Eating Disorder epidemiology

Importance of Understanding Eating Disorders

Eating Disorders (ED) are categorised by disturbed eating behaviours as well as a self-concept that is heavily concerned with body weight and shape (Polivy & Herman, 2002). Symptoms of restrictor type Anorexia Nervosa (AN) include food restriction, excessive exercise and intense fear of gaining weight. To be diagnosed with AN an individual must be less than 85% normal weight range for their height and age (Polivy & Herman). AN is associated with higher mortality rates compared to other forms of distress due to the physical complications associated with decreased calorie intake as well increased risk of suicide (Crow et al. 2009). The occasionally fatal consequences of AN make understanding ED aetiology an important issue for public health professionals and clinicians alike (Abebe, Torgersen, Lien, Hafstad & von Soest, 2014). Socio-cultural explanations of ED as well as schematic theories will be discussed with the intention of integrating social and cognitive concepts to gain a better understanding of the development of ED.

Socio-cultural explanations

ED are often considered to be bound up in problematic cultural ideals and mechanisms. A major assumption of socio-cultural explanations of ED is that eating behaviours are somehow dependent upon social frameworks and that some environments may be less conducive to the development of ED (Markey, 2004). For example, in Fijian culture bigger figures are preferred and bigger meal portions are quite central to social interactions. This is often thought to act as a protective factor against ED (Becker, Burwell, Herzog, Hamburg & Gilman, 2002). Thereby, it has been suggested that cultural body ideals stem from what is difficult to achieve in particular social contexts. This helps explain why obsession with thinness characterises Western cultures where food is in abundance (Polivy & Herman, 2002). It is important to note here, that aesthetic ideals differ for males and females and these are potentially linked to differential experiences of disordered eating. For example, men with ED are more likely to engage in excessive exercise than women with ED as dominant cultural ideals for males emphasise a strong, well-built body as opposed to thinness ideals for women (Tata, Fox & Cooper, 2001). This social pressure to conform to beauty standards appears to be pervasive in other cultures beyond Western countries. For example, young Chinese adults who express ED symptomology report more experiences of appearance related pressures from peers, parents and the media (Jackson & Chen, 2007). The media does not just sell products but also sells a view of how women, in particular, are supposed to look (Conley & Ramsey, 2014).

The media is often accused of distorting reality and transmitting harmful cultural ideals to individuals, making them more at risk of developing an ED (Conley & Ramsey, 2014: Polivy & Herman, 2002). Exposure to thin media ideals has been linked to dissatisfied body image across 25 different studies (Groesz, Levine, & Murmen, 2002). Media use amongst women, especially the consumption of magazines, predicted ED symptomology (Harrison & Cantor, 1997). Furthermore, the introduction of television to a village in Fiji has been implicated in the development of ED behaviours amongst the adolescent girls in the village (Becker et al., 2002). This highlights that consumption of media that emphasises unrealistic thin ideals may make a person more likely to engage in disordered eating behaviours in an attempt to live up to these culturally endorsed expectations (Conley & Ramsey).

It is evident that the media may play an important role in the development of ED by increasing body dissatisfaction (Groesz et al., 2002). However, it is important to note that is possible to be dissatisfied with one’s body without developing an ED. For instance, individuals may choose to behave in a healthy way to lose weight or choose to address their confidence on a more emotional level (Polivy & Herman, 2002). Furthermore, research on this topic has been reliant on correlational statistics and reveals no concrete evidence of media consumption causing ED. It seems equally as likely that symptomatic individuals may seek out media that emphasises thin ideals as it reinforces the social rewards of thinness and confirms their worldview (Conley & Ramsey, 2014).

