Exploring the Role of Psychedelic Experiences on Wellbeing and Symptoms of Disordered Eating

Abstract

Accumulating psychedelic research has demonstrated a potential for improving mental health and wellbeing, yet studies in the context of eating disorders (EDs) are limited. This study aims to explore the subjective effects of psychedelic experiences to gain insight into the benefits and risks for people with EDs. Semi-structured interviews were conducted with eight adults aged 25–54 (mean age = 36.9), reporting to have had experiences with EDs and psychedelics in both naturalistic and clinical settings. Participants had multiple diagnoses and suffered chronic EDs, (mean age of onset = 13), diagnosed (N = 7) and undiagnosed (N = 1). Reports of cessation or the reduction of ED symptoms were unanimous and long-lasting for seven, with two participants reporting recovery attributed to psychedelic use. Two participants reported relapsing, attributed to environmental factors in the months following. Thematic analysis resulted in two superordinate themes, each comprising three subordinate themes. The first superordinate theme, ‘Exploring’ via the ‘gateway to healing’, illustrates mental, emotional, and transcendental elements of psychedelic experiences. The second superordinate theme, ‘Transformation’ and being ‘able to do the work’, illustrates cognitive and behavioural outcomes, with retrospective safety perceptions. These findings may provide more in-depth information on what benefits and experiences people with EDs can obtain from the use of psychedelic drugs and may inform more robust investigations of psychedelic-assisted therapy for the treatment of EDs.

1. Introduction

Eating disorders (EDs) are serious and often chronic health conditions, marked by the highest risk of suicide and mortality rates of any psychiatric disorder [1,2,3,4]. Characterised by abnormal eating behaviour, nutritional imbalances, persistent cognitive inflexibility, and emotional distress, EDs are associated with a wide array of health complications and prognoses that are often severe, linked to complex comorbid mental health symptoms, and genetic and environmental factors [5,6,7,8,9]. The worldwide prevalence is thought to be anywhere between 7.8–33.2%, with a lifetime prevalence ranging between 4–25% (weighted mean = 10.6%) [10]. Furthermore, EDs are among the most difficult to treat with healthcare costs 48% higher than the general population, altogether constituting a major public health concern [11,12].

Common EDs have three major types: anorexia nervosa (AN), characterised by extreme dietary restrictions and an inability to maintain an adequate healthy body weight, binge eating disorder (BED), characterised by episodes of binge eating, and bulimia nervosa (BN) which combines BED with extreme compensatory behaviours, such as purging by vomiting. Orthorexia nervosa (ON) is marked by a maladaptive and extreme obsession with health and restrictive diets [13]. Other feeding and eating disorders include avoidant restrictive food intake disorder (disturbed and extreme picky eating resulting in a persistent failure to meet nutritional needs), pica (a persistent craving for unnatural, nonnutritive substances), rumination disorder (the repeated regurgitation and re-chewing of food), and other specified and non-specified eating disorders (selective symptoms of EDs) [14].

It is important to note that ED pathology is far more intricate than the few symptoms listed. Greater recognition is needed for their complex aetiology which involves transactions among sociocultural, psychological, and biological influences. Contributing factors include sociocultural (e.g., media idealisation, aesthetic pressures, and peer influence), family (e.g., enmeshment, criticism, and abuse), biological (e.g., genetic risk) and personality traits (e.g., perfectionism and negative affect). EDs may also represent ways of coping with deeper personal issues and experiences [15,16].

ED diagnoses can be difficult, and few receive specialist services. Life-threatening inequalities, delays and failings in adult ED services leave many to rely on potentially dangerous, inadequate resources with a significantly hampered wellbeing [17,18,19,20]. The primary approved treatment for EDs consists of talking therapies and antidepressants; however, effective treatment options are still limited and long-term remission remains difficult to achieve, resulting in urgent calls for investigations into new interventions [21,22,23,24].

Simultaneously, there has been a renewed interest in the therapeutic potential of psychedelic drugs, with accumulating clinical evidence for safety and treatment efficacy across a range of prevalent mental disorders [25,26,27], most notably, serotonergic psychedelics for illnesses characterised by rigid thought patterns and treatment resistance [28,29,30]. Central to this revival is the re-emergence of a psychedelic-assisted therapy paradigm, emphasising therapeutic support, patient mind set, and setting for positive outcomes [31,32,33].

Psychedelic therapies have recently been identified as a possible avenue for novel ED treatments and efficacy research for EDs is nascent. Preliminary findings have so far been promising [34,35]. Multiple clinical trials are currently underway, including one proof of concept and two pilot studies [36,37]. Preliminary research has so far demonstrated marked reductions in ED symptoms and improvements in wellbeing following experiences with ceremonial and serotonergic psychedelics [38,39,40,41], both long-term [42] and short-term [43], primarily via mystical/spiritual and emotional pathways that facilitate healing. Further, a recent preliminary paper reviews the hypothesis that psilocybin may be effective for the treatment of EDs, based on biological plausibility, transdiagnostic evidence, and preliminary results [44]. However, the data are insufficient to draw firm conclusions. This study therefore seeks to provide an understanding of psychedelic usage on EDs and subjective benefits and risks by exploring the experiences of individuals with chronic EDs.

2. Eating Disorders

2.1. Eating Disorders: Theoretical Underpinning

A core feature of all EDs is the disruption of eating behaviour and nutritional regulatory systems [45]. One key aspect of ED pathology is the dysregulation of serotonergic signalling, such as in regions involved with appetite and reward, associated with mood instability, body image distortion, and impulsivity [46,47]. It is thought that complex genetic and environmental factors contribute to ED pathology with alterations in emotional–cognitive function and interoception; however, greater recognition is needed of the full spectrum of EDs and their diverse global representations [7,48,49].

The transdiagnostic theory underpinning EDs derives from the cognitive behavioural model, delineating core low self-esteem with clinical perfectionism, mood intolerance, and interpersonal and emotional difficulties [6,12]. These beliefs and altered brain reward circuits are associated with harmful maladaptive behaviours, resulting in a cycle of comorbid issues, malnutrition, and physical consequences [8,50,51]. The wide array of comorbid conditions and psychological symptoms include poor concentration, impulse control, emotional dysregulation, depression, anxiety, obsessive–compulsive disorder (OCD), post-traumatic stress disorder (PTSD), body dysmorphic disorder (BDD), and substance use problems or addictions (SUD) [48,51,52,53,54,55].

Specifically, PTSD is associated with intense reactions to reminders of trauma, imminent threat, and hypervigilance. OCD is marked by distressing, intrusive thoughts (obsessions) and extreme avoidant and impulsive ritualistic behaviours (compulsions), while BDD consists of distressing and intrusive preoccupations with imagined or slight defects in appearance [56]. The high comorbidity emphasises the complex aetiology and heterogeneous trajectories of EDs [8,11].

An issue raised by those with lived experiences and their families is the need for an improved recognition and understanding of the underlying root causes and potential biological explanations for EDs [49,50,57]. Genetic studies, for example, have now advanced the understanding of AN as a metabo-psychiatric disorder with significant genetic correlations between comorbid psychiatric disorders, physical activity, and biological and anthropometric traits, which may differ from the underlying biology in binge-type EDs, further elucidating the complexity of ED aetiology [58,59]. Furthermore, as with other areas of ED research, genetic studies fall short in representing the diverse population of people living with EDs, which may constrain scientific discovery and current understandings [60].

2.2. Current Treatment for Eating Disorders

The leading empirically supported psychotherapeutic treatment for EDs is enhanced cognitive behavioural psychotherapy (E-CBT), which rectifies dysfunctional ED thoughts and reduces ED behaviours [61,62]. However, with less than 50% achieving remission, CBT is associated with high relapse (>30%) and dropout rates (>24%) [63,64,65,66]. While recovery rates are still low, recent meta-analyses and a multivariable meta-regression analysis of current treatments confirm that E-CBT, family-based therapy (in adolescents), and psychodynamic therapy (treatments based on an interpretive–supportive continuum) are associated with better outcomes [8,22,67,68].

Psychotherapy is often combined with pharmacological treatments, primarily selective serotonin reuptake inhibitors (SSRIs) as antidepressants (e.g., fluoxetine) and central nervous system stimulants for BN and BED in adults, yet there is no approved medication for the treatment of AN. The efficacy for antidepressants has been debated and pharmacotherapy for EDs has overall failed to demonstrate a significant benefit in effect sizes [22,51,69,70,71]. A recent review suggests that these pharmacological treatments may aid psychotherapy in BN and BED but are associated with a higher mortality and lower recovery in AN; however, further research and developments are needed to define the clinical utility of these treatments [8,71]. Moreover, a key argument made by AN patients, carers, and researchers is that current treatments focus on the normalisation of weight, or cognitive behavioural aspects that are more likely consequences than causes, highlighting a crucial gap in leading treatments [50,57].

To date, evidence-based treatments are limited in efficacy, there is no specific drug to treat EDs, and new treatment data are scarce [8,45,72]. Addressing the urgency for new approaches is deemed to have the largest potential effect on the population’s disease burden [21,22]. Given the high comorbidity and genetic correlations, some experts have suggested that novel research and pharmacological developments, particularly the use of psychedelic drugs that can enhance psychotherapeutic approaches (i.e., psychedelic-assisted psychotherapy), may extend future options for ED treatments [29,51].

3. Psychedelics

Psychedelics are powerful psychoactive substances that produce altered states of consciousness (ASC), characterised by alterations in perception, mood, and numerous cognitive processes including the sense of self, emotional state, and reality [25,73]. Psychedelics of plant extraction referred to as serotonergic or classic psychedelics have an ancient history of medicinal use and are known to lead to perceived spiritual and/or psychologically insightful experiences [26,74,75,76]. These substances have demonstrated strong psychopharmacological properties and therapeutic efficacy, particularly during psychedelic-assisted psychotherapy (PAP) (see

Table 1. Examples of classic psychedelics under investigation for potential benefits as adjuncts to psychotherapy.

