \u0026ndash; Participants must have been diagnosed with an ED by a psychiatrist or clinical psychologist according to DSM-5 criteria.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eAlthough qualitative studies in the literature range from single-case designs to samples of up to 64 participants, smaller samples of 1\u0026ndash;15 participants are generally preferred for IPA, as they allow for more in-depth engagement with each participant\u0026rsquo;s account [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e]. In the present study, interviews were conducted with eight female participants aged between 18 and 29 years. Demographic characteristics of the study group are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic Characteristics of the Study Group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParticipant\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDiagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEDE-Q-13\u0026sup1;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSFS\u0026sup2;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMarital Status\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eEducation Level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eEmployment Status\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e14.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e159\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHigh school graduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHigh school graduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e38.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eHigh school graduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eStudent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eUniversity graduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBED\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eUniversity graduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e131\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eUniversity graduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eUniversity graduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePrimary school graduate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eNote. AN\u0026thinsp;=\u0026thinsp;Anorexia Nervosa; BN\u0026thinsp;=\u0026thinsp;Bulimia Nervosa; BED\u0026thinsp;=\u0026thinsp;Binge Eating Disorder; BMI\u0026thinsp;=\u0026thinsp;Body Mass Index; EDE-Q-13\u0026thinsp;=\u0026thinsp;Eating Disorder Examination Questionnaire\u0026ndash;Short Form; SFS\u0026thinsp;=\u0026thinsp;Social Functioning Scale.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026sup1; Eating Disorder Examination Questionnaire\u0026ndash;Short Form.\u003c/p\u003e\u003cp\u003e\u0026sup2; Social Functioning Scale.\u003c/p\u003e\n\u003ch3\u003eData Collection and Analysis\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eContext and Data Collection\u003c/h2\u003e\u003cp\u003eParticipants were recruited from individuals who had sought treatment at the psychiatry outpatient clinic or inpatient unit of Başakşehir \u0026Ccedil;am and Sakura City Hospital in Istanbul between 2021 and 2023. Following ethical approval, 14 potential participants were contacted via the hospital\u0026rsquo;s telephone system. Of these, three declined participation, two repeatedly postponed scheduled appointments and were therefore not interviewed, and one was excluded after the interview upon determining that diagnostic criteria were not met. After the informed consent process, eight participants meeting the inclusion criteria were enrolled in the study.\u003c/p\u003e\u003cp\u003eInterviews were conducted either face-to-face (n\u0026thinsp;=\u0026thinsp;3) or online (n\u0026thinsp;=\u0026thinsp;5), based on participant preference. Face-to-face interviews were held in the hospital outpatient clinic, while online interviews were conducted via WhatsApp or FaceTime. All participants received an informed consent form and were informed of their right to withdraw from the study at any time. The Demographic Information Form, the Eating Disorder Examination Questionnaire\u0026ndash;Short Form (EDE-Q-13), and the Social Functioning Scale (SFS) were completed either in person (paper format) or online (Google Forms). These instruments were used solely for participant selection and diagnostic confirmation and were not included in the qualitative analysis.\u003c/p\u003e\u003cp\u003e Each participant took part in a single interview lasting between 45 and 65 minutes. The researcher took notes on key observations during the sessions, and all audio recordings were transcribed verbatim. Participant identities were anonymized to ensure confidentiality. Data collection was completed between October 2023 and February 2024.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData collection and analysis were carried out concurrently. Interview audio recordings were first transcribed verbatim and then integrated with the researcher\u0026rsquo;s field notes. The analytic process followed the standard IPA procedures outlined by [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Initially, transcripts were read and re-read to ensure familiarity with the data. For each interview, an individual coding table was created to capture initial codes. The coding process involved identifying and categorizing descriptive units in the data [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAfter initial coding, similar codes within each interview were grouped into categories. In the context of this study, the term \u0026ldquo;category\u0026rdquo; was used to refer to early thematic groupings rather than final superordinate themes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Categories generated from each interview were then compared across participants.\u003c/p\u003e\u003cp\u003eThe analysis process was conducted under the supervision of two researchers and independently reviewed by two doctoral-level clinical psychologists. Feedback from these reviews informed subsequent revisions. The results, including participant quotations and interpretative commentary, are presented in the following section.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, the influence of social functioning\u0026ndash;related factors on the course of eating disorders was examined using the Interpretative Phenomenological Analysis (IPA) approach. In-depth interviews were conducted with eight participants, and analysis of the interview data led to the identification of four overarching themes: The analysis yielded four superordinate themes. Roots of Impaired Social Functioning reflected adverse childhood experiences\u0026mdash;such as neglect, abuse, early social isolation, and a pervasive sense of being a \u0026ldquo;lonely child\u0026rdquo;\u0026mdash;that shaped early interpersonal patterns. The Worsening Spiral: Impaired Social Functioning and Illness Progression captured how a perceived lack of family care and reliance on a \u0026ldquo;social mask\u0026rdquo; deepened disconnection and intensified illness severity. The Self-Perpetuating Cycle of Loneliness and Eating Disorders described loneliness as a driver of symptom escalation, with deliberate withdrawal and self-imposed isolation creating a \u0026ldquo;closing circle\u0026rdquo; that reinforced the disorder. Reconnecting and Recovering: The Healing Role of Social Support highlighted that improved family, peer, or therapeutic relationships were associated with symptom reduction, underscoring the importance of sustained social support in recovery.