It has been suggested that becoming accustomed to Western cultural standards through social mechanisms such as media consumption has resulted in women from ethnic minorities being at increased risk for developing ED (Markey, 2004). Strong correlations have been observed between Western-Anglo orientation and ED symptomology amongst a Mexican-American community sample. For every 1-point increase in orientation towards Anglo-American culture, probability of having an ED doubled for Mexican-American women (Cachelin, Phinney, Schug & Stiegel-Moore, 2006). Subsequently, women and girls from ethnic minorities may be more at risk of developing ED due to increased pressure to fit into idealised physical moulds (Markey) that are even more difficult for them to live up to compared to their non-ethnic counterparts (Cacheli et al.). Although intriguing, the results of this study are unreliable as it focuses on measuring unstable, difficult to define variables such as language preferences. Studies of ED must be refined so that analyses can go beyond group comparisons into more complex examinations of the impact of several factors across cultures (Nolan & Zane, 2005).

In China, it has been found that ED symptoms were more strongly connected to preoccupations with facial appearance than obsessions with fat and body shape (Jackson & Chen, 2007). Furthermore, in a longitudinal study, only 41% of Chinese patients diagnosed with an ED, according to Western standards, experienced fat phobia (Lee, 2001). Evidently, ED can occur in the absence of preoccupation with body weight (Jackson & Chen). This indicates that the use of diagnostic criteria from the DSM (Diagnostic and Statistical Manual) may be problematic within non-Western populations as ethnocentric concepts such as fear of fat may not capture the breadth of experiences of ED across the world (Nolan & Zane, 2005). It seems that unique cultural values and practices may produce similar outcomes in the development of ED (Markey, 2004). Therefore, models of ED development based on Caucasian samples may be limited to that particular cultural framework (Perry, Silvera, Neilands, Rosenvinge & Hanssen, 2008).

Research into the influence of culture on the development of ED is often limited by pragmatic considerations, as it is difficult to isolate and accurately measure social factors. Furthermore, data is often gathered from self-report measures, which can often be inaccurate (Markey, 2004). However, these methodological issues are secondary to perhaps the most important theoretical limitation of socio-cultural explanations.  Although culture has been consistently shown to be an important determinant of ED development (Markey), very few members of these cultural groups develop ED (Polivy & Herman, 2002). Clearly, other psychological factors must play a role in shaping vulnerability to the socio-cultural pressures that influence the development of ED (Markey). It has been proposed that the family environment, which is also a mechanism through which cultural lessons are learned, may promote ways of conceptualising the self that make individuals vulnerable to developing an ED (Haworth-Hoeppner, 2000).

Familial Relationships and Maladaptive Schemas

Parents play an important role in helping children and adolescents adjust to life challenges and navigate social relationships (Lobera et al., 2011; Bretherton, 2000; Bowlby, 1969). Early dysfunctional relationships between children and their caregivers influence the way children perceive themselves and may result in dysfunctional self-schemas (Bretherton). Self-schemas consist of highly stable subjective patterns of memories, emotions and cognitions about the self. Maladaptive schemas have been consistently linked to ED symptomology and develop when a child’s emotional needs are not met (Tetley, Moghaddam, Dawson & Rennoldson, 2014; Voderholzer et al., 2013).

There is no specific family environment that definitively causes AN (Lobera et al., 2011). However, people diagnosed with ED tend to describe their family environments as highly critical, excessively controlling (Abebe et al., 2014; Haworth-Hoeppner, 2000) and low in parental care (Lobera et al.). It is important to maintain an air of caution when examining results of these studies as many people with ED experience distortions of memory to confirm their world-view and therefore this perception may not be genuine representation of parenting style (Polivy & Herman, 2002). Nevertheless, the most frequently reported parenting style amongst ED patients is low care and high control (Tetley et al., 2014).

Parental lack of care has been found to significantly influence the development of body dissatisfaction amongst young males and females (Tata et al., 2001). Furthermore, neglectful parenting style has also been associated with specific AN diagnostic criteria such as extreme drive for thinness (Lobera et al., 2011). It has often been proposed that neglectful parenting leads to the development of low self-esteem and negative affect which in turn causes ED. Thereby, low levels of parental care may lead individuals to believe that they are fundamentally flawed in some way, even unworthy of love and affection (Perry et al., 2008). But this relationship is not unique to eating disorders and is a recurrent theme in several forms of psychopathology. Indeed, those diagnosed with ED have been found to only differ significantly from depressed groups and anxiety groups in terms of high perceptions of maternal control (Deas, Power, Collin, Yellowlees & Grierson, 2010).

