Eating disorder

"Approximately two-thirds of adolescent girls at any age are dissatisfied with their weight, the proportion increasing with actual weight. Slightly more than half of all girls are dissatisfied with the shape of their bodies, an attitude which also is positively correlated with body weight. Girls are most likely to be distressed about excess size of their thighs, hips, waist and buttocks, and inadequate size of their breasts. Those who are dissatisfied with their bodies are more likely to engage in potentially harmful weight control behaviors, such as dieting, fasting, self-induced vomiting, diuretic use, laxative use and diet pill use. Those who diet are more likely to begin in early adolescence, to be white than black, to be of higher socioeconomic status, to engage in other eating-related practices and to have a poor body image and self esteem. Boys who are underweight are most likely to be dissatisfied with their weight and many with normal weight wish to weigh more. Approximately one-third of boys are dissatisfied with their body shape, desiring larger upper arms, chest and shoulders. Dieting and purging are less likely than exercise to be chosen by boys as methods of weight control. Dieting among boys is more likely to be associated with increased body weight and some sports, such as wrestling. Body consciousness and altered body image are widespread among adolescents, and may be associated with potentially harmful eating practices in both sexes, but more so in girls."

"Gynecological problems are one of the most frequent somatic complications of eating disorders. The purpose of the present study was to assess the role of improper eating habits in the aetiology of menstrual disturbances, anovulation and hormonal related changes. Bulimia nervosa is the focus of attention since amenorrhea is considered a diagnostic criterium in anorexia nervosa. Subjects of the BITE (Bulimia Investigation Test, Edinburgh) test who were infertile were studied (n = 58) In the studied population there were 6 cases of clinical and 8 cases of subclinical bulimia nervosa. Symptoms and severity subscales of the BITE test significantly correlated with body mass index (p = 0.003). All 14 patients suffering from clinical and subclinical bulimia nervosa had pathologically low FSH and LH hormone levels. In those with clinical bulimia nervosa (n = 6) we diagnosed 4 cases of multicystic ovary (MCO) and in the eating disorder not otherwise specified (EDNOS) group (n = 22) there were 2 cases of MCO and 5 cases of polycystic ovary syndrome (PCOS). The results suggest that unsatisfactory nutrition (binges and "crash diet") in bulimia nervosa results in hormonal dysfunction, menstrual disturbances and infertility. The authors question the necessity for immediately estrogen replacement: they consider the reversibility of the hormonal status by early treatment of eating disorders is more appropriate. Excessive use of hormonal contraceptives in therapy has to be questioned."

"In recent years, anorexia and bulimia nervosa, whether combined into a single clinical picture or considered as distinct syndromes, have reached epidemic proportions among adolescents. Professionals in the educational and physical and mental health care fields need to be aware of the influence of social pressures on teenagers' perceptions of body image and appearance. This article reviews the sociocultural, socioeconomic, and sex-related factors which contribute to the development of eating disorders. It is recommended that professionals help adolescents resist societal pressure to conform to unrealistic standards of appearance, and provide guidance on nutrition, realistic body ideals, and achievement of self-esteem, self-efficacy, interpersonal relations and coping skills."

"Prior research on non-clinical samples has lent support to the sexual competition hypothesis for eating disorders (SCH) where the drive for thinness can be seen as an originally adaptive strategy for women to preserve a nubile female shape, which, when driven to an extreme, may cause eating disorders. Restrictive versus impulsive eating behavior may also be relevant for individual differences in allocation of resources to either mating effort or somatic growth, reflected in an evolutionary concept called "Life History Theory" (LHT). In this study, we aimed to test the SCH and predictions from LHT in female patients with clinically manifest eating disorders. Accordingly, 20 women diagnosed with anorexia nervosa (AN), 20 with bulimia nervosa (BN), and 29 age-matched controls completed a package of questionnaires comprising measures for behavioral features and attitudes related to eating behavior, intrasexual competition, life history strategy, executive functioning and mating effort. In line with predictions, we found that relatively faster life history strategies were associated with poorer executive functioning, lower perceived own mate value, greater intrasexual competition for mates but not for status, and, in part, with greater disordered eating behavior. Comparisons between AN and BN revealed that individuals with BN tended to pursue a "fast" life history strategy, whereas people with AN were more similar to controls in pursuing a "slow" life history strategy. Moreover, intrasexual competition for mates was significantly predicted by the severity of disordered eating behavior. Together, our findings lend partial support to the SCH for eating disorders. We discuss the implications and limitations of our study findings."

"Previous research demonstrates that the relationship between socio-economic status (SES) and eating disorders is not consistent. The present study compares SES and demographic factors among Swedish women, randomly drawn from the population register and female patients seen for treatment."

"ED's have a higher SES background and live in more privileged socio-demographic areas than CONT. ED's have lower social status, have more separations, and are more often single than CONT."

"These data demonstrate a connection between high socio-economic and demographic data, low social status and eating disorder patients compared to normal controls."