\u003c/p\u003e\u003cp\u003eThe sub-themes and their corresponding subthemes are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and Subthemes Emerging from the Analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub Themes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRoots of Impaired Social Functioning\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdverse Childhood Experiences\u003c/p\u003e\u003cp\u003eLoneliness as an Early and Persistent Experience\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe Worsening Spiral: Impaired Social Functioning and Illness Progression\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFeeling Unseen: Lack of Family Care\u003c/p\u003e\u003cp\u003eLiving Behind a Social Mask\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eThe Self-Perpetuating Cycle of Loneliness and Eating Disorders\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLoneliness as a Catalyst for Symptom Escalation\u003c/p\u003e\u003cp\u003eThe Closing Circle: Choosing Solitude and Losing Connection\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReconnecting and Recovering: The Healing Role of Social Support\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eRoots of Impaired Social Functioning\u003c/h3\u003e\n\u003cp\u003eParticipants shared experiences of childhood loneliness, neglect, and abuse. Such experiences appear to have negatively influenced their ability to establish and maintain healthy social relationships later in life, thereby deepening feelings of social isolation and loneliness. Two interrelated subthemes emerged: Adverse Childhood Experiences and Loneliness as an Early and Persistent Experience\u003c/p\u003e\n\u003ch3\u003eAdverse Childhood Experiences\u003c/h3\u003e\n\u003cp\u003eParticipants described experiences of neglect from an early age, as well as emotional or physical abuse, and exposure to bullying. These accounts suggest that impairments in social functioning are closely linked to the development of eating disorders, with adverse childhood experiences acting as a significant precipitating factor in this relationship.\u003c/p\u003e\u003cp\u003eOne participant reflected on the violence, insecurity, and loneliness she experienced:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eMy father, yes, he was bad\u0026mdash;he would hurt us and speak harshly\u0026mdash;but my mother would never respond to it. She would not protect us, stand by us, or be there for us. I remember crying alone; when I was beaten, I remember being beaten alone\u0026hellip;\u0026rdquo; (Participant 4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBullying, as a form of emotional and/or physical abuse, was also frequently mentioned:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;As I said before, people always focus on flaws\u0026mdash;they would always focus on some flaw of mine. Either my arm, my weight, a spot on my face, or a pimple. It\u0026rsquo;s been that way since childhood. I was always bullied, or I always felt like I was being bullied. And the main bullying was always about my weight\u0026hellip;\u0026rdquo; (Participant 2)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eLoneliness as an Early and Persistent Experience\u003c/h2\u003e\u003cp\u003eAcross participants, early life was characterized by a pervasive sense of loneliness that often coexisted with neglect, abuse, and limited social connection. This loneliness emerged not only from the absence of supportive family relationships but also from difficulties forming and maintaining peer relationships during childhood and adolescence.\u003c/p\u003e\u003cp\u003eParticipants described growing up largely in isolation, engaging in solitary activities, and lacking positive social memories from early life. One participant explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I remember always doing things on my own. I don\u0026rsquo;t remember having happy memories from childhood\u0026mdash;none at all. I remember my mother and father always being in a rush.\u0026rdquo; (Participant 7)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor some, loneliness was tied to unmet emotional needs, even when basic material needs were met. One participant reflected:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In childhood, I didn\u0026rsquo;t have much of a relationship with my family. Whenever I needed something\u0026mdash;and I mean emotional needs, not material ones\u0026mdash;and those needs went unmet, the more I realized my family was never there for me, the lonelier I felt. I had a lonely childhood. My mother and father were hardly ever around when I was a child\u0026mdash;I don\u0026rsquo;t remember them being at home at all.\u0026rdquo; (Participant 4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis early sense of disconnection often extended into the school environment, where participants described minimal engagement in friendships and social activities:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t have any friends. I wouldn\u0026rsquo;t go anywhere with friends. I wouldn\u0026rsquo;t join trips. I didn\u0026rsquo;t do anything related to friendship.\u0026rdquo; (Participant 6)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCollectively, these accounts highlight how early-onset loneliness may have laid the groundwork for long-standing social difficulties, fostering patterns of isolation that persisted into adulthood and influenced the course of eating disorder development.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eThe Worsening Spiral: Impaired Social Functioning and Illness Progression\u003c/h2\u003e\u003cp\u003eThis theme reflects the role of impaired social functioning in intensifying and perpetuating eating disorder symptoms. Pre-existing deficits in family functioning and interpersonal skills appeared to exacerbate relational difficulties following the onset of the disorder, further deepening both social and emotional disconnection. Two interrelated subthemes emerged: \u003cem\u003eFeeling Unseen: Lack of Family Care\u003c/em\u003e and \u003cem\u003eLiving Behind a Social Mask\u003c/em\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eFeeling Unseen \u0026ndash; Lack of Family Care\u003c/h2\u003e\u003cp\u003eAll participants reported receiving little to no effective support from their families during their struggle with the eating disorder. Even before the onset of symptoms, participants described minimal emotional sharing with family members, and during the illness, most continued to refrain from disclosing their difficulties. Nearly all expressed that speaking openly about their condition was challenging and that, when they did, their experiences were often dismissed or trivialized:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I wanted them to see me, and when they finally noticed, I was actually a little happy because I thought they would stop me. But they didn\u0026rsquo;t care at all\u0026hellip; I mean, if I had a child who ate and vomited, I would take them to a psychologist, ask what\u0026rsquo;s wrong. But nothing like that happened.