High maternal control involves mothers behaving in an over protective fashion that can nurture the child’s view of themselves as incompetent (Deas et al., 2010). The relationship between high maternal control and ED symptomology has been shown to be mediated by negative self-schemas of feeling defective and dependent upon others (Turner, Rose & Cooper, 2005). Excessively controlling mothers may over-emphasise the importance of remaining in control of emotions. This may lead to individuals engaging in maladaptive behaviours, such as excessive exercise, to attempt to remain in control of their distressful emotions (Haslam, Mountford, Meyer & Waller, 2008). Essentially, parents who exhibit low levels of caring but are highly controlling can unintentionally make their children lack confidence in their appearance and sense of self (Voderholzer et al., 2013).  As a result, those at risk for developing ED may attempt to regain a sense of competency and power through control of eating behaviours (Deas et al., 2010).

For both males and females self-concept instability has been positively and significantly correlated with disordered eating in young adulthood (Abebe et al., 2014).  Self-concepts associated with ED include lack of clarity in identity, low self-liking, and an external locus of control (Perry et al., 2008).  Thinness is often thought to be pursued by those that see no other avenue than restrictive dieting to resolve their identity based issues (Polivy & Herman, 2002). For example, amongst AN diagnosed, schema networks for control have been linked to weight loss, success, self-esteem and attractiveness. Although self-restrained eaters seem to over value self-control as a means to improving their confidence and exerting influence in their life, it still remains unclear why these beliefs reach pathological levels for those with ED (Morris, Goldsmith, Roll & Smith, 2001).

Individuals with instable identity issues may channel these concerns into disordered eating in order to make these anxieties easier to cope with. For instance, those diagnosed with ED tend to score higher on the early maladaptive schema of emotional inhibition (Voderholzer et al., 2013). This indicates that those with ED desperately seek to avoid confronting emotions associated with their dysfunctional parental relationships and subsequent identity issues (Lawson, Waller, & Lockwood, 2007). When confronted with negative self-beliefs, perfectionist tendencies seem to arise as a coping mechanism (Boone, Breat Vandereycken & Claes, 2012). Rigid standards are applied to the self, especially in terms of weight and shape, to narrow and shift the individual’s focus away from undesirable emotional stimuli (Shafran, Cooper & Fairburn, 2002). For example, female secondary students in Ghana report starving themselves as a method of self-control as opposed to method of avoiding weight gain (Bennet, Sharpe, Freeman & Carson, 2004).

Studies of the relationship between family dysfunction, maladaptive schemas and ED are correlational in nature, and therefore subject to many of the same limitations as explorations into socio-cultural influences. Although this makes it difficult to draw meaningful conclusions about causal relationships of ED (Polivy & Herman, 2002) therapies involving families tend to be more successful than those involving individuals alone. This indicates that interpersonal problems within the family at the very least play an important role in the maintenance of ED symptomology, if not their development (Lobera et al., 2011; McIntosh et al., 2005).

Integration of Social and Cognitive factors

As ED are a complex form of distress, no single factor can be defined as the cause (Perry et al., 2008). In this case, neither socio-cultural nor parental and schematic explanations are enough in isolation. There is a need to understand how individuals interpret the social world and selectively engage with particular environmental factors. As with normal development, several paths can lead to problematic trajectories and the development of distress (Markey, 2004). Furthermore, there is a constant interaction between these causal factors and this represents a unique pattern over time. The impact of factors such as media can often be overstated as they are appealing to the general public’s sensibility, but there is no on-off switch for ED symptoms (Harrison, 2000).

