Eating disorder

"One potential pitfall of genetic research on eating disorders is the misinterpretation that environmental factors such as the media do not matter. Western media’s idealization of an ultra-thin female body type has long been viewed as an important sociocultural risk factor for eating disorders. However, given the ubiquity of this influence in Western cultures, other factors must influence vulnerability to the thin cultural ideal. As Bulik suggests, genetically vulnerable individuals might seek out experiences, such as exposure to thin-ideal media images, which reinforce their negative body image. This hypothesis is supported by a longitudinal study which found that adolescent girls whose eating disorder symptomatology increased over a 16 month period also reported significantly greater fashion magazine reading at Time 2, compared with Time."

"Similarly, individuals genetically predisposed to eating disorder symptomatology such as thin-ideal internalization might also actively choose to affiliate with peers who place a similar high value on weight and appearance. One potential example of this form of active selection could be the decision to join a sorority (particularly for European-American women). European-American sorority members report high levels of eating disorder symptomatology, including weight preoccupation, drive for thinness, and body dissatisfaction. A longitudinal study found that sorority and non-sorority members did not differ on three measures of disordered eating (EDI Drive for Thinness, Body Dissatisfaction, and Bulimia) at Time 1 and Time 2 (first and second year of undergraduate, respectively). However, by Time 3 (third year of undergraduate), non-members’ drive for thinness scores had decreased, while members’ scores on this measure remained roughly the same, and this difference was statistically significant. Thus, the authors concluded that characteristics of the sorority environment could contribute to the persistence of a higher degree of drive for thinness. Although this study did not include a measure of actual or putative genetic vulnerability to eating disorders, it is plausible to speculate that an environment that promotes the maintenance of eating disordered characteristics would be particularly problematic for a genetically vulnerable individual."

"One fascinating and modifiable environmental factor that has emerged as a possible buffer against the development of eating disorders in adolescent girls is family meals. Likewise, breakfast eating may also play a role in preventing the development of eating problems. For example, Fernández-Aranda and colleagues found that women with eating disorders were less likely to have eaten breakfast regularly during childhood compared to non-eating disordered controls. Although retrospective, these findings are consistent with those of a large (n = 2216), longitudinal study which found that breakfast eating frequency was inversely associated with dieting and weight-control behaviors, and positively related to dietary quality and physical activity in adolescents. Overall, these studies offer preliminary insight into potential buffers against eating disorders; however, research in this area has not yet progressed to assess the differential effect of these protective factors in individuals at high-risk for eating disorders versus the general population."

"Another factor that offers promise as a potential buffer against the development of eating disorders is the enhancement of emotion regulation skills. As noted above, individuals with eating disorders experience relatively high levels of perceived stress and difficulties regulating emotion. Thus, interventions aimed at enhancing emotion regulation skills might be of particular benefit to high-risk groups. However, research incorporating mindfulness techniques has not specifically targeted high-risk groups. For example, a recent study investigated the effectiveness of a primary prevention program incorporating elements of mindfulness (e.g., yoga), targeting fifth-grade girls. This program integrated mindfulness into an empirically-based curriculum, which also included other elements, such as media literacy, and the promotion of dissonance regarding idealization of an ultra-slim body type. Compared to a control group, girls in the intervention reported lower body dissatisfaction and uncontrolled eating, and higher social self-concept at post-testing. However, there were no significant changes on other variables assessed including drive for thinness, perceived stress, physical self-concept and perceived competence. Nonetheless, these outcomes do provide some support for the inclusion of mindfulness-based activities in prevention. In contrast, a study with undergraduate women did not find any differences between participants in a yoga program and a control group on eating disorder symptoms at post-testing. Future studies should target high-risk groups, to evaluate the efficacy of mindfulness-based techniques within this specific sample."

"Results from focus groups and clinical case studies suggest that mothers with eating disorders are eager to learn about how best to care for their children, especially with respect to feeding. However, they report that the level of assistance they desire is not routinely offered by their health care providers. In one of the only published interventions conducted with this population, Stein et al. studied 80 mothers with eating disorders and their four to six month old infants to test whether a 13 session intervention of video-feedback treatment in conjunction with cognitive behavioral self-help was more effective than cognitive behavioral self-help alone in reducing mealtime conflict and other aspects of maternal-child interaction. Those mothers in the video-feedback group exhibited significantly less conflict than control mothers as well as significant improvements in infant autonomy and several other interaction measures. In addition, maternal eating psychopathology was reduced across both groups. Such interventions could help break the “cycle of risk” associated with eating disorders, by providing parents with useful buffering strategies."

"Patients read enormous amounts about their illness and are often aware of the genetic research on eating disorders yet they struggle to understand what the data mean for them and the challenges they face every day during recovery. Helping patients to understand the genetic literature is a first step. Although they might not initially see its relevance to their situation, helping them map how disordered eating and temperamental traits track in their families by using techniques such as labeling family trees can provide a useful context for understanding genetic and environmental contributions to their current situation. An understanding of genetic and environmental interplay can provide them with an explanatory model for not only their illness, but also for understanding their sensitivity to the environment. It can help provide them with the motivation to acquire skills that may help buffer them from the environment and combat their biology most effectively."