\u0026rdquo; (Participant 2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I made some comments about my parents\u0026rsquo; neglect, and they didn\u0026rsquo;t care much. My father even laughed and said, \u0026lsquo;What were we supposed to do\u0026mdash;stand next to you all the time?\u0026rsquo; He mocked me. That really made me angry. That was probably the last straw for me.\u0026rdquo; (Participant 4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLiving Behind a Social Mask \u0026ndash; Distrust and Avoidance in Relationships\u003c/h2\u003e\u003cp\u003eA reluctance to form close relationships emerged in all interviews. Most participants reported a deep-seated mistrust of others, coupled with intense anxiety about being judged in social settings. A recurring belief was that people are inherently \u0026ldquo;bad,\u0026rdquo; which contributed to patterns of devaluing social interaction, approaching social situations with extreme caution, or engaging through a socially constructed \u0026ldquo;mask\u0026rdquo; rather than authentic self-expression. Ultimately, these patterns served to maintain distance from meaningful relationships.\u003c/p\u003e\u003cp\u003eThe impact of judgment-related anxiety on withdrawal was vividly illustrated in the following account:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;After a while, I didn\u0026rsquo;t want to see people\u0026rsquo;s faces, hear their voices, or be around them, because I thought they were judging me and only saw my flaws.\u0026rdquo; (Participant 2)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome participants linked lifelong trust issues directly to an inability to form friendships:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think I just don\u0026rsquo;t trust people, so I don\u0026rsquo;t make friends with anyone. I don\u0026rsquo;t trust easily\u0026hellip; I guess I\u0026rsquo;ve had this mistrust for as long as I can remember.\u0026rdquo; (Participant 7)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOthers described maintaining a socially competent but emotionally distant presence:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;On the surface, in class, I was known as the funny, joking person everyone talked to and liked. But once I left class, I wouldn\u0026rsquo;t talk to anyone, wouldn\u0026rsquo;t do any activities outside of school with them\u0026hellip; I can communicate easily, but I can\u0026rsquo;t really form strong bonds or deepen friendships.\u0026rdquo; (Participant 4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eThe Self-Perpetuating Cycle of Loneliness and Eating Disorders\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003eLoneliness as a Catalyst for Symptom Escalation\u003c/h2\u003e\u003cp\u003e Participants described engaging in binge\u0026ndash;purge behaviors primarily as a means of achieving emotional relief. They reported that feelings of distress and the need for such relief were most intense during times of solitude. The direct link between loneliness and eating disorder symptoms was evident:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The emergence of these symptoms is somewhat related to me being alone. For example, even if I\u0026rsquo;m not feeling bad, when I\u0026rsquo;m home alone on the weekend, I constantly feel the need to eat something.\u0026rdquo; (Participant 4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eLoneliness was perceived as a driver of symptom severity, as illustrated in the following accounts:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Then, when I stopped going out, I realized that I was eating more at home and vomiting more.\u0026rdquo; (Participant 2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When I stay home on weekends, I binge again and say to myself, \u0026lsquo;I\u0026rsquo;ll throw up.\u0026rsquo; The idea comes to my mind again\u0026hellip; Binges happen when I\u0026rsquo;m at home. Even now, when I\u0026rsquo;m upset, I still eat like that.\u0026rdquo; (Participant 6)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eThe Closing Circle: Choosing Solitude and Losing Connection\u003c/h2\u003e\u003cp\u003eAs noted in previous themes, all participants had a limited social network. However, they often framed their solitude as a personal preference, explaining that they typically chose solitary activities and struggled to build or sustain adequate social connections and support systems.\u003c/p\u003e\u003cp\u003eOne participant linked the progression of their illness to increased isolation, noting that they withdrew to prevent others from discovering their condition, turning it into a \u0026ldquo;huge secret\u0026rdquo;:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;After my illness progressed, I started to become more and more alone. I had always felt lonely deep down, but I had never truly felt it like that. When I saw that no one was by my side, I felt startled and scared. It made me feel even more terrible. My communication with my family collapsed\u0026hellip; I stopped eating with them. I stopped eating outside. Only in my room\u0026hellip; I was already making my own meals after I started vomiting, because I was afraid they might notice if I went to the bathroom right after eating with them. And they did notice. Communication with them broke down even more\u0026hellip; Nobody knew I was vomiting. It was such a hard thing to say\u0026mdash;it was one of my most hidden secrets.\u0026rdquo; (Participant 2)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eInternalized loneliness was expressed even more starkly by another participant:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;After a certain age, I think I will commit suicide because I will always be alone, and at a certain point, I won\u0026rsquo;t want to continue alone anymore. I already have a plan in my mind about it.\u0026rdquo; (Participant 4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eReconnecting and Recovering: The Healing Role of Social Support\u003c/h2\u003e\u003cp\u003eAll participants reported that their eating disorder was ongoing. While most had previously received psychiatric treatment, they had discontinued medication; three participants were still engaged in psychotherapy. Across interviews, individuals indicated that when family relationships improved or when they received support from parents, friends, or romantic partners, their symptoms diminished. Conversely, when social support was withdrawn, illness severity tended to increase. These narratives suggest that establishing a consistent and effective social support network is vital in eating disorder treatment.