Psychosocial and cognitive risk factors for orthorexia nervosa: an integrative review of recent literature

Fatores de risco psicossociais e cognitivos para ortorexia nervosa: uma revisão integrativa da literatura recente

Factores de riesgo psicosociales y cognitivos para la ortorexia nerviosa: una revisión integradora de la literatura reciente

1. Vitória Moreli Guerrazzi

Affiliation of authors:

1, 2, 3, 4 [Graduandos, Medicina, Pontifícia Universidade Católica de Campinas, PUCC, Campinas, SP, Brasil]

5 [Graduando, Medicina, Centro Universitário de Várzea Grande, UNIVAG, Várzea Grande, MT, Brasil]

6 [Pediatra, Hospital PUCC, Pontifícia Universidade Católica de Campinas, PUCC, Campinas, SP, Brasil]

Chief Editor responsible for the article: Marsal Sanches

Authors contributions according to the Taxonomia CRediT: Guerrazzi VM, Abbondanza IP [1,2,5,6,13,14], Passarella LB [2,6,13,14], Pereira EG [2,6,11,13,14], Bonafé T [7,10], Ribeiro MP [13,14]

Disclosure of potential conflicts of interest: none

Funding: none

Approval Research Ethics Committee (REC): not applicable

Received on: 2025/05/19 | Accepted on: 2025/08/13 | Published on: 2025/08/19

How to cite: Guerrazzi VM, Abbondanza IP, Passarella LB, Pereira EG, Bonafé T, Ribeiro MP. Psychosocial and cognitive risk factors for orthorexia nervosa: an integrative review of recent literature. Debates Psiquiatr. 2025;15:1-35. https://doi.org/10.25118/2763-9037.2025.v15.1465

Abstract

Introduction: Orthorexia nervosa (ON) is a dysfunctional eating behavior characterized by an obsession with healthy eating. This disorder is influenced by psychological, social, and behavioral factors, with social media being a central factor. Digital content that promotes restrictive diets and fitness practices has contributed significantly to the dissemination of rigid and potentially harmful eating patterns, especially among adolescents and women. Objective: This review aimed to identify the main psychosocial and cognitive predisposing factors associated with ON, with an emphasis on the role of social media and other underlying mechanisms. Method: This is an integrative literature review, conducted according to the PRISMA guidelines. The review protocol was registered with PROSPERO CRD42024594857. Fourteen recently published studies were analyzed, totaling a sample of 12,628 participants. Inclusion criteria involved studies that addressed psychological, social, or behavioral risk factors related to ON. Results: Social media was strongly associated with ON, especially those that promote restrictive diets and fitness content. Dietary patterns such as vegan or gluten-free diets, combined with compulsive exercise, contribute to the maintenance of a pathological cycle. Psychological factors such as insecure attachment styles, low self-esteem, and difficulties in emotional regulation increase the risk. Mindfulness showed varied effects, while self-compassion stood out as a possible protective factor. Conclusion: Coping with ON requires a multifaceted approach, with clearer diagnostic criteria, public health actions to reduce the impact of social networks, and interventions focused on underlying psychological factors. Future research should prioritize early identification and prevention strategies.

Keywords: orthorexia nervosa, eating disorder, social media, mental health, restrictive diets.