"Clinical observation has long suggested a link between personality and eating disorders. Research has consistently linked anorexia (particularly when the patient does not also have bulimic symptoms) to personality traits such as introversion, conformity, perfectionism, rigidity, and obsessive-compulsive features. The picture for bulimia is more mixed. Traits such as perfectionism, shyness, and compliance have consistently emerged in studies of individuals with bulimia or with anorexia, although research has often found bulimic patients to be extroverted, histrionic, and affectively unstable. Research on personality disorders has also examined the relation between eating disorders and personality and has documented considerable, but highly variable, rates of comorbidity, ranging from 21% to 97% for the presence of any personality disorder in patients with various eating disorder diagnoses. Conversely, patients with personality disorders have a higher than normal prevalence rate for eating disorders. The situation is similar for many axis I disorders, such as mood and anxiety disorders, for which comorbidity with axis II disorders hovers around 50%."

"The findings of this study raise questions about the concept of comorbidity as applied to eating disorders and suggest the likely utility for both research and clinical practice of considering eating-disordered symptoms in their characterological context (e.g., references 12, 34). The data from this study suggest that individuals who develop eating disorders who are constricted in most areas of their lives—e.g., who are passive and unassertive, emotionally constricted, and interpersonally avoidant—are likely to express this pattern with anorexic, rather than bulimic behavior. Clinically, these patients tend to be just as constricted in their sexual lives as they are with food, denying themselves pleasure, avoiding sexual relationships, feeling too ashamed or guilty to indicate to their partners what feels good, and so forth. Conversely, individuals with eating disorders whose ability to regulate their impulses and affects is tenuous—as expressed in spiraling emotions, tantrums, clinging to others for soothing, self-mutilation, and other impulsive acts—are likely to lose control over their eating in binges and to use self-destructive compensatory measures such as vomiting that momentarily help them regulate their affects. From this point of view, the question of whether bulimic symptoms should be regarded as impulsive behavior may be misplaced. The answer is probably that it depends on the personality configuration within which bulimic symptoms are contextualized. In low-functioning, emotionally dysregulated, type II bulimic patients, binge eating and purging may be functional equivalents of substance abuse, self-mutilation, and promiscuity. For these patients, bulimic symptoms may represent desperate efforts to regulate intense negative affects that call for immediate, and often maladaptive, responses. In contrast, high-functioning, perfectionistic, type I bulimic patients do not struggle with affects of the same intensity, and they have more adaptive coping strategies at their disposal for dealing with their distress. For these patients, binge eating is not equivalent to impulsive behaviors such as drinking or self-mutilation. More broadly, the data suggest that eating-disordered symptoms can be one expression, albeit a highly visible and sometimes life-threatening one, of a more general pattern of impulse and affect regulation. Thus, treating eating disorders primarily as disorders of food intake—and hence focusing primarily on altering the behavior, providing nutritional information (to patients who often know more about calories than the nutritionists who work with them), and so forth—may be taking the symptoms too literally. As in the treatment of trauma survivors, safety must be the clinician’s primary concern in treating patients with eating disorders when their symptoms are life-threatening or pose serious consequences for their current or future health. Particularly at those times, pharmacological and cognitive behavioral interventions can be essential components of a treatment plan, as they may be at various other points in the treatment."

"At the same time, however, symptom-focused treatment strategies may fail to address the personality structure that provides a context for understanding disordered eating. Patients whose personality profiles match the overcontrolled, constricted prototype, for example, rarely recognize their stance toward their own impulses and relationships as a problem. What brings them into treatment is typically someone else’s concern about their weight. If their attitudes toward their needs and feelings in general (and not just toward food) do not become the object of therapeutic attention, they are likely to change with treatment from being starving, unhappy, isolated, and emotionally constricted people to being relatively well fed, unhappy, isolated, and emotionally constricted people. The data also raise questions about the extent to which axis II is adequate for describing clinically meaningful patterns of personality pathology, at least for women with eating disorders. Patients in the high-functioning/perfectionistic cluster generally lacked diagnosable axis II pathology; indeed, in our study (as in the other studies that have isolated a similar cluster), they were defined by the absence of such pathology. These patients are articulate, conscientious, and empathic, and they tend to elicit liking in others. Yet they clearly have personality pathology—that is, enduring, problematic patterns of thought, feeling, motivation, and behavior. They are self-critical, perfectionistic, competitive, anxious, and guilt-ridden, and these aspects of their personality require clinical attention. The data reported here make sense in light of other findings that roughly 60% of patients treated for clinically significant personality pathology do not have problems severe enough to be diagnosable on axis II and that their personality problems (e.g., perfectionism and chronic feelings of guilt) generally are not reducible to any axis I syndrome (21, 22). Available data suggest that these patients represent the majority of patients treated in clinical practice and are not simply the “worried well.” Either axis II needs to be expanded from a personality disorderaxis to a personalityaxis that includes the range of functioning (from relatively healthy to relatively impaired), or subtypes such as those uncovered here need to be built into axis I. From a methodological standpoint, the results of this study suggest that we should routinely test for subtypes in our data sets rather than assuming homogeneity of categories. Group means may not be very meaningful when substantial intracategory heterogeneity exists, particularly if this heterogeneity is ordered, not random. The problem is particularly pronounced if pathology can be expressed in phenotypically opposite directions, leading to means that cancel out patterned within-group variability. Thus, although the etiological data on sexual abuse reported here are correlational and preliminary, they suggest that the same risk factor—sexual abuse—may manifest in opposite personality and behavioral styles—constriction and inhibition on the one hand, and dyscontrol and promiscuity on the other. Whether this is true of other etiologically significant psychosocial variables, such as harsh parental criticism (which, from a clinical point of view, appears sometimes to lead to self-criticism, sometimes to hostility and criticism toward others, and sometimes to both in adulthood), is an important question for future research."