\u003c/p\u003e\u003cp\u003eA participant with historically distant family relationships described how reconnection brought notable improvement:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The reason my depression somewhat ended, and I became motivated again, more eager and excited to participate in life, was because I repaired my relationship with my family. I visited them during the holiday. When things got better with my family, I automatically became more motivated. I started caring about my appearance again, cooking at home, and feeling better.\u0026rdquo; (Participant 4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome described times when shared dietary efforts with mothers or friends marked their healthiest eating patterns:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;At school, I started dieting together with the other teachers in the room, and we began supporting each other. During that period, I was doing better.\u0026rdquo; (Participant 5)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOne participant attributed symptom reduction to improved social functioning during psychotherapy:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Since starting therapy, I began to improve. In the first six months, I didn\u0026rsquo;t see results, but later, I began to get better, and I\u0026rsquo;ve become more social. I think I\u0026rsquo;ve started to overcome that anxiety, but from time to time, I still fall into three-month periods of depression. Right now, I\u0026rsquo;m fine\u0026hellip; I think. Lately, I\u0026rsquo;ve become more sociable with my friends. Before that, I wasn\u0026rsquo;t this social\u0026hellip; Because I\u0026rsquo;ve been able to push myself outside more, but when I can\u0026rsquo;t get myself outside, I stay home and binge a lot again.\u0026rdquo; (Participant 3)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study was conducted to explore the role of factors associated with social functioning in the onset of eating disorders (EDs), as well as the bidirectional interaction between social functioning and eating disorders, and its influence on illness trajectories and treatment processes. Employing a qualitative approach, the analysis drew on in-depth accounts from participants\u0026rsquo; lived experiences. The findings indicate that impairments in social functioning often originate from early-life traumatic experiences, neglect, and abuse, which initiate processes of social withdrawal in childhood and lead to persistent difficulties in establishing and maintaining interpersonal relationships. From these early disruptions onward, the deterioration of social functioning and the ensuing loneliness emerge as significant contributors to the development of eating disorders.\u003c/p\u003e\u003cp\u003eMoreover, the results suggest a cyclical interplay between eating disorders and social functioning, in which impaired family and interpersonal functioning drive individuals toward deeper loneliness and social isolation. Within this cycle, social support networks tend to be weak or insufficient, and help-seeking behaviors are limited. The study highlights the critical importance of both the continuity and quality of social support in the recovery process. Support derived from family, friends, or romantic relationships was found to facilitate substantial symptom improvement, whereas the withdrawal of such support was associated with a resurgence in illness severity. Overall, these findings suggest that the relationship between loneliness-fueled social dysfunction and eating disorders is multidimensional, cyclical, and persistent.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eRoots of Impaired Social Functioning\u003c/h2\u003e\u003cp\u003eThe data indicate that impairments in social functioning most frequently stem from early-life traumatic experiences, including emotional and physical neglect, abuse, and peer bullying, which create enduring challenges in social relationships later in life. Participants reported experiences of neglect and abuse during childhood, as well as peer victimization. Such adverse childhood experiences are known to hinder the development of social skills and to precipitate early withdrawal from social contexts.\u003c/p\u003e\u003cp\u003eResearch consistently shows that childhood trauma histories are prevalent among individuals with eating disorders, with emotional neglect emerging as the most frequently reported subtype [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Emotional and physical neglect undermine self-esteem, heighten body dissatisfaction, and disrupt eating patterns, often triggering weight-related anxieties and compensatory behaviors [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. Children deprived of adequate care and emotional support from parents often struggle to communicate effectively within their families, further exacerbating maladaptive weight-control behaviors and body image concerns [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNeglected individuals frequently experience intense feelings of familial loneliness, a sense of exclusion, and difficulties in establishing healthy interpersonal boundaries [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Emotional neglect is associated with limitations in recognizing, experiencing, and expressing emotions, with disordered eating sometimes serving a compensatory role in emotion regulation [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. The literature also points to strong associations between childhood trauma and later social functioning deficits, showing that neglect and abuse erode trust, foster avoidance of interpersonal relationships, and weaken social networks [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEmotional abuse is another prevalent childhood trauma linked to eating disorders [\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e]. Such experiences are associated with heightened concerns about appearance and weight, increased disordered eating, and the use of compensatory strategies [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. Furthermore, emotional abuse is linked to reduced self-esteem, interpersonal difficulties, and impaired daily functioning [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Growing up in families characterized by low emotional connectedness, fractured unity, and invalidating parenting practices often fosters abandonment fears and avoidance of intimacy [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition to family-based neglect and abuse, peer bullying represents another critical form of childhood trauma. Evidence indicates that individuals with eating disorders are more likely to experience peer victimization, particularly weight-related bullying, which exacerbates unhealthy weight-control behaviors and deepens body dissatisfaction [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Peer bullying may leave victims feeling more vulnerable in interpersonal contexts and weaken their social bonds [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTaken together, the findings underscore the high prevalence of adverse childhood experiences among individuals with eating disorders, positioning these experiences as significant risk factors for both ED onset and social functioning impairment. Neglect, abuse, and bullying erode family functioning, interpersonal competence, and trust, leading to narrower social networks. However, the limited number of qualitative studies directly examining the impact of childhood trauma on social functioning development highlights the need for more in-depth research. The present study contributes to the literature by providing insight into the subjective experiences of individuals with eating disorders regarding their childhood trauma and its repercussions for social functioning.