Resumo

Introdução: A ortorexia nervosa (ON) é um comportamento alimentar disfuncional caracterizado por uma obsessão por alimentação saudável. Esse transtorno é influenciado por fatores psicológicos, sociais e comportamentais, sendo as redes sociais um fator central. O conteúdo digital que exalta dietas restritivas e práticas fitness tem contribuído significativamente para a disseminação de padrões alimentares rígidos e potencialmente prejudiciais, especialmente entre adolescentes e mulheres. Objetivo: Esta revisão teve como objetivo identificar os principais fatores predisponentes psicossociais e cognitivos associados à ON, com ênfase no papel das redes sociais e outros mecanismos subjacentes. Método: Trata-se de uma revisão integrativa da literatura, conduzida segundo as diretrizes PRISMA. O protocolo de revisão foi registrado no PROSPERO CRD42024594857. Foram analisados 14 estudos publicados recentemente, totalizando uma amostra de 12.628 participantes. Os critérios de inclusão envolveram estudos que abordassem fatores de risco psicológicos, sociais ou comportamentais relacionados à ON. Resultados: As redes sociais mostraram-se fortemente associadas à ON, sobretudo aquelas que promovem dietas restritivas e conteúdo fitness. Padrões alimentares como dietas veganas ou sem glúten, aliados à prática compulsiva de exercícios físicos, contribuem para a manutenção de um ciclo patológico. Fatores psicológicos como estilos de apego inseguros, baixa autoestima e dificuldades na regulação emocional aumentam o risco. A atenção plena apresentou efeitos variados, enquanto a autocompaixão destacou-se como possível fator protetor. Conclusão: O enfrentamento da ON exige uma abordagem multifacetada, com critérios diagnósticos mais claros, ações de saúde pública para reduzir o impacto das redes sociais e intervenções focadas nos fatores psicológicos subjacentes. Pesquisas futuras devem priorizar a identificação precoce e estratégias de prevenção.

Palavras-chave: ortorexia nervosa, transtorno alimentar, redes sociais, saúde mental, dietas restritivas.

Resumen

Introducción: La ortorexia nerviosa (ON) es un comportamiento alimentario disfuncional caracterizado por una obsesión con la alimentación saludable. Este trastorno está influenciado por factores psicológicos, sociales y conductuales, siendo las redes sociales un factor clave. El contenido digital que promueve dietas restrictivas y prácticas fitness ha contribuido significativamente a la propagación de patrones alimentarios rígidos y potencialmente perjudiciales, especialmente entre adolescentes y mujeres. Objetivo: Esta revisión tuvo como objetivo identificar los principales factores predisponentes psicosociales y cognitivos asociados a la ON, con énfasis en el papel de las redes sociales y otros mecanismos subyacentes. Método: Se trata de una revisión integradora de la literatura, realizada conforme a las directrices PRISMA. El protocolo de revisión fue registrado en PROSPERO CRD42024594857. Se analizaron 14 estudios publicados recientemente, con un total de 12.628 participantes. Los criterios de inclusión abarcaron estudios que abordaran factores de riesgo psicológicos, sociales o conductuales relacionados con la ON. Resultados: Las redes sociales se asociaron fuertemente con la ON, especialmente aquellas que promueven dietas restrictivas y contenido fitness. Patrones alimentarios como dietas veganas o sin gluten, junto con la práctica compulsiva de ejercicio físico, contribuyen a la perpetuación de un ciclo patológico. Factores psicológicos como estilos de apego inseguros, baja autoestima y dificultades en la regulación emocional aumentan el riesgo. El mindfulness mostró efectos mixtos, mientras que la autocompasión surgió como posible factor protector. Conclusión: El abordaje de la ON requiere un enfoque multifacético, con criterios diagnósticos más claros, estrategias de salud pública para reducir el impacto de las redes sociales e intervenciones centradas en factores psicológicos subyacentes. Futuros estudios deben priorizar la identificación precoz y estrategias preventivas..

Palabras clave: ortorexia nerviosa, trastorno alimentario, redes sociales, salud mental, dietas restrictivas.

Introduction

The growing pursuit of a healthy lifestyle, driven by the adoption of strict diets and exercise routines, reflects a concern for preventing chronic non-communicable diseases (NCDs) like hypertension and diabetes. However, this pursuit can paradoxically trigger eating disorders such as Orthorexia nervosa (ON). ON is a syndrome characterized by an obsessive fixation on the purity and quality of food, in which a healthy concern becomes excessively restrictive and harmful . Rather than a single disordered behavior, ON encompasses cognitive, emotional, and behavioral dimensions that impair social and psychological functioning.

Studies show that a combination of social, psychological, and cultural factors significantly contributes to the development of ON. Exposure to social media that promotes ideals of perfect bodies and extreme eating habits is one such factor, leading to internalization of unattainable standards and constant comparisons . These digital spaces exert considerable pressure, encouraging rigid eating patterns and obsessive behaviors related to diet and health . Individuals who consume content promoting “clean eating” or extreme dietary control are more likely to develop orthorexic tendencies, especially when influenced by visual glorification of idealized bodies and wellness perfectionism.