Substance	Derivation or Chemical Analogues	Properties and General Effects	Potential Harms *	Potential Therapeutic Use Under Investigation **
Psilocybin	An active agent in Psilocybe genus mushrooms.   Used ritualistically for thousands of years by Indigenous communities in Central and North America.	Primarily through the activation of 5HT2A receptors and the activation of a 5-HT2AR-mGluR2 receptor complex.   - Altered consciousness (visions, auditory distortions, ideations). - Altered mood (happy, sad, fearful, irritable). - Distorted sense of space, time.	Psychosis   Hallucinogen persisting perception disorder.   Dizziness, weakness, tremors, paraesthesia.	Alcohol and other substance use disorders/addictions.   Depression, treatment-resistant depression.   End of life anxiety.   OCD   Possibly anorexia nervosa.
LSD (lysergic acid dimethylamide)	Ergot fungus (Claviceps purpurea); morning glory (Turbina corymbosa); Hawaiian baby woodrose (Argyreia nervosa)—sources of ergine or lysergic acid amide.   Available through Switzerland as an adjunct to psychotherapy for the treatment of a number of different mental health conditions.	Binds with a high affinity to several 5-HT receptors.   Dopamine (D1, D2, D4) receptor agonist.   - Altered consciousness (visions, auditory distortions, ideations). - Altered mood (happy, sad, fearful, irritable). - Distorted sense of space, time.	Psychosis   Hallucinogen persisting perception disorder.   Dizziness, weakness, tremors, paraesthesia.	Currently being studied for the treatment of the following:   Alcohol and other substance use disorders/addictions.   Depression   Anxiety disorders.   OCD   Attention-deficit hyperactivity disorder (ADHD).
Ayahuasca brew	Typically, an admixture of the Banisteriopsis caapi vine and the DMT-containing leaves of the Psychotria viridis shrub, although other plants, such as Diplopterys cabrerana, are at times used to make decoctions that are also referred to as ayahuasca.   Used ceremonially in the Amazon Basin for at least hundreds of years and is used widely today in shamanic and other religious contexts within and outside of South America.	Binds with a high affinity to several 5-HT receptors.   MAO-inhibiting beta-carboline alkaloids.   DMT also acts as a TAAR agonist, and a sigma receptor agonist and may mediate effects at metabotropic glutamate receptors.   - Nausea, vomiting. - Altered consciousness (visions, auditory distortions, ideations). - Altered mood (happy, sad, fearful, irritable). - Distorted sense of space, time.	Psychosis   Serotonin syndrome and other dangers from medication interactions due to monoamine oxidase inhibitory activity.   Dizziness, weakness, tremors, paraesthesia.	Alcohol and other substance use disorders/addictions.   Depression   Anxiety   Possibly eating disorders.
DMT (N,N-Dimethyltryptamine) and 5-MeO-DMT (5-methoxy-N,N-dimethyltryptamine)	DMT is a substituted tryptamine that constitutes one of the primary active ingredients in ayahuasca and is structurally similar to the psychedelic compounds 5-MeO-DMT and bufotenin (5-HO-DMT).	A high binding affinity at a number of 5-HT receptors. TAAR agonist, and a sigma receptor agonist and may mediate effects at metabotropic glutamate receptors.   - Subjective effects are short-lasting. - Altered consciousness (visions, auditory distortions, ideations). - Altered mood (happy, sad, fearful). - Distorted sense of space, time.	Psychosis   Dizziness, weakness, tremors, paraesthesia.	Clinical data are currently limited.   Currently being studied for the treatment of major depressive disorder.
Ibogaine	West African Tabernanthe iboga bush.   Used as a part of the Bwiti religious tradition in the jungles of Gabon.   Has been administered over the last few decades at drug and alcohol treatment centres in Latin America and the Caribbean	Binds dopamine and serotonin (5-HT) receptors.   Acts as both an NMDA and a3b4-nicotinic receptor antagonist.   Acts as a kappa opioid receptor agonist.	Cardiac and neurological risks complicate its use as a therapeutic.	Potential to be an effective anti-addiction therapeutic for a number of different substance use disorders.   Currently under investigation as a potential therapeutic for alcohol misuse, and for drug use, dependence, and withdrawal.
Mescaline	Found in four species of cacti: Bolivian Flame, Peruvian Flame, San Pedro, and Peyote, the last of which has been used in rituals by Native American communities for thousands of years.	5-HT2A agonist   - Altered consciousness (visions, auditory distortions, ideations). - Altered mood (happy, sad, fearful, irritable). - Distorted sense of space, time.	Psychosis   Dizziness, weakness, tremors, paraesthesia.	Alcohol addiction.   Clinical research is still in its infancy. May attenuate symptoms of anxiety, PTSD, depression, and both alcohol and substance use.
MDMA (Methyl enedioxy methamphetamine)	Sassafras tree (Sassafras albidum)—source of safrole, a precursor chemical.	Serotonin, dopamine and noradrenaline agonist. Acts on monoamine transporters. Inhibits 5-HT vesicular transporter (VMAT2) and activates the intracellular presynaptic terminal receptor (TAAR1). Downstream of serotonin efflux, promotes release of oxytocin.   - Euphoria. - Arousal. - Perceptual alteration. - Enhanced empathy and sociability.	Potential neurocognitive deficits (e.g., memory impairment).   Sleep disruption.   Short-term depression.	Typically administered in conjunction with therapy.   PTSD   Recently investigated for use in the following indications: Social anxiety Illness-related anxiety Adjustment disorder Eating disorders.
Ketamine	Established aesthetic and animal tranquilizer.   A dissociative with psychedelic-like effects.   The mechanism of the action of ketamine (NMDA antagonism) is a contributor to the effects of several classic psychedelics (such as ibogaine and DMT).	Selective NMDA antagonist.   - Altered consciousness (visions, auditory distortions, ideations). - Altered mood, can be abrupt (happy, sad, fearful, irritable). - Distorted sense of space, time. - Memory impairment. - Impaired motor function - Analgesia, sedation. - Disorientation, paranoia, dysphoria, anxiety, confusion, slurred speech, dizziness, ataxia, dysarthria, trismus, muscular rigidity, psychomotor, psychomimetic, or acute dystonic reactions.	Psychosis   Dizziness, weakness, tremors, paraesthesia, nausea, vomiting.   Respiratory complications.   Addiction   Cardiovascular complications.   Seizure, stupor, coma.	Recently found new use as a fast-acting albeit temporary treatment for depression.   Possibly anxiety and PTSD.

Note: PTSD = post-traumatic stress disorder, OCD = obsessive–compulsive disorder. * The potential harms identified here are primarily associated with unsupervised uses of psychedelic substances at worst cases; current clinical studies on psychedelic agents have not reported such chronic adverse sequelae. ** Potential harms and therapeutic uses are identified based on evidence from the past (i.e., 1950s–1960s) and current research of psychedelic drugs, from “Psychedelic medicine: a re-emerging therapeutic paradigm” by Tupper, K. W., Wood, E., Yensen, R., and Johnson, M. W., 2015. Cmaj, 187(14), 1054–1059 [32]. Updated information is from “Psychedelic therapies reconsidered: compounds, clinical indications, and cautious optimism” by Mitchell, J. M., and Anderson, B. T. (2024), Neuropsychopharmacology, 49(1), 96–103 [27], and “Ketamine toxicity” by Orhurhu, Vwaire J., Rishik Vashisht, Lauren E. Claus, and Steven P. Cohen. (2019) [79].

) [25,29]. These compounds work by stimulating brain serotonin receptors known to produce the psychedelic effects during ASCs, primarily acting as agonists/partial agonists on 5-hydroxytryptamine 2A (5-HT2A) receptors expressed in brain regions relating to emotional processing, mood regulating, introspection, and self and body-consciousness [28,77,78].

Other substances that are sometimes classified as psychedelics include 3,4-methylenedioxy-methamphetamine (MDMA), an empathogen with multiple mechanisms of action [80], ketamine (an old established dissociative anaesthetic and glutamate receptor agonist) [29] and ibogaine (a naturally occurring hallucinogenic alkaloid with distinct psychoactive/somatic effects and a complex neuropharmacology that is not yet fully understood), suggested to have anti-addictive properties [81].

In clinical contexts, these substances are known to promote robust functional and structural neural plasticity, particularly in the prefrontal cortex of the brain which modulates cognitive control [82,83]. For example, increased global brain integration can be demonstrated in patients with depression after psilocybin therapy, shown to induce rapid and persistent cell growth in the frontal cortex with decreased amygdala reactivity, thus enhancing positive mood [84,85]. Behavioural and neuroimaging data demonstrate that they are among the most effective chemical modulators of neural plasticity to date, with the potential to produce significant and sustained reductions in symptoms of mood and affective disorders [86,87,88].

Furthermore, positive psychology research (i.e., of healthy functioning and wellbeing) has provided strong evidence for positive effects on wellbeing, prosocial behaviours, creativity, personality, values, and mindfulness from 77 clinical trials and epidemiological studies (N = 9876) using psychedelics [89]. Altogether, amassing research has led to the general acceptance that psychedelic compounds are clinically and physiologically safe, with a low abuse liability and low potential for dependence and medical harms [25,90,91,92]. The influx of renewed research interest constitutes a uniquely promising avenue for future healthcare developments.

To date, the most significant database now exists for classic compounds psilocybin (an active compound in “magic mushrooms”) and MDMA (a synthetic psychostimulant otherwise known as “ecstasy”) [77], designated by the U.S. Food and Drug Administration (FDA) in 2017 as “breakthrough therapies” for treatment-resistant depression and PTSD, respectively [93]. MDMA-assisted therapy, however, has recently been rejected by the FDA on grounds of “insufficient evidence for drug efficacy” and critiques that the risks do not outweigh the benefits—a current area of contention that points towards issues within research politics, drug rescheduling, and the corporatisation of psychedelic drug development [94]. Additionally, pharmaceutically established synthetic dissociative drug ketamine has shown antidepressant properties, resulting in its licensing in the USA and Europe [29].

Data on ayahuasca are typically centred around naturalistic settings, which are thought to be inextricably linked to therapeutic outcomes (e.g., positive effects on cognition, mindfulness and ego-dissolution) [95,96]. This is primarily due to its indigenous origins and the spiritual, ceremonial, and ritualistic community contexts in which it is used (with varying social/cultural/religious elements that form integral parts of the ayahuasca ceremony itself). Scientific data on ayahuasca are therefore less well developed compared to other psychedelics. The largest global dataset analysis on associations between ayahuasca use and mental health and wellbeing outcomes (N = 7576, mean age = 41, 47% female) has recently been published, reporting highly significant and sustained positive associations with current mental health status. Importantly, the strength of mystical experience, self-insights, and community/social variables were positively associated with current mental health and psychological wellbeing change, while extreme fear and integration difficulties were negatively associated. These findings were based on individuals both with and without a history of mental illness [97]. This finding supports research investigating the healing effects of communitas (the spirit of community) when necessitated by psychedelic use [98,99].

As stated previously, there has been increasing clinical evidence supporting the transdiagnostic effects of psychedelic-assisted therapies (PAT) for disorders of restrictive or maladaptive habitual patterns of cognition, emotion, and behaviour, including EDs [100]. Furthermore, PAT is emerging as a radical innovation to meet the decline in novel psychiatric medications amidst the rise in mental disorders, linked to debates criticising current symptom-focused approaches [101].

Evidence for pharmacological properties and the therapeutic efficacy of psychedelics has been demonstrated in clinical studies for depression, anxiety, addictions, OCD, and PTSD [25,27,28,30,32,86,102]. Meta-analysis of psychedelic-assisted randomised placebo-controlled trials for treating these disorders provide further evidence of feasibility and early efficacy data for therapeutic effects, lasting weeks to months in the majority of patients [75], including patients with PTSD, and for anxiety among adults with autism [103]. Furthermore, large scale studies of biochemical mechanisms underlying classic psychedelic-induced neuroplasticity and the non-addictive nature add weight to their therapeutic potential [104,105].

Though complex and vastly different in aetiology, prognoses, and pathology, researchers have investigated PAT’s transdiagnostic mechanisms from research domain criteria (RDoC). The RDoC is a framework for mental health research that focuses on empirically derived dimensions of behavioural and psychological functioning and their implementing neural circuits [106,107]. Kelly [100] highlights a primary shared feature of symptomology among the conditions listed above, thought to be the internalising nature that is characterised by negative rumination, intrusive thoughts, and high comorbidity with EDs. Interestingly, the brain activity control systems and circuits that encode these habits, particularly the default mode network (DMN), are thought to be dysregulated by psychedelics via receptor agonism, allowing them to recalibrate thereafter as the acute effects subside [29,108].

Specifically, this modulation of the serotonergic system is thought to be associated with the anxiolytic and antidepressant effects with lasting mental health improvements. This suggests the potential to normalise dysfunctional neurobiological systems via the global increase of brain network integration, thus becoming more functionally interconnected and flexible [84,105,109,110]. Such hypotheses have long been supported by numerous scientific reviews [111,112,113,114].

3.1. Psychedelics: Theoretical Underpinnings

Current biomedical theories suggest that the therapeutic use of psychedelics improve clinical functioning by regulating affective states (such as anhedonia) and self-referential cognitive processes (such as aberrations in bodily self-awareness—core to several psychiatric disorders) and therefore may involve interrelated neural circuits across a range of conditions [27,115].

To further understand how psychedelics alter brain function and consciousness, a unified model has been proposed, called the relaxed beliefs under psychedelics (REBUS) and the anarchic brain model [109]. The key principle is that the action of psychedelics, via entropic effects on spontaneous cortical activity, liberate bottom-up information flow (often overweighted by top-down predictive processing in contexts of mental illnesses) by relaxing the precision of high-level top-down priors/beliefs (instantiated by the DMN) via intrinsic control systems in the brain. The result is a heightened sensitivity to bottom-up signalling from intrinsic sources such as the limbic system, rather than top-down processes, thus enabling greater cognitive flexibility and the revision of pathologically rigid or conditioned beliefs and emotion. This key assumption is consistent with empirical evidence that relaxation and the revision of negative self-belief confidence mediates positive psychological and wellbeing outcomes [108]. Similarly, both naturalistic and lab studies indicate mediating roles of anxious ego dissolution, spirituality, and boundlessness on symptoms of anxiety, depressed mood, and disordered eating [42,73,116] via acute effects on emotion, cognition, creativity, and sensory perception, with notably limited aversive side effects [75,92,117]. Furthermore, population studies indicate a reduced burden of mental health symptoms in lifetime psychedelic users compared to non-users, suggesting a link between psychedelic use and wellbeing [89,118,119].