\u003c/p\u003e\u003cp\u003eIn this study, early-onset loneliness emerged as a shared experience among nearly all participants. Emotional or physical absence of caregivers, inadequate family communication, and exclusion in peer relationships contributed to the multidimensional entrenchment of loneliness. Prior research similarly indicates that early loneliness not only increases the risk of psychopathology but also disrupts the developmental trajectory of social functioning [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudies examining the relationship between eating disorders and loneliness have found that loneliness-related difficulties are common across all ED subtypes (AN, BN, BED), with negative interpersonal experiences and perceptual distortions reinforcing the sense of isolation [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Childhood adversity appears to play a critical role in the formation of loneliness. \u0026Ouml;z and Saltukoğlu (63) found that while neglect and abuse are linked to ED development, not all trauma experiences result in EDs; instead, deficits in mentalization, social isolation, and loneliness operate as additional risk factors.\u003c/p\u003e\u003cp\u003eAccordingly, the present findings suggest that impairments in social functioning are not merely byproducts of the eating disorder process but rather phenomena shaped from early life onward, fostering isolation and subsequently influencing illness development.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe Worsening Spiral: Impaired Social Functioning and Illness Progression\u003c/b\u003e Findings reveal that eating disorders deepen existing deficits in family and interpersonal functioning, gradually weakening social ties. Social dysfunction emerges not as an accompanying feature but as a core driver in both the escalation and maintenance of eating disorder symptoms. The results indicating that participants felt they did not receive adequate care from their families are consistent with the widely emphasized view in the literature that family functioning plays a critical role in the maintenance and exacerbation of eating disorders [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In particular, limited emotional sharing appears to contribute to the concealment of struggles and the avoidance of help-seeking. In this way, a lack of intrafamilial support not only prevents the visibility of symptoms but also reinforces the process of social withdrawal. Prior research has shown that families\u0026rsquo; difficulties in communication and conflict resolution increase interpersonal emotional distance and thereby fuel eating disorder symptoms [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In line with this, participants in the present study reported that their illness became more invisible and intensified when they were unable to receive support from their families. However, the current findings add an additional dimension to existing literature. Specifically, participants\u0026rsquo; accounts suggest that families\u0026rsquo; inability to make sense of the eating disorder was experienced as \u0026ldquo;not being cared for\u0026rdquo; and \u0026ldquo;not being understood,\u0026rdquo; highlighting a vulnerability rooted not only in functional deficits but also in emotional invisibility. In this respect, the study demonstrates that family support is critical not only at the behavioral level but also in recognizing the illness and validating the individual\u0026rsquo;s lived experiences. Furthermore, the alignment between participants\u0026rsquo; narratives and the literature emphasizing \u0026ldquo;supportive but non-controlling\u0026rdquo; parental attitudes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] underscores the importance of the quality of family support. Thus, the study reaffirms the multidimensional need for family support among individuals with eating disorders, while its unique contribution lies in showing that experiences of \u0026ldquo;being unseen\u0026rdquo; and \u0026ldquo;being misunderstood\u0026rdquo; are not merely consequences of insufficient support but also factors accelerating the course of the illness.\u003c/p\u003e\u003cp\u003eA lack of trust in social relationships and heightened fears of being judged led participants to develop a \u0026ldquo;social mask\u0026rdquo; as a self-protective strategy. While this strategy appeared to reduce anxiety about negative evaluation in the short term, it ultimately hindered the formation of genuine relationships, increased social isolation, and contributed to the maintenance of the disorder. Within this framework, adopting a masked identity emerged as a factor negatively influencing not only interpersonal connections but also engagement in the recovery process.\u003c/p\u003e\u003cp\u003eThe findings largely converge with existing literature demonstrating impaired interpersonal functioning in eating disorders [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Previous studies have shown that interpersonal distrust [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and avoidance of self-disclosure, commonly observed among individuals with eating disorders, hinder the establishment of close relationships and exacerbate loneliness, thereby maintaining symptoms [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The present study supports this framework, as participants reported adopting social masks due to difficulties in trust, fear of judgment, and challenges in developing intimacy. At the same time, the research extends existing findings by identifying three distinct social attitudes\u0026mdash;devaluing relationships, setting cautious boundaries, and adopting a masked identity. Notably, even participants who attempted to socialize more through a masked identity were unable to establish authentic relationships in the long term, resulting in deepening isolation. This aligns with Brown and Levinson\u0026rsquo;s [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] argument that while avoidance may temporarily reduce anxiety, it reinforces fear over time and creates a vicious cycle.\u003c/p\u003e\u003cp\u003eAccordingly, this study expands the perspective on interpersonal difficulties in eating disorders, which have often been explained primarily through distrust and fear of judgment, by highlighting the masking strategies individuals adopt in social interactions. This finding is significant in showing that the maintenance of eating disorders is influenced not only by withdrawal from relationships but also by the ways in which individuals participate in them.