Psychological factors, particularly perfectionism, also play a crucial role. The compulsion to meet rigid healthy eating standards, often accompanied by compulsive exercise, reflects an attempt to control anxiety and preserve self-image . ON shares features with other disorders, including obsessive-compulsive disorder and anorexia nervosa, especially in relation to cognitive rigidity, intolerance to uncertainty, and high levels of self-criticism. Self-compassion, conversely, appears to be a protective factor, as its absence is linked to a broad range of psychopathologies, including eating disorders. Additionally, insecure attachment patterns—commonly observed in other mental health conditions—have also been associated with orthorexic behaviors.

Given the increasing academic interest in Orthorexia Nervosa and the growing recognition of its multifactorial origins, it is essential to examine how recent developments in research have contributed to understanding its risk factors. The years 2023 and 2024 were selected to capture the most current perspectives, particularly in light of post-pandemic shifts in digital behavior, public health messaging, and lifestyle norms, all of which may influence the manifestation of orthorexic traits. This temporal focus allows for an updated synthesis that reflects emerging trends, including novel conceptualizations, assessment tools, and cultural dynamics. Therefore, the aim of this review is to identify and analyze the primary psychological and sociocultural factors associated with the development of ON in studies published between 2023 and 2024, offering an integrative view that may inform future research and targeted prevention strategies.

Method

Search Strategy

A systematic search was conducted in the PubMed, EMBASE, SciELO, and Scopus databases for studies published from January 2023 to March 2024. The following search terms and Boolean combinations were used: ("orthorexia" OR "orthorexia nervosa") AND ("social media" OR "psychological factors" OR "compulsive exercise"). Filters for full-text availability, English and Portuguese languages, and publication year were applied. The decision to include only recent studies aimed to capture the most up-to-date evidence, reflecting recent developments in the literature, especially following behavioral changes observed in the post-pandemic context.

Eligibility criteria

Studies were included if they: 1. Focused on Orthorexia Nervosa as the central theme; 2. Addressed the relationship between predisposing factors and the development of Orthorexia Nervosa; 3. Were available as full-text articles for free; 4. Were published between 2023 and 2024; 5. Were cohort studies.

Studies were excluded if they: 1. Were case reports or literature reviews; 2. Were duplicates; 3. Did not focus on Orthorexia Nervosa as the central theme; 4. Were observational studies.

Screening and data extraction

All relevant studies identified through electronic database searches were imported into a spreadsheet, and duplicates were removed. The study selection process was carried out in three phases. Two independent reviewers (IA & VG) screened the article titles, followed by the abstracts, and then the full texts, based on the inclusion criteria. Studies meeting the eligibility criteria were included in the review. Disagreements were resolved through consensus or by consulting a third author (LP). One reviewer (EG) extracted the following information: article title, publication date, author names, study characteristics, participant details, and primary and secondary outcomes. The extracted data were verified by the remaining authors.

Study Selection Summary

A total of 284 articles were initially identified. After removing 140 duplicates, 144 articles remained for screening. Following title and abstract review, 19 articles were assessed in full, of which 13 met the eligibility criteria and were included in the final review. These studies involved 8,179 participants aged 15 years and older. Among them, five studies examined the relationship between ON and social media, two focused on compulsive exercise, one investigated self-compassion and mindfulness, and five explored psychological factors and restrictive diets. The summary of the screening process is depicted in Figure 1.

Quality assessment and risk of bias

The quality of the included studies was independently assessed by two authors (IPA & VMG) using the Newcastle-Ottawa Scale (NOS) adapted for observational studies. The potential risk of bias in each study was also evaluated by the same authors using the Tool to Assess Risk of Bias in Cohort Studies. Any discrepancies between the reviewers were resolved by consulting a third reviewer (LBP).

Data analysis

The data analysis stage involved synthesizing the findings of the included studies following a narrative synthesis approach, as described by . Studies were grouped according to the thematic focus (e.g., social media, exercise, psychological traits) and numerically classified based on the type of factor investigated. Similarities and differences across the studies were analyzed in light of the guiding research question, allowing the identification of relevant patterns, recurring themes, and gaps in the current literature on Orthorexia Nervosa.