"Interest in all forms of eating disorder in children, adolescents and adults continues to grow steadily across the world. The number of publications grows from day to day but, despite the increasing body of knowledge, the causes and origins of eating disorders are as abffling and obscure as ever. Death from anorexia nervosa (AN) was recorded by both Lasegue (1873a,b) and Gull (1874), who first described it. In 1895, both Stephens and Marshall published postmortem finding in the Lancet for a 16-year-old and an 11-year-old patient respectively. In the last five decades there have been several reports of cases of AN with fatal outcomes and subsequent ausopsies (Siebenmann, 1955; Martin, 1955, 1958; Hack, 1959; Mosli, 1967; Chikasue et al., 1988). Gradually work began to be published which covered long observation periods and produced yet more mortality figures. In 1988 in Britain, Patton presented a study of a group of 460 consecutive patients with eating disorders covering the years from 1971-1981. These were divided into two groups for AN and bulimia nervosa (BN) with resulting crude mortality rates of 3.3 percent for the former and 3.1 percent for tha latter. He also carried out a critical evaluation of the methodological problems and the results obtained from earlier studies. Hsu et al. (1979) reported that more than 2 percent had died during an average follow-up period of 5.9 years; Isafer et al. (1985) gave a crude mortality rate of 8.2 percent with an average follow-up period of 12.5 years; and Theander (1985) a crude morality rate of 18 percent over 33 years. Even allowing for the differences in these data, it is clear that AN has the highest mortality rate of all the psychiatric illnesses (Licht et al., 1993). However these differences in crude mortality rates are unsatisfactory from a methodological point of view for a number of reasons. These include the way cases were selected and the differing lengths of the observation periods."

"The severity and type of eating disorder symptoms have been shown to affect comorbidity. The DSM-IV should not be used by laypersons to diagnose themselves even when used by professionals there has been considerable controversy over the diagnostic criteria used for various diagnoses, including eating disorders."

"The speculation about whether there may be a positive association between sexual abuse in childhood and the later development of clinical eating disorder has been widely considered over the past 15 years. It has sometimes been accepted uncritically as established truth. It is certainly plausible. After all, bulimia and anorexia nervosa differentially affect girls and seem to involve complex feelings about the body which might well have originated in adverse early sexual experience. Furthermore, many patients disclose such experiences in the clinic. The evidence from early research studies, however, does not consistently support all of the clinical speculation. More than one review reached broadly negative conclusions.1,2 The study by Wonderlich et al systematically re-examines publications up to the end of 1994. The authors of this review had to grapple with studies employing a wide variety of methods and samples. They used predetermined criteria of quality but not meta-analysis to sort out which studies could contribute to their conclusions. They were appropriately strict in applying their criteria. This review supports the position of clinicians who consider that a history of childhood sexual abuse is worth seeking and may be an important consideration in their patients with eating disorders, but no more important than in many other patients. It may be especially relevant for those who have bulimia nervosa with comorbidity. Patients with such complex problems require careful thought. Finding a background of sexual abuse may prove to be important but should not lead to the conclusion that “all is now explained”. Furthermore, most studies show that only a minority of patients with eating disorders report abuse and inferring past abuse from the fact of present eating disorder is unjustified."

"There is good evidence that children of parents with psychological disorders are themselves at increased risk of disturbances in their development. Although there has been considerable research on a variety of disorders such as depression and alcohol, research on the children of parents with eating disorders has been relatively recent. This paper aims to review the evidence and covers a number of areas, including genetic factors, pregnancy, the perinatal and postpartum period, infancy, and the early years of life, focusing on feeding and mealtimes, general parenting functions, and growth. This is followed by a consideration of psychopathology in the children, parental attitudes to children's weight and shape, and adolescence. What is clear is that although there are numerous case reports and case series, the number of systematic controlled studies is relatively small, and almost nothing has been written about the children of fathers with eating disorders. What is evident from the available evidence is that children of mothers with eating disorders are at increased risk of disturbance, but that the risk depends on a variety of factors, and that difficulties in the children are far from invariable. The paper concludes by summarizing five broad categories of putative mechanisms, based on the evidence to date, by which eating disturbance in parents can influence child development."

"This study explored friendship variables in relation to body image, dietary restraint, extreme weight-loss behaviors (EWEBs), and binge eating in adolescent girls. From 523 girls, 79 friendship cliques were identified using social network analysis. Participants completed questionnaires that assessed body image concerns, eating, friendship relations, and psychological family, and media variables. Similarity was greater for within than for between friendship cliques for body image concerns, dietary restraint, and EWLBs, but not for binge eating. Cliques high in body image concerns and dieting manifested these concerns in ways consistent with a high weight/shape-preoccupied subculture. Friendship attitudes contributed significantly to the prediction of individual body image concern and eating behaviors. Use of EWLBs by friends predicted an individual's own level of use."

"While historically, eating disorders were conceptualized as primarily afflicting Caucasian adolescent or young adult women within high-income, industrialized Western Europe and North America, eating disorders are increasingly documented in diverse countries and cultures worldwide. This study highlights recent trends that reflect the changing landscape of culture and eating disorders: stabilization of the incidence of anorexia nervosa and possibly lower incidence rates of bulimia nervosa in Caucasian North American and Northern European groups; increasing rates of eating disorders in Asia; increasing rates of eating disorders in the Arab region; and increasing rates of binge eating and bulimia nervosa in Hispanic and Black American minority groups in North America."