Also of importance is the acute psychedelic experience itself, thought to be the main contributing factor of enduring therapeutic effects [74,120,121]. Psychedelics are known to reliably induce experiences characterised as spiritual, existential, religious, and theological [122]. The best outcomes with psilocybin for example, have been demonstrated in patients experiencing breakthrough, peak, or mystical experiences; in other words, the most powerful psychedelic effects [123]. This coincides with clinical, neuroimaging, naturalistic, and population studies that highlight the relationship between mystical or subjective effects, insight, and therapeutic outcomes on brain network function [75,113]. These findings are further supported in the most recent comprehensive population survey of psychedelic drug users to date, the Canadian Psychedelic Survey. Additionally, significant correlates of “intense positive experiences” included a “higher perceived psychedelic experience” (higher intensity of the experience), with “fun” and “self-exploration” as motivations for use (pp. 98–110) [124].

More specifically, mystical and insight effects are thought to be a necessary counterpart to positive enduring outcomes [125]. Supportive neurobiological evidence indicates that key contributors to the therapeutic effects of psychedelic experiences are changes in self-experience, emotional processing, and social cognition [126]. Further analyses of PAT emphasise the key role of connectedness, spirituality, and meaningfulness from mystical experiences to improved and sustained outcomes [113,121,127]. Consequently, experiencing ‘emotion awe’ has been hypothesised as an underlying mechanism that fosters a sense of oneness and connectedness with others [128]. Taken together, insights correlating with mystical experiences are suggested catalysts for change [129].

Another integral part of the psychedelic experience and PAT is referred to as the ‘set and setting’, which considers contextual elements that are not directly produced by the drugs themselves, but rather other psychosocial mechanisms relating to preparedness, cognition, and meaning that are also fundamental to harm reduction. ‘Set’ refers to various factors of one’s mindset, and ‘setting’ refers to the diverse environmental dimensions before and during the psychedelic experience and its outcomes [31]. Set and setting theory examines how non-biological factors shape responses to psychedelics by considering crucial factors such as expectancy, preparation, and beliefs regarding psychedelics, and has been used to explain adverse reactions and experiences [130]. Recent research has suggested that personal growth motivations, natural and safe settings, as well as the presence of significant others may predict less psychopathology, greater wellbeing and meaningfulness of psychedelic experiences, while problematic motivations may predict the reverse [131]. Furthermore, as psychedelic preparedness is thought to be crucial for safe and potentially beneficial outcomes, the Psychedelic Preparedness Scale (PPS) has been recently developed. The PPS highlights four key factors, “Knowledge-Expectations”, “Intention-Preparation”, “Psychophysical-Readiness”, and “Support-Planning” [132]. Testing of the PPS has suggested predictive utility in measuring pre-treatment preparatory behaviours and attitudes in relation to mental health and wellbeing outcomes.

Further, it is important to note that naturalistic settings of psychedelic ingestion are typically a collective activity with an integral social component pertaining to spirituality and/or community (i.e., ceremony communitas), thought to form a large part of the healing process and associated with long-term increases in psychological wellbeing and social connectedness [33,98]. Conceptualising the social group dimension of the psychedelic experience, as seen in naturalistic indigenous and community contexts, has resulted in the ‘social cure’ model which emphasises the importance of group contexts and social-identity-based relationships in the therapeutic effects of psychedelics [99]. Studies that acknowledge the importance of psychosocial factors in psychedelic settings point towards the intersubjective experience, rapport, and emotional support for long-term outcomes of psychedelic use.

3.2. Risks of Harm/Adverse Effects

A final aspect to consider regarding safety and risks is the adverse effects and challenging psychedelic experiences. In the recent Canadian Psychedelic Survey (N = 2045), half reported challenging psychedelic experiences, 56% of which said ‘some good’ came from the experience thereafter [124]. Exploring those who have experienced extended post-psychedelic difficulties lasting longer than a day, a recent study [133] recruited 608 participants and found that feelings of anxiety and fear, existential struggle, social disconnection, depersonalisation, and derealisation were the most frequently reported forms of extended difficulty. These problems persisted for over a year in one third of the sample and were endured for more than three years for ~16.6%. Importantly, knowledge of dose and drug type, and lower levels of difficulty during the trip predicted a shorter duration of difficulties, while taking the drug in a guided setting predicted a lower range of difficulties, thus pointing towards the importance of education, support, and harm reduction [134].

Furthermore, psychedelic experiences may lead to states of heightened suggestibility, especially in conjunction with increased feelings of connectedness [135], which may make users particularly vulnerable to boundary violations by those present during the experience, including therapists, facilitators, guides, and other psychedelic community members, and, although the incidence of this appears to be relatively low, it can cause intense suffering [92,134,136]. Additionally, some comorbid psychiatric conditions or those with a higher genetic vulnerability to them, such as bipolar disorder, may elevate risks of psychiatric symptoms [137,138,139]. Pre-existing anxiety is also linked to unwanted and persistent symptoms of hallucinogen persisting perception disorder (HPPD), which is a heightened risk factor for those using psychedelics (though not restricted to these drugs alone), and can cause prolonged distress, although its prevalence is relatively low [140].

3.3. Psychedelics and Eating Disorders

It is now plausible to consider the application of psychedelic therapy for those suffering from EDs, particularly with the use of classic psychedelics [51,115,141]. As previously stated, the past two decades of research into classic compounds, particularly psilocybin, have shown promise for alleviating anxiety and depression-like symptoms with lasting improvements in wellbeing and enhanced cognitive flexibility, which may have the potential to normalise dysfunctional neurobiological systems in AN, such as cognitive inflexibility [28,36,47,142].

Early research on psychedelic use in EDs is limited but promising. Both clinical and naturalistic reports of psychedelic use and EDs have so far demonstrated long and short-term cessation or reductions of ED and mental health symptoms, most notably with ayahuasca [39,40,41] and psilocybin [37,43]. Additionally, due to the high comorbidity of EDs with PTSD, one clinical trial investigating MDMA-assisted psychotherapy as a treatment for comorbid ED-PTSD (N = 82) showed promising results with significant reductions in ED symptoms [38].

Several reviews have recently emerged to summarise findings on the present topic, highlighting that classic psychedelics may have transdiagnostic efficacy through mechanisms relevant to ED pathology and could augment the efficacy of current interventions; however, high quality efficacy data are still lacking [143] and the overall conclusion is that more research is needed to determine safety and efficacy [144]. Specifically, there is preliminary evidence that PAT may benefit the treatment of AN and BN by normalizing reward processing, promoting cognitive flexibility, facilitating trauma processing, and improving beliefs affecting body image; however, less is known about BED [145]. Another systematic review included three clinical trials investigating PAT for AN, one for BED and one for BDD, all using psilocybin and having demonstrated positive effects on core symptoms, primarily through thematic analysis and self-reports [146]. Finally, a scoping review exists on outcomes of psychedelic use for people reporting an ED, comprising six clinical and non-clinical studies (including psilocybin, ayahuasca, DMT/5-MEO-DMT, LSD, mescaline, and ketamine). This review reports diminished and reduced symptoms of the ED, of anxiety, self-harm and suicidality, with some showing complete remission [147]. Improvements in wellbeing and depression were also reported, along with changes in self-perception and several reports of profound spiritual healing or deep insights into the origins of their ED. Overall, there are shared hopes for more rigorous investigations of PAT for EDs with a focus on the safety and risks, and careful attention drawn towards ethical considerations for future research and practice [144] as previously discussed.

When looking at specific effects of ayahuasca on EDs, LaFrance’s [39] investigation of ceremonial ayahuasca (a traditional Amazonian tea used in sacred healing rituals) reported significant improvements in emotional regulation and processing, linked to decreased symptom engagement or sustained remission in 11 out of 16 participants with AN and BN diagnoses. Furthermore, Renelli’s [41] investigation reported that ayahuasca experiences were more effective than conventional ED treatments in a sample of 13, primarily by enabling the processing of intense emotions or memories, thus deeper healing via a spiritual component that enhanced recovery progression.

Importantly, both studies found that the psychedelic experiences provided tangible, emotional insights about the causes of illness, self-love, care, and acceptance, altogether allowing for the revision of core ED beliefs. Revisions of self-compassion, criticism, and emotional regulation are consistent with reports on ayahuasca and wellbeing [148]. Data on the potential for ayahuasca-assisted therapy as a healing tool for treating EDs are summarised and reviewed in LaFrance’s [149] paper, detailing associated perceived risks and recommendations for integrating ayahuasca into a Western context.

Furthermore, these findings point towards numerous reviews of broader psychedelic research which demonstrate that emotional breakthroughs, release, the revision of core beliefs, mindfulness, and cognitive flexibility are key mechanisms associated with classic psychedelic use and enduring changes in wellbeing and psychological functioning [75,113,150].

Emotional aspects are particularly pertinent, given that a central function of EDs is an attempt to manage difficult emotions, often manifesting as high avoidance or low emotional awareness and low motivation [6,151]. It is therefore important to reiterate that psychedelic emotional breakthroughs are known to catalyse significantly increased psychological/cognitive flexibility, openness, and connectedness associated with neural plasticity, as demonstrated in fMRI studies of brain mechanisms in patients with treatment-resistant depression [152]. Furthermore, the first quantitative demonstration of positive psychological aftereffects in those with an ED planning to take a psychedelic drug has provided overwhelming evidence for improvements in depression and wellbeing scores thereafter [43].

Subsequently, the first clinical trials for AN using psilocybin (e.g., NCT04052568, 2019; NCT04505189, 2021; NCT04661514, 2022) and BED have begun. Furthermore, the protocol for a pilot study on psilocybin-assisted therapy for AN to assess feasibility, brain mechanisms, and preliminary outcomes [37] integrates the voices of those with lived experiences using Public Patient Involvement (PPI) focus groups that incorporate patient opinions to inform research directions [153]. The authors emphasised the importance and benefit of PPI to the study, participants, and psychedelic research, by integrating information-rich qualitative accounts to inform future trials.

Finally, from the perspective of individuals with EDs themselves, Harding’s [154] survey (N = 200) found that nearly 70% used complementary spiritual treatments such as yoga, meditation, and relaxation techniques to manage their ED, and believed psychedelic research to be worthwhile. Only 29.5% felt they would never participate in a clinical trial using psychedelics, with the main concern being weight gain (74%), and although not associated with weight gain, psychedelics are suggested to induce self-care effects that could facilitate healthy lifestyles, exercise, and diet [148,155,156,157]. Participants expressed ‘education around psychedelics’ and ‘endorsement from professionals’ as solutions to their concerns. When considering the overlaps between the phenomenology and neurophysiology of meditation practices with psychedelic ASCs associated with improved wellbeing [158] and the demand for effective ED treatments, further research could indeed benefit this population.

4. Aims

The urgent need for novel ED treatments is growing, alongside clinical evidence and numerous reviews supporting the transdiagnostic therapeutic potential of serotonergic psychedelics [51]. Small-scale preliminary studies have so far demonstrated marked reductions in ED symptoms and improvements in wellbeing following experiences with ceremonial ayahuasca [39,40,41,149], psilocybin [37], long-term psychedelic use [42], and short-term [43], via spiritual and emotional pathways that facilitate healing. However, data is insufficient to draw firm conclusions [144].

As abnormal serotonin functioning and high emotional avoidance are associated with EDs [6,151,159], there is mechanistic grounding warranting further investigation of psychedelics in the context of EDs [42,44,100,145,160,161]. The present study therefore seeks to investigate further how people with EDs make sense of the psychedelic phenomenon and the factors that influence perceived outcomes, benefits, and risks.

5. Method

5.1. Participant Recruitment

Participants were recruited via social media advertisements for volunteers who could talk about their positive and negative experiences of both EDs and psychedelics. Out of the total 14 respondents, 11 were selected for semi-structured interviews according to the following inclusion criteria: (1) reporting to have had a prior diagnosis of an ED or suffered symptoms without professional diagnosis, and (2) have had at least one psychedelic experience. From these 11 interviews, information-rich cases were then sought using “criterion-based sampling” [162], aiming to yield insight and understanding of the participant so that the highest quality explorations could be analysed.