It is easy to fail to appreciate importance of socio-culture factors in the development of ED, as individuals can never remove themselves fully from their influence (Markey, 2004). Eating behaviours, perception of health and body shape ideals are all passed down through generations, both within the family unit and within the culture at large. The family unit is a vital source of cultural transmission and therefore it is impossible to completely remove conceptualisations of parental influence on ED from culture (Haworth-Hoeppner, 2000). Furthermore, slightly different cultural variables may be involved in the onset as opposed to the maintenance of eating disorder symptomology (Engler et al., 2006).

Women who experience lower self-esteem may be more vulnerable to internalising societal pressures and thin ideals. For example, ED symptomatic Chinese young adults reported more teasing and social pressure to look a certain way than their non-symptomatic peers (Jackson & Chen, 2007). Furthermore, women with ED evaluate themselves more poorly when body weight self-schemas are activated in working memory by external environmental factors such as the media (Corte & Stein, 2005). The mass media is a form of social pressure that may influence ED development through the transmission of values, norms and aesthetic standards popular in particular cultures (Harrison & Cantor, 1997). Individuals whom over-adapt to these beauty ideals may be predisposed to do so due to feelings of incompetency that arise from poor relationships with their caregivers (Deas et al., 2010). These individuals chose to focus on the pursuit of these media-endorsed ideals to channel their undesirable emotional responses to their problematic parental relationships (Luck, Walker, Meyer, Ussher & Lacey, 2005).

ED diagnosed individuals hold greater number of maladaptive schemas and hold more negative views towards bonds with their parents than comparison groups (Voderholzer et al., 2013; Deas et al., 2010). Maladaptive schemas are inevitably connected to social experiences and cultural phenomenon; especially in terms of the scripts ED diagnosed individuals may use to respond to emotional distress (Pugh, 2015). However, maladaptive schema styles are characteristics of a number of disorders (Voderholzer et al., 2013). Furthermore, patients that perceive their fathers as affectionless report higher levels of trait anxiety and depression (Lobera et al., 2011). Therefore, certain environmental factors, such as higher endorsement of cultural body image ideals, must interact with these maladaptive schemes in order to stimulate development of an ED as opposed to a mood or obsessive disorder (Voderholzer et al., 2013; Fairchild & Cooper, 2010). Knowledge of schema outcomes and how they interact with social factors may be helpful in understanding and predicting the success of recovery efforts for individuals with ED (Voderholzer et al., 2013; Luck et al., 2005).

Future research

As ED are multifaceted issues, research must incorporate multidimensional models that explore the importance of several influential factors. However, it is very difficult to measure the interaction between abstract causal factors such as culture and perceptions of parenting (Polivy & Herman, 2002). As the overwhelming majority of research into cultural and schematic theories of ED has involved correlations, more in depth analyses is required. A hierarchical regression analysis could yield interesting results about the relative importance of exposure to media representing thin ideals, perception of parenting practices and maladaptive schemas. The overall strength of the model would help inform potential limitations in our understanding of ED (Perry et al., 2008).

In order to help understand why some individuals are more at risk of developing ED as opposed to other forms of psychopathology it could be useful to engage with the diagnosed individuals themselves and discuss their conceptualisations of their condition (Haslam et al., 2008). It is important to interact with the ED diagnosed in order to capture the genuine experience of this form of distress. This can help researchers develop a more holistic understanding of ED.

As ED have only been a serious clinical problem since the late 1970’s, knowledge of their causes is limited compared to other conditions. Although self-report measures can be biased (Engler et al., 2006), theme analysis of interviews with ED diagnosed individuals combined with a hierarchical regression could provide enlightening results about the accumulative pressure applied by several risk factors in the development of ED (Polivy & Herman, 2002.

As ED are a highly complex psychological and social phenomenon, no single explanation of their cause is satisfactory. Cultural explanations of ED have been proposed but these do not account for individuals exposed to the same social influences as others not developing ED (Polivy & Herman, 2002). Evidently, some people must be more susceptible to the influence of socio-cultural pressures within their environment. Those who hold negative views of themselves as incompetent and unworthy, which can develop through problematic parental ties and socialisation, may channel their psychopathology into eating behaviours and the pursuit of thinness, a socially desirable trait in many Western cultures (Polivy & Herman).

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