"The purpose of this study was to assess the relative contribution of personality and emotional experience to self-reported eating attitudes in a group of patients with clinically diagnosed eating disorders, a weight-reduction training group (Weight Watchers), and a control group without body weight problems. Participants in this study (N = 114) completed Estonian versions of the Eating Disorder Inventory-2 (EDI-2; Garner, 1991), NEO Personality Inventory (Costa & McCrae, 1989), and Positive Affect and Negative Affect Schedule, Expanded Form (Watson & Clark, 1994). Data demonstrated validity of the Estonian version of EDI-2 in its ability to identify problems on a continuum of disordered eating behavior. Among the Big Five personality dimensions, Neuroticism made the largest contribution to EDI-2 subscales. Two other dimensions, Openness to Experience and Conscientiousness, also predispose individuals to eating problems. Personality traits made a larger contribution to the self-reported eating pathology than the self-rated effects experienced during the last few weeks. It was argued that personality dispositions have a larger relevancy in the etiology of eating disorders than emotional state."

"Some contributory factors appear to be necessary for the appearance of eating disorders, but none is sufficient. Eating disorders may represent a way of coping with problems of identity and personal control."

"Although it remains unclear whether the prevalence of eating disorders is higher in those with DRCHCs compared with the general population, overall findings suggest that young people with DRCHCs may be at risk of endorsing disordered eating behaviors that may lead to diagnosis of an eating disorder and other health problems over the course of their treatment. Thus, health care providers should be aware that young people with DRCHCs may be at risk of eating disorders and carefully monitor psychological changes and the use of unhealthy weight control methods. It is also important to develop and evaluate theory-based interventions and disease-specific eating disorder risk screening tools that are effective in halting the progression of eating disorders and negative health outcomes in young people with chronic health conditions."

"The development of eating disorders including anorexia nervosa, bulimia nervosa, binge eating disorder, and atypical eating disorders that affect many young women and even men in the productive period of their lives is complex and varied. While numbers of presumed risk factors contributing to the development of eating disorders are increasing, previous evidence for biological, psychological, developmental, and sociocultural effects on the development of eating disorders have not been conclusive. Despite the fact that a huge body of research has carefully examined the possible risk factors associated with the eating disorders, they have failed not only to uncover the exact etiology of eating disorders, but also to understand the interaction between different causes of eating disorders. This failure may be due complexities of eating disorders, limitations of the studies or combination of two factors. In this review, some risk factors including biological, psychological, developmental, and sociocultural are discussed."

"It has been hypothesized that eating disorders have multiple and often shared etiologies including biological, psychological, developmental, and sociocultural. A tightly woven network of causes, symptoms, and outcomes of eating disorders makes the study of etiology of these disorders very challenging. Some suggested risk factors for eating disorders require to be defined as either integral parts of eating disorders syndrome such as body dissatisfaction, and perfectionism or outcome of prolonged disordered eating such as functional alterations in serotonin, and some mood disturbances. Researchers should structure their thought processes around this concept that some of currently well-known risk factors for eating disorders are concurrent symptoms of eating disorders. Hence paying special attention to the new and evolved concepts is highly recommended while studying the etiology of eating disorders."

"Studies have reported that the oral health status is jeopardized in patients with eating disorders. The aim was to review the oro-facial manifestations in patients with eating disorders. The address the focused question was "What is the oro-dental health status in patients with eating disorders?" MEDLINE/PubMed and Google Scholar databases were searched from 1948 to March 2012 using the following terms in various combinations: "Anorexia nervosa", "bulimia nervosa", "eating disorders", "dental", "oral health status". Letters to the editor, unpublished data and articles published in languages other than English were excluded. Dry lips, burning tongue and parotid gland swelling are common manifestations in patients with eating disorders as compared to medically healthy controls. The association of dental caries and periodontal disease in patients with eating disorders remains debatable. Temporomandibular disorders have also been reported to be more prevalent in patients with eating disorders as compared to healthy controls. A critical oral-dental examination during routine dental check-ups may reveal valuable information regarding the presence or absence of eating disorders in routine dental patients. This may be important information, updating the medical history, supporting the role of the physician."

"Comorbid personality disorders in eating disordered patients may seriously affect the treatment and course of their illness. Several studies show such a comorbidity, though with inconsistent findings. Qualitative reviews attribute this to methodological shortcomings, but the qualitative method may itself create new shortcomings. To circumvent this, the present, more extensive review applies a meta-analytic approach. Using the databases MEDLINE and PSYCHLIT, the 28 articles published between 1983 and 1998 that presented empirical evidence for an eating disorder and personality disorder comorbidity suitable for meta-analysis were included. We found a higher proportion of eating disordered patients with any personality disorder (average proportion = 0.58) related to comparison groups (average proportion = 0.28). Compared with anorexia nervosa patients, a higher proportion of patients with bulimia nervosa had a concurrent cluster B personality (average proportion = 0.44) and a borderline personality disorder (average proportion = 0.31). However, no differences between anorexia nervosa and bulimia nervosa patients in proportions of cluster C were found (average proportion = 0.45 and 0.44 respectively). Patients with eating disorders and patients with bulimia nervosa in particular, should be routinely assessed for a concurrent personality disorder using structured clinical interviews. In future research, more stringent assessment procedures are highly recommended to address the question of causality between eating disorders and personality disorders, and how eating disorder symptoms and personality disorder symptoms are related to treatment effects."

