A systematic review of social rank perception and contribution to eating disorder psychopathology in individuals with eating disorders

Social rank theory states that achieving enhanced social rank is an essential biosocial goal for human beings, with individuals considering themselves to be high or low social rank on the basis of how they perceive that others view them. High social rank is associated with assertiveness, competence, and talent, whereas low social rank is associated with feelings of defeat and inferiority and submissive behavior. This theory has been applied to understand the etiology and psychopathology of eating disorders (EDs). The objective of this narrative systematic review was to summarize existing literature exploring perceptions of social rank and related constructs (e.g., submissiveness and inferiority) in EDs, to shed light on how individuals with EDs perceive their social rank, and to examine the relationship between perceived social rank and ED psychopathology. A systematic search of cross-sectional or longitudinal studies involving a clinical sample of individuals with EDs and using a validated measure of social rank or a related construct was conducted for studies published up to September 12, 2023 (PROSPERO, CRD42021227028). Five databases (Embase, Medline, PsycINFO, Web of Science, and PubMed) were systematically searched. Altogether, 1106 studies were included in the title and abstract screening. Seventeen studies (13 cross-sectional, 3 prospective cohort studies, and 1 ecological momentary assessment study) were included in the analysis and data extraction. The methodological quality of the studies was rated as generally good. There was evidence that individuals with EDs perceive their social rank as lower compared with healthy controls (N = 5 studies) and present features indicative of perceptions of low social rank (N = 9 studies). The perception of being of low social rank was significantly associated with more severe ED psychopathology (N = 10 studies). The findings of the review are discussed alongside limitations, implications for treatment models, and directions for future research.