Results

Study characteristics

Key study characteristics are presented in Frame 1. All studies were published between 2023 and 2024. Most included studies had quantitative designs: cross-sectional study (n = 9); cross-sectional descriptive study (n = 2); cross-sectional cohort study (n = 1); cross-sectional and retrospective study (n = 1); full report (n = 1). Two were qualitative studies using face-to-face interviews, ten were studies using Form or online questionnaire, and two were studies using other ways of searching online.

The included studies reported a combined total of 12,628 participants with various issues related to ON. Study sample sizes ranged from 96 to 4405 participants. Most studies were conducted with young adults and adults, within an age range of 18 to 65 years, while one study specifically focused on adolescents aged 15 to 18 years. All of the studies had more women in the sample. The studies used different data collection methods.

What factors are associated with ON?

In total, fourteen papers (n=14) reported factors in the development of ON. The details of these factors: social media, restrictive eating patterns and self-compassion, mindfulness, compulsive exercises, and attachment theory are provided in Frame 2.

Social media

The analysis of the selected articles (n=5) indicates a significant association between the use of social networks and higher reported ON symptoms. One study found that the risk of ON was 2.4 times higher in individuals who followed pages promoting healthy eating and 1.68 times higher in those who followed pages focused on physical exercise. The study highlighted that adolescents and women are particularly at risk, largely due to the pressure of social networks and the propagation of the thin ideal. Additionally, individuals prone to ON spent an average of 161.1 minutes per day on social networks, significantly more than those without a tendency toward ON. Another study revealed that ON can also be influenced by exposure to specific content on social networks, such as profiles promoting restrictive diets or "pure" and "natural" foods. This constant exposure may be associated with stronger obsessive and compulsive food-related tendencies and more severe ON symptoms. The study found that individuals who did not follow entertainment and restaurant pages reported higher ON tendencies, suggesting a potential association between limited content exposure and ON .

An additional study indicated that using social media to consume and share content on healthy eating is most prevalent among individuals with both ON and eating disorders. Also, a study found that occurrence of ON was greater among obese individuals with higher social media addiction scores. Engaging with social media can affect body image and dietary habits. Educating obese individuals on these influences can help protect against trendy social media diets and potential eating disorders.

A further study found that social media content, often showcasing restrictive diets and idealized body images, encourages constant comparisons between bodies and lifestyles. This comparison can intensify the obsession with adhering to a strict diet in an attempt to attain the same ideal, leading to the development or exacerbation of pathological eating behaviors . Social media, by facilitating access to these ideals and information, provides fertile ground for the growth of ON, where the pursuit of a healthy lifestyle evolves into an unhealthy obsession.

Restrictive eating patterns and self-compassion

A significant link between ON and restrictive eating patterns has been demonstrated (n=5), with self-compassion emerging as a potential moderating factor for these behaviors. found that dieting was associated with higher ON symptoms, and that food-related worries and preoccupations, related to restrictive eating habits, appeared to mediate a significant portion of the variance in ON symptoms.

One study revealed that the rigid dietary rules and pursuit of a perfect diet in ON may be attributed to perfectionist tendencies, potentially increasing the risk of eating disorder symptoms.

Other study found that ON is closely associated with diets that excessively focus on food quality and rigid dietary restrictions, such as vegan and gluten-free diets. This orthorexic tendency is more pronounced in women and individuals with a history of disordered eating, highlighting a strong connection between ON and overly controlled eating patterns. In a sample of 251 Canadian adults (85.7% women), two profiles of orthorexic behaviors were identified: 68.9% exhibited low levels of ON and healthy orthorexia, while 31.1% showed moderate levels of both. Participants with a moderate profile demonstrated more disordered eating behaviors, including a greater likelihood of practicing vegetarianism and engaging in frequent physical activity.