"The cognitive model of eating disorders (EDs) states that the processing of external and internal stimuli might be biased in mental disorders. These biases, or cognitive errors, systematically distort the individual's experiences and, in that way, maintains the eating disorder. This chapter presents an updated literature review of experimental studies investigating these cognitive biases. Results indicate that ED patients show biases in attention, interpretation, and memory when it comes to the processing of food-, weight-, and body shape-related cues. Some recent studies show that they also demonstrate errors in general cognitive abilities such as set shifting, central coherence, and decision making. A future challenge is whether cognitive biases and processes can be manipulated. Few preliminary studies suggest that an attention retraining and training in the cognitive modulation of food reward processing might be effective strategies to change body satisfaction, food cravings, and eating behavior."

"An individual who is a first degree relative of someone who has had or currently has an eating disorder is seven to twelve times more likely to have an eating disorder themselves. Twin studies also show that at least a portion of the vulnerability to develop eating disorders can be inherited, and there is evidence to show that there is a genetic locus that shows susceptibility for developing anorexia nervosa."

"Of the empirical studies undertaken, few investigated a cultural group's eating pathology in both its country of origin and a Western country using the same methodology. To date, the research findings are mixed and it is still unclear if the presentation of an eating disorder differs across cultures. Acculturation has not been consistently taken into consideration and psychological control has not been examined in relation to eating disturbances in non‐Western groups."

"Patients with eating disorders (ED) frequently exhibit additional psychiatric disorders. This study aimed to examine whether psychiatric comorbidity in ED patients is associated with increased severity of ED symptoms in a sample of 277 women with a current ED (84 anorexia nervosa, 152 bulimia nervosa, 41 eating disorders not otherwise specified). Psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview (SCID) for DSM-IV. Severity of ED-related symptoms was assessed using interviewer-rated scales from the Structured Interview for Anorexia and Bulimia Nervosa (SIAB). Affective and anxiety-related disorders of both axes were linked with increased intensity of weight- and appearance-related fears and concerns. Frequency of binge-eating and frequency of purging both were associated with Axis I anxiety disorders, substance-related disorders, and Cluster B personality disorders. Frequency of dieting was related to anxiety disorders on both axes. Multivariate analyses revealed that Axis I anxiety disorders were more closely linked with severity of ED symptoms than affective or substance-related disorders. The results showed that psychiatric comorbidity of both axes is linked with increased severity of ED symptoms and that there are associations between specific ED symptoms and specific forms of comorbidity."

"Eating disorders, such as anorexia, bulimia, and binge eating disorder, commonly involve a dysregulation of behavior (e.g., a lack or excess of inhibition and impulsive eating patterns) that is suggestive of prefrontal dysfunction. Functional neuro-imaging studies show that prefrontal-subcortical systems play a role in eating behavior and appetite in healthy individuals, and that people with eating disorders have altered activity in these systems. Eating behavior is often disturbed by illnesses and injuries that impinge upon prefrontal-subcortical systems. This study examined relationships between executive functioning and eating behavior in healthy individuals using validated behavioral rating scales (Frontal Systems Behavior Scale and Eating Inventory). Correlations demonstrated that increased dysexecutive traits were associated with disinhibited eating and greater food cravings. There was also a positive association with cognitive restraint of eating, suggesting that increased compensatory behaviors follow disinhibited eating. These psychometric findings reinforce those of other methodologies, supporting a role for prefrontal systems in eating."

"Eating disorders are significant causes of morbidity and mortality in adolescent females and young women. They are associated with severe medical and psychological consequences, including death, osteoporosis, growth delay and developmental delay. Dermatologic symptoms are almost always detectable in patients with severe anorexia nervosa (AN) and bulimia nervosa (BN), and awareness of these may help in the early diagnosis of hidden AN or BN."

"Of the empirical studies undertaken, it is clear that anxiety disorders are significantly more frequent in subjects with eating disorders than the general community. Researchers have shown that often anxiety disorders pre-date eating disorders, leading to a suggestion that early onset anxiety may predispose individuals to developing an eating disorder. To date however, the research presents strikingly inconsistent findings, thus complicating our understanding of eating disorder and anxiety co-morbidity. Furthermore, despite indications that eating disorder prevalence amongst individuals presenting for anxiety treatment may be high, there is a distinct lack of research in this area."

"Substance abuse has been shown to predict poor outcome in eating disorder (ED) samples, and prior cross-sectional data on personality subtypes of EDs suggest that substance abuse is associated with dysregulated and possibly avoidant-insecure subtypes."