A purposive sample of eight participants was then selected for analysis. The reason for purposive sampling is for the better matching of the sample to the research aims to improve the rigour of the study and the trustworthiness of data and results [163]. Three of the 11 interviews were excluded due to the remaining eight fitting the study aims and inclusion criterion to a stronger degree (i.e., having suffered chronically from their EDs). The three exclusions, for instance, had fewer ED symptoms to self-report (i.e., ‘preoccupation with appearance, diet and gym’ for one year during the pandemic during which an LSD trip at home helped to alleviate anxiety in an ‘otherwise healthy’ individual), more dominant mental health conditions beyond the scope of the study (i.e., serotonergic psychedelic-induced recovery from chronic opioid addiction that affected nutrition and eating behaviour), and reports on microdosing rather than full psychedelic experience (i.e., microdoses of psilocybin that alleviated severe anxiety that affected eating behaviour).

The final sample (N = 8) included one non-binary and seven female participants, with ages ranging between 25–54 years old (M = 36.9). The age for onset of ED symptomology was between 12–16 years old (M = 13.4), meaning all participants had suffered chronic, life enduring EDs for the duration of 11–42 years (M = 23.5) (

Table 2. Sample demographics.

	M (SD)	Range	N (%)
Age	36.9 (11.33)	25–54	8
Gender
Female			7 (87.5%)
Non-binary (NB)			1 (12.5%)
Education (highest level completed)
GCSEs			1 (12.5%)
A level			1 (12.5%)
Undergraduate degree			2 (25%)
Postgraduate degree			4 (50%)
Eating disorder (multiple diagnosis)
Anorexia nervosa			7 (87.5%)
Bulimia nervosa			2 (25%)
Other specified feeding or eating disorder			1 (12.5%)
Orthorexia nervosa			1 (12.5%)
Binge eating disorder			1 (12.5%)
Disordered eating			1 (12.5%)

Note. Anorexia nervosa (AN) is characterised by extreme dietary restrictions and an inability to maintain an adequate healthy body weight. Orthorexia nervosa (ON) is marked by a maladaptive and extreme obsession with health and restrictive diets in avoidance of perceived unhealthy foods. Binge eating disorder (BED) is characterised by episodes of binge eating, and bulimia nervosa (BN) combines BED with extreme compensatory behaviours, such as purging by vomiting. Other specified feeding or eating disorder (OSFED) is diagnosed when symptoms do not fit a specific ED [14].

).

Seven participants had multiple ED diagnoses and had used multiple modes of conventional therapy. Five participants had used antidepressants with poor outcomes. Only one participant (P6) had never received ED treatment (besides a diet plan) and was the only participant to report lifetime recreational psychedelic use. P6 and P8 were the only participants to have reported full recovery (attributed to psychedelic use). Three participants were current users of private therapy (P2, P3, and P5), and P1 was back on the NHS waiting list. Further sample characteristics and outcome information are presented in

Table 3. Participant descriptive information including diagnosis, drug usage, context, and outcomes.

Participant	Age	Age of Onset	Gender	Education (Country)	ED and Other Diagnoses - Outcome Following Psychedelic Use	Psychedelics Used (and General Context of Use)	Year of First Time, Number of Times Used
P1	25	14	F	MSc (UK)	AN, BN. MDD, SAD, Autism spectrum disorder (ASD) - Significant improvement on wellbeing; short-term. - Relapsed.	Psilocybin (Clinical trial)	~2021 3 separate times
P2	25	12	F	GCSE (UK)	AN, BDD. MD - Significant improvement on wellbeing; enduring.	Psilocybin (Clinical trial)	~2020 3 separate times
P3	31	12	F	BA (UK)	Disordered eating. PTSD, OCD, panic disorder. - Significant improvement on wellbeing; enduring.	Psilocybin (Personal development)	~2018 micro-dosing ~2020 full trip <5 times
P4	32	13	F	A Level (UK)	AN, BN. SUD - Sustained remission from ED and SUD for 6 months. - Relapsed. - Cessation of restrictive ED symptoms; enduring. - Significant improvement on wellbeing; enduring.	Ibogaine Ayahuasca 5-MEO-DMT (Psychedelic rehab)   LSD (Personal development/social)	~2018 2 times each at psychedelic rehab.   <10 times
P5	36	15	NB	MSc (UK)	AN, BN, BED (no formal diagnosis). - Cessation of BED symptoms. - Significant improvement on wellbeing; enduring.	Ketamine (Personal development) LSD (Personal development)	Year unknown,   <10 times collectively
P6	39	13	F	MA (UK)	AN. Tobacco SUD. - Recovered (from ED and SUD > 10 years ago). - Significant improvement on wellbeing; enduring.	Psilocybin DMT MDMA (Social)	~2000   Lifetime recreational use
P7	53	16	F	BA (USA)	AN, ON. - Cessation of majority of compulsive ED symptoms. - Significant improvement on wellbeing; enduring.	Psilocybin (Personal development)   Ayahuasca ceremony (Personal development)	~2021 >10 times     ~2021 Once
P8	54	12	F	PhD (USA)	AN, OSFED. TRD, problematic substance use. Autism spectrum disorder (ASD). - Recovered. - Significant improvements on wellbeing; enduring.	Psilocybin (Personal development)   Ketamine infusion (Prescribed for chronic pain)	~2021 <5 times     Once

in the results.

5.2. Data Collection: Semi-Structured Interview and Procedure

Following ethics approval from the university Research Ethics Committee and recruitment, advertisement respondents were contacted via email and sent further information. Having read and signed the information and consent form, participants were interviewed for 30–90 min (M = 57). Data were collected using a self-report method with semi-structured online interviews using Microsoft Teams (audio only) and recorded.

At the start of the interview, consent was reconfirmed, and participants were reminded of their rights to omit questions, stop the interview, and withdraw. The interview schedule was then administered, using probes to explore psychedelic phenomena and relevant aspects. The interviewing style was flexible with open questions allowing participants to elaborate on details important to them. Participants were made aware of the interview schedule ahead of time to strengthen the quality of recall. At the end of the interview, participants provided a personal code which was attached to their debriefing form containing additional information for support services. Interview recordings were transcribed verbatim and uploaded to qualitative data software, Nvivo, for analysis.

5.3. Qualitative Analysis

Eight interviews were analysed using reflexive thematic analysis (TA) [164]. Analysis and coding efforts were conducted in accordance with guidelines provided by Braun and Clarke [165]. This approach allowed for a flexible exploration into participants’ reality regarding the psychedelic phenomenon, and therefore conducted within a realist/essentialist paradigm. Its epistemology assumes a unidirectional relationship between experience, meaning, and language; thus, the analysis methodology was inductive with codes and themes identified at a semantic level, elicited by the interview data alone.

The primary goal of analysis was to systematically organise what participants reported about their psychedelic experiences and perceived outcomes on wellbeing and ED symptoms into themes, answering specifically to the research question. Overarching categories were pre-determined to classify findings: the context, the experience, and outcomes. Themes were created in terms of coding and prevalence patterns. A theme was defined as a pattern in the data if it occurred for more than half of the transcripts.

The start of the thematising process involved re-reading transcripts to familiarise with the data. The second phase involved a cyclical coding process. Initial open coding was based on participant perspectives without finite interpretations from the researcher, and relationship codes that broke data down into various incidents/events. These were then subject to pattern coding by identifying patterns across and within transcripts to condense data into more manageable segments as analytic concepts, thus in line with a more nomothetic approach typical of TA [166,167,168].

Codes were then clustered by thematic similarity into provisional subthemes and iteratively reviewed and refined, allowing for clearer identification of initial themes. This led to the construction of superordinate themes that subsumed subthemes, followed by further analysis to determine the significance of patterns, prevalence, and broader meanings. Initial themes were then reviewed by project supervision and defined to ensure a thorough capturing of explored content, before names were finalised. Nvivo provided the prevalence of each code and theme, highlighting the repetitions of specific themes across the dataset which guided the final process of writing up the results.

5.4. Ethics Commentary

No physical or emotional harm was caused, and measures to avoid risk were implemented throughout all online procedures for safety. This includes disclosing the interview schedule and clarifying aims to only assess perceptions of the psychedelic experiences, their meaning, and perceived effects deemed relevant by the participant. Efforts were maintained to avoid prying into more personal and potentially triggering aspects, unless initiated by the participant. Participants were treated according to BPS guidelines. Interview questions were considerate of risk of emotional harm in discussing participants’ personal experiences. Strict participant anonymity and confidentiality was maintained throughout.

6. Results and Discussion

All eight participants had reported reductions and/or cessation of ED symptoms attributed to psychedelic experiences. Descriptive results of the participants and psychedelic drugs used with reported outcomes are presented in Table 3. Following thematic analysis, two superordinate themes, each comprising three subordinate themes were identified, presented in

Table 4. Superordinate and subordinate themes.

Superordinate Themes	Subordinate Themes
‘Exploring’ via ‘the gateway to healing’	‘Freedom’ to ‘expand’ and ‘explore your mind’
	‘Navigating the roadmap through your subconscious emotions’
	Transcendence: ‘it’s not a theoretical knowledge, it’s a deep knowing’
‘Transformation’ and being ‘able to do the work’	Cognitive: ‘they’ve opened me up’
	Behavioural: ‘start making changes’
	Safety perceptions: ‘medicine’ but ‘not a magic pill’

. The following sections unpack each theme to provide a deeper understanding of the experiences reported, each starting with a brief summary of the overarching superordinate theme to introduce their respective subordinate themes.

6.1. Superordinate Theme 1. ‘Exploring’ via ‘The Gateway to Healing’

Participants unanimously emphasised and discussed the significant ‘catalysing’ role of their psychedelic experiences, describing how it ‘opened’ their minds, or ‘doors that needed opening’ having ‘kick started something, quite heavily’:

“Until you’ve actually tried them, you don’t really understand like, how life changing it can be and how it can free your mind to kind of see other possibilities and other pathways that you could choose to reinforce if you wanted to. So, like, once I had my first couple of psychedelic experiences, I got excited about what I might be able to do with it.”

(P5)

This action enabled positive change in participants’ lives by providing renewed abilities, insights, and perspectives:

“…my brain was a lot more open and available to think, and, there was more possibility and hope”.

(P1)

These experiences encompassed mental, emotional, and transcendental elements presented as subthemes that facilitated healing from ED causes by addressing ‘things that blocked having a full life and being healthy’:

“…these are concepts I’ve been working on my whole life, but I’ve not been able to put into practice… So, I think that when I took the psilocybin, I was able to put into practice all the work that I’ve been doing. I realised that it wasn’t for nothing, it wasn’t lost, and that I was working, I was fighting like hell. And um, psilocybin opened the door.”

(P8)

This theme therefore unpacks the ‘profound’, ‘unimaginable’ ways that psychedelic ASCs were experienced, as essential precursors to positive outcomes.

6.1.1. Subordinate Theme 1. ‘Freedom’ to ‘Expand’ and ‘Explore Your Mind’

All participants described being given ‘freedom’ or ‘space’ to explore their thoughts, and to ‘choose to do something else rather than just going through the same habits’, whereby detaching from ‘habitual judgemental views’ and ‘obsessive thoughts’ enabled connections to new insights about their ED:

“They help me realise why I’m having these urges, why I’m feeling that way. But also showed me that the eating disorder is part of something bigger, something deeper, which I need to go back and look at.”

(P3)

This process was frequently referred to as being ‘present’. Participants unanimously described a more rational and relaxed state, giving them the ‘ability to focus’ and ‘realise’ faulty thinking, leading to resolutions and new approaches upon self-reflection:

“… I could focus my mind, which was brand new to me. I could choose, if I didn’t want to think about something, I could just let it go. It, it was brilliant… That’s what I noticed first. That I could observe my thoughts, and see what was going on in my mind…

I could not before, I could know what I was thinking, but wasn’t able to… Place myself, like see myself as the observer, other than the person wrapped up in the thoughts. And I thought, wow, so this is how I’m thinking… And most importantly without judgement, my judgements, criticisms, self-criticisms… Just turned into real curiosity and wonder… And admiration for how truly, sneaky my mind is.”