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eThe Self-Perpetuating Cycle of Loneliness and Eating Disorders\u003c/h2\u003e\u003cp\u003eThe findings of this study demonstrate that loneliness is not only confined to early life experiences but rather functions as a reinforcing factor in the course of eating disorders. Participants reported that feelings of loneliness, rooted in adverse family and interpersonal experiences since childhood, evolved into social isolation following the onset of illness, with binge\u0026ndash;purge behaviors becoming closely intertwined with loneliness. In an attempt to cope with the destructive effects of loneliness, individuals appeared to develop strategies of struggling with the illness on their own. These results highlight that loneliness operates as a central mechanism that both exacerbates symptoms and contributes to the chronicity of eating disorders.\u003c/p\u003e\u003cp\u003e Participants frequently described binge\u0026ndash;purge behaviors as a means of emotional relief, typically engaged in when alone. This finding parallels prior research demonstrating a direct link between loneliness and the severity of AN, BN, and BED symptoms [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. As Levine [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] emphasized, childhood trauma and emotional abuse erode self-confidence, increasing vulnerability and obstructing help-seeking. This process contributes to interpersonal difficulties, loss of trust, and a deepening sense of loneliness, while low levels of social functioning further accelerate illness progression and intensify feelings of isolation. Previous studies have also established the reciprocal relationship between loneliness and eating disorders, showing that they mutually trigger and reinforce one another [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Consistent with Kinnear and colleagues [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], participants in this study indicated that binge\u0026ndash;purge behaviors became nearly synonymous with loneliness, serving as an escape from overwhelming negative affect. However, the findings also illustrate that although disordered eating behaviors may appear to function as a form of emotion regulation, in the long term they perpetuate both loneliness and illness symptoms.\u003c/p\u003e\u003cp\u003eThe data suggest that participants, having encountered loneliness since early life through problematic family and social relationships, became increasingly isolated as anxiety and mistrust escalated during the illness, and ultimately sought refuge in eating disorder symptoms to alleviate loneliness. Within this cycle, individuals became trapped in solitude and unable to establish effective social support networks. This theme illustrates how loneliness, often perceived as a personal choice, is in fact socially constructed, reinforcing social withdrawal and contributing to the chronicity of illness.\u003c/p\u003e\u003cp\u003ePrevious studies have shown that individuals with eating disorders already had limited social networks before illness onset and that these networks shrink further as the disorder progresses [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. Moreover, a tendency toward solitary activities beginning in childhood and persisting into adulthood has been documented [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e]. Our findings extend this perspective, demonstrating that such tendencies toward loneliness are not simply personal preferences but rather processes intertwined with mistrust and impaired social functioning. The literature also emphasizes that high levels of interpersonal distrust and poor social functioning increase social isolation and restrict access to support resources [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e]. Our findings corroborate this view, as participants described both limited existing relationships and a tendency to choose solitude. Furthermore, as noted by Makri and colleagues [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], the reduction of social support contributes to increased loneliness and depression, thereby laying the groundwork for chronicity.\u003c/p\u003e\u003cp\u003eIn this context, the present study underscores that loneliness in eating disorders should not be conceptualized merely as an emotional state or the passive outcome of diminished social networks. Rather, it emerges as a defensive mechanism shaped by adverse early experiences, impaired social functioning, and illness symptoms, which is perceived as an \u0026ldquo;individual choice.\u0026rdquo; This socially constructed choice legitimizes social withdrawal while simultaneously deepening it, thereby reinforcing chronicity. By framing loneliness as an active and sustaining factor, this study provides a more nuanced understanding of its role in the persistence of eating disorders.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eReconnecting and Recovering: The Healing Role of Social Support\u003c/h2\u003e\u003cp\u003eAll participants reported that their eating disorders were ongoing. Although most had previously received psychiatric treatment, many had discontinued pharmacotherapy, and only three were still engaged in psychotherapy. The most striking finding regarding treatment processes was the direct influence of social support on symptom severity: as support from family, friends, or partners increased, symptoms diminished; when support was withdrawn, the illness intensified. This underscores the vital role of a consistent social support network in recovery.\u003c/p\u003e\u003cp\u003eThe present findings are consistent with studies emphasizing the critical importance of social support in the treatment of eating disorders [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. While participants had discontinued medication and experienced only partial benefit from psychotherapy, existing research has shown that pharmacological interventions have limited effects, and that standard approaches such as Cognitive Behavioral Therapy achieve only moderate success with high relapse rates [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. Taken together, prior research and current findings suggest that therapy alone, medication, and limited social support are insufficient for recovery. Therefore, the role of interventions targeting social functioning\u0026mdash;such as interpersonal psychotherapy (IPT), family-based therapies (FBT), and group psychotherapy\u0026mdash;requires greater attention in eating disorder treatment.\u003c/p\u003e\u003cp\u003eInterpersonal Psychotherapy (IPT) focuses on fostering healthy relationships, enhancing the use of social support networks, and developing skills to manage interpersonal deficits. Research has shown IPT to be effective particularly in the treatment of Bulimia Nervosa (BN) and Binge Eating Disorder (BED) [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. While IPT aims to reduce bulimic attitudes and behaviors in BN [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], in BED it improves interpersonal functioning and assists in managing emotional eating and weight control [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Considering the interpersonal difficulties reported by participants in this study, IPT appears especially relevant due to its potential to intervene directly in these dynamics.