"The present review focused on the personality profiles of patients with eating disorders. Studies using the Structured Clinical Interview for DSM-III-R Personality Disorder showed high rates of diagnostic co-occurrence between eating disorders and personality disorders. The most commonly observed were histrionic, obsessive-compulsive, avoidant, dependent and borderline personality disorders. Studies using the Cloninger's personality theory suggested that high Harm Avoidance might be relevant to the pathology of anorexia nervosa and high Novelty Seeking and Harm Avoidance to bulimia nervosa. Moreover, high Self-Directedness was suggested to be associated with favorable outcome in bulimia nervosa. The assessment of personality in a cross-sectional study, however, might be influenced by the various states of the illness. Therefore, a sophisticated longitudinal study will be required to advance this area of research."

"One out of four subjects showed a significant risk of an eating disorder and 6-7% probably already had one. No significant differences were found between the two samples. Significant differences were found in risk behaviors: more Spanish girls reported body dissatisfaction and binging; more Mexican girls had a history of psychiatric and psychological treatment, pressure from parents and friends to lose weight, dieting, physical activity and vomiting to lose weight, and a history of greater weight loss. In both the groups around 50% of subjects wanted to increase the size of their breasts. However, significantly more Mexican girls desired thinner arms and narrower shoulders and back, and more Spanish girls wanted thinner hips, buttocks, and legs, parts of the body that many Mexicans wanted to increase."

"Risk behaviors and the ideal body models of these Spanish and Mexican adolescent girls varied significantly, indicating major socio-cultural differences. However, the prevalence of ED was similar. Further research should aim to clarify whether the similarities found between this Spanish sample and a Mexican sample taken from an upper-middle class urban environment, a minority that is unrepresentative of the general population, are also observed in samples from other sectors of Mexican society."

"This Seminar adds to the previous Lancet Seminar about eating disorders, published in 2003, with an emphasis on the biological contributions to illness onset and maintenance. The diagnostic criteria are in the process of review, and the probable four new categories are: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. These categories will also be broader than they were previously, which will affect the population prevalence; the present lifetime prevalence of all eating disorders is about 5%. Eating disorders can be associated with profound and protracted physical and psychosocial morbidity. The causal factors underpinning eating disorders have been clarified by understanding about the central control of appetite. Cultural, social, and interpersonal elements can trigger onset, and changes in neural networks can sustain the illness. Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery."

"There are a number of differences in the aetiology of subtypes of eating disorder. The present results suggest that cognitive styles pertaining to the social arena in adolescence, and prior to the onset of any eating disorders, may play a causal role in the development of anorexia nervosa of the binge/purge subtype, but not anorexia nervosa of the restricting subtype."

"Eating disorders, including anorexia and bulimia nervosa, are characterised by abnormal eating behaviour and typical psychopathological features, including fear of fatness, drive for thinness, and body image disturbance. In most patients, there is no detectable focal brain abnormality. Nonetheless, associations of anorexia and bulimia nervosa with history of perinatal complications and head injuries suggest a role of cerebral pathology in some cases. A number of case studies describe eating disorders with intracranial tumours, injuries, or epileptogenic foci. However, many clinical descriptions are limited to changes in appetite and lack psychopathological features characteristic of eating disorders. A previous review of 21 anorexia cases associated with brain tumours found that only three of them fulfilled formal diagnostic criteria. In the present paper, we provide a systematic review of published case reports and highlight those relatively rare cases where typical eating disorders appear to be causally associated with localised brain damage."

"This review of published case reports challenges the traditional view that hypothalamic disturbance underlies eating disorders. Although hypothalamic lesions are the most commonly reported neural causes of anorexia-like syndrome, most of them lack the typical psychopathology. Of the eight cases with characteristic psychopathological presentation and suggestive evidence for a causal association, four had frontal and temporal cortical lesions, two brain stem tumours, one hypothalamic tumour, and one hydrocephalus. Implication of frontotemporal circuits is consistent with functional neuroimaging research in eating disorders and with benign changes in eating, such as the gourmand syndrome.49 Therefore, we conclude that evidence favours cortical mechanisms in the genesis of eating disorders over hypothalamic ones. An association of disordered eating with epilepsy was reported in 12 cases. In six of these, remission after a surgical removal of an epileptogenic focus or anticonvulsant treatment suggests that eating disorder may be actively maintained by an epileptogenic focus rather than being a deficit syndrome due to missing normal brain tissue. In five of the reviewed cases, disturbed eating occurred alongside obsessive compulsive psychopathology. This finding parallels the comorbidity and familial cooccurrence of eating disorders and obsessive compulsive disorder50 51 and suggests a common or overlapping neural substrate of the two."

"All dominant models of the eating disorders implicate personality variables in the emergence of weight concerns and the development of specific symptoms such as bingeing and purging. Standardized measures of personality traits and disorders generally confirm clinical descriptions of restricting anorexics as constricted, conforming, and obsessional individuals. A less consistent picture suggesting affective instability and impulsivity has emerged from the assessment of subjects with bulimia nervosa. Considerable heterogeneity exists within eating disorder subtypes, however, and a number of special problems complicate the interpretation of personality data in this population. These include young age at onset, the influence of state variables such as depression and starvation sequelae, denial and distortion in self-report, the instability of subtype diagnoses, and the persistence of residual problems following symptom control."