Another study emphasized that ON significantly impacts individuals' quality of life. According to another article ON negatively affects the physical health of the person as well as their interpersonal relationships, stress management, and mental health. However, self-compassion-based interventions appear to mitigate these effects. Self-compassion, which involves treating oneself with kindness and understanding in the face of flaws, helps reduce the eating perfectionism typical of ON. The study suggested that individuals with greater self-compassion tend to have fewer orthorexic tendencies, as they are less prone to self-judgment. Furthermore, it was identified a complex relationship between ON and mindful eating, where ON correlated positively with emotional eating, challenging previous expectations . This finding suggests that while ON is often linked to rigid eating control, it can also coexist with elements of mindful eating, complicating the understanding of ON in relation to eating behaviors.

Another study , proposed that cultivating self-compassion could be an effective strategy for reducing the rigidity of eating patterns associated with ON and improving quality of life.

Mindfulness

The role of mindfulness in mindful eating reveals a complex and sometimes contradictory relationship with ON (n=2). Studies present a complex relationship between mindfulness and ON. It was reported negative correlations between mindful eating subscales and ON tendencies, suggesting a potential inverse association . However, it was found a positive correlation between ON and certain dimensions of mindful eating, such as emotional eating .

One study found negative correlations between ON and mindful eating subscales, such as mindful eating, hunger, and satiety. These results suggest that individuals with higher levels of mindfulness tend to exhibit lower orthorexic tendencies, implying that mindful eating practices may protect against ON. By promoting a more intuitive and less rigid relationship with food, mindful eating may reduce orthorexic behaviors. As such, interventions aimed at increasing mindful eating could be effective in mitigating the negative impacts of ON on individuals' quality of life. However, another study offers a different perspective, challenging the expected relationship between mindfulness and ON. This study identified a positive correlation between ON and mindful eating, particularly in dimensions such as emotional eating and attention to eating. These findings suggest that, in some cases, mindful eating may coexist with orthorexic behaviors, and individuals with an obsessive relationship with food may use mindful eating dysfunctionally. This complexity highlights the need for a more nuanced understanding of how mindful eating is linked to ON, as the practice may serve both as a tool for emotional regulation and a potential contributor to the obsession with healthy eating.

Compulsive exercises

Studies have consistently reported an association between frequent participation in physical activity and higher ON tendencies. A study found that individuals with more regular physical activity were more likely to exhibit moderate orthorexic eating behaviors .

One study found that individuals who engage in physical activity more regularly are significantly more likely to exhibit moderate orthorexic eating behaviors compared to those with lower levels of ON. While physical exercise is generally considered healthy, excessive participation has been associated with health issues and dysfunction, and this may co-occur with higher ON tendencies. Both excessive exercise and ON share a rigid, extreme nature, which, when combined, can result in physical complications, injuries, and emotional distress.

Another study explored the hypothesis that an obsession with health underlies both ON and compulsive exercise, suggesting that these behaviors are interconnected. This could create a mutually reinforcing cycle, where ON intensifies compulsive exercise, which in turn worsens ON.

Another study found that nurses who engaged in regular physical activity, monitored their caloric intake, and followed a structured diet showed significantly elevated levels of orthorexic tendencies. An organized approach to eating often aligns with behaviors associated with ON, which involves an intense focus on healthy eating. It’s suggested that individuals who prioritize exercise, carefully consider the types and amounts of foods they consume, and plan meals in detail may exhibit a stronger inclination toward ON due to their heightened dietary attentiveness. Additionally, emotional dysregulation has been found to be positively associated with disordered eating, which in turn is linked to both ON and compulsive exercise.

A further study highlighted that the combination of physical exercise and an overly regulated diet, often motivated by the pursuit of a healthier lifestyle and an idealized body image, can, in pathological cases, develop into exercise addiction and lead to injuries. In these individuals, the motivation for exercise seems strongly influenced by compulsive behaviors and feelings of guilt.

Attachment theory

Attachment theory explores how relationships between infants and their parents influence emotional development, concepts of love, social interactions, and adult bonding. Four attachment patterns are commonly identified: 1. secure attachment, 2. avoidant and dismissive, 3. anxious and fearful, and 4. preoccupied attachment. Insecure attachment styles have been linked to eating disorders, with patients showing more avoidant and anxious behaviors and less security compared to those without such disorders.