(P8)

The consistent reports of therapeutic and enhanced self-experience during their trips (seemingly relaxed thinking, improved focus, and cognitive flexibility) that reportedly helped alleviate habitual negative ruminations and intrusive thoughts can be likened to research suggesting that the brain circuits encoding these habits, particularly the DMN, are dysregulated during psychedelic ASCs [29,102,169]. This is particularly relevant given that many with EDs (~70%) use complementary meditative relaxation modalities to manage their EDs and are in support of psychedelic research for future treatment avenues, indicating therapeutic value [154].

Importantly, participants signalled the fact that the use of psychedelics facilitated meditative, introspective and therapeutic processes as a means to achieve deeper self-healing that were otherwise unattainable. Specifically, their accounts reference the five facets of mindfulness (observe, describe, act with awareness, non-judging, and the non-reactivity of inner experience) [170]. As mindfulness is broadly defined as paying attention in a purposeful way, present and non-judgingly [171], findings may therefore coincide with research suggesting mindfulness and cognitive flexibility to be potential mechanisms for therapeutic effects of classic psychedelics [96,129,172].

This subtheme is therefore synthesised by the unanimous notion of mental clarity that enhanced self-awareness, allowing participants to separate from and challenge the ‘oppressive’, ‘harsh’, or ‘anxious’ inner ‘critic’ dictating their ‘reality’, linked to their ED. This enabled progress towards recovery by re-approaching aversive, more challenging stimuli, ‘drawn out into the light to be looked at’ with a more ‘forgiving’, ‘relaxed’, ‘accepting and carefree’ mindset.

Participants reported aversive stimuli stemming from compulsive thoughts, loss of control during the trip (challenging experience), and/or unresolved trauma, contributing to or ‘realised’ as the ED root cause. One participant from a clinical trial described somatic distortions and muscle clenching that became throat tightness, triggering an “oh God, what’s happening, maybe it’s doing something bad and I’m gonna die” reaction, followed by an automatic “oh well, I’m sure it’s safe, they’ll sort it, if this is what happens, this is what’s happening” response, and then the insight that follows:

“…I noticed with the muscle clenching, when I relaxed, and noticed it was clenching, I realised it was me clenching it? So, I could relax… As soon as I realised that, and I relaxed, that sort of went? Almost made me realise a lot of the pressure, I think, kind of indicated to me a lot of the pressure is my own doing… And it’s my own tension, it’s like… Yeah, like just, under my control? If that makes sense. Like I’m doing all the pressure, if I relax into things, and just, loosen up a bit, things get easier…”

She then recalled ‘lots of fighting’ in her mind over compulsions to overcome inhibitions with the therapists, like asking to dance or hold her hand, ‘because I’d never normally ask or know what I need’:

“It was weird. And it felt bad, like awkward and silly, but it got easier and… They were doing it as well, and it felt kind of alright by the end… Just like, trying things and… Tryna get out of this… Control… and everything.”

(P1)

The unanimous reports of being able to detach from and question their usual ED selves suggest changes in self-experience, possibly through anxious ego-dissolution, and potentially bolstered by more neutral approaches via acute effects on cognition, sensory perception, and creativity of thought, as seen in findings examining how psychedelic experiences can facilitate therapeutic outcomes [73,126].

Altogether, participant accounts could be explained using Carhart-Harris and Friston’s [109] REBUS model. Overweighted high-level priors and beliefs, such as compulsive ED thoughts and criticisms stemming from participants’ anxious-ego, seem relaxed. If so, this could coincide with neuroimaging evidence of brain function alterations, particularly in the DMN, consistent with anxiolytic and antidepressant effects [152,173]. The potential alteration of DMN function could explain the seemingly intercepted high-level cortex constraining influences on participants’ perception, cognition, and emotion with spontaneous cortical activity. This possible explanation for participants’ creative approaches towards self-reflection and their ability to revise pathologically rigid beliefs in relaxed states suggests a key pathway through which PAT may hold relevance to EDs, by decompressing the mind.

Five participants linked this to ‘being able to establish’ ‘much healthier relationships with food’. P5 emphasised ‘becoming really interested in food and nourishing myself’ near the end of an LSD trip, recalling how food became ‘absolutely incredible on acid’, as follows:

“I really got to explore something that was usually a very scary, threatening, complicated… Stressful thing in my life, in a totally new way and developing my relationship to it”.

(P5)

Changes in approach to food, a typically aversive stimuli, were emphasised by five participants, in addition to unanimous relaxed beliefs and possible ego-dissolution. Taken together, these findings point towards the modulation of cognitive control and psychological flexibility delineated in Kelly’s [100] review, congruent with the REBUS model. The example of food can be likened to the notion of psychedelic effects recalibrating hyper responsiveness in valence systems responsible for emotional responses, often a ‘trigger’ reported by participants. Importantly, this finding is pertinent to both the nutritional and emotional dysregulation aspects of EDs, particularly since naturalistic psychedelic use is associated with relaxed emotional reactivity which could also translate towards food aversion/avoidance and eating behaviours [117].

6.1.2. Subordinate Theme 2. ‘Navigating the Roadmap Through Your Subconscious Emotion’

Participants unanimously emphasised abilities to access and ‘reprocess’ or ‘re-experience’ ‘buried’ or ‘blocked’ intense negative and/or positive emotions. This then enabled the ‘forgiving’, ‘releasing’, and ‘letting go’ of ‘strong emotions’ that they linked to the source of their ED or a ‘trigger’. This was a central process associated with emotional insight, which enabled a ‘deeper healing’ than their usual ‘numb’, ‘critical’, or ‘serious’ states would allow:

“I was able to heal, a lot of the childhood trauma that led to the eating disorder, and… Understand, where it originated… I just, was able to go back to being a child… Um, being traumatised by my mum, and, able to see her as a little girl, being traumatised by her mum. So, I was able to understand that this is generational trauma… And, I was able to just forgive, so much of that, and release it. And, I was angry, I was angry, a lot. And, and I took that anger out on myself, by, just punishing myself. But I don’t have any anger about that, anymore.”

(P7)

P7 explained how ‘being shown the parts that are broken’ from ‘the shadows’ of her ‘subconscious’ and how ‘seeing them in a different way’ enabled resolving trauma and releasing ‘all of that toxic negativity’, which gave her a ‘new sense of love’ for herself and ‘everything she had survived’. She summarised:

“You know, making poor choices because I, I didn’t have any self-confidence, I had no self-esteem, I had no self-worth. And, it helped me to… Find, those parts of me that are there, and embrace them. And, love myself, more fully”.

(P7)

Participants described how their significant psychedelic experiences facilitated emotional processing and release, via visceral changes in self-experience of strong emotions, typically avoided by default and blocked out of conscious awareness. Comparisons could be drawn to Vollenweider and Preller’s [126] neurobiological evidence for contributing factors of therapeutic effects from the psychedelic experience itself. This process circles back to traditional PAT assumptions that emotional insight is facilitated by relaxed ego defences, allowing unconscious material to transpire into awareness, reinstating its clinical relevance.

The ability to access, experience, and reprocess suppressed emotions is especially interesting, particularly where participants portray insights as to the root causes of EDs, accompanied with a greater self-love and acceptance, consistent with ED and ayahuasca reports [39,40,41]. Given that high emotional avoidance and the causes associated with EDs are often overlooked in primary treatments [57], this may support further investigations into the potential application of PAT for EDs.

Importantly, participants unanimously described being ‘able to feel’ or ‘realise’ ‘love’, ‘compassion’, ‘joy’, or ‘gratitude’ towards themselves or others as a significant experience, symbiotic with that of emotional pain coming into awareness. Five participants summarised love as the source of perceived healing effects. The ‘very strong emotional reactions’ were automatic, as P3 described, having ‘no control over’ journaling sources of ‘resentment and pain’, but was able to forgive, as she ‘had to process it, and let it do its own thing’:

“Another thing was, if you don’t mind me sharing, when I was younger, I had an abortion. Um, and I was still holding on to the pain of that, that I didn’t, sorry *crying* I didn’t know that I was holding on to? Uh, and I forgave myself, during that trip. Which was very beautiful… I think, it just brings about more love. And therefore, you start to see the fears and illusions etc… To be honest, to summarise, I think it brings you closer to yourself… It helps you, love yourself, which then helps you love everyone else around you”.

(P3)

The notion of heightened emotional awareness and self-experience of unfamiliar positive emotions is further consistent with Kelly’s [100] description of psychedelic action mechanisms that recalibrate deficiencies in emotional valence systems. This is significant given that a central function of EDs is to manage emotions via low emotional awareness or avoidance, addressing challenges faced by current treatments aiming to normalise behaviour and thought processes [6,151].

Additionally, six participants emphasised the challenge of having to ‘trust’ or ‘surrender’ as an essential precursor to the aforementioned ‘emotional insight’, amidst personal difficulties with ‘letting go’. P8 described ‘one of the most beautiful experiences’ ever had, explaining how grief had been ‘a real issue’ in her life that psilocybin allowed her to re-experience. She described ‘drowning’ in the trip due to ‘resisting’, before deciding to ‘surrender to the experience’ by allowing herself to drown, as follows:

“… wave after wave, as I fell into the grief, and I’m crying, I also accessed this profound love. And I realise that it’s like the same thing. I’m grieving because I love, and then I felt elated and joy, gratitude, incredible gratitude. And just the gratitude in the surprise, wonder, ah, that holy cow, this is what I’ve been avoiding my whole life… Grieving.

And grief, surrender, letting go of what I thought was, true? It’s really a jumping off point, it’s really um, terrifying, and I was afraid of the pain of it, and I didn’t want to let go. I guess. It felt like I was letting go of the person… But. I found that when I let go of things… I was present. And my presence enabled me to… Well, my presence enabled everything.”

(P8)

These findings may relate to changes in self-experience, ego-dissolution, spiritual boundlessness, and the effects thought to reduce anxious and fearful avoidant symptoms via acute effects on emotion and sensory perception [73,115,126]. A prominent theory that could help make sense if this process is the REBUS model’s assumption of disrupted DMN high-level behaviours, such as perspective taking, paired with significant notions of ‘letting go’ of control, allowing for spontaneous emotional insights that may have therapeutically influenced and relaxed participants’ long-held beliefs.

Taken together, participants’ accounts coincide with reports of ayahuasca experiences that enable intense root cause or emotional memory processing, leading to deeper ED healing of a spiritual nature, and changes in emotional and self-experience [39,40,41,96]. The magnitude and significance of profound emotional change and perceived effects reported by five participants using psilocybin can be likened to research suggesting that the most powerful (breakthrough or mystical) effects are associated with greater therapeutic outcomes [123,150]. Taken together, these findings may point towards the importance of emotional breakthroughs and release during classic psychedelic experiences, as symbiotic with the revision of core beliefs that participants linked to their repressed intense emotions and ED symptoms, thus serving to catalyse improved psychological functioning [108].

6.1.3. Subordinate Theme 3. Transcendence: ‘It’s Not a Theoretical Knowledge, It’s a Deep Knowing’

All participants’ experiences were transcendent and/or mystical in nature. Five reported connecting to a loving, ‘supporting’ ‘higher power’ or ‘oneness’, providing insight and new views of life and death, existence and meaning, synonymous with profound feelings of ‘joy’ and ‘elation’.

“… they’re also really, like fun, and… Put you back in touch with what’s really, really beautiful about the world and people, and can be an incredibly moving, kind of connecting thing”.

(P5)

These accounts may reflect the occasioning and significant role of mystical experiences and subjective effects demonstrated in Johnson’s [113] integrative review of meaningful therapeutic outcomes associated with psychedelics and other accounts using psilocybin [74,120,172,174].

Participants’ experiences were accompanied by profound positive emotions that provided a sense of ‘reassurance’ and ‘hope’ behind ‘motivation’, frequently described as ‘putting things into perspective’. One participant described this as ‘very securing’, despite having ‘just died and come back’ during an intense 5-MEO-DMT experience as part of a four-day psychedelic rehab retreat in Mexico, each day ingesting either ayahuasca, ibogaine or 5-MEO-DMT. She explained how this ‘deep knowing’, being ‘part of a bigger consciousness’ changes ‘self-perception’:

“…when you know that, all your, like your problems kind of pale into insignificance… A little bit, or they get put into perspective… A bit more… Like let go. Chill out, I’m self-sufficient, I’ll be fine whatever happens. I have so much life left, so make the most of it, don’t die early because of bulimia. I’m human, I don’t need perfection.”