"Social media have become a significant means for peer-related communication, self-presentation, and identity management. So-called eating disorder websites that propagate a drastic thin ideal and unhealthy eating behaviors have triggered a debate about the harmful facets of social Internet activity. Little research has addressed the language that is used by the authors of these websites. The present study focuses on personal weblogs, a popular form of mostly text-based, diary-like, online journals. We compared 31 pro–eating disorder blogs, 29 recovery blogs, and 27 control blogs by the means of computerized quantitative text analyses. The language of pro–eating disorder blogs featured lower cognitive processing, a more closed-minded writing style, was less emotionally expressive, contained fewer social references, and focused more on eating-related contents than recovery blogs. A subset of 12 language indicators correctly classified the blogs in 84% of the cases. The distinct language patterns appear to reflect the psychological conditions of the blog authors and provide insight into their various stages of coping."

"I was intrigued when my articles on eating disorders began to be translated, over the past few years, into Japanese and Chinese. Among the members of audiences at my talks, Asian women had been among the most insistent that eating and body image weren’t problems for their people, and indeed, my initial research showed that eating disorders were virtually unknown in Asia. But when, this year, a Korean translation of Unbearable Weight was published, I felt I needed to revisit the situation. I discovered multiple reports on dramatic increases in eating disorders in China, South Korea, and Japan. “As many Asian countries become Westernized and infused with the Western aesthetic of a tall, thin, lean body, a virtual tsunami of eating disorders has swamped Asian countries,” writes Eunice Park in “Asian Week” magazine. Older people can still remember when it was very different. In China, for example, where revolutionary ideals once condemned any focus on appearance and there have been several disastrous famines, “little fatty” was a term of endearment for children. Now, with fast good on every corner, childhood obesity is on the rise, and the cultural meaning of fat and thin has changed. “When I was young,” says Li Xiaojing, who manages a fitness center in Beijing, “people admired and were even jealous of fat people since they thought they ahd a better life. . . . But now, most of us see a far person and think ‘He looks awful’”"

"Because of their remote location, the Fiji islands did not access to television until 1995, when a single station was introduced. It broadcasts programs from the United States, Great Britain, and Australia. Until that time, Fiji had no reported cases of eating disorders, and a study conducted by anthropologist Anne Becker showed that most Fijian girls and women, no matter how large, were comfortable with their bodies. In 1998, just three years after the station began broadcasting, 11 percent of girls reported vomiting to control weight, and 62 percent of girls surveyed reported dieting during the previous months. Becker was surprised by the change; she had though that Fijian cultural traditions, which celebrate eating and favor voluptous bodies, would “withstand” the influence of media images. Her explanation for the Fijian’s vulnerability? They were not sophisticated enough about media to recognize that the television images were not “real.”"

"In their world, there is a size zero, and it’s a status symbol. The chronic dieters have been as it since they were eight and nine years old. “Epidemic of eating disorders” is old stuff; being preached to about it turns them right off. Their world is one in which the anorexics swap starvation diet tips on the Internet, participate in group fasts, offer advice on how to hide your “ana” from family members, and share inspirational photos of emaciated models. But full-blown anorexia has never been the norm among teenage girls; the real epidemic is among the girls with seemingly healthy eating habits, seemingly health bodies, who commit or work their butts off as a result form of anti-fat maintenance. These girls not only look “normal” but consider themselves normal. The new criterion circulating among teenage girls: If you get rid of it through exercise rather than purging or laxatives, you don’t have a problem. Theirs is a world in which groups of dorm girls will plough voraciously through pizzas, chewing and then spitting out each mouthful. Do they have a disorder? Of course not-look, they’re eating pizza."

"When I wrote Unbearable Weight, it was widely believed that privileged white girls had the monopoly on eating and body-image problems. The presumption was a relic of the old medical models, which accepted the “profile” presented by the typical recipient of therapy-who was indeed largely white and upper middle class- as definitive, and which failed to recognize the central role of media imagery in “spreading” eating and body-image problems across race and class (and sexual orientation). Like the Black Africans and the Fijians and the Russians (and lesbians and [Latins]] and every other “subculture” boasting a history of regard for fleshy women), African Americans were believed “protected” by their alternative cultural values. And so, many young girls were left feeling stranded and alone, dealing with feelings about their bodies that they weren’t “supposed” to have, as they struggled, along with their white peers, with unprecedented pressure to achieve, and watched Janet Jackson and Halle Berry shrink before their eyes. Many medical professionals, too, were trapped in what I’d call the “anorexic paradigm.” They hadn’t yet understood that eating problems take many different forms and inhabit bodies of many different sizes and shapes. Binge eating-a chronic problem among many African American women-is no less a disordered relation to good than habitual purging, and large women who don’t or won’t diet are not necessarily comfortable with their bodies. Exercise addiction is rarely listed among the criteria for eating problems, but it has become the weight control of choice among an generation emulating Jennifer Lopez’s round tight buns rather than Kate Moss’s skeletal collarbones. Just because e a teenager looks healthy and fit does not mean that she is not living her life on a treadmill-metaphorically as well as literally-which she dare not step off lest food and fat overtake her body. Until recently, most clinicians were not receptive to the arguments of feminists like Susie Ohrbach (and later, myself) that “body image disturbance syndrome,” binge/purge cycling, bulimic thinking,” and all the rest needed to be understood as much more culturally normative than generally recognized. They wanted to draw a sharp dividing line between pathology and normality-a line that can be very blurry when it comes to eating and body-image problems in this culture. And while they acknowledged that images “play a role,” they clung to the notion that only girls with a “predisposing vulnerability” get into trouble. Trained in a medical model which seeks the ause of disorder in individual and family pathology, they hadn’t yet understood just how powerful, ubiquitous, and invasive the demands of culture are on our bodies and souls."

