The relationship between insecure attachment styles and eating disorder symptoms: The mediating role of mentalization and eating disorder beliefs

Abstract

BACKGROUND:

Eating disorders cause severe psychological and medical risks, necessitating an in-depth understanding of potential predisposing factors. This study examines the mediating roles of mentalization and eating disorder beliefs in the relationship between insecure attachment styles and eating disorder symptoms.

MATERIALS AND METHODS:

In terms of the purpose, the research was fundamental, and the research method was among the descriptive researches of the correlation type. A total of 490 students (Islamic Azad University, South Tehran Branch) were selected using convenience sampling based on a correlational design. They completed the Eating Disorder Diagnostic Scale, the Adult Attachment Scale, the Mentalization Questionnaire, and the Eating Disorder Belief Questionnaire. This research uses descriptive statistics methods including frequency, mean, and standard deviation and inferential methods including model structural equations.

RESULTS:

Avoidant attachment shows a significant indirect effect on eating disorder symptoms with eating disorder beliefs as a mediator (β = 0.109; P = 0.000), mentalization (certainty) as a mediator (β = 0.186; P = 0.000), and mentalization (uncertainty) as a mediator (β = 0.068; P = 0.000). Similarly, anxious attachment has a significant indirect effect on eating disorder symptoms, with eating disorder beliefs as a mediator (β = 0.072; P = 0.000), mentalization (certainty) as a mediator (β = 0.125; P = 0.000), and mentalization (uncertainty) as a mediator (β = 0.063).

CONCLUSION:

These findings highlight the critical influence of insecure attachment and cognitive distortions in the development and maintenance of eating disorder symptoms, suggesting that interventions targeting mentalization and eating disorder beliefs could mitigate the impact of insecure attachment on these disorders.

Introduction

Eating disorders can have profound and widespread effects on an individual’s life. Several factors may play a role in the development and exacerbation of these disorders, including genetic factors, social factors, psychological factors, and past experience.[1] The psychodynamic theory suggests that eating disorders are often related to unconscious conflicts, repressed emotions, and unmet psychological needs. For example, an individual may develop an eating disorder as a way to cope with anxiety or depression stemming from traumatic events or childhood experiences.[2] The years of undergraduate studies coincide directly with the average age of onset for eating disorders. Studies conducted at universities in the United States suggest that, according to estimates, eating disorders have a prevalence of about 19% among women and approximately 8 to 13% among men.[3] Insecure attachment, by negatively affecting the ability to regulate emotions, can lead to the development of various psychiatric symptoms, including eating disorders.[4]

Attachment theory, first introduced by John Bowlby, emphasizes the importance of early relationships with caregivers in shaping an individual’s emotional and relational patterns. Secure attachment is characterized by a healthy balance of autonomy and intimacy, while insecure attachment can manifest as either avoidant or anxious behaviors.[5] Individuals with avoidant attachment styles tend to withdraw emotionally and suppress their emotions, whereas those with anxious attachment styles are often preoccupied with fears of abandonment and may exhibit heightened emotional responses. Numerous studies have demonstrated a robust link between insecure attachment styles and the development of eating disorders. For instance, individuals with avoidant attachment may engage in restrictive eating as a means of exerting control over their bodies and emotions, while those with anxious attachment may turn to binge eating as a way to cope with emotional distress. These maladaptive behaviors often serve as mechanisms to manage the unresolved emotional conflicts stemming from early attachment experiences.[6] Studies show that secure attachment protects against psychological issues, while anxious and fearful attachments, which are associated with a negative self-view, increase the likelihood of psychological problems and mental instability.[7]

Mentalization refers to the capacity to understand and reflect upon the mental states of oneself and others. It is a crucial aspect of emotional regulation and interpersonal functioning. Individuals with high levels of mentalization are better equipped to navigate complex emotional experiences and maintain healthy relationships. Conversely, deficits in mentalization can lead to difficulties in identifying and processing emotions, often resulting in maladaptive coping strategies such as disordered eating.[8] Research has shown that individuals with eating disorders often struggle with mentalization, particularly in recognizing and understanding their own emotional states. This lack of insight can exacerbate the symptoms of eating disorders as these individuals may misinterpret hunger and satiety signals or use food as a means of emotional regulation. Moreover, poor mentalization may hinder the ability to form secure attachments, further perpetuating the cycle of disordered eating.[9]