\u003c/p\u003e\u003cp\u003eFamily-Based Therapies (FBT) have proven efficacy, particularly in cases of AN and severe BN [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. This study highlights that problematic family relationships pose a risk for the development of eating disorders and that inadequate family support exacerbates the illness. By aiming to enhance parental involvement and strengthen family dynamics [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], FBT may offer a promising approach to addressing family-related difficulties identified among participants.\u003c/p\u003e\u003cp\u003eGroup Psychotherapies, which emphasize interpersonal development and allow simultaneous access to multiple clients at relatively low cost, also present an effective alternative [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Given the prevalence of interpersonal dysfunction in eating disorders and its role in the onset, exacerbation, and chronicity of the illness [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], group therapies may be particularly beneficial. The findings of this study, showing that few participants had access to therapy and that full recovery was not achieved when interpersonal difficulties were unaddressed, further support the value of group therapies. By enhancing interpersonal skills, reducing treatment costs, and improving accessibility, such interventions could play a critical role in clinical practice.\u003c/p\u003e\u003cp\u003eIn conclusion, the present findings suggest that adverse childhood experiences may hinder the development of social functioning, fostering early isolation and constituting a major risk factor for the onset of eating disorders. Furthermore, the illness appears to further impair social functioning, making it increasingly difficult for individuals to maintain existing relationships, establish new ones, and sustain daily functioning. As a result, participants became socially isolated, entrenched in loneliness, and relied on binge\u0026ndash;purge behaviors as a maladaptive coping strategy. Consequently, their illnesses intensified, and access to social support remained extremely limited, with symptoms worsening when support was withdrawn. Throughout this process, impaired social functioning and eating disorders appear to exert a mutually reinforcing influence, trapping individuals in a vicious cycle of deepening loneliness. The findings emphasize that disturbances in social functioning and loneliness not only contribute to the onset of eating disorders but also drive their exacerbation and chronicity.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eOne of the main limitations of this study is the sample size. Interviews were conducted with eight female participants, a number lower than that typically reported in similar studies. Furthermore, the inclusion of only female participants restricts the generalizability of the findings to male populations. In addition, although the study involved individuals diagnosed with AN, BN, and BED, diagnostic differences were not examined separately. While the overall aim was to illuminate the shared experiences of individuals with eating disorder diagnoses, future research may benefit from addressing intergroup differences to provide a more nuanced understanding.\u003c/p\u003e\u003cp\u003eNevertheless, the originality of the study is noteworthy. In the literature, there are very few qualitative studies exploring social functioning in adults with eating disorders across both family and interpersonal dimensions. By addressing this gap, the present research highlights that adverse childhood experiences play a critical role not only in the development of the illness but also in the early disruption of social functioning. Focusing on participants\u0026rsquo; subjective experiences makes visible the long-term impact of trauma and family attachment difficulties on social functioning, emphasizing the need to systematically consider these factors in clinical assessment and intervention.\u003c/p\u003e\u003cp\u003eThe most significant contribution of this study lies in its conceptualization of loneliness not as a passive outcome of eating disorders, but as an active mechanism shaped by the interaction of adverse early experiences, impaired social functioning, and illness symptoms. This perspective suggests that loneliness is not a matter of individual choice but gradually becomes legitimized as a defensive strategy, playing a sustaining role in the chronicity of the illness. Moreover, by showing that experiences of \u0026ldquo;being unseen\u0026rdquo; and \u0026ldquo;being misunderstood\u0026rdquo; function not only as indicators of insufficient support but also as factors accelerating symptom severity, the study offers an original contribution to the literature.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eImplications for Intervention and Future Research\u003c/h2\u003e\u003cp\u003eThe findings of this study underscore the importance of early identification and intervention for individuals exposed to adverse childhood experiences, with a particular focus on mitigating the long-term impact of neglect, abuse, and peer victimization on social functioning. Interventions should prioritize strengthening emotional literacy, enhancing interpersonal skills, and fostering trust in relationships, alongside addressing core eating disorder symptoms. Clinicians may benefit from incorporating targeted modules on social reconnection and loneliness reduction into treatment programs, as sustained and high-quality social support emerged as a pivotal factor in recovery. Furthermore, longitudinal research is needed to disentangle the temporal dynamics between social functioning impairments and ED symptom progression, as well as to evaluate the efficacy of early preventive programs designed to disrupt this self-perpetuating cycle. By integrating relational rehabilitation into both prevention and treatment frameworks, it may be possible to reduce the chronicity of EDs and improve long-term recovery outcomes.