"Families matter, of course, and so do racial and ethnic traditions. But families exist in cultural time and space-and so do racial groups. Thus, no one lives in a bubble of self-generated dysfunction” or permanent immunity-especially today, as mass media culture increasingly has provided the dominant “public education” in our children’s lives. The “profile” of girls with eating problems is dynamic, not static; heterogenous, nut uniform. Therapists now report treating the anorexic daughters of anorexics, and are coming to realize the role parents play, not just in being “over-controlling” or overly demanding of their children, but in modeling and obedience to cultural norms. And the old generalizations about race and “fat acceptance” while perhaps valid for older generations of Black Americans, do not begin to adequately describe the complex and often conflicted attitudes of younger people, many of whom are aware of traditional values but constantly feel the pull of contemporary demands. While working on Unbearable Weight”, I called up organizations devoted to Black women’s health issues, asking for statistics and clinical anecdotes, and was told: “That’s a white girl’s thing. African American women are comfortable with their bodies.” For twenty-something Tenisha Williamson, who suffers from anorexia, such notions are almost as oppressive as her eating disorder: “From an African American standpoint,” she writes, “we as a people are encouraged to ‘embrace our big, voluptuous bodies,’ This makes me feel terrible because I don’t want a big voluptuous body! I don’t ever want to be fat-ever, and I don’t ever want to gain weight. I would rather die from starvation than gain a single pound. [This makes me feel like] the proverbial Judas of my race. . . and so incredibly shallow.” In fact, the starving white girls were just the forward guard, the miners’ canaries warning of how poisonous the air was becoming for everyone. I could see it in the magazines the videos, and in my students’ journals. I could see it, as I write in “Material Girl,” in the transformations of Madonna and other performers of Italian, Jewish, and African American descent who seemed at the start of their careers, to represent resistance to the waifs and willows but who just couldn't hold out against what, indeed, had begun to look like a tsunami, a cultural tidal wave of obsession with achieving a disciplined, normalized body."

"At the 1983 meetings of the New York Center for the Study of Anorexia and Bulimia, Steven Levenkron charged feminism with sacrificing the care of “helpless, chaotic, and floundering” children in the interests of a “rational” political agenda. Is he right? Does maintaining a continuity between eating disorders and “normal” female behavior entail a denial of the fact that anorexia and bulimia are extreme and debilitating disorders? I think not. The feminist perspective has never questioned the reality of the anoretic’s disorder or the severity of her suffering. Rather, what is at stake is the conception of the pathological as the indicator of a special “profile” (psychological or biological) that distinguishes the eating-disordered woman from the women who “escape” disorder. Feminist analysts see no firm boundary on one side of which a state of psychological comfort and stability may be said to exist. They see, rather, only varying degrees of disorder, some more “functional” than others, but all undermining women’s full potential. At one end of this continuum we find anorexia and bulimia, extremes which set into play physiological and psychological dynamics that lead the sufferer into addictive patterns and medical and emotional problems outside the “norms” of behavior and experience. But it is not only anoretics and bulimics whose lives are led into “disorder.” This is a culture in which rigorous dieting and exercise are being engaged in by more and younger girls all the time-girls as young as seven or eight, according to some studies. These little girls live in constant fear- a fear reinforced by the attitudes of the boys in their classes-of gaining a pound and thus ceasing to be “attractive.” They jog daily, count their calories obsessively, and risk serious vitamin deficiencies and delayed reproductive maturation. We may be producing a generation of young, privileged women with severely impaired menstrual, nutritional, and intellectual functioning."