Eating disorder beliefs are cognitive distortions that play a significant role in the development and maintenance of eating disorders. These beliefs often revolve around themes of control, perfectionism, and body image. For example, individuals with anorexia nervosa may hold the belief that their self-worth is contingent upon maintaining a low body weight, leading to extreme dietary restrictions. Similarly, those with bulimia nervosa may believe that purging behaviors are necessary to compensate for episodes of overeating, reinforcing the cycle of binge eating and purging.[10] Cognitive-behavioral models of eating disorders emphasize the importance of addressing these distorted beliefs in treatment. Interventions that challenge and modify these beliefs have been shown to be effective in reducing eating disorder symptoms. However, the interaction between eating disorder beliefs and other psychological factors, such as attachment style and mentalization, is not fully understood.[11]

Eating disorders pose significant psychological and medical risks, making it essential to understand their underlying factors. These disorders often lead to high rates of physical illness, psychiatric issues, and suicide, with symptoms typically emerging in early adolescence. Psychodynamic theory associates eating disorders with unconscious conflicts, repressed emotions, and unmet psychological needs, often as coping mechanisms for anxiety or depression stemming from trauma or childhood experiences.[12] Recent research has identified biological factors, such as neurotransmitter imbalances and genetic predispositions, as contributors to the development of these disorders. Additionally, the onset of eating disorders often coincides with undergraduate studies, with estimates indicating about 19% of women and 8% to 13% of men in American universities experiencing such disorders.[13]

This study is grounded in attachment theory and the mentalization-based approach to understanding eating disorder symptoms. The theoretical framework posits that insecure attachment styles contribute to deficits in mentalization, which in turn lead to the development of distorted eating disorder beliefs. These cognitive distortions then exacerbate the symptoms of eating disorders. By examining the interplay between these factors, the study seeks to elucidate the mechanisms that underlie the relationship between insecure attachment styles and eating disorder symptoms.

Based on the literature of the research, the conceptual model of the study is as follows [Figure 1]:

Figure 1.

Conceptual model of the study

Based on the literature review, the study proposes the following hypotheses: 1. Insecure attachment styles (both avoidant and anxious) are positively associated with eating disorder symptoms. 2. Mentalization mediates the relationship between insecure attachment styles and eating disorder symptoms. 3. Eating disorder beliefs mediate the relationship between insecure attachment styles and eating disorder symptoms.

Materials and Methods

Study design and setting

This study employs a correlational research design to explore the mediating roles of mentalization and eating disorder beliefs in the relationship between insecure attachment styles and eating disorder symptoms. The target population for this study includes all students enrolled in the Economics and Religious Studies faculties at the Islamic Azad University, South Tehran Branch, during the second semester of the 1402–1403 academic year.

Study participants and sampling

A total of 490 students were selected as the sample for this study through convenience sampling. According to Kline formula, an adequate sample size for structural equation modeling should be at least five times the number of items in the instruments.[14] Given that the study’s instruments comprise a total of 98 items, the selected sample size meets this criterion. Inclusion criteria for the study included a willingness to participate and current enrolment at the university. Exclusion criteria included self-reported use of psychiatric medications and incomplete questionnaire responses.