One study found that individuals with eating disorders often exhibit avoidant and anxious attachment, being less secure than those without eating disorders. However, research on the connection between attachment styles and ON remains limited, particularly among adolescents. The study also highlighted that insecure attachment, especially in females, is a significant risk factor for ON. Furthermore, emotion regulation and alexithymia (difficulty identifying and expressing emotions) were identified as key mediators in this relationship, suggesting that interventions addressing these areas could be vital for preventing and treating ON.

Another study demonstrated that self-esteem plays a mediating role in this relationship. Secure attachment styles are associated with lower ON tendencies, while low self-esteem increases the risk of developing the disorder. A recent analysis of Lebanese adolescents revealed that insecure attachment styles, such as anxious and avoidant attachment, are strongly linked to higher ON tendencies. These adolescents also exhibited higher levels of compulsive exercise, poor emotion regulation, concerns about weight and body shape, body dissatisfaction, and controlling parenting practices.

BMI

One study examines the relationship between Body Mass Index (BMI) and ON, using BMI as an indicator of difficulties in maintaining appropriate body weight, which may drive individuals to adopt restrictive diets. Research on this topic has shown mixed results: some studies report a significant association between both overweight and underweight conditions and ON, while others do not. This study highlighted the association of ON with BMI categories, specifically distinguishing between normal and non-normal BMI (underweight, overweight, or obese), finding a significant relationship at certain BMI thresholds. Interestingly, respondents with normal BMI had lower mean scores on the ORTO-15 test compared to those with non-normal BMI. This suggests that BMI may be associated with ON tendencies, potentially serving as a factor to consider in identifying individuals who report higher levels of ON.

Another study found that individuals categorized as obese had higher scores on the Social Media Addiction Scale for Adults (SMBÖ-SF) than those classified as overweight, according to their Body Mass Index (BMI). This could imply that obesity is associated with a greater tendency to engage with social media, possibly influencing behaviors related to body image and health.

Discussion

The findings of this integrative review underscore the multifactorial nature of Orthorexia Nervosa (ON), revealing how psychological and social elements, such as social media use, restrictive eating patterns, mindfulness, compulsive exercise, and attachment styles, interact in shaping the development and maintenance of this condition. Rather than operating in isolation, these factors often reinforce one another, forming a complex web of behaviors and cognitions centered on control, perfectionism, and identity.

Social media platforms have proven to be a significant risk factor for ON, with exposure to idealized body images and restrictive dietary behaviors fostering a heightened focus on food quality and control. Studies show that individuals who engage with content promoting healthy eating, exercise, and idealized body images are more likely to develop ON symptoms. This is particularly concerning for adolescents and women, who seem to be more vulnerable to the pressures exerted by social media. The constant exposure to unattainable ideals, reinforced by comparisons with others, appears to intensify obsessive behaviors related to food and exercise, ultimately facilitating the development of ON. Future research could further explore how to mitigate these harmful effects, perhaps by promoting more diverse content and raising awareness of the mental health risks associated with these platforms.

Restrictive eating patterns, such as veganism and gluten-free diets, are often associated with ON, where rigid eating behaviors exacerbate the disorder's symptoms. Self-compassion has emerged as a potential moderating factor, with studies suggesting that individuals with higher levels of self-compassion are less prone to the perfectionistic tendencies that fuel ON. By fostering a more compassionate relationship with food and self, interventions aimed at increasing self-compassion may help reduce the rigidity of eating patterns and improve overall well-being. However, this relationship is nuanced, self-compassion may be moderated by emotional regulation and mindfulness, highlighting the need for further research into how these psychological constructs interact in different populations.

The role of mindfulness in ON presentes a paradox. On one hand, mindful eating may promote a healthier, more intuitive relationship with food by reducing automatic, emotionally driven eating. On the other hand, individuals with orthorexic tendencies may co-opt mindfulness practices in rigid or controlling ways, using them to further entrench food-related rules or suppress distress. This paradox calls for a more nuanced understanding of how mindfulness can both alleviate and contribute to ON symptoms. Effective interventions should simultaneously target eating behaviors, exercise patterns, and emotional regulation, recognizing the interconnected nature of these domains.