(P4)

One participant ‘in the heart of it’, recalled how experiencing a ‘full connection to a higher power’ had affected her, telling her that ‘it’s okay to be happy’, as she broke into tears:

“And I think that was really, really powerful… But I feel like, it was less direct insight and more just a feeling of like… Connection, and unity, and things that… I feel like it helped… *crying*, my depression, more than it helped my eating disorder, but because they’re like comorbid, I feel like, it helped in turn”.

(P2)

She summarised her insight and impact on her perspective, influencing her ED symptoms:

“I think, its… To do with, joy, and… There’s so much, I think, it’s to do with the feeling of um… Life is so big, and I am so small, like, the things that I think really matter, don’t matter? Like, what I look like in a pair of jeans or like, if I’ve eaten like x, y, and z today… Like those things really don’t fucking matter in comparison to like the… Largeness of the universe, and the part that I have to play in it, and what matters is… Relationship, and connection, and… Making meaning of the things that happen to us… And I felt as though… That place, will always be there for me, but I still have work to do here… and that’s okay?”

(P2)

P2’s reported emotional breakthrough and mood improvements induced by connecting to a higher power may point towards fMRI studies on psilocybin and brain mechanisms in depression, indicating its role as a catalyst for notably enhanced psychological flexibility, openness, and connectedness [127]. Participants’ profundities and strong sense of unity experienced, further relate to that of emotional ‘awe’, a discrete emotion analogous to mystical qualities and ego-dissolution, suggested to catalyse change [128].

Participants’ reports could illustrate the downstream effects of mystical experiences, relative to their EDs and beliefs about domain-general narratives on the world, self, and states of being [117], describing fostering a transcendental sense of connection to a higher oneness, others, and the world as a transformational point in their lives. The personal meaning participants attached to such transcendent experiences, in view of healing, may represent trickle-down effects on functional brain organisation systems. This could signal the notion of acute subjective effects of the connectedness associated with mystical experiences as a potential mediator for improved psychological wellbeing associated with effective and enduring therapeutic outcomes [74,120,127,155].

P7 recalled emasculating a formation of cartoon men with a giant sword, which she connected to having ‘suffered a lot of abuse at the hands of men’, before ‘giving them their hearts back’, so they were ‘whole people, not the version of them that was horrible’ then seeing herself as a ‘goddess’, perceived as ‘being able to take her power back’:

“I think it was me, being able to understand that my experience of men has been, the ego aspect of men, and, this just showed me that you know, they have a higher self too, this isn’t who they really are? Um, and that they are shaped by a society that diminishes women, and… I don’t know, just helped me to… Forgive that. You know, to forgive the abuse that I’ve suffered, because ultimately, it’s all led me to this… This healing journey…

And, there’s just not, there’s just not a reality that I want to live in where I can’t forgive people. I don’t want to hold on to… Anger, and resentment, and, I think by, yes, castrating them and giving their heart back, was… A way for me to… Acknowledge that they are better than the person that they are in this lifetime.”

(P7)

P7’s experience of empowering compassion and forgiveness from initial ‘resentful’ and ‘angry’ attitudes, may again depict the REBUS [109] explanations for the psychedelic-enabled revision of core beliefs and emotions [108] from a qualitative and subjective lens. Altogether, participants’ reports may support Renelli’s [40] findings of a deeper healing enabled via spiritual components and LaFrance’s [42] of spirituality and emotional processing as mediators for ED, anxious and depressive symptoms. Particularly when used intentionally to promote self-development by revising personal coping strategies and enhancing self-knowledge, as was the case for seven participants [175].

These findings may illustrate how participants’ transcendent mystical experiences and seemingly relaxed ego defences/ego-dissolution can shift beliefs towards the notion of spirituality, suggested to be a mediator for deeper healing and improved wellbeing through reducing emotional reactivity and self- consciousness [117]. This then seemed to translate into participants’ reduced ED symptom engagement and negative emotional reactivity, akin to quantitative measures of life-time psychedelic users and ED symptoms [42] and several reviews [35,147].

6.2. Superordinate Theme 2. ‘Transformation’ and Being ‘Able to Do the Work’

All participants explicitly linked their psychedelic experiences to their improved wellbeing. This was long-lasting for six, and highlighted as more effective than any ED treatment previously received by more experienced service users (P3, P4, P7, and P8):

“…working with the medicine has really helped me a lot to release that (trauma), and I honestly feel better than I have… Since, before I can remember… Physically, mentally, emotionally, just all of it.”

‘Hard work’ was emphasised unanimously, varying between ‘support’ from peers, professionals, spiritual and/or creative therapeutic outlets:

“You still have to… Integrate those lessons, and… Catch yourself when you’re falling back into old negative thinking patterns, but it has certainly been a catalyst… To a deeper kind of heeling than I have ever experienced before, through any kinds of conventional methods”.

(P7)

Major personal shifts resulting in the cessation or reduction of ED symptoms were described by seven as ‘profoundly’ ‘life changing’ and ‘transformative’:

“…My life has meaning. I connected with meaning that there was meaning even in my suffering itself, I think this was probably the most significant factor… I saw that I really needed to change. And what I didn’t realise was, how much I would change. I’m not that person anymore. I see a thread to that person, but I cannot. I can’t go back. Like I’m not worried that my depression or my eating disorder will remerge because I feel like I can’t even find those pathways.”

(P8)

This theme unpacks cognitive and behavioural ways these outcomes manifested, including subsequent safety perceptions, each presented as subthemes.

6.2.1. Subordinate Theme 1. Cognitive: ‘They’ve Opened Me up’

A unanimous increased ‘motivation’, ‘hope’, and improved mental health was reported to varying degrees and durations following the ‘visceral experience’ that personal change was not ‘impossible’ or ‘unimaginable’ as participants believed, linked to mood improvements:

“They give me hope, which when… I’ve been struggling with addictions and bulimia for, so long, like hope, is… So cool to have, and is so important. Because, before I tried psychedelics, I was just hopeless, like I had no hope, I wanted to die, I really didn’t give a shit. And now, like, they’ve opened my life up, they’ve opened me up spiritually, which is incredibly important. They give me hope that one day recovery, like I know, that one day I will recover. And, they’ve also, given me a lot of really cool friends. Which is great. So, yeah, I’m very, very grateful.”

(P4)

The improved mood and positive change in outlook associated with emotional transcendental/mystical experiences reported by participants point toward notions of the mediating role of spirituality and emotional processing found in Lafrance’s [42] quantitative study. This is further akin to Sprigg’s [43] “overwhelming evidence” for improvements in depression and wellbeing scores following psychedelic experiences in 28 people with lifetime ED diagnoses, where emotional breakthrough also correlated with mental health improvements. For instance, 36% reported lifetime comorbid major depression and 32% were within the moderate to very severe range for depression—there were no participants scoring within the moderate–severe range for depression two weeks after the psychedelic experience. That improvements in depression scores were highly correlated with changes in wellbeing scores may echo reports of people who have recovered from EDs, reporting positive wellbeing to be a central component of recovery, beyond remission of core ED pathology [176].

Interestingly, psychedelics are associated with re-enchanted experience of the world and belief changes [177,178] due to the typically spiritual nature of the psychedelic experience itself, which is further thought to play a mediating role in psychedelic therapy, spirituality, and creativity [121]. Interestingly, key character changes around spirituality, emotional attitudes, and creativity were also reported by participants in connection to their decreased symptom engagement and/or sustained remission, also reported in LaFrance’s [39] ED/ayahuasca study. It is therefore intriguing to compare such reports to positive psychology and psychedelic population studies demonstrating improved mental health and shifts in domains such as personality, values, and mindfulness towards spirituality, resulting in lower levels of depression and anxiety [89]. These findings are further echoed in a small community sample of psychedelic users (N = 195) that additionally found reductions in disordered eating and better emotional regulation attributed to classic psychedelic use [42].

Even without explicit notions of spirituality, these experiences were symbiotic with having a ‘changed perspective on life’ with ‘priorities’ relating to self-care/healing and interpersonal relationships that were informed by ‘a sense of knowing as opposed to might be’ and the renewed possibility and motivation to ‘do the work’ which facilitated healing for seven participants:

“I think for the first time, everything else in my brain got shut off, and I got to just actually just be there and feel it, and I think that sensation is sort of what motivates me in that, I sort of know what it feels like… Before, because I’d never felt like that, it was like not plausible, it was incomprehensible… And because I was allowed to have a taste of it, I now feel like I have something to work towards, whereas before it felt like impossible.”

(P2)

This notion of actualising a broader perspective with motivating consequences could illustrate how major changes in self-experience from psychedelic experiences can produce enduring improvements to mental health via the revision of core beliefs [108,123,126,150]. The renewed outlook or belief as to the possibility of recovery and significantly more positive way of thinking reported by participants could point towards a possible recalibration of highly weighted compressive functions typically associated with the maintenance of internalising disorder pathology [109]. When compared to neurobiological evidence, this finding could be clinically relevant when considering the low motivational aspect of EDs in response to difficult emotions, the subsequently hampered wellbeing, and the comorbid depressive symptoms associated with negative beliefs [151,176,179].

P5, who reported on their naturalistic use of ketamine and LSD (rather than psilocybin), built on the notion of ‘seeing’ progressive outcomes, and why this was so significant:

“Seeing that I have changed over time is really encouraging and encourages you to carry on trying because you know that like, even if progress is going to be slow, it does happen if you work at it, because when you’ve never experienced that kind of change before then it feels impossible. Because it’s so relentless sometimes the thoughts so, the urges…”

(P5)

They described how it helped them feel ‘very much more comfortable’ with their body and ‘finally got on top of bingeing’ after one particularly significant at-home ketamine experience four years ago, where they were ‘able to see the neural connections’ in their mind, thought to be the location of the thinking pattern that they wanted to correct. They had used ketamine with therapeutic intent to address their EDs, and went on to describe how the use of LSD/acid at home had further contributed to nurturing and nutritional aspects of their healing journey:

“Acid kind of…, sort of gave me permission to just like, be at home in my body, appreciate like, looking after myself and feeding myself and, it’s hard to put into words, but you’re really kind of confronted by what you are… Which is a creature, like this weird, complicated, miraculous thing that that needs to absorb stuff from other stuff to exist”.

(P5)

P5’s account could reflect literature detailing how a sense of ‘awe’ and greater connection to intrinsic needs and inherent worth may be a central process behind transformative experiences [127,128,155,156]. Furthermore, the enduring positive outcomes resulting from participants’ naturalistic use, having ‘integrated’ new beliefs into their lives, could indicate mechanisms of creative and/or relaxed ways of thinking attributed to psychedelics [114,121,178,180]. Again, the notion of long-lasting improvements in wellbeing and mental health is also reflected in population studies, whereby lifetime psychedelic users typically report significantly lower emotional difficulties, depressive, suicidal, and anxious tendencies, with greater life satisfaction than non-users [97,118,119] and additional reduced ED symptoms in a smaller community sample [42].

In terms of reduced cognitive symptoms, five participants reported ‘significant reductions’ in ‘intrusive thoughts’, ‘emotions’, and ‘urges’ that ‘would often lead’ to ED behaviours, or described these thoughts as ‘a lot easier to rationalise, which ‘changes everything’. This shift in aberrant thinking and alleviated thought patterns reportedly assisted in the hard work towards ‘healing’ that participants had been struggling with, and could point towards modulations in a key area of ED pathology [115]:

“My thoughts are not obsessive. And if they do get obsessive, I notice it. And I’m like oh… that’s interesting… wonderfully interesting. And then I move on… It’s… The ability to notice, it’s a DBT skill, notice, describe and participate… I would practice the skills, but they just didn’t click in a way that seemed like they should be… And I wasn’t present, I was avoiding. Yeah, I have to be present to experience, you have to be present to observe, and to participate… And I didn’t know how to bring myself present, I did everything I could think of.”