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study underscores the central role of impaired social functioning in the onset and maintenance of eating disorders, showing how individuals become increasingly isolated and trapped in a vicious cycle throughout the illness process. By foregrounding the lived experiences of individuals with eating disorders, the study emphasizes that loneliness is not merely a by-product of the disorder, but rather an active, self-reinforcing mechanism shaped by adverse early life experiences, disrupted interpersonal functioning, and illness-related symptoms. These findings extend the current literature by demonstrating that impaired social functioning is both a precipitating and sustaining factor in eating disorders, and they highlight the necessity of addressing interpersonal and family contexts in clinical interventions. Ultimately, this research contributes to a more comprehensive understanding of the onset, chronicity, and high relapse rates characteristic of eating disorders, while underscoring the importance of integrating social functioning into assessment and treatment strategies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAN Anorexia Nervosa\u003c/p\u003e\n\u003cp\u003eBED Binge Eating Disorder\u003c/p\u003e\n\u003cp\u003eBN Bulimia Nervoza\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eED Eating Disorder\u003c/p\u003e\n\u003cp\u003eFT Family Therapy\u003c/p\u003e\n\u003cp\u003eIPA Interpretative Phenomenological Analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIPT Interpersonal Psychotherapy\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e This project has been approved the University of Sabahattin Zaim Research Ethics Board (REB) (Number:2023/07). All participants signed a written consent form prior to the interviews.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003cp\u003eConflict of Interest\u003c/p\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003cp\u003eAcknowledgments\u003c/p\u003e\u003cp\u003eThe authors would like to thank Dilara Eren for the preparation of the manuscript and all participants for their valuable contributions.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSCA conducted the interviews, transcribed the material, conducted the analysis, and wrote the article. Both authors discussed the analytical approach and manuscript structure. EEO translate the article, reviewed the manuscript and made improvements to the article several times. Both authors made substantial contributions and has approved the submitted version.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank Dilara Eren for the preparation of the manuscript and all participants for their valuable contributions.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eBecause this article includes personally identifiable information that may compromise individual privacy, data sharing is not applicable. The supporting data are presented within the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAckard DM, Neumark-Sztainer D, Story M, Perry C. Parent\u0026ndash;child connectedness and behavioral and emotional health among adolescents. 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Child Abuse Negl. 2018;76:533\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.chiabu.2017.05.002\u003c/span\u003e\u003cspan address=\"10.1016/j.chiabu.2017.05.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Eating disorders, Anorexia nervosa, Bulimia Nervosa, Binge Eating Disorder, Loneliness, Social Functioning, Family Functioning, Interpersonal Functioning, Adverse childhood experiences","lastPublishedDoi":"10.21203/rs.3.rs-7759539/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7759539/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nEating disorders are serious psychiatric conditions with increasing prevalence, typically characterized by chronicity and substantial impairment in physical and psychosocial functioning. This study explores the role of social functioning in eating disorders, aiming to identify the roots of its impairment, examine its influence on illness progression, and understand how loneliness perpetuates the disorder, while also investigating the role of social support in recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nUsing an interpretative phenomenological approach, semi-structured interviews were conducted with eight participants diagnosed with Anorexia Nervosa, Bulimia Nervosa, or Binge Eating Disorder. Interviews explored personal experiences of social functioning, loneliness, and recovery. Data were analyzed to generate themes that captured both shared and individual experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nFour superordinate themes were identified:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eRoots of Impaired \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Social Functioning\u003c/strong\u003e – Adverse childhood experiences, including neglect, abuse, early \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;social isolation, and a pervasive sense of being a “lonely child,” shaped \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;participants’ early interpersonal patterns.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eThe Worsening \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Spiral: Impaired Social Functioning and Illness Progression\u003c/strong\u003e – A perceived lack of family \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;care and the tendency to interact from behind a “social mask” deepened \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;interpersonal disconnection and exacerbated illness severity.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eThe \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Self-Perpetuating Cycle of Loneliness and Eating Disorders\u003c/strong\u003e – Loneliness emerged as a \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;catalyst for symptom escalation, while deliberate withdrawal and \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;self-imposed isolation formed a “closing circle” that reinforced the \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;disorder.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReconnecting and \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Recovering: The Healing Role of Social Support\u003c/strong\u003e – Improvements in family, peer, or \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;therapeutic relationships were linked to symptom reduction, highlighting \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;the centrality of sustained social support in the recovery process.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nThe findings illustrate that impaired social functioning often originates in adverse early experiences and contributes to the development and maintenance of eating disorders. Loneliness plays a pivotal role in intensifying symptoms, while self-imposed isolation further entrenches the disorder. Conversely, meaningful social connections act as a protective factor, facilitating recovery. These results underscore the importance of integrating social functioning enhancement and sustained support networks into eating disorder treatment and prevention strategies.\u003c/p\u003e","manuscriptTitle":"The Vicious Cycle of Loneliness: Social Functioning in Eating Disorders – A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-06 11:21:53","doi":"10.21203/rs.3.rs-7759539/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a11c3dc5-4758-45a4-adb8-c3e84cae26d6","owner":[],"postedDate":"November 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-26T12:54:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-06 11:21:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7759539","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7759539","identity":"rs-7759539","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}