"But how can a cultural analysis account for the fact that only “some” girls and women develop full-blown eating disorders, despite the fact that we are all subject to the same sociocultural pressures? Don’t you require the postulation of a distinctive underlying pathology (familial or psychological) to explain why some individuals are more vulnerable than others? The first of these questions is frequently presented by medical professionals as though it dealt a decisive blow to the cultural argument, and it is extraordinary how often it is indeed accepted as a devastating critique. It is based, however, on an important and common misunderstanding (or misrepresentation) of the feminist position as involving the positing of an “identical” cultural situation for all “women” rather than the description of ideological and institutional parameters governing the construction of “gender” in our culture. The difference is crucial, yet even such a sophisticated thinker as Joan Brumberg misses it completely. “Current cultural models,” Brumberg argues, “fail to explain why so many individuals “do not” develop the disease, even though they have been exposed to the same cultural environment.” But of course we are “not” all exposed to “the same cultural environment.” What we “are” all exposed to, rather, are homogenizing and normalizing images and ideologies concerning “femininity” and female beauty. Those images and ideology press for conformity to dominant cultural norms. But people’s identities are not formed “only” through interaction with such images, powerful as they are. The unique configurations (of ethnicity, social class, sexual orientation, religion, genetics, education, family, age, and so forth) that make up each person’s life will determine how each “actual” woman is affected by our culture. The search for distinctive patterns, profiles, and abnormalities underlying anorexia nervosa and bulimia is thus not, as man researchers claim, “conceptually” demanded; a myriad of heterogeneous factors, “family resemblances” rather than essential features, unpredictable combinations of elements, may be at work in determining who turns out to be most susceptible. It may be, too, that patterns and profiles could one be assembled but are now breaking apart under the pressure of an increasingly coercive mass culture with its compelling, fabricated images of beauty and success."

"The shallow and unanalyzed conception of slenderness as merely “an external body configuration “rather than” an internal spiritual state,” an ideal without psychological or moral depth, still predominates in the literature on anorexia and bulimia. Why? One explanation is that so long as eating disorders remain situated within a medical model, those who are entrusted with the conceptualization of anorexia and bulimia will be medical professionals who have little experience in or inclination toward cultural interpretation and criticism. But more important is the fact that to begin to incorporate such interpretation and criticism within the medical model would be to transform that model itself. Susceptibility to “images” can still be conceptualized in terms of a passive subject and a mechanical process. To acknowledge, however, that meaning is continually being produced at all levels-by the culture, by the subject, by the clinician as well-and that in a fundamental sense there “is” no body that exists neutrally, outside this process of making meaning, no body that passively awaits the objective deciphering of trained experts, is to question the presuppositions on which much of modern science is built and around which our highly specialized, professionalized, and compartmentalized culture revolves. Or, to put this another way: it is to suggest that the study of the disordered body is as much the proper province of cultural critics in every field and of nonspecialists, ordinary but critically questioning citizens, as it is o the “experts.” This audacious challenge is the legacy of the feminist reconceptualization of eating disorders."

"Although genetic research in eating disorders is frankly in its infancy, patients, families, and clinicians are aware of this research and face challenges in incorporating this knowledge into either their personal conceptions of their (or their family member’s) illness, or in the case of clinicians, helping patients and their families to understand the implications of this knowledge. Simplistic nature versus nurture dichotomies are easy to understand, yet rarely capture the complexity of reality, and definitely fail to do so in the case of eating disorders. Clinicians and researchers must become educated in the nuances of gene x environment interplay and avoid perpetuating purely environmental or purely genetic conceptualizations of eating disorder etiology."

"By definition, eating disorders are complex traits. That means that their inheritance pattern in families does not follow traditional Mendelian patterns, and that they are influenced by multiple genetic and environmental factors of small to moderate effect. There is not one gene for anorexia nervosa or one gene for bulimia nervosa. More likely there are a number of genes that code for proteins that influence traits that index vulnerability to these disorders. Complicating the risk picture even further, these genes exist in concert with other genetic factors that may confer protection against eating disorders, along with main effects of risk and protective environments, as well as gene x environment interplay as we discuss in the following section."

"For decades, parenting styles have been unrightfully blamed for causing eating disorders. Considerable care must be taken when discussing gene x environment interplay not to convey the message that somehow parenting is to blame for these pernicious illnesses. Conversely, a purely genetic explanation should not be taken to mean that parents need not examine their parenting style and the influence that might have on their children."

"In addition to having concerns about their own shape and weight, women with eating disorders may similarly be over-concerned about their children’s weight, even when it is well within normal limits. One study found that 15% of mothers with a history of bulimia nervosa had attempted to “slim down” their normal weight infants. Similarly, Waugh and Bulik found that 20% of the mothers with eating disorder histories in their sample tried to change their children’s appearance. Maternal restriction of children’s eating is a concern, as previous research suggests that maternal control of children’s eating interferes with the development of dietary self-regulation. These effects have been found among children as young as two years of age."

"The influence of maternal perceptions on daughters’ eating disordered behavior appears to continue into adolescence and young adulthood. For example, mothers whose daughters engaged in eating disordered behavior were more likely to view their daughters as overweight than were mothers of non-eating disordered daughters (controlling for weight differences between groups). Further, this appearance pressure is not necessarily limited to weight, as mothers of daughters with eating disorder symptomatology also rated their daughters as less attractive than the daughters rated themselves. These results are concerning, as they suggest that daughters who engage in eating disordered behaviors may not only lack a maternal role model of healthy eating, but also feel maternal pressure to lose weight and enhance their appearance. This of course could reflect several complex intergenerational processes. On one hand, mothers may harbor threshold or subthreshold eating disturbances themselves, and their comments or behaviors could reflect their underlying pathology. Alternatively or complementarily, the daughters’ pathology could render them more sensitive to maternal comments that in other situations may be perceived as culturally normative. These environmental experiences could facilitate the expression of an existing genetic predisposition for eating disorder symptomatology."