(P8)

Obsessive–compulsive symptoms, anxiety, and perfectionism are closely tied together with EDs [181,182]. Interestingly, reductions in intrusive compulsive cognitions and obsessive beliefs have been highlighted in Moreton’s [180] study as mediators of therapeutic effects on OCD symptomology. Furthermore, the positive mental health and personal development outcomes described by participants may mirror therapeutic outcomes lasting weeks–months following psychedelic use/experiences in more rigorous studies of their comorbid disorders [27,28,75,86,88] that are further reflected in extant ED specific systematic reviews [35,145,146].

To summarise, participants’ descriptions of perceived healing effects on the mind, emotions, and patterns of thought relating to ED symptomology, in line with the literature [35,145,146], could be further conceptualised using Kelly’s [100] proposal of the multimodal transdiagnostic therapeutic action of PAT from a research domain criteria (RDoc) framework. For instance, the modulation of aberrations in negative and positive valence systems (e.g., fear/threat, emotional avoidance, rumination vs. positive reward responsiveness/learning, motivation), social processing (connectedness, empathy, pro-social behaviours), cognitive (altered control/flexibility) and sensorimotor (altered habit/agency) systems. In this context, participant reports could signal grounds for further developments exploring PAT and ED pathology using an integrative approach, especially given the high comorbidity with other mental illnesses [106].

Moreover, the reductions in ED cognitions following (and in relation to) participants’ emotional experiences, perceived as relevant to the root causes of illness, draws attention to the high emotional avoidance associated with EDs and criticisms of current symptom-focused treatments with calls to investigate PAT for people with EDs [51,57,101,144]. Findings from this subtheme therefore point towards the notion of psychedelics possibly inciting more cognitive flexibility in EDs when combined with therapeutic work, facilitating deeper personal insights [35,103,141]. When considering the current literature, participant reports may help to explore how psychedelics could enhance traditional methods and add to extant reports comparing conventional ED treatments with the therapeutic use of psychedelics from the perspectives of patients [41,42].

6.2.2. Subordinate Theme 2. Behavioural: ‘Start Making Changes’

All participants described behavioural changes resulting from feeling ‘able’ to ‘make changes’, ‘break habits’, and ‘do things differently’, summarised by P7 as being able to ‘manage things in life I can control and letting go of things I can’t’. Recovered P8 also shared details of this process:

“… not just having the experience with psilocybin, but putting it into practice, in their lives. Start making changes, do a lot of writing, figure out what you need to transform and um the psilocybin will help the person to do that, and to be just completely honest. With themselves. I know that when it becomes chronic it’s learned, and you can unlearn it”.

(P8)

Participants linked their notable improvements in psychological flexibility and reduced cognitive symptoms to their ability to pursue an active role in their personal development and wellbeing. This again could reflect the notion of control circuits recalibrating as the acute effects of the dysregulation of self-limiting beliefs and narratives subside [75,108,169,178]. That participants reported renewed motivations to enact change, it is interesting to consider the possible modulation of participants’ serotonergic systems, associated with normalising dysfunctional systems by increasing brain network integration, manifesting as healthier behaviour changes [84]. Further, the unanimous reports of being significantly more able to separate from their habitual behaviours could indicate shifts from ED pathology.

When describing their outcomes, each brought up examples of personally meaningful behaviour changes to signal the extent of their motivations to maintain their wellbeing and manage their ED, with reduced ‘compulsive symptoms’ weeks/months onwards:

“After that journey, I just noticed that… Some of my compulsive um, symptoms, had dramatically reduced, as far as just obsessing about my weight…

…there were times when I would weigh myself 20, times a day *laughs* and that just seemed to… Kind of, evaporate. The need, to do that just, really was greatly diminished… So, I continued, using psilocybin mushrooms from then, about 7 times, and I had just… Been able to get to the point where I don’t weigh myself at all… Anymore.”

(P7)

The enduring nature of reduced behavioural symptoms and improved wellbeing reported could indicate potential for clinical use, especially when considering meta-analytic efficacy data for PAT, producing similarly long-lasting transdiagnostic therapeutic effects for the full range of comorbid disorders that participants reported [75,103]. There is also preliminary evidence for the transdiagnostic effects of PAT, capable of catalysing cognitive behavioural changes via spiritually emotionally meaningful pathways, which may extend to EDs [51,100,128,145].

A further pattern emerged where participants described engaging in prosocial behaviours and shared interests with others as a significant outcome. Enduring positive outcomes were summarised by P4 as being ‘so full inside of like, good juju’ after returning from psychedelic rehab that the ‘urges are so much diminished’. P4’s report also points towards the psychosocial healing capabilities of community:

“I started getting involved with like, I went to Breaking Convention, and a couple of psychedelic meetups, and it was just like, eye opening, like it was a whole new world… I started volunteering for Psycare, and felt like I had found my tribe. Like, for the first time, in a long time. And my symptoms were just fine, I was completely normal… It was beyond, like words. I couldn’t even, like I’d never had that before. I was just absolutely okay?”

(P4)

Despite relapsing six months later with comorbid SUD and ED symptoms after ‘a long string of very stressful events’, she described still finding it ‘easy just to eat’ normally and had mentioned becoming certified in nutrition as a result of her healing with psychedelics:

“… normally my body will feel quite stressed, and I’m rushing around, finding it quite hard to stay grounded, and… Connected, in the moment… But now, I just don’t put much drama into, like oh no, it has to be perfect, or has to be at a certain time, like I’m a lot more flexible with my food.”

Similarly, six participant reports pertaining to healthier lifestyles and/or diets, coinciding with suggestions of psychedelics inciting health behaviour changes [156] and alleviating ED symptoms [147]. Furthermore, reports of reduced social anxiety and increased motivation to engage in activities and connect with external environments could coincide with findings of relaxed social information processing and beliefs that reduce prior inhibitory notions of social isolation, leading to prosocial effects on social cognition and decision making associated with 5HT2A activity [73,183,184,185].

Additionally, given the complex overlap between ASD and EDs [186], it is interesting to note that these subjective effects were also reported by both participants with ASD (P1 and P8). P1, for instance, described ‘lots of fighting’ her inhibitions when she felt compelled to ask to dance, hold hands, and do nail painting, for example, with the clinical trial therapists as she ‘would never normally ask or know’ what she wants. P8 described transitioning from a reclusive ‘hoarder’, to decluttering her house, giving things away, and delving into yoga, later holding yoga classes for others within the ED community. Both noted improvements in eating and attitudes towards food. Positive behavioural outcomes associated with psychedelics such as enhanced mood, social processing, and reduced social anxiety have been observed in ASD [27,187]. However, the potential for heightened risk is emphasised and it is unclear if the benefits outweigh the risks for people with ASD, as P1’s relapse (attributed to accessibility issues regarding professional support and psychedelics, after receiving clinical trial aftercare) may suggest.

Overall, participants’ accounts involved an increased interest in others and enhanced awareness of self-schemas, emotion, and interpersonal relationships, potentially highlighting a way through which wellbeing, lifestyle, and support networks could be actively improved for people with EDs, following psychedelic experiences.

Moreover, the six participants reporting sustained outcomes and new prosocial commitments may point towards the healing psychosocial elements of psychedelic use regarding community, such as ‘just doing things, meeting people, making friends, joining activities’ of meditative, spiritual, or creative natures. P6, for instance, attributed her recovery from AN to recreational psychedelic use during her early 20s in social contexts, which catalysed her ‘creative process’ as an artist by ‘helping to connect to people’ and herself. Further, P6 disclosed that she was qualifying as an art therapist when describing her longstanding recovery, which could signal enduring pro-social behaviour. She described psychedelics as a ‘meditative practice’:

“…after having this experience with my eating disorder, and being sort of more withdrawn from my creativity and my creative voice, it really connected me to that voice. And, profoundly changed um… The direction of my artwork? For quite some time, I didn’t really have the words, you know, to sort of, to really go into that process deeply, or. It didn’t flow as naturally, let’s put it that way. And it just seemed like um… Yeah, the dots were… Connected… I guess when I was battling with it, my perception was sort of more, um, introverted I guess, and then sort of expanded with the use, with the help of psychedelics”.

(P6)

In addition to improved social behaviours and attitudes centred around communities, new interests, spirituality, and creativity, these reports may hint towards shifts in personality, although only one participant (P6) reported lifetime psychedelic use and could signal this notion effectively. Her accounts could point towards psychedelic-induced mediating roles of anxious ego-dissolution on her personality and sustained recovery from AN via acute effects on creativity and a sense of ‘connection’ to herself, others, and overall improved wellbeing and mental health. This could notion the safety and value of psychedelic use in positive psychology and in therapeutic contexts [127].

Taken together, all participants reported positive behaviour changes linked to their psychedelic experiences that encompassed mental clarity, emotional processing, and mystical experiences, which was long-lasting for seven. It is interesting to compare participants’ descriptions of change in self-experience to biomedical theories of the psychedelic-induced regulation of affective states relating to depressive symptoms and self-referential cognitive processes, such as prior aberrations in self-perception and potentially bodily self-awareness [27,115].

Finally, given the similarities between changes in self-experience and bodily awareness induced by meditation and by psychedelics, it is intriguing to speculate that this disruption of self-narratives and possible modulation of intrusive thoughts may be associated with improved wellbeing, as seen in experienced meditators [158]. This change in self-experience and self-identity could relate to participants’ long-term positive outcomes that they had linked to new interests, prosocial behaviours, and individual traits, such as increased empathy and compassion, thought to be antecedents of prosocial behaviour [188]. Furthermore, the healing psychosocial and behavioural elements and outcomes attributed to participants’ psychedelic experiences (i.e., integrating into communities via creative, spiritual, and meditative outlets) can point back to Harding’s [154] findings of high receptiveness to meditative practices (70% use complimentary spiritual treatments such as yoga and meditation) and high interest in the therapeutic use of psychedelics (70% would take part in a psychedelic clinical trial) in a sample of 200 people with EDs, suggesting a potential compatibility between these areas that may be worth investigating further.

6.2.3. Subordinate Theme 3. Safety Perceptions: ‘Medicine’ but ‘Not a Magic Pill’

This theme is characterised by an overarching high regard for the ‘medicinal’ capabilities of psychedelics, which represent ‘healing’, ‘hope’, and ‘connection’ to participants, and that the ‘danger’ lies in the context of use, in line with set and setting theory [31]. All participants emphasised the importance of the mental preparation and ‘research’, of ‘trusted’ environments, and ‘support’ for ‘integration’, reflecting both scientific and naturalistic safety perceptions [33,189,190]. P2, who’s psychedelic experiences came from taking part in a clinical trial, expressed her views when asked about potential dangers:

“…they mean… Healing. And they mean, medicine, and they mean connection, and they mean… Hope, and for me they feel like… A gift, that’s given to us? By like, the earth, and… I think, there’s danger of, putting all our hopes and dreams in the basket of like, if I eat this mushroom then my life is going to be like sorted and I’m gonna have no problems ever again… I think that is not what they’re there for, and I think they’re there to allow us to see some, the possibility. See possibility where we couldn’t see it before. Um, so I’d try not to put them on a pedestal, but um, I think they’re fucking cool.”

(P2)

Seven participants expressed the importance of ‘respect’ for the ‘medicines’, of ‘research’, ‘educating’ and ‘preparing’ themselves to appropriately ‘get the most’ of the ‘healing potential’ safely, while emphasising the crucial role of external support.

“The caution would be, make sure you do your research, and be with people that, you know you can trust… Um, and if somebody has severe mental or psychological problems, they need to work with a therapist or a doctor to make sure they’re gonna be safe doing that…”

(P7)

The overall perception was that dangers lie in drug ‘abuse’, ‘mixing’ recreational drugs, or ‘trying to take medicine in a chaotic environment’ and ‘without any support’, inviting the risk of unmanageable outcomes that ‘could be traumatic for someone’. Although not personally experienced by participants, their safety perceptions coincide with current understandings that the same uncontrolled variables can result in adverse reactions and psychological distress [191]. Participants’ emphasis on education and understanding of the ‘medicines’ reflect recent research examining challenging psychedelic experiences and subsequent difficulties, demonstrating that the knowledge of the drug and dose predict a smaller risk for experiencing extended difficulties after-the-fact [133]. Altogether, participants’ safety perceptions reflect current understandings and clinical approaches that place guided settings, participant knowledge, and support at the forefront [25,92].