Data collection tool and technique

Eating disorder diagnostic scale (EDDS)

The EDDS is a 22-item self-report questionnaire and a Likert scale developed to assess symptoms of anorexia nervosa, bulimia nervosa, and binge eating disorder based on DSM-IV criteria.[15] It has been widely validated and used in various populations to diagnose eating disorders and to measure the severity of symptoms. The reliability coefficient of the test–retest for diagnosing eating disorders ranges from 0.80 to 0.90.[15] The Cronbach’s alpha in a study was reported as 0.87 for the normal-weight sample and 0.83 for the overweight sample.[16] Based on the validity and reliability, assessment of this scale in Iran was conducted on 431 individuals, resulting in high validity and reliability.[17] The split-half reliability coefficient calculated using Spearman’s correlation was between 0.82 and 0.84. The calculated Cronbach’s alpha of 0.89 indicates internal consistency of this scale. Additionally, the validity of this scale, assessed through confirmatory factor analysis for each item, showed suitable factor loadings of 0.90, 0.97, 0.93, 0.90, 0.93, 0.91, and 0.06, respectively. In the present study, the reliability of this scale was also examined using Cronbach’s alpha, which was calculated to be 0.82.

Revised adult attachment scale (RAAS)

This scale, developed in 1996, consists of 21 items and a Likert scale that assesses adult attachment styles, including secure, anxious, and avoidant attachment styles.[18] The Cronbach’s alpha values obtained for the above styles were 0.87%, 0.94%, and 0.86%, respectively. Also, the reliability of the scale was measured in Iran by Cronbach’s alpha at 0.82 for the whole scale, and those for the secure, anxious, and avoidant attachment styles were 0.89, 0.81, and 0.77, respectively.[19] The Cronbach’s alpha coefficient of this scale in the present study was 0.80.

Self-report measure of mentalizing: The reflective functioning questionnaire

This questionnaire measures an individual’s capacity for mentalization—the ability to understand and interpret the mental states of oneself and others.[20] The questionnaire covers various dimensions of mentalization, including self-mentalization, other mentalization, and affective mentalization. This questionnaire uses a 7-point Likert scale ranging from completely disagree[1] to completely agree,[7] and the uncertainty subscale is scored in reverse. The internal consistency for the confidence and uncertainty components was reported as 0.63 and 0.67, respectively. In the validation and reliability study of the Persian version of the mentalization questionnaire, Cronbach’s alpha was 0.88 for the confidence factor and 0.66 for the uncertainty factor.[21] Cronbach’s alpha coefficient of this scale in the present study was 0.79.

Eating disorder belief questionnaire (EDBQ)

The EDBQ assesses cognitive distortions related to eating, body image, and self-worth.[22] This 50-item questionnaire evaluates the degree to which individuals hold maladaptive beliefs that contribute to the development and maintenance of eating disorder symptoms. This tool has 32 items and 4 subscales: 1. Negative self-beliefs (11 items), 2. Weight and shape accepted by others (9 items), 3. Weight and shape accepted by self and self-acceptance (6 items), and 4. Overeating control (6 items). Each item is rated on a 100-point scale from 0 (does not apply to me at all) to 100 (applies to me completely). To get the overall score, the scores of the four subscales are added together and the total is divided by the four subscales. Cronbach’s alpha coefficient was calculated for each item using the questionnaire to evaluate the internal consistency of the factors. These values include negative self-esteem, 0.94; acceptance by others, 0.95; self-acceptance, 0.90; and control over eating, 0.89. Also, the validity of the questionnaire in Iranian research was mentioned with a Cronbach’s alpha coefficient of 0.86–0.94 for each factor and the subscales had a significant correlation with each other in the range of 0.47–0.71.[23] The Cronbach’s alpha coefficient of this scale in the present study was 0.80.

Data analysis

The mean and standard deviation were used to describe the data. Data were analyzed through structural equation modeling and using SPSS (version 26) and AMOS (version 24) software. The assumptions of this method include normality of data (using skewness and kurtosis results), correlation between variables (using Pearson correlation), linearity of the relationship between independent and dependent variables (by checking the scatter diagram), and noncollinearity between independent variables. It was confirmed by examining the variance inflation index (VIF). In the measurement model of the present study, two latent variables of insecure attachment styles, mentalization and eating disorder beliefs, were examined using confirmatory factor analysis with the maximum likelihood method. Fitting the measurement model using Chi-square index (χ²), Chi-square ratio index to degree of freedom (χ²/df), Tucker–Lewis index (TLI), comparative fit index (CFI), normed fit index (NFI), and root mean squared error of approximation (RMSEA) has been investigated. CFI, NFI, and TLI fit indices above 0.95; RMSEA less than 0.08 and (χ²/df) less than 3 with P > 0.01 indicate a good fit of the measurement model. To check the path coefficients, we used the bootstrap test (with 5000 sampling times) with a confidence interval of 95%. All statistical analyses were performed at a significance level of 0.05.

Ethical considerations

Permission from the Islamic Azad University, Central Tehran Branch, was obtained, and the ethics code IR.IAU.CTB.REC.1402.051 was obtained to conduct the study. After the necessary coordination, in order to select the sample size, the Faculties of Economics and the Faculty of Religious Sciences of Islamic Azad University, South Tehran Branch, were referred and students were identified who were willing to participate in the current research. They explained the ethical considerations, purpose, and content of the questionnaires to the students; the questionnaires were completed by them. Also, the participants were asked to respond to demographic information (sex, age, and education level) through self-reports at the beginning of the questionnaire.

Results

Out of a total of 490 sampled individuals, 195 are men (39.8%) and 295 are women (60.2%). Additionally, in terms of age classification, the largest group falls within the age range of 18 to 23 years, totaling 245 individuals (50%). The other age groups are as follows: The 23 to 28 age group includes 100 individuals (20.4%), the 28 to 33 age group includes 89 individuals (18.2%), the 33 to 38 age group includes 27 individuals (5.5%), and the 38 to 43 age group includes 29 individuals (5.9%). Furthermore, regarding educational level, 234 individuals (47.8%) are at the bachelor’s level, and 256 individuals (52.2%) are at the master’s level. In total, all individuals across these two educational levels add up to 490 individuals.

Table 1 shows the mean, standard deviation, skewness, and kurtosis of the variables. The skewness and kurtosis of all variables were in the range of −2 to +2, which indicated the normality of the research variables.

Table 1.

Descriptive information of research variables

Variant	Subscale	Mean	SD	Skewness	Kurtosis
Eating disorder symptoms	Diagnosis of mix symptoms	60.02	1.82	0.120	−0.605
	Symptoms of eating disorder	68.94	2.01	−0.228	−0.307
	Total	128.97	3.78	−0.052	−0.460
Not having eating disorder beliefs	Self-negative beliefs	47.09	1.75	0.840	2.313
	Form and weight accepted by others	61.06	3.60	0.144	2.598
	Accepted form and weight self and self-acceptance	40.75	2.37	0.144	2.737
	Over eating control	66.36	3.28	0.747	2.164
	Not having eating disorder beliefs	53.83	2.64	0.758	2.067
	Total	269.09	13.64	2.633	11.879
Mentalization	Not confidence	28.04	2.30	0.215	1.445
	Confidence	27.31	2.52	−0.195	0.126
Unsecure attachment	Anxious	19.58	3.22	−0.663	2.247
	Avoidant	18.18	3.11	0.546	2.260

According to Table 2, eating disorder beliefs showed a correlation of 0.707, with mentalization including certainty at −0.837, uncertainty at 0.760, anxious attachment at 0.633, and avoidant attachment at 0.685, all having significant correlations at the 0.01 error level with the eating disorder symptoms among students. This indicates that as mentalization (certainty) increases among students, the symptoms of eating disorders decrease, while an increase in eating disorder beliefs, mentalization (uncertainty), and insecure anxious and avoidant attachment is associated with an increase in the severity of eating disorder symptoms.

Table 2.

Correlation between research variables

Variables	1	2	3	4	5	6
1. Eating disorder symptoms	1
2. Eating disorder beliefs	0.707*	1
3. Mentalization (confidence)	−0.837**	−0.590**	1
4. Mentalization (not confidence)	0.760**	0.549**	−0.770**	1
5. Anxious attachment	0.633**	0.443**	−0.534**	0.510**	1
6. Avoidant attachment	0.685**	0.521**	0.630**	0.523**	0.413**	1

**P < 0.01

In the present study, at first, the assumptions of the structural equation model were checked and confirmed, including the normality of the data, linearity, and the absence of collinearity. The results of the analysis of the goodness-of-fit indices for the structural equation model are presented examining the relationship between insecure attachment styles and eating disorder symptoms, with the mediating role of mentalization and eating disorder beliefs [Table 3]. The results indicate that the Chi-square ratio to degrees of freedom is 4.806, which is less than 5, thus confirming this index. The Normed Fit Index (NFI) is 0.935, the Comparative Fit Index (CFI) is 0.938, and the Parsimony Normed Fit Index (PNFI) is 0.901, all of which exceed 0.90, confirming their validity. Finally, the Root Mean Square Error of Approximation (RMSEA) index is 0.072, which is less than 0.08. Figure 2 illustrates the results of the modified structural equation model examining the relationship between insecure attachment and eating disorder symptoms, with the mediating roles of mentalization (certainty and uncertainty) and eating disorder beliefs. The results indicate that anxious insecure attachment has a significant direct effect on eating disorder beliefs with a coefficient of 0.285, on mentalization (certainty) with a coefficient of −0.330, on mentalization (uncertainty) with a coefficient of 0.355, and on eating disorder symptoms with a coefficient of 0.185, all at a 5% significance level. This suggests that as anxious attachment increases, mentalization (certainty) among students decreases, while mentalization (uncertainty), eating disorder symptoms, and eating disorder beliefs increase. The results also show that avoidant attachment has a significant direct effect on eating disorder beliefs with a coefficient of 0.422, on mentalization (certainty) with a coefficient of − 0.493, and on mentalization (uncertainty) with a coefficient of 0.376. This indicates that as avoidant insecure attachment increases, mentalization (certainty) among individuals decreases, while mentalization (uncertainty) and eating disorder beliefs increase.

Table 3.

Goodness-of-fit indices

CMIN/DF	NFI	CFI	RMSEA	PNFI
4.806	0.935	0.938	0.072	0.901

Figure 2.

Modified structural equation model of the relationship between insecure attachment and eating disorder symptoms with the mediation of mentalization (confidence and non-confidence) and eating disorder beliefs

Avoidant attachment shows a significant indirect effect on eating disorder symptoms with eating disorder beliefs as a mediator (β = 0.109; P = 0.000), mentalization (certainty) as a mediator (β = 0.186; P = 0.000), and mentalization (uncertainty) as a mediator (β = 0.068; P = 0.000). Similarly, anxious attachment has a significant indirect effect on eating disorder symptoms, with eating disorder beliefs as a mediator (β = 0.072; P = 0.000), mentalization (certainty) as a mediator (β = 0.125; P = 0.000), and mentalization (uncertainty) as a mediator (β = 0.063) [Table 4]. The VAF coefficient for the avoidant attachment is calculated to be 1.46, and for the variable of anxious attachment, it is 1.65. This indicates that the strength of the indirect effect is strong as it is above 0.8.

Table 4.

Bootstrap test results for direct effect, indirect effect, and total effect

Variables	Indirect standard coefficient	P	β	Upper bounds	Lower bounds
Avoidant Attachment style	Mediating role of beliefs: 0.109	0.000	0.055	0.480	0.267
	The mediating role of mentalization (confidence): 0.186
Eating disorder symptoms	Mediating role of mentalization (not confidence): 0.068
	Total: 0.367
Anxious attachment style	Mediating role of beliefs: 0.072	0.000	0.057	0.367	0.178
	The mediating role of mentalization (confidence): 0.125
Eating disorder symptoms	Mediating role of mentalization (not confidence): 0.063
	Total: 0.266

Bootstrap test with 5000 resampling of original data and a 95% confidence interval

Discussion

This study provides significant insights into the complex interplay between insecure attachment styles, mentalization, eating disorder beliefs, and eating disorder symptoms among university students. The findings underscore the critical role of insecure attachment—both avoidant and anxious—as a significant predictor of eating disorder symptoms, mediated by individuals’ beliefs about eating disorders. This aligns with prior research, confirming that attachment styles fundamentally influence emotional and psychological health, particularly in the context of eating disorders.[4,7] The results indicate that as avoidant attachment increases, so do symptoms of eating disorders. This correlation suggests that individuals with avoidant attachment styles may struggle with emotional expression and vulnerability, leading to maladaptive coping strategies such as disordered eating behaviors.[24] Psychoanalytic specialists also believe that individuals with binge eating disorder lack the control of the superego and the strength of the ego compared to their anorexic counterparts. Many of these individuals have a history of difficulties in separating from their caregivers, which is manifested by a lack of transitional objects in their childhood. These individuals use their bodies as a transitional object. In these cases, the struggle to break away from the maternal symbol is expressed in a duality concerning food, where eating may represent a desire to merge with the caregiver and a simultaneous urge for separation and independence.[25]

The results also showed that insecure attachment (anxious and avoidant) has a significant and direct effect on eating disorder beliefs. This indicates that as insecure attachment (anxious and avoidant) increases, beliefs related to eating disorders also rise. This result aligns with prior studies.[24,26] In explaining the above findings, it can be said that Winnicott’s theory (1978) emphasizes the importance of the mother–child bond and mutual attachment. According to Winnicott, in the early stages of development, the survival of the infant depends on maternal care, and without it, the child’s innate capacities cannot fully develop. Attachment is a natural and instinctive response to the care and nurturing provided by caregivers. Therefore, it can be argued that insecure attachment, characterized by fear of abandonment and mistrust of others, can profoundly affect an individual’s self-image. For individuals with anxious attachment, there may be persistent concerns about acceptance and approval from others, leading to behaviors aimed at achieving an ideal body image as a means of securing validation and affection. In contrast, those with avoidant attachment often struggle with emotional intimacy and may resort to irregular eating patterns as a way to cope with emotional distress, effectively distancing themselves from their feelings and those around them. As levels of insecure attachment increase, whether through anxious preoccupations or avoidant behaviors, individuals are more likely to develop inconsistent beliefs about food, weight, and body image. This correlation suggests that the emotional turmoil experienced from insecure attachments can manifest in unhealthy attitudes and behaviors surrounding eating as individuals may turn to controlling their body shape and food intake in an attempt to manage their insecurities.[27]

The results indicated that insecure attachment (anxious and avoidant) has a significant and direct effect on mentalization (certainty and uncertainty). The discussion also reflects on the importance of mentalization—the ability to understand and interpret one’s own and others’ mental states. The ability to mentalize can significantly impact emotional regulation, which is crucial in managing eating behaviors. This results was in line with previous study.[7] Based on the above results, it can be explained that one of the fundamental aspects of mentalization is its capacity for emotional regulation. By reflecting on and understanding their own and others’ emotional states, individuals can manage their emotions in a healthy and adaptive manner. Furthermore, mentalization enables individuals to identify and cope with negative emotions such as anxiety, anger, or sadness before they escalate into more severe emotional disturbances or mental health issues. Additionally, mentalization is essential for establishing and maintaining secure attachment relationships. Insecure attachment relationships are often associated with psychological problems, which can lead to challenges in forming and sustaining close and meaningful connections. On the other hand, individuals who can internalize their emotional needs and those of others are more likely to develop secure attachments based on trust, empathy, and mutual understanding.[28]

The results also indicate that eating disorder beliefs has a significant and direct effect on eating disorder symptoms. This suggests that as beliefs related to eating disorders increase, the symptoms of the eating disorder also intensify. The results also indicate that the mediating variable of mentalization, including certainty and uncertainty, has a significant and direct effect on eating disorder symptoms. Specifically, as certainty among individuals increases, the symptoms of the eating disorder decrease, while greater uncertainty and eating disorder beliefs lead to an increase in eating disorder symptoms. The results align with prior studies.[29,30] One of the fundamental aspects of mentalization is its capacity for emotional regulation. By reflecting on and understanding their own and others’ emotional states, individuals can manage their emotions in a healthy and adaptive manner. Furthermore, mentalization enables individuals to identify and cope with negative emotions such as anxiety, anger, or sadness before they escalate into more severe emotional disturbances or mental health issues. Therefore, it can be said that when individuals have confidence in their abilities, self-worth, and understanding of their emotional states, they are better equipped to manage their eating behaviors and resist societal pressures regarding body image. Confident individuals may be more engaged in positive coping mechanisms and healthy eating patterns, thereby reducing the likelihood of developing or exacerbating eating disorder symptoms.[28]

