Rethinking anorexia nervosa through the lens of control, compulsion and reward: Neurobiological insights into addiction-like features via the dopaminergic, endocannabinoid, and orexinergic systems − A narrative review

BACKGROUND: Anorexia nervosa (AN) is a severe psychiatric disorder associated with high mortality, characterized by persistent food restriction and compulsive weight-loss behaviors. Increasing evidence suggests that certain features of AN may involve addiction-like mechanisms related to reward processing, compulsivity, and habit formation. Other perspectives conceptualize AN within the compulsivity spectrum, emphasizing overlaps with obsessive-compulsive disorder and behavioral addictions. Despite these frameworks, the neurobiological basis of addiction-like features in AN remains unclear, hindering the development of effective treatments. This narrative review synthesizes current evidence on psychological conceptualizations of AN with addiction-like features and examines key neurobiological systems implicated in both AN and addiction, namely the endocannabinoid, dopaminergic, and orexin systems. METHODS: A narrative literature review was conducted using Scopus, PubMed, and Web of Science, covering publications from 1998 to February 2026. Search terms included "anorexia nervosa addiction," "endocannabinoid system anorexia nervosa," "orexin system anorexia nervosa," "orexin system addiction," and "dopaminergic system anorexia nervosa." RESULTS: The review integrates psychological models highlighting addiction-like features of AN with neurobiological findings demonstrating dysfunctions in the orexin, endocannabinoid, and dopaminergic systems. These systems are critically involved in reward processing, motivation, and habit formation and show convergent alterations in both AN and addictive disorders. CONCLUSIONS: AN may be conceptualized at the intersection of addiction and compulsivity, with starvation-induced reward processes and habitual restriction contributing to illness persistence. Based on the reviewed evidence, we hypothesize a Starvation-Drive Model of Addiction-Like Features in AN.