Also of importance was the magnitude of ‘unexpected’ change following positive outcomes, necessitating supportive resources. A pattern could be observed whereby older participants who were more experienced service users acknowledged the general benefits of conventional therapy but seemed to place more personal value in psychosocial elements of healing [98], such as spiritual, meditative, and creative therapeutic modalities/communities, having reached sustained cessation of symptoms or full recovery. Younger participants generally seemed to emphasise a higher need for professional support and extended ‘aftercare’ to manage their wellbeing and sustain positive subjective effects (i.e., new behaviours), with ‘the problem’ being ‘returning to normal life’, not ‘ideally set up for aftercare’ as P4, who previously relapsed after a ‘series of stressful live events’, described:

“If I’m going to do psychedelics on my own at home, I’ll still get lessons, but it will be more spiritual lessons, or reflective lessons around my life, but my eating disorder is still… The symptoms will still be there. You know, even though I’ll have more knowledge… There symptoms will still be there. Whereas when I go to psychedelic rehab, the symptoms are reduced, and I get more knowledge. Just cause everything’s more intense in there”.

(P4)

At the point of interviewing, P4 reported the cessation of her ED symptoms. The danger of inadequate aftercare is also reflected in P1’s account, having relapsed after her first and only psychedelic experiences from participating in a clinical trial, which she now sees as ‘a wasted opportunity’ for her to ‘change’ when ‘there was a lot more possibility and hope’:

“…it didn’t feel like I was working on, it felt like I should’ve been working on problems and thinking… Like, new ways to behave and… Putting things into action, cause I felt really… Yeah just open to things and more… Like my brain was a lot more active and hopeful and stuff. But I didn’t know what to do with that, and then it sort of trailed off… and… It just feels, I feel almost worse now… Cause I feel really disappointed.”

(P1)

P1’s experience from an extreme high (feeling hopeful and happy, having tangibly experienced reduced symptoms) to low (disappointment, end of trial, no longer having access to psychedelics and being back on the NHS waiting list for therapy) raises an important caveat regarding hopes and expectations, and the opportunity that clinical trials could represent for people who suffer chronically. This further points towards the need to investigate safety and the sensitive nature of extended aftercare that may be needed, particularly for those, like P1, with multiple diagnoses such as ASD and MDD. A review by Zeifman [108], for instance, suggests that recent clinical trials provide no evidence of increased suicidality but rather the contrary; however, McNamee [134] found increases of suicidal ideation and self-injury in over 7% of trial participants using MDMA and psilocybin.

Consistent with research, P1 was the only participant reporting adverse experiences and difficulties linked with feelings of anxiety, fear, and existential struggle [124]. Interestingly, P1’s psychedelic experience descriptions were notably darker, more fear/anxiety inducing, and isolating than the rest. She frequently credited the support from trial therapists and relayed positive experiences almost exclusively with them. Taken together, all participants and P1’s higher levels of difficulty during and extended difficulty after-the-fact reflect findings on difficulties following psychedelic use, specifically that shorter duration of difficulties were predicted by lower levels of difficulty reported during the trip [133]. P1’s case points towards the crucial importance of aftercare and support, the profound psychosocial healing capabilities that come with psychedelic experiences (i.e., appropriate set and setting [33], and the need for further research into safety, ED harm reduction, and mitigating risk after clinical trials [144], with further consideration for the diverse needs of individuals with ASD [187] given the overlaps and unmet needs [186].

The other participants acknowledged the risk of ‘disappointment’, but from unrealistic expectations of a ‘magic pill’ outcome, without appreciating ‘it’s hard’ and ‘requires so much more than just taking a drug’. As P3 explained, ‘they showed me where I need to do the work, at its core, in order to tackle the ED’ rather than directly alleviating symptoms:

“So, if people take a psychedelic and think, oh I’m gonna be cured, then they’re in for a very rude awakening, because that’s not the way it works. You have to be determined to commitment. Determined to work hard.”

(P3)

Overall, the therapeutic safety of psychedelics was confidently expressed. As was the case for seven participants, approaching psychedelics with clear therapeutic intention has long been associated with positive mental health outcomes [31,130,132,150]. Participants emphasised the need for ‘doing the work’ alongside and beyond the psychedelic experience itself, referring to the new behaviours they made efforts to instil, the complementary therapeutic modalities they engaged in, and the support mentioned throughout their descriptions of positive outcomes. Attention was drawn to the support of professional therapists (mentioned by P1 and P2), spiritual guides (mentioned by P7), and social bonds (mentioned by P3, P4, P5, P6, P7, and P8) that participants felt added to their integration and sustained positive outcomes. This coincides with evidence that a stronger therapeutic alliance may predict a greater emotional breakthrough and mystical experiences, which in turn is associated with more positive and sustained therapeutic outcomes [33,98]. Taken together, findings may reflect data supporting the general safety and benefit of use in both naturalistic and lab settings for people with histories of mental health, suggesting that this is an area worth investigating in the context of EDs, particularly as this notion is supported by experts as well as individuals with EDs [35,51,113,141,143,144,145,154].

7. Summary

These findings are based on the experiences of eight individuals with chronic EDs. The ways in which psychedelics had impacted their wellbeing and symptoms are conceptualised into themes. Psychedelic experiences were cited as having a profound potential to induce visceral changes in self-experience and insights, relating to cognitive and behavioural ED symptoms and the root causes of suffering that were collectively associated with positive changes in beliefs and behaviours. All participants described how these experiences gave them hope and motivated them to keep working on getting better, leading to decreased symptom engagement and lasting improvements in wellbeing. Psychosocial support outside of the psychedelic experience was also emphasised as a crucial element of healing and harm reduction. Improvements in wellbeing and symptoms were long lasting (N = 7), with two participants reporting recovery attributed to psychedelic use. Two participants had relapsed due to environmental factors and a lack of support outside of their psychedelic experiences, highlighting the need to better understand safety and risk factors in EDs.

The study findings are primarily centred around the experiences of individuals with chronic AN, due to the majority (N = 7) of the sample reporting to have AN for the duration of 11 to 42 years (mean = 23.5) and the therapeutic use of serotonergic psychedelics, particularly psilocybin (N = 6), used primarily within naturalistic settings, with two reports from clinical trials. Though two participants (P4 and P5) had not used psilocybin, both had reported on experiences with LSD used with therapeutic intent at home and reported on psychedelics that the others had not. P4, for instance, reported therapeutic outcomes following ibogaine, ayahuasca, and 5-MEO-DMT use as part of psychedelic rehab, while P5 spoke of therapeutic outcomes following ketamine use at home with therapeutic intent. Furthermore, though majority of participants had AN, a full range of EDs (AN, BN, BED, ON, OSFED, and ARFID) were present in the sample.

8. Limitations

This study is not without limitations. Firstly, due to the voluntary recruitment method that sought individuals who could speak on psychedelic experiences, self-selection may have resulted in biased participant reports of positive experiences. Although the recruitment advertisement specified interest in both positive and negative experiences, with one participant sharing in detail of her challenging experiences, being worse off after the clinical trial and relapsing, others that may have had negative experiences may choose to avoid the topic of psychedelics completely. Second, participants were relatively well educated and emphasised the importance of ‘research’ before use; thus, insights may have been gleaned from personal reading, potentially inviting placebo effects. Third, the semi-structured interview prompts may have influenced participants’ reflections or prevented discussion of potentially relevant information, possibly resulting in demand characteristics and deterministic interpretations. Additionally, due to the small sample size vs. the full range of both EDs and psychedelic substances considered, subthemes for the wide breadth of content covered were kept relatively broad and may be reductive. Though the study aimed to explore the full range of psychedelics and EDs, these findings predominantly concern the experiences of women with chronic AN, and psilocybin use. Finally, there remains a Eurocentric bias throughout this research due to participants being of European descent. Though EDs can present in all ethnicities and nations, no individuals that were black, indigenous, or any people of colour (BIPOC) had volunteered to participate, and more recruitment efforts could be made in to reach these communities.

9. Conclusions

This research may provide more in-depth information on what benefits and experiences individuals with chronic EDs can obtain from the use of psychedelic drugs, which may inform a more robust future study of the topic matter. Importantly, findings may shed light on the positive role that psychedelic-induced mystical experiences, emotional breakthroughs, changes in self-experience, and the supportive psychosocial elements associated with intentional psychedelic use can play, and how people with EDs make sense of such experiences in relation to their mental health and recovery journey. In line with the literature, these aspects of serotonergic psychedelic experiences are not only associated with enduring positive outcomes in people with and without mental health conditions, but are key aberrations in ED pathology. Further, the preliminary literature suggests promise in transdiagnostic approaches towards PAT and theory such as the REBUS model for understanding psychedelics and psychopathology, including EDs.

Findings also point towards the literature highlighting the need to understand the safety and risks involved for people with EDs and additional heightened risks, such as multiple diagnoses (e.g., ASD, MDD, SUD) who may stand to benefit from psychedelics. Further study is therefore needed to understand how to reduce risks of harm and optimally meet the complex and diverse needs of this particular diagnostic category of people with treatments such as PAT in clinical trials and naturalistic use.

This study may provide a starting point to help develop more robust, large-scale studies that include objective parameters of ED (e.g., such as food intake and BMI) and quantitative measures accounting for harm reduction (e.g., preparedness, set and setting, heightened risk) psychedelic experiences, outcomes, and optimal aftercare.

Taken together, these findings may therefore help explore pathways of psychedelic therapy for individuals with chronic EDs and inform measurements for future studies that address the urgency to investigate novel treatment options [37,42,43,49,51].

10. Reflexivity Statement

NL acknowledges her position as a qualitative researcher and wishes to signal the subjective context of the study findings [192]. DL did not perform any interviews or formal analysis and therefore does not present a formal reflexivity statement; however, he has had extensive personal experience with psychedelics but no personal experience of EDs. NL expresses the view that EDs are poorly understood, stigmatised, and often marginalised in healthcare, making being seen/heard and attaining support and efficient treatment extremely challenging. Similarly, psychedelics are often misunderstood and stigmatised, and people who use drugs are marginalised by drug prohibition. While we reject the overarching stigmas, we acknowledge that some practices and patterns of drug use are harmful. NL believes that people with lived experiences of EDs and psychedelics are valuable to research and should be empowered to influence novel treatments in a way that can benefit their diverse unmet needs.

NL’s pursuit of the study topic stemmed from epistemological values of intuitive inquiry that ‘incorporates intuitive and compassionate ways of knowing’, where ‘researchers listen to the prompting of their hearts about what to study and then listen with open hearts to the experiences relayed by others, attending to what speaks to them individually and collectively in the hope that their findings will serve the greater good’ [193]. NL therefore acknowledges that her role, situated from an interpretivist ontology construing people, the world, and reality as dialogically interrelated [194], could have shaped the data more favourably towards the therapeutic potential of psychedelics for EDs, thus registered any prior assumptions held about the subject matter throughout the study and endeavoured to be aware of unconscious biases. NL recognised that her perception of psychedelics may be biased towards the research followed and personal experiences with psychedelics for enjoyment, self-development, healing, and spiritual growth.

NL recognises personal motivations for conducting this research as someone who has suffered with eating disorders for over a decade. NL does not attribute her ED recovery to psychedelic use, but states that psychedelics have greatly assisted in sustaining long-term recovery, resulting in the inquiry about the experiences of others and the ways in which psychedelics could be beneficial or not for people with EDs. NL therefore endeavoured to conduct this research in a way that promotes the systematic collection of both potential benefits and adverse effects.

NL maintained intentions to adopt a neutral stance to appropriately explore the variation in reports, the diversity of others, and effectively draw out any limitations and risks throughout data collection without projecting personal thoughts and experiences, in attempt to mitigate bias. NL expresses deep gratitude for her interactions with the participants who spoke generously of their personal experiences, informing vibrantly on the nature of EDs and psychedelics in a therapeutic context. NL acknowledges that this adds a personal dimension to the study, and therefore notes that personal interests and observations beyond the study partly informed incentives to research this area and adds weight to her support for continued research towards the application and accessibility of psychedelics in therapeutic contexts.