The results indicated that the insecure attachment (avoidant and anxious) has an indirect and significant effect on eating disorder symptoms through the mediating eating disorder beliefs. Specifically, as avoidant attachment increases, the symptoms of eating disorders also rise among individuals, thereby confirming the research hypothesis. The results align with previous studies.[24,31] Furthermore, the study’s reference to family systems theory, as articulated by Minuchin, enriches the understanding of the familial context in which these dynamics unfold. Dysfunctional family relationships, characterized by rigid boundaries and lack of emotional support, can significantly hinder a child’s emotional development and contribute to the onset of eating disorders. The evidence that inadequate parental care and unhealthy attachment patterns play a critical role in the development of eating disorders necessitates further exploration of family dynamics in therapeutic settings.[32]

The results indicated that the insecure attachment (avoidant and anxious) has an indirect and significant effect on eating disorder symptoms through the mediating mentalization (certainty and uncertainty). The results align with previous studies.[29,30] Individuals with an avoidant attachment style often struggle with mentalization due to their tendency to downplay the importance of emotional connections and suppress their emotional experiences. Those with avoidant attachment typically learn to rely on self-sufficiency and often view emotional expression as a vulnerability. This reliance on oneself can lead to minimizing interpersonal relationships and cause avoidant individuals to have difficulty recognizing and understanding the emotional cues and perspectives of others. As a result, their capacity for mentalization is often disrupted as they may unconsciously avoid engaging with the emotional complexities of social interactions. Mentalization, also referred to as reflective functioning, encompasses the ability to understand and decode one’s own and others’ thoughts, feelings, desires, intentions, and behaviors. This concept includes the ability to acknowledge that behavior is driven by internal mental states and to infer the underlying mental states of oneself and others in order to understand their actions and interactions.[33] Therefore, it can be argued that the concept of mentalization—understanding one’s own and others’ mental states—has been identified as an important factor in this process. Low mentalization skills can hinder an individual’s ability to recognize emotions and lead to misinterpretation of social cues and feelings, which may exacerbate the effects of eating disorder beliefs and subsequently the symptoms of eating disorders.

Limitations and recommendations

This research included only students enrolled in the Faculty of Economics and the Faculty of Religious Sciences at the Islamic Azad University, South Tehran branch, during the 2023–2024 academic year, and generalizing the findings to other age groups and cities should be done with caution. Also, using self-report questionnaires to measure variables was another limitation of this study. It is recommended that the current study be conducted in other cities and with different age groups. In order to prevent the development of insecure attachment styles in children, parents and caregivers should be trained to establish secure and supportive relationships with their children. This training could include communication techniques, stress management, and how to provide emotional support to children. Enhancing mentalization as a factor related to eating disorders and influenced by attachment styles can improve the interpretation and understanding of others’ mental states and the accurate recognition of signs. Therefore, it is recommended that this focus on mentalization be included in the agenda of the university counseling center.

Conclusion

Overall, this research indicates that individuals with insecure attachment (avoidant and anxious) are at greater risk for developing eating disorders, primarily due to the interplay between attachment style, maladaptive beliefs about eating, and disruption in mentalization skills. Addressing these underlying issues through therapeutic interventions can be crucial in reducing eating disorder symptoms in affected individuals.

Author’s contributions

MT: Writing the manuscript (based on her thesis), data collection, data analysis. SS: This manuscript is based on MT thesis, I was her supervisor, writing the manuscript, interpretation of the data.

Data availability and statement

The data are available upon requesting by the journal board committee.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.