Compulsive exercise is frequently associated with ON, with studies showing that excessive physical activity can worsen eating behaviors and emotional distress. This finding aligns with the concept of a mutually reinforcing cycle between ON and compulsive exercise, where each behavior fuels the other, creating a pathological loop that can lead to physical and emotional harm. Addressing this cycle through interventions that target both dietary habits and exercise behaviors could be crucial for individuals at risk of ON. Given that emotional dysregulation is also a key feature of this cycle, it is important to incorporate strategies aimed at improving emotional regulation in treatment plans.

Attachment theory provides a deeper emotional framework for understanding ON. Insecure attachment styles, particularly anxious and avoidant, are consistently associated with higher orthorexic tendencies. Individuals with these attachment profiles often experience difficulties with emotion regulation and self-worth, seeking external control (such as food rules) to manage internal chaos. These dynamics may also explain why such individuals are especially sensitive to external influences like social media and dietary ideologies. Interventions aimed at enhancing attachment security, such as emotion-focused therapy or compassion, based approaches, may improve emotional stability and reduce reliance on rigid eating behaviors for psychological comfort.

Implications for Research and Practice

The findings of this review suggest several important implications for both research and clinical practice. First, future research should focus on developing clear diagnostic criteria for ON, as the current lack of formal recognition in diagnostic manuals like the DSM-5 limits the ability to identify and treat individuals at risk. This could involve exploring the psychological and social factors that contribute to the disorder in greater depth, particularly the influence of social media and restrictive eating behaviors. Investigating how self-compassion, mindfulness, and emotional regulation influence ON could provide valuable insights for developing more effective prevention and intervention strategies.

In clinical practice, there is a need for multidisciplinary approaches to address the complex nature of ON. Interventions should incorporate strategies to combat the negative impacts of social media, such as promoting diverse and realistic portrayals of body image and eating behaviors. Furthermore, fostering self-compassion and emotional regulation, particularly in vulnerable populations like adolescents, could reduce the risk of developing ON. Professionals should also be aware of the intertwined relationship between compulsive exercise and restrictive eating, as addressing one without the other may not be sufficient for effective treatment. Finally, integrating attachment-based therapies into ON treatment may offer a promising approach for enhancing emotional regulation and improving self-esteem, particularly in individuals with insecure attachment styles.

By advancing our understanding of the factors that contribute to ON and implementing targeted interventions, both research and practice can work together to mitigate the prevalence and impact of this disorder on individuals' mental and physical health.

Strengths and limitations

This review has several strengths, including its comprehensive analysis of psychological and social contributors to ON and its integration of emerging evidence from multiple disciplines. However, several limitations must be acknowledged. First, all included studies relied on self-report measures, introducing potential recall and response biases. Second, heterogeneity in outcome definitions and assessment tools limited comparability across studies. Third, many studies focused on specific populations (e.g., adolescents, women), which constrains generalizability. Fourth, few studies accounted for cultural context, despite the likelihood that ON manifests differently across cultural settings and dietary norms.

Despite these limitations, this review provides critical insights into the role of social media in developing and exacerbating ON. The influence of platforms promoting dietary extremism and the ideal of physical perfection should not be overlooked in discussions on disordered eating behaviors. This provides a strong foundation for targeted, intervention-based recommendations for reducing ON risk. Further research is also needed on the psychological mechanisms linking social media use to ON, as well as potential preventive interventions targeting at-risk groups like adolescents and frequent social media users.

Conclusion

In conclusion, ON is a complex disorder influenced by psychological, social, and behavioral factors. Elements such as social media, restrictive eating patterns, mindfulness, compulsive exercise, and attachment styles are interconnected in its development and worsening. The influence of social media highlights the need for public health actions focused on mental health. Future research should explore the underlying psychological mechanisms and develop interventions to reduce negative impacts, helping lower the prevalence of ON and improve the quality of life of those affected.

We extend our deepest gratitude to our advisor, Maira Pieri, for her unwavering support and guidance throughout this journey. A special thanks to Sofia Vitte for her invaluable suggestions, which greatly enriched our work. Above all, we recognize the dedication, perseverance, and collective effort of our entire group, whose commitment to achieving